Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health www.birthbythenumbers.org With support from: The Transforming Birth Fund Slides Updated through January 15,2015 BirthByTheNumbers.org US Cesarean Rates, 1989-2013 34 32 30 % 28 % 26 1,284,339 cesareans in 2013 24 22 20 '89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 '13 % Tot US 23 22. 22. 22. 21. 21. 20. 20. 20. 21. 22. 23 24 26 28 29 30 31 32 32 33 33 33 33 33 If the 2013 cesarean rate was the same as in 1996, there would have been 475,000 fewer cesareans in the U.S. in ’13. Source: National Center for Health Statistics Annual Birth Reports US Cesarean Rates, 1989-2013 34 32 30 % 28 % 26 24 22 20 '89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 '13 % Tot US 23 22. 22. 22. 21. 21. 20. 20. 20. 21. 22. 23 24 26 28 29 30 31 32 32 33 33 33 33 33 Source: National Center for Health Statistics Annual Birth Reports BirthByTheNumbers.org US Cesarean Rates, 1989-2013 34 32 30 % 28 % 26 24 22 20 '89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 '13 % Tot US 23 22. 22. 22. 21. 21. 20. 20. 20. 21. 22. 23 24 26 28 29 30 31 32 32 33 33 33 33 33 Source: National Center for Health Statistics Annual Birth Reports BirthByTheNumbers.org US Cesarean Rates, 1989-2013 34 32 30 % 28 % 26 24 22 20 '89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 '13 % Tot US 23 22. 22. 22. 21. 21. 20. 20. 20. 21. 22. 23 24 26 28 29 30 31 32 32 33 33 33 33 33 Source: National Center for Health Statistics Annual Birth Reports BirthByTheNumbers.org Commonly Used Explanations for the High Cesarean Rate • • • • • • Mothers are getting older More multiples being born Maternal obesity increasing Babies are getting bigger Mothers are generally less healthy Mothers are asking for it BirthByTheNumbers.org Older Mothers? % Births to Mothers 30 +, U.S. 1990-2013 45% 40% >30 35% 30% 25% 20% Between 2003 & 2010 CS Rate increased by 20% From 2010-2013, CS rate unchanged 15% 10% 5% > 35 > 35 19 90 19 91 19 92 19 93 19 94 19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 0% BirthByTheNumbers.org Total Cesarean Rates (per 100 births) by Age of Mother: United States, 1996 and 2013 Overall increase, 1996-2013: 58.0% 60 1996 50 2013 49.6 Percent 41.6 40 35.5 31.6 31.3 27.6 30 23.8 21.8 20 10 14.5 27.4 20.6 17.4 50% 59% 52% 49% 52% 57% <20 20-24 25-29 30-34 35-39 40-54 0 Source: National vital statistics system, NCHS, CDC. BirthByTheNumbers.org Multiple Births? Proportion of all babies in multiple births, U.S., 1980-2013 4.0% 3.5% 3.0% 2.5% 2.0% 1.5% 1.0% 0.5% 0.0% Source: National Center for Health Statistics Annual Birth Reports BirthByTheNumbers.org Cesarean Rates for Multiple Births, U.S. 1990-2013 80% 74% 75% 76% 70% 65% 60% 60% 56% 56% 1990 1995 55% 50% 2000 2006 2013 BirthByTheNumbers.org Are Babies Getting Bigger? % Singleton Babies by Birthweight, U. S., 1991-2013 3500-3999gms 4000+gms 50% 41% 40% 41% 39% 36% 36% 30% 30% 30% 29% 20% 28% 28% 10% 11% 11% 10% 8% 8% 1991 1996 2001 2006 2013 0% BirthByTheNumbers.org % Cesareans in Singleton Births, U.S. by Birthweight, 1991-2013 55% 3500 - 3999gms 4000 - 4499gms 4500+gms 50% 45% 40% 53.6% 38.2% 38.6% 35% 30% 25% 31.3% 27.8% 20% 21.8% 15% 10% 1991 1996 2001 2006 2013 BirthByTheNumbers.org Mothers’ Health? Prepregnancy Obesity, U.S. 2003, 2006, 2009, 2011 22% 20.3% 2009 2011 19.5% 20% 18% 20.5% 17.6% 16% 14% 12% 10% 2003 2006 Sources: 2003-2009 -- S. Fisher. Is obesity still increasing among pregnant women? Preventive Medicine 2013; 56: 372-378; 2011 – CDC VitalStats. BirthByTheNumbers.org Mothers’ Health? Cesarean Rate Singleton Births by Prepregnancy Weight Range, U.S. 2013 60% 54.0% 50% 45.4% 39.7% 40% 30% 33.6% 27.1% 22.3% 20% 10% 0% Source: CDC VitalStats, 2013. BirthByTheNumbers.org Mothers’ Health? Diabetes* & Hypertension*, 1992,2002,2013 7% 6% Any Diabetes 6.4% 6.0% Any Hypertension 5% 4.4% 4% 3.4% 3.2% 3% 2.2% 2% 1% 0% 1992 2002 * Either gestational or chronic condition Source: CDC VitalStats, selected years. 