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Are we paying a high price for soaring caesar rates?

The latest national figures show the Australian health system is paying a high price for the ever-increasing rate of caesarean sections.

In 2006, 30.8% of births were by caesarean section, compared with 20.3% in 1997. The Australia’s mothers and babies 2006 report, by the AIHW National Perinatal Statistics Unit at the University of New South Wales, also found that the median length of hospital stay for women giving birth was three days. But for those having a caesar, the median stay was five days.

As Lesley Barclay and colleagues recently wrote on Crikey, it seems very likely that structural incentives promoting private health insurance and private hospital use are contributing to the rising caesar rates.

Hubert van Griensven, a consultant physiotherapist in the UK, with a keen interest in evidence-based health care, argues below that some women may pay a long-term price for the trend:

“Over the last ten years, the rate of caesarean section births has risen considerably in many countries. For women it may represent a relatively easy way out, while a benefit for the health service is a reduction of unpredictability. Book your date, have your child, and everyone is home on time for dinner. The drive-by baby is born.

However, there are emerging concerns about the long-term impact of this trend upon women’s health.

Research investigating possible after-effects of caesareans has been slow to develop, although one study, published by researchers in Denmark found that that 12% of a group of over 200 women had long-term pain in the operated area.

In 2007, a large study at the Maxima Medical Centre in The Netherlands investigated persistent pain over and around a bikini line scar. The majority of women in the study group had caesareans and some had hysterectomies. Pain was reported as regular or constant by more than 8% of women, and described as moderate or severe by nearly 9%. In total over 30% of participants experiencing pain of any severity or frequency. The risk of persistent pain was found to increase with repeated incisions. 93% of responders had caesareans, so it is likely that the percentages are representative for this group.

Over the last year I have made a point of asking experienced GP and women’s health clinicians in the UK whether they have come across post-caesarean scar pain. Most deny that it exists, while others can recall only a couple of cases in many years of practice. This could lead one to believe that while researchers have established that pain may result from caesareans, it is not sufficient for women to seek help. Unfortunately the truth may be more complex than that.

I carried out an analysis of entries on open access internet discussion sites and message boards. The number of women asking questions about signs and symptoms over and around the scar is considerable. Many women reply, sometimes with reassuring messages but often with stories of difficulties of their own. It did not take me long to collect over 160 reports of personal experience, mentioning not only pain but also difficulty healing, unpleasant scars and disrupted activities.

While informal internet information is clearly insufficient to make healthcare decisions, it does suggest that there is a discrepancy between awareness in the medical profession and the reality as experienced by women. Indeed, some women report interesting experiences with doctors, such as being advised to stop lifting (try that with a new baby) or getting a string of diagnoses and operations.

I am undertaking a study at Southend University Hospital NHS Foundation Trust and the University of Brighton in the UK to investigate a range of post-caesarean scar problems and their impact, as well as the role of the healthcare professions. Hopefully it will tell us how to help women following caesarean section and improve medical care and education.

Meanwhile, we should pause to think what we are doing if there is a risk of turning thousands of previously healthy young women into patients with persistent pain.”

Comments 2

  1. kidsdoc says:

    The controversy surrounding the increasingly high rate of Caesarean sections in Australia and other developed countries tends to focus on the negative maternal outcomes (i.e. the short and long-term complications of open abdominal surgery) and ignores the negative neonatal outcomes which C-sections ameliorate.

    Caesarians have a crucial role to play in the appropriate obstetric management of pregnancies. A certain rate of Caesarian sections leads to reduced maternal and neonatal morbidity and mortality. This rate has been somewhat arbitrarily defined by the WHO as 15%. A recent ecological study showed that increasing rates of Caesarian section in low income countries, where C-section rates are on the whole less than ten percent, are associated with reduced perinatal morbidity and mortality. On the other hand, increasing C-section rates in middle and high income countries show no similar improvements.

    The real question is what level of risk obstetricians and their patients are willing to accept in pregnancy outcomes. Anecdotally, the perceived risks of not proceeding with a C-section greatly outbalance the side effects to the mother and baby of undergoing a C-section. There are clear psychological reasons for this: (1) the many and relatively unknown outcomes of not having a C-section are far more frightening than the few known side effects of surgery; (2) the opportunity to ‘do something’ to actively manage a pregnancy is tempting to both doctor and patient and in itself is anxiolytic.

    Hence, an important reason for the dramatic increase in rates of C-section in Australia may be that the ‘prevented’ unknown adverse outcomes of pregnancy have become far less tolerable to the general public than the known adverse outcomes of a C-section, which due to its prevalence is now a widely acceptable method of managing a pregnancy. This is the converse of the immunisation controversy, where outcomes which are exceedingly rare due to vaccination (e.g. tetanus, measles) are now outbalanced, by perception if not by fact, by the rare side effects of vaccination.

    In the end, obstetricians, and doctors in general, do not practice in a vacuum, but are guided by changing social mores and patient preferences. Any real attempt at reducing the rate of Caesarean section will have to address the attitudes of the public at large.

  2. nairl says:

    I had a c-section too, and had similar pains. But when I when to see my GP about it, I was told that the pains are unrelated to the c-sect. Thousands of other women have had it too and nonwe have complained. So this may actually be an issue of doctors treating these complains are a trivial issue.

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Cultural Solutions - Healing Foundation forum 2014
Lowitja Institute Continuous Quality Improvement conference 2014
National Suicide Prevention Conference 2014
Racism and children/youth health symposium 2014
Rural & Remote Health Scientific Symposium 2014
2015 conferences
#CPHCEforum
#CRANAplus15
#HSR15
#NRHC15
#OTCC15
Population Health Congress 2015
2016 conferences
#AHHAsim16
#AHMRC16
#ANROWS2016
#ATSISPEP
#AusCanIndigenousWellness
#cphce2016
#CPHCEforum16
#CRANAplus2016
#IAMRA2016
#LowitjaConf2016
#PreventObesity16
#TowardsRecovery
#VMIAC16
#WearablesCEH
#WICC2016
2017 conferences
#17APCC
#ACEM17
#AIDAconf2017
#BTH20
#CATSINaM17
#ClimateHealthStrategy
#IAHAConf17
#IDS17
#LBQWHC17
#LivingOurWay
#OKtoAskAu
#OTCC2017
#ResearchTranslation17
#TheMHS2017
#VMIACConf17
#WCPH2017
Australian Palliative Care Conference
2018 conferences
#6rrhss
#ACEM18
#AHPA2018
#ATSISPC18
#CPHCE
#MHED18
#NDISMentalHealth