Rising Cesarean Delivery Rate Research Articles

The Rising Cesarean Delivery Rate in America: What Are the Consequences?

The Rising Cesarean Delivery Rate in America: What Are the Consequences?

Is a Rising Cesarean Delivery Rate Inevitable?: Trends in Industrialized Countries, 1987 to 2007

: Background: Cesarean delivery rates have been rising rapidly in many countries in the last decade. The objective of this research is to examine cesarean rates in industrialized countries and assess patterns in the trends toward increasing rates. Methods: We examined cesarean delivery rates per 1,000 live births from 1987 to 2007 in 22 industrialized countries. To enhance comparability, the inclusion criteria were at least 50,000 births annually and a per capita gross domestic product of at least U.S.$10,000 in 2007. Poisson regression was selected to model the cesarean delivery rates of countries across time. Results: We examined overall cesarean delivery rates, absolute changes in these rates, and changes in trend lines for cesarean rates for the period from 1987 to 2007. In 2007, 11 of the 21 countries reported overall cesarean rates of more than 25 percent, led by Italy (39%), Portugal (35%), the United States (32%), and Switzerland (32%). Five countries, the Slovak Republic, Czech Republic, Ireland, Austria, and Hungary more than doubled their cesarean delivery rate between 1992 and 2007. Comparing changes in rates across time periods, 14 countries experienced a greater increase in rates in the period between 1998 and 2002 compared with the period between 1993 and 1997. Comparing trends from 2003–2007 to 1998–2002, eighteen countries experienced a slowing down of rate increases across these two periods. Conclusion: Although cesarean delivery rates continue to rise, the rate of increase appears to be slowing down in most industrialized countries. (BIRTH 38:2 June 2011)

The Rising Cesarean Delivery Rate in America

Cesarean delivery is now the most common operation in the United States, and it has increased dramatically from 5.8% in 1970 to 32.3% in 2008. This rise has not resulted in significant improvement in neonatal morbidity or maternal health. Three recent studies of elective repeat cesarean deliveries performed before 39 completed weeks of gestation have demonstrated increased respiratory and other adverse neonatal outcomes. Maternal mortality in the United States has increased from 10 per 100,000 to 14 per 100,000 from 1998 to 2004. Contributing to this in an increasing incidence of placenta accreta associated with multiple uterine scars requiring the need for emergency cesarean hysterectomy, blood transfusion, and maternal mortality due to obstetric hemorrhage. To reverse the trend of the rising cesarean delivery rate, obstetricians must reduce the primary rate and avoid the performance of a uterine incision unless absolutely necessary for fetal or maternal indications. For women with one previous low transverse cesarean delivery, obstetricians should promote a trial of labor after previous cesarean delivery in those women who desire three or more children.

Is a Rising Cesarean Delivery Rate Inevitable? Trends in Industrialized Countries, 1987 to 2007

Cesarean delivery rates have been rising rapidly in many countries in the last decade. The objective of this research is to examine cesarean rates in industrialized countries and assess patterns in the trends toward increasing rates. We examined cesarean delivery rates per 1,000 live births from 1987 to 2007 in 22 industrialized countries. To enhance comparability, the inclusion criteria were at least 50,000 births annually and a per capita gross domestic product of at least U.S.$10,000 in 2007. Poisson regression was selected to model the cesarean delivery rates of countries across time. We examined overall cesarean delivery rates, absolute changes in these rates, and changes in trend lines for cesarean rates for the period from 1987 to 2007. In 2007, 11 of the 21 countries reported overall cesarean rates of more than 25 percent, led by Italy (39%), Portugal (35%), the United States (32%), and Switzerland (32%). Five countries, the Slovak Republic, Czech Republic, Ireland, Austria, and Hungary more than doubled their cesarean delivery rate between 1992 and 2007. Comparing changes in rates across time periods, 14 countries experienced a greater increase in rates in the period between 1998 and 2002 compared with the period between 1993 and 1997. Comparing trends from 2003-2007 to 1998-2002, eighteen countries experienced a slowing down of rate increases across these two periods. Although cesarean delivery rates continue to rise, the rate of increase appears to be slowing down in most industrialized countries.

Academy of Breastfeeding Medicine Founder's Lecture 2010: Breastfeeding: An Obstetrician's View

The value of breastfeeding for mothers, babies, and society is well established, yet in the United States too many women do not breastfeed. The U.S. Public Health Service set forth breastfeeding goals for 2010 and subsequently developed report cards so that breastfeeding trends could be followed for each state. Many efforts are made by healthcare professionals to encourage and support new mothers, but some areas in the United States have low levels of breastfeeding. This report examines aspects of obstetricians' education, role, and responsibility to promote and support breastfeeding. Additionally, some current trends affecting the practice of breastfeeding are considered, including shorter hospital stays, rapidly rising cesarean delivery rates (soon to approach 50%), and increasing proportion of working mothers. Because obstetricians often have the first contact with expectant mothers and there are over 20 million prenatal visits annually in the United States, obstetricians have many opportunities to promote breastfeeding. Together with the efforts of other physicians, nurses, and lactation specialists, we can improve the efforts to promote and support breastfeeding.

