The authors report no financial relationships relevant to this article.
The year that has followed our inaugural “Update on Obstetrics” [OBG Management, January 2011, available at www.obgmanagement.com] saw a resurgence of interest in a number of aspects of obstetric care. We want to highlight four of them in this Update because we think they are particularly important—given the attention they’ve received in the medical literature and in the consumer media:
- the ever-increasing cesarean delivery rate
- home birth
- postpartum hemorrhage
- measurement of cervical length and the use of progesterone.
Taming the cesarean delivery rate—how can we
accomplish this?
No one should be surprised to learn that the cesarean delivery rate increased nearly sevenfold from 1970 to 2011—from a rate of approximately 5% in 1970 to nearly 35%. Recall that, in the 1990s, the US Public Health Service proposed, as part of Healthy People 2010, a target cesarean rate of 15%, with a vaginal birth after cesarean (VBAC) rate of 60%. Today, the cesarean delivery rate is, as we said, nearly 35% and the VBAC rate is less than 10%.
Many factors have been cited for the rise, including:
- the obesity pandemic
- delaying childbearing
- increasing use of assisted reproduction
- multiple gestation (although the incidence of higher-order multiple gestations is now decreasing, the rate of twin births remains quite high relative to past decades).
So, how did this happen? And what can we do?
For one, VBAC is not likely to gain in popularity. More than 60% of US hospitals that provide OB services handle a volume of fewer than 1,000 deliveries a year. Such low volumes generally will not be able to support (either with dollars or staffing) the resources needed to safely provide VBAC.
Other options have been proposed: Loosen the guidelines for VBAC, change the personnel requirements, gather community groups of doctors, attorneys, and patients to agree on guidelines that, if followed, would protect physicians from being sued1—and so on. The medicolegal reality, however, is that these options have not been shown to be viable. We have concluded that increasing VBAC utilization is not the answer. Rather, addressing ways to prevent primary cesarean delivery holds the most promise for, ultimately, reducing the current rising trend.
On a positive note: The most recent data available from the National Center for Health Statistics suggest that the cesarean delivery rate has dropped slightly: from 32.9% in 2009 to 32.8% in 2010. The drop is truly slight; we’ll watch with interest to see if a trend has begun.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
Considering that the cesarean delivery rate in 1970 was 5%, and that the dictum at the time was “once a section, always a section,” it seems clear (to us, at least) that the solution to this problem lies in preventing first cesarean deliveries. How can the specialty and, in some ways, you, in your practice, work toward this goal? Here are possible strategies:
- Eliminate elective inductions of labor when the modified Bishop score is less than 8
- Return to defining “post-term” as 42—not 41—completed weeks’ gestation
- Eliminate all elective inductions before 39 weeks’ gestation
- Provide better and more standardized training of physicians in the interpretation of fetal heart-rate tracings
- Improve communication between obstetricians and anesthesiologists in regard to managing pain during labor
- Institute mandatory review of all cesarean deliveries that are performed in the latent phase of labor and all so-called “stat cesareans”
- Readjust the compensation scale for physicians and hospitals in such a way that successful vaginal delivery is rewarded.
Even if all these measures were implemented, we think it’s unlikely that we will ever see a 5% cesarean delivery rate again—although probably for good reason. But even a return to a more manageable 20% rate seems a reasonable goal.
Home birth: Consider where you stand
We suppose that one way to avoid cesarean delivery would be to deliver at home. The topic, and practice, of home birth has mushroomed in the past few years—for a number of social and economic reasons, probably. It seems to us that there are a few basic issues that must be addressed, however, before it’s possible to come to grips with home birth in the 21st century in an enlightened way:
- In 1935, the maternal mortality rate approached 500 to 600 for every 100,000 births; most of those deaths occurred at home. In 2009, the maternal mortality rate was approximately 8 for every 100,000 births. Both rates are very low, but the difference would be significant to the 492 to 592 women who met a potentially preventable death.
- Methods of identifying who might be an appropriate candidate for a home birth are, at best, imprecise.
- Infrastructure for rapidly transporting mother and baby to a hospital if matters go awry is inadequate.