In 2014 the U.S. national cesarean rate was 32.2%, 1.3 million U.S. women gave birth by cesarean. According to the World Health Organization, “cesarean section rates up to 10-15% at the population level are associated with decreases in maternal, neonatal and infant mortality. Above this level, increasing the rate of cesarean section is no longer associated with reduced mortality.” Medical, business, insurance and hospital associations are finally beginning to take this issue seriously.
One of the scheduled sessions at this year’s annual American College of Obstetricians and Gynecologists meeting in Chicago will address the “cesarean epidemic.” A popular OB/GYN online newsletter is questioning the necessity of 1 in 3 surgical births and is recommending more patience by physicians before calling a cesarean for failure to progress.
A study of severe obstetric complications in the United States from 1998 to 2005, found an increase in renal failure, maternal respiratory distress syndrome, shock, the need for ventilation, pulmonary embolism, and blood transfusions. The study concluded that the increase in complications paralleled the increase in cesarean sections during those years.
According to the California Maternal Quality Care Collaborative (CMQCC), cesareans in the U.S. have risen by over 50% in the last 15 years without any benefit for mothers or babies. The rates for cerebral palsy and neonatal seizures have not changed since 1980. However, maternal and neonatal complications from the surgery have increased. Over the last 15 years OB hemorrhage increased by 50% and blood transfusions during birth increased by 270%. The CMQCC found that both complications correlate with the rise in cesarean sections.
The National Institutes of Health has set a goal of reducing first cesareans for low-risk women to 23.9% by the year 2020. California’s health insurance exchange, Covered California, has set a policy of excluding approved provider networks with a cesarean rate higher than 23.9% beginning in 2019. The state wants to reduce the number of medically avoidable cesarean births to reduce complications and costs.
Research shows us that repeat cesareans may do more harm than good for low-risk mothers who can labor for a VBAC. Mothers and babies experience these harms both in the short- and long-term. Cesareans put mothers’ next pregnancy and fetus at risk for complications. Downstream complications include difficulty becoming pregnant again, an embryo that implants in the cesarean scar (ectopic pregnancy), and an increased risk for preterm birth and low birth-weight.
Since almost 90% of women in the U.S. with a prior cesarean will have a repeat operation (most of them as a routine procedure), the CMQCC is set to publish guidelines in April to prevent low-risk first cesareans and support vaginal birth. The CMQCC Toolkit to Support Vaginal Birth and Reduce Primary Cesareans, a collaborative project, includes the contributions of multi-stake-holders such as ACOG, ACNM, AWHONN, AAFP, Blue Shield of California, California Hospital Association, California Department of Public Health, Pacific Business Group on Health, Kaiser Permanent, various university health systems, birth centers and birth professional groups including Lamaze International, Coalition for Improving Maternity Services and Doulas of North America.
Although national consumer advocacy and maternity care quality improvement organizations have brought attention to the risks of cesareans, the addition of the recent release of Safe Prevention of the Primary Cesarean and increasing interest in lowering maternal and infant complications of avoidable cesareans may finally move the country towards reducing cesareans in a significant way.
VBAC Education Project, Module 3: A Closer Look at Repeat Cesareans: Benefits & Risks
VBAC Education Project, Module 5: Four Main Reasons for a First Cesarean: What You Can Do Differently This Time
Coalition for Improving Maternity Services, CIMS Fact Sheet: The Risks of Cesarean Section & Expectant Mother’s Checklist