Cesarean Sections in the News: Are Women Fully Informed?

Delivery by cesarean section is a hot topic these days.  In recent months newspapers have reported that the rate of c-sections in the U.S. has reached an all-time high; that the federal government has issued new guidelines to encourage vaginal birth after c-section (VBAC); and that health care reform has targeted unfair insurer practices, including the treatment of c-sections as pre-existing conditions.  All of these stories make one wonder, do women understand what they are getting into when they undergo a c-section?    The consequences are far-ranging, and unfortunately, will likely remain until 2014, when most of the health insurance reforms curbing unfair insurer practices go into effect.

The N.Y. Times recently reported that, in 2007 (the most recent year for which data is available), 1.4 million c-sections were performed, accounting for 32% of all births. Although c-sections undoubtedly save the lives of women and children when medically indicated, the World Health Agency suggests that the rate of c-sections should be around 15%.  A c-section is major abdominal surgery, with risks to both mother and child.  Moreover, c-sections increase the risk of complications in future pregnancies and limit women’s future delivery options.

C-sections are also more expensive than vaginal delivery, and can significantly impact a woman’s future insurance coverage, as the N.Y. Times first reported two years ago. Insurers often treat a prior c-section as a pre-existing condition, and take any range of actions including refusing to issue a policy, excluding maternity coverage, or charging a premium. The N.Y. Times echoed the concern of advocacy groups that, “[n]ot only are women feeling pressure to have Caesareans that they do not want and may not need, but they may also be denied coverage for the surgery.”   Insurance companies are not required to provide coverage to adults without regard to pre-existing conditions until 2004.

So why are c-sections on the rise?  One Philadelphia Inquirer piece suggests that two interrelated forces are driving up the numbers: doctors’ increasing use of the “surprisingly unreliable” fetal heart monitoring as a screening tool, and fear of being sued. The N.Y. Times pointed to such factors as higher rates of multiple births due to fertility treatments, a greater number of older mothers giving birth, and the increasingly common tendency to induce labor, which is more likely to result in a c-section than natural labor.

Another major reason that c-sections are on the rise is because of the dropping rates of VBACs.  Repeat c-sections account for 40% of all c-sections, and “[f]ewer than 10 percent of women who had Caesareans now have vaginal births, compared with 28.3 percent in 1996.” Many attribute the drop in VBACs to professional guidelines that “require that surgical and anesthesia teams be ‘immediately available’ during labor if a woman has had a prior Caesarean,” which caused many hospitals to simply ban VBACs. However, a NIH panel is recommending that doctors and professional groups reconsider these guidelines, after finding that “70 percent of women who have had Caesareans are good candidates for trying for a normal birth, and 60 percent to 80 percent of those who try succeed.”

Hospitals have demonstrated that certain measures can reduce the high rate of c-sections.   For example, the N.Y. Times reported on a hospital on Staten Island that has kept its c-section rate around 23%, by prohibiting unnecessary inductions before the 41st week, refusing to provide c-sections that are requested by the mother but not medically indicated, and encouraging VBACs.

Hopefully, advocacy groups and news organizations will continue to keep the debate about c-sections in the spotlight, ensuring that both women and their health care providers understand the risks, alternatives, and the potential ramifications for future healthcare coverage.

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