The Rising Rate of C-Sections Exemplifies What's Wrong With U.S. Healthcare
By Christine Cupaiuolo — June 28, 2010
Judy Norsigian, executive director of Our Bodies Ourselves, and Timothy R. B. Johnson, MD, chair of the Department of Obstetrics and Gynecology at the University of Michigan and an OBOS advisory board member, have penned an op-ed in today’s Boston Globe on the high cost of medically unnecessary caesarean sections, both in terms of a mother’s health and rising medical costs:
Even though caesareans are associated with higher rates of complications than vaginal births, they are becomingly increasingly common. Problems range from infections, including the more serious antibiotic-resistant ones, to blood clots, prematurity, respiratory problems for the baby, and more complications with subsequent pregnancies. There is even a small but measurably higher risk of death for the mother.
Between 2000 and 2006, while the Massachusetts caesarean rate climbed from 16th to 10th highest among all states, the state’s ranking on neonatal mortality has slipped from 4th best to a tie for 9th. Six hospitals in the state have caesarean rates greater than 40 percent for first time mothers, yet none of these hospitals is designated as a high-risk center. So much for the argument that high-risk pregnancies are the reason for these rates.
There are also cost consequences for taxpayers — the caesarean rate for Massachusetts mothers on Medicaid is increasing at a faster pace than among privately insured mothers. Nationally, in 2008, average hospital charges for an uncomplicated caesarean section were $14,894, while such charges for an uncomplicated vaginal birth were $8,919.
In the United States, about one in three births are via c-section, and in some communities the rate is much higher. Childbirth Connection explains the myriad conditions that have led to the increase, including: low priority of enhancing women’s own abilities to give birth; side effects of common labor interventions; refusal to offer the informed choice of vaginal birth; casual attitudes about surgery and cesarean sections in particular; limited awareness of harms that are more likely with cesarean section; providers’ fears of malpractice claims and lawsuits; and incentives to practice in a manner that is efficient for providers.
In the op-ed, Norsigian and Johnson argue that while the media often focuses on how extreme obesity can raise the risk of having a caesarean, more emphasis is needed on “system-based approaches” — steps that hospitals and obstetricians can take, such as instituting policies that restrict the induction of labor, unless there is a good medical reason, and following the new National Institute of Health recommendations to offer the option of vaginal birth after a caesarean for women who want to avoid repeat surgery.
Finally, they note, hospitals should expand access to nurse-midwifery care:
Enhancing access to midwifery care might well be the most effective approach to safely reducing the overall caesarean rate — and could lead to significant cost savings and improvement in other priority areas such as breastfeeding. It would also address the impending shortage of obstetric providers. The Legislature should pass a bill to expand access to midwifery care in Massachusetts. We must finally make midwives more central in maternity care — as do all other countries whose birth outcomes are superior to ours.
Read the full op-ed here.
Related:
What can we do to lower the caesarean rate? Considerable media attention has focused on how extreme obesity can raise the risk of having a caesarean, but more emphasis is needed on these system-based approaches:
Before we can begin to lower “the cesarean rate” we need to better understand that BOTH the obstetrical provider AND the physical characteristics of pregnant women affect “the cesarean rate”. The article mentions extreme obesity but fails to include prior delivery history, maternal age, initial body mass index, pregnancy weight gain, fetal weight and maternal height as other physical factors that significantly affect “the cesarean rate”. Pregnant women have gotten older, heavier and babies are bigger than years ago. Less inductions, more VBACs and more use of midwives may result in less cesarean deliveries but you will only be able to prove that by using a cesarean birth measure and not a “cesarean rate”. A cesarean birth measure takes into account the physical characteristics of the pregnant woman so that we can compare apples to apples. For example, it is misleading to say that a hospital with a lower “cesarean rate” is doing better than one with a higher “cesarean rate” because hospitals that care for younger, thinner, taller women who have several babies SHOULD HAVE a lower “cesarean rate” than hospitals that care for older, heavier, shorter women who have less babies. Using a cesarean birth measure that accounts for the prior delivery history, age, height and size of the pregnant women as well as the size of their babies may reveal that hospitals with lower “cesarean rates” are actually doing more unnecessary cesarean deliveries than hospitals with higher “cesarean rates”. Widespread use of a cesarean birth measure is the only way that we will be able to identify and decrease the number of unnecessary cesarean deliveries, until then there will continue to be a lot of complaining about the increasing “cesarean rate”.
