The Cesarean Rate- What it means, why it exists, and what to do about it.

This article was originally written in 2013 in response to a Jezebel post, and has been updated for 2016:

The headline was, to say the least, shocking- “PREGNANT WOMEN EVERYWHERE ARE BEING BULLIED INTO HAVING A C-SECTION”, followed by a short article detailing all of two incidents, where intimidation and legal action were used to effect a cesarean section.

Beyond that, the article was low on facts about surgical birth, so we’ll look at some basics:

The World Health Organization had originally cited an ‘acceptable’ cesarean rate of 15%- that was withdrawn in 2010, citing a lack of “empirical evidence” and “…cesareans should be available to any woman who needs them.” (low tech countries may have been using the suggested rate as an excuse to avoid providing needed interventions), but many still use that number as a benchmark.

The United States cesarean rate for 2015 was 32.2%, little changed from 2010, indicating a plateau after years of steady rise- the rate in 1996 was 21%. (When the rate was first measured, in 1965, it was 4.5%)

This means that, of all the pregnant women in the US, of all demographics, almost 1/3rd of them will give birth surgically, as opposed to vaginally.

That is a significant number, and puts the US in the upper range of cesarean rates worldwide. In addition, cesarean section is the 2nd most used surgical procedure in the US, after angioplasty & heart imaging.

“Isn’t Cesarean birth safer than vaginal birth?”

Pause for a moment to think about the implications of this question. On the surface it seems to be a reasonable thing to ask, and there are clearly cases where the use of a cesarean section is safer for mother and baby than proceeding with a vaginal birth.

But, in the absence of medical need, what that question asks is “Is a major surgical procedure safer than the biologic standard of birth?” Bluntly, is it safer to cut a woman open than it is to use the opening provided?

While both vaginal and cesarean birth hold risks, cesarean birth holds significantly more:

All of the complications and risks associated with any surgery; including infection, blood loss, adhesions, injury to other organs, longer recovery time, longer hospital stay, need for repeat or corrective surgery, etc
Scarring to the uterine muscles & abdominal wall, may cause increased pain during healing, and limit activities.
Risk of hysterectomy
Limitation of options for future births
Increased risk of placental complications (some life threatening) in future pregnancies.
Increased risk of ectopic pregnancy
Negative reactions to associated interventions like anesthesia, catheters, etc.
Physical limitations inhibit contact with and care of infant even after returning home (1 in 14 had pain at the incision site 6 months later)
Significant separation immediately following birth, separation from support if they go to the nursery with the baby.
Complex emotional response to birth that may inhibit or complicate infant care.
Higher likelihood that the infant will be premature in development.
Increased post-delivery interventions for the infant.
Infant is more likely to experience breathing difficulty & low APGAR scores
Possibility of injury to infant.
Possible negative impact on breastfeeding
Evidence for increased health issues in infant development following cesarean

The risks of a vaginal birth (NOT including those caused by any interventions or pre-existing conditions) are;

Spontaneous injury or trauma to the perineum, anus & urethra
Need for sutures following episiotomy
Increased tenderness in the vagina and perineum
Blood loss
Infection
Infant scalp molding & bruising

As you can see, there is much more risk to mother and baby, in the short and long term, with having a surgical birth.

“Is the increase in surgical births saving the lives of mothers and babies?”

That is the whole reason for the existence of the cesarean, isn’t it?

First, you need to understand that the USA does not collect maternal mortality information as part of the National Vital Statistics System. When looking at the data from the Centers for Disease Control, the numbers are based on voluntary yearly reporting by 52 US regions (states and territories) using information gleaned from submitted death certificates. Since there is no standardized national death certificate, the actual cause of death related to pregnancy may go unrecorded, some pregnancy related deaths may be unreported, and all of the information is subject to human interpretation when it is transcribed.

This is what the numbers show for Maternal Mortality:

The Maternal Mortality Rate (MMR) in 1987 was 7.2 deaths per 100,000 live births- .0072% -less than one hundredth of one percent.
In 2008 the US official numbers set the MMR at 15.5% deaths per 100,00 live births, in 2012 it dropped to 15.9. (The spike in 2009 and 2011 to 17.8 is directly attributable to the H1N1 epidemic.)
Compared to other countries, we rank approximately 34-40th depending on the source of the data often the US’ numbers in these surveys are estimated based on various data sources, including the CDC numbers.

