Birth data for 2008 recently published by the U.S. Centers for Disease Control (CDC) and National Center for Health Statistics show that the U.S. cesarean rate rose for the 12th consecutive year. Cesarean section, the most common major surgical procedure performed in the U.S., accounted for 32.2 percent of all births in 2008. Despite concerns about the health risks of cesareans for mothers and infants physicians performed 2 percent more cesareans in 2008 than in 2007. The cesarean rate increased 56 percent since 1996 when the rate was 20.7 percent.
According to the CDC the rise in the total cesarean delivery rate since the mid 1990s has been driven by increases in primary cesareans and decreases in vaginal births after cesarean delivery (VBAC) . The increase in primary cesareans and decline in VBACs may have been influenced by shifts in demographics, maternal choice and other nonclinical factors, as well as VBAC guidelines from the American College of Obstetricians and Gynecologists (ACOG) and increased medico-legal pressure.
Hospital charges for a cesarean delivery are almost double those for a vaginal birth, adding significant cost to childbearing families. In 2007-2008, the average cost of a hospital vaginal delivery without complications was $ 8,919 compared to $14,894 for a cesarean without complications.
Earlier this year the CDC confirmed that a cesarean is major abdominal surgery and is associated with higher rates of surgical complications and maternal rehospitalization, as well as with complications requiring admission to a neonatal intensive care unit. (NCHS Data Brief ■ No. 35 ■ March 2010)
When the number of cesareans increase so does the risk for serious complications in a subsequent pregnancy including placenta previa (placenta covers the internal os) and placenta accreta (placenta abnormally attaches to the uterine wall). With a placenta accreta mothers are at increased risk for hemorrhage and blood transfusion. Mothers are more likely to develop life threatening blood clots, have a hysterectomy, and more likely to die in childbirth. With a prior cesarean the odds of having placenta accreta increase with each additional repeat cesarean
According to the California Maternal Quality Care Collaborative (CMQCC) the rising incidence of placenta accreta is due to the rapidly rising numbers of primary and repeat cesarean births.
This chart, developed by the CMQCC shows the increased risk for placental problems when women have a repeat cesarean.
Infants are also affected. With a planned primary non-medically indicated cesarean there is a 69 percent higher risk of neonatal mortality than with a planned vaginal birth.
Despite efforts to reduce cesarean rates and increase access to VBAC some states surpassed the national average for the number of cesareans performed. State cesarean rates varied widely ranging from 22.0 percent in Utah to 38.7 percent in New Jersey. Louisiana (38.0 percent) and Florida (37.6 percent) had the second and third highest cesarean rate. Alaska (22.6 percent) and New Mexico (22.9) had the second and third lowest. The highest number of cesareans were performed in Puerto Rico, where 48.5% percent of women gave birth by major surgery.
According to 2008 birth data non-Hispanic black women were more likely to deliver by cesarean (34.5 percent) than non-Hispanic white (32.4 percent) and Hispanic (31.0 percent) women. Although the rise in cesarean rate has slowed in recent years among many states, in 2008, 22 states had higher cesarean delivery rates than in 2007, an average increase of 2.5 percent.
Healthy People 2020 Goals for Reducing Cesareans
The increasing cesarean rate runs contrary to the Healthy People 2020 national health goals to reduce primary and repeat cesareans and the rate of maternal mortality.
To improve maternal and child health the U.S. Department of Health and Human Services Healthy People 2020 goals are to reduce the number of cesareans for low-risk (full-term, singleton, vertex presentation) women giving birth for the first time from 26.5 percent in 2007 to 23.9 percent. To increase the number of low risk women who have repeat cesareans from 90.8 percent in 2007 to 81.7 percent and to reduce maternal deaths.
The maternal mortality rate in 2007 was 12.7 per 100,000 the goal is to reduce the rate to 11.4 by 2020, all goals target a 10 percent improvement. Researchers found that healthy women who plan a cesarean are at increased risk of death compared to healthy women who plan a vaginal birth. Maternal deaths were due to complications of anesthesia, birth-related infection, and venous thromboembolism (blood clots).
To help an expectant mother understand the health implications of cesarean section for herself and her baby, the Coalition for Improving Maternity Services developed a checklist for mothers to read during pregnancy and discuss with her care provider. Reviewing this checklist can help mothers make an informed decision about planning a non-medically indicated cesarean.
Coalition For Improving Maternity Services
About The Risks of Cesarean Section
A Checklist For Mothers To Read During Pregnancy
Birth is a normal, natural, process and the vast majority of women can have safe, normal, vaginal births. There are health conditions where a cesarean birth is necessary for the well being of the mother or her baby. However, more and more mothers these days are giving birth by cesarean section for non-medical reasons. A cesarean poses risks as well as benefits for mother and baby, and should not be undertaken lightly. This educational material is provided by the Coalition for Improving Maternity Services (CIMS) to help all expectant parents become better informed about the risks of cesarean section.
