Caesarean births on the rise

Caesarean births on the rise
PHILADELPHIA — For a peek into the future of childbirth, look to Puerto Rico.

Nearly half of all babies born in the U.S. protectorate are delivered by cutting open their mothers' abdomens.

On the mainland, the Caesarean section rate is not as high, but it has been climbing for a decade. In 2005, almost a third of the nation's 4.1 million births were surgical.

No one can explain why the United States keeps shattering its own Caesarean records. Many experts say there is no "ideal" Caesarean rate, but there is also no evidence that a vast, growing segment of the female population wants or needs major abdominal surgery to give birth. While a dramatic decline in maternal deaths coincided with higher rates of Caesarean, that trend ended 20 years ago. Today, ill effects such as life-threatening placental problems are being linked to C-sections.

Yet natural delivery is not enjoying a rebirth.

Groups that have demonstrated the will and the way to reduce Caesareans — midwives, birthing coaches, lactation consultants, and other fans of natural birth — are far less influential than in the 1980s, when they led a modestly successful fight against rising Caesarean rates.

"This is mostly about changes in culture," said Eugene Declercq, an expert in maternal and child health at Boston University's School of Public Health. "In all the gray areas of clinical decision-making, obstetricians have moved to Caesareans. Mothers are more accepting, too."

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Caesarean critics worry that doctors are frightening mothers into the surgery.

"A woman who is given reason to be scared that something bad might happen to her unborn child will do anything to avoid it," said Jose Gorrin Peralta, a University of Puerto Rico obstetrician. "If the doctor says, 'Your baby could die unless I do a Caesarean,' what woman is going to say, 'Don't do it'? I call it obstetrical terrorism."

Through the 1940s, Caesarean delivery was a rare, last resort to save the baby, often at the cost of the mother's life. One in 16 women died.

With the advent of modern anesthesia, antibiotics, transfusions and surgical techniques, the procedure became truly lifesaving.

The doctor could perform a rescue within minutes if the mother's blood pressure or blood sugar soared. If she hemorrhaged. If the placenta separated from her womb or blocked her birth canal. If the baby began suffocating because a shoulder got stuck after the head emerged.

Gradually, though, Caesareans became more about caution and convenience than life and death. Most are done because labor has gone too long or at the first hint of trouble, such as a "nonreassuring" fetal heart rate on a monitor.

Two years ago, a few prominent U.S. obstetricians argued for a radical change. They contended that pushing a baby through the birth canal was inherently riskier for the mother's pelvic anatomy and the child's health than a Caesarean. Surgery, they said, should be a woman's choice, even for her first pregnancy, even if she didn't need it.

This went far beyond the consensus that after a Caesarean, a woman could choose surgery for subsequent pregnancies.

The American College of Obstetricians and Gynecologists decided to weigh in on the ethics of this controversial notion of "maternal choice" Caesarean.

It concluded that data on the risks and benefits were lacking. Therefore, the group said, performing one is ethical if the physician "believes" it promotes the patient's health — and unethical if the physician "believes" it doesn't.

Before long, the media were reporting that growing numbers of women were demanding that they go under the scalpel for their first births because, well, they preferred to.

But efforts to quantify this demand have found it doesn't really exist.

Healthgrades, a health-care ratings firm, used hospital discharge data to estimate that maternal-request Caesareans rose from 1.6 percent of all Caesareans in 1999 to just 2.6 percent in 2003.

Seattle public-health researchers pored over even more years of national hospital data, combing information on 459,000 women who gave birth, then narrowing the numbers down to those who had first Caesareans without any medical reason or any labor. Between 1991 and 2004, they found only 309 such women.

Childbirth Connections, a maternity-care advocacy organization, sponsored a national survey of 1,500 women who gave birth in 2005.

"Only one woman met the criteria for maternal-request Caesarean," said Boston University's Declercq, the lead author of the survey analysis. "We figured we'd have maybe 20 women."

Study after study has found that obese women are more likely than thin ones to develop serious complications in pregnancy. They are also more likely to have babies born with debilitating spinal-cord defects, prematurely, or "macrosomic" — 10 pounds or more.

These factors give an obese woman up to a 50-50 chance of Caesarean, which, because of her weight, will not be easy.

"I have huge anxiety for these women," said Laura Riley, a high-risk obstetrician-gynecologist at Massachusetts General Hospital in Boston. "On one hand, I applaud them for wanting a vaginal birth. But I'm fearful because not only do you labor a long time, it's a big baby, it's hard to establish how big the baby is, then you end up with a failed vaginal delivery. And then the C-section is harder, there's greater blood loss, greater danger of infection in the incision. In addition, there's greater risk for a DVT (deep-vein blood clot) or pulmonary embolism than with someone who's thinner and up and out of bed faster."

Prodded by Riley, the American College of Obstetricians and Gynecologists two years ago issued guidelines that say obstetricians should warn patients about these risks and encourage weight loss "before attempting pregnancy."

"We need to fess up that this is a medical problem," Riley said. "It's not about passing judgment on women who don't look like they belong on the cover of Cosmo."

Yet for plus-size women, that's too often exactly what it seems like.

Maria Barroso, 23, of Queens, N.Y., is 5-foot-5 and 325 pounds. When she got pregnant in 2004, she and her husband were thrilled.

Her doctors were nervous. They warned her, she said, that she was likely to develop gestational diabetes. And even though estimates of fetal weight are notoriously inaccurate and don't justify a Caesarean, "they kept telling me I was going to have a big baby, and that many plus-size women can't have a baby naturally."

She wound up with a Caesarean she thinks could have been avoided.

In 2005, newly trained as a birthing coach and under a different doctor's care, Barroso gave birth to her second child vaginally. She labored for 26 hours.

"I stuck it out 'cause I didn't want the recovery I had had the year before," she said. "I knew that unless my life or my son's life was in danger, I was going to give birth vaginally."

Barroso's experience raises the question: Are changing demographics fueling first-time C-section rates?

Declercq and his Boston University colleagues used birth-certificate data to examine two periods: 1991 to 1995, when first-time Caesareans decreased slightly, and 1996 to 2002, when they shot up like uncorked champagne. The researchers looked at maternal, fetal and labor-delivery factors — incompetent cervixes, dysfunctional placentas, diabetes, genital herpes, breech position, macrosomic size, and much more.

The fall and rise of first-time Caesareans "were not related to shifts in maternal risk profiles," they concluded.

A similar analysis in Puerto Rico also found no link between risks and rates.

In Chinese tradition, July is the "ghost month," when spirits come out from the lower world to visit earth.

Because many Chinese believe July is an inauspicious time for any type of surgery, researchers at Taipei Medical University looked at Caesarean rates.

Sure enough, in a study published last year, they found Caesareans were unusually low in July — and unusually high in June.

While the United States doesn't have a ghost month, the specter of lawsuits heavily influences the use of Caesarean.