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Speaker 1: Welcome to the Kick Your Expert led podcast, helping you

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Speaker 1: explore and learn everything about gettingant, pregnancy, birth, and becoming

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Speaker 1: a parent.

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Speaker 2: On the podcast and our online pregnancy program grow My Baby,

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Speaker 2: we share my experience of helping more than four thousand

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Speaker 2: babies to be.

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Speaker 1: Born, and our experience of running a women's health clinic

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Speaker 1: and parenting for boys.

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Speaker 2: We're here to help everyone to feel empowered in pregnancy

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Speaker 2: and birth with real life, practical information.

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Speaker 1: Welcome everyone.

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Speaker 2: I'm Brigid Maloney and I'm Obstatrician doctor Patrick Mine.

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Speaker 1: And today we've got a very big, but great and

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Speaker 1: juicy topic that we're going to do over two parts,

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Speaker 1: and it comes from my own curiosity about people coming

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Speaker 1: up to me and saying, hey, ah, cesarean rates increasing?

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Speaker 1: Why is everyone having a caesarean lately? Yeah?

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Speaker 2: Does it feel like everyone's having a section?

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Speaker 1: Yeah? And I think maybe it's just now that I've

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Speaker 1: become a bit more aware of people asking me that

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Speaker 1: question that I think, actually, let's dig deep and let's see.

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Speaker 3: Whether it is true, look at the data, see what's

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Speaker 3: going on.

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Speaker 1: Yeah. So I've had a very big look at the

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Speaker 1: Australian Institute of Health and Welfare, National Maternity Indicators and

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Speaker 1: if anyone loves data, jump on there. It's really great.

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Speaker 1: You can really sort of interrogate it and get some

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Speaker 1: really great answers.

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Speaker 3: So what does it say, What does it say?

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Speaker 1: Let's go our Pat, tell me our caesarean rates increasing?

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Speaker 2: I think, well, the simple answer is yes, they've increased

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Speaker 2: over the last sixty years, unquestionably in a way that

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Speaker 2: has corresponded probably with an improvement in outcomes, which we'll

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Speaker 2: get to later on, but one of the costs of

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Speaker 2: that has been a higher section rate.

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Speaker 1: And they sort of Now we're seeing some data that

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Speaker 1: is differing between countries, and you know, if we just

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Speaker 1: consider sort of developed countries first, and we did a

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Speaker 1: bit of a deep dive on the stats around Australia,

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Speaker 1: United Kingdom and the United States. For everybody outside of

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Speaker 1: those three countries, I'm sorry, it was just expediency. So

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Speaker 1: let's talk about Australia first, Pat. What's been happening in Australia.

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Speaker 2: I think if we look back way before my career

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Speaker 2: into the nineteen sixties, as few as five percent of

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Speaker 2: deliveries were by cesarian section, and there were a big

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Speaker 2: number of reasons for that, which I said we'll get

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Speaker 2: to a little bit later, but really it was a

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Speaker 2: somewhat different cohort, a much younger group of women having

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Speaker 2: bigger families, and so the rate was as low as

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Speaker 2: five percent, but the outcomes were undoubtedly worse and statistically numerically.

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Speaker 1: And over time that's sort of been just in rapid

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Speaker 1: and I'll sort of had a slow increase to begin with,

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Speaker 1: but then a rapid increase in the last sort of

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Speaker 1: you know, ten years, hasn't it.

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Speaker 2: Yeah, And we think that rapid increase has been driven

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Speaker 2: by a number of factors which we're going to discuss today,

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Speaker 2: but an older population of patients, people having smaller families,

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Speaker 2: and a push towards if you've had one ceazy perhaps

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Speaker 2: more likely to have another, and IVF and weight gain

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Speaker 2: changes and so forth.

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Speaker 1: So in the nineteen twenties, like sorry, in the twenty twenties,

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Speaker 1: like twenty twenty five, in Australia it's up around forty

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Speaker 1: one percent.

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Speaker 2: Yeah, yeah, yeah, and that's you know, that matches the

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Speaker 2: numbers in a lot of public and private delivery environments

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Speaker 2: in Australia. It's a closest to the numbers in my

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Speaker 2: own practice.

