Hospitals with Midwives on Staff Have Better Outcomes

Here are two recent studies showing that hospitals with midwives and doctors practicing together ("interprofessional" centers) have better outcomes than hospitals with only doctors. One study is on first-time mothers (nulliparous), and the other study is on women who have given birth before (multiparous), to separate out the possible effects of parity.

In first-time mothers, women were much less likely to be induced or have oxytocin augmentation of labor in interprofessional/collaborative centers. The cesarean rate was 12% lower in interprofessional centers too.

For multiparous mothers (multips), women were again much less likely to be induced or have augmentation of labor in interprofessional centers. The first-time cesarean rate was 36% lower, and the Vaginal Birth After Cesarean (VBAC) rate was 31% higher than in institutions with only doctors. Neonatal outcomes were similar between the two types of centers.

The implication here is that not only do midwives lower the rates of interventions without endangering outcomes, they also influence the hospital culture in a positive way. Doctors who work with midwives tend to be more flexible about interventions, less likely to push a cesarean without need, and more likely to support VBACs.

If you are considering a hospital birth, try to choose a hospital with both doctors and midwives on staff, one with low overall cesarean rates, and strongly consider hiring a doula for professional labor support. Most women can safely be attended by a midwife, so make that your first choice if you can. If a risk comes up that means that you need to see an OB or high-risk maternal fetal medicine (MFM) specialist, the midwife will refer you to one, probably one that is supportive of the parents' birth wishes whenever conditions allow.



References

Birth. 2018 Nov 11. doi: 10.1111/birt.12407. [Epub ahead of print] Midwifery presence in United States medical centers and labor care and birth outcomes among low-risk nulliparous women: A Consortium on Safe Labor study. Neal JL, Carlson NS, Phillippi JC, Tilden EL, Smith DC, Breman RB, Dietrich MS, Lowe NK. PMID: 30417436

...Our objective was to compare labor processes and outcomes for low-risk nulliparous women birthing in United States medical centers with interprofessional care (midwives and physicians) versus noninterprofessional care (physicians only). METHODS: We conducted a retrospective cohort study using Consortium on Safe Labor data from low-risk nulliparous women who birthed in interprofessional (n = 7393) or noninterprofessional centers (n = 6982). .. women at interprofessional medical centers, compared with women at noninterprofessional centers, were 74% less likely to undergo labor induction (risk ratio [RR] 0.26; 95% CI 0.24-0.29) and 75% less likely to have oxytocin augmentation (RR 0.25; 95% CI 0.22-0.29). The cesarean birth rate was 12% lower at interprofessional centers (RR 0.88; 95% CI 0.79-0.98). Adverse neonatal outcomes occurred in only 0.3% of births and were thus too rare to be modeled. CONCLUSIONS: The care processes and birth outcomes at interprofessional and noninterprofessional medical centers differed significantly. Nulliparous women receiving care at interprofessional centers were less likely to experience induction, oxytocin augmentation, and cesarean than women at noninterprofessional centers. Labor care and birth outcome differences between interprofessional and noninterprofessional centers may be the result of the presence of midwives and interprofessional collaboration, organizational culture, or both.

Birth. 2018 Nov 9. doi: 10.1111/birt.12405. [Epub ahead of print] Influence of midwifery presence in United States centers on labor care and outcomes of low-risk parous women: A Consortium on Safe Labor study. Carlson NS, Neal JL, Tilden EL, Smith DC, Breman RB, Lowe NK, Dietrich MS, Phillippi JC. PMID: 30414200

...We sought to use national United States data to analyze the association between midwifery presence in maternity care teams and the birth processes and outcomes of low-risk parous women. METHODS: We conducted a retrospective cohort study using Consortium on Safe Labor data from low-risk parous women in either interprofessional care (n = 12 125) or noninterprofessional care centers (n = 8996). .. women at interprofessional centers, compared with women at noninterprofessional centers, were 85% less likely to have labor induced (risk ratio [RR] 0.15; 95% CI 0.14-0.17). The risk for primary cesarean birth among low-risk parous women was 36% lower at interprofessional centers (RR 0.64; 95% CI 00.52-0.79), whereas the likelihood of vaginal birth after cesarean for this population was 31% higher (RR 1.31; 95% CI 1.10-1.56). There were no significant differences in neonatal outcomes. CONCLUSIONS: Parous women have significantly higher rates of vaginal birth, including vaginal birth after cesarean, and lower likelihood of labor induction when cared for in centers with midwives. Our findings are consistent with smaller analyses of midwifery practice and support integrated, team-based models of perinatal care to improve maternal outcomes.

The High Price of Multiple Cesareans

A recent study once again reinforces the message that the more cesareans are done, the higher the risk for complications.

In previous posts, we have mostly discussed cesarean risks in terms of future pregnancies. We have written about Placenta Accreta Spectrum several times here already. This is where the placenta implants too deeply into the uterus. This is a life-threatening potential complication of pregnancies after cesareans, and the risk goes up with the number of prior cesareans. 

However, the risks with multiple cesareans aren't limited only to future pregnancies.

This new study highlights that the risk for other problems occurring during and after surgery also rises with the number of prior cesareans. The study found that: 

• After 2 cesareans, the risk for organ injury and hysterectomy increased
• After 3 cesareans, the risk for hemorrhage (massive bleeding) and surgical site complications increased

Injuries to organs around the area are serious because they usually involve the bladder or intestines. The more abdominal surgery someone has, the greater the risk for adhesions, scar tissue that can cause internal organs to stick together. This can make it difficult to operate in the area without causing collateral damage to organs nearby. If organ injury occurs, it can have lifelong consequences for the mother's urinary and/or G.I. system. Even if organ injury does not occur, adhesions alone can cause significant pain. For some people, it causes life-long severe pain. 

Obviously, the risk for major bleeding increases with surgery. Each successive surgery takes longer because of the scar tissue, and that increases the risk of hemorrhage even more. Some women need blood transfusions during or after the surgery. Many suffer problems with anemia, which can affect milk supply. Those with very severe hemorrhages may even experience Sheehan's Syndrome, life-long endocrinological problems because severe bleeding affected the pituitary gland. 

The risk for completely losing your uterus (hysterectomy) also increases with more cesareans. This is usually due to cases of accreta or in response to severe bleeding. The placenta cannot detach properly with accreta, or the uterus doesn't clamp down properly during surgery and the bleeding can't be stopped. Often the only way to keep the mother alive may be to take her uterus out, forever altering her fertility. . 

In addition, surgical site complications increase with each surgery. These can include infections, which can go septic and spread to the entire body. Although rare, some women die due to infections after cesareans. Others lose their uterus. Other surgical complications include seromas and hematomas (pockets of fluid or blood around the wound), and the surgical wound not healing (dehiscence). While these can be treated, they often cause long-term wounds and a painful recovery. They complicate recovery and make mothering difficult.

The Take Away Message

Sometimes when cesareans are questioned, people get all defensive. Mothers who had their babies by cesarean may feel like they are being judged or that some may think them less of a mother because of their cesarean. Doctors may feel defensive and point out the many times that cesareans have saved lives.

That's not what this is about. This is not about any one person's cesarean or a judgment about whether that cesarean was necessary or lifesaving. This is a public health issue about the overuse of cesareans and the potential consequences of that. The take away message here is:

All of the potential complications of cesareans need to be taken more seriously and cesareans used only when truly necessary. 

Cesareans are not evil. They can be a wonderful, life-saving intervention, and no one should feel like less of a mother because they had a cesarean. However, cesareans do carry risk. When overused or done without need, they can cause severe problems and even death, especially when multiple repeat cesareans are being done. 

