A closer look at a new study on cesareans

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.
  • Fears about VBAC

    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."Pregnant Graffiti

    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

    Can the VBAC make a comeback?

    Let's interrupt our Women's History Month programming to consider the news. The National Institutes of Health today begins a three-day session on vaginal birth after Caesarean, a hot topic, given that this practice, which was commonplace 15 years ago, has become scarce in the United States, at the same time that the Caesarean section accounts for nearly one-third of American births.

    The VBAC has some passionate champions. While it isn't for everyone, it can work for many mothers, enabling them to avoid major surgery, and perhaps also to enjoy birth as they have always imagined it. The VBAC's decline has attended a steady rise in reliance on the Caesarean section, in part because the VBAC does carry a risk of rupture to the uterus, which can be life-threatening.

    So it will be exciting to see what comes out of this conference, which aims to bring the best research available to bear on determining the safety and efficacy of the practice.

    The VBAC is also one subject of an article by Denise Grady in the New York Times on Sunday, about a hospital in Tuba City, Ariz., where 32 percent of women who previously had Caesarean sections delivered vaginally, compared with a national average of less than 10 percent.

    The rate of Caesarean births at the Tuba City Regional Health Care Corp., where about 500 babies are born a year, is 13.5 percent, less than half the national rate of 31.8 percent. The hospital is run by the Navajo Nation and is partially funded by the Indian Health Service, and it largely serves a Native American population.

    What I love about Grady's account is how well this small, poor hospital appears to be doing in addressing one of the major tensions in the modern birth story -- how to keep the blissful experience of childbirth from being swamped by the technology that has been developed to keep it safe.