In a bid to reduce rates of cesarean sections that have climbed more than 60% in the past 15 years, two major medical societies issued guidelines today that urge women and doctors to have more patience during labor, allowing nature to take its course rather than rushing to surgery.
The growing use of C-sections, accounting for one-third of all deliveries in the USA, has raised concerns on a number of fronts.
Although the surgeries are performed out of caution for newborns, they sharply increase the risk of complications and death for women.
The death rate is more than three times higher in mothers who undergo C-sections – 13 deaths per 100,000 women – than in those who deliver vaginally, according to the new report, issued by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine.
The risks to women increase sharply with each additional C-section, says study co-author Aaron Caughey, a professor at Oregon Health and Science University. Performing a C-section, without allowing women to experience contractions, also increases the risk of respiratory problems in babies, says Uma Reddy, a medical officer at the Eunice Kennedy Shriver National Institute of Child Health and Human Development. That's because contractions help to squeeze extra fluid out of a newborn's lungs.
Backers of natural childbirth have long urged doctors to "stop watching the clock," says Michele Ondeck, president of Lamaze International.
"I have to say 'Hurray,'" Ondeck says. "This is a game-changer."
The report notes that the standards doctors have traditionally used to define a slow or stalled labor come from the 1950s. More recent studies, which included more than 62,000 women, show the range of time for a normal labor is much broader than previously understood, the report says.
Reddy calls the new report "a really important document," partly because it "lays out the case that labor nowadays is much slower than we thought."
Caughey says C-sections are clearly the safest option for certain circumstances, such as when the uterus ruptures or when the placenta blocks the opening of the uterus. The World Health Organization says C-sections are needed in only about 10% to 15% of deliveries.
Kjersti Aagaard, an associate professor of obstetrics and gynecology at Baylor College of Medicine in Houston, says it's especially important to reduce the number of C-sections in first-time moms. Women who deliver their first baby vaginally can usually deliver their later children vaginally, as well.
Among other recommendations, the report says doctors should not automatically perform a C-section for women whose babies are in the breech position, or positioned to be born feet first, instead of head first. Instead, doctors should attempt to turn the baby by applying external pressure to the mother's belly. This can help prevent a breech birth in more than half of cases, Reddy says.
Doctors should not automatically perform a C-section because the baby seems very large, the report says.
The report says women are less likely to have a C-section if they receive support in labor, such as from a doula, a birth attendant who helps women get through labor but does not assist in delivery.
A review of 12 trials, involving more than 15,000 women, found that mothers who receive "continuous one-on-one support during labor and delivery" are more satisfied with the birth experience and are less likely to need to a C-section.
C-section rates vary dramatically from place to place. C-sections are used in 22% of births in Alaska, for example, but nearly 40% in Kentucky, the report says.
Some women and doctors also see C-sections as more convenient, because they can be scheduled in advance, Caughey says. Some women want to guarantee that their preferred doctor will be available when they deliver. The American College of Obstetricians and Gynecologists says doctors earn roughly the same amount of money, whether they deliver a baby vaginally or via C-section.
The costs and charges for childbirth can vary greatly from location to location. But in general, insurers pay out 50% for a C-section than for a vaginal birth, partly because women stay in the hospital longer and require more services, such as anesthesia, according to a 2013 Truven Health Analytics Marketscan Study.
Costs do come into play, however, through the fear of malpractice suits, the report says. Doctors who are afraid of being sued may err on the side of caution, performing a C-section for fear of being later being accused of not doing enough to protect a baby.
Studies have found that rates of C-sections are related to malpractice insurance premiums, as well as state limits on what patients can collect from lawsuits, the report says.