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C-Section Rate Reductions Panned

 |  By John Commins  
   July 01, 2013

The rate of U.S. births by cesarean section is holding steady at 31%, says the CDC. But "we are seeing an increase in cesareans for longer gestational ages—for full term. That is very disturbing," says the head of a hospital quality watchdog group.

After more than a decade of alarming and persistent growth in cesarean sections, the procedure appears to have leveled off in the past three years, but still is used for nearly one-in-three deliveries, new federal data shows.

According to a report from the Centers for Disease Control and Prevention, the total U.S. cesarean delivery rate reached a high of 32.9% of all births in 2009, rising 60% from 20.7% in 1996. However, since 2009 the rate has held at 31.3%.

Leah Binder, president and CEO of The Leapfrog Group, an employer-supported hospital quality watchdog group, said in an interview that the CDC report contained "good news and bad news."  

"The good news is the rate of cesarean sections for gestational age below 39 weeks has been decreasing. So we are seeing fewer and it's consistent with the trend Leapfrog has noted in the reduction of early elective deliveries. That is very positive," Binder says.  

"The bad news is we are seeing an increase in cesareans for longer gestational ages, for full term. That is very disturbing. It's part of an overall trend of increased use of cesarean sections for normal births and that trend has obviously been rising significantly since the 1990s from 20% back in 1996 to the current 31%. It is a very steep increase."

The CDC report does not suggest what an acceptable rate of cesarean section births should be, but Binder says the World Health Organization has stated that cesarean section rate should be about 15%.

"It is extremely disturbing to see increases in the rates of cesarean after 39 weeks. It is masked by the overall numbers of cesareans because there has been this successful effort to reduce them at the early stages. They ought to be reduced at all stages," Binder said.  

"One-in-three women do not need major abdominal surgery to have a baby. That is not how it works. It doesn't make sense. None of the literature supports it and it suggests that when a pregnant woman walks through the hospital door someone is holding a knife. Women's bodies are built for child birth and we can do a lot better than this."

The CDC study found that:

  • After 12 years of consecutive increases, the preliminary cesarean delivery rate among singleton births was unchanged from 2009 to 2011 (31.3%).
  • Cesarean delivery rates decreased more than 5% among births at 38 weeks of gestation, but increased 4% among births at 39 weeks.
  • Decreases in cesarean delivery rates for births at 38 weeks occurred for non-Hispanic white, non-Hispanic black, and Hispanic women, as well as for all maternal age groups.
  • Increases in cesarean delivery rates for births at 39 weeks occurred among non-Hispanic white, non-Hispanic black, and Hispanic women, as well as for all maternal age groups.
  • The cesarean delivery rate at 38 weeks decreased in 30 states; the cesarean delivery rate at 39 weeks increased in 23 states.

Asked for comment, the American College of Obstetricians and Gynecologists did not provide anyone to speak about the report. However, ACOG spun the findings slightly differently and said in a media release that it was "encouraging" that C section births had leveled off since 2009.

"The College believes that its ongoing efforts to reduce non-medically indicated deliveries before 39 weeks' gestation has helped to achieve this plateau," ACOG said.  

"The College is also encouraged that the cesarean delivery rate decreased by more than 5% for singleton births at 38 weeks' gestation from 2009 to 2011. This decrease in cesareans occurred for women of all races and maternal ages, and in more than half of all states. However, the encouraging news is offset by data showing the cesarean rate at 39 weeks gestation has increased by 4%. More research is needed to find out the reason(s) for this increase."

Binder says that a recent survey from the Childbirth Connection [PDF], a non-profit maternity care advocacy group, found that only 1% of new mothers said they requested a C section.  

"They also found that a lot of women were given C sections or inductions for reasons that are known not to be medically indicated," she says. "For example many women were told that they had big babies. That is not in and of itself an indication for a C section but 80% of those women were either given the induction or a C section. We know that based on that study and other and literature we know that there is a high prevalence of unnecessary C sections and certainly the increase over the last 20 years is a very disturbing phenomenon."

Binder says ACOG has listened to critics and taken some steps to address the overuse of cesareans. "For example, ACOG now does not now automatically recommend a cesarean section when a woman has had a cesarean in the past," she says.  

"There has been a major push and frankly Leapfrog was the first domino to push on this. We launched a campaign on early elective deliveries that are scheduled without a medical reason either by C section or induction prior to 39 weeks gestation. That is too early. If you have a delivery at that gestational age, 37 to 39 weeks, babies end up on respirators and in (neo-natal intensive care units) and it's not safe."

Even with the support of the March of Dimes and decades of warnings from ACOG, Binder says the early elective deliveries were occurring "at a very high rate."

"Finally, in 2010 Leapfrog put out rates of early elective deliveries by hospital. That really galvanized things very quickly. We got a lot of attention," Binder says.

"The March of Dimes was very excited by the amount of attention we got for this announcement and they were able to use it to accelerate their own campaign against these deliveries. There has been a real movement around reducing early elective deliveries and these results do reflect that."

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John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.

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