Continuation of the “Injustice in Maternity Care” Series
Throughout my time as a labor and delivery nurse at a large urban hospital in the Northeast, I have mentally tallied up a list of patients and circumstances that make me go “WHAT!?! Are you SERIOUS!? Oh come ON!” Because of this I was inspired to start the “Injustice in Maternity Care” blog series, or more appropriately the “Don’t Let This Happen to You” series. If you are pregnant or planning on becoming pregnant, this series is dedicated to you! If haven’t already read it, I invite you to check out the first addition to the countdown: DLTHTY #25: Sarah & John’s Unnecessary Induction.
Sometimes I feel like I am starting to sound like a broken record…. Why? Because I am about to start this post the same way I started my last “DLTHTY” post. But with a national cesarean section rate of approximately 32% and a c-section rate rapidly approaching 35% at my place of employment, I feel like I cannot write about our country’s cesarean crisis enough!
You might be thinking to yourself, “Why is it the case that when I or a loved one enters the hospital in the United States to have a baby we have a 1 in 3 chance of ending up with major abdominal surgery? One thing I hear often, both from health care professionals and lay persons is that women are the cause of our country’s embarrassing cesarean section rate; that women are requesting and demanding cesarean sections as just another way to have a “designer birth.” I hear this all the time.
For example, the other day I was at a birthday party and I was conversing with the grandfather of the birthday boy. We got to talking about our careers, which were quite different being that I am a labor & delivery nurse and he is a computer engineer. Long story short he remembered an article that he had read in TIME magazine in the beginning of the year, and from his description I have concluded it was probably Using C-Section Scars to Predict Future Deliveries by Kathleen Doheny. He said he was surprised and concerned to read that the c-section rate in the U.S. was approximately one third of all births! I echoed his concern but stated that a big part of it is related to the way we practice obstetrics in this country, mainly defensive medicine and control obstetrics. “Yah! I know!” he said as if we were on the same wavelength, “It’s because of all those 40+ women who chose career over family for all those years that have now decided to use fertility treatments to get pregnant. And then they go and demand a cesarean section so they can complete their quest for a ‘designer birth’ and ‘designer baby.’ It’s ludicrous!!” With all due respect I had to disagree with him and it turned out that in doing so I inadvertently ended the conversation. I guess it’s not politically correct to call someone out at a birthday party, no matter now nice you do it!
But is this really true? Does the research support the hypothesis that women are driving the cesarean rate up?
The answer is a big fat N – O, NO! In the DVD Special Features section of the amazing 2008 documentary Orgasmic Birth, Dr. Eugene R. Declercq, PhD, a professor of Maternal and Child Health at the Boston University School of Public Health, is featured in a 20 minute clip entitled “Birth By The Numbers” where he presents the sobering statistics of birth in the United States today and shares the most recent data available from the National Center for Health Statistics as well as Listening to Mothers II, the largest survey of women’s experiences during pregnancy, childbirth, and the postpartum period. Dr. Declercq shares that one quarter of the survey participants, who had undergone either a primary (first time) or repeat (second or more) cesarean section reported that they had experienced pressure from a health professional to have a cesarean section (more on that below).
The following is a list of other mind-blowing statistics and research results that I learned from watching “Birth By The Numbers.” I have posted about this video clip before and I am posting about it again because it is that important to watch it! If you have any questions about any of these bulleted points, please watch the video for yourself first, look at all the graphs and tables presented (since I could not directly post the images here), and then feel free to comment!
Lets Talk About Stats
- In 2005 there were 4,138,349 births in the United States therefore even a 1% change in any statistic impacts approximately 40,000 births a year!
- In 2005 there were 1,248,815 cesarean surgeries performed on women in the United States.
- Cesarean surgery is a valuable and potentially life saving operation but is an overused intervention in the U.S.
- In low income/developing countries, an increase in the cesarean section rate is related to a lower neonatal mortality rate, since access to this life saving operation can address the tragic situations that occur because of a lack of resources.
- In middle income countries, regardless of the cesarean section rate, the neonatal mortality rate is not affected either positively or negatively.
- In high income countries, like the United States, there is a slightly positive relationship between the cesarean and neonatal mortality rates. That is, the higher the cesarean section rate, the higher the neonatal mortality rate which means that there comes a point in time where more and more cesarean sections are not helping and are even hurting our mothers and babies!
Cesarean Sections for Low Risk Moms Just Don’t Add Up!
- To get a cesarean rate of over 30% (which the U.S. currently has), you have to be doing cesarean sections on low risk mothers!
- When you perform a cesarean section (which carries many risks for both mothers and babies) on a mother because either the mother or the baby has a true medical indication that requires surgery to assure the safety and wellbeing of all, then and only then do the benefits of the surgery outweigh the risks.
- When you perform a cesarean section on a low risk mother and there are NO true, unavoidable, or untreatable medical indications for the surgery, then the mother and baby carry all the risk of the surgery without any of the benefits to her or her baby. (Side note: I like to think of this point in this way. If you are on the 3rd floor of a burning building and not jumping would certainly result in serious physical harm, disfigurement, or even death, then the risks of staying in the building outweigh the risks of jumping out the window and hence, even though you might acquire some serious injuries in doing so, jumping out the window is the best option for you. On the other hand, picture yourself on the third floor of that same building but this time there is no fire. Do you think it’s a good idea to jump out that window? I didn’t think so.)
What Is NOT To Blame For Our Cesarean Rate?
