Caesarean Sections on the Rise

W A S H I N G T O N, Aug. 29, 2000 -- Caesarean sections started dropping slowly inthe early 1990s after an outcry that American women undergo toomany — 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 womenlive determines how likely they are to wind up on the operatingtable — 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 newguidelines to reduce unnecessary C-sections and reserve the surgeryfor mothers and babies who truly need it.

There are many suspects in the C-section rise — state-by-statevariation particularly suggests doctors’ habits sometimes canovershadow medical need.

Are We Too Technical?

“Maybe we’ve become too technical,” says Dr. Jean Walker, anattending obstetrician at Chicago’s Rush-Presbyterian-St. Luke’sMedical Center, which is taking new steps to lower C-sections.“We’re going back to natural things like walking more often andbirthing balls and really encouraging natural descent of thefetus.”

To do that, Rush just began a nursing change — back to morecontinuous, hands-on care during early labor, especially forfirst-time moms whose labor takes longer, a big reason forC-sections. After all, studies show women who have continual carefrom nurses or midwives get fewer C-sections than when busy nursesjust pop by every so often to check how early labor is progressing.

Make no mistake: Caesareans can be a life- or health-saving procedure formany mothers and babies. Fetal distress, disorders that make laborrisky for the mother, a baby simply too big or wrongly positionedall are important reasons for C-sections — and hospitals thatspecialize in high-risk pregnancies will perform more.

But avoiding unnecessary C-sections also is important. Women’srisk of death, although still small, is three to seven times higherthan during vaginal delivery, says the American College ofObstetricians 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 4percent in 1999 to account for 22 percent of live births, thegovernment reported this month.

That’s lower than the nation’s high of 25 percent in 1988 — butnowhere near the federal goal of a 15 percent C-section rate thisyear. And it reverses a steady decline in C-sections between 1989and 1996.

Now look state-by-state: Fewer than 17.5 percent of births inUtah, Wisconsin, Colorado, Alaska or Vermont are C-sections. Butmore than one in four births are C-sections in Mississippi,Louisiana, Arkansas and New Jersey.

Worse, the most dramatic variations in hospitals’ C-sectionrates are among first-time moms with healthy babies in the rightbirth position, says the ACOG.

Those discrepancies suggest doctors’ habits play a big role,says Dr. Roger Freeman of the University of California, Irvine, whochaired the new ACOG guidelines that outline practices andconditions linked to higher C-sections — and urge doctors to checkfor ways to improve.

Ways to Improve

A previous C-section is the biggest risk factor for havinganother. If the surgical cut was in the lower abdomen — not theupper — ACOG says most healthy women can try vaginally deliveringtheir next baby as long as a surgeon is standing by if emergencysurgery is needed. Most low-risk mothers who try can delivervaginally, says ACOG, encouraging women to carefully discuss thisoption with their doctors.

Yet the rate of vaginal births after C-section fell to 23.4percent 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 alsostressed patience, saying here that nurses are key. “With youngernurses, I get more phone calls saying, ‘Nothing’s happening, sheneeds a C-section,’” while older nurses are “a little moreattentive, more patient” with slow labor. ACOG says demanding a painkilling epidural too early, beforethe cervix is dilated 4-5 centimeters, increases your C-sectionrisk. But this is controversial — Walker urges women to ask for aless potent “walking epidural” that she says doesn’t increase therisk. For breech, or feet-first, babies, doctors should considertrying to turn the baby headfirst by “external version,” pushingon the mother’s abdomen before automatically operating, ACOGadvised.

While ACOG targets doctors, consumer advocates advise pregnantwomen to ask about C-section rates when choosing a physician andhospital. Pick one with a lower rate, or who’s open to a secondopinion for nonemergency surgery, and “it’s more likely you’regoing to avoid an unnecessary C-section,” says Public Citizen’sDr. Sidney Wolfe.