Monday, April 4, 2011

A Peek Into The Future?

Here's an interesting little study with possibly big implications for the future. I haven't seen the full text yet, just the abstract, but I hope the study will generate some dialogue in the birth community during this Cesarean Awareness Month.

For years, birth activists have been decrying the increasing cesarean rate, while some doctors shrugged off the increase as unimportant. "A healthy baby is all that matters, and it doesn't matter how it gets here," is the refrain.

Yes, a healthy baby is always everyone's priority, but a healthy mama should be important too.  And generally speaking, a mama recovering from surgery is less healthy than a mama recovering from vaginal birth. And it's not just about the actual surgical recovery but also about the long-term complications that may ensue. As a result, more and more research is finding that a high cesarean rate has major public health implications.

This study uses computer modeling to predict just how high our cesarean rate may go in the future and what the implications will be for women's health. It predicts that the U.S. cesarean rate could top 55% by the year 2020 (which is not that far away!).

Now, I saw that and thought.....55% by 2020?  Really? The national rate is nearly 33% as of 2009, and they expect an increase of 20% more in just 11 years?  Seems like the prediction is a little excessive to me.  On the other hand, some hospitals in some areas of the country are already there.  If enough of them develop these outrageously excessive rates, who knows?

Currently, the cesarean rate is at or near 40% in some states. In the Miami area, the rate is around 50% already.  Twenty-four hospitals in California have rates between 40-50%, and five hospitals in California have rates already over 50%. At Kendall Regional Medical Center in Miami and in Corona Regional Medical Center in California, the cesarean rate is more than 70%.  What are the long-term implications for women in these areas?

It's very clear from research that cesareans increase the risk for placental complications in future pregnancies.  Conditions like placenta previa (a low-lying placenta, which can cause severe bleeding, prematurity, and death) and placenta accreta (where the placenta grows into the muscle of the uterus and sometimes even into the bladder or other structures near the uterus, which can cause catastrophic bleeding, hysterectomy, and death) will only increase as the cesarean rate goes up. 

We are already seeing increases in the rates of placenta previa and accreta due in large part to the rise in the cesarean rates. And rates seem to have a dose-response relationship ─ the more cesareans, the higher the risk for previa or accreta. 

For example, Clark (1985) found  that the risk of previa "increased almost linearly with the number of prior cesarean sections." They tracked the rates of previa by number of prior cesareans and found:
  • 0.26% rate in an unscarred uterus
  • 0.65% after one prior cesarean
  • 1.8% after two prior cesareans
  • 3.0% after three prior cesareans
  • 10.0% after four, five, or six prior cesareans
Silver 2006 tracked the rates of accreta by number of prior cesareans and found:
  • Placenta Accreta with second cesarean - 0.31%
  • Placenta Accreta with third cesarean -     0.57%
  • Placenta Accreta with fourth cesarean -   2.13%
  • Placenta Accreta with fifth cesarean -      2.33%
  • Placenta Accreta with sixth or more cs-   6.74%
The only reason we do not already have an epidemic of these complications is because most women have smaller family sizes now. The more cesareans a woman has, the more likely things like previa become. So the smaller family sizes of today has been somewhat protective...but is not enough.

Women who are having "only" their second or third cesarean are not safe from complications. Even just one cesarean increases your risk for placenta previa or abruption (tearing away of the placenta, which can kill the baby) next time.  Getahun (2006) found that the risk for previa in a second pregnancy after a first-pregnancy vaginal birth was 0.38%, but the risk was 0.63% if the first birth was by cesarean.  A similar increase in the risk for placental abruption was seen; there was a risk of 0.74% after a vaginal first birth, which increased to a risk of 0.95% after a cesarean first birth.

Although rarer in low-order cesareans, major complications can occur even after only 1 or 2 cesareans.  Fleisch 2007 is a case report of a 30-year-old woman, pregnant with her second child after one cesarean 2 years previously.  At only 20 weeks of pregnancy, she experienced a uterine rupture because of placenta percreta (an accreta that's grown into surrounding structures).  She lost her baby and her uterus.  She was lucky not to lose her life.  And there are other case reports similar to that one, too.

And although maternal death is a very rare outcome of cesareans, if you do enough cesareans, more women are going to die, as the study suggests.  Cesareans increase the rate of blood clots, which can be deadly, and hemorrhaging, which can be life-threatening if they can't stop it.  Anesthesia accidents, although very rare, do happen.  Do enough anesthesia, and even the less-risky regional anesthesia (epidural/spinal) cesareans will eventually cause some deaths.