National Public Radio has been running an excellent series on maternal mortality in pregnancy, as well as on near-misses (where the mother almost dies during or just after pregnancy), that highlights many of these complications: 

...according to the CDC, the rate at which women are suffering nearly fatal experiences in childbirth has risen faster than the rate at which they're dying. Based on the rate per 10,000 deliveries, serious complications more than doubled from 1993 to 2014, driven largely by a fivefold rise in blood transfusions. That also includes a nearly 60 percent rise in emergency hysterectomies — removal of the uterus and sometimes other reproductive organs, often to stem massive bleeding or infection. In 2014 alone, more than 4,000 women had emergency hysterectomies, rendering them permanently unable to carry a child. The rate of new mothers requiring breathing tubes increased by 75 percent, as did the rate of those treated for sepsis, a life-threatening inflammatory response to infection that can damage tissues and organs. 

"These numbers are really high, and far too many of them are preventable," said Dr. Elliott Main, medical director of the California Maternal Quality Care Collaborative and a national leader in efforts to reduce maternal deaths and injuries...

...more than 135 expectant and new mothers a day — or roughly 50,000 a year, according to the Centers for Disease Control and Prevention — endure dangerous and even life-threatening complications that often leave them wounded, weakened, traumatized, financially devastated, unable to bear more children, or searching in vain for answers about what went wrong.

Although certainly not the only factor in the rising rate of complications, many of these near-death and fatal experiences begin with cesareans. The same NPR article noted:

Only about one-third of U.S. C-sections are medically justified, according to [Eugene]  DeClercq, the Boston University maternal health expert. A web of factors explains the rest, including hospital culture (C-section rates vary widely from one institution to the next); efforts to make childbirth more convenient (C-sections can be scheduled); and indirect financial incentives. Because C-sections normally take much less time than vaginal deliveries, they are more cost-effective for hospitals and providers. Additionally, several studies point to the influence of "defensive medicine," a term for doctors' fears of being blamed by their patients for not having done everything possible to avoid medical problems.

The culture of cesareans is strong in many hospitals, and as a result many unnecessary cesareans are being done. And once a woman has had a cesarean, she is often pressured into further cesareans by doctors who say Vaginal Birth After Cesarean (VBAC) is "too risky." But the fact is that multiple repeat cesareans are not risk-free either. Both VBAC and Repeat Cesarean have risks to mother and baby that must be carefully weighed. It should be up to the mother to decide which choice to pursue.

Research is clear that taken as a group, cesareans are not risk-free and should not be taken lightly or done routinely. 



References

Am J Perinatol. 2018 Oct 29. doi: 10.1055/s-0038-1673653. [Epub ahead of print] Risk of Maternal Morbidity with Increasing Number of Cesareans. Sondgeroth KE, Wan L, Rampersad RM, Stout MJ, Macones GA, Cahill AG, Tuuli MG. PMID: 30372778

OBJECTIVE: To estimate the risk of perioperative morbidity with increasing number of cesareans. STUDY DESIGN: We conducted a retrospective cohort study from 2004 to 2010. Patients delivered by cesarean were included. Outcome measures were a composite organ injury (bowel or bladder), hysterectomy, hemorrhage requiring transfusion, severe morbidity, or surgical site complications... RESULTS: Of the 15,872 women in the cohort, 5,144 had cesarean delivery: 3,113 primary, 1,310 one prior, 510 two prior, and 211 three or more prior cesareans. There was a significant increase in organ injury, hysterectomy, and surgical site complications with increasing number of cesareans. In multivariable analysis, the risk of organ injury and hysterectomy was increased compared with primary cesarean after two prior cesareans, and after three or more cesareans for hemorrhage requiring transfusion and surgical site complications. CONCLUSION: The risks of organ injury and hysterectomy are increased after two or more prior cesareans, and risks of hemorrhage and surgical site complications are increased after three or more cesareans.

Arch Gynecol Obstet. 2017 Feb;295(2):303-311. doi: 10.1007/s00404-016-4221-8. Epub 2016 Oct 21. Incidence of adhesions and maternal and neonatal morbidity after repeat cesarean section. Arlier S, Seyfettinoğlu S, Yilmaz E, Nazik H, Adıgüzel C, Eskimez E, Hürriyetoğlu Ş, Yücel O. PMID: 27770246

PURPOSE OF INVESTIGATION: We investigated the effect of repeat cesarean sections (CSs) and intra-abdominal adhesions on neonatal and maternal morbidity. MATERIALS AND METHODS: We  analyzed intra-abdominal adhesions of 672 patients. RESULTS: Among the patients, 173, 206, 151, and 142 underwent CS for the first, second, third, and fourth time or more, respectively. There were adhesions in 393 (58.5 %) patients. Among first CSs, there were no adhesions, the rate of maternal morbidity [Morales et al. (Am J Obstet Gynecol 196(5):461, 2007)] was 26 %, and the rate of neonatal morbidity (NM) was 35 %. Among women who have history of two CSs, the adhesion rate was 66.3 %, the adhesion score was 2.05, MM was 14 %, and NM was 21 %. Among third CSs, these values were 82.1, 2.82, 23, and 14 %, respectively. Among women who have history of four or more CSs, these values were 92.2, 4.72, 31.7, and 18 %, respectively. Adhesion sites and dense fibrous adhesions increased parallel to the number of subsequent CSs. Increased adhesion score was associated with 1.175-fold higher odds of NM and 1.29-fold higher odds of MM. The rate of NM was eightfold higher in emergency-delivered newborns (emergency: 39.4, 40 %; elective: 4.9 %). MM was 20 and 26 % for elective and emergency CSs, respectively. CONCLUSIONS: Emergency operations and adhesions increased complications.

• https://www.npr.org/2017/05/12/527806002/focus-on-infants-during-childbirth-leaves-u-s-moms-in-danger - National Public Radio article on maternal mortality in childbirth nationwide
• https://www.npr.org/2017/12/22/572298802/nearly-dying-in-childbirth-why-preventable-complications-are-growing-in-u-s  - National Public Radio article on near-misses and serious maternal morbidity, one in an excellent series of articles about maternal mortality in the U.S.
• https://news.aetna.com/2015/10/c-section-most-common-surgery-often-unnecessary/ - article about the increase in cesarean rate and how many cs are unnecessary

Women Are Dying From This: Taking Cesareans Seriously

When women have cesareans, they are rarely warned that a possible complication can be placental problems in future pregnancies.

Many women (and especially higher weight women) are pressured into cesareans in their first pregnancy. Many of these same women are counseled away from Vaginal Birth After Cesarean (VBAC) and into repeat cesareans in subsequent pregnancies.

Few of these women have been told that cesareans raise the risk for Placenta Accreta, a very serious complication, and that every cesarean increases the risk for it. I know *I* wasn't told this. This is a tremendous disservice to parents and to the importance of informed consent.

About Accreta

In Placenta Accreta, the fertilized egg implants near or on scar tissue in the uterus. This scar tissue is usually from a prior cesarean, but can also be from a D&C procedure, fibroid removals, a perforation from an IUD, or any uterine surgery or instrumentation. The placenta then grows into the uterine wall in this scar tissue. After the baby is born (often prematurely), the placenta can't separate properly and bleeding can become prolific. If the bleeding is not resolved, the mother can die.

There are degrees of Placenta Accreta. When the placenta grows into the uterine wall, that's Placenta Accreta. 

When the placenta invades the muscles of the uterus, that's known as Placenta Increta.

When the placenta grows through the uterine wall and into nearby organs like the bladder, that's called Placenta Percreta. All are extremely serious conditions, but percreta is the most serious of all.

The accreta rate has risen over the years as the cesarean rate has increased. Doctors are seeing more and more cases these days of what used to be a very rare complication. Some data indicate that the accreta rate has risen from about 1 in 4000 in the 1970s to about 1 in 533 now.

