What You Need to Know About Cesarean Section: An Interview with Dr. Carol Sakala of Childbirth Connection

Carol Sakala, PhD, MSPH, is director of programs for Childbirth Connection (formerly Maternity Center Association), a national nonprofit organization based in New York City. Dr. Sakala recently led an analysis of over 300 studies comparing cesarean section and vaginal birth outcomes, which was used to develop an educational booklet. This resource, “What Every Pregnant Woman Needs to Know About Cesarean Section,” has been endorsed by the National Healthy Mothers, Healthy Babies Coalition and the nation’s most respected authorities on maternal and child health. We sat down with Dr. Sakala recently to discuss the latest findings on cesarean section, and what they mean for pregnant women.

Q. How common is cesarean section?

A. Although most childbearing women are healthy, c-section is now the most common procedure performed in US hospitals. This major abdominal surgery accounts for well over one million US births per year. In 2004, 29.1% of American women gave birth by cesarean section – a new national record. We estimate that about one woman in three is giving birth by cesarean in 2006. In 1970, c-sections accounted for five percent of births.

Q. Why is the cesarean rate rising?

A. Many factors – medical, legal, social and financial – contribute to the rising cesarean rate. Labor induction and electronic fetal monitoring are both quite common and have the side effect of increased risk of leading to cesarean. Also, attitudes about cesarean are becoming quite casual, and some caregivers are comfortable moving to a cesarean section before trying other measures that are less invasive – they may fail to attempt to turn breech babies or succumb to time pressures in busy hospitals and medical practices. Care that promotes normal vaginal birth processes, such as continuous labor support from a doula, can greatly lower the likelihood of cesarean, but is rarely given priority. There’s also pressure on caregivers today to practice “defensive medicine,” believing that performing a c-section reduces their risk of being sued or of losing a lawsuit. There is also the problem of forced cesareans: more and more women who have had a previous cesarean or whose babies are in a breech rather than head-first position are unable to find doctors or hospitals willing to offer vaginal birth, due to fear of lawsuits. Finally, there’s a growing misperception that a c-section, especially a planned one, is safe and equivalent to – or even preferable to – a vaginal birth.

Q. What are the major concerns about cesarean vs. vaginal birth?

A. In our systematic review, we found a broad range of adverse effects that were more likely with cesarean than vaginal birth. C-section can increase a woman’s risk for a number of physical problems – ranging from less common but potentially life-threatening problems like severe bleeding, blood clots and emergency hysterectomy to much more common problems like longer-lasting and more severe pain and infection – in comparison with a vaginal birth. A woman who has had a c-section also typically stays in the hospital longer and is at greater risk of being re-hospitalized.

Q. Does the method of delivery affect the newborn?

A. A c-section can, in some cases, have a negative impact on newborn health. The studies we reviewed found that a baby who was born by cesarean is less likely to be breastfed and get the benefits of breastfeeding, most likely because the transition from surgery poses challenges for successful initiation of breastfeeding. The mother’s relationship with her baby can be adversely affected, because a woman who has a cesarean gets less early contact with her baby and is more likely to have initial negative feelings about the baby. C-section can also cause other problems for a baby, who may be cut (usually minor) during surgery. Cesarean-born babies are also more likely to have breathing problems around the time of birth and to experience asthma in childhood and adulthood. Breathing problems are associated with being born too soon (babies born at even 39 weeks of gestation have been found to be more likely to have respiratory problems than babies born after that point). Respiratory benefits also appear to be associated with experiencing the onset and occurrence of labor. The connection to asthma is less clear and may relate to exposure to beneficial microbes during vaginal birth.

Q. Is there evidence of longer-term effects for a woman who has a cesarean?

A.This is an area of great concern that has not been communicated well to pregnant women and the general public. Longer-term impacts relate to both future reproductive capacity and a woman’s ongoing health. A cesarean section puts a woman at higher risk for future ectopic pregnancies, including a type known as “cesarean scar pregnancy” that develops within the scar from a past c-section. Her future fertility is lower than a woman who has a vaginal birth. In future pregnancies, a woman who has had a cesarean is more likely to experience serious problems with the placenta – for example, growing across the cervix (placenta previa) or into the scar (placenta accrete), or coming apart from the uterus too early (placental abruption). And the scar in her uterus is also more likely to open, whether she has a vaginal or cesarean birth. Uterine rupture is commonly attributed to vaginal birth: we need to recognize that nearly all cases in more affluent countries occur in women who have had a cesarean. The evidence that we reviewed found that babies from future pregnancies are more likely to die before or shortly after the birth if the mother has previously had a cesarean section. Pre-term birth and low birth weight may also be concerns. And future babies appear to be at increased risk for a physical abnormality or injury to their brain or spinal cord. Investigators have hypothesized that these problems are due to “placental insufficiency.” The likelihood of a number of these future reproductive harms increases as the number of previous cesareans increases. Fortunately, with just one or two previous cesareans, most of these outcomes occur infrequently. Unfortunately, however, most of these are serious and even life-threatening for mothers and babies. Many pregnancies are unplanned, and some women who don’t intend to have more children change their minds. And a growing number of pregnant women lack access to vaginal birth after cesarean (VBAC), which leaves them no choice but repeat cesarean. Moreover, there are other longer-term effects of cesarean on women, beyond childbearing, that appear to be a consequence of scarring and adhesions that often accompany surgery. Women who have had a cesarean are at increased risk for chronic pelvic pain and for bowel obstruction, and the tough adhesion tissue can complicate procedures that a woman may need in the future, such as gynecologic surgery.

