The NSW Mothers and Babies report for 2021 was released the other week, and as it usually does, it sparked a big conversation about rising rates of intervention, especially caesarean section, assisted deliveries, episiotomies, and induction/augmentation of labour.
But why does it matter? What's the problem with having more intervention?
If these are questions you have thought to yourself, strap yourself in! Let me give you my thoughts on the matter.
Reason 1: Birth Trauma
Rising rates of intervention are being accompanied by rising rates of birth trauma. Now, correlation does not equal causation, but there is more and more research happening on birth trauma, and intervention does seem to play a part - particularly when women perceive the intervention to have been unnecessary.
Trauma is usually a response to either an actual or percevied threat to safety, and when women are receiving interventions in labour and birth, someone is usually telling them they or their baby are at risk without the intervention, and so there is a sense of danger (either real or perceived) that can create birth trauma.
Intervention can often leave women feeling like they have 'failed' or that they are bad mothers because of how their baby was born. I don't believe in such a thing as 'failed' birth, but when women are unaware of just how much intervention is happening in hospitals, they can often feel like it is their fault or specific to how they laboured or how their body 'behaved' that influenced the 'need' for intervention, when the reality is that hospital is just a pretty poor environment for supporting physiological birth, much less vaginal birth.
That's when we look at birth trauma from the emotional angle alone - birth trauma can also be physical, and assisted deliveries are a major contributing factor to severe physical birth trauma, as well as, of course, caesarean section.
Reason 2: Money
Intervention costs more. Straight up. Intervention requires more pharmaceuticals and equipment, more hours of labour, and more time in hospital, which all costs more money. Studies in multiple countries have shown savings of up to thousands of dollars per woman birthing at home vs birthing at hospital.
This is important whether you pay for private health insurance or go public. Tax is what pays for public health care, at the end of the day, and so a public health system that costs less will cost the individual less. For private health, premiums are calculated based on how much the companies are paying out, so the more they are paying out for maternity services, the more your premiums increase.
Lower intervention rates save everyone money.
Reason 3: The Cascade
The cascade of interventions is something that I often see disputed by care providers, but I see it happen as a doula and read about it happening time and time again, even when it's not described in such terms.
This is a common example of what it can look like:
fundal height measurements starting to stray slightly through pregnancy so growth scan is recommended,
growth scan is done once and a 'big baby' is diagnosed,
induction is recommended at 39 weeks because of a big baby (despite RANZCOG guidelines actually stating that this is not recommended because of the inaccuracy of ultrasounds to determine size of unborn babies),
woman agrees to induction for fear of shoulder dystocia or baby 'not fitting' but wants it to be a low intervention as possible so starts with foley catheter overnight before ARM (waters breaking) in morning,
foley catheter is incredibly uncomfortable and woman is unable to sleep well, if at all, overnight and is already exhausted by the time ARM is done in the morning,
woman gives her best effort at getting labour moving after ARM but after four hours is just more exhausted and contractions have not started or are inconsistent so syntocinon infusion is started,
being hooked up to the drip and with CTG monitoring on makes it difficult to get into a rhythm as baby's trace is constantly lost and she needs to drag an IV pole with her making it tough to move intuitively,
syntocinon in the blood stream increases without passing the blood brain barrier and so the pain of labour kicks off hard without the natural endorphins building alongside and the woman struggles to manage the pain,
she needs an epidural to cope with the pain and get some rest,
the epidural slows down her contractions so she needs more and more syntocinon to keep them steady,
the amount of syntocinon required sends baby in distress and she ends up needing either an assisted delivery if her baby is close enough to being born or a caesarean section if they aren't.
her baby is born weighing 3.4kg but doctors will tell her how lucky she was to have the caesarean or assisted delivery because her baby might've otherwise died, despite the fact that the reason she was induced in the first place is irrelevant now the baby is born at a bang-smack average weight
Of course, the cascade doesn't always happen and there will ALWAYS be women with a genuine need for intervention, or those that have made a truly informed decision to have intervention because it is the best decision for them or their baby. There are exceptions to every rule. But, we know from research that most women going into hospital to give birth say they want an intervention-free birth, yet only about 10% of women are getting that, according to the stats in NSW Mothers and Babies from 2021.
Rising rates of one intervention are likely to lead to rising rates of others, both within the one birth and future births. For example, the most common reason for a caesarean section is a prior caesarean section.
Reason 4: Future Implications (physical, emotional, attachment, oxytocin, etc)
There is a whole lot that we don't actually know about the long term impacts of many of the interventions happening routinely. There's also a whole lot that we're only just learning about. And then, there's a lot we do know about.
Dr. Sarah Buckley, for example, is leading some excellent research on the topic of oxytocin and how interruptions to natural oxytocin production in labour and birth impact breastfeeding and mother-baby bonding, and the future implications of those processes being interrupted.
Prof. Hannah Dahlen released a sixteen-year population-based study on the long term impacts of induction that was well overdue and clearly demonstrated increased risks of long term health complications for babies born via induction.
Caesarean sections are associated with future fertility issues, complications such as placenta praevia, and even stillbirth. There are implications for babies born via caesarean, such as immune system development issues, asthma, and allergies. We also have research demonstrating links between caesarean sections and more chronic conditions, such as back pain and pain with sex years after the caesarean.
The reasons we should be concerned about increasing rates of intervention are multifaceted. Life-saving interventions are an important part of a functional maternal health care system, but they are overused and the long term consequences under-appreciated. Why is it that the same group of women (for research purposes) birthing at home compared to hospital are having better outcomes? I feel that in itself is proof that there is unnecessary intervention happening in hospital environments and we should be questioning it and demanding better for our mothers and babies.
References & Resources
My name is Katelyn Commerford and I am a doula and birth after caesarean guide located in Western Sydney. If you want to know more about what I do and how I can help you, please visit my website (where you can also get your free cheat sheet of my favourite VBAC resources), or find me on instagram @katelyn.doulaandnbac where I answer commonly asked questions about planning the next birth after caesarean and share loads pregnancy, birth, postpartum and parenting content.
Katelyn Commerford - Doula and NBAC Guide
Phone: 0431 369 352