Thank-you, Dr. San Roman, for injecting some perspective into this discussion. I want to point out that the blanket statement “caesareans are associated with higher rates of complications than vaginal births” is not exactly correct. I chose a caesarean after doing some research and concluding that the risks to both me and the baby are slightly higher for a breech-position vaginal birth than for a caesarean. So, although I was game for an attempt at a breech vaginal birth, I chose to have a caesarean up front, instead of after what probably would have turned out to be a few days of unfruitful pain.
IMO, it’s pretty upsetting to hear MD’s and any healthcare provider say “You are doomed to a c-section because you are fat, short, older, had a c-section before, gained “too much” weight in pregnancy, we think the baby is too big… etc” Scare tactics, I say. None of these are true indications for needing a CS. How about moms and care providers work with what they’ve got- and do their best to have a healthy low risk pregnancy and birth. I believe care providers need to stop the scare tactics, and moms need to take more responsibility for their reproductive health. Got gestational diabetes? Then what can you do about it: exercise, eat well. Why do so many HCPs “manage” pregnancy and labor by adding often unneeded drugs and surgery- when a mom really needs help to look at the pillars of proper nutrition, exercise, and really learning about and practicing for labor. Docs- Handing a mom a pamphlet is not really very helpful compared to really keeping track of the details. Moms- spending more time planning your wedding than preparing for your upcoming birth– not helpful, get ready for your c-section. The c-section rate in the US is over 32% yet our maternal and infant mortality rates are not improving… in fact as our CS rates increase each year, so do the number of moms and babies that die in this country. That is obviously not good.
If you want my credentials, I had a CS and then fought like heck for my VBAC. I might not have letters after my name, but I can read. The recent NIH conference on VBAC highlighted a lot of this already.
Since when does being short indicate a need for a cesarean?!? I’m a short woman, and I’m insulted. I’ve had 5 babies vaginally, each one around 8 lbs., and the most recent was a breech birth at home.
Sarahbee, I don’t know what research you did that showed the risks of vaginal breech to be more than the risks associated with cesarean, but I disagree with your opinion. I’m so glad I was at home to birth my breech baby and I was able to avoid the surgery that would likely have been required in the hospital.
I think Kelly hit everything right on the mark. Let’s talk about the REAL indications for cesarean, like placenta previa and placenta acreta (which, might I add, is a possible complication from having a prior cesarean), instead of using scare tactics to make women think their unnecessary surgery was somehow necessary.
The really sad thing about all this is that our medical leaders have not seen fit to study possible solutions to the rising use of cesarean delivery in the USA and around the world. Almost all published research papers on the subject are retrospective (meaning looking back in time) and such research is inherently flawed. Many groups tried to find ways to lower C/S rates in the 1990’s – all were unsuccessful. This area of research has essentially dried up in this century and we are left adrift with slowly increasing national C/S rates.
We do know that there are multiple factors that increase the risk of cesarean delivery. With all respect to Cherylyn, being short ( 30), age > 35, history of chronic hypertension, weight gain > 30 lbs, gestational diabetes, history of large baby ( 4000 gms), history of vacuum or forceps delivery, etc etc. And in all fairness to our national C/S rate, our national rates of obesity and gestational diabetes are increasing, and the average age at pregnancy is increasing. So as per Dr. Roman’s comments, we should be expecting our national C/S rate to be increasing if levels of risk are increasing and our approach to obstetrical care remains constant.
However, we would all like to see an approach to care that could modify these increased levels of risk so as to keep the rate of C/S the same or even lower it. Such an approach (or such approaches) to care would be examples of “preventive care”. I am an academic Family Physician. All successful methods of preventive care require four elements: 1) understanding the disease or problem you want to prevent; 2) identifying risk factors for the problem you want to prevent; 3) having a sufficiently long time period between when risk is identified and when the problem develops so that you can do something about the risk state; and 4) finding an intervention that successfully prevents the problem. Take any successful preventive strategy and you can usually identify those 4 elements.
For cesarean delivery the two main indications for the surgery are a) cpd – cephalop-pelvic disproportion – e.g. fetus too large for maternal pelvis; or b) upi – utero-placental insufficienty – e.g. placenta unable to support the fetus during labor. Multiple risk factors have been identified (see above) and most are well know to both the public and to providers. With pregnancy we have a very significant time period to work with [9-10 months of gestation!]. What is lacking is an effective intervention that can lower the occurrance of the two main indications for cesaran delivery.
