Time Magazine published an article yesterday, Too Many C-Sections: Docs Rethink Induced Labor, examining the relationship between this country's rising cesarean section rate and an increase in induced labor between 37 and 41 weeks gestation (when the American College of Obstetricians and Gynecologists medical standards are not to induce prior to 39 weeks).
There are many reasons why the c-section rate is rising in this country and it's refreshing to read a piece that looks at a problematic cause: the decision to impede natural labor with intervention too early, when it may not be medically necessary. However, as I always want to make sure I note, there are real and serious reasons for cesarean sections. There are many women and newborns whose lives have been saved by this procedure. Unfortunately, it's the indiscriminate and overuse of this surgery and a variety of medical interventions, in place of natural labor and vaginal birth, in healthy women which is clearly wreaking havoc.
One out of every three laboring women birth via c-section now and it's not because women "prefer" major surgery or because women have evolved to become less able to birth vaginally. It also may not be, as this article suggests, due to an increase in multiple births or women birthing later in life. According to the advocacy organization, Childbirth Connection, after completing an extensive Listening to Mothers survey, and based on other independent studies, "researchers have found that cesarean section rates are going up for all groups of birthing women, regardless of age, the number of babies they are having, the extent of health problems, their race/ethnicity, or other breakdowns (Declercq et al. 2006b) [emphasis added]."
Cesarean sections are being performed more frequently for many reasons, in fact, including: a de facto ban on VBACs (vaginal births after c-sections) which may soon be helped by a recent ACOG statement changing its policy on the safety of VBACs; provider fear of malpractice claims "given the way our health care system currently works," according to Chidlbirth Connection, as well as a fee system that does not encourage providers to facilitate a less "controlled", often time more time-consuming vaginal birth; as well as a sometimes incomplete understanding, on the part of the patient, of the full risks and complications associated with c-sections; and, finally, as this article is about, the side effects which arise from increased interventions including labor induction, electronic fetal heartrate monitoring, and epidurals.
Given the precipitous rate of c-sections in the United States, the article notes, "obstetrics experts are actively seeking ways to drive down the number of C-sections." This is good news even if my cynical side wonders why obstetrics experts aren't just paying closer attention to what midwives and midwifery advocates have been saying (and doing) for years: birth, for most women, is a healthy experience which requires minimal medical intervention.
One of the ways they are looking to decrease the c-section rate is by examining the relationship between labor induction and c-sections:
"The use of labor induction in the U.S. has risen from less than 10% of deliveries to more than 22%, between 1990 and 2006, according to data from the Centers for Disease Control and Prevention, and research suggests that induced labor results in C-sections more often than natural labor."
According to a study (cited in the Time article) of 7,304 women birthing for the first time (delivering single babies, between 37 and 41 weeks gestation), undertaken by Dr. Deborah Ehrenthal, director of women's health programs at Christiana Care Health System in Delaware, and published in the most recent issue of American Journal of Obstetrics and Gynecology (AJOG), labor was induced in a whopping 43.6% of the cases. When she looked at the women in this group who ended up having a c-section, she found that induction caused 20% of those c-sections to occur.
About this rate, Dr. Ehrenthal remarked, "We need to be a little less ready to do an induction...We need to understand it's not without risk to be doing this...There are significant risks to moms for C-sections."
Dr. Ehrenthal also found that 40% of those inductions were considered "elective." A finding discussed by Dr. Caroline Signore an ob-gyn at the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) at the US National Institutes of Health (NIH), in a commentary accompanying the published study:
"Many women believe that delivering a few weeks early is just as safe as delivering on the projected due date and may request delivery for any number of reasons of comfort or convenience," Signore writes. "However, we must remember that incautious use and timing of interventions — particularly in elective cases — can lead to unnecessarily poorer outcomes for women and newborns."
"...women aren't making decisions about their mode of delivery in a vacuum; rather, they are deeply impacted by the opinions and guidance of their providers. Lamaze International explains, "What women hear from obstetricians powerfully influences what they think. Some obstetricians think so little of the risks, pain, and recovery of cesarean surgery that they feel that ‘convenience,' ‘certainty of delivering practitioner,' and ‘[labor] pain' justify performing this major operation on healthy women." When physicians talk up convenience and don't give air time to possible complications resulting from c-section, it's no wonder women make decisions in the same terms."
The good news is that some hospitals are changing their policies regarding labor induction:
In 2006, the Magee-Womens Hospital in western Pennsylvania began limiting the pool of women eligible for elective inductions to those delivering after 39 weeks. The hospital also established stricter protocols for elective induction in women after 39 weeks — insisting on high levels of cervical "ripeness" as measured by the standard Bishop score before induction — and prohibited other labor-hastening efforts, such as the use of cervical ripening agents.
This has led to a reduction of both inductions as well as c-sections in that hospital.
The larger issue is that these sorts of "revelations" based on evidence are paving the way for greater access to information for pregnant women about their choice in childbirth; it's paving the way for a transformation or overhaul of our current health provision system which values profit-making over women's and newborns' health and lives, efficiency over evidence; and it's helping to inform better public policy that will support greater options for healthy, pregnant women who wish to birth out-of-hospital or with a midwife. Ultimately, it's helping to protect womens' and newborns' health and lives.