What's the big deal? Well, while cesareans save lives, they come with inherent risk to both mother and baby. A cesarean is a major abdominal surgery. Each subsequent cesarean brings more risks than the one before. This means that a woman having one cesarean is exposed to less risk than a woman having her second or third cesarean. Cesareans are of maximum use when we get the most benefit with the least amount of risk. The problem is that the U.S. performs twice as many cesareans than what is considered safe. In other words, we may be doing more harm than good. The World Health Organization (WHO) has determined that to maximize safety, cesareans would be performed in 10-15% of births. WHO representatives state that rates higher in that mean we are likely introducing unnecessary risks to mothers and babies. (I wonder how this ties into our infant mortality rate.) The U.S. overall cesarean rate is over 30%. Minnesota's was 28% in 2007.
What is the problem? Are we performing unnecessary cesareans? Or, are we performing preventable cesareans, ones where the need was brought on by the way we manage birth? Some argue that routine use of medical interventions leads to cesareans. Others argue that our unhealthy American population has lead to the increasing numbers.
While I am not aware of anyone who has provided evidence truly explaining the cause, I believe that our cultural perspective on birth is a major contributing factor. I think our fear of birth, our lack of exposure to normal birth, and our mismanagement of normal birth (i.e. unnecessary medical interventions in a healthy labor) are the largest contributors to the high cesarean rates. That is the only way we can explain why hospitals in the same geographic areas have widely varying cesarean rates. If it were the population as a whole that cause the problem - such as saying that America's women are unhealthy and obese - then the cesarean rates should not fluctuate from hospital to hospital, especially within the same city, county, and state. I guess you can say that I do not believe it's women's fault. I don't think we can say, "Hey, we have a lot of obese, unhealthy women, which explains why our cesarean rate is so high."
I also don't think we can blame increase use of fertility treatment. Yes, we do have more multiple births with increased use of fertility treatments that often result cesarean births, but I do not believe the number of those births are high enough to actually double the cesarean rate. It is a contributing factor, but it isn't the explanation.
I am listing the Twin Cities cesarean rates below. Among the highest on the list are Minnesota's two "high risk" hospitals. These are hospitals that have specialties in high risk pregnancies and cases where it is known the baby will require a high level of intensive care. I need to address a common response to figures like these. Some argue that hospitals that have specialists in high-risk pregnancies have higher cesarean rates. To some degree, I agree with that. There are probably more cesarean births at those hospitals than would occur if they did not take in a higher number of high risk cases than other hospitals.
I have heard some rebut the "high risk" explanation by stating that the high risk births cannot significantly influence the cesarean rate to result in the drastically higher rates we see at those facilities. The two high risk hospitals in the Twin Cities also have among the largest numbers of total births. How many high risk births would a hospital of this size have to take in in order for the high risk births to impact the total cesarean rate to the degree that it is ten percent or more higher than other hospitals in the area? If a hospital has 4,000 births a year, how many would need to be "high risk" to result in a cesarean rate over ten percent higher than the hospital down the street? It would seem that there would need to be a lot of high risk births to impact the rate to that degree. But I am not a statistician, so maybe this is possible.
Those who argue against the "high risk" explanation state that it is not the number of high risk births that these hospitals take in that impact the cesarean rates but rather it is the high risk mentality of birth at these facilities that increases the cesarean rates. In other words, the argument is that these hospitals respond to healthy mothers and babies the same way they do to high-risk mothers and babies. They argue that these facilities apply medical management to normal labors that do not require medical intervention, resulting in unnecessary or preventable cesareans. I agree that this likely plays a significant factor in the outcomes of births at high risk hospitals.
Below are the 2007 data (source: mnhospitalpricecheck.org - maintained by the Minnesota Hospital Association). The hospitals in bold are those that have midwife-attended births, and those with an asterisk are the hospitals that have water births. Those in italics have hospital doula programs.
- Abbott Northwestern (Minneapolis) 36%
- Southdale (Edina) 32%
- United (St. Paul) 32%
- Fairview Lakes (Wyoming) 30%
- Fairview University/Riverside (Minneapolis) 29%
- Fairview Ridges (Burnsville) 27%
- Mercy (Coon Rapids) 26%
- Methodist (St. Louis Park) 25%
- North Memorial (Robbinsdale) 25%
- Northfield 25%
- St. Francis (Shakopee) 24%
- *Woodwinds (Woodbury) 24%
- Unity (Fridley) 24%
- Regions (St.Paul) 23%
- Stillwater 22%
- St. John's (Maplewood) 21%
- *HCMC (Minneapolis) 20%
- *St. Joseph's (St. Paul) 13%