Cesarean Births are at an all time high

By: Denise Grady from Nytimes.com

The Caesarean section rate in the United States reached 32 percent in 2007, the country’s highest rate ever, health officials are reporting.

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A Continuing Trend

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The rate has been climbing steadily since 1996, setting records year after year, and Caesarean section has become the most common operation in American hospitals. About 1.4 million Caesareans were performed in 2007, the latest year for which figures are available.

The increases — documented in a report published Tuesday — have caused debate and concern for years. When needed, a Caesarean can save the mother and her child from injury or death, but most experts doubt that one in three women need surgery to give birth. Critics say the operation is being performed too often, needlessly exposing women and babies to the risks of major surgery. The ideal rate is not known, but the World Health Organization and health agencies in the United States have suggested 15 percent.

The continuing rise “is not going to be good for anybody,” said Dr. George A. Macones, the chairman of obstetrics and gynecology at Washington University in St. Louis and a spokesman for the American College of Obstetricians and Gynecologists. “What we’re worried about is, the Caesarean section rate is going up, but we’re not improving the health of babies being delivered or of moms.”

Risks to the mother increase with each subsequent Caesarean, because the surgery raises the odds that the uterus will rupture in the next pregnancy, an event that can be life-threatening for both the mother and the baby. Caesareans also increase the risk of dangerous abnormalities in the placenta during later pregnancies, which can cause hemorrhaging and lead to a hysterectomy. Repeated Caesareans can make it risky or even impossible to have a large family.

The new report notes that Caesareans also pose a risk of surgical complications and are more likely than normal births to cause problems that put the mother back in the hospital and the infant in an intensive-care unit. The report states, “In addition to health and safety risks for mothers and newborns, hospital charges for a Caesarean delivery are almost double those for a vaginal delivery, imposing significant costs.”

Fay Menacker, an author of the report and a statistician at the National Center for Health Statistics, which published the report, said, “There’s been an increase for women of all ages and racial and ethnic groups, and all states.”

The highest rates of Caesarean births were in New Jersey (38.3 percent) and Florida (37.2 percent), and the lowest were in Utah (22.2 percent) and Alaska (22.6 percent).

The report notes that the rate in the United States is higher than those in most other industrialized countries. But rates have soared to 40 percent in some developing countries in Latin America, and the rates in Puerto Rico and China are approaching 50 percent. A report by the World Health Organization published earlier this year in The Lancet, a medical journal, said hospitals in China might be doing unnecessary operations to make money.

There is no single reason for the continuing increase in the United States. Rising multiple births because of fertility treatments have a role, because they often require Caesareans. But, the report notes, Caesarean rates for singletons increased substantially more than those for multiples. Another factor is that more older women are giving birth nowadays, and they are more likely to have Caesareans — but women under 25 had the greatest increases in Caesareans from 2000 to 2007.

Nonmedical issues are also involved. Obstetricians, fearful of being sued if there is harm to a baby after a normal labor and delivery, are quicker than they used to be to perform a Caesarean.

“The threshold for doing a Caesarean section is going down, and one of the major factors is professional liability, ending up in court,” Dr. Macones said.

In an article last month in the journal Obstetrics and Gynecology, the obstetricians’ college reported that a poll of 5,644 of its members found that 29 percent said they were performing more Caesareans because they feared lawsuits. Eight percent said they had quit delivering babies, and nearly a third of those said it was because of liability issues.

Some of the increase in Caesareans has also come from women requesting the surgery even when it is not medically necessary, Dr. Macones said. Caesareans have become so common that many people do not realize they are major abdominal surgery, with all the attendant risks.

In addition, the increased tendency to induce labor before a woman’s due date, for reasons of convenience, has helped push up the Caesarean rate, because induction is more likely than natural labor to fail and result in a Caesarean.

“We should do inductions for good solid medical reasons, not for convenience or the day of the week,” Dr. Macones said. “Sometimes patients push you.”

Another obstetrician also said patients requested what she called “social inductions,” for example, because a grandmother was visiting from out of town and hoping to see the baby before she had to leave. Another reason is the pending deployment of a husband to Iraq or Afghanistan.

Repeat Caesareans are another part of the problem. They account for about 40 percent of the total and have become increasingly common in the past 15 years as more and more hospitals have refused to allow women who have had a Caesarean to try to give birth normally. Fewer than 10 percent of women who had Caesareans now have vaginal births, compared with 28.3 percent in 1996. Many hospitals banned vaginal birth after Caesarean because of stringent guidelines set by the obstetricians’ college, which said surgery and anesthesia teams should be “immediately available” whenever a woman with a prior Caesarean was in labor.

An expert panel convened earlier this month by the National Institutes of Health said there were too many barriers to vaginal birth after a Caesarean and suggested ways to reduce them. It urged the obstetricians’ group to reassess its guidelines on “immediate availability,” and it urged hospitals to publicize their rates of vaginal birth after a Caesarean, so women could make informed choices about where to give birth. It also acknowledged the problem of malpractice suits but did not make a specific recommendation about how to solve it.

Dr. Macones said the panel’s advice made sense, but he added: “The first thing we should be trying to do is lower the primary C-section rate. Then we wouldn’t get into this trouble.”

Dr. Menacker said: “It looks as if this is a trend that is continuing. I don’t know what the future will hold.”