Cesarean and Vaginal Birth in Canadian Women: A Comparison of Experiences

Many publications have examined the reasons behind the rising cesarean delivery rate around the world. Women's responses to the Maternity Experiences Survey of the Canadian Perinatal Surveillance System were examined to explore correlates of having a cesarean section on other experiences surrounding labor, birth, mother-infant contact, and breastfeeding. A randomly selected sample of 8,244 estimated eligible women stratified primarily by province and territory was drawn from the May 2006 Canadian Census. Completed responses were obtained from 6,421 women (78%). Three-quarters of the women (73.7%) gave birth vaginally and 26.3 percent by cesarean section, including 13.5 percent with a planned cesarean and 12.8 percent with an unplanned cesarean. In addition to more interventions in labor, women who had a cesarean birth after attempting a vaginal birth had less mother-infant contact after birth and less optimal breastfeeding practices. Findings from the Maternity Experiences Survey indicated that women who have cesarean births experience more interventions during labor and birth and have less optimal birthing and early parenting outcomes.

Hippocratic ideal, Faustian bargain and Damocles' sword: erosion of patient autonomy in obstetrics

Respect for patient autonomy remains a foundational principle guiding the ethical practice of medicine-a mission first articulated by Hippocrates. Damocles, another figure from ancient Greece, provides a useful parable for describing performance under distress: Damocles loses his desire for opulence and power when he notices a sword dangling precariously above his head. Contemporary obstetricians deciding whether to forestall or impose major abdominal surgery on parturients entrusted to their care struggle valiantly in the chasm dividing Hippocratic idealism from the economic realism driven by the medicolegal sword of Damocles. Given the inherent risk of unforeseeable and unsalvageable fetal catastrophe during labor and vaginal delivery, and the often unsubstantiated, yet automatic, allegation of negligence that follows a labor-associated adversity, obstetricians-and their liability insurance carriers-have recalibrated obstetric practice in alignment with the increasingly risk-averse preferences of most patients. Indeed, less intrapartum risk for patients and less corresponding medicolegal exposure for obstetricians help explain the rising cesarean delivery rate and, more importantly, the steady disappearance of higher-risk interventions such as vaginal birth after cesarean (VBAC). Is this increasing reluctance to offer VBAC supervision ethically defensible? This paper argues that it is. Fiduciary professionalism mandates physician self-sacrifice, not self-destruction; a VBAC gone awry without negligence or substandard care may, nevertheless, render future affordable liability coverage unattainable. Yet, the unavailability of VBAC infringes on the autonomy of women who want to assume the intrapartum risks of a VBAC in lieu of a repeat cesarean delivery. The proposed solution is the regionalization of VBAC care provision in designated medical centers and/or the implementation of binding arbitration in an ethical trade-off to enhance patient autonomy regarding the preferred mode of delivery despite parallel constraint on legal options.

Changing trends in peripartum hysterectomy over the last 4 decades

The purpose of this study was to identify changing trends in peripartum hysterectomy (PH) in a single large obstetric population over the last 40 years. A retrospective cohort study was performed from 1966-2005 of patients who had PH in any of the 3 Dublin obstetric hospitals. Cases were identified, and details were obtained from the combined patient databases of each hospital. There were 872,379 deliveries during the study period, among which 358 women underwent PH (0.4/1000 deliveries). In a comparison of the study decades 1966-1975 with 1996-2005, PH decreased from 0.9 per 1000 deliveries to 0.2 of 1000 deliveries. Although the overall cesarean delivery rate has increased from 6-19% during these 2 decades, the percentage of PH that occurs in the setting of a previous cesarean delivery has increased from 27-57% (P < .00001). Indications for PH have changed significantly in this time period, with "uterine rupture" as the indication for PH decreasing from 40.5-9.3% (P < .0001) and placenta accreta as the indication increasing significantly from 5.4-46.5% (P < .00001). PH has decreased over the last 4 decades. However, alongside the rising cesarean delivery rate, there has been a marked increase in the incidence of placenta accreta.

