The cesarean section rate in the US has reached an all time high. What is most concerning with the recent statistics is that primary (first) cesarean rate is now 30%. With the VBAC (vaginal birth after cesarean section) rate also declining, this increasing primary cesarean rate places our country on course for an overall rate that could soon reach 50%, which seems absurd.
The reasons for this have been examined by government analysts, insurance companies and patient advocacy groups alike. Doctors blame lawyers and increasing malpractice litigation, while insurance groups blame “greedy” doctors who get paid more for cesarean section. While patients are left on the sidelines asking, “What’s really going on, and what can I do to help reduce my risk of a cesarean section?”
In the midst of the rhetoric, some helpful ideas have emerged such as making public each hospital and physician’s personal cesarean section rate, so patient’s can be aware of true outliers of the norm. Additionally ACOG has recently adopted more evidence based guidelines for interpreting fetal heart rate tracings, which can help physicians make decisions based on these guidelines and not make decisions out of fear of lawsuit. The NIH has also revised its VBAC guidelines, to once again encourage this practice.
The decision to perform a cesarean section is never one I take lightly, but after these new statistics came out, it has caused me to search for even more ways to help bring my rate down. Certain risk factors for cesarean section such as maternal age >35, twins and placenta previa are not preventable. However, there are some patient risk factors that are modifiable.
The biggest risk factor for cesarean section is actually something that is best addressed before pregnancy: obesity.
The adult obesity rate in the US is rising at a startling rate. Approximately 30% of reproductive age women are obese, defined as a BMI of 30 or greater. Obesity doubles your risk of cesarean section, and also doubles the complication rate of cesarean section. Additionally, it increases your risk for other pregnancy complications such as pre-eclampsia, gestational diabetes, and blood clots. The risk is even higher if you are both vertically challenged and overweight.
If you do enter pregnancy in the overweight range, limiting weight gain and daily exercise are your best tools to help avoid further complications.
Ten percent of women still continue to smoke during pregnancy, with this number approaching 17% among teenagers. In addition to risks of preterm labor and still birth, smoking also increases the risk of placental abruption which then increases the risk of cesarean section.
Excess weight gain in pregnancy, even in normal weight women, has also been shown to increase the risk of cesarean section. Making wise food choices and continuing a doctor approved exercise regime can help prevent gestational diabetes and excess weight gain in pregnancy.
Limit Elective Inductions
With first pregnancies especially, one of the biggest set ups for unnecessary cesarean sections is unnecessary inductions. Induction increases the rate of cesarean section by 15% in women having their first baby. In subsequent pregnancies the risk is much lower at 1%. There are medical reasons for inductions such as high blood pressure or diabetes. However, swollen ankles, back pain and misery are not good enough reasons to put yourself at an increased risk for the complications that can occur with cesarean section.
Be Open to Forceps/ Vacuum
On nearly every birth plan I read, the patient will write something like, “prefer to have cesarean section rather than forceps.” In actuality, judicious use of vacuum and forceps is key to help reducing the cesarean section rate. I try to explain to patients that the true risks of vacuum and forceps when performed properly can be lower than those of cesarean section. The decision as to which is safer is determined by how deep the baby’s head is in the birth canal. When the head is near crowning and there is need for urgent delivery, usually a vacuum or forceps is the best option for both mother and baby.
Finding a Doctor you Trust
If you are looking for a competent, patient and caring physician (I think these are the top three qualities an OB/GYN should have) talk to a labor and delivery nurse at your local hospital for a recommendation. Once you find a physician that you can trust and with whom you feel comfortable, talk to them about your thoughts on cesarean section and ask them for additional ways that you can reduce your risk.
Yes, there is much that needs to be done to reduce the cesarean section rates in the US. Just as there is not one specific cause, there is also not one specific answer. The medical community will continue to look for ways to safely reduce this rate. Hopefully these tips will help you as the patient, make proactive decisions for a healthier pregnancy and delivery.