Carolyn Havens Niemann, MSN, CNM

Many words have been written about the rise in cesarean section rates over the past few years, but did you know that New Jersey leads the nation in c-sections?  Many are aware, thanks to articles in major media outlets and films like Rikki Lake’s 2008 documentary The Business of Being Born, that the c-section rate in the United States is now at an all-time high of 32%.  This is more than double the target rate of 15% set forth by the World Health Organization and the Healthy People 2000/2010 initiatives.  But few are aware that the c-section rate in New Jersey leads the United States and is now close to 40%.

Once upon a time, a cesarean section was a treatment of last resort.  In 1970, only 5.5% of deliveries in the United States were via c-section.  By 1980 this figure had risen to 16.5%; by 1985 to 22.7%.  For the next 15 years, the rate held steady around 22%, and even dropped slightly, before rising sharply again in the early 2000s. By 2007, the rate had risen to 32%.  (Source:  American Congress of Obstetricians and Gynecologists, “Cesarean Section Rates in the United States.”)

What changed, you might ask?  Myriad articles have been written on the topic, but several factors have contributed.  Medical malpractice cases have contributed sharply to the rise in c-section rates.  For many obstetricians, the experience of going through a lawsuit related to a bad obstetrical outcome, or even a colleague’s experience, has created a culture of intervention.  Many obstetricians reason, and often rightfully so, that the only cesarean they’re going to get sued for is the one they didn’t perform.  In other words, practicing medicine defensively is legally safer sometimes than doing what might be in the best interests of the patient.  The overwhelming use of electronic fetal monitoring is another huge contributor to the rise in c-section rates.  When the fetal monitor was introduced in the early 1970s, the developers theorized that its use would help prevent cerebral palsy by identifying which fetuses were at risk.  In actuality, despite its nearly ubiquitous use on labor and delivery units across the country, rates of cerebral palsy have not dropped.  The main effect of the use of fetal monitoring is that the cesarean section rate has risen.

As for the leveling off, and subsequent sharp rise, of c-section rates in more recent years, this trend mirrors the availability of vaginal birth after cesarean section (VBAC) in this country.  Whereas many years ago the motto among obstetricians was, “Once a Cesarean, Always a Cesarean,” in the mid-1980s VBAC began to be encouraged – and in some places a scheduled repeat c-section was not even offered as an option.  During that time, c-section rates held steady and even dropped slightly because fewer repeat c-sections were being performed.  However, when ACOG published guidelines related to VBAC in 2003 stating that VBAC should only be offered in a setting with an obstetrician and an anesthesiologist immediately available, in other words “in-house” 24 hours a day, most hospitals backed away from offering VBACs – and the c-section rate rose sharply in response.  Today not only are women with a previous cesarean section offered, and often encouraged, to undergo a repeat cesarean, but many obstetricians even offer a primary elective c-section to patients who request a surgical delivery for no medical reason.

What can you do to help stem the tide of the rising c-section rate?  First of all, realize that preventing the initial c-section is the most important step, since the most common reason for a second cesarean is simply a history of a cesarean delivery.  While some of the rise in the c-section rate is provider-driven to be sure, some of it is patient-influenced as well.  Two of the most common risk factors for having a first c-section are having your labor induced, and arriving at the hospital early in labor.

If your doctor recommends inducing your labor, make sure you understand why.  Certain medical conditions like gestational diabetes and blood pressure conditions like preeclampsia can be legitimate reasons for induction.  But remember that it is perfectly normal to be pregnant up to two weeks after your due date, so being two days “late” is hard to justify as a  reason for induction in an otherwise healthy pregnancy.  A desire to deliver on their doctor’s day on-call is often a reason women accept induction, but you should think long and hard about choosing a significantly increased risk of c-section for this reason alone.  Very few obstetricians practice in a solo private practice, so from the outset of your prenatal care you should get to know all of the providers in the group and become comfortable with the idea of any one of them delivering your baby.  If you are unable to do that, find a different group.  Finally, don’t ask your obstetrician to induce you because you’re hot and tired, you’re not sleeping well, you’re sick of being pregnant, or your mother is only coming to visit for two days and you must produce a baby before she goes home.  Your OB wants to please you; she wants you to have what you want, but you put her in a difficult position when you insist on induction to suit your schedule or comfort.  It’s not what’s best for you or your baby except in very limited circumstances.

We also need to adjust our cultural attitudes about the normalcy of labor.  Don’t be afraid to labor at home.  Labor, especially with a first baby, takes a long time:  18 hours, on average.  There is rarely an advantage to being at the hospital in early labor.  Labor is, by and large, a natural process and early labor is very unpredictable in its length.  Waiting to present to the hospital until active labor has begun is a good predictor of avoiding a c-section.  This is partly because when women come to the hospital early in labor, their caregivers feel they need to do something actively to get labor going.  Often the woman has her water broken, and then medication started to bring on contractions stronger and more frequently.  She is usually confined to the bed with continuous fetal monitoring, and one intervention leads to another.  Eventually, labor stalls or she develops an infection (which is more common when the water is broken for a prolonged time) and a third of the time she winds up in the OR with a c-section.

Cesarean section is, to be certain, a life-saving intervention that we are fortunate to have as an option when necessary in this country.  However, it is surely overutilized in a state where nearly 40% of our babies are delivered via surgery.  Do your part to lower our state’s shameful statistic.  Choose a caregiver who supports the normalcy of birth.  Take time to educate yourself about your options, and work hard on changing your attitude toward birth if you regard it as dangerous and scary.  Surround yourself with positive messages about the ability of your body to function as it was intended to.  Respect the process, trust nature, give in and let go.

Carolyn Havens Niemann, MSN, CNM is a midwife with Princeton Midwifery Care which provides full-scope women’s health care to women of all ages.  She and her colleagues provide obstetrical services at University Medical Center of Princeton. To get a convenient appointment with one of our four midwives or information on childbirth classes, please call (609) 896-0777 Lawrenceville or our new East Windsor office at (609) 336-3266.