The Debate Over Rising Rates of Cesarean Delivery
When she learned she was pregnant with her second child, Missy Beiting issued an ultimatum to her obstetrician. “Schedule me for c-section or I’ll find a doctor who will,” she remembers saying. Beiting gave birth to her first child, a 10-pound, 14-ounce son, by c-section after a failed induction and a stressful nine hours waiting for a labor that never began. She avoided the stress the second time around and welcomed her 10-pound, 11-ounce son after a scheduled c-section at 37 weeks.
Like a growing number of women across the country and around the world, Beiting, 39, of Southgate, Kentucky, determined to gain more control over her childbirth experience by requesting a cesarean section. Stanford University’s Dr. Maurice Druzin and colleagues observe that “the issue of cesarean section on maternal request has been described as being part of a ‘perfect storm’ of medical, legal, and personal choice issues, and the lack of an opposing view.”
Cesareans on the Rise?
According to the US Centers for Disease Control, c-sections account for more than one of every four deliveries in the US. The rate of c-sections increased 7% from 2001 to 2002, up to 26.1% of all US births, and rising further to 29% in 2004, the highest rate ever reported and an overall 40% increase since 1996. The large increase can be attributed to a 7% rise in c-sections for first-time mothers as well as a 23% decline in the rate of vaginal births after cesarean (VBAC). Currently, over 90% of women who have had a previous c-section deliver their next baby by cesarean.
Reasons for c-sections range from life-threatening emergencies to simple convenience to threats of malpractice. Doctors agree that, when indicated because of complications involving either mother or baby, c-sections can save lives. And in the face of patients who demand the procedure and threaten malpractice suits if a vaginal birth goes wrong, the surgery may also save them time with their lawyers. Still, the major abdominal surgery has risks, including rare cases of infection, excessive bleeding, reactions to medications, urinary tract infections and injury to the baby. Many doctors and patients worry that rising cesarean rates indicate too much of a good thing.
The World Health Organization (WHO), for example, continues to work to lower the c-section rate in developed countries to between 10%-15%, citing those levels as optimal for the best outcomes for mothers and babies. The WHO, like many community health professionals, recommends that cesareans be accessible to moms-to-be, but reserved for use only when medically necessary. If this less invasive standard of care were adhered to on a widespread basis, it could surely lower the high c-section rates not only in America, but also in countries like Nigeria (34.6%) and Italy (32.9%).
Too Posh to Push?
The debate over the c-section rate gained a higher profile after surgical deliveries by illustrious mothers such as Victoria “Posh Spice” Beckham, actress/model Elizabeth Hurley, and Madonna. Tabloids posed implausible questions about a new generation of parents: Do celebrity mothers who bounce back into perfect pre-pregnancy condition owe it to their c-sections?
Dubbed “too posh to push,” the purported trend among wealthy moms-to-be soon gained notoriety in the press. But research published in the June 2004 British Medical Journal failed to make a connection between social status and c-section rates in England.
In the US, similar research led to surprising findings. After surveying insurance claims from hospitals, Health Grades (a company that rates hospitals and doctors) released a nonscientific estimate that 80,000 women chose a pre-planned c-section for their deliveries in 2002, including those pre-planned due to a prior cesarean, breech positioning, and multiples. That’s 2.2% of all deliveries, amounting to a 20% increase in selective cesareans between 2000-2002. Since breech presentation and prior cesarean have become medical indications for cesarean, “on-demand” c-sections without medical indication currently have an uncertain numerical impact on the total numbers performed. As the National Institutes of Health’s (NIH) Dr. Fay Menacker notes, the majority of the increase in rates comes from a major decrease in the rate of vaginal birth after previous cesarean section (VBAC), as well as a modest rise in the primary section rate.
Health Grades reported that, in the hospitals surveyed, mothers and babies suffered slightly fewer negative consequences during pre-scheduled c-sections than during vaginal births. This view, however, is not echoed in the National Institute of Health’s consensus assessment which cites “weak quality” evidence that infection rates, placenta previa in subsequent pregnancies (a risk for dangerous bleeding), and anesthesia complications are all elevated among women who have scheduled cesarean sections.
