The rate of Caesarean sections is on the increase at the three main Dublin maternity hospitals – despite public health concerns, writes PAUL CULLEN
THE RATE of Caesarean section deliveries in the three main Dublin maternity hospitals has reached record levels, according to figures obtained by The Irish Times.
Both the National Maternity Hospital (NMH) at Holles Street and the Coombe Women’s Hospital recorded their highest levels of Caesarean sections last year, according to the figures obtained under freedom of information. The Rotunda Hospital also delivered a record number of babies by Caesarean section, though the rate fell slightly as a proportion of overall births.
Caesarean section rates have been rising in Ireland and other developed countries for years, despite widespread public health concerns. As the Master of the NMH at Holles Street, Dr Michael Robson, says: “The advantages of a safe vaginal delivery over a Caesarean section are clear: safe vaginal delivery is associated with lower maternal and neonatal morbidity and costs less.”
The latest figures show a disparity in the rates recorded in each of the three hospitals. More than 26 per cent of deliveries in the Rotunda last year were by Caesarean section, compared with 24 per cent in the Coombe and 19 per cent in Holles Street. However, the gap is narrowing, with the Rotunda’s figures moving downwards and those in Holles Street climbing rapidly.
The Master of the Rotunda, Dr Sam Coulter Smith, puts forward a number of reasons why his hospital has a higher incidence of Caesarean sections than the other two Dublin maternity hospitals. The Rotunda, he says, has huge experience in foetal medicine, especially for multiple births. It therefore records a disproportionately high number of twin and triplet births, which tend to involve higher rates of Caesarean section.
He also says the hospital’s catchment area in Dublin’s north inner city has seen one of the biggest influxes of immigration over the past decade, and although this has evened off, the result has been an increase in women presenting late, or with conditions rarely seen before in Ireland or with HIV/Aids, all factors which make the need for a Caesarean greater.
Coulter Smith acknowledges that a regular delivery is six times safer than a Caesarean, but points out that given the general high standards of obstetric care in Ireland “six times of not very much is very low”.
One reason for the boom in Caesarean sections, he identifies, is the trend towards bigger babies, which in turn is linked to the general increase in weight of the population. “We’ve seen a dramatic change in lifestyles, which have become much more sedentary. Too many women are overweight or obese, and they are having bigger babies.”
Where once he used to deal with seven or eight pregnant women in his weekly diabetes clinic, Coulter Smith now treats up to 100, he says.
Another commonly quoted reason for the upwards trend is a fear of litigation. An obstetrician may not be convinced that a court will retrospectively accept the situation of uncertainty and give fair consideration to the professional decision made at the time, says Robson.
“Society has become far less tolerant of poor outcomes generally, and the trend has continually been towards finding blame, either with individuals or systems,” he says.
The World Health Organisation (WHO) recommends that rates of Caesarean births not exceed 15 per cent. It says a growing body of research shows the negative effect of high rates, but admits there is no empirical evidence for an optimum percentage.
The data obtained by The Irish Timesalso reveals a substantial difference in the rate of Caesarean sections for public and private patients. Almost one baby out of every three delivered privately in the Coombe comes into the world via Caesarean section; last year, the figure for private patients was 32.2 per cent, compared with 21.7 per cent for public and semi-private patients.
In the same hospital, the rate of elective, or planned, Caesareans among women who had a previous section was twice as high for private patients compared with women in the public health system.
In Holles Street, the rate of Caesareans among private patients last year was 21.2 per cent, compared with 17.3 per cent for public patients.
On average, private patients can expect to pay fees of about €4,000 in any of the Dublin maternity hospitals.
In the Rotunda, the number of private and semi-private sections almost matches the number of public cases, even though far more babies overall are delivered in public wards. Holles Street did not provide a breakdown between private and public.
While most sections are emergency procedures carried out during the birthing process, an increasing number of elective Caesareans are featuring in hospital records. In the Rotunda, for example, the number of elective Caesareans grew from 602 in 2000 to 994 in 2007, and dropped only slightly to 977 last year. Elective procedures now account for more than 43 per cent of all Caesareans performed in the hospital, and more than 11 per cent of all births.
As Coulter Smith points out, elective sections may be performed in cases where the woman has had a complicated pregnancy, or has a low-lying placenta or pre-eclampsia. Equally, though, it may be performed at the request of the woman, though not necessarily because she is “too posh to push”.
“There are many reasons why a woman might elect to have a section: she might have had a traumatic experience on a previous occasion, or have a morbid fear of vaginal delivery or wish to avoid future incontinence,” he says.
The figures currently available do not distinguish between the various causes for elective sections, including maternal requests, so at this stage it is not possible to say for certain that more women are opting for sections for non-medical reasons.
More generally, analysis of this controversial issue is handicapped by a lack of information and standardised comparators. As Robson, who has developed one internationally used classification systems for Caesarean sections, points out: “A Caesarean section rate can only be considered appropriate if the information is available to explain and justify it. Common to all professionals has been the problem of lack of information.”
Holles Street remains the hospital with the lowest rate of Caesarean section, but even here rates are rising – from 14 per cent in 2000 to 19 per cent last year.
The figures also show that multiple births are much more likely to occur via Caesarean section; in the Coombe, half of all twins and all triplets were delivered in this way last year.
Alone among the three hospitals, Holles Street provided The Irish Times with a breakdown of the number of Caesarean sections carried out by each consultant in the hospital. This shows that Dr Michael Foley carried out the greatest number last year, with 104 procedures to his name, followed by Dr Ogunlewe with 99 and Dr Oluyade with 81.
The Rotunda said it did not insist on the mandatory collection of information about the consultant involved in a Caesarean at the time of birth and its records were therefore incomplete.
The Coombe said its obstetricians operated as a team “in the context of practice” and did not provide the breakdown requested.
In spite of the heated debate on the issue, it doesn’t seem much is going to change. “You can talk all you like about lowering the Caesarean section rate, but you have to look at each case on an individual basis,” says Coulter Smith.
Robson comments: “The question that should be answered in the future is not whether the Caesarean section rate is too high or too low, but rather what is it, why and is it appropriate.”
And the verdict of the WHO: “Ultimately, what matters most is that all women who need Caesarean sections actually receive them.”