Caesarean sections started dropping slowly in the early 1990s after an outcry that American women undergo too many — but now they’re on the rise again.
Most puzzling: Why C-sections are increasing in first-time moms, not just in women who previously had one. And where pregnant women live determines how likely they are to wind up on the operating table — C-sections are more common in the South than out West.
Now, with Caesareans inching back up to 22 percent of U.S. births, the nation’s leading obstetricians’ group is issuing new guidelines to reduce unnecessary C-sections and reserve the surgery for mothers and babies who truly need it.
There are many suspects in the C-section rise — state-by-state variation particularly suggests doctors’ habits sometimes can overshadow medical need.
Are We Too Technical?
“Maybe we’ve become too technical,” says Dr. Jean Walker, an attending obstetrician at Chicago’s Rush-Presbyterian-St. Luke’s Medical Center, which is taking new steps to lower C-sections. “We’re going back to natural things like walking more often and birthing balls and really encouraging natural descent of the fetus.”
To do that, Rush just began a nursing change — back to more continuous, hands-on care during early labor, especially for first-time moms whose labor takes longer, a big reason for C-sections. After all, studies show women who have continual care from nurses or midwives get fewer C-sections than when busy nurses just pop by every so often to check how early labor is progressing.
Make no mistake: Caesareans can be a life- or health-saving procedure for many mothers and babies. Fetal distress, disorders that make labor risky for the mother, a baby simply too big or wrongly positioned all are important reasons for C-sections — and hospitals that specialize in high-risk pregnancies will perform more.
But avoiding unnecessary C-sections also is important. Women’s risk of death, although still small, is three to seven times higher than during vaginal delivery, says the American College of Obstetricians and Gynecologists. Not to mention increased pain, longer hospital stays and a higher risk of post-delivery infection.
On the Rise
C-sections have risen for three years, climbing another 4 percent in 1999 to account for 22 percent of live births, the government reported this month.
That’s lower than the nation’s high of 25 percent in 1988 — but nowhere near the federal goal of a 15 percent C-section rate this year. And it reverses a steady decline in C-sections between 1989 and 1996.
Now look state-by-state: Fewer than 17.5 percent of births in Utah, Wisconsin, Colorado, Alaska or Vermont are C-sections. But more than one in four births are C-sections in Mississippi, Louisiana, Arkansas and New Jersey.
Worse, the most dramatic variations in hospitals’ C-section rates are among first-time moms with healthy babies in the right birth position, says the ACOG.
Those discrepancies suggest doctors’ habits play a big role, says Dr. Roger Freeman of the University of California, Irvine, who chaired the new ACOG guidelines that outline practices and conditions linked to higher C-sections — and urge doctors to check for ways to improve.
Ways to Improve
A previous C-section is the biggest risk factor for having another. If the surgical cut was in the lower abdomen — not the upper — ACOG says most healthy women can try vaginally delivering their next baby as long as a surgeon is standing by if emergency surgery is needed. Most low-risk mothers who try can deliver vaginally, says ACOG, encouraging women to carefully discuss this option with their doctors.
Yet the rate of vaginal births after C-section fell to 23.4 percent last year, down 17 percent since 1996. Slow labor is a big reason for C-sections in first-time moms. ACOG cautioned against surgery too early, and Chicago’s Walker also stressed patience, saying here that nurses are key. “With younger nurses, I get more phone calls saying, ‘Nothing’s happening, she needs a C-section,’” while older nurses are “a little more attentive, more patient” with slow labor. ACOG says demanding a painkilling epidural too early, before the cervix is dilated 4-5 centimeters, increases your C-section risk. But this is controversial — Walker urges women to ask for a less potent “walking epidural” that she says doesn’t increase the risk. For breech, or feet-first, babies, doctors should consider trying to turn the baby headfirst by “external version,” pushing on the mother’s abdomen before automatically operating, ACOG advised.
While ACOG targets doctors, consumer advocates advise pregnant women to ask about C-section rates when choosing a physician and hospital. Pick one with a lower rate, or who’s open to a second opinion for nonemergency surgery, and “it’s more likely you’re going to avoid an unnecessary C-section,” says Public Citizen’s Dr. Sidney Wolfe.