Birth Story

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.

Talk about your scheduled C-section. A Machesney Park, Ill., couple went out of their way last weekend to have their twins born in two different years.

Ashley Fansler, 23, and Brendan Lewis, 24, welcomed daughter Madisen Carin Lewis at 11:59 p.m. on New Year's Eve. Aiden Everette Lewis was born a minute later, at 12 a.m. on New Year's Day.

The twins were born by Cesarean section at Rockford Memorial Hospital in Rockford, Ill.

The couple and their doctors purposefully timed the scheduled C-section so the babies could have separate birthdays. Fansler's due date was Jan. 28 but doctors reportedly were concerned about complications.

"We decided to do it that way [bridging the new year] and everything worked out,” Lewis told Matt Williams of the Rockford Register Star. “They said they would do it if there was no complications or anything. Everything was safety first.”

Check out footage of the parents and the newborns here:

The full text of the article "Contemporary cesarean delivery practice in the United States" published on-line in the American Journal of Obstetrics and Gynecology reveals some interesting insights into the particulars of the study. Birth Story published an earlier post this week based on the abstract.

"The national rate of cesarean delivery in the United States has increased more than 50 percent since 1996, to 31.8 percent in 2007," the report states. "This upward trajectory appears likely to continue in the near future."

The study was performed as part of the Consortium on Safe Labor, an initiative of the National Institute of Child Health and Human Development. It used electronic medical records of 228,668 births at 19 American hospitals between 2002 and 2008.

Here are some highlights:

A total of 93 percent of babies who presented "nonvertex" — with any body part other than the head in the lead— came into the world via C-section.

Almost 66 percent of multiples — twins or more — were delivered by cesearean section. Most of these moms did not attempt a trial of labor.

The C-section rate doubled from 21 percent at age 20 to 42 percent after age 35, "mainly due to repeat pre-labor cesarean deliveries."

Half of cesareans performed once labor had begun were because of "failure to progress" or  the belief that the baby's head was too large for the mother's pelvis. More than a quarter were performed because of "fetal distress."

Among women who had had previous deliveries, most C-sections occurred before labor began, and that was true no matter when they delivered.

More than 60 percent of deliveries at 28 weeks gestation were C-sections. That rate went down as pregnancies progressed.

The trial of labor in women with a uterine scar was 48 percent in 1999, 31 percent in 2002, and 29 percent by 2007.

The success rate of vaginal births after cesarean (VBAC) in the study was 57 percent (of the 28 percent of women who attempted a VBAC), "markedly lower" than in "previous large studies," which had ranged as high as 87 percent.

Overall, 84 percent of women with a uterine scar delivered by C-section.

Pre-labor repeat C-sections "have a profound impact on the overall cesarean rate."

"Truly elective" cesareans accounted for 9.6 percent of C-sections before labor commenced, and 2.1 percent undertaken during labor.

The hospitals in the study represented a wide range in rates of C-sections, from 20 to 44 percent.

Nearly 10 percent of the women who participated in the study added more than one delivery to the database; only the first delivery for each was included in the analysis.

Two of the hospitals in the study were non-teaching community hospitals. Nine were teaching community hospitals and eight were university-affiliated teaching hospitals.

The most telling finding of a new study on cesarean sections in hospitals in the United States is that 31.2 percent of first-time mothers had C-sections.

"Reducing primary cesarean delivery is the key" to bringing down the overall C-section rate, the researchers concluded. In 2007, the last year studied, America's C-section rate stood at 32 percent, a new high.

The study, an analysis of nearly 229,000 births at 19 hospitals between 2002 and 2008 published on-line ahead of a print article in the American Journal of Obstetrics and Gynecology, was conducted under the aegis of the National Institute of Child Health and Human Development.

The study found that 44 percent of women attempting a vaginal delivery were induced. Half of the women who had C-sections for dystocia — slow or difficult labor — were cervically dilated to less than 6 cm, far short of the 10 cm dilation that signals that birth is imminent, when the decision was made to operate.

Of the 29 percent of women in the study who had previous C-sections, and were allowed a trial of labor, 57 percent delivered vaginally.

The overall cesarean rate was 30.5 percent.

The abstract of the study concludes, "To decrease cesarean delivery rate in the United States, reducing primary cesarean delivery is the key. Increasing vaginal birth after previous cesarean rate (sic) is urgently needed. Cesarean section for dystocia should be avoided before the active phase is established, particularly in nulliparous women and in induced labor."

