The Cesarean baby boom

It is not surprising that the first hospital that responded to a request from Haaretz for data about the rate of cesarean sections carried out there was Jerusalem's Shaare Zedek Medical Center. In 2008, only 11.2 percent of the births at that hospital ended in the operating room - about half of the national average for that year. There are two factors that contribute to that low rate, according to the director of its obstetrics and gynecology department, Prof. Arnon Samuelov.

"We serve a population where women give birth many times - about a quarter of the births here are the sixth one or more," he explains. "This population is motivated to give birth by vaginal delivery since a C-section limits the number of possible births." The other factor? "The approach in the hospital that prefers to avoid operations."

From biological and other points of view, of course, there is no difference between women in Jerusalem and the rest of the country, but nevertheless the number of C-sections in the country is constantly on the rise. In 1998, the national average of cesarean sections, out of the total number of deliveries, was some 13 percent. In 2008, it was 20.1 percent - a significant increase of 46 percent.

What has led the hospitals to increasingly prefer surgery, which inherently has more risks and also limitations? Information that Haaretz has obtained indicates that the hospital's policy plays a significant role in the trend. In general, however, medical establishments are not eager to divulge data about cesarean sections, and instead leave pregnant women (and her partners) to try and find such information from Internet forums. When data are not otherwise available, it is these forums which describe to the expectant mother the "hospital roulette" she may confront. It appears that concluding the birth process in the operating room is a matter of timing and luck, and may depend on the personalities of the attending medical team.

The data indicate huge gaps between the different hospitals. Together with Shaare Zedek and Bikur Holim in Jerusalem - where the rate of cesareans is 10.5 percent - there are hospitals where the rate is more than 25 percent, which means that one out of every four births are by surgical delivery. However most of the hospitals are closer to the national average.

Prof. Haim Yaffe, head of obstetrics and gynecology at Bikur Holim, attributes the low rate of surgical births in his department to the population it serves, which is largely ultra-Orthodox: "When hospitals serve a secular public and assume in advance that the woman is planning to have three or four children, it is easier in certain cases to recommend surgery."

Doctors recommend that women not have more than four C-sections. Furthermore, after the second one, in the vast majority of local hospitals, a woman will not be encouraged to have a vaginal delivery because of fear of harming the already-scarred womb.

"The best way to bring down the number of C-sections is to reduce the number of women who have them during their first birth," says Prof. Mark Glazerman, head of obstetrics and gynecology at Beilinson Hospital in Petah Tikva.

Indeed, the most common reason a woman chooses to have a C-section is that she already had one: Almost half these procedures are performed on women who are not able to have, or not interested in having, a vaginal delivery after already undergoing a C-section in the past. Other reasons? The fear that the fetus is in distress or is positioned in a way that makes vaginal delivery impossible, the decision to induce a birth that is not proceeding as it should, problems with the placenta and emergency situations. Only some four percent of cesarean sections are carried out at the request of the mother without any medical justification per se.

A risky undertaking

There are clear risks in a C-section, as Glazerman points out. "During the operation itself there is a possibility of damaging organs close to the womb: the bladder and intestines. There is also a much greater risk of hemorrhaging and infection. The death rate of mothers after a C-section is 2.5 or 3.5 times higher than in a regular birth," he says, noting that in Israel the death rate is 11 cases out of 100,000 births.

In addition there are dangers associated with anesthesia, even though most of the surgery is done with the more localized epidural, which carries a lower risk. In addition, like all abdominal surgery, there is a chance after a cesarean of internal organs eventually adhering to one another because of damage to the membranes that surround them.

Furthermore, Glazerman continues, the risks do not end when the surgery is over: "After such an operation, there is a 20-percent increase in extra-uterine pregnancies and more chance of miscarriages. With every additional surgery, the danger of problems with the placenta in the next pregnancy goes up dramatically. In addition, the chance that a woman who had a C-section will suffer from tearing of the womb in a subsequent pregnancy is six times higher than with a woman who has not undergone one."

