Caesareans are rising fast in the UK – but giving birth is getting worse for women

Caesarean births are rising worldwide, but the UK has one of the highest rates in Europe, with the fastest increase in recent years.

In England, 42% of all births are now by caesarean section compared with 29% five years ago.

Rates have gone up particularly steeply since the end of 2021, when they were at 35%. International evidence shows that national caesarean section rates over 10-15% are not associated with benefits and could harm some healthy mothers and babies.

Although stillbirth rates have fallen slightly in recent years, rates of both maternal and neonatal deaths in the UK have gone up, and increasing numbers of women report traumatic birth experiences.

Given that the reasons for performing caesarean sections include reducing mother and baby deaths and birth trauma, it is surprising that higher rates of surgical birth do not seem to be associated with significant improvements at the population level in many of these outcomes, though these operations do benefit individual women and babies who need and want them. Indeed, not performing a caesarean when it is needed or wanted is unacceptable, and can risk serious adverse outcomes for mother or baby.

Recent media reports claimed that one in four women in England gives birth by caesarean section, in contrast to the actual rate of more than two in five. In fact, half of women aged 30 to 39 have caesarean births. For those over 40, this is now the most common way for their baby to be born.

Why is caesarean use increasing?

One explanation for the increase in caesarean births is the increase in conditions such as diabetes and obesity, and women being older when they have a child. However, over the last ten years, none of these factors has risen dramatically enough to explain the rapid changes in caesarean use.

In fact, the average age of women at the birth of their first baby only went up from 28 to 29 between 2012 and 2022.

Obesity rates in adults have gone up by about 5% since 2016, and the total number of people newly diagnosed with diabetes did not change markedly between 2017 and 2022.

Despite similar changes in Europe, similar effects on how babies are born don’t seem to be happening in other countries. For example, Norway has less than half the rates of surgical birth than the UK, with better outcomes.

There is very little recent good-quality evidence on how many pregnant women would choose a caesarean when they don’t have any complications. A recent survey of women thinking of ever having a family suggested about 15% might make that choice. It isn’t clear, though, how many of these women had medical conditions, or if their decision changed once they were pregnant.

On the flip side, the same survey showed that almost 80% of respondents would choose either (what the survey called) a “natural” birth or a home birth. In direct contradiction to these choices, in March 2023, for the first time in England, less than half of all women had a spontaneous vaginal birth, without surgery, forceps or vacuum suction. This figure has continued to decrease.

Benefits and risks

There are both short- and longer-term risks and benefits of planned surgical birth compared with planned vaginal birth, according to the UK’s National Institute for Health and Care Excellence (Nice). For the mother, some outcomes are better and some worse. For example, incontinence and vaginal tears are higher with planned vaginal birth.

However, both hysterectomy and maternal deaths, though rare, are higher with planned caesarean section when compared with planned vaginal birth, even when taking into account conditions that might influence outcomes in either case. For the baby, Nice does not list any improved outcomes with planned caesarean section, and there are higher rates of neonatal death and more chances of childhood asthma.

The Lancet Series on Optimising Caesarean Use reports a range of other short- and longer-term consequences, noting that, both for the mother and for future babies, the risk of harm increases with every pregnancy after the first caesarean section. And many women have repeat operations for each subsequent birth.

Because of these outcomes, The Lancet issued a “global call to action” on excessively high rates of surgical birth. Organisations and countries worldwide are now trying to safely reduce country-level rates of caesarean births while also making sure that all women and babies who need and want the operation get it.

In contrast, in the UK, there does not seem to be a particular concern about rapid changes in how babies are born. The public health consequences will be increasingly significant if caesarean birth becomes the UK norm, while alternative options become less available.

The Lancet has published a model showing what influences high surgical birth rates and how these can be safely reduced. Coming into line with European countries with the best track records in this area is likely to bring significant benefits for those using and providing maternity care into the future.

Soo Downe received funding from the World Health Organisation to undertake research related to their guideline on Non-Clinical Interventions to Reduce Unnecessry Caesarean Section. She is also a co-researcher on the MRC funded C-Safe study, looking at the provision of safe caesarean section in India and Tanzania, and co-lead researcher on the NIHR funded Cherish project, aimed at designing a care bundle to support safe physiological birth in England.

Carol Kingdon received funding from the UNDP/UNFPA/UNICEF/ WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research (RHR), World Health Organization to undertake systematic reviews for their 2018 Guideline on recommendations for non-clinical interventions to reduce unnecessary caesarean sections and 2021 technical working group to improve incidence and outcomes of assisted vaginal birth. She is also a co-investigator for C-Safe a 5-year Programme (2022-2027) looking at the provision of caesarean section in India and Tanzania.