Nearly 1.4 million babies are born surgically in the United States each year. That's a third of all births, and the numbers are only getting bigger. The trend is due in part to an increase in elective cesarean sections, or surgical births that aren't medically necessary. Why are women in the United States being encouraged to undergo unnecessary surgery? Certainly, money is a factor. Hospitals save money if they can schedule births months in advance, and they make money from a procedure that is on average more expensive than vaginal birth. But women are taking more than a financial hit. Some studies suggest that elective C-sections may pose health risks to mothers — and long-term health complications for babies.
Since the 1990s, C-sections have become the most common operating room procedure in the United States. Without question, these procedures are absolutely necessary in certain circumstances, usually when there's danger to the mother or baby (like a uterine rupture, a breech baby, or a placental abruption). Nobody is arguing that women should stop having C-sections when they are needed.
It's the overuse of cesarean delivery in the absence of an identifiable health risk that's the growing concern. First, these elective C-sections seem to be the result of doctor recommendations, rather than patient requests. A 2008 study by Marian MacDorman and Eugene Declercq noted that "Increases in primary cesareans in cases of ‘no indicated risk' have been more rapid than in the overall population and seem the result of changes in obstetric practice rather than changes in the medical risk profile or increases in ‘maternal request.'"
In other words, while a small proportion of women do ask to have an elective cesarean, it's more often on the advice of their obstetrician or hospital that they decide to go through with the procedure — even in the absence of an "indicated risk." Studies show that few women prefer cesareans in the absence of medical or obstetrical factors. So the rise in C-sections is likely not coming from patient choice, but pressure from doctors and hospitals.
To understand what's going on, and why there's a trend towards elective cesareans, we contacted Maureen Corry, the Executive Director of Childbirth Connection, a not-for-profit that seeks to improve the quality and value of maternity care.
"I am concerned that women don't have full, accurate and unbiased information about the benefits and harms of having an elective C-section," she told io9. "And if they don't have that information and really consider it in relation to their values and goals for their pregnancy, then they cannot make a truly informed decision." The consequence, says Corry, is that women may decide to have an elective procedure that is unnecessary, and thereby exposing themselves and their babies to unnecessary risks.
And in terms of explaining the trend, Corry pointed her finger at the medical profession, saying the business aspect can't easily be cast aside.
"The hospitals stand to make a lot more money on cesareans than they do on vaginal births," she said, "and we know this because we issued a cost report back in January called ‘The Cost Of Having A Baby in the U.S.'"
Looking at the report, the average cost of a C-section in 2010 was $27,000 compared to $18,000 for a vaginal birth.
"We know that the greatest portion of the costs are in the hospital facility fees," she told io9, "so, it's one of the incentives for having a high cesarean rate in a hospital setting."
While most elective cesareans are relatively uneventful, Corry says many will have poor outcomes and morbidities (an increased rate of health problems or disease) associated with having what is largely an unnecessary intervention.
"Babies born via C-sections have an increased chance of having to be administered into the NICU [the neonatal intensive care unit] and suffer from breathing problems," she said. "Mothers are more likely to have a major infection, they are at higher risk for embolisms, for bleeding, and for long term consequences with each additional C-section, some of which can be life threatening." On that last item, Corry was referring to placental complications in subsequent pregnancies — a frustratingly common problem.
Corry pointed us to a 2012 report by Amy Romano and Carol Sakala, "Vaginal or Cesarean Birth: What Is At Stake For Women And Babies?," in which the various risks are assessed, both for cesarean and vaginal births. In the report, the authors write, "Overuse of cesarean delivery in low-risk women exposes more women and babies to potential harms of cesarean with minimal likelihood of benefit."
Indeed, the scientific literature on the matter is sobering.
According to a 2010 study, mothers are three times more likely to die from complications stemming from a C-section than a vaginal delivery. The authors write that cesareans are "increasingly perceived as a low-risk procedure. However, the present study clearly demonstrates that the risk of maternal death due to [C-sections are] significantly high, particularly when performed in labor. Therefore, [it] should only be practiced when conditions clearly demand it."
Compared to vaginal births, cesareans lead to an increased risk for cardiac arrest (Liu et al 2007), urgent and/or unplanned hysterectomies (Liu 2007, Kacmar et al. 2003, Knight et al. 2008), blood clots (or thromboembolic events) (Koroukian 2004), anesthetic complications (Koroukian 2004), hematomas (Liu 2007), major infections (Tita et al. 2009), persistent pain (Latthe 2005), and problems with physical recovery (Thompson 2002).
These studies have led Kirstin Hendrickson of Arizona State University to conclude that:
an uncomplicated vaginal delivery is safest for mother and baby, while a planned C-section is safer than a complicated vaginal delivery that results in an unplanned C-section. Unfortunately, it's impossible to know in advance who will have an uncomplicated vaginal delivery.