Q. Is a planned cesarean any less risky than one that is unplanned or “emergency”?

A. It is clear that surgical technique has improved over the years. However, it is incorrect to state that cesareans are “safe.” Both planned and unplanned c-sections result in scarring and carry similar risks in future pregnancies and for the mother’s ongoing health. A planned cesarean appears to offer some advantages over an unplanned c-section (which happens after labor is already in progress), such as fewer surgical injuries and fewer infections. However, women with vaginal births avoid these surgical risks altogether. Unplanned c-sections can take a greater emotional toll than planned cesareans. It’s important to understand that a planned cesarean still involves the risks associated with major surgery.

Q. Is a vaginal birth always optimal?

A. If there’s not a clear and compelling need for a cesarean, a vaginal birth is likely to be the safest option for mothers and babies. We found that women with vaginal births are more likely to have problems with bowel or urinary incontinence than those who have c-sections. However, we did not find a single study that had tried to sort out the effects of common practices that can cause harm – such as episiotomy, forceful staff-directed pushing, and pushing while lying on one’s back – to see if vaginal birth per se imposes any problems. Also, even with these concerning standards of vaginal birth care, most of these problems are mild and resolve during the recovery period. Several large studies found no difference in levels of later-life incontinence between vaginal birth and cesarean mothers. By contrast, maintaining a healthy weight, avoiding smoking and staying off hormone therapy are things that can help avoid pelvic floor problems. As advocates for women and babies, we think that it’s very important to improve standards for vaginal birth practice and limit use of cesarean to situations when benefits are well-supported.

Q. What goals should a woman set to increase her baby’s chances for good health?

A. There are no guarantees, but a woman can take steps to increase her chances for a vaginal birth. Advance preparation in pregnancy can make all the difference. Carefully choosing a health care provider and a birth setting with low rates of medical intervention is extremely important. When considering birth settings and caregivers, women should look for signs of caution rather than casualness about the use of such interventions as epidurals, artificially induced labor, episiotomies, synthetic oxytocin to speed labor, electronic fetal monitors and IV drips. A woman can lower her chances of having a cesarean by about one-fourth by having a doula or other labor companion who is present solely to support her throughout labor. Being fit and well-rested and –nourished can help her meet the challenges of labor. Good use of gravity through movement and upright positioning may make a difference. Our cesarean booklet provides more information about these and many other tips for avoiding unnecessary cesareans and having a safe vaginal birth.

Q. How can a woman respond when her health care provider proposes a cesarean?

A. If a health care provider suggests a c-section and it is not an emergency situation, a woman should ask why it’s being recommended, the rationale for and risk of the procedure, and she should inquire about other possible approaches – including just waiting longer. If she isn’t already in labor, she will have time to do her own research and talk things over with her partner before making a decision. If it’s early enough in her pregnancy and there is no clear reason, she may wish to consider finding another caregiver. In our recent national Listening to Mothers survey, about 9% of women who gave birth in 2005 reported feeling pressure from a health professional to have a cesarean.

Q. Are women themselves asking to have a planned cesarean section when there is no medical reason?

A. The National Institutes of Health just held a state-of-the-science conference on this topic. The authors of a specially-commissioned report for the conference did not find a single study to clarify the extent to which this is happening in the US – trends and effects associated with so-called “maternal request” cesarean. Some people have assumed that any cesarean that does not have a possible medical reason on a birth certificate or in hospital discharge records is due to the mother’s choice, but those sources have no information at all about the decision-making processes and mothers’ preferences. The only recent data from the US on this topic became available after the commissioned report was completed. Childbirth Connection’s second national Listening to Mothers survey was conducted by Harris Interactive in January and February of this year among women who gave birth in the US in 2005. Just one woman among all 1,574 survey participants met the NIH definition of a maternal request cesarean; she had a planned initial cesarean by her own choice and felt that there was not a medical reason. We need to look elsewhere to understand causes of the steadily rising cesarean rate.

Q. What can HMHB and its partners do to have an impact on – and educate about – this important issue?

A. Unfortunately, many women are not hearing all the facts about cesarean section, and it is our responsibility to educate the public and promote truly informed decision-making. Sharing evidence-based information is one way we can work together to improve maternal and child health. Thank you for the opportunity to do this today. After spending nine months doing all that they can to increase the baby’s chances for the best possible start, mothers want the best possible care during labor and birth.

For more information, go to Childbirth Connection’s website, . To contact Dr. Sakala, call 508.651.2442 or send email to: