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C-sections: Do we need so many performed or not?
- Jan 19, 2009 at 2:23 AM
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- Comments (6) Total Views (137) Everyone can see this journal post.
Poll
Question: Did you feel pressured by your healthcare professional to do a c-section? This includes being told things to purposely scare you into agreement with the doctor.
Total Votes: 9
http://www.childbirthconnection.org/article.asp?ck=10456
Recent studies reaffirm earlier World Health Organization recommendations about optimal cesarean section rates. The best outcomes for mothers and babies appear to occur with cesarean section rates of 5% to 10%. Rates above 15% seem to do more harm than good (Althabe and Belizan 2006).
The national U.S. cesarean section rate was 4.5% and near this optimal range in 1965 when it was first measured (Taffel et al. 1987). In more recent years, large groups of healthy, low-risk American women who have received care that enhanced their bodies' innate capacity for giving birth have achieved 4% cesarean section rates and good overall birth outcomes (Johnson and Daviss 2005, Rooks et al. 1989). However, the national cesarean section rate is much higher and has been increasing steadily over the past decade. When a national rate is available for 2007, we will find that about one mother in three is now giving birth by c-section, a record level for the United States.
Most mothers are healthy and have good reason to anticipate uncomplicated childbirth. Cesarean section is major surgery and increases the likelihood of many short- and longer-term adverse effects for mothers and babies (some of these harms are listed below). There are clear, authoritative recommendations for more judicious use of this procedure (U.S. Department of Health and Human Services 2000). So why does a pregnant woman's chance of having a cesarean section keep going up?
Two Myths about the Rising Cesarean Section Rate
To explain this steady rise, health professionals and journalists often point the spotlight on mothers themselves. Many assume that leading factors in the trend are: 1) more and more women are asking for c-sections that have no medical rationale, and 2) the number of women who genuinely need a cesarean is increasing. Neither appears to account for a large portion of the increase.
Despite a lot of talk about "maternal request" cesareans, few women appear to be taking this step. Childbirth Connection's national Listening to Mothers survey of women who gave birth in hospitals in 2005 was the first study to poll women about these decisions in the United States. When we asked mothers who had had a cesarean why they had it and who had initiated it, just one woman among nearly 1600 survey participants reported that she had had a planned first c-section with no medical reason at her own request (Declercq et al. 2006a). Those who have looked at this question in other countries have found similar results (McCourt et al. 2007).
Many have also pointed to changes in the population of childbearing women, such as more older women who have developed medical conditions and more women with extra challenges of multiple births. While there are some overall changes in this population, researchers have found that cesarean section rates are going up for all groups of birthing women, regardless of age, the number of babies they are having, the extent of health problems, their race/ethnicity, or other breakdowns (Declercq et al. 2006b). In other words, there is a change in practice standards that reflects an increasing willingness on the part of professionals to follow the cesarean path under all conditions. In fact, one quarter of the Listening to Mothers survey participants who had cesareans reported that they had experienced pressure from a health professional to have a cesarean (Declercq et al. 2006a).
Reasons for the Rising Cesarean Section Rate
The following interconnected factors appear to be pushing the cesarean rate upward.
Low priority of enhancing women's own abilities to give birth
Care that supports physiologic labor, such as providing continuous support during labor through a doula or other companion and using hands-to-belly movements to turn a breech (buttocks- or feet-first) baby to a head-first position, reduces the likelihood of a cesarean section. The decision to switch to cesarean is often made when caregivers could use watchful waiting, positioning and movement, comfort measures, oral nourishment and other approaches to facilitating labor progress. The cesarean section rate could be greatly lowered through such care.
Side effects of common labor interventions
Current research suggests that some labor interventions make a c-section more likely. For example, labor induction among first-time mothers when the cervix is not soft and ready to open appears to increase the likelihood of cesarean birth. Continuous electronic fetal monitoring has been associated with greater likelihood of a cesarean. Having an epidural early in labor or without a high-dose boost of synthetic oxytocin ("Pitocin") seems to increase the likelihood of a c-section.
Refusal to offer the informed choice of vaginal birth
Many health professionals and/or hospitals are unwilling to offer the informed choice of vaginal birth to women in certain circumstances. The Listening to Mothers survey found that many women with a previous cesarean would have liked the option of a vaginal birth after cesarean (VBAC) but did not have it because health professionals and/or hospitals were unwilling (Declercq et al. 2006a). Nine out of ten women with a previous cesarean section are having repeat cesareans in the current environment. Similarly, few women with a fetus in a breech position have the option to plan a vaginal birth.
Casual attitudes about surgery and cesarean sections in particular
Our society is more tolerant than ever of surgical procedures, even when not medically needed. This is reflected in the comfort level that many health professionals, insurance plans, hospital administrators and women themselves have with cesarean trends.
Limited awareness of harms that are more likely with cesarean section
Cesarean section is a major surgical procedure that increases the likelihood of many types of harm for mothers and babies in comparison with vaginal birth. Short-term harms for mothers include increased risk of infection, surgical injury, blood clots, emergency hysterectomy, intense and longer-lasting pain, going back into the hospital and poor overall functioning. Babies born by cesarean section are more likely to have surgical cuts, breathing problems, difficulty getting breastfeeding going, and asthma in childhood and beyond. Perhaps due to the common surgical side effect of "adhesion" formation, cesarean mothers are more likely to have ongoing pelvic pain, to experience bowel blockage, to be injured during future surgery, and to have future infertility. Of special concern after cesarean are various serious conditions for mothers and babies that are more likely in future pregnancies, including ectopic pregnancy, placenta previa, placenta accreta, placental abruption, and uterine rupture (Childbirth Connection 2006).
