Advice for Pregnant Women about
Cesarean Section Facts
These facts are presented by the ICEA Cesarean Options committee with the hope that parents, childbirth educators, nurses, midwives and doctors together can effectively reduce the rate of unnecessary cesarean sections and consequently, their effects.
A cesarean section is major abdominal surgery. When a cesarean is necessary, it can be a life saving technique for both mother and infant.
The World Health Organization (WHO) states that no region in the world is justified in having a cesarean rate greater than 10 to 15 percent.
In the past twenty years, the cesarean section rates have nearly quintupled in the US to 23.8% in 1989 and nearly quadrupled in Canada to 18.3% in 1987-8.
A cesarean section poses documented medical risks to the mother's health, including infections, hemorrhage, transfusion, injury to other organs, anesthesia complications, psychological complications, and a maternal mortality two to four times greater than that for a vaginal birth.
An elective cesarean section increases the risk to the infant of premature birth and respiratory distress syndrome, both of which are associated with multiple complications, intensive care and burdensome financial costs. Even mature babies, the absences of labor increases the risk of breathing problems and other complications.
Cesareans can delay the opportunity for early mother-newborn interaction, breastfeeding and the establishment of family bonds.
In the US and Canada, over one-third of all cesareans are repeat cesareans. The American College of Obstetricians and Gynecologists (ACOG) recommends that the concept of routine repeat cesarean be replaced by a specific indication for surgery, and that most women can be counseled and encouraged to labor and have a vaginal birth after a cesarean (VBAC).
In 1989, 81.5% of all US women with a previous cesarean had a repeat cesarean. The VBAC rate was 18.5%. The VBAC rate is greater in every eastern and western European country.
The "once a cesarean, always a cesarean rule is outdated now that most of uterine incisions are low and horizontal and the risk of rupture of the old scar is almost nonexistent. A review of all VBAC literature from 1985-1990 found a rupture rate of 0.22% for low transverse scars in 22,000 planned labors after cesarean. (In developed nations the rupture rate was 0.18%.) By comparison, the incidence of other childbirth emergencies, such as prolapsed cord, placental separation, or sudden fetal distress is 1-3%.
ACOG states that the hospital requirements for VBAC are the same standards for all obstetrics. These include the capacity to respond to acute obstetric emergencies by performing a cesarean within 30 minutes. However, many hospitals in North America that offer maternity care do not allow or encourage women to labor and have a VBAC.
In a review of all the medical reports published on VBAC from 1926-1990, 75% of all women who planned labor after a cesarean gave birth vaginally. Several medical studies record VBAC rates of over 90%.
The latest statistics indicate that 967,000 cesareans were performed in the US in 1989. The Public Health Citizen's Research Group estimates that over one-half the cesareans performed in 1987 were unnecessary and resulted in 25,00 serious infections, 1.1 million extra hospital days and a cost of over $1 billion. About 500 women a year die from bleeding, infections and other complications of cesarean sections, although these may be related to the reasons the operation was performed and not just to the procedure itself.
A cesarean costs nearly twice as much as a vaginal birth ($7,186 average vs. $4,334 average in 1989 in the US). It has been estimated that in Quebec, Canada, if the current rate of cesareans (18.8%) were reduced to that of Finland (11.9%), costs incurred by the provincial health care system could be reduced approximately $19 million per year.
The four most common medical causes contributing to the increase in cesarean section rates in North America are: routine repeat cesareans; dystocia (non-progressive labor); breech presentation; and fetal distress. Some reports suggest that more careful diagnosis and management of dystocia could halve the primary section rate. Combined with fewer cesareans for breech presentation (along with more cephalic versions), careful diagnosis of fetal distress and active encouragement of VBAC, these efforts have resulted in lowering cesarean rates to less than 12% in various parts of the world.
Up to 77% of women for whom the indication for cesarean delivery was a non-progressive labor (sometimes diagnosed as cephalopelvic disproportion or CPD) and who tried labor again, had a VBAC for a subsequent birth. Approximately one-third of these women gave birth to babies that were larger than their previous "CPD" baby.
