C-Sections on Rise as View of Risks Changes

The number of U.S. women giving birth by caesarean section is rising rapidly, signaling an apparent end to an ambitious, decade-long public health effort to reduce the nation’s C-section rate.

Though about one in four babies was born by C-section in the late 1980s, rates fell throughout much of the last decade at the urging of health authorities who thought that the numbers were unnecessarily high and that too many surgeries were motivated by doctors’ fear of lawsuits.

Now, as the furor over the issue has quieted, C-section rates are on the rise again, with some experts predicting that as many as 30% of all babies will be delivered by surgery within a year or two.

The reasons for change include a reluctance among some doctors to allow women who have previously delivered a baby by C-section to opt for vaginal birth for their next baby, experts say. Also, there is a growing belief among obstetricians that C-sections--once considered riskier for women due to surgical complications--are as safe as vaginal births.

Also, women today may be less tolerant of undergoing vaginal deliveries that include long, unpredictable and painful labors. Delivery by C-section, in contrast, can be more predictable and convenient--even if the post-delivery recovery is typically longer and more uncomfortable, doctors, midwives and childbirth educators say.

“This is a wave about to break,” said Dr. T. Murphy Goodwin, chief of maternal-fetal medicine at USC’s Keck School of Medicine. “You have these forces converging and very little to hold it back.”

The wave has begun to break both nationally and in Southern California. In the United States, the percentage of births by C-section rose in both 1998 and 1999, according to the American Academy of Obstetrics and Gynecology.

California does not compile an official statewide C-section rate. But a review of state data by The Times showed that C-section rates rose at 31 of 38 Southern California hospitals between the end of 1997 and June 1999, the latest date for which information was available. The Times looked at data from the state Healthcare Information Resource Center for hospitals in Los Angeles, Orange, Riverside and San Bernardino counties with the largest numbers of births.

Obstetricians acknowledge that a decline in vaginal births among women with previous C-sections is a major reason for the recent surge.

Beginning in the late 1980s, women who had undergone C-sections were often encouraged to attempt vaginal delivery for the birth of a subsequent child. The practice, called vaginal birth after caesarean, or VBAC, was widely promoted by insurers and public health officials as a way of lowering C-section rates and reducing health care costs. Studies at the time showed that most healthy women were good candidates for the practice.

In recent years, however, the health care industry has backed away from recommending VBACs, concerned about potential liability as more is known about the risks of the procedure. For example, 1% of women who attempt a vaginal birth after caesarean experience a ruptured uterus, a complication that requires surgery and can sometimes be fatal.

As a result, rates for the procedure nationwide have fallen 17% since 1996, according to the American College of Obstetrics and Gynecology.

Though the VBAC procedure is safe for certain patients, says Goodwin, “there are patients for whom it is not appropriate.”

In 1999, the American College of Obstetrics and Gynecology advised its members that the procedure should be attempted only when a doctor and anesthesiologist are “immediately available” to perform emergency care.

The recommendation makes it difficult for smaller hospitals to offer the procedure, says Dr. Bruce Flamm, an obstetrician for Kaiser Permanente in Riverside who has done research showing how the procedure can be done safely.

C-Sections Are Safer, Some Say

The debate over VBAC is not the only reason for the changing tide in C-section rates, however. Some obstetricians now say that, given the possible complications of a long, arduous vaginal birth, a scheduled caesarean is a safer alternative for a healthy woman. Even the president of the American Academy of Obstetrics and Gynecology, W. Benson Harer Jr., a Riverside physician, has repeatedly stated that elective C-sections are safer for the baby and nearly as safe for the mother.

Elective caesarean should be weighed against the often overlooked risks associated with vaginal birth, such as the development of urinary or fecal incontinence, sexual dysfunction or prolapse, a slipping of the uterus that can require a hysterectomy, says Goodwin.

Doctors may also be more reticent to use methods such as forceps or vacuum aspiration in difficult vaginal deliveries.

Although the devices, used to help extract the baby, are still considered safe when used by experienced doctors, the Food and Drug Administration in 1998 warned of an increase in serious, even fatal, complications from their use.

“There is a real question as to whether a C-section is a reasonable option, because a number of complications of vaginal delivery are eliminated if you do a C-section,” Goodwin said.

And fewer women today seem to be good candidates for vaginal birth. At Torrance Memorial Medical Center, the C-section rate rose from 19.2% in 1995 to 26.5% through June 1999. Hospital officials attribute the rising rates in part to more births to first-time mothers in their 30s and 40s, who are more likely to encounter complications that lead to C-sections.

First-time mothers today are typically older, gain more weight and have bigger babies--all factors that can increase the difficulty of vaginal birth. One of the most common reasons caesareans are performed is long, difficult labor--typically because the baby is too large to navigate the birth canal and the mother is unable to push the baby out.

“When you’ve done a difficult vaginal birth or a C-section after a long labor and the baby is barely breathing and the mom is worn out, you have to ask, ‘Did I really do the right thing?’ ” says D. Campbell Walters, a Mount Vernon, Ill., obstetrician and author of a book on C-sections titled “Just Take It Out!”

“I came to the realization that it is probably at least as safe for the mother to have a C-section,” Walters says. “And almost no one would argue that it is safer for the baby.”

But relatively few doctors support elective C-sections without an immediate medical need. The majority of physicians believe that C-sections are riskier.

“It’s still an old-fashioned, major operation,” Flamm says.

Critics of elective C-sections say the practice mainly benefits obstetricians by limiting their exposure to malpractice lawsuits and easing their jobs because of fewer middle-of-the-night deliveries.

“The No. 1 reason for the lawsuits against ob-gyns is failure to perform a timely C-section,” says Dr. Robin Richman, a medical director for the Tufts Health Plan in Waltham, Mass. “They feel the best way to protect themselves from a lawsuit is to go to a caesarean sooner rather than later.”

It is so-called “defensive medicine” that was partly blamed for the rise in C-sections in the 1980s and subsequently led to the nationwide effort to lower rates, experts say.

Now, however, some reproductive health experts charge that proponents of caesarean births are frightening women into believing that natural childbirth is more dangerous than it really is.

“I’ve seen less and less confidence among women in their ability to give birth vaginally and more worry about what can go wrong,” says Nicette Jukelevics, a longtime childbirth educator in Rancho Palos Verdes. “They are afraid, and they have a lower tolerance for pain.”

Although obstetricians say the number of U.S. women opting for so-called “patient-choice caesareans” is still relatively small, the idea is more popular among certain groups of women in other countries. In Brazil, women from higher-income families often have an elective C-section. And a 1997 study of female obstetricians in Britain found that 31% favored C-section for themselves.