Exploring the likely reasons that the increasing cesarean rate is at an all-time high.
As the cesarean rate approaches 30%, many people are starting to question the reason for the cesarean rate to have doubled in the last several decades. There are many possibilities that have likely contributed to the increasing rate. Let’s take a look at what many experts in the birthing community are saying about the causes of the increasing cesarean rate in the United States.
Electronic Fetal Monitoring
Some believe that the increase in the use of electronic fetal monitoring is a likely reason for the increase in the cesarean birth rate. One of the biggest problems with fetal monitoring is exactly how to interpret the results. A claim made for the use of electronic fetal monitoring is that it identifies a baby who is having difficulty in labor (known as fetal distress or non-reassuring fetal heart rate.) However, several studies have shown that external electronic fetal monitoring is not any more accurate in diagnosing fetal distress than periodic manual checks of the baby’s heart rate (also called auscultation.)
One interesting perspective on the misuse of external monitoring comes from the inventor, Dr. Edward Hon. Dr. Hon, along with another physician, Dr. Orvan Hess, invented the electronic fetal monitor in 1957 to treat women with high-risk pregnancies. In the 1960’s, electronic fetal monitoring began in widespread use.
Thirty years later, Hon said at a conference on “Crisis in Obstetrics: The Management of Labor,” “If you mess around with a process that works well 98% of the time, there is much potential for harm….[most women in labor may be] much better off at home [than in the hospital with the electronic fetal monitor.]” Is our misuse of electronic fetal monitoring in hospitals causing unintended problems?
Since the research on electronic fetal monitoring indicates that it has not improved outcomes, it is not surprising that there are critics of external fetal monitoring even among medical professionals. An editorial in the British Medical Journal (Goddard, 2001) stated that intermittent auscultation of the baby’s heart rate by a nurse or midwife during labor is ideal. Goddard states that, “There is good evidence that one to one care alone has a powerful effect on the labouring woman, reducing intervention.8 The cardiotocograph (fetal monitor) can become a surrogate for this best quality care and has a major impact on the caesarean section rate.”
If, in fact, electronic fetal monitoring has been a contributor to the cesarean rate, the numbers of women being “monitored” during labor paints a very large picture. In the LIstening to Mothers survey, 90% of women had electronic fetal monitoring during their labors.
Some experts blame the rising induction rate on the increase in cesarean births. There is a strong possibility that as the induction rate continues to climb, we will also see the cesarean rate follow suit. The Listening to Mothers Survey indicated the rate of labor inductions may be approaching nearly 44%. Inductions bring with them a combination of multiple interventions such as continuous electronic fetal monitoring and IV’s as well as restriction of movement and foods/fluid, and the increased likelihood of epidural anesthesia. We can only guess then, that the rising induction rate, if not the sole culprit for increasing cesareans, is a significant contributor.
Epidural rates in some hospitals in the US today hover between 60-90%. Given that epidural anesthesia also requires continuous electronic fetal monitoring, it may be hard to isolate which medical intervention may be increasing the cesarean rate the most; the monitoring or the medication.
There is some speculation that epidurals may either cause the baby to rotate into a posterior position or make it harder for a baby already in a posterior position to rotate to a more favorable anterior position. Babies in a posterior position (also called OP or occiput posterior) are notorious for causing labor to be slower, more painful and potentially harder to be born vaginally. This alone could be a possible cause for the increasing cesarean rate.
One study in 2005 showed that if the mother received an epidural when her baby’s head was still “high” in her pelvis, that it did, in fact, make it more likely for the baby to be in a posterior position. Another study (Green Journal, 2005) showed that epidural analgesia was associated with OP. Of the women with epidurals 12.9% had OP babies at delivery compared to only 3.3% without epidural analgesia.
There is speculation that care providers have increasing worries today about malpractice. Are doctors, primarily those involved with obstetrics, more likely today to be involved in malpractice issues? Is this reaction fear-based or is it real?
The AMA reports that Americans are filing 3 times more lawsuits than they did 10 years ago. The startling reality is that 50% of obstetricians have been sued for malpractice in the last 4 years. As a result, insurance premiums are also soaring to the point where many obstetricians are paying up to 30% of their annual income or more for malpractice insurance. So the threat of lawsuits is indeed real. The big question is how to find balance between being patient if mothers need to more time to labor, (especially in cases where there are no indicated risks,) and a physician’s legal concerns.
Another factor is that the number of breech babies now delivered by cesarean have greatly increased. Years ago, the mode of delivery for breech babies was nearly always a vaginal birth and physicians were trained to handle this more complicated delivery. However, about 97% of breech babies are now delivered by elective cesarean, often before 40 weeks, with only a small handful of physicians and midwives skilled to perform breech births. Even though they only make up for about 4% of all births, this number is nearly all but become another brick added to the cesarean pile.
Some have suggested that mothers are asking for more cesareans with a first baby (called cesarean demand on maternal request or CDMR) and that this is one of the reasons for the cesarean rate to increase. The Listening to Mothers I and II surveys dispute this theory, however. The most recent interview of over 1315 women showed only .08% (or 1 woman) chose a cesarean with a first baby for no medical reason. Cesarean demand on maternal request is not likely to be a major factor in the current increase in the cesarean rate.
It is very likely that all of these factors have played a role in the increasing cesarean rate in this country. Will the cesarean rate peak and begin to decline? Will it continue to rise? Some have speculated that we could see a 50% cesarean rate. Only time will tell.
What are reasons you think there are so many cesareans? Discuss it.