Are induced labours affecting caesarean rates?

Today, more than one third of all babies almost 50% of babies born in Australian Private Hospitals are being born by c-section.

So why are so many more women choosing C-sections? Do women have enough information to make informed decisions? What role do physicians and perhaps, most importantly, hospitals play in C-section rates?

The Link between C-Sections and Induced Labor

Today, more and more expectant mothers are scheduling their babies’ births rather than leaving the timing to the whims of Mother Nature they arrange to have their physicians induce labor; using drugs or mechanical devices to ripen the cervix two or three weeks before their due-date.

Over the past two decades, the odds that a doctor will jump-start labor have doubled, rising to 22.5 percent of all births

Some of these inductions are medically necessary: For example, the mother may be suffering from uncontrolled diabetes, or the baby may be diagnosed with a heart condition that needs medical attention. But research recently published in Obstetrics and Gynecology reveals that nearly 40% of induced labors studied were “elective.” In other words, there was no medical indication for forcing labor.

Not all inductions are planned ahead of time. Frequently the choice is made at some point after labor begins, usually because the mother’s cervix is opening very slowly which is not unusual for a first time labouring woman.  But in most instances, neither the mother nor the infant is in danger.

When labor is induced, the chances that the mother will then require a C-section climb precipitously. A study published last year in Obstetrics & Gynecology reveals that among more than 7,800 women giving birth for the first time, those whose labor was induced were twice as likely to have a C-section as those who experienced spontaneous labor.

No wonder the rate of C-sections and inductions have been growing in tandem. As health care economist J.D. Kleinke put it recently in a post about childbirth on The HealthCare Blog “The blessing and the curse of modern medicine.  . . is its ability to stimulate its own demand, and obstetrical practice is the quintessence of this cost-curve-sustaining paradox.” In other words, one intervention creates the need for another.

C-sections also lead to more C-sections. Once a woman has had one, many doctors will advise that she should not attempt a vaginal birth when she has more children.  And today’s expectant mother is quicker to accept the recommendation than her mother was. According to Choices in Childbirth, a nonprofit group that strives to improve maternity care, as recently as 1995, one out of four women  who had a Cesarean  went on to give birth to another  child without surgery. But today, “vaginal birth after Cesarean”(VBAC) rates have plummeted to less than one in ten.

Why Do Mothers Elect for Induction and C-Sections?

An induced labor can be harrowing. “Medications and interventions used can create a ‘domino-effect with synthetic forms of the hormone oxytocin creating a wave of violent painful contractions.” These contractions are often “unnaturally close to one another, providing inadequate rest in between, often making the labor a lot more tiring than giving birth naturally,” explains Female Care.net, a website that offers health information to women.

In contrast to a spontaneous labour when the body prepares itself for delivery and a cocktail of hormones are released to wash away any pain.

“The baby and the placenta enact a series of complex changes in the days leading up to labor,” writes Mayri Sagady Leslie, CNM, MSN, a midwife on the faculty at the School of Nursing and Health Studies at Georgetown University. “The cervix shortens and softens, while the uterus develops sensitivity to the hormone oxytocin which your body will produce. Your brain’s hormone control center and the uterus engage in a complex feedback mechanism to control the length, strength and closeness of contractions.”

By contrast, “during an induction, this mechanism is not engaged.” Instead many women report these labors as being particularly painful. It is therefore not surprising that induced women commonly have epidurals. These, in turn, [can] increase their chances of a vacuum or forceps delivery so again, one intervention becomes the catalyst for another.

As for C-sections, recovery from having someone slice into your abdomen is not easy. A Cesarean is, after all major surgery. .

Elective Interventions Raise Risks for Mother and Child

Not only do inductions and C-sections add to the pain of childbirth, they hike up hospital bills. Most importantly, they can pose potentially serious risks, both for the mother and her infant. In a recent post on the New America Foundation’s “New Health Dialogue,” Vanessa Hurly spelled out “The Real Cost of Early Elective Deliveries” in blunt terms:

“What if I told you that across the country there’s a procedure being performed on pregnant women that makes their newborns more likely to end up sick and in a $3,000-a-day Neonatal Intensive Care Unit (NICU). Too outrageous to believe? It’s true.”

To be fair, “scheduling” a birth offers some clear advantages:  For a woman with a demanding career, the opportunity to time the event—two weeks after her annual report to investors is due, and three weeks before she and her husband have planned a celebration /vacation—must be appealing.

But it is not at all clear that most mothers who select their babies’ birthdates have all of the information they need to weigh the benefits against the potential hazards.

“Babies born as a result of induced labors can be born too early. This is because, even with the best technology we have, your estimated due date is just that—an estimate, plus or minus two weeks,” Georgetown’s Mayri Sagady Leslie explains.

Even if the EDD (estimated due daet) is accurate, some babies have a good reason to hang back for an extra week or so. “When labors are started artificially, before or near your due date, babies are at risk of being born before their bodies are ready,” Leslie observes. “This can lead to extra medical care, and prolonged hospital stays.”

