Sunday, September 28, 2008

Cesarean section by the numbers

One of the reasons I started this blog was to have a place to put some of the more academic musings I knew I'd be doing over the next two years. I am in the first semester of a masters in public health, focusing on maternal and child health. I knew that I'd be taking advantage of class assignments to learn more about areas I've been interested in since I became a doula four years ago but haven't had the resources or time to explore. Now that I'm a full-time student, with access to the full text of almost any journal you could name, I have the opportunity to tackle some of those areas.

I had to write a couple papers in the last week, and I wanted to share a couple things I learned from the research process from one of them. It was a somewhat open-ended assignment; we could choose a country, and a demographic, for which to pose the question "Is it healthier or safer to be a _______ [pregnant woman, infant, or child] in __________ [country of your choosing] than it was ___ [number of your choosing] years ago?" I chose to fill in my blanks with pregnant woman, the United States, and 25.

One interesting fact I discovered was that the U.S. maternal mortality rate has risen - in fact, doubled - in the past 25 years, and yet we can't actually tell if maternal mortality has changed. Because of a recent focus on better reporting maternal deaths (a hugely important undertaking), the rise in maternal deaths may be entirely due to improved reporting. I couldn't find any research out there untangling the numbers to try to determine what is actually happening out there - if any exists, I'd love to know about it!

Without reliable mortality data, I looked at cesarean rates, which have risen from 22.7% in the early 1980's to 31.1% in 2006. That figure - 31.1% - represents double the maximum cesarean rate recommended by the World Health Organization. If we take this to its logical conclusion, that means that half of all women who undergo a cesarean are having unnecessary surgery.

I also spent some time on the risks of cesarean section - often touted as just as safe as vaginal delivery (so why not schedule yours now!) - one study found deaths after cesarean to be more than triple those after vaginal delivery, in mothers who had similar risk factors. There is also significant risk of health problems associated with the surgery, and those increase with every subsequent cesarean.

All of this was the sad, stark "what", but I was really engaged in going through studies that ask "why?" Because of the way the question was set up, I wasn't exploring the "why" for its own merits, but rather to show that the increase in cesarean does indeed reflect a rise in unnecessary surgeries, and not a response to outside factors (unhealthier mothers, for example). And that turned out to be true; since 1996, cesareans have risen for women in all risk groups, of all ages. I found a lot of speculation on why; the one I think would strike birth activists as most plausible is that the "threshold of risk" has been lowered for c-section - doctors are now more willing to jump to a cesarean for a particular indication than they would in the past - and that it may be linked to malpractice concerns and/or a changing culture of practice. The other one, not called out in the research but by almost any birth activist you talk to, was increasing levels of obstetric "management" of labor. Maybe I can take my next opportunity to search out data around labor management and outcomes...I already know, from writing the other paper on obstructed labor in the developing world, that this is also a very complicated question from a sorting-out-all-the-data perspective.

It's interesting stuff! (To me anyway.) It kind of follows on my last post about misplaced anger over cesareans. Statistically, if you got a cesarean, there's a one in two chance that it wasn't necessary. But unless you go to an ICAN meeting, you won't meet many women who will tell you their cesarean was unnecessary. Maybe it's not so hard to hide the havoc we're wreaking if you create a huge cultural perception of birth as terrifying and dangerous? And then have a third of all mothers ready to tell their story about the c-section they had because their baby was in danger?

I got pretty good feedback on the paper (although I was dinged for my use of semi-colons - I love them, but maybe a little too much) and I'm looking forward to be able to explore more issues like this. If anyone is interested in citations, I'm happy to send them to you or post my list. God I love my full-text access.


Anonymous said...

I'd be interested to know how these numbers stack up in Canada and how socialized health care affects some of these issues. I know the current cesarean rate is 26-point-something percent and that this hsa gone up in the last 10 years. I read an interesting abstract somewhere on the internets - mid-90s, I think - that detailed how cesarean rates at an Ottawa hospital went down after the hospital changed its billing policy such that doctors were paid a flat rate rather than per procedure. Scary stuff.

publichealthdoula said...

I'd be curious too! I took an online advanced doula training earlier this year with a Canadian midwife named Gloria Lemay. She actually just started a blog ( and one of her posts mentions c-section. She conflates the rate as "North American" being around 30%, and when I took the course she didn't make much differentiation between systems.

...and looking up the numbers, it looks like the '06 rate for Canada was 26.3%. Better than the U.S. rate, although apparently also climbing. I can definitely see the billing changing c-section rates. If nothing else, when you believe two things are equally risky (...even if they aren't) you'll go for the more lucrative of the two (even unconsciously). It is scary, and all the scarier that even the most low-risk people end up getting put through this system that is designed to thwart normal birth and ends up pushing up everyone's c-section rates.