Editor’s note: This article first appeared in Midwifery Today, Issue 92, Winter 2009/2010.
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Abstract: A recently coined term, unne-Cesareans, concisely describes the mode of delivery for 25% of low-risk first births in most Western countries. Evaluation of Cesarean Delivery, published by the American College of Obstetricians and Gynecologists (ACOG) in 2000, showed a lack of evidence of improved medical outcomes with the widespread use of cesareans for low-risk, full-term primiparas. Therefore, the term “unnecessary” is appropriate in the sense of medical outcomes. Although the complete causality of this phenomenon has probably not been elucidated, eighteen causes for this common practice have been documented in published research. Conclusion: UnneCesareans have multiple causes and therefore, a reverse in current trends is unlikely.

When I tell people that I am a homebirth midwife, they often respond by asking, “Why do women choose to give birth at home?” It would be wonderful if hospital morbidity and mortality outcomes were comparable to attended homebirths and I could expand on the pleasures of having your own food, bed, bathroom, privacy, lighting and music during birth. But since US hospitals delivered 32% of low-risk women by cesarean surgery in 2007 and 1 in every 3000 of those died from the surgery, the answer is simple: to avoid dying in childbirth or being scarred for life by unnecessary surgery. Then, the second question the listener naturally asks is, “Why do doctors do unnecessary surgery?” Many doctors and midwives are also concerned with this question and have researched it extensively. The following is a review of the recent research, most of it published since 2006, regarding the causes of unneCesareans.

1. Provided free (or covered by insurance) everywhere but New South Wales, Australia: In 2007 the Department of Health of New South Wales, Australia, passed Policy Directive #2007-024, demanding that “maternal request is not an indication for elective caesarean section.” Compliance with the directive is mandatory and a condition for subsidy. However, no other government in the world distinguishes between unne-Cesareans and medically indicated cesarean surgery.
2. Private medical practices: The consummate example of this is in Brazil, where the cesarean rate in a private hospital among primiparous women was 97.8% vs. 47% in public hospital.(1)
3. High socioeconomic level of the pregnant woman.(2)
4. Highly urbanized setting.(3)
5. Physician convenience: Weekday, day shift: 66% of emergency cesareans took place between 8 am and 3 pm, and not a single one between 5 am and 6 am.(4) UnneCesareans are not performed on weekends or national holidays, in order not to interfere with leisure time.(5)
6. Action bias: Doctors and judges exhibit an action-bias towards cesareans. Surgery is considered by the courts to be heroic and the ultimate effort, regardless of the outcome—even death. No one gets sued for doing a cesarean, only for not doing one.(6)
7. Dystocia has no medical definition: The most recent ACOG Practice Bulletin on dystocia specifies no time frame for dystocia, referring only to slower than “normal” or complete cessation of progress, allowing doctors to define it arbitrarily.(7) This undefined phenomenon of “dystocia” is held responsible for between 50% and 70% of all cesareans experienced by otherwise healthy nulliparous women.(8) An example of an arbitrary but frequently applied definition of dystocia is giving women with an epidural in place an extra hour to give birth before defining them as having “second stage dystocia.”(9) Even so, the strongest risk indicator for dystocia was use of epidural analgesia.(10)
8. Elective induction: Lowe reported a 1.5 to 2.5 times greater risk of cesarean in nine controlled international studies using large samples of healthy first births at term with a singleton cephalic pregnancy with elective induction. The primary indication for cesarean was dystocia.(11)
9. Overeating high glycemic index foods combined with lack of exercise: About 10% of fetuses weigh over 4000 g (approximately 8 lb 13 oz).(12) Mulik reported an overall cesarean rate of 16.4%.(13) Full-term, cephalic pregnancies not complicated by any medical or surgical disorders—with the exception of 0.5% gestational diabetics with birth weights of 2500–3999 g (about 5 lb 8 oz to 8 lb 13 oz)—had a cesarean rate of 14.7%, but babies born weighing over 4000 g had a 30% cesarean rate and those over 4500 g had a 60% cesarean rate. Therefore, in this study, a 9% rate of macrosomia was demonstrated to increase the overall cesarean rate from 14.7% to 16.4%, or an addition of 1.7%. Birth weights of 2500–3000 g can be achieved by avoiding high glycemic index foods combined with daily exercise.(14)
10. High and rising malpractice insurance premiums and lack of caps or limits on payments for non-economic damages: Multivariable analyses demonstrated that for each annual $10,000 insurance premium increase, the primary cesarean birth rate increased by 15.7 per 1000 for nulliparous women and 4.7 per 1000 for multiparous women.(15) A $10,000 decrease in premiums for obstetrician-gynecologists would mean an associated decrease of 0.15% in the rates of primary cesarean section and an increase of 0.35% in the VBAC rate. Two types of tort reform caps on non-economic damages and pretrial screening panels were associated with lower rates of cesarean section and higher rates of VBAC.(16)
11. Breech/VBAC cesarean section protocols do not differentiate between small and large fetuses: Vaginal breech delivery of 2500 g is safe. Breech delivery of 4000 g is risky. VBAC of a 2500 g baby is associated with the low uterine rupture risk of 1 in 1000, smaller than the risks of repeat cesarean section. VBAC of a baby over 4200 g has a risk of uterine rupture of 1 in 50.(16) Current protocols do not take fetal weight estimations into consideration for the purposes of avoiding cesarean or repeat cesarean. Manual and ultrasound fetal weight estimations are considered reliable enough to justify cesarean when the baby is big but are not used to justify avoiding cesarean when the baby is small.
12. Epidurals: Randomized trials that do not show an effect of epidural anesthesia on cesarean section rate lack external validity.(17) The limited data available suggest that epidurals and low-dose oxytocin used together increase the cesarean section rate.(18)
13. Longer hospitalization and re-hospitalization is more likely and more profitable: After a planned primary cesarean, women were 2.3 times more likely to require a re-hospitalization in the first 30 days postpartum.(19) The average initial hospital cost of a planned primary cesarean was 76% higher than the average for planned vaginal births and length of stay was 77% longer (4.3 days to 2.4 days). This creates more profit if the hospital is reimbursed per day.(20)
14. False claims that maternal request cesarean section is popular: Existing evidence for large numbers of women requesting cesarean sections in the absence of medical indications is weak.(21)
15. Continuous fetal monitoring of labor of low-risk pregnancies: Continuous cardiotocography (electronic fetal monitoring in the US) was associated with a significant increase in cesarean section. There was no difference in the number of babies who died during or shortly after labor, and no difference in the incidence of cerebral palsy.(22)
16. Lack of hospital-provided doulas: For middle-class women laboring with the support of their male partner, the continuous presence of a doula during labor significantly decreased the likelihood of cesarean birth.(23)
17. Midwifery model of care replaced by risk-focused, policy-driven, non-woman-centered care: Studies with Certified Nurse Midwives and Certified Professional Midwives have found that intended home and birth center births for low-risk women have significantly lower cesarean rates than for comparable low-risk women in hospitals with equally low infant mortality.(24)
18. Lack of practitioners with 90% success rate at external cephalic versions.

