By Carla Pedret - March 2019

“It’s been two years since my C-section and I still haven't got over it,” explains Marta, in tears. “I blamed myself. I thought I didn't know how to give birth,” says Patricia. Both are part of Apoyo Cesáreas, a group of women in Catalonia who have been meeting once a year for the past seven years to share the psychological scars of their caesarean sections.

It’s a sunny Saturday morning, and the community centre where the meeting takes place seems to become too small. Strong emotions are held in check, threatening to burst free. Natalia is one of the first to speak: “I could move my feet and I warned the doctors. I felt how they cut me. The worst part was when they ripped my placenta out. I went through so much pain that I wish I had died in the operating theatre.” She weeps as she recalls her experience. Her pain is so intense that some of the attendees start to cry.

When giving birth, the brain is ready to react to a new situation and records every gesture. The moment is overwhelming. As a result, a woman in labour who fears for her life or her baby's life may develop post-traumatic stress disorder. According to psychologist Raquel Quílez, these mothers may have similar symptoms to women who have been raped.

Risks of C-sections

When a woman gets pregnant, she automatically starts to imagine giving birth. Most mothers want a fast, vaginal delivery with minimum intervention. Few childbirth-preparation classes cover C-sections, sometimes treating them almost as taboo.

A caesarean section is an operation to deliver a baby through a cut made in the abdomen and womb. It saves lives but, like any other surgery, also carry risks. In addition to psychological consequences, mothers may experience side effects such as internal bleeding, infections, thrombosis or uterine rupture. Babies may experience breathing difficulties, immune-system disturbances or scalpel injuries.

Governments, doctors, midwives and the World Health Organization (WHO) have been warning for years about the alarming increase in C-section rates. According to a recent study published in The Lancet , the global C-section rate has doubled in the last 15 years. The medical journal defines the current situation as a ‘global epidemic’. Establishing the causes of this growth and finding solutions to reduce it are not straightforward.

When and why a C-section is performed

The most common reason for a caesarean section is when labour does not progress normally and there is a risk to the mother or the baby. However, “the criteria vary between professionals and centres. The main cause for a C-section is foetal distress, but determining it can be very variable,” points out Dr. Angels Vives, head of obstetrics at the main public hospital in Terrassa, the third most populous city in Spain’s autonomous Catalonia region. Not pressuring mothers and applying rigorous protocols led this public hospital to register a C-section rate of 11.6% in 2017, one of the lowest in the country.

More and more women feel that the likelihood of their delivery ending in a caesarean section is equivalent to flipping a coin. They share their doubts and anxiety in Facebook groups, blogs, and forums, determined to avoid the surgery if possible. “There are doctors who do C-sections like someone cutting ham,” says Cristina, another attendee at the Apoyo Cesáreas meeting.

Fear and uncertainty is the feeling of many women in the delivery room (Photo: Alex Hockett)

For almost 30 years, the World Health Organisation considered the ideal rate for caesarean sections to be between 10% and 15% but this guideline changed in 2015 when it published a new statement qualifying its recommendations. Based on a new study, WHO experts now consider that there is no evidence that, above a rate of 10%, caesarean sections help to reduce maternal or neonatal mortality.

Few countries or regions achieve these goals. The rate of caesarean sections in Catalonia in 2016 was 22.3% in public hospitals, and 37.7% in private ones, according to data of the Catalan government. Before drawing conclusions from the numbers, “the type of patients should be taken into account,” claims Dr. Anna Suy, a gynaecologist at the private Hospital de Barcelona. Dr. Suy mostly attends to women over 35 and oversees numerous twin births due to fertility treatments. She points out that these facts, along with increases in obesity, diabetes or hypertension, help explain her hospital’s C-section rate of 35%. However, the World Health Organisation considers that neither increases in maternal age nor the rise in the prevalence of obesity and of multiple pregnancies are "unlikely to explain the wide variations in C-section rates across the countries."

Unnecessary C-sections: an organisational issue

The upward trend, according to the WHO, has more to do with organisational, economic and cultural issues, as well as doctors’ fear of being sued.

In fact, in a report published in 2013, the Spanish Department of Health recognised that ‘C-section rates may, in fact, be more linked to clinical practice rather than to patient complications.’ Different ‘practices’ are evident among Spanish regions. In 2017, the Basque Country had a gross C-section rate of 15.6%, while Valencia registered 29%, the highest in the country.

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When comparing European countries, the gap is also significant. Nordic countries have the lowest rates, in contrast to countries like Italy, Hungary and Poland, which have rates above 30%.

