Monday, April 1, 2013

Cesarean Rates: Debunking the Mother-Blaming

It's April, Cesarean Awareness Month, so I'll be blogging about several cesarean-related topics this month.

Let's start off with an interesting video from Eugene DeClercq about the rise in cesarean rates. The video was done about data through 2009, so it doesn't have the most recent information in it, but it still has some valuable observations and commentary.

First, look at the cesarean rate graphs above.  Notice the c-section rate in 1970 vs. 2010.  Huge increase.  This is not all bad, as some babies and mothers are undoubtedly saved by cesareans. However, a too-high rate exposes mothers and babies to significant risks, presenting more risks than benefits.  So what we need is to find the right balance.

It's important to notice that the increase in cesareans hasn't been steady. It exploded in the late 70s and early 80s, dipped in the late 80s and early-to-mid 90s when there was pressure to reduce rates, and then steeply increased again until just recently when it leveled off a bit for the first time in years.  This fluctuating rate is important when examining the usual mother-blaming excuses for why the cesarean rate has risen over the years.

DeClercq debunks the usual excuses given by many in the maternity care community for why the cesarean rate has risen so much, including:
  • Women are too old
  • Women are having more twins
  • Babies are getting bigger
  • Women are requesting more cesareans
DeClercq addresses and debunks each of these.

For example, he notes that the trend towards older mothers slowed greatly a while ago, as did the trend towards more twins.....yet the cesarean rate continued to rise strongly afterwards. It wouldn't have done so if these factors were really what was pushing the rise in cesareans.

And in fact, babies are NOT getting bigger.  However, our management of big babies has changed.  As Henci Goer and CNM Amy Romano note in their book, "Optimal Care in Childbirth":
Cesarean rates have increased in all weight categories, the incidence of macrosomia declined from 1990 to 2000, and cesarean rates with macrosomia have soared: U.K. physicians delivered only 3% of babies weighing 4000 g or more via cesarean in 1958, while U.S. obstetricians today may perform cesareans on as many as half the women with babies of this size.  
And most women are NOT requesting elective cesareans.  While there are some women who do want elective primary cesareans, the number of these women is quite small, probably less than 1%.  So this factor can't be blamed for the rising cesarean rate either.

DeClercq also addresses the common defensive reply from some OBs that "There is nothing wrong with a high cesarean rate," because they feel a cesarean is the best way to guarantee a good outcome.  Turns out it's not.  Non-indicated cesareans increases risks for both mothers and babies. What a shock.

DeClercq is a professor at Boston University School of Public Health, and has an MBA and a PhD.  He's not afraid to speak his truths, whatever the audience.  You have to love his Baaawstan accent, but he has a great way of being able to communicate complicated concepts in simple and understandable ways.  I'm a big fan.

I saw him speak at an ICAN conference a few years ago.  I was quite impressed by him. He's a data wonk, but a layperson's data wonk as well as a data wonk's data wonk (if you know what I mean). I like that he can communicate effectively both with the statisticians/medicos and with the general public ─ without dumbing things down.

An Unquestioning Eye Towards Obesity?

That doesn't mean we agree about everything. In that lecture at our ICAN conference, he pointed out the problems with blaming women for the rise in cesarean rates, and debunked everything but obesity.

He noted that many doctors are blaming increasing cesarean rates on the "obesity epidemic." When he looked at the data, he found that high-BMI women do have high cesarean rates and have for a while. So he basically said there might be some truth to obesity being tied to a rise in cesarean rates. Augh!

Yet Goer and Romano point out in their book that, like the trends in older mothers and twin births, the rise in maternal weight leveled off a while ago, yet the cesarean rate kept on rising:
The relationship between maternal weight and cesarean rate cannot be ascertained directly, but the proportion of high-weight women increased from 1991 to 1996 while cesarean rates were falling and held steady from 1999 to 2004 when cesarean rates were once again on the rise.  
This casts doubt on the idea that obesity is to blame for the rise in cesarean rates.

I'd also point out that while it's true that high-BMI women have a high cesarean rate now, he didn't go back far enough into the past.  If you go back far enough, high-BMI women didn't have cesarean rates anywhere nearly as high as now, and often had very similar cesarean rates to average-BMI women.

