The Link Between Inductions & C-Sections: What American Women NEED to Know
Every now and then there’s a partner (of a client) that really imprints on me. To be honest, it’s usually the ones that challenge me. They question everything. Sometimes they even go out and seek their own research to share at our next prenatal. These are my faves. I can see how much they love their spouse. How much they care. How much they want to protect and understand. Sometimes it’s anxiety and sometimes its fear. But, sometimes, and these are the ones that get me, it’s from a place of truly understanding the injustices in our medical system and they are equipping themselves to be an anchored place of support during a very natural event that our society has somehow medicalized. They recognize the essential need to educate and prepare themselves in order to protect their partner.
So there I was, sitting in a prenatal with a wonderful couple I had grown to love over the last few months of working together planning for their birth. This dad knew his wife’s worst fear was a c-section. We had openly talked about her fear and how she didn't have too many preferences, but avoiding a c-section was definitely #1. I had shared with them how much induction increases your risk of having a cesarean birth and then he asked a question I didn’t know the answer to.
“Do other countries see this same trend with inductions causing c-sections?”
I had never looked beyond the US to see what other countries reported their induction rates to be and if they are correlated with their c-section rates... So there I went, into the abyss of research, numbers, stats, and tons of randomized-controlled trials. Here’s what you need to know about inductions, c-sections, and how they impact one another from a worldly view.
**Trigger warning** Infant mortality is highly intertwined with c-sections and inductions. It is mentioned below.
What You Need to Know
First, one of the biggest reasons we see women manipulated into c-section in The United States of America is “being past due”. I’ve even had providers tell clients that their baby is more likely to be stillborn if they go “any bit” past their due date. This simply is not true and is fear mongering. This article also shares two trials and "neither trial found an increase in the risk of Cesarean or forceps/vacuum during birth with 41-week induction compared to continuing to wait for labor until 42 weeks. Both of these trials took place in countries that follow the Midwifery Model of Care, and the overall Cesarean rates were low (only 10-11%)." So this alone shares that if we wait you decrease your risk from 33% of the average American women (increase that up to 70% for an induction) down to 10-11% for the midwifery model of care and 3-4% using our approach and the birth lounge videos. It's very important to understand that Obstetrical care and midwifery care yield very different results as far as birth outcomes are concerned.
Sweden has been a country that has stood out to me from the beginning of my practice. This is a country that truly cares about it’s people. This study from Sweden shares finding that suggest, "Induced labor was associated with 2-3 times greater risk of unplanned cesarean delivery among all women, except multiparas in gestational week 37-38, and with a 20-50 percent higher risk of vacuum extraction after the adjustment for confounding factors." It is a little bit older, published in 2016.
They (Sweden) also found that inducing between 41 and 42 weeks reduces the rates of complications of large babies so waiting until that "prime time" window is up is also right on track with thinking about induction which is your plan so that's perfect. We know (very hard science here, not anything anyone can negate or argue) that first born babies are expected to arrive between the gestational window of 40+5 to 41+2. This means that right off the bat, from the very beginning, your due date is wrong.
A first time mom should not expect her baby any sooner than 5 days after her original due date.
This Austrian study, published in 2017, shares how the hands off approach (rather than active management/trying to control) to labor has better outcomes for women. Very simply put, "The routine use of various interventions such as episiotomy, electronic fetal monitoring and pain control has strongly increased during recent years [3–5], although such interventions are not recommended in the the guidelines of the World Health Organization (WHO) on the care of women giving birth, nor have they been demonstrated to improve maternal or neonatal outcomes." Surprisingly enough (or is it?) , American women are subjected to such things on a daily basis in conjunction with being forced to push in positions we know are not conducive to the way the human body works to eject a baby, being yelled at for advocating for themselves, or brutal obstetrical violence at the hands of providers who want things done their way and their way only.
You have so much control as a birthing person, but you have to know what the actual science says...rather than what medical school and a medical system founded on racist and sexist beliefs has fed to your doctor for them to recite to you. Remember, despite popular misconceptions, your doctor doesn’t have the final word. Their malpractice insurance is. Their facility policies are. Their governing body (The American College of Obstetrics and Gynecology) is. BUT, none of that negates the fact that hospital policy is not the law. It is merely a suggestion, a preference. It’s what your hospital wants you to do in order to be a “good patient” and make their job as easy as can be while getting you in and out as fast as possible to continue depositing into their bottom line.
In the end, the only person that can save you from a birth you don’t want is you.