Term Neonatal Asphyxial Seizures and Peripartum Deaths: Lack of Correlation with a Rising Cesarean Delivery Rate

Term Neonatal Asphyxial Seizures and Peripartum Deaths: Lack of Correlation with a Rising Cesarean Delivery Rate

Term neonatal asphyxial seizures and peripartum deaths: Lack of correlation with a rising cesarean delivery rate

The purpose of this analysis was to study the relationship between an increasing cesarean delivery rate and term neonatal seizures and peripartum deaths. This was a retrospective analysis of annually collated institutional data on cesarean delivery and perinatal outcome. Of 77,350 women who delivered at 37 weeks' gestation or more through 12 years (1989 to 2000), the cesarean rate increased from 6.9% to 15.1%; perinatal mortality at term, average 3.1/1000, was unchanged. The cesarean rate for nulliparas doubled from 8.3% to 17.5%. The overall neonatal term seizure rate (overall 1.3/1000; and for nulliparas 2.5/1000) did not change. The overall peripartum death rate (0.8/1000) was unchanged, although the rate for nulliparas (1.5/1000) showed a significant decline. Overall seizure rate in nulliparas was 5-fold higher than in multiparas; presumed intrapartum asphyxia was associated with 84% of both seizures and neonatal deaths in nulliparas. Among 2547 prelabor cesarean deliveries, there were no peripartum deaths and one neonatal seizure, an incidence comparable with that in multiparas who labored. Despite a greater than 2-fold rise in cesarean section rate, the seizure rate and overall peripartum death rate at term did not alter significantly. Neonatal seizures occurred 5 times more often following first deliveries.

Obstetric critical care

Despite advances in healthcare, maternal morbidity and mortality rates have been rising over the last three decades. Potential contributors to this alarming trend include advances in assisted reproductive technologies allowing women to conceive at older ages than previously possible, an increasing number of pregnancies affected by chronic diseases, a rising cesarean delivery rate resulting in complications such as abnormal placentation, and medical advances allowing women with complex illnesses to conceive. Expert consensus has endorsed simulation over traditional teaching methods for improving learner skill and patient outcomes, particularly in a setting of rarely encountered illnesses and increasingly complex patients. Maternal cardiac arrest simulations are one of the more extensively studied obstetrical critical care scenarios, and participation has been associated with improved learner performance. With such promising data in the setting of growing numbers of obstetrical simulation programs, a logical next step is the incorporation of obstetric critical care scenarios into simulation curricula. This chapter will discuss the use of simulation for teaching critical care obstetrics.

Geburtshilfliche Aspekte bei Zustand nach Sectio caesarea

A rising Caesarean delivery rate is the reason, why the obstetrician should be very well informed about the management of vaginal birth after Caesarean section: It is feasible in almost all women with nonrecurrent indication for the preceeding Caesarean section. Suspected foetal macrosomia, twin gestation and breech presentation represent relative contraindications. External cephalic version is a reasonable option. In case of history of uterine scar dehiscence or rupture and in women with vertical uterine scar, repeat section should be performed.

Reasons for the Rising Cesarean Delivery Rates

Epidemiology Branch and the Pregnancy and Perinatology Branch, National Institute of Child Health and Human Development, NIH, Bethesda, Maryland

Cesarean Births and Trial of Labor Rates-Reply

In Reply.— Dr Iffy's letter misinterprets our conclusion. We did not say that National Institute of Child Health and Human Development—sponsored Consensus Development Conference on Cesarean Childbirth failed to affect the increasing rates of abdominal deliveries. We stated that substantial increases have been observed in the rates of trial of labor and vaginal births after a previous cesarean delivery. However, these changes have not been sufficient to stem the rising cesarean delivery rates. There is a difference between these two conclusions. We believe that although cesarean delivery rates are still rising, the rates would be substantially higher without the recent trend toward trial of labor and VBAC. Dr Iffy also cites operating-room availability as a factor possibly limiting adoption of VBAC. On the contrary, crowding of operating facilities might be reducible if more VBACs were done. Dr Poma's letter discusses several factors that may contribute to the increasing cesarean

Recent Trends in Cesarean Birth and Trial of Labor Rates in the United States

A national probability survey was conducted to evaluate changes since 1979 in cesarean delivery and trial of labor rates after a previous cesarean delivery. Questionnaires were mailed to 538 hospitals and 87% responded. In 1979, of women with a prior cesarean birth 2.1% (+/- 0.3%) were given a trial of labor. By 1984, the rate increased fourfold to 8.0% (+/- 0.7%). Trials of labor increased dramatically with the size of the delivery service. The rates ranged from 2% in smaller hospitals to 25% in larger hospitals. More than 50% of the trials of labor were successful. However, the fraction of hospitals with no trials of labor remains high (54%). Cesarean birth rates increased from 14.1% (+/- 0.1%) in 1979 to 19.0% (+/- 0.2) in 1984. Hospitals with fewer births had a larger variation in cesarean birth rates; the fifth and 95th percentiles were 5% and 33%, respectively, for hospitals with fewer than 500 deliveries per year, and 14% and 31% for hospitals with 1000 deliveries or more per year. Fetal distress accounted for a larger proportion of primary cesarean deliveries in 1984 (21%) compared with 1979 (14%). The observed increase in the rate of trial of labor does not seem to be large enough to stem the rising cesarean delivery rate. This survey and other national surveys provide no evidence that the cesarean delivery rates are leveling off or decreasing.