For moms-to-be, deciding the details of labor and delivery can be difficult. Should you wait to go into labor naturally and try for a vaginal birth? Induction? Elective Caesarian? And everyone has an opinion. There's the friend who is a staunch advocate of vaginal birth, the sister-in-law who is all about elective Caesarians, and the coworker who has cautionary tales about every option. So how do you know what's right for you?
Increasingly, childbirth in the United States has become a process characterized by medical intervention. Last year, in a report by the national not-for-profit organization Childbirth Connection, maternal health care in the U.S. was described as "procedure-intensive."
The rate of labor induction in the U.S. has increased dramatically in the past 15 years, from 9.5 percent in 1990 to 22.3 percent in 2006, according to the National Vital Statistics Report by the U.S. Department of Health & Human Services. Meanwhile, caesarian-delivery rates in 2006, the last year for which there are official numbers, skyrocketed to an all-time high of 31.1 percent of all births in the U.S. That's up more than 10 percent from 1996 and double the recommended rate of Caesarians set forth by the World Health Organization. It's estimated that somewhere between 0.3 and 14 percent of deliveries are Caesarian deliveries on maternal request, or what are commonly called elective C-sections. Some experts say these numbers are a cause for concern and that mothers are not sufficiently aware of the risks that Caesarians pose for mother and baby or of the implications that a first-time Caesarian may have for future pregnancies.
"When I think about maternity care, it's characterized by overuse of many practices that are lifesaving when necessary. But when they're not necessary, they expose mothers and babies to potential harm, they offer few benefits, they're more costly, and they waste scarce resources," says Maureen P. Corry, executive director of Childbirth Connection. "Inductions and Caesarians are glaring examples of that."
Why Are the Numbers so High?
Some of the increase in Caesarians is a result of women being older when they have their first pregnancies and the increase in the rate of multiples due to fertility treatments, which can result in more-complicated pregnancies. Women who are obese or diabetic may also have complications that lead to necessary medical intervention. Dr. Alan R. Fleischman, medical director at the March of Dimes, a leading nonprofit for maternal and neonatal health, says there has also been an increase in labor inductions that are performed when the mother's body and baby are not necessarily ready for delivery.
Some of the increase is attributed to women requesting elective Caesarians, as vaginal birth can result in pelvic-floor problems and sexual dysfunction. However, scheduling conflicts may be as much to blame. "Obstetrics is a 24-hour, seven-day-a-week practice. So if, as a doctor, you want to deliver your patient, the best way to be sure of that is to schedule it—to induce," says Fleischman. "If you don't, you may not be on call, or you may have an office full of other appointments, so someone else may end up delivering your patient."
Induction frequently fails, Fleischman notes. Early induction may mean that the cervix isn't ready to give birth. It won't dilate or soften. There is a failure to progress. "So now the woman is getting tired. She's had a lot of discomfort, and nothing is happening, so the next step is to say, 'Well, we've tried this for 12 hours,' or 'We've tried it for 18 hours, so now we'll do the Caesarian,'" says Fleischman. "So a big part of the increased Caesarian rate is the increased induction rate. It's not unusual at all to have that occur on a scheduled basis: The woman comes in the evening, she is induced overnight, and then in the morning it's decided to go ahead and have the Caesarian."