To give the expectant mother time to reflect on this information and consider the impact of cesarean surgery on her health and the health of her baby, care providers are encouraged to introduce and discuss this evidence-based information throughout pregnancy and no later than at 32-34 weeks. The expectant mother is encouraged to take the form home, read and initial the statements, discuss the information with her partner, and raise any questions or concerns she may have with her care provider. The form may then be placed in her chart.
Expectant Mother’s Name: ____________
Care provider’s Name: _______________
A cesarean section is an operation by which a baby is born by making a cut in the mother’s lower abdominal wall (abdominal incision) and a cut in her uterus (uterine incision). I understand that a cesarean operation may be more dangerous than a vaginal birth for my baby and me.
POSSIBLE PROBLEMS FOR ME WITH A CESAREAN AS COMPARED TO A VAGINAL BIRTH:
1. _____I am more likely to have more blood loss and a longer recovery time.
2._____ I am more likely to have accidental surgical cuts to my bladder, bowel, or gastrointestinal tract.
3._____ I am more likely to have a serious infection in my incision, uterus, or bladder.
4. ____ I am more likely to have thick scarring (adhesions) inside my abdomen that may cause chronic pain years after my cesarean. This scarring can make any future abdominal operation I may need more difficult.
5.____ I may have uncontrolled bleeding and need an emergency hysterectomy (removal of the uterus) if the bleeding cannot be stopped.
6.____ I am more likely to have complications from anesthesia.
7. ____ I am more likely to develop serious and life-threatening blood clots that can travel to my lungs (pulmonary embolism) or my brain (stroke).
8.____ I am more likely to be admitted to intensive care.
9.____ I am more likely to need to return to the hospital for complications from the cesarean operation.
10.____ I am more likely to feel pain and/or numbness at the site of the operation for several months after my surgery.
11.____ I am less likely to breastfeed successfully. I may lose out on the health benefits of breastfeeding for myself, including: weight loss, reduced risks of cancers, heart disease, diabetes, and osteoporosis.
12.____ I am less likely to have a satisfactory birth experience. I am more likely to have emotional problems such as post-partum depression and post-traumatic stress. Many women experience a profound sense of happiness after a normal birth that flows naturally into bonding with the baby and breastfeeding.
13_____ I am more likely to die.
POSSIBLE PROBLEMS WITH A CESAREAN FOR ME WITH A FUTURE PREGNANCY AS COMPARED TO A VAGINAL BIRTH:
14.____ I am more likely to have trouble becoming pregnant again.
15.____ I am more likely to have complications in a future pregnancy due to the scar in my uterus. If the new placenta attaches over my previous scar, it is more likely to cause serious problems, including: serious bleeding, placenta coming in front of the baby (placenta previa), placenta growing into or even through the wall of the womb (placenta accreta), miscarriage, or pre-term birth.
16 .____ I am more likely to have a baby with a congenital malformation, central nervous system injury, or low birth weight due to problems with the placenta.
17. ____ I am more likely to have a stillbirth.
18. ____ I am more likely to require major surgery to remove cells from the lining of my uterus that may grow outside my womb (endometriosis).
19. ____ Since it is difficult to find a physician or hospital supportive of a vaginal birth after a cesarean (VBAC), I am more likely to have a repeat cesarean for the birth of all my future children, although a vaginal birth after a cesarean birth is usually safe. Each additional operation I have increases the odds for complications.
20.____ Research shows that having a cesarean will not protect me from urine, gas, or stool incontinence in the future, or from future sexual problems.
21.____ I may not be able to get healthcare coverage since some insurance providers consider a cesarean to be a pre-existing condition.
POSSIBLE PROBLEMS FOR MY BABY:
1. ____ My baby is more likely to be born prematurely if the cesarean surgery is performed anytime before labor begins. A premature baby is more likely to experience the following:
-admission to the intensive care nursery
-trouble breastfeeding, digesting food, and regulating body temperature
-brain development problems and difficulties in learning in school
2.____ My baby is more likely to face complications from anesthesia and postpartum pain medication.
3.____ My baby is more likely to be accidentally cut during surgery.
4.____ My baby is more likely to have breathing difficulties since labor contractions clear the lungs.
5. ___ If I agree to a scheduled cesarean, it is normally best to wait for labor to begin before performing the operation.
6 .____ My baby is more likely to have difficulty breastfeeding. My baby is less likely to benefit from skin-to-skin contact with me and is less likely to get the health benefits from breastfeeding including: reduced risk for asthma, allergies, respiratory infections, type 1 diabetes, childhood leukemia, and SIDS (sudden infant death syndrome). If I do have a cesarean, I can request special care to help me and my baby breastfeed successfully before I am discharged from the hospital.
I have read and discussed this information with my care provider.
Expectant Mother’s Signature____________ Date_____________
Care provider’s signature_______________ Date____________
This information is provided for expectant mothers and their care providers by the Coalition for Improving Maternity Services (CIMS). CIMS strongly recommends that cesarean surgery be reserved for situations when potential health benefits clearly outweigh the risks. Please see The Risks of Cesarean Section, a CIMS Fact Sheet for the references that support this form, available as a free download from http://www.motherfriendly.org/downloads/php