C-section Deliveries in Pennsylvania, 1999 - Foreword

Foreword

Delivery by Cesarean section (C-section) remains the most frequently performed operation within the Commonwealth, accounting for 29,473, or 21.1%, of all Pennsylvania hospital deliveries in 1999. After years of a declining trend in C-section rates across the nation and in Pennsylvania, the C-section rate rose in 1998 and again in 1999.

Background

C-sections have long been the subject of public scrutiny, resulting from concerns related to both quality and utilization. For many years the adage was, “Once a C-section, always a C-section.” As the 
C-section rate rose throughout the 1980s, so did concern for the economic impact, risk of complications, and recovery time associated with this procedure. 
What is a C-section?

A C-section is a surgical procedure associated with childbirth in which the infant is delivered through an incision made in the mother’s abdominal and uterine wall. In the past, physicians performed repeat C-sections automatically due to fear that a woman’s uterus would rupture during labor. However, almost all C-sections done today are performed with a transverse incision (bikini cut) low in the uterus, which greatly reduces the risk of rupture during labor in a subsequent pregnancy.

 

As a result, many strategies to reduce the C-section rate were proposed. Of these strategies, Vaginal Birth After Cesarean (VBAC) was favored because it would affect the most women, those who would otherwise have a repeat C-section. In recent years, however, some articles published in the medical literature have questioned the safety of VBACs. The New England Journal of Medicine reported that women undergoing a VBAC, which involves a trial of labor, are at twice the risk of complications than women who have an elective repeat C-section.8 Meanwhile, Obstetrics and Gynecology found higher risks of uterine rupture for women attempting a vaginal birth following a previous C-section, but concluded the procedure is relatively safe because the occurrence is low (0.5%).4 As more is known about potential complications, physicians recognize that decisions concerning mode of delivery must be made on a case by case basis.

Concerns surrounding the rising C-section rate and inappropriate utilization also led to the creation of the Healthy People 2000 C-section objectives. These goals, established in 1990 by the United States Department of Health and Human Services, set a target to reduce the national C-section rate to 15%. Healthy People 2010 has modified and further refined these goals with new national targets established for the year 2010.16 The national C-section rate objective has been replaced by a target of 15% for women who are delivering for the first time and who are at low-risk for C-section delivery.16 Healthy People 2010 also adjusts the target for women who have had a previous C-section from 65 to 63 per 100 deliveries.