Safe delivery of the baby is one of the most common goals in performing a cesarean section, yet cesareans carry additional risks to infants as well. It is well-established that infants born via cesarean section are at a significant risk for all types of respiratory issues than infants delivered vaginally, often necessitating newborn neonatal intensive care unit admission (Dodd and Grivell, 2011). Cesarean surgery can also make it more difficult to establish breastfeeding because it is often impossible or impractical to nurse the infant during the first hour of life due to the challenges of anesthesia and suturing (Marasco and West, 2005). Another risk to infants from cesarean sections that is often not discussed is birth injury. Birth injuries complicate about 6-8 our of every 1,000 deliveries in the United States (.6 to .8 percent) (Laroia and Rosenkrantz, 2015). However, a 2006 report from the American College of Obstetricians and Gynecologists by Alexander, Leveno and Hauth found that fetal injury occurred at a rate of 1.1 percent for cesarean deliveries- higher than the overall average.

Along with the risks to mothers and babies, there are significant healthcare costs that accompany a high c-section rate. A cesarean section costs $12,739 as opposed to $9,048 for a vaginal birth for private health insurers in 2010. The cost difference for cesarean surgery has significant implications for Medicaid since public insurance pays for about half of all births in the United States. In 2009, Medicaid paid $3 billion for cesarean sections (Kozhimnnil, Law and Virnig, 2003). Along with the costs for cesarean surgery itself, there are also accompanying costs for infections, intraoperative and birth injuries, NICU stays, blood clots and transfusions as well as the increased risk of subsequent cesarean birth. In short, cesarean sections are a very expensive way to give birth.

Hospitals also take on additional costs when their cesarean rates become too high. Hoag Memorial Hospital Presbyterian in Orange County, California was almost dropped by its insurer when its maternity costs became too high from too many c-sections. With an aggressive action plan that monitored doctors’ cesarean rates, decreased financial incentives to perform cesarean surgery and policies that allowed women more time to labor before opting for a cesarean, the hospital administration managed to decrease cesarean deliveries by approximately 5 percent and increase vaginal births after cesarean by 11 percent (Gorman, 2015).

When the choice is between death or serious injury to the mother or baby and a cesarean delivery, then the costs and risks are worth it. But in the majority of cesarean sections, there is no clear indication of imminent harm to the mother and baby. In fact, many of the physicians at Hoag pointed out that cesareans were frequently performed at the hospital because doctors did not want to wait out a labor and a perception among both doctors and patients that a cesarean section was an easy way to time a birth and a relatively harmless procedure (Gorman, 2015). A study from the Harvard School of Public Health found that a hospital’s culture and practices can substantially influence whether a mother ends up having a cesarean section or delivering vaginally. Liability and insurance, being a teaching hospital, hospital admission practices, and the presence of midwives may influence c-section rates as do lack of clinical guidelines or standards on when a cesarean should be performed (Harvard School of Public Health, 2013).

Fear of liability influences the decision to perform a cesarean section for many doctors. The perception that a c-section means the doctor has done everything to intervene and therefore protects him or her from a liability remains a powerful idea and adds significant pressure to many doctors- whether the situation is statistically low-risk or not. Parents are also frequently subject to perception errors in making a decision about birth. Stories from family, friends and the news can weigh more heavily in their decision making process than actual statistics and medical facts about their own situation simply because these isolated incidents carry so much emotional weight (Lake, 2012).

Doctors have been reluctant to talk about actually decreasing cesarean section rates. Dr. W. Lawrence Warner stated in his 2013 article for the ACOG, that “Care must be taken to not have the unintended consequence of physicians becoming reluctant to proceed with clearly indicated cesarean deliveries because they fear criticism after later review of the care by the quality committee.” A 2015 study from Stanford University argues that the World Health Organization’s upper limit for cesareans of 10 to 15 percent should be reexamined and raised to 19 percent. However, while the results from this study argue that there is no additional risk of maternal or neonatal mortality from a 19 percent cesarean rate, they do not address the increased health and financial costs that come from performing cesarean sections that have no clear medical indication.

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