You can read more about this in my blog series on Placenta Accreta.

• Part One - What Is Placenta Accreta?
• Part Two - Life-Threatening Complication of Prior Cesarean 
• Part Three - Risks to Mother and Baby
• Part Four - Diagnosis, Treatment, and a Cautionary Story

The absolute numerical risk of accreta occurring in any one person is low, even with prior cesareans. Most women who have had cesareans will not experience an accreta. However, it is such a life-threatening condition that even a relatively small incidence carries a tremendous burden of complications, cost, and potential loss of life.

The more cesareans you have had, the greater the risk for accreta. In one very large study (Silver 2006), accreta was present in:

• 0.24% of women undergoing their first cesarean (previously unscarred)
• 0.31% of women undergoing their second cesarean (one prior cesarean)
• 0.57% of women undergoing their third cesarean (two prior cesareans)
• 2.13% of women undergoing their fourth cesarean (three prior cesareans)
• 2.33% of women undergoing their fifth cesarean (four prior cesareans)
• 6.74% of women undergoing their sixth or more cesarean (five or more prior cesareans)

This is why it is important to avoid automatic repeat cesareans and to keep VBAC a viable choice. Multiple repeat cesareans are the single most preventable factor for accretas. 

Accreta does sometimes occur after only one cesarean, like the woman in the video below, and that's why it's important to prevent a first cesarean whenever possible as well.

One Mother's Accreta Story

This mother had only had ONE prior cesarean, but still developed accreta with baby #2. Her first cesarean was a planned cesarean, urged by her OB. She was never warned that her cesarean meant accreta was a potential risk for the future.

THIS is why the high cesarean rate matters. On a case-by-case basis, a cesarean can be a good thing. But the public health implication of a high cesarean rate is that more women will develop life-threatening complications like placenta accreta, more babies will be born prematurely, and more women will die or experience permanent damage. Sometimes even after only one cesarean.

If we want to decrease maternal mortality rates and prevent complications from accreta, we MUST decrease cesarean rates. As the mother in the video below states:

A cesarean can be a life-saving intervention. The goal is not to eliminate cesareans. The goal is to make decisions regarding cesareans appropriately, and to recognize that even an uncomplicated cesarean and recovery can still put the mother at significant future risk....

She continues:

"There are too many cesareans now, 1 in 3 births, and researchers estimate that as many as 50% of those are unnecessary. 

And since a prior cesarean is a significant risk factor for developing a future accreta, that means that there are women developing accreta when it could have been prevented. So the easiest way to reduce the amount of accretas is to reduce cesarean levels... 

Women are dying from this, and mothers are dying from this. We need to take the risks of a cesarean seriously."

Estimating Fetal Weight Increases Risk for Cesarean

Think twice about doing ultrasounds to estimate fetal weight before birth.

In this very large, multi-center study, just the act of estimating fetal weight raised the cesarean rate if the baby was predicted to be big, even when controlling for actual fetal size. It doubled the risk for cesarean in non-diabetic mothers who were thought to be carrying large babies.

Most women predicted to have a large baby will not actually have a large baby, yet fear of a large baby lowers the surgical threshold for many providers, resulting in unnecessary cesareans. Despite limited evidence of improved outcomes, estimating fetal weight is a very common intervention in most obstetric practices, particularly for women of size who tend to have larger babies on average. It is likely a major driver of the high cesarean rate in "obese" women.

Providers need to stop doing so many fetal weight estimates and over-managing the labors of suspected big babies. This is especially important in women of size.


Reference

Obstet Gynecol. 2016 Sep;128(3):487-94. doi: 10.1097/AOG.0000000000001571. Association of Recorded Estimated Fetal Weight and Cesarean Delivery in Attempted Vaginal Delivery at Term. Froehlich RJ1, Sandoval G, Bailit JL, Grobman WA, Reddy UM, Wapner RJ, Varner MW, Thorp JM Jr, Prasad M, Tita AT, Saade G, Sorokin Y, Blackwell SC, Tolosa JE; MSCE, for the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network. PMID: 27500344

OBJECTIVE: To evaluate the association between documentation of estimated fetal weight, and its value, with cesarean delivery. METHODS: This was a secondary analysis of a multicenter observational cohort of 115,502 deliveries from 2008 to 2011. Data were abstracted by trained and certified study personnel. We included women at 37 weeks of gestation or greater attempting vaginal delivery with live, nonanomalous, singleton, vertex fetuses and no history of cesarean delivery. Rates and odds ratios (ORs) were calculated for women with ultrasonography or clinical estimated fetal weight compared with women without documentation of estimated fetal weight. Further subgroup analyses were performed for estimated fetal weight categories (less than 3,500, 3,500-3,999, and 4,000 g or greater) stratified by diabetic status. Multivariable analyses were performed to adjust for important potential confounding variables. RESULTS: We included 64,030 women. Cesarean delivery rates were 18.5% in the ultrasound estimated fetal weight group, 13.4% in the clinical estimated fetal weight group, and 11.7% in the no documented estimated fetal weight group (P<.001). After adjustment (including for birth weight), the adjusted OR of cesarean delivery was 1.44 (95% confidence interval [CI] 1.31-1.58, P<.001) for women with ultrasound estimated fetal weight and 1.08 for clinical estimated fetal weight (95% CI 1.01-1.15, P=.017) compared with women with no documented estimated fetal weight (referent). The highest estimates of fetal weight conveyed the greatest odds of cesarean delivery. When ultrasound estimated fetal weight was 4,000 g or greater, the adjusted OR was 2.15 (95% CI 1.55-2.98, P<.001) in women without diabetes and 9.00 (95% CI 3.65-22.17, P<.001) in women with diabetes compared to those with estimated fetal weight less than 3,500 g. CONCLUSION: In this contemporary cohort of women attempting vaginal delivery at term, documentation of estimated fetal weight (obtained clinically or, particularly, by ultrasonography) was associated with increased odds of cesarean delivery. This relationship was strongest at higher fetal weight estimates, even after controlling for the effects of birth weight and other factors associated with increased cesarean delivery risk.

Stop Blaming Women for Cesarean Rates

For many years, the cesarean rate rose, virtually unchecked. When this was questioned, care providers resorted to the old mantra of blaming the women.

At first they said that the cesarean rate was rising because women wanted cesareans to avoid the pain and bother of labor, or for the sake of convenience. The Brits called this being "too posh to push," implying that women were selfish, lazy, and couldn't be bothered to go through labor.

In the U.S., doctors implied that women wanted cesareans for the sake of convenience; they implied the increase in cesareans was simply in response to demands from women themselves.

Of course, there are a few women request elective cesareans, but those women are rare, probably around 1-3%. By and large the cesarean rate was NOT being driven by mother request or because women couldn't be bothered to labor.

When data came out questioning this, doctors started blaming women instead. 

They said the cesarean rate was rising because women were too old, were waiting too long to have babies, were too fat, or were too sick. Numerous articles said that was what was REALLY driving the increase in cesareans. Here is a quote from one Canadian article:

Doctors said several factors are driving the push for surgical births, from fear of pain during childbirth and the convenience factor to the growing proportion of expectant mothers who are obese.

Ugh. I've been arguing against the "women are too fat" argument for years. Fat women have had plenty of babies in the past and the cesarean rate for them then was far lower than it is now. In some studies it was no different than that of average-sized women.

It's not women's size that is directly driving the cesarean rate. Instead what seems to have changed is providers' practice patterns around handling the pregnancies of fat women.

One German study really zeroed in on this by showing that the cesarean rate for obese women had drastically risen over a 12-year period. In the study, the cesarean rate for "morbidly obese" women (BMI over 40) increased from 26.9% in 1990 to 55.2% in 2012. Basically, it doubled.

