New National Data Show Higher Complications Among Mothers With Cesarean Deliveries

Health Letter, February 2016

By Azza AbuDagga, M.H.A., Ph.D.

“There is no justification for any region to have a [caesarean section] rate higher than 10-15%.” World Health Organization[1]

An increasing number of women are undergoing unnecessary cesarean deliveries in the U.S. Though “cesareans” or “C-sections” made up only 5.5 percent of all deliveries in 1970,[2] by 2014 they had grown in frequency to make up 32.2 percent of deliveries.[3] They have also become the most common surgical procedure in the U.S. (almost 1.5 million are performed every year).[4]

There is no doubt that cesarean delivery can offer lifesaving benefits to the mother, the fetus or both in certain high-risk situations. Yet research generally has shown that this procedure carries an increased risk for serious complications compared with vaginal delivery.[5],[6]

Healthy People 2020 — a federal program that focuses on nationwide health promotion and disease prevention — has set a goal of reducing the number of C-sections in low-risk, full- term women to 23.9 percent.[7] This goal is still much higher than the never-achieved 15 percent target rate for Healthy People 2010,[8] as well as the World Health Organization’s (WHO’s) target rate of 10 to 15 percent.

While the upsurge in C-sections is due in part to an increase in primary cesareans (first cesarean deliveries), it also is due to a decline in the number of women who attempt to have vaginal deliveries after their first cesareans.[9] The most effective approaches for reducing C-sections and their related complications are both avoiding the first cesarean delivery[10] and attempting normal delivery for low-risk women who had a previous cesarean delivery.[11]

A recent report from the Centers for Disease Control and Prevention (CDC), published in National Vital Statistics Reports in May 2015, uses national data available for the first time to compare cesarean and vaginal deliveries.[12] The report examined the rates of four adverse outcomes that are usually associated with severe complications affecting mothers during childbirth: ruptured uterus, excessive bleeding requiring a blood transfusion, unplanned hysterectomy and intensive care unit (ICU) admission.

The CDC report

The report used data from all births registered in 41 states and the District of Columbia, representing 90 percent of all U.S. births in 2013. The report showed that, overall, C-sections accounted for 32.6 percent of all live births in 2013. Cesarean rates among mothers with no previous C-sections and those with repeat C- sections were 22.8 percent and 89.4 percent, respectively.

Among women delivering in 2013 who’d had a single previous C-section, only one in five attempted vaginal delivery, yet 70 percent of them were successful. Only 7 percent of women with a history of two or more previous cesarean deliveries attempted vaginal deliveries, with about half of those succeeding.

The report found that blood transfusion was the most common of the four adverse outcomes among all women, occurring at a rate of 280 per 100,000 live births, followed by ICU admission (155), unplanned hysterectomy (41) and ruptured uterus (26) (see figure).

Women who had vaginal deliveries and no previous C-sections had the lowest rates for all four adverse outcomes. In contrast, women with primary cesareans had the highest rates of transfusion and ICU admission, and mothers with repeat C-sections had the highest rates of ruptured uterus and unplanned hysterectomy.

A critical finding was that women with vaginal birth after cesarean (VBAC) deliveries had lower rates for all four maternal adverse outcomes, compared with women with repeat cesareans. They also had lower rates of transfusion and ICU admissions, compared with women who had primary cesarean deliveries.

Cesarean rates
Image: National Vital Statistics Reports

Further Results From the CDC Study

Results for women with no previous cesarean
  • Women who attempted and succeeded in having a vaginal delivery had significantly lower rates for all four adverse outcomes compared with women who delivered by C-section, regardless of whether they attempted vaginal delivery or not.
  • In contrast, women who underwent cesarean deliveries without first attempting vaginal delivery had significantly higher rates of ICU admission than women who had failed trials of labor (421 versus 318 per 100,000 live births, respectively). However, women who underwent cesarean deliveries without first attempting vaginal delivery had significantly lower rates of maternal transfusion than women who had failed trials of labor (487 versus 601 per 100,000 live births, respectively).
  • For women who underwent a first cesarean, the rates of ruptured uterus and unplanned hysterectomy did not differ significantly for those who first attempted vaginal delivery compared with those who did not.
Results for women with a previous cesarean
  • Women with successful VBAC deliveries in 2013 had lower rates for three adverse outcomes (transfusion, unplanned hysterectomy and ICU admission), compared with women with cesarean deliveries who did not attempt vaginal delivery after a previous cesarean.
  • Women with successful current VBAC deliveries had lower rates for all four outcomes, compared with women who had failed in vaginal delivery, resulting in repeat cesarean deliveries.
  • Women who had unsuccessful attempts at vaginal delivery (resulting in repeat cesarean deliveries) had higher rates of transfusion, ruptured uterus and ICU admission, compared with women with repeat current C-sections without trial of labor.