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Speaker 1: Yeah, and United Kingdom at the moment, And the only

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Speaker 1: data I could really find was that about now forty

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Speaker 1: five percent of all births in the UK are cesarean, Yes,

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Speaker 1: and the States is lower, so thirty two point four percent.

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Speaker 2: It's interesting, isn't it. I wonder what the variation is

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Speaker 2: there across the units. In the US. Certainly there's a

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Speaker 2: reputation for high levels of intervention in a higher socioeconomic

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Speaker 2: environment and lower in a lower Yeah.

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Speaker 1: So for someone like my mum who was having her

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Speaker 1: babies in the sixties and seventies, it would look like

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Speaker 1: everybody's having a Caesar for someone who had their babies

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Speaker 1: back then.

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Speaker 2: Yes, And I think this is probably the origin of

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Speaker 2: the cliched grandma comment about why is this, why is

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Speaker 2: it different? And the you know it is different, They're right, Yeah,

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Speaker 2: there are higher numbers. And I think someone having a

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Speaker 2: baby by cesarian section, if it was five percent, then

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Speaker 2: that would be that would stand out for its rarity.

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Speaker 2: And in fact, you may have hardly ever met someone

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Speaker 2: who had their babies by cesarean section, and you know,

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Speaker 2: at five percent it was just about reserved for place

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Speaker 2: enda previa multiple grand multiple's triplets or above and people

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Speaker 2: with significant pre existing obstetric problems. I think one of

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Speaker 2: the things that we have got better rat but the

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Speaker 2: rising season rate has been part of the cost of

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Speaker 2: is that we know about all those people in advance now,

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Speaker 2: So ultrasound's got so good that we can pick all

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Speaker 2: of these things or just about all of them, so

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Speaker 2: that a woman doesn't have to go through a highly

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Speaker 2: traumatic and problematic first berth before she realizes that she's

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Speaker 2: got condition x y Z and have the remaining babies

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Speaker 2: by cesarean section. These days, we would know about that

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Speaker 2: problem most of the time. And like someone with a

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Speaker 2: big lower segment five roid, for example, that's going to

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Speaker 2: block the birth back. In the pre ultrasound ere you

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Speaker 2: just had to have a baby, and then they realized

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Speaker 2: it wouldn't fit out, and then they did a caesar

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Speaker 2: found the giant fireboard and all their problem. But now

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Speaker 2: we've got an ultrasound telling us that there's an eight

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Speaker 2: centime lower segment firebroid there or fifteen CENTI medal lower

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Speaker 2: segment five broid. Baby's never going to get past well

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Speaker 2: just to a section up.

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Speaker 1: God, I just you know, that just makes me feel

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Speaker 1: so sad for women back then, and we'll get onto

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Speaker 1: the differences as well. And avid listeners will remember me

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Speaker 1: telling the story about our little Catholic church when I

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Speaker 1: was growing up in the eighties and the one person

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Speaker 1: that we knew who had her babies via cesarean, and

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Speaker 1: then the whole congregation had to pray for us.

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Speaker 2: I had to pray for Yeah. Well, I'm sure that

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Speaker 2: was that. I'm sure that was a lovely thing to

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Speaker 2: have done at the time. But it seems funny now

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Speaker 2: like that because you know that's this is changed. Yeah,

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Speaker 2: things have changed, yep.

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Speaker 1: So I do want to ask though, and and for

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Speaker 1: those people that say, oh my god, the cesarean rate

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Speaker 1: is rising so dramatically, does this mean that we're doing

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Speaker 1: something wrong?

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Speaker 2: Well, this is the great question. There are two ways

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Speaker 2: of looking at this. We might be doing.

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Speaker 3: Something wrong i e.

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Speaker 2: We're interfering too often, or we might be doing something right,

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Speaker 2: i e. Improving outcomes to the point where to have

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Speaker 2: a baby in Australia in twenty twenty six is amongst

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Speaker 2: the best data in the world, but also amongst the

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Speaker 2: best data there has ever been in terms of maternal

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Speaker 2: and fetal safety. But that's not the whole story. There is,

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Speaker 2: quite apart from the safety argument, a natural inclination amongst

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Speaker 2: our patients to want to have their babies vaginally most

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Speaker 2: of the time. And so we're winning by some measures,

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Speaker 2: but we're not winning by every measure.

