The C-section epidemic

http://www.latimes.com/news/opinion/la-oe-block24sep24,0,6378847.story?coll=la-opinion-center

From the Los Angeles Times

More women are dying in childbirth thanks to the high numbers of doctors and mothers who opt out of normal delivery.

By Jennifer Block

September 24, 2007

Pre-term births are on the rise. Nearly one-third of women have major abdominal surgery to give birth. And compared with other industrialized countries, the United States ranks second-to-last in infant survival. For years, these numbers have suggested something is terribly amiss in delivery wards. Now there is even more compelling evidence that the U.S. maternity care system is failing: For the first time in decades, the number of women dying in childbirth has increased.

The Centers for Disease Control and Prevention last month released 2004 data showing a rate of 13.1 maternal deaths per 100,000 live births. For a country that considers itself a leader in medical technology, this figure should be a wake-up call. In Scandinavian countries, about 3 per 100,000 women die, which is thought to be the irreducible minimum. The U.S. remains far from that. Even more disturbing is the racial disparity: Black women are nearly four times as likely to die during childbirth than white women, with a staggering rate of 34.7 deaths per 100,000.

These high rates aren’t a surprise to anyone who’s been investigating childbirth deaths. Physician researchers who have conducted local case reviews across the country consistently have found death rates much higher than what the CDC has been reporting. In New York City between 2003 and 2005, researchers found a death rate of 22.9 per 100,000; in Florida between 1999 and 2002, the rate was 17.6. Other reports by CDC epidemiologists have acknowledged that deaths related to childbirth are probably underreported by a factor of two to three.

What’s to blame for the poor U.S. showing? True, we are the only industrialized country without universal healthcare. But when it comes to childbirth, we basically have it. Ninety-nine percent of women give birth in a hospital with access to all the bells and whistles — high-tech machines that continuously monitor the baby’s heart rate, drugs that can control the speed of contractions like the volume on a stereo, instruments that can coax a reluctant head out of the birth canal, and surgeons at the ready to perform the mother of all interventions, the caesarean section.

The C-section, now used to deliver 30% of American babies, is such a norm these days that, in some places, doctors and women have taken to calling it “C-birth” or even just “having a ‘C.'” Pet names aside, the procedure is major surgery, and although it saves lives when performed as an emergency intervention, it causes more harm than good when overused. Here’s why: Caesareans are inherently riskier than normal, vaginal birth. They also lead to repeat caesareans. And repeat caesareans carry even greater risks.

Placenta accreta is one of them. The placenta embeds into the uterine scar from a previous surgery, causing a catastrophic hemorrhage at the time of delivery. Most women with placenta accreta lose their uteri; as many as 1 in 15 bleed to death. In 1970, accretas were so rare that most obstetricians never encountered one in their career. Today, according to a University of Chicago study, the incidence may be as high as 1 in 500 births. And that is all because of caesareans and repeat caesareans.

Obesity plays a part as well because obese women are more likely to have health problems that make a caesarean more likely, and more likely to suffer surgical complications. Still, it all comes back to the “C,” which could easily stand for “culprit.”

According to a sweeping 2006 study by the World Health Organization, published last year in the medical journal Lancet, a hospital’s caesarean rate should not exceed 15%. When it does, women suffer more infections, hemorrhages and deaths, and babies are more likely to be born prematurely or die.

Too many caesareans are literally medical overkill. Yet some U.S. hospitals are now delivering half of all babies surgically. Across the nation, 1 in 4 low-risk first-time mothers will give birth via caesarean, and if they have more children, 95% will be born by repeat surgery. In many cases, women have no choice in the matter. Though vaginal birth after caesarean is a low-risk event, hundreds of institutions have banned it, and many doctors will no longer attend it because of malpractice liability.

American maternity wards are fast becoming surgical suites. We’ve become dangerously cavalier about it, but the caesarean rate should be a major public health concern. Universal care alone won’t solve the problem; what pregnant women need is entirely different care. They need doctors and hospitals that promote normal labor and delivery. Of course, reducing obesity belongs on the healthcare agenda, and so does curtailing the scalpel.

Jennifer Block is the author of “Pushed: The Painful Truth About Childbirth and Modern Maternity Care.”

Listening

Having had a “medically indicated” c-section with my first child and then 3 consecutive vaginal births thereafter, I am absolutely distraught over the comments I often hear from women who seek affirmation in their decision for elective cesarean. I recently had a conversation with a woman who is 6 months along with her second child. Her first child, whom she did not know she was carrying until her 7th month of pregnancy, arrived surgically after “some blood was in the water when it broke.” She stated that she was not coping well at all with the labor pain and her doctor was frustrated with her and said, “All things considered I think we should consider a c-section.” So she considered it for about 30 seconds and the doctor walked out of the room to scrub up for surgery. With this second pregnancy her new OB/GYN said after reading her chart that a surgical birth was the safest way for her body to give birth. She said she asked if she’d die or if the baby would die if she tried to. The doctor said, “Well maybe not, but would you wnat to risk that?” She was given no diagnosis of CPD, nor did she have any other contraindications for vagina birth.  I wanted to scream.  I wanted to cry.  I wanted to hit someone.  I wanted to hug her. This poor poor woman has been lied to, misinformed, told repeatedly that her body is broken. After hearing it so many times, one begins to console oneself in the fact that nature made a mistake with our pelvis and afterall… a healthy baby is all that matters. Right?Wrong.The birth process involves SO much more than just the physical act of bringing a baby outside the womb to live. It is raw emotion – positive or negative – empowering or defeating – enriching or deflating – harmonious and full or systematic and flat. Which of these traits will characterize our births depends largely on the support people we choose to attend us and the environment we choose to have this sacred event unfold within. But I digress… back to the original statement. Women who seek affirmation in their decision to surgically give birth to their babies. Why do they seek it? Should we give it? What questions are ours to ask, and how far to do we go against the grain in our attempts to re-beautify birth and empower these women to take the birth process back? These are questions I will likely always struggle with. Partly because I’ve been on both sides of the fence and I have a very keen awareness that those women who have been taught to believe this is the only way they can birth are often very afraid. They are often traumatized from a previous birth that ended in surgical birth (warranted sometimes). They feel inadequate and cloak that in numerous ways. They have been TOLD that they are inadequate by doctors (AKA: gods). They believe it. They go home, cry quietly, say goodbye to dreams of birthing naturally, make plans to have extra help while they recover from giving birth and having major abdominal surgery all in the same day.  We succumb to the loss. We reason it away. Like good little girls we tell ourselves that “Just because we didn’t have a natural birth like Sally’s down the road” it doesn’t mean we didn’t have a “good birth”. Acceptance of the loss without listening to it, tasting it – feeling it – is very dangerous.I will likely always struggle with these questions because I have the scars. I have walked that path. I have been that mother. And though I wouldn’t have admitted it to anyone THEN, I was scared. I was scared to death and I felt broken and as if I had missed something birthing that way. And it’s because I had. I was lied to at the birth and then again years later when I wanted a VBAC and my first OBGYN would not give me one. I have walked the steep path of fighting my way to a “trial of labor” with my first VBAC. To partial shoulder dystocia  and the threat of a section being the only way to handle it with my 3rd. I have walked the road. I felt the loss and I listened to it.So how do we mother these mothers? The only concrete decision I can come to on this is that we must listen to them. For it is their path to walk. Some will hear the pain of losing childbirth to the medical establishment immediately and mourn it fully. They will come to us ready to give birth. Ready to take back what was stolen from them. Some will not mourn the loss until years later when menopause brings about a remembering of their childbearing years.  Some will put it on the back shelf until they are pregnant again and we find ourselves counseling a 5 month pregnant mother who wants a vaginal birth but is afraid to try. Some will tenaciously and stoically press toward a VBAC and their labor will stall at 7 or 8 cm until the fear has been released. And some will choose to birth surgically. I will listen to them all. I will tell them the truth. We will get their records, and read them through together. We will cry together as they mourn the loss of trust in a caregiver, the loss of their innocence, the loss of their birth. I will listen and I will wait until an informed decision is reached and the tomorrows face us full on. I will walk quietly beside her, holding her hand, helping her if she falls. I won’t make the same mistake doctors make and try to force her into a vaginal birth. Or scare her more by telling her horrible tales of sections gone bad and post-operative risks. Because I know I would have given anything to have such a woman walk alongside me during the journey. And I thank my God everyday for the few that were brave enough to do so for even a short time