My Recent Experience at a Public Hospital in Jerusalem, March 2009

Workers in the delivery room consider delivering babies a job—a job which they want to keep. To keep their jobs, all workers in the delivery room cover for each other. A worker who wants to keep his or her job will not complain against a staff member who causes or performs an unneCesarean. UnneCesareans may be caused by staff members, whose camaraderie is proven by their preference for talking to another staff member during report or outside the patient room, rather than staying with the patient. A non-reassuring heart rate may develop but not be responded to in a timely fashion. As a result of lack of timely intervention and lack of emotional support, unneCesareans may result.

Inaccurate monitor readings: The fetal monitor, in some cases, fails to show reactivity of the fetal heartbeat. The staff will notice that the next woman put on the same monitor also has no variability and subsequently realize that the machine was and is broken. However, the previous patient will not be informed that she had an unneCesarean, but instead, the staff covers for each other’s malpractice. Fetoscopes are often unavailable in the hospital, which in this case, resulted in an unneCesarean.

Dysfunction of Foley catheter: In addition to dysfunctions of the monitor, thermometers and blood pressure detectors, all of which can cause unneCesareans, I was told by my fellow co-workers about a woman who had a Foley catheter that was defective—not flowing, but only leaking 1 cc per hour. Cesarean section was performed for arrested descent. During the surgery, a full bladder was noticed and the staff realized that the Foley catheter was not working. Due to the full bladder, the head could not descend. The woman was never informed of the reason for her unneCesarean.

In another case, a nurse pre-prepared a bag of IV fluids with Pitocin, labeled it with a large red “PITOCIN 10 U” label and hung it for future use. An anesthesiologist put in an epidural, and the woman’s blood pressure fell dramatically as commonly happens. The anesthesiologist connected the bag of fluids containing the Pitocin and let it run in, not noticing the large red label that said “PITOCIN 10 U.” The woman’s uterus burst and she had an emergency unneCesarean and hysterectomy. She was not informed of the cause of her unneCesarean.

Summary

“Caesarean sections, unless strictly indicated, may be harmful to the health of mothers and their newborn babies. Two questions remain. Why are rates still on the increase? What can be done to reverse current trends?”(25) As a head obstetrician recently said, “If highly-paid soccer goalies won’t practice evidence-based diving for the ball when they are paid millions of dollars a year, what hope is there for obstetricians?”(26)

UnneCesareans have multiple causes and therefore, a reverse in current trends is unlikely.

