Caesareans have transformed from life-saving intervention into risky procedure performed for one in three births – and often geography is the deciding factor

'A third of people get major surgery to be born': why are C-sections routine in the US?

Carmen Walker didn’t realize how bad things had gotten until she heard her doctor’s voice from across the operating room: “I’m going to try to save her uterus.”

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Walker had delivered her first child by caesarean section, so when she became pregnant a second time, doctors didn’t think twice before scheduling another. And then another and another. Now, giving birth to her sixth child, she was experiencing the consequences: placenta accreta, a condition which is linked to multiple C-sections and can result in fatal bleeding.

Caesarean sections have saved the lives of millions of infants who might have otherwise been killed or permanently injured during difficult births. But in the US, the rate of caesareans has increased so much over the decades that the surgery has been transformed from a life-saving intervention into a procedure performed as a matter of course during one in three US births.

In 2015, the latest year for which the Centers for Disease Control has data, the share of births by C-section was 32%. The World Health Organization has suggested that the rate should not be higher than 10% - 15%, while other experts have suggested it should not be higher than 19%. The last time the US’s rate was that low was during the 1970s.

Facebook Twitter Pinterest Carmen Walker and her sixth child, Olivia. Photograph: Carmen Walker

“We are quite worried when the C-section rate goes above 30%, as it is in the United States,” said Dr Flavia Bustreo, the assistant director general for family, women’s and children’s health at the World Health Organization. “It becomes routine but it is still a major surgery. That carries a long-term effect on maternal health.”

A C-section rate of 10% to 15% is “natural”, she said. “Above 15%, you don’t have additional benefits, and you have the risks, and you have the unnecessary health costs.”

“A third of people get major surgery to be born,” said Dr Neel Shah, a practicing OB-GYN and an assistant professor at the Harvard School of Medicine who works on ways to reduce avoidable C-sections. Many of the mothers in that equation were having a low-risk birth, he added – that is, there were few or no medical indications that a C-section was necessary.



“That is hundreds of thousands of women every year who get surgery they never need in the first place. That’s crazy. We can do much better than that.”

The associated risks are serious. For the mother, they carry the potential for deadly bleeding, a lengthy recovery, organ damage and permanent injury. Compared with women having a vaginal birth, those having a C-section for the first time have 3.1 times greater risk of blood transfusions, a 5.7 times greater risk of an unplanned hysterectomy and a six times greater risk of being admitted into intensive care.

The rate of C-sections is now well beyond what is medically justifiable to save the lives of infants, experts say.

As C-section rates in the US have gone up, there has been no accompanying rise in infant survival rates. “In the case of low-risk mothers, there’s not a lot of evidence of improved outcomes,” said Eugene Declercq, a professor at the Boston University School of Health who studies caesareans. “It’s just not there.”

In fact, some experts believe this rise in caesareans is one of the many intertwining factors contributing to crisis rates of maternal mortality, or death, and morbidity – defined as significant injury related to a pregnancy.

“It’s certainly one of the downstream consequences” of performing avoidable C-sections, said Jill Arnold, who runs a website that tracks individual hospitals’ C-section rates, and works as a consultant to Consumer Reports. “It’s connected to seeing more women bleed out, or have near misses.”



Placenta accreta, for example, the condition that nearly killed Walker, is roughly 600 times more common today than it was in the 1950s, an increase scientists have linked to the rise in C-sections.

A 2007 analysis of more than two million birth outcomes in Canada found that women with low-risk pregnancies were three times more likely to die or be seriously injured if they had a C-section rather than a vaginal delivery. The findings helped move the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine to put out a joint call in 2014 for reducing avoidable C-sections.

“For most pregnancies, which are low-risk, caesarean delivery appears to pose greater risk of maternal morbidity and mortality than vaginal delivery,” the groups said.

In the US, the rate of maternal deaths per 100,000 live births is 26.4, and it has been rising since 2000. Just about every other western country has seen a decline in maternal death rates since 2000, and the next closest western country, the UK, has a mortality rate of 9.2 per 100,000 live births.

“It is very, very clear to me the connection between the number of C-sections and mortality and morbidity,” said Dr Shah.

What’s not so clear is whether c-sections are what’s causing maternal mortality rates in the US to rise. Declercq, who notes he is “no fan of unnecessary C-sections”, says the bigger drivers of maternal mortality probably include factors like the opioid crisis and the fact that many new mothers are dropped from Medicaid, the government-run health program, shortly after they give birth.

Just addressing the C-section rate alone won’t reduce the maternal mortality rate. Other developed countries have C-section rates that are as high as the United States’. A 2012 international comparison found that the C-section rate was 21.8% in Norway and 24.4% in the UK but 31.7% in Germany and 26.2% in Canada.

But those countries also have medical teams that are better at recognizing and treating life-threatening pregnancy complications, investigations have found, and experts note they do not face factors like poor access to maternity care.

Why is the C-section rate rising?

The factors that drove up the rates of C-sections are numerous and difficult to untangle. Women who are older, heavier or have certain health conditions can be more likely to need a C-section to deliver a healthy baby.

But changes in the US population don’t completely explain the increase seen since the 1970s. One factor is that doctors recommend C-sections when they believe the fetus is showing signs of distress, but many hospitals have a culture or use technologies that send a physicians’ better-safe-than-sorry instincts into overdrive.

Fetal heart monitoring strips, which produce a steady stream of information about a fetus’s vital signs, are a prime example, said Declercq, because they furnish physicians with a torrent of information – including, inevitably, false positives – to scrutinize for signs of trouble. The rise in C-sections since the early 1970s closely tracks the introduction and widespread adoption of fetal heart monitors.

Then there’s the fact that C-sections don’t look like a public health disaster to those up close and personal with them.

“I didn’t realize this was a problem until you zoom way out,” said Dr Shah. “They’re so common they look fine. And people are usually fine. They had their babies and they love their babies. Even people who had a stressful birth experience tend to look back fondly.”

Many doctors and hospitals are in the dark about the rate at which they perform C-sections for low-risk births, because none of the government agencies or accreditors who oversee hospitals require the figures to be public. Arnold said she once heard of a hospital CEO crying the first time she learned her hospital’s figures.

Pilot programs have found that, just as in Arkansas, the simple act of disclosing the numbers can cause hospitals to reduce their rates.

Many hospitals have a long way to go. Healthy People 2020, a federal initiative to improve US health outcomes and Leapfrog, a nonprofit that lobbies hospitals to release various health metrics as a way to improve overall care, deems a hospital to meet acceptable standards if C-sections account for no more than 23.9% of births.

In 2016, 55% of hospitals who voluntarily reported data to Leapfrog had a C-section rate that was higher than 23.9%, or 730 hospitals out of more than 1,300. At 223, or nearly 17%, more than one in three births takes place via C-section.

“Honestly, it should be lower,” Arnold said, referring to the 23.9% threshold. “Even hospitals with high-risk patients, every hospital should be able to hit that number.”

Geographical disparities



And yet, in the US, a woman’s odds of undergoing this risky operation are completely untethered from whether or not her circumstances require it.

A woman’s greatest risk factor for having a C-section is what hospital she chooses. Looking at a map, it’s normal for one hospital to have double the caesarean rate of a neighboring hospital located less than a mile away and serving the same community. Other times, geography equals destiny. The south in particular contains whole communities served only by hospitals where the caesarean rate is 33% or greater.

Walker’s story illustrates the point. Her first caesarean was necessary, she says. She was in labor for 36 hours, but she never dilated enough to deliver vaginally.

But by the time she was pregnant with her second child, she lived in Mississippi, a state that had a C-section rate of 36.8% in 2014 and where scarcely any OB-GYNs are willing to attempt a vaginal delivery after a woman has already had a C-section. Her lack of options, she says, locked her into a succession of increasingly risky operations.

Walker wound up lucky. Although she spent three days on high-risk watch in the hospital and would still be undergoing a painful recovery months later, her doctor stopped the hemorrhage. The blood loss meant she remembers little about the initial aftermath, but she remembers being unable to stand up under her own power.

Her complications could have been far more severe. Placenta accreta patients account for 38% of caesarean-related hysterectomies, and up to 7% of women with placenta accreta die.

Lessons from Arkansas

In the face of this crisis, researchers, policymakers, insurance carriers, doctors and hospital administrators are confronting this question with more urgency now than ever.

A revealing effort is ongoing just across the border from Mississippi, in Arkansas. The two states have similar populations, similar public health deficits and until a few years ago, similarly high rates of C-sections for first-time, low risk births.

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“Arkansas was another Mississippi,” said Arnold, who lives in Arkansas. “We were always 49th and 50th in the rankings, and fighting for that coveted 48th ranking. Public health here is a nightmare.”

In 2012, the state’s Medicaid agency began to offer monetary incentives to hospitals that reduced their high rates of caesarean sections. The rate of C-sections for Medicaid patients dropped nearly seven percentage points over the next four years. “I didn’t expect it to happen that quickly,” said Dr William Golden, the Medicaid director for Arkansas.

But the drop in caesareans wasn’t only fueled by a change in the needs or health of Arkansas’s Medicaid patients, a fact that lays bare just how many C-sections in her state were avoidable.

“It’s payment-based. It wasn’t about the patients.”