Many of the births included in the study took place at teaching hospitals, where more complicated birth often land, the study's authors noted.

Taffy Brodesser-Akner's first-person piece in the Los Angeles Times today about her impending birth is a candid, affecting counterpoint to a symposium the National Institutes of Health held last month in Washington, D.C.

With her first baby, born 2 1/2 years ago, Brodesser-Akner endured an emergency Caesarean section after 29 hours of labor, she writes. The experience left her traumatized. Now in the early weeks of her third trimester, waiting to deliver her second child, she is hoping for a vaginal birth after Caesarean, or VBAC.

The VBAC has been the subject of a lot of discussion lately. The NIH held a three-day conference on the topic that encouraged supporters of the VBAC -- and there are many -- by recommending that the VBAC be a more readily available option than it has been in the past.

In her essay, Brodesser-Akner writes, "I agree that women should have the right to try for a VBAC; I'm just not sure if they should try for one. Rather, I'm not sure if I should."

Of women who want a VBAC in a particular pregnancy, she writes, "the more honest and maybe the more uncomfortable way to say it, is that they want to give it a shot. They want a TOLAC, a trial of labor after a C-section."

Only 60 to 80 percent of women who attempt a VBAC actually get to have that vaginal delivery, Brodesser-Akner writes; the remaining women wind up getting another C-section. And perhaps 1 percent will have a uterine rupture (with a previous low transverse uterine incision, the most favorable for a VBAC; other types of incisions carry more risk), which can threaten the lives of both mother and child.

"When a uterus ruptures...things go wrong fast — and they go wrong big," she writes, adding that a high-risk obstetrician told her that one-quarter of those ruptures end in hysterectomies, brain damage and/or the baby's death.

"As that doctor said to me, 'The risk may be low, but it's 100% when it's happening to you,' she writes.

Brodesser-Akner is right. Every pregnancy is different, and I can assure you from experience that when you find yourself living out that small, shocking statistic, it is 100 percent real. And I am one of the lucky ones.

But why couldn't she be in that 60 to 80 percent of women who have the "normal" birth experience she says she desires? And if she births in a hospital with capable OB/GYNs who perform a good number of Caesareans -- and 24-hour anesthesiology coverage -- she should have the backup she requires in case of an emergency. That shouldn't be hard to find in Los Angeles.

Any birth can take a turn toward the worst-case scenario, and it's impossible to fully predict which ones actually will do so. It is probably all too easy for a woman who had a wretched experience during her last birth to imagine all the things that could go wrong.

But the numbers are with mothers in general; that is, the odds are in their favor. The fact that the pendulum might be swinging back toward a trial of labor in some challenging situations is, I think, a good thing. And I am by no means alone.

I would tell Brodesser-Akner what I tell my own daughters, not only about childbirth but about life in general: Don't let your fears rule your life. Don't be foolhardy, but don't think the cosmos is out to get you, either. I know it's a cliche, but it's true: The most dangerous thing many of us will ever do is ride around in  cars (or worse yet, on bikes), and nobody seems to spend much time worrying about that.

Whatever she decides, I hope Brodesser-Akner has a beautiful birth story to tell this time. It should be one of the best days of her life.

Image by Petteri Sulonen

The rate of births that ended in Caesarean-sections climbed by 53% in the years between 1996 to 2007, when they stood at 32%, the highest rate ever reported in the United States, the National Center for Health Statistics reported on Tuesday.

The rate is higher than those most other industrialized countries are experiencing, according to the report from the NCHS , which is an arm of the Centers for Disease Control, based in Atlanta, Ga. The cost of a C-section is almost double that of a vaginal delivery, the report notes.

C-sections were up for all groups across the board in the 11 years that were the major focus of the study, in terms of age, race, location, and how far along women were in their pregnancies.

About 1.4 million women gave birth by Ceasarean in 2007. In 2006, Caesarean delivery was the surgical procedure most often performed in American hospitals.

Here are the major findings of the report:

The U.S. C-section rate, 21 percent in 1996, was 32 percent in 2007, an increase of 53 percent. The steepest rise occurred between 2000 and 2007.

C-section rates went up by 50 percent or more in 34 states. In six states -- Colorado, Connecticut, Florida, Nevada, Rhode Island, and Washington -- the rate increased by more than 70 percent.

