|
|
|
|
|
|
Why Does the National U.S. Cesarean Section Rate Keep Going Up?The national U.S. cesarean section rate was 4.5% and near this optimal range in 1965 when it was first measured (Taffel et al. 1987). In more recent years, large groups of healthy, low-risk American women who have received care that enhanced their bodies' innate capacity for giving birth have achieved 4% cesarean section rates and good overall birth outcomes (Johnson and Daviss 2005, Rooks et al. 1989). However, the national cesarean section rate is much higher and has been increasing steadily over the past decade. When a national rate is available for 2007, we will find that about one mother in three is now giving birth by c-section, a record level for the United States. 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 (some of these harms are listed below). There are clear, authoritative recommendations for more judicious use of this procedure (U.S. Department of Health and Human Services 2000). So why does a pregnant woman's chance of having a cesarean section keep going up? Two Myths about the Rising Cesarean Section Rate To explain this steady rise, health professionals and journalists often point the spotlight on mothers themselves. Many assume that leading factors in the trend are: 1) more and more women are asking for c-sections that have no medical rationale, and 2) the number of women who genuinely need a cesarean is increasing. Neither appears to account for a large portion of the increase.Despite a lot of talk about "maternal request" cesareans, few women appear to be taking this step. Childbirth Connection's national Listening to Mothers survey of women who gave birth in hospitals in 2005 was the first study to poll women about these decisions in the United States. When we asked mothers who had had a cesarean why they had it and who had initiated it, just one woman among nearly 1600 survey participants reported that she had had a planned first c-section with no medical reason at her own request (Declercq et al. 2006a). Those who have looked at this question in other countries have found similar results (McCourt et al. 2007). Many have also 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 (Declercq et al. 2006b). 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. 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 (Declercq et al. 2006a). Reasons for the Rising Cesarean Section RateThe following interconnected factors appear to be pushing the cesarean rate upward.Low priority of enhancing women's own abilities to give birth Care that supports physiologic labor, such as providing continuous support during labor through a doula or other companion and using hands-to-belly movements to turn a breech (buttocks- or feet-first) baby to a head-first position, reduces the likelihood of a cesarean section. The decision to switch to cesarean is often made when caregivers could use watchful waiting, positioning and movement, comfort measures, oral nourishment and other approaches to facilitating labor progress. The cesarean section rate could be greatly lowered through such care. Side effects of common labor interventions Current research suggests that some labor interventions make a c-section more likely. For example, labor induction among first-time mothers when the cervix is not soft and ready to open appears to increase the likelihood of cesarean birth. Continuous electronic fetal monitoring has been associated with greater likelihood of a cesarean. Having an epidural early in labor or without a high-dose boost of synthetic oxytocin ("Pitocin") seems to increase the likelihood of a c-section. Refusal to offer the informed choice of vaginal birth Many health professionals and/or hospitals are unwilling to offer the informed choice of vaginal birth to women in certain circumstances. The Listening to Mothers survey found that many women with a previous cesarean would have liked the option of a vaginal birth after cesarean (VBAC) but did not have it because health professionals and/or hospitals were unwilling (Declercq et al. 2006a). Nine out of ten women with a previous cesarean section are having repeat cesareans in the current environment. Similarly, few women with a fetus in a breech position have the option to plan a vaginal birth. Casual attitudes about surgery and cesarean sections in particular Our society is more tolerant than ever of surgical procedures, even when not medically needed. This is reflected in the comfort level that many health professionals, insurance plans, hospital administrators and women themselves have with cesarean trends. Limited awareness of harms that are more likely with cesarean section Cesarean section is a major surgical procedure that increases the likelihood of many types of harm for mothers and babies in comparison with vaginal birth. Short-term harms for mothers include increased risk of infection, surgical injury, blood clots, emergency hysterectomy, intense and longer-lasting pain, going back into the hospital and poor overall functioning. Babies born by cesarean section are more likely to have surgical cuts, breathing problems, difficulty