Why Caesarean Section Rates Are Rising in the US

By ANNIE ATURA

April 1, 2010

This past week illu­mi­nated yet another instance of the health care system’s unsa­vory influ­ence on women’s health deci­sions: on Tues­day, the National Cen­ter for Health Sta­tis­tics released a report detail­ing the inap­pro­pri­ate increase in Cae­sarean sec­tions over the past decade, due in no small part to hos­pi­tal pol­icy. The New York Times has reported that med­ical cor­po­ra­tions’ fear of mal­prac­tice suits has encour­aged these lengthy – and expen­sive – pro­ce­dures, despite evi­dence that sug­gests that Cae­sarean sec­tions often favor the baby’s health at the expense of its mother’s. The increase has affected all racial and eth­nic groups, in all ages of moth­ers, in every state.

The lat­est report from the National Cen­ter for Health Sta­tis­tics (http://www.cdc.gov/nchs/data/databriefs/db35.pdf) found that in 2007 (the most recent year data is avail­able), 32% of babies were deliv­ered via Cae­sarean sec­tion. That sta­tis­tic is a high-water mark for sur­gi­cal deliv­er­ies in the United States, and makes C-sections the most com­mon sur­gi­cal pro­ce­dure per­formed in Amer­i­can hos­pi­tals. The report found that the high­est rates of Cae­sarean births occurred in New Jer­sey and Florida, and the low­est in Utah and Alaska.

We often con­sider sur­gi­cal births to be less painful or dan­ger­ous than vagi­nal births, and in many cases C-sections do indeed save moth­ers and babies alike. But accord­ing to the World Health Orga­ni­za­tion, about half of the C-sections cur­rently per­formed in the United States are inap­pro­pri­ate. The orga­ni­za­tion has esti­mated that surgery is proper in only about 15% of deliveries.

The spike in C-sections has been spurred in no small part by the fear that the uteruses of moth­ers who have already under­gone a Cae­sarean will rup­ture under the pres­sure of a vagi­nal birth, par­tic­u­larly around the seam of the inci­sion. Fewer than 10% of moth­ers who have pre­vi­ously had a C-section deliver vagi­nally, and their surg­eries account for 40% of the total of C-sections in the United States. Some hos­pi­tals even man­date C-sections for such women. Yet a panel con­vened by the National Insti­tutes of Health found ear­lier this month that such bar­ri­ers were unjus­ti­fied by med­ical con­cerns, and sug­gested that hos­pi­tals pub­lish their rates of vagi­nal births so that women would know the institution’s pol­icy on man­dated C-sections. Women could then weigh the risk of a rup­tured uterus against an increased like­li­hood of complications.

Some blame the unprece­dented pop­u­lar­ity of surgery on the increas­ing median age of preg­nancy, or on the like­li­hood of a mother hav­ing already under­gone a Cae­sarean. Sur­pris­ingly, how­ever, the largest pro­por­tional increase in sur­gi­cal births has been found in moth­ers under the age of 25. C-sections can sub­ject these younger women to a litany of future prob­lems, includ­ing rup­tures dur­ing future preg­nan­cies and an increased risk of abnor­mal­i­ties in the pla­centa, which leads to hem­or­rhag­ing and poten­tial hys­terec­tomy. Com­pli­ca­tions occur more fre­quently dur­ing surgery than dur­ing vagi­nal births, and women who undergo surgery dur­ing deliv­ery are more likely to remain in the hos­pi­tal with such com­pli­ca­tions. In prob­lem cases, C-sections may make it dif­fi­cult or impos­si­ble for women to choose to have large families.

Why, then, do doc­tors choose to oper­ate twice as often as they should? Cyn­ics will notice that C-sections gen­er­ally cost twice as much as vagi­nal births. The World Health Orga­ni­za­tion has been quick point out that the prof­itabil­ity of C-sections may be the cause of the ridicu­lously high rate of sur­gi­cal birth in China, where half of moth­ers undergo surgery. The same logic may apply here in the States.

The increase might also be attrib­uted to a fear of mal­prac­tice law­suits; the sci­en­tific jour­nal Obstet­rics and Gyne­col­ogy pub­lished a study last month that found that 29% of its polled mem­bers reported per­form­ing more C-sections to avoid being sued when a vagi­nal birth went wrong. 8% of OB/GYNs had cho­sen to stop deliv­er­ing babies, and a third of that por­tion said they had done so because of lia­bil­ity issues.

In other cases, induc­tions are at fault – moth­ers induced into labor (i.e. given drugs that pre­ma­turely begin the process of labor) are more likely to have C-sections. Obste­tri­cians have reported the advent of “social induc­tions,” when moth­ers effec­tively chose their date of labor for rea­sons unre­lated to their health. This poses a whole new set of issues; women may feel pres­sure to sub­ject them­selves to unnec­es­sary risk in order to deliver on week­ends or in the pres­ence of family.

In the debate over the effect that pol­i­tics and insur­ers have on women’s access to abor­tion, we might also cast a crit­i­cal eye on insti­tu­tional impacts on women’s health deci­sions at large. In the case of Cae­sare­ans, both a reform in pol­icy and a raise in aware­ness are in order. Women may not real­ize the more ques­tion­able aspects of this sur­gi­cal pro­ce­dure, which is cur­rently per­formed at twice the rec­om­mended rate – and which is grow­ing more pop­u­lar still.

Annie Atura is a junior in Yale Col­lege. She is a staff writer for Broad Recog­ni­tion.