March 10, 2010 -- Cesarean births are at an all-time high and fewer women who've had a C-section are opting for vaginal births on subsequent pregancies, according to the National Institutes of Health.
The trend has spurred the NIH to reassess current recommendations on birthing practices.
At this week's Consensus Development Conference on Vaginal Birth After Cesarean (VBAC), the NIH is seeking to provide better guidance to clinicians on this topic. The results of this meeting will be presented Wednesday afternoon in a consensus report.
"The rise in cesareans is disheartening," says Dr. Marjorie Greenfield, director of general obstetrics and gynecology at University Hospitals MacDonald Women's Hospital. "It is driven by many forces including economic incentives and malpractice fears, but also by our management of 'normal labor,'" she says, referring to a growing perception by mothers of the need to have "perfect outcomes" with deliveries despite the imperfect nature of the birthing process.
But experts were optimistic about the conference and felt that practice-changing recommendations may come out of this meeting.
"The mood at the conference," notes Dr. Lucky Jain, "has been overwhelmingly in favor of promoting VBAC, [especially] if we can improve our ability to identify those [rare] mothers that might have complications with VBAC."
Risks of Cesarean
Nearly one in three babies born today are delivered by C-section, according to the Centers for Disease Control and Prevention.
Though C-sections are associated with lower rates of birth injuries and are perceived as a lower-risk procedure in the face of a long and difficult labor, they are not without risks of their own.
In the short term, C-sections can result in longer hospital stays, higher risk for infection, and possible respiratory issues for the baby.
Jain says that cesarean delivery can interrupt the natural process through which newborns transition to breathing in an air environment.
His work has found that babies born from C-sections have higher rates of respiratory distress after birth, and a higher risk long term of developing asthma.
This, he says, is in large part because of babies' inability to clear lung fluid -- a process that is aided by certain hormones released during spontaneous labor.
The mother's health can also be compromised by C-section, especially after repeated cesareans.
Complications escalate with each C-section, Jain says. "This became clear at the meeting: that uterine rupture or the need for a hysterectomy after cesarean is much higher in mothers who will have multiple children."
"If you look at this country compared to any other industrialized country, we have one of the highest c-section rates of any," Nan Strauss of Amnesty International told "Good Morning America, "and along with the increase is coming an increase in very severe complications, and in deaths as well."
Explaining the Rise in C-Sections
This becomes more of an issue considering that many doctors are hesitant to perform VBAC -- women given a cesarean section with their first child who wish to have several children will have to cope with increasing risk to their health and the health of their baby with each additional child.
Considering the risks, not to mention the medical costs of this procedure, why have C-sections become so prevalent?
The answers are unclear, experts note, but involve many factors, including economic incentives, law suits, America's risk-averse medical practice, and the resources available to hospitals.
For most of the 20th century, the NIH notes, it was assumed that a woman who had a cesarean section would need to deliver all future babies by the same procedure because the process of labor would put her at risk for a rupture of the uterus along the old incision mark -- a complication that can become deadly for the newborn within 15 minutes.
But considering the risk of complications with vaginal births is very small and can be addressed with proper emergency care, VBAC became more common in the 1980s and 1990s in an effort to lower cesarean rates, says Dr. Mark Landon, chief of obstetrics at Ohio State University Medical Center and VBAC researcher.
"Over the last decade, however, we seem to have lost interest in this process," he says, and now "everyone recognizes that far too many cesarean sections occur," but the rate continues to rise.
A major factor in this trend, says Dr. Lauren Streicher, obstetrician gynecologist at Northwestern Memorial Hospital, is the incentive structures in place that lead obstetricians to deliver babies by cesarean.
"Obstetricians must sit in labor for 12, 24 hours and cancel their office appointments," but they are not financially compensated for this time and effort. C-sections, on the other hand, pay out nearly twice as much, and can be scheduled for convenient times and done in an hour and a half.
There is also a tendency in the field, Streicher says, to say that birth problems that occur after a C-section were "unavoidable," while concluding that birth problems that occur in VBAC could have been avoided with a C-section. As a result, obstetricians are often plagued by malpractice suits when there are problems with a baby born vaginally.
One study presented at the conference, Jain notes, looked at the reasons some doctors had stopped offering VBAC that encapsulates the complicated nature of this trend.
The number one reason doctors stopped offering VBAC, the study said, was because a mother ruptured her uterus. The second most common reason cited by doctors was prior experience having a lawsuit, as Streicher highlights.
The number three reason given was a lack of available resources to handle a serious complication (such as a ruptured uterus) -- a problem which leads many small, rural hospitals to employ a no VBAC policy.
What's "alarming," Landon says, is that this VBAC "ban" is being extended to hospitals that are clearly equipped to deal with emergency birth situations, leading to unnecessary repeat cesarean procedures.
Finding the Middle Ground
There is certainly a time and a need for both repeated cesarean deliveries and vaginal births, Streicher emphasized:
"It's really a case-by-case thing. You're not doing anyone any favors by having a 36-hour delivery -- the idea that a vaginal delivery is always better for mother and baby is simply not true."
But while often used in an attempt to reduce the risk of complications at all costs, "the pendulum has swung too far" in favor of C-sections, Landon says.
He feels that the conference will advise that "we need to start utilizing VBAC again."
Jain agrees that the consensus report will advise improved access to VBAC, but what's more, he feels confident it will provide a "balanced approach to the subject" and emphasize "giving the women the right to choose" which procedure and which risks they are willing to live with.