Why Are More Expecting Mothers Having C-Section Deliveries?

IRA FLATOW: This is Science Friday. I am Ira Flatow. For anyone having a baby, the decision to have a C-section is not unusual. But what is unusual is the number of C-sections happening all over the world.

Listen to this. The worldwide rate has nearly doubled from 12% to 21% in the past 15 years. And in the United States, one out of three births is by C-section now.

A series of studies in the journal The Lancet looked at this trend to see what is behind this uptick. What are the effects on mothers and babies? And what interventions can be done to decrease that number. And that’s what we’re going to be talking about, C-section rates globally, also what’s happening here in the US.

And my question for you listeners is, did you or your partner get a C-section? What factored into that decision? What was your experience like? You can phone it in, or you can tweet us. Our phone number 844-724-8255. You can tweet us @SciFri.

Let me introduce my guest. Holly Kennedy is an author on that Lancet series. She’s also a professor of mid-wife wifery at the Yale School of Nursing. Thank you for joining us today Holly Kennedy.

HOLLY KENNEDY: Thank you.

IRA FLATOW: Tell us, the Lancet series looked at 169 countries. And overall, there is a rising C-section rates. Can you give us some of the numbers of different regions? It must have varied around the world.

HOLLY KENNEDY: Well, it does. And what we found was that over 60% of countries over use C-sections, and 25% under use the procedure. So there’s quite a disparity. And there are multiple reasons.

Part of it has to do with the sociocultural acceptance of surgery as a normative thing to do. Part of it has to do with insurance and access. And a large part of it has to do with women not being able to get a vaginal birth after they’ve had their first Cesarean. So it’s complicated. We’ve seen the rise particularly in North America, Western Europe, Latin America, and the Caribbean. For example, in Latin America, it’s gone from 32% to 44%.

And there’s a bit of a paradox when what we would call too much, too soon and too little, too late. So in the countries that overuse Cesarean, they are probably intervening too much in low-risk women that really don’t need the procedure. And in countries such as in Africa that don’t have enough access, probably are under using it. The World Health Organization suggests that 15% is about right. So when you think about one in three women in the United States having a Cesarean, we’re way over.

IRA FLATOW: Well, let’s talk about over about– there’s a statistic, for example, in Brazil, 90% of the women that go into a private hospital are getting C-sections. Are they requesting that before they go in? What is the mechanism? What happens there?

HOLLY KENNEDY: Well, I can’t speak specifically to the interaction. But you’re right, women who are wealthier, who have insurance, are much more likely– the majority of them will have a C-section. And it’s an accepted normative part of the culture in Brazil.

IRA FLATOW: Now, there are big differences within countries. In China, the range is from what, 4% to 62% depending on the province?

HOLLY KENNEDY: Exactly. And again, that has to do with access, and wealth, education. Interestingly enough, women that have greater education are more likely to have a Cesarean, which is a bit of a paradox in itself because a Cesarean is not a low-risk surgery. It’s major surgery.

And there are small, but serious risks, both with the immediate surgery, and then later in terms of the scar, and stillbirth, and pre-term birth later with subsequent pregnancies. And it’s one small part of the piece of the puzzle. In the United States, we’re increasing maternal mortality rate.

IRA FLATOW: You mentioned that in some places, there’s too much, in some places, not enough. What are those not enough places like, and why?

HOLLY KENNEDY: The not enough places are places that don’t have access in particularly in Africa and in countries that have lower resources. So they just don’t have the facilities to do a Cesarean sometimes when a woman really needs it. And I think it’s important to state it at the out site, there are women and babies that it is a life-saving procedure. But it’s not one that should be done for the majority of women.

IRA FLATOW: I want to focus on a little bit about what’s happening here in the US and why C-sections are increasing here. Toni Golen is the Vice Chair of Quality in the Department of Obstetrics and Gynecology at the Beth Israel Deaconess Medical Center in Boston. Welcome to Science Friday, Dr. Golen.

