Today, close to one-third of all babies born in the U.S. enter the world through a slit in their mother’s abdomen, usually just above her pubic bone. Since 1975, the share of mother who undergo a Cesarean has more than tripled, rising from roughly 10.5 percent to nearly 32 percent according the Public Citizen Research Group, a health care watchdog based in Washington D.C.
These numbers have been widely reported, most recently by Leap Frog, the employer-driven hospital quality watchdog. But a central question remains unanswered: Why are so many more women choosing C-sections? Do they have enough information to make informed decisions? What role do physicians and perhaps, most importantly, hospitals play in C-section rates?
The Link between C-Sections and Induced Labor
Today, more and more expectant mothers are scheduling their babies’ births. Rather than leaving the timing to the whims of Mother Nature, they arrange to have their physicians induce labor; using drugs or mechanical devices to ripen the cervix two or three weeks before their due-date. Over the past two decades, the odds that a doctor will jump-start labor have doubled, rising to 22.5 percent of all births, reports the National Center for Health Statistics (NCHS).
Some of these inductions are medically necessary: For example, the mother may be suffering from uncontrolled diabetes, or the baby may be diagnosed with a heart condition that needs medical attention. In addition, if a doctor is quite certain that the pregnancy has lasted for 41 weeks, it is standard operating procedure to induce labor. But research recently published in Obstetrics and Gynecology reveals that nearly 40% of induced labors studied were “elective.” In other words, there was no pressing medical indication for forcing labor.
Not all inductions are planned ahead of time. Frequently the choice is made at some point after labor begins, usually because the mother's cervix is opening very slowly. Once again, the decision to intervene may be based on medical necessity. But in most instances, neither the mother nor the infant is in danger. The mother has a choice, though it is not clear how many patients fully understand their choices, or the potential risks and benefits of each option.
When labor is induced, the chances that the mother will then require a C-section climb precipitously. A study published last summer in Obstetrics & Gynecology reveals that among more than 7,800 women giving birth for the first time, those whose labor was induced were twice as likely to have a C-section as those who experienced spontaneous labor.
No wonder the rate of C-sections and inductions have been growing in tandem.
This is yet another example of how, in a hospital, “one thing leads to another.” Or as health care economist J.D. Kleinke put it recently in a post about childbirth on The HealthCare Blog “The blessing and the curse of modern medicine. . . is its ability to stimulate its own demand, and obstetrical practice is the quintessence of this cost-curve-sustaining paradox.” In other words, one intervention creates the need for another.
C-sections also lead to more C-sections. Once a woman has had one, many doctors will advise that she should not attempt a vaginal birth when she has more children. And today’s expectant mother is quicker to accept the recommendation than her mother was. According to Choices in Childbirth, a nonprofit that strives to improve maternity care, as recently as 1995, one out of four women who had a Cesarean went on to give birth to another child without surgery. But today, “vaginal birth after Cesarean”(VBAC) rates have plummeted to less than one in ten.
The high rate of inductions helps explain the meteoric rise in C-sections. But this only begs the question: Why do so many women elect to have labor started artificially in the first place? Why do so few attempt a vaginal birth after a prior C-section? What has changed so radically in the past 15 to 25 years?
Why Do Mothers Elect Induction and C-Sections? The Downside for the Mother
An induced labor can be harrowing. “Medications and interventions used can create a ‘domino-effect,’” warns Choices in Childbirth. When “Pitocin, a synthetic form of the hormone oxytocin, which is secreted during natural childbirh, is intravenously fed to the mother to induce labor, it can generate a wave of violent contractions.” These contractions are often “unnaturally close to one another, providing inadequate rest in between, often making the labor a lot more tiring than giving birth naturally,” explains Female Care.net, a website that offers health information to women. “Pitocin also causes intense contractions to start earlier than they do in a natural delivery, before the cervix is significantly dilated. And if all that wasn’t enough, the mother has to be wired up to an electronic monitoring device, adding to her discomfort, to detect any fetal distress which may be caused by the drug.”
When labor is spontaneous, the body prepares itself for delivery. “The baby and the placenta enact a series of complex changes in the days leading up to labor,” writes Mayri Sagady Leslie, CNM, MSN, a midwife on the faculty at the School of Nursing and Health Studies at Georgetown University. “The cervix shortens and softens, while the uterus develops sensitivity to the hormone oxytocin which your body will produce. Your brain’s hormone control center and the uterus engage in a complex feedback mechanism to control the length, strength and closeness of contractions.”
By contrast, “during an induction, this mechanism is not engaged.” Instead, Leslie explains, “the speed with which the contractions intensify varies according to each institution’s Pitocin administration policies and each laboring mother’s individual physical response. Many women report these labors as being particularly painful. This may also be because their ability to move freely in response to the growing strength of labor is severely limited, since induced mothers will be connected to at least one IV pole as well as various monitoring devices. It is therefore not surprising that induced women commonly have epidurals.” (A local anesthetic drug that is given in the epidural space of the spine.) “These, in turn, [can] increase their chances of a vacuum or forceps delivery.” Again, one intervention becomes the catalyst for another.
