Understanding the Cesarean Epidemic

Janelle Durham, MSW, ICCE, LCCE. Program Coordinator for Great Starts Birth & Family Education

(Note, this is a detailed article for birth professionals. If you’re expecting a baby, you may prefer a more basic article on cesarean.)

Recommended Rate and Current Rate

Proposed Reasons for the Increasing Rate of Cesareans

Indications for Why Individual Cesareans are Performed

Risks of cesarean

Benefits of Cesarean:

Mortality rates compared to cesarean rates

What’s a Childbirth Educator or a Doula To Do: Tools for You to Use

 

Recommended Rate and Current Rate

Healthy People 2010 guidelines,[1] the World Health Organization[2], and Coalition for Improving Maternity Services[3] recommend a primary cesarean rate (women having a cesarean for the first time) of 15% or less. Cesarean is a vital tool for preserving the well-being of mothers and babies in high risk situations, and is often a life-saving procedure. However, it is also major surgery, and is a tool which should be used only when necessary, and only when the benefits of the surgery outweigh the possible risks associated with it. The recommendation of 15% is based on research[4] indicating that if a location’s cesarean rate rises significantly above 15%, morbidity and mortality may also begin to increase.

In 2005[5], the primary cesarean rate was 20.3 – 24.3%. The overall cesarean rate was 30.3 in 2005, and 31.1% in 2006.[6] The cesarean rate has increased by 50% over the past decade, reaching a new record level every year since 2000. Rates vary state-by-state, from 21-36%.[7]  Rates also vary by facility. In Washington state, hospitals ranged from 15% - 36% in 2006 (with one outlier at 48%).[8]

 

1996

2001

2002

2003

2004

2005

2006

change 1996 - 2006

Total Cesareans

20.7%

24.4

26.1

27.5

29.1

30.2

31.1%

á 50%

 

 

1996

2001

2002

2003

2004

2005

Change 1996-2004

Primary C-S

14.6%

16.9

18

19.1

20.6

20.3-24.3%

á 41%

VBAC

28.3%

16.4

12.7

10.6

9.2

7.9-12%

â 67%

 

Proposed Reasons for the Societal Trend of Increasing Cesarean Rates

There are many factors which influence the increase in the cesarean rate.

Changes in demographics of birthing women:

Older moms. The average age of birthing women increased from 24.5 in 1975 to 27.4 in 2005. Older women have higher cesarean rates. In 2005, cesarean rate for women from 35-40 years old was 39.9%, and for women over 40, 46.2% vs. 21.5% for teen moms. However, this does not account for the increase in cesarean rates, as rates have gone up for all age groups. [9]

More multiple births. In 1990, the rate of twins was 22 in 1000 births; in 2005, it was 32 in a 1000; for triplets and higher order multiples, the rates were 72/100,000 in 1990 and 152/100,000 in 2005. Two-thirds of multiples are a result of fertility-enhancing treatments). [10] Multiples are more likely to be delivered by cesarean (about 50% of twins, about 90% of triplets).

More obese moms. Obesity is epidemic in the United States. In 1996, 15% of Americans were obese. In 2005, the rate was 24%.[11] Obese women are at greater risk for many pregnancy-related complications, including hypertension and gestational diabetes. These increase the risk of cesarean, which is approximately twice as likely for a woman who is obese.[12]

Fewer moms are being considered low-risk: Declercq (et al)[13] propose a category of women defined as no indicated risk, based on birth certificate data, which would include only women “with full term, vertex, singletons with birth weight <4000 g with no reported medical risk factors or complications of labour and delivery.” They report that the number of women in this category decreased from 46.3% in 1991 to 41.8 in 2001. Although the authors do not make note of this decrease, it may indicate two possibilities: the first being that women on average have more health complications than they did a decade before, or second, that physicians are more likely to label women as high risk than they were a decade before (perhaps due to defensive medicine as described below).

Changes in obstetrics and modern maternity care:

Surgery is safer: with modern anesthesia, antibiotics, transfusions, and surgical techniques, cesarean is generally a quite safe surgery, with predictable and manageable risks. This makes cesarean an easier choice than in the past.

Loss of skills: fewer physicians are being trained in forceps, and in vaginal breech deliveries, possible alternatives to cesarean.