The fetus is also likely to suffer: "Babies that are born by surgical delivery suffer more from respiratory problems both because they are born sometimes before their lungs have managed to develop, and because the [natural] passage through the birth canal activates hormones that are vital to the development of the lungs," Glazerman says, adding that research has revealed there also may be problems in the bonding between mother and baby after a surgical birth, because instead of being free to take care of her baby, the mother is busy recovering from abdominal surgery.

So, one may ask, does the increase in surgical interventions in general, during labor, indicate that there are more risks associated with births in Israel? No, says Samuelov, noting that the rise in the number of induced births is a significant factor here. "But when the conditions in the cervix are not suitable, the chance that the induction will succeed is low," he adds.

Zohar Karmi, a veteran doula, has her own Web site, on which she publishes data about various local maternity wards. She explains that inducing labor is the first step in an "avalanche of interventions," and claims that as soon as there has been one intervention in the natural birth process, more will inevitably follow - until the pregnant woman is taken into the operating room.

"In general, when the body has to start a birth from zero (because of induction of labor) - that is a forgone conclusion," she says. "I get hundreds of C-section reports and it is clear from them how an induction leads to surgery. In many cases, the excuse is fear of distress to the fetus. I don't remember more than five C-sections where the baby was born with less than 90 percent vitality."

Dr. Avner Shiftan, an obstetrician who does home births, recently published a comprehensive study of the differences in the number of C-sections in Israel between home births - in which there is hardly any medical intervention - and births in a hospital.

"True, in the hospitals they don't classify the operations according to a pregnancy that was at risk and another that was not, but it is still not possible to attribute the fact that only 3.3 percent of home births end in a trip to the hospital and in surgery, to the fact that home births carry less of a risk, in advance," he says.

Part of the explanation, Shivtan adds, must be connected with the fact that there are no unnecessary medical interventions in the home.

On the other hand, Glazerman is wary of placing the blame on induction of labor: "It cannot be stated with certainty what leads to what. Perhaps the reason the women in these cases needed intervention is the same as the reason that would have anyway led to surgery, and it is not the induction that led to the surgery."

Still births

The increase in the number of C-sections has not necessarily led to a substantial change in the number of still births. A study carried out in Iceland showed that increased incidence of surgery, from 12 percent to 16 percent over 19 years, did not change the data. Yaffe concurs that there are no differences in the mortality rate among mothers and fetuses in his department, as compared with other departments in other parts of the country, despite the huge difference in their numbers of C-sections. But the increase in cesareans has raised other questions: Is it possible that doctors are too hasty in deciding to operate, perhaps because of their fear of unnecessary delays that could threaten the birth and lead to malpractice suits?

Says Dr. Ron Oslander, head of obstetrics and gynecology at the Carmel Medical Center: "Obstetrics has the highest potential for malpractice suits, because it has the greatest number of unexpected or unknown elements. There are two patients and the information about one of them - the fetus - is received indirectly," he says. "After the long journey the woman has taken during her pregnancy to ensure the baby is perfect - and in Israel the desire for a perfect child is more extreme than anywhere else - doctors are not prepared to risk failure."

Yaffe agrees that with the risk of a possible lawsuit hanging over their heads, doctors today prefer to avoid any potential risks. "The public, because of the large number of lawsuits, has brought defensive medicine down upon itself," he observes. "And it is the public, also, that is paying the price in health."

And this is why today, when to avoid taking risks, some doctors send women in labor who would previously have had vaginal deliveries - such as in the case of twins or breech births - to operating rooms. Other births, where there is disagreement among attending physicians about the level of risk, may also end in a C-section. In many departments, there is a tendency to induce birth when the due date has passed. The woman who has gone into labor, and those accompanying her, are not always familiar with all the fine points and their implications, nor are they always in the right frame of mind to criticize the doctors.

Nevertheless, one cannot ignore the impact of C-sections on the general health of the population. "A safe Cesarean section is a most important tool and it has changed modern obstetrics profoundly," Glazerman admits, but he is proud of the fact that his hospital has decreased the rate of surgery to 17 percent below the national average. "However, it must only be used when there are real indications for this. Our aim is not to bring down the number of cesarean sections, but to give the best obstetric care we can. If by doing this we can reduce their number - then it's all the better."