A New Report on the Health Consequences of too many C-sections

Three reports were released within the last month that we hope will make a huge dent in how obstetric care is practiced in America.  C-sections have dominated American deliveries over the last couple of decades and while the consequences of all these surgeries (the #1 surgical procedure performed in the US) have received a lot of chatter, there hasn’t been enough action to radically reduce our 33% C-section rate to the internationally recognized safe rate of about 15%. 

Reports like these three (reported by Childbirth Connection) spell out what happens when we trade normal vaginal birth for C-sections. These reports detail the health consequences for mothers and babies from unnecessary c-sections, the medical costs of both vaginal and C-section deliveries and theimpact of the health care liability system on maternity care in the United States. The report that really caught our eye is directly related to Every Mother Count’s mission to reduce maternal mortality and is titled: Vaginal or Cesarean Birth: What Is at Stake for Women and Babies? A Best Evidence Review.

Childbirth Connection is a national not-for-profit organization founded in 1918 to improve the quality and value of maternity care through consumer engagement and health system transformation. Inspired by the work of the National Priorities Partnership Maternity Action Team, a group of 30 major organizations that collaborate to improve the quality of maternity care by reducing early elective delivery and cesarean section in low-risk women, they created the report that addresses the health consequences to mother and baby as a result of our ever-increasing C-section rate. 

What they report is scary stuff.  Not only are we doing too many C-sections, we’re doing harm to a wide range of mothers and babies instead of providing better quality health care. Amy Romano, CNM, MSN and Associate Director of Programs at Childbirth Connection said, “It’s often said we’re doing more c-sections now than in past decades because the patient population is higher risk, presuming that older mothers, obese mothers and those with health complications going into pregnancy are driving up the numbers.  But the research shows that c-sections rates are going up in all populations – in first and repeat pregnancies, high and low-risk mothers, preterm and term pregnancies and in all age groups, races and ethnicities. We can’t just say it’s the older mothers or the obese mothers anymore.  Doctors are doing more C-sections on everyone.”  

The report states: Overuse of cesarean delivery in low-risk women exposes more women and babies to potential harms of cesarean with minimal likelihood of benefit.  Of particular consequence are downstream effects including childhood chronic illness and placental complications in any subsequent pregnancies. These include life-threatening complications that occur more frequently with accumulating surgeries. 

What kind of harm are we talking about here?  Check out this list:

Maternal consequences:

• Maternal death
• Cardiac arrest
• Urgent hysterectomy
• Thromboembolic events (blood clots)
• Anesthetic complications
• Major infection
• Rare, life-threatening complications including amniotic fluid embolism or uterine artery pseudoaneurysm
• Wound infections
• Hematoma
• Wound disruption
• Increased length of hospital stay
• Hospital readmission
• Problems with physical recovery including general health, bodily pain, extreme tiredness, sleep problems, bowel problems, ability to carry out daily activities, and ability to perform strenuous activities
• Chronic pelvic pain 

Newborn and Childhood Consequences: 

• Neonatal mortality
• Respiratory distress syndrome
• Pulmonary hypertension
• Not breastfeeding
• Asthma
• Type 1 Diabetes
• Allergic Rhinitis
• Symptomatic Food Allergies
• Obesity

Romano says, “Maternity care quality is on the national agenda. We’ve seen incredible leadership and multi-stakeholder cooperation to reduce elective deliveries before 39 weeks. That’s kind of the low hanging fruit and we’re seeing rapid success on that as hospitals and doctors are doing fewer early deliveries.  Now, women’s health advocates, policy-makers, payers, and a growing number of doctors are turning attention to finding ways to safely reduce c-section rates. We’re seeing pockets of success on that, but we need to spread best practices more widely.” The World Health Organization states that c-section rates in a country should be lower than 15%. When a nation does too few c-sections, that indicates they don’t have enough resources or capacity to provide for emergency obstetric needs.  But when a nation does more than that, we know they’re not being done for strictly medical reasons.

What’s it going to take to make a serious dent in America’s 33% C-section rate? I asked David Keefe, MD, chairperson of the OB-GYN department at New York University-Langone Medical Center to share his thoughts. Keefe says: 

 “There isn’t anything in this report to disagree with and I’d expect 100% of obstetricians would agree it’s accurate information.  The problem is, doing too many C-sections is like speeding.  Even though the law says you shouldn’t, people do it.  Even with guidelines for when doctors should and shouldn’t do C-sections doctors do too many. We’ve developed a culture of normalcy around C-sections that includes doctors and patients. Doctors who are exhausted, torn between office and hospital patients and worried about insurance issues will do C-sections when they know they could wait it out and their patient would probably be fine.  Patients don’t consider C-sections abnormal now that everyone has them. At a recent conference where high-level medical officials were talking about reducing C-section rates, a group shared that even their own daughters say, ‘eh, I just want to have a C-section.  It’s easier.’  This mindset has to change. We know patients die from C-sections, but it doesn’t happen so often that individual doctors and patients will be impacted, but again, it’s like speeding.  You get away with it most of the time, but people die in car crashes from speeding too.   It’s going to require culture change and traffic cops to make a difference.”

The Joint Commission, which provides accreditation for hospitals is zeroing in on this and becoming the traffic cops. Keefe says, “The culture change will come as doctors become motivated to lower their individual C-section rates.  Doctors are really competitive and they’ll compete against each other, once the Joint Commission says they have to.” 

Check out Childbirth Connections other two reports: Maternity Care and Liability and The Cost of Having A Baby in the United States

Check out Childbirth Connections Campanion Booklet: What Every Woman Needs to Know About Cesarean Section