C-sections: Weigh The Risk

The Cesarean section has become so prevalent that it is the most-performed surgical procedure in the U.S. It is a vitally necessary procedure that has saved countless mother and child lives; however, statistics now show that many C-sections aren’t only not medically necessary, they increase the risk of adverse health events for both mother and child.

For the nine months of her pregnancy, Ocala resident Renee Albright made regular visits to her local obstetrician. Two days prior to her due date, he told her that he would be going on vacation and wouldn’t be present at the birth of her first child.

“I was absolutely devastated,” she says. “This was my first child. I had no idea what giving birth would be like, and I had seen only him for my entire pregnancy.”

Several days later, when Renee began feeling the first twinges of labor, she called his office, and staff told her to go to the hospital.

“I entered the hospital around 10am, and by 6pm, I was dilated to 8 centimeters,” she says. “My husband was with me, and everything seemed to be progressing. Around 7pm, the delivery staff began pressing me to get an epidural. They said, ‘If you want an epidural, you have to have it now. The anesthesiologist is going home.’ This went on for quite a while, and I felt so intimidated that I finally gave in and had the epidural. I knew I didn’t need it, but they pushed me so hard to have it done that I gave in and did it.”

Renee had been lying in bed for 10 hours. She says that she wasn’t told to walk, take a warm shower or exercise to encourage labor and dilation.

“They started telling me that I wasn’t progressing and just before midnight the obstetrician on call came in and told me that he wanted to do a C-section. I knew it was major surgery, and I just wanted to have my baby naturally. I was healthy and strong, and I really felt that if I pushed I could have my baby. I could understand if I had been in labor for 24 or 48 hours and wasn’t progressing, but it had barely been 12 hours. I tried to argue against it, but it was all so intimidating for me.”

Renee was wheeled into surgery shortly after midnight.

“The anesthesiologist, who was supposed to be going home around 7pm, came in and gave me another epidural just prior to the operation,” Renee says. “I was totally unprepared for a C-section. My arms were strapped down, and I didn’t get to hold my daughter until hours later. I ended up in a dark recovery room for hours, and it was days before I could get up and walk. The recovery was so painful, and it was at least a year before I feel that I fully recovered.”

Renee’s experience occurred in 2003. Many things have changed since then, but unnecessary C-sections during primary births remain as big a problem today as they did 15 years ago.

“We use standards set by the American Congress of Obstetricians and Gynecologists (ACOG) based on the Friedman Curve,” says Dr. Raymond Marquette, medical director for AdventHealth Ocala (formerly Munroe Regional Medical Center). “These standards determine how quickly labor and dilation should progress. If a woman’s dilation remains at a certain rate for a certain period of time and doesn’t progress (called dystocia), then we would talk with her about getting a C-section.”

Friedman’s Curve was established in 1955 using a minimal population of women in a New York hospital. It was used unchallenged until 2013 when the curve was adjusted by the ACOG to the standard used today. Prior to 2013, active labor was determined to begin at 2 centimeters dilation; today that number is 6 centimeters. More in-depth research shows that the characteristics of labor are changing over time with labor lasting longer and babies being born slightly larger today than when Friedman’s Curve was created.

“When the patient is at 6 centimeters, the amniotic membrane has ruptured, the patient has had four hours of adequate contractions or six hours of inadequate contractions, only then can you call that arrest of labor or dystocia,” adds Dr. Marquette. “You can see that’s a huge difference. Now it’s giving patients more time to get the baby out vaginally.”

Failure to progress is the leading cause of C-sections being performed on first-time mothers, and research shows that its determination is subjective. Rates of diagnosis vary greatly between countries, regions of countries and even hospitals. Research published in 2013 showed that failure to progress was diagnosed in more than 40 percent of C-sections in primary deliveries in hospitals. The rate was only 4 percent in births that included midwives, and research shows that worldwide only 3 to 6 percent of women have what would be called “true” arrested labor or dystocia (Dolea and AbouZhar, 2003). 

As for standardization of C-section protocols across the nation, even the ACOG admits that guidelines that should be followed aren’t always followed. They cite studies showing that for 78 percent of all medical guidelines produced, 10 percent of physicians aren’t even aware of their existence. 

C-section Rates

Everyone agrees that medically necessary C-sections are invaluable medical tools when it comes to saving the lives of mothers and children in distress; however, researchers have noted a disturbing trend that has been taking place over the last several decades. Medically unnecessary C-sections are being performed on low-risk women who could be having vaginal deliveries.