I think that debunks the idea that obesity itself causes a high cesarean rate, and suggests instead that the highly-interventive way obese pregnancies/labors are now being handled, with more intervention and a lower surgical threshold, has more to do with higher cesarean rates in obese women.

In other words, it's how the management of obese women has changed that has impacted the cesarean rate, rather than obesity itself, and perhaps a more realistic solution than universal weight loss is to change the way those pregnancies are managed instead.  That will help lower the cesarean rate in this group.

In other words, yes, the cesarean rate in fat women is high.....but it probably doesn't have to be that way.  If we change the over-interventive way we manage pregnancy and labor in obese women, then that will lower the c-section rate in them, and in turn may have a modest influence on the overall cesarean rate.

I've written about this many times before on this blog and elsewhere.  Rather than repeat the information here again, I've included links to articles I've written about the idea that obesity causes cesareans and an increase in fat mothers automatically necessitates a high cesarean rate:
  • Supersized Women and Cesareans: A Tale of Two Cities - blog post comparing two recent research studies with similar populations (BMI of 50 and up) but one had twice the cesarean rate of the other. If obesity were an intractable "cause" of cesareans, their cesarean rates should have been similar, but one was much higher, nearly twice the rate of the other. Obviously, management is relevant too
  • News Flash: Labor Managed Differently in High-BMI Women! - blog post discussing a recent study that found that the labors of high-BMI women had more interventions, were intervened in earlier, and had a lower threshold for surgery.  When interventions were controlled for, the difference in cesarean rate was far smaller.  In other words, it's not just about women's obesity, it's also about the way our labors are over-intervened in and the fear level among some providers
  • The Fat Vagina Theory: "Soft Tissue Dystocia" - blog post debunking one of the most common reasons given for a higher cesarean rate in obese women, Soft Tissue Dystocia (adipose tissue crowding the vagina and not letting a baby pass)
  • Ghettoizing Fat Pregnant Women - blog post decrying the new trend to limit fat women's choices in birthplace, care provider, and birth options, solely by BMI
  • Scapegoating Fat Women Once Again - blog post debunking yet another media press release blaming fat women for the rise in cesarean rates and calling for a more nuanced (and less mother-blaming) approach
  • Women of Size and Cesarean Sections: Tips for Avoiding Unnecessary Surgery - article for the Our Bodies, Ourselves website, with practical ways that women of size can lower their risk for a cesarean and increase their chances of a VBAC
  • Avoiding Surgery: Lowering the Cesarean Rate in Big Moms - article I wrote for a healthcare consumers e-zine about lowering your risk for a cesarean
Finally, for care providers reading this blog, I'd suggest reading the series I wrote on the Science and Sensibility blog last year. While acknowledging the potential risks of obesity and pregnancy, it also suggests rethinking the paradigm with which most care providers approach obese pregnant women.
Science and Sensibility: Rethinking the Obesity Paradigm: An Insider's View
Declercq is right that cesarean rates are elevated in high-BMI women, but they don't have to be.  It's not a causal relationship. And it's not what drove the rise in cesarean rates in recent years.  I wish he would acknowledge that, and the fact that cesarean rates in this group can be reduced.

If the desired end is improved outcomes for women of size and their babies, then we need to consider all possible management options for them, not just the highly-interventive management style currently used for them, and individualize our approach based on the actual needs of the woman.  

Yes, some obese women will have complications and require more interventive care, but many will not, and we do considerable harm (via very high cesarean rates, risky inductions, and more iatrogenic premature births) when we force highly-interventive management on all obese women, as the trend towards "bariatric obstetrics" does.

Save the high-intervention management for those cases that truly need it; utilize the low-tech tools that work well to lower cesarean rates in other groups (fewer early inductions, more quality labor support, more attention to fetal position and fetal re-positioning techniques, more patience in labor, fewer automatic repeat cesareans, etc.). In that way we can likely bring down the cesarean rate in women of size too.

Care providers (and public health advocates) must stop shrugging their shoulders and writing off women of size as a lost cause in the cesarean department.  A high cesarean rate is NOT endemic to obesity if we change our management of it, our fear of it, and our nearly-automatic reach for the scalpel when a fat pregnant women walks into the hospital.
Final Thoughts

Many care providers have excused the rising cesarean rate by blaming mothers.  According to them, women are too old, too fat, gain too much weight in pregnancy, have huge babies, have too many multiple births, or are requesting all these cesareans.

