U.S. Cesarean Rate Dips Slightly: Is There Hope for More VBACs?

19 Nov

This week the Centers for Disease Control and Prevention released their report  on preliminary data for 2010 births in the United States. There were 4,000,279 births in 2010, 3 percent less than the year before. The cesarean section rate declined slightly from 32.9 percent to 32.8 percent, the first decline in cesareans since rates started climbing in 1996. Seventeen states and the District of Columbia however, had a higher cesarean rate in 2010 than in 2009.

Recently, there has been a long-awaited call by academics, healthcare quality improvement groups, business groups, hospital associations and state lawmakers to bring down the number of cesareans. To reduce the number of maternal and newborn complications associated with the surgical procedure as well  reduce healthcare costs.

Some in the medical community are also trying to increase access to VBAC by redefining ACOG’s restrictive recommendation to have a surgical team “immediately available” for all women laboring for a VBAC regardless of their risk status. Although there is nowhere near agreement about what the ideal cesarean rate should be, there is an increasing awareness that mothers and newborns should not be subjected to unnecessary health risks associated with the operation when health outcomes are not improved.

More than 4 out of 10 births in the U.S. are paid for by Medicaid  and shrinking state budgets make cesarean section, a high-ticket item,  a logical focus of expense cuts. In 2009 the average cost of a cesarean section ranged from $13,000 to $20,000 compared to $11,400 for a vaginal birth.

Research has shown that non-medically indicated early elective deliveries (between 37 and 39 weeks gestational age)  are associated with short and long-term neonatal morbidities,  increased neonatal deaths and no health benefits for  mothers. Repeat cesarean sections puts mothers at increased risk for death.  There is now a nation-wide focus on reducing elective (medically unnecessary) cesareans before 39 completed weeks of gestation. Elective inductions before 39 completed weeks are also associated with poor birth outcomes.

According to the Leapfrog Group, a leading national non-profit organization that helps employers with value-based purchasing of healthcare, several hospital associations and state health departments have been actively working to  lower their elective delivery rates.

In an editorial in the August 2011 issue of Obstetrics & Gynecology Dr. John T. Queenan’s commentary, How to Stop the Relentless Rise in Cesarean Deliveries, warns colleagues that the U.S. cesarean rate is likely to reach 50% unless cesarean rates are reduced and access to VBAC is increased. Dr. Queenan’s recommendations for lowering cesarean rates include evidence-based patient education on the benefits and risks of cesareans, increasing the number of midwives who attend low-risk women, paying physicians a higher reimbursement rate for supporting VBAC and retraining physicians in the art of vaginal breech birth.

Despite a recommendation by the National Institutes of Health Consensus Development Conference on VBAC that ACOG should reconsider its controversial and confusing guidelines that call for an “immediately available” surgical team for all women who labor for a VBAC, current guidelines have not changed. However, some physicians are looking for ways to increase access to VBAC.

In an article by James R. Scott, MD, titled, Vaginal Birth After Cesarean: A Common-Sense Approach, also published in the August 2011 issue Obstetrics & Gynecology, Scott presents a positive and flexible approach to support women who want to labor for a VBAC without increasing providers’ exposure to malpractice suits. “We need to do what is best for the patient,” he writes despite fear of malpractice suits. This is an ethical approach to caring for women with a previous cesarean that has not been considered for more than a decade.

Scott refers physicians to the evidence-based protocols of the Northern New England Perinatal Quality Improvement Network (NNEPQIN) VBAC Project risk stratification method that hospitals can use to provide care for women who labor for a VBAC in community hospitals, dismissing the assumption that only facilities that care for high-risk childbearing women can provide safe care for VBAC.

In the September 2011 issue of Obstetrics and Gynecology Dr. Howard Blanchette of New York Medical College argues that contrary to common belief, the rise in cesarean sections has led to increased adverse health outcomes for mothers and newborns.”  In his commentary, The Rising Cesarean Delivery Rate in America: What Are the Consequences?, he urges physicians to “reduce the primary cesarean delivery rate and avoid the performance of a uterine incision unless absolutely necessary.” His recommendations for reducing the cesarean rate include promoting support for women who want to plan a VBAC and refraining from performing a cesarean on first-time mothers for failure to progress (dystocia) until they are in the active phase of labor (4 or more centimeters of dilation).  A recent Yale University study found that primary cesarean births (first cesarean) accounted for 50 percent of the increasing cesarean rate in the U.S. and that non-progressive labor was a subjective indication for performing a cesarean which contributed more than other more objective indications (such as placental problems and  malpresentation) to the increase in cesareans.

A one tenth of one percent decrease in the U.S. cesarean rate, an increased awareness of the health implications of a surgical birth and a call for fewer cesareans and more VBACs is a trend we have not seen in decades. Whether or not this trend will continue and how many years it will take to make a significant dent in the cesarean rate is yet to be seen.

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