Professor Gene Declercq PhD Boston University School of Public Health wwwbirthbythenumbersorg With support from The Transforming Birth Fund Slides Updated through January 152015 US Cesarean Rates ID: 640301
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Slide1
Myth and Reality Concerning Cesarean Section in the U.S.
Professor Gene Declercq, PhD
Boston University School of Public Health
www.birthbythenumbers.org
With
support from:
The
Transforming Birth
Fund
Slides Updated through January 15,2015Slide2
US Cesarean Rates,
1989-2013
Source: National Center for Health Statistics Annual Birth Reports
%
1,284,339
c
esareans
in 2013
If the
2013
cesarean rate was the same as in 1996, there would have been
475,000
fewer cesareans in the U.S. in
’13.Slide3
US Cesarean Rates,
1989-2013
Source: National Center for Health Statistics
Annual
Birth Reports
%
BirthByTheNumbers.orgSlide4
US Cesarean Rates,
1989-2013
Source: National Center for Health Statistics Annual
Birth
Reports
%
BirthByTheNumbers.orgSlide5
US Cesarean Rates,
1989-2013
Source: National Center for Health Statistics
Annual
Birth Reports
%
BirthByTheNumbers.orgSlide6
Commonly Used Explanations for the High Cesarean Rate
Mothers are getting olderMore multiples
being bornMaternal obesity increasingBabies are getting biggerMothers are generally less healthyMothers are
asking for itSlide7
Older Mothers?
% Births to Mothers 30 +, U.S. 1990-2013
Between 2003 & 2010 CS
Rate
increased by 20%
>
35
>
35
>30
BirthByTheNumbers.org
From 2010-2013,
CS rate unchangedSlide8
Total Cesarean Rates (per 100 births) by Age of Mother: United States, 1996 and 2013
Source: National vital statistics system, NCHS, CDC.
Percent
Overall increase,
1996-2013: 58.0%Slide9
Multiple Births?
Proportion of all babies in multiple births,U.S., 1980-2013
BirthByTheNumbers.org
Source: National Center for Health Statistics Annual Birth ReportsSlide10
Cesarean Rates for Multiple Births, U.S. 1990-2013
BirthByTheNumbers.orgSlide11
Are Babies Getting Bigger?
% Singleton Babies by Birthweight, U. S., 1991-2013
41%
41%
39%
36%
36%
BirthByTheNumbers.orgSlide12
% Cesareans in
Singleton Births, U.S. by Birthweight, 1991-2013
53.6%
38.6%
31.3%
21.8%
27.8%
38.2%
BirthByTheNumbers.orgSlide13
Mothers’ Health?
Prepregnancy Obesity, U.S. 2003
, 2006, 2009, 2011
Sources: 2003-2009 -- S
. Fisher. Is obesity still increasing among pregnant women?Preventive Medicine 2013; 56: 372-378; 2011 – CDC VitalStats. Slide14
Mothers’ Health?
Cesarean Rate Singleton Births by Prepregnancy Weight Range, U.S. 2013
Source:
CDC VitalStats, 2013. Slide15
Mothers’ Health?
Diabetes* & Hypertension*, 1992,2002,2013
* Either gestational or chronic condition
Source: CDC VitalStats, selected years. Slide16
Mothers’ Health?
Cesarean Rates, Singleton Births, U.S.,
1990, 1996, 2004, 2013
Source: CDC VitalStats, selected years. Slide17
Mothers’ Health?
Cesarean Rates, Singleton Births, U.S.,
1990, 1996, 2004, 2013
Source: CDC VitalStats, selected years. Slide18
Mothers asked for itHave maternal request cesareans played a major role in these increases?Slide19
http://www.childbirthconnection.org
Asking Mothers about
Maternal Request CesareansSlide20
Two Components to Maternal Request Primary Cesarean
1.
Mother made request for planned cesarean before laborSlide21
Two Components to Maternal Request Primary Cesarean
1. Mother made request for planned cesarean before labor
2. Cesarean for no medical reasonSlide22
Patient Choice Primary Cesareans
Combining reason for cesarean and timing of decision found only about 1% of respondents had a planned primary cesarean for no medical reason.
“
I think that [cesarean] is… the best way … to give birth. It is a planned way, no hassle, no pain, the baby doesn’t struggle to come out, the baby is not pressed to come out …I think that … everybody should have the baby by cesarean section.” (quote from LtM2)
Studies from
England, Canada and U.S. states confirm very low rates of maternal request cesareansSlide23
Pressure to Accept Interventions
by Method of Delivery
Did you feel pressure from any health professional to have a cesarean? % yes
Source: Declercq et al.
2013.
