By Katherine Harmon
Despite medical advances and increasing access to improved obstetric care across the globe, surgical childbirths are still more risky for both mother and baby, according to an ongoing international survey by the World Health Organization (WHO).
A new report from the survey, which was published online today in the medical journal The Lancet, found that in Asia—in both developed and developing nations—cesarean section births only reduced risks of major complications for mother and child if they were medically recommended. Elected surgical deliveries, on the other hand, put both at greater risk.
"Cesarean section should be done only when there is a medical indication to improve the outcome for the mother or the baby," the authors of the report concluded. Common reasons for a recommendation for cesarean delivery included a previous cesarean section, cephalopelvic disproportion (when the baby's head cannot fit through the mother's pelvic opening) and fetal distress.
In the nine countries studied (Cambodia, China, India, Japan, Nepal, the Philippines, Sri Lanka, Thailand and Vietnam), more than a quarter of the 107,950 births analyzed (27.3 percent) were C-sections, and in China, which had the highest rate of operations, nearly half (46.2 percent) of the births in the survey were cesarean. With these surgeries comes increased risk of maternal death, infant death, admission into an intensive care unit, blood transfusion, hysterectomy or internal iliac artery ligation (to control bleeding in the pelvis) compared to spontaneous vaginal delivery, according to the report.
But these risks have not necessarily been absorbed into popular, or even medical culture. The rates of cesarean section procedures are on the rise in many countries across the globe, the authors report, and in some countries they "have reached epidemic proportions." Among the nations studied, China had the highest rate of cesarean sections that were performed without medical indication—11.7 percent; the overall rate for the facilities studied had a rate of 1.9 percent.
Most cesarean sections (15.8 percent of births) were begun during labor, as opposed to before it starts. But these later procedures—both elected (0.5 percent) and medically required (15.3 percent)—also carry the most risks for adverse outcomes, the authors found.
In a commentary accompanying the report, Yap-Seng Chong of the National University of Medicine in Singapore and Kenneth Y C Kwek of the KK Women's and Children's Hospital also in Singapore call the results "surprising and chilling." The findings, they say "should help us to prioritize our strategies to reduce unnecessary interventions in childbirth," they wrote. "There is little wrong with medical interventions when indicated, but for those who are still inclined to consider caesarean delivery a harmless option, they need to take a cold hard look at the evidence against unnecessary cesarean section."
The investigators were able to analyze some 96 percent of the births reported in the 122 hospitals that participated in the survey over two to three months between 2007 and 2008. Facilities were located in the capital city of each country and two randomly chosen regions. To qualify for the survey, hospitals had to be delivering at least 1,000 babies a year and performing cesarean surgeries, so as the authors noted, "the results therefore cannot be generalized to smaller facilities" or to the countries overall.
Despite the increased risks associated with cesarean deliveries, no mothers or babies in the study died after an elected cesarean before hospital release. The most dangerous form of childbirth proved to be vaginal operative delivery, which includes using forceps or a vacuum to assist in delivery and is more rare, occurring in just 3.2 percent of the births analyzed.
The findings confirm a previous WHO report published in 2006 in The Lancet, analyzing the rates and safety of various childbirth approaches in Latin America, where the investigators found that "increasing rates of cesarean section do not necessarily lead to improved outcomes and could be associated with harm." Taking the two reports together, the authors concluded, lends "strong multiregional support for the recommendation of avoiding unnecessary cesarean sections."
Surgical childbirth also requires more resources than a natural vaginal delivery, the authors note. Especially in countries where money, medical practitioners or proper equipment is more limited, unnecessary cesarean sections can drain resources away from those cases in which it can improve the chances of a healthy mother and baby.
http://www.scientificamerican.com/blog/post.cfm?id=elective-cesarean-sections-are-too-2010-01-11
Showing posts with label cesarean. Show all posts
Showing posts with label cesarean. Show all posts
Thursday, January 21, 2010
Monday, October 5, 2009
Sunday, September 27, 2009
CDC Says Cesarean Triples Neonatal Death Risk
by Misha Sanfranski
While the increased risks of cesarean section to neonatal and maternal health have long been known, an even more grim issue came to light in a study released in the September, 2006 issue of Birth Journal. The CDC conducted research on cesarean section and neonatal mortality, expecting to
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find that the neonatal mortality rate (defined as death within the first 28 days of life) following cesarean section correlated directly with medical complications of the mother and baby. What they found, instead, was that regardless of risk factors, babies born by cesarean section face a risk of death nearly three times that of vaginally born babies.
MacDorman, et al. analyzed national birth and death data for 5,762,037 live infants and 11,897 neonatal deaths, for the years 1998-2001. The purpose of the study was to examine the neonatal outcomes of primary cesarean delivery in women who had no other known complications or medical risk factors. The logical result of this examination would seem to be comparable neonatal mortality rates among cesarean and vaginally born infants. In fact, what the results show is that cesarean independently raises the risk of neonatal death by almost three-fold - .62 per 1000 deaths among vaginal births versus 1.77 per 1000 infant deaths among cesarean babies.
Even more astounding than the simple fact that cesarean section raises the risk of infant death - regardless of the reason the cesarean was performed - is that even when the researchers adjusted for sociodemographic, medical and congenital factors, and removed infants with APGARs under 4, the risk of death was only reduced "moderately". A stark difference in the death rates between cesarean born infants and vaginally born infants remained even with no medical explanation.
We aren't talking about babies dying from the few, rare complications that can arise in childbirth. We're talking about healthy, low-risk mothers electing for a primary cesarean section with no medical indication resulting in a nearly three times higher rate of death than those who have a vaginal birth.
According to Marian MacDorman, the CDC's study leader, "These findings should be of concern for clinicians and policymakers who are observing the rapid growth in the number of primary Caesareans to mothers without a medical indication."
While the findings of this research on cesarean and neonatal mortality were reported by major media outlets upon its release, publicity for the issue quickly waned. It is evident that care providers and mothers have continued to discount the disturbing results of the CDC study on neonatal
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mortality and cesarean, as the rate of surgical delivery has continued to climb to a record-breaking high of 31.8% in 2007, up from 31.1% in 2006.
The World Health Organization recommends no more than a 10% cesarean rate in developed countries, based upon research indicating more harm than good to both mothers and babies when the cesarean rate tops 15%. Until mothers and obstetricians start taking the risks of elective cesarean section seriously, we will likely continue to see tragic consequences of the interference of surgery in childbirth.
References:
MacDorman MF, Declercq E, Menacker F, Malloy MH.
Division of Vital Statistics, NationalCenter for Health Statistics, Centers for Disease Control and Prevention,
Hyattsville, Maryland20782, USA. Birth. 2006 Sep;33(3):175-82.
While the increased risks of cesarean section to neonatal and maternal health have long been known, an even more grim issue came to light in a study released in the September, 2006 issue of Birth Journal. The CDC conducted research on cesarean section and neonatal mortality, expecting to
Costumes | Party Ideas | Kids and Safety | Movies and Music | Scary Stories | More »
find that the neonatal mortality rate (defined as death within the first 28 days of life) following cesarean section correlated directly with medical complications of the mother and baby. What they found, instead, was that regardless of risk factors, babies born by cesarean section face a risk of death nearly three times that of vaginally born babies.
MacDorman, et al. analyzed national birth and death data for 5,762,037 live infants and 11,897 neonatal deaths, for the years 1998-2001. The purpose of the study was to examine the neonatal outcomes of primary cesarean delivery in women who had no other known complications or medical risk factors. The logical result of this examination would seem to be comparable neonatal mortality rates among cesarean and vaginally born infants. In fact, what the results show is that cesarean independently raises the risk of neonatal death by almost three-fold - .62 per 1000 deaths among vaginal births versus 1.77 per 1000 infant deaths among cesarean babies.
Even more astounding than the simple fact that cesarean section raises the risk of infant death - regardless of the reason the cesarean was performed - is that even when the researchers adjusted for sociodemographic, medical and congenital factors, and removed infants with APGARs under 4, the risk of death was only reduced "moderately". A stark difference in the death rates between cesarean born infants and vaginally born infants remained even with no medical explanation.
We aren't talking about babies dying from the few, rare complications that can arise in childbirth. We're talking about healthy, low-risk mothers electing for a primary cesarean section with no medical indication resulting in a nearly three times higher rate of death than those who have a vaginal birth.
According to Marian MacDorman, the CDC's study leader, "These findings should be of concern for clinicians and policymakers who are observing the rapid growth in the number of primary Caesareans to mothers without a medical indication."
While the findings of this research on cesarean and neonatal mortality were reported by major media outlets upon its release, publicity for the issue quickly waned. It is evident that care providers and mothers have continued to discount the disturbing results of the CDC study on neonatal
Costumes | Party Ideas | Kids and Safety | Movies and Music | Scary Stories | More »
mortality and cesarean, as the rate of surgical delivery has continued to climb to a record-breaking high of 31.8% in 2007, up from 31.1% in 2006.
The World Health Organization recommends no more than a 10% cesarean rate in developed countries, based upon research indicating more harm than good to both mothers and babies when the cesarean rate tops 15%. Until mothers and obstetricians start taking the risks of elective cesarean section seriously, we will likely continue to see tragic consequences of the interference of surgery in childbirth.
References:
MacDorman MF, Declercq E, Menacker F, Malloy MH.
Division of Vital Statistics, NationalCenter for Health Statistics, Centers for Disease Control and Prevention,
Hyattsville, Maryland20782, USA. Birth. 2006 Sep;33(3):175-82.
Thursday, August 20, 2009
Reducing Infant Mortality
This is an awesome video on reducing infant mortality here in the states. Take the time and watch it - it is under 17 minutes long.
Reducing Infant Mortality from Debby Takikawa on Vimeo.
Friday, August 14, 2009
The Real Risk of C-Section - Medscape Interview
Editor's Note:
Cesarean section (c-section) is the most commonly performed surgery in the United States. The frequency of surgical birth has increased from 4% in 1965 to about 33% today, despite World Health Organization (WHO) recommendations that a 5% to 10% rate is optimal and that a rate greater than 15% does more harm than good.[1-3]
Reasons for this increase have been discussed profusely:
- The surgical focus of obstetrics and the need to train residents;
- The low priority and few practical skills for supporting women's abilities to labor and give birth naturally;
- A rigid view of the duration of normal labor; and
- A low threshold of definition for 'labor dystocia' (the justification for up to 60% of cesarean births[4]).
Surgical birth is also a 'side effect' of interventions associated with actively managed labor: induction, artificial rupture of membranes, labor medications, and fetal monitoring.[5,6] Policies against vaginal birth after cesarean (VBAC) and, increasingly, unsupported 'supply-side' justifications such as "baby seems large," also drive the trend toward cesareans. A recent report by the Lamaze Institute associates surgical birth with obstetricians' personalities -- specifically their anxiety levels.[7-9]
The risks for birth by surgery have also come under discussion. Maternal risks include a higher overall death rate, rehospitalization for wound complications and infection, placenta accreta and percreta (both with 7% mortality rate), placenta previa, uterine rupture with subsequent pregnancy, and preterm birth, with its own set of risks and complications for the newborn.[10-15]
Pamela K. Spry, BSN, MS, CNM, PhD, the President of Lamaze International, a leading childbirth-advocacy group, spoke with us about the risks for birth by scalpel.
Medscape: Childbirth methods are often trend-driven. In the 1960s and 1970s, there was a big push for natural childbirth. What has driven women away from that method since then?
Dr. Spry: In the 1960s, women were rebelling against twilight sleep -- childbirth under heavy narcotics that required being strapped down to the delivery table. There was also the push for fathers to be in the delivery room, which wasn't allowed, and certainly not during heavily sedated birth. Now we have a widespread availability of local and regional methods of pain relief that let women be awake and aware, share the birth with their families, and basically rely on technology to assist them at birth. I think this drive has been somewhat alleviated, but there is still a push for natural childbirth. This is the reason women are still seeking classes, making birth plans, and choosing home birth and birthing centers.
"Natural childbirth" can mean different things to different people. For Lamaze, it means a birth that's allowed to happen on its own without the use of unnecessary medical interventions, to provide women the safest and healthiest birth possible.
Medscape: Are rates of surgical delivery being driven up by women or clinicians? Is this the age of Blackberry birth -- scheduling everything ahead of time?[16]
Dr. Spry: Actually, there are 2 parts to this question. One is, what has driven up the rate of repeat cesareans, and that answer is easy: there has been a big decrease in the availability of choosing to labor and deliver vaginally (VBAC) after having 1 or 2 previous cesarean births, causing a huge increase in the rate of surgical delivery [for repeat cesareans]. Compared with the early 1990s when VBACs were encouraged and acceptable, many hospitals, insurance companies, and clinicians now refuse to allow women to try laboring after a previous c-section because of perceived medical and legal risks.
The second part of the question is whether women or clinicians are responsible for the increase in the primary c-section rate, and I think that's more difficult to answer. In a study of more than 1500 women, we tried to determine just that. The research results indicated that only 1 woman in the study actually reported that she requested a cesarean, which leaves the decision for the vast majority of cesarean deliveries up to clinicians. So understanding when cesareans are medically necessary, as well as the risks involved, is important in achieving a safe and healthy birth.
Although it might be convenient, babies who are born before they are ready are at increased risk for major medical problems.
Medscape: Could fear be the reason for women agreeing to surgical birth? Are women enduring pain differently than in previous decades? Is the surgical scenario easier to contemplate than the unknowns of a natural labor and delivery?
Dr. Spry: Exactly. I think all of that has to do with the fact that our culture actually breeds fear around childbirth. We've got TV shows, popular culture, and horror stories from friends and families; women are taught to expect a negative experience and incredible pain. Lamaze is focused on trying to help women get the facts, know what to expect, and help take the fear out of the process. But the unknown parts, such as labor, its duration, birth, and even the unknown of when labor will start, makes it more appealing for some women to schedule a cesarean.
Medscape: The culture of hospital obstetrics seems designed for interventions, with cesarean procedures bringing in more money than natural delivery. Do you think hospital financial incentives are a reason for the rise in cesareans? Or would the costs for longer hospital stays with cesarean procedures balance out the revenues from them?[17]
Dr. Spry: I think that sometimes financial concerns, convenience, or concerns over lawsuits do rule medical decision-making around childbirth. When women have a good understanding of what constitutes quality care, they are in a better position to ask for it from their care providers. Interestingly enough, I just returned from our nurse-midwifery convention in Seattle, and I heard a speaker address this very thing: reducing the cesarean rate. Among his suggestions was the provocative notion that providers should be reimbursed the highest rate for labor and vaginal birth after cesarean, followed by labor and vaginal birth, and the lowest reimbursement for scheduled, elective cesarean delivery. That way, providers would be compensated for their actual time involved in the process, and scheduled c-sections would have the lowest reimbursement. He thought that would make a difference.
Medscape: What are the main risks these days with c-sections? Are these risks underplayed by obstetricians, and, if so, why?
Dr. Spry: Many of them were covered in the introduction. Any time we schedule a surgery or an induction, we are assuming that we know the baby's due date. Anything that's scheduled before a woman's estimated due date could result in a baby being born before it's ready. [And iatrogenic prematurity is a reality with any scheduled birth -- that is, due dates may have been calculated wrong and inadvertently, babies are born before they are actually term.] We're getting more research looking at the near-term preemie. We find that they have breathing and developmental problems and that the risk for death is increased. Certainly, cesarean delivery increases the risk for the baby being injured from the incision. Surgery also carries risks for women, such as blood loss, clotting, infections, severe pain, and adverse anesthesia-related events. This is something that we haven't focused on, and I'm not certain that informed consent includes this information -- that there are complications during future pregnancies and that it does risk future children. There is an increased risk for stillbirth with a second or third c-section, as well as placental problems like percreta and accreta (abnormal growth and attachment of the placenta into the uterus), increasing the risk for hemorrhage. Women may experience dire complications as a result -- bladder injury, hysterectomy, and maternal death. I don't know that I would describe these risks as "underplayed" by obstetricians, but rather that women are not prepared to ask the right questions that lead to informed decision-making.
It would be interesting to read the informed-consent documents for cesarean deliveries, and see what risks are included.
Medscape: A story in The New York Times recently reported that women who have c-sections seem to have fewer children. That story provoked over 200 comments, from women who have had all of their children by planned cesarean to women who had had births at home. A strong fear-driven contingent regarded childbirth as fraught with pain and danger, and that anyone who risked giving birth outside of a hospital was committing child abuse. Can you discuss any evidence comparing the risks to mothers and children between in-hospital and at-home births?[18]
Dr. Spry: A number of studies have looked at this. Some of the criticism of these studies has been that hospitals end up with higher-risk women, so it's an unfair comparison. But there are studies of low-risk women who had a planned home birth with a qualified birth attendant, compared with low-risk women who chose hospital births; the outcomes for home birth were better or as good as outcomes for women who birthed in hospitals.
Each study limits what kind of comparisons are made, but certainly women with previous surgical uterine scars, medical complications, or breech babies are all considered high-risk.
Medscape: The recovery period after any birth, from time immemorial known as the "lying-in" period, used to last several weeks after a birth. Now, even after surgical birth, women are up and around within a few days. Postpartum depression is another health consideration that has been much in the news lately. Do you think we have lost something with this shortened period of rest and recovery?[19]
Dr. Spry: I do. Studies have shown that it's better for mothers and babies to stay together after birth. Experts agree that unless a medical reason exists, healthy mothers and babies should not be separated following birth. Interrupting, delaying, or limiting the time that a mother and her baby spend together may have a harmful effect on their relationship and on breast-feeding. Babies stay warm, cry less, and have a better start on breast-feeding if moms and babies are together.
[As for the question about depression], women with postpartum depression do experience difficulty bonding with their babies. But this could be a result of depression rather than the cause, so it's really hard to answer [whether a shortened period of recovery is related to causing postpartum depression]. Most people get 6 weeks off of work, but even in those 6 weeks, women are still running around [trying to take care of other children, do chores, and manage the household]. I don't know whether we, as a culture, discourage mothers and babies to be together in the postpartum period by no longer posting signs on the doors that say "Don't knock, baby sleeping!" I'm just not aware of any comparative studies on how different postpartum protocols correlate with postpartum depression.
Medscape: There's a marked trend toward inducing delivery -- vaginally or surgically -- before 40 weeks, with mounting evidence that this is risky business. Where is this coming from?[20,21]
Dr. Spry: This increased induction rate has occurred for several reasons: the desire on the part of the women or the providers to arrange a convenient time for delivery. Again, it's a scheduling issue. Concerns about postmaturity, or a post-dates baby, with a fear of adverse outcome and litigation may have contributed to this. But despite the large number of women experiencing induction, one-half of the women who responded to the "Listening to Mothers" study said that they felt that labor should not be interfered with unless it's medically necessary. Eleven percent of the mothers also said that they had experienced some pressure from their care providers to have an induction. Lamaze gives this information to women to help them select their place of birth and communicate with their healthcare provider. These tools can assist women in having a safe and healthy birth.
Medscape: Even truly full-term infants born by cesarean end up in intensive care more frequently than their vaginally born peers. Is this because such infants born by cesarean are high-risk to begin with, or is the procedure itself responsible for this?
Dr. Spry: I think that it's both. I definitely think that some medically indicated surgical deliveries do end up with babies that were higher-risk to begin with. But if you compare low-risk babies that are born by cesarean with vaginal-birth babies, vaginal-birth babies do better. There is an increased likelihood of babies born surgically having problems with fluid in the lungs and less ability to clear it. So actually going through the birth canal seems to be better for the baby.
Medscape: In 2005, surgical birth was the most common Medicaid-billed procedure, performed on women who are most likely at risk for the poorest aftercare, complications, and support. Why is this population at highest risk for c-section?[21]
Dr. Spry: I don't think this statistic indicates that the Medicaid population is at highest risk if they were compared to the insured population. I think that a large part of the Medicaid population consists of pregnant women, because this is a time when they can get coverage. So Medicaid often ends at the 6-week postpartum exam. A childbearing woman would be more likely to be covered under Medicaid than a woman in her forties who needed gallbladder surgery.
There have been a couple of studies that looked at the cesarean delivery rate of women with private insurance delivering in private hospitals, and found that privately insured women had a higher surgical risk than the Medicaid population. The rate in New York was 30% for private vs 21% for Medicaid, if the Medicaid women delivered in a public hospital (a teaching hospital). So what has happened is that we've had somewhat of a shift of Medicaid patients moving into the private sector; they've shifted their deliveries from teaching hospitals to private institutions, and this has increased their probability for cesareans.
A study from Kaiser in California showed that this increased risk persists even after adjusting for patient demographics and clinical factors. The risk was associated not so much with Medicaid, but with delivering in a private institution. Teaching hospitals tend to follow evidence-based practice, and encourage women to deliver vaginally.
Medscape: What's your perspective on recent reports about the rate of repeat cesareans jumping from 65% to 90% between 1997 and 2006?[22]
Dr. Spry: Again, I think it's litigation fear. There have been more and more restrictions placed on women who want to have VBACs. Some insurance companies won't cover clinicians or hospitals [if they provide a trial of labor after cesarean; and] there are certainly clinicians who won't do VBACs. Women are finding it more and more difficult to seek and have a vaginal birth after a prior cesarean.
I just went to a conference where I talked to a number of women whose previous experience was with c-section, but who wanted a vaginal birth. Some of them chose home birth for their next pregnancies because it was their only option.
Medscape: As the concept of birth transitions from a physical, sexual, and societal passage to a billable surgical procedure, placing women in a more passive role, how is the overall well-being of women affected?
Dr. Spry: Within the maternity system, there's a distinct drive toward convenience: predictable process of labor and birth, maximized reimbursement, and limited liability. All of these factors can lead any care provider to make decisions that aren't necessarily based on the mother's and baby's needs. Women's decisions are affected as well, because without maximum reimbursement, they can't select a place of birth that they can't afford. I think it's critical for every birthing woman to recognize the realities of the environment and be prepared to advocate for herself, taking a more active role in her birth. This is something that Lamaze focuses on.
Studies have been done where a woman has experienced a kind of birth that she didn't want, and she felt that she had no control over it. Penny Simkin just gave an excellent talk on the risk of posttraumatic stress syndrome resulting from a birth in which a woman felt not in control, who felt decisions were made for her and were imposed on her. I think that sense of control is really important to the mental health and to the feeling of being competent and OK after birth.
Medscape: Obstetrics is a surgical specialty. So far, the significant numbers of women now practicing in the field have done little to change the surgical view of birthing women. Do you think there will be a tipping point away from the surgical approach to birth among obstetricians?
Dr. Spry: Sometimes it takes us years to figure out what we've been doing wrong; this is an alarming aspect of surgery, and few women are aware of the poor state of maternity care that we have in the United States. Many women assume that because they're birthing in the United States, they're getting quality care. Research and outcome studies suggest that this isn't necessarily the case, but I don't think our population knows that yet. We're seeing an increased number of maternal deaths. We haven't seen an increase in maternal deaths in this country for a long time. [An example of a delay in recognizing risk of accepted treatment is, that] in the 1950s, 1960s, and 1970s, we gave diethylstilbestrol to women to prevent miscarriage. It wasn't until the next generation, and even after the next generation -- 30 years -- that we got rid of that practice. So I think change will come. And I think that we need to continue to perform research, monitor maternal morbidity, and look at these statistics, and then we'll see a shift.
The other issue is that really adverse, terrible events are rare; maternal deaths are rare, even though they are increasing. So an obstetrician having a personal experience of a maternal death is infrequent.
Essential skills are being lost in obstetrics -- for example, breech deliveries or twins. However, they are preserved in the world of midwifery.
I hope that we get the message across that women want and need a positive birthing experience, and that they will choose a birth team that will support that goal. We would like for everybody to have a safe and healthy birth.
Wednesday, July 22, 2009
Cesarean vs, VBAC - a dramatic difference
This is such a touching video and eye opening video. Most people do not realize the force needed to get a baby out during a cesarean section - in the second birth, a vacuum is used as well as manual force. It is 16 minutes long, but worth the time.
Cesarean vs. VBAC: A Dramatic Difference from Alexandra Orchard on Vimeo.
The unspoken risk of csections...
Babies scarred as they're born: With thousands of infants injured each year due to Caesarean births, why are mothers not warned of risks?
By Tanith Carey
Last updated at 3:48 PM on 21st July 2009
Matthew Watson is only two years old, but already he has what his mother Wendy calls 'a war wound' - a 31/2in scar which runs from his eyebrow up to his hairline.
It is the legacy of an accident during his Caesarean birth when a surgeon dropped a surgical instrument on his head.
An isolated case? Far from it - Matthew is one of an estimated 3,000 newborns injured during the procedure every year in the UK, and with the Caesarean rate rising, it is likely the number affected will also increase.
Marked for life: Matthew Watson, pictured just after a Caesarean birth, has a scar across his forehead, which his mother Wendy says is not fading
Even if the injury is just a nick, it exposes the newborn to possible infection; in other cases, the wound is also deep enough to scar the child for life.
Like many mothers-to-be, Wendy Watson had no idea that Caesareans carried this risk. Wendy, 32, from Kent, had an emergency C-section after her labour failed to progress.
'Suddenly, during the operation, the surgeon started shouting and swearing at his colleague from the other side of the surgical screen,' says Wendy. 'The surgeon was saying: "Buck your ideas up. Can't you see the position we are in with this patient?''
'It turned out that his assistant, who had been holding the instrument keeping the incision open, had lost his grip and dropped the tool on Matthew's head as he was being delivered.'
But it wasn't until Wendy was handed her baby an hour later that she discovered what had happened.
'Then the surgeon came to apologise for his colleague - he even had a couple of tears in his eyes as he talked to us,' says Wendy, who is married and works as a government finance officer.
'At the time, I'd had such a difficult labour that we were just relieved to have a healthy baby. I was also taken very ill shortly afterwards, with blood clots on my lungs, so it was never discussed any further.'
Newborns: An estimated 3,000 babies are injured during the Caesarean procedure, including cuts that leave deep scars
But far from fading with age as his parents expected, Matthew's scar has stretched as his skull has grown. Wendy says: 'He's too young to notice it and it's currently covered by hair, but he will probably have it for ever now.'
At least the surgeon apologised. In some cases, parents are simply not told about the injuries.
Sarah Fitch was given a Caesarean after her baby was found to be breach at her 40-week check-up.
'It wasn't until I changed Sophia's nappy for the first time that I noticed the cut on her bottom - about 2cm long, and looking fairly deep.
'It was a shock. She was a brand new baby. She was crying all the time, and all I could think was: "You poor little thing. No wonder you're screaming."
'I was really worried because the cut was on her bottom and it could easily have got infected from her nappy,' says Sarah, 32, a financial advisor from Hornchurch, Essex.
'There was no explanation or apology. I had to phone the hospital a week later because the wound had not closed properly and it didn't heal for ten days.'
Dangers: Mothers have complained that they were not warned of the riskis of having a Caesarean birth
For some children, the damage is even more serious. Tyler Robinson, now five, was awarded £10,000 in damages after she suffered a 5.3in cut into the muscle of her thigh and buttocks.
It's not just the babies who suffer - the experience can also prove traumatic for their mothers. Janet Davies was so horrified by the injury to her second child, Lucius, she suffered post-natal stress.
'As soon as he was lifted out of my tummy, I noticed there were several people huddled over him,' says Janet, 39, a project manager from Trafford, Manchester.
'When they eventually brought him over to me, I was shocked to see he had a plaster across his cheek, almost up to his eye.
'Initially I was told it was just a nick from when the doctors had cut through the final layer to get Lucius out. But a week later the plaster came off and I saw a huge cut. I was heartbroken.
'When I finally got through to one of the senior midwives at the hospital, she told me: "You took the risk by wanting to have a C-section."
'Then she reminded me that I had signed a consent form - as if I had signed away all my rights. The main priority seemed to be to fend off lawsuits.
'In the weeks after, I became very depressed. At first, I was diagnosed with post-natal depression. But when I started having flashbacks and nightmares about the birth, I was diagnosed with post-traumatic stress.
'Every time I saw the scar - and it became clear it would never fade - it all came flooding back. For the first year, I hardly ever took pictures of him because I found it so upsetting. In the sunlight it's very clear; it's a real ridge at the top of his cheek.'
The risk of a baby being injured during a Caesarean is about 2 per cent, according to the Royal College of Obstetricians and Gynaecologists. Although many of these injuries are superficial, experts say deeper cuts can also put babies at risk of superbug infections such as MRSA.
The problem usually occurs during emergency Caesareans, explains Pat O'Brien from the Royal College.
Occupational hazard: More experienced surgeons are better at judging the thickness of the womb lining
This is because when a woman has been in labour for a long time, her womb lining becomes very thin - as little as a few millimetres thick. And if her waters have also broken, there is no cushion to protect the baby when the incision is made.
Surgeons often have difficulty telling the wall of the uterus and the baby's skin apart - and heavy bleeding can make it difficult to see what they are cutting.
Sailesh Kumar, a consultant obstetrician and gynaecologist at the country's leading maternity hospital, Queen Charlotte's in London, says cuts to babies are more likely during emergency Caesareans because of the rush to get the baby out.
'Cuts are an occupational hazard,' he says. 'Anyone who has done a lot of C-sections and hasn't seen it happen has been very lucky.'
However, the seniority of the surgeon plays a large part, adds Mr Kumar - more experienced surgeons are better at judging the thickness of the womb lining.
There are also techniques that can be used to reduce the risk, he says. For example, the surgeon can use a finger, rather than a scalpel, to pull apart the final layer of the womb.
Another technique is to gently cut along the womb lining with a pair of scissors - while running a finger under the blade to avoid hurting the baby.
For consultant Pat O'Brien - who performs around 200 Caesareans a year - training is the best way to cut the number of injuries.
'Any cut is one too many. It is important to educate junior doctors so they are cautious during that last incision - and they know to use their fingers rather than a knife. Also, the greater the consultant presence on labour wards, the better.'
Mr O'Brien said the issue of whether mothers should be warned beforehand that babies can be cut was a difficult one.
He said: 'There has to be a balance. Women are warned about many other dangers already. You have to be honest and open, but you don't want to scare women witless.
'But what is absolutely clear is that if a mistake of this sort is made, patients should be told and get an apology.'
• www.babycentre.co.uk
Tuesday, June 30, 2009
C-section Births Cause Genetic Changes That Could Increase Odds For Developing Diseases In Later Life
Swedish researchers have discovered that babies born by Caesarean section experience changes to the DNA pool in their white blood cells, which could be connected to altered stress levels during this method of delivery, according to the July issue of Acta Paediatrica.
It is thought that these genetic changes, which differ from normal vaginal deliveries, could explain why people delivered by C-section are more susceptible to immunological diseases such as diabetes and asthma in later life, when those genetic changes combine with environmental triggers.
Blood was sampled from the umbilical cords of 37 newborn infants just after delivery and then three to five days after the birth. It was analysed to see the degree of DNA-methylation in the white blood cells - a vital part of the immune system.
This showed that the 16 babies born by C-section exhibited higher DNA-methylation rates immediately after delivery than the 21 born by vaginal delivery. Three to five days after birth, DNA-methylation levels had dropped in infants delivered by C-section so that there were no longer significant differences between the two groups.
“Delivery by C-section has been associated with increased allergy, diabetes and leukaemia risks” says Professor Mikael Norman, who specialises in paediatrics at the Karolinska Institutet in Stockholm, Sweden. “Although the underlying cause is unknown, our theory is that altered birth conditions could cause a genetic imprint in the immune cells that could play a role later in life.
“That is why we were keen to look at DNA-methylation, which is an important biological mechanism in which the DNA is chemically modified to activate or shut down genes in response to changes in the external environment
The authors point out that the reason why DNA-methylation is higher after C-section deliveries is still unclear and further research is needed.
“Animal studies have shown that negative stress around birth affects methylation of the genes and therefore it is reasonable to believe that the differences in DNA-methylation that we found in human infants are linked to differences in birth stress.
“We know that the stress of being born is fundamentally different after planned C-section compared to normal vaginal delivery. When babies are delivered by C-section, they are unprepared for the birth and can become more stressed after delivery than before. This is different to a normal vaginal delivery, where the stress gradually builds up before the actual birth, helping the baby to start breathing and quickly adapt to the new environment outside the womb.”
The authors point out that the surgical procedure itself may play a role in DNA-methylation and that factors other than the delivery method need to be explored in more detail.
“In our study, neonatal DNA-methylation did not correlate to the age of the mother, length of labour, birth weight and neonatal CPR levels - proteins that provide a key marker for inflammation” says Professor Norman. “However, although there was no relation between DNA-methylation and these factors, larger studies are needed to clarify these issues.”
Professor Norman states that the Karolinska study clearly shows that gene-environment interaction through DNA-methylation is more dynamic around birth than previously known.
“The full significance of higher DNA-methylation levels after C-section is not yet understood, but it may have important clinical implications” he says.
“C-section delivery is rapidly increasing worldwide and is currently the most common surgical procedure among women of child-bearing age. Until recently, the long-term consequences of this mode of delivery had not been studied. However, reports that link C-section deliveries with increased risk for different diseases in later life are now emerging. Our results provide the first pieces of evidence that early ‘epigenetic’ programming of the immune system may have a role to play.”
The authors feel that their discovery could make a significant contribution to the ongoing debate about the health issues around C-section deliveries.
“Although we do not know yet how specific gene expression is affected after C-section deliveries, or to what extent these genetic differences related to the mode of delivery are long-lasting, we believe that our findings open up a new area of important clinical research” concludes lead author Titus Schlinzig, a research fellow at the Karolinska Institutet.
It is thought that these genetic changes, which differ from normal vaginal deliveries, could explain why people delivered by C-section are more susceptible to immunological diseases such as diabetes and asthma in later life, when those genetic changes combine with environmental triggers.
Blood was sampled from the umbilical cords of 37 newborn infants just after delivery and then three to five days after the birth. It was analysed to see the degree of DNA-methylation in the white blood cells - a vital part of the immune system.
This showed that the 16 babies born by C-section exhibited higher DNA-methylation rates immediately after delivery than the 21 born by vaginal delivery. Three to five days after birth, DNA-methylation levels had dropped in infants delivered by C-section so that there were no longer significant differences between the two groups.
“Delivery by C-section has been associated with increased allergy, diabetes and leukaemia risks” says Professor Mikael Norman, who specialises in paediatrics at the Karolinska Institutet in Stockholm, Sweden. “Although the underlying cause is unknown, our theory is that altered birth conditions could cause a genetic imprint in the immune cells that could play a role later in life.
“That is why we were keen to look at DNA-methylation, which is an important biological mechanism in which the DNA is chemically modified to activate or shut down genes in response to changes in the external environment
. As the diseases that tend to be more common in people delivered by C-section are connected with the immune system, we decided to focus our research on early DNA changes to the white blood cells.”
The authors point out that the reason why DNA-methylation is higher after C-section deliveries is still unclear and further research is needed.
“Animal studies have shown that negative stress around birth affects methylation of the genes and therefore it is reasonable to believe that the differences in DNA-methylation that we found in human infants are linked to differences in birth stress.
“We know that the stress of being born is fundamentally different after planned C-section compared to normal vaginal delivery. When babies are delivered by C-section, they are unprepared for the birth and can become more stressed after delivery than before. This is different to a normal vaginal delivery, where the stress gradually builds up before the actual birth, helping the baby to start breathing and quickly adapt to the new environment outside the womb.”
The authors point out that the surgical procedure itself may play a role in DNA-methylation and that factors other than the delivery method need to be explored in more detail.
“In our study, neonatal DNA-methylation did not correlate to the age of the mother, length of labour, birth weight and neonatal CPR levels - proteins that provide a key marker for inflammation” says Professor Norman. “However, although there was no relation between DNA-methylation and these factors, larger studies are needed to clarify these issues.”
Professor Norman states that the Karolinska study clearly shows that gene-environment interaction through DNA-methylation is more dynamic around birth than previously known.
“The full significance of higher DNA-methylation levels after C-section is not yet understood, but it may have important clinical implications” he says.
“C-section delivery is rapidly increasing worldwide and is currently the most common surgical procedure among women of child-bearing age. Until recently, the long-term consequences of this mode of delivery had not been studied. However, reports that link C-section deliveries with increased risk for different diseases in later life are now emerging. Our results provide the first pieces of evidence that early ‘epigenetic’ programming of the immune system may have a role to play.”
The authors feel that their discovery could make a significant contribution to the ongoing debate about the health issues around C-section deliveries.
“Although we do not know yet how specific gene expression is affected after C-section deliveries, or to what extent these genetic differences related to the mode of delivery are long-lasting, we believe that our findings open up a new area of important clinical research” concludes lead author Titus Schlinzig, a research fellow at the Karolinska Institutet.
Sunday, June 21, 2009
Canadian docs to stop automatic C-sections for breech babies
Unfortunately here in St. George, there are no providers at the hospital that will do a planned vaginal breech birth. Hopefully, the US will take notice of Canada's new stance on breech birth and follow.
Vaginal breech birth is possible and surgical birth should not be the only choice. Your best chance for a vaginal breech birth, if you find yourself in that position, is a homebirth midwife. Do your research.
___________________________________________________________________
By Sharon Kirkey, Canwest News Service
Vaginal breech birth is possible and surgical birth should not be the only choice. Your best chance for a vaginal breech birth, if you find yourself in that position, is a homebirth midwife. Do your research.
___________________________________________________________________
By Sharon Kirkey, Canwest News Service
In a major shift in medical practice and another assault on Canada's rising cesarean section rate, Canada's delivery doctors are being told to stop automatically scheduling C-sections for breech babies and attempt a normal delivery instead — something significant numbers of obstetricians aren't trained to do.
New guidelines issued Wednesday by the Society of Obstetricians and Gynaecologists of Canada say women carrying babies in the breech, or bottom-first, position should be given the right to choose to attempt a traditional delivery when possible.
The society says that women in Canada want the choice, and that some women with breech babies are delivering at home "because they knew if they went to hospital A, B or C it would not be offered," says Dr. Andre Lalonde, executive vice-president of the obstetricians' group and an adjunct professor of obstetrics and gynecology at McGill University and the University of Ottawa.
Lalonde says the group is working aggressively to ensure future specialists are trained in breech vaginal deliveries and is organizing courses across Canada for practising doctors to refresh their training.
"Paramount is the safe birth of the child," he said.
Most babies are positioned in the head-down position when labour starts. With breech babies, the feet or buttocks come out first during birth.
Breech babies account for about three to four per cent of all pregnancies in Canada, or about 11,000 to 14,500 pregnancies each year.
"Breech pregnancies are almost always delivered using a cesarean section, to the point where the practice has become somewhat automatic," Dr. Robert Gagnon, a principal author of the new guidelines and chair of The Society of Obstetricians and Gynaecologists of Canada's maternal fetal medicine committee, said.
"What we've found is that, in some cases, vaginal breech birth is a safe option and obstetricians should be able to offer women the choice to attempt a traditional delivery."
An international, Canadian-led study reported in 2000 that the safest way for breech babies to enter the world was via C-section. The study of more than 2,000 women found babies of mothers in the cesarean group were three to four times less likely to die, or have serious problems in the first six weeks of life, compared to those in the vaginal birth group (1.6 per cent versus 5.0 per cent).
The study had widespread influence worldwide. Many doctors stopped doing vaginal deliveries for breech babies, and many medical schools stopped training doctors in how to do them.
But the doctor who led the study said the risks, while different, were never huge. "The risks were still quite low," says Dr. Mary Hannah, a professor in the department of obstetrics and gynecology at the University of Toronto and Sunnybrook Health Sciences Centre.
More recent studies, including a study of more than 8,000 French and Belgian women carrying breech babies, found no significant differences in risks to babies whether they were born vaginally or via C-section.
Hannah says that a planned vaginal delivery of breech babies can be a safe and reasonable option. But, she said, most women she knows "will still want the option that is possibly safer, and that will be a planned cesarean section."
The main concern has always been delivery of the head — that the body will deliver, but that the baby's head will get caught.
"You can push the baby all the way back up into the uterus and do a cesarean section. But that's very traumatic," Hannah says. "And by the time that you are able to do that the baby may have suffered severe hypoxia," or lack of oxygen.
The new guidelines say that many breech deliveries will still require a C-section, and that a vaginal birth is not recommended for a "footling" breech, where the baby is positioned feet-first, with one or both feet pointing directly down toward the birthing canal.
Vaginal breech births also aren't recommended if the woman's pelvis is narrow or small, if the umbilical cord is likely to become entangled or compressed during delivery, or for babies that are too big (weighing more than 4,000 grams, or 8.8 pounds) or too small (less than 2,500 grams, or 5.5 pounds).
Breech deliveries are one of the main reason for C-sections, "and, if you do one (C-section), you increase the risk for another" in future pregnancies, Lalonde says. Repeat C-sections account for 30 to 40 per cent of all cesareans.
Monday, June 15, 2009
Neonatal Outcomes May Be Better With Vaginal Birth After Cesarean Delivery
News Author: Laurie Barclay, MD
CME Author: Charles Vega, MD, FAAFP
CME Author: Charles Vega, MD, FAAFP
June 3, 2009 — Neonates born after elective subsequent cesarean delivery have significantly higher rates of respiratory morbidity and neonatal intensive care unit (NICU) admission and longer length of hospital stay vs those with vaginal birth after cesarean (VBAC), according to the results of a retrospective cohort study reported in the June issue of Obstetrics & Gynecology.
"Controversy remains on whether a trial of labor or an elective repeat cesarean delivery is preferable for a woman with a history of cesarean delivery," write Beena D. Kamath, MD, MPH, from the University of Colorado School of Medicine in Denver, and colleagues. "Historically, concerns regarding the increased risk of uterine rupture and perinatal asphyxia in trial of labor after cesarean compared with planned repeat cesarean have swayed obstetricians away from recommending a trial of labor after cesarean delivery; however, the absolute risk of perinatal asphyxia remains small."
The goals of this study were to compare the outcomes of neonates born by elective subsequent cesarean delivery vs VBAC in women with 1 previous cesarean delivery and to compare the cost differences between these procedures. The study cohort consisted of 672 women with 1 previous cesarean delivery and a singleton pregnancy at or after 37 weeks of gestation. Participants were categorized based on their intention to have an elective subsequent cesarean delivery or a VBAC, whether successful or failed. The main endpoints of the study were NICU admission and measures of respiratory morbidity.
Compared with the VBAC group, neonates born by cesarean delivery had higher NICU admission rates (9.3% vs 4.9%; P = .025). Rates of oxygen supplementation were also higher in the subsequent cesarean group for delivery room resuscitation (41.5% vs 23.2%; P < .01) and after NICU admission (5.8% vs 2.4%; P < .028). The rates of delivery room resuscitation with oxygen were lowest in neonates born by VBAC and highest in neonates delivered after failed VBAC.
Although the costs of elective subsequent cesarean delivery were significantly higher vs VBAC, the highest costs for the total birth experience were for failed VBAC, considering both delivery and NICU use.
"In comparison with vaginal birth after cesarean, neonates born after elective repeat cesarean delivery have significantly higher rates of respiratory morbidity and NICU-admission and longer length of hospital stay," the study authors write.
Limitations of this study include relatively short postpartum follow-up of the mothers to determine the additional costs of postsurgical complications and insufficient data to allow estimation of costs other than those for hospital care.
"Given the increasing rates of primary cesarean delivery and the concomitant decrease in VBACs, once a woman has had a primary cesarean delivery, we must consider the risks that this places on her subsequent deliveries and subsequent neonates," the study authors conclude. "Indeed, this argues for greater selectivity in performing a cesarean delivery in the first place, and certainly a greater need for counseling before a primary elective cesarean delivery. As investigators continue to search for ways to make cesarean delivery safer, we may be better served by exploring other means for reducing overall cesarean delivery rates and recognizing our own preoccupation with the individual that will be our patient, whether it be mother or neonate."
The study authors have disclosed no relevant financial relationships.
Obstet Gynecol. 2009;113:1231-1238.
Clinical Context
The rate of cesarean delivery has reached an all-time high in the United States, and the current study provides an overview of the epidemiology of cesarean delivery. In 2006, 31.1% of all deliveries were via cesarean, and this rate was fueled by an increase in the rate of primary cesarean delivery by 60% between 1996 and 2005.
Women with a primary cesarean delivery have a greater than 90% chance of having another cesarean delivery. Overall, more than half of cesarean deliveries are performed electively, before the onset of labor.
The current study examines neonatal outcomes in women with a history of primary cesarean delivery, with the primary variable being VBAC vs subsequent elective cesarean delivery.
Study Highlights
- The study was a retrospective review of cases at 1 Colorado hospital between 2005 and 2008.
- Researchers focused on women with a history of 1 previous cesarean delivery who were pregnant with a singleton pregnancy at 37 weeks or more of gestation. 51% of these women had planned an elective subsequent cesarean delivery, and 49% had planned for VBAC.
- The primary outcome of the study was admission to the NICU. Researchers conducted a multivariate regression analysis to account for the effects of maternal demographic and disease factors as well as birth factors on the study outcome. Other outcomes included the need for neonatal resuscitation and the cost of care.
- 672 women were included in the analysis. The mean maternal age was 29 years, and approximately half of women were of Hispanic origin.
- 35.6% of the study cohort had a planned elective cesarean delivery without labor, 15.5% had an elective cesarean delivery after the onset of labor, 36.3% of women had a successful VBAC, and 12.6% had a failed VBAC requiring cesarean delivery.
- Older women and women with higher educational achievement were more likely to have an elective subsequent cesarean delivery.
- 9.3% of neonates delivered by elective subsequent cesarean delivery required admission to the NICU vs only 4.9% of neonates delivered by intended VBAC. The adjusted odds ratios for NICU admission in neonates delivered with elective subsequent cesarean delivery without and with labor vs successful VBAC delivery were 2.93 and 2.26, respectively.
- Infants in the cesarean group were more likely to require blow-by oxygen and continuous positive airway pressure after delivery vs infants delivered by VBAC, and they also had higher rates of NICU admission for hypoglycemia.
- Conversely, infants delivered by VBAC were more likely to require bag mask ventilation and endotracheal intubation after delivery.
- Infants delivered via cesarean after a failed VBAC had rates of NICU admission similar to rates of admission in the elective subsequent cesarean delivery group. However, infants delivered after failed VBAC required the most resuscitation efforts after delivery.
- Factors associated with failed VBAC included chorioamnionitis and induction of labor.
- Neonates delivered at 37 weeks of gestation required more resuscitation efforts vs more mature neonates.
- Successful VBAC was associated with the shortest hospital stay and the lowest overall cost of care. Although failed VBAC was associated with the highest cost of care from all groups, planned VBAC still cost less than planned elective subsequent cesarean delivery overall.
Clinical Implications
- The rate of cesarean deliveries in the United States was 31.1% in 2006, and an increase in the rate of primary cesarean deliveries was primarily responsible for this high rate. In addition, women with a primary cesarean delivery have a greater than 90% chance of having another cesarean delivery, and more than half of all cesarean deliveries are performed electively, before the onset of labor.
- The current study finds that the rate of NICU admission is higher in infants delivered via elective subsequent cesarean delivery vs VBAC. Overall, elective subsequent cesarean delivery was estimated to be a more costly strategy.
Sunday, May 10, 2009
Births on cue: C-sections soar in S. Florida
More babies in Miami-Dade are now born by cesarean section than by natural childbirth, state records reveal. Experts won't predict how much higher the rate will go.
BY JOHN DORSCHNER
jdorschner@MiamiHerald.com
Last year, for the first time, more babies in Miami-Dade County were born by cesarean section than were born vaginally, according to state records, and Broward's not far behind, with a rate of 43.7 percent -- both far above the national average.
At Kendall Regional Medical Center in Southwest Miami-Dade, seven out of 10 babies were delivered by C-section, a rate that University of Miami obstetrician Gene Burkett called ``just astounding.''
Locally and nationally, the cesarean rate has been creeping up annually for years. In 2007, the U.S. rate reached 31.8 percent, according to the National Center for Health Statistics -- an increase of more than 50 percent over the past decade.
Many of the reasons have been oft-repeated: doctors afraid of being sued if something goes wrong with natural childbirth and expectant mothers, particularly professional women, wanting to schedule a birth into tight work schedules.
In South Florida, virtually no obstetrician has malpractice insurance, and most believe that they're less likely to be sued if they choose to be active in a crisis, such as operating to remove a baby from the womb, rather than allowing nature to take its course.
But Amitabh Chandra, a Harvard professor of public health policy, said Miami also has a long-standing reputation for high healthcare costs in many programs, including Medicare.
''There is an extraordinary culture of medicine you have there in Miami,'' he said. ''Miami has always been very aggressive in its practice of medicine,'' with specialists dominating treatment patterns and being highly active in care options. ``And cesareans would just be another example.''
Such decisions drive up costs. Data from the Florida Agency for Health Care Administration shows cesareans in South Florida hospitals range from $11,000 and $30,000 -- about twice the $5,000 to $16,000 range for natural births.
THE RISKS
Traditionally, many doctors have warned against cesareans because of the risks anytime a patient is cut open. ''Definitely surgery always has a chance of a serious complication,'' said Douglas Richards, a professor of obstetrics-gynecology at the University of Florida.
Still, in recent years, such warnings have been muted. ''The risks and benefits are much more balanced than they used to be,'' Richards said. ``Cesareans have become so safe and relatively easy for women.''
He means in particular planned C-sections -- ''no rushing around, the baby doesn't have to come out right away.'' Improved anesthetics allow patients to rebound quickly. ``They're happy and pain-free and walking around the first day. Many go home after 48 hours.''
There's also been an opinion shift about the risks of ''V-backs,'' giving birth vaginally after having had a C-section. Some studies have shown that in some situations, such as when the baby is in a breech position, a V-back should be avoided. ''Certain hospitals will not do vaginal deliveries after cesareans,'' said UM's Burkett, who delivers babies at Jackson Memorial, where he says the staff remains committed to V-backs if clinically possible.
Burkett and some other obstetricians also say that some women have abandoned the view that natural childbirth is a badge of honor for womanhood. ''I don't think it's so much a rite of passage anymore.'' But Zulma Berrios, chief of obstetrics at South Miami Hospital, said she has seen no evidence to back that up.
Another key issue is patient choice. The American College of Obstetricians and Gynecologists ''now says the consumer has a right to choose'' a cesarean if they so desire after being informed of the risks and benefits, Burkett said. That's a departure from the past, when many doctors actively discouraged patients from seeking C-sections.
No one in South Florida has statistics on how many women are choosing C-sections, but Berrios at South Miami said, ''Some patients want to be on a planned schedule. They have to juggle work and the baby.'' She says many professional women, including physicians, choose cesareans because they're squeezed for time.
In fact, a recent study from the University of California-Berkeley, found that mothers who took a leave in their last month of pregnancy were less likely to have cesarean deliveries than mothers who worked right up to the end.
HEALTH FACTORS
Obesity also has become an issue. Richards says 25 percent of the expectant mothers seen in Gainesville are clinically obese at the start of their pregnancy, meaning they are more likely to have complications at birth.
More debated is the mother's ''pelvic floor.'' G. Willy Davila, a urogynecologist at the Cleveland Clinic in Weston, said natural childbirth can lead to tendencies later in life for problems like ``leaky bladders.''
Davila said for women planning to have one or two children, C-sections ''could be beneficial . . . an acceptable delivery option'' to avoid urinary problems later.
Three other ob-gyns, however, said that idea is still being debated. ''The jury is still out,'' Berrios said.
Davila and others emphasized that repeat C-sections for women planning to have many babies could pose considerable dangers. ``The risk goes way up for the third, fourth or fifth cesarean for things like the placenta being in the wrong place and other issues.''
AHCA's most recent data measured births from July 2007 through June 2008. Miami-Dade's C-section rate was 51.2 percent.
In addition to Kendall Regional, the hospitals with rates higher than 50 percent were South Miami (59.9), Mercy (58), Hialeah (52), Baptist (50.3) and Jackson Memorial (50.4). In Broward, the lone hospital higher than 50 percent was Holy Cross, at 51.6.
Many of the hospitals didn't want to discuss cesareans. Kendall Regional spokesman Peter Jude acknowledged the AHCA numbers were correct and said the hospital is ``first and foremost committed to the well being and health of our mothers and infants. There are a number of factors patients and physicians consider when determining the delivery method.''
Berrios at South Miami said her hospital has been designated a center for high-risk cases and was close to an infertility clinic, where many of the patients had various risk factors, including multiple fetuses.
Jackson Memorial's rate is high because the hospital gets most of the high-risk births for the entire county, said Burkett, noting that he had just been notified a woman carrying a fetus with heart problems was on her way from the Virgin Islands.
While supporting many reasons for C-sections, Richards in Gainesville emphasized he didn't want to appear to be endorsing rates of 50 percent to 70 percent. ''That's pretty astounding.'' He noted one reason ``not to have a more liberal cesarean policy is that babies born without labor tend to have more respiratory problems.''
Still, when Richards and three other ob-gyns were asked whether there was an upper limit on how high the C-section rate could go, in South Florida or the nation, none wanted to venture a guess. ''We just don't know,'' Berrios said.
Tuesday, April 14, 2009
C-Section Birth Raises Risk of Asthma in Newborns by 79 Percent
(NaturalNews) Children delivered by cesarean section (c-section) are significantly more likely to develop asthma and allergies later in life than children delivered through natural, vaginal birth, according to a study conducted by researchers from National Institute for Public Health and the Environment in Bilthoven, the Netherlands.
A c-section is a procedure in which a child is surgically removed through a mother's abdomen, rather than emerging naturally through the vaginal opening. It is medically recommended only in cases where vaginal delivery would seriously endanger the life of infant or mother, but is becoming more common as many women's preferred method of childbirth.
Researchers compared the rates of asthma and allergies among 2,917 eight-year-olds, comparing the rates between those who had been delivered vaginally and those who had been delivered by c-section. They found that the risk of asthma was 79 percent higher in those delivered by c-section compared with those delivered vaginally. The correlation between c-section and asthma risk was even higher among children born to one or more parents with allergies.
"Our results emphasize the importance of gene-environment interactions on the development of asthma in children," the researchers wrote. "The increased rate of cesarean section is partly due to maternal demand without medical reason. In this situation, the mother should be informed of the risk of asthma for her child, especially when the parents have a history of allergy or asthma."
C-section is already known to raise a child's risk of diabetes by 20 percent, compared with vaginal delivery. In spite of this known health risk, rates of the procedure have been steadily rising in the United States over the last 25 years, increasing by 46 percent since 1985 to a current level of more than 30 percent of all births.
Childhood asthma rates have also been on the rise, particularly among urban populations, with rates increasing by two to four times in the last 30 years in some countries.
Sources for this story include: www.reuters.com.
A c-section is a procedure in which a child is surgically removed through a mother's abdomen, rather than emerging naturally through the vaginal opening. It is medically recommended only in cases where vaginal delivery would seriously endanger the life of infant or mother, but is becoming more common as many women's preferred method of childbirth.
Researchers compared the rates of asthma and allergies among 2,917 eight-year-olds, comparing the rates between those who had been delivered vaginally and those who had been delivered by c-section. They found that the risk of asthma was 79 percent higher in those delivered by c-section compared with those delivered vaginally. The correlation between c-section and asthma risk was even higher among children born to one or more parents with allergies.
"Our results emphasize the importance of gene-environment interactions on the development of asthma in children," the researchers wrote. "The increased rate of cesarean section is partly due to maternal demand without medical reason. In this situation, the mother should be informed of the risk of asthma for her child, especially when the parents have a history of allergy or asthma."
C-section is already known to raise a child's risk of diabetes by 20 percent, compared with vaginal delivery. In spite of this known health risk, rates of the procedure have been steadily rising in the United States over the last 25 years, increasing by 46 percent since 1985 to a current level of more than 30 percent of all births.
Childhood asthma rates have also been on the rise, particularly among urban populations, with rates increasing by two to four times in the last 30 years in some countries.
Sources for this story include: www.reuters.com.
Monday, April 6, 2009
Caesarean link to surge in hysterectomies
Jan Battles
Doctors in Dublin’s maternity hospitals are performing an increasing number of life-saving hysterectomies on mothers who have previously had caesarean sections. The upsurge in the number of births by c-section has led to a marked increase in emergency operations to remove women’s wombs due to a condition called placenta accreta, according to a new study.
The problem is caused where the placenta, or afterbirth, attaches too deeply into the wall of the womb. The risk of the condition is increased by the presence of scar tissue from previous caesareans.
Doctors from the Rotunda, Holles Street and the Coombe hospitals analysed charts of all patients who had emergency hysterectomies after giving birth in the 40 years between 1966 and 2005. Of the 320 cases, 43 of them were due to placenta accreta. It accounted for only one in 20 emergency hysterectomies from 1966 to 1975 but 47% of those between 1996 and 2005 when almost half (20) the cases occurred. The caesarean rate rose from 6% to 19% over the same period and now stands at about one in four births.
The findings are consistent with international studies. One study in the Netherlands where the rate of c-sections was 14% found that accreta accounted for 50% of cases of peripartum hysterectomy.
Writing in the American Journal of Obstetrics & Gynecology, the authors of the Irish survey say: “There is a concern that there will be a rise in the number of obstetric hysterectomies required in the future because of placenta accreta alongside significant maternal morbidity.”
The doctors cite international studies that show women who have had one previous c-section have more than double the risk of emergency hysterectomy in the next pregnancy and those who have had two or more have at least 18 times the risk.
“The only thing you can do is be cautious with the number of c-sections that are done,” said Fergal Malone, professor of obstetrics and gynaecology at the Rotunda hospital and the Royal College of Surgeons. “We are seeing more patients back again for their second and third c-section and it would appear that the lining of the uterus is much stickier than if you never had one, therefore the placenta is probably going to be more adherent.
“When it comes to take the placenta out it is stuck, and that leads to a much higher chance of having to do a hysterectomy.”
Tracy Donegan, author of The Better Birth Book, said: “This is an unfortunate side-effect of the increase in the caesarian rate, but I don’t think women really understand the implications. It has become so routine now women don’t consider it a big deal even though it’s major abdominal surgery.”
Donegen said the rate of caesareans has also increased because hospital policy is to induce births that are more than 10 days past the due date. “Nearly half of those women, especially first-time mothers, are likely to have a c-section because they’ve been induced at 10 days,” said Donegan, founder of Doula Ireland, an organisation of birth assistants.
“The World Health Organisation recommends the rate be 15% at the most,” said Donegan. “Anything above that is unnecessary. We’re at about 25% nationally, but some hospitals are up to 29%.”
It is not automatically the case that a woman who has had one baby by caesarean has to have all subsequent children the same way.
“Most women should be encouraged after having a caesarean to go for a normal vaginal birth, assuming everything is fine,” said Donegan. “The three Dublin hospitals have a fairly good record of encouraging women to have vaginal birth after caesarean (VBAC) because with the next pregnancy you are looking at a placenta accreta. Women aren’t getting the information so they can make that informed decision as to whether they go for VBAC or another caesarean.”
Malone said the number of women choosing caesareans because they are “too posh to push” is exaggerated. “It’s much spoken about in the press but in reality the number of patients who come in for maternal request c-sections is very small.”
He said the recent increase in c-sections was partly due to changes in practice. “Up until about 10 years ago delivering breech babies vaginally was commonplace. But recent data shows that they have about five times higher chance of brain injury than a breech baby delivered by caesarean. Very few babies that are breech are now delivered vaginally. Also, patients are giving birth much older now than in the past. About 25% of babies born in the Rotunda are to mothers over 35, whereas 15 years ago it was only about 15%.”
Emergency hysterectomies due to other causes, such as rupture of the womb, fell in the last four decades as medical techniques have improved, according to the study.
http://www.timesonline.co.uk/tol/news/world/ireland/article6037134.ece
Doctors in Dublin’s maternity hospitals are performing an increasing number of life-saving hysterectomies on mothers who have previously had caesarean sections. The upsurge in the number of births by c-section has led to a marked increase in emergency operations to remove women’s wombs due to a condition called placenta accreta, according to a new study.
The problem is caused where the placenta, or afterbirth, attaches too deeply into the wall of the womb. The risk of the condition is increased by the presence of scar tissue from previous caesareans.
Doctors from the Rotunda, Holles Street and the Coombe hospitals analysed charts of all patients who had emergency hysterectomies after giving birth in the 40 years between 1966 and 2005. Of the 320 cases, 43 of them were due to placenta accreta. It accounted for only one in 20 emergency hysterectomies from 1966 to 1975 but 47% of those between 1996 and 2005 when almost half (20) the cases occurred. The caesarean rate rose from 6% to 19% over the same period and now stands at about one in four births.
The findings are consistent with international studies. One study in the Netherlands where the rate of c-sections was 14% found that accreta accounted for 50% of cases of peripartum hysterectomy.
Writing in the American Journal of Obstetrics & Gynecology, the authors of the Irish survey say: “There is a concern that there will be a rise in the number of obstetric hysterectomies required in the future because of placenta accreta alongside significant maternal morbidity.”
The doctors cite international studies that show women who have had one previous c-section have more than double the risk of emergency hysterectomy in the next pregnancy and those who have had two or more have at least 18 times the risk.
“The only thing you can do is be cautious with the number of c-sections that are done,” said Fergal Malone, professor of obstetrics and gynaecology at the Rotunda hospital and the Royal College of Surgeons. “We are seeing more patients back again for their second and third c-section and it would appear that the lining of the uterus is much stickier than if you never had one, therefore the placenta is probably going to be more adherent.
“When it comes to take the placenta out it is stuck, and that leads to a much higher chance of having to do a hysterectomy.”
Tracy Donegan, author of The Better Birth Book, said: “This is an unfortunate side-effect of the increase in the caesarian rate, but I don’t think women really understand the implications. It has become so routine now women don’t consider it a big deal even though it’s major abdominal surgery.”
Donegen said the rate of caesareans has also increased because hospital policy is to induce births that are more than 10 days past the due date. “Nearly half of those women, especially first-time mothers, are likely to have a c-section because they’ve been induced at 10 days,” said Donegan, founder of Doula Ireland, an organisation of birth assistants.
“The World Health Organisation recommends the rate be 15% at the most,” said Donegan. “Anything above that is unnecessary. We’re at about 25% nationally, but some hospitals are up to 29%.”
It is not automatically the case that a woman who has had one baby by caesarean has to have all subsequent children the same way.
“Most women should be encouraged after having a caesarean to go for a normal vaginal birth, assuming everything is fine,” said Donegan. “The three Dublin hospitals have a fairly good record of encouraging women to have vaginal birth after caesarean (VBAC) because with the next pregnancy you are looking at a placenta accreta. Women aren’t getting the information so they can make that informed decision as to whether they go for VBAC or another caesarean.”
Malone said the number of women choosing caesareans because they are “too posh to push” is exaggerated. “It’s much spoken about in the press but in reality the number of patients who come in for maternal request c-sections is very small.”
He said the recent increase in c-sections was partly due to changes in practice. “Up until about 10 years ago delivering breech babies vaginally was commonplace. But recent data shows that they have about five times higher chance of brain injury than a breech baby delivered by caesarean. Very few babies that are breech are now delivered vaginally. Also, patients are giving birth much older now than in the past. About 25% of babies born in the Rotunda are to mothers over 35, whereas 15 years ago it was only about 15%.”
Emergency hysterectomies due to other causes, such as rupture of the womb, fell in the last four decades as medical techniques have improved, according to the study.
http://www.timesonline.co.uk/tol/news/world/ireland/article6037134.ece
Tuesday, March 31, 2009
Caesarean sections linked to future birth risks
by Ginger Rough - Mar. 31, 2009 12:00 AM
The Arizona Republic
The Arizona Republic
Flagstaff mom Jody Borrero was only five weeks along in her pregnancy when doctors told her something had gone awry.
An ultrasound confirmed her placenta had implanted itself at the bottom of her uterus, across her cervix. What's worse, it also had attached itself too deeply, perforating the uterine wall and invading her bladder.
Borrero's physicians at St. Joseph's Hospital and medical center kept her stable for as long as they could. But on Feb. 2, they were forced to deliver Ethan Jr. nearly four months early.
He's still struggling to survive, and his 28-year-old mother, who hemorrhaged during the delivery, can no longer bear children.
Borrero's conditions, called placenta previa and placenta accreta, are both still relatively rare.
But physicians say they're turning up in more women, and medical experts believe the trend is tied to record numbers of moms-to-be delivering their children via Caesarean section.
C-sections, in which a baby is delivered via an incision made through the abdominal wall, leave a scar on the uterus. It now appears that scar is a key risk factor for the complication in subsequent pregnancies, physicians say.
Many women are unaware of the danger, however.
"I wanted to have four children, so after the first one was born by Caesarean, I knew I was going to have lots of C-sections," Borrero said. "I thought it would be fine. It wasn't. It's devastating."
Rise in C-sections
In the mid-1990s, roughly 1 in 5 babies were born via Caesarean section. But over the past decade, the rate of C-section births has jumped more than 50 percent.
Statistics released earlier this month by the U.S. Centers for Disease Control and Prevention showed that nearly 32 percent of babies born in 2007 were through Caesarean delivery.
That's a new record, and the 11th straight year of increase.
Doctors say that in many cases, C-sections are medically necessary, even life-saving.
A woman may be unable to deliver vaginally, for example, if the baby is breech, meaning its feet or bottom has entered the birth canal first. In some instances, labor stops or the baby is simply too big to pass through the birth canal.
But C-sections also have increased in popularity simply because mothers see them as less painful or more convenient than a vaginal birth. They can be scheduled around work and home events. There is no prolonged labor.
Physicians say they fear that women who choose C-sections for these elective reasons may not realize that they are still putting their bodies through major trauma and could be setting themselves up for problems in future pregnancies.
"We tend to think about the immediate circumstance," said Dr. Marlin Mills, medical director of perinatal services with Banner Desert Medical Center. "But it's important to think about the consequences down the line, especially if you want to have a big family."
Future complications
Tracy Alexander, 31, had no reason to suspect that her most recent pregnancy would be any different than her first six. Her last delivery, via Caesarean, had been smooth.
But early in her second trimester, the Queen Creek mother got the bad news. Like Borrero, she had developed placenta accreta, a complication generally characterized by an improper attachment of the placenta to the uterine wall.
And like Borrero, hers was the most severe form of accreta, known as placenta percreta. It went through the uterus and intertwined with her other organs, including the bladder.
Alexander, who had started bleeding lightly at six weeks, eventually contracted an infection in her uterus. Her son Samuel was born at Banner Desert in Mesa 16 weeks early, on Jan. 24. He, too, remains in intensive care.
Doctors aren't sure exactly why Borrero and Alexander developed placenta accreta. But they believe it has something to do with their previous C-sections.
"We think that whenever the uterus has a scar on it . . . for some reason, that scar increases the chance that you have this," said Dr. Linda Chambliss, director of maternal-fetal medicine at St. Joseph's Hospital and Medical Center.
Studies and textbooks suggest that the risk of developing an accreta is as high as 40 percent in women who have had two previous Caesareans; that jumps to 60 percent with three C-sections, their physicians said.
And while Valley hospitals can't say exactly how many women they are seeing with the complication, those that traditionally deliver the most babies say it's a trend they're watching.
Earlier this year, St. Joseph's saw three women with the condition in one week, Chambliss said.
"In the 1950s, the incidence was something like 1 in 30,000 women," Mills said, adding that newer studies, conducted within the last decade, suggest that the rate has climbed to as high as 1 in 2,500 or even 1 in 500.
"So there is definitely an increase in occurrence," he said. "And in women with C-sections, that's where we've really seen an explosion."
New protocols
The uptick in accretas, and the emergency deliveries they cause, has prompted several Valley hospitals, including St. Joseph's in Phoenix and Banner Desert in Mesa, to establish new protocols.
Chief among them: creating on-call teams of surgeons and specialists to lend their expertise during the emergency surgery.
At Banner Desert, for example, the team draws in not only obstetricians but urologists, general surgeons and vascular surgeons. Patients with severe placenta accretas frequently need a total hysterectomy and, in many cases, subsequent surgeries to repair damage to the urinary tract and other organs.
Excessive bleeding is also a common problem. At St. Joseph's, a protocol allows the hospital to notify the blood bank of a "catastrophic situation," Chambliss said, giving the patient the highest priority for blood products.
Last year, one woman needed more than 100 units, roughly the equivalent of 100 pints, of blood. The average human body typically holds 10 pints.
Hospitals also are encouraging more pre-natal counseling of C-section risks, particularly if a woman is interested in having multiple children. They say it is possible for a woman who has delivered her first baby via Caesarean to give birth vaginally the second time.
Physicians have historically shied away from the option because it was thought to carry risks of uterine rupture. But those dangers now are believed to be very small in many patients.
In fact, the American Pregnancy Association suggests that as many as 90 percent of women who have had a Caesarean are candidates to later give birth vaginally.
"The real complications from vaginal births after C-sections are minuscule," said Dr. Mike Foley, a specialist in maternal-fetal medicine and chief medical officer at Scottsdale Healthcare . "Women shouldn't make a snap decision to have a C-section just because they've had one previously."
Most importantly, Borrero said, women need to educate themselves before they decide on an elective Caesarean.
"Women say they are too scared of the pain (of a vaginal delivery)," she said. "But I could lose my baby.
"I can't imagine anything more painful than that."
Monday, March 23, 2009
ICAN State by State VBAC Hospital Policy Summary
The information collected here was collected to identify VBAC policies in individual hospitals. We wanted to identify those hospitals that have official bans against VBAC in place. In some ways, these were the simplest calls. It is unlikely that we are mistaken about these hospitals. The more difficult hospitals were those with de facto bans in place. This is defined as a hospital that indicates there is no official policy against VBAC but in reality there are no doctors who will agree to attend one, or the restrictions on a VBAC are so extreme as to make it very unlikely a VBAC would be achieved. Our callers asked a series of questions to try to accurately identify hospitals where there is no official ban but there is no option for VBAC. Obviously, this is a “softer number”, because we were dependent on more subjective information to make this determination. It is important to acknowledge this when using these numbers, especially when giving them to a reporter. If you have time, it would be worth calling these hospitals yourself and seeing what responses you get. You can find the contact information on the VBAC Hospital Policy Database.
It is also very important to understand that even the hospitals that do “allow” VBAC, and that were able to give us names of physicians who are known to support VBAC, very few of these hospitals actually do very many VBACs. We would estimate that no more than 10% of the hospitals we called were truly “VBAC supportive”, based on the comments of the people we talked to. Making sure you emphasize this point is crucial in presenting the VBAC access crisis accurately – the number of official bans is truly only the tip of the iceberg.
I’ve also included the state cesarean rate and VBAC rate data for each state. These numbers are from the National Vital Statistics Report. Births: Final Data for 2006. A couple of comments on these numbers: the cesarean rate is defined as the percentage of births that end in a cesarean. However, some states only report “low risk” cesareans in this rate – in other words, cesareans of breech or multiples are NOT included in this number. Unfortunately, I don’t have a good list of which states do this, we just know it does happen. Obviously, the states are not eager to let us know if they report this way. VBAC rate is defined as the percentage of women with a previous cesarean who then have a subsequent vaginal birth. The percentage is NOT that of total births (unlike the cesarean rate) but a percentage of ONLY the women with a previous cesarean who had a birth that year. So, if you wanted to find out the VBAC rate relative to the total number of births, you’d need to divide the total number of VBACs by the total number of births. Needless to say, that number is going to be very small.
Alabama:
51 total hospitals
8 Official Bans (16%)
6 de facto
33.4% c/s rate
5.2% VBAC rate
Alaska:
17 total hospitals
5 Official Bans (29%)
2 de facto
23% c/s rate
17.7% VBAC rate
Arizona:
27 total hospitals
9 Official Bans (33%)
4 de facto
26.5% c/s rate
5.5% VBAC rate
Arkansas:
43 total hospitals
16 Official Bans (37%)
9 de facto
33.2% c/s rate
4.6% VBAC rate
California:
251 total hospitals
96 Official Bans (38%)
17 de facto
31.3% c/s rate
5.2% VBAC rate
Colorado:
56 total hospitals
24 Official bans (43%)
3 de facto bans
25.3% c/s rate
10.2% VBAC rate
Connecticut:
28 total hospitals
1 Official ban (4%)
2 de facto bans
34.1% c/s rate
6.2% VBAC rate
District of Columbia:
5 total hospitals
0 Official bans (0%)
0 de facto bans
30.6% c/s rate 2006
6.4% VBAC rate
Delaware:
5 total hospitals
2 official bans (40%)
0 de facto bans
30.7% c/s rate
9.8% VBAC rate
Florida:
101 total hospitals
25 Official bans (25%)
31 de facto bans
36.1% c/s rate
5.4% VBAC rate
Georgia:
78 total hospitals
12 official bans (15%)
16 de facto bans
31.3% c/s rate
4.7% VBAC rate
Hawaii:
12 total hospitals
6 official bans (50%)
1 de facto bans
25.6% c/s rate
11.0% VBAC rate
Idaho:
26 total hospitals
14 official bans (54%)
1 de facto ban
22.8% c/s rate
17.5% VBAC rate
Illinois:
111 total hospitals
19 official bans (17%)
5 de facto bans
29.6% c/s rate
8.0% VBAC rate
Indiana:
97 total hospitals
26 official bans (27%)
16 de facto bans
29% c/s rate
5.8% VBAC rate
Iowa:
70 total hospitals
45 official bans (64%)
8 de facto bans
27.7% c/s rate
7.9% VBAC rate
Kansas:
67 total hospitals
31 official bans (46%)
13 de facto bans
29.3% c/s rate
10.6% VBAC rate
Kentucky:
30 total hospitals
6 banned (20%)
3 de facto bans
34.5% c/s rate
6.1% VBAC rate
Louisiana:
50 total hospitals
5 official bans (10%)
12 de facto bans
35.4% c/s rate
2.5% VBAC rate
Maine:
27 total hospitals
15 official bans (56%)
5 de facto bans
29.9% c/s rate
5.5% VBAC rate
Massachusetts:
49 total hospitals
13 official bans (27%)
5 de facto bans
33.2% c/s rate
8.2% VBAC rate
Maryland:
34 total hospitals
3 official bans (9%)
0 de facto bans
32.2% c/s rate
8.7% VBAC rate
Michigan:
93 total hospitals
29 official bans (31%)
5 de facto bans
29.8% c/s rate
7.8% VBAC rate
Minnesota:
96 total hospitals
30 official bans (31%)
25 de facto bans
25.4% c/s rate
9.7% VBAC rate
Mississippi:
38 total hospitals
8 official bans (21%)
6 de facto bans
35.4% c/s rate
3.1% VBAC rate
Missouri:
66 total hospitals
16 official bans (24%)
11 de facto bans
30.2% c/s rate
7.3% VBAC rate
Montana:
26 total hospitals
12 official bans (46%)
2 de facto bans
28% c/s rate
10.2% VBAC rate
Nebraska:
58 total hospitals
28 official bans (48%)
14 de facto bans
28.8% c/s rate
9.7% VBAC rate
Nevada:
18 total hospitals
8 official bans (44%)
5 de facto bans
32.3 % c/s rate
4.4% VBAC rate
New Hampshire:
22 total hospitals
6 official bans (27%)
3 de facto bans
29.9% c/s rate
13.4% VBAC rate
New Jersey:
48 total hospitals
5 official bans (10%)
6 de facto bans
37.4% c/s rate
8.8% VBAC rate
New Mexico:
23 total hospitals
12 official bans (52%)
3 de facto bans
23.3% c/s rate
12.0% VBAC rate
New York:
141 total hospitals
24 official bans (16%)
15 de facto bans
32.6% c/s rate
9.8% VBAC rate (excludes NYC)
13.1% VBAC rate, NYC
North Carolina:
67 total hospitals
17 official bans (25%)
9 de facto bans
29.9% c/s rate
7.7% VBAC rate
North Dakota:
11 total hospitals
5 official bans (45%)
1 de facto ban
27.8% c/s rate
14.1% VBAC rate
Ohio:
112 total hospitals
37 official bans (33%)
8 de facto bans
29.3% c/s rate
12.6% VBAC rate
Oklahoma:
60 total hospitals
28 official bans (47%)
19 de facto bans
33.3% c/s rate
2.6% VBAC rate
Oregon:
54 total hospitals
23 official bans (42%)
9 de facto bans
28.2% c/s rate
9.3% VBAC rate
Pennsylvania:
97 total hospitals
6 official bans (6%)
17 de facto bans
29.7% c/s rate
13.8% VBAC rate
Puerto Rico:
24 total hospitals
0 official bans (0%)
12 de facto bans
48.3% c/s rate
7.5% VBAC rate
Rhode Island:
7 total hospitals
3 official bans (43%)
0 de facto bans
31.1% c/s rate
8.4% VBAC rate
South Carolina:
46 total hospitals
13 official bans (28%)
7 de facto bans
32.9% c/s rate
10.2% VBAC rate
South Dakota:
21 total hospitals
2 official bans (10%)
2 de facto bans
27% c/s rate
16.1% VBAC rate
Tennessee:
60 total hospitals
13 official bans (22%)
6 de facto bans
32.4 % c/s rate
11.3% VBAC rate
Texas:
138 total hospitals
20 official bans (14%)
24 de facto bans
33.2% c/s rate
9.4% VBAC rate
Utah:
36 total hospitals
9 official bans (25%)
7 de facto bans
21.5% c/s rate
18.7% VBAC rate
Virginia:
53 total hospitals
8 official bans (15%)
6 de facto bans
32.4% c/s rate
5.4% VBAC rate
Vermont:
12 total hospitals
3 official bans (25%)
0 de facto bans
26% c/s rate
20.9% VBAC rate
Washington:
68 total hospitals
28 official bans (41%)
2 de facto bans
28.4% c/s rate
12.4% VBAC rate
West Virginia:
23 total hospitals
9 official bans (39%)
2 de facto bans
35.2% c/s rate
4.9% VBAC rate
Wisconsin:
72 total hospitals
19 official bans (26%)
6 de facto bans
24.6% c/s rate
12.1% VBAC rate
Wyoming:
21 total hospitals
13 official bans (62%)
3 de facto bans
26.3% c/s rate
8.5% VBAC rate
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