No, these factors are not entirely irrelevant, but by and large they are NOT responsible for the tremendous rise in cesarean rates in recent years.  As Goer and Romano note:
U.S. cesarean rates have increased sharply at every maternal age, in every ethnic group, and for every demographic or medical risk factor.
This is not a matter of a rising tide of high-risk mothers driving up the cesarean rate, but rather a deep and increasing trend towards more intervention (and a lower surgical threshold) in ALL groups.

By blaming mothers, caregivers avoid taking responsibility for their own actions which have pushed up the cesarean rate. 

The induction and "pushed birth" epidemic, the over-intervention in normal labors, the lack of support for vaginal breech birth, the virtual abandonment of VBAC, the loss of skills in manually turning poorly-positioned babies, the lack of patience during labor, the increasingly narrow definition of "normal," and the lowering of surgical thresholds have all been caregiver-driven reasons for the rise in the cesarean rate.

Eugene DeClerq has been one of the leading voices pointing out the flaws in blaming mothers for the rising cesarean rate, and bravo to him for doing so.  We need MORE respected voices speaking up and pushing back against the mother-blaming culture of many maternity care providers.

Unfortunately, the one finger-pointing he doesn't seem to question is obesity.  I wish he would apply the same questioning eye to the historical data on cesareans in obese women that he does to other possible "causes."  I'm tired of obesity-blaming getting a free ride (no questions asked!) from even the best public health advocates.

However, I'm pleased to report that a few researchers and childbirth advocates (like Goer and Romano) are beginning to push back on this issue.  Let's hope this is the start of a new trend.

Even though Eugene and I don't see completely eye-to-eye about this one issue, I still find much to admire in his writings and his research analysis.  He has a lot of valuable things to say about cesarean rates and birth in general, he says it in a very understandable way, and we need to listen carefully to it.

Now if we can only get him to dig a little deeper on the obesity question....