getting breastfeeding going, and asthma in childhood and beyond. Perhaps due to the common surgical side effect of "adhesion" formation, cesarean mothers are more likely to have ongoing pelvic pain, to experience bowel blockage, to be injured during future surgery, and to have future infertility. Of special concern after cesarean are various serious conditions for mothers and babies that are more likely in future pregnancies, including ectopic pregnancy, placenta previa, placenta accreta, placental abruption, and uterine rupture (Childbirth Connection 2006). Providers' fears of malpractice claims and lawsuits Given the way that our legal, liability insurance, and health insurance systems work, caregivers may feel that performing a cesarean reduces their risk of being sued or losing a lawsuit, even when vaginal birth is optimal care. Incentives to practice in a manner that is efficient for providers 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. All of these factors contribute to a current national cesarean section rate of over 30%, despite evidence that a rate of 5% to 10% would be optimal. ReferencesAlthabe F, Belizan JF. Caesarean section: The paradox. The Lancet 2006;368:1472-3. Childbirth Connection. What Every Pregnant Woman Should Know About Cesarean Section, 2nd ed. New York: Childbirth Connection, December 2006. Available at http://www.childbirthconnection.org/cesareanbooklet/ Declercq ER, Sakala C, Corry MP, Applebaum S. Listening to Mothers II: The Second National U.S. Survey of Women's Childbearing Experiences. New York: Childbirth Connection, October 2006a. Available at http://www.childbirthconnection.org/listeningtomothers/ Declercq E, Menacker F, MacDorman M. Maternal risk profiles and the primary cesarean rate in the United States, 1991-2002. Am J Public Health 2006b;96:867-72. Johnson KC, Daviss B-A. Outcomes of planned home births with certified professional midwives: Large prospective study in North America. BMJ 2005;220:1416. Available at http://www.bmj.com/cgi/content/full/330/7505/1416 McCourt C, Weaver J, Statham H, Beake S, Gamble J, Creedy DK. Elective cesarean section and decision making: A critical review of the literature. Birth 2007;34:65-79. Available at http://www.blackwell-synergy.com/toc/bir/34/1 Rooks JP, Weatherby NL, Ernst EK, Stapleton S, Rosen D, Rosenfield A. Outcomes of care in birth centers: The National Birth Center Study. New Engl J Med 1989;321:1804-11. Taffel SM, Placek PJ, Liss T. Trends in the United States cesarean section rate and reasons for the 1980-85 rise. Am J Public Health 1987;77:955-9. 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. [Objective 16-9] Available at http://www.healthypeople.gov/Document/tableofcontents.htm#Volume2 A version of this article appears in the second edition of The New York Guide to a Healthy Birth (New York: Choices in Childbirth, 2007). Most recent page update: 7/3/2008
© 2010 Childbirth Connection. All rights reserved.
Childbirth Connection is a national not-for-profit organization founded in 1918 as Maternity Center Association. Our mission is to improve the quality of maternity care through research, education, advocacy and policy. Childbirth Connection promotes safe, effective and satisfying evidence-based maternity care and is a voice for the needs and interests of childbearing families. |
News and Features
"2020 Vision" and "Blueprint for Action" Reports Available
Rising Maternal Mortality
Maternity Care Fact Sheet Available
US Cochrane Center (USCC)/Consumers United for Evidence-based Healthcare (CUE) Maternity Care, a Major Segment of Health Industry, Must Be Overhauled for Health Care Reform to Succeed
Help Transform Maternity Care!  Please join our efforts to make quality maternity care a top national priority. Your support will help make the transformation possible.View 2009 Supporter Roster  New Mothers Speak Out National Report Released The latest report in Childbirth Connection's Listening to Mothers series is now available. Get an eye-opening look at the reality of life as a mother of young children in the United States, based on national surveys conducted by Harris Interactive. Learn more, get the report  Read the Wall Street Journal story and listen to the podcast Download Quick Facts (PDF) New Content!
 Journey to Parenthood Full Book Available Online! A family-friendly book covering the trimesters, pregnancy resources, and the latest information on baby's first year of development. Available online (free) and for purchase in the Bookstore. Browse through Journey to Parenthood  Buy this book and learn more
Popular Pages
"The most frustrating thing is that they try to put a nursing mom on schedule; instead of letting the nursing mom set her own schedule. It got so irritating being woken up while the baby and I were asleep, that I left the hospital a day early so that I could get some sleep."
Every woman has the right to accept or refuse procedures, drugs, tests and treatments, and to have her choices honored. She has the right to change her mind. (Please note that this established legal right has been challenged in a number of recent cases.)
|