Sizeable differences also exist between public and private hospitals. One of the reasons, according to Dr. Vives, is that private hospitals perform too many C-sections on first-time mothers. “When there has been a previous caesarean section and a second child comes along, there are hospitals that do a C-section automatically. It's a vicious circle. Many women don’t believe it, but it is possible to have a vaginal delivery after a C-section,” she adds.

Patience is key. The active phase of labour, when the cervix dilates from 3 to 10 centimetres, lasts an average of 8 hours in first-time mothers. Midwives have long criticised pressure to speed up the process. “I remember a patient who was going to have her second child. The induction started at 10 a.m. Before lunchtime, doctors decided to do a C-section. It had been only three hours since the delivery had begun. That’s not reasonable,” says Laura Espart, a member of the Catalan Midwives Association.

Small changes can have a big impact. La Seu d'Urgell Hospital created a new unit to improve maternal and child health care in Alt Urgell, a county in the Catalan Pyrenees with a population of 20,000 people. The team managed to cut the caesarean section rate from 30% to 16% in just six years, applying new protocols and delivering breech babies vaginally when possible.

Do doctors get paid more for C-sections?

There is a widespread belief that C-sections are more rewarding financially. Both Dr. Vives and Dr. Suy strongly deny it.

Obstetricians who work for private hospitals are normally self-employed and do not charge by the hour, but per process. A doctor receives between 300 and 500 euros (gross) for a C-section. “You get more money for a vaginal delivery because, in a caesarean section, you have to pay the salary of an assistant. Also, after a C-section, the patient stays in the hospital for more days and we are not paid for ward visits,” explains Dr. Suy. “If you were paid by the hour, you'd do something else. If you take into account the responsibility you have, what is being paid is a pittance,” she claims.

Why are there more caesarean sections in the early morning?

Doctors’ incentive to perform C-sections may not be economic, but their working hours and shift patterns could have a real impact, according to a study by the Pompeu Fabra University. Analysing unscheduled C-sections in four Spanish hospitals over a two-year period, researchers found out that the caesarean-section rate was highest between 11 p.m. and 4 a.m. The study concluded that a hospital’s shift structure could affect the decision making of physicians, and make them ‘less tolerant’ of the natural progression of childbirth.

Many women have a bad memory of their C-section because of emotional issues (Photo: Cassie Ehard/Flickr)

Accountability is another key difference between public and private hospitals. Doctors who work for private hospitals assist with deliveries then leave without justifying their actions. “Hospital de Barcelona has many doctors and, although the hospital has a compulsory protocol, there is no head of service to regulate what is happening at any given moment. Each doctor applies the protocol at his or her discretion,” says Dr. Suy. In contrast, teams in public hospitals are always held accountable for their decisions.

No solution without data

What if doctors published their C-section rates? “I have nothing to hide and neither do 95% of doctors,” Suy points out. She has one condition though: “Data should be rigorous. Relying solely on the gross caesarean section rate is obsolete.”

Data from countries or regions is not comparable at present because there is no commonly agreed procedure to collect the information. As a global standard, the World Health Organisation proposes the Robson classification. This system takes into account characteristics such as previous C-sections, first-time motherhood or multiple and high-risk pregnancies when comparing groups of women. Hospitals in Catalonia, however, have been slow to adopt it. “The rest of the world has talked about Robson but here we are far behind, as in so many other things,” complains Dr. Suy.

Without comparable data, it is impossible to know the real magnitude of the problem and to find an effective solution.

Loneliness in the delivery room

Many experts claim that statistics should not only assess the number of surgeries, but also take into account factors such as mothers’ satisfaction, their ability to enjoy pain-free sexual activity after childbirth, and the percentage who go on to breastfeed.

Natalia, Patricia and Marta’s complaints about their C-sections have nothing to do with the surgeries or the scars, but with feelings. Loneliness, fear and respect are the words the three of them repeat. “If the emotional support had been better, the experience would not have been so traumatic,” acknowledges Marta.

But times are changing. More and more women ask their doctors for clarifications and say what they want and need, explains Dr. Vives. Trust and communication are the cornerstones. “If the patient trusts you and you explain your decisions, you won’t have any problems,” argues Dr. Suy.

After an intense day, the women of the Apoyo Cesáreas group hug each other goodbye. Nuria, one of the organisers, already knows many of the stories that have been told, but every time she listens to them, she gets emotional. “You can have a caesarean section, but in a more human and respectful way”, she says. Natalia, now calm, rocks her daughter, while she and her partner pick up their things to leave. In spite of her bad experience, she is optimistic and does not give up: “We have to be able to do things in a different way.”