A new report showing that the cesarean section rate in New York has climbed to an all-time high has prompted groups that promote the use of midwives and natural birthing methods to call for more education about the risks associated with C-sections and other birthing options.
The report, which was released Tuesday by the U.S. Center for Disease Control’s National Center for Health Statistics, shows that New York’s cesarean section rate in 2007 was 33.7 percent, the highest it has ever been, and has increased 47 percent since 1996. Nationally, the cesarean section rate was 31.8 percent, a 53 percent increase from 1996 and also the highest rate ever recorded in the U.S.
A cesarean section is delivery of a baby by major abdominal surgery.
“This is something we should be concerned about,” said Mary Applegate, associate dean for academic affairs at the School of Public Health at the University at Albany. Reducing the C-section rate “will take major changes in how we think about childbirth,” she said.
Women who have cesarean sections face greater risk of infection and other complications; their babies are more likely to be born early and require neonatal intensive care unit admission. Hospital charges for a cesarean delivery are almost double those for a vaginal delivery, “imposing significant costs,” according to the CDC report.
Cesarean section rates at local hospitals have increased, reflecting the national trend. At St. Mary’s Hospital in Troy, the C-section rate is 20.7 percent, while the C-section rate at Albany Medical Center is 43.1 percent.
Reasons for increase
Dr. Camille Kanaan, chief of the Division of Maternal-Fetal Medicine at Albany Medical Center, said that C-section rates are on the rise for “many, many reasons.” He said that C-section rates vary from hospital to hospital and that hospitals that perform a greater volume of high-risk deliveries, as Albany Medical Center does, are more likely to have higher rates.
“We get referrals from 20 different hospitals for high-risk patients,” he said. “That’s a disproportionate amount. We see more women with diabetes at Albany Med, and women with diabetes have a higher risk of C-section. We do 2,300 deliveries a year, with a disproportionate amount of high-risk situations.”
Women are also having babies at an older age, and more women are having multiple births, which physicians are more reluctant to deliver vaginally.
Legal issues are also a factor, Kanann said. “You also have the effect of higher malpractice insurance rates and chance of being sued,” he said.
“Liability is always in the background here,” Applegate said. “Obstetricians, along with neurosurgeons, are the most-sued medical professions. OB/GYNs pay huge amounts in malpractice insurance.”
Kanann said it was difficult to say what “an appropriate C-section rate [would be].
“We do look at C-section rates, and if there are issues, if there are C-sections being performed unnecessarily, we do address that. But we don’t think there are. I’m not saying that the rate is ideal. We do work at lowering it if we can. It is a concern because C-sections carry risks of complications. But to say we’re going to set a goal of lowering the rate overall may not be realistic.”
After the surgery
Niskayuna resident Melissa Kane heads the Capital Region chapter of the International Cesarean Awareness Network.
One of the group’s goals is to make women aware that they can have a vaginal birth after a cesarean section, or VBAC, and provide them with support and information on how to do that.
“VBACs are safe for the vast majority of women,” Kane said. “The more cesareans we do, the more moms and babies are going to be harmed by it. High cesarean rates contribute to poor health outcomes for moms and babies.”
Last month an independent panel convened by the National Institutes of Health found that many women have limited access to clinicians and facilities that allow VBACs because many hospitals have “VBAC bans.”
The panel confirmed that a vaginal birth is a reasonable option for many women who have had a cesarean section and urged that VBAC guidelines be revisited.
Fewer women are having vaginal births after cesarean sections, Kanaan said, because fewer women are requesting them.
Kane said, “It would be nice if hospitals and providers could find a way to open up options.”
Saratoga Hospital, Nathan Littauer Hospital in Gloversville and Glens Falls Hospital do not offer VBACs.
In 2007, Kane gave birth to a daughter via VBAC.
When Kane gave birth to her son, her labor was prolonged and the baby had a hard time descending the birth canal.
Because of the baby’s “failure to progress,” she had a C-section. But the surgery troubled her because she didn’t know whether it was necessary.
“Some women can say, ‘I know my cesarean wasn’t necessary,’ ” she said. “Some women can come out of a C-section and say, ‘It saved my life.’ Then there’s another group of women that just don’t know. For me, it kind of felt like defeat. I wanted a different experience. Recovering from a cesarean is no picnic.”
The New York chapter of the American College of Obstetricians and Gynecologists referred questions about the CDC report to the organization’s national office and provided a copy of a decade-old report on the issue. In ACOG’s 2000 report, titled “Evaluation of Cesarean Delivery,” the group expresses concern over rising cesarean rates.
midwives speak out
On April 12, midwives and supporters will rally at the state Capitol in support of the Midwifery Modernization Act. Right now, midwives must maintain a written practice agreement with a physician to practice; the Midwifery Modernization Act would eliminate this requirement.
Carolyn Keefe, co-founder of the local nonprofit group BirthNet, said allowing midwives to operate without a written agreement would expand access to midwives and improve infant and maternal well-being. She said that right now, many physicians are unwilling or unable to enter into written practice agreements, which makes it impossible for many midwives to establish practices. The written agreement requirement “isn’t a tool for collaboration,” Keefe said. “It’s a tool for control.”
Women who use midwives have lower C-section rates.
“In terms of making pregnancy a successful family experience, midwives do an excellent job, and the end result is a much lower C-section rate than obstetricians,” Applegate said. “Midwives expect that women are going to have a vaginal delivery. That makes a difference.”
St. Mary’s in Troy and St. Peter’s in Albany both have midwives on their hospital staff.
Applegate said women who have had C-sections face new risks in their next pregnancy. For example, having a scar on their uterus can result in the placenta attaching to the wall of the uterus in the wrong place, which can cause problems, some of which are life-threatening.
According to the CDC report, the cesarean birth rate among women in all age groups and in all racial and ethnic groups has increased.
Applegate served as medical director of the bureau of women’s health at the state Department of Health from 1993 to 2005. During that time, the DOH became considered about the rising C-section rate, and she worked closely with the American College of Obstetricians and Gynecologists to address the issue and come up with guidelines.
“We set up criteria so people wouldn’t be rushing to C-section, and we promoted VBACs,” she said.
But when a study found that VBACs carried a risk of uterine rupture, hospitals became less enthusiastic about allowing them, and ACOG recommended that VBACs only be allowed if a C-section was also immediately available, Applegate said.
“This made the C-section rate shoot back up immediately, because so many women had already had C-sections,” Applegate said. “The VBAC movement was pretty severely damaged.”