Cesarean Sections: Increase in Procedure in the United States

Cesarean sections, once rarely performed, were only used in desperate situations in which a woman or her child would have died if a vaginal birth were attempted. In these instances, the training of doctors became very useful, and families were rightfully grateful for their services.

When cesareans were first performed in the United States, a surgeon made the incision at the top of the uterus for easier delivery of the baby. Because the top of the uterus is the part that contracts the hardest, many subsequent deliveries resulted in rupture of the uterus and they bled horribly before being sewn up. Many women and babies died from this experience. That is why the term "Once a cesarean, always a cesarean" was coined (Craigin). It was just too dangerous to attempt a vaginal birth after cesarean, or VBAC.

Times have changed. Now, obstetricians, who are aware of the function of the uterus, are trained to perform cesareans. They decided it was safer to use a "low-transverse" incision (also know as the bikini cut), where the uterus does not contract as much. Since then, studies have shown that with VBAC there are less cases of rupture, less chance of hemorrhage and infection, resulting in more healthy moms and babies. Unfortunately, now that cesareans are safer and easier, doctors are relying on them more and more for their convenience and peace of mind (lest someone sue them for not getting the baby out sooner).

The World Health Organization (WHO) stated that a cesarean rate over 15% represents a danger to both women and babies. If a rate over 15% is dangerous, then we should be wondering why the United States has a 30.2% cesarean section rate (CDC, NVSR, Vol 55, No. 11, 2006). This is a record setting, and an increase of 46% in 9 years! The Maternity Center Association published an article that included several reason why our cesarean rate has been steadily increasing. These include:
* Provider's fear of lawsuits
* Forced cesareans (for women who are unable to find a supportive doctor to deliver them vaginally)
* Casual attitudes about surgery
* Growing belief that c-section is "safe" and vaginal birth is "harmful"
* Side effects of other common procedures (induction, electronic fetal monitoring, etc.)
* Failure to support normal physiologic labor

The Maternity Center Association found in their research that women who had a cesarean delivery experienced more adverse effects than women who gave birth vaginally. When comparing maternity care costs of U.S. hospitals in 2003, they found that c-sections with no complications cost on average $5,285 more than a vaginal birth with no complications. A standard vaginal birth costs about $6,239. This is their summary on the issue: "Unless there is a clear, compelling and well-supported justification for cesarean section or assisted vaginal birth, a spontaneous vaginal birth minimizing use of interventions that may be injurious ot mothers and babies is the safest way for women to give birth and babies to be born". For a full description of their research, visit the following website: www.maternitywise.org/cesarean_response.html .

The largest ever study of women who gave birth at home (Johnson, 2005) found that only 4% required transport resulting in a cesarean section. This rate and type of care placed no extra risk for mothers and babies compared to mothers and babies experiencing hospital birth. There are many differences between hospital and home births, but a 4% cesarean rate is a good goal for U.S. hospitals to attain, one that would likely take many years to develop, even with much effort.

Not only is our section rate climbing, but our VBAC rate has declined as well. It had been climbing steadily and peaked at almost 76% in 1996. It would seem that we had begun to realize the benefits of a vaginal delivery after cesarean, but now we are back to a VBAC rate of 10.6% (CDC, 2005). The reasons are similar to those listed above for cesarean births.

The Journal of Obstetricians and Gynecologists recently released a study which was conducted between 1999 and 2002, and included the cases of 14,529 women who underwent a trial of labor after a previous cesarean section. The report stated that 73.6% of these women succeeded by delivering vaginally. With the average woman having a 70.1% chance of having a vaginal birth, whether or not she had had a previous cesarean, the woman attempting a vaginal delivery after cesarean has just as good a chance of achieving a vaginal delivery as the woman who has never had a cesarean.

One of the major excuses people still use when trying to convince women that it's unsafe to have a VBAC is that her uterus could rip open in labor and that she could die from internal hemorrhage or at least lose her child. What many do not realize, or do not believe, is that if a woman is going to rupture, she will most likely do so before labor begins. Also, "it is important to remember that no uterus is immune to rupture. Rupture in an unscarred uterus is far more catastrophic for both mother and baby"¹. Why, you ask? Because with an unscarred uterus, the tear is most likely to occur at the top of the uterus, which is hardest to recover from. For a VBAC mom to have a rupture, it simply means that the previous incision will open gently and neatly, leaving a "nice" job for an obstetrician to sew up. Not only that, but Cohen and Estner also found a study of 93 rupture cases in in which two thirds of them occurred in normal uteri. There were nine maternal deaths, all in the group of women who had not had a cesarean section. They go on to say that "the incidence of fetal death with VBAC is agreed to be less than with elective repeat cesareans, even by the most reluctant VBAC skeptics"².

Advantages of waiting till labor begins to have an elective repeat cesarean include: establishing fetal maturity, the contractions stimulate and prepare the fetal lungs, the contractions thin out the uterus and minimize maternal blood loss.

"We also conclude that the rising cesarean section rate is a matter of concern. It is a matter of grave concern. The cesarean epidemic must be brought under control. Too many mothers and babies are being needlessly exposed to avoidable risks, and too many physicians are refusing to admit it. As it becomes increasingly apparent that the medical profession is not going to put constraints upon itself, it becomes more and more obvious that we, the consumers, are going to have to take control"³. This statement is as true today as the day it was made.

If you are planning a VBAC, I highly recommend two books: "Pregnancy, Childbirth and the Newborn: The Complete Guide" by: Simpkin, Whalley and Keppler (2001) and "The VBAC Companion" by: Diana Korte (1997). Learning and utilizing the information they give will increase your chances of having a successful VBAC.

Sources:
1,2 & 3 - "Silent Knife" by Cohen and Estner. 1983