TONI GOLEN: Thank you for having me.

IRA FLATOW: Let’s talk about this. There’s also this idea of planned C-sections, right? Do you have to approach this– do you have– have you seen this in your experience?

TONI GOLEN: It’s quite interesting. I think there’s a natural suspicion that this is a major contributor to this C-section epidemic in the United States at this point. And while it’s true that families, women can request to have a delivery via Cesarean, it turns out that that’s not really the most significant driver. In our experience at Beth Israel Deaconess, for example, which is a tertiary care institution, an academic hospital in the middle of Boston, it really only contributes to about 1% of our deliveries per year.

So while some of this could be attributed to patient opinions, or patient desires, or their perceptions of what’s safer, the truth is is that I think that we as health care providers need to realize that we are probably the major, major contributors to the rise in Cesarean delivery rate here in the US.

IRA FLATOW: When you say health care providers, you’re talking about the doctors who actually are performing it?

TONI GOLEN: Yeah. So certainly the doctors, the obstetricians, they are the ones who make the recommendation for a Cesarean. At the end of the day, that’s who’s responsible. It’s a complex environment to practice obstetrics.

So there are other things that put pressure possibly on obstetricians. We have incomplete, somewhat inaccurate data about health of fetuses during labor that might contribute to our decision making. The progress during labor in terms of those cervical dilation is subjective. So that can contribute to some inaccuracy. There’s other things that happened on our unit that might put pressure on us, other emergencies that might be happening on a labor and delivery unit that might put some pressure on us to make quicker decisions to move toward delivery.

But at the end, it’s really our decision as obstetricians to make that recommendation. And generally speaking, when we make a recommendation like that, patients and families do say yes. And they ask questions, but they generally do say yes.

IRA FLATOW: Holly, what’s your reaction to this?

HOLLY KENNEDY: Well, I would completely agree with her that the culture of the unit where a woman is giving birth is very instrumental. There are a number of strategies we can do to promote a first-time mother having a vaginal birth. But you have to have the staffing. You have to have the commitment to do the kind of care that’s going to help her and her physiology to best achieve a vaginal birth.

IRA FLATOW: Let’s go to the phones. Let’s go to Northern Kentucky. Hi, Lauren welcome to Science Friday.

LAUREN: Hi Ira. Thank you for having me.

IRA FLATOW: You’re welcome. Go ahead.

LAUREN: So, I actually had an emergency C-section at 31 weeks. And I was super thankful for that being available to me. But when I got pregnant for a second time, I really wasn’t given the option of having a vaginal birth after a C-section. I had to do all of that education, investigation on my own.

So I had to look at CDC website. I had to look at rates and what were the risks for me, and my baby, and for future pregnancies. And it really was up to me. It wasn’t– my provider said, do you want to have a repeat? And at the time, I was like, oh, sure. I’ll have a repeat C-section.

But I wasn’t given the risks and benefits of both to be able to make a truly educated decision. And so I think that I was able– I actually had a planned C-section, a repeat. And then I changed my mind at 36 weeks. And my provider was really awesome with that. And I was able to have a VBAC.

But I feel like there wasn’t a lot of information given to me by my provider. I really had to search it out. And a lot of the information was very emotional. And it was really hard to find the facts.

IRA FLATOW: All right, Lauren. That’s a great, great call. Let me get a reaction. Toni, truth be told, I’m a C-section baby. And I’m one of three. Back in the day, everybody had to have one C-section after another. And Lauren was sort of saying, you know, I didn’t know that maybe I didn’t have to have that.

TONI GOLEN: Access to VBAC or a vaginal birth after a Cesarean is going to be– is one of the critical interventions that we all as a health care community are going to have to embrace, indeed to embrace, in terms of lowering the overall Cesarean delivery rate. It’s really a matter of exactly what the caller said, which is grabbing hold of accurate information. We see that as our obligation as obstetricians and midwives to really spell out what the risks are.

I think we tend to sometimes overemphasize the risk of VBAC. The risk of VBAC can be something quite catastrophic. But it’s rare.