Critics would argue that the cesarean rate has increased in all groups over time, which is correct. However, it has not increased equally over all groups, suggesting that something about the management of certain groups has changed.

For example, the rate has increased MOST in the women with the highest BMIs. In the German study, the cesarean rate increased 15.3% in the "normal" BMI group, whereas it increased 28.3% in the "morbidly obese" group.

This strongly suggests that it is not obesity itself that is driving the increase, but the way that obese pregnancies are being managed. Obese women are subjected to more interventions, more exaggeration of fear around their pregnancies, and a lowering of the surgical threshold for a cesarean.

But it's not just about blaming obesity. Women are being blamed across the board for higher cesarean rates in order to deflect criticism from how births are being managed these days.

I have written about this topic of mother-blaming for cesarean rates many times. That's why I was delighted recently to see this mother-blaming thoroughly debunked in an article from Australia. (The article is not new; it is from 2012, but I only recently saw it.) It was written by maternity care professionals there. Sadly, they were mostly addressing the cesarean rate in Australia, although they did reference the rates in the U.S. Wish more U.S. providers had the guts to chime in on this issue.

But at least the Australian authors said out loud what few in the obstetric world have been willing to admit until recently ─ that the increase in cesareans has largely been driven by provider practice, not by differences in women themselves.

Here is a quote from the authors (my emphasis):

When we’re not using the “too posh to push” or “asking for it” explanation for rising caesarean rates, health professionals resort to the “too old, too sick and too fat” mantra to explain away our responsibility for the rise. In other words, women are giving birth at older ages, they have more health complications and are increasingly overweight. 

All of this is true on one level – women are older and more likely to be overweight and this all increases the chance of complications – but caesareans are rising among all groups, regardless of age, risk factors and weight...

It’s time to abandon the “too old, too fat, too sick and asking for it” mantra and stop blaming women for the high rates of caesarean births. 

Instead, we need to address the real problem: we health providers are too often scared, impatient and inadequately informed to give women a real choice.

About time someone in the profession is saying what consumers have been saying for years! Yet many in the medical world are still scapegoating women for high cesarean rates.

It 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. As Henci Goer and CNM Amy Romano note in their book, "Optimal Care in Childbirth":

U.S. cesarean rates have increased sharply at every maternal age, in every ethnic group, and for every demographic or medical risk factor.

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," the fear around lawsuits, and the lowering of surgical thresholds have all been caregiver-driven reasons for the rise in the cesarean rate.

The conversation needs to stop being about mother-blaming. It should be about caregivers taking responsibility for the patterns of management that have driven up cesarean rates over the years. Providers have conveniently managed to deflect this for years by blaming women instead of turning a critical eye to their own practices, but this must end.

Changing demographics may play a small role and women do have a responsibility to be proactive in their health habits to minimize the risk for complications, but providers need to acknowledge that the way they manage births has been a very significant factor in the tremendous rise in the cesarean rate.

It's time to stop scapegoating women for the high cesarean rate, and it's time for caregivers to take responsibility for their own contributions to the high cesarean rate.

References

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.

PLoS Med. 2014 Oct 21;11(10):e1001745. doi: 10.1371/journal.pmed.1001745. eCollection 2014. Maternal clinical diagnoses and hospital variation in the risk of cesarean delivery: analyses of a National US Hospital Discharge Database. Kozhimannil KB1, Arcaya MC2, Subramanian SV2. PMID: 25333943

BACKGROUND: Cesarean delivery is the most common inpatient surgery in the United States, where 1.3 million cesarean sections occur annually, and rates vary widely by hospital. Identifying sources of variation in cesarean use is crucial to improving the consistency and quality of obstetric care. We used hospital discharge records to examine the extent to which variability in the likelihood of cesarean section across US hospitals was attributable to individual women's clinical diagnoses. METHODS AND FINDINGS: Using data from the 2009 and 2010 Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project--a 20% sample of US hospitals--we analyzed data for 1,475,457 births in 1,373 hospitals. We fitted multilevel logistic regression models (patients nested in hospitals). The outcome was cesarean (versus vaginal) delivery. Covariates included diagnosis of diabetes in pregnancy, hypertension in pregnancy, hemorrhage during pregnancy or placental complications, fetal distress, and fetal disproportion or obstructed labor; maternal age, race/ethnicity, and insurance status; and hospital size and location/teaching status. The cesarean section prevalence was 22.0% (95% confidence interval 22.0% to 22.1%) among women with no prior cesareans. In unadjusted models, the between-hospital variation in the individual risk of primary cesarean section was 0.14 (95% credible interval 0.12 to 0.15). The difference in the probability of having a cesarean delivery between hospitals was 25 percentage points. Hospital variability did not decrease after adjusting for patient diagnoses, socio-demographics, and hospital characteristics (0.16 [95% credible interval 0.14 to 0.18]). A limitation is that these data, while nationally representative, did not contain information on parity or gestational age. CONCLUSIONS: Variability across hospitals in the individual risk of cesarean section is not decreased by accounting for differences in maternal diagnoses. These findings highlight the need for more comprehensive or linked data including parity and gestational age as well as examination of other factors-such as hospital policies, practices, and culture--in determining cesarean section use. 

J Perinat Med. 2014 Jun 10. Impact of maternal body mass index on the cesarean delivery rate in Germany from 1990 to 2012. Kyvernitakis I, Köhler C, Schmidt S, Misselwitz B, Großmann J, Hadji P, Kalder M. PMID: 24914711

ABSTRACT AIMS: Maternal obesity is a risk factor for cesarean delivery (CD). The aim of this analysis was to determine the association between early-pregnancy body mass index (BMI) and the rate of CD over the past two decades. METHODS: We retrospectively analyzed data from the perinatal quality registry of singleton deliveries in the state of Hesse in Germany from 1990 to 2012. We divided the patients into groups according to the WHO criteria for BMI: underweight (<18.5), normal weight (18.5-<25), overweight (25-<30), obese class I (30-<35), obese class II (35-<40), and obese class III (≥40). RESULTS: The analysis included 1,092,311 patients with available data regarding maternal BMI and mode of delivery. The CD rates for underweight (<18.5), normal weight (18.5-<25), overweight (25-<30), obese class I (30-<35), obese class II (35-<40), and obese class III (≥40) women increased from 14.4%, 16.1%, 19.5%, 22.3%, 25%, and 26.9% in the year 1990 to 27.9%, 31.4%, 38.8%, 45.1%, 50.2%, and 55.2% in the year 2012, respectively (P<0.001). CONCLUSION: Maternal BMI in early pregnancy is linearly associated with the incidence of CD. We found a disproportionate increase of CD in morbidly obese women compared with the CD incidence in the reference BMI population over the past two decades.

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.

Placenta Accreta Rates Reflect High Cesarean Rates and VBAC Bans

October is Accreta Awareness Month. The International Cesarean Awareness Network (ICAN) is featuring Accreta Awareness as part of its focus this month, and is promoting the importance of donating blood in order to help women who experience accretas.

Placenta Accreta is a condition in which the placenta attaches too deeply to the uterine wall, or actually grows into the uterine wall. Occasionally it even grows through the uterine wall and into adjoining tissues. This means the placenta can't separate during birth. It causes massive bleeding, and frequently requires a hysterectomy in order to control the bleeding. Placenta Accreta has about a 7% maternal mortality rate and is one of the most serious obstetric situations a woman can face.

You can read more about Placenta Accreta in my series about it here:

• Part One: What Is Accreta?
• Part Two: Life-Threatening Complication of Prior Cesarean
• Part Three: Risks to Mother and Baby
• Part Four: Diagnosis, Treatment, and a Cautionary Story

Accretas have several different risk factors, including maternal age, parity, smoking, infection, pregnancy after fertility treatment, and prior uterine procedures such as D&C or fibroid removal.

