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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 1st-time mothers: one in four 1st-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 1st-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 1st-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.
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:
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 1st-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 1st-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 1st-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.