Current approaches by the OB community to lower cesarean delivery rates are focusing on labor unit system issues – team approaches to care and laborist models and such. These approaches are NOT working, and they are not working because they do nothing to address the link between risk factors and the cause for cesarean delivery. A team approach or a laborist does nothing to make a fetus smaller or a placenta healthier.
HOWEVER, we know that fetuses continue to grow larger throughout pregnancy, so a fetus at 38 1/2 – 39 weeks is smaller than a fetus at 41 weeks – and so a woman laboring at 38 1/2 – 39 weeks will be more likely to pass her baby vaginally. WE ALSO KNOW that the placenta reaches its peak functionality at around 39 weeks, and then begins to age slowly until 41 1/2 weeks, and then ages very quickly. Hence, a fetus at 38 1/2 – 39 weeks will be better supported during labor than a fetus at 41 weeks – and so a woman laboring at 38 1/2 – 39 weeks will be more likely to have a fetus that experiences labor without “distress’. FURTHERMORE, the multitude of risk factors for cesarean delivery play on the relationship between increasing gestational age at term and risk of cesarean delivery – so a woman who is short, obese, measures size > dates, and has a history of a large baby will be much more likely to deliver vaginally if she enters labor at 38 weeks gestation than if she waits until 41 weeks. Similarly, a 39 year old woman with mild chronic hypertension, anemia, poor weight gain/nutrition, and size < dates will be much more likely labor without fetal distress if she labors at 38 weeks gestation than if she labors at 41 weeks gestation.
I am hoping that no one disagrees with this line of logic so far. The controversy surrounds what intervention to use. In other works – what could make a difference in the link between risk factors, increasing gestational age and the increasing need for cesarean delivery?
To me the answer seems obvious: assist women – if they want – to enter labor relatively early in the term period. YES this means a higher labor induction rate. And consider that the more risk factors they have for cesarean delivery, the earlier in the term period they might be offered labor induction so as to avoid the need for cesarean delivery. I rarely rercommend labor induction earlier than 38 weeks 0 days of gestation and I only offer preventive induction to women with good dating (LMP + ultrasound or two ultrasound). Often women having preventive labor induction need cervical ripening (I prefer Cervidil). And labor induction certainly takes longer than waiting for the onset of spontaneous labor. But what abouit the impact of the regular use of preventive labor induction on cesarean delivery rates (BECAUSE THAT IS WHAT I THINK WE ARE MOST CONCERNED WITH!!!)
I have used this method of care for 15 years, I have researched this issue and have multiple articles published in prominent journals (AJOG, Annals of Family Medicine, J Women's Health). One can google my name (James M. Nicholson) of the method's acronym (AMOR-IPAT – stands for the Active Management of Risk in Pregnancy at Term). There have been five retrospective articles and one prospective study. All retrospective studies showed dramatically lower cesarean delivery rates than groups treated with usual care, and the prospective study showed benefit to moms and babies (including a lower NICU admission rates, a lower Adverse Outcome Index [AOI] score, a higher uncomplicated vaginal delivery rate, and a not-statistically significant but lower C/S rate). There is a group using AMOR-IAPT in Italy that is having similar success. There have been groups in New Jersey and Florida using AMOR-IAPT with success (currently being prevented from using this method because of the un-supportable claim that labor induction causes higher cesarean delivery rates [consider that its not the labor induction but the reason that labor induction was required that leads to higher C/S rates in women needing labor induction]). I have presented related research findings in Norway, Canada, Italy and Australia -but cannot get funding through the NIH to do a larger study because my method of care has been deemed "un-ethical" by "experts" in the OB community who sit on the NIH panels.
So here is my final 10 cents. I believe that a method of care exists that could lower group cesarean delivery rates to well below 15%, and in the process lower group NICU admission rates and rates of term stillbirth. However, this method involves the regular use of preventive labor induction – upward to a 50% rate – and my reading of our society is that we are not willing to deem pregnancy as a state that requires regular active management – but rather want to consider pregnancy as natural and under the benign oversight of Mother Nature. However, every day on the labor and delivery unit I see senarios playing out that indicate that Mother Nature is not so benign, and that our current mix of increasingly frequent risk factors and expectant management OB strategy will continue to provide us with an increasing cesarean delivery rates as the coming years unfold. If anyone else has ideas about potential preventive interventions that might lower cesarean delivery rates I would like to hear about them. However, I predict that lowering our national labor induction rate….and thereby INCREASING the average gestational age at delivery (remember that means bigger babies and older placentas) will further fuel the progressive increases in our national cesarean delivery rates.