Over-use of maternity care practices known to increase the risk of cesarean: continuous electronic fetal monitoring, and induction of labor.[14],[15]

Under-use of practices which may improve chances of a vaginal birth: manual rotation of baby’s position, external version of breech babies[16], vaginal breech deliveries,[17],[18] VBAC, upright moving positions for labor and birth, continuous labor support.[19],[20]

VBAC may be unavailable in some areas: VBAC (vaginal birth after cesarean) is no longer offered at over 300 hospitals nationwide, which will certainly lead to an increase in cesarean.[21] See below for a full discussion of VBAC.

Hospital policies: Hospitals also may institute policies or put pressure on their care providers to put artificial time limits on the length of labor by augmenting it with Pitocin (which increases cesarean risk) or by moving to cesarean sooner, because hospitals and care providers get paid the same amount for a patient whether it’s an 8 hour labor, or 28 hour labor. For hospital staffing, and convenience of care providers, there is an appeal to scheduled inductions and scheduled cesareans. This is evident by the increasing discrepancy between how many births happen on weekdays during business hours versus how many births occur on weekends.[22] An average of 7000 births happen on a Sunday in the U.S. versus 13,000 a day on a Tuesday, Wednesday, or Thursday.[23]

Defensive medicine and hospital policies.

Risk-prevention orientation: In general, western medicine has a focus on early diagnosis and intervention before problems worsen. The tendency for some physicians is to use the procedure most likely to be effective first, even if it is also the most interventive tool. For example, when faced with a slow labor that is failing to progress, the least interventive option would be to wait and see what happens, which might or might not be effective. A cesarean in guaranteed to be more effective in reaching the goal of a quick delivery.

Malpractice and liability: Malpractice insurance premiums may consume 10-20% of a physician’s gross income. [24] 76% of obstetricians have been sued at least once, OB-Gyn’s have an average of 2.6 claims filed against them during their career. Half of claims are dropped; of the suits that go to court, OB’s win 81.3% of the time. However, even when OB’s “win”, they have put a lot of money and time into fighting the claim: the average length of time to resolve a claim is 4 years.[25]

Effects of liability on care: The ever-present specter of lawsuits effects the way that doctors practice. They practice defensive medicine, saying things like “if you think of a test, you order it” and “the only cesarean you get sued for is the one you didn’t do.” A 2002 Harris survey[26] of physicians found that because of fear of liability: 79% order unnecessary tests, 74% make unnecessary referrals, and 51% suggest unnecessary biopsies. 94% say unnecessary or excessive care is sometimes or often given because of fear of liability. For cesareans in particular, 0ne study found that malpractice premiums and the physician’s view of his risk of being sued is correlated with the likelihood of cesarean.[27] 14.8% report that they stopped offering VBAC’s because of the risk of being sued.[28] Birthing women suspect this is true: 42% felt doctors might perform an unneeded cesarean to avoid being sued.[29]

Cultural perspectives:

View of vaginal birth as harmful, painful, out of control: A quick review of popular television shows, movies, and newspaper articles shows how this view is shaped. On birth reality shows, every birth is portrayed as an emergency waiting to happen, with technology the savior for every challenge. Many women mistakenly believe that cesarean is guaranteed to be safer for babies. Popular movies and television shows all show women screaming in unbearable agony during their labor and being totally out of control, screaming horrible things to their partners. On the other hand, women may view cesarean as pain-free for them due to anesthesia, and so controllable it can be scheduled months in advance. Elective cesarean may well be an appealing alternative to their media-informed view of vaginal birth.

Surgery and technology is more socially accepted: In general, western culture embraces technology, and surgery fits within the realm of accepted technological tools. This trust in surgical procedures can be seen in the increase in elective surgeries. Between 2000 and 2006, the number of women choosing breast reduction surgery increased 23% and the number choosing breast augmentation increased 55%.[30] When a surgical birth is proposed, women may feel more confident about that option than they do about the unpredictability of letting labor take its natural course.

Consumer choice: We live in a consumer-driven society, where every time we enter a convenience store, we can choose between over 100 different beverages, just to have the exact one which most appeals to our taste-buds, sense of style, and brand identity. We are continually given the message that we deserve the right to choose exactly the products we want. It is only logical that this consumer choice attitude finds its way into the health care realm. Women appear at doctor’s appointments armed with research from the internet, and with names of medications they’ve seen advertised, and with requests for induction at 38 weeks, because they’ve heard that 38 weeks is “full-term” for a pregnancy. Some care providers adopt the perspective that their patient is a consumer, they are suppliers of what the consumer requests.

