Delivery Room Decisions

June 18, 2007 — -- Think about all the mothers you know, and you probably know someone who had a cesarean section delivery, as roughly one out of three births are now handled this way.

After rates for cesarean sections (or c-sections as they are often called) dipped lower in the mid-1990s, they are now up dramatically in America. The rate of these procedures rose 39 percent from 1994 to 2004, according to the National Center for Health Statistics, a division of the Centers for Disease Control and Prevention.

In fact, it is one of the most common surgeries. Of about 7 million surgical procedures done each year in the U.S., more than 1 million are c-sections.

The World Health Organization has said the ideal rate for c-sections would be about 15 percent of all births. But in this country, final figures for 2004 — the last year for which data is available — show the national rate is nearly 30 percent of all births.

American women have more c-sections than women in the United Kingdom, Canada and many European countries.

So what gives? Why are so many women having c-sections instead of delivering their babies the old fashioned way? It turns out the answer is very complicated. There is no one single reason behind the rising numbers.

Schedules, Risks Come Into Play

A small part of the rise in c-sections has to do with convenience.

Lynn Sheridan-Davis was in labor for 13 painful hours before her first child was born by c-section. After consulting with her doctor, she decided not to try a vaginal birth with her second child, in part because it would simply be easier to have another c-section and avoid all that pain.

"My mom lives in Canada, and I wanted her help. And trying to plan with a 3-year-old at home, it just seemed easier just to do a repeat c-section, so that kind of everything is taken care of," Sheridan-Davis said.

But the convenience of planning a c-section is only a small part of the story.

For a woman like Sheridan-Davis, who has already had one c-section, there is an increased risk to delivering another child vaginally. These days, most women who've had a prior c-section choose to have another with subsequent births.

And, for doctors, the threat of lawsuits also comes into play. Obstetricians are among the most vulnerable to litigation if something goes wrong in the delivery room. Choosing to perform a c-section, in some cases, can help reduce the possibility of being sued.

"They're never faulted for doing a c-section," said Faith Frieden, chief of obstetrics and gynecology at Englewood Hospital and Medical Center in New Jersey. "It's never the wrong decision to do a c-section. No one's ever going to say to them, 'why were you so quick to do the cesarean section?'

"Usually what happens is, if anything goes wrong, then they're questioned later on, 'wouldn't it have been better if you did the cesarean section a little sooner?' 'Why didn't you do the c-section?' 'Wouldn't that have been the easiest way to deliver this baby — the less traumatic way to deliver this baby?'" Frieden explained.

Doctors Debate Impact of Rising C-Sections

Another part of the rise in numbers has to do with advances in medicine and changing norms for parenthood, as more older women are having babies. They are at greater risk for complications that can lead to emergency c-sections. Fertility advances mean more multiple births, which are often delivered by c-section.

And Americans have just generally become more comfortable with the idea of surgery.

"You can come in and you can have your baby an hour after you arrived and I can sew you up neat and tidy and you're all done. Versus, 'well, let's wait up to another few weeks for you to go into labor by yourself," said Dr. Lauren Plante, an associate professor of obstetrics, gynecology and anesthesiology at Thomas Jefferson University in Philadelphia, and a critic of the high rate of c-sections.

Plante and many others worry that women and doctors have become too cavalier about c-sections, too willing to call for what can be an unnecessary surgery.

"It's not a decision that I think we should be making all that lightly," she said. Whether or not a c-section can be more risky for a mother or her baby's health is another area of intense debate in the obstetrics community.

A National Institutes of Health conference last year reviewed all the available evidence — comparing dozens of competing and overlapping risks for having a c-section for no medical reason versus going through labor the old-fashioned way.

The result of their exhaustive review: The NIH said "more research is needed."

There is no question, though, that a c-section is major abdominal surgery. And while the number of women and infants who die during childbirth is very small, studies have found that mothers and babies are more likely to die during or after a cesarean delivery. That may be, in part, due to the condition in which the mother enters the operating room, but it is a sobering statistic, nonetheless.

"I think we're engaged in a great big uncontrolled experiment as to what happens when cesarean section rates rise," said Plante.

As a public health issue, many doctors worry that it is costing the health care system — and, therefore, all of us — more money to have so many women delivering by c-section and staying in the hospital for longer recoveries. Some say it is an unnecessary drain on resources.

But in the end, the NIH and every expert we spoke with said each mother needs to make her own informed decision in consultation with her doctor. "The bottom line is that we want to have healthy mother, healthy baby," said Frieden. "And if we're achieving that, then I don't think we have to apologize for our c-section rate."