Listening to Mothers III.BirthByTheNumbers.orgSlide24
Commonly Used Explanations for the High Cesarean Rate
Mothers are getting olderMore
multiples being bornBabies are getting biggerMaternal health is worse: obesity, diabetes & hypertension
Mothers are asking for itSlide25
Commonly Used Explanations for the High Cesarean Rate
Mothers are getting older – NO
More multiples being born Babies are getting biggerMaternal health is worse: obesity,
diabetes & hypertensionMothers are asking for itSlide26
Commonly Used Explanations for the High Cesarean Rate
Mothers are getting older – NO
More multiples being born– NOBabies are getting bigger
Maternal health is worse: obesity, diabetes & hypertensionMothers are asking for itSlide27
Commonly Used Explanations for the High Cesarean Rate
Mothers are getting older–
NOMore multiples being born – NOBabies are getting bigger –
NO !!Maternal health is worse: obesity, diabetes & hypertension
Mothers are asking for itSlide28
Commonly Used Explanations for the High Cesarean Rate
Mothers are getting older–
NOMore multiples being born – NOBabies are getting bigger –
NO !!Maternal health is worse: obesity, diabetes & hypertension –
Some Mothers are asking for it Slide29
Commonly Used Explanations for the High Cesarean Rate
Mothers are getting older– NO
More multiples being born – NOBabies are getting bigger –
NO !!Maternal health is worse: obesity, diabetes & hypertension –
Some Mothers are asking for it – NOSlide30
If the usual explanations for the rising cesarean rate don’t account for the changes w
hat does? Slide31
If the usual explanations for the rising cesarean rate don’t account for the changes w
hat does?
Practice ChangesSlide32
Leading Indications for Cesareans
Source: ACOG & SMFM.
Safe Prevention of Primary Cesarean Delivery. 3/2014. Slide33
Cesarean Rates, Low Risk*, First-Time Mothers for Medical Risk Factors & Labor Complications
*Singleton, Vertex, Full Gestation Births
BirthByTheNumbers.orgSlide34
Source: National Center for Health Statistics
Annual
Birth Reports
%
Revisiting the trend in cesareans
in the US for comparison
BirthByTheNumbers.orgSlide35
Cesarean Rates, Low Risk*, First-Time Mothers for Medical Risk Factors & Labor Complications
*Singleton, Vertex, Full Gestation Births
BirthByTheNumbers.orgSlide36
Cesarean Rates, Low Risk*, First-Time Mothers for Medical Risk Factors & Labor Complications
*Singleton, Vertex, Full Gestation Births
BirthByTheNumbers.orgSlide37
Women have not changed nearly as much as practice patterns have
BirthByTheNumbers.orgSlide38
Any other evidence that this is about a culture of practice?
BirthByTheNumbers.orgSlide39
Let’s look at variation.
If the practice of maternity care is evidence based, then differences in rates should be based primarily on different risk profiles of mothers.
BirthByTheNumbers.orgSlide40
BirthByTheNumbers.orgSlide41
MT
WY
ID
WA
OR
NV
UT
CA
AZ
ND
SD
NE
CO
NM
TX
OK
KS
AR
LA
MO
IA
MN
WI
IL
IN
KY
TN
MS
AL
GA
FL
SC
NC
VA
WV
OH
MI
NY
PA
MD
DE
NJ
CT
RI
MA
ME
VT
NH
AK
HI
31.6%+
22.6-31.5%
DC
Cesarean
Delivery
Rates
1
, 2012
1
Percentage of all live births by cesarean delivery
Source: Martin J, et al.
Births Final Data
2012
.
National Vital Statistics System,
2014
.
BirthByTheNumbers.orgSlide42
MT
WY
ID
WA
OR
NV
UT
CA
AZ
ND
SD
NE
CO
NM
TX
OK
KS
AR
LA
MO
IA
MN
WI
IL
IN
KY
TN
MS
AL
GA
FL
SC
NC
VA
WV
OH
MI
NY
PA
MD
DE
NJ
CT
RI
MA
ME
VT
NH
AK
HI
DC
1960 Electoral College Map
Nixon 219
Harry Byrd 15
Kennedy 303
BirthByTheNumbers.orgSlide43
JFK 1960 Vote and
2012 Cesarean Rates
2012 Cesarean Rate
JFK % Vote
Each dot represents a U.S. stateSlide44
Variation is not just at the state level but at the hospital level as wellSlide45
% Cesarean Deliveries by Hospital
for
ALL
MA
Births, 2004-2006
N = 49 Mean =31.2 σ2 =29.6
All 49 Hospitals
Source: Caceres I, et al. Hospital Differences in Cesarean Deliveries in Massachusetts
(US) 2004–2006: The Case against Case-Mix Artifact. PLOS One.2013; 8 (3): e57817
BirthByTheNumbers.orgSlide46
% Cesarean Deliveries by Hospital
for
NTVS, Spontaneous Labor, BWT 2500-4000g
Births
N = 49 Mean =21.1 σ2 =37.1Source: Caceres I, et al. Hospital Differences in Cesarean Deliveries in Massachusetts (US) 2004–2006: The Case against
Case-Mix Artifact. PLOS One.2013; 8 (3): e57817
BirthByTheNumbers.orgSlide47
How does a culture of intervention get manifested in a hospital setting?