As for C-sections, recovery from having someone slice into your abdomen is not easy. A Cesarean is, after all, major surgery. As one guide to recovery points out: “C-section patients typically stay just three or four days in the hospital before going home. But your recovery will be measured in weeks, not days.” For a new mother who just wants to enjoy her new baby, this can be at best, frustrating, and at worst, it may exacerbate post-partum depression.
Elective Interventions Raise Risks for Mother and Child
Not only do inductions and C-sections add to the pain of childbirth, they hike hospital bills. Most importantly, they can pose potentially serious risks, both for the mother and her infant.
In a recent post on the New America Foundation’s “New Health Dialogue,” Vanessa Hurly spelled out “The Real Cost of Early Elective Deliveries” in blunt terms:
“What if I told you that across the country there’s a procedure being performed on pregnant women that makes their newborns more likely to end up sick and in a $3,000-a-day Neonatal Intensive Care Unit (NICU).
"Too outrageous to believe?
To be fair, “scheduling” a birth offers some clear advantages: The mother can be sure that her Ob/Gyn will be there. She won’t be racing to the hospital at 3 a.m., wondering, "Will he make it? Is he working tonight?"
When the date for the delivery is set ahead of time, she knows that her mother already has flown in, and will be prepared to help out the day the baby comes home. For a woman with a demanding career, the opportunity to time the event—two weeks after her annual report to investors is due, and three weeks before she and her husband have planned a celebration /vacation—must be appealing.
I can well imagine how a busy mother-to-be might well decide that the trade-off between a spontaneous birth and a predictable delivery is worth it. The only downside is the likelihood that an induced labor may be more intense, but she probably plans on having an epidural. She may know that if she has a C-section, it will be weeks before she can exercise, and return her body to its former fit self. On the other hand, if she opts for a C-section, she can be sure that she will not find herself pregnant two weeks longer that she anticipated.
But it is not at all clear that most mothers who select their babies’ birthdates have all of the information they need to weigh the benefits against the potential hazards.
“Babies born as a result of induced labors can be born too early. This is because, even with the best technology we have, your estimated date of birth is just that—an estimate, plus or minus two weeks,” Georgetown’s Mayri Sagady Leslie explains.
Even if the ETA is accurate, some babies have good reason to hang back for an extra week or so. “When labors are started artificially, before or near your due date, babies are at risk of being born before their bodies are ready,” Leslie observes. “This can lead to extra medical care, and prolonged hospital stays.”
Leap Frog agrees: “Earlier use of induction has resulted in more infants being delivered before term. . . at 37-38 weeks, up from 19% in 1992 to 29% in 2000… Induction also increases the chances that a baby will need to be admitted to a Neonatal Intensive Care Unit (NICU) which can delay the opportunity for mother and baby to bond. Some studies have also found a significantly higher chance of other postpartum complications,” Leap Frog adds, “including any of the following: hematoma, wound dehiscence, anemia, endometriosis, urinary tract infection, and sepsis.”
C-sections also ramp up the risks–and the costs. As the National Center for Health Statistics (NCHS) cautioned in 2010: “Cesareans are associated with higher rates of surgical complications and maternal re-hospitalization as well as with complications requiring neonatal intensive care unit admission… In addition hospital charges for a Cesarean delivery are almost double those for a vaginal delivery.”
Public Citizen Research Group confirms the hazards, pointing to “a very recent study that looked at 115,000 low-risk deliveries in 10 different hospitals…The authors found that women without a previous cesarean who had an elective cesarean section were at a 6.57-fold increased risk of hysterectomy at term.” The authors concluded that: ‘The advantages of an elective delivery are the convenience of being able to plan delivery and perhaps more control over who is the delivering provider. These advantages pale in comparison to 3.21 times the risk of hysterectomy at term for an elective induction or 6.57 [times] increased risk for unlabored cesarean at term… Given that the advantages of elective delivery are primarily social or logistical and not medical, an argument could be made not to offer an elective delivery at all given the maternal risks. At minimum, patients should be well informed of the fetal and maternal risks of elective delivery.’”
In a study released just last month, Leap Frog, issued a “Call to Action” in response to its new data showing that elective deliveries before 39 weeks are rising at “alarming rates”—despite the fact that “the American College of Obstetricians and Gynecologists (ACOG) has indicated for some time, in a series of guidelines, that elective deliveries with no medical indication in the gestational period of 37 completed weeks to 39 completed weeks is not acceptable practice.”
These are the reasons why many experts have begun to discourage elective interventions. Public Citizen calls the rising rate of C-sections an “epidemic.” The Agency for Healthcare Research and Quality (AHRQ), part of the United States Department of Health and Human Services [DHHS]) agrees, stating that “cesarean delivery has been identified as an overused procedure. As such, lower rates represent better quality.” AHRQ also called “VBAC [vaginal birth after cesarean] “a potentially underused procedure.
