The Overuse of Cesarean Delivery



Nancy K. Lowe Editor

In the decade between 1998 and 2007, the national rate of cesarean delivery in the United States rose by 50% from 21.2% to 31.8% (MacDorman, Menacker, & Declercq, 2008). Although this rate seems to have reached a plateau at just less than 33% for 2009–2011 (Hamilton, Martin, & Ventura, 2012), the practical reality is that one in every three pregnant American women now give birth via cesarean. This high rate has been fueled by increases in primary and repeat cesarean deliveries. Notably, more than 26% of low-risk women nulliparous women undergo cesarean delivery, and these rates are greatest for women more than 25 years of age, women carrying a male fetus, Black or African American women, and married women (National Center for Health Statistics, 2013). It is clear that to address this issue, we must implement strategies targeting the reduction of primary cesarean deliveries.

Recently, several important publications have called attention to the overuse of cesarean delivery as a critical public health issue requiring action. In a report titled “Preventing the First Cesarean Delivery,” Spong and colleagues (2012) summarized the results of a joint workshop convened by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Society for Maternal-Fetal Medicine, and the American College of Obstetricians and Gynecologists. Unfortunately, despite the interdisciplinary nature of care for childbearing women and their families, the Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN) was not invited to participate in the workshop. Recommendations from this workshop included performing labor induction primarily for medical indications (non-medically indicated inductions should be done only for women who are at least 39 weeks gestation and have a favorable cervix); adhering to standard definitions for failed induction and arrest of labor progress; providing adequate time for the various phases of labor with the understanding that adequate time is longer than traditionally thought; considering operative vaginal delivery as a safe and acceptable approach to preventing unnecessary cesarean delivery; and counseling patients about the effect of cesareans on future reproductive health. Algorithms presented in the report for induced labor, spontaneous labor, and assessment of fetal heart rate will assist providers, nurses, and institutions in initiating practice changes that may ultimately reduce the incidence of unnecessary primary cesarean delivery.

Main and colleagues (2012) summarized their conclusions about the high rates, variations in rates, and the risks and costs associated with cesarean deliveries in the state of California. They pointed out that a quick fix is not apparent; rather, a simultaneously implemented multi-strategy approach is needed to reduce the overuse of cesarean. This approach includes “clinical quality improvement strategies with careful examination of labor management practices to reduce those that lead to the development of indications for cesarean deliveries; payment reform to eliminate negative or perverse incentives; health care provider and consumer education to recognize the value of normal vaginal birth; and full transparency through public reporting and continued public engagement” (p. 1196). Further, Main et al. concluded that national attention to the problem of unnecessary cesarean deliveries is needed as a public health concern in the search for value and quality in U.S. health care.

On the heels of these two publications from the obstetric literature are reports released in early January 2013: “The Cost of Having a Baby in the United States” (Truven Health Analytics, 2013); “Vaginal or Cesarean Birth: What is at Stake for Women and Babies? A Best Evidence Review” (Childbirth Connection, 2012); and “Maternity Care and Liability: Pressing Problems, Substantive Solutions” (Sakala, Yang, & Corry, 2013). It should be no surprise that the cost of cesarean delivery for maternal and newborn care regardless of payment source (Medicaid or commercial) is approximately 50% higher than for vaginal birth (Truven Health Analytics, 2013). Therefore, a reduction in the rate of cesarean delivery can significantly reduce the cost of maternity related health care. Childbirth Connection's 2012 evidence review provides data to demonstrate that “overuse of cesarean delivery in low-risk women exposes more women and babies to potential harms of cesarean with minimal likelihood of benefit” (p. 4). For women, these potential harms include significantly increased risks of cardiac arrest, urgent hysterectomy, thromboembolic events, complications of anesthesia, major infection, wound infection, hematoma, hospital readmission, and problems with physical recovery. For infants, these potential harms may include increased neonatal mortality, respiratory distress syndrome (especially when birth occurs before 39 weeks), pulmonary hypertension, and not being breastfed. Cesarean delivery is also linked to increased incidence of childhood asthma, Type 1 diabetes, allergic rhinitis, and obesity. The well-known adverse effects of cesarean on future pregnancies, births, and infants are also documented in this report. Finally, Sakala, Yang, and Corry (2013) concluded that “the best available research does not support a series of widely held beliefs about the impact of the liability system on maternity care, including the economic impact of liability insurance premiums on maternity care clinicians, the existence of extensive defensive maternity practice, and the impact of limiting the size of awards for non-economic damages in a malpractice lawsuit” (p. 1). Based on extensive review and analysis, these authors recommended evidence-based interventions for averting harm to women and infants, alleviating stress among maternity care providers, and improving value for the payment sector that include rigorous maternity care quality improvement programs, disclosure/empathy/apology programs, health courts, administrative compensation systems, and high-low agreements among attorneys.

In 2008, an independent multidisciplinary team envisioned a high-quality, high-value maternity care system for the United State by 2020 that is woman-centered, safe, effective, timely, efficient, and equitable (Carter et al., 2010). These most recent publications and reports provide additional evidence and impetus for tackling the persistent problem of the overuse of cesarean delivery that is a significant deterrent to attainment of this vision. The overuse of cesarean delivery is a public health problem that requires concerted effort by health care systems and institutions; health care providers, including nurses and midwives and our respective professional societies; payers for health care; policy makers; and the public. There is no evidence to demonstrate that a 33% cesarean delivery rate is beneficial to women or their infants. Rather, this rate exposes women and infants to unnecessary risks in the perinatal period and long term and results in considerable unnecessary health care costs. As the members of the most publically respected profession, nurses must participate in multifaceted initiatives to reduce the incidence of unnecessary cesarean delivery. We must embrace our responsibilities to educate women about overuse of cesarean and the risks of unnecessary cesarean to themselves and their infants, provide evidence-based care to individual women and their families, participate in multidisciplinary teams and quality improvement initiatives to change local maternity care cultures and hold providers responsible for evidence-based care, and use our institutional and professional leadership avenues to change health care policy. Women, their infants, and their families deserve no less.