However, the strongest risk factor for accretas is a history of prior cesarean sections. The discovery of placenta previa (a low-lying placenta) in a woman with a history of prior cesareans is particularly predictive of an accreta.

In addition, the risk for accreta rises strongly as the number of prior cesareans increases. Silver 2006 found the following risk for accreta by number of prior cesareans:

• First cesarean:                  0.24%
• Second cesarean:             0.31%
• Third cesarean:                0.57%
• Fourth cesarean:              2.13%
• Fifth cesarean:                 2.33%
• Sixth or more cesarean:   6.74%

A recent large Nordic study found:

The risk of AIP [abnormally invasive placenta] increased seven-fold after one prior caesarean section (CS) to 56-fold after three or more CS.

Accretas are associated with poor outcomes, but very high-order repeat cesareans are particularly associated with poor outcomes.

Many accretas occur in women who have a cesarean in their first pregnancy and are automatically scheduled for repeat cesareans thereafter. Women who have larger families are particularly impacted. Yet many of these women say that they were never counseled about the risk of accreta with repeat cesareans. This is wrong. Informed consent should include discussions of all the risks of both VBAC and repeat cesareans.

Alarmingly, the incidence of placenta accreta cases seems to be on the rise. As noted by ACOG in the graphic above, this is likely in response to the rising cesarean rates. This reflects an increase in both primary cesareans and routine repeat cesareans as a result of de facto VBAC bans.

The increase in accretas is not just a U.S. phenomenon. A recent study from Hong Kong, where there is a high underlying cesarean rate, demonstrates that the rate of accreta increased over time as the cesarean rate increased. The authors note:

The overall rate of morbidly adherent placenta...increased from 0.17/1000 births in 1999-2003 to 0.79/1000 births in 2009-2013.

For such a rare condition, that's a significant increase. A similar result was found in an Italian region with a strong increase in cesarean rates over the years. Researchers found that:

The incidence increased from 0.12% during the 1970s, to 0.31% during the 2000s. During the same period, cesarean section rates increased from 17 to 64%. Prior cesarean section was the only risk factor showing a significant concomitant rise. Our results reinforce cesarean section as the most significant predisposing condition for placenta accreta.

One recent analysis concluded:

The incidence of placenta accreta has increased 13-fold since the early 1900s and directly correlates with the increasing cesarean delivery rate.

Alarmingly, the increase in accreta rates also seems to parallel the rise in maternal mortality rates over time. There are many other factors that play into the maternal mortality rate, mind, but the high cesarean rate and resulting accretas is one major piece of the puzzle.

If we hope to reduce the number of women impacted by accretas, we must reduce the cesarean rate. The authors of the recent Nordic study pointed this out, saying:

Our findings indicate that a lower CS rate in the population may be the most effective way to lower the incidence of AIP [Abnormally Invasive Placenta]. 

This means not only reducing the number of women who have first cesareans but also the number of women who have automatic repeat cesareans. In order to do that, we must increase access to VBACs. Far too many women have difficulty finding providers who will support them in labor after cesarean. Many hospitals have outright VBAC bans.

Of course, it's only fair to note that most women who have higher-order cesareans will not experience an accreta. However, accreta is such a serious and life-threatening condition that even relatively small incidences carry a huge burden of complications, cost, and potential loss of life. That's why it is vital that women have balanced risk counseling after a prior cesarean and real access to VBAC if they want it.

There are many birth stories online of women who have experienced accretas. It's important to emphasize that many of them have good outcomes, but also important to point out that many of them have challenging outcomes, and some of them have even had tragic outcomes.

This is the bottom line. Real women have died because of accretas, leaving their children motherless. Others have lost their uterus to hysterectomy or their babies to prematurity. Although I have not personally known anyone who died from accreta, I have known several women who have had very close near-misses due to accreta. Nearly all lost their uteri as a result of their accreta, and some lost their babies as well.

This is the real consequence of a too-high cesarean rate. This is why it's so important to avoid non-indicated cesareans and improve VBAC access. 

*If you can, give blood to help support women who have been affected by accreta. 


References

Support Groups

• http://www.hopeforaccreta.org/
• https://www.facebook.com/hopeforaccreta/
• http://www.circleofmoms.com/survivors-of-placenta-accreta-increta-or-percreta 
• http://community.babycentre.co.uk/groups/a3859975/placenta_accreta_support

Accreta Studies

Semin Perinatol. 2012 Oct;36(5):315-23. doi: 10.1053/j.semperi.2012.04.013. Implications of the first cesarean: perinatal and future reproductive health and subsequent cesareans, placentation issues, uterine rupture risk, morbidity, and mortality. Silver RM. PMID: 23009962

Rates of cesarean delivery have substantially increased worldwide during the past 30 years. Indeed, almost one-third of deliveries in the United States are cesareans. Most cesareans are safe, and major complications are uncommon. However, there is a "concealed" downside to cesarean deliveries. There are rare but life-threatening morbidities that may occur, which are often overlooked because most cesareans go well. In addition, subsequent pregnancies are fraught with an increased risk of both maternal and fetal complications. The worst of these are associated with placental problems such as previa, abruption, and accreta. The risk dramatically worsens in patients with multiple repeat cesarean deliveries. This article will summarize and highlight the implications of the rising cesarean rate on maternal and fetal morbidity and mortality.

Hong Kong Med J. 2015 Dec;21(6):511-7. doi: 10.12809/hkmj154599. Epub 2015 Nov 6. Rising incidence of morbidly adherent placenta and its association with previous caesarean section: a 15-year analysis in a tertiary hospital in Hong Kong. Cheng KK1, Lee MM1. PMID: 26554269

OBJECTIVES: To identify the incidence of morbidly adherent placenta in the context of a rising caesarean delivery rate within a single institution in the past 15 years, and to determine the contribution of morbidly adherent placenta to the incidence of massive postpartum haemorrhage requiring hysterectomy. SETTING: A regional obstetric unit in Hong Kong. PATIENTS: Patients with a morbidly adherent placenta with or without previous caesarean section scar from 1999 to 2013. RESULTS: A total of 39 patients with morbidly adherent placenta were identified during 1999 to 2013. The overall rate of morbidly adherent placenta was 0.48/1000 births, which increased from 0.17/1000 births in 1999-2003 to 0.79/1000 births in 2009-2013. The rate of morbidly adherent placenta with previous caesarean section scar and unscarred uterus also increased significantly. Previous caesarean section (odds ratio=24) and co-existing placenta praevia (odds ratio=585) remained the major risk factors for morbidly adherent placenta. With an increasing rate of morbidly adherent placenta, more patients had haemorrhage with a consequent increased need for peripartum hysterectomy. No significant difference in the hysterectomy rate of morbidly adherent placenta in caesarean scarred uterus (19/25) compared with unscarred uterus (8/14) was noted. This may have been due to increased detection of placenta praevia by ultrasound and awareness of possible adherent placenta in the scarred uterus, as well as more invasive interventions applied to conserve the uterus. CONCLUSION: Presence of a caesarean section scar remained the main risk factor for morbidly adherent placenta. Application of caesarean section should be minimised, especially in those who wish to pursue another future pregnancy, to prevent the subsequent morbidity consequent to a morbidly adherent placenta, in particular, massive postpartum haemorrhage and hysterectomy.