Cesarean on maternal request There is a lot of media buzz about women choosing elective cesareans. Does this account for the rise in cesareans? Depends on who you ask.

Physicians report that women are asking for cesarean deliveries. In 2006, the National Institutes of Health held a conference on “Cesarean Delivery on Maternal Request” (CDMR) which was defined as a planned first (primary) cesarean requested by the mother who understands that there is not a medical need for cesarean. The panel estimated that the extent of maternal request cesareans was between 4 and 18% of all cesareans, although they confess there is little confidence in the validity of the estimate.[31]

National birth certificate data shows that there is an increase in cesareans for women with “no indicated risk factors.” That rate has increased from 3.3% in 1991 to 5.5% in 2001. Amongst women over 40 with no indicated risk, the rate is 10.2%.[32] Although this population is often used as a proxy for maternal request, the data doesn’t actually tell us anything about why the cesarean was done, and who initiated the decision making.

In a survey of 1573 American women, only one woman (.06%) initiated a planned elective cesarean for no medical indication. Of the 257 women in the survey who had primary cesareans, only that mother had a maternal request cesarean, 2% had scheduled cesareans for non-medical reasons that they report were initiated by a health professional. The other 98% of women with primary cesareans believed that there was a medical reason for the surgery, including fetal heart rate variations, position or size of baby, and long labor. Amongst all women in the study, 9% reported feeling pressured by their care provider to have a cesarean.[33]

How do we explain the discrepancy between physician reports of consumer demand, and mother’s report of pressure from their care providers? One possibility is that a woman may go to her care provider with questions about elective cesarean, where she is hoping to be reassured that vaginal birth will be a good option for her,  but instead the care provider hears it as a request for elective cesarean, and begins discussing how that could be a good option for her.

One mother who had birthed by elective cesarean said “Here’s my complicated decision-making process: My doctor said it, so I did it.”[34]

In 2003, the Ethics Committee for ACOG (American College of Obstetricians and Gynecologists) released a statement that “if a physician believes that [elective] cesarean delivery promotes the overall health and welfare of the woman and her fetus… then he or she is ethically justified in performing a cesarean delivery.” In response, women’s health care professionals, including Lamaze International, the American College of Nurse-Midwives, Doulas of North America, Coalition for Improving Maternity Services, and the Association of Nurse Advocates for Childbirth Solutions issued a joint statement with a warning about cesarean on demand, stating “No evidence supports the idea that cesareans are as safe as vaginal births for mother or baby, and pregnant women should be given all of the facts they need to make an educated decision…”[35] There have been studies which show increased risks of cesarean. For low-risk healthy women, overall rates of severe complications were 27.3/1000 women having planned cesareans versus 9.0/1000 for women having planned vaginal births.[36]

In 2006, the NIH panel summarized their recommendations: “there is insufficient evidence to evaluate fully the benefits and risks of cesarean delivery on maternal request… [decisions] should be carefully individualized and consistent with ethical principles… [CDMR] is not recommended for women desiring several children… [CDMR] should not be performed prior to 39 weeks or without verification of lung maturity, because of the significant danger of neonatal respiratory complications.”[37] In response, Childbirth Connection published commentary criticizing and rebutting much of the panel’s statement.[38]

Their critique may be summarized as stating that very few women are actually requesting cesarean, but media coverage and the NIH  conference may lead women to believe that CDMR is a “notable and safe trend” which may increase requests, when instead, we should be focusing on practices that increase the safety of vaginal birth for healthy, low-risk women.

In a survey of female OB-Gyns: 36% say they would not perform a cesarean at a woman's request if not medically necessary, 32% say they would, and 28% say it would depend upon the woman's circumstances.[39]

The summary of all this controversy is that there is some evidence of women in the U.S. requesting cesarean delivery for no medical reason and there are some physicians who feel it is ethical to provide this option. This likely does account for some of the increase in the overall cesarean rate, but is only one piece in the pie described here.

Indications for Why Individual Cesareans are Performed

Planned:

Clear medical indications (consensus among most providers that benefits of cesarean outweigh risks)[40]

Other medical indications (Some care providers will recommend cesarean based on these, others will not)

No medical indication

Unplanned / situations that arise in labor (see below)

Emergency:

 

What about cesarean to prevent urinary incontinence, and improve sexual function?

