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The two most common reasons women have a first caesarean section


Research in context

In Australia and many high-income countries, the rate of caesarean section (CS) is increasing. There is no evidence that higher rates of CS improve health outcomes, which raises concerns about overuse of the surgical procedure (ACOG et al., 2014).

In 2000, 1 in 5 Australian women had a caesarean section. That rate is now more than 1 in 3 (AIHW, 2018). For women having their first baby in Australia the risk of CS is 37% (AIHW, 2020). Once a woman has experienced a CS, future vaginal birth is much less likely. In Australia, 7 out of 8 women will have a repeat CS for their next baby (AIHW, 2020). Therefore, preventing the first caesarean section (called a “primary CS”) is paramount wherever safely possible (ACOG et al., 2014).

Some have attributed the significant rise in CS rates to the increase in older and more obese pregnant women (RANZCOGAIHW releases data on caesarean section in Australia). Indeed, age ≥35 years and obesity can increase the chances of health issues including high blood pressure, diabetes, and multiple pregnancies. Nevertheless, this change alone is unlikely to explain the magnitude of the rise in CS rates, nor the differences in CS rates in different settings (WHO, 2018).

What the research did 

New research led by PhD candidate Haylee Fox, supervised by TMCC Deputy-Director, Associate Professor Emily Callander, aimed to build our knowledge in this area:

Fox et al. (2021) used routinely collected hospital data to analyse the main reasons recorded by clinicians for primary CS in Queensland Health hospitals. Nearly 100,000 women either having their first baby or having a subsequent baby after previous vaginal birth were included in the study. Women who had experienced a previous CS were excluded.

What the research found

The top two reasons women in Queensland public hospitals had a primary CS were: ‘abnormal fetal heart rate’ (23%) and ’primary inadequate contractions’ (23%). Medical interventions including artificial rupture of membranes (ARM), oxytocin augmentation or induction of labour, and epidural analgesia predicted CS for fetal heart rate concerns (as did obstructed labour). Where a primary CS was performed due to “inadequate” contractions, epidural analgesia, ARM, fetal stress, and oxytocin augmentation or induction were predictive factors.

So what does this mean?

Induction of labour and epidural analgesia predict the two most common reasons for primary CS.  Accurate, evidence-based information about the potential consequences of induction of labour or epidural should be provided to all women (Fox et al, 2021). Indeed, these results warrant professional reflection on the use of induction of labour and epidural analgesia, alongside critical review of relevant policies, given the clear link with primary CS.

An Australian study including 1.25 million reported women who accessed birth centre or homebirth had lower rates of oxytocin augmentation and epidural use. Maternal and perinatal outcomes by planned place of birth in Australia 2000 – 2012: a linked population data study | BMJ Open. The Cochrane systematic review found women receiving midwife-led care in a hospital setting were less likely to receive an epidural, although it appeared to make no difference to rates of induction of labour or oxytocin augmentation. Midwife-led continuity models of care compared with other models of care for women during pregnancy, birth and early parenting | Cochrane

Midwifery continuity of care models and out-of-hospital birth protect against overuse of medical interventions including CS. Universal access to continuity of midwifery care should be a national policy priority.


American College of Obstetricians and Gynecologists (College); Society for Maternal-Fetal Medicine, Caughey AB, Cahill AG, Guise JM, Rouse DJ. (2014). Safe prevention of the primary cesarean delivery. American Journal of Obstetrics and Gynecology, 210(3), 179-93. https://doi.10.1016/j.ajog.2014.01.026

Australian Institute of Health and Welfare. (2020). Australia’s Mothers and Babies 2018 – In Brief. AIHW.

Fox, H., Topp, S. M., Lindsay, D., & Callander, E. (2021). A cascade of interventions: A classification tree analysis of the determinants of primary cesareans in Australian public hospitals. Birth: Issues in Perinatal Care, 00, 1-12.

Homer, C.S.E., Cheah, S.L., Rossiter, C. et al. (2019). Maternal and perinatal outcomes by planned place of birth in Australia 2000 – 2012: a linked population data study. BMJ Open, 9, e029192. https://doi.10.1136/bmjopen-2019-029192

Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD004667. https://doi.10.1002/14651858.CD004667.pub5

World Health Organization. (2018). WHO Recommendations Non-Clinical Interventions to Reduce Unnecessary Caesarean Sections. WHO.

VBAC: How risk perception contributes to the caesarean section rate. An opinion piece.

During the final year of the Bachelor of Midwifery at Griffith University, midwifery students are asked to write an opinion piece focussed on normal birth that could be published. Dr Jyai Allen convenes this course and supported the students to complete this work. Several of these were of such good quality that we offered students the option of having them published here. This is the final one of five articles in a series. The author of this article preferred to publish anonymously. 

The current caesarean section birth rate in Australia is approximately 34% (Australian Institute of Health and Welfare [AIHW], 2019). After a caesarean section, most Australian women choose to have an elective caesarean section for subsequent births, with only 12-13% of women choosing to attempt a vaginal birth after caesarean section (VBAC) (Meredith & Hugill, 2016). The reason for this seems to be the perceived risks of VBAC as opposed to an elective caesarean, with the primary concern for women being an increased risk of uterine rupture (Black et al., 2016). Repeat elective caesarean births contribute to Australia’s high caesarean section rate, far above the World Health Organization’s recommendation based on evidence that caesarean section rates over 10% do not improve health outcomes. Given that the success rate for vaginal birth after caesarean section is 72-75%, increasing to 85-90% for women who have had a vaginal birth before (Royal Australian and New Zealand College of Obstetricians and Gynaecologists, 2019), the question can be asked why the VBAC attempt rate is so low, considering the risks of this type of birth is low.

Birth has biological, cultural, social, and political influences (Behruzi et al., 2013). Socially, birth is shaped by the society women live in, with culture, social class, and resources contributing to decision-making (Behruzi et al. 2013). Research shows that decisions regarding the mode of birth are partially influenced by discussions of birth stories with other women, which often focus on negative aspects and experiences of their births (Latifnejad Roudsari et al., 2015). Social conformity also influences birth and birth choices, with values and ideas of women often reflecting the views of those around them, including family, friends and health professionals (Behruzi, et al., 2013). In a society and country where birth primarily takes places in a medicalised environment where maternity care providers are influenced by medical culture, these views can be projected onto women in a direct or indirect way. This is certainly true during consultation and provision of information regarding mode of birth after caesarean section, with evidence showing that both direct and subtle influences by maternity care providers greatly impacting women’s decisions on mode of birth (Black et al., 2016). How statistics and information are presented to women alters their perception of risk, with VBAC often being perceived by woman as much more risky than in actuality (Meredith & Hugill, 2016).

Medicalisation of birth is an issue that women and midwives are constantly contending with while trying to achieve normal birth. Medical models of birth take a risk-based approach that assumes birth to be risky and leads women to believe that these risks can be managed and reduced with the aid of medical technology (Cummins, 2020). Media contributes to the medicalisation of birth, as most portrayals of birth in film and television are overly medicalised. While most women might be consciously aware that these depictions of birth are not factual nor a reality, it has been shown that media representations of birth are subconsciously still informing women and providing them with expectations (Cummins, 2020). With this expectation that birth should be medically managed, trust in birth decreases and women are more easily influenced into birth interventions. Research also shows that births portrayed in film and television generates fear of birth and this affects the birth choices made by women (Luce et al., 2016). Takeshita (2017) finds that as well as creating fear of birth, media trivialises women’s capacity to give birth and overlooks midwifery. Collectively this contributes to the culture of birth in Australia, where many women and families consider birth to be considerably risky. In a birth culture focused on risk, perception of risk can be disproportionate to actual risk and this is apparent when looking at the low rates of VBAC in Australia.

One way to help combat these socio-cultural issues is through provision of an antenatal care environment that is encouraging of active participation by the woman in care and discussions (Chen et al., 2019). This is especially important for women making decisions on mode of birth after a caesarean section and improves the VBAC attempt rate (Chen et al., 2019). Continuity of care with a known midwife would be the ideal model of care for active participation and holistic conversation, however fragmented care is still the norm in maternity care in Australia. Women planning VBAC who had continuity of care with a midwife felt more in control of decision- making, more confident, and more supported than those who received fragmented care or care with a doctor (Keedle et al., 2020). Midwives have a professional obligation to promote normal birth (Australian College of Midwives [ACM], 2018). However, midwives also acknowledge the necessity to remove bias when presenting women with evidence-based information and this can lead them to omit the positive aspects of vaginal birth. When providing information on VBAC, midwives should present evidence to women on both the actual risk of VBAC as well as risks associated with caesarean section birth. In addition to this, in order to promote holistic health and wellbeing, midwives should also discuss the positive benefits of vaginal birth for women and babies, rather than focusing solely on the risks of both modes of birth. According to women seeking VBAC this in not demonstrated in practice, with communication being mostly risk-orientated (Nilsson et al., 2017). In a culture that is both risk adverse and reliant on technology, failing to highlight the benefits of normal birth focusses on risk and women are more inclined to choose a medicalised technocratic approach to birth (Behruzi, 2013). Understanding social attitudes about birth is important to foster a positive understanding and attitude towards vaginal birth, in order to decrease population caesarean section rates and promote health (Latifnejad Roudsari et al., 2015). Thus fulfils midwives’ professional standards to promote health and wellbeing by identifying what is important to women as the foundation for using evidence to promote informed decision-making, participation in care, and self-determination (ACM, 2018).

Analysis of successful VBAC in countries with high VBAC rates has confirmed the importance of provision of information in a supportive manner, understanding of benefits of VBAC, the support of trusting maternity care provider during birth, letting go of past negative birth experiences, and viewing VBAC as the goal when no other complications are present (Nilsson et al., 2017). Continuity of care with a midwife for women would help all of these factors associated with increased VBAC rate. Given the low risk involved in VBAC for most women, midwives and doctors can have confidence in recommending and supporting VBAC to change the default mode of birth after caesarean section from a repeat caesarean to VBAC.


Australian College of Midwives. (2018). Midwife standards for practice. Retrieved from 81&dbid=AP&chksum=kYbO0%2bO7kx9I%2fBlvmKH%2bwg%3d%3d

Australian Institute of Health and Welfare. (2019). National Core Maternity Indicators. birth/b5

Behruzi, R., Hatem, M., Goulet, L., Fraser, W., & Misago, C. (2013). Understanding childbirth practices as an organizational cultural phenomenon: A conceptual framework. BMC Pregnancy and Childbirth, 13(1), 205. doi:10.1186/1471-2393-13-205

Black, M., Entwistle, V. A., Bhattacharya, S., & Gillies, K. (2016). Vaginal birth after caesarean section: Why is the uptake so low? Insights from a meta-ethnographic synthesis of women’s accounts of their birth choices. BMJ Open, 6(1), e008881. doi:10.1136/bmjopen-2015- 008881

Chen, M. M., McKellar, L., & Pincombe, J. (2017). Influences on vaginal birth after caesarean section: a qualitative study of Taiwanese women. Women and Birth, 30(2), e132-e139. doi:1016/j.wombi.2016.10.009

Cummins, M. W. (2020). Miracles and home births: The importance of media representations of birth. Critical Studies in Media Communication, 37(1), 85-96. doi:10.1080/15295036.2019.1704037

Keedle, H., Peters, L., Schmied, V., Burns, E., Keedle, W., & Dahlen, H. G. (2020). Women’s experiences of planning a vaginal birth after caesarean in different models of maternity care in Australia. BMC Pregnancy and Childbirth, 20(1), 1-15. doi:10.1186/s12884-020-03075-8

Latifnejad Roudsari, R., Zakerihamidi, M., & Merghati Khoei, E. (2015). Socio-cultural beliefs, values and traditions regarding women’s preferred mode of birth in the north of Iran. International Journal of Community Based Nursing and Midwifery, 3(3), 165-176.

Luce, A., Cash, M., Hundley, V., Cheyne, H., van Teijlingen, E., & Angell, C. (2016). “Is it realistic?” the portrayal of pregnancy and childbirth in the media. BMC Pregnancy and Childbirth, 16(1), 40. doi:10.1186/s12884-016-0827-x

Meredith, D., & Hugill, K. (2016). ‘Once a caesarean, always a caesarean’? Challenging perceptions around vaginal birth after caesarean. British Journal of Midwifery, 24(9), 616-623.

