Tag Archives: elective cesarean

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.

Elective Inductions, Cesareans, and Preterm Birth

20 Nov

November is Prematurity Awareness Month when the March of Dimes (MoD) encourages care providers and the public to focus on the high number of preterm births in the United States and what can be done to reduce them. The March of Dimes, along with state and national health services are concerned that increasing elective inductions and scheduled cesareans may be contributing to the rising number of babies born preterm. Premature birth is the number one cause of newborn death in this country.

In addition to encouraging women to stop smoking, avoiding multiples from fertility treatments and providing progesterone treatments for women with a history of preterm birth, the MoD recommends avoiding unnecessary cesareans and inductions before 39 weeks and encourages women with a healthy pregnancy to wait for labor to begin on its own.

Between 1990 and 2006  the number of babies born after 39 weeks decreased sharply and the number of babies born between 36-38 weeks gestation rose sharply. Experts associate this trend with increasing rates of induction of labor and cesarean sections. An integrated health care system based in Salt Lake City, Utah reported that in 2001, 28%  of their elective deliveries were performed prior to 39 weeks.

In 2008 12.3%  of all U.S. births were preterm. Based on records from the National Center For Health Statistics, the March of Dimes developed a score card for national and state preterm birth rates. Comparing the  national preterm birth rate to the Healthy People 2020 goal of 7.6%  the MoD gave the U.S. a “D” grade.

Preterm birth is defined as a live birth before 37 completed weeks gestation. A baby born between the 34th and 36th week of pregnancy is considered  late preterm. A full term pregnancy is 40 weeks. When cesareans are scheduled or labor is induced there is a margin of error in pinpointing fetal maturity. Being born only one week earlier can make a difference in terms of complications babies are likely to suffer.

The number of cesareans increased by 71% between 1996 and 2007. The rate rose for women in all age, racial and ethnic groups. The National Center for Health Statistics  found that non-medical factors including physician practice style and women’s preferences contributed to the widespread and continuing rise of cesareans (NCHS Data Brief No. 35, March 2010).

A large percentage of the increase in preterm and late preterm singleton (one baby) births between 1996 and 2004 occurred among women who delivered by c-section.

The last few weeks of pregnancy are extremely important to a baby’s health because many organs, including the brain and lungs, are not completely developed yet. Babies born a few weeks too soon can face serious health challenges and are at risk for lifelong disabilities, such as cerebral palsy, lung problems, vision and hearing loss, and learning disabilities.

Expectant mothers however, are not aware of the importance of keeping the pregnancy full term. In a recent U.S. survey over 90% of women believed that giving birth at 39 weeks was safe, unaware of the crucial brain development that occurs in the last weeks of pregnancy. Women who agree to or choose to induce labor or schedule an elective cesarean don’t consider the additional interventions and days in the hospital that premature babies often need nor are they aware of the financial costs.

Elective inductions also increase the risk for cesarean section.

A national campaign is in full force to educate care providers, hospitals, and the public about the importance of maintaining a full term, 40 weeks, pregnancy. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the national body that accredits hospitals, recommends that hospitals track and reduce their induction rates as one criteria to gain accreditation.

On November 15, 2010 the Mineapolis – St. Paul Star Tribune reported that the Minnesota State Department of Human Services is leading the nation in discouraging birth by convenience. It has  created a policy against elective, non-medically indicated inductions by asking hospitals to establish policies to reduce convenience inductions by the year 2012.

Although the national preterm birth rate dropped 3% in the last two years, the U.S. still has one of the highest preterm birth rates in the world. Hopefully, the progress that has been made in the last two years will continue.

For additional information on the impact of labor induction and preterm birth see, Labor Induction Exposed, posted November 15, 2010 on Mother’s Advocate Blog.

Sources for this article:

March of Dimes/California Maternal Quality Care Collaborative, Elimination of Non-medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age, A California Tool Kit To Transform Maternity Care.

March of Dimes, 2010 Prematurity Birth Report Cards

March of Dimes, www.prematurityprevention.org

March of Dimes, Professional Resources

Educational Resources

U.S. Surgeon General Dr. Regina Benjamin’s message on preterm birth, video

March of Dimes, Why The Last Weeks of Pregnancy Count

Lamaze International, Let Labor Begin On It’s Own

Mother’s Advocate, Let Labor Begin On It’s Own, video