It is now believed that more than 30 percent of all births in the U.S. are Cesarean deliveries. Among obstetricians, these are called Cesarean Delivery on Maternal Request or CDMR. But they’re more commonly called C-section-on-demand. But the question remains why so many American women having C-sections. Is it a matter of convenience? Or are medical reasons driving the trend? To help us understand this trend, let’s examine the pros and cons of Cesarean-on-demand.
Has the rate of Cesarean deliveries in the United States gone up? Is this a worldwide phenomenon?
The high rate is pretty much an American issue: the latest statistics (reported in the New England Medical Journal) are that the Cesarean delivery rate is this country is greater than 30 percent. This means that over 1.2 million births a year are performed with abdominal surgery. The highest rate of Cesarean delivery — 35 percent — has been reported in New Jersey for the year 2000 (and the number is now probably higher). Compare this to the rate of 15 percent recommended by the World Health Organization. WHO haS found that Cesarean delivery rates, which exceed 15 percent “offer no population health benefits.”
Are there medical reasons for these high rates in the United States or do they simply reflect the desire for convenience and the containment of malpractice costs?
Our U.S. obstetrical population has changed in the 21st century and this may impact our cesarean delivery rates. But here are some other reasons:
- Older women are having babies. Since 1990 there has been an increase of over 40 percent in the number of women between the ages of 35 and 39 who have babies, and over 60 percent for women between the ages of 40 and 44.
- Women are also heavier. (There has been a doubling of obesity rates in the past 21 years). Heavier moms are likely to have a bigger babies and in order to protect overly large babies from traumatic vaginal delivery, especially one that can cause fracture of the collar bone and paralysis of the arm (brachial plexus injury), Cesarean delivery is often planned without a trial of labor.
- More multiple gestations (the rate is currently two times greater than it was in 1980). A pregnancy of twins, triplets or more increases the risk of fetal growth retardation, premature delivery and other complications that lead to cesarean sections. There’s no question that women who undergo fertility care, especially IVF are currently more likely to have multiple gestations. These expensive and more difficult “to make” babies are also considered “premium.” As a result, even with singleton births, women who underwent fertility care are more likely to be delivered by C-section.
- Vaginal breech deliveries are no longer recommended. There is a three percent risk of injury to the breech newborn with a vaginal delivery; this is concerning both to the mother whose baby is in breech position and to the physician who does not want to incur difficulty in the delivery and/or a malpractice suit. As fewer and fewer physicians are delivering breech babies vaginally, they are also becoming less capable if called upon to do so. Fewer doctors are trained for vaginal breech delivery and as a result, most breech babies are now delivered with C-sections. In the future many predict that none will be delivered vaginally.
- Concerns that operative vaginal delivery (forceps and vacuum) can cause harm to the baby.
- Fewer attempts at vaginal delivery after Cesarean sections (VBAC). Many institutions feel that they do not want to allow physicians to try VBAC after a C-section because of the possible occurrence of rupture in the previous scar in the uterus. Patient and physician concern about this potential complication has caused the rate of VBAC to greatly diminish in the past few years.
- An increase in induction of labor. (When labor is induced there is higher risk of Cesarean sections). Approximately 20 percent of labors were induced in 2003, compared to 9.5 percent in 1990. Labors are often induced because of more active surveillance with ultrasounds in the last few weeks of pregnancy. (This is done in order to check the amount of amniotic fluid as well as movement and growth of the fetus.) There’s also a concern about “allowing” a women to go too long past their due dates. And, of course, there’s the issue of convenience. Parents want to know when to leave their job, when to show up for delivery and when to arrange child care. Frequently a doctor is on call for a particular period of time, or, less frequently, may be out of town. If parents want that particular doctor to be present at the delivery they may decide to set an induction date.
