This is a guest article by Silvio Aladjem M.D.

The fact that cesarean section rate is too high, has been a subject that has been debated for years. One can read “editorials”, “retrospective studies”, “opinions”, “blogs”, “letters to editors”, you name it, and it has been written. At one time, hospital protocols required that two physicians/obstetricians agree to the need for cesarean section (this failed miserably). Some insurance companies thought that by not reimbursing the differential fee between normal vaginal delivery and cesarean section, would curb the rising cesarean section rates. This not only had no effect, but studies showed that rates for cesarean section were similar for physicians in private practice, and those that work on a strict salary as hospital employees and have no incentives to perform a cesarean section.

To accommodate public demand for “normal deliveries” in “a home environment”, “birthing centers” were opening where no cesarean sections were ever performed and care was being rendered exclusively by midwives. It was home delivery all over again, but under supervision. If complications occurred, the patient was to be transferred to a nearby hospital.  The tragic death of a baby that occurred in Lansing MI in March of 2012, showed the pitfalls of such arrangements.

Back in the 50’s and 60’s cesarean section rates were between 3 and 5%. Why was that? A cesarean section was a procedure of last resort, because it was considered a major operation which put the mother’s life in danger. And so it was.

If you think that those were the “good old times” think again. A baby born at 24 weeks was considered an abortion/miscarriage. Infants below 30 weeks were considered non-viable and nothing was done in terms of care, other than placing the baby in a warm incubator with plenty of oxygen. Unbeknown to us, the excessive oxygen in those incubators, blinded many of the children who were exposed to such treatment.

There were number of obstetrical manipulative procedures to deliver the babies when labor did not progress normally. One in particular comes to mind, where the undilated cervix was cut so that a forceps could be introduced into the uterus to grab the baby’s head and pull the baby out. This was a procedure described in standard textbooks.  If we were still be doing this procedure today, we would probably be prosecuted for manslaughter if the baby or the mother would die as a consequence of it, a distinct possibility.

If babies were born blue because of lack of oxygen and were not crying, we used to slap the baby’s behind to “stimulate breathing”.

These were some of the reasons why cesarean section rates were so low. Shall I continue? I don’t think so.

By late 60’s and early 70’s. things began to change.   It was always thought that a newborn baby is nothing but a small child. This was to be proven wrong.  At birth, extraordinary physiologic changes occur in the baby in order to allow him/her to survive outside the uterus, where it lived for 9 months floating in the amniotic fluid. These changes include drastic adjustment in the respiratory and circulatory systems. The newborn baby must now survive with the oxygen provided through the baby’s own lungs and not from the mother, through the placenta.  If the baby’s lungs were immature because of prematurity, the necessary changes would not happen, and the baby may not survive or suffer irreparable damage.

With this understanding, a new breed of Pediatricians appeared, who had additional training, and became Neonatologists.  They are now in charge of the newborns who are being taken care in sophisticated intensive care units known as NICU (Neonatal Intensive Care Unit)

Obstetrics also changed, and new technologies appeared, which gave us information about the course of labor and how the baby tolerates the stress of labor. Improvement in surgical techniques, blood banks, antibiotics, anesthesia and general surgical care, made the cesarean section safer and no longer the dreaded procedure that put the mother’s life on the line.

With younger and younger babies surviving, the public perception as to what can be done, increased dramatically.  As a result our tolerance for “complications” decreased and our expectations increased. Every baby was expected to survive and be healthy. Never mind that its weight was barely a pound or less and that its future was anything but bright.

Tort lawyers had their influence on cesarean section rates as well. This was, after all, a new fertile ground for multimillion dollars awards and defensive medicine appeared.

If we look at the entire picture, it becomes obvious that no one single factor is responsible for the high rate of cesarean sections. It was not the result of physicians  suddenly deciding to now deliver by cesarean section, since they were safer to perform.

No professional organization had ever suggested what would be an “acceptable” rate. All of them, without exceptions, caved to the public pressure that “cesarean section rates are too high” and continued to talk about what to do about the high rate. They still do. That is not good enough. Rates will not come down just because we think they are too high and talk about it. Beating the dead horse that “cesarean-sections must be lowered”, without offering a solution, is not going to get us anywhere in terms of the high rate of cesarean  sections.

The whole purpose of obstetrical care is to end up with a healthy mother and baby. Years ago the only goal was to have a healthy mother. The baby’s health was secondary. The death of a newborn was dismissed with: ”You’ll get pregnant again, don’t worry”. No more.

We need to refocus on what made the cesarean section rate skyrocket, in the first place. Without such a discussion nothing will change. Cesarean section, in itself, is not the problem. Our technological advances allow us today to tackle medical problems that were either unknown or not approachable before. Today many cesarean sections are performed to  save a baby who did not use to count before.

The 3% to 5%  cesarean section rate will never be back. Nor should it.

We should also address the issue of “Cesarean section on demand”. Is the maternal autonomy, about which we talk a lot, entitled to chose to be delivered by a cesarean section for no apparent medical reason?

We will talk about this issue on our next blog.
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SILVIO ALADJE MD, an obstetrician/gynecologist and Maternal Fetal Medicine (high risk obstetrics) specialist, is Professor Emeritus in obstetrics and gynecology at Michigan State University, College of Human Medicine, in Lansing, MI.  He is the author of “10,000 babies: my life in the delivery room” now available on Amazon, Barnes and Noble and other book stores. Dr. Aladjem published extensively in Scientific Medical Journals and wrote several textbooks in the specialty. He can be reached through his website, www.drsilvio.com

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