C-section rates continue to rise at record pace as infant mortality improves minimally
C-section rates continue to rise at record pace as infant mortality improves minimally
By Monica Fleming
Staff Reporter Delaware's
C-section rate in 1995 statewide was 21.48%; in 2005, it was 29.94%. Sussex County's C-section rate in 1995 was 21.58%; in 2005, it was 33%. VBACs statewide in 1995 were 3.52%; no statistics were available for 2005. (source: CDC) As rates for C-sections continue to rise both nationally and regionally, options for women in subsequent pregnancies — in particular for a trial of labor with the goal of vaginal birth after Cesarean, or VBAC (pronounced vee-back) — are dwindling. C-Sections rise at record paceC-Sections rise at record pace
What was once a decision to be made between a women and her healthcare provider is many times now being decided by a hospital, or more specifically, lawyers and insurance companies, putting women in this area at increased risk for losing control over their own health care and at more risk for future surgical births.
In the past 10 years, as VBACs have decreased and C-sections have increased; infant mortality — the traditional concern that led to Caesarian delivery — has stayed nearly the same, decreasing only slightly, from 7.57 (per 1,000 births) to 6.78 (per 1,000 births).
According to the Centers for Disease Control (CDC), the national C-section rate rose to more than 30 percent in 2005, a full 4 percent higher than 2004 and a new United States record. The same report stated that the Cesarean rate had fallen dramatically between 1989 and 1996 — a period when VBAC was more widely accepted and encouraged — but has risen 46 percent since.
“The increase in the total Cesarean rate over this period reflects the steep rise in primary (first) Cesarean deliveries, and the decline in rate of vaginal birth after Cesarean, VBAC,” according to the report.
Many feel this decline is because of literature put out by The American College of Obstetricians and Gynecologists (ACOG), which describes itself as a voluntary, non-profit membership organization and the nation’s leading group of professionals providing health care for women, with more than 52,000 members.
Their 1999 report stated VBAC should be attempted only in institutions equipped to respond to emergencies with physicians immediately available — meaning a hospital had to have in-house, 24-hour anesthesia (as opposed to on-call) and an operating room and physician available immediately should the need arise during a VBAC for an emergency C-section.
In Delaware in 2005, according to the latest statistics from the CDC, the C-section rate was 29.94 percent. The C-section rate for Sussex County was 33 percent. (No VBAC information was available for 2005.)
Those percentages are up from 21.48 percent (statewide) and 21.58 percent (Sussex County) in 1995, for a total increase of 8.46 percent statewide and 11.52 percent in Sussex County. That year, VBACs made up 3.52 percent of vaginal births in the state.
Dr. Maxime Moise, an obstetrician-gynecologist and owner of Del Med Health in Lewes, says those are alarming statistics.
“It’s an invasive procedure with major risk that carries two to four times the chance of dying for the mother,” he said of C-sections. “It is so common that women now believe they have the right to choose C-section as an option without fully understanding the consequences and risks.”
According to the CDC, a National Institute of Health panel recommended against Cesareans that are not medically indicated for women desiring several children and for pregnancies of less than 39 weeks gestation.
“With each subsequent C-section, there are higher risks of placenta previa, hemorrhage in pregnancy, and a higher chance of losing your uterus,” continued Moise.
Moise spoke of an OB/GYN friend who would perform “C-hists,” or a Cesarean that becomes a Cesarean plus a hysterectomy, because of one reason or another.
“Ten or 15 years ago, he used to do one of those a year, and now he does one a month,” he said, emphasizing the frequency of complications that arise with each subsequent C-section. “To go in to have a baby and walk out without a uterus, that’s not right.”
“More and more physicians feel threatened,” Moise explained of some of the factors behind the trend. “To practice obstetrics is a pricey situation and, due to malpractice premiums, there is a trickle-down effect. Physicians ask, ‘Why should I increase my liability?’”
Moise admitted that uterine rupture is possible in women attempting to have a vaginal birth after a previous C-section, but he emphasized that with proper care and support that risk is not any higher than for someone without a history of C-section.
“If labor progresses and is monitored in the proper environment, the risks are not any higher,” said Moise.
“There are certain criteria [for attempting VBAC],” he explained. “You have to look at the reason for the first C-section. If a woman had a big baby and a very small pelvis, the chances are with the second it will be the same. But for a woman with placenta previa, a non-recurring factor, it would be different.
“You have to have the environment in which support is present. You have to have an O.R. available for a stat C-section in five to 10 minutes, a qualified staff, an anesthesiologist and physician qualified to perform a C-section. Not all hospitals provide that,” he said.
Legal concerns lead reasons why VBAC are uncommon
“They are discouraged mainly because of the legal aspect,” Moise added. “Physicians do not want to increase their liability, even though there are increased risks for women.”