ACOG states that a woman with two or more previous cesareans deliveries with low transverse incisions who wishes to plan a VBAC should not be discouraged from doing so in the absence of contraindications.
Cesarean rates are influenced by non-medical factors. Rates are higher for women who have private medical insurance, are private rather than public clinic patients, are older, are married, have higher levels of education and are in a higher socio-economic bracket.
In 1989, a medical study done in Houston, Texas, concluded that epidural analgesia is associated with significant increases in the incidence of cesarean section for dystocia in women having their first labor.
Cesarean sections are sometimes performed for other than maternal or fetal well-being, such as avoidance of patient pain, patient or provider convenience, provider legal concerns or provider financial incentives.
Although rare, there have been reports of court-ordered cesareans performed on women against their will. One such case was appealed, supported by 118 US organizations, claiming that the decision was unconstitutional and raises complex legal, moral and religious issues. The appeal judge issued a forceful decision asserting that "in virtually all cases the question of what is to be done is to be decided by the patient -the pregnant woman- on behalf of herself and her fetus."
In March 1990, an ACOG survey of 2,213 obstetricians documented the changing attitude about VBAC in the US. The survey reported that women under the care of younger physicians and physicians in practice for fewer years were more likely to accept the option of VBAC than women under the care of older physicians and those in practice the longest.
Of 11,814 women admitted for labor and delivery and attended by midwives to 84 free standing birth centers in the US, 15.8% were transferred to the hospital and 4.4% had a cesarean section. Although the women were lower than average risk of a poor pregnancy outcome, their cesarean rate is one-fifth of the national average.
According to the
What is a reasonable
cesarean section rate? Only
10 to 15%!
Copyright © Citizens for Midwifery 2002. Permission to reprint with attribution.
QUADRUPLES THE RISK OF MATERNAL DEATH
FOR IMMEDIATE RELEASE
October 1, 2003
Contact: Rae Davies, Executive Director
Phone: (888) 282-CIMS Fax: (904) 285-2120
The Coalition for Improving Maternity Services views with alarm a recent study showing that U.S. women having cesarean sections are four times more likely to die compared with women having vaginal births.1 Investigators reported a maternal death rate of 36 per 100,000 cesarean operations versus 9 per 100,000 vaginal births. This is the difference attributable to the surgery itself, not any complications that might have led to the need for surgery. Based on calculations of what constitutes a reasonable cesarean rate versus the actual U.S. cesarean rate,* 135 women die every year as a result of having surgery they did not need.
Moreover, the difference in mortality rates between cesarean section and vaginal birth is almost certainly larger than it appears. Investigators only considered deaths occurring up to 1 year after delivery. Some surgically-related deaths—scar tissue causing a twisted bowel, for example—may occur after the 1-year cut-off.
In a press release entitled “Weighing the Pros and Cons of Cesarean Delivery,” the American College of Obstetricians and Gynecologists offered the theory that cesarean section benefits mothers by protecting against pelvic floor prolapse as a counterbalance to the fact that it was associated with an increased maternal death rate.2 The research, however, does not support this theory. While some studies do report a short-term benefit with cesarean section for a few women,3 none find long-term differences in symptoms resulting from pelvic floor weakness or injury to maternal tissues.3-7 Other studies report considerable percentages of women with urinary or bowel problems in the early weeks and months after cesarean surgery.8-9
The finding that cesarean section offers no long-term advantages holds true even without taking into account that many features of standard obstetric management cause or contribute to weakness or damage, and the use of these features could be greatly reduced or eliminated. These include episiotomy, fundal pressure (pushing down on the woman’s belly to expel the baby), vacuum extraction, forceps delivery, and how and in what positions women are directed to push.10 Indeed, the ACOG press release acknowledges that vaginal instrumental delivery produces the worst results. Epidural analgesia also contributes indirectly by increasing the need for vaginal instrumental delivery and episiotomy.11-12 Had women birthing vaginally received optimal care, the incidence of pelvic floor laxity and genital injury would likely have been much smaller.
