A recent New York Times piece, Majority of Caesareans Are Done Before Labor, discusses a study on cesearean section by the Consortium on Safe Labor. The actual study report covered by the Times is currently an “in press” article from the American Journal of Obstetrics and Gynecology, entitled “Contemporary cesarean delivery practice in the United States” with lead author Jun Zhang.
The researchers reviewed the medical records from more than 200,000 births at 19 hospitals around the country. The authors report an overall cesarean rate of 30.5%, varying from 20% to 44% among different hospitals, with a rate of 31.2% for first births (and 30.0% for women with previous births).
According to the Times, “Dr. Zhang said one thing that surprised him about the study was that a third of first-time mothers were having Caesareans. Although it was known that the overall Caesarean rate was 32 percent, some of that was thought to be due to repeat Caesareans.”
That finding is pretty similar to the figure provided in recent CDC report, which indicated that the cesarean rate was 23.9% for first births in 1990, decreased slightly in the mid-to-late 1990s (to around 21% for a few years), and then increased up to 27.1% in 2003. We know that the rate of cesareans overall has continued to increase since 2003 (where the CDC report stopped), so it’s not altogether surprising that Zhang et al (whose study covered 2002-2008) found an even higher rate (31.2%) among the first-time moms in the study.
The paper includes quite a bit more data and analysis on various factors. There is too much to detail all of it here, but here are some snippets highlighted by the authors:
- The induction rate was 36.2% overall, and 43.8% among women attempting vaginal delivery.
- The cesarean rate was twice as high in induced labor than in spontaneous labor overall (21.1% vs 11.8%).
- In women with a previous uterine scar, only 28.8% had a trial of labor, which the authors called “disappointingly low.” Among them, the rate of successful VBAC was 57.1%.
- Almost all (92.8%) of the nonvertex presentations were delivered by cesarean.
- Just over half of the cesareans were “prelabor,” with the most frequent reason being a previous cesarean.
The authors conclude with this statement on the increasing cesarean rate in the United States:
To make a significant impact on the high cesarean delivery rate in the United States, the focus should be preventing unnecessary primary cesarean deliveries from several aspects. First, we need to decrease the rate of cesarean delivery associated with a high rate of induction of labor. Cesarean section for dystocia should be avoided before active phase of labor is established particularly in nulliparous women, induced labor, and VBAC attempts. Second, there should be a clinically accepted indication for performing cesarean delivery. Finally, increasing access to and patient education on trial of labor in women with a previous uterine scar and improving the success rate are urgently needed.
Related: I haven’t checked it out myself yet, but recently learned about A Woman’s Guide to VBAC: Navigating the NIH Consensus Recommendations, a VBAC advocacy project inspired by the recent NIH consensus development conference on VBAC.