Cesareans are over performed, here's why

The medical journal The Lancet recently condemned unnecessary cesarean section surgery as a “global epidemic.” In the U.S., almost one in three births today is by cesarean section — a dramatic change from a even a few decades ago. In the early 1970s, fewer than one in 20 births was by cesarean section. By 1987, however, cesareans accounted for one in four births in the U.S. And since then, the surgery’s frequency has surged worldwide.

How did this major, risky abdominal surgery become mainstream so fast? New obstetric technology — specifically the electronic fetal monitor — its effect on malpractice threats and changes in doctor training converged to make cesareans seem less risky than vaginal births, changing notions of what is “necessary” during childbirth.

Consider two births, one in 1971 and the other in 1984. Both women were first-time mothers who experienced classically low-risk pregnancies — and both had a cesarean.

In 1971, the first woman — call her Carol — checked into a hospital at 2 a.m. after going into labor spontaneously. Although only 20, she was not nervous. Her mother had given birth to nine children vaginally, and Carol assumed her own first birth would be a “natural thing.” In the labor room, someone periodically checked the baby’s heart rate with a fetal stethoscope. By dawn, Carol remembered, “they were having a little more trouble finding his heartbeat.” At 10 a.m., doctors decided to perform a cesarean, although they didn’t tell Carol. Rather, they informed her husband, who was consigned to the waiting room. Only after her son’s birth did Carol learn the reason for the surgery: Doctors feared fetal distress. But the explanation didn’t satisfy Carol. Her son’s Apgar score, a numerical rating of a newborn’s condition, had been first-rate. Today, she remains certain the cesarean was unnecessary.

In 1984, “Leanne” was two weeks past her due date. Her obstetrician ruptured her amniotic sac, hoping to jump start labor. By then, the electronic fetal monitor, which provides continuous information about the fetal heart rate, had replaced intermittent use of the fetal stethoscope. Her baby’s heart rate fluctuated, probably in reaction to the drain of amniotic fluid. The obstetrician told Leanne, “We’ve got to get this baby out of here.” Leanne reacted unhesitatingly. “Just do what you need to do.” After the birth, she harbored no regrets. She was certain surgery had been necessary given what seemed to be the potential risks to her child as indicated by the fetal monitor.

Cesareans can be lifesaving. But the grave conditions that demand the surgery are rare — each occurs in fewer than 1 percent of births. These conditions include the umbilical cord dropping into the birth canal before the baby does, several different placental complications and a full-term fetus lying sideways in the uterus. Yet the electronic fetal monitor helped cement the view that vaginal birth is far riskier than it actually is.

In hindsight, it’s clear that physicians and hospitals adopted the monitor too quickly. The monitor was introduced in 1969, but the first clinical trial regarding its use was not published until 1976. By then, all but one of the hospitals housing obstetric residency programs in the U.S. had adopted the machine, making it central to training new obstetricians.

The authors of the 1976 article in the American Journal of Obstetrics and Gynecology found the monitor did not change outcomes. Apgar scores, stillbirths, neonatal and perinatal deaths, incidence of cerebral palsy and admissions to the neonatal intensive care unit were effectively identical whether the heartbeat had been tracked by the electronic monitor or a fetal stethoscope.

The only difference between the two groups was that the mothers connected to monitors had a cesarean rate of 16.5 percent while those checked with a fetal stethoscope had a cesarean rate of 6.5 percent. Subsequent studies confirmed these findings. But having been taught that the electronic fetal monitor was vital, obstetricians ignored the studies.

The monitor also helped create the current malpractice climate in obstetrics. Since the mid-1980s, the continual record produced by fetal monitors has become a tool of trial lawyers to “prove” to juries that a timely cesarean would have prevented cerebral palsy, even though the cerebral palsy rate, at one in 500 births, has not decreased even slightly with the advent of the monitor.

This change has not been good for mothers. Cesareans carry risks, including intractable postpartum infections, that vaginal births seldom do. One of the most frightening downstream effects of a cesarean is placenta accreta, when the placenta grows into the uterine scar left by a previous cesarean. The condition, which causes life-threatening hemorrhage, has increased 55-fold since the 1950s. Accretas almost always require emergency hysterectomies; 7 percent prove fatal.

Jacqueline H. Wolf is professor of the history of medicine in the Department of Social Medicine at Ohio University and the author of “Cesarean Section: An American History of Risk, Technology, and Consequence.” This essay was originally written for Zócalo Public Square.

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