If the primary and overall cesarean rates continue to escalate at the same pace as in recent years, the cesarean rate will be over 56% by 2020, warns two prominent obstetricians in the August edition of Obstetrics and Gynecology. Although cesareans are safer than ever before, they are still riskier for both mothers and babies than vaginal births. And, cesarean surgery increases the risks in future pregnancies for placenta previa, placenta accreta, hysterectomy, and mortality relative to vaginal births. Indeed as the cesarean rate has skyrocketed in recent years,  the incidence of potentially catastrophic complications caused by the first cesarean has increased dramatically. Obstetricians are alarmed and are seeking ways both to decrease the primary cesarean rate and to increase the VBAC rate.

In the August edition of Obstetrics and Gynecology, Dr. John T. Queenan, Deputy Editor, addresses the challenge of reducing the primary cesarean rate. He warns that, “if cesarean delivery rates spiral upward, our profession [obstetrics] will lose both credibility and the opportunity to determine our direction, as third-party payers and the government will become involved.”   Two of his most important recommendations are that OBs do fewer inductions and that they eliminate cesareans performed for dystocia before active labor is established. Both of these topics need to be addressed in childbirth education classes. An innovative program at St. John’s Mercy Medical Center in St. Louis, MO proved that adding detailed information about the risks and benefits of elective induction to the childbirth class curriculum can decrease the number of elective inductions. Childbirth educators also can help to reduce the number of cesareans done for dystocia before labor is well established. Encourage women to labor at home for as long as possible; to not be too disappointed if they are sent home from the hospital in early labor; and to ask for more time if cesarean surgery is suggested for “failure to progress” as long as both mother and baby are coping well with labor. Also, emphasize that there is a lot of variation in the length of “normal” labor and that recent research from National Institutes of Health supports that labor may take more than 6 hours to progress from 4 to 5 cm and more than 3 hours to progress from 5 to 6 cm. In addition, Dr. Queenan calls for better patient education using evidence-based information about the risks and benefits of vaginal birth and cesarean delivery (presumably to highlight the benefits of vaginal birth and the risks of cesarean surgery); for more births by nurse-midwives; for equal compensation for vaginal births and cesarean surgeries; and for re-establishing medical training for breech and operative vaginal deliveries.

In the same issue of Obstetrics and Gynecology, Dr. James R. Scott, Editor-in-Chief, discusses strategies to increase access to and the desirability of VBACs.  In the August 2010 practice bulletin on VBAC, ACOG (The American College of Obstetricians and Gynecologists) continues to recommend that TOLACs (trial of labor after cesarean) only be done in hospitals capable of emergency deliveries.  However, ACOG acknowledges that not all facilities have this ability and that patients should be allowed to accept the increased level of risk if they want to have a TOLAC in a facility that cannot immediately perform cesarean surgery. Dr. Scott recognizes that immediate availability [for cesarean surgery] is not mandated for other obstetric emergencies such as placental abruptions or umbilical cord prolapse. As have virtually all other experts on the cesarean crisis, Dr. Scott calls for tort reform so that physicians need not fear malpractice suits in case a well-planned TOLAC turns disastrous. He also discusses the factors that are associated with successful TOLAC such as spontaneous onset of labor. Childbirth educators need to present information about TOLAC and VBAC even in a class of first-time parents in order to encourage TOLAC for those women for whom it may be appropriate in the future.

It is reassuring that ACOG leadership recognizes the role of education in bringing down the cesarean rate. Now, more than ever, childbirth educators need to teach about the healthy birth practices that promote safe and healthy birth. For those who teach in hospitals, they should not be prevented from presenting current evidence about factors that may increase risks for cesarean surgery. It’s time we were all on the same page.

Among many health care professionals, it is fashionable to attribute our skyrocketing cesarean rate to increasing numbers of “older” and obese women having babies. As women age, the rate of health complications such as hypertension and diabetes do increase. And obesity is associated with increased risks for both mothers and babies. But is this the reason for our escalating cesarean rate?

Last year, in an article published in the American Journal of Obstetrics and Gynecology, researchers for the Consortium on Safe Labor found that cesareans done for women with advancing maternal age were mainly due to repeat, prelabor cesareans. Obesity was associated with substantially higher cesarean rates in all categories (primary vs repeat, and prelabor vs intrapartum). But the most important concern raised in this study was the increase in the primary cesarean rate. Researchers found that high numbers of cesareans were done in the first stage for dystocia before 6 centimeters and high numbers of cesareans were done in second stage before 3 hours was reached in nulliparous women and before 2 hours was reached in multiparous women. As in many other studies, they found that the cesarean rate among induced labors was twice as high as among spontaneous labors. The authors called upon clinicians to reduce the rate of cesarean delivery associated with a high rate of induction of labor AND to avoid cesarean surgery for dystocia before active labor is established. They also called for increased access to and education about VBAC.

