Unnecessary C-Sections on the Rise

Interested in home birth, hospital birth or private midwifery care? Questions or comments? Email Melissa Maimann or call 0400 418 448. Australia's caesarean rate was 31.1% in 2008.

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Five years ago, Jill Arnold got some unwanted news at her obstetrician's office. At 37 weeks pregnant, Arnold was told her baby was too big for her body to deliver naturally. Flipping open a calendar, the obstetrician asked when Arnold would like to schedule a cesarean section.

Fact: You cannot know that a baby is "too big" until you give labour a go.

Unconvinced she needed the surgery — the doctor "couldn't provide any statistics or data" her baby was too large — Arnold delivered her 10-pound, 3-ounce (4.6 kilogram) baby the old-fashioned way. Since then, the now 36-year old ... delivered another baby weighing 11 pounds, and now pens a blog called The Unnecesarean.

Women like Arnold, however, are becoming increasingly rare. Between 1996 and 2007, the number of C-sections performed in U.S. hospitals rose by more than 50 percent to an all-time high: Almost one in three pregnant women ...

"The most concerning problem is the high rate in first-time mothers," ...

... The shift is toward a more streamlined labor and delivery, and profoundly affects mothers-to-be.

... this shift is not likely to reverse any time soon.

In 2009, 26-year old Ann Carter ... labored for 14 hours. With her cervix dilated to only 6 centimeters ... her doctor told her it was time for a C-section.

"I was devastated and scared," Carter said, "I knew it was a possibility but I was hoping it wouldn't happen."

During the surgery, the doctor discovered the umbilical cord had wrapped around the baby's neck, which explained why Carter's labor had stalled. The C-section saved the baby boy's life.

Um, actually, it is very common for the cord to be around the baby's neck, and it rarely causes concerns.

"Most times the decision to perform a C-section is based on the physician's judgment," Zhang said, "but there are great variations in decision-making among physicians."

... there are "few clear-cut indications" of when to do one.

... For example, the American Congress of Obstetricians and Gynecologists (ACOG) lists "failure to progress" during labor, as an indication that cesarean delivery is needed ... When things slow down, there is an element of judgment involved where a physician determines whether to continue to wait, induce or perform a C-section ... it can take hours to determine whether or not labor is progressing.

In Zhang's study, however, he found that many patients weren’t given a sufficiently long time period to allow their labor to progress. In other words, doctors were calling it quits on waiting and opting for a C-section too soon — often before the patient's cervix was dilated to 6 centimeters.

This was especially true in cases of induced labor ... Almost half of the C-sections in these women occurred before they were 6 centimeters dilated ...

Still, it is not clear whether inducing labor raises the risk of C-section, or whether other factors are involved that contribute to why women were induced in the first place ...

... Another factor contributing to the record-high cesarean rates is a drastic decline in vaginal births after cesarean ... 70 percent of women in his study who had previously undergone a cesarean delivery had C-sections with their subsequent pregnancies, without attempting vaginal delivery.

One reason for this is a fear of lawsuits. If a physician doesn't perform a C-section, and something goes wrong with a patient who previously had a C-section, the law often does not protect the physician ...

... the number of malpractice claims involving obstetric and gynecologic surgery are the second highest of all medical specialties. In 2009, the claims totaled over $133 million.

Fears of legal action also explain why at least 30 percent of all U.S. hospitals have official bans prohibiting VBACs ...

The risks associated with a vaginal birth following a C-section have been somewhat exaggerated, however, Zhang said.

"Women and physicians may be concerned about uterine rupture, but the risk is less than 1 percent," ...

To help reduce rising cesarean rates, the American Congress of Obstetricians and Gynecologists announced less restrictive guidelines in July, stating that vaginal birth "has fewer complications than a repeat cesarean….restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against her will." ...

... some medical experts have suggested the rapid rise of C-sections in the last decade is also due in small part to mothers-to-be requesting them, not doctors. Still, data on "patient choice cesareans" is lacking, as statistics used as support of their frequency are often based on ambiguous procedural codes used on hospital discharge records.

In any case, women who opt for a C-section may not be getting adequate information about risks, and may fear they have no other option ...

... To curb the rise, many advocate giving women more autonomy over their labor and delivery, and combining the strengths of modern medicine with the principles and practices of midwifery.

La Follette's California office is an example of this more comprehensive approach: After participating in a larger practice for 12 years, she now works with two experienced midwives and another physician. Her practice has a successful VBAC rate of 75 percent.

"We take into account the expectations and ideas of the mom and balance that with medical guidance," La Follette said.

As more women consider practices with midwives and home births — which can be dangerous if complications arise — much of the medical establishment has been digging in its heels. In 2008, the American Medical Association's House of Delegates proposed a resolution to declare hospitals the only safe place for labor, and only midwives who work under the supervision of physicians as safe.

The Midwives Alliance of North America declared the resolution "seriously out-of-step with the ethical concept of patient autonomy in healthcare [that] distracts from other critical issues in maternity care."

If there is any chance of lowering the rates of C-sections, professional organizations will need to review all the available evidence, Zhang said.

But any change won't be easy. On the one hand, doctors need to include expectant moms in their own care; on the other, it sometimes seems that doctors who are worried about potential legal consequences can't focus on a patient's best interests.

"We're fighting a cultural issue," Scott said, that extends beyond C-sections.

She said, "We need to change the entire way we view birth and we have to be able to trust our caregivers. The alternative would be terrifying."

Melissa Maimann, Essential Birth Consulting 0400 418 448