Answers to why C-sections are on the rise

Why is the Cesarean rate so precipitously on the rise, from 21 percent of all American births in 1996 to 33.2 percent in 2007? The journal Obstetrics and Gynecology has the results of a new study that examines that question.

The Yale University Schools of Medicine and Public Health in New Haven, Conn., reacted to a spike in C-sections during births at Yale-New Haven Hospital between 2000 and 2002 by setting to work gathering comprehensive data on the 32,443 births that occurred there between 2003 and 2009, even while the hospital's C-section rate ballooned from 26 percent to 36.5 percent.

Not surprisingly, the study found that actual birth complications remained steady, while subjective judgments about the births changed.

The new study, presented at the February meeting of the Society for Maternal-Fetal Medicine, looks at the decision-making on the part of individual doctors that drove that increase.

"In this study, we examined physician-documented indications for Cesarean delivery at a major urban academic medical center in Connecticut, a state with one of the largest rate increases in the nation, to determine which specific indications contributed to the increase in our Cesarean delivery rate over a seven-year period," the researchers wrote.

First-time mothers accounted for half of C-sections during the study.

Indications for Cesarean delivery included "nonreassuring fetal heart tracing," an interruption in dilation, more than one fetus, pre-eclampsia, an especially large baby (which begins to be a concern just shy of nine pounds), and the mother's expressed desire for a Cesarean, the study's authors reported.

Complications like breech presentations, an interruption in the baby's progress into the birth canal and cord prolapse  did not increase significantly over time, the study found.

Slow dilation and those unsatisfactory fetal heart rate reports displayed only slight increases over time but contributed to an outsize degree to the increase in C-sections, the study showed. Concern for the baby's well-being, based on fetal-heart monitoring, was the top indicator for a Cesarean section at Yale-New Haven Hospital during the period studied.

Maternal request, suspected macrosomia (a large baby), more than one fetus and pre-eclampsia also showed big annual increases as indications for Cesareans.

Interestingly, the C-section rate among patients of physicians in private practice was 33.2 percent. For "university patients," who received care from the hospital service's residents and faculty midwives, supervised by attending physicians, the rate was 25.6 percent. The rate for "high-risk" patients (whose care was provided by some of the same maternal-fetal specialists who supervised in the "university" cases) was 44.6 percent.

Fathers changed birth story — and parenting

Fathers who pushed to be included in their children's births beginning in the 1950s have brought real change to the modern birth, according to historian Judith Walzer Leavitt's 2009 book Make Room for Daddy.

Buoyed by changing perceptions of how men should function in society, fathers have created "unprecedented new roles for themselves in a traditionally women's event"  and have "helped to make hospitals more flexible in how they handled birth," Leavitt writes.

Dads' participation in birth has helped to break down the "mystique of modern medicine and further opened the world of obstetrics to lay participation and interpretation," she writes.

Fathers often report that witnessing a child's birth is one of the best experiences of their lives.

"It was better than any game I've played or any big hit I've had," said Ian Desmond, the Washington Nationals' shortstop who recently took advantage of Major League Baseball's new paternity leave to attend the birth of his son, Grayson.

However, the journey has not always been easy for men, who in their public lives often are far more in control than they feel attending the birth of one of their own children.

Leavitt quotes the writer Stephen Harrigan, who wrote in Reader's Digest in March, 1979, about attending the birth of his son. Before the birth, Harrigan worried that he would be no more than a spectator metaphorically holding out Gatorade to his wife, the "athlete who would finish the race."

Harrigan found the experience to be more profound and involving than he expected, but some other fathers feel "at sea, abandoned and out-of-control" at birth, Leavitt writes.

Some fathers cringe at the idea of watching their wives in pain or perhaps fear the experience will damage the desire they feel for their wives. Fathers attending birth are now so ubiquitous that a reluctant dad may well feel pressured to go.

Nevertheless, men's foray into the birth process, which may begin with their attending prenatal classes, has led to their increased participation in their families' lives and experiences, compared with those 1950s dads who began the process, Leavitt writes.

Dads who don't attend their children's birth lose a crucial opportunity, according to researcher Jessica Weiss, who goes so far as to say they risk having "missed the boat of shared parenting."

Dads enter the American childbirth picture

American fathers began making their way into the childbirth picture in the 1950s, according to Make Room for Daddy: The Journey from Waiting Room to Birthing Room, historian Judith Walzer Leavitt's 2009 book. Birth had migrated from home to hospital by that time.Make Room for Daddy

Two developments helped bring dad into the birth process, Leavitt writes — the growing influence in this country of British obstetrician Grantly Dick-Read's 1933 book Childbirth Without Fear and the "natural birth" movement it helped launch; and the development of regional anesthesia for childbirth.

Dick-Read's book inspired couples to begin exploring ways to experience childbirth together. The introduction of regional anesthesia meant that women were conscious during birth, but often alone for long periods during labor.

Women asked for their husbands to be allowed to attend their births, and doctors and hospital officials eventually realized that the fathers' presence could make birth safer and more satisfying for mothers.

The phenomenon of fathers attending their children's birth was not just new, it was news. For the June 13, 1955 issue of Life magazine, photographer Burton Glinn snapped reporter John Stouffer gaping in amazement at the birth of his son at Virginia Mason Hospital in Seattle.

London flashmob for safety in childbirth

Don't try this at home.

From the producers (2008):

If you think this is dangerous, try giving birth in poor countries without a midwife, hospital or medicine. This flashmob is one of a series happening in Paris, Berlin, Utrecht and across Canada to highlight the scandal that millions of women in poor countries and around the world aren't getting the healthcare they need for a safe and healthy pregnancy.

(And just to put your minds a rest - the dancing expectant mums in this video aren't pregnant, they were professional dancers wearing pregnancy suits!)

Some doctors refuse to care for obese women

Fourteen of 105 obstetrics-gynecology practices surveyed by the South Florida Sun-Sentinel last month said they will not take on obese women as patients.

Representatives of six of the practices cited higher rates of complications in women who are obese, but other respondents said heavier women tax their exam tables and other equipment.

"People don't realize the risk we're taking by taking care of these patients," the paper quoted Dr. Albert Triana as saying. Dr. Triana is one of two physicians in a South Miami practice that turns away obese patients, according to the article. "There's more risk of something going wrong and more risk of getting sued."

Seventy-two million Americans — about one in three — meet the criteria for obesity, according to the Centers for Disease Control and Prevention in Atlanta, Ga.

"If I had that policy, I wouldn't have a practice. I'd lose half my patients," Dr. Maureen Whelihan, a West Palm Beach ob-gyn, told the Sun-Sentinel's Bob LaMendiola. "We never turn down anyone."

In a followup article in American Medical News, reporter Christine S. Moyer asked doctors to comment on the practice of turning patients away because of their weight.

"This is [primary care physicians'] patient population, and [they're] here to serve the patients," said one of them, Dr. David Bryman, a Phoenix family physician specializing in bariatric medicine, which deals with the causes, treatment and prevention of obesity. Dr. Bryman is president-elect of the American Society of Bariatric Physicians. "If that requires getting a little extra equipment to accommodate them, it's just part of the practice of medicine."