- It is NOT the case that the rising U.S. cesarean rate is because of U.S. women requesting cesarean surgery (a.k.a “Maternal Request” cesarean section).
- It is NOT the case that the rising U.S. cesarean rate is because of age related factors (i.e. more very young or older moms are having more and more cesarean sections and therefore throwing off the rate.) In fact from 1996 to 2006, the rates of cesarean section jumped the same amount (a 50% increase!) in every single age group at the same rate.
- It is NOT the case that the rising U.S. cesarean rate is related to the gestational age (how old the baby is at the time of birth) of babies being born by cesarean. In fact, from 1996 to 2006, the rates of cesarean section jumped the same amount in every single gestational age group at the same rate.
- It is NOT the case that the rising U.S. cesarean rate is caused by upper middle class white women demanding their cesarean by appointment (aka “Maternal Request” cesarean). In fact from 1996 to 2006, the rates of cesarean section jumped the same amount in every single racial/ethnic group, but not at the same rate. Cesarean sections rates for black mothers are higher than for any other race/ethnic group.
- State by state, strong regional patterns exist regarding cesarean section rates. That is, some areas of the country boast cesarean section rates that are greater than 30%…with some regions higher than 50%!…while others are less than 25%. While this may be related to local obstetrical culture, it is NOT a reflection of evidenced based medicine being practiced at the same level in every state. If evidenced-based medicine was being practiced at the same level in every part of the country, different regions of our country would not vary so wildly in their c-section rates!
Maternal Request Cesarean Section: Are They To Blame?
- According to the Listening To Mothers II survey “Maternal Request” cesarean was defined as a cesarean that 1) the mother had made a planned request for before labor began, and 2) was performed for NO medical indications (either mother or baby).
- The survey found that only 1 respondent out of 1600 survey participants (252 of which had had a cesarean) had planned a primary cesarean for no medical reason. Research studies from England and Canada confirm very low rates of maternal request cesareans as well.
- While they do exist and are being carried out in the United States, MATERNAL REQUEST CESAREANS ARE NOT TO BLAME FOR OUR COUNTRY’S SKYROCKETING CESAREAN RATE!!!
So What IS To Blame For Our Skyrocketing Cesarean Rate?
- PRACTICE CHANGES, that is, changes in the nature of maternity care in the United States, ARE TO BLAME FOR OUR RISING CESAREAN RATE!
- The current philosophy of contemporary maternity care in the United States is much like the “One Percent Doctrine.” That is, when you set up a system that focuses on the 1% of problems that might occur, you undermine the care of the 99% of mothers who don’t need those services and interventions.
Mothers Feel Pressure From Health Professionals to Have Cesareans!
- In the LTM II survey, 26% of women that had had a primary cesarean section, 25% of women that had had a repeat cesarean section, 35% of women that had had a successful vaginal birth after cesarean (VBAC), and 7% of mothers that had had a vaginal birth reported that they DID feel pressure from a health care professional to have a cesarean section.
“Unfortunately history shows that advances in the practice of medicine and surgery are rarely attained in a thoroughly rational manner, but that a period of undue enthusiasm, or even of almost reckless abuse, usually precedes the establishment of the actual value of a given procedure. [Cesarean Section] requires only a few minutes of time and a modicum of operative experience: while [vaginal birth] often implies active mental exertion, many hours of patient observation, and frequently very considerable technical dexterity.”
~John Whitridge Williams, MD [1866-1931], early 20th century pioneer of academic obstetrics & author of biggest selling obstetrics textbook ever
So let’s talk a bit about what these “Practice Changes” are that are causing our very scary and embarrassingly high cesarean section rate. The Childbirth Connection is a national not-for-profit organization founded in 1918 whose mission is to improve the quality of maternity care through research, education, advocacy and policy. They promote safe, effective and satisfying evidence-based maternity care and are a voice for the needs and interests of childbearing families. The Childbirth Connection is the group that developed the “Listening to Mothers” surveys which were conducted by Harris Interactive and carried out in partnership with Lamaze International.
In their article, “Why Does the National U.S. Cesarean Section Rate Keep Going Up?”, the Childbirth Connection lists SEVEN evidenced based interconnected factors that appear to be pushing the cesarean rate upward. (Please refer to the original article for explanations of each factor.)
#1 Low priority of enhancing women’s own abilities to give birth.
#2 Side effects of common labor interventions.
#3 Refusal to offer the informed choice of vaginal birth.
#4 Casual attitudes about surgery and cesarean sections in particular.
#5 Limited awareness of harms that are more likely with cesarean section.
#6 Providers’ fears of malpractice claims and lawsuits.
#7 Incentives to practice in a manner that is efficient for providers.
All of these factors contribute to the current national cesarean section rate of over 30%, despite recent studies that reaffirm earlier World Health Organization recommendations about optimal cesarean section rates. According to the WHO and the research that supports its recommendation, the best outcomes for mothers and babies appear to occur with cesarean section rates of 5% to 10%. High-risk hospitals have the best outcomes with cesarean section rates of less than 15%. Cesarean rates above 15% seem to do more harm than good.
Bottom Line: Our rising cesarean section rate is a BIG problem for our mothers and babies!
Up For Next Time:
* What is the difference between “Primary Elective” cesarean section and “Maternal Request” cesarean section?
* Are “elective” cesarean section, that is without medical indication, the same as “maternal choice” cesareans or should they really be called “physician choice” cesareans?
* Why were Gina & Tony scheduled for a cesarean section and was it really their choice?