What's best for baby?

“Did you really need that C-section?” asked the headline in last Sunday’s Post-Standard. The story reported that “about one of every three babies born at Syracuse’s two biggest hospitals is being delivered by Caesarian section surgery.”

The newspaper reported that a number of factors contribute to the C-section rate, including life threatening emergencies, patient convenience, medical malpractice risk, and possibly economic factors.

Community General's C-section rate was 24.4% last year (through September). I also checked our rate for the recent past: 24.7% (2006) and 26.0% (2005). That means, about one-quarter of the babies born at Community are delivered by C-section, somewhat lower than the 30%-plus rate experienced nationally and reported in the Post-Standard.

Community's total C-section rate is made up of two parts: primary C-sections (that is, first time deliveries) and repeat C-Sections. The primary rate for Community was 16.6% (2005) and 14.2% (2006). I don’t have the final numbers yet for 2007.

Following the news report, I checked recent literature on VBACs (vaginal birth after previous C-section). A report by Drs. Ecker and Frigoletto in the New England Journal of Medicine last year suggested that the national C-section rate is the result of forces more complicated than patient convenience or the profit motive. The authors said:

A more dispassionate analysis, however, reveals that the [C-section] trend is widespread, crossing state and national boundaries, and suggests that multiple, convergent factors are responsible, including changes in patients and their pregnancies, in options and recommendations for delivery, and in patients' and providers' expectations and evaluation of risk.

Drs. Ecker and Frigoletto note that obesity rates have doubled among childbearing women in the past two decades, that childbearing women are older, and that there has been an increase in “the number of premature and low birth-weight neonates,” all factors that push up the C-section rate.

The authors also report that breech deliveries are not recommended because of potential newborn injuries, and that the use of forceps and vacuum extraction has declined due to “better data describing the complications” associated with such procedures.

There are risks associated with C-sections themselves, and the doctors cite them in their article: the potential for an infection, potential damage to the pelvic organs, and possible future reproductive problems. Ultimately, say the authors, the decision to have a C-section (or, having had one, the decision to attempt a VBAC) comes down to a patient’s and physician’s judgment about risks.

As practicing obstetricians, we find that the risk that women are now willing to assume in exchange for a measure of potential benefit, especially for the neonate, has changed: for many, the level of risk of an adverse outcome that was tolerated in the past to avoid cesarean delivery is no longer acceptable, and the threshold number needed to treat has thus been reset.

As an editorial writer in the New England Journal of Medicine put it a few years ago: “After a thorough discussion of the risks and benefits of attempting a vaginal delivery after cesarean section, a patient might ask, 'But doctor, what is the safest thing for my baby?'"