- Fetal monitoring and evidence that the fetal heart rate and oxygenation of the baby is compromised during labor. Fetal monitoring has become an integral part of labor and delivery care in most hospital institutions. If changes are noted that could indicate fetal distress, “to be safe” rapid delivery by cesarean section is often performed. Of interest is the fact that fetal monitoring, per se, has not changed perinatal mortality rates and often the babies that appear compromised during monitoring are born with robust breathing, movement, and heart rates and no underlying distress. But, no one wants to take that chance.
What part does malpractice concerns play in decisions to perform a Cesarean delivery?
There is no question that malpractice issues play a part. Many lawsuits are about failure to perform a “timely” Cesarean delivery. A recent survey performed by the American College of Obstetricians and Gynecologists (ACOG) on professional liability of its members found that obstetricians average three lawsuits during their years of practice. This may cause many of them to change the way they practice or even to decide to give up delivery of high-risk patients (or any patients). Insurance rates have risen and in states where there is no cap on medical lawsuit amounts for pain and suffering, obstetricians’ insurance rates can be hundreds of thousands of dollars a year. These are probably the chief reasons that the average age at which physicians stop practicing obstetrics in the US is 48. Considering the years of training and the need to practice to become truely expert, this is a terrible shame.
How many Cesarean deliveries are currently done on demand?
We actually don’t know. CDMRs are not tracked separately and often are not reported as such. The only way to “guesstimate” the number is to look at state records and see when a cesarean delivery was done without labor and without a medical indication or when it was done on a very low risk patient, again, with no stated indication. In New Jersey, in 2000, records show that this accounted for six percent of deliveries. The National Institute of Health recently estimated that 2.5 percent of all births in the U.S. in 2004 were CDMRs. Most of our knowledge about the possible pros and cons of CDMRs is indirect and is based on data from C-sections done for a myriad of reasons compared to vaginal deliveries.
What are the potential advantages of cesarean delivery on demand?
- Convenience factor. This allows patients to know when and how long to take time off, get help from relatives, especially if there are other children at home, and ensures that their preferred physician is present at time of delivery. It also gives a woman the feeling that she has a degree of control of the birth process.
- Fear of pain. Some women feel that if they have a Cesarean delivery they will have epidural anesthesia throughout the procedure without the potential of having to deal with labor and delivery pains.
- Fear that the consequences of labor and delivery may compromise the health and quality of life of the mother.
- Pelvic prolapse and urinary or rectal incontinence. There are at least nine articles that deal with the issue of urinary incontinence (loss of urine with coughing or sneezing) subsequent to vaginal versus cesarean delivery. There is indeed more documented urinary incontinence immediately after a vaginal delivery (23 percent), forceps (35 percent), than Cesarean section after labor (nine percent) and elective cesarean sections (four percent). One year later these differences continue, but are less frequent; 10 percent of women who had vaginal deliveries had some urinary incontinence where 3.4 percent with elected c-sections complained of this problem. However, studies have shown that subsequent to menopause there are few differences between the two modes of delivery and then its menopause and age that really determines whether a woman will have prolapse and incontinence.
There is also a question as to whether sexual function and vaginal contraction is diminished after vaginal delivery; but there are few studies that looked at this concern and those that have been reported show only a weak correlation. (Although anecdotally, women do tell me they feel different after delivering a large baby, and go on to say that their ability to contract the vagina or feel pressure during intercourse has diminished.)
What about potential risks of CDMR?
These need to be divided between the risk to the mother and risk to the newborn. With regard to the mother, there can be injury to organs adjacent to the enlarged uterus, including the bowel, bladder, blood vessels. There is also an increased risk of infection, development of thrombophlebitis or blood clots in the legs that subsequently can cause a pulmonary embolism. There is an increase in the risk of re-hospitalization, two times that of vaginal deliveries. (But in all fairness, most of this data has been found to be true for cesarean sections done after labor. A recent NIH conference suggested that a small study of Cesarean section on demand before labor did not been show an association with higher risks and the actual chance of maternal mortality was lower than that for vaginal delivery.)
As far as the newborn is concerned, Cesarean-on-demand has been associated with an increased risk in respiratory distress (five percent vs. 0.5 percent for vaginal delivery) and need for resuscitation as well as subsequent admissions to a special care nursery.
