25-Year Rise in Cesarean Births Levels Off : Medicine: The number of women returning to normal deliveries after having the procedure also jumps dramatically.
The rapid escalation in the rate of Cesarean section deliveries in the United States over the last 25 years appears to have come to a halt, while the number of women returning to vaginal births after an earlier Cesarean has jumped dramatically.
The shifts, seen by many experts as encouraging, have come after years of effort by some consumer activists and medical policy-makers to stop the proliferation of a form of surgery that many view as expensive, sometimes risky and often unnecessary.
“We have a way to go,” Mort Lebow, a spokesman for the American College of Obstetricians and Gynecologists, said of the Cesarean section rate, at 23.8% in the latest statistics. “But at least it’s moving in the right direction.”
Others, too, were restrained in their reaction.
“I think we have to remember that 20 years ago, doctors would have been flabbergasted by a 25% rate,” said Dr. Bruce Flamm, research chairman of Kaiser-Permanente Riverside and an expert in the field.
“So on the one hand, it’s a welcome trend that it seems to be leveling off,” he said. “But I don’t think it’s no longer an issue if one in four American babies are being delivered by Cesarean section.”
In a report to be published Friday, the U.S. National Center for Health Statistics found no significant change in the Cesarean section rate between 1986 and 1989. After a five-fold rise since 1965, the rate leveled off at about 24 Cesarean sections per 100 births.
The agency also found that the rate of vaginal birth after Cesarean section rose from 8.5% of women with a previous Cesarean in 1986 to 18.5% in 1989--indicating, the agency said, a shift among obstetricians and patients away from Cesarean sections.
“After years of waiting, people are now becoming aware of the possibility of vaginal birth after Cesarean,” said Mary Moien, assistant to the director of the agency. “(The authors of the study) really see it taking off now.”
The U.S. Cesarean section rate is said to be the highest in the Western industrialized world, having risen from 4.5 per 100 births in 1965 to 24.7 in 1988. The rapid rise has been traced to defensive medicine--fear of malpractice suits resulting from difficult deliveries.
Cesarean sections are considered appropriate in high-risk cases, such as for delivering twins or a particularly large infant, or for a mother with diabetes. But critics say the procedure is often used unnecessarily, sometimes for the patient’s or physician’s convenience.
While Cesarean sections have become safer, Flamm said the risk of infection in the mother is much higher than with a vaginal birth. Furthermore, Cesarean sections require on average an extra two days in the hospital, costing perhaps $1,000 a day.
“Cesarean section, though it has become very safe, is still a major operation,” said Flamm. “Inherent in any major operation (of this kind) is the risk of anesthesia, risk of bowel or bladder injury and the risk of pelvic infection and hemorrhage.”
“(The agency) is just looking for what is thought to be the best medical care,” said Moien. “Right now, there is a question whether the best medical care needs this large number of Cesarean sections.”
In its report, the National Center noted that the sudden rise in the Cesarean section rate to 16.5% in 1980 prompted the U.S. National Institutes of Health to convene a meeting of experts to draw up new guidelines to stem the increase.
The rate continued to climb in the early and mid-1980s, while the rate of vaginal births after Cesarean hovered under 10%. So in 1982, 1985 and 1988, the obstetricians’ group issued liberalized guidelines for vaginal births after a Cesarean.
Records of hospital discharges compiled by the statistics agency show that the vaginal birth rate rose from 12.6% in 1988 to 18.5% in 1989, while the Cesarean rate was 24.1% in 1986, 24.4% in 1987, 24.7% in 1988 and 23.8% in 1989.
Experts disagree on whether there is an optimal Cesarean section rate. Some have suggested 15% to 20%. “We can generally agree that this rate is too high,” said Lebow, who said Ireland has one of the lower rates, at between 6% and 7%. “But what the optimal rate will be is anybody’s guess.”
Noting that some hospitals have a rate of vaginal birth after Cesarean as high as 50%, the health statistics agency said some hospitals say they cannot meet recommended guidelines for facilities and personnel when performing such deliveries.
The guidelines recommend 24-hour blood banking, continuous electronic fetal monitoring, patient blood screening, immediate presence of a physician throughout labor, on-site anesthesia coverage and other precautionary measures.