Providers' fears of malpractice claims and lawsuits
Given the way that our legal, liability insurance, and health insurance systems work, caregivers may feel that performing a cesarean reduces their risk of being sued or losing a lawsuit, even when vaginal birth is optimal care.
Incentives to practice in a manner that is efficient for providers
Many health professionals are feeling squeezed by tightened payments for services and increasing practice expenses. The flat "global fee" method of paying for childbirth does not provide any extra pay for providers who patiently support a longer vaginal birth. Some payment schedules pay more for cesarean than vaginal birth. A planned cesarean section is an especially efficient way for professionals to organize hospital work, office work and personal life. Average hospital charges are much greater for cesarean than vaginal birth, and may offer hospitals greater scope for profit.
All of these factors contribute to a current national cesarean section rate of over 30%, despite evidence that a rate of 5% to 10% would be optimal.
So ladies, do you feel you really needed a c-section?Did your doctor pressure you to do it and how so? Did your doctor go over the risks of surgery with you before you agreed and signed your form? Did your c-section have any adverse outcomes healthwise? Did it interfere with the initiation and continuation of breastfeeding for you?
I will answer these question first. I don't think my c-section was necessary at all. Had I been more educated about all the risks of each of my interventions I would not have agreed to them in the first place and would not have had a c-section. The doctor did pressure me, he basically yelled at me and said something would go wrong with my girls and it would have a bad outcome. My girls were doing very well, they were having no trouble dealing with labor inside me. He argued with me for about five minutes until I basically felt like I was a horrible person if I didn't agree to do what he wanted. The doctor never went over the risks that could go along with the c-section with me, the only thing he said was there's a very minimal chance of death but it's very rare and not really a concern for you. One of my twins ended up in the special care nursery for three weeks, but I honestly can't say if it was related to the c-section or not. She had low blood sugar(from my gd), jaundice(normal for babies, esp. breastfed babies), and trouble with her suck, swallow, breath reflex. I think it was more attributed to the fact they were born at 37 weeks. Although my older twin is exhibiting some signs of asthma, which has been associated with cesarean section. I am in pain often in the area of my incision. I have worse menstrual cramping and heavier flow. I have trouble with going to the bathroom much more often. It did interfere with the initiation of breastfeeding, in that I didn't get to breastfeed in the first hour. I breastfed my older twin after about 1 and a half, and baby b after about 6 hours. It did not interfere with the continuation of breastfeeding at all. I was determined to breastfeed them, as I did my son, come hell or high water. It actually turned out to be easier to nurse them than it was to nurse my son(I have oald, and breastfeeding twins is essentially constant block feeding so it worked out well for us!).
Comments:
I educated myself and really am against csections but in my particular case if I hadnt have had one or been induced for that matter I would have had a stillborn... I listened to my body and I knew knew knew something way wrong and insisted I be induced I wasnt surprised when I ended with a c but I fought it all the way! my doc said it was my choice but bc my water was broken I needed to keep that in mind and that he would wait as long as I wanted he didnt try to scare me he gave me the facts of the situation and let me decide for myself
i had a c-section for a few reasons: i have had chronic back pain and on meds since '02, i had a failed spine surgery (have to have another) so the pain is worse, and because the hardware they put in my spine has been recalled-the cables supporting the spine were snapping under pressure causing life-threatening emergencies. they were very worried that the cables would snap during labor, so they (neurosurgeons) recommended a c-section. i am having another surgery to replace the cables and a disk, so for future births (if any) i will do a VBAC, and i would really love to do a water birth.
the docs went over everything with me several times (because it was planned) before i signed the consent. i still have tenderness/numbness in the c-section area. i also think i have some bladder issues now, but don't know if that is from the c-section or just pregnancy. i was adamant that i was going to breastfeed, i was very clear NO FORMULA, NO PACI's. i didn't get my daughter back within the first hour, i kept asking and asking. they said there was an emergency and i couldn't have her until the doc saw her, and the doc was busy with the emergency. as soon as i got her we tried breastfeeding, she didn't get a good latch until about 4 a.m. saturday, we started around 11 a.m. friday. but we have been going strong since then! yay breastfeeding mommies!
no i wasnt pressured i had to or my baby would of died her heart rate was going down and she was stuck my pelvis is too small to push out a baby
I felt no pressure...fear but not pressure. My cervix is tilted back further than normal, my son was face up and stuck in a "pocket" on my right side. I was already a high risk patient and had experienced 2 miscarriages. I was told the C-section would offer the best chance for both of us but that if I wanted we could attempt natural childbirth. I trust my doctor completely! He'd already stopped my body from leaking abiotic fluid by finding a condition that NO OTHER doctor had tested for (see my post MTHFR) and had stopped a third miscarriage from occurring. I do not doubt that this was the best route for me and my son and I bless this great doctor everyday for all he did for our family!
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Yes I felt somewhat pressured by fear, but no because my son would have died had the cesarean not been done. So I'm torn. But I think c-sections are an over used answer to some complications (not all). Great post.
- OmsYankeeMama
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