Are Women Having Too Many C-sections?
At 30 percent of all deliveries, the current national Caesarean-section rate in the United States is twice the 15 percent maximum rate recommended by the World Health Organization and three times the preferred rate cited by many researchers.
All of which Dr. Bruce Flamm, an obstetrician with Kaiser Permanente in Riverside, Calif., says is remarkable.
But he isn't sure if it's remarkably good or remarkably bad.
Flamm says that notwithstanding the WHO recommendation -- which followed the same official U.S. health recommendations in the Healthy People 2000 initiative -- there isn't enough data to say what the appropriate C-section rate should be.
"Some of my colleagues think it should be higher," Flamm says. "I have heard some doctors say that all women should have babies by C-section, that vaginal births are archaic. Some docs have a C-section rate of 50 percent because they believe in their hearts it's the best thing for their patients."
Flamm does not include himself in the group of doctors who think vaginal births are archaic, but he does agree with the October 2006 recommendation by the American College of Obstetricians and Gynecologists -- to which he belongs -- issued against out-of-hospital births.
Even though the chance of something going wrong is very small, Flamm thinks it's safer to have all necessary equipment and personnel immediately available in case of an unforeseen emergency, which can happen even in low-risk pregnancies.
The physician organization's recommendation -- combined with the rising rate of C-sections -- is a hot topic among midwives.
Nurse-Midwife Protest Letter
The American College of Nurse-Midwives sent a letter in late November 2006 to the physician's organization taking issue with the idea that safety could only be provided in a hospital.
"The safety of birth in any setting is of utmost priority," the letter read. "The implication that there is insufficient evidence to support the safety of planned out-of-hospital birth is unsubstantiated ... Furthermore, we are not aware of evidence supporting the assertion that the hospital is the safest setting for labor, birth and the immediate post-partum period for low-risk women."
The letter went on to say that by discouraging support for out-of-hospital birth providers the organization's position could harm the culture of safety around birth, for patients and providers. It appealed for collaboration to ensure women's safety.
Stacy Brooks, a spokeswoman for the physicians' organization, says the decision to recommend only hospital births was not based on data showing home births are dangerous, but just to minimize any possible complication.
The midwives' organization, on the other hand, lists multiple studies on its Web site supporting the safety of home births.
One large study, published in June 2005 by the British Medical Journal, concluded that the safety of "planned home birth for low-risk women" in North America involving certified midwives "was associated with lower rates of medical intervention but similar mortality to that of similar hospital births."
Many midwives also say that the growing preference for hospital settings automatically leads to unnecessary and often uncomfortable interventions. A prime example is the fetal monitor, which Flamm says he thinks is used on virtually all women who labor in hospitals.
Fetal Monitors Studied
Meredith Goff, a practicing midwife on the faculty of the Yale School of Nursing, is writing a paper about the reliability of fetal monitors versus the old-fashioned fetoscope.
The former is an electronic device, usually attached to the outside of a woman's belly and less often attached through the vagina to the baby's head. The latter is a hand-held instrument a medical provider moves over the women's belly to periodically check the baby's heartbeat.
"There is absolutely no evidence to support continuous fetal monitoring since it came about in the late 1960s," Goff says, "yet in 2002, it was used on 85 percent of women in labor in the U.S. It's the most commonly performed obstetrical procedure. And every professional organization agrees there is no evidence of its usefulness."
In fact, she says, the procedure has a very high false positive rate, meaning that in most cases when the monitor indicates fetal distress, the baby is fine. "So we're doing all these C-sections for no reason because we can't divorce ourselves from this technology," Goff adds.
One of the trends that many midwives find particularly troubling is the decline in vaginal births after Cesareans.
They point to a June 2006 study by researchers at the University of Utah of more than 30,000 women. Published in Obstetrics and Gynecology, the study found several serious complications, including hysterectomy and the need for a major blood transfusion, increased significantly with each C-section.
Dr. Robert Silver, chief of high-risk obstetrics at the University of Utah, is the primary author of the study. Only 9 percent of babies born to a woman who has had a C-section are delivered vaginally now, down from 30 percent a decade ago.
"Vaginal deliveries after a C-section are pretty safe, the risk is quite low," Silver says, "but I think people have gotten scared off."
Downsides to Both Options
Silver says there are downsides to both options. Vaginal deliveries can damage the pelvic floor, possibly leading to urinary and fecal incontinence and pro-lapse (in which the pelvic organs descend, causing discomfort). C-section births lead to more maternal morbidity, increased recovery time, less bonding and more difficulty with breastfeeding.
Paula Cate, a midwife who's delivered more than 4,000 babies in 28 years, says a factor in the rocketing rise of C-sections is the economic incentives of highly skilled medical specialists favoring a high-tech birth, like the rise in the participation of anesthesiologists in even routine births.
"There are now lots of places where there are anesthesiologists on the labor and delivery floor, but when I started in 1978 that wasn't true; you had to call them to come," says Cate.
Midwife Deborah Cibelli argues that C-sections are being driven by a fear of lawsuits. "It's a rare provider who gets sued for doing a C-section," she says, "but if there's any outcome that's less than perfect, you can get sued for not doing a C-section."
With the cost of malpractice insurance for both midwives and physicians skyrocketing, many providers find it more prudent to do C-sections if there's any hint -- however remote or even mistaken -- of complications.
Midwives say current popular culture does little to subdue the sense of danger and complication surrounding childbirth.
Cibelli, for instance, says "The Baby Story," a program on the Learning Channel that shows labor and birth experiences, recorded several of her patients delivering their babies in the hospital, but none of them was shown.
"The filmmakers told us that mine were just too normal. What really sells is drama. They love the rushing down the hallway to save the baby's life to do a C-section. Mine were quiet, with dimmed lights. The people filming thought they were wonderful, but they knew they were not going to sell because they were not sensational."