Cesarean Delivery Crisis: How We Got Here and How to Address

Although research shows that benefits in terms of maternal and neonatal mortality plateau at cesarean delivery rates of 19% and that cesarean delivery can pose serious risk to women with low-risk pregnancies, the overall rate of cesarean deliveries in the United States has dramatically increased in the past few decades, reaching 32.9% in 2009.

Since then, the rate slightly declined to 32.0% in 2015, but physicians agree that significant changes must be implemented to continue this downward trend. In fact, maternal mortality rates in the United States have been increasing in the past 2 decades, and neonatal mortality rates are higher than those in many other wealthy countries.

At the Annual Clinical and Scientific Meeting of the American College of Obstetricians and Gynecologists (ACOG), held May 6 to 9, 2017, in San Diego, CA, Aaron B. Caughey, MD, of Oregon Health & Science University, discussed the probable causes as well as potential solutions to the high rates of cesarean delivery. He argued that, of the 3 potential causes for the high rates of cesarean delivery in the United States—changing demographics of American women, the current medicolegal environment, and maternal preferences—the medicolegal environment is the primary factor driving up rates of cesarean delivery.

Women are becoming pregnant later in life, and average body mass index is increasing, but, Caughey noted, rates of cesarean delivery are increasing in every demographic, suggesting that demographics are not the primary driving factor. Furthermore, coding information and national surveys indicate that the rates of elective cesarean delivery are relatively low.

However, in states with medical malpractice damage caps, rates of vaginal birth after cesarean delivery increase and rates of cesarean delivery decrease. States with tort reform have lower rates of cesarean delivery, demonstrating that it is the medicolegal environment that needs to change in order for rates of cesarean delivery to decrease.

"Litigation has increased over recent decades without a subsequent improvement in neonatal or maternal outcomes," adds Brenna Hughes, MD, MSc, the associate medical director of Labor and Delivery at Duke, "and lawsuits can be devastating to a physician’s confidence in caring for women."

With that in mind, Caughey suggested several possible reforms—many of which are outlined in more detail in a 2014 obstetric care consensus document developed jointly by ACOG and the Society for Maternal–Fetal Medicine (SMFM)—that could help decrease rates of cesarean delivery:

  • Increase reimbursement for vaginal deliveries
  • Assess the fetal position in the second stage of labor and attempt to rotate the fetus before considering cesarean delivery
  • Prolong the maximum timeframe for the latent phase and arrest of labor in the first and second stages of labor

He added that, even after controlling for risk, the health care facility where a neonate is delivered is the single biggest risk factor for cesarean delivery, suggesting that the power to change the situation rests with physicians and policymakers. To that end, institutions across the country have adopted the ACOG/SMFM consensus document guidelines.

Hughes recommends that labor units also work to change their culture and consider ways to involve all members of the health care team as well as patients when brainstorming ways to minimize cesarean deliveries. "At Duke, in addition to adopting the guidelines in our unit, we are fortunate to have a multidisciplinary approach to labor management: Physicians, midwifery staff, and nursing leadership and staff all embrace a culture of optimizing obstetric outcomes with the least intervention possible while caring for a very high-risk population," Hughes says.