In June, Yale researchers reported in the journal Obstetrics & Gynecology that for the sample in their study, the rate of cesarean sections reached 36 percent in 2009. The data was gathered from over 32,000 births at Yale-New Haven Hospital starting in 2003, showing that the rate had climbed from 26 percent to over one third of births in six years.
It’s part of a trend that we know well. Last spring, for example, the National Center for Health Statistics, part of the CDC, released a report on the climbing C-section trend finding that between 1996 and 2007, the cesarean rate rose by 53 percent. The increase was seen across all ages, all ethnic backgrounds, and for babies of all gestational stages. C-sections have become more popular throughout the U.S., although the trend is uneven from state to state. In 2007, for example, Alaska, Idaho, New Mexico, and Utah had only a 25 percent cesarean rate, whereas in states like New Jersey and Florida, the rate was over 35 percent. In Colorado, Connecticut, Rhode Island, and more, there was a 70 percent increase over nine years.
Even though the pattern has been clear for some time, researchers are now getting a hold on exactly what’s causing it. Contrary to popular belief, very few moms actually choose a cesarean without a medical reason – in the Yale study, for example, only eight percent of the increase in C-sections could be attributed to moms’ choice.
The most dramatic of all C-section trends, and one that plays heavily into the rise, is the evaporating number of moms who have a VBAC – a vaginal birth after cesarean with a previous baby. In the mid-90′s, roughly 30 percent of moms with previous cesareans had vaginal births. That number has dwindled to between five and 10 percent. In the Yale sample, the VBAC rate went from 44 percent to 7.8 percent between 1998 and 2009. It’s a self-perpetuating cycle: with first time cesareans becoming more popular and VBACs falling precipitously out of style, the overall C-section rate has been set up on a dramatic snowball course. VBACs are uncommon because of the worry of uterine rupture and, even though last year the American College of Obstetricians and Gynecologists said that, “a VBAC is a safe and appropriate choice for most women who have had a prior cesarean delivery,” it remains the exception.
But VBACs are only half the story. The other 50 percent of the C-section rise comes from first time births, and the most common reason doctors cite for surgery in that case is a baby’s “non-reassuring status.” With most moms’ bellies hooked to fetal monitors, an abnormal heart rate is one of the most frequent triggers for the operating room. The other popular reason is mom’s slow or stalled labor. In the Yale study, for example, worry over the fetus made for 32 percent of the C-section rise, while slow labor made for 18 percent. Other documented reasons were: multiples (16 percent), suspected big baby (10 percent), preeclampsia (10 percent), and maternal fetal conditions (5 percent).
In other words, C-sections are going up for what could be called subjective reasons. Doctors debate the reliability of data from fetal heart monitors and there’s a wide variability of interpretation when it comes to their meaning. And slow or stalled labor is somewhat in the eye of the beholder, because what one doctor sees as too long or too risky, another one might see as just the natural course of things. Especially with the common practice of inducing labor at 38, 39 or even 40 weeks, (which logically makes for slower labor since it’s an uphill battle for mom to deliver when her body and the baby haven’t decided to do so) many moms and doctors end up in the predicament of what to do when it seems labor is at an impasse. Meanwhile, C-sections for objective reasons – like having a breech baby or placenta previa – haven’t gotten more popular.
Doctors have a whole lot of data – maybe too much – but in the end, the C-section decision has increasingly come down to interpretation. Moms are outfitted with fetal monitors but not everyone agrees on what to do when things seem abnormal. We have data on uterine ruptures but shifting tides as to how to proceed – all this with the fear of malpractice looming.
In the end, there’s no doubt that the advent of the C-section has saved countless lives. But when you consider the fact that the U.S. infant mortality rate hasn’t budged since 2000 and is higher than most developed countries, it seems hard to make the case that ever-climbing cesareans are making birth a safer endeavor.