Monday, March 10, 2008

The Cesarean Epidemic

The most common operating room procedure in U.S. hospitals, c-section involves considerable morbidity in women and babies and considerable expense for private payers/employers and Medicaid/taxpayers. - Childbirth Connection

The percentage of United States’ births delivered by cesarean section has increased substantially in recent years, climbing 50 percent over the last decade from 20.7 percent of all births in 1996 to a new record high of 31.1 percent in 2006 (1,2). These statistics are featured in a new report released in December 2007 by U.S. Centers for Disease Control and Prevention (CDC) National Center for Health Statistics, and are based on data from over 99 percent of all births for the United States in 2006. Consistent with the rise in the national rate, the 2006 C-section delivery rate was 36.0% of all deliveries in Florida up from 22.6% in 1997. In a 2006 report from the Agency for Health Care Administration (AHCA) Center for Health Statistics C-section rates were found to be higher among women of Hispanic ethnicity and among women ages 30 years and older in 2004. South Florida had the highest rate of any region. Of the ten facilities statewide who had the highest cesarean rate six were located in Miami-Dade County. (9) In 2006, the C-section rate for Miami-Dade was a staggering 44.8%. While many experts contend that there is no “ideal” cesarean rate, the World Health Organization (WHO) maintains that in a developed country, the proportion of cesareans should not exceed 15%; beyond that, the maternal injury and death consequent to major abdominal surgery being to eclipse the lives and health saved.(3) More women suffer from infection, hemorrhage and death, and babies are more likely to be born prematurely or die.

There is little evidence that a vast, growing segment of the female population wants or needs major abdominal surgery to give birth. (5) Until the 1940’s, cesarean delivery was rare and only utilized as a last resort to save the baby, many times at the cost of the mother’s life. One in 16 women died. Advances in surgery, antibiotics, transfusions and anesthesia have made an operation that was nearly always fatal as recently as the mid-19th century routine 150 years later. Despite these advances, serious consideration should be given to the risks involved in cesarean surgery. Recent mortality figures from a large study of over 150,000 elective Cesarean operations in Britain show that mothers run nearly three times the risk of dying from a Cesarean section than from a natural delivery. Additionally a woman having a repeat C-section is twice as likely to die during delivery and twice as many women require re-hospitalization after a C-section than after a vaginal birth. (6)

Not only is the health of the mother impacted. Since vital statistics data on cesarean sections was first collected in 1989, the infant mortality in the United States for total cesarean deliveries has consistently been about 1½ times that of vaginal delivery. (7) It had long been assumed that the difference was due to the higher risk profile of mothers who undergo the operation. Many have pointed to changes in the population of childbearing women, such as more older women who have developed medical conditions and more women with extra challenges of multiple births. While there are some overall changes in this population, researchers have found that cesarean section rates are going up for all groups of birthing women, regardless of age, the number of babies they are having, the extent of health problems, their race/ethnicity, or other breakdowns (7). A study of almost six million births published in the September 2006 found that the risk of death to newborns delivered by voluntary Cesarean section is much higher than previously believed. This study, according to the researchers, is the first to examine the risk of Cesarean delivery among low-risk mothers who have no known medical reason for the operation. Study authors used the Healthy People 2010 criteria for low-risk (women with a full-term, singleton infant in head down presentation) and included only women who had no reported risk factors or complications of labor and delivery identified on the birth certificate. (14) Among this group there was a 49% increase in odds of cesarean delivery from 1996 to 2001, after statistical adjustment for maternal age, race, education, birth weight and parity. Researchers found that the neonatal mortality rate for Cesarean delivery among low-risk women was 1.77 deaths per 1,000 live births, while the rate for vaginal delivery was 0.62 deaths per 1,000. The risk in first Cesarean deliveries persisted even when deaths from congenital malformation were excluded from the calculation. (7) In other words, 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.

Despite these cautionary statistics the rising trend of surgical birth persists. The overall increase in cesarean sections is due in large part to a notable rise in primary section rates, from 14.6 percent in 1996 to 29.0% in 2004. This increase is also partly attributable to the decline in Vaginal Birth After Cesarean (usually abbreviated VBAC) at an all-time low of 9.2 percent in 2004. (13)A woman who has a primary cesarean section has a greater than 90 percent chance of having a subsequent cesarean delivery. A policy statement published by The American College of Obstetricians and Gynecologists (ACOG) in 1998 recommended a surgical team and anesthesiologist must be available twenty-four hours a day in order for VBAC to be safe. Many hospitals who fall short of this criteria have been choosing not to allow women to attempt VBACs within their facilities because they cannot provide 'immediate' surgery if needed. A large number of physicians feel that the risks of uterine rupture (developing a tear in the wall of the uterus) that accompany VBAC are too high and that an elective or scheduled c-section is the best option for a mother who had the surgery for a prior pregnancy. Yet evidence is growing that scars in the uterus which accompany cesarean surgery can cause placental abnormalities that endanger both mother and baby in future pregnancies, and that the risk of these abnormalities increases dramatically with a subsequent cesarean. (8) Cesareans are inherently riskier than normal vaginal birth, but repeat cesareans carry even higher risks.

