Why so many women have C-sections

Dr. Judith Reichman TODAY contributor • Profile • E-mail

It is now believed that more than 30 percent of all births in the U.S. are Cesarean deliveries. Among obstetricians, these are called Cesarean Delivery on Maternal Request or CDMR. But they’re more commonly called C-section-on-demand. But the question remains why so many American women having C-sections. Is it a matter of convenience? Or are medical reasons driving the trend? To help us understand this trend, let’s examine the pros and cons of Cesarean-on-demand.

Has the rate of Cesarean deliveries in the United States gone up? Is this a worldwide phenomenon?
The high rate is pretty much an American issue: the latest statistics (reported in the New England Medical Journal) are that the Cesarean delivery rate is this country is greater than 30 percent. This means that over 1.2 million births a year are performed with abdominal surgery. The highest rate of Cesarean delivery — 35 percent — has been reported in New Jersey for the year 2000 (and the number is now probably higher). Compare this to the rate of 15 percent recommended by the World Health Organization. WHO haS found that Cesarean delivery rates, which exceed 15 percent “offer no population health benefits.”

Are there medical reasons for these high rates in the United States or do they simply reflect the desire for convenience and the containment of malpractice costs?
Our U.S. obstetrical population has changed in the 21st century and this may impact our cesarean delivery rates. But here are some other reasons:

• Older women are having babies. Since 1990 there has been an increase of over 40 percent in the number of women between the ages of 35 and 39 who have babies, and over 60 percent for women between the ages of 40 and 44.
• Women are also heavier. (There has been a doubling of obesity rates in the past 21 years).  Heavier moms are likely to have a bigger babies and in order to protect overly large babies from traumatic vaginal delivery, especially one that can cause fracture of the collar bone and paralysis of the arm (brachial plexus injury), Cesarean delivery is often planned without a trial of labor.
• More multiple gestations (the rate is currently two times greater than it was in 1980). A pregnancy of twins, triplets or more increases the risk of fetal growth retardation, premature delivery and other complications that lead to cesarean sections. There’s no question that women who undergo fertility care, especially IVF are currently more likely to have multiple gestations. These expensive and more difficult “to make” babies are also considered “premium.” As a result, even with singleton births, women who underwent fertility care are more likely to be delivered by C-section.
• Vaginal breech deliveries are no longer recommended. There is a three percent risk of injury to the breech newborn with a vaginal delivery; this is concerning both to the mother whose baby is in breech position and to the physician who does not want to incur difficulty in the delivery and/or a malpractice suit. As fewer and fewer physicians are delivering breech babies vaginally, they are also becoming less capable if called upon to do so. Fewer doctors are trained for vaginal breech delivery and as a result, most breech babies are now delivered with C-sections. In the future many predict that none will be delivered vaginally.
• Concerns that operative vaginal delivery (forceps and vacuum) can cause harm to the baby.
• Fewer attempts at vaginal delivery after Cesarean sections (VBAC). Many institutions feel that they do not want to allow physicians to try VBAC after a C-section because of the possible occurrence of rupture in the previous scar in the uterus. Patient and physician concern about this potential complication has caused the rate of VBAC to greatly diminish in the past few years.
• An increase in induction of labor. (When labor is induced there is higher risk of Cesarean sections). Approximately 20 percent of labors were induced in 2003, compared to 9.5 percent in 1990. Labors are often induced because of more active surveillance with ultrasounds in the last few weeks of pregnancy. (This is done in order to check the amount of amniotic fluid as well as movement and growth of the fetus.) There’s also a concern about “allowing” a women to go too long past their due dates. And, of course, there’s the issue of convenience. Parents want to know when to leave their job, when to show up for delivery and when to arrange child care. Frequently a doctor is on call for a particular period of time, or, less frequently, may be out of town. If parents want that particular doctor to be present at the delivery they may decide to set an induction date.
• Fetal monitoring and evidence that the fetal heart rate and oxygenation of the baby is compromised during labor. Fetal monitoring has become an integral part of labor and delivery care in most hospital institutions. If changes are noted that could indicate fetal distress, “to be safe” rapid delivery by cesarean section is often performed. Of interest is the fact that fetal monitoring, per se, has not changed perinatal mortality rates and often the babies that appear compromised during monitoring are born with robust breathing, movement, and heart rates and no underlying distress. But, no one wants to take that chance.

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