Part 1: How Can You Avoid an Avoidable First Cesarean?

For more than a decade, the U.S. cesarean rate has stood at 33%.⁵ That’s one in every three pregnant women for over ten years having their baby via major abdominal surgery. One reason for this is the rate in 1^st-time mothers: one in four 1^st-time mothers at low risk for surgical delivery has a cesarean.⁵ The other is that once women have a first cesarean, they almost all—about nine out of ten of them—go on having cesareans for all subsequent deliveries.⁵

While cesareans can be a life-saving operation, no reasonable person could think that one in three women overall or that one in four 1^st-time mothers lacking the main factors that increase need for surgery requires a surgical delivery in order to be a healthy mother giving birth to a healthy baby. Clearly, way too many are being done, which raises the question: “How can you avoid a cesarean that isn’t really needed?”

In this post, the first of a two-part series, we’ll look at what the cesarean rate should be and how you can avoid an avoidable cesarean with a first baby. In Part 2, we’ll turn our attention to avoiding unnecessary repeat surgery if you’ve already had one or more cesareans.

What Should the Cesarean Rate Be?

Let’s start with the overall cesarean rate. Based on the correlation between cesarean rate and maternal and newborn outcomes, the World Health Organization established back in 1985 that the sweet spot for countries and regions was a cesarean rate in the 10-15% range.⁷ That’s somewhere between 1 in 10 and 1 in 7 women, not 1 in 3. The years have passed, and studies and analyses have become more sophisticated, but that conclusion still holds. Fall much below 10%, and maternal and newborn mortality rates rise because rates this low indicate inadequate medical resources and access to cesareans. Once rates reach 10% to 15%, however, no further improvements are seen, and as the rate climbs higher still, maternal mortality begins to rise.

Why should this be? As with any operation, cesarean surgery has potential harms, including the possibility of severe and life-threatening complications. When it is used only when mother, baby, or both are jeopardized by continuing the pregnancy or labor, its potential benefit outweighs the risks, but as indications for it expand, extending into populations at less and less risk or even at no risk, cesareans begin to do more harm than good. Furthermore, as the number of first cesareans increases and those women go on to have repeat cesareans, the likelihood of cesarean-related adverse outcomes increases because the risks of pregnancy with a scarred uterus and of performing repeat cesarean surgery rise with each succeeding operation.

Unfortunately, I can’t give you a rate in 1^st-time mothers overall because that statistic isn’t reported. As for low-risk women having a first baby, that is, they’ve reached 37 weeks of pregnancy and have one, head-down baby, a rate around 14% is about right, according to a U.S. study of women cared for by midwives.³ At 26%, the U.S. national rate in women with these characteristics, is nearly double that.

Even if you have health or obstetric complications, it’s still useful to find an obstetrician with a cesarean rate down where it should be. OBs who are judicious in their use of cesareans in low-risk women will also almost certainly be more judicious when caring for women with health or obstetric complications.

How Can You Avoid an Avoidable Cesarean with Your First Baby?

The problem is how can you tell whether your care providers are too quick to cut? Numerous studies have established that your odds of cesarean delivery depend largely on your care provider’s practice style and only in small part on your characteristics or factors in your pregnancy. (Scroll down to “Taking a Deeper Dive” if you want more details from studies confirming this.) Therefore, your best way of protecting yourself is to explore your doctor’s or midwife’s (or prospective doctor’s or midwife’s) attitude and approach. Here are some questions that will help you do that.

• Will you or someone in your practice be attending my birth? Some hospitals use “laborists,” obstetricians employed by the hospital who manage labors and births there. There’s no point continuing with the rest of these questions if your doctors or midwives won’t be responsible for your care in labor. With laborists, you have no control over who oversees your care, and cesarean rates can vary enormously among them.⁶ You may wish to choose (or change) to a birth location where you choose who provides labor care as well.
• Under what circumstances would you recommend a cesarean? These should be serious medical conditions or labor complications or when all measures to promote labor progress have been to no avail. In particular, avoid doctors or midwives who have preset time limits for making progress in labor.
• What percentage of the women in your care have a cesarean? We’re speaking here of an overall rate. Be leery of a care provider who won’t give you even a ballpark figure because this is a nationally recognized measure of quality of care. As I said earlier, the World Health Organization recommends a maximum rate of 15% for countries or regions because no improvements are seen in maternal or newborn outcomes as rates rise higher. You will probably need to allow some leeway over the World Health Organization’s 15% maximum. Few U.S. obstetricians have a rate this low, and while midwives are more likely to have rates in the 15% range or lower, a fair number also miss the mark. I’d consider rates as high as the low 20 percents acceptable for an obstetrician. A midwife’s rate should be substantially lower because they only care for women at low risk for complications.
• How do your practices and policies promote vaginal birth? You want someone whose labor policies and practices promote the unfolding of the natural process, for example, by encouraging mobility and eating and drinking in labor and using alternatives to epidurals such as laboring in warm water or laughing gas (N2O) inhalation to manage pain, and you want someone who refrains from the routine use of practices that can interfere with progress, for example, routine continuous fetal monitoring, IVs, or rupturing membranes (breaking the bag of waters). You especially want someone who only induces labor for medical indication, not for reasons such as going past your due date or the baby estimated to be bigger than average. Beware the doctor who recommends routine labor induction at 39 weeks as a means of increasing vaginal births.
• Do all doctors/midwives in your practice have similar policies and practices to yours? If not, how can I ensure that I will be attended by someone who does or that the person who attends me will abide by agreements that we may make? Most doctors and midwives are in group practices and rotate who is on call for births. You would think that members of the same practice would have the same approach, but this is not necessarily the case.

