Why Is the National U.S. Cesarean Section Rate So High?
The nations leading professional obstetric societies conclude that women and babies have not benefited from this increase in cesarean section, which is overused. While cesarean birth is safer than vaginal birth for certain high-risk conditions, it likely poses greater risk of harm in low-risk women. They recommend safe, appropriate prevention of overuse.7
Cesarean section is major surgery and increases the likelihood of many short- and longer-term adverse effects in mothers and babies (some of these harms are listed below). There are clear, authoritative recommendations for more judicious use of this procedure.8,9 Why, then, is the cesarean rate so high?
Three Myths about the Cesarean Section RateTo explain the high cesarean birth rate, 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 cesarean sections that have no medical rationale, 2) the number of women who genuinely need a cesarean is increasing, and 3) liability pressure is driving rates up. None appears to account for a large portion of the growth in the cesarean rate since it began to rise in 1996.
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 2011-2012 polled U.S. women about these decisions. Just one percent of women who had had initial (primary) cesareans said that they had planned and carried out surgical birth with the understanding that there had been no medical reason for this procedure.10 Researchers who have looked at this question in other countries have found similar results.11
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 have gone 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 characteristics.12 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.13
Finally, fear of malpractice liability is frequently cited as a major driver of the extensive use of cesarean section. However, a series of studies have examined this question and have concluded that the role of liability pressure is modest at best and can account for just a fraction of the steep recent rise.14 Further, this factor is overpowered by the role of variation in professional practice style.15
Reasons for the High Cesarean Section RateThe following interconnected factors appear to contribute to the high cesarean rate.
1 Taffel, S.M., Placek, P.J., & Liss, T. (1987). Trends in the United States cesarean section rate and reasons for the 1980-85 rise. American Journal of Public Health, 77(8), 955-959. Retrieved 24 September 2015, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1647267/pdf/amjph00259-0027.pdf
2 Johnson, K.C. & Daviss, B.A. (2005). Outcomes of planned home births with certified professional midwives: Large prospective study in North America. BMJ, 330, 1416. Retrieved 24 September 2015, from http://www.bmj.com/cgi/content/full/330/7505/1416
3 Rooks, J.P., Weatherby, N.L., Ernst, E.K., Stapleton, S., Rosen, D., & Rosenfield, A. (1989). Outcomes of care in birth centers: The National Birth Center Study. New England Journal of Medicine, 321(26), 1804-1811.
4 Stapleton, S.R., Osborne, C., & Illuzzi, J. (2013). Outcomes of care in birth centers: Demonstration of a durable model. Journal of Midwifery and Womens Health, 58(1), 3-14. Retrieved 24 September 2015, from http://onlinelibrary.wiley.com/doi/10.1111/jmwh.12003/full
5 Hamilton, B.E., Martin, J.A., Osterman, M.J.K., & Curtin, S.C. (2015). Births: Preliminary data for 2014. National Vital Statistics Report, 64(6), 1-19. Retrieved 24 September 2015, from http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_06.pdf
6 Weiss, A.J., Elixhauser, A., & Andrews, R.M. (2014). Characteristics of operating room procedures in U.S. hospitals, 2011. HCUP Statistical Brief #170. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved 24 September 2015, from http://www.hcup-us.ahrq.gov/reports/statbriefs/sb170-Operating-Room-Procedures-United-States-2011.pdf
7 American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine. (2014). Safe prevention of the primary cesarean delivery. Obstetric Care Consensus, March (1). Retrieved 24 September 2015, from http://www.acog.org/Resources-And-Publications/Obstetric-Care-Consensus-Series/Safe-Prevention-of-the-Primary-Cesarean-Delivery
9 U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2010). HealthyPeople.gov: Maternal, Infant, and Child Health. Retrieved 24 September 2015, from http://www.healthypeople.gov/2020/leading-health-indicators/2020-lhi-topics/Maternal-Infant-and-Child-Health
10 Declercq, E.R., Sakala, C., Corry, M.P., Applebaum, S., & Herrlich, A. (2013). Listening to Mothers III: Pregnancy and birth. New York: Childbirth Connection. Retrieved 24 September 2015, from http://www.childbirthconnection.org/listeningtomothers/
11 McCourt, C., Weaver, J., Statham, H., Beake, S., Gamble, J., & Creedy, D.K. (2007). Elective cesarean section and decision making: A critical review of the literature. Birth, 34(1), 65-79. Retrieved 24 September 2015, from http://onlinelibrary.wiley.com/doi/10.1111/j.1523-536X.2006.00147.x/full
12 Declercq, E., Menacker, F., & MacDorman, M. (2006). Maternal risk profiles and the primary cesarean rate in the United States, 1991-2002. American Journal of Public Health, 96(5), 867-72. Retrieved 24 September 2015, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1470600/
13 See note 10.
14 Sakala, C., Yang, Y.T., & Corry, M.P. (2013 January). Maternity care and liability: Pressing problems, substantive solutions. Womens Health Issues, 23(1), e7-13. Retrieved 24 September 2015, from http://www.whijournal.com/article/S1049-3867(12)00090-4/fulltext
15 Baicker, K., Buckles, K.S., & Chandra, A. (2006). Geographic variation in the appropriate use of cesarean delivery. Health Affairs, 35, w355-w367.
16 Buckley, S.J. (2015). Hormonal physiology of childbearing: Evidence and implications for women, babies, and maternity care. Washington, DC: National Partnership for Women & Families. Retrieved 24 September 2015, from http://www.childbirthconnection.org/hormonalphysiology/
17 See note 10.
18 Clark, S.L., Belfort, M.A., Hankins, G.D.V., Meyers, J.A., & Houser, F.M. (2007). Variation in the rates of operative delivery in the United States. American Journal of Obstetrics and Gynecology, 196(6), 526.e1-526.e5.
19 Childbirth Connection. (2012). Vaginal or cesarean birth: What is at stake for women and babies? A best evidence review. New York: Childbirth Connection. Retrieved 24 September 2015, from http://transform.childbirthconnection.org/reports/cesarean/
20 See note 10.
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