The Optimistic Futurist

Opportunity to decrease healthcare costs

and

improve health quality by reduction of Cesarean Section Deliveries

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Cesarean section (c-section) is the most commonly performed surgery in the United States. The frequency of surgical birth has increased from 4% in 1965 to about 33% today, despite World Health Organization (WHO) recommendations that a 5% to 10% rate is optimal and that a rate greater than 15% does more harm than good.^[1-3]

Reasons for this increase have been discussed profusely:

• The surgical focus of obstetrics and the need to train residents;
• The low priority and few practical skills for supporting women's abilities to labor and give birth naturally;
• A rigid view of the duration of normal labor; and
• A low threshold of definition for 'labor dystocia' (the justification for up to 60% of cesarean births^[4]).

Surgical birth is also a 'side effect' of interventions associated with actively managed labor: induction, artificial rupture of membranes, labor medications, and fetal monitoring.^[5,6] Policies against vaginal birth after cesarean (VBAC) and, increasingly, unsupported 'supply-side' justifications such as "baby seems large," also drive the trend toward cesareans. A recent report by the Lamaze Institute associates surgical birth with obstetricians' personalities -- specifically their anxiety levels.^[7-9]

The risks for birth by surgery have also come under discussion. Maternal risks include a higher overall death rate, rehospitalization for wound complications and infection, placenta accreta and percreta (both with 7% mortality rate), placenta previa, uterine rupture with subsequent pregnancy, and preterm birth, with its own set of risks and complications for the newborn.^[10-15]

1. The Childbirth Connection. Why does the national U.S. cesarean section rate keep going up? Available at: http://www.childbirthconnection.org/article.asp?ck=10456 Accessed June 18, 2009.
2. The Childbirth Connection. Relentless rise in cesarean section rate. Available at: http://www.childbirthconnection.org/article.asp?ck=10554 Accessed June 18, 2009.
3. Hamilton BE, Martin JA, Ventura SJ; Division of Vital Statistics. Births: preliminary data for 2006. Natl Vital Stat Rep. 2007;56:1-18. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_07.pdf Accessed June 18, 2009.
4. Joy S, Scott PL, Lyon D. eMedicine Obstetrics and Gynecology. Abnormal labor. Available at: http://emedicine.medscape.com/article/273053-overview Accessed June 18, 2009.
5. Buckley SJ. The hidden risk of epidurals. Mothering Magazine. Available at: http://www.mothering.com/hidden-risk-epidurals Accessed June 18, 2009.
6. Childbirth Connection. Cesarean section, Available at: http://www.childbirthconnection.org/article.asp?ck=10167#factors Accessed June 18, 2009.
7. Sakala C, Corry MP. Evidence-based maternity care: what it is and what it can achieve. Available at: http://www.milbank.org/reports/0809MaternityCare/0809MaternityCare.pdf Accessed June 18, 2009.
8. Romano AM. Woman's risk of having cesarean surgery may depend on her obstetrician's personality. Lamaze Research Summaries. 2008;5 Available at: http://www.lamaze.org/LinkClick.aspx?fileticket=2drWyVEO4IA%3d&tabid=120&mid=566 Accessed June 18, 2009.
9. Burns LR, Geller SF, Wholey DR, The effect of physician factors on the cesarean section decision. Med Care. 1995 ;33:365-382. Abstract
10. Cesarean delivery associated with increased risk of maternal death from blood clots, infection, anesthesia. ACOG Office of Communications, News Release, August 31, 2006. Available at: http://daraluznetwork.com/CesareanTriplesMaternalDeath.pdf Accessed June 18, 2009.
11. Rosen T. Placenta accreta and cesarean scar pregnancy: overlooked costs of the rising cesarean section rate. Clin Perinatol. 2008;35:519-529. Abstract
12. Rosen T. Placenta accreta and cesarean scar pregnancy: overlooked costs of the rising cesarean section rate. Clin Perinatol. 2008;35:519-529.
13. Cunningham FG, et al. Placenta accreta, increta, and percreta. In: Williams Obstetrics. 19th Ed. New York: McGraw-Hill; 1993:620-622.
14. Bettegowda VR, Dias T, Davidoff MJ, Damus K, Callaghan WM, Petrini JR. The relationship between cesarean delivery and gestational age among US singleton births. Clin Perinatol. 2008;35:309-323 1 Abstract
15. Declerq G, Norsigian J. Mothers aren't behind a vogue for caesareans. Boston Globe, April 3, 2006. Available at:
    http://www.boston.com/news/globe/editorial_opinion/oped/articles/2006/04/03/mothers_arent_behind_a_vogue_
    for_caesareans/?p1=email_to_a_friend Accessed June 18, 2009.
16. Declerq G, Norsigian J. Mothers aren't behind a vogue for caesareans. Boston Globe, April 3, 2006. Available at: http://www.boston.com/news/globe/editorial_opinion/oped/articles/2006/04/03/mothers_arent_behind_a_vogue_
    for_caesareans/?p1=email_to_a_friend Accessed June 18, 2009.

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