WHO criticises Malta’s high Caesarean birth rate

Malta’s high rate of Caesarean sections has been criticised by both the World Health Organisation and, among others, local midwives, the latter partly attributing the blame to doctors.

The WHO recently repeated its long-standing recommendation that a country’s rate of Caesarean sections – which in Malta stands among the highest in the EU – should hover between 10-15% of its total births.

In a statement from its Geneva headquarters, the WHO warned that C-sections can cause significant complications, disability or death, particularly in settings that lack the facilities to conduct safe surgeries or treat potential complications.

For years Malta’s C-section rate has been among the highest in the EU – in 2013, 31.2% of births in Malta were carried out through C-sections, higher than in most EU countries. In the EU only Italy, Cyprus, Portugal, Romania, and Slovenia had a higher rate.

Midwives are all too aware of the situation and some have ascribed a shocking factor to it. 

“Sometimes, doctors advise pregnant women to induce their pregnancies and undergo a C-section on the pretext that, for example, their babies will be born with large heads,” an experienced midwife who chose to remain anonymous told MaltaToday.

“In reality, the C-section operation will simply be more convenient for the doctors themselves. Maltese women need to become more assertive and not simply treat their doctors’ words as law,” the midwife said.

A European Perinatal Health Report published in 2010 found that 28% of Malta’s births were induced, giving Malta one of the highest rates of inducement in Europe. 

A second anonymous midwife, a representative from the Malta Midwives Association, claimed that this trust in doctors has now become part of Maltese culture.

“It has become part of our culture now – if you get pregnant, you visit a doctor. Yet, people don’t visit a doctor unless they’re sick, and pregnancy isn’t a sickness. The vast majority of pregnancies don’t have any complications, and midwives should be entrusted with low-risk mothers.

“Unfortunately, for many Maltese women, a doctor’s word is sacred. While C-sections are major operations, natural childbirths are natural and hence a better option.” 

The Malta Union of Midwives and Nurses has long sounded warning bells about these persistent figures, and union president Maria Cutajar has repeatedly called for an independent audit on obstetrics to ascertain its cause. 

“I recently attended a meeting of the European Midwives’ Association and Malta’s high C-section rate was criticised,” Cutajar told MaltaToday. “Look, the numbers are there, they have been for a while, and they’re reflecting badly on Malta. I cannot stick my head in the sand and say that it isn’t a problem, both health-wise and as a financial burden to the Health Department. However, we can only start finding ways to decrease the numbers once we have the facts in front of us.”  

She said that a number of factors could have a role to play in this high rate – such as the high labour inducement rate, women giving birth at a later age, the majority of breech babies and twins being delivered through C-sections, and people becoming more trusting of technology.

“If we find out that it is the women themselves who are choosing to undergo C-sections, then we could start focusing on educating mothers of the benefits of natural childbirth,” Cutajar said. “However, I’m not an extremist and we must be careful not to portray mothers who had undergone C-sections in a negative light. Mothers have the right to make their own decisions after all.” 

‘C-sections a poor price to pay for newborn morbidity’

Despite the WHO’s warnings, obstetricians see another side of the coin. 

Professor Charles Savona-Ventura, head of the University’s Department of Obstetrics, pointed out that the WHO’s 15% recommendation does not take newborn morbidity into account.

“The effects of a difficult prolonged birth process causing birth anoxia results in significant life changing morbid conditions such as learning disabilities, ADD, cerebral palsy, epilepsy, visual impairment and significant cognitive and developmental disorders,” Savona-Ventura told MaltaToday. “A C-section is a poor price to pay to safeguard the newborn from these complications.” 

He added that Maltese women are the most obese in Europe and have the highest rate of diabetes. 

“These factors promote foetal growth, resulting in big babies, prolonged labour, and a higher risk of the foetus being deprived of oxygen,” Savona-Ventura said. “This becomes even more relevant when one considers that Maltese women than average are shorter than their Central and Northern European counterparts.

“These women have an option – to persist in achieving a vaginal delivery and risk a severely damaged child or to intervene with a Caesarean Section. I know what option I would choose in those circumstances.”

He added that Maltese women are delaying having children into their 30s and that this, coupled with the “generally increased promiscuity of the modern generation” has resulted in a rise in infertility, requiring the use of artificial means of reproduction. 

“This itself carries an increased risk of multiple pregnancies and the obstetric problems that this situation brings about,” he said.

He criticised the WHO for setting a blanket target without taking local realities into account and called for detailed, scientific, multifactorial studies to properly audit Malta’s situation.

“Until then, emotional statements by pro-natural birth supporters will remain simply that – irrelevant emotional outbursts,” he said. 

Apart from the modern pregnancy delay and Malta’s high obesity and diabetes rate, obstetrician Yves Muscat Baron also believes that Malta’s C-section rate has been pushed up by the increasing number of foreigners giving birth in Malta. 

“Around 13.8% of the babies born in Malta in 2013 were foreign, when that figure only stood at around 1.8% in 2001,” he said. “A lot of them cannot speak English or Maltese, making cooperation between themselves, midwives and doctors during labour a difficult task. Also, a lot of them, particularly Libyans at the moment, would have a high anxiety level after having had traumatic experiences. To make matters worse, they don’t have their extended family to support them as Maltese women often do, further increasing their anxiety.” 

He dismissed criticism by midwives that obstetricians are encroaching on their professions.

“I respect midwives, but the truth is that there are limits of safety to both mother and child that must be considered,” Muscat Baron said. “Around 50 years ago, 25% of babies used to die in labour. In parts of Africa, one in every 20 pregnant women dies in labour. The truth of the matter is that nature kills.”