All four serious adverse outcomes occurred at relatively small rates among all women. Yet women with vaginal deliveries had the lowest rates of these adverse outcomes. This underscores the importance of avoiding primary cesarean deliveries whenever possible, and attempting vaginal delivery after a first C-section unless normal delivery presents a reasonably high risk for the mother or baby.

Our recommendations

Public Citizen’s Health Research Group has long been concerned about the rising number of C- sections in the U.S. We continue to offer the following recommendations that have been shown to reduce the number of unnecessary C-sections:[13],[14]

  • Pregnant women should talk to a doctor or midwife early about their preferences, find out the rates of cesarean and VBAC deliveries in the hospitals they are considering for delivery, and consider using either a licensed midwife or a doula (a woman experienced in childbirth who provides continuous labor support) in conjunction with the obstetrician.
  • Health departments should require all hospitals to offer the alternative of delivery by a licensed midwife, adopt peer review in all aspects of maternal and fetal care, require all obstetricians to get a second opinion before deciding on a primary cesarean, standardize care right before and after birth, and eliminate financial incentives for performing cesareans.

References

[1] World Health Organisation. Appropriate technology for birth. Lancet. 1985;2:436-437.

[2] Centers for Disease Control and Prevention. Rates of cesarean delivery — United States, 1993. Morbidity and Mortality Weekly Report. 1995;44(15):303-307.

[3] Hamilton BE, Martin JA, Osterman MJ, Curtain SC. Births: Preliminary data for 2014. National Vital Statistics Reports. 2015;64(6):1-19.

[4] Guise J-M, Eden K, Emeis C, et al. Vaginal Birth After Cesarean: New Insights. Rockville, MD: Agency for Healthcare Research and Quality; 2010.

[5] Spong CY, Berghella V, Wenstrom KD, et al. Preventing the first cesarean delivery: Summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop. Obstetrics and Gynecology. 2012;120(5):1181-93.

[6] Gray KE, Wallace ER, Nelson KR, et al. Population-based study of risk factors for severe maternal morbidity. Paediatric and Perinatal Epidemiology. 2012;26(6):506- 514.

[7] Healthy People 2020. Maternal, Infant, and Child Health. http://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child- health/objectives. Accessed December 29, 2015.

[8] Healthy People 2010 Operational Definition. https://www.citizen.org/sites/default/files/o1609a_0.pdf. Accessed December 29, 2015.

[9]Spong CY, Berghella V, Wenstrom KD, et al. Preventing the first cesarean delivery: Summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop. Obstetrics and Gynecology. 2012;120(5):1181-93.

[10] Spong CY, Berghella V, Wenstrom KD, Mercer BM, Saade GR. Preventing the first cesarean delivery: Summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop. Obstetrics and Gynecology. 2012;120(5):1181-93.

[11] American College of Obstetricians and Gynecologists. Vaginal birth after previous cesarean delivery. Obstetrics and Gynecology. 2010;116(2 Pt 1):450-63.

[12] Curtin SC, Gregory KD, Korst LM, Uddin SF. Maternal morbidity for vaginal and cesarean deliveries, according to previous cesarean history: New data from the birth certificate, 2013. National Vital Statistics Reports. 2015;64(4):1-14.

[13] Wolfe S. Guide to Avoiding Unnecessary Cesarean Sections in New York State. Washington, DC: Public Citizen’s Health Research Group; April 2010. https://www.citizen.org/sites/default/files/1906.pdf. Accessed December 29, 2015.

[14] Guide to avoiding unnecessary cesarean sections in New York state. Health Letter. 2010;26(5):3-6. https://www.citizen.org/sites/default/files/hl_201005.pdf. Accessed December 30, 2015.