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Where to turn for more information about C-sections

Cesarean sections have proved to be an important option for obstetricians and expectant parents. For a variety of medical reasons, some women are unable to give birth any other way. But a debate continues to rage in the medical community, and among some parent groups, about whether too many of the surgeries are being performed. Expectant parents researching C-sections, or childbirth in general, are likely to find a lot of contradictory information. Partisans of the various ongoing debates dominate the conversation – and are often misinformed. Here’s where to find unbiased advice.

Websites

March of Dimes

The nonprofit’s mission is to improve the health of babies, and it has no perceived ideology about how to best do that. The information presented on its website generally reflects the state of the art of mainstream medical opinion in the United States. March of Dimes also provides tips on selecting a childbirth education class. (En español)

Childbirth Connection

Around since 1918, this nonprofit is committed to evidence-based maternity care. Many obstetric practices are based on tradition and expert opinion rather than actual evidence, but the Childbirth Connection’s website translates science so that it is clear and readable.

Lamaze International

One of the most trusted names in childbirth, Lamaze International is a nonprofit that supports a “natural, healthy and safe approach to pregnancy, childbirth and early parenting.” Its recommendations are based on evidence. To locate a Lamaze class, click here.

Cocharne Collaboration

To go straight to the scientific source, check out this organization, which performs systematic reviews of all existing medical science. Unfortunately, when it comes to childbirth, there is often not enough evidence on any given topic to make a simple recommendation one way or the other, which means one has to wade deep into science. Here are the reviews on pregnancy and childbirth.

Books

CSectionRecovery.com

This site steers clear of the debate while providing practical advice and useful reviews of books about preparing for – and recovering from – cesarean sections.

Birth Day: A Pediatrician Explores the Science, the History, and the Wonder of Childbirth

Pediatrician Mark Sloan recently published Birth Day, a very readable overview of how people have evolved for birth and how the medical field has been shaped by history.

Pushed: The Painful Truth About Childbirth and Modern Maternity Care

Jennifer Block’s book explores the politics of the medical science surrounding birth. It’s disturbing, highly readable, and well researched.

Want to contact an organization mentioned in the story?

American Congress of Obstetricians and Gynecologists District IX (California)

Call: 916.446-2264

E-mail: district9@ca.acog.org

Website: www.acog.org/acog_districts/dist_web.cfm?recno=13

Facebook: http://www.facebook.com/pages/The-American-Congress-of-ObGyns-ACOG-District-IX-California/316398426680

En español: http://www.acog.org/departments/dept_web.cfm?recno=45

Expert Q&A

What do rising C-section rates mean for maternal health? We asked Amy Romano, a certified nurse-midwife who manages Lamaze International’s Science & Sensibility blog and consults on perinatal research and advocacy. Romano has written extensively about maternity care research, patient-centered care, and how social media can drive health care quality improvement.

1. Why does the spike in the rate of low-risk C-sections – and the strikingly different rates from hospital to hospital – matter?

A woman who has a C-section is far more likely to have health problems after giving birth and to experience problems in future pregnancies. Cesareans pose health risks for babies as well and can also make the experience of early motherhood – holding, nurturing, and breastfeeding – more difficult. 

Still, C-sections are for some women and babies the safest and healthiest way to give birth. More often, though, the reason for the cesarean is more of a gray area: a longer-than-usual labor or high fetal heart rate pattern. Many if not most of the babies in either scenario could be born safely vaginally, but the problem is that no one knows for sure which ones. In order to manage the uncertainty, doctors or hospitals may favor doing cesareans more often. As hospitals do more C-sections, healthy women and babies experience cesareans and their consequences – while reaping minimal or no benefit in return.

Whenever there is a gray area in health care, there exists the opportunity for nonmedical factors like financial incentives, hospital culture, and imbalances of power to creep into decision making.

Additional reading:

Why Transparency Matters: A Fact Sheet for Birth Advocates

Joint Commission Measures: Elective Delivery and Cesarean Section

2. When should expectant mothers opt for a C-section? 

In all but a few specific situations, the decision to have a C-section is a judgment call. A complication such as placenta previa or placental abruption can make vaginal birth so risky that a cesarean is the only reasonable and safe option. Other situations that necessitate a C-section include when the umbilical cord loops in front of the baby's head (cord prolapse), when the baby is in an abnormal position, and when the mother has had certain kinds of uterine surgery in the past. To make the best decision possible, a woman will want to understand her individual likelihood of experiencing different outcomes and can ask her provider questions like:

  • If I continue in my plan for a vaginal birth, how likely is it that I will actually have a vaginal birth?
  • What problem are we hoping to avoid by opting for a C-section and how likely is that problem to occur if we avoid or hold off on a C-section?
  • Does my situation make a C-section any more or less risky than it is typically? (For example, obese or older women or those with chronic health problems may be at greater risk for some cesarean complications such as infection and blood clots. Women with these factors may have a different threshold for agreeing to a C-section in light of these additional risks.)
  • How experienced and comfortable are you assisting a vaginal birth in my situation? (This is an important question for a woman deciding between vaginal birth and cesarean section for breech or twin births.)

It is also important to consider the questions every woman must answer for herself:

  • What resources and support will I have available during my recovery?
  • Do I expect to have more children after this baby, and how do I feel about the risk of complications in future pregnancies?
  • How much do I value the experience of birthing my baby vaginally?
  • What are the costs associated with each option, and do I have the resources to cover these costs?

Not every woman will have the same priorities and preferences when it comes to birthing. A woman can make the choice that is right for her by becoming educated about all of her options and participating actively in decision making about her care.

Additional Reading:

Childbirth Connection Cesarean Section Resources

Lamaze International Healthy Birth Practices

3. What are the added risks associated with C-sections versus vaginal births?

In the short term, women who give birth by C-section are at excess risk of infection, hemorrhage, blood clots, anesthesia complications, and hysterectomy and remain in the hospital longer than women who give birth vaginally. Maternal death, although very rare, appears to be more common after C-section than vaginal birth. Babies born by C-section are at decreased risk of certain types of birth injuries such as nerve injury but have a higher risk of breathing problems and lacerations (cuts from surgical instruments).

Additional reading:

Childbirth Connection Cesarean Section Resources

Coalition for Improving Maternity Services Fact Sheet on Cesarean Risks

4. Are there long-term side effects or risks that can be linked with C-sections?

Long-term risks linked to C-sections include health issues for the mother and baby as well as problems in future pregnancies.

Women who have had C-sections are more likely to be readmitted to a hospital in the months following birth, generally to treat serious infections. Blood clots, gall bladder surgery, and delayed postpartum hemorrhage are other common reasons for hospital readmission and occur more frequently in women who have had C-sections. Women who have had C-sections report postpartum pain that is more disruptive and lasts longer than pain reported in women who have had vaginal births. Some develop endometriosis, a chronic painful condition, in their cesarean scars. Although rare, cesarean scar tissue may cause serious bowel or bladder problems months or years after giving birth, and may complicate future abdominal or pelvic surgeries.

New research is beginning to show that C-sections may put infants at risk for developing asthma or allergies in childhood. Researchers believe this is because infants born by C-section are exposed to hospital bacteria instead of beneficial maternal bacteria during the birth process. Babies born by cesarean may also be at excess risk for type 1 diabetes.

In future pregnancies, placental complications are significantly more common with a prior cesarean scar, and increase further in women with multiple prior cesareans. These complications include placenta previa (in which the placenta grows over the cervix), placental abruption (in which the placenta begins to detach from the uterus before the baby is born), and placenta accreta (in which the placenta adheres abnormally and begins to grow through the uterine muscle or into nearby organs). Placental complications can be life-threatening for the mother, the baby, or both, and may necessitate hospitalization during the pregnancy and/or early delivery of the infant.

Additional reading:

Childbirth Connection Cesarean Section Resources

Coalition for Improving Maternity Services Fact Sheet on Cesarean Risks

A Woman's Guide to VBAC

5. How much will a C-section or vaginal birth cost me? Is insurance coverage generally the same for both?

Although a cesarean costs significantly more than a vaginal birth ($12,000 versus $7,000 for a vaginal birth), in most cases the out-of-pocket cost for an insured woman is about the same. However, a woman who has a C-section is more likely to be readmitted to a hospital after birth and to stay in the hospital longer if readmitted. This may represent a significant additional cost, especially if a woman has become ineligible for state insurance because she is no longer pregnant. Individual insurance plans vary, so a woman should check with her insurance plan and hospital to plan for likely out-of-pocket expenses.

Additional reading:

Childbirth Connection Charges for Giving Birth By Facility and Mode of Birth

March of Dimes Costs for Maternity and Infant Care

6. How could I find out whether a hospital has doctors employed to work in labor and delivery full time – as opposed to hospitals that rely entirely on doctors going back and forth from their private practices?

Call the hospital or visit its website to find out whether it employs an ob-gyn hospitalist or laborist. Hospitalists are professionals whose primary focus is the care of hospitalized patients. A laborist focuses specifically on the care of women in labor and is available for obstetrical emergencies. Some hospitals employ nurse-midwives to work as laborists. Because of their background and training in the midwifery model of care, nurse-midwife laborists may provide more individualized care and comfort to laboring women than physician laborists and although they cannot perform C-sections, nurse-midwife laborists have undergone special additional training to assist at cesarean surgery.

Teaching hospitals may have ob-gyn residents who are also in-house around the clock and function in many ways like hospitalists. However, residents have not completed their medical training so the benefits of their immediate availability may be offset by the disadvantages of having less experience providing obstetric care.

7. Does choosing a hospital with full-time labor and delivery doctors, or shift workers, mean having a doctor other than your primary ob-gyn deliver your baby?

Different hospitals work differently. In some, the hospitalist or laborist manages the decisions about care in labor and an obstetrician from your regular practice will come to deliver the baby. In other hospitals, the hospitalists handle all of the births. Women should talk to their prenatal care providers to find out who is likely to be involved in which aspects of the labor and birth care. There are advantages and disadvantages to having a hospitalist caring for you in labor. While you may not have developed the trust and connection that comes with a longer-term relationship, the hospitalist is not juggling office hours and labor care and, because he or she works on shifts rather than on call, a hospitalist is less likely to be sleep deprived, which can improve safety.

Regardless of how care is arranged, in most cases nurses provide most of the care and support to laboring women, and the doctor checks in periodically in labor or when interventions are needed, and only stays continuously once the woman is pushing. Midwives are more likely to stay continuously with a woman throughout her labor, but busy midwifery practices may also rely on nurses or hospitalists for a significant portion of the labor care. Continuous emotional and physical support, but not medical care or advice, can also be offered by a labor support professional known as a doula.

Additional reading:

Lamaze International information on the importance of continuous labor support

Mother’s Advocate: Finding a Doula

8. If you have questions about your doctor’s recommendation for a C-section, are there steps you should take?

If your care provider suggests a C-section, take time to carefully consider the recommendation and ask plenty of questions. [See question 2]. If cesarean is recommended during a prenatal visit, consider seeking a second opinion and ask someone knowledgeable, such as a local childbirth educator or doula, to recommend a care provider known for having a low C-section rate to provide that second opinion.

Unless the situation is urgent (it usually is not), ask to see a research study that shows that a cesarean in your situation improves the chance of a healthy outcome. Some care providers recommend C-sections even when there is research showing that it does not improve outcomes. These situations include:

  • The baby is thought to be large. Ultrasound and hands-to-belly techniques to estimate the baby’s size before birth cannot reliably predict which babies will have difficulty being born vaginally. Scheduling a C-section because the baby may be big has not been shown to improve outcomes for the baby and may unnecessarily expose the mother to the risks of cesarean.
  • Labor is progressing slowly. Studies show that even when a woman’s labor stalls completely (no change in cervical dilation for several hours), if given more time many or even most will deliver vaginally.
  • Induction of labor isn’t working.Half of cesareans in induced labors occur before active labor is established. Some care providers are more patient than others when induced labors get off to a slow start. A woman undergoing an induction may be able to safely avoid a cesarean with a care provider who is willing to allow a full day or longer for active labor to begin. The best way to reduce the number of C-sections for “failed induction” is to avoid induction unless it is clearly medically necessary.

Additional reading:

Childbirth Connection Cesarean Section Resources

Mother’s Advocate: Changing Your Care Provider

9. Could the increase in C-section rates be a good thing?

There is such thing as a C-section rate that is too low. Hospitals in developing countries, for instance, may improve outcomes by increasing their use of cesarean surgery. However, almost all experts agree that in the United States the high C-section rate is already doing more harm than good. The World Health Organization states that the C-section rate should not exceed 15 percent.  In 2007, the national rate was 31.8 percent. In 2008, California had a C-section rate of 31.25 percent.

Our increasing C-section rate may reflect larger trends and issues that aren’t easily addressed by hospital-level policies and practices. With increasing use of fetal testing, we have seen a cultural shift among both women and care providers resulting in the widespread belief that nearly all bad outcomes can be avoided with high-tech surveillance and early intervention, including the preemptive use of cesarean surgery. Another complex issue is the fact that the population of women giving birth these days includes more obese and older women, as well as women with chronic health problems, and women who have used assisted reproductive technologies to get pregnant. All of these are associated with a higher risk of C-section, however the C-section rate has increased across all age groups and among women with all levels of risk, which tells us that women’s risk factors do not entirely explain the higher C-section rate.

Additional reading:

Childbirth Connection: Why Does the Cesarean Section Rate Keep Going Up?

Lamaze International Video: Birth by the Numbers

10. Since C-section rates are now being used to measure hospital quality, is it possible that they could affect a hospital’s accreditation? 

At this stage it is unlikely that a hospital’s C-section rate would affect its accreditation status because the Joint Commission and other accrediting organizations currently allow hospital leaders to choose the measures they track and report, which means all hospitals will not track and report C-section rates. This means an accredited hospital may have a high C-section rate.

This does not mean that the new C-section quality measure will not make any difference. In states such as New York and Massachusetts, hospitals are required to publicly report their C-section rates. This type of mandated public reporting makes it possible for women to have more information available to them when they are deciding where they want to give birth. In other states, such as California, the hospital rates are publicly reported through a government agency and voluntarily reported to the public at www.calhospitalcompare.org. Ultimately the public should be aware that powerful and well-respected national organizations have outlined C-section rates as a measure of the quality and safety of the care that women and their newborns receive. Women will most likely want to use this knowledge to compare the low-risk cesarean section rates of the hospitals in their area before deciding where they want to give birth.

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