Are there any implications on future pregnancies for women who’ve had cesarean delivery either on demand or because of a medical indication?
Yes. It appears that it takes longer to get pregnant after C-section (however, this may be voluntary). Because of potential scarring in the uterus or in areas near the uterus there seems to be an increased risk in subsequent ectopic pregnancies and miscarriage. There is also twice the risk of unexplained stillbirth in the next pregnancy. Additionally, we know that the scarring of the uterine wall can lead to abnormal placement of the placenta (placenta previa) in the next delivery and this can lead to hemorrhage and a premature Cesarean section. The placenta may also grow into the uterine wall, a condition called placenta accrete and create serious bleeding on attempts to remove it after delivery.
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And finally, the placenta can separate before delivery (abruption), resulting in hemorrhage, fetal distress or even fetal demise. There are also higher rates of surgical complications in subsequent cesarean sections (especially injury to the bladder). The rate for hysterectomy due to bleeding is 60 times higher after more than one cesarean delivery, the risk of transfusion is greater and the average hospital stay is increased among women with multiple prior cesarean sections. A woman who is having repeat C-sections is twice as likely to be readmitted to the hospital.
What about cost?
The centers for Medicare and Medicaid have found that the average physician’s charges for uncomplicated vaginal delivery in the U.S. is just under $4,500. But for an uncomplicated cesarean deliver, it is $7,000. Hospitalization costs are doubled, going from an average of a little over $5,000 to over $10,000.
I know I have presented a lot of statistics, but what surprised me most as I researched this subject was the fact that 15 percent of current in-patient surgeries nationwide are Cesarean deliveries. This means that they may be exhausting hospital, surgical, or and nursing services and as a result increase the waiting time and nursing coverage for other needed procedures. For every 5 percent increase in U.S. C-section rates we can expect 14 to 32 more maternal deaths and $750 million to $1.7 billion in health-care expenditures.
What are the current recommendations regarding CDMR?
The American College of Obstetricians and Gynecologists (ACOG) and the National Institute of Health (NIH) have stated that it is ethically permissible for physicians to perform Cesarean deliveries purely on maternal request. ACOG has also recommended that if a physician does not feel comfortable in performing a CDMR, she or he should refer the patient to a physician who will do so. It should also be stated that the International Federation of Gynecology and Obstetrics feels that “because hard evidence of net benefit does not exist, performing cesarean sections for non-medical reasons is not ethically justified.”
Finally, are there psychological implications to performing a cesarean section on demand versus going into a labor and having a vaginal delivery?
Six studies that were recently reviewed found that women who had unplanned Cesarean birth or instrumental vaginal delivery were more likely to have adverse psychological outcomes compared with women who had spontaneous vaginal deliveries or planned Cesarean births. There was no difference between those who had a Cesarean-on-demand with those who had spontaneous vaginal deliveries.
Ultimately, the choice for CDMR has to be made by the patient after thorough consultation with her doctor. She should be advised of the possible complications and consequences to future pregnancies. Many women feel that they do not want to take “any chances” when it comes to medical concerns about their babies health and well-being, the timing of delivery, or fear of pain and subsequent pelvic problems. Once they have discussed all of these issues with their physician, if they wish to have scheduled Cesarean deliveries, their voice and choice should be considered.
Dr. Reichman’s Bottom Line: Ultimately, the choice for CDMR has to be made by the patient after thorough consultation with her doctor.
Dr. Judith Reichman, the TODAY show's medical contributor on women's health, has practiced obstetrics and gynecology for more than 20 years. You will find many answers to your questions in her latest book, "Slow Your Clock Down: The Complete Guide to a Healthy, Younger You," which is now available in paperback. It is published by William Morrow, a division of HarperCollins.
PLEASE NOTE: The information in this column should not be construed as providing specific medical advice, but rather to offer readers information to better understand their lives and health. It is not intended to provide an alternative to professional treatment or to replace the services of a physician.