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Speaker 1: Well, let's talk about some of those measures. So you

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Speaker 1: say that outcomes have improved, maybe let's tell the listeners

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Speaker 1: what happened in nineteen sixties for the mothers.

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Speaker 2: Yeah, so maternal death is one outcome that is a

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Speaker 2: horrifying outcome. We never want to see that happen. And

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Speaker 2: you know, it's the hard case that makes the bad

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Speaker 2: law because the because maternal death has you know, is rare.

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Speaker 2: And if we reduce maternal death by making a massive

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Speaker 2: intervention in pregnancy care, there are small numbers and the

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Speaker 2: reduction will be small numbers. And we have to always

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Speaker 2: think we don't want that to happen to anybody. But with

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Speaker 2: all without the intervention, the numbers are small.

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Speaker 3: Okay.

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Speaker 2: So in Australia in nineteen in the nineteen seventies, the

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Speaker 2: matern death threat was about double what it is now,

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Speaker 2: but it was only twelve per hundred thousand versus six

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Speaker 2: per one hundred thousand.

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Speaker 1: Yeah, and again, you know, some people go, well, how

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Speaker 1: many births in general? So in twenty twenty three there

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Speaker 1: was twenty three deaths in total. Yes, so it's a

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Speaker 1: very small amount excess about it because it is such

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Speaker 1: a terrible outcome.

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Speaker 2: Absolutely, we also have to look at what's causing those deaths.

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Speaker 2: So some of them are, if you like, unrelated to

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Speaker 2: the mode of delivery, so that the hemorrhages. There's still

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Speaker 2: a small number of postpartum hemorrhage deaths. There's a small

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Speaker 2: number of deep venus thrombosis and pulmonary emberless deaths, and.

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Speaker 3: You could get those in either group.

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Speaker 2: Yeah.

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Speaker 1: And can we hang our hat on the fact that

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Speaker 1: it's half now on the rate of caesarean No.

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Speaker 2: I think we can claim that that risk reduction has

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Speaker 2: happened through a number of different interventions, not just the

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Speaker 2: rising section rate, And the major critics of the rising

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Speaker 2: section rate would say some of those things we got,

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Speaker 2: we've improved anyway.

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Speaker 1: Yeah.

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Speaker 2: Yeah, So undoubtedly we're better at trading postpartum hemorrhage now

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Speaker 2: than we were at the start of my career. Undoubtedly,

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Speaker 2: the drugs are better, the protocols are better, the teaching

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Speaker 2: is better the drills we do. Drills are quite day

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Speaker 2: in labor world. We drill for the next post partum hemorrhage?

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Speaker 1: Is there every quite day in plaborhood.

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Speaker 3: If there is no, people just don't go to a cup.

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Speaker 2: But then we sit around and practice the next post

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Speaker 2: partum hemorrhae how we're going to run it. So there's

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Speaker 2: no doubt that all of that stuff is better. So

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Speaker 2: you can't just say that the improvement has happened because

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Speaker 2: we do more caesus.

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Speaker 1: I want to just pick up, you know, if anyone

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Speaker 1: was to google the fact check us, please do and

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Speaker 1: then tell us whether whether we got things right or wrong.

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Speaker 1: And we're open to all of that. But I did

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Speaker 1: a quick google AI on higher maternal rates mortality rates,

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Speaker 1: and it says that there's higher mortality in cesarean versus

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Speaker 1: vaginal birth and the World Health Organization and you know,

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Speaker 1: it was it was. It did have some reputable sites

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Speaker 1: that maternal mortality, but it didn't differentiate between a developed

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Speaker 1: and an undeveloped well, so you know, can we unpack

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Speaker 1: that a little bit?

