The Unkindest Cut
Cesarean is the most common surgery performed on women in the United States. A cesarean (si-‘zar-E-an) section is major abdominal surgery used for the delivery of an infant through an incision in the mother’s abdomen and uterus. According to the Centers for Disease Control, the cesarean rate in 2007 hit an all time record high of 31.1% of all births. This is a 50% rise over the past decade, and almost a six-fold increase since 1970, when 5.5% of women gave birth via cesarean section. To combat this alarming trend, professionally trained Doulas should be offered to all laboring women because the support they offer has been shown to significantly reduce the cesarean rate.
Obstetricians often offer the excuse of defensive medicine for rising U.S. cesarean rate. This means that they are choosing to perform unnecessary surgery in the belief that it will help avoids lawsuits. I think it’s unconscionable to put a woman’s a life, quality of life, relationship with her husband and family, relationship with her child, and future childbearing at risk; not to mention costing the healthcare industry billions each year; simply in the hope of avoiding a lawsuit. Their logic is understandable, but faulty. According to a study published in the Lancet, “decision to take legal action was determined not only by the original injury, but also by insensitive handling and poor communication after the original incident” (Why do people sue Doctors? Lancet 1994, p343). A doula’s role in a hospital setting is often one of interpreter; being trained both in hospital protocols and communicating with women under the influence of labor hormones and stress, she is in a unique position to prevent misunderstandings which lead to litigation. We also know that a doula’s support during labor increases a woman’s satisfaction with her experience. In a recent study, of 422 couples who had the support of a doula during their birth, 100% rated their experience with the doula positively (Birth Journal June 2008 pg 2).
The risk to mothers and babies, as well as the financial costs the of all of these unnecessary operations births, has prompted leading medical agencies such as the World Health Organization, the Centers for Disease Control and Prevention, and the National Institutes of Health to call upon the medical community to reduce the cesarean rate to 15% or less. Last year over 4 million babies were born in United States which translates to 1.8 million unnecessary surgeries.
A cesarean poses serious risk the mother and her child, and those risks can only be accepted when the reason for the cesarean has higher risks then the operation. Some of the risks to the mother include infection, blood loss, hemorrhage, hysterectomy, transfusions, bladder and bowel injury, endometriosis of the site of the incision, heart and lung complications, blood clots in the legs, anesthesia complications, and re-hospitalization. Fully one-half of all women who have undergone a cesarean section suffer complications, and the death rate for mothers is two to four times higher then with vaginal birth. Approximately 200 women die yearly in the United States from complications of elective repeat (cesareans, done at women’s request for no medical need) cesarean. Each successive cesarean greatly increases the risk of developing placenta problems in future pregnancies (such as placental previa, accreta and abruption).These complications pose life-threatening risks to both mother and baby. Cesareans also increase the odds of secondary infertility, miscarriage and ectopic pregnancy in subsequent pregnancies.
A cesarean also poses documented medical risks to the baby’s health as well. These risks include respiratory distress syndrome, iatrogenic prematurity (this is when surgery is performed because of error in determining the due date), persistent pulmonary hypertension (PPH), and surgery-related fetal injuries such as lacerations.
Having a trained non-medical support person, or doula, present during labor reduces the need for medical intervention, and raises parents’ satisfaction after childbirth. A tremendous amount of research has been done surrounding the importance and benefit of having a labor doula assist as a part of the birth team. Research shows that having a labor doula “reduces the overall cesarean rate by 50%, the length of labor by25%, Oxytocin use by 40%, pain medication by 30%, the need for forceps by 40%, and requests for epidurals by 60%”. Mothers who were attended by labor doulas also felt their birth experiences were more positive, their self-image was improved; they felt their babies were healthier, and they felt their relationship with their husband or partner was improved. (Mothering the Mother by Klaus, Kennell, and Klaus ). Furthermore, in 1999, the Cochrane Library reported on 14 clinical studies involving more than 5000 women. They found that with the continuous presence of a trained support person, the likelihood of episiotomy, cesarean delivery, operative vaginal delivery, medication for pain relief, and a 5-minute apgar score for the baby was reduced.
Unnecessary cesarean surgery costs the US government billions in health care costs each year. Last year alone, over four million babies were born; 1.2 million of them by this largely preventable operation. While vaginal delivery typically requires two days of hospitalization and a one-week recovery, C-section requires four days of hospitalization and a two-week recovery. According to the Agency for Healthcare Research and Quality in Rockville, Md., the average cost of a vaginal delivery is $5,574, while the average cost of C-section is $11,361. If we were able, by the benefit of doulas supporting women in hospitals, to reduce the national rate of cesareans from 31- 15% we could save insurance companies, taxpayers, business owners and private citizens roughly $1,704,150,000 annually. These numbers do not even include the cost of anesthesia, prescription pain relief often used in the days and weeks following a cesarean, prolonged hospital stay or the use of neonatal intensive care for infant.
The Colorado statewide cesarean rate is below the national average at only 25.9%; however that is still 10% higher then it should be. If we were able to lower just our state of Colorado’s cesarean rate to about 15%, which is what the World Health organization, the Centers for Disease Control and Prevention, and the National Institutes of Health have all called “the highest rate that is acceptable”, the cost savings would have been approximately $5,264,778,905. In 2007, there were 4,315,000 babies born in Colorado hospitals. 25.9% of those babies were born by cesarean section surgery at a cost to area hospitals of $6,008,639,905. A hospital based doula program would allow more mothers to have their babies without costly, painful and dangerous risks of a preventable cesarean surgery.
copyright Carrie Anderson 2008, refrences available upon request