Reproduction - The Labors Of Love

Babies are born in two ways. They are either brought into the world through the labor of mother and child in a "normal" vaginal delivery or they are removed from the mother's uterus in a surgical procedure called a cesarean delivery or cesarean section (C-section). The cesarean section has existed in some form since ancient times. Until the early 20th century it was used almost exclusively when the mother was already dead or dying and it was necessary to cut the baby out in order to try and salvage at least one life.

Even today, a cesarean section is a major abdominal surgery but, happily, it is one that saves the lives of many women and children during high risk and complicated deliveries. Nonetheless, according to the World Health Organization no country or region is justified in having cesarean delivery rates greater than 10% to 15%. Why then are the rates in the United States so much higher (24.4% in 2001) and why have they risen sharply in the last years of the 20th century?

The graph presents rates of cesarean deliveries, both total and primary (those to women with no previous C-section) and the rate of vaginal delivery for women with one or more previous cesarean deliveries. The percentage change from 1996 to 2001 for each of these rates is also provided. The percentage change is measured from the year 1996 because that is the year in which the lowest rates were registered for the period presented. The patterns are clear.

The rate of cesarean delivery in 1970 was approximately 5%⁷. By 1988 the rate had shot up to 24.7%. For several years thereafter it fell slightly. Then, in 1997 it began again to rise and in 2001 had almost climbed back to the 1988 peak reaching 24.4%.

There is great uncertainly as to why we deliver so many babies by C-section. Some claim that new mothers are unwilling to endure the pain and inconvenience of having a baby the "old-fashioned' way. Are some mothers today "too posh to push" as is suggested in an article by that title in U.S. News and World Report ? Although some few cesarean deliveries probably result from this attitude, this alone can hardly explain a rise in cesarean deliveries of 400% in 30 years, or even 18% in the last 5 years presented on the graph.

C-sections have become much safer during the last 40 years but they are still serious abdominal surgery and are not undertaken lightly. The primary medical reasons given for performing a cesarean section are:

1. Dystocia or non-progressive labor. This is experienced more often when painkillers are used during labor (including epidurals), an increasingly common and popular practice. As one expectant mother put it, "Would you use breathing techniques for a root canal?"⁸
2. Breech presentation — the baby is not positioned headfirst.
3. Fetal distress.
4. Mother underwent a previous cesarean delivery.

There are many reasons for the changing rates of cesarean deliveries. It is a combination of two in particular that goes furthest in explaining the sharp increases: fear of litigation and technology.

A technology used to monitor a fetus during delivery — electronic fetal monitoring (EFM) — was introduced in the 1960s and began to be used widely in the 1970s. This technology allows obstetricians and gynecologists to monitor very closely both the mother and baby during labor and delivery.

Interestingly, when EFM is used regularly it results in much higher rates of cesarean section than are found in practices that do not regularly use EFM. The explanation for this has to do with the fact that EFM monitoring picks up on small abnormalities in fetal condition but can not accurately link these with any sort of negative outcome. This may cause a cautious physician to decide on a C-section more quickly than he or she would otherwise.

Here is where the fear of litigation comes into the equation. The number of malpractice lawsuits filed in the United States has risen over the last decades, and during the 1990s malpractice jury awards have sky rocked. Obstetrics is a specialty that has been particularly hard hit by malpractice suits and sharply rising insurance premiums.

Physicians, concerned about the risk of lawsuits tend to practice "defensive medicine.⁹" A practitioner viewing a mildly abnormal pattern on a monitor or seeing a mother's labor slow might choose to "give it a little time." However, a physician operating under considerable fear of a malpractice lawsuit will be less willing to give it a little time and will likely practice "defensive medicine," in this case, proceed quickly to a cesarean delivery.

As Doctors A. Shinha and S. Arulkumaran state in their 1999 presentation before the First World Congress On: Controversies in Obstetrics, Gynecology & Infertility:

"The litigious climate that has enveloped medicine in general and Obstetrics in particular has probably resulted in the universal use of EFM which perhaps increases the diagnosis of 'fetal distress' and hence cesarean section as the mode of delivery."

Will the trend towards more cesarean deliveries continue to increase? In 1990 the U.S. Department of Health and Human Services published a report entitled Healthy People 2000 in which targets were set for a number of health care indicators. The target set for C-sections was a national rate of between 10% and 15% by the year 2000. Clearly, we did not meet that goal. The national rate of cesarean sections in 2000 was 22.9%.

The Healthy People 2010 report has revised upwards the target rates for cesarean sections. This reflects changed thinking within the medical community on the desirability of continuing to press for reductions in cesarean delivery for women who have undergone the procedure before.

As the debate continues, studies will be made, recommendations will change as our understanding of "best practices" change, and doctors and midwives will continue to assist mothers as they give birth to new generations.

Source: U.S. Department of Health and Human Services, Centers for Disease Control, National Vital Statistics Report, "Births: Final Data for 2000," page 72 and "Births: Preliminary Data for 2001," page 3. The cesarean delivery rate estimate for 1970 is from the National Institute of Health, Cesarean Section — A Brief History, available online at http://www.nlm.nih.gov/exhibition/cesarean/cesarean_1.html. The New England Journal of Medicine article mentioned in the graphic was summarized in and article by Rhonda Rowland, "C-section or Labor," CNN Interactive, September 5, 1996, available online at http://cgi.cnn.com/HEALTH/9609/05/caesarean/. Susan Brink, "To Posh To Push," U.S. News & World Report, August 5, 2002, page 42-44. Jeffrey Zurlinden, RN, MS, ACRN, High-Tech Birthing is Back, Nursing Spectrum, August 26, 2002, available online at http://www.nursingspectrum.com/. A. Sinha and S. Arulkumaran, Does Electronic Fetal Monitoring Increase CS Rates, a paper presented at the First World Congress On: Controversies in Obstetrics, Gynecology & Infertility, Prague, Czech Republic, 1999. Centers for Disease Control, Healthy People 2000 and 2010, available online at http://www.cdc.gov/nchs/hphome.htm.