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Speaker 2: Yeah, I mean, I think the most obvious devil in

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Speaker 2: the detail of that data is that if you were

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Speaker 2: laboring away in an undeveloped country where you were several

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Speaker 2: days away from from surgical care, and you went into

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Speaker 2: obstructed labor and then eventually you were transferred to a

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Speaker 2: district hospital and from there to a to a city hospital,

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Speaker 2: and this took several days and you eventually had a

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Speaker 2: stillborn baby by caesarean section. That that may have terrible

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Speaker 2: outcomes for you as the mother. You might go into

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Speaker 2: interseptic shock and die, but it wouldn't be because you

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Speaker 2: had a section, but you would be you would be

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Speaker 2: analyzed as a death occurring in the section group. Okay,

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Speaker 2: Whereas if we look at someone having obstructed labor in

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Speaker 2: Melbourne in twenty twenty six and has a has an

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Speaker 2: evening caesar in the setting of no progress, that's an

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Speaker 2: extremely safe, extremely safe individual.

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Speaker 1: And it's interesting because you know, I did deep dive

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Speaker 1: on this. You can't on the ai HW. You count

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Speaker 1: that they don't have how the death. They have how

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Speaker 1: the death was caused, but not mode of delivery during

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Speaker 1: that birth, so you know, you can't even see there

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Speaker 1: whether it was a cesaian or vaginal birirth.

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Speaker 2: So in a in a developed country, that the problem

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Speaker 2: with looking at looking at it in terms of maternal safety,

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Speaker 2: is that the numbers of poor outcomes for the mother's

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Speaker 2: are extremely small, and there are statistical problems with analyzing

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Speaker 2: small numbers, and also that it's unlikely to be the

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Speaker 2: caesar that was the problem.

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Speaker 1: All right, well, what about babies then? Have we improved

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Speaker 1: the data for babies?

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Speaker 2: Well, unquestionably, over the same period of time, through a

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Speaker 2: number of interventions, the data for babies has improved. If

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Speaker 2: you are born today, you're six to seven times less

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Speaker 2: likely to die in the first year of life than

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Speaker 2: a baby born in nineteen sixty And there would be

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Speaker 2: so many reasons for that. Better care of prems would

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Speaker 2: be a big one, but some of that would be

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Speaker 2: babies being born in roughly better condition because over that

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Speaker 2: same period of time, we are reaching forces are insection

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Speaker 2: as a tool to be used more frequently in the

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Speaker 2: setting where there's serious concerns for the feed of well being.

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Speaker 1: During the labor And I know that, you know, we

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Speaker 1: are just focusing on infant or maternal death and we're

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Speaker 1: going to get onto other outcomes of birth. But you know, honestly,

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Speaker 1: that's about the most data that we've got. It's weird

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Speaker 1: like you try and look for other data and it

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Speaker 1: seems like an inconsequential finding that you know, not really,

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Speaker 1: but you know it's we focus so highly on death.

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Speaker 3: Yes, which is.

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Speaker 1: Nice easy round data point.

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Speaker 2: Yeah, which is which is probably not the best way

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Speaker 2: to look at it. So that developed something when I

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Speaker 2: was when I was a registrar called the Robson Criteria

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Speaker 2: for cesarean section and that was actually a way more

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Speaker 2: useful tool to look at caesars, in particular for the

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Speaker 2: comparison of one unit versus another. So for example, if

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Speaker 2: you if you started up a a tertiary referral unit

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Speaker 2: in a big city hospital and you only treated triplets,

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Speaker 2: then the appropriate cesarean section rate in your unit would

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Speaker 2: be one hundred percent. Or if you only received referrals

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Speaker 2: for placenta previa, one hundred percent would be the only

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Speaker 2: justifiable number. So that's not a fair comparison. So what

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Speaker 2: this criteria system did was break down the caesars into

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Speaker 2: someone will tell me ten groups maybe, and some of

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Speaker 2: them were no brainer caesars, and some of them were

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Speaker 2: kind of caesars that honestly you maybe it never had

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Speaker 2: to do, or you shouldn't have done, or whatever, it

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Speaker 2: shouldn't have done the wrong way to put it that

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Speaker 2: it was arguable whether that was necessarily certainly groups where

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Speaker 2: there's room for improvement, and that became a way more

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Speaker 2: useful tool to compare. Really compare apples with apples. So

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Speaker 2: a unit with a high cesarean section rate, you might

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Speaker 2: think that's worse. Well, no, they might just do way

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Speaker 2: more complicated work. And so it was a way. It

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Speaker 2: was a way of comparing two low intervention, low risk

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Speaker 2: units with each other in terms of the performance.