The rate rose for women of all age groups, with women under 25 having greatest rate of increase, 57 percent.

All racial and ethnic groups experienced increases. Black women had the highest C-section rate in 2007, 34 percent. Native American women had the lowest rate, 28 percent.

Caesarean rates increased for deliveries of infants of all gestational ages. C-sections for pre-term babies (less than 34 weeks gestational age) increased 36 percent; the rates for late pre-term babies (34 to 36 weeks) and term and post-term babies (37+ weeks) went up nearly 50 percent.

Early and late pre-term babies were more likely to be delivered by Caesarean section than were babies born at 37+ weeks.

The report cited possible reasons for the increases in Caesarean sections, in addition to medical indications for the surgery, as "maternal demographic characteristics," like advanced maternal age, fears of malpractice suits among physicians, doctors' preferences, and maternal preferences.

Dr. Howard A. Kelly

In 1888, nine years after Robert Felkin brought back his amazing story from Uganda, Dr. Howard A. Kelly of Philadelphia, a brilliant young obstetrician who would go on to help found the medical school at Johns Hopkins University in Baltimore, announced at a convention of the fledgling American Gynecological Society that he had performed the first successful Caesarean section in Philadelphia in 51 years—that is, the mother had survived the operation.

Very few members of the audience he was addressing that day had ever attempted even one Caesarean section because, at the time, the procedure virtually always ended in the mother's death.

Robert Felkin, a British physician and missionary, reported witnessing a Caesarean section performed by an indigenous healer in Kahura, Uganda, in 1879 that featured antisepsis, anesthesia, cauterizing and sutures.

The woman had been given banana wine, and had been secured to a table with bark cloth at her chest and thighs. A couple of men held her waist and ankles. The practitioner cleaned his hands and the woman's belly with banana wine and water, and then he made one quick, vertical incision through the skin, and a second through the uterus.

An assistant cauterized the wound when it bled with a red-hot iron. The baby was lifted out and the placenta removed. The woman was rolled over so the fluid could drain out of her abdomen, and then the abdominal wall, but not the uterus, was sutured with bark cloth and sharp skewers. A paste made of chewed roots was slathered over the incision and covered with a banana leaf and a cloth bandage.

The skewers were removed after a week. The wound had healed by the time Dr. Felkin left 11 days later, and mother and baby, who mostly had been nursed by a friend, were doing fine, he reported.

One big surprise of the WHO survey of Asian births was that "operative vaginal delivery" -- the use of forceps or vacuum -- had the highest death rate for mothers of any method.

Ninety-seven women died during the 108,000 surveyed births. Of those, 53 died during spontaneous vaginal births, as would be expected, given that those were the majority of births (75,000 deliveries), for a rate of less than .1 percent.

However, of 3,465 OVD births, nine mothers died, a rate of nearly .3 percent. In a commentary that accompanied the WHO report in the medical journal The Lancet, the editors called the figures "a sobering reminder of the dangers of operative deliveries," although they noted that most OVDs are "high-risk situations that cannot be easily avoided."

Twenty-three of the 16,500 mothers having Caesaean sections "with indications" during labor died (more than .1 percent), and one woman died of the 554 having elective C-sections during labor (a rate of nearly .2 percent).

The report also found that women undergoing elective Caesarean section were  far more likely to spend time after the birth in intensive care than women whose births were spontaneous.

The irony is that while many unnecessary C-sections are being performed in some areas, women in other areas who desperately need them are not able to get them, the WHO report notes.

The rising rate of birth by Caesarean sections has hit Asia, with China reporting that 46 percent of its births now end in surgery, according to a global survey by the World Health Organization reported in the medical journal The Lancet.

Nine countries were targeted in the WHO study -- Cambodia, China, India, Japan, Nepal, Philippines, Sri Lanka, Thailand, and Vietnam -- with births in both small and large institutions examined for two or three months in the capital city and two other regions in each country. In all, about 108,000 births were scrutinized at 122 institutions.

China had the highest rate of Caesarean births in the survey. The country with the next-highest rate was Vietnam, with 36 percent, followed by Thailand, with 34 percent, and Sri Lanka, with 31 percent.

Cambodia had the lowest rate of Caesarean births, 15 percent, which is the rate the WHO and other health groups recommend. The C-section rate over all for the Asian countries surveyed was 27 percent.