Forget Lamaze, and all those radical notions about truly experiencing childbirth. Women have decided that epidural anesthesia is just fine, especially with half the family watching the delivery – though one in three babies now arrives in the operating room, by Caesarean section.
Dr. Donald R. Coustan, head of obstetrics and gynecology at Women & Infants Hospital and of the ob/gyn department at Brown University’s School of Medicine, would be loath to paint the state of his specialty in such broad strokes, but if you ask him how things have changed in recent years, that’s what he will tell you.
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It’s nothing like the shifts he saw in the ’70s and ’80s, when the way American women gave birth was truly revolutionized. But the current trends are making an impact. And while women’s more pragmatic attitudes and family members’ growing involvement are generally viewed as positive, the rise in C-sections is not.
When Coustan started his residency at Yale-New Haven Medical Center in 1968, he said, the C-section rate there was about 5 percent. By the time he arrived at Women & Infants, in 1982, C-sections had become more common, and the rate at the Providence hospital was about 20 percent.
There were efforts in the ’80s and ’90s to reverse the trend, and they worked for a while. But now the C-section rate at Women & Infants is 33 percent, Coustan said, and “we don’t know where that’s going to end up.”
This isn’t an issue just at Women & Infants – though, as the site of southeastern New England’s only high-risk obstetrical unit and largest neonatal intensive-care unit, the hospital does treat a disproportionately large share of women who might need a C-section.
Nationwide in 2004, a record 29.1 percent of births were by C-section, according to a recent National Institutes of Health “state of the science” statement, up from 20.7 percent in 1996. There’s also been a sharp decline in the share of women who’ve previously had a C-section who go on to deliver a second child vaginally. And a growing number of women are specifically requesting C-sections – one study cited by the NIH said that occurred in about 5.5 percent of births in 2001, though other studies suggest the actual rate may be much lower.
Still, for veteran doctors such as Coustan, the trends are distressing, especially because for decades, C-sections were viewed as something to be done only when truly needed – because of the cost, the risks of any surgery, and the extra stress, in most cases, on the mother.
“If I were dead,” Coustan said, “I’d be rolling in my grave.”
For the health care system, the rise in C-sections carries a big price tag: The average C-section, without complications, cost $11,500 in 2003, according to the Agency for Healthcare Research and Quality, whereas a vaginal birth without complications cost $6,200. Altogether, nearly 1.2 million C-sections were done in 2003 in the nation’s community hospitals, the AHRQ says, at a cost of nearly $14.6 billion.
For Women & Infants, which delivers nearly 72 percent of Rhode Island’s newborns – 9,718 babies in fiscal 2005 – the rise in C sections has also created a space crunch, said spokeswoman Amy Blustein. That’s a key reason the hospital is adding 30 ob/gyn beds as part of a major expansion, because C-section patients can stay twice as long, for up to 96 hours.
For doctors concerned about being sued, on the other hand, a higher C-section rate is not a bad thing. Ob/gyns know that the chances of something going terribly wrong for the baby are greater with a vaginal birth – and they know the huge liability they can face if that happens.
And though in recent decades, women who’d had a prior C-section were often encouraged to deliver vaginally for their next child, newer studies have quantified the risk that the scar will rupture and the baby will be badly harmed or killed.
“If by increasing the Caesarean section rate, you reduce the risk [of babies dying] from 1 in 1,000 to 1 in 5,000, who is to say that isn’t worthwhile?” Coustan said. Most Americans would like to reduce costs, he added, “but if I said, ‘One of you is going to lose a baby in order to achieve this,’ I think we would get a very different answer.”
C-sections for no discernible medical reason, on the other hand, remain controversial.
The doctors who authored the NIH’s “state of the science” statement said there are too many open questions for them to draw clear lines, so instead, they urged “carefully individualized” decision-making.
They did discourage optional C-sections in women who plan to have more children, because of the added risks the next time, regardless of how they deliver. And they stressed that it’s not OK to do a C-section just to avoid the pains of birth; instead, hospitals should ensure that effective pain management is available to all women.
What about the rest of that one-third of deliveries at Women & Infants? Why do they involve C-sections?
Expect them with a large share of premature births, Coustan said, and anytime the fetal monitor shows possible complications. And, of course, for the most old-fashioned of reasons: “dystocia,” when the baby can’t make it through the birth canal, and “breech” deliveries, when the baby starts coming out feet or hind-end first.
The latter is what put Shawn Gibbison in the OR when she had her daughter, Hanna – born at 9 pounds, 2 ounces. But Gibbison didn’t mind going in for a second C-section the morning after Thanksgiving, to give birth to her son, Quinn – 8 pounds, 9 ounces.
“I’ve never had a labor pain,” she said as she sat on her hospital bed three days later, still achy from the surgery, with her husband, Greg, and the new baby at her side. “A C-section is still scary, but that out-of-control pain – I think that would be harder for me.”