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Speaker 1: And do we still use that, Yeah.

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Speaker 3: Yeah, I think so. I think that's a way.

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Speaker 2: Those sort of things are a way better system for

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Speaker 2: analyzing how things are going. Because if you look at plusent,

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Speaker 2: a preview or a triplets, we don't want to do

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Speaker 2: less sections. We want to do all of those by section.

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Speaker 2: So that there's the group that we really want to

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Speaker 2: look at is in labor sections for spontaneous labor as

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Speaker 2: a term, there's room for improvement.

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Speaker 1: There, yea. And for those people that might say yes,

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Speaker 1: but the World Health Organization says that we should be

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Speaker 1: doing ten percent cesarian sections. You and I've talked about

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Speaker 1: this before. It might just be useful to it's ten

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Speaker 1: at least ten percent.

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Speaker 2: Yes, I think that that statistic is bandied about on

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Speaker 2: the socials a bit incorrectly. I think that people say

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Speaker 2: that the World Health Organization says it should be ten percent.

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Speaker 2: I don't think they're quite saying that. I think they're

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Speaker 2: saying that there should be facilities in your country such

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Speaker 2: that ten percent of the babies could be born by

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Speaker 2: caesarean section, because we know the outcomes are poorer at

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Speaker 2: less than ten, So at less than ten, you're not

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Speaker 2: catching all the people who really really really need a section,

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Speaker 2: So that they're saying that you basically need to have

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Speaker 2: a level of at least that, and then when levels

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Speaker 2: are much higher than ten, we have to continually say,

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Speaker 2: hang on a minute, are we continuing to improve outcomes

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Speaker 2: by letting the numbers come up? And we may be

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Speaker 2: experiencing a concept called the law of diminishing returns, where

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Speaker 2: if you increase your section rate from ten percent to

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Speaker 2: twenty percent, you get a dramatic improvement in ninatal outcomes,

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Speaker 2: but you may not keep on seeing that improvement when

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Speaker 2: you go up to thirty fifty sixty.

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Speaker 1: What isn't being considered in any of this it's all

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Speaker 1: very much medical, medically based caesarean section, but there's also choice,

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Speaker 1: so you know, people actually choosing caesarean section. I want

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Speaker 1: everybody to know I'm not pro or against caesarean section.

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Speaker 1: I'm pro choice.

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Speaker 3: So you were just discussing, yeah, yeah, which is choice?

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Speaker 1: Choice? Yeah? So, I mean the question is what point

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Speaker 1: do higher rates stop improving outcomes from a medical perspective.

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Speaker 1: But if a hospital's being run based on the caesarean rate,

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Speaker 1: how do they factor in choice.

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Speaker 2: It's really interesting because in Australia choice is much more commonly.

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Speaker 2: People much more commonly choose a caesarean section without a

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Speaker 2: medical indication. Remember, we've got to be careful when we

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Speaker 2: use words like elective section and so forth. Typically elective section,

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Speaker 2: what we mean is it's it's planned, but it may

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Speaker 2: have a perfectly good medical reason behind it. And so

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Speaker 2: if we talk about a cesarean section for a moment

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Speaker 2: that has no medical reason behind it and is just

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Speaker 2: the woman's preference for how she has her baby, then

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Speaker 2: that preference is much easier to get in the private

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Speaker 2: sector than the public. So if someone comes to see me,

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Speaker 2: I'll put my cards on the table. If someone comes

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Speaker 2: to see me and says I want to have my

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Speaker 2: baby by cesarean section, I say absolutely, yes, that is

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Speaker 2: your choice, and we discuss the pros and cons risks

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Speaker 2: and benefits. But if that's what the woman wants, of

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Speaker 2: course you can have that. In the public, publicly funded

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Speaker 2: public sector in Australia, that choice does exist, but it's

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Speaker 2: a little harder to get to get what you want. Yeah,

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Speaker 2: you face more barriers. You probably face more people trying

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Speaker 2: and talk you out of us, and it's harder to

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Speaker 2: get the decision have a planed section off the ground,

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Speaker 2: but ultimately you can.

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Speaker 1: I think you've oversimplified your consultation there, Patty, because I

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Speaker 1: know that you talk to people about the reasons why

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Speaker 1: they're choosing a plant Cesairean.

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Speaker 3: Yeah, that's what I said.

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Speaker 1: So you I know, you said that you would go

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Speaker 1: risks and cons but like you know, there might be

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Speaker 1: that there's a trauma.

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Speaker 3: Oh yeah, so you have to you have to.

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Speaker 2: Yeah, you're right, you have to look into it a

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Speaker 2: little bit and work and just make sure that the

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Speaker 2: reason the person is choosing a section isn't based on

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Speaker 2: incorrect information or isn't something that they're doing out of

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Speaker 2: out of fear when you might be able to treat

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Speaker 2: that fear differently.

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Speaker 3: Yeah. So I've had a few.

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Speaker 2: People have changed their mind when they've been the psychologists

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Speaker 2: and talked about their fears and worked the way around it.

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Speaker 2: But no, the point I'm trying to make is that

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Speaker 2: if at the end of the day that's what the

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Speaker 2: woman wants, then then she can have it. That is

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Speaker 2: probably going up a little bit, but I think it's

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Speaker 2: only going up a little bit because people are having

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Speaker 2: are starting later and having fewer babies. So let's say,

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Speaker 2: for example, there was no preference at all out in

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Speaker 2: the community for caesar or vaginal birth. No, people didn't

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Speaker 2: feel strongly about it. It was entirely up to you

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Speaker 2: and people there was fifty to fifty with it, which

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Speaker 2: however you want. Then one of the main reasons to

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Speaker 2: avoid caesarian section was if you were going to have

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Speaker 2: four or five babies, because when we talk about the

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Speaker 2: risks of caesarean section, it's a very very very safe procedure,

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Speaker 2: but there are some significant risks when you get up

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Speaker 2: to four or five caesars in a row and the

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Speaker 2: scar related to the previous caesarian section can be surgically

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Speaker 2: difficult to navigate, and there's a problem called placenta cret

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Speaker 2: where if the placenta implants over a bunch of previous

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Speaker 2: caesarian section scars, then that can be quite dangerous. So

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Speaker 2: the main risk of CAESAR is not that you'll be

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Speaker 2: harmed by any of your first two or three. It's

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Speaker 2: that if you want five babies, there's a really big

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Speaker 2: safety impetus to have them all va giantly. Whereas if

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Speaker 2: you're thirty six when you have your first and you

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Speaker 2: only want to then you could choose to have two

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Speaker 2: and statistically not run into the problems that apply to

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Speaker 2: four or five, and it becomes a choice that you

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Speaker 2: can make based on personal preference rather than rather than

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Speaker 2: being unduly worried about safety.

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Speaker 1: All right, Patty, I want to stop it there because

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Speaker 1: you've picked up so many things that I want to

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Speaker 1: talk about as to why we think that the rate

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Speaker 1: of caesarean section is increasing. So I want to start

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Speaker 1: our part two with talking about the maternal landscape and

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Speaker 1: comparing it with nineteen sixty to now, And I think

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Speaker 1: that'd be a really great place to stop it here,

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Speaker 1: and we'll come back with part two of Seserian sections

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Speaker 1: increasing in our community.

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Speaker 3: Perfect, We'll see you next week.

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Speaker 1: All right, everyone, I hope that was great listening and

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Speaker 1: we'll see you next week for some more juicy content.

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Speaker 1: Until then, keep well, keep growing those babies. Bye for now. Hey,

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Speaker 1: even though doctor Pat is well a doctor and we

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Speaker 1: get lots of other doctors and other experts on our podcast,

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Speaker 1: I just need to remind you that this podcast is

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Speaker 1: for informational purposes only. We share lots of medical insights

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Speaker 1: and experience, but everything we talk about is general in

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Speaker 1: nature and may not apply to your specific situation. Please

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Speaker 1: always consult with your own healthcare provider for your individual

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Speaker 1: medical advice when you grow your baby