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Special Report: Cesareans for All?
By John C. Hobbins, MD
Cesarean Section Rate Trends
It is clear that the United States’ Cesarean section rate (CSR), while tailing off in the late 1990’s, is now again rapidly heading upward. For example, the CSR in 1988 reached 24.7% after rising steadily from 1980 when it was 16.6%. Then, probably through various attempts to control the numbers of Cesarean sections, the rate dropped slowly to 20.8% in 1997. However, for reasons stated below, the percentage of C-sections in the United
States in 2002 rose to 26%, representing a 20% increase. Data from Latin America indicate a very rapid rise in CSR in some countries but not others. For example, in 1997 the CSR in Chile was 40% while in Peru it was only 7%. In some cities in Asia, such a Taipei, the rate is 32%.
What Should be the Ideal CSR?
In 1985, a WHO document noted that "there is no justification for any region to have a rate higher than 10-15%." However, this opinion was simply that—an opinion—which, whether valid or not, was not really based on any compelling data. Rates do vary among various populations and depend upon attitudes, resources, and policies. Undoubtedly, biases play a major role but, of late, there is no general agreement on what the CSR should be.
Why the Recent Rise in CSR?
1. A lack of enthusiasm for vaginal birth after Cesarean (VBAC’s)
In 2 years, the VBAC rate in the United States dropped from 26% attempted in 1998 to 20% in 2000 while the CSR rose in those same years. Now, figures from 2002 indicate a rate of only 12.7% in those eligible for this option.
Among many reasons for this trend, a New England Journal of Medicine randomized controlled trial (RCT) quantifying the risk of uterine rupture got the attention of many providers already gun-shy of the legal implications of this complication, no matter how low the risk. The American College of Obstetricians and Gynecologists (ACOG) even drafted VBAC guidelines that required providers to be "immediately available" when a patient choosing a VBAC was laboring.
As long as prostaglandins are not used for cervical ripening in these patients, the incidence of true uterine rupture in VBAC is, at most 1%, and fetal oxygen deprivation would occur in less than 10% of those, thus resulting in a risk of 1 in 1000 of fetal compromise in VBAC.
Nevertheless, once a trend like this starts, it gains momentum when the process has liability and logistic ramifications.
2. Increased rate of inductions
The rate of inductions in the United States (NCHS statistics) from discharge data rose from 9% of all deliveries in 1990 to 21% in 2002. Again, there are a variety of reasons for this which have to do with patient and provider convenience, as well as the over-diagnosis of impending fetal jeopardy.
As indicated in a previous Clinical Alert, induction of labor is associated with a doubling of Cesarean sections. Yet Kaufman et al have shown induction to not be associated with overall cost savings.
3. Changing management of breeches
A much discussed RCT in the New England Journal of Medicine showed a higher rate of fetal mortality and morbidity with vaginal delivery of breeches compared with elective Cesarean section. Although the absolute numbers of adverse fetal outcomes were small, the difference was enough to make many providers abandon this option for patients.
Even the practice of external versions for breeches has lost momentum of late because of the possibility of fetal bradycardia during version attempts.
4. The plummeting use of forceps
There is recent evidence that forceps deliveries are associated with higher rates of maternal pelvic and fetal complications. Although both may be due to the reasons why the forceps were used (long labors, maternal exhaustion, CPD, and fetal distress), rather than to the forceps themselves, this trend away from forceps is certainly understandable.
There is no way that this tendency will reverse itself in the near future because so few practitioners are being trained in the nuances of the techniques. For example, obstetrical residents in the United States do an average of 28 forceps deliveries, (only a very small percentage of which are mid-forceps) during their 4 years of training and soon there will be nobody willing or able to train our upcoming residents.
Given the apparent risk of mid-forceps delivery, it probably is good that this is a dying art, but it is likely that there will always be a need for low forceps or vacuum extraction, hopefully performed by competently trained practitioners.
5. More patients of Advanced Maternal Age
CDC-P data indicate that in 1975 the birth rate of mothers 35-39 years was 20/1000 and 30-34 years to be 50/1000. These rates increased to 40/1000 in 2000 for the former group and 90/1000 for the latter. In just one year (1999 to 2000), the birth rate rose 5% in women 30-34 years and those 35-39 years. Interestingly, this rate went from 7.5 to 7.9/1000 in those 40-44 years and 0.4 to 0.5/1000 in those 45-54 years. For a variety of reasons, these patients have a very high CSR.
Patient-Requested Cesarean Section
We recently were visited by an obstetrician who trained in the United States and now practices in his city of birth, Teheran. He indicated that he did the vast majority of his deliveries by elective Cesarean because of patient preference and his convenience.
In a private practice setting in Mexico City, the elective CSR exceeds 75%. A professor from our university visiting Mexico City was told that most private patients wish to avoid pelvic morbidity caused by a vaginal delivery.
In the 1985 WHO report noted above, this quote reflects the feeling at that time about patient-request Cesareans ". . . maternal request is not on its own an indication for Cesarean section and specific reasons for the request should be explored, discussed, and recorded." It further indicates that if there is no identifiable reason for a Cesarean section, the clinician has the right to decline the women’s decision, but should offer referral for a second opinion.
Because of the increasing demand for Cesarean section, the ACOG Ethics Committee was pressed into action. In a news release from ACOG on October 31, 2003, the following statements were made: "If the physician believes that Cesarean delivery promotes the overall health and welfare of the mother and fetus more than a vaginal birth, he or she is ethically justified in performing a Cesarean delivery."
