Efforts to reduce cesarean epidemic

About 32% of all births in the United States-or roughly 1.2 million-are cesarean deliveries, which is a 50% increase over the past decade. But are all of these cesareans necessary? Unlikely, according to a presentation at the 2018 Annual ACOG Meeting in Austin that outlined the reasons for the epidemic and strategies to reduce it.

“To minimize maternal and neonatal morbidity and mortality, we think the appropriate cesarean rate is somewhere between 10% and 20%,” said Aaron Caughey, MD, chair of the Department of Obstetrics and Gynecology at Oregon Health & Science University (OHSU) School of Medicine in Portland.

Dr. Caughey told Contemporary OB/GYN that maternal mortality has risen over the past 10 years. “This higher rate is probably not due primarily to cesareans, but a mother is more likely to die if she has a cesarean delivery as opposed to a vaginal delivery,” he said.

The biggest reason for a cesarean is a previous cesarean delivery, followed by prolonged labor and fetal indications. “It is important to be more patient in the first and second stages of labor,” said Dr. Caughey. “Similarly, fetal heart monitoring has been shown to be a really poor tool. It does not have a high sensitivity or specificity for the outcome it was trying to prevent, which is cerebral palsy. As a result, in the 1990s, as we became more conservative in how we used the information gleaned from fetal heart monitoring, this likely led to more cesarean deliveries.”

Furthermore, in 1995, the success rate for vaginal birth after cesarean (VBAC) was about 25% but is now less than 10%. “Is this because women decided they did not want a VBAC or is it because healthcare facilities decided they did not want to provide the resources?” said Dr. Caughey. “It is probably more the latter than the former, given the fact that about half of the hospitals in the United States do not offer trial of labor after cesarean, even though many of these hospitals probably could.”

Less influential, according to Dr. Caughey, is physician convenience. “What we have seen increasingly over the last 10 to 15 years is the adoption of hospital-based laborists at many institutions, particularly the largest ones,” he said. This has decreased the incentive to perform a cesarean because of a physician’s call schedule or convenience.

Regardless, Dr. Caughey believes obstetricians should be alarmed by the high rate of cesareans. “We are definitely overusing an invasive, expensive surgery in the setting of childbirth for minimal to no benefit in most instances,” he said.

Mothers can help lower the rate by asking questions of their doctors and midwives about why they are being scheduled for cesareans. “Our philosophy should be in sync with the patient’s,” said Dr. Caughey. “I suspect that if women were more inquisitive, we would see a decrease in cesareans, but we do not have great data on that issue.”

Interestingly, in the past in many setting, physician reimbursement for cesareans was about twice that for vaginal birth. But because of policy changes in the 1980s and 1990s to reduce that differential, “the difference is much smaller now, so there appears to be minimal financial incentive to physicians to perform more cesareans,” said Dr. Caughey. However, because of the medical-legal environment and the interest in minimizing fetal and neonatal injury, those pressures likely contributed to the rise in cesareans.

In addition, despite hospitals now receiving about twice the amount for a cesarean compared to a vaginal delivery, patient hospital stay is at least twice as long with a cesarean. “In most cases, a hospital loses more money on a cesarean than it loses on a vaginal delivery,” said Dr. Caughey.

One encouraging trend is the slight reduction in cesareans in the United States from 33% to 31.9% between 2009 and 2016. “Although a 1.1% reduction may not seem like much, it translates into about 40,000 fewer cesareans annually,” said Dr. Caughey. “This is in light of women being sicker and obesity rates continuing to rise.”

Also, back in 1989, the United States had the highest reported cesarean rate in the world. “But by the year 2000, even though our cesarean rate had increased slightly, we were no longer No. 1,” said Dr. Caughey. “In fact, between 1990 and 1995 was the only time that a developed country was able to lower its cesarean rate. And that was us.”

Even countries that have had traditionally low cesarean delivery rates, like the Netherlands, Sweden and the United Kingdom, have seen their cesarean rates rise at least as much as in the United States, if not higher, according to Dr. Caughey.

“Previously, all we cared about was the VBAC rate and the cesarean rate,” said Dr. Caughey. “However, we need to care about the patient’s experience as well. By focusing on our patients and ensuring that they are receiving good care, I think we can both lower the cesarean rate and do it in a way that does not lead to more complications.”

Disclosures:

Dr. Caughey reports no relevant financial disclosures.