How your care provider (or potential care provider) interacts with you is as important as the content. You want someone who listens and who respects your thoughts and feelings. Watch out for red flag responses. These include:

• Vagueness: “I only do cesareans when they are necessary.”
• Scare tactics: “I’d like to induce labor when you reach 39 weeks. There’s no reason not to, and even though you’re healthy, you never know what might happen if we wait.”
• Patronizing: “Don’t worry; just relax and let me take care of everything.”
• Anger: “And what medical school did you go to?”
• Bullying: “Decisions will be made by me and are not negotiable.”

For more on choosing a care provider and place of birth and on avoiding a cesarean, see CBU’s Optimal Care in Childbirth masterclass series, which includes “Choosing an Optimal Care Provider,” “Choosing the Optimal Place of Birth,” and “Preventing the Preventable Cesarean.”

Taking a Deeper Dive

How do we know that care provider practice style and hospital culture are the main determinants of likelihood of cesarean?

Many studies have consistently demonstrated over the years that practice style and hospital culture are the main determinants of likelihood of cesarean. Here are a few of the more recent ones.

One study evaluated the effect of individual practice style. Investigators examined the variation in cesarean rates among 2224 1^st-time mothers at term (37 weeks or more) with one, head-down baby at a Colorado hospital where all deliveries were managed by laborists, that is, obstetricians employed by the hospital who worked shifts.⁶ The overall cesarean rate was 24%. They divided the 20 laborists into 3 groups according to whether their cesarean rate was low (range: 13%-22%), medium (range: 23%-25%), or high (range: 25%-36%). This amounted to a 3-fold difference between the lowest and highest rate despite the women’s demographics and clinical characteristics being similar among the three groups. When hypertension, gestational age at delivery, race, and maternal age were also taken into account, the effect of the delivering physician increased to 3.5-fold.

Other studies compared cesarean rates at the hospital level. Most recently, investigators analyzed 185,693 deliveries of 1^st-time mothers who gave birth at term to a single, head-down baby at 83 Michigan hospitals.² The average cesarean rate was 29% and ranged from 15% to 42%, nearly a three-fold difference. Among the many factors affecting likelihood of cesarean, only maternal BMI and infant weight had a significant effect. After adjusting for these factors, statistical calculation showed that moving from a low cesarean rate hospital to a high cesarean rate hospital increased a woman’s odds of cesarean by 30%. A study of 49 Massachusetts hospitals got similar results when it compared cesarean rates in 80,265 1^st-time mothers at term with a single, head-down baby.¹ The overall cesarean rate was 27%, and individual hospital rates ranged between 14% and 38%. As was expected, likelihood of cesarean varied according to a long list of factors known to influence cesarean rate ranging from socio-demographic factors such as race or maternal age to health conditions such as hypertension or diabetes to pregnancy and labor characteristics such as birth weight or whether labor was induced. Adjusting for these factors, however, had no mitigating effect on the variance in cesarean rates among hospitals. In a third study, investigators used a U.S. national database to compare cesarean rates in 1,475,457 women delivering at 1,373 hospitals.⁴ The average cesarean rate was 33% and ranged from 19% to 48%. Among low-risk women (37 weeks or more, one baby, head-down, no prior cesarean), hospital rates ranged from 8% to 32%. Among high-risk women (preterm birth, multiple gestation, breech or other malpresentation, prior cesarean), rates ranged from 56% to 96%. As with the other studies, adjustment for a long list of factors affecting likelihood of cesarean failed to reduce hospital variation in likelihood of cesarean delivery.

References

1. Caceres IA, Arcaya M, Declercq E, et al. Hospital differences in cesarean deliveries in Massachusetts (US) 2004-2006: the case against case-mix artifact. PLoS One 2013;8(3):e57817.
2. Ebott JA, Abshire C, Kamdar JS, et al. Maternal care matters: An analysis of hospital cesarean delivery rates in Michigan. Am J Obstet Gynecol 2020;Suppl to Jan 2020:S237-S8.
3. Jolles DR, Langford R, Stapleton S, et al. Outcomes of childbearing Medicaid beneficiaries engaged in care at Strong Start birth center sites between 2012 and 2014. Birth 2017;44(4):298-305.
4. Kozhimannil KB, Arcaya MC, Subramanian SV. Maternal clinical diagnoses and hospital variation in the risk of cesarean delivery: analyses of a National US Hospital Discharge Database. PLoS Med 2014;11(10):e1001745.
5. Martin JA, Hamilton BE, Osterman MJK, et al. Births: Final data for 2018. Natl Vital Stat Rep 2019;68(13):1-46.
6. Metz TD, Allshouse AA, Gilbert SAB, et al. Variation in primary cesarean delivery rates by individual physician within a single-hospital laborist model. Am J Obstet Gynecol 2016;214(4):531 e1- e6.
7. World Health Organization. Appropriate technology for birth. Lancet 1985;2(8452):436-7.