Far too many women in the U.S. continue to give birth by cesarean section, leading to unnecessarily high rates of maternal and infant deaths, according to research published in JAMA.
About 33% of pregnant women in the U.S. deliver babies via C-section, but an optimal rate would be around 19%, according to the study. The researchers looked at outcomes of more 23 million cesarean deliveries from 194 countries and examined the relationship between C-section rates and maternal and neonatal mortality.
Alternatively, researchers found that in many countries, not enough C-sections were being performed, suggesting inadequate access to safe and timely emergency obstetrical care.
"This suggests on a policy level that benchmarks for C-section rates a on countrywide level should be re-examined and could be higher than previously thought," said Dr. Alex Haynes, the primary investigator. He's a researcher with Ariadne Labs, a joint center of Brigham and Women's Hospital and the Harvard School of Public Health. Researchers from the Stanford University School of Medicine also participated in the study.
While the surgical procedure is can be lifesaving for women who experience obstructed labor, patient safety experts say too many pregnant women and their physicians in the U.S. schedule the surgery for convenience. Like any operation, the procedure carries risks, such as potential infections, blood loss and scarring.
There have been major national campaigns aimed at significantly reducing the rates. A total of 1,284,339 (or 32.7%) of all deliveries were done by C-section in 2013, according tofederal estimates released this year (PDF). Those rates had steadily increased every year since 1996 before peaking in 2009. They dropped 0.1% between 2012 and 2013.
Maternal mortality rates and costs are higher for women who undergo C-section compared with those for women who have a vaginal birth. For women with newborns who had employer-provided health insurance, the average total charge for cesarean births was about $20,000 higher than for women who had vaginal births, according to estimates from the Center for Healthcare Quality and Payment Reform.
Other studies have found that the rates of women giving birth by C-section vary widely by location. For example, a Consumer Reports investigation in 2014 showed higher rates among for-profit hospitals and facilities that serve large urban areas. The lowest rates were in the Mountain states, the Upper Midwest and West Coast.
While groups such as the March of Dimes, American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine have sounded the alarm in the U.S., the JAMA study notes that the opposite problem exists in other countries, where surgery may not be an available option. The study also suggests that the World Health Organization's 10% to 15% “ideal rate” for cesarean births is too low.
The study notes several limitations. Causality could not be inferred for the relationship between cesarean delivery rates and mortality. Nor could differences in delivery rates related to regional differences or wealth be accounted for.
Still, the findings highlight the need for a re-evaluation of international efforts to lower rates, Drs. Mary D'Alton and Mark Hehir of the Columbia University College of Physicians and Surgeons suggest in an accompanying editorial. Scheduling fewer C-sections has long been seen as a marker of better quality, but the rates alone may not be a strong enough measure, they said.
“Viewed in isolation they provide inadequate information regarding the quality of practice in a healthcare system,” they wrote. Determining what rate works best “cannot be as simple as a one-fits-all figure.”