Low-risk women are those who have had no prior C-sections, are close to or at full-term, are delivering a single child and whose child is properly positioned for a vaginal birth. Since the 1970s, the percentage of C-sections performed on low-risk mothers has increased along with the number of overall C-sections at a prodigious rate that cannot be medically explained. According to a 2017 study released by Consumer Reports, approximately 26 percent of low-risk mothers deliver by C-section. These procedures are being performed on women of all races, ages, places of residence and gestational ages.

Dr. Marquette states that the rate of C-sections for primary births at AdventHealth Ocala is 17 percent, a number they “are very proud of.”

In 1965, C-sections in the United States were performed for 4.5 percent of the total births. According to the Centers for Disease Control and Prevention (CDC), in 2016, that number had risen to 32 percent. The state of Florida presently has the third highest rate in the nation at 37.4 percent.

Risks To Mother And Child

A Canadian study shows that women who have C-sections are three times more likely to suffer risk of injury to the bladder or bowel, severe blood loss, major infections, heart attack, kidney failure and deep vein thrombosis.

According to the WHO, “Cesarean sections are associated with short- and long-term risk, which can extend many years beyond the delivery and affect the health of the woman, her child and future pregnancies.”

Children born by C-section have their own unique set of risks. The greatest is respiratory distress syndrome. This condition is most prevalent in children delivered by “scheduled” C-section when the mother doesn’t experience any of the contractions that come with normal labor. Medical experts surmise that contractions normally taking place in a vaginal birth stimulate the child to produce chemicals necessary for proper lung development. Also contributing to this problem, there is a degree of error when it comes to determining the exact gestational age of a child in the womb. If this determination is off by just one to two weeks, the child can be delivered by C-section after only 34 to 36 weeks of pregnancy, during the period called “late-preterm.” Infants born in this gestational age group are more likely to suffer from respiratory problems of all kinds than full-term infants.

Immediate risks to the child include physical injury during delivery, neonatal respiratory depression and breastfeeding problems. The latter two are due to the fetus’s exposure to anesthesia and analgesics given to the mother prior to the C-section.

Recent research also shows that children born by C-section have an increased risk of obesity and of later developing autoimmune diseases such as Crohn’s disease, type 1 diabetes and multiple sclerosis along with allergic diseases, such as asthma, allergic rhinitis and atopic dermatitis.

Researchers theorize that during a vaginal birth the child is naturally exposed to microbes in the birth canal that help to properly establish their immune system. When the child is removed by C-section, there is no physical contact with this important microbiota, and the basic development of the child’s immune system is compromised. Some physicians have sought to remedy this problem through “vaginal seeding,” a process whereby, following a C-section, the doctor swabs fluids from the mother’s vagina and then transfers the vaginal flora to the child’s mouth, nose or skin.

Why Are C-section Rates Increasing?

The reasons for such a prodigious rate of increase in C-sections are varied and complex. Researchers have identified several possible causes but reasons vary between individual physicians and specific hospitals.

According to the National Bureau of Economic Research (NBER), fear of litigation is one of the reasons that both physicians and hospitals perform medically unnecessary C-sections. The premise is that if a C-section is performed and the delivery goes poorly, if there is litigation, then the physician or hospital can argue in court that they did everything possible to ensure the mother and child’s health—even to the point of performing a C-section. If a C-section isn’t performed and the delivery goes poorly, then the mother or family member filing the lawsuit could argue that the physician or hospital didn’t do enough, i.e., a C-section.

Studies have shown that in busy hospitals, many times C-sections take less time than waiting for an expectant mother to dilate fully and deliver vaginally. Thus, C-sections are a way to keep things moving smoothly in a busy delivery room.

An increase in medical technology, especially in the area of fetal monitoring during delivery may contribute to this problem. Studies show that there is no standard protocol being followed by delivery staff nationwide when it comes to interpreting the data received through fetal monitoring. Many times, interpretation of this data (fetal heartrate and rhythm in conjunction with uterine contractions) is the primary determinant as to whether a C-section will be performed. Researchers are asking that guidelines be set for data interpretation and be strictly followed.

Some women choose scheduled C-sections because they fear vaginal deliveries. The reasons may include fear of death, pain, vaginal stretching or tearing, loss of body control and fear of the unknown.

