After a decade in which the rate of Caesarean-section births performed in the U.S. fell, rates have been rising again in the past couple of years and are now at or near record levels, according to recent studies.
The rates at which C-sections have been rising vary widely by state, according to Health Grades, a healthcare quality ratings company based in Lakewood, Colo., with C-section births ranging from an average of 17% in Arizona to an average of 30.8% in Texas. Health Grades obtained data from 18 states, using hospital discharge records from 1998 to 2000 for most of the states. The company obtained only 1999 and 2000 data for Illinois, North Carolina and Texas.
"The rates vary a lot by hospital and by state, and that's something expectant mothers should take into consideration, given the higher complication rate and mortality rate associated with C-sections," said Sarah Loughran, senior vice president of Health Grades. There's also the issue of cost, Loughran said, which can be up to $3,000 more per birth.
Although the World Health Organization and the HHS both put the ideal C-section rate at 15% for low-risk women, there's no agreement by physicians and other experts on what that rate should be. The American College of Obstetricians and Gynecologists has no official statement in its guidelines.
In 1970, C-sections were performed at a rate of 5% or less. As advances in medicine and technology made the option more accessible to women, rates soared. In 1988, C-section deliveries accounted for 25% of births, before consumer groups and others brought rates down to the low levels of the 1990s (See chart).
According to Health Grades' survey data from the 18 states, the national C-section average is 25.9%. And preliminary 2001 data from the National Center for Health Statistics at the Centers for Disease Control and Prevention in Atlanta show the average has risen to 24.4% from 22.9% in 2000.
"I don't know if it's a good thing or a bad thing, but it's certainly a significant thing," said Bruce Flamm, M.D., an OB/GYN with Kaiser Permanente in Riverside, Calif., and the ACOG section officer for California. "It's an amazing transition."
As for why rates vary widely by state, Flamm attributed it, at least in part, to differing malpractice laws from state to state, which could discourage some doctors from taking the perceived risks associated with vaginal births.
In Las Vegas, for instance, the cost of malpractice insurance is causing OB/GYNs to take their practices elsewhere, Flamm said.
Another reason that C-section rates are higher in some states could be that since 1999, ACOG guidelines have called for hospitals to provide standby crews of physicians and anesthesiologists during the vaginal births of women who have previously undergone a Caesarean delivery. Because of the extra personnel required, these births can be too costly for some rural hospitals, which often go with Caesarean deliveries instead.
But the big story about C-section births, Flamm said, is the rate at which they've been rising in recent years.
In the March/April 2000 issue of ACOG Clinical Review, the ACOG's then-president, W. Benson Harer Jr., M.D., wrote an editorial called "Patient choice Caesarean."
"Perhaps the time has come when risks, benefits and costs are so balanced between Caesarean and vaginal delivery that the deciding factor should simply be the mother's preference for how her baby is to be delivered," Harer wrote. "The statistics shouldn't matter."