And these are only the most serious of complications.  How many women will suffer the less lethal yet still serious complications?  Hysterectomy rates also increase significantly with each cesarean.  Infection is always a potential issue after any surgery, and especially so for women of size.  Internal scar tissue is extremely common after abdominal surgery, and it can cause great pain for some women, and even bowel and bladder complications years later.  Small bits of uterine lining can inadvertently be deposited outside the uterus and cause aggravating and painful endometriosis. The rate of tubal pregnancies and pregnancies in the scar goes up.  Fertility after a cesarean may decrease too. 

Of course, it's important not to panic. On an individual basis, the increase in cesarean rate is not that earth-shaking. Let me reassure you that if you personally have a cesarean, the odds are quite good that you will survive it and that you will recover just fine.  Although surgery is not the ideal way to start out your life as a parent, it obviously can be done, and many of us have indeed done it.  You'd get through it if you had to. A cesarean is not the end of the world, and it certainly doesn't mean you are any less of a mother or a woman if you have one.

But if you look at it from a public health point of view, the increase in cesareans has serious implications.  On a population-wide basis, a high cesarean rate means more women and babies will die, and even more will have other complications. The only thing that's kept it in relative check up till now is the smaller family size of most women these days.  But although the more serious complications tend to happen in those with multiple repeat cesareans, even women with only one or two cesareans are still at risk. Clearly, cesareans should only be done when the benefits outweigh the risks.

Even if you don't have children, never plan to have children, or don't care about whether people have cesareans or not, your health insurance costs will go up, just to pay for the complications that accompany a high cesarean rate. 

As a matter of public health, a high cesarean rate does matter, and we all need to care about it. 

Study Abstract

Solheim KN, Esakoff TF, Little SE, Cheng YW, Sparks TN, Caughey AB.  The effect of cesarean delivery rates on the future incidence of placenta previa, placenta accreta, and maternal mortality.  J Matern Fetal Neonatal Med. 2011 Mar 7. [Epub ahead of print]

Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA, USA.

Objective. The overall annual incidence rate of caesarean delivery in the United Sates has been steadily rising since 1996, reaching 32.9% in 2009. Primary cesareans often lead to repeat cesareans, which may lead to placenta previa and placenta accreta. This study's goal was to forecast the effect of rising primary and secondary cesarean rates on annual incidence of placenta previa, placenta accreta, and maternal mortality.

Methods. A decision-analytic model was built using TreeAge Pro software to estimate the future annual incidence of placenta previa, placenta accreta, and maternal mortality using data on national birthing order trends and cesarean and vaginal birth after cesarean rates. Baseline assumptions were derived from the literature, including the likelihood of previa and accreta among women with multiple previous cesarean deliveries.

ResultsIf primary and secondary cesarean rates continue to rise as they have in recent years, by 2020 the cesarean delivery rate will be 56.2%, and there will be an additional 6236 placenta previas, 4504 placenta accretas, and 130 maternal deaths annually. The rise in these complications will lag behind the rise in cesareans by approximately 6 years.

Conclusions. If cesarean rates continue to increase, the annual incidence of placenta previa, placenta accreta, and maternal death will also rise substantially.

PMID: 21381881


Anonymous said...

Well written: I appreciate an article that 1# sites their sources (biig stickler for that with my educational backgroud) and 2# You walked the fine line of impressing the facts & their probable outcomes, but not in a fear mongering or shaming way.

I take issue with a lot of pregnancy/child books & articles that seem almost to use a shaming technique for convincing people. They focus on sentiment and some sort of appeal to your "mother morality" and leave you telling you WHY they take a given position.

Articles like this should leave you inspired, educated, and maybe a good kind of angry- but not "oh gosh, I had a c-sect.- I'm a terrible mom!! I didn't feel comfortable with a home birth, I've done hard to my child!" Don't women put enough presure on themselves without other people making them feel bad??

*big fan!!

Sarah said...

kmom, I want to start this by saying that I am both a huge fan and a statistics teacher. I just want to point out that this post has the same sort of statistical hysteria that usually surrounds women of size having babies. An increase fro 0.74% to 0.95% *might* be statistically significant, but it is far, far from meaningful on the decisionmaking level for individual women. This reminds me very much of the OMGfat=GD nonsense that you so lucidly decry. I'm sure there are terrifying case studies about "morbidly obese" patients who have horrifying outcomes that are used to scare women, much as your cited example about the 2nd-time c-section mom who lost her baby and her uterus. I'm all for reducing c-sections, but not through scare tactics and statistical hysteria.

Well-Rounded Mama said...

