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    The cesarean epidemic: Are we too quick to cut?

    Cesarean delivery may be a safe alternative to vaginal delivery but its use in 1 of 3 women giving birth in the US seems to high.

    In 2014, 1.3 million women in the United States delivered via cesarean, placing the rate at 32.2%, down just .7% from the peak in 2009.1 That year, cesarean rates hit 32.9%, capping steady increases that started in 1996, when the rate was 20.7%.2 The rapid rise (a 50% increase over 13 years) came on the heels of a decline in the cesarean rate from 23.7% in 1987 to 20.8% in 1997— the only time in the past 3 decades that it fell in a developed country.3

    The drop in the late 1980s and early 1990s was accomplished primarily because trials of labor after cesarean (TOLACs) had been rare and the rate of attempts rose to more than 40% in women with prior cesareans. Interestingly, the rise in TOLAC was accompanied by a slight decline in primary cesarean deliveries.4 In the 1990s, the increasing rates ran contrary to guidance from Healthy People 2010 (and then Healthy People 2020), which set a 15% goal for primary cesareans.5

    More: The cost of having a baby in the United States

    The wide variation in cesarean rates among institutions is striking.6 The rate varies significantly even when controlling for characteristics that would account for indicated cesareans.7 The statistics are dramatic and concerning, leading to these key questions: Why is the cesarean rate rising, and is the rise influencing maternal or neonatal outcomes?

    Why is the rate rising?

    One possible reason for the rise in the cesarean delivery rate may be that there has simply been a rise in the need for cesarean. The most common indication for a primary cesarean is cephalo-pelvic disproportion, or arrest of progress in labor. It is unlikely that maternal pelvis size has changed over the past 3 decades, but it is possible that birth weight has increased. In fact, evidence suggests that rates of macrosomia have increased over the past 2 decades.8 Other issues that contribute to increasing rates of cesarean delivery, possibly through the mechanism of birth weight, are maternal obesity and gestational weight gain.9,10 Without question, the proportion of obese women has increased over the past decade and higher weight classes are associated with even higher rates of cesarean.11,12 In addition, increased gestational weight gain has been associated with cesarean delivery and is commonly above standard guidelines.13

    Another reason for increasing cesarean rates may be a rise in elective cesarean delivery, also known as cesarean delivery by maternal request (CDMR). Because there was no ICD-9 code for CDMR, it is unclear what proportion of cesareans are due to it. One recent study, however, estimated the proportion as high as 4% in the United States.14 Interestingly, CDMR is more common in other countries, such as Brazil, Taiwan, and Chile. A study in Chile comparing women receiving private care (cesarean rate >40%) to women receiving public care (cesarean rate <20%) found that 8% of those receiving private care and 11% of those receiving public care stated a preference for cesarean delivery, with the vast majority preferring to deliver vaginally.15 Thus, even in this setting, it is unclear that maternal preferences are driving the increase in cesarean delivery rate.

    The topic of CDMR led to a National Institutes of Health (NIH) state-of-the-science conference in 2006. The conclusion from this meeting was that future research was necessary to examine both the “current extent of CDMR and attitudes about it.”16 More recently, a study in the United States found that the vast majority of women would prefer to deliver vaginally.17

    So, while some maternal demographics have changed and maternal preferences may account for a small proportion of cesarean deliveries, it appears that much of the rise in cesarean rates may be due to cultural pressures and norms. Some of these pressures are due to the medical-legal considerations that ob/gyns face. Physicians in one study reported that they were more likely to perform a cesarean in a number of scenarios if they had been sued recently or if they thought about being sued frequently.18 In another study, tort reform was associated with cesarean deliveries; in particular, overall cesarean rates were lower and vaginal birth after cesarean (VBAC) rates higher in states that had caps on noneconomic damage awards.19

    How does cesarean delivery affect pregnancy outcomes?

    Much is known about the effect of cesarean delivery on maternal and neonatal outcomes. Generally, there are positive and negative effects related to cesarean delivery on both mother and baby.20 Cesarean delivery has been associated with higher rates of maternal hemorrhage, infection, and even death but it is protective against perineal lacerations. 21,22 In turn, some evidence suggests that vaginal delivery may be associated with pelvic organ prolapse and fecal and urinary incontinence. Importantly, cesarean delivery has ramifications for future pregnancies, such as the risk of a TOLAC.23 In particular, the risk of abnormal placentation that can lead to a need for preterm delivery and cesarean hysterectomy, and the fact that it can be complicated by severe maternal hemorrhage, should receive significant attention when considering the risks of a cesarean delivery.24,25

    Cesarean delivery is associated with lower rates of intrapartum hypoxic injury and neonatal mortality.26 With vaginal delivery, there is also always a risk of shoulder dystocia and permanent brachial plexus injury. Alternatively, neonates delivered via cesarean appear to experience higher rates of transient tachypnea and possibly primary pulmonary hypertension.11 Infants born to mothers who have had prior cesareans are at increased risk of stillbirth, and in cases of TOLAC, uterine rupture carries a risk to the neonate.27 For pregnancies complicated by abnormal placentation, delivery before term may be required.

    What to do?

    The cesarean rate has risen without improving maternal or neonatal outcomes. The NIH, the American College of Obstetricians and Gynecologists (ACOG), and the Society for Maternal-Fetal Medicine (SMFM) convened a consensus conference 3 years ago on prevention of primary cesarean delivery. Approaches suggested at that meeting were published in a 2012 document.28 Further, a consensus statement cosponsored by ACOG and SMFM delineated the many approaches discussed here.29 When discussing lowering the cesarean rate, it is important to consider the most common indications for cesarean delivery, which are a prior cesarean, failed progression in labor, and abnormal fetal heart rate (FHR) tracing. Less common indications are malpresentation, multiple gestations, suspected fetal macrosomia, and herpes simplex virus.30

    NEXT: Vaginal birth after cesarean

    Aaron B Caughey, MD, PhD
    Dr Caughey is Professor and Chair, Department of Obstetrics and Gynecology, School of Medicine, Oregon Health & Science University, ...

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    • Since VBACs are now frowned upon, physicians will not do them. In fact, there is no incentive to do them. You have to spend much more time in labor and delivery because you have to be "readily available". If you are a solo practitioner, you basically have to close down your office and baby sit that one patient. You do not get reimbursed for all of the extra time, in fact you get reimbursed as if it was a routine vaginal delivery. On another point reimbursement on a Cesarean Section is a lot more than that of a vaginal delivery. With all of the health care cuts and reimbursments down, why on earthh should a physician ever do a vaginal delivery. I am not an advocate of practicing this way and I still do VBACs, I do spend a lot of time with these patients and I am proud to say that I have one of the lowest Cesarean section rates in the country. I am just giving reasons why I think that the Cesarean section is higher than it should be.
    • Dr. Tomas Hernandez
      It is always interesting to review articles like this as I think we keep on digging into a problem that has not real solution as training and unrealistic expectations have taken obstetrics to a different field of play. Fear of litigation, lack of training on operative deliveries, lack of training on difficult deliveries, lack of incentives for trial of labor after cesarean section, and so on and so forth weigh on the increased cesarean section we currently observe. The attitude, as one of my senior residents used to say when I was in training, in obstetrics there is only two options: an easy vaginal delivery or an easy cesarean section. Of the group currently delivering at my institution in Washington State, I think only a couple of us do forceps deliveries and I dare to say that I am the only one in town who is comfortable with mid-pelvis forceps deliveries, which have helped me to keep a reasonable and safe primary cesarean section rate.
    • Dr. RS-obgyn physician
      Consider the disincentives of the medicolegal system. Many more lawsuits for failure to perform cesarean than for "unnecessary" cesarean. Any complication associated with instrumental delivery is judged harshly. "zero birth trauma" expectations judge harshly even the slightest signs of birth trauma. Some personnel on l&d units seem against active management of labor. A side issue, but all the alarms on labor units (HCFA driven) can increase the stress on a large unit-IV, epidural pump, bp monitor, pulse Ox, fetal monitor, buzzer to enter unit, phones, etc. When in doubt......., deliver the baby. Bob Stockburger DO FACOG
    • Dr. Tomas Hernandez
      Agree. To date I have not read or heard about a physician being sued for an "unnecessary" cesarean section.

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