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.

Twins born in two different years

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:

Too many first-time moms get C-sections

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.

Storytime?

Amber Strocel is one of my favorite bloggers. A Vancouver, B.C. "crunchy granola mom" (and engineer), Strocel writes with equal aplomb about the pleasures of domesticity and more serious issues like Internet privacy.

Strocel also writes a good bit about childbirth, and one recent post got me thinking. In “Scare Tactics,” Strocel considers which kinds of stories about birth and breastfeeding women should share, in particular with pregnant women.

As anyone who has ever been pregnant knows, that bump is a powerful magnet for women who had a 78-hour labor, or whatever, and believe you need to hear a blow-by-blow description, complete with sound effects.Pregnant Graffiti

“I don’t see much value in sharing horror stories,” Strocel wrote, adding that during a discussion she shared on Twitter, others had disagreed, saying they thought “negative stories can prepare women” for the possibility of problems with birth or breastfeeding.

Strocel relates that during the birth of her first child, precipitated at 34 weeks by an infection, she experienced severe hemorrhaging, which required surgery and a blood transfusion.

“I was actually not all that afraid of labour when I was pregnant the first time around… Being armed with someone else’s story of severe blood loss wouldn’t have changed anything for me,” she writes. “Thinking about it, I believe there’s a difference between sharing a horror story that scares someone out of her pants, and useful information that you can use to avoid problems.”

Strocel offers an example of the latter: "If I had a very negative experience with a health care provider, I might share that with someone who was considering seeing the provider."

I agree that would be useful information, but the key would be to catch a woman before she had committed to that provider. By the time other people know a woman is pregnant, she has usually settled on a birth attendant.

In fact, I’m not sure any birth stories have utility for a pregnant woman. Let's think about a really positive one. Would hearing about supermodel Gisele Bundchen’s painless water birth really be encouraging to the average mortal? No pressure, girlfriend, but Gisele had zero pain.

I suspect one reason why people deluge pregnant women with birth stories is that we assume they have some interest in a topic we don't actually get to talk about that much.

The birth story occupies a place very near the heart of the narrative of most mothers’ lives. I have two birth stories myself. One tells of a vaginal delivery in a hospital that required foiling an obnoxious resident itching to perform a Caesarean-section; the other is a near-miraculous survival story.

I hardly ever tell these stories out loud. They are great stories, full of colorful characters, conflict and drama but, practically speaking, who can I press them on? The people who are willing to listen to me use words like “vagina” and “transfusion” do not include, for example, my brother-in-law.

As I think about these stories, though, it occurs to me that even though the near-death experience is more dramatic, the birth of my first daughter is more satisfying, more reassuring, more the kind of narrative prospective parents are looking for: A family overcomes obstacles to have the experience it was hoping for (more or less). It was certainly more pleasant to live through.

I'm not sure it is the more helpful of the two stories. Knowing what it takes to live through a calamity — in our case, speedy access to a competent surgeon and anesthesiologist, and plenty of blood — seems to me to be extremely useful information.

But perhaps the stories we mothers like best are the ones where the fair damsel saves herself.