I recently posted on the rise of maternal mortality rates over the past two decades in both Canada and the USA (and to a slight degree, the UK as well), countries known for their ever-increasing rates of interventions, and specifically, c-sections.  The problem is that the c-section has been seen as an equal alternative (or sometimes even better alternative) to vaginal birth for people with no medical reason to have a c-section.  But there are repercussions to this for both the mother and child and it’s my hope to explore those herein.  Notably, in order to avoid the confound of a previous c-section (in which there is a heightened risk of health problems for a vaginal birth), the outcomes described herein are based on first c-sections only.  A comparison of VBACs and second caesarean sections is a topic for another day with its own unique set of considerations and outcomes.

Most commonly, people discuss the morbidity and mortality factors (rightfully so).  Giving birth via caesarean section has been found to be associated with a two to seven times increase in risk of death for the mother

[1][2] and morbidity is estimated at five to ten times that of a vaginal birth[3], even when the planned versus unplanned nature of the c-section is considered[4].  The mortality and morbidity rates for infants are similar to that for mothers, with a near three times increase in risk of mortality[5] and morbidity, most notably for respiratory problems[6].  The problem for most is that while the data shows an increased risk, the overall risk is very, very small and thus it gets masked.  But the risks are real and have been replicated time and again and yet the c-section rate in many countries continues to rise.

In a review of 79 studies on outcomes for c-sections and vaginal births (with or without other interventions), the authors found significant risks associated with rising c-section rates[7].  Specifically, c-sections were associated with greater risks of “maternal mortality, hysterectomy, ureteral tract and vesical injury, abdominal pain, neonatal respiratory morbidity, fetal death, placenta previa, and uterine rupture in future pregnancies” (p. 485).  While some of the 79 studies were observational—which means that some of these outcomes may be quite strong not because of the c-section, but because of a condition which led to the c-section—the authors did their best to control for that possibility.  Thus while their results may overestimate the risk, it is doubtful that the risk would completely disappear if one were to remove those cases in which an underlying cause was present.

So while we have ample evidence of the physical problems that can manifest from c-sections, especially when they are not undertaken for true medical reasons, that isn’t the only outcome we should be interested in.  In the concern for the medical (rightfully so to some degree), many people overlook the psychological and behavioural consequences of the caesarean section.  In an early meta-analysis on the topic[8], researchers found that mothers who birthed via c-section expressed less immediate and long-term satisfaction with the birth, were less likely ever to breast-feed (which was even greater for unplanned c-sections), experienced a much longer time to first interaction with their infants, had less positive reactions to them after birth, and interacted less with them at home.  This isn’t to say that all mothers will react this way, but that having a c-section heightens the risk of these psychosocial outcomes.  Interestingly, when the baby is breech, the psychosocial outcomes at 2 years post-partum are equivalent between those women who planned a caesarean section and those who planned a vaginal birth[9].

Given the previous meta-analysis findings on poor psychosocial outcomes after the birth, this raises the question of whether all c-sections are equal.  A planned c-section for a breech position (particularly historically when it was believed to be safest, despite that claim now being challenged) meant a woman was making a birth choice that arguably was safest for her and her child compared to a planned c-section for convenience in which a mother may not bond that well after more because of pre-existing ideas about motherhood.  And for women who end up with emergency c-sections, the terror and trauma that can lead up to that moment when labour isn’t progressing, or they run into problems that make them fear for their baby’s life, post-birth stress is something that must also be considered.  Thus, while the psychosocial outcomes of c-sections are real, it is worth exploring how the different types of c-sections affect maternal and infant outcomes and how the events leading to the c-section play a role in these outcomes as well.  The previous meta-analysis included this when possible, but sadly many early studies failed to make the distinction, making it impossible for the authors to determine many differences.

More recently, however, a detailed research review (focused only on methodologically sound studies) included such information in their review of the psychosocial effects of a c-section.[10]  These authors found that lower childbirth satisfaction (including feelings of powerlessness, lack of control, report a terrible or traumatic experience) was more prominent in women with c-sections, regardless of whether or not they were planned or unplanned.  With respect to depression, c-sections were related to an increased risk of depression for mothers with a history of depression only; however, unplanned caesarean sections were found to be associated with a large risk of symptoms and reactions in line with post-traumatic stress disorder.

(I think at this point it’s worth noting that not all unplanned c-sections need to be happening.  Yes, there are women with true complications that require medical interventions, but sadly, the cascade of interventions most women face in the hospital put them at increased risk for having to have an unplanned c-section.  Inductions, epidurals, pitocin, and having to give birth according to a schedule increase a woman’s risk for birthing via c-section and we’d be wise to remember these real emotional outcomes when we consider the “need” for these interventions.)

Returning to the research review[10], the relationship to parent-infant interactions was found to be somewhat mixed, with most studies on the topic (n=9) finding a reduction in interactions with their children – less play, less tactile stimulation, less favourable ratings more generally – as well as a reduction in breastfeeding rates and duration.  However, the authors note that there were two studies that were methodologically sound that failed to find these outcomes.  One positive outcome associated with c-sections was for women to plan around the birth, be it for employment, child care, or other responsibilities.  Some women also reported being relieved by the c-section as it ended labour when labour had been long and painful.  And finally, some women who are very much in favour of medicalized birth much prefer the c-section to vaginal birth and may not show any of the negative effects found in other research.  The psychosocial outcomes for these women are going to be very different because of the mindset going into it and we must be cognizant that this may be a preferable birthing method for some.

