In Cesarean Surgery

According to the U.S. National Center for Health Statistics, the U.S. cesarean rate in 2018 was 32%, having held steady at 1 in 3 U.S. women for over a decade.27 Among 1st-time mothers who reached full term (37 weeks) with a single, head-down baby, 26%, or 1 in 4 women delivered via major abdominal surgery, likewise the case for more than a decade. One reason the overall rate is so high is because almost all women who have a first cesarean go on having cesareans thereafter. In 2018, only 13% of women with one or more prior cesareans had a vaginal birth after cesarean (VBAC). What is a defensible cesarean rate? What could the VBAC rate be? And most importantly, what can you do to avoid a cesarean? Let’s take a look.

What Is a Reasonable Cesarean Rate?

The U.S. cesarean rate has been so high for so long it has come to seem normal and inevitable. It’s neither. 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.34 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.

What’s a reasonable rate? For low-risk 1st-time mothers, 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.22 That’s 1 in 7, as opposed to the national rate of 1 in 4. If, in addition, they have no medical complications, anywhere from 7-13% is a reasonable percentage based on studies of women eligible for birth in birth centers or at home.1, 5-7, 19-21, 29, 33

What Could the VBAC Rate Be?

We saw above that only 13% of all women with a prior cesarean have a subsequent vaginal birth. Mostly, this low number has to do with how few women try for a vaginal birth. Despite planned VBAC being a reasonable, even preferable, choice in most cases,3 most women schedule a repeat cesarean. This may be because their doctors talk them out of VBAC or because their doctors or hospital refuse to allow them or because they never knew VBAC was an option.30 In addition, women planning VBAC may have avoidable repeat cesareans because of their doctor’s policies. Their doctors may, for example, insist that they go into labor by their due date or not give them enough time to progress in labor.

What’s an achievable rate? A study of 11,000 women giving birth at 10 U.S. hospitals reported a VBAC rate of 84% in a mixed population of women with and without prior vaginal births while studies of labors attended by midwives achieved rates of 87%.12, 18, 26 However, women with a vaginal birth either before or after a cesarean rarely need a repeat cesarean at subsequent births. Looking solely at vaginal birth rates in women with a prior cesarean and no prior vaginal births, midwives achieved a rate of 81%. By contrast, studies of labors managed by obstetricians report rates ranging from 61% to 79%, or as much as 20 fewer per 100 VBAC labors.2, 4, 9-11, 14-17, 24, 25, 31, 32

The Take-Away

As you can see by the wide variation in rates in similar women, your likelihood of having a first or repeat cesarean depends largely on your care providers’ practice style. (Scroll down to “Taking a Deeper Dive” if you want more details from studies confirming this.) 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.

If this is your first baby, ask:

  • 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.28 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. 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? Be leery of a care provider who won’t give you even a ballpark figure because this is nationally recognized measure of quality of care. 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.

If you have had a prior cesarean:

  • 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. Having laborists may be an advantage. Many hospitals use lack of 24/7 obstetric coverage as an excuse to refuse VBAC, which is obviously not an issue with laborists. Still, with laborists, you have no control over who oversees your care, and cesarean rates can vary enormously among them.28 You may wish to choose (or change) to a birth location where you choose who provides labor care as well.
  • What percentage of your patients with a prior cesarean plan a VBAC? This number tells you whether this care provider truly encourages VBAC. While I don’t have a research-based number, a best guess would be at least the majority since few circumstances contraindicate VBAC.
  • What percentage of those who plan a VBAC have a vaginal birth? As we saw above, rates in the mid 80 percents are achievable, but I’d call anything in the mid 70 percents or above acceptable.
  • Under what circumstances would you recommend a repeat cesarean? These should be serious medical conditions or labor complications, not circumstantial reasons such as having a prior cesarean for slow progress, the baby estimated to be bigger than average, going past your due date, or failing to meet preset time limits for making progress in labor.
  • What are your criteria and policies for VBAC labors? The only difference from care in a non-VBAC labor for which a case can be made is continuous fetal monitoring.
  • Do all the others in your practice feel as you do about VBAC? If not, how can I ensure that I will be attended by someone who does? Most doctors and midwives are in group practices and rotate who is on call for births. It is entirely possible that some of the practice members don’t permit VBAC or hedge it about with so many non-evidence-based restrictions that it amounts to the same thing.

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: “Certainly you can attempt a VBAC if you don’t care what happens to your baby.”
  • 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.”

For more on the pros and cons of planning VBAC versus repeat cesarean and on how to maximize your chances of a vaginal birth, see CBU’s VBAC masterclass: “Vaginal Birth after 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 (³ 37 wk) 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.28 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.13 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.8 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 of 1,475,457 women delivering at 1,373 hospitals.23 The average cesarean rate was 33% and ranged from 19% to 48%. Among low-risk women (³ 37 wk, 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

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