On the other hand, "if the physician believes that a Cesarean would be detrimental. . . he or she is ethically obliged to refrain from performing the surgery."
Also, "physicians are under no obligation to initiate discussions regarding elective Cesarean—when not considered medically acceptable to the physician." In other words, it is ethically acceptable for the provider either to do the Cesarean section or to refuse to do it, but the provider need not bring it up as an option.
Let’s explore the pluses and minuses of patient-requested elective Cesarean section:
1. Pelvic relaxation and incontinence.
Perhaps the best study comparing Cesarean section with vaginal delivery comes from Norway. Rortreit et al surveyed 15,307 women younger than 65 years of age. They found the prevalence in the entire population of any incontinence was 20.7%. The difference between never pregnant individuals, those having had Cesarean section, and those having had vaginal deliveries involved stress incontinence only. Nullips had stress incontinence in 4.6%. Cesareans were associated with stress incontinence in 7% and vaginal deliveries (age corrected) in 12.2% (OR, 2.2).
In another study, Buchsbaum found the incidence of stress incontinence in parous individuals to be roughly similar to nulliparous post-menopausal women. Other studies have had similar results to the Norwegian study indicating that vaginal delivery was not associated with any increase in any type of incontinence (anal, urge incontinence) other than stress incontinence, and pregnancy, in general, had the greatest effect on pelvic organ instability.
2. Complications with Cesarean delivery vs vaginal delivery
3. The following represents an itemized summary of various complications from vaginal and Cesarean delivery based on a review of the literature. Data on elective Cesarean delivery alone are difficult to come by.
Who’s Most Apt to Either Offer or Comply with Patient-Requested Cesarean Section?
Two recent studies from The Netherlands and the United States involving provider surveys indicate that the more compliant caregivers were: older, more experienced, and more often practicing in an academic center. The sex of the practitioner was not a factor. In the New York study, 13% of physicians offered elective Cesarean sections and 8.8% of patients requested it without indication.
The Cost of Elective Cesarean Section
One British study specifically addressed the cost of requested Cesarean sections. Based on data from England and Wales, the authors indicated that 7% of all Cesarean sections in the year 2001 were done for maternal request only. The authors calculated that, based on UK cost figures, this represented an extra £1257 ($2,255) per individual section over vaginal delivery. They also figured that if these operations were not undertaken, a total of £11 million (approximately $19.7 million) could be saved in England and Wales per year. One can imagine that dollar figure in the United States where there are 4 million births per year, compared with half a million births in the United Kingdom.
The increasing demand for elective Cesarean section represents an ethical and logistic dilemma. On one hand, all providers should respect patient autonomy (the major reason in the Dutch study that providers granted their patients’ wishes for Cesarean section). On the other hand, Cesarean section is still a "major" operation that is not devoid of maternal and fetal complications. It puts stress on today’s available resources and is downright costly.
Autonomy is based on informed choice and it is extremely important for patients to know that the most common rationale used for avoiding a vaginal delivery is flawed. Stress incontinence happens even in nuns. Clearly, pregnancy alone has an effect in those pre-disposed to it, but the difference between the modes of delivery is very small when one excludes those with difficult forceps deliveries and excessively long second stages of labor. Wilkes et al have suggested that in some cases a clinical backdrop will evolve in which a vaginal delivery is destined to fail. However, in the majority of situations where there is no clinical indication for Cesarean section, it would seem preferable to set guidelines with the patient for "bail out," thereby avoiding prolonged labor and instrumental delivery. This would seem preferable to sectioning everyone at the front end.
1. Caesarean Section Clinical Guideline, April 2004. National Collaborating Centre for Women’s and Children’s Health. Commissioned by the National Institute for Clinical Excellence. Access at: http://www.nice.org/uk/pdf/CG013fullguidelines.pdf
2. Martin JA, et al. Births: Preliminary Data for 2000. National Vital Statistics Report. 2001;49(5):1-20.
3. MacLennan AH, et al. BJOG. 2000; 107: 1460-1470.
4. Rortveit G, et al. N Engl J Med. 2003;348(10):900-907.
5. International Cesarean Awareness Network, Inc. Access at: http://www.ican-online.org/resources/statistics4.htm
6. Goldberg RP, et al. Am J Obstet Gynecol. 2003; 188(6):1447-1450.
7. Thompson JF, et al. Birth. 2002;29(2):83-94.
8. Kwee A, et al. Eur J Obstet Gynecol Reprod Biol. 2004; 113:186-190.
9. Minkoff H, Chervenak FA. N Engl J Med. 2003;348: 946-950.
10. Nygaard I, Cruikshank DP. Obstet Gynecol. 2003;102: 217-219.
11. Surgery and patient choice: the ethics of decision making. ACOG Committee Opinion No. 289. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2003;102:1101-1106.
12. Martin JA, et al. National Vital Statistics Reports. 2003;52(10):1-113.
13. Kalish RB, et al. Obstet Gynecol. 2004;103(6): 1137-1141.
14. Minkoff H, et al. Obstet Gynecol. 2004;103(2):387-392.
15. Kaufman KE, et al. Am J Obstet Gynecol. 2002;187: 858-863.
16. Rayburn EF, et al. Obstet Gynecol. 2002;100:164-167.
17. Lydon-Rochelle M, et al. N Engl J Med. 2001;345:3-8.
18. Wilkes PT, et al. Obstet Gynecol. 2003;102(6): 1352-1357.
John C. Hobbins, MD, Professor and Chief of Obstetrics, University of Colorado Health Sciences Center, Denver is Associate Editor for OB/GYN Clinical Alert.