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."

Making a difference in maternal mortality

It isn't that childbirth is more inherently dangerous in countries where many women die in childbirth than in those where relatively few die. The women who survive, statistically speaking, are getting appropriate help from trained attendants.

"...The main complications that lead to death during pregnancy or childbirth are fairly common among all women, regardless of where they live," write the authors of an article titled "Are We Making Progress in Maternal Mortality?" in the May 26 issue of the New England Journal of Medicine.Pregnant Graffiti

Hemorrhage, which most often occurs right after birth, is the leading cause of pregnancy-related deaths globally, accounting for 35 percent of all deaths in childbirth, according to the World Health Organization. And in fact, hemorrhage was the second most common complication seen in pregnancies in the United States in 2000.

However, most U.S. women who suffered hemorrhage were treated quickly, and survived, say the article's authors, Anne Paxton and Tessa Wardlaw.

WHO identified the second most common cause of maternal death as hypertensive disorders — pre-eclampsia/eclampsia, for example. Again, these disorders are a common problem all over the world, but women with access to good medical care have a good chance of surviving them.

The countries that are most dangerous for pregnant women are those suffering through wars, or burdened with a large population with HIV/AIDS, the authors write.

In general, poor women die in childbirth more often than affluent ones, rural women more often than urban ones. These populations are more vulnerable because they often deliver their babies without the benefit of skilled birth attendants, and lack access to obstetrical services like surgery by Cesarean section.

Sub-Saharan Africa, with widespread political unrest and HIV/AIDS infection, "has the greatest burden of maternal mortality," even though most countries there are seeing "small but promising" decreases in pregnancy-related deaths.

Worldwide, there is considerable cause for hope, Paxton and Wardlaw write. Maternal mortality has decreased globally by more than one-third since 1990, according to United Nations estimates.

"Dramatic improvements in China and other Asian countries...are associated with economic improvement, decreasing fertility rates and strengthening of health systems...," the authors write.

"The overall rate of decline in global maternal mortality, 2.3 percent, is lower than the 5.5 percent MDG target but is heartening nonetheless," they write.

Image: "Pregnant Graffiti" by Petteri Sulonen


Home-birth share small but rising

A study released this week on home birth in America shows a substantial increase in the still very small numbers of women who are choosing to have home births.

The study, released online in Birth: Issues in Perinatal Care, shows that of the 4.2 million births in the United States in 2008, 28,357 were home births. That is 2/3 of one percent of the total, but it represents a 20 percent increase, from 0.56 percent in 2004.

Non-Hispanic white women accounted for most of the growth, with an increase of 28 percent between 2004 and 2008. More than 1 percent of those women now have their births at home.

The study was based on United States birth-certificate data.

The doctor who delivered President Obama

The family of David A. Sinclair MD, the late Honolulu obstetrician who delivered Barack Obama on August 4, 1961, were surprised and honored to learn of his role when the President recently released his long-form birth certificate.

David Sinclair MD
David Sinclair MD

Dr. Sinclair was a freshly minted young doctor in 1961. Born in Portland, Ore., Dr. Sinclair had moved to Hawaii with his family as a child. He served as a fighter pilot in World War II, settling back down in Hawaii after the war. There, he attended college at the University of Hawaii, where he met his wife, Ivalee.

Dr. Sinclair received his medical training, including his residency in obstetrics and gynecology, at the University of California at San Francisco. He returned to Hawaii in 1960.

He delivered babies all over Hawaii, but his practice was centered at a hospital now known as Kapi'olani Medical Center for Women & Children in Honolulu, where President Obama was born, according to news accounts.

Dr. Sinclair died in 2003 at the age of 81.

"I'm just honored and proud of my father," said Karl Sinclair, one of Dr. Sinclair's six children.

"I think it's great," said Dr. Brian Sinclair, another son. "Hawaii was a very small place back then so I guess I'm not surprised."