The Public Health Case For Reducing Cesareans, Part 3

While doctors’ fears seem to be that a lower rate of cesarean surgery will mean greater mortality and morbidity for mothers and babies, the statistics indicate this fear is not well-founded. There really is no data showing that higher cesarean rates equate with lower rates of maternal or neonatal mortality (Lake, 2012). Many circumstances where a cesarean is clearly indicated such as placenta previa or severe preeclampsia should be clear to any competent obstetrician as they will be accompanied by symptoms of a life-threatening emergency like vaginal bleeding and hemorrhage, seizures, blood pressure changes, and vision disturbances. In the case of transverse lie, a simple ultrasound will show the position of the baby. In cases such as maternal infection with HIV or hepatitis B where a cesarean section is indicated to prevent transmission of the infection to the baby, testing can be done to ascertain the mother’s infection status. Other circumstances for a cesarean surgery need to be more clearly outlined by hospitals and even in medical school curriculum and practice.

Helping both doctors and patients understand the actual risks and benefits of a cesarean surgery will be crucial in decreasing the overall rates of cesareans. Patients need to understand that a cesarean section is a major surgery and not a benign procedure. While vaginal birth entails risks, so do cesarean sections and the choice between a vaginal birth and cesarean is not a choice between a dangerous option and a risk free option, but rather weighing the actual risks and benefits in each patient’s specific case.

The risks and benefits of vaginal birth after cesarean may not be fully understood by many women. The risk of uterine rupture is frequently cited as a a reason that a VBAC could be too dangerous, but the actual risk of uterine rupture and even the actual risks to the baby are not necessarily well communicated to mothers. The ACOG’s 2010 bulletin on VBAC shows that the risk of uterine rupture is 0.4 to 0.5 percent for planned, elective cesarean, 0.7 to 0.8 percent for a trial of labor after one cesarean and between 0.9 and 1.8 percent for a trial of labor after two cesareans. Ironically enough, it is statistically more likely that a baby will be injured during a cesarean section than suffer from a uterine rupture- especially with a trial of labor after one cesarean.

ACOG’s 2010 bulletin further explains that many risks associated with VBAC are negligible when compared with those of elective repeat cesarean section. The risk of neonatal death during a trial of labor after cesarean is 0.05 percent for elective cesareans and 0.08 percent for a trial of labor after cesarean (TOLAC). The rate of perinatal death due to hypoxia was greater for TOLAC than elective repeat cesarean mothers at 0.13 percent versus 0.01 percent, though still extremely rare. Helping more women to accurately weigh the risks and benefits for their pregnancy and achieve a successful VBAC will help with reducing cesarean rates and the accompanying costs and risks.

The usage of cesarean surgery has been controversial, but based on data about the risks to mothers and infants and the accompanying costs associated with cesarean rates, it would be in the best interest of women, infants and healthcare costs to reduce the rate of cesarean sections. This will require doctors and expectant parents to adjust some of their perceptions about vaginal birth and cesarean birth, but a reduction in cesarean rates is possible and desirable. Reducing cesarean sections does not have to mean that cesareans are withheld from women who need them or that doctors should be reluctant to perform them when medically indicated. Instead, care should be taken to establish the circumstances when a cesarean is actually necessary and reserve the usage of cesarean surgery for instances when it is truly needed. A cesarean section is major surgery and should never be performed for the comfort and convenience of the physician. Women should also be fully aware of the real risks and benefits when they decide to have an elective cesarean.

References

Alexander, James M., Leveno, Kevin J., Hauth, John, Landon, Mark B., Thom, Elizabeth, Spong, Catherine Y., Varner, Michael W., Moawad, Atef H., Caritis, Steve N., Harper, Margaret, Wapner, Ronald J., Sorokin, Yoram, Miodovnik, Menachem, O’Sullivan, Mary J., Sibai, Baha M., Langer, Oded, and Gabbe, Steven G. (2006). Fetal Injury Associated with cesarean delivery. American College of Obstetricians and Gynecologists 108(4). Retrieved from http://content.lib.utah.edu/utils/getfile/collection/uspace/id/395/filename/3560.pdf

American College of Obstetricians and Gynecologists (2010). Vaginal birth after previous cesarean delivery. Practice Bulletin- Clinical Management Guidelines for Obstetrician-Gynecologists, no. 115. Retrieved from http://www.acog.org/Resources-And-Publications/Practice-Bulletins/Committee-on-Practice-Bulletins-Obstetrics/Vaginal-Birth-After-Previous-Cesarean-Delivery

Gorman, Anna (2015, May 13). How one hospital reduced unnecessary C-sections. The Atlantic. Retrieved from http://www.theatlantic.com/health/archive/2015/05/how-one-hospital-reduced-unnecessary-c-sections/392924/