Sarah, I definitely hear what you are saying.

Personally, I was not too worried about the cited increase in risk in abruption (the numbers you cite) after my first cesarean. On an individual level, I didn't feel that much more at risk.

OTOH, when you have a population-wide increase (even a small-looking one) in a normally really really really rare event like accreta, that's a concern. It has implications that deserve to be discussed.

Again, it does make a difference to consider something on a population-wide public health basis and the implications of that, vs. on an individual decision basis. I try to make that point on the blog but I probably don't say it often enough or strongly enough.

As for individual horror stories being used, I take your point there too. I do think this is a little different though, at least in my intent.

The way most media handles the fat-and-pregnant angle, they use the horror story to imply this is a common and typical outcome among fat women and to try and scare women out of pregnancy at larger sizes.

I tried to make the point that MOST women with prior cesareans aren't going to have these horror stories, BUT that when looking at a large population, they are going to occur sometimes. Not that they are the typical outcome, but that they do sometimes happen and we can't be too complacent about it.

I think it's wrong to suppress the complications and poor outcomes that can happen occasionally in women of size...those are part of the truth about plus-size-pregnancy. I don't try to pretend those cannot happen. But that's only one small part of the picture, and shouldn't be presented as a typical or common outcome.

I don't think I'm doing that with cesareans here. I think I make the point that most women who have them will be okay, although some will suffer less severe issues that are bothersome but not life-threatening. It's more serious on the population-wide level or for those who have had quite a few multiple repeat cesareans.

It's a fine line to walk sometimes, trying to raise awareness about the public health implications of something, while also not trying to sound moralistic and condemning of that something, whether it's a cesarean or formula or induction or whatever. I struggle with that line all the time.

But I'm all for informed choice, and I think that includes discussion about the public health implications of maternity care trends. But yes, we have to be careful to realize that this is different than decision-making on an individual level in many ways.

Anonymous said...

dear kmom,
do you have information about the c/s risk years after a woman had her cs? all i know about it is adhesion.

Anonymous said...

I find it incredibly fascinating when people say "I am not concerned about the risks TO ME but I recognize the statistics and that it happens to others." Well, it is GOING to happen to SOMEONE and it MIGHT be you!

Having had 5 cesareans, I know full well the complications and risks of cesarean deliveries and multiple cesarean deliveries (my OB had told me 9 or 10 cesareans were fine, no increased risks!) I have also experienced an ectopic pregnancy, a placental abruption, and a uterine rupture. It's interesting how doctors tend to not be honest about the placental problems and they certainly don't acknowledge that uterine rupture happens even in the case of a scheduled cesarean, particularly if you have multiple cesareans.

Thank you so much for your article. I hope that WHO's stance against a higher then 15% cesarean rate will catch on here in the US. I would love to see doctors with unusually high cesarean rates and hospitals with equally high cesarean rates closed down, they have no business offering their 'services' to women. But women also need to be educated. Maybe it can be included in sex ed in high school? LOL

Anonymous said...

I'm still suffering the ill effects of my c-section 5 years later. An over zealous OB tore through my vaginal floor all the way down to my rectal muscle while trying to force my baby back up through my birth canal and out the my scar. She also failed to recoginze she had done this and so did not repair it. I'm left with no vaginal floor to speak of (the muscle is paper thin according to my new doctor) and will need it surgically repaired.

They most certainly did not warn me about this risk when when sending me off to my c-section. I'm now left with life-long consequences of my doctor's quick to section mentality.

A 55% c-section rate is outrageous! Your article did not mention the serious emotional/phsycological side effects. A national rate this high could have a huge impact. Postpartum depression, PTSD, postpartum anxiety, decrease in breastfeeding, and on and on.

C Section said...

What a terrifying prediction, if it comes true then it will reflect a true failure of the medical system.

While the statistical percentages for increased risk look small, turn them into real numbers and put a woman's face to each, then add the effect on her family and it's a picture of avoidable suffering.

There are so many other risks and future health problems for both mom and child (as mentioned in previous comments), all of which add to the stress and suffering and of course the millions and millions of dollars all this costs.

In short, the prediction of more than half of all births being by c-section must not be allowed to come true.


Becca I. said...

My 2nd c-section was literally a life-saver for my son. No one was aware that his cord was knotted until he was removed by c-section and had I had a vaginal birth, things would have been very, very different. Yes he was a planned c-section and yes I had one before him, after 40 hours of labour, when I and my daughter were in distress from the intensity of labour and being stalled at 9.5 cm for several hours. I am thankful for c-sections.