CIMS contends that reducing the use of injurious practices would do far more to improve maternal health and well-being than substituting major abdominal surgery. Increased risk of maternal death is but one of the many hazards of cesarean section. (See CIMS fact sheet, The Risks of Cesarean Delivery to Mother and Baby.)
*The 2002 cesarean rate was 26%. This means that about one million of the 4 million U.S. women giving birth every year have cesarean sections.13 The World Health Organization recommends no more than a 10% to 15% cesarean rate.14 If the U.S. cesarean rate were halved, 500,000 fewer women annually would have had cesarean sections. The death rate among them would have been 9 per 100,000 (45 women) rather than 36 per 100,000 (180 women) – a difference of 135 lives.
1. Harper MA et al. Pregnancy-related death and health care services. Obstet Gynecol 2003;102(2):273-8.
2. ACOG. Weighing the pros and cons of cesarean delivery. ACOG News Release, Jul 31, 2003. Access at: http://www.acog.org/from_home/publications/press_releases/nr07-31-03.cfm
3. Rortviet G et al. Urinary incontinence after vaginal delivery or cesarean section. N Engl J Med 2003;348:900-7.
4. Gordon H and Logue M. Perineal muscle function after childbirth. Lancet 1985;2:123-5.
5. MacLennan AH et al. The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. Br J Obstet Gynaecol 2000;107:1460-70.
6. Nygaard IE, Rao SSC, and Dawson JD. Anal incontinence after anal sphincter disruption: a 30-year retrospective cohort study. Obstet Gynecol 1997;89(6):896-901.
7. Viktrup L et al. The symptom of stress incontinence caused by pregnancy or delivery in primiparas. Obstet Gynecol 1992;79(6):945-9.
8. Declercq ER et al. Listening to Mothers: Report of the First National U.S. Survey of Women’s Childbearing Experiences. New York: Maternity Center Association, Oct 2002.
9. Lydon-Rochelle MT, Holt VL, and Martin DP. Delivery method and self-reported postpartum general health status among primiparous women. Paediatr Perinat Epidem 2001;15:232-40.
10. Goer H. Preserving pelvic floor, genital, and anal sphincter integrity in childbirth: elective cesarean is not the solution. Medscape Ob/Gyn & Women’s Health 2003, in press.
11. Carroll TG et al. Epidural analgesia and severe perineal laceration in a community-based obstetric practice. J Am Board Fam Pract 2003;16(1):1-6.
12. Robinson JN et al. Epidural analgesia and third- or fourth-degree lacerations in nulliparas. Obstet Gynecol 1999 B;94(2):259-62.
13. Hamilton BE, Martin JA, and Sutton PD. Births: preliminary data for 2002. Nat Vital Stat Rep 2003;51(11).
14. World Health Organization. Appropriate technology for birth. Lancet 1985;2(8452):436-437.
P.O. Box 2346¦ Ponte Vedra Beach, FL 32004¦888-282-CIMS¦Fax 904-285-2120¦www.motherfriendly.org
Stillbirth after Cesarean:
Since the famous Gordon Smith article in the Lancet in 2003* that analyzed 120,000 singleton second births, it is well-known that a previous cesarean section causes an unexplained stillbirth - in the next pregnancy in 1 in 1000 pregnancies. Women are not informed of this fact when they sign the consent for cesarean section.
Since there are 1 million cesareans per year in America, all of them lacking proper informed consent, I am looking for women who are willing to join a class-action suit for damages that resulted from lack of informed consent.
Conservatively, 120,000 women have another pregnancy after the cesarean, which results in 120 unexplained stillbirths (not the result of birth defects, diabetes, high blood pressure, etc.) in America per year. Even 10 or 20 angry women with unexplained stillbirths following a cesarean will compose an impressive class-action suit.
I am hoping to interest women who have experienced stillbirth after cesarean in joining a class-action suit that will change the current trend of increasing cesareans (27.6% in 2003) or at least improve informed consent.
— Judy Slome Cohain Certified Nurse Midwife email@example.com
*Cesarean section and the risk of unexplained stillbirth in subsequent pregnancy. Lancet 2003; 362: 1779–84.
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