The World Health Organization recommends that the cesarean rate for developed countries should be somewhere between 10-15%. Studies show that the best outcomes for mamas and babies occur with cesarean rates of 5% to 10%. Rates above 15% seem to do more harm than good (Althabe and Belizan 2006). The average cesarean rate in the US is around 32.8% - much higher than the WHO recommendation. The average cesarean rate in Kentucky is actually a bit higher than the national average at 35.4%. The hospital with the highest cesarean rate in KY is Paul B Hall Regional Medical Center, with a rate of a whopping 71%.
Why are cesarean rates in our country so high? More importantly, why are cesarean rates in our state even higher than our high national average? A few reasons come to mind:
- Lack of evidence-based care
- Lack of support for the laboring mother
- High instance of unnecessary labor intervention
- Small amount of care providers who offer VBAC
- Lack of awareness of the harm that can sometimes come from cesarean
- Obstetricians are paid the same amount whether you deliver vaginally or by cesarean. Sadly, a planned cesarean is a great way for doctors to work births around their own schedule.
So, is it even possible to meet that WHO recommendation of 10-15%? It is.. and there is actually a place in our country whose cesarean rate is well below the national average, as well as the WHO recommendation. The Farm Midwifery Center in Summertown, TN has maintained an average cesarean rate of 1.7% from 1970-2010. Of 2,844 pregnancies, only 50 ended in cesarean. This really gives us an idea of just how many cesareans performed in the US are actually necessary, doesn't it? It certainly shows what is possible when evidence-based care and education are provided to mamas who absolutely deserve it! Why shouldn't every mama receive this kind of care?
Before delving into how to avoid an unecessary cesarean, I first want to talk about the risks that come with having a cesarean (whether necessary or not). Most importantly, the maternal mortalitly and morbidity rates are much higher with cesarean than with vaginal birth. Many women who have a cesarean section also sometimes have negative feelings about their birth that last well into the postpartum period. There's the possibility of a reactions to one of many medications that are associated with cesarean (anesthesia, pain medication etc.). With a cesarean, the average hospital stay is 3-5 days - with a vaginal birth it is only 24 hours. Along with the extended hospital stay comes an extended recovery time that can have a negative effect on bonding with baby and breastfeeding. Cesarean surgery itself can cause a delay in the milk ejection reflex, and mamas who deliver babies via cesarean often experience a delay in their mature milk coming in. 1 in 14 mamas report incisional pain six months or more after surgery (Declerq ER , Sakala C, Corry MP. Listening to Mothers: Report of the First National U.S .Survey of Women’s Childbearing Experiences. New York: Maternity Center Association, Oct 2002). There is a risk of scar tissue that can lead to complications in future pregnancies including placenta previa, placenta accreta and placental abruption. Infection can occur at the incision site, in the uterus and in other pelvic organs. There is a chance of injury during the surgery to other organs that are close to the uterus. There is more blood loss in a cesarean than in a vaginal delivery, 1 in 6 women require a blood transfustion (Shearer El. Cesarean section: medical benefits and costs. Soc Sci Med 1993;37(10): 1223-31). Along with all of these things comes the risk of additional surgeries - hysterectomy, organ repair, future cesarean.
The previous mentioned risks are those for mama, there are also risks for baby involved with cesarean delivery. Babies who are born via cesarean are more likely to have lower APGAR scores, reasoning behind this can come from a number of problems with cesarean - the anethesia and the lack of natural stimulation for baby provided by a vaginal birth to name a few. If your due date was not estimated correctly, a baby born by planned cesarean can be born prematurely. Babies born by cesarean are much more likely to have breathing problems and are more likely to need assistance breathing shortly after birth than babies born vaginally. Rarely, there is a risk of injury to the baby during a cesarean. On average 1-2 babies in 100 are cut during the surgery (Van Ham MA, van Dongen PW, Mulder J. Maternal consequences of cesarean section. A retrospective study of intraoperative and postoperative maternal complications of cesarean during a 10-year period. Eur J Obstet Gynecol Reprod Biol 1997; 74 (1): 1-6).