A Global Perspective
The world c-section rates are gathered here and corroborated by this article that shares the undeniable correlation between infant mortality and c-sections. Now the interesting thing that I found when I dove into all of this was that there's not great research out there on induction rates, but there is a clear influence of cesarean births and infant mortality in these countries. From top to bottom, it's a predictable pattern. As the c-section rate grows, the infant mortality does as well. Take a look!
Sweden takes the cake with the #2 spot in the world! They almost never do c-sections with a 16.4% rate country wide. Their infant mortality rate is just over 2%. This can be explained by natural causes.
The UK comes in #4 on the world chart with a c-section rate of 23-27% and an infant death rate of 3.6%.
The USA has a c-section rate of 32-33% (these articles says 32%, but the stats that are commonly used in the birth world by providers is 33%), putting us at #10 on the world list. Our national infant death rate of 5.6%.
Turkey just blows the whole world away with a whopping 50% c-section rate. I mean, can you even imagine? Can you even wrap your head around the fact that half of all women have a major abdominal surgery when they have a baby? Similarly, we can see this dangerous trend ripples into impacting infants, too, as their infant mortality rate is 9.1%. Nothing about nearly 10% of babies not surviving is explainable by nature. Nothing.
Disclaimer: Netherlands took the board with the #1 spot of lowest cesareans, but their infant mortality rate was above 3%. I didn't find any reason this might be true, but they are the wildcard as it doesn't fit the pattern.
If you are worried about a c-section and fear being tricked into an unnecessary major abdominal surgery, check out this masterclass to learn how to have an informed and confident birth without being rushed or feared into decisions.
If you look at the trends, you will also notice that as Sweden drops, so does the UK, followed by the US. I believe this is evidence of how countries seem to adopt new birth cultures. First Sweden masters it, then the UK adopts it, and then the US will eventually shift, too! We see this currently with things like eating in labor, the rise in popularity of midwifery care, and the dwindling demand of hospital staff about erythromycin cream on baby's eyes. These are all things that other countries have changed to match current research, but US hospital policy hasn't quite made it there yet. I can’t say I’m surprised, but I am hopeful. I’m hopeful that if we all raise our voices together, we can demand that our maternity care is evidence-based and individualized (meaning your care is tailored to you & not based on outdated science and racist/sexist measurables) --that is the bare minimum that our medical system can provide to its patrons.
One Last Thing Before You Go
Finally, I wanted to share two pieces of information that I think will be key for you in your journey of achieving your dream birth. The idea that one thing leads to another and quickly spirals out of control is not new to the birth space. We know good and well that the concept of “cascade of interventions” rings true way too often and leaves so many women feeling broken, confused, and second-guessing their own abilities. In order to feel powerful and confident in making decisions for yourself during labor, you need to have the whole story--not just what your hospital wants you to know (see the problem with hospital based childbirth education?).
These little tidbits may be a gamechanger.
Here is a bit of evidence that shares it has been determined that it is not beneficial to have cervical exams and in fact, it TRIPLES your risk of your waters breaks prematurely (before contractions) so that alone is a reason to not have any cervical exams until we are out of that 40+5 to 41+2 window. You can see here that our idea of "normal" labor is distorted because it is based in the 1950's (literally) and this ideation can be super harmful to women when we are setting realistic expectations for labor. Stay in control of knowing what we expect from a first time mama and concrete into your brain that your baby knows their perfect timing.
In this new training, I share The BRACE Technique that teaches women how to evaluate what is evidence based during labor and how to navigate the decision making process. This new training is based on this research and I think it'd be worth the watch for you! It's less than an hour of your time!
Finally, one of the worst things women share with me is being told they have a
“Big baby,” but when the baby is born they are much smaller than expected. These women often have feelings of being lied to, manipulated, or taken advantage of by their provider. Here is some evidence for Inducing for Suspected "Big Baby" and here's a helpful webinar. This evidence is why I feel so strongly that we don't induce for a baby baby. Even the methods we use to “diagnose” a big baby are incredbily inaccurate.
Here's one last thing: this one isn’t common, but it comes up every now and again and is yet another reminder that our current medical care system does not make all decisions based on evidence and science. Check out the evidence on Low Amniotic Fluid and why inducing for this reason may not be the best answer when it’s used as a “blanket statement” solution... Also a bit of information showing that inducing for due dates actually usually causes more harm than good if there is not a solid, medically founded reason for it.
The Final Word
You are responsible for you birth. You are responsible for planning and educating yourself. You are responsible for speaking up and using your voice. You are responsible for saying “no” when it counts.
You can do this.
If you are concerned about having an unwanted c-section or being feared into decisions that are not based in evidence and science, let us help! Join The Birth Lounge to have an informed and confident birth experience, push for less than one hour, and avoid a c-section!