The cesarean delivery rate reached an all-time high of 31.8% in 2007.1 This was due to a primary cesarean delivery rate of more than 20% and a vaginal birth after cesarean (VBAC) rate of less than 10%. Interestingly, although we have seen the cesarean rate rise 50% since 1995, there has been no concomitant reduction in neonatal morbidity and mortality.2 In fact, what has been seen is that the risk of maternal mortality has been on the rise.3 Although the risk of maternal mortality is associated with maternal factors such as obesity and chronic medical conditions, it is also seen at higher rates in women undergoing a cesarean delivery.4 Furthermore, the risks of maternal mortality and neonatal complications appear to be increased in the setting of placenta previa as well as accreta.5, 6 Thus, given the strong association between multiple cesarean deliveries and placenta previa and accreta,7 it is not surprising that this rise is being seen.
In the current edition of the Journal of Perinatology, Galyean et al. examine how having a prior cesarean delivery impacts future pregnancy outcomes beyond abnormal placentation.8 They found that having had a prior cesarean delivery increased the risk in the subsequent pregnancy of requiring a blood transfusion or being admitted to an intensive care unit for the mothers, and a longer length of stay as well as a greater likelihood of needing a ventilator for the neonates. For the mothers, this difference was primarily seen only in those who underwent a repeat cesarean delivery. Similarly for the neonates, these findings were only worse when born to a woman who did not undergo a trial of labor after cesarean.
Thus, some of the future morbidity may be mitigated by offering a trial of labor after cesarean, particularly one which results in a VBAC. In an elegant analysis, Grobman et al. showed that women with a 70% chance of a successful VBAC had better maternal and neonatal outcomes than women who underwent an elective repeat cesarean delivery.9 Unfortunately, VBAC rates are at an all time low for the past 20 years and, as discussed by Dr Rybak in the current issue of the Journal of Perinatology, the availability of VBAC is diminishing due to a decreasing number of hospitals and providers willing to offer the option to women.10 Thus, the burden of prevention of future adverse pregnancy outcomes falls to reducing the risk of cesarean delivery in the first pregnancy.
Such a reduction can be accomplished by dedication from each clinician to look for opportunities to reduce the cesarean delivery rate, proper incentives to clinicians who care for pregnant women, and health policy approaches such as tort reform. Clinicians can likely reduce primary cesareans by offering external cephalic version to women with a breech fetus,11 extending the diagnosis of active phase arrest to at least 4 h,12, 13 using manual rotation of the fetal occiput in the setting of persistent occiput transverse or posterior positions,14, 15 and suppression of HSV lesions in women who are herpes simplex virus positive.16 However, clinicians have little incentive to extend the diagnosis of active phase arrest, do external cephalic versions or attempt manual rotation because each of these involves the expense of clinical time without reimbursement. As opposed to many other areas of health care, clinicians caring for pregnant women are not rewarded economically for spending more time with a patient in labor and delivery. As the actual time spent during a cesarean delivery is greater than a vaginal delivery, the reimbursement has traditionally been greater. However, if one factors in the time spent during labor, most vaginal deliveries consume more clinician time. Perhaps if clinicians were reimbursed at a higher level for a vaginal delivery as compared with a cesarean delivery, such proper incentives might help turn the rising cesarean tide.
Although there need not always be immediate direct compensation to provide what is perceived as the best care, in this setting, the time cost of providing patient care to pregnant and laboring women is not the only issue. Unfortunately, the other perverse incentive placed on clinicians caring for pregnant women is the hostile medical-legal environment. Two recent studies both found associations between malpractice premiums and cesarean delivery.17, 18 It is a commonly understood dictum in medical-legal discussions that a clinician does not get sued for the cesarean performed ‘too soon’. Unfortunately, it appears that the current practice environment encourages cesarean delivery early and often without much concern given to the effects on future pregnancies from the first cesarean.
Thus, reversing the trend seen over the past decade is going to be complex and require work on a variety of fronts. It will require research such as the work by Galyean et al. and commentary similar to that provided by Dr Rybak. It will involve patient and clinician education and thoughtful work by policymakers to establish the proper incentives to provide the best care. In the end, without a reversal in this trend, it appears that the rates of both maternal and neonatal complications may continue to rise in the near future.
References
Hamilton BE, Martin JA, Ventura SJ . Births: Preliminary Data for 2007. National vital statistics reports, Editor. 2009. National Center for Health Statistics: Hyattsville.
MacDorman M, Menacker F, Declercq E . Cesarean birth in the United States: epidemiology, trends, and outcomes. Clin Perinatol 2008; 35: 293–307.
Kung HC, Hoyert DL, Xu J, Murphy SL . Deaths: final data for 2005. Natl Vital Stat Rep 2008; 56: 1–120.
Clark SL, Belfort MA, Dildy GA, Herbst MA, Meyers JA, Hankins GD . Maternal death in the 21st century: causes, prevention, and relationship to cesarean delivery. Am J Obstet Gynecol 2008; 199: 36 .e1–5.
Clark SL, Yeh S-Y, Phelan J, Bruce S, Paul RH . Emergency hysterectomy for obstetric hemorrhage. Obstet Gynecol 1984; 64: 376–380.
Zlatnik MG, Cheng YW, Norton ME, Thiet M-P, Caughey AB . Placenta previa and the risk of preterm delivery. J Matern Fetal Neonatal Med 2007; 20: 719–723.
Silver RM, Landon MB, Rouse DJ . Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006; 107: 1226–1232.
Galyean AM, Lagrew DC, Bush MC, Kurtzman JT . Previous cesarean section and the risk of postpartum maternal complications and adverse neonatal outcomes in future pregnancies. J Perinatol 2009; 29: 726–730.
Grobman WA, Lai Y, Landon MB, Spong CY, Leveno KJ, Rouse DJ et al. Can a prediction model for vaginal birth after cesarean also predict the probability of morbidity related to a trial of labor? Am J Obstet Gynecol 2009; 200: 56 .e1-6.
Rybak EA . Hippocratic ideal, Faustian bargain and Damocles' sword: erosion of patient autonomy in obstetrics. J Perinatol 2009; 29: 721–725.
Clock C, Kurtzman J, White J, Chung JH . Cesarean risk after successful external cephalic version: a matched retrospective analysis. J Perinatol 2009; 29: 96–100.
Rouse DJ, Owen J, Savage KG, Hauth JC . Active phase arrest: revisiting the 2 h minimum. Obstet Gynecol 2001; 98: 550–554.
Henry DM, Cheng YW, Shaffer BL, Kaimal AJ, Bianco K, Caughey AB . Perinatal outcomes in active phase arrest and vaginal delivery. Obstet Gynecol 2008; 112: 1109–1115.
Reichman O, Gdansky E, Latinsky B, Labi S, Samueloff A . Digital rotation from occipito-posterior to occipito-anterior decreases the need for cesarean section. Eur J Obstet Gynecol Reprod Biol 2008; 136: 25–28.
Shaffer BL, Cheng YW, Vargas J, Laros Jr RK, Caughey AB . Manual rotation of the fetal occiput: predictors of success and delivery. Am J Obstet Gynecol 2006; 194: e7–e9.
Little SE, Caughey AB . Acyclovir prophylaxis for pregnant women with a known history of herpes simplex virus: a cost-effectiveness analysis. Am J Obstet Gynecol 2005; 193: 1274–1279.
Murthy K, Grobman WA, Lee TA, Holl JL . Association between rising professional liability insurance premiums and primary cesarean delivery rates. Obstet Gynecol 2007; 110: 1264–1269.
Yang YT, Mello MM, Subramanian SV, Studdert DM . Relationship between malpractice litigation pressure and rates of cesarean section and vaginal birth after cesarean section. Med Care 2009; 47: 234–242.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Caughey, A. Reducing primary cesarean delivery: can we prevent current and future morbidity and mortality?. J Perinatol 29, 717–718 (2009). https://doi.org/10.1038/jp.2009.132
Published:
Issue Date:
DOI: https://doi.org/10.1038/jp.2009.132