Acta Obstet Gynecol Scand. 2013 Apr;92(4):457-60. doi: 10.1111/aogs.12080. Placenta accreta: incidence and risk factors in an area with a particularly high rate of cesarean section. Morlando M, Sarno L, Napolitano R, Capone A, Tessitore G, Maruotti GM, Martinelli P. PMID: 23347183

...The aim of this study was to investigate the change in the incidence of placenta accreta and associated risk factors along four decades, from the 1970s to 2000s, in a tertiary south Italian center. We analyzed all cases of placenta accreta in a sample triennium for each decade. The incidence increased from 0.12% during the 1970s, to 0.31% during the 2000s. During the same period, cesarean section rates increased from 17 to 64%. Prior cesarean section was the only risk factor showing a significant concomitant rise. Our results reinforce cesarean section as the most significant predisposing condition for placenta accreta.

Obstet Gynecol. 2015 Sep;126(3):654-68. doi: 10.1097/AOG.0000000000001005. Abnormal Placentation: Placenta Previa, Vasa Previa, and Placenta Accreta. Silver RM1. PMID: 26244528

Placental disorders such as placenta previa, placenta accreta, and vasa previa are all associated with vaginal bleeding in the second half of pregnancy. They are also important causes of serious fetal and maternal morbidity and even mortality. Moreover, the rates of previa and accreta are increasing, probably as a result of increasing rates of cesarean delivery, maternal age, and assisted reproductive technology....

BJOG. 2016 Jul;123(8):1348-55. doi: 10.1111/1471-0528.13547. Epub 2015 Jul 29. Abnormally invasive placenta-prevalence, risk factors and antenatal suspicion: results from a large population-based pregnancy cohort study in the Nordic countries. Thurn L, Lindqvist PG, Jakobsson M, Colmorn LB, Klungsoyr K, Bjarnadóttir RI, Tapper AM, Børdahl PE, Gottvall K, Petersen KB,Krebs L, Gissler M, Langhoff-Roos J, Källen K. PMID: 26227006

OBJECTIVE: The objective was to investigate prevalence, estimate risk factors, and antenatal suspicion of abnormally invasive placenta (AIP) associated with laparotomy in women in the Nordic countries. DESIGN: Population-based cohort study. SETTING AND POPULATION: A 3-year Nordic collaboration among obstetricians to identify and report on uterine rupture, peripartum hysterectomy, excessive blood loss, and AIP from 2009 to 2012 The Nordic Obstetric Surveillance Study (NOSS). METHODS: In the NOSS study, clinicians reported AIP cases from maternity wards and the data were validated against National health registries. MAIN OUTCOME MEASURES: Prevalence, risk factors, antenatal suspicion, birth complications, and risk estimations using aggregated national data. RESULTS: A total of 205 cases of AIP in association with laparotomy were identified, representing 3.4 per 10 000 deliveries. The single most important risk factor, which was reported in 49% of all cases of AIP, was placenta praevia. The risk of AIP increased seven-fold after one prior caesarean section (CS) to 56-fold after three or more CS. Prior postpartum haemorrhage was associated with six-fold increased risk of AIP (95% confidence interval 3.7-10.9). Approximately 70% of all cases were not diagnosed antepartum. Of these, 39% had prior CS and 33% had placenta praevia. CONCLUSION: Our findings indicate that a lower CS rate in the population may be the most effective way to lower the incidence of AIP. Focused ultrasound assessment of women at high risk will likely strengthen antenatal suspicion. Prior PPH is a novel risk factor associated with an increased prevalence of AIP.

Am J Obstet Gynecol. 2015 Sep;213(3):384.e1-11. doi: 10.1016/j.ajog.2015.05.002. Epub 2015 May 5. Morbidity associated with cesarean delivery in the United States: is placenta accreta an increasingly important contributor? Creanga AA, Bateman BT, Butwick AJ, Raleigh L, Maeda A, Kuklina E, Callaghan WM. PMID: 25957019

OBJECTIVE: The purpose of this study was to examine cesarean delivery morbidity and its predictors in the United States. STUDY DESIGN: We used 2000-2011 Nationwide Inpatient Sample data to identify cesarean deliveries and records with 12 potential cesarean delivery complications, including placenta accreta. We estimated cesarean delivery morbidity rates and rate changes from 2000-2011, and fitted Poisson regression models to assess the relative incidence of morbidity among repeat vs primary cesarean deliveries and explore its predictors. RESULTS: From 2000-2011, 76 in 1000 cesarean deliveries (97 in 1000 primary and 48 in 1000 repeat cesarean deliveries) were accompanied by ≥1 of 12 complications. The unadjusted composite cesarean delivery morbidity rate increased by 3.6% only among women with a primary cesarean delivery (P < .001); the unadjusted rate of placenta accreta increased by 30.8% only among women with a repeat cesarean deliveries (P = .025). The adjusted rate of overall composite cesarean delivery morbidity decreased by 1% annually from 2000-2011 (P < .001). Compared with women with a primary cesarean delivery, those women who underwent a repeat cesarean delivery were one-half as likely (incidence rate ratio, 0.50; 95% CI, 0.49-0.50) to experience a complication, but 2.13 (95% CI, 1.98-2.29) times more likely to have a placenta accreta diagnosis. Both cesarean delivery morbidity and placenta accreta were positively associated with age >30 years, non-Hispanic black race/ethnicity, the presence of a chronic medical condition, and delivery in urban, teaching, or larger hospitals. CONCLUSION: Overall, cesarean delivery morbidity declined modestly from 2000-2011, but placenta accreta became an increasingly important contributor to repeat cesarean delivery morbidity. Clinicians should maintain a high index of suspicion for abnormal placentation and make adequate preparations for patients who need cesarean deliveries.

BJOG. 2013 Jan;120(1):85-91. doi: 10.1111/1471-0528.12010. Epub 2012 Oct 24. Multiple repeat caesarean section in the UK: incidence and consequences to mother and child. A national, prospective, cohort study. Cook JR1, Jarvis S, Knight M, Dhanjal MK. PMID: 23095012

OBJECTIVE: To estimate the incidence of multiple repeat caesarean section (MRCS) (five or more) in the UK and to describe the outcomes for women and their babies relative to women having fewer repeat caesarean sections. DESIGN: A national population-based prospective cohort study using the UK Obstetric Surveillance System (UKOSS). SETTING: All UK hospitals with consultant-led maternity units. POPULATION: Ninety-four women having their fifth or greater MRCS between January 2009 and December 2009, and 175 comparison women having their second to fourth caesarean section. METHODS: Prospective cohort and comparison identification through the UKOSS monthly mailing system. MAIN OUTCOME MEASURES: Incidence, maternal and neonatal complications. Relative risk, unadjusted (OR) and adjusted (aOR) odds ratio estimates. RESULTS: The estimated UK incidence of MRCS was 1.20 per 10 000 maternities [95% confidence interval (CI), 0.97-1.47]. Women with MRCS had significantly more major obstetric haemorrhages (>1500 ml) (aOR, 18.6; 95% CI, 3.89-88.8), visceral damage (aOR, 17.6; 95% CI, 1.85-167.1) and critical care admissions (aOR, 15.5; 95% CI, 3.16-76.0), than women with lower order repeat caesarean sections. These risks were greatest in the 18% of women with MRCS who also had placenta praevia or accreta. Neonates of mothers having MRCS were significantly more likely to be born prior to 37 weeks of gestation (OR, 6.15; 95% CI, 2.56-15.78) and therefore had higher rates of complications and admissions. CONCLUSIONS: MRCS is associated with greater maternal and neonatal morbidity than fewer caesarean sections. The associated maternal morbidity is largely secondary to placenta praevia and accreta, whereas higher rates of preterm delivery are most likely a response to antepartum haemorrhage.