2013 BirthByTheNumbers.org Mothers’ Health? Cesarean Rates, Singleton Births, U.S., 1990, 1996, 2004, 2013 70% 60% Prepregnancy Diabetes Chronic Hypertension 50% 40% 30% 1990 1996 Source: CDC VitalStats, selected years. 2004 2013 BirthByTheNumbers.org Mothers’ Health? Cesarean Rates, Singleton Births, U.S., 1990, 1996, 2004, 2013 70% 60% Prepregnancy Diabetes Chronic Hypertension 50% 40% 30% 1990 1996 Source: CDC VitalStats, selected years. 2004 2013 BirthByTheNumbers.org Mothers asked for it Have maternal request cesareans played a major role in these increases? BirthByTheNumbers.org Asking Mothers about Maternal Request Cesareans http://www.childbirthconnection.org Two Components to Maternal Request Primary Cesarean 1. Mother made request for planned cesarean before labor BirthByTheNumbers.org Two Components to Maternal Request Primary Cesarean 1. Mother made request for planned cesarean before labor 2. Cesarean for no medical reason BirthByTheNumbers.org Patient Choice Primary Cesareans • Combining reason for cesarean and timing of decision found only about 1% of respondents had a planned primary cesarean for no medical reason. “I think that [cesarean] is… the best way … to give birth. It is a planned way, no hassle, no pain, the baby doesn’t struggle to come out, the baby is not pressed to come out …I think that … everybody should have the baby by cesarean section.” (quote from LtM2) Studies from England, Canada and U.S. states confirm very low rates of maternal request BirthByTheNumbers.org cesareans Pressure to Accept Interventions by Method of Delivery Did you feel pressure from any health professional to have a cesarean? % yes Repeat Cesarean 22% Primary Cesarean 28% VBAC 28% Vaginal 7% 0% 5% 10% 15% 20% Source: Declercq et al. 2013. Listening to Mothers III. 25% 30% BirthByTheNumbers.org Commonly Used Explanations for the High Cesarean Rate • Mothers are getting older • More multiples being born • Babies are getting bigger • Maternal health is worse: obesity, diabetes & hypertension • Mothers are asking for it BirthByTheNumbers.org Commonly Used Explanations for the High Cesarean Rate • Mothers are getting older – NO • More multiples being born • Babies are getting bigger • Maternal health is worse: obesity, diabetes & hypertension • Mothers are asking for it BirthByTheNumbers.org Commonly Used Explanations for the High Cesarean Rate • Mothers are getting older – NO • More multiples being born– NO • Babies are getting bigger • Maternal health is worse: obesity, diabetes & hypertension • Mothers are asking for it BirthByTheNumbers.org Commonly Used Explanations for the High Cesarean Rate • Mothers are getting older– NO • More multiples being born – NO • Babies are getting bigger – NO !! • Maternal health is worse: obesity, diabetes & hypertension • Mothers are asking for it BirthByTheNumbers.org Commonly Used Explanations for the High Cesarean Rate • Mothers are getting older– NO • More multiples being born – NO • Babies are getting bigger – NO !! • Maternal health is worse: obesity, diabetes & hypertension – Some • Mothers are asking for it BirthByTheNumbers.org Commonly Used Explanations for the High Cesarean Rate • Mothers are getting older– NO • More multiples being born – NO • Babies are getting bigger – NO !! • Maternal health is worse: obesity, diabetes & hypertension – Some • Mothers are asking for it – NO BirthByTheNumbers.org If the usual explanations for the rising cesarean rate don’t account for the changes what does? BirthByTheNumbers.org If the usual explanations for the rising cesarean rate don’t account for the changes what does? Practice Changes BirthByTheNumbers.org Leading Indications for Cesareans 3% Labor Arrest 3% 4% Nonreassuring fetal tracing Malpresentation 4% 5% 34% Multiple Gestation 7% Maternal-Fetal Macrosomia 17% Other Obstet. 23% Preeclampsia Maternal Request Source: ACOG & SMFM. Safe Prevention of Primary Cesarean Delivery. 