What+is+the+Issue?

WHAT //IS// THE ISSUE?



It is now believed that more than 30 percent of all births in the United States are Cesarean deliveries. Among obstetricians, these are called Cesarean Delivery on Maternal Request or CDMR. But they are most commonly called C-section-on-demand. But the question remains: why so many American women are having C-sections? Or are there medical reasons driving the trend?

 The high rate is pretty much an American issue: the latest statistics (reported in the New England Medical Journal) are that the Cesarean delivery rate in this country is greater than 30 percent. This means that over 1.2 million births a year are performed with abdominal surgery. The highest rate of Cesarean delivery – 35 percent – has been reported in New Jersey for the year 2000 (and the number now is probably higher). Compare this to the rate of 15 percent recommended by the World Health Organization. WHO has found that Cesarean “offer no population health benefits”. But are there medical reasons for these high rates in the United States or do they simply reflect the desire for convenience and the containment of malpractice costs? The U.S. obstetrical population has changed in the 21st century and this may impact our cesarean delivery rates. But here are some other reasons: - Older women are having babies. Since 1990 there has been an increase of over 40 percent in the number of women between the ages of 35 and 39 who have babies, and over 60 percent for women between the ages of 40 and 44. - Women are also heavier. (There has been a doubling of obesity rates in the past 21 years). Heavier moms are likely to have heavier babies and in order to protect overly large babies from traumatic vaginal delivery, especially one that can cause collar bone and paralysis of the arm (brachial plexus injury), Cesarean delivery is often planned without a trial of labor. - More multiple gestations (the rate is currently two times greater that it was in 1980). A pregnancy of twin’s triplets or more increases the risk of fetal growth retardation, premature delivery and other complications that lead to cesarean sections. There’s no question that women who undergo fertility care, especially IVF are currently more likely to have multiple gestations. These expensive and more difficult “to make” babies are also considered “premium.” As a result, even with singleton births, women who underwent fertility care are more likely to be delivered by C-section. - Vaginal Breech deliveries are no longer recommended. There is a three percent risk on injury to the breech newborn with a vaginal delivery; this is concerning both to the mother whose baby is in breech position and to the physician who does not want to incur difficulty in the delivery and/or a malpractice suit. As fewer and fewer physicians are delivering breech babies vaginally, they are also becoming less capable if called upon to do so. Fewer doctors are trained for vaginal breech delivery and as a result, most babies are now delivered with C-sections. In the future many predict that none will be delivered vaginally. - Fewer attempts at vaginal delivery after Cesarean sections (VBAC). Many institutions feel that they do not want to allow physicians VBAC after a cesarean because of the possible occurrence of rupture of the previous scar in the uterus

- An increase in the induction of labor. (When labor is induced there is a higher risk of C-sections). Approximately 20 percent of labors were induced in 2003, compared to 9.5 percent in 1990. Labors.

 The National U.S cesarean rate was 4.5% and near this optimal range in 1965 when it was first measured (Taffel et. al 1987). In more recent years, large numbers of healthy; low-risk American women who have received care that enhanced their bodies’ innate capacity for giving birth have achieved 4 percent cesarean section rates and good overall birth outcomes (Johnson and Davis’ 2005, Rooks et. al 1989). However, the national C-section rate is much higher and has been increasing steadily for more than a decade.

There is no question that malpractice issues play a part. Many lawsuits are about failure to perform a “timely” Cesarean delivery. A recent survey performed by the American College of Obstetricians and Gynecologists (ACOG) on professional liability of its members found that obstetricians average three lawsuits during their years of practice. This may cause many of them to change the way they practice or even decide to give up delivery of high-risk patients (or any patients). Insurance rates have risen and in lawsuit amounts for pain and suffering, obstetricians’ insurance rates can be hundreds of thousands of dollars a year.

The above statistics unveil a rising trend of surgical births in the United States, but sometimes in order to fully understand the extent and magnitude of the issue one has to experience it firsthand.