Grivell, Rosalie M. and Dodd, Jodie M. (2011). Short- and long-term outcomes after cesarean section. Expert Review of Obstetrics and Gynecology, 6(2). Retrieved from http://www.medscape.com/viewarticle/739458_1

Harvard School of Public Health (2013, March 19). Pregnant women’s likelihood of cesarean delivery in Massachusetts linked to choice of hospitals. Retrieved from http://www.hsph.harvard.edu/news/press-releases/pregnant-womens-likelihood-of-cesarean-delivery-in-massachusetts-linked-to-choice-of-hospitals/

Kozhimannil, Katy Backes, Law, Michael R. Virnig, Beth A. (2013). Cesarean delivery rates Vary 10-fold among US hospitals; reducing variation may address quality, cost issues. Health Affairs 32(3). Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3615450/

Lake, Nell (2012, November). Labor, interrupted. Harvard Magazine. Retrieved from http://harvardmagazine.com/2012/11/labor-interrupted

Laroia, Nirupama (2015). Birth trauma. Retrieved from http://emedicine.medscape.com/article/980112-overview#a1

Marasco, Lisa and West, Diana (2005). How to get your milk supply off to a good start. New Beginnings, 22(4). Retrieved from http://www.lalecheleague.org/nb/nbjulaug05p142.html

Stanford University (2015, December 1). Optimal C-section rate may be as high as 19 percent to save lives of mothers and infants. Stanford Medicine News Center. Retrieved from chttps://med.stanford.edu/news/all-news/2015/12/optimal-c-section-rate-may-be-as-high-as-19-percent-to-save-lives.html

Warner, Lawrence W., (2013). Arriving at the appropriate cesarean delivery rate. American Congress of Obstetrician-Gynecologists. Retrieved from http://www.acog.org/About-ACOG/ACOG-Departments/District-Newsletters/District-VIII/July-2013/Cesarean-delivery-rate

The Public Health Case For Reducing Cesarean Rates, Part 2

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 et.al. 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.

The Public Health Case For Reducing Cesarean Rates, Part 1

This is the first part of a paper I wrote for one of my classes on the public health benefits of reducing cesareans. Please feel free to quote from this as long as you give proper attribution to me and the authors of the cited sources of this paper. Thanks and enjoy!

The cesarean section is now the most common surgical procedure in the United States and accounts for 32.8 percent of all deliveries as of 2011 (Kozhimnnil, Law, and Virnig, 2013). This is a substantial increase from what it was decades ago. As Dr. W. Lawrence Warner stated in a 2013 article for the American College of Obstetrics and Gynecology, “When I began medical school in 1970, the overall cesarean delivery rate was 5.5%… I practice in Utah, where the rate is 22.2%, the lowest in the country. In New Jersey, the rate is 38.3%, the highest in the country. There are some individual hospitals with rates well over 50%.”

There are many factors that have been cited as driving the increase in cesarean rates, including an increase in multiple gestations due to fertility treatments, rising rates of maternal obesity and conditions such as gestational diabetes and preeclampsia. However, other issues that are not related to the actual health of the mother or baby also come into play, such as convenience and doctors’ concerns about liability and malpractice (Kozhimnnil, Law, and Virnig, 2013).

Cesarean sections play a vital role in maternal and child health. There are situations which absolutely indicate the use of a cesarean, such as transverse lie, preeclampsia or other hypertensive disorders of pregnancy that have progressed to a life-threatening stage, cord prolapse and placenta previa. However, these cases account for only a small number of c-sections performed, which means that many c-sections are not actually a medical necessity. This has important implications from both a cost and health perspective for mothers, babies, hospitals, insurance companies and Medicaid. C-sections are more costly than vaginal births and also carry increased risks for both mothers and newborns. Lowering the overall rate of cesarean surgery could mean reduced healthcare costs as well as important gains for maternal and child health.

Though cesarean surgery has become extremely common, it is actually a procedure which entails more risks for both mothers and babies than a vaginal birth. Intraoperative damage to internal organs such as the bowels, bladder, urinary tract and unintentional damage to the uterus or cervix are relatively common, occurring in approximately 12 percent of cesarean sections. Other maternal complications include an increased occurrence of placenta abnormalities in subsequent pregnancies, admission to the intensive care unit, blood transfusion, infection, blood clots, hysterectomy and death, with the chances of these complications increasing with each subsequent cesarean (Dodd and Grivell, 2011).

Kozhimnnil, Law and Virnig (2003) found that even among women who fit the American College of Obstetrician-Gynecologists’ (ACOG) definition for low-risk pregnancy, cesarean rates are still very high and that clinical factors alone could not explain the increase in cesarean surgery. They theorize that rising cesarean rates might be explained by physicians’ practice patterns and hospital policies along with a failure to educate women about the real instead of perceived benefits and risks of cesarean and vaginal delivery.