Avoiding an unecessary cesarean, and the risks that come with it, can be done in a number of ways:
- First and foremost, if you aren't in an emergency situation, question your care provider. Why is this being recommended? What are my other choices? What are the risks and benfits of having the surgery? Of not having the surgery?
- Plan a birth that is low intervention and find a care provider who is supportive of natural childbirth and supportive of your decisions. Each intervention in birth (induction, epidural, continous monitoring) greatly increases your chances of cesarean. These things can also sometimes be necessary - but when they aren't you have to ask yourself, is it worth the risk?
- When you find a care provider, be sure to ask their cesarean rate. It may be higher than even the national average and that's never a good sign.
- Educate yourself by taking good (out of hospital) childbirth classes, reading books recommended by your CBE or doula and by asking lots of questions of your care provider and support team.
- Discuss with your care provider spending early labor at home. A common reason for cesarean failure to progress. Usually, when given enough time, mama will progress just fine on her own.
- Avoid continuous monitoring.
- Avoid getting an epidural, especially early in labor.
- Avoid induction, unless medically necessary.
- Hire an experienced, professional doula. A doula will be able to help keep you comfortable without the use of modern medications and will also be able to help you find positions that are conducive to the natural progression of labor. If something does come up during your labor, your doula will be there to answer any questions you have and provide you with accurate information to help you make the best decision for both you and your baby.
- If you've had a previous cesarean, find a doctor who is supportive of VBAC and discuss your options. "Once a cesarean, always a cesarean" usually isn't the case.
While cesareans are scary and come with plenty of potential side effects, they are sometimes necessary can be life saving. Some cases in which a cesarean may be necessary are placenta previa, placental abruption, placenta accreta, uterine rupture, cord prolapse, fetal distress, active genital herpes, preeclampsia, some birth defects and some cases of multiple births (not always necessary). In these cases the benefits of a having a cesarean can greatly outweigh the risks. If you find yourself in a situation where cesarean is necessary, it doesn't have to be a negative experience. Knowing that you are making the safest choice for you and your baby is a great start. Some other tips for creating a positive experience when cesarean is neccesary can be found here.
Why are cesarean rates in our country so high? More importantly, why are cesarean rates in our state even higher than our high national average? A few reasons come to mind:
- Lack of evidence-based care
- Lack of support for the laboring mother
- High instance of unnecessary labor intervention
- Small amount of care providers who offer VBAC
- Lack of awareness of the harm that can sometimes come from cesarean
- Obstetricians are paid the same amount whether you deliver vaginally or by cesarean. Sadly, a planned cesarean is a great way for doctors to work births around their own schedule.
So, is it even possible to meet that WHO recommendation of 10-15%? It is.. and there is actually a place in our country whose cesarean rate is well below the national average, as well as the WHO recommendation. The Farm Midwifery Center in Summertown, TN has maintained an average cesarean rate of 1.7% from 1970-2010. Of 2,844 pregnancies, only 50 ended in cesarean. This really gives us an idea of just how many cesareans performed in the US are actually necessary, doesn't it? It certainly shows what is possible when evidence-based care and education are provided to mamas who absolutely deserve it! Why shouldn't every mama receive this kind of care?
