The rise in the average cesarean section rate is undeniable in Canada: from 18% of births in 1995, it rose to 29.1% in 2017, according to the most recent data published in the Journal of Obstetrics and Gynecology Canada. This type of childbirth, which consists of incising the mother’s belly and uterus to quickly remove the baby, is the most common surgical intervention with hospitalization in the country.
However, in a recent study, a team of health economists finds it difficult to explain more than half of the increase, which would not be explained by the available data.
For researcher Nils Chaillet, from the CHU de Québec Research Center, the increase observed in Quebec is not alarming, since it tends to stabilize. « The caesarean section rate has only increased by 25% to 27% from 2016 to 2022 », underlines the professor in the Department of Obstetrics and Gynecology at Laval University, who specializes in reproduction and maternal health and of the child. However, he does not take the situation lightly. “We actually have little or no data on the mother’s experience, her state of mind during childbirth, the reasons behind her choice, all of the parameters that could explain part of the phenomenon. But we can find part of the answer by looking closely at the characteristics of the mother and the medical context, in particular. Health personnel and researchers are still working to understand this increase in caesarean sections and to find solutions to favor the best type of delivery according to the circumstances.
Cesarean or vaginal birth?
The World Health Organization (WHO) recommends not to exceed a rate of 10% to 15% of births by caesarean section, since this operation is not without risk, in the same way as any surgical intervention.
In addition, vaginal delivery has multiple benefits for the baby: fewer injuries and fewer respiratory and pulmonary complications, because labor during vaginal delivery helps the baby to evacuate secretions from his lungs and improves transition between the liquid medium of the uterus and the ambient air.
For Nils Chaillet, these percentages are an ideal which does not necessarily correspond to the reality of all regions of the world. Like many experts, he thinks that a proportion of around 20% would be more realistic in Canada, in particular because one in five babies is born there to a mother aged 35 or over. « We must not forget that the caesarean section makes it possible to avoid serious complications and can save lives, among other things when the placenta is placed in front of the cervix or the baby is in respiratory distress », mentions- he.
A caesarean section is also required when the baby does not descend properly into the uterus, when labor is abnormal or the infant’s well-being is compromised. More than 30% of caesarean sections are performed for these reasons in Quebec, says Nils Chaillet. In addition, 21% of caesarean sections are justified by a baby who does not come from the head, but from the seat or transversely.
The specialist admits, however, that some caesareans could be avoided, for example those performed to better plan the birth or because the mother fears vaginal delivery. Indeed, a cesarean section that is not medically necessary can increase the risk of complications during childbirth or a subsequent pregnancy, such as infections, hemorrhages, injuries or post-surgical problems in the mother.
But even by reducing these unjustified cases, « we should not necessarily expect a considerable drop in the rate in all settings, because there are several factors involved in the increase in the number of caesarean sections », specifies Nils Chaillet .
Older mothers
The age of the mother at childbirth is one of great importance. From 2006 to 2016, the proportion of mothers aged 35 and over rose from 15% to 21%. « And it’s probably more today, » notes the researcher. A more advanced maternal age is generally synonymous with more numerous complications – disorders of the placenta, in particular – which can lead to a medically indicated caesarean section.
« Women over the age of 35 also have a higher risk factor for pelvic floor disorders, pain or incontinence after childbirth, which justifies in some cases, and in some contexts, the use of a caesarean section. planned,” says the specialist.
Different clinical settings
The hospital environment can also influence and increase the rate of caesareans, which varies greatly from one institution to another in Quebec, from 17% to 31%. “For example, a hospital that receives a more at-risk clientele will do more caesarean sections. And a facility that does not have 24-hour medical professionals or an intensive care room to handle a risky vaginal birth will tend to resort to a caesarean more quickly to avoid putting the baby or mom at risk at because of a longer response time, for example at night, » explains Professor Chaillet.
The vicious circle of second caesareans
In nearly 40% of caesarean section cases performed in Quebec, the mother has already undergone such an intervention. This practice dates back to the early 2000s, when studies showed that the uterine scar formed after the previous C-section is at risk of tearing during a vaginal birth. Thus, only 25% of Quebec women who have had a first cesarean then give birth naturally. A vicious circle that is gaining momentum with mothers giving birth at a later age than before.
“During a second pregnancy, most women who have already had a caesarean section have a difficult choice to make,” points out Nils Chaillet. They may attempt a vaginal birth and accept a rare risk of uterine rupture, which can have serious consequences for them and their child. For example, a higher risk of hysterectomy for the mother, which could compromise her entire future reproductive life. Women can also plan a second caesarean section, which is not without the risk of complications either. »
But medical practices are changing. For more than five years, Nils Chaillet and his colleague Dr.r Emmanuel Bujold are piloting the PRISMA study in 40 hospitals in the province to validate the relevance and reliability of new decision-making tools. Thanks to ultrasound techniques, it is indeed possible to measure the thickness of the scar on the uterus, to detect healing defects and thus to predict the risk of uterine rupture. For women who are not at risk, a vaginal birth could therefore be considered without fear.
“After a first caesarean section, confidence is the key to attempting natural childbirth, believes Nils Chaillet. If the results of the study are conclusive, we should see a drop in the rate of caesareans in a few years. »
The right procedure, to the right patient, at the right time
On reflection, it is not so much the number of caesarean sections that matters, but why they are performed, underlines the specialist. “It is important to take into account the risks of complications for the baby and the mother when choosing a type of delivery, this is the main indicator. Thus, a higher caesarean section rate could be beneficial if associated with lower risks of complications, and vice versa, depending on the context.
The researcher strongly believes in encouraging attempts at vaginal birth when possible. “And if, in the end, it ends in a caesarean section, it is not necessarily negative if the risks of complications are reduced. »
Considering that Quebec is one of the provinces of Canada with a rate of complications considered low, mothers and babies are in good hands!
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