References:

• Shorten, B., and A. Shorten. 2004. Impact of private health insurance incentives on obstetric outcomes in NSW hospitals. Aust Health Rev 27(1): 27–38; Mandarino, N.R., et al. 2009. [Aspects related to choice of type of delivery: a comparative study of two maternity hospitals in São Luís, State of Maranhão, Brazil] Article in Portuguese. Cad Saude Publica 25(7): 1587–96.
• Ghetti, C., B.K.S. Chan and J.M. Guise. 2004. Physician response to patient-requested cesarean delivery. Birth 31(4): 280–84.
• Chen, C.S., et al. 2008. Urbanization and the likelihood of a cesarean section. Eur J Obstet Gynecol Reprod Biol 141(2): 104–10.
• Goldstick, O., A. Weissman and A. Drugan. 2003. The circadian rhythm of “urgent” operative deliveries. Isr Med Assoc J 5(8): 564–66.
• Morita, N., et al. 2002. Nationwide description of live Japanese births by day of the week, hour and location. J Epidemiol 12(4): 330–35.
• Bar-Eli, M., et al. 2007. Action bias among elite soccer goalkeepers: The case of penalty kicks. J Econ Psychol 28(5): 606–21.
• American College of Obstetrics and Gynecology Committee on Practice Bulletins-Obstetrics. 2003. ACOG Practice Bulletin Number 49, December 2003: Dystocia and augmentation of labor. Obstet Gynecol 102(6): 1445–54.
• Shields, S.G., et al. 2007. Dystocia in nulliparous women. Am Fam Physician 75(11): 1671–78; Gifford D.S., et al. 2000. Lack of progress in labor as a reason for cesarean. Obstet Gynecol 95(4): 589–95.
• Kjaergaard, H., et al. 2009. Incidence and outcomes of dystocia in the active phase of labor in term nulliparous women with spontaneous labor onset. Acta Obstet Gynecol Scand 88(4): 402–07.
• Kjaergaard H., et al. 2008. Obstetric risk indicators for labour dystocia in nulliparous women: a multi-centre cohort study. BMC Pregnancy Childbirth 6(8): 45.
• Lowe, N.K. 2007. A review of factors associated with dystocia and cesarean section in nulliparous women. J Midwifery Womens Health 52(3): 216–28.
• Zamorski, M.A., and W.S. Biggs. 2001. Management of suspected fetal macrosomia. Am Fam Physician 63(2): 302–06.
• Mulik, V., et al. 2003. The outcome of macrosomic fetuses in a low risk primigravid population. Int J Gynaecol Obstet 80(1): 15–22.
• Cohain, J.S. 2009. Can Low Glycemic Diet Increase VBAC Success? MIDIRS Midwifery Digest 19(1): 71–75. www.gentlebirth.org/archives/cohainVBAC.html.
• Murthy, K. 2007. Association between rising professional liability insurance premiums and primary cesarean delivery rates. Obstet Gynecol 110(6): 1264–69.
• Yang, Y.T., et al. 2009. Relationship between malpractice litigation pressure and rates of cesarean section and vaginal birth after cesarean section. Med Care 47(2): 234–42.
• Kotaska, A.J., M.C. Klein, and R.M. Liston. 2006. Epidural analgesia associated with low-dose oxytocin augmentation increases cesarean births: a critical look at the external validity of randomized trials. Am J Obstet Gynecol 194(3): 809–14.
• Ibid.
• Ophir, E., et al. 2008. Delivery mode and maternal rehospitalization. Arch Gynecol Obstet 277(5): 401–04.
• Declercq, E., et al. 2007. Maternal outcomes associated with planned primary cesarean births compared with planned vaginal births. Obstet Gynecol 109(3): 669–77.
• Weaver, J.J., H. Statham, and M. Richards. 2007. Are there “unnecessary” cesarean sections? Perceptions of women and obstetricians about cesarean sections for nonclinical indications. Birth 34(1): 32–41.
• Alfirevic, Z., D. Devane, and G.M.L. Gyte. 2006. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database Syst Rev (3): CD006066. DOI: 10.1002/14651858.CD006066.
• McGrath, S.K., and J.H. Kennell. 2008. A randomized controlled trial of continuous labor support for middle-class couples: effect on cesarean delivery rates. Birth 35(2): 92–97.
• “Out-of-Hospital Midwifery Care: Much Lower Rates of Cesarean Sections for Low-Risk Women.” Citizens for Midwifery fact sheet. www.cfmidwifery.org/pdf/cesarean2x.pdf. Accessed 28 July 2009.
• Victora, C.G., and F.C. Barros. 2006. Beware: Unnecessary caesarean sections may be hazardous. Lancet 367: 1796–97.
• See note 6 above.