Sharp Rise of C-Sections Defies Best Evidence and Best Practice
The U.S. c-section rate jumped to 29.1% in 2004. This record-setting preliminary figure from the Centers for Disease Control and Prevention represents a sharp increase of more than 40% over 8 years (Hamilton 2005).
Why is the c-section rate rising?Many factors are driving cesarean rates up, including:
Why are healthy mothers and babies experiencing surgical birth when there is no medical reason?Birth certificates are the primary source of national data on cesarean births. A recent analysis found that more and more U.S. women who have c-sections have no sign of any medical need for this surgery on their birth certificate (Declercq 2005).
What is driving these surgical procedures? Many policy, research and media reports assume that "elective" cesareans (with no medical rationale) are "maternal request" or "patient choice" cesareans. Because birth certificates and most other data sources provide no information about decision making processes and the motivation of participants, it is wrong and irresponsible to equate c-sections that had no apparent medical cause with "patient choice" cesareans.
One report that looked at this question found that most cesareans with no medical rationale were proposed by doctors, not mothers (Kalish 2004). When mothers ask for such surgery, it is important to understand their motivation, including whether they had access to balanced accurate information on harms and benefits of cesarean versus vaginal birth, access to choices and support for their choices. We need to better understand why women request a c-section with no medical reason, but this should not divert attention from physician and hospital led influences on escalating cesarean rates (Gamble 2000).
Many obstetricians have begun to support "patient choice" cesarean, but do not support women's right to choose vaginal birth after cesarean (VBAC), vaginal breech birth, and out-of-hospital birth, although the best research suggests that these would be reasonable choices for many women.
This selective support for women's right to choose surgical birth raises important questions about motivation and conflicts of interest. Cesareans may be attractive to providers who feel that the surgical procedures reduce their risk of being sued or help them better schedule and control their professional and personal lives. They may be attractive to hospitals due to increased revenue relative to vaginal birth (see "What are the financial implications...", below). An independent investigation is urgently needed to clarify whether these conflicts of interest are driving cesarean rates up and jeopardizing the health of mothers and babies.
What are the health costs of c-sections with little or no benefit?To provide evidence-based guidance to women and other stakeholders, Childbirth Connection carried out the first and only systematic review to identify the full range of harms that may be worse with c-section or vaginal birth.
Many adverse effects did differ, and nearly all favored vaginal birth. Here is the main conclusion:
The following adverse effects were more likely with c-sections:
In short, unnecessary c-sections pose plenty of risk to mothers and babies, and offer no clear benefit.
What are the financial implications of a runaway c-section rate?There is another cesarean-related cost. On average, hospitals charge many thousands of dollars more for a c-section than for vaginal birth. And among the hundreds of procedures performed in U.S. hospitals, c-section is the most common one.
In 2003, U.S. hospitals charged an average of
The most common reason for hospitalization in the U.S. is a woman having a baby, and there are over 4 million births every year. Avoidable cesarean surgery adds billions of dollars to the burden of health care costs for governments, employers and individuals in the U.S. Access to health care coverage is jeopardized, and health care costs threaten the economic stability of governments, businesses and families. We cannot afford to tolerate costly, avoidable surgical procedures.
What is the ideal c-section rate?As c-sections have troubling health and financial downsides, they should only be used when they offer a clear, established health benefit. Although needs vary from woman to woman, very low c-section rates are possible for the majority of mothers and babies who are healthy. Both the largest ever study of women giving birth in birth centers (Rooks 1989) and the largest ever study of women giving birth at home (Johnson 2005) found that just 4% of those who began labor in those settings had a c-section. Moreover, neither study found evidence that these low rates and this type of care posed extra risk for mothers and babies when compared to similar healthy mothers and babies experiencing hospital birth. However, as the Johnson report points out, 19% of low-risk mothers end up with c-sections in U.S. hospitals.
"Practice style" (and thus, the likelihood of using cesareans and other maternity interventions) can vary greatly from one maternity provider to another and one place of birth to another. The largest birth center and home birth studies underscore the value of careful choice of maternity caregiver and place of birth.
Variation in practice style also has major cost implications, as shown in the birth charges graph (PDF): in comparison with average hospital charges of $6,239 (plus charges for newborn care and anesthesiology services) for an uncomplicated vaginal birth, the average birth center charge was $1,624 (with no extra newborn or anesthesia charges) in 2003.
Our in-depth Maternity Topics provide more information on these and related issues:
ReferencesDeclercq E, Menacker F, MacDorman M. Rise in "no indicated risk" primary caesareans in the United States, 1991-2001: Cross-sectional analysis. BMJ 2005;330:71-2.
Gamble JA, Creedy DK. Women's request for a cesarean section: a critique of the literature. Birth 2000;27:256-63.
Hamilton BE, Ventura SJ, Martin JA, Sutton PD. Preliminary births for 2004: infant and maternal health. Health E-stats. Released November 15, 2005.
Johnson KC, Daviss BA. Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ 2005;330:1416.
Kalish, R.B., McCullough, L, Gupta, M., Thaler, H.T., & Chervenak, F.A. (2004). Intrapartum elective cesarean delivery: A previously unrecognized clinical entity. Obstet Gynecol, 103, 1137-1141.
Rooks JP, Weatherby NL, Ernst EK, Stapleton S, Rosen E, Rosenfield A. Outcomes of care in birth centers: The National Birth Center Study. N Engl J Med 1989 321:1804-11.
U.S. Agency for Healthcare Research and Quality. HCUPnet, Healthcare Cost and Utilization Project. Rockville, MD: AHRQ, 2005. [DRGs 370-373.]
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Childbirth Connection is a national not-for-profit organization founded in 1918 as Maternity Center Association. Our mission is to improve the quality of maternity care through research, education, advocacy and policy. Childbirth Connection promotes safe, effective and satisfying evidence-based maternity care and is a voice for the needs and interests of childbearing families.
Most recent page update: 6/30/2008