Sponsored by International Cesarean Awareness Network (ICAN), April is Cesarean Awareness Month. It is an opportunity for raising awareness about this over-used surgery and for making information about resources and support available.
Cesarean section rates continue to rise
For the 12th consecutive year, the national cesarean section rate increased in 2008, even as total births dropped two percent. According to preliminary data from the Centers for Disease Control and Prevention’s National Center for Health Statistics (NCHS), the 2008 rate reached 32.3 percent, up from 31.8 percent in 2007. Of the more than 4.25 million births in 2008, approximately 1.37 women underwent surgical birth. The 2008 total is equivalent to the population of Philadelphia or the combined populations of Alaska and Washington, D.C.
Cesarean section stats / characteristics from a recent 2007 NCHS report:
- Cesarean section is the most performed surgery in the United States
- Cesareans are up for all women irrespective of age, race, state of residence or gestational age of infant(s) at birth
- Women under age 25 experienced the greatest increase in cesarean deliveries from 2000 to 2007
- Cesareans are up for infants of all gestational ages
- Repeat cesarean rate exceeds 90% (not in NCHS report)
Oregon and Lane County Cesarean Rates
2007 cesarean rates increased in all states, and by more than 70% in six. Oregon’s cesarean rate increased 67% from 16.9% in 1996 to 28.2% in 2007. 2009 data reported in Summary of Birth Statistics of Oregon indicates a Lane County cesarean rate of 34%.
What’s the problem?
If cesarean section has the potential to save life, why should women and families be concerned about the current rate? Because cesarean section, never intended for routine use, is over-employed in Lane County and elsewhere. The World Health Organization recommends a rate no higher than 15%. Past this point, preventable deaths and complications occur. In other words, we’re not solving problems – we’re making them.
Risks for babies include low birth weight, prematurity, respiratory problems, lacerations and breastfeeding complications. Risks for women include hemorrhage, infection, hysterectomy, re-hospitalization and placental abnormalities in future pregnancies.
Women’s choices for subsequent births are deeply constrained by providers, facilities and insurers that formally or informally ban vaginal birth after cesarean (VBAC). Fortunately, neither Sacred Heart Medical Center nor McKenzie-Willamette has formal VBAC bans, though women encounter informal barriers beginning with inaccurate information and spotty provider support. For more information on bans, see VBAC Policies in US Hospitals.
A 1996 New England Journal of Medicine editorial describes the unending complexity an initial cesarean introduces into women’s reproductive lives:
It is, after all, the initial procedure that scars the uterus, and it is this scar that raises the specter of morbidity throughout a woman’s later reproductive years. In turn, this concern has led to the policy of encouraging elective cesarean section in subsequent pregnancies, which, as noted earlier, accounts for so many of the cesarean sections performed today.
In short, cesarean section ought not be taken lightly.
Scrutiny on the Rise
A recent National Institutes of Health (NIH) panel concluded scientific evidence does not support banning VBAC. (Read my blog post on the NIH VBAC panel here.) The panel unfolded against a backdrop of growing concern about the connection between over-use of cesarean section and maternal mortality. The Joint Commission, the leading health care accreditation body, recently issued Preventing Maternal Death highlighting preventable errors specific to cesarean section: (1) failure to pay attention to vital signs following cesarean section and (2) hemorrhage following cesarean section.
On the heels of the Joint Commission alert, news broke that a special California task force found mortality rates for California women dying from causes directly related to pregnancy tripled in the past decade. (ABC News coverage) According to task force investigator Elliott Main, MD as reported to California Watch:
it’s hard to ignore the fact that C-sections have increased 50 percent in the same decade that maternal mortality increased. The task force has found that changing clinical practice could prevent a significant number of these deaths.
What’s the “take away”?
Increased scrutiny does not translate into provider- and facility-level reform. Consumer awareness is necessary for protecting normal birth for low-risk, healthy women.
Despite the frequency of cesarean section, most women are uninformed until presented with a provider recommendation during labor. This is a poor time for discussion. Making an informed decision is quite difficult, if not impossible, under these circumstances. Learning about cesarean section before pregnancy and as a part of childbirth preparation is ideal. Having this awareness will help women ensure surgical birth is reserved for appropriate, medical indication.
Women are well served to use prenatal appointments to learn more about their provider’s cesarean section rate and philosophy. It’s important to have this conversation early in pregnancy.
Birth after cesarean resources
International Cesarean Awareness Network