“The final decision-making person is the one who is pregnant,” continued Moise. “We should be educating women that they have the right [to a vaginal birth] as long as they understand what the risks are and what they are asking. Patients should not be intimidated by the physicians. It should be a mutual trusting relationship. Childbirth is a wonderful experience. Why deprive them of that?”
Christiana Care, in Newark, in addition to Kent General in Dover, is one of two Delaware hospitals that meet the ACOG recommendations of 24-hour in-house anesthesia to safely offer VBAC. In 2007, 7,100 babies were born there.
Dr. Gordon J. Ostrum Jr., an OB/GYN at Christiana Care, estimates that the C-section rate there is about 30 to 32 percent.
“People have become more uncomfortable with the risks [of rupture], they’ve become a little more conservative with that, but for some it is an acceptable risk. It is a risk-benefit situation,” explained Ostrum. “The risk to the fetus in a rupture is 1 in 1,000 to 1 in 1,500 – still not overwhelmingly bad odds by any means.”
Ostrum estimated that Christiana Care is right on track with the national average of about 10 percent of births after Caesarean being VBAC. That means 90 percent of primary C-sections result in repeat C-sections.
“Without question, both the primary rate and repeat rate of C-sections has gone up,” he said. “People are much less uncomfortable with C-sections. They are a phenomenon that are here with us to stay, and there’s not much we can do to change it. Personally, I don’t think it is something to be looked upon lightly.”
But what choices exist for women in areas such as coastal Sussex, where the closest hospital is a 45-minute drive in either direction? What are their options?
“The choices are to have the repeat C-section, or to make arrangements with providers closer to a hospital that does them [VBAC], as long as you have a provider on board and a back-up provider closer to home should you have to present at one of those hospitals,” said Ostrum.
Moise added that should a laboring woman need to present at one of the hospitals that does not have the support system for a VBAC in place, her situation can be seen as an emergency, thus requiring the hospital to accept her for care, but she has the right to the type of care she wants, even if that is a vaginal birth after Cesarean.
“In order for a VBAC to be safe, there has to be continuous monitoring of the baby, the mother and the situation. And if Mrs. Jones rides two hours to Christiana, her situation can’t be monitored,” he said.
Sharon Painter, director of Maternal Child Health at Bayhealth, said that Kent General Hospital in Dover had 1,815 deliveries in 2007 and 485 C-sections, or 26 percent of deliveries. There were 24 VBACs, for a total of 1.3 percent.
Milford Memorial Hospital had 455 deliveries, 155 of which were C-sections, or 33 percent. Because Milford does not have in-house 24-hour anesthesia available and a 24-hour surgical team, at the recommendation of ACOG, they do not perform VBACs there.
“Physicians are sharing the risk with patients,” said Painter. “In all births there are risks, but with VBAC there is a known risk [of uterine rupture].”
Painter describes it as ultimately a private matter between patients and physicians and she recommends that women who live in an area that does not provide or support VBACs change providers.
At Peninsula Regional Medical Center in Salisbury, Md., 2,263 babies were delivered in 2007. Of these, about 20 percent were primary C-sections and about 16 percent were repeat C-sections, for a total of 36.6 percent. Of the vaginal deliveries, 13 (or .57 percent) were VBAC.
Doctors are divided on trend toward C-section
According to Regina Kundell, director of Women’s and Children’s Services at PRMC, statistics there are rising, just as they are nationally, and literature support arguments on both sides of the issue of “elective” or repeat C-section.
“Our C-section rate is climbing, as is the national rate,” she said. “There is some literature that supports that C-sections done without medical indication leads to a higher neonatal mortality, but we have not seen that here. There is also literature that indicates, depending upon the condition of the baby, a Cesarean section can greatly reduce neonatal mortality,” said Kundell.
On the western side of Sussex County, at Nanticoke Memorial Hospital in Seaford, in 2007, 1,027 babies were delivered. Of those, about 24 percent were C-sections; about 11.5 percent primary and about 12.5 percent repeat C-sections. Three births were classified as VBAC, although Nanticoke Memorial doesn’t officially offer them.
“Of the 1,027 births, three were VBAC,” stated Nancy Oyerly, director of Maternal Child Health at Nanticoke Memorial. “If a patient refuses a C-section or comes in fully dilated, that’s what those numbers represent.”
Nanticoke Memorial is one of the area hospitals that changed its VBAC guidelines in response to ACOG guidelines.
“A couple of years ago, ACOG changed the definition of ‘immediate’ availability,” noted Oyerly.
Oyerly said that before that language, 30 minutes was the accepted rule for having support “immediately available,” even though many emergency C-sections can and were performed much more quickly than that.
So, for a hospital that can routinely perform emergency C-sections on a non-VBAC mother, what is the difference between a regular emergency C-section and a planned VBAC that necessitates an emergency C-section?