Birth by the Numbers is a website focused on collating and examining this data, and is an important resource when looking at and discussion our national maternal mortality and cesarean rates

The updated for 2014 Birth By The Numbers video discusses national statistics clearly:
https://www.youtube.com/watch?v=a_GeKoCjUQM

BBtN also discusses cesarean birth rates in specific detail, looking at each of the common reasons given for cesarean increases, and comparing those to what the actual data says (hint- the data usually doesn’t support the argument…) :
https://www.youtube.com/watch?v=M_SKMMs2qfM

Sidebar: In California, when they began to examine their rising MMR, they needed to standardise the information that was being reported, so they could not only find the MMR, they could figure out how to address it. Interestingly, using the same data available to the CDC, they came up with different US MMR numbers- Their national number for 2013 is a disturbing 22.0

Since collecting cleared data, and institution policy and law reforms based on that data, California has been able to reduce their MMR from 16.9 in 2006, to 7.3 in 2013 https://www.cmqcc.org/focus-areas/maternal-mortality/california-and-us

So the maternal mortality rate can be reduced; with standardized data collection and focused, targeted policy change.

What about Infant Mortality? Here’s those numbers; based on the UN’s World Populations Prospects Report (using 5 year averages):

Between 2000 and 2005, the IMR (deaths per 1,000 live births) was 6.9, a low from all the previous years.
In 2005-2010, that number was 6.8, not a statistically significant change.
That ranks the US 34th of 182 countries; 33 countries have better IMRs

If mortality rates aren’t going down when the cesarean rate is going up, then why are so many women having cesareans?

In popular discussion, most people think it is one of these:

Maternal Request- more mothers are making a fully informed choice to have a cesarean for non-medically indicated reasons.
More women have a medical need for a cesarean, due to multiple gestation, fetal weight, age, weight, health issues, social status or race.
Doctors are concerned about liability and malpractice.

But, when those points were looked at closely, few of them held up as true:

In a survey of 1600 women who gave birth in a hospital, only 1 said she requested the cesarean. The Listening to Mothers surveys find 1% or less maternal request cesareans. Research in other countries has had similar results- women aren’t requesting non-medically indicated cesareans.
The cesarean rate has risen evenly across the board, for all demographics. No one type of woman has a significantly greater rate of increase than another (Several demographics have higher rates than the national average, but their rate of increase has been the same.). The same holds true for multiple gestation and birth weight.
A comparison of studies shows that fear of malpractice liability has only a small to moderate influence on cesarean rates.

So, if those aren’t the smoking gun, why is the cesarean rate going up? Birth By the Numbers clearly implicates changes in the way the US practices maternity care -both medically and culturally- as the cause of the increase in the cesarean rate since 1996; and this holds up under deeper examination.

Cultural Presentation of Birth & Access to Care

Women in the United States women are not exposed to physiological birth. That is, birth that happens without even routine medical intervention. What is presented culturally as ‘the usual’ is a high stress, high intervention experience to be feared and endured. Modern ‘reality’ shows use editing and music to emphasize drama and danger in birth. Use of medication and interventions is seen as inevitable and preferable.

Physiological normal birth is culturally portrayed as abnormal and undesireable. Unmedicated vaginal birth is out there or “XTREME”, something those hippy anti-science weirdos do. Women who express a desire for that standard are brushed off, mocked, or reacted to in a condescending way. Evidence of women having positive (even pleasurable) no-to-low intervention births are dismissed as outliers or unusual.

Birth is singled out as an isolated (usually medical) happening, rather than being integrated into a woman’s social & emotional life.

Surgery (even non-birth related) is seen as an accepted and expected part of life, even for non-medically indicated reasons. Culturally, we are bombarded with messages encouraging us to seek out interventions.

Women are not encouraged or supported in ‘comparison shopping’ for childbirth providers. Outside factors like insurance coverage determines who a woman will be served by, rather than her needs and preference.

Childbirth education is seen as a luxury, and is usually limited to less than 30 hours of ‘crash course’ in the last 6 weeks of pregnancy. Private, unaffiliated classes are paid for out of pocket. Classes offered by hospitals or insurance often focus on policy and procedure and available interventions, rather than preparation for normal birth variants.

Non-medical support in childbirth is expected to be provided by a layperson, often a partner or spouse, with minimal exposure or training in support skills. The partner or spouse’s needs (physical, emotional and spiritual) are unaddressed by our culture.

There is a clear correlation between socioeconomic status, and cesarean rate that “…cannot be accounted for by differences in maternal age, parity, birth weight, race, ethnic group, or complications of pregnancy or childbirth.” Lack of access to adequate prenatal care, lower quality care provided in areas of poverty, and provider attitude towards ethnicity and poverty all contribute to higher cesarean rates.

