Births in Scotland: Why are caesareans at a record high?

In the year to March 2023, there were a total of 43,770 live singleton births in Scotland, but 51.1% of these newborns arrived thanks to a mixture of planned or emergency caesarean sections and instrumental interventions such as forceps or suction cups which are used to speed up delivery where labour is taking too long and there are fears for the baby's wellbeing.

By far the biggest change over the past 20 years has come from the surge in elective C-sections.

Elective C-sections have more than doubled, with figures this week showing that fewer than half of all births are now 'spontaneous' (Image: Public Health Scotland)

Back in 2003/4, fewer than one in ten (8.6%) of infants were delivered by planned caesarean; last year, that reached a peak of 19.2%.

Emergency caesareans have seen a more modest uptick over the same period, from just under 15% of births to 20% last year - also an all-time high for Scotland.

This has coincided with a steady increase in the number of pregnancies occurring in older mothers as well as much higher rates of maternal obesity and gestational diabetes, all of which raise the risk of birth complications.

So-called "geriatric pregnancies" - those in women aged 35 and over - continue to rise.

Nearly one in 20 (4.6%) babies born in Scotland last year were to mothers aged 40-plus. More than 20% were to mothers aged 35-39.

Twenty years ago, more than 4000 babies a year in Scotland were being born to teenage mothers compared to around 1,500 to women over 40; today, that has flipped around to a ratio of around one-to-two.

This reflects both lifestyle changes - people tend to want to start their families later - as well as the increased availability, and advances in, fertility treatment.

Scotland is the only part of the UK which offers eligible couples three cycles of IVF or ICSI (where sperm is injected directly into the egg) on the NHS, with demand for private treatment also on the rise.

Elective C-sections seven times more common in women over 40 compared to the youngest mothers (Image: PHS)

Older mothers are much more likely to undergo C-sections, particularly planned ones.

Last year, one in three deliveries in mothers over 40, and more than a quarter of those in mothers aged 35-39, were elective caesareans. That compares to 10% in mothers aged 20 to 24.

There is less variation in rates of emergency C sections, which are roughly 20% across the board.

Obesity and gestational diabetes also increase the probability that a C-section will be needed or recommended in advance, and both are at record levels.

Last year, obesity was recorded in nearly 28% of expectant mothers, and diabetes - whether pre-existing, or gestational - affected almost one in 10 pregnancies compared to fewer than one in 100 15 years ago.

Rates of maternal diabetes (top) and diabetes are at an all-time high (Image: PHS)

The World Health Organisation advises that a maximum of 15% of births should be by C-section, but is difficult to see how that can be achieved unless there is a dramatic turnaround in maternal health and demographics.

Such benchmarks are also controversial in the wake of maternity scandals including that of Shrewsbury and Telford Hospitals Trust in England, where hundreds of babies died as a result of an overzealous pursuit of natural birth targets which resulted in fatal decisions not to perform C-sections when needed.

The goal has to be what is best, and safest, for mother and baby.

A caesarean is not an easy option, however; it is a major surgery which carries risks of wound infections, haemorrhaging, damage to reproductive organs, and blood clots.

A 2019 study found that severe complications - mostly bleeding after delivery - were roughly twice as common in caesarean births compared to vaginal births, with the risk increasing with age.

Pregnant women aged 35 or older who had emergency C-sections were four times more likely to suffer complications unrelated to any pre-existing health problems than mothers of the same age who delivered vaginally.

And while complications are much less frequent in elective C-sections compared to emergency ones, in mothers aged 35 and older the rate of complications was still five-fold higher compared to vaginal births.

According to the Royal College of Obstetrics and Gynaecology, the chances that a woman will have to undergo a hysterectomy due to heavy bleeding is one in 670 following a caesarean birth and one in 1,250 after a vaginal birth.

The risk of maternal death is also higher - at one in 4,200 versus one in 25,000 - while neonatal mortality ranges from one per 2000 in caesarean births to one per 3,300 for vaginal births.

Children born via C sections also have an increased risk of developing asthma, obesity, allergies, and eczema.

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Staffing shortages may be another factor driving the trend towards more interventions.

It is known, for example, that the fewer midwives and doctors there are available, the more likely mothers are to end up with a caesarean.

But something else has puzzled medical specialists: the massive geographical variations in the elective caesarean rate, which spans a low of 4.1% in the Borders to a high of 23.3% in the Western Isles.

This is particularly striking given that the rate of emergency sections in the Borders - at 21.8% - is the third highest in Scotland.

The rate in the Western Isles is unusually high compared to other island communities too; in Orkney, just 6% of babies are delivered by planned caesarean.

Speaking to the Herald last year, Dr Rosemary Townsend, a consultant obstetrician and senior clinical research fellow at Edinburgh University, said this "massive variation" between health board regions deserved further investigation.

While it has always been the case in theory that mothers who requested a C-section could have one, in practice they tended to encounter quite a lot of pushback and interrogation.

In recent years, some boards have adopted more flexible policies.

However, Dr Townsend cautioned against any attempt to start "chasing the numbers" to bring figures closer to the WHO recommendations, stressing that this would lead to "unacceptable" risks.

"We should be less concerned with the numerical value of the rates and more concerned with metrics of 'was the Caesarean appropriate?'," she added.