Indeed, it's important to note that when the baby is in the breech position (a complicated delivery), infant mortality and serious morbidity are significantly lower in planned cesareans compared to planned vaginal delivery (Hannah et al. 2000).
Women who have cesareans are more likely to be sent to intensive care or to be re-admitted to the hospital (Lydon-Rochelle et al. 2000, Sanchez-Ramos et al. 2002, Hannah et al. 2005). And needless to say, C-sections also increase the length of a hospital stay by as much as two (expensive) days compared to vaginal births (Sanchez-Ramos 2002).
For the baby, C-sections increase the chances of respiratory distress syndrome (Hansen et al. 2008), pulmonary hypertension (Hansen et al. 2008), and the (very slight) chance of being cut.
Other experts — including physicians themselves — have waded into the discussion. Daghni Rajasingham, an obstetrician and spokeswoman for the Royal College of Obstetricians and Gynaecologists, told AP back in 2010 that: "As long as it's safe for both mother and baby, a vaginal birth is absolutely the best way for anyone to deliver." She noted that, while C-sections are safe, the operation comes with risks — including infections, bleeding, and the potential for problems with future pregnancies.
She also said that the physical stress put on a baby's lungs during labor helps them adapt to breathing after being born. And indeed, this hints to another, perhaps non-intuitive issue. It's not just the risks that need to be considered, but also the potential benefits that may conferred by vaginal deliveries.
In an unprecedented study led by Anita Kozyrskyj of the University of Alberta, it was shown that babies born by cesarean are deficient in a specific group of bacteria found in babies born vaginally. This gut bacteria is important for newborns, as it helps them digest food, regulate bowels, develop their immune systems, and protect against infection.
It's literally a one-time shot for a baby to get exposed to his or her mother's microbes — and it can only happen during a vaginal birth. Cesareans, it would seem, deny them that opportunity.
"The Canadian Medical Association Journal article is the first publication of our SyMBIOTA research program to show the effects of C-section delivery of term infants on their gut microbiome," Kozyrskyj told io9 via email. "Even among 24 infants, we were able to find differences in the gut microbiome at four months of age according to method of delivery, notably, that Bacteroides was virtually absent in infants born by C-section. Increasingly, we are learning about the importance of this group of bacteria in training the infant's immune system to prevent overreaction (and allergy) to ingested substances which are not harmful."
Cesarean delivery, she said, interferes with a newborn's acquisition of vaginal and perianal microbes from the mother, which is required for "seeding" the normal development of the infant gut microbiome.
In her paper, she wrote:
Further, C-section is not an isolated event. Mothers undergoing C-section receive prophylaxis with antibiotics and often delay breastfeeding. Their infants are more likely to be born with respiratory distress, which increases the likelihood of additional (and direct) exposure to antibiotic treatment to rule out infection. All of these events are known to affect the composition of the infant's gut microbiome and in several studies, have been found to increase the risk of allergies and asthma in children. Unless indicated otherwise to protect the health of the woman and her fetus, the benefits of vaginal delivery are clear to me: avoidance of exposures that interfere with the normal development of the gut microbiome in infants.
Kozyrskyj admitted that her preliminary report on 24 infants offered "insufficient evidence" to support recommendations that doctors refrain from performing non-medically indicated C-sections. Moreover, these decisions are always made in consultation with expectant mothers. What the woman wants is paramount.
But looking forward, Kozyrskyj plans to report on C-section disruption of the gut microbiome composition of 2,500 infants at four months and one year of age — and it's significance to subsequent development of childhood allergy and asthma.
"With this large amount of data, we will be in a better position to provide stronger evidence and reassurance to parents, physicians and nurses on the unseen consequences in the infant of non-medically indicated C-section," she says.
And indeed, Kozyrskyj is not the only one investigating the allergy connection. Researchers are gathering more evidence for the "hygiene hypothesis."
In an unrelated study presented on February 24th, 2013 at the American Academy of Allergy, Asthma and Immunology's annual meeting in San Antonio, Dr. Christine Cole Johnson presented evidence that babies born by C-section are five times more likely to develop allergies than babies born vaginally. Specifically, babies born via C-section are at heightened risk of developing Immunoglobulin E, or IgE, after exposure to allergens (which is linked to the onset of allergies and asthma).
"This further advances the hygiene hypothesis that early childhood exposure to microorganisms affects the immune system's development and onset of allergies," she noted in a statement. "We believe a baby's exposure to bacteria in the birth canal is a major influencer on their immune system."
When we brought the hygiene hypothesis to Corry's attention she said she was familiar with it, but that more work needs to be done to get the word out.