Medical Management of Birth & Provider Training

A culture of intervention exists in many hospitals; more support & encouragement is given within the policy and peer structure of the hospital for the use of interventions (even when those interventions may not be evidence based) with all births- often interventions (like an IV, or Electronic Fetal Monitoring) are instituted immediately upon admittance. Very little support is given to providing non-interventive care to mothers.

The use of multiple interventions has a known cascade effect- the more interventions that are used in a birth, the more (and greater) interventions that are needed, often leading to surgical delivery.

Staffing limits and inhibits support and care- even the best nurse is hampered by having multiple women under her care at one time; interventions that should be intermittent or limited are prolonged by staff absences, women are left alone without professional support & information for long periods of time.

Increased use of ‘hands off’ monitoring & telemetry separates providers from the patient, reducing them to a set of numbers. Major decisions can be made based on those numbers alone, even before they are interpreted by a trained professional.

Dr. Neel Shah, Assistant Professor at the Harvard Medical School, has found that things as simple as how a hospital’s maternity ward is physically laid out may impact cesarean rates: https://www.youtube.com/watch?v=9-X-S8EHkFg

Modern obstetric students are trained in fewer hands-on procedures for managing normal birth variations; things like external version, vaginal breech birth, twin birth management, perineal massage etc. are not covered, or covered only briefly.

Obstetrics training uses a strict medical model of care, often focused on crisis intervention & procedure, rather than the wide spectrum of physiological birth.

Personal preference, practice style, and attitude towards interventions impact the care provided.

The system of payment for childbirth procedures tacitly supports provider speed and convenience- a provider will be paid less for spending a large amount of time supporting a woman through physiological birth, than they will be for a surgical birth.

The hospital environment encourages high turnover of patients, cesareans may be encouraged where waiting is a medically acceptable option.

Physician organizations may overstate the benefits of surgical birth, the risks of VBAC, and overlook evidence that contradicts long standing practices.

Hospital rules or provider preference may actively prevent or inhibit a woman from attempting a Vaginal Birth After Cesarean. There is evidence that some women may be given a medical reason for VBAC refusal, even when there is no clear medical indication.

The threshold of when a cesarean should be used has changed, even when populations haven’t. Even when there is a change that supports low-intervention birth, it can take many many years for systemic change to be implemented.

Cesarean Birth Awareness

Women are not given full information on the risks surgical birth pose to mother and child Cesarean birth is not accurately represented as major abdominal surgery, with the recovery period and limitations that abdominal surgery imposes.

Many women feel coerced or shamed into having a cesarean section. In the Listening to Mothers survey, 25% of the women reported having been pressured by a professional to have a cesarean. Review of websites discussing cesarean birth find many similar results.

Women are in an altered state of consciousness during birth; in addition to the diminishing of higher cognitive function in labor, a recent study found that oxytocin, which is the primary hormone released in labor, also increases a woman’s feeling of trust; this may lead to women agreeing to procedures they might not approve otherwise.

Many women have reported the use of fear & threat based language surrounding the birth of their child. Phrased such as “Don’t you want your baby to be healthy?” and “Something bad might happen if we don’t (insert intervention here).” Many low-intervention birth professionals call it “playing the dead baby card”, where the specter of death or damage is held over the parents’ heads if they don’t follow doctor orders.

Now that we know there is a problem, what do we do about it?

There’s a few things that need to happen:

Change the culture of intervention in the hospital & provider mindset
This is both the most crucial piece, and the most difficult. Women can know all about why and how to ‘avoid’ a cesarean and have all the data about cesarean rates, maternal mortality, etc… but until the hospitals and providers are willing to recognize their role in the cesarean rate (and not continue to place the whole burden on ‘risky populations’ or ‘maternal health’), and make significant changes, then women as consumers of a service can only do so much.

Increase women’s access to & exposure to physiological birth
If women know what the wide range of ‘normal’ is for birth, and are educated in the appropriate uses of birth technology, they are less likely to accept interventions that are not medically indicated.

Increase women’s understanding of the appropriate and compassionate use of interventions
Interventions themselves are not the ‘enemy’, and have appropriate, timely and compassionate applications in childbirth. Rather than an ‘natural’ vs ‘intervention’ model that teaches avoidance and distrust, women should understand what the tools are, and when to recognize (and even request) their use, without guilt or fear of ‘failure’.

Increase women’s access to doulas/trained labor support
Multiple studies have shown that continuous labor support by a trained professional has a profound impact on the outcome of labor, birth and the postpartum period. With the average cost of doula care hovering around $500, the potential savings for both public and private insurance coverage vs. the cost of cesareans is in the millions of dollars.