Now, in the July 2011 edition of Obstetrics and Gynecology, another study looks at indications contributing to the increasing cesarean delivery rate. The authors flat-out state that:

“Studies examining differences in medical risk factors for expectant mothers, including obesity, have not concluded that changes in maternal risk profile explain the increasing cesarean delivery rate.”

They also say that, “Maternal request for elective cesarean also does not appear to account for the magnitude of the increased cesarean rate.”

In this study, researchers analyzed the rates and indications for primary and repeat cesarean delivery among 32,443 live births at Yale-New Haven Hospital between 2003 and 2009. The cesarean rate increased during this time period from 26% to 36.5%. They noted that the prevalence of advanced maternal age and weight of 4,500 grams or more were stable over time. They found that the greatest increases in cesarean delivery were due to subjective indications such as nonreassuring fetal heart tracings, labor arrest disorders, and suspected macrosomia. The authors acknowledged that the rising cesarean rate may be linked to medico-legal issues, scheduling issues, economic pressures, provider-driven and patient-driven medicalization of birth, increased labor induction rates, and a broader perception of cesareans as safe. In order to reverse the rapidly escalating cesarean delivery rate, these authors call on clinicians to develop clearer evidence-based guidelines regarding fetal status, labor arrest, and assessment of macrosomia. They also recommend increased provider accountability for the decision to perform cesarean delivery at the practice, departmental, hospital, or state level. Finally, they also call for increased patient education and involvement in decisions during pregnancy as well as changes in methods of reimbursement, and medico-legal reform.

Childbirth educators can help meet this challenge by continuing to present information on factors that increase the risk for cesarean surgery such as induction and admission to the hospital before labor is well established. Educators can do a better job of encouraging greater participation in decision-making during labor by having students role-play situations such as one in which the physician recommends a cesarean for slow labor progress before 6 centimeters has been reached. Women need to know that too many cesareans are being done for the wrong reasons. And childbirth educators need not to be afraid to say so.

Once again, my hopes are raised that we may turn the corner and reverse our skyrocketing cesarean rate. The reason for my optimism is the increasing concern I am seeing in medical journals about the risks associated with common obstetric interventions. In the April 2011 edition of The Journal of Maternal-Fetal and Neonatal Medicine, Dr. J. Christopher Glantz of the University of Rochester School of Medicine looked at the relationship between rates of labor induction and primary cesarean delivery and rates of adverse neonatal outcomes. “If labor induction and cesarean section are beneficial in terms of improving neonatal outcome, then higher rates of intervention should be associated with lower frequency of risk-adjusted adverse neonatal outcomes.” Right?

Wrong. Dr. Glantz analyzed records from the Statewide Perinatal Data System, a validated electronic birth certificate database available for analysis though the New York Department of Health. The study used data from January 2004 through December 2008. In the labor induction group, Dr. Glantz analyzed 28,883 records and in the primary cesarean delivery group, he analyzed 29,764 records. A little over 80% of patients were common to both groups. In order to reduce variance caused by women with high-risk conditions during pregnancy, Dr. Glantz only looked at data from level I (low-risk, no NICU) hospitals. He also used risk adjustment to further reduce variance caused by differences in risk and patient demographics among the patients giving birth at the ten hospitals included in the study.  He concluded that differences in rates of labor induction and primary cesarean delivery were due to differences in practice styles rather than differences in risk status and patient demographics. Not surprisingly, he found a positive association between induced labor and primary cesarean delivery. But most importantly, he found that hospitals who had the highest rate of labor induction and primary cesarean delivery did NOT have better neonatal outcomes. (Neonatal outcomes were defined as 1) neonatal transfer, 2) immediate assisted ventilation, and 3) low 5 minute Apgar score, <5.) There was no correlation at all between labor induction and/or primary cesarean delivery and neonatal outcomes.

“Medical and surgical interventions are supposed to improve outcomes. Certainly some labor inductions and cesarean sections – presumably those done for specific, established indications – lead to improved outcomes, but hospitals in this study with high intervention rates had outcomes indistinguishable from hospitals with low rates, before and after risk adjustment.”

Dr. Glantz goes on to say, “A corollary to the medical dictum ‘First do no harm’ might be ‘Second, do some good.’ In obstetrics, this applies to the mother and also to the infant. It is difficult to justify high rates of obstetrical interventions (especially elective) in a low-risk population of pregnant women in the absence of demonstrable neonatal benefits, given that these interventions have finite maternal risks.”

Certainly, there is no question about the increased risks associated with a surgical rather than a vaginal delivery and the increasing risks for the mother with each subsequent cesarean delivery. Kudos to Dr. Glantz for asking the question, “Are increased rates of labor induction and primary cesarean section improving outcomes for babies?”