April 21, 2010

Guide to Avoiding Unnecessary Cesarean Sections in New York State

Sidney Wolfe, M.D.
Public Citizen Health Research Group

Full report as a pdf
Statements from press conference

Introduction
Objectives
Methods
About New York
Variations in Cesarean Sections, VBACs, and Midwife Availability by County and by Hospital Within Each County
Healthy Outliers: Two New York Hospitals that Have Bucked the Trend
Factors Possibly Associated with Variation in Rates
What is Driving Cesareans in New York?
How a Woman Can Avoid an Unnecessary Cesarean in New York State
What Health Departments and Hospitals Can Do to Reduce Unnecessary Cesareans
New York Hospital Birth Statistics by County

Introduction

The steep rise in cesarean sections has become a growing concern for those committed to improving the health of mothers and infants.  A report in March 2010 from the U.S. National Center for Health Statistics concerning the rising rate of cesarean births stated that:

Cesarean delivery involves major abdominal surgery, and is associated with higher rates of surgical complications and maternal rehospitalization, as well as with complications requiring neonatal intensive care unit admission. In addition to health and safety risks for mothers and newborns, hospital charges for a cesarean delivery are almost double those for a vaginal delivery, imposing significant costs.[1]

There is a growing epidemic of cesarean sections in the United States. The rate of cesarean sections rose from 10.4 percent of all deliveries in 1975[2] to 22.7 percent by 1990. It then fell for a few years to 20.7 percent by 1996[3] but has risen sharply since then to the highest rate ever in 2007: 31.8 percent of all deliveries.[4]

The Agency for Healthcare Research and Quality (AHRQ, part of the United States Department of Health and Human Services [DHHS]) has stated that: “cesarean delivery [overall rates and primary rates] has been identified as an overused procedure. As such, lower rates represent better quality.” They also stated that “VBAC [vaginal birth after cesarean] has been identified as a potentially underused procedure. As such, higher rates represent better quality.”[5]

Healthy People 2000 included objectives for cesarean delivery for the year 2010. These established a target of 15 percent for women with uncomplicated pregnancies giving birth for the first time, and 63 percent for women who had had a prior cesarean section (a VBAC rate of 37 percent).[6]

Neither of these objectives has been achieved; in fact, the rate for cesarean births has moved in the opposite direction since 2000, away from the target.[7] This means that nationally, in 2007, a significant proportion of the 1.4 million cesarean operations performed on women in this country may have been unnecessary. In New York State, as will be discussed below, there may be as many as 33,000 unnecessary cesarean sections (one-third of all cesareans) in 2007.

The recent increase has been exacerbated by two linked factors:

First, the rapidly rising rate of cesarean sections in women who had never had one before. In 1996, this rate was 21.3 percent,[8] but by 2002 it had risen to 25.8 percent. Although more than half (53 percent) of the recent increase in overall cesarean rates resulted from rising primary rates, the increases were not related to shifts in maternal risk profiles.[9]

Second, a sharp decline in the rate of women who undergo a vaginal birth after a previous cesarean (VBAC). Although the VBAC rate underwent an important increase in the 1990s, rising from 19.9 percent to 28.1 percent between 1990 and 1996, it declined abruptly after the latter date and, in 2006, was only 9.7 percent. The combined effect of a rapid increase in primary cesarean section rate and the greatly increased chance of additional cesareans after the first one explains why the overall cesarean rate has risen more than 53 percent (from 20.7 percent to 31.8 percent) in the 11 years between 1996 and 2007 nationally. The actual number of cesarean births increased by 71 percent from 1996 (797,119) to 2007 (1,367,049).

Recent studies have underlined the risks of cesarean sections.

A government study examined data from eight million births, including 17,000 infant deaths in the U.S. from 1999 through 2002. This study found a 69 percent increase in neonatal mortality in women with no labor complications who had a cesarean section compared to women who had planned vaginal deliveries. Data were adjusted for socio-demographic and medical risk factors.[10]

Another very recent study looked at 115,000 low-risk deliveries in 10 different hospitals. The authors found that women without a previous cesarean who had an unlabored (elective) cesarean section were at a 6.57-fold increased risk of hysterectomy at term. The authors concluded that:

The advantages of an elective delivery are the convenience of being able to plan delivery and perhaps more control over who is the delivering provider. These advantages pale in comparison to 3.21 times the risk of hysterectomy at term for an elective induction or 6.57 [times] increased risk for unlabored cesarean at term… Given that the advantages of elective delivery are primarily social or logistical and not medical, an argument could be made not to offer an elective delivery at all given the maternal risks. At minimum, patients should be well informed of the fetal and maternal risks of elective delivery.[11]