Shoddy journalism in action: article on c-sections in Iowa

When I was in college nearly 20 years ago, I remember reading an article in the Des Moines Register about the rising rate of births by cesarian-sections in Iowa. At some rural hospitals, the rate was approaching 25 percent, and that was alarming to some doctors.

Now almost a third of all births in Iowa are by c-section, and in some counties that figure is above 40 percent.

During the past week, the Des Moines Register, Cedar Rapids Gazette and several other newspapers  published this piece from the Associated Press about the rising rate of cesarean births, which quotes several women in Linn County and Johnson County.

Unfortunately, the article does a poor job of assessing the causes of the this trend and ignores the most significant problems associated with unnecessary c-sections. I explain why after the jump.

The article provides several examples of medically necessary c-sections (for example, to deliver twins who were breech, or following an unsuccessful labor induction because of maternal pre-eclampsia).

However, the journalist does not address the issue of unnecessary cesarean births.

Many people do not realize that where you give birth, and the provider who delivers your baby, greatly affects your likelihood of having a c-section versus a vaginal birth. To cite the most extreme example, Brazil now has a c-section rate of more than 80 percent, the highest in the world. Clearly, the majority of those operations are not medically necessary.

The central Iowa chapter of the International Cesarean Awareness Network has statistics on its website comparing the percentages of births by c-section in Iowa’s 10 largest counties in terms of the number of births, as well as the c-section rates in Iowa’s largest hospitals.

Are the women who give birth in Dubuque or Black Hawk counties anatomically different from the women who give birth in Cerro Gordo? Certainly not, but the c-section rates for those counties are quite different.

Statistics for all 99 counties are not available on the website of ICAN’s central Iowa chapter, but I have seen a map they’ve produced with c-section rates for all the counties. For a few counties in the northeast corner of the state, the rate is very low, near 10 percent. In at least one county (I think it was Webster, but I am not sure), the rate is around 45 percent. Such disparity suggests that in counties with a high c-section rate, many of the operations are being performed without medical necessity.

How about women’s ability to have a vaginal birth after cesarean (VBAC)? Are the women of Johnson and Dubuque counties magically more able to do this than women in other counties? No, but the VBAC rates in those counties are several times higher than in many other large Iowa counties.

In fact, the VBAC rate in Johnson County is ten times as high as the VBAC rate in Cerro Gordo.

The International Cesarean Awareness Network’s website notes that

In 2004, ICAN surveyed every hospital in the U.S. with regard to VBAC policy,and found over 300 hospitals with official policies banning VBAC. Many other hospitals had de facto bans because there were no attending physicians willing to support VBAC.

The medical evidence does not support these bans. On the contrary:

Scientific investigation has led to considerable information about this process, and by reviewing this information, and discussing this issue with a physician or midwife, patients can determine if they wish to have another c/section or to try for a vaginal delivery. VBAC’s are successful on average 60-80% of the time and are considered by most to be a valid way to reduce the overall c/section rate.

Because of the barriers to having a VBAC, a woman who has one c-section is increasingly likely to be forced to deliver all her subsequent babies surgically as well.

Are there any problems associated with cesarean births? The Associated Press pieces cites exactly one:

The experience can be isolating and disappointing for some.

That’s putting it mildly, since research suggests that

An unanticipated cesarean is more likely to increase the risk for postpartum depression and post-traumatic stress disorder (PTSD).

The AP article notes that many women find it comforting to know that the surgery was necessary. Right, except that in many cases, it isn’t.

Furthermore, it is highly misleading to suggest that the only risk associated with c-sections is that mothers may be disappointed.

Here is a list of some significant medical risks:

There are many benefits of vaginal delivery, for both mother and baby. During a vaginal delivery the amniotic fluid is squeezed from the baby’s lungs, making it easier for him or her to breathe. This does not happen as much during c/section.

Furthermore, it is a misconception that c/section is always safer for babies than vaginal delivery. Scalpel injuries and trauma to babies during c/section, although rare, can certainly occur. In most cases vaginal deliveries are safer for mothers than c/sections, with some medical studies indicating that the chance of death for a mother is 7 times higher when delivered by c/section versus vaginally. Contrary to popular belief, a c/section is a major operation, not unlike a hysterectomy in it’s complexity and potential complications! These complications may include infection, hemorrhage, scar tissue formation (which may produce lifelong abdominal or pelvic pain), anesthesia complications, opening of the skin incision leading to a very large scar, damage to the bladder or intestines, and the formation of blood clots within blood vessels or the lungs.

Here’s more detail on the risks for mother and baby (click the link if you want to see the medical references in the footnotes):

Dangers for the Mother: Although cesarean section is safer than ever before, it is still major abdominal surgery with inherent risks. A woman who has one cesarean will always be at risk for a uterine rupture in a subsequent pregnancy, whether she labors for a VBAC or has an elective repeat cesarean delivery.

With one prior uterine scar, the risk of a uterine rupture is 1 in 500, compared to 1 in 10,000 for a woman without a cesarean scar. Each additional cesarean increases that risk. Postoperative complications include risk of injury to other organs (2 percent), hemorrhage (1 to 6 percent of women will need a blood transfusion), blood clots in the legs (0.06 to 2 percent), pulmonary embolism (0.01 to 2 percent), infection (up to 50 times higher), and complications from anesthesia. A woman is four times as likely to have a placenta previa (low-lying placenta) in her next pregnancy, putting her at risk for miscarriage, bleeding during pregnancy and labor, placental abruption, and premature delivery. One birth by cesarean puts a mother at 10 times the risk for placenta accreta (placenta grows into or through the uterus), for which women often require a hysterectomy to stop the hemorrhaging. The incidence of placenta accreta has increased tenfold in the last 50 years.7

A US study found that mothers are four times more likely to die from a cesarean unrelated to health problems, compared with women who have vaginal births.8

[…] Dangers for the Baby: Healthy babies born by cesarean are more likely to have breathing problems and to need admission to intensive-care units. The odds of developing persistent pulmonary hypertension, a life-threatening complication, are higher. Mothers who give birth by cesarean are more likely to have difficulty with establishing and maintaining breastfeeding.13 Breastfeeding, which offers optimal long-term health benefits for mothers and their children, is more likely to be compromised with a cesarean birth.14

When a surgical delivery is medically warranted, as with fetal distress or certain types of breech presentation, we should gladly accept those risks.

But what about a c-section that is scheduled for the convenience of the mother, or the obstetrician? What about the repeat c-section that is forced on the mother because she cannot find a provider to allow her to try for a VBAC?

The monetary cost of all those unnecessary c-sections is another area left unexplored in that Associated Press article. A cesarean birth costs more than twice as much as a vaginal birth with no significant medical interventions. Furthermore, mothers and babies usually stay in the hospital for four days after a c-section, as opposed to a day or two following a vaginal birth.

Where c-sections are done purely for convenience, with no medical justification, huge costs are passed along to insurance companies and, by extension, to everyone who pays health insurance premiums.

The cesarean rate would start to drop if insurance companies announced that they would no longer cover elective c-sections, or if insurance companies leaned on hospitals to accommodate women who want to try for a VBAC. But that seems unlikely to happen.

The Associated Press article reads like a human-interest feature, rather than an exploration of the medical risks and benefits of the rising number of c-sections being performed. If you aren’t going to do serious research on a topic like this, it would be better not to write anything at all.

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