Cesarean section is the number one surgery performed in US
today, even surpassing all the orthopedic and heart surgeries. About 1.3
million babies are delivered by Cesarean every year, which roughly equals to every 1
in every 3 children born in US. This is
in stark contrast to a world cesarean section rate of 19%, according to data
published in the Journal of the American Medical Association in December,
2015.
United states have seen a steep rise in the C-section rate
from 5 percent in 1970 to nearly 33% in 2016.
Consumer report finds a wide variation across US and also
among different hospitals in the same region. The rate for low risk deliveries
varies from 11% to 53% state wise to 17% to 30% in the same community. In fact Hialeah
Hospital, outside of Miami,
had the highest C-section rate of 66% of all hospitals in US. In fact, there
were 221 hospitals in the U.S.
with C-section rates above 33.3 percent for low-risk deliveries.
The National Target is 23.9% for nulliparous, low risk
women, with only 40% of the hospitals meeting the target. Researchers estimate
that almost half of all the C-sections could be avoided and babies delivered
safely by vaginal route.
The American Congress of Obstetricians and Gynecologists
(ACOG) and the Society for Maternal-Fetal Medicine (SMFM) were so concerned by
the rising rate that they jointly issued a recommendations to prevent the first
C-section.
Dr. Thomas Weiser, an assistant professor of surgery at
Stanford School of Medicine says “As countries increase the number of
C-sections they provide, mortality goes down— but only to a point, when the
C-section rate tops 19 percent, benefits for maternal and infant health plateau.”
Aaron B. Caughey, M.D., chair of the Department of
Obstetrics and Gynecology at Oregon Health & Science University School of
Medicine in Portland
and a lead author of the new ACOG/SMFM recommendations says “Once cesarean
rates get well above the 20s and into the 30s, there are probably a lot of
non-medically indicated cesareans being done, that’s not good medicine.”
But, the rise in Cesarean rates have not helped in bringing
down the mortality and infant mortality rates in US, which sadly stands at 14
deaths per 100,000 live births and 5.6 per 1000 babies respectively, far worse than other
developed countries, according to CDC statistics.
So, what are the causes for such high C section rates in US?
- Repeat cesarean section was the most common indication with low rate of VBAC constituting about one third of all cesarean deliveries.
- Experts blame a part of it on technology advances like continuous fetal monitoring. Continuous FHR monitoring is not backed by extensive research when it comes to interpreting the results. Different obstetricians have different policies and when they see ups and down in the FHR tracing, it may trigger a Cesarean Section, even if it is not clear whether the baby is actually in distress.
- In approximately 44% of patients, the labor was induced instead of allowing them to go into spontaneous labor. These patients had C-section rate twice that of patients who opted for a natural onset of labor.
- Obstetricians in USA are sued a lot, so the idea of practicing ‘defensive medicine’ prevails in the labor room also. It is always justified to explain a mishap in labor when cesarean section was performed than being delivered vaginally.
- Women is US can choose to be delivered by cesarean section like most western countries. According to a study Zhang et al in American Journal of Obstetrics and Gynecology elective cesarean section accounts for less than 10% of all scheduled procedures.
- And the current focus in obstetrics is to manage postpartum hemorrhage, prevention of thromboembolism and ecclampsia which have all shown an increasing trend.
So, to bring down the cesarean section rate in US,
preventing unnecessary primary cesarean deliveries is the key, because they
contribute to one third of total cesarean deliveries.
If first Cesarean is
prevented than we are preventing the subsequent ones down the lane. According
to Dr. Shah from Harvard Medical school Right now in the U.S., if you get a
C-section the first time, you have a 90 percent chance of getting another one
the second time.
If the fetus status is reassuring than awaiting for vaginal
births in patients with dystocia could also bring down the rate. A further
small reduction can be achieved by external cephalic version (2-3%) and
attempting VBAC.
References:
https://www.statnews.com/2015/12/01/cesarean-section-childbirth/
No comments:
Post a Comment