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.

Results. If 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