Pediatrics. 2003 May;111(5 Pt 2):1181-5. Contribution of excess weight gain during pregnancy and macrosomia to the cesarean delivery rate, 1990-2000. Rhodes JC, Schoendorf KC, Parker JD.  PMID: 12728135
OBJECTIVE: After declining for many years, cesarean delivery rates recently increased. To explore whether this increase is associated with excess weight gain during pregnancy, resulting in macrosomic infants who require cesarean delivery, we examined trends in excess weight gain, macrosomia, and cesarean delivery...CONCLUSIONS: Excess weight gain and macrosomia do not seem to be the primary factors that contribute to the recent increase in cesarean delivery because cesarean delivery rates have increased in all weight gain categories and macrosomia rates have decreased steadily from 1990-2000. Nonetheless, women who gain excess weight account for a growing proportion of cesarean deliveries because their relative numbers have grown.
Am J Public Health. 2006 May;96(5):867-72. Epub 2006 Mar 29. Maternal risk profiles and the primary cesarean rate in the United States, 1991-2002. Declercq E, Menacker F, Macdorman M. PMID: 16571712
OBJECTIVES: We examined factors contributing to shifts in primary cesarean rates in the United States between 1991 and 2002. METHODS: US national birth certificate data were used to assess changes in primary cesarean rates stratified according to maternal age, parity, and race/ethnicity. Trends in the occurrence of medical risk factors or complications of labor or delivery listed on birth certificates and the corresponding primary cesarean rates for such conditions were examined. RESULTS: More than half (53%) of the recent increase in overall cesarean rates resulted from rising primary cesarean rates. There was a steady decrease in the primary cesarean rate from 1991 to 1996, followed by a rapid increase from 1996 to 2002. In 2002, more than one fourth of first-time mothers delivered their infants via cesarean. Changing primary cesarean rates were not related to general shifts in mothers' medical risk profiles. However, rates for virtually every condition listed on birth certificates shifted in the same pattern as with the overall rates. CONCLUSIONS: Our results showed that shifts in primary cesarean rates during the study period were not related to shifts in maternal risk profiles.
J Matern Fetal Neonatal Med. 2013 Apr;26(6):547-51. doi: 10.3109/14767058.2012.745506. Epub 2012 Nov 28. Cesarean delivery in obese women: a comprehensive review. Wispelwey BP, Sheiner E.  PMID: 23130683
BACKGROUND: Obesity (BMI ≥30) is a significant independent risk factor for many gestational complications, including cesarean delivery (CD). While CD rates are increasing in women of every BMI, the trend is more pronounced as maternal weight increases. OBJECTIVE: This review seeks to describe the risk modulators that explain the high prevalence of CD in obese women, as well as to discuss the excess complications of the procedure in this group of parturients. In assessing the rationale for the procedure and weighing this against the excess risks involved, a clearer indication of when to perform CD in obese women might be developed. RESULTS: A thorough review of the literature indicates that a decreased cervical dilation rate, an increased induction rate, the presence of comorbid conditions, concern about shoulder dystocia, and weight gain in excess of recommendations during pregnancy all may contribute to the high rate of CD in obese women. Obese women are at increased risk of CD-related complications including anesthetic complications, wound complications, venous thromboembolism (VTE), and failure of vaginal birth after CD. CONCLUSIONS: Given the excess risks associated with CD in obese women, and that some of the rationale for the procedure (e.g. slower labor, concern about shoulder dystocia) may not be justified based on current evidence, a reassessment of the threshold at which obese women are recommended for CD is necessary.
J Obstet Gynaecol Can. 2011 May;33(5):443-8. Higher caesarean section rates in women with higher body mass index: are we managing labour differently? Abenhaim HA, Benjamin A. PMID: 21639963
BACKGROUND: Higher body mass index has been associated with an increased risk of Caesarean section. The effect of differences in labour management on this association has not yet been evaluated. METHODS: We conducted a cohort study using data from the McGill Obstetrics and Neonatal Database for deliveries taking place during a 10-year period. Women's BMI at delivery was categorized as normal (20 to 24.9), overweight (25 to 29.9), obese (30 to 39.9), or morbidly obese (≥ 40). We evaluated the effect of the management of labour on the need for Caesarean section using unconditional logistic regression models. RESULTS: Data were available for 11 922 women, of whom 2289 women had normal weight, 5663 were overweight, 3730 were obese, and 240 were morbidly obese. After adjustment for known confounding variables, increased BMI category was associated with an overall increase in the use of oxytocin and in the use of epidural analgesia, and with a decrease in use of forceps and vacuum extraction among second stage deliveries. Higher BMI was also found to be associated with earlier decisions to perform a Caesarean section in the second stage of labour. When adjusted for these differences in the management of labour, the increasing rate of Caesarean section observed with increasing BMI category was markedly attenuated (P < 0.001). CONCLUSION: Women with an increased BMI are managed differently in labour than women of normal weight. This difference in management in part explains the increased rate of Caesarean section observed with higher BMI.


Kelly said...

Kmom, thank you again for another excellent post! Reinforcing why this is one of my all-time favorite sites that I share with others!

nsv said... Not that you need it, WRM, but here's another example of a mother-blaming approach, this time cloaked as social justice:

"Whether it is genetics, nutrition, lifestyle, social or health factors or the cumulative affects of generation after generation of intense stress, the truth is, race matters. African American women have higher rates of diabetes, hypertension and obesity, three conditions that contribute to increased maternal deaths."

Race DOES matter for people's health status, as does socio-economic status, but for heaven's sake, can we stop running everything through the Obesity Epidemic filter? To its credit, the article goes on to note the danger of non-medically-indicated c-sections, but fails to make your perceptive connection between bias toward fat patients and increased c-sections.

Steph in Lex said...

The only way my "obese" status nearly caused my second c-section was due to the fact that my original hospital had a policy against "allowing" mothers with a pre-pregnancy BMI which put them into the obese category to VBAC. I changed hospitals and went on to have an uncomplicated, natural, unmedicated VBAC which lasted four hours from check-in to birth. (Not that I wasn't told that I'd end up in the OR 20 minutes before pushing my daughter out.) The idea that the original hospital attempted to act like my pre-pregnancy BMI was some kind of indicator that a vaginal birth would be an issue is completely ridiculous.

I know the anecdotal evidence such as mine is overwhelming, and I appreciate having research to back it up. As always, love your blog.