Nilsson, C., van Limbeek, E., Vehvilainen-Julkunen, K., & Lundgren, I. (2017). Vaginal birth after caesarean: Views of women from countries with high VBAC rates. Qualitative Health Research, 27(3), 325-340. doi:10.1177/1049732315612041

Royal Australian and New Zealand College of Obstetricians and Gynaecologists. (2019). Birth after previous caesarean section.

Takeshita, C. (2017). Countering technocracy: “Natural” birth in The Business of Being Born and Call the Midwife. Feminist Media Studies, 17(3), 332-346. doi:10.1080/14680777.2017.1283341

Optimising infant gut health in midwifery practice: An opinion piece

During the final year of the Bachelor of Midwifery at Griffith University, midwifery students are asked to write an opinion piece focussed on normal birth that could be published. Dr Jyai Allen convenes this course and supported the students to complete this work. Several of these were of such good quality that we offered students the option of having them published here. This is the second of five articles in a series. The author of this article preferred to publish anonymously. 

Optimising infant gut health in midwifery practice: An opinion piece

Women are becoming increasingly aware of the importance of their baby’s gut health. Asthma, allergies, diabetes type 2, inflammatory bowel disease, obesity and cancer are on a growing list of chronic illnesses linked to disruptions of the gut microbiota (Azad et. al., 2013). The benefits of probiotics and prebiotics in infant and toddler formulas are heavily promoted by advertisers persuading parents to buy their products. Microbiota Transfer Therapy (MTT) has recently been found to improve autism symptoms (Kang, et. al., 2019). This treatment involves the transfer of faecal bacteria and microbes from a healthy individual to another person to improve their depleted gut microbiome.

How science is changing our approach health and chronic diseases

Many parents are unaware of how the mode of birth plays a vital part in establishing a healthy gut microbiome. Babies born vaginally have a gut microbiome akin to their mother’s vaginal and faecal flora. This transfer occurs as the baby passes through the birth canal absorbing the mother’s microbes. (Azad et. al., 2013; Dominguez-Bello et. al., 2010; Dunn et al., 2017; Yang, et. al., 2016).

In contrast, babies born by planned c-sections develop a gut microbiome that resembles the mother’s skin flora and microbes in the hospital environment (Dominguez-Bello et. al., 2010). This is because the baby’s first points of contact are the mother’s skin and the surfaces and air in the operating theatre in the moments following birth. Babies born by caesarean section are extracted from a relatively sterile womb therefore avoiding exposure to the birth canal and the mother’s microbiota (Mueller et. al., 2019). Babies born by unplanned caesarean section fare a little better, acquiring more bacterial abundance and diversity than those born by planned caesarean section. Babies born after unplanned caesarean section had a similar microbiome to vaginally born babies (Azad, et. al., 2013), suggesting that some microbe transfer from the mother to baby occurs during the labour process.

As the rates of caesarean sections continue to rise across the globe, information sharing with parents about the potential impacts this form of birth on the baby’s gut microbiome is important. Other interventions are also commonly used during birth such as: the use of antibiotics, vaginal examinations, and artificial rupturing of the membranes (Johansson et. al., 2012; Yang et. al., 2016). These too can disrupt the baby’s gut microbiome.

The human microbiome is a new field of research…

Midwives need to be informed about the latest research and be confident to educate parents about the impact of the mode of birth on their baby’s gut microbiome. This is no easy feat considering the flood of evidence recently published on the topic (Lokugamage & Pathberiya, 2019). To provide some perspective, very little was known about human microbiome before April 2003 when the human genome was first sequenced (National Human Genome Institute, 2020). Since then, the science has grown exponentially and there remains much yet to be understood. But what we do know is that preventative health approaches will be the way of the future for eliminating chronic disease (Lewis et. al., 2020). Midwives in continuity of care models are ideally placed to maximise this opportunity as part of woman-centred care. This requires a great deal of open mindedness, continuous learning, and expansion in practice.

Vaginal seeding as prevention during planned caesarean sections

Vaginal seeding is a preventative intervention to help counter a baby’s compromised microbiome after a caesarean section. It involves the swabbing of the baby’s face, mouth, and nose with secretions from the mother’s vagina immediately after birth. Growing awareness of the benefits of healthy gut bacteria for newborn infants has parents demanding vaginal seeding as part of planned caesarean section (Wissemann, 2018). The feature-length documentary Microbirth was a powerful film which showed the microscopic world of microbes and how seeding takes place around the time of birth. The short and long-term effects of changes in the newborn’s microbiome are explored in the film along with the implications of altered microbiomes on the health of future generations. This documentary did much to raise public awareness about the importance of the human microbiome for health (Harman & Wakeford, 2014).