A certain percentage are scheduled for various medical reasons, such as the baby isn’t properly positioned, the mother has had multiple C-sections in the past, the mother has pre-eclampsia, the child is exceptionally large, there have been ongoing health problems for mother or child, etc.

According to NBER, physicians and hospitals receive hundreds to thousands of dollars more for performing a C-section than a vaginal birth. When this amount is compounded over several thousand births per year, the profits can be quite substantial. According to the CDC, more than 90 percent of all births are paid for by either Medicaid or private insurance plans. Recognizing this problem, the WHO has recommended equalizing insurance payments for C-sections and vaginal deliveries, so money will no longer be an incentive to perform unnecessary C-sections.

Although no one reason is the cause for an overabundance of C-sections being performed on low-risk women, several independent studies and meta-analysis information supplied by the NIH show that financial incentives to both physicians and hospitals is most likely the primary cause.

According to information supplied by Florida Blue Cross and Blue Shield, “There can be many variables, but in general, Florida Blue reimburses physicians at the same rate for Cesarean section births and vaginal births without complications. It is important to note that the actual reimbursement rate to a physician will vary depending on their contract. Hospital rates in the Ocala market have different reimbursement rates for C-sections and vaginal births without complications.”

Whatever the reasons might be for performing unnecessary C-sections, a mother-to-be should be aware that outside factors other than her and her child’s health could come into play when it comes time to deliver her child. And this doesn’t go for first-time mothers only, it also goes for women who might have had a prior C-section birth.

“As I was recovering from my C-section, I began to plan for the birth of my next child,” says Renee. “I read about vaginal birth after Cesarean (VBAC), and I knew that this is what I wanted for my next child. When I discovered I was pregnant three years later, I was armed with a plethora of information, and I made out a “birth plan.” In it, my No.1 priority was that any doctor or hospital staff member who didn’t believe in VBACs wasn’t welcome in my hospital room. I delivered my next three children by VBAC, and I think that pretty much proves that my first delivery could just as easily have been a vaginal delivery.”

C-sections carry a certain amount of risk but are a necessary medical procedure in the right situation. For reasons that cannot be pinpointed, there are more procedures being performed on low-risk women than what statistical analysis shows should be performed. It’s up to you and your spouse, whether it’s the birth of your first child or a birth following a prior C-section, to be informed of your options before your delivery date arrives. Weigh the risks and make the informed decision that is best for you and your baby.

Sources: Vaginal birth after cesarean (VBAC); mayoclinic.org/tests-procedures/vbac/about/pac-20395249: Diagnosing and Managing Neonatal Respiratory Depression; ncbi.nlm.nih.gov/pmc/articles/PMC2327826/: U.S. Maternal Mortality Trends; ncbi.nlm.nih.gov/pmc/articles/PMC5001799/: Diagnosing Expertise: Human Capital, Decision Making, and Performance among Physicians; ncbi.nlm.nih.gov/pmc/articles/PMC5736164/: (Accessed 1/2/19)


What To Expect Locally

According to the NIH, hospital C-section-to-total-birth percentage rates range from a low of approximately 7 percent to a high of more than 70 percent. A Consumer Reports study of more than 1,300 U.S. hospitals shows that C-section rates for low-risk deliveries don’t just vary from hospital to hospital across the country, they vary just as widely between facilities located in the same communities, serving the same population of patients.

Facility: AdventHealth Ocala*

2000 % of C-Sections: 18.72%

2017 % of C-Sections: 31.64%

VBAC Rates: 23 out of 361

 

Facility: UF Health Shands Hosptial

2000 % of C-Sections: 26.96%

2017 % of C-Sections: 36.44%

VBAC Rates: 106 out of 594

 

Facility: Citrus Memorial Hosptial

2000 % of C-Sections: 25.75%

2017 % of C-Sections: 33.69%

VBAC Rates: < 5 out of 74

 

Facility: AdventHealth Waterman, Tavares*

2000 % of C-Sections: 22.22%

2017 % of C-Sections: 30.04%

VBAC Rates: < 5 out of 82

 

Facility: Leesburg Regional Medical Center

2000 % of C-Sections: 25.79%

2017 % of C-Sections: 41.01%

VBAC Rates: 6 out of 288

 

* These numbers reflect C-section rates prior to ownership by AdventHealth.

Source: Newborns and Cesarean Rates 2000-2017; floridahealthfinder.gov/researchers/QuickStat/cesarean-buffer.aspx

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