Birthing globally is in crisis, and regurgitated myths don’t help. For example, under common misconceptions, birth is considered an event that is solely personal and decided on by each family; one that is relatively untouched by politics except for hospital and institutionalised policy. I assure you, this couldn’t be further from the truth.
In the developing world, maternal and infant health is collapsing, despite some improvements arising from the ambitious and laudable United Nations Millennium Development Goal five. Half a million women in the poor regions of the planet continue to die each year in childbirth or pregnancy, an inexcusable figure which highlights the yawning gap in maternal conditions that exists between – and within – countries. One only needs to witness the poor health status and misapplied, often ill-planned health support for Australian Aboriginal and Torres-Strait Islanders to see that these inequalities lie right in front of us.
This is an issue of critical importance which justifiably commands much attention. Yet there is another, sinister problem lying at the heart of birthing politics; one which faces maternal outcomes everywhere, but tends heavily towards the developed world boasting affluent health sectors. We are becoming a system that works according to one motto and it goes something like this; more money spent means better health outcomes. In many cases, principally when pathology is involved, this theory can hold ground. When it comes to birth, it is a concept leading us in a dangerous direction. In an over-medicalised system, fear and intervention manifest and women can suffer. When women suffer, birth suffers, and inevitably, infant health suffers.
The disparity in these two birthing crises is presented statistically in a report by the World Health Organisation (2010). The report estimates that every year there is a need for 0.8 to 3.2 million caesarean sections in developing countries, where 60 per cent of the world’s births occur (Gibbons, Belizán, Lauer, Betrán, Merialdi & Althabe, 2010). On the other end of the spectrum, 4 to 6.2 million caesarean sections are performed in middle to high-income countries, where only 37.5 per cent of the world’s births occur. When assessing this from a population-based approach, the latter statistic is likely to be ‘medically unjustified’ (Gibbons et al., 2010).
In New South Wales the caesarean section rate increased from 1998 to 2008 from 19.1 to 29.5 per 100 births (Stavrou, Ford, Shand, Morris, & Roberts, 2011). In statistics gathered from 132 countries – which collectively represented 95 per cent of the global births in the year 2008 – it was discovered that approximately half had caesarean rates above 15 per cent (Gibbons et al., 2010). In China alone, the caesarean rate among primiparous women in urban areas rose from 18 per cent to 39 per cent between 1990 and 2002. The rural rate currently lies above 25 per cent (Xing Lin, Ling, Yan, & Ronsmans, 2012).
Information collected over 20 years (1987 to 2006) through the Icelandic birth registry showed a varied caesarean section rate between 11.9 and 16.7 per cent. The values showed no correlation to reduced perinatal mortality in infants weighing over 2.5 kg at birth (Jonsdottir, Smarason, Geirsson, Bjarnadottir, 2009).
For both the increasing caesarean section rates and the question of medical justification, the international community has expressed concern. The World Health Organisation has suggested that global caesarean section rates should not exceed 15 per cent, as research has shown that rates above this mark are not associated with any reduction in maternal or neonatal morbidity or mortality.
Without delving into the risks associated with a caesarean birth, it is important to remember the fundamental role of medicine in our society. The sole outcome should always be an improvement of health, so we must stop and ask whether we are going backwards.
There is no one explanation for the rising rates of caesarean section worldwide. Reasons include medical litigation, less time given to birthing in hospitals due to a growing population, fear, lack of support and education, and misconceptions. So, you see, we are facing two predicaments. One ruled by a lack of medical support and the other by its chronic overuse.
In improving global maternal and infant health, birth requires a very fine balance. There must be constant protection applied to the sacredness of diverse birthing cultures and traditions, whilst presenting an application of evidence-based and safe practice with access to conventional, current medical care. It is disgraceful that Indigenous women in Australia are being removed from their land to birth in isolated health centres, with unfamiliar procedures and minimal to no family support. Traditions must be honoured, in a holistic approach combining safe and sacred birth. Improving maternal outcomes in the developing world must come about without leading women (even further) down the track many states in the developed world are headed.
This is not about birth judgement, nor a campaign against necessary, safely applied caesarean section. Birth is about informed choice and the rights of a woman to have the birth that she desires, with support and care provided no matter what her culture, socio-economic status, religion or ethnicity. But birth is political. It is business. And it is in trouble.