Vaginal seeding can modify the baby’s microbial composition which may help override the disturbance caused by  caesarean section (Dominguez-Bello et. al., 2010). To date only one pilot study has investigated the efficacy of this intervention. Although the sample group was very small (four babies), within the first week of life the results showed these babies had developed microbiomes that compared to babies born vaginally (Wissemann, 2018). Although the seeded microbiomes were only partially restored, the results were promising. Clearly, more research into this intervention is needed before it can be implemented into clinical practice on a wide scale.

The information age

The deluge of information available means healthcare is becoming increasingly consumer driven. This is not a bad thing. Consumer involvement helps to move our health systems in the right direction. Public access to science journals means astute parents have more information at their fingertips about health than ever before. Well informed parents can leave doctors and midwives underprepared when asked about vaginal seeding for a planned caesarean. The lag in time between the announcement of an exciting new discovery and the reality of its safe introduction into practice often means consumer expectations are way ahead of practice.

Midwives may serve women better by promoting normal birth as the preferred option for protecting a baby’s microbiome when a planned caesarean section is negotiable. Supporting and encouraging women to birth vaginally, followed by immediate skin to skin and early breastfeeding, is the ideal for establishing a baby’s healthy gut microbiome.

Home is where the good bacteria live

There is also strong evidence to support home as the optimal birth environment for protecting a newborn’s microbiome. Every person has a unique microbial thumb print which transfers to our living environments. Skin shedding, respiratory activity and skin to surface contact permeates our habitats with our unique flora. This creates microbial diversity within our homes which effects immune defence and disease transfer among the inhabitants. People who live together share the same microbiome (Lax et. al, 2014). A baby born at home is entering an environment where there is already a shared microbiome established. This is in direct contrast to clinical environments which expose a baby to unfamiliar microbes which can be very harmful to health.

Vaginal seeding… is it safe?

Concerns about infectious diseases are at the centre of the argument against vaginal seeding. Chlamydia, HIV, group B streptococci (GBS) and bacterial vaginosis are among the pathogens under the spotlight (Haahr et. al., 2017). The Royal Australian College of Obstetricians and Gynaecologist [RANZCOG] (2016) offers scant information about vaginal seeding. Instead it refers to a British Medical Journal [BMJ] article (Haahr et. al., 2017) via a link for those seeking further information. The BMJ article does not recommend the practise of vaginal seeding in maternity wards. The Danish Society of Obstetrics and Gynaecology’s stance strongly opposes the intervention, highlighting significant risks to babies exposed to GBS and those less than 37 weeks gestation. Early skin to skin to encourage breastfeeding is recommended which is said to “indirectly” boost beneficial gut microbiota (Haahr et. al., 2017, p. 3).

There is notable hesitance from RANZCOG to formalise an opinion about the safety of vaginal seeding. This ambivalence is highlighted in the infection argument with a suggestion that all vaginal births are inherently risky due to inadvertent exposure to pathogens. A hint of resignation is evident in the conclusion which states that the risk associated with vaginal seeding is “probably very low, but in contrast to vaginal birth, vaginal seeding is not a natural process” (Haahr et. al., 2017, p. 3).

So how does a midwife approach vaginal seeding in practice?

The best option to addressing the ongoing debate and controversy surrounding vaginal seeding is to bring it into a women-centred framework. Discussions with women about the general risks associated with caesarean section should also include the changes to the baby’s gut microbiome and the possible long-term effects this can have on immunity and health. It is appropriate to share this information in order to ensure women are supported in the informed decision making process. Health institutions and their employees are not under any obligation to provide vaginal seeding as part of their maternity services. However, conversations should take place with parents about the current evidence. Furthermore, there should be no overt or covert obstructions from doctors or midwives for parents who do wish to practise vaginal seeding independently (Lokugamage, & Pathberiya, 2019).

