Of interest?
Pamela Morrison IBCLC
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From Medscape Medical News
One Third of First-Time Pregnancies Delivered by Cesarean
Fran Lowry
August 30, 2010 — The rate of cesarean deliveries
in the United States is continuing its upward
trajectory, according to a new study released
today. Now accounting for 30% of all deliveries,
the rate of cesarean delivery has increased 50%
from 1996 to 2007 and shows no signs of diminishing.
Results of a large, retrospective, observational
study conducted by the National Institute of
Child Health and Human Development and National
Institutes of Health, in collaboration with 12
institutions across the United States, show that:
1 in 3 women pregnant for the first time are now being delivered by cesarean.
Repeat cesarean after a previous caesarean
delivery now accounts for one third of all cesarean deliveries.
The rate of trial of labor after a previous
cesarean is low, at 29%, and the success rate for
a trial of labor has declined to 57%.
44% of women attempting vaginal delivery had
their labor induced, and their rate of cesarean
delivery is twice as high as women who have spontaneous labor.
Half of cesarean deliveries were conducted before
6 cm of cervical dilation — which is considered
an early phase of labor, especially in first-time
mothers — induced labor, or women who are
attempting vaginal birth after cesarean delivery (VBAC).
The results were announced by lead researcher Jun
Zhang, PhD, MD, from the Eunice Kennedy Shriver
National Institute of Child Health & Human
Development. The findings are published in the
September issue of the American Journal of Obstetrics and Gynecology.
Speaking at a teleconference today, Dr. Zhang
told reporters he was particularly surprised by
the finding that 1 of every 3 first-time mothers are delivering via cesarean.
"This has important consequences for future
pregnancies, since vaginal delivery after
C-section is still thought to be somewhat risky,
despite recommendations by the American College
of Obstetrics and Gynecology (ACOG) to the contrary," he said.
Another surprising finding was that many cesarean
deliveries are being done very early in labor,
before 6 cm of dilation, Dr. Zhang added.
The study, called the Consortium on Safe Labor,
was conducted to collect comprehensive
information on current labor and delivery
practice across the United States. It included 12
clinical centers, made up of a total of 19
hospitals, located across 9 ACOG districts. Most
were university or community teaching hospitals,
and only 2 were nonteaching community hospitals.
They were chosen because electronic medical
records were available at each institution and
because they were geographically representative
of all ACOG districts in the United States.
Dr. Zhang told Medscape Medical News that several
factors may be driving the increase in cesarean deliveries.
"Delayed child bearing, increased maternal body
mass, more twin pregnancies, and low use of
vaginal birth after previous C-section, which is
increasing because of 2 forces — the increasing
C-section rate in first-time mothers and the
decrease in VBACs. Put all these together, and it
looks as if the upward trajectory may continue for a little while."
He admitted that the study has limitations. The
participants are not a random sample of what is
going on in the United States, and academic
institutions are overrepresented in the study
sample, he told Medscape Medical News.
"Although this is quite a comprehensive database,
it is not totally representative of the United
States population. That is one drawback."
The second is that the study is retrospective.
"We think that the quality of information we have
is very good, but we still have to rely on what
is recorded in the medical records. We extracted
the information from the hospital database, so
our data are only as good as the medical record. That is another deficiency."
Dr. Zhang said that reducing this high rate of
cesarean delivery will need to focus on
preventing unnecessary primary cesarean deliveries "from several aspects."
"First, we need to decrease the rate of cesarean
delivery associated with a high rate of induction
of labor. Cesarean section for dystocia should be
avoided before active phase of labor is
established, particularly in nulliparous women,
induced labor, and VBAC attempts."
He added that there should be a clinically
accepted indication for performing cesarean
delivery. Also, physicians and patients should be
educated about trial of labor in women with a previous uterine scar.
"We agree with ACOG. They have just issued
guidelines that call for increased use of VBAC,
and we are in accordance with this," he noted.
S. Katherine Laughon, MD, MS, a fellow and
maternal–fetal medicine specialist working with
Dr. Zhang, said that barriers to VBAC exist but
the study was not set up to address the specific reasons why.
"Recently, there was a National Institutes of
Health consensus conference on what are the
barriers to women getting access to providers and
to healthcare facilities that will provide the
opportunity for a trial of labor after a prior
cesarean section, and also what are the barriers
for physicians," Dr. Laughon said. "This
particular study does not address that exact
question, but it is something that both
clinicians and policy makers at the national
level need to investigate and find answers for."
Dr. Zhang and Dr. Laughon have disclosed no relevant financial relationships.
Presented August 30, 2010, in a teleconference at
the National Institutes of Health.
Am J Obstet Gynecol. Published online August 13, 2010.
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