By Christine Morton
When I gave birth to my first child in 1995, the U.S. cesarean birth rate was 21%. By 2013, the total cesarean rate had risen to 33%, a nearly 60% increase! What has happened in the 18 years since I had my first baby to reach a point where 1 in 3 women give birth through major abdominal surgery?
A recent article in the Huffington Post highlights the risks of cesarean birth for both mother and baby and asks why the U.S. cesarean rate is more than double the World Health Organization recommended rate.
- Are there medical factors that explain this increase?
- Have women’s bodies become less capable of vaginal birth due to age or health issues?
Are women choosing surgical birth because it’s less painful, or as safe as vaginal birth?
- Are cesareans being done because women and babies are getting bigger?
Is the increase due to more women having twins, triplets and so on?
Has the increase in cesareans resulted in better health outcomes for women and babies?
The short answer to all these questions is NO.
Most primary (first) c-sections are done for “labor complications” – meaning labor is taking too long or the baby is not tolerating labor well. However, these indications depend on provider judgment, and there is little well-defined clinical research supporting these decisions. Some hospitals or providers say their cesarean rate is higher because they have high-risk patients. The Huffington Post article quotes a doctor who says, “it is difficult to apply the WHO recommendation (15% cesarean rate) to the United States.” The WHO recommendation refers to the total, or overall cesarean rate, which includes two major sub-types: primary or first, and repeat cesarean.
When there is a large degree of variation in c-section rates, especially among first births, it means that not all maternity clinicians will respond the same way to the same situation. There is huge variation in cesarean rates across states, regions and hospitals, and this means factors other than women’s characteristics or choices are driving the increase.
To enable a fair comparison, a metric was developed that looks at cesarean births among first time mothers, with a single baby who is head down at term (37 weeks gestation) who are low risk, meaning they do not have pre-existing or co-occurring complications, such as gestational diabetes or hypertension. This metric allows hospitals and providers to be compared on the same population of women—those with no medical risk factors. Data from California shows hospitals range from 10% to over 75% on this metric! Just 36% of California hospitals meet the national Healthy People 2020 target of 23.9% for these low-risk, first-birth cesareans.
In addition to an increase in women having a first (primary) cesarean, there are more repeat cesareans: Since 1999, about 90% of women with a prior cesarean have had their subsequent babies by cesarean. In 2010, the practice of VBAC (vaginal birth after prior cesarean) was largely discontinued across the country when the American College of Obstetricians and Gynecologists (ACOG) issued a practice bulletin recommending hospitals have “immediate availability of staff to perform a cesarean birth” for women who want to try for a vaginal birth after a prior cesarean. Insurance providers required hospitals and physicians to follow this guideline and it turned out to be quite difficult for smaller hospitals. Given that nearly 70% of all US births occur in hospitals with less than 1400 births a year, this policy has effectively restricted most women’s access to VBACs.
To reduce the US cesarean rate, we have to address socio-cultural factors, and ask:
- Are physicians less skilled at performing assisted vaginal birth using forceps or vacuum because they go immediately to a cesarean?
- Are nurses less trained in supporting vaginal birth?
- Are “perverse economic incentives” at play, with doctors (and hospitals) paid more for cesarean births?
- Do hospitals constrain physicians and nurses with restrictive policies that effectively result in higher cesarean rates?
- Is fear of lawsuits a factor?
- Is US culture more accepting of surgery overall, and birth is just one more example?
- Why are African American women more likely to have cesarean births than women of other race/ethnicities for no obvious medical reason?
- Are women less likely to advocate for vaginal birth and less likely to attend childbirth classes or use a doula?
- Does the fact that midwives attend less than 10% of all US births play a role?
- Does the rise in cesareans correlate with an increased number of female obstetrician-gynecologists in practice, who are themselves caught in work-family conflicts?
- Does the lack of a national maternity leave policy affect the cesarean birth rate?
The answers to these questions are more complex because less research has explored socio-cultural factors. But an emerging picture points to a complex interplay among these factors. In particular, work circumstances likely affect both childbearing women and their obstetric providers. We know that maternity leave is correlated with fewer cesareans. Very little research has been done on obstetricians’ views of birth, but one study from Canada showed that younger obstetricians (who are mostly women), have less appreciation of the role of a woman in her own birth, and view cesarean as just another way to have a baby, as well as a solution to many perceived labor and birth problems. The study authors argue this is more of a generational, rather than gendered, effect citing their own results showing both women and men residents were equally attracted to the discipline of obstetrics for its surgical component rather than the caring aspects of this specialty.
With the rising cesarean rate now widely acknowledged as a public health concern for women and their infants, we need more research that unpacks the gendered and cultural meanings of birth among women and maternity clinicians (physicians, midwives and nurses). We need to understand how to educate providers and the public on the health risks of cesarean birth and the value of vaginal birth; develop more quality measures and publicly report them; assemble strong evidence and package change initiatives into quality improvement tool kits for hospitals to implement; create payment incentives and address liability concerns.
Christine Morton, PhD, is a research sociologist at the California Maternal Quality Care Collaborative at Stanford University, and member of Lamaze International Board of Directors.