The figures are alarming: The cesarean rate in this country has increased 50% since 1996; hitting an all-time high of 32% of all deliveries. What could possibly be fueling this dramatic rise in surgery?
The latest figures come from a report released yesterday by the National Center for Health Statistics
and have added more fire to an already simmering debate over the increased use of cesarean sections. Cesarean deliveries carry greater risks for mothers and newborns; require longer recovery times and incur hospital costs that are almost double those for a vaginal delivery, according to the report.
In the past, some medical groups have attributed the rise in c-sections to factors like older mothers and an increase in multiple births. But the NCHS report found that the rate of c-sections rose in all age groups between 1996 and 2007; with women under age 25 experiencing a 57% increase in cesarean deliveries, the largest increase of all. Increases were found across the board in all racial and ethnic groups and at all gestational ages. And surprisingly, the rate of c-sections for single births increased substantially more than cesarean rates for multiple births.
Dr. George A. Macones, the chairman of obstetrics and gynecology at Washington University in St. Louis and a spokesman for the American College of Obstetricians and Gynecologists told the New York Times that the continuing rise “is not going to be good for anybody.” “What we’re worried about is, the Caesarean section rate is going up, but we’re not improving the health of babies being delivered or of moms.”
The proof of that is clear from findings released by Amnesty International that the maternal mortality rate in the US has doubled from 6.6 deaths per 100,000 births in 1987 to 13.3 deaths per 100,000 births in 2006. According to the report, “women in the USA have a higher risk of dying of pregnancy-related complications than those in 40 other countries.” The rise in c-sections, according to the report, has a clear role in this rise in maternal mortality.
Most doctors blame the fear of lawsuits for the dramatic increase in c-sections over the last decade or so. Obstetricians do face higher insurance premiums than many other specialists and there is evidence that it is one reason some leave the field. In a report in the journal Obstetrics and Gynecology, some 29% of ACOG members polled said they performed more c-sections because they worried about being sued. This is one issue that could be partially addressed by providing clear guidelines about the use of cesarean section and also by increasing patient education about the risks of these procedures.
In the Times, Macones says another reason for the rise is that women sometimes request cesarean sections. The article adds, “Caesareans have become so common that many people do not realize they are major abdominal surgery, with all the attendant risks.” Macones also says that the rise in patient requests for induced delivery—delivering an infant before its due date for reasons of convenience—also helps drive up the c-section rate because induction is more likely to lead to complications.
This reasoning makes sense—until you actually talk to women.
The advocacy group Childbirth Connection discounts the suggestion that the c-section rate has skyrocketed because so many more women request the procedure. In their survey, “Listening to Mothers” published in 2006, only one out of 1600 women surveyed indicated this was the case for them. Instead, most women undergo the procedure because their doctor recommends it:
“There is a change in practice standards that reflects an increasing willingness on the part of professionals to follow the cesarean path under all conditions. In fact, one quarter of the Listening to Mothers survey participants who had cesareans reported that they had experienced pressure from a health professional to have a cesarean.”
It turns out that women find having c-sections quite traumatic, according to a survey conducted by the group Healthy Baby Network:
“Of the women who were surveyed, almost half (46.8%) described their experience as traumatic, while 7.4% described it as empowering. Participants were also given an opportunity to expand on their answers and rate their emotional recovery. On a scale of 1 through 10, one being no emotional issues, and 10 being described as Post Traumatic Stress Disorder, the majority of the women surveyed rated their emotional recovery between 5 and 10.”
The fact of the matter is that options for delivering without c-sections have decreased substantially since 1996. This is especially true for women who have already had a c-section and would like to try to deliver their next baby vaginally. Studies have found that 75% of women who choose to go this route deliver with no complications. Yet the rate of this procedure, called VBAC (vaginal birth after cesarean), has plummeted from a high of 28% in 1996 to a low of 10% in 2007, according to a report issued earlier this month by an independent consensus panel convened by the NIH. The drop followed a change in recommendation by ACOG in 1999—from encouraging VBAC to stating that a “term of labor” would only be recommended in a hospital that could respond to emergencies with immediate surgery. Many doctors and hospitals took this new recommendation as a sign that performing VBAC opens practitioners and medical centers up to liability. The result: some 30% of hospitals do not provide access to VBAC; in the ones that do, the procedure is performed very infrequently.
For women who are not high-risk, hospital policies like labor induction and continual fetal-heart rate monitoring increase the rate of the surgery. There is really no downside from the hospital’s point of view: medical charges are increased for mother and baby and liability is reduced. Doctors don’t get paid for time spent attending to a lengthy labor but they also have clear financial incentives—whether from fees or from the expectation that they will avoid costly lawsuits—to perform cesareans. In some regions and at some hospitals, cesarean-sections are imbedded in the culture that pushes continual medicalization of birth.
One solution pointed out by many experts is to change this culture by increasing the number of midwives attending births and providing maternity care. Unlike physicians, midwives have no financial incentive to encourage c-sections. They also promote a patient-centered, empowered view of pregnancy and birth that results in significantly fewer interventions. That approach makes sense when you think about the fact that some 85% of births in this country are considered normal and don’t require medical intervention. But there remain some tough barriers to expanding the use of midwives in this country. Some insurance plans don’t cover their services and in many states, hospitals are not required to grant midwives admitting privileges. In still other states, midwives cannot write prescriptions.
The NCHS report has alerted us to a pressing problem: Increased rates of cesarean sections are bad for mothers and bad for many infants. At the same time, they drive up health care costs. As health reform legislation moves into practice, the problem clearly deserves more study. One important finding is that although there was a universal rise in c-section rates around the country, there was enormous variation between states: For example, six states (Colorado, Connecticut, Florida, Nevada, Rhode Island, and Washington) had increases of over 70%. In 34 states, cesarean delivery rates increased by 50% or more. The net result is that in 2007, cesarean rates ranged from less than 25% in Alaska, Idaho, New Mexico, and Utah, to over 35% in Florida, Louisiana, Mississippi, New Jersey, and West Virginia.
These regional differences are similar to the stark discrepancies seen in health care utilization and costs documented by the Dartmouth Atlas data. A good starting point for making inroads into reducing the cesarean rate would be to try and identify which policies and practices in high-incidence areas might contribute to over-use. Hospitals should be required to make their c-section rates public and to adopt evidence-based guidelines—not liability based guidelines—for when the procedure should be employed. It’s only then that we can begin to stop over-treating the very natural experience of birth.