Obstetrician: Several factors behind rising C-section rate

The HSE’s National Women and Infants Health Programme clinical lead Cliona Murphy said 'there are increasing risks with increasing numbers of sections'. File picture

Fear of litigation, growing rates of obesity, and older mothers are among the potential reasons that Ireland’s caesarean section rate is higher than many EU countries, a top obstetrician has suggested.

Maternity advocacy group Aims Ireland has expressed alarm at Ireland’s rising C-section rates, finding that in five out of the 19 maternity units, over 50% of first-time mothers had a C-section.

The HSE’s National Women and Infants Health Programme clinical lead Cliona Murphy said the reasons for the trend are not clear-cut.

While a C-section is generally a safe procedure, it is still regarded as major surgery and normally has a long recovery time of six to eight weeks. There is also the potential for infection and other complications.

“There are consequences, certainly," said Dr Murphy. "It’s not to say we don’t care what the caesarean section rate is, we absolutely do.

We do know that there are increasing risks with increasing numbers of sections, and countries with higher section rates can have higher complication rates, and particular complications that we need to be aware of.” 

Hospitals are seeing an increased number of older mothers giving birth and an increased rate of gestational diabetes, she said.

“We have seen an older age mother, and some of those will come with more complications,” she said, pointing to data showing births to mothers over the age of 40 rose by 33% between 2011 and 2021.

The impact of obesity on pregnancy and birth is often not fully appreciated, she suggested.

“What we are seeing is people developing diabetes in pregnancy and we do know that is more likely to happen if you are a higher weight,” added Dr Murphy.

“So there are fewer people attending services who are under a BMI of 30. A BMI of 35 for a 5ft 4in woman is over 14st, so there are then added complications which occur.

“It’s not to be shaming of people over a certain weight. Obesity is being recognised as a disease of industrialised countries. It is to do with our obesogenic environment, but I do think we need to realise that there are implications for pregnancy.” 

The latest Eurostat data shows 26% of Irish women of all ages were considered obese compared to 10.7% of Italians.

Fear of litigation against medics could also be a factor, she suggested.

“When you look at any of the cerebral palsy cases, or the catastrophic birth claims, often the criticism is there was a chance to deliver this baby earlier, a chance to deliver by caesarean section earlier, and it wasn’t taken.

“I don’t recall one where somebody was criticised for doing a caesarean section, so litigation may be a factor.” 

This is more likely to be the case during an emergency C-section, she felt, rather than a planned section.

“Evidence-wise, it's hard to know how much of a factor that is.

But that is one significant difference between Ireland and other European countries — the litigation and the catastrophic claims that we have and the way our system goes.” 

Dr Murphy said the rising induction of labour rate here is also on the radar.

HSE data for 2019 shows an overall induction rate of 32%, then 34% during 2020, up to 35% during 2021, and, she said, “2022 is looking at about 37%”.

She acknowledged there are variations between maternity units for many procedures.

“We probably need to work better to make sure that anyone walking into any of the units gets similar information about their pregnancy, and if something comes up in pregnancy, and if induction of labour is discussed, that it is shared decision making and that similar guidance is used.” 

She also highlighted successes such as greater survival rates of premature babies, even as young as 25 weeks' gestation.

She said she would like to see greater emphasis on the experience women have in birth, so they have a good experience whether it is a vaginal birth or a C-section.

She said the time a woman is separated from her baby after a C-section is much shorter than it used to be, saying: “Those things have changed an awful lot in a generation or so.

“Wherever you have babies being born, you will have midwives supporting the woman, how she feeds her baby, how she bonds with her baby. We recognise that is critical and such a memory for people.

“That needs to be said — it’s about the quality of the birth.” 

Last year, more than 57,000 births were registered in Ireland.