Leap Frog agrees: “Earlier use of induction has resulted in more infants being delivered before term. . . at 37-38 weeks, up from 19% in 1992 to 29% in 2000… Induction also increases the chances that a baby will need to be admitted to a Neonatal Intensive Care Unit (NICU) which can delay the opportunity for mother and baby to bond. Some studies have also found a significantly higher chance of other postpartum complications, including any of the following: hematoma, wound dehiscence, anemia, endometriosis, urinary tract infection, and sepsis.”

C-sections ramp up the risks-and the costs.

As the National Center for Health Statistics (NCHS) cautioned in 2010:  “Cesareans are associated with higher rates of surgical complications and maternal re-hospitalization as well as with complications requiring neonatal intensive care unit admission… In addition hospital charges for a Cesarean delivery are almost double those for a vaginal delivery.”In a Public Citizen Research Group the authors concluded that: ‘The advantages of an elective delivery are the convenience of being able to plan delivery and perhaps more control over who is the delivering provider. These advantages pale in comparison to 3.21 times the risk of hysterectomy at term for an elective induction or 6.57 [times] increased risk for unlabored cesarean at term… Given that the advantages of elective delivery are primarily social or logistical and not medical, an argument could be made not to offer an elective delivery at all given the maternal risks. At minimum, patients should be well informed of the fetal and maternal risks of elective delivery.’”

In a study released just last month, Leap Frog, issued a “Call to Action” in response to its new data showing that elective deliveries before 39 weeks are rising at “alarming rates”. That said, let me be clear: Most cesareans do not lead to serious problems. The vast majority of babies who are brought into the world through an incision in their mothers’ bellies experience no ill effects. And for the average individual mother, the only downside is the longer recovery period, combined with the likelihood that, in the future, many doctors will insist that she should not even try vaginal delivery.

When a C-section is medically necessary, a mother should realize that this is not considered a dangerous surgery. Indeed it has become a routine procedure. But when a C-section is purely elective, a mother should consider the risks before agreeing.

Are Expectant Mothers Aware of the Downside?

Why are so many women opting for procedures that are likely to cause them more pain than spontaneous labor and a vaginal birth? The conventional wisdom has it that C-sections have become commonplace for three reasons: women are having children at a later age; an increase in multiple births (thanks to fertility treatments) and finally, the convenience of a planned birth.

But as Naomi observed on HealthBeat last spring, we can cross off the first two reasons: “the most recent National Center of Health Statatics (NCHS) report found that the rate of C-sections rose in all age groups between 1996 and 2007” (not just among older mothers), “with women under age 25 experiencing a 57% increase in cesarean deliveries.  And surprisingly, the rate of c-sections for single births increased substantially more than cesarean rates for multiple births.”

This leaves convenience as the major factor driving these elective procedures. For some, an induced labor is a “lifestyle choice’ observed an editorial in the July issue of Obstetrics and Gynecology, referring to “health care providers’ and new parents’ desire to control the timing of delivery.  . . Many women believe that delivering a few weeks early is just as safe as delivering on the projected due date.”

Fear of labor may also be a factor. I suspect that the majority of expectant mothers assume that inciting labor at 38 or 39 weeks will do the baby no harm precisely because the intervention has become so popular. Why would Ob/Gyns do so many, if there was, in fact, a serious danger that the baby would be a frail “preemie” who winds up in a neo-natal ICU? No doubt Ob/Gyns who frequently recommend elective induction firmly believe that intervention is safe.

Still, one wonders: when an OB/GYN recommends scheduling the birth do they tell the mother that the American College of Obstetricians and Gynecologists (ACOG) guidelines say that elective deliveries with no medical indication in the gestational period of 37 to 39 weeks is not acceptable practice?

It is telling, I think, that inductions have jumped by 57% among women under age 25. These very young mothers may be slower to question a doctor’s recommendation, or to ask questions based on what they have read or heard over the years. They also are less likely to have talked to other women about their experience recovering from a C-section, or how hard their induced labor turned out to be.

Moreover, twenty-somethings who are members of the millennial generation tend to be confident, impatient and tech savvy. Raised in an era of instant messaging, they are accustomed to using technology to control their world, and may be less inclined to wait until the baby decides to be born. Young parents born in the late 1980s often view spontaneous labor and vaginal birth as a left-over from the “hippie” culture of the late 1960s and early 1970s when so many women took Lamaze classes in order to learn “natural childbirth.”

Is an induction of labour necessary? In many cases the answer is no, so please be sure that you are fully informed about the risks, benefits and other options you have before consenting to an induction of labour. HypnoBirthing teaches couples to be well educated, to ask the right questions, and to know that is ALWAYS your choice, whether you accept an induction of labour or any form of intervention in birth. This is your baby, your body, your choice.