3/2014. BirthByTheNumbers.org Cesarean Rates, Low Risk*, First-Time Mothers for Medical Risk Factors & Labor Complications Prolonged Labor 70 Nonreassuring Fetal Tracing Macrosomia 60 Twins 50 40 30 20 1990 *Singleton, Vertex, Full Gestation Births 1996 2011 BirthByTheNumbers.org Revisiting the trend in cesareans in the US for comparison 34 32 % 30 28 % 26 24 22 20 '89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 '13 % Tot US 23 22. 22. 22. 21. 21. 20. 20. 20. 21. 22. 23 24 26 28 29 30 31 32 32 33 33 33 33 33 Source: National Center for Health Statistics Annual Birth Reports BirthByTheNumbers.org Cesarean Rates, Low Risk*, First-Time Mothers for Medical Risk Factors & Labor Complications Prolonged Labor Nonreassuring Fetal Tracing 70 Macrosomia Twins 60 50 40 30 1990 *Singleton, Vertex, Full Gestation Births 1996 2011 BirthByTheNumbers.org Cesarean Rates, Low Risk*, First-Time Mothers for Medical Risk Factors & Labor Complications Prolonged Labor Nonreassrg Fetal Trace 70 Macrosomia Twins 60 50 40 30 1990 *Singleton, Vertex, Full Gestation Births 1996 2011 BirthByTheNumbers.org Women have not changed nearly as much as practice patterns have BirthByTheNumbers.org Any other evidence that this is about a culture of practice? BirthByTheNumbers.org Let’s look at variation. If the practice of maternity care is evidence based, then differences in rates should be based primarily on different risk profiles of mothers. BirthByTheNumbers.org BirthByTheNumbers.org Cesarean Delivery Rates1, 2012 WA MT ME ND VT NH MN OR ID WI SD PA IA NE NV IL UT CO CT MI WY IN OH WV KS CA KY MO VA OK NM TX AR LA RI NJ DE MD DC NC TN AZ MA NY SC MS GA AL AK FL HI 22.6-31.5% 31.6%+ 1Percentage of all live births by cesarean delivery Source: Martin J, et al. Births Final Data 2012. National Vital Statistics System, 2014. BirthByTheNumbers.org 1960 Electoral College Map WA MT ME ND VT NH MN OR ID WI SD WY MI IL CO OH IN WV KS CA AZ PA IA NE NV UT NY MO KY RI NJ DE MD DC NC TN OK AR NM VA MA CT SC MS AL GA TX LA FL AK HI Nixon Kennedy 219 303 Harry Byrd 15 BirthByTheNumbers.org JFK 1960 Vote and 2012 Cesarean Rates 65 JFK % Vote 60 Each dot represents a U.S. state r = +.28 55 50 45 40 35 20% 25% 30% 35% 2012 Cesarean Rate 40% 45% BirthByTheNumbers.org Variation is not just at the state level but at the hospital level as well BirthByTheNumbers.org % Cesarean Deliveries by Hospital for ALL MA Births, 2004-2006 %CS All 49 Hospitals 45 41.9 40 35 30 25 1 2 3 4 5 6 7 8 9 N = 49 Mean =31.2 σ2 =29.6 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 21.1 20 15 10 5 0 Hospital Rank Source: Caceres I, et al. Hospital Differences in Cesarean Deliveries in Massachusetts (US) 2004–2006: The Case against Case-Mix Artifact. PLOS One.2013; 8 (3): e57817 BirthByTheNumbers.org % Cesarean Deliveries by Hospital for NTVS, Spontaneous Labor, BWT 2500-4000g Births All Hospitals %CS 40 35.0 35 30 25 20 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 N = 49 Mean =21.1 σ2 =37.1 15 10.3 10 5 0 Hospital Rank Source: Caceres I, et al. Hospital Differences in Cesarean Deliveries in Massachusetts (US) 2004–2006: The Case against Case-Mix Artifact. PLOS One.2013; 8 (3): e57817 BirthByTheNumbers.org How does a culture of intervention get manifested in a hospital setting? BirthByTheNumbers.org How does a culture of intervention get manifested in a hospital setting? Consider the Cascade of Interventions BirthByTheNumbers.org Cascade of interventions in first-time mothers with term births who experienced labor Base: first-time mothers with term births who experienced labor First-time mothers with term births (37-41 weeks’ gestation) who experienced labor n=750 Induction Yes 47% Induction No 53% Epidural No 39% Epidural Yes 61% Epidural No 22% Epidural Yes 78% Cesarean Yes Cesarean Yes Cesarean Yes Cesarean Yes 5% 20% 19% 31% In this group, which included 85% of first-time mothers, the overall epidural rate was 69% and overall cesarean rate was 21%. BirthByTheNumbers.org What about Vaginal Birth After Cesarean (VBAC) ? BirthByTheNumbers.org VBAC Rates*, U.S.,1990-2011 30% 25% 20% NOTE: Rates for 2005-2011 are unofficial 15% 10% 19 90 19 91 19 92 19 93 19 94 19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 5% * Number of VBACs among women with prior cesarean Source: NCHS Vital Stats. http://www.cdc.gov/nchs/VitalStats.htm BirthByTheNumbers.org % VBAC Lower Risk* Mothers, U.S., Monthly Rates, 1990-2012 33% 30% 27% 24% 21% 18% 15% 12% 9% 6% ACOG guidelines encourage VBAC, 1/82 10/88 Reaffirmed 1991 McMahon NEJM 9/96 Sachs, NEJM 1/99 Lydon-Rochelle & Greene 7/01 Flamm Studies 1988,’90, ‘94 ACOG New VBAC Guidelines 10/98 & 7/99 Landon NEJM 12/04 Revised ACOG Guidelines 8/10 0 0 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 0 0 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 0 0 1 1 2 2 - 9 l-9 n- 9 l-9 n- 9 l-9 n- 9 l-9 n- 9 l-9 n- 9 l-9 n- 9 l-9 n- 9 l-9 n- 9 l-9 n- 9 l-9 n- 0 l-0 n- 0 l-0 n- 0 l-0 n- 0 l-0 n- 0 l-0 n- 0 l-0 n- 0 l-0 n- 0 y-0 n- 0 y-0 n- 0 l-0 n- 1 l-1 n- 1 l-1 n- 1 l-1 n l l u u u u u u u u u u u u u u u u u u u u u Ja J Ja J Ja J Ja J Ja J Ja J Ja J Ja J Ja J Ja J Ja J Ja J Ja J Ja J Ja J Ja J Ja J Ja Ju Ja Ju Ja J Ja J Ja J Ja J * Full-gestation(37+ weeks), vertex presentation, singleton births BirthByTheNumbers.org VBAC Rates Industrialized Countries, 2010 6 7 Cyprus Latvia U.S. Italy Lithuania Scotland Slovenia Czech Republic Luxembourg Estonia England Denmark Belgium France Germany Norway Netherlands Finland Iceland Malta 0 VBAC % = VBACS Women w/ Prior CS 9 10 11 10 21 21 20 28 28 29 30 33 34 35 36 30 Source: Adapted from Peristats & US Data 40 46 47 50 52 52 74 60 70 80 BirthByTheNumbers.org August, 2010 BirthByTheNumbers.org U.S. Mothers Report of Experience Seeking a VBAC, 2000, 2005, 2012 Mother had cesarean in the past, and did not have the option of a VBAC for recent birth. LTMI 2000-02 LTMII 2005 LTMIII 2011-12 Did not have the option because caregiver was unwilling to do a VBAC 36% 45% 24% Did not have the option because hospital was unwilling to allow a VBAC 12% 23% 15% Medical reason unrelated to prior cesarean 38% 20% 45% Source: Listening to Mothers 3. New VBAC Guidelines BirthByTheNumbers.org So is a rising cesarean rate inevitable? BirthByTheNumbers.org So is a rising cesarean rate inevitable? ABSOLUTELY NOT BirthByTheNumbers.org US Cesarean Rates, 1989-2012 34 32 30 %28 % 26 24 22 20 '89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 % Tot US 23 22.722.622.321.821.220.820.720.821.222.0 23 24 26 28 29 30 31 32 32 33 33 33 33 Source: National Center for Health Statistics Annual Birth Reports BirthByTheNumbers.org Trends in Cesarean Rates (per 1000 births), Comparison Countries, 1990-2011 400 350 300 250 200 150 100 20 10 20 08 20 06 20 04 Sources: OECD Health Data 2013; WHO Health for All Database, 2014. 20 02 20 00 19 98 19 96 19 94 19 92 19 90 50 BirthByTheNumbers.org Trends in Caesarean Rates (per 1000 births), Comparison Countries, 1990-2011 400 350 300 250 200 150 100 20 10 20 08 20 06 Sources: OECD Health Data 2013; WHO Health for All Database, 2014. 20 04 20 02 20 00 19 98 19 96 19 94 19 92 19 90 50 BirthByTheNumbers.org Questioning the Rising Cesarean Rate Safe Prevention of Primary Cesarean Delivery www.acog.org/Resources_And_Publications/Obstetric_Care_Consensus_Series/Safe_Prevention_of_the_ Primary_Cesarean_Delivery BirthByTheNumbers.org Evidence Based Advocacy BirthByTheNumbers.org Prematurity and Low Birthweight, U.S., 1990-2012 13 Prematurity 12 9.8% Decrease 2006-12 11 10 % 9 Low Birthweight 8 7 6 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 Year BirthByTheNumbers.org BirthByTheNumbers.org Evidence Based Advocacy http://www.choicesinchildbirth.org/ BirthByTheNumbers.org Evidence Based Advocacy https://www.childbirthconnection.org/ www.birthbythenumbers.org Follow Birth by the Numbers on Social Media: RSS (blog): www.birthbythenumbers.org www.facebook.com/BirthByTheNumbers Twitter: @BirthNumbers Email: birthbynumbers@gmail.com “Birth by the Numbers” on Pinterest