Another side effect of c-sections that rarely gets any discussion is food allergies.  Researchers have hypothesized that one pathway (of many) to food allergies is a delay in the colonization of a newborn and one study did find that children who were already at risk of developing allergies (due to family history) were four to seven times more likely to develop the allergy if born via caesarean section.  Importantly, there was no increase for children who were not at risk due to family history.[11]

Are there any medical benefits to the caesarean section (in general, obviously there are benefits when it’s medically necessary)?  The only health benefit I could find was a lower risk of urinary incontinence throughout the lifespan – both mild and more severe – compared to women who had vaginal births.[12]  This is probably not too surprising given the wear that the bladder can face during a vaginal delivery.  Interestingly, though, c-sections were also a risk factor for urinary incontinence relative to women who had never delivered, but the risk was greatest for women who had vaginal deliveries.

What can we do?

One of the considerations I spoke of in the recent piece on maternal mortality is obesity.  In the US, rates of obesity are higher than nearly any other Western nation and there is evidence that severely obese women require c-sections at relatively high rates.  One study found that 62% of morbidly obese women ended up with a c-section (compared to 24% of controls – still too a high number).[13]  A society that can place an emphasis on overall health is important.

A second factor that must be discussed is fear.  There are myriad reasons why women are far less versed with birth than our ancestors (and I mean going further back than grandparents or even great-great-grandparents) and women in other cultures, but regardless of the reasons, many women know virtually nothing about natural childbirth.  And it’s a problem.  Not just because women should know about their own biology and what to expect when giving birth (and not the typical stories nowadays where women just speak of how much it hurt), but because a fear of childbirth has been linked to an increased risk for c-sections[14].  In examining nearly 2,000 women during pregnancy, a severe fear of childbirth increased the risk of an emergency c-section in labour three-fold.  Given the risk of PTSD after c-sections, it would seem that women who already have strong negative feelings about birth may be at a particularly high risk of developing strong anxiety and stress post-birth.  This means we need to find ways to ensure women are truly educated about birth so that they can alleviate their fears and understand how their bodies work with the baby to birth.

But the final and most general thing we can do is offer SUPPORT.  Whether a c-section is a choice or not, some women may suffer effects that can have negative outcomes on their relationship with their child.  And for any woman who does end up down that path, she needs to be supported, cared for, and given the chance to get out of that frame of mind and be the best parent she can be without having to worry about depression, anxiety, or stress from a birth procedure.  (In fact, I would think all women should have access to this type of support as even vaginal births can end up going horribly wrong and women there need to be supported as well, but the addition of recuperating from surgery makes this potentially even more important for moms who had a c-section.)  This goes back to something I’ve written about before (see here) which is that as much as our society likes to put up the ideal that if your baby survives, you should be happy and ignore everything else, that is not the way we should proceed.  Birth – no matter what it looks like (natural, with pain relief, c-section, etc.) – can be empowering, lovely, and wonderful.  It can also be traumatic, scary, and painful.  And to parent, we need to ensure that all women have the tools to handle the negative aspects they may encounter to build a healthy and happy relationship with their child.

[1] Eckner JL.  Once a pregnancy, always a caesarean? Rationale and feasibility of a randomized control trial.  American Journal of Obstetrics & Gynecology 2004; 190: 314-8.

[2] Wagner M.  Choosing caesarean section.  The Lancet 2000; 356: 1677-80.

[3] Murphy DJ, Liebling RE, Verity L, Swingler R, Patel R.  Early maternal and neonatal morbidity associated with operative delivery in second stage of labour: a cohort study.  The Lancet 2001; 358: 1203-7.

[4] Hager RM, Daltveit AK, Hofoss D, Nilsen ST, Kolaas T, Oian P, et al.  Complications of caesarean deliveries: rates and risk factors.  American Journal of Obstetrics & Gynecology 2004; 190: 428-34.

[5] MacDorman MF, Declercq E, Menacker F, Malloy MH.  Infant and neonatal mortality for primary caesarean and vaginal births to women with no indicated risk, United States, 1998-2001 birth cohorts.  Birth 2006; 33: 175-82.

[6] Penna L, Arulkumaran S.  Caesarean section for non-medical reasons.  International Journal of Gynaecology and Obstetrics 2003; 82: 399-409.

[7] Belizan JM, Althabe F, Cafferata ML.  Health consequences of increasing caesarean section rates.  Epidemiology 2007; 18: 485-6.

[8] DiMatteo MR, Morton SC, Lepper HS, Damush TM, Carney MF, Pearson M, Kahn KL.  Caesarean childbirth and psychosocial outcomes: A meta-analysis.  Health Psychology 1996; 15: 303-314.

[9] The 2-year maternal follow-up Term Breech Trial Collaborative Group.  Maternal outcomes at 2 years after planned cesearean section versus planned vaginal birth for breech presentation at term: the international randomized Term Breech Trial.  American Journal of Obstetrics & Gynecology 2004; 191: 917-27.

[10] Lobel M, DeLuca RS.  Psychosocial sequelae of caesarean delivery: review and analysis of their causes and implications.  Social Science & Medicine 2007; 2272-84.

[11] Eggesbo M, Botten G, Stiqum H, Nafstad P, Magnus P.  Is delivery by caesarean section a risk factor for food allergy?  The Journal of Allergy and Clinical Immunology 2003; 112: 420-6.

[12] Rortveit G, Daltveit AK, Hannestad YS, Hunskaar S.  Urinary incontinence after vaginal delivery or caesarean section.  The New England Journal of Medicine 2003; 348: 900-7.

[13] Hood DD, Dewan DM.  Anesthetic and obstetric outcome in morbidly obese parturients.  Anesthesiology 1993; 79: 1210-8.

[14] Ryding EL, Wijma B, Wijma K, Rhydhstrom H.  Fear of childbirth during pregnancy may increase the risk of emergency caesarean section.  Acta Obstetrica et Gynecologica Scandinavica 1998; 77: 542-7.