Obstet Gynecol. 2011 Sep;118(3):687-90. doi: 10.1097/AOG.0b013e318227b8d9. The rising cesarean delivery rate in America: what are the consequences? Blanchette H1. PMID: 21860302

Cesarean delivery is now the most common operation in the United States, and it has increased dramatically from 5.8% in 1970 to 32.3% in 2008. This rise has not resulted in significant improvement in neonatal morbidity or maternal health. Three recent studies of elective repeat cesarean deliveries performed before 39 completed weeks of gestation have demonstrated increased respiratory and other adverse neonatal outcomes. Maternal mortality in the United States has increased from 10 per 100,000 to 14 per 100,000 from 1998 to 2004. Contributing to this in an increasing incidence of placenta accreta associated with multiple uterine scars requiring the need for emergency cesarean hysterectomy, blood transfusion, and maternal mortality due to obstetric hemorrhage. To reverse the trend of the rising cesarean delivery rate, obstetricians must reduce the primary rate and avoid the performance of a uterine incision unless absolutely necessary for fetal or maternal indications. For women with one previous low transverse cesarean delivery, obstetricians should promote a trial of labor after previous cesarean delivery in those women who desire three or more children.

Estimating Fetal Weight Increases Cesarean Risk

Image from Wikimedia

One intervention often seen in pregnancies these days is estimation of fetal weight. But does this improve outcomes?

Bigger babies are more at risk for getting stuck, which is called "shoulder dystocia." Although the actual numerical risk for shoulder dystocia with big babies is not very great (and small babies get stuck too), the risk for shoulder dystocia is higher with a bigger baby. Most of the time it is resolved without damage, but in some cases babies or moms are hurt, sometimes seriously. In rare cases, babies even die. Damage from shoulder dystocia is one of the main reasons care providers get sued.

As a result, a big baby make many care providers nervous. So they routinely employ estimation of fetal weight near the end of pregnancy, either by hands-on estimation or by ultrasound estimation. But the critical question is whether estimating fetal weight actually improves outcomes.

Here is yet another study that shows that estimating fetal weight does NOT improve outcomes and that it increases the risk for cesareans. 

In this very large multi-center MFMU study, a baby estimated to be above 4000g (8 lbs., 13 oz.) was more than twice as likely to be born by cesarean. A diabetic mother with a baby estimated to be above 3500g (about 7 lbs. 12 oz.) was more than nine times as likely to have a cesarean.

This relationship persisted even when adjusted for actual birth weight and other variables, showing it was not just about the baby's size. The mere prediction of a large baby (whether baby was actually large or not) increased the risk for cesarean, suggesting that it is the way big babies are managed that makes the difference.

This is a particularly pertinent issue for women of size. Because "obese" women tend to have larger babies on average, care providers can get very anxious about fetal size in their pregnancies. Fear of big baby (and the resulting interventions) is one of the top drivers around the outrageously high cesarean rate in high-BMI women.

Sadly, this study does not directly address the effect of fetal weight estimation in the sub-population of obese women. It would be great to have data actually examining a practice that is so common in the management of obese women.

However, this is a very large and very powerful study showing that the practice of estimating fetal weight is harmful in pregnant women in general.

And it is just the latest in a long series of studies that show that the common practice of estimating fetal weight increases the cesarean rate.

Given that it is such a common practice in obstetrics these days, the practice of estimating fetal size before birth needs to be re-evaluated. 

There are times when estimating fetal size can be appropriate, but most of the time it is more harmful than helpful. Care providers need to stop using it routinely.

And its use especially needs to be evaluated in the management of women of size.


Reference

Obstet Gynecol. 2016 Sep;128(3):487-94. doi: 10.1097/AOG.0000000000001571. Association of Recorded Estimated Fetal Weight and Cesarean Delivery in Attempted Vaginal Delivery at Term. Froehlich RJ1, Sandoval G, Bailit JL, Grobman WA, Reddy UM, Wapner RJ, Varner MW, Thorp JM Jr, Prasad M, Tita AT, Saade G, Sorokin Y,Blackwell SC, Tolosa JE; MSCE, for the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network. PMID: 27500344

OBJECTIVE: To evaluate the association between documentation of estimated fetal weight, and its value, with cesarean delivery. METHODS: This was a secondary analysis of a multicenter observational cohort of 115,502 deliveries from 2008 to 2011. Data were abstracted by trained and certified study personnel. We included women at 37 weeks of gestation or greater attempting vaginal delivery with live, nonanomalous, singleton, vertex fetuses and no history of cesarean delivery. Rates and odds ratios (ORs) were calculated for women with ultrasonography or clinical estimated fetal weight compared with women without documentation of estimated fetal weight. Further subgroup analyses were performed for estimated fetal weight categories (less than 3,500, 3,500-3,999, and 4,000 g or greater) stratified by diabetic status. Multivariable analyses were performed to adjust for important potential confounding variables. RESULTS: We included 64,030 women. Cesarean delivery rates were 18.5% in the ultrasound estimated fetal weight group, 13.4% in the clinical estimated fetal weight group, and 11.7% in the no documented estimated fetal weight group (P<.001). After adjustment (including for birth weight), the adjusted OR of cesarean delivery was 1.44 (95% confidence interval [CI] 1.31-1.58, P<.001) for women with ultrasound estimated fetal weight and 1.08 for clinical estimated fetal weight (95% CI 1.01-1.15, P=.017) compared with women with no documented estimated fetal weight (referent). The highest estimates of fetal weight conveyed the greatest odds of cesarean delivery. When ultrasound estimated fetal weight was 4,000 g or greater, the adjusted OR was 2.15 (95% CI 1.55-2.98, P<.001) in women without diabetes and 9.00 (95% CI 3.65-22.17, P<.001) in women with diabetes compared to those with estimated fetal weight less than 3,500 g. CONCLUSION: In this contemporary cohort of women attempting vaginal delivery at term, documentation of estimated fetal weight (obtained clinically or, particularly, by ultrasonography) was associated with increased odds of cesarean delivery. This relationship was strongest at higher fetal weight estimates, even after controlling for the effects of birth weight and other factors associated with increased cesarean delivery risk.

Reducing Failure-to-Wait Cesareans

A while ago, experts developed guidelines to help reduce "failure to progress" cesareans, called the Consensus for the Safe Prevention of the Primary Cesarean Delivery. Among other things, they changed the definition of active labor from 4 cm to 6 cm and encouraged providers to wait longer before resorting to a cesarean in order to reduce "arrest of dilation" cesareans.

But would these new guidelines actually translate into lower cesarean rates in real life? Here is a study at a single academic medical center which compared the cesarean rate in induced or augmented first-time moms before and after the guidelines were implemented. Would the new guidelines result in a meaningful decline in primary cesarean rates? Would outcomes be improved?

In a nutshell, yes, the cesarean rate was definitely lowered and outcomes improved. The cesarean rate in induced or augmented women dropped from 35.5% to 24.5%, and the overall cesarean rate dropped from 26.9% to 18.8%. And indeed, maternal morbidity was reduced.

Of course, because the new guidelines are very recent, the study size is limited. More research is needed to confirm that this change is helpful. But this study is very encouraging that indeed, many primary cesareans can be prevented with just a little bit more patience and time.

Now let's apply these lessons to the labors of "obese" women too. I would love to see a study that looked specifically at whether more time and patience in labor in high-BMI women could lower the rate of primary cesareans in this group too. My guess is that it would, since research shows that we tend to have longer first stages of labor and that care providers are often too quick to surgically intervene in the labors of high-BMI women. But wouldn't it be nice if we had research proving that more patience for women of size was helpful?