Build a system of cooperative, socially-focused care with midwives as the primary provider
In the countries with the lowest infant and maternal mortality rates, midwifes are the primary care providers for normal, low-risk pregnancies, with referrals to obstetricians if complications arise. Many studies have shown that midwife-attended births are safe, with fewer medical interventions and significantly lower cesarean rates. (As an aside, the USA is the only country that differentiates between midwives who have had previous nursing training, and those who went into midwifery directly.)

Increase childbirth preparation/education to 9+ months
Can you imagine if a runner, preparing for the Boston Marathon, only trained for 2-3 hours a week, one day a week, in the 3 months leading up to the marathon, all while going through significant physical changes? That’s what we expect from pregnant women, when we recommend they take childbirth preparation classes at all. Increasing class time can:

Give women a better understanding of the process of pregnancy, labor & birth. Many women have limited time with their care provider, so questions and concerns can be glossed over or forgotten- full pregnancy education can fill in that gap.
Build a pain-coping mindset beginning early in pregnancy, so that coping skills are ingrained and reflexive, rather than ‘crammed’ for like a test.
Prepare women not only for the many facets of physiologically normal birth, but help them be aware of and ready to adapt to the unexpected or unwanted.
Prepare women for the postpartum period with increased information and support in self-care, infant care, and physiologically standard infant feeding.

De-stigmatize, legally protect and fund out of hospital birth
Study after study shows that a planned home birth attended by a trained professional is a safe option for many women, yet few women are exposed to this option. Even in studies that have shown a higher relative risk to infants, the overall risk is still less than 1%- just like a hospital. When a women does discover the option, they often find they will need to pay out of pocket, and they are faced with social censure and ridicule. In some states, choosing home birth with a trained midwife may result in parents and/or the midwife facing legal action.

Bring back the VBAC
A controversial position paper in 1999 from the American Congress of Obstetricians and Gynecologists (a voluntary fraternal and lobbyist organization) said that Vaginal Birth After Cesarean should be “offered” with “emergency support immediately present.”. This paper was accompanied by an editorial by a Dr. Greene stating that VBAC was dangerous, and there was widespread media attention. This had the effect of causing absolute bans in 28% of all American hospitals and de facto bans in an additional 21%; which in turn caused the VBAC rate to drop from 23% in 1996 to 10% in 2010.

In 2010, the NIH held a “Consensus Conference on VBAC”, finding that the risks of VBAC were minimal, and had not changed in the time since they first became widespread in 1980. And while the ACOG followed that conference with a ‘revised’ position paper, the general availability & support for VBAC in hospitals has not appeared to change significantly- there is a slow increase, but the US still has the lowest VBAC rate of all industrialized countries.

The Bottom Line

Major abdominal surgery should only be happening when there is a clear medical indication for it. Obviously, no one disputes this.

The fact is that nearly 1/3rd of pregnancies in the USA end in this major surgery, costing millions of dollars a year, and having as yet unknown impacts on thousands of children. The only way this will change is by demanding accountability and change from providers and facilities, and through increasing awareness & education Not just for expectant mothers, but for our whole society- asking ourselves if this significant deviation from the physiological standard is really beneficial, how is it impacting our culture, our economy, our standards of care, and why are we allowing it to happen?

The advent of awareness of this as a consumer and national expenditure issue (illustrated by the 2016 Consumer Reports series of articles on childbirth and cesareans) rather than just a ‘pregnant woman’ issue, may be the thing that finally makes the difference.

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CDC Data:
http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html

This infographic gives a clear picture of the 2011 data:
http://www.facethefactsusa.org/facts/more-us-mothers-dying-despite-expensive-care/

Consumer Reports
http://www.consumerreports.org/doctors-hospitals/childbirth-what-to-reject-when-youre-expecting/
http://www.consumerreports.org/doctors-hospitals/your-biggest-c-section-risk-may-be-your-hospital/

Socioeconomic Status:
http://www.ncbi.nlm.nih.gov/pubmed/2747759

http://www.jstor.org/stable/10.1525/sp.2012.59.2.207

Amnesty International’s “Deadly Delivery” report:

http://www.amnestyusa.org/sites/default/files/pdfs/deadlydelivery.pdf and 1 year follow up http://www.amnestyusa.org/research/reports/deadly-delivery-the-maternal-health-care-crisis-in-the-usa

Other:

Maternal Mortality in the United States: A Human Rights Failure

http://www.indexmundi.com/g/r.aspx?v=2223

Oxytocin increases trust in humans Michael Kosfeld1,5, Markus Heinrichs2,5, Paul J. Zak3, Urs Fischbacher1 & Ernst Fehr1,4

Systematic Reviews-Continuous Support for Women During Childbirth