"That is certainly not a message that most women get when they're trying to make these decisions," she told us.
Further downsides to cesareans include their potential to disrupt other natural processes, such as breastfeeding and mother-infant bonding.
Anne Weeks, an International Board Certified Lactation Consultant working in Ontario, is concerned about how elective C-sections may interfere with early breastfeeding — something that, ideally, should be initiated moments after birth.
"The mode of birth impacts early breastfeeding success," she told io9. "Newborns are hardwired to learn how to breastfeed in the first hour following a non-medicated, vaginal birth. When placed skin-to-skin upon their mother's chest immediately following delivery, a non-medicated, healthy newborn has the innate ability to seek, find, and self-attach to the mother's breast." She says that medications can greatly interfere with this process and all pain medications used in obstetrics affect the baby — including epidural and spinal medications.
Weeks makes the case that the successful establishment of breastfeeding is enhanced when newborns are allowed unlimited access to the breast. When babies are not breastfed "early and often" after birth, mother's mature milk may be delayed and a full milk supply may be compromised.
"Babies born by C-section are routinely separated from their mothers immediately following delivery," says Weeks. "They may require deep suctioning which can cause oral aversions in some babies." Separation frequently continues in the first few days, she adds, as the mother recovers from major and painful abdominal surgery. Additionally, mothers report more challenges finding comfortable positions in which to breastfeed, and they report more breast engorgement, a side-effect of the fluids they received during the surgery — yet another early breastfeeding challenge.
Weeks worries that disruptions — like cesareans — may discourage mothers from breastfeeding, particularly inexperienced moms. Early challenges with breastfeeding can quickly snowball into many complex problems that become difficult to overcome, she says, even with skilled assistance. And when early difficulties with breastfeeding are not overcome, many mothers simply opt to pump their milk to provide to their children, rather than directly breastfeed (thus reducing the much-needed skin-on-skin interaction); many others wean their babies to formula far earlier than their original intentions.
A 2013 paper published in BJOG by A. Karlström adds scientific evidence to Weeks's claim.
In this study, Karlström looked at 5,877 births of women undergoing caesarean sections with no medical indication, and a control group of 13,774 women undergoing births through the spontaneous onset of labour (a subset of which had emergency C-sections). Analysis showed that maternal complications occurred more frequently among women undergoing C-sections. Specifically, among women opting for elective cesareans, the data showed an increased chance for bleeding and infections (which is consistent with previous studies). The risk of hypoglycaemia was at least twice as high for infants in the cesarean group.
Moreover, as Karlström noted in the paper, "Breastfeeding complications were most common in women having an elective caesarean section," leading her to conclude that, "Caesarean sections without medical indication as well as emergency caesarean sections were associated with higher risks for maternal and infant morbidity."
An earlier study by Karlström showed postoperative pain after cesarean births affects breastfeeding and early infant care.
Word about the risks associated with elective cesareans is starting to get out, leading some to complain that modern women have become "too posh to push." And this backlash is not just happening in the United States; similar sentiments are being echoed in Canada, Australia, and Europe. But it's an accusation (and a stereotype) that's completely unfair; as noted, most women are simply following the advice of their doctors.
But there are some women who say that elective cesareans are a valid option — and that women have the right to choose the mode of birth that's most suitable for them.
According to Pauline Hull, who blogs about elective C-sections from her home in Surrey, UK, doctors tend to overexaggerate the risks, while underestimating those of vaginal births. The tagline of her website makes her opinion explicitly clear: "The informed decision to choose a planned cesarean with no medical or obstetrical indication is perfectly legitimate." At the same time, however, she warns that it's no "walk in the park."
Many women agree with Hull, including Madonna and former Spice Girl Victoria Beckham — both of whom have had scheduled procedures. It's a hot-button topic that touches upon many different domains, including women's rights, the responsibilities of doctors and hospitals — and the nature of the medical profession as big business.
Corry believes there are ways to reverse the trend toward elective c-sections. "If a hospital wants to genuinely do the right thing — to improve the health of mothers and babies — then they need to put policies in place which will reduce the likelihood that their providers will schedule unnecessary or elective C-sections or inductions." Corry says this has to happen from the board on down. "And they have to make sure that their providers are onboard and they understand the reasons for the policy."
Induced births, adds Corry, are a significant contributor to unplanned cesarean deliveries.
Corry says it's already starting to happen in various locations across the county. "There are new facilities and institutions within hospitals that are leading the way," she says. She hopes more hospitals will follow their lead. "They need to ensure that these [education] programs include all the information that's important for women to know."
Images: Mikhail Tchkheidze/Shutterstock, Maureen Corry, University of Alberta, Henry Ford Hospital, Sayanjo65/shutterstock, Sang Tan/Associated Press.