Wednesday, December 29, 2010

Contemporary Cesarean Patterns in the USA

This is an interesting new study out on cesarean patterns in the United States. 

Examining this study will be particularly compelling given that the cesarean rate has risen again (for the 13th straight year) to a new all-time high of 32.9%(Notice how this information was conveniently released just before Christmas, thereby not making the news cycle in most publications?)

The data in this new study was taken from 19 hospitals all over the USA, so it's a reasonably robust representation of common practice in the States. 

What struck me in the study immediately was the extremely high induction rate....44%!  Nearly half? That is just outrageous.  But at least it's a more accurate reporting of induction rates than some previous studies.  And I bet that at some hospitals, the induction rate is even higher than that.  No wonder the cesarean rate is so high!

They also noted in a companion study that many of the inductions were converted to cesareans before active labor had even really begun, what we call a "failure to wait" cesarean.  They recommended that care providers wait until active labor has been well-established before jumping to a cesarean, especially in first-time moms and in women who are being induced. 

Another thing that struck me was that the cesarean rate for first-time mothers (primary cesareans) was so high.  Nearly 1 in 3 first-time moms had a cesarean.  Usually, first-time moms should have a LOWER cesarean rate than the overall c-section rate.....but not in this study.  I think that's a reflection of how many were induced...and such a high primary cesarean rate is an ominous sign.

It was great that the authors seem to call for reducing primary cesareans, and I was especially pleased that they seem to be calling for more widespread access to VBAC

Such a call for change was quite refreshing.  And it's wonderful that such a call for change was published in the American Journal of Obstetrics and Gynecology, one of the main OB-GYN research journals. 

The $64,000 question is ─ will the publication of this study make any difference?  Will hospitals change their policies and induce less women?  Will doctors wait longer before resorting to cesareans?  Will doctors and hospital administrators reverse their formal and informal VBAC bans?  Will everyone involved make a concerted effort to reduce the cesarean rate ─ or will it just continue to be business as usual?

It's positive that the questions are being asked and dialogue is being opened ─ but I am not holding my breath.  Perhaps this is the beginning of a reversal of the pendulum, but the momentum is so strong towards inductions and cesareans right now that it's going to take a mighty counterforce indeed to really reverse things. 

It's up to us to be part of that counterforce for change.


Zhang J, et al.; Consortium on Safe Labor.  Contemporary cesarean delivery practice in the United States.  Am J Obstet Gynecol. 2010 Oct;203(4):326.e1-326.e10. Epub 2010 Aug 12. PMID: 20708166

Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA.

OBJECTIVE: To describe contemporary cesarean delivery practice in the United States.

STUDY DESIGN: Consortium on Safe Labor collected detailed labor and delivery information from 228,668 electronic medical records from 19 hospitals across the United States, 2002-2008.

RESULTS: The overall cesarean delivery rate was 30.5%. The 31.2% of nulliparous women were delivered by cesarean section. Prelabor repeat cesarean delivery due to a previous uterine scar contributed 30.9% of all cesarean sections. The 28.8% of women with a uterine scar had a trial of labor and the success rate was 57.1%. The 43.8% women attempting vaginal delivery had induction. Half of cesarean for dystocia in induced labor were performed before 6 cm of cervical dilation.

CONCLUSION: To decrease cesarean delivery rate in the United States, reducing primary cesarean delivery is the key. Increasing vaginal birth after previous cesarean rate is urgently needed.

Cesarean section for dystocia should be avoided before the active phase is established, particularly in nulliparous women and in induced labor.


Lenore said...

The above link is an article about a presentation given to Kaiser by a doctor, how much medicine is guesswork, including this quote:

"Even today, with a high-tech health-care system that costs the nation $2 trillion a year, there is little or no evidence that many widely used treatments and procedures actually work better than various cheaper alternatives. [...] He traced one common practice -- preventing women from giving birth vaginally if they had previously had a cesarean -- to the recommendation of one lone doctor."

NatalieMac said...

That is frightening and crazy. I hope that more women learn to speak up and avoid all these unnecessary interventions into a natural process.

boo said...

Such an interesting post. Hey, would you consider doing a post about the appalling ad for the next season of "The Biggest Loser" that implies fatness causes miscarriages?

Anonymous said...

You can't really "speak up" in our med. system. Unless you are rich.
Refusing a recommended treatment, like induction, can cause your insurance to drop you.
I told my dr. that I wanted to try to refrain from having an induction. He let me go to my due date, but my fluid levels were low, and I was walking around @ 5cm dialated, so the induction was easy and needed (broken bag of water held little fluid). Honestly, I'm glad I was induced with both births. For a variety of reasons, but mostly safety concerns. Things did start to look a bit cloudy. Maybe they would have been brighter later. But I couldn't risk waiting to find out...The main thing was I desired to make it as close to term as possible, and I waited until I was 3cm plus dialated. I had my mds perform membrane stripping, it seemed to prime me pretty well, but I know some ppl prefer not to have that done...
Oddly enough, the death (still born) rate has gone down as the induction rate has climbed for babies. Now this could be do to many things...but it is an important side note.

Christine Hemming said...

There is now increasing evidence on the connection between medical induction and c-sections. Also between c-sections and a variety of health risks.

There are a variety of causes for the high rates of c-section births, but a significant influence is clearly the 'medicalising' of birth itself!

Jen said...

Thankyou for this post. Im a woman of size and I don't think I looked that great at all during my pregnancies. My first was really out there and big but at the end I felt good. My second was a very small belly and by then I had that skin left over from the first that hung down a bit. I hid my belly in long flowing skirts in truth.

But now I look at my flabby belly and while I don't love to see it much I'm very respectful of how it got that way. I just remind myself that while its not all neat and trim it does grow people and that is a pretty special super power in my opinion.