Today, more than ever physicians may be turning to Cesareans sections in order to avoid potential litigation. Under the specter of lawsuits C-sections have gradually become more about caution and convenience than life or death. Many obstetricians contend that patients are driving this trend with their almost unreasonable aversion to even the smallest risk. (4) The tragedy behind this phenomenon is that a cesarean is not a guarantee of a happy outcome. In comparison with other industrialized nations, the United States ranks second-to-last in infant survival and for the first time in decades the number of women dying in childbirth has increased. (10) Some experts cite consumer demand as a contributing factor in the rising cesarean rate. A New York Times article published December, 2007 noted that there was some evidence that a growing number of women were requesting Cesareans. (4) Yet, findings from the large and well-designed United States national study, Listening to Mothers, reported that less than 1 percent of mothers (only 1 of 1,300 women surveyed) who had a first cesarean actually requested one. The survey, conducted by the Childbirth Connection (a leading nonprofit organization that works to improve maternity care), also noted that, in contrast, nearly 10 percent of those surveyed reported feeling pressure by a health professional to have a cesarean delivery, and 42 percent believed that fear of being sued leads physicians to perform unnecessary cesareans (9).

In the US, the profit motive explains may explain rising rates of Cesarean. According to the HealthCare Cost and Utilization Project (HCUP), a 2000 study conducted by the U.S. Department of Health and Human Services Agency for Healthcare Research and Quality, childbirth accounts for more than four million hospitals stays annually and over $33 billion dollars in aggregate charges in 2003 alone. Many health professionals are feeling squeezed by tightened payments for services and increasing practice expenses. The flat "global fee" method of paying for childbirth does not provide any extra pay for providers who patiently support a longer vaginal birth. Some payment schedules pay more for cesarean than vaginal birth. A planned cesarean section is an especially efficient way for professionals to organize hospital work, office work and personal life. Average hospital charges are much greater for cesarean than vaginal birth, and may offer hospitals greater scope for profit. (11) In the private American healthcare system, doctors and hospitals find cesarean sections more profitable than natural births.

There is no denying that cesareans save lives when performed as an emergency intervention. Many cesareans are the clear result of medical necessity, but others occur in circumstances where there are other options available including many which are medically appropriate. A great majority are performed as a result of a labor that has gone on too long or at the first deviation from the norm, such as a “non-reassuring” fetal heart rate on a monitor. There is an overall lack of support for normal physiological birth evidenced by the dwindling number of women who labor without the assistance of induction or augmentation. A rising number of women are being pushed into the operating room after failed inductions and fetal distress caused by augmentation. (12) The practice of “defensive” medicine, heightened by rising malpractice premiums has created a climate of fear which not only affects the care providers, but the clients they serve. The escalating C-section rate in the U.S. should be a major public health concern. It represents a complex and difficult problem whose solution demands strategies that are multifaceted and comprehensive. Although doctors, hospital, and insurance companies (who often represent warring interests), do contribute to the high rate of cesareans, it is not only with them that blame should be placed. These facts point to a failure in the United States’ system of maternity care. Yet this is not the only issue. The increased rate of cesarean deliveries nationwide may be partly due to a lack of consumer knowledge. Most mothers are healthy and have good reason to anticipate uncomplicated childbirth. Cesarean section is major surgery and increases the likelihood of many short- and longer-term adverse effects for mothers and babies.(1) One primary influence in determining routine care regardless of its proven risks and benefits lies in the perception of birth as a dangerous and life threatening event. Consumers must take a proactive approach to educating themselves about the physiological process of natural birth and the impact of interventions on a woman's ability to birth normally. (15) Education is the key word in preventing unnecessary cesareans and having a safe birth experience. When a cesarean section is necessary, it can be truly life-saving, but birth is a safe and natural process that generally succeeds without intervention.

(1). Childbirth Connection. New National Survey Results from Mothers Refute Belief That Women Are Requesting Cesarean Sections Without Medical Reason. Press release. March 20, 2006.

(2). Declercq E, Norsigian J. Mothers aren’t behind vogue for Cesareans. Boston Globe April 3, 2006.

(3) WHO, Appropriate Technology for Birth; Jose Villar et al., Caesarean Delivery Rates and Pregnancy Outcomes: The 2005 WHO Global Survey on Maternal and Perinatal Health in Latin America, Lancet 367 (2006): 1819-29.

(4). Bakalar, N. Voluntary C-Sections Result in More Baby Deaths. New York Times Sept 6, 2006.

(5). McCullough, M. C is for caution: C-sections on the rise. Philadelphia Inquirer June, 10, 2007

(6) Hall MH, Bewley S. Maternal mortality and mode of delivery [letter]. Lancet, 1999; 354: 776

(7) Declercq, E, Menacker F, MacDorman MF, Malloy, M, Infant and Neonatal Mortality for Primary Cesarean and Vaginal Births to Women with “No Indicated Risk, United States, 1998-2001 Birth Cohorts, Birth: Issues in Perinatal Care 33:3 2006 175-182

(8) Health Outcome Series: Cesarean Deliveries in Florida Hospitals, AHCA State Center for Health Statistics May 2006

(9) Declercq, E. et al., Listening to Mothers II: Report of the Second National U.S. Survey of Women’s Childbearing Experiences (New York: Childbirth Connection, 2006)

(10) Organisation for Economic Co-operation and Development (OECD) Health Data 2007: Statistics and Indicators for 30 Countries July 18, 2007

(11) Why Does the National U.S. Cesarean Section Rate Keep Going Up? (New York: Childbirth Connection, 2007)

(12) Block, J. The C-section epidemic. Los Angeles Times September, 24, 2007.

(13). Declercq, E, Menacker F, MacDorman MF, Rise in “no indicated risk” primary cesareans in the United States, 1991-2001: Cross sectional analysis, BMJ 2005; 330:71-72.

(14) U.S. Department of Health and Human Services. Maternal, infant and child health. In: Healthy People 2010, 2nd ed. Washington DC: U.S. Government Printing Office, November 2000, pp. 16-30-31.

(15) The Cesarean Epidemic - A Response, Independent Childbirth, 2007

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