BirthByTheNumbers.orgSlide48
How does a culture of intervention get manifested in a hospital setting?
Consider the Cascade of Interventions
BirthByTheNumbers.orgSlide49
Induction
No53%
EpiduralNo39%Epidural
Yes61%Induction
Yes47%EpiduralNo22%EpiduralYes78%First-time mothers with term births (37-41 weeks’ gestation) who experienced laborCesarean Yes
20%Cesarean Yes5%Cesarean Yes31%Cesarean Yes19%
In this group, which included 85% of first-time mothers, the
overall
epidural rate was 69% and overall cesarean rate was 21%.
Cascade
of interventions in first-time mothers with term births who experienced labor
Base: first-time mothers with term births who experienced labor
n=750
BirthByTheNumbers.orgSlide50
What about Vaginal Birth After Cesarean (VBAC) ?
BirthByTheNumbers.orgSlide51
VBAC
Rates*, U.S.,1990-2011
Source: NCHS Vital Stats. http://www.cdc.gov/nchs/VitalStats.htm
*
Number of VBACs among women with prior cesarean
NOTE
: Rates for
2005-2011
are unofficial
BirthByTheNumbers.orgSlide52
% VBAC Lower Risk* Mothers, U.S., Monthly Rates, 1990-2012
* Full-gestation(37+ weeks), vertex presentation, singleton births
Sachs, NEJM
1/99
ACOG New
VBAC Guidelines
10/98 & 7/99
Lydon
-Rochelle
& Greene 7/01
Landon
NEJM 12/04
Flamm
Studies
1988,’90, ‘94
McMahon
NEJM
9/96
ACOG guidelines encourage
VBAC, 1/82 10/88 Reaffirmed 1991
Revised
ACOG
Guide-
lines 8/10
BirthByTheNumbers.orgSlide53
VBAC Rates Industrialized Countries, 2010
Source: Adapted from
Peristats &
US
DataVBAC % = VBACS Women w/ Prior CS
BirthByTheNumbers.orgSlide54
August, 2010
BirthByTheNumbers.orgSlide55
Mother had cesarean in the past, and did not have the option of a VBAC for recent birth.
LTMI
2000-02
LTMII 2005
LTMIII2011-12
Did not have the option because caregiver was unwilling to do a VBAC
36%
45%
24%
Did not have the option because hospital was unwilling to allow a VBAC
12%
23%
15%
Medical reason unrelated to prior cesarean
38%
20%
45%
U.S. Mothers Report of Experience
Seeking a VBAC, 2000, 2005, 2012
Source:
Listening to Mothers 3
.
New VBAC Guidelines
BirthByTheNumbers.orgSlide56
So is a rising cesarean rate inevitable?
BirthByTheNumbers.orgSlide57
So is a rising cesarean rate inevitable?
ABSOLUTELY NOT
BirthByTheNumbers.orgSlide58
US Cesarean Rates, 1989-2012
Source: National Center for Health Statistics
Annual
Birth Reports
%
BirthByTheNumbers.orgSlide59
Trends in Cesarean Rates
(per 1000 births), Comparison Countries, 1990-2011
Sources:
OECD Health Data
2013; WHO Health for All Database, 2014.BirthByTheNumbers.orgSlide60
Trends in Caesarean Rates
(per 1000 births), Comparison Countries, 1990-2011
Sources:
OECD Health Data
2013; WHO Health for All Database, 2014.BirthByTheNumbers.orgSlide61
www.acog.org/Resources_And_Publications/Obstetric_Care_Consensus_Series/Safe_Prevention_of_the_Primary_Cesarean_Delivery
Safe Prevention of Primary Cesarean Delivery
Questioning the Rising Cesarean Rate
BirthByTheNumbers.orgSlide62
Evidence Based
Advocacy
BirthByTheNumbers.orgSlide63
Prematurity and Low Birthweight, U.S., 1990-2012
Year
BirthByTheNumbers.orgSlide64
BirthByTheNumbers.orgSlide65
http://www.choicesinchildbirth.org/
Evidence Based Advocacy
BirthByTheNumbers.orgSlide66
https://www.childbirthconnection.org/
Evidence Based AdvocacySlide67
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