You may have heard that some women choose cesarean for these reasons.

About 3% of women have urinary incontinence (accidentally leak urine) after birth. It is unclear whether incontinence is caused by vaginal birth, or by care practices associated with vaginal birth, like: episiotomy, vacuum extractor, forceps, and forceful pushing. Studies indicate that incontinence is lower in the 6 months after elective cesarean than after vaginal birth. But over time the incontinence resolves. Cesarean is not guaranteed to prevent incontinence. Some women will be incontinent in later years regardless of whether they have ever been pregnant or ever birthed vaginally. Better options for limiting incontinence would be doing kegel exercises, quitting smoking, and maintaining a healthy body weight.

Research shows that “any differences in sexual function based on route of delivery were no longer evident by 6 months postpartum. Factors that affect sexual functioning, such as changing family roles, relationship satisfaction, physical recovery or continuing morbidities, mood, and lack of sleep, have not been adequately studied.” [42]

How common is each reason?

The most common reasons for cesarean are: failure to progress (20-30%), fetal heart rate concerns (20-25%), repeat cesareans (20%), maternal health issues, fetal health issues, breech babies. [43] About 40% of cesareans are planned, about 60% are unplanned and arise during labor[44].

The indications for planned and emergency cesareans are usually things that are beyond your control. For unplanned cesareans, at the point the recommendation for cesarean is made, it often is the best option. However, some of these may have been “preventable cesareans”; there may be things that could have been done earlier on to prevent reaching that point. For example, if a woman is stalled at 4cm after 24 hours of labor, is feverish, and has a baby with an elevated heart rate, cesarean may be a good option at that point. However, she may have been able to prevent this situation by: waiting till active labor to go to the hospital, being active throughout early labor to help baby move to a good position, and delaying epidural (having an epidural in place for many hours can lead to fever for mom and elevated heart rate for baby).

Risks of cesarean[45]

The following are things which are more likely to happen after a cesarean birth than after a vaginal birth. They are listed in order from most common side effects to rare complications.

Effects on mother

effects on babies:

 

Effects on future pregnancy and birth

The more cesareans a woman has, the more risks she will have for future fertility and future pregnancies.

Benefits of Cesarean:

Less likely to have

 

Mortality rates compared to cesarean rates [from CDC data]

 

 

Year

Cesarean rate

Infant Mortality (per 1000)

Maternal Mortality (per 100,000)

1940’s

 

45

300

1970

5.5

20.0

21.5

1975

10.4

16.1

12.8

1980

16.5

12.6

9.2

1985

22.7

10.6

7.8

1990

22.7

9.2

8.2

1995

20.8

7.5

6.3

2000

22.9

6.9

9.8

2001

24.4

6.9

9.9

2002

26.1

6.9

8.9

2003

27.1

6.7

12.1*

2004

29.1

6.7

13.4*

2005

30.2

 

 

2006

31.1

 

 

 

* Note, there were changes in birth certificate reporting in these years, and it has been proposed that this apparent increase in maternal mortality may be related to changes in how data is reported.

What’s a Childbirth Educator or a Doula To Do: Tools for You to Use

Talk to girls and women who aren’t yet pregnant about normal birth, and build their confidence in their bodies’ ability to give birth without the aid of surgery.

Offer pre-conception classes that encourage pre-conception health, and begin raising awareness of issues such as obesity, and cesarean prevention.

In your childbirth classes:

·         address the increasing rates of cesarean and the reasons for the increase on the first day of class

·         talk to parents about what they can do to be sure they are making informed choices about what is truly the best option for them and their babies

·         when discussing comfort techniques, also point out that these are also all techniques that aid labor progress and increase their chance of a vaginal birth

·         when discussing cesarean, role-play how they would make the decision if it was presented to them

Offer VBAC classes, which address the risks in a calm manner, and present tools for ensuring VBAC success.

Offer Planned Cesarean Classes which address how to have the best possible cesarean birth (and gently present information about why you might not want to choose a cesarean if you have other options.)

Advocate for the on-going availability of VBAC in your community.

Know the information, know the options, and refer your clients to research-based, mother friendly information about cesareans. Check out: