Rise in older mothers cited as factor behind Ireland’s high Caesarean rates

A fear of litigation among doctors and midwives is contributing to the rise in Caesarean birth rates, according to a study of Irish maternity staff.

A fear of adverse outcomes, personal preference, varying thresholds for intervening in a pregnancy and the culture of practice within the system are also cited as factors by researchers from Trinity College Dublin.

More than a third of first-time mothers give birth by Caesarean section despite a lack of evidence of any additional benefits to mothers and babies. The proportion has risen year-on-year in the past decade.

The study published in PLOS-One journal is based on one-to-one interviews with 20 obstetricians and 15 midwives in Irish maternity units.

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Advancements in anaesthesia and a perceived low morbidity and mortality associated with planned Caesareans had an influence on the belief system among clinicians and women, the study notes, and this influenced staff’s acceptance of women’s requests as a reasonable choice, particularly for older women with histories of infertility.

“It drives me insane when they keep comparing us to the Netherlands [which has one of the lowest Caesarean section rates in the world],” an obstetrician commented. “I mean…they are…taller than the average Irish person…healthier [and]…slimmer. We are fat, old and short. That’s basically the Irish population of women who are giving birth. So it is a huge influence in terms of what the Caesarean section rate should be for your country.”

The researchers from Trinity’s school of nursing and midwifery say three interrelated themes emerged: a “fear factor”, “clinician-driven factors” and “a system perspective”.

“Findings suggested that decisions to perform CS are based on clinicians’ perceived fear, personal beliefs, and organisational factors,” the authors say. “A deep insight into these factors will help clinicians identify and evaluate modifiable factors in practice to avoid excess CSs.”

“I think our society, we have become more litigious…nobody wants to stand in the court and defend themselves. So definitely one of the reasons why the rate of Caesarean section is going over the board is the fear of litigation,” according to one doctor interviewed by researchers.

Another obstetrician said: “I think that those who are working in obstetrics…appreciate the fact that…we will be subject to litigation, no matter what we do. And it’s kind of like part of what you live with. It’s part of the job.”

A midwife felt consultants are under “a lot of pressure” because “in Ireland at the moment… the media are really out to get maternity services. And anything bad that happens, whether it’s malpractice or not, once something ends up in a coroner’s court the doctors are always named”.

A rise in older mothers and pressure on resources were also mentioned as factors leading to more Caesareans, and the study says staff were more inclined to intervene more quickly for women attending the consultant privately.

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“If you have a consultant obstetrician looking after you, they’d be much quicker to bailout of a labour,” one midwife told the authors.

“I always think that women who book privately anyway think that they own the consultant and they just make demands and often consultants feel like their hands are tied,” said an obstetric registrar.

The most recent maternity safety statements available for 2022 show five units with a first-time mother Caesarean birth rate of over 50 per cent, and another three with a rate of over 40 per cent, according to Dr Krysia Lynch, a private childbirth services provider and chair of AIMS (Association for Improvements in the Maternity Services) Ireland. “These rates are perhaps partially informed by our equally high induction of labour rates.”