The National Institutes of Health panel also presents “weak quality” evidence that post-delivery urinary symptoms may be fewer (at least in the short-term), and that surgical complications may be less severe among women who have elective sections. Weak evidence also suggests that injuries to the baby (including serious brain injury) may be reduced by cesarean section. However, this evidence is balanced by better quality evidence showing that babies born by c-section are more likely to suffer respiratory problems shortly after birth.
As the NIH experts point out, these assessments suffer greatly from a lack of high quality studies weighing the relative merits of both forms of birthing. Whatever the actual balance of risks and benefits, doctors and patients alike point out that the relative safety and predictability of c-sections makes the procedure more attractive, even to first-time mothers. Older mothers who have struggled with fertility, along with mothers concerned about potential complications from a vaginal delivery, may well consider c-section to be the lower-stress choice, a position echoed by the NIH panel which concluded that the benefits of on-demand section probably outweigh risks for older mothers who have used reproductive technologies ( in vitro fertilization and others) to become pregnant.
In light of conflicting evidence, the American College of Obstetricians and Gynecologists (ACOG) now advises that doctors and patients carefully weigh the benefits and risks associated with both cesarean and vaginal deliveries on a case-by-case basis. The earlier pregnant women begin conversations with their doctors or midwives about their delivery options, the better.
In 2003, ACOG released a statement proclaiming “both sides to this debate must recognize that evidence to support the benefit of elective cesarean is still incomplete.” Calling on-demand c-sections “unproven scientifically,” ACOG avoided endorsement either for or against elective surgery.
Instead, the organization advises women to speak frankly with their healthcare providers and ask plenty of questions, such as:
- What is your rate of cesarean versus vaginal deliveries?
- Under what circumstances do you deem a c-section necessary?
- How is the hospital/birth center where I will give birth prepared for emergencies?
- What if I want to schedule a c-section before I go into labor?
- What if I don’t want a c-section as part of my birth plan?
- What are my odds of having a VBAC (vaginal birth after cesarean) if I have a cesarean with this baby?
- If you were me (or if I were your wife), would you recommend that I schedule a pre-planned cesarean? Why or why not?
With current research inconclusive and c-section rates still rising, experts agree that the debate over choosing how a baby is born merits much more investigation. In the meantime, more and more women like Beiting will likely have less control over their maternal destiny in the future. In 2004, ACOG released a restriction on VBACs, limiting this option to moms with a history of only one prior cesarean. As a result, this may cause a continued increase in the cesarean rate.
American College of Obstetricians and Gynecologists
International Cesarean Awareness Network, Inc.
The Society of Obstetricians and Gynaecologists of Canada
Women's Health Matters
The American College of Obstetricians and Gynecologists, Cesarean Delivery on Maternal Request, Committee Opinion, No.394, December, 2007.
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Centers for Disease Control National Clearinghouse for Health Statistics website. Available at http://www.cdc.gov/. Accessed August 2004.
D’Altin ME, et al. NIH state-of-the-science conference: Cesarean delivery on maternal request. March 26-9, 2006. National Institutes of Health website. Available at http://consensus.nih.gov/2006/CesareanStatement_Final053106.pdf. Accessed October 23, 2006.
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Health grades quality study: ‘patient choice’ cesarean section rates continue to rise rapidly in the United States. June 2004. Health Grades website. Available at: http://www.healthgrades.com/. Accessed August 2004.
Ibekwe PC. Rising trends in cesarean section rates: an issue of major concern in Nigeria. Niger J Med. 2004; 13(2):180-1.
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World Health Organization’s indicators to monitor maternal health goals. World Health Organization website. Available at: http://www.who.int/. Accessed August 2004.
Last reviewed June 2008 by Ganson Purcell Jr., MD, FACOG, FACPE
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