“The goal is to get the baby as quickly as possible,” said Oyerly. “And the fastest way to do that is to put the mother to sleep, with general anesthesia, which can be harmful to the baby and its breathing.
“With a scheduled C-section,” she noted, “you have time to get the room ready, the instrumentation ready, and most likely the mother will have a spinal and be awake. The difference is the reason you are doing the C-section.”
According to Dr. Marsden Wagner, a neonatologist and perinatal epidemiologist, the guildelines put forth by ACOG that set so many hospitals in the motion of retracting opportunity for VBACs can be seen as suspect. In his article “What Every Midwife Should Know About ACOG and VBAC: Critique of ACOG Practice Bulletin No. 5, July 1999, Vaginal Birth After Previous Cesarean Section,” published on midwifery.com, Wagner finds fault with the ACOG guideline, citing a lack of scientific evidence backing it as written.
“By the American College of Obstetricians and Gynecologists’ (ACOG’s) own admission, there is no evidence to back up this recommendation,” Wagner wrote. “This is, of course, the reason this recommendation has been placed in Level C, thus making it ACOG’s confession that since there are no data, ACOG will simply have to go on the basis of ‘expert opinion.’ So this recommendation — ‘VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available’ — has no data to support it, no studies showing improvements in maternal mortality or perinatal mortality related to the characteristics of institutions or availability of physicians.”
“What ACOG doesn’t say,” Wagner asserts, “is that one study included in their reference list in their document compared VBAC and repeat Cesarean section in three types of hospitals — community, regional and tertiary care — and while community and regional hospitals had more repeat Cesarean sections and more failed VBAC, no difference in mortality rates for these two procedures by type of institution is reported (McMahon, M. (1996). Comparison of a trial of labor with an elective second Cesarean section. New Eng J Med 335 (10): 689-695.) This study suggests the ACOG recommendation is scientifically unfounded.”
Oyerly explained that the risks most often noted regarding VBACs are often too much for hospitals to take.
“The risks have overtaken us,” she said. “In such a litigious society it is hard for any organization to accept that risk.”
She stated that, although Nanticoke Memorial’s numbers are some of the lowest in the area, they are rising as well.
“In 2000, our rate was 19 percent. It’s unfortunate. We used to have a large midwifery population and our C-section rates were very, very low.”
Though C-sections ostensibly occur to protect an at-risk child and mother, does evidence support that the rising C-section rate results in the slightly lower infant mortality rate? Oyerly said it is a hard thing to look at because of all the factors involved.
“One of the major reasons for infant mortality is low birth weight. And that number is rising with fertility issues, and twins and multiple gestations. We are saving babies that are younger. Obviously, with C-sections, you are saving some [that otherwise would have died] but to quantify that is difficult.”
As for the future of obstetrics in light of these trends, Ostrum said he believes that people will see more and more physicians become track-oriented, with more specialization. He sees obstetrics as becoming mostly an operative specialty.
“I think there’ll be an expansion of midwives,” said Ostrum. “My first love is general OB/GYN, but with the evolution of lifestyle and litigation, like all parts of general OB/GYN, I’m not sure it has a long future in the ever-changing face of medicine.”
Moise said that, short-term, obstetrics does not paint a pretty picture, but he has hope for the future.
According to Moise, “50 or 60 years ago it was ‘once a C-section always a C-section,’ with a rate of 5 to 7 percent. And, as both primary and repeat C-sections have risen, those numbers have skyrocketed. And now, we have come full circle, back to ‘once a C-section always a C-section.’
“Still, in all the developed countries, the numbers are safer for vaginal birth,” he added. “As there are more and more C-sections, and more and more repeat C-sections, we will reach a point where we say that’s enough. The complications will be so common that people will say we need to do things differently. Physicians can’t change it. Patients will change it. When patients take responsibility and say it’s enough, then things will change.”
For more information regarding VBAC and patients’ rights, including information on what to do if a hospital has “banned” VBACs, visit the International Cesarean Awareness Network at www.ican-online.com on the Internet. For more information on the American College of Obstetricians and Gynecologists, visit www.acog.org.
FACT: About 99 percent of births each year occur in hospitals, the other percent being births at free-standing birth centers and home births. The Birth Center, in Wilmington – Delaware’s only free-standing birth center – is midwife-owned and operated. At the Birth Center, the annual C-section rate is 4 to 7 percent, compared to 29.94 percent statewide. (The Birth Center only delivers for patients without known complications and with labor at less than 42 weeks gestation.) For more information, visit thebirthcenter.com.
This is the first article in a new Coastal Point series of articles about the birth and pregnancy care options available to women in coastal Sussex County, Delaware. Published in Coastal Point, April 18. 2008, Volume 5, No. 16