Jaime Lewis (Host): This is Checkup Chat with EvergreenHealth. I'm Jaime Lewis. In this episode, we are discussing a critical issue in maternity care; the rising rates of Cesarean births. While Cesarean sections can be life-saving procedures with clear benefits when vaginal birth is not safe; the extraordinary increase in variation in Cesarean rates raise significant concerns.

We'll explore the social, economic, and cultural reasons associated with C-sections, including their impact on both mothers and babies. Joining us are Dr. Lauren Swords and Dr. Maheen Fallah with EvergreenHealth, OBGYN Care to help us understand the unintended effects of primary Cesareans, the risks for neonates and the value of vaginal delivery.

We'll also discuss why some women are choosing elective Cesareans and what can be done to support informed decision making in childbirth. Thank you both for joining us today.

Maheen Fallah, MD: Thank you for having us.

Lauren Swords, MD, FACOG: Thank you.

Host: Of course. Well, let's start with Dr. Swords. Can you provide an overview of the current trends in Cesarean birth rates in the United States?

Lauren Swords, MD, FACOG: Of course, Jaime, and again, thanks for having us today. This is a really important topic for us. And I just want to reiterate that no one can dispute that Cesarean birth is a life-saving procedure and when indicated, it has great benefits for mother and babies. But sometimes we need to look at what's happening in the national trends. And unfortunately, there are extraordinary rises and variation of rates of C-section births, for both quality and cost of maternity care. According to the CDC, the number of Cesarean deliveries in the United States has increased by 60% between 1996 and 2009, and unfortunately, this doesn't equate with better outcomes for moms or babies.

The overuse of this major surgical procedure has significant social, economic, and health costs, including higher rates of maternal complications. We see longer recoveries, higher rates of NICU admissions, increased barriers to breastfeeding, and kind of the relationship between mother and baby bonding. Other major contributors to the overuse of C-sections right now is unfortunately an elective choice amongst low risk first time moms and birthing people.

Host: That's a very high number and one that surprises me. I'm sure most listeners would be surprised to hear how much it's gone up. Dr. Fallah, what are the potential effects of primary Cesarean sections for maternal health?

Maheen Fallah, MD: Yeah, so the most important effect that I can think of is the likelihood of subsequent Cesareans, because truly the rate of a successful, or the rate of giving an option for a VBAC remains less than 15% in the United States. So the biggest risk is the likelihood of subsequent Cesareans. There are other risks as well, such as uterine rupture. There is a condition called uterine atony where the uterus doesn't contract after delivery and it bleeds a lot. There are placental abnormalities that can happen, such as a placenta previa, placenta accreta, and the risk of surgical adhesions increase with each Cesarean. The placental conditions that I talked about, they increase the morbidity and the mortality so patients get sicker each time. For example, by the third Cesarean, the risk of placenta previa nearly triples. And 40% of women with placenta previa will also have a placenta accreta. Now, these women do need more extensive surgeries, and they're higher risk for getting a hysterectomy right after they give birth, which is very, very stressful. There are other associated risks with the C-section. For example, psychological stress, anxiety. There's PTSD. Women also have to have longer hospital stays. They have more pain, more fatigue, and generally they have a slower return to normal activities and they're less productive after a C-section.

Host: Right and right when they need to be at their best. Right. That makes it very, very difficult.

Maheen Fallah, MD: When you have a baby and you have to be more active, you know.

Host: Dr. Swords, what are the risks of Cesarean births for neonates?

Lauren Swords, MD, FACOG: Yeah, so unfortunately the risks of C-section for neonates are equally concerning. So apart from a baby who's upside down or breach presentation, neonates have reaped few benefits from this rising C-section birth rate. As Cesarean section increased in recent decades, cerebral palsy has remained unchanged. And evidence also indicates that significant health consequences such as higher rates of serious respiratory complications and higher admission into NICUs are more common when babies are born by C-sections. Overall, C-section remains a barrier to early breastfeeding support that I mentioned earlier and delays that first feeding sometimes and can interfere with the skin to skin contact and mother bonding that baby has.

Host: Okay. Well, we've talked about some of the complications of Cesarean section. Dr. Fallah, what are the benefits of having a vaginal birth?

Maheen Fallah, MD: So a vaginal birth does have a lot more benefits than a Cesarean section. Of course, when a Cesarean is indicated, we will do it, but after a vaginal birth, moms have a shorter recovery period. They experience less blood loss. The pain that's associated with childbirth is much less after a vaginal birth. The risk of infection is less. Moms also breastfeed more successfully, and the baby is less likely to be admitted to the NICU.

Host: Dr. Swords, you mentioned elective C-sections. Why are women choosing those over vaginal delivery?

Lauren Swords, MD, FACOG: Well, Jaime, I think that's a great question and one that's a little bit hard to pin down and is multifactorial for sure. But I feel like in the social media landscape, cultural narratives have perpetrated the kind of portrayal of pregnancy as conflicting and polarizing, right? So we have labor pain that is characterized as excruciating or empowering. Childbirth is variously depicted as transformative or debilitating. Right, so it overall confuses women and can increase their fears, is what I see in my office, especially when we're talking about pain. And my overall goal is to inform women that the pