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Sharp Rise Seen in Needless C-Sections

Study finds increase with no indicated medical reasons in 1990s

THURSDAY, Nov. 18, 2004 (HealthDayNews) -- A new study finds that, during the 1990s, there was a dramatic increase in Caesarean sections in the United States among women who faced no real medical risks.

It's not clear why this is taking place, said the study, which appears in the Nov. 20 issue of the British Medical Journal.

Other research has reported rises in C-sections, but those have mostly been local, in some cases covering only a single hospital, said study author Eugene Declercq, a professor of maternal and child health at Boston University School of Public Health.

Declercq and his colleagues looked at information on 4 million births per year between 1991 and 2001, selecting mothers who had had C-sections without any medical risk or labor and delivery complication noted on the birth certificate. They then further focused their attention on mothers who had had a first-time C-section.

In that decade, first-time C-sections in women at no increased risk increased by 67 percent, from 3.3 percent to 5.5 percent overall. The increase was gradual from 1991 to 1996, and then more rapid toward the end of the study period.

First-time mothers older than 34 were the most likely to have what the authors called a "no indicated risk" Caesarean, with almost one in five (19.5 percent) giving birth this way in 2001. More than 5 percent of mothers over 34 who had had previous vaginal births had "no indicated risk" Caesareans in 2001. And among mothers under 30 with no indicated risk, the first-time C-section rate grew by 58 percent, to 4.9 percent of all births in this age group.

In real numbers, the "no indicated risk" first-time Caesareans increased from 54,866 in 1996 to 80,028 in 2001.

The one major limitation of the study is that the information listed on the birth certificates may have been inaccurate or incomplete. "There is always the potential that there was another medical indication that didn't happen to be noted," Declercq acknowledged. "The other potential is that these do represent more elective-type Caesarean births, but nothing allows us to say that this is the mother's choice."

The study did not address why this increase is taking place, although in the past many have presumed that individual choice on the part of the mother has played a role.

"A lot of people want safe and effective maternity care, but they also want more control over care, and planning their birth is important. And what better way to plan it than to have a C-section?" said Dr. Andrei Rebarber, an associate professor of obstetrics and gynecology and maternal-fetal medicine at New York University School of Medicine. "A lot of birth injury cases that have been magnified in the media have frightened people. We live in a culture of fear."

That fear extends to physicians, who face growing malpractice costs associated with delivering babies.

But while certain dangers come with vaginal birth (pelvic floor damage, skin tears), Caesareans have higher rates of hospitalization, higher rates of pain, greater likelihood of placental problems, and less contact with the baby, Declercq pointed out.

"People assume that vaginal birth is so much riskier than C-section, but there are risks to that as well," Rebarber said. "There's really no free ride."

What particularly concerned Declercq is that so many women may be getting Caesareans without a medical reason. "Caesarean, as with all surgery, was developed with good reason to address certain problems," he said. "Part of the area of concern is when there isn't this countervailing risk."

But national statistics may mask the regional nature of the problem. "The American College of Obstetrics and Gynecology looked at regional care, and there are disparities in unindicated C-sections," Rebarber said. "These things may actually happen more in more affluent areas, particularly on either coast."

Rebarber said that, at his hospital, about 26 percent or 28 percent of all births are C-section and, of those, only about 2 percent to 3 percent are unindicated. At other hospitals in the New York City, though, the rate of C-sections is as high as 40 percent.

"States could actually use [this data] for their own purposes," Declercq said. "It wouldn't be very hard for them to develop a simple model to look at hospitals in the state to see which are doing most of the C-sections and which aren't."

In the meantime, Declercq is now researching the medical bottom line: How dangerous are these unindicated C-sections? "That's the next logical step -- looking at the outcomes of those mothers," he said.

More information

The National Institutes of Health has a brief history of the Caesarean section.

SOURCES: Eugene Declercq, Ph.D., professor, maternal and child health, Boston University School of Public Health, Boston; Andrei Rebarber, M.D., associate professor, obstetrics and gynecology and maternal fetal medicine, New York University School of Medicine, New York City; Nov. 20, 2004, British Medical Journal
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