Optional Caesareans Carry Higher Risks, Study Finds
Caesarean sections performed without a medical reason result in longer hospital stays, higher costs and more than twice as many rehospitalizations as vaginal deliveries, a new study reports.
After adjusting for age, number of previous births, race and ethnicity, researchers found that these optional Caesareans resulted in hospital stays that were 77 percent longer and cost 76 percent more than normal deliveries. Mothers who had the optional surgery were 2.3 times as likely to return to the hospital within 30 days, usually because of wound complications or major systemic infections.
“There are trade-offs in having an elective Caesarean,” said Eugene R. Declercq, the study’s lead author and a professor of maternal and child health at the Boston University School of Public Health. “Among them are longer recovery time and a higher chance of being rehospitalized, which shouldn’t be surprising — it’s major surgery.”
According to background information in the article, published in the March issue of Obstetrics and Gynecology, the overall rate of Caesareans has increased by 40 percent over the past decade.
The researchers used a Massachusetts database that linked birth certificates with hospital records from 1998 to 2003. They selected 244,088 healthy women with no prior Caesareans and no documented prenatal risk. Those women were divided into two comparison groups: 3,334 Caesareans done without a medical reason and 240,754 normal vaginal deliveries. The larger group included 20,916 unplanned Caesarean deliveries chosen at the time of birth.
Over the five years covered by the study, 1.4 percent of the births were by optional Caesarean section, but rates varied widely among subgroups. The highest was 3.1 percent among women over 40. African-Americans and first-time mothers, with rates of 2.3 percent and 2.1 percent, respectively, were also substantially more likely than average to have a Caesarean without a medical reason.
The authors point out that these operations were not necessarily done at the request of the mother. The study produced no data revealing which optional procedures were done at the mother’s inclination, a health professional’s suggestion or by mutual agreement, and it recorded no information about the outcome for the baby.
Dr. Edmund F. Funai, an associate professor of obstetrics and gynecology at Yale who was not involved in the study, said that it helped quantify the risks. “We already knew that these moms were at risk of things like infection and embolism, but we didn’t have such precise data to peg a number to it,” he said. “This allows me to counsel these moms a little more precisely.”
One rationale for optional Caesareans is the convenience for the mother, but the finding that Caesareans lead to longer hospital stays does not support that reasoning, and the increased cost of the procedure raises the question of who should pay for it. If the surgery is truly without a medical reason and only the result of a patient’s request, the researchers write, should the patient be required to pay the additional cost?
Although optional Caesareans are safer than they were in the past, the authors write, there are significant risks, and it is not clear that they are as safe as planned vaginal births.
“In a very general sense,” Dr. Funai said, “Caesarean delivery tends to be modestly more safe for the baby, while more risky for the mother.”
The researchers acknowledge weaknesses in the study. There may have been unrecorded medical reasons for what appeared to be optional Caesareans, and this could have contributed to the increased number of rehospitalizations. In addition, the study examined outcomes only up to one year after birth, and those advocating for planned Caesareans contend that problems with vaginal birth can show up years later.
The researchers say that although Massachusetts differs demographically from the United States as a whole, the growth in elective Caesareans in the state is parallel to the national trend.