birthbythenumbers.org myth and reality concerning cesarean section in the u.s. professor gene...

BirthByTheNumbers.org

Myth and Reality Concerning Cesarean Section in the U.S.

Professor Gene Declercq, PhDBoston University School of Public Health

www.birthbythenumbers.org

With support from: The Transforming Birth Fund

Slides Updated through January 15,2015

US Cesarean Rates, 1989-2013

20

22

24

26

28

30

32

34

% 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

'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

%

Source: National Center for Health Statistics Annual Birth Reports

%

1,284,339cesareans

in 2013

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.

US Cesarean Rates, 1989-2013

20

22

24

26

28

30

32

34

% 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

'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

%

Source: National Center for Health Statistics Annual Birth Reports

%

BirthByTheNumbers.org

US Cesarean Rates, 1989-2013

20

22

24

26

28

30

32

34

% 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

'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

%

Source: National Center for Health Statistics Annual Birth Reports

%

BirthByTheNumbers.org

US Cesarean Rates, 1989-2013

20

22

24

26

28

30

32

34

% 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

'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

%

Source: National Center for Health Statistics Annual Birth Reports

%

BirthByTheNumbers.org

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

Older Mothers? % Births to Mothers 30 +, U.S. 1990-2013

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Between 2003 & 2010 CS Rate increased by 20%

> 35> 35

>30

BirthByTheNumbers.org

From 2010-2013, CS rate unchanged

BirthByTheNumbers.org

Total Cesarean Rates (per 100 births) by Age of Mother: United States, 1996 and 2013

14.517.4

20.623.8

27.431.6

21.8

27.631.3

35.5

41.6

49.6

0

10

20

30

40

50

60

<20 20-24 25-29 30-34 35-39 40-54

1996 2013

50% 59% 52% 49% 52% 57%

Source: National vital statistics system, NCHS, CDC.

Per

cent

Overall increase, 1996-2013: 58.0%

Multiple Births? Proportion of all babies in multiple births,

U.S., 1980-2013

19801982

19841986

19881990

19921994

19961998

20002002

20042006

20082010

20120.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

BirthByTheNumbers.orgSource: National Center for Health Statistics Annual Birth Reports

Cesarean Rates for Multiple Births, U.S. 1990-2013

56% 56%

60%

74%76%

50%

55%

60%

65%

70%

75%

80%

1990 1995 2000 2006 2013

BirthByTheNumbers.org

Are Babies Getting Bigger?% Singleton Babies by Birthweight, U. S., 1991-2013

11% 11% 10% 8% 8%

30% 30% 29%28% 28%

0%

10%

20%

30%

40%

50%

1991 1996 2001 2006 2013

3500-3999gms

4000+gms41% 41% 39%

36% 36%

BirthByTheNumbers.org

% Cesareans in Singleton Births, U.S. by Birthweight, 1991-2013

10%

15%

20%

25%

30%

35%

40%

45%

50%

55%

1991 1996 2001 2006 2013

3500 - 3999gms

4000 - 4499gms

4500+gms53.6%

38.6%

31.3%

21.8%

27.8%

38.2%

BirthByTheNumbers.org

BirthByTheNumbers.org

Mothers’ Health?Prepregnancy Obesity, U.S. 2003, 2006, 2009, 2011

2003 2006 2009 201110%

12%

14%

16%

18%

20%

22%

17.6%

19.5%

20.5% 20.3%

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

Underwei

ght

Normal

Wei

ght

Ove

rwei

ght

Obes

e I

Obes

e II

Obes

e III

-10%

0%

10%

20%

30%

40%

50%

60%

22.3%27.1%

33.6%39.7%

45.4%

54.0%

Source: CDC VitalStats, 2013.

BirthByTheNumbers.org

Mothers’ Health?Diabetes* & Hypertension*, 1992,2002,2013

1992 2002 20130%

1%

2%

3%

4%

5%

6%

7%

2.2%

3.2%

6.0%

3.4%

4.4%

6.4%Any Diabetes

Any Hypertension

* Either gestational or chronic condition

Source: CDC VitalStats, selected years.

BirthByTheNumbers.org

Mothers’ Health?Cesarean Rates, Singleton Births, U.S.,

1990, 1996, 2004, 2013

1990 1996 2004 201330%

40%

50%

60%

70%

Prepregnancy DiabetesChronic Hypertension

Source: CDC VitalStats, selected years.

BirthByTheNumbers.org

Mothers’ Health?Cesarean Rates, Singleton Births, U.S.,

1990, 1996, 2004, 2013

1990 1996 2004 201330%

40%

50%

60%

70%

Prepregnancy DiabetesChronic Hypertension

Source: CDC VitalStats, selected years.

BirthByTheNumbers.org

Mothers asked for it

Have maternal request cesareans played a major

role in these increases?

http://www.childbirthconnection.org

Asking Mothers about

Maternal Request Cesareans

BirthByTheNumbers.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 cesareans

Pressure to Accept Interventions by Method of Delivery

Did you feel pressure from any health professional to have a cesarean? % yes

7%

28%

28%

22%

0% 5% 10% 15% 20% 25% 30%

Vaginal

VBAC

PrimaryCesarean

RepeatCesarean

Source: Declercq et al. 2013. Listening to Mothers III.BirthByTheNumbers.org

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

34%

23%

17%

7%

5%

4%4%

3% 3%

Labor ArrestNonreassuring fetal trac-ingMalpresentationMultiple GestationMaternal-FetalMacrosomiaOther Obstet.PreeclampsiaMaternal Request

Source: ACOG & SMFM. Safe Prevention of Primary Cesarean Delivery. 3/2014.

Cesarean Rates, Low Risk*, First-Time Mothers for Medical Risk Factors & Labor Complications

20

30

40

50

60

70

1990 1996 2011

Prolonged Labor

Nonreassuring FetalTracing

Macrosomia

Twins

*Singleton, Vertex, Full Gestation Births BirthByTheNumbers.org

20

22

24

26

28

30

32

34

% 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

'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

%

Source: National Center for Health Statistics Annual Birth Reports

%

Revisiting the trend in cesareans in the US for comparison

BirthByTheNumbers.org

Cesarean Rates, Low Risk*, First-Time Mothers for Medical Risk Factors & Labor Complications

30

40

50

60

70

1990 1996 2011

Prolonged Labor

Nonreassuring Fetal Tracing

Macrosomia

Twins

*Singleton, Vertex, Full Gestation Births BirthByTheNumbers.org

Cesarean Rates, Low Risk*, First-Time Mothers for Medical Risk Factors & Labor Complications

30

40

50

60

70

1990 1996 2011

Prolonged Labor

Nonreassrg Fetal Trace

Macrosomia

Twins

*Singleton, Vertex, Full Gestation Births 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

MT

WY

ID

WA

OR

NV

UT

CA

AZ

ND

SD

NE

CO

NM

TX

OK

KS

AR

LA

MO

IA

MN

WI

IL IN

KY

TN

MS AL GA

FL

SC

NC

VAWV

OH

MINY

PA

MDDE

NJ

CTRI

MA

ME

VTNH

AK

HI

31.6%+

22.6-31.5%

DC

Cesarean Delivery Rates1, 2012

1Percentage of all live births by cesarean delivery

Source: Martin J, et al. Births Final Data 2012. National Vital Statistics System, 2014. BirthByTheNumbers.org

MT

WY

ID

WA

OR

NV

UT

CA

AZ

ND

SD

NE

CO

NM

TX

OK

KS

AR

LA

MO

IA

MN

WI

IL IN

KY

TN

MS AL GA

FL

SC

NC

VAWV

OH

MI

NY

PA

MDDE

NJ

CTRI

MA

ME

VTNH

AK

HI

DC

1960 Electoral College Map

Nixon 219

Harry Byrd 15

Kennedy 303

BirthByTheNumbers.org

BirthByTheNumbers.org

JFK 1960 Vote and 2012 Cesarean Rates

20% 25% 30% 35% 40% 45%35

40

45

50

55

60

65

r = +.28

2012 Cesarean Rate

JFK

% V

ote

Each dot represents a U.S. state

BirthByTheNumbers.org

Variation is not just at the state level but at the hospital level as well

% Cesarean Deliveries by Hospital for ALL MA Births, 2004-2006

N = 49 Mean =31.2 σ2 =29.6

41.9

21.1

0

5

10

15

20

25

30

35

40

45

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

Hospital Rank

%CSAll 49 Hospitals

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

All Hospitals

10.3

35.0

0

5

10

15

20

25

30

35

40

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

Hospital Rank

%CS

% Cesarean Deliveries by Hospital for NTVS, Spontaneous Labor, BWT 2500-4000g Births

N = 49 Mean =21.1 σ2 =37.1

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

InductionNo

53%

EpiduralNo

39%

EpiduralYes61%

InductionYes47%

EpiduralNo

22%

EpiduralYes78%

First-time mothers with term births (37-41 weeks’ gestation) who experienced labor

Cesarean Yes

20%

Cesarean Yes

5%

Cesarean Yes

31%

Cesarean Yes

19%In this group, which included 85% of first-time mothers, the overall epidural rate was 69% and overall cesarean rate was 21%.

Cascade of interventions in first-time mothers with term births who experienced labor

Base: first-time mothers with term births who experienced labor n=750

BirthByTheNumbers.org

What about Vaginal Birth After Cesarean

(VBAC) ?

BirthByTheNumbers.org

VBAC Rates*, U.S.,1990-2011

5%

10%

15%

20%

25%

30%

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

Source: NCHS Vital Stats. http://www.cdc.gov/nchs/VitalStats.htm

* Number of VBACs among women with prior cesarean

NOTE: Rates for 2005-2011 are unofficial

BirthByTheNumbers.org

% VBAC Lower Risk* Mothers, U.S., Monthly Rates, 1990-2012

6%

9%

12%

15%

18%

21%

24%

27%

30%

33%

* Full-gestation(37+ weeks), vertex presentation, singleton births

Sachs, NEJM 1/99

ACOG New VBAC Guidelines 10/98 & 7/99

Lydon-Rochelle & Greene 7/01

LandonNEJM 12/04Flamm

Studies1988,’90, ‘94

McMahon NEJM 9/96

ACOG guidelines encourage VBAC, 1/82 10/88 Reaffirmed 1991

Revised ACOG Guide-

lines 8/10

BirthByTheNumbers.org

VBAC Rates Industrialized Countries, 2010

MaltaIcelandFinland

NetherlandsNorway

GermanyFrance

BelgiumDenmark

EnglandEstonia

LuxembourgCzech Republic

SloveniaScotland

LithuaniaItalyU.S.

LatviaCyprus

0 10 20 30 40 50 60 70 8074

5252

4746

363534

333029

2828

2121

1110

97

6

Source: Adapted from Peristats & US Data

VBAC % = VBACS Women w/ Prior CS

BirthByTheNumbers.org

August, 2010

BirthByTheNumbers.org

Mother had cesarean in the past, and did not have the option of a VBAC for recent birth.

LTMI 2000-02

LTMII 2005

LTMIII2011-12

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%

U.S. Mothers Report of Experience Seeking a VBAC, 2000, 2005, 2012

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

20

22

24

26

28

30

32

34

% 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

'89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12

%

Source: National Center for Health Statistics Annual Birth Reports

%

BirthByTheNumbers.org

Trends in Cesarean Rates (per 1000 births), Comparison Countries, 1990-2011

50

100

150

200

250

300

350

400

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

Sources: OECD Health Data 2013; WHO Health for All Database, 2014. BirthByTheNumbers.org

Trends in Caesarean Rates (per 1000 births), Comparison Countries, 1990-2011

50

100

150

200

250

300

350

400

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

Sources: OECD Health Data 2013; WHO Health for All Database, 2014. BirthByTheNumbers.org

www.acog.org/Resources_And_Publications/Obstetric_Care_Consensus_Series/Safe_Prevention_of_the_Primary_Cesarean_Delivery

Safe Prevention of Primary Cesarean Delivery

Questioning the Rising Cesarean Rate

BirthByTheNumbers.org

Evidence Based Advocacy

BirthByTheNumbers.org

Prematurity and Low Birthweight, U.S., 1990-2012

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

6

7

8

9

10

11

12

13

Prematurity

Low Birthweight

9.8%Decrease 2006-12

%

YearBirthByTheNumbers.org

BirthByTheNumbers.org

http://www.choicesinchildbirth.org/

Evidence Based Advocacy

BirthByTheNumbers.org

https://www.childbirthconnection.org/

Evidence Based Advocacy

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