Thinking outside the square

The World Health Organisation states that caesarean sections are medically necessary in 10 to 15% of cases. However, in Brazil over 60% of babies are now born by caesarean section. This is a global trend and it is not sustainable (Mueller, et. al, 2019). In fact, it is vital to robustly challenge the rising rate as the evidence increasingly shows the long-term damage we are inflicting on the health of future generations. The science behind the human microbiome may well be in its infancy but it offers hope for the rebirth of normal birth.


Azad, M., Konya T., Maughan, D., Guttman, C., Field, R., Chari, M., Sears, A., Becker, J., Scott, A. & Kozyrskyj. (2013). Gut microbiota of healthy Canadian infants: profiles by mode of delivery and infant diet at 4 months. Canadian Medical Association Journal, 185(5), 385-394.

Dunn, A., Jordan, S., Baker, B. & Carlson, N. (2017). The maternal infant microbiome: Considerations for labor and birth. The American Journal of Maternal/Child Nursing, 42(6), 318–325.

Dominguez-Bello, M., Costello, E., Contreras, M., Magrisd, M., Hidalgod, G., Fierere, N.& Knight, R. (2010). Delivery mode shapes the acquisition and structure of the initial microbiota across multiple body habitats in newborns. Proceedings of the National Academy of Sciences of the United States of America, 107(26), 11971-11975.

Haahr, T., Glavind, J., Axelsson, P., Bistrup Fischer, M., Bjurström, J., & Andrésdóttir, G. et al. (2017). Vaginal seeding or vaginal microbial transfer from the mother to the caesarean-born neonate: a commentary regarding clinical management. BJOG: An International Journal of Obstetrics & Gynaecology, 125(5), 533-536.

Harman, T. & Wakeford, A. (2014). Microbirth. Alton Film Production.

Johansson M., Saghafian-Hedengren S., Haileselassie, Y., Roos, S., Troye-Blomberg, M., Nilsson, C. & Sverremark-Ekström, E. (2012). Early-life gut bacteria associate with IL-42, IL-102 and IFN-c production at two years of age. PLoS One, 7(11), e49315.

Kang, D., Adams, J., Coleman, D., Pollard, E., Maldonado, J., McDonough-Means, S., Gregory Caporaso, J., Krajmalnik-Brown, R. (2019). Long-term benefit of Microbiota Transfer Therapy on autism symptoms and gut microbiota. Scientific Reports, 9(1), 1-9.

Lax, S., Smith, D., Hampton-Marcell, J., Owens, S., Handley, K., Scott, N., Gibbons, S., Larsen, P., Shogan, B., Weiss, S., Metcalf, J., Ursell, L., Vázquez-Baeza, Y., Van Treuren, W., Hasan, N., Gibson, M., Colwell, R., Dantas, G., Knight, R. & Gilbert, J. (2014). Longitudinal analysis of microbial interaction between humans and the indoor environment. American Association for the Advancement of Science, 345(6200), 1048-1052.

Lewis, C., Obregón-Tito, A., Tito, R., Foster, M. & Spicer, P. (2012). The Human Microbiome Project: lessons from human genomics. Trends in Microbiology, 20(1), 1-4.

Lokugamage, A. & Pathberiya, S. (2019). The microbiome seeding debate – let’s frame it around women-centred care. Reproductive Health, 16(91). 1-9.

Mueller, N., Dominguez‐Bello, M., Appel, L., & Hourigan, S. (2019). ‘Vaginal seeding’ after a caesarean section provides benefits to newborn children: FOR: Does exposing caesarean‐delivered newborns to the vaginal microbiome affect their chronic disease risk? The critical need for trials of ‘vaginal seeding’ during caesarean section. BJOG: An International Journal of Obstetrics & Gynaecology, 127(2), 301-301.

National Human Genome Institute. (2020, September 16). The Human Genome Project.

Royal Australian and New Zealand College of Obstetrics and Gynaecology. (2016). Vaginal seeding.

Wissemann, K. (2018). Exploring Western Australian midwives’perspective on vaginal seeding and how it will affect their practice. Women and Birth, 31(S1), S45-S46.

Yang, I., Corwin, E., Brennan, P., Jordan, S., Murphy, J., & Dunlop, A. (2016). The infant microbiome. Nursing Research, 65(1), 76-88.