Before delving into how to avoid an unecessary cesarean, I first want to talk about the risks that come with having a cesarean (whether necessary or not). Most importantly, the maternal mortalitly and morbidity rates are much higher with cesarean than with vaginal birth. Many women who have a cesarean section also sometimes have negative feelings about their birth that last well into the postpartum period. There's the possibility of a reactions to one of many medications that are associated with cesarean (anesthesia, pain medication etc.). With a cesarean, the average hospital stay is 3-5 days - with a vaginal birth it is only 24 hours. Along with the extended hospital stay comes an extended recovery time that can have a negative effect on bonding with baby and breastfeeding. Cesarean surgery itself can cause a delay in the milk ejection reflex, and mamas who deliver babies via cesarean often experience a delay in their mature milk coming in. 1 in 14 mamas report incisional pain six months or more after surgery (Declerq ER , Sakala C, Corry MP. Listening to Mothers: Report of the First National U.S .Survey of Women’s Childbearing Experiences. New York: Maternity Center Association, Oct 2002). There is a risk of scar tissue that can lead to complications in future pregnancies including placenta previa, placenta accreta and placental abruption. Infection can occur at the incision site, in the uterus and in other pelvic organs. There is a chance of injury during the surgery to other organs that are close to the uterus. There is more blood loss in a cesarean than in a vaginal delivery, 1 in 6 women require a blood transfustion (Shearer El. Cesarean section: medical benefits and costs. Soc Sci Med 1993;37(10): 1223-31). Along with all of these things comes the risk of additional surgeries - hysterectomy, organ repair, future cesarean.
The previous mentioned risks are those for mama, there are also risks for baby involved with cesarean delivery. Babies who are born via cesarean are more likely to have lower APGAR scores, reasoning behind this can come from a number of problems with cesarean - the anethesia and the lack of natural stimulation for baby provided by a vaginal birth to name a few. If your due date was not estimated correctly, a baby born by planned cesarean can be born prematurely. Babies born by cesarean are much more likely to have breathing problems and are more likely to need assistance breathing shortly after birth than babies born vaginally. Rarely, there is a risk of injury to the baby during a cesarean. On average 1-2 babies in 100 are cut during the surgery (Van Ham MA, van Dongen PW, Mulder J. Maternal consequences of cesarean section. A retrospective study of intraoperative and postoperative maternal complications of cesarean during a 10-year period. Eur J Obstet Gynecol Reprod Biol 1997; 74 (1): 1-6).
Avoiding an unecessary cesarean, and the risks that come with it, can be done in a number of ways:
- First and foremost, if you aren't in an emergency situation, question your care provider. Why is this being recommended? What are my other choices? What are the risks and benfits of having the surgery? Of not having the surgery?
- Plan a birth that is low intervention and find a care provider who is supportive of natural childbirth and supportive of your decisions. Each intervention in birth (induction, epidural, continous monitoring) greatly increases your chances of cesarean. These things can also sometimes be necessary - but when they aren't you have to ask yourself, is it worth the risk?
- When you find a care provider, be sure to ask their cesarean rate. It may be higher than even the national average and that's never a good sign.
- Educate yourself by taking good (out of hospital) childbirth classes, reading books recommended by your CBE or doula and by asking lots of questions of your care provider and support team.
- Discuss with your care provider spending early labor at home. A common reason for cesarean failure to progress. Usually, when given enough time, mama will progress just fine on her own.
- Avoid continuous monitoring.
- Avoid getting an epidural, especially early in labor.
- Avoid induction, unless medically necessary.
- Hire an experienced, professional doula. A doula will be able to help keep you comfortable without the use of modern medications and will also be able to help you find positions that are conducive to the natural progression of labor. If something does come up during your labor, your doula will be there to answer any questions you have and provide you with accurate information to help you make the best decision for both you and your baby.
- If you've had a previous cesarean, find a doctor who is supportive of VBAC and discuss your options. "Once a cesarean, always a cesarean" usually isn't the case.
While cesareans are scary and come with plenty of potential side effects, they are sometimes necessary can be life saving. Some cases in which a cesarean may be necessary are placenta previa, placental abruption, placenta accreta, uterine rupture, cord prolapse, fetal distress, active genital herpes, preeclampsia, some birth defects and some cases of multiple births (not always necessary). In these cases the benefits of a having a cesarean can greatly outweigh the risks. If you find yourself in a situation where cesarean is necessary, it doesn't have to be a negative experience. Knowing that you are making the safest choice for you and your baby is a great start. Some other tips for creating a positive experience when cesarean is neccesary can be found here.
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