Reference

Obstet Gynecol. 2016 Jul;128(1):145-52. doi: 10.1097/AOG.0000000000001488. Reduction in the Cesarean Delivery Rate After Obstetric Care Consensus Guideline Implementation. Wilson-Leedy JG1, DiSilvestro AJ, Repke JT, Pauli JM. PMID: 27275806 DOI: 10.1097/AOG.0000000000001488

OBJECTIVE: To evaluate the rate of primary cesarean delivery after adopting labor management guidelines. METHODS: This is a before-after retrospective cohort study at a single academic center. This center adopted guidelines from the Consensus for the Prevention of the Primary Cesarean Delivery. Nulliparous women attempting vaginal delivery with viable, singleton, vertex fetuses were included. For the primary outcome of cesarean delivery rate among induced or augmented patients, 200 consecutive women managed before guideline adoption were compared with 200 similar patients afterward. Secondary outcomes of overall cesarean delivery rate, maternal morbidity, neonatal outcomes, and labor management practices were analyzed with inclusion of intervening spontaneously laboring women. RESULTS: Between September 13, 2013, and September 28, 2014, 275 women preguideline and 292 postguideline were identified to include 200 deliveries after induction or augmentation each. Among women delivering after induction or augmentation, the cesarean delivery rate decreased from 35.5% to 24.5% (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.38-0.91). The overall cesarean delivery rate decreased from 26.9% to 18.8% (adjusted OR 0.59, CI 0.38-0.92). Composite maternal morbidity was reduced (adjusted OR 0.66, CI 0.46-0.94). The frequency of cesarean delivery documenting arrest of dilation at less than 6 cm decreased from 7.1% to 1.1% postguideline (n=182 and 176 preguideline and postguideline, respectively, P=.006) with no change in other indications.  CONCLUSION: Postguideline, the cesarean delivery rate among nulliparous women attempting vaginal delivery was substantially reduced in association with decreased frequency in the diagnosis of arrest of dilation at less than 6 cm.

Your Hospital Choice Significantly Influences Your Cesarean Risk

Image from Consumer Reports 

Consumer Reports has a new report out for Cesarean Awareness Month, focusing on the variations in cesarean rates at hospitals across the United States. It highlights how different a woman's risk for a cesarean is, depending on which hospital she chooses.

One analysis points out the wide variations in cesarean rates for low-risk mothers in the Consumer Reports investigation. For example, Crouse Hospital in Syracuse, New York had an 11% cesarean rate in low-risk mothers, while Hialeah Hospital in Miami, Florida had a high of 68% for the same group. That kind of massive variation suggests there is more to the cesarean story than simple medical need.

Disclaimer: It's always important to remind people that no one begrudges a cesarean that is truly needed. No one is less of a woman or a mother if she has a cesarean, and it's perfectly okay to be happy with your cesarean. Don't make this about any one person's particular birth story, but rather focus on the big picture.

The big picture here is that over-utilization of cesareans brings significant risks on a public health level. Mothers and babies are being endangered by doing too many cesareans. 

It's time to shine a light on hospitals' cesarean rates so consumers can make fully-educated decisions about where they want to give birth.

Cesarean Rates in Low-Risk Mothers

The Consumer Reports article focuses on the cesarean rate in first-time, low-risk mothers. These rates act as a sort of canary-in-the-coal-mine warning of excessive cesarean rates. Their article explains further (my emphasis):

Consumer Reports’ analysis focuses on first-time mothers-to-be who should be at low risk of needing a cesarean: pregnant women expecting just one child (not twins, triplets, or other multiples) whose babies are delivering at full-term in the proper position, which means coming out head first. 

The target C-section rate for those births, set by the Department of Health and Human Services, is 23.9 percent or less. That’s 10 percent less than the rate for such births in 2007, which the government uses as a baseline from which to improve. 

But many experts say that the ideal C-section rate for those births is even lower. “Getting under 24 percent for low-risk births is something all hospitals should be able to do, but for those deliveries, hospitals should be aiming even lower,” Main says.

Yet nearly six in 10 of the hospitals we looked at had C-section rates above the national target for low-risk births. That means that 40 percent of hospitals already achieved this goal. “This sends a message that almost all hospitals should be able to achieve this rate,” Main says. 

The risk of having a C-section also varied depending on where in the country women lived. In general, rates were higher in the Northeast and South, and lower in the West and Midwest. 

Three states plus the District of Columbia had C-section rates of 30 percent or higher: Mississippi (31 percent), Kentucky (32 percent), Florida (32 percent), and D.C. (35 percent). 

And four states had rates below 18.5 percent: South Dakota (14 percent), Wyoming (17 percent), New Mexico (18 percent), and North Dakota (18 percent).

It's nonsensical to think that the uteri of women in South Dakota are vastly more efficient than the uteri of women in Mississippi. There is something else influencing cesarean rates here besides true medical need.

The Science and Sensibility analysis points out that hospital culture plays a very strong role in influencing cesarean rates, as demonstrated by wide variations of cesarean rates in hospitals serving the same basic community: 

For example, 30 percent of low-risk deliveries at the University of Chicago Medical Center were by C-section, while at Northwestern Memorial Hospital, another teaching hospital just 10 miles away, only 17 percent were. 

In southern California, 22 percent of low-risk deliveries at Kaiser Permanente Riverside Medical Center were cesareans, compared with 35 percent of low-risk deliveries at nearby Riverside Community Hospital.

According to this analysis, some hospitals have been able to substantially reduce their cesarean rates over time simply by internally publishing the rates for individual providers within the hospital. When care providers saw their rates compared to those of their colleagues, they often changed behaviors that led to a reduction of cesarean rates. 

So why not make the cesarean rates for EVERY hospital in the country publicly available? Perhaps peer pressure can work on a hospital level too.

If hospitals had to acknowledge that other hospitals with similar patient risk levels and demographics could safely have lower cesarean rates than they did, they might put more effort into policies which would help change their own rates.

Transparency in Cesarean Rates

Transparency in healthcare is vitally important. Consumers have the right to know how their local hospitals rate in measures of quality of care, and to make an educated decision on where to take their business as a result.

Many hospitals are already reporting on their infectious morbidity and other measures of quality ─ why shouldn't parents be able to research the cesarean risk at their local hospital? Parents deserve to be able to make an educated choice, yet right now these reports are completely voluntary and many hospitals don't report results at all.

For example, some of the most prominent hospitals in the U.S., like Mount Sinai in New York City or Yale-New Haven in Connecticut, do NOT practice transparency in cesarean rates. The Consumer Reports article notes (my emphasis):

Consumer Reports does not have C-section rates for more than half of the estimated 3,000 U.S. hospitals that deliver babies. That’s because hospitals are not required to publicly report that information, and many choose not to.

This urgently needs to change. Hospitals should be required to have transparency in quality measures such as infectious morbidity and low-risk cesarean rates.

I'd go even further and suggest that the cesarean rates for EVERY PROVIDER be made publicly available. Sure, you can ask your providers their rates, but not every provider tracks this, and some lie about their rates. Providers need to be held accountable for their rates, and we know that publishing rates is effective in reducing non-indicated cesareans.

Most importantly, though, prospective parents deserve to be able to learn about their likelihood of surgery with a particular provider. How can you be an informed partner in your own care when you can't get basic information like about the performance of your hospital and your provider? Consumers have every right to this information. 

Furthermore, transparency can have the added benefit of providing motivation for hospitals and providers to improve their results so consumers are more likely to bring their business. Experience shows that when substandard results are highlighted and a program is developed to address the issues, outcomes can be improved.

Transparency is powerful stuff in healthcare, and it has the potential to motivate major changes.

Kudos to Consumer Reports for shining a major spotlight on this issue. Now it's time for the hospitals who are not being transparent to change their policies and be accountable too. Otherwise, who knows what's really happening in those hospitals? Or how many women are being subjected to the immediate and future risks of major surgery on dubious grounds?