The United States spends over $2.5 trillion each year on health care (Medical Mutual), with around $111 billion of that going directly to child birth (Childbirth Connection). Unfortunately, however, despite the fact that the United States spends far more than any other country on childbirth, for every 100,000 live births 21 women and 5.9 infants die (CIA). What’s worse is that these numbers are actually on the rise, alongside with the already high rates of cesarean sections. For optimal maternal and newborn outcome, the World Health Organization recommends that a country’s C-section rate be kept between 5%-10% of all live births, and that it does not exceed 15% (cesarean section). Despite these recommendations, the current C-section rate here in the U.S. is a shocking 32.9%, and it is likely that this number continues to rise (CDC). So why then, if all the scientific evidence points to lower C-section rates correlating with lower infant and maternal mortality rates, do C-section rates continue to increase? Some of the strongest factors contributing to this trend may include the increase in the number of labors that are induced, clinical impatience, and the decrease in the number of facilities that are willing to perform a vaginal birth after cesarean sections, or VBAC.
The famous words: “Once a cesarean, always a cesarean” have echoed and reverberated throughout the medical community since their utterance by Edwin Cragin in the early 1900s (Ugwumadu). However, well over 70% of all VBACs are successful, and the likeliness of their success substantially increases for mothers who have had previous vaginal births or successful VBACs (Caughey). Between 1988 and 1996, these odds were taken advantage of and there was a 4% drop in the number of C-sections being performed (Caughney). During this time around 40% of women who had had a previous cesarean, were able to attempt a VBAC (Caughney). Unfortunately, however, in 1999 the American College of Obstetricians and Gynecology, or ACOG, changed its guidelines pertaining to the conditions under which facilities could perform VBACs (Caughney). Under these new guidelines the financial burden to perform VBACs dramatically increased, which resulted in a decrease in the number of facilities able to offer them as a birthing option. Consequently, the overall number of VBACs preformed began to decline. Today, only one out of every ten women who has had a C-section will go on to have a vaginal birth; numbers which substantially increase the nation’s overall cesarean rate (“cesarean section”). However, the decrease in the number of facilities able to offer VBACs fails to address why there are so many C-sections in the first place.
The increase in the number of first time mothers whose labors are induced, is one of the biggest factors contributing to the overall number of C-sections that occur here in the U.S. (Leggit). In a 2010 study, published in the journal of Obstetrics & Gynecology, out of 7,800 first time mothers, 44% had their labor induced before 41 weeks (O’Callaghan). Out of the women whose labors had been induced before 41 weeks, 40% had been classified as elective with no medical implications for the induction (O’Callaghan). Numerous studies have indicated that for first time mothers whose labor is induced are at much greater risk of that induction failing and they’re about two-fold as likely to end up needing a C-section (Dekker). According to one study, 42 percent of all first time mothers whose labor is induced require an emergency C-section (“induction Math”). However, the further along a woman is in her pregnancy, the more favorable the conditions of her cervix become and the more likely an induction will be successful. One of the most common reasons for induction failure is dystocia, or in layman’s terms “failure to progress” (Healthline). According to Jose Mata, a medical doctor and professor at the University Of Utah School Of Medicine, dystocia is the most common indication for a C-section and its diagnosis accounts for an estimated 60% of all cesarean deliveries (et al Mata). Unfortunately, the diagnosis of “failure to progress” has repeatedly been criticized as more accurately being defined as a “failure to wait.”
The notion that clinical impatience may be resulting in the over diagnosis of dystocia, which in turn may be resulting in an increase in the cesarean rate, is far from novel. In 1996 the country’s overall C-section rate was around 21%, however, this rate was only around 7% for mothers admitted to Zuni-Ramah, a hospital in northwestern New Mexico (Rubin). One of the reasons this hospital had such low C-section rates in comparison to the rest of the country was attributed to the fact that first time mothers who gave birth at Zuni- Ramah were around 80% less likely to have a C-section as a result of receiving dystocia as a diagnosis (Rubin). Since the hospital was not equipped to do C-sections, if one was needed, the laboring mother would have to be transported to a larger facility 35 miles away. To obtain permission to transport a patient, hospital policy required that two doctors concede that a cesarean was in fact necessary. According to a couple, known as the Leemans, who practiced medicine at the Zuni-Ramah facility, “the logistics of obtaining a C-section motivate[d] doctors and patients to wait out slow labor[s],” an approach that has had no notable ill effect on the outcome of expectant mothers or their babies (Rubin). Jane Singer, a midwife who teaches medical students and residence at the Women & Infants Hospital of Rhode Island, states that ” ‘failure to progress’ is perhaps the most preventable reason for cesareans” (Lake). This implies that maternal and clinical impatience, which can hasten the decision to perform a C-section, are likely very influential underlying factors contributing to the increase in our nation’s rate of cesarean sections.
The rate of cesarean deliveries in our nation continues to rise, and most astoundingly it continues to rise against medical implication. According to recent studies, the risk of maternal death during a planned C-section is three times higher than that of a vaginal birth, and for emergency C-sections the risk increases to four times higher (qtd. in Kresser). With current C-section rates more than double what the World Health Organization deems safe, there is much room for improvement. The health and wellness of our nation’s mothers and children depends not only on bringing these numbers to a halt, but turning them around. If the U.S. can increase the availability of facilities that are willing to perform VBACs, decrease the number of women who undergo elective inductions, and alter policies so that there is more incentive for clinicians to wait out lengthy labors, then not only will we be decreasing our nation’s C-sections rates, we will be decreasing the financial burden brought on by the expense of this procedure. Most importantly, however, we will be increasing the number of women who return home safely to their husbands and children after bringing life into this world.
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