Public Citizen notes that “Healthy People 2000” laid out goals for cesarean delivery for the year 2010. The report established a target of 15 percent for women with uncomplicated pregnancies giving birth for the first time, and 63 percent for women who had had a prior cesarean section (a VBAC rate of 37 percent). Last year, we didn’t even come close to those targets.
That said, let me be clear: Most cesareans do not lead to serious problems. The vast majority of babies who are brought into the world through an incision in their mothers’ bellies experience no ill effects. And for the average individual mother, the only downside is the longer recovery period, combined with the likelihood that, in the future, many doctors will insist that she should not even try vaginal delivery.
When a C-section is medically necessary, a mother should realize that this is not considered a dangerous surgery. Indeed it has become a routine procedure. But when a C-section is purely elective, a mother should consider the risks before agreeing.
Are Expectant Mothers Aware of the Downside?
Why are so many women opting for procedures that are likely to cause them more pain than spontaneous labor and a vaginal birth? The conventional wisdom has it that C-sections have become commonplace for three reasons: women are having children at a later age; an increase in multiple births (thanks to fertility treatments) and finally, the convenience of a planned birth.
But as Naomi observed on HealthBeat last spring, we can cross off the first two reasons: “the most recent National Center of Health Statatics (NCHS) report found that the rate of C-sections rose in all age groups between 1996 and 2007” (not just among older mothers), “with women under age 25 experiencing a 57% increase in cesarean deliveries. And surprisingly, the rate of c-sections for single births increased substantially more than cesarean rates for multiple births.”
This leaves convenience as the major factor driving these elective procedures. Not long ago, Dr. Ware Branch, Medical Director of Intermountain’s Women and Newborns Clinical Program told ABC News, "The pressure has built over the years. I think, on the part of busy clinicians and busy patients with families to at least consider scheduling when they deliver."
For some, an induced labor is a “lifestyle choice’ observed an editorial in the July issue of Obstetrics and Gynecology, referring to “health care providers' and new parents' desire to control the timing of delivery. . . Many women believe that delivering a few weeks early is just as safe as delivering on the projected due date.”
Fear of labor may also be a factor. I once heard a young investment banker describe why that his wife had made an appointment for a C-section months before the baby was due: “She’s not into ‘the labor thing,’” he explained. “And I don’t want anything to change down there.”
“Does she mind having surgery?” his friend asked.
“I explained it to her,” the expectant father replied.
I suspect that the majority of expectant mothers assume that inciting labor at 38 or 39 weeks will do the baby no harm precisely because the intervention has become so popular. Why would Ob/Gyns do so many, if there was, in fact, a serious danger that the baby would be a frail “preemie” who winds up in a neo-natal ICU? No doubt Ob/Gyns who frequently recommend elective induction firmly believe that intervention is safe. When a physician has performed a particular procedure many times, he is likely to rely on his own experience, and may well ignore published “guidelines.”
Still, one wonders: when an OB/GYN recommends scheduling the birth does he or she always tell the mother that the American College of Obstetricians and Gynecologists (ACOG) guidelines say that elective deliveries with no medical indication in the gestational period of 37 to 39 weeks is not acceptable practice?
It is telling, I think, that inductions have jumped by 57% among women under age 25. These very young mothers may be slower to question a doctor’s recommendation, or to ask questions based on what they have read or heard over the years. They also are less likely to have talked to other women about their experience recovering from a C-section, or how hard their induced labor turned out to be. Most of a 23-year-old’s friends have not yet had babies, and older women are always reluctant to say too much to very young women about the rigors of childbirth. No one wants to scare her.
Moreover, twenty-somethings who are members of the millennial generation tend to be confident, impatient and tech savvy. Raised in an era of instant messaging, they are accustomed to using technology to control their world, and may be less inclined to wait until the baby decides to be born. Young parents born in the late 1980s often view spontaneous labor and vaginal birth as a left-over from the “hippie” culture of the late 1960s and early 1970s when so many women took Lamaze classes in order to learn “natural childbirth.” (Back in 1975 only 10.4 percent of American women had C-sections.)
“I have to confess that I have no understanding of … or preference for the ‘natural’ way here. . . In an attempt to prospectively minimize the ‘uncontrollability’ inherent in any biological process, I chose the best, biggest and most comprehensive academic medical center I could find, the most experienced and highly educated OB I could locate and every darn advantage science and technology had to offer. Expensive? You bet. Statistically redundant? Perhaps, but the only relevant sample I considered was that One baby in that one moment in time. In J.D.’s story I would have opted for a C-section, right then and there, immediately, no waiting, no tinkering.”
In part 2 of this post, I’ll explore the larger question: “Who chooses these elective interventions during childbirth: the mother, the doctor—or the hospital? In that context, I’ll take a look at C-section and induction rates at specific hospitals in New York City and its suburbs, as well as at hospitals in some other parts of the country. I’ll also examine why some hospitals prefer interventions (no surprise that the reasons include fear of malpractice suits), while other institutions have purposefully set out to raise the rate of spontaneous labor and vaginal delivery. I’ll talk about the role of shared decision-making. Finally, I’ll discuss what an expectant mother should do if she would prefer a natural delivery.