And the benefit of a VBAC is that for births that happen there after, it’s highly more likely. For example, if someone’s going to have a third or a fourth baby, it’s highly more likely that that person would have a vaginal delivery if she’s once had a VBAC. And that really is something that contributes to the overall lifelong health of a woman.

Because the risk of a Cesarean delivery is not only related to the hour or so, or even the days or so that follow a first Cesarean delivery, but it traces back and forward to the years that follow, sometimes in some cases decades that follow women who have had Cesarean deliveries are just more likely to have repeat Cesarean deliveries as your caller almost did, increasing the risk of life-threatening complications.

The other thing that’s very interesting about VBAC is that in units– in hospital units, labor and delivery units, where VBAC is embraced, where vaginal birth is something that’s valued, it turns out that the primary Cesarean delivery rate, which has no direct relationship to VBAC because these are women who are having their first baby, and by definition, VBACs are not your first baby, those units who have higher VBAC rates, of even trying to have VBACs, and supporting women in having VBACs, have lower primary Cesarean delivery rates. It really speaks to this idea of the culture of a unit and really valuing the safety of a vaginal delivery.

IRA FLATOW: Lots of callers. 844-724-8255. Let me get to some of the tweets because we have never had so many tweets before. Let me choose out some interesting ones.

Colleen writes, I had three Cesareans, all my three kids. The first was an emergency one. But my concern now are that my children did not receive the bacteria from the birth canal. And I’m seeing possibly weak microbiomes affecting their digestive health. Holly, Toni, what do you think about that?

HOLLY KENNEDY: You know, as Tony was talking about the culture of the unit in VBAC, I think the additional things that are as really important for families to know when they’re trying to make a decision is the value of a spontaneous labor. There’s neurophysiology that prepares the baby to be born, actually contributes to health later in life, but that based on population-base studies. And the travel of the baby through the birth canal does seed the baby with microbiome.

So she’s right, that that does contribute to long-term health. It’s been worked on, we’ve looked at different things to do that with the baby after a C-section. But if you can do it just naturally, that is better.

The other thing is that babies born by C-section tend to have more respiratory distress and particularly, if they don’t have spontaneous labor. So there’s something about that spontaneous labor that contributes to the neurophysiology and the health of the baby.

IRA FLATOW: I’m Ira Flatow. This is Science Friday from WNYC Studios. So many questions. Let’s go back to the phones to Wendy in Portland, Oregon. Hi Wendy.

WENDY: Hi. Thanks for taking my call.

IRA FLATOW: Go ahead.

WENDY: So I’m actually an obstetrician/gynecologist. But I’m working just in a hospital. So I’m an obstetrical hospitalist. And one of the things that I do is just stay in the hospital to manage labor patients. So I think one of the ways the country is responding is that my type of job is becoming more and more popular, so that there are just physicians that are managing labor, and hopefully are allowing VBACs and allowing patients to labor as long as possibly safe.

I’m from Portland, Oregon. And we have the second highest rate of attempted out-of-hospital births. And we have really the best data from our birth certificates looking at transport backs into the hospital.

And I guess my concern is that when I hear– when I hear people talking of the very important things that result from having labor, I have seen some attempts at labor that really should have never been there, and have really resulted in some catastrophic outcomes for both mom and baby. So I love vaginal deliveries. I think they’re great.

But I think there are some moms and some babies that need C-sections. And we need to support that as well. And we provide it when it’s necessary.

IRA FLATOW: Tony Golen, reaction? Thanks for that call.

TONI GOLEN: I couldn’t agree more. Cesarean delivery is a life-saving procedure. And there are certainly many women who should not undergo a vaginal delivery. There’s a number of different conditions that make that unsafe.

The important thing, I think, to keep in mind is also that regarding the example of home birth in the United States, and that being an extension of the health care system, and promoting vaginal birth, while home birth in many countries is a safe option and is a way to promote vaginal birth, we haven’t quite figured that out in the United States.

It is important in a health care system that promotes home birth to be able to make a really clear connection between home and hospital. And when certain thresholds are reached, then a patient needs to be moved from home to hospital. That’s the part that we haven’t quite figured out here yet.

And until we figure that out, I think it’s going to be challenging to really embrace that as an option to promote vaginal birth. We can try to mimic that as best as we can in the hospital setting, and certainly have patients stay at home for as long as is reasonable. But home birth is not yet something in the United States that we have a really great system to support.

IRA FLATOW: All right. We’re going to have to take a break. Lots more questions. We’re going to spend another good 10 minutes on this. So we’re going to talk with Holly Kennedy and also Toni Golen. Our number, 844-742-8255. Stay with us. We’ll be right back after this break.

This is Science Friday. I’m Ira Flatow. We’ve been talking this hour about the increase in the number of C-sections and what that means for women’s health. My guests are Dr. Holly Kennedy, Professor of Midwifery at the Yale School of Nursing, Dr. Toni Golen, Vice Chair of Quality in the Department of Obstetrics and Gynecology at the famous Beth Israel Deaconess Medical Center in Boston.

And lots, lots of folks on the line. Let’s see, we only– gosh, we can’t get to everybody. Let me ask you, Holly. You worked in research midwifery in the UK. How does the approach there compared to what we do here in the US?

HOLLY KENNEDY: Well, it differs in several ways. And actually, when this Lancet series on C-section came out the, World Health Organization also issued a new guideline to help us look at decreasing Cesareans. And one of the things that they have recommended is what the UK does, which is to have a collaborative midwife obstetrician model of care where the midwife does most of the primary care.

And that’s what happens in the UK. All women have a midwife. And some women have an obstetrician too when it’s really needed. And the Lancet also published a series on midwifery, a very extensive review of the evidence. And they found that midwifery was associated with improved outcomes, including decreasing C-sections.

And so one what I’d like to just mention is in the United States, a study came out earlier this year that mapped the integration of midwifery across each state to see how friendly the state was in a regulation and reimbursement independent practice to midwifery practice. And so if you look at New Mexico, which has the lowest C-section rate of just about 18%, 26% of births are attended by midwives in that state. Conversely with New Jersey, who has the highest rate of 33%, and only 7% of births are attended by midwives. And then they map that with outcomes.

And if you look at Alabama, Alabama has some of the worst maternal and infant outcomes in the country. And only 1% of births are attended by midwives. So that’s not a causation. It is an association-type study. But it is pause for thought. And that is what we saw in the UK is that when you have a model of care when women have access to continuity of care with their midwife, their midwife knows them, they feel respected, you have better outcomes.

IRA FLATOW: Toni Golen, you work to drive down, the rate down at your hospital at Yale. And after a decade, it went from 40% to 29% in a decade? What did you do there?

TONI GOLEN: Well first, we recognized that we had a problem. And I think that’s step one in trying to solve it. And then we looked toward the evidence, not just our own evidence, but the national evidence about what was contributing mostly in terms of the indications for Cesareans and focus very narrowly on primary Cesarean.

First looked at the interpretation of how we monitor fetuses while women are in labor. That kind of monitoring, called fetal heart rate monitoring, is very tricky. It’s quite inaccurate. And it predicts quite well for us when babies are well, but does not do a good job of telling us when babies are unwell. And nonetheless, obstetricians base decisions on this test.

I often say that in no other area in medicine would we make surgical decisions based on such a faulty test. Nonetheless, it’s ubiquitous. And people use fetal heart rate monitoring. So we focused on really trying to focus on describing the fetal heart rate tracings using science and objective criteria rather than subjective words. We focused on our documentation, our communication.

We also really tried to make sure that people were using scientific modern definitions for progress in labor. Old definitions were assumed that women would move much faster in labor than newer, more modern data really proved to us. We wanted to make sure that people used modern definitions for what we thought was normal labor. As I mentioned earlier, we focused on improving access and enthusiasm for VBAC and then also some other operations, issues for our unit to change the culture of our unit.

IRA FLATOW: I misspoke. You are with Beth Israel. And I said you were with Yale where Holly is from. So, I apologize for that.

TONI GOLEN: No, I’m here in Boston

IRA FLATOW: So, does this all mean that the hospital you go to determines, more or less, if you’ll have a C-section or not?

TONI GOLEN: Unfortunately it does. And so one of the reasons why we know that we have room to improve on Cesarean delivery rates is that if you look from one hospital to the next, even separated by one or two miles from one another, who take care of patients who have similar medical problems, are of similar demographics, their Cesarean delivery rates may vary by as much as 10%. This is unexplainable by any other reason other than the environment, the unit that you work in, the people that you work with, and the general enthusiasm for vaginal birth.

IRA FLATOW: We have a tweet that’s relevant to this. And Sarah says, I have to wonder how much of the increase has to do with how much money insurance companies make on them versus a typical delivery. Did you study that in your report Holly?

HOLLY KENNEDY: Well, not specifically, except that the recommendation is that the financial strategies– women who have more money, who are wealthier, will have more C-sections, which implies that they can get reimbursed for that. And one of the recommendations that the series made was to not pay more for Cesarean to really level that playing field. And in addition to liability reform, in studies that I’ve conducted, obstetricians have said to me, I won’t get sued if I do a C-section. But I can get sued if I don’t do one in time or perceived to be in time.

IRA FLATOW: Yeah, go ahead, Toni.

TONI GOLEN: The issue of reimbursement is interesting here in the US, where, by and large, physicians or obstetricians do not get a vastly different amount of money for a vaginal delivery than a Cesarean delivery. However, the hospital does. And that is something that I think isn’t quite transparent for patients.

And probably reimbursement itself doesn’t influence a lot of obstetrician decision making here in the US. The reimbursement is greater. But it really goes more toward the hospital side because of the length of stay.

IRA FLATOW: Let’s go to Sarah in Somerville, Mass. Hi Sarah.

SARAH: Hi. I’ve had two C-sections. They were mandated by the doctor due to complications from Crohn’s disease. And so I really appreciate this nuanced discussion. But I just wanted to give a perspective of how this is actually playing out among laypeople and patients.

And I think a lot of the talk about this has become very anti-woman. When I told people that I was having a planned C-section due to my chronic illness complications, I had male friends saying things like, well, are you sure you don’t want to just labor for a little bit? Maybe you could just ask if you could labor for a little bit? And I really interpreted that as questioning can I be a woman if I don’t push the baby out vaginally? And that was really upsetting to me because my two beautiful daughters wouldn’t be here if the C-sections were not available to me.

And I just think it’s really important for those at the academic and provider levels to understand that people are hearing these discussions and I think taking them in inappropriate and different directions. So I’d love to hear the response to that.

IRA FLATOW: All right. I’ve got about a minute, Toni or Holly, which one?

HOLLY KENNEDY: I would completely agree with you that one of the most important things in this conversation is for the provider and the woman to talk through what is important to her so that she can make an informed decision about the best strategy for her. I would completely agree that it’s important that you have that conversation, and the risks and benefits of both diagonal birth and cesarean are fully, fully discussed.

IRA FLATOW: And Toni, what about this charge of sexism here?

TONI GOLEN: Point well taken. I think any extreme is going to be dangerous. I think it is important to realize that regardless of how a baby is born, the person who gives birth to the baby becomes a parent after that happens. It’s no less or no more regardless of what the mode of delivery is. And Cesarean delivery certainly makes you just as much as a mother as having a vaginal delivery.

IRA FLATOW: Great way to end. Holly Kennedy, Professor of Midwifery at Yale School of Nursing, Toni Golen, Vice Chair of Quality in the Department of Obstetrics and Gynecology at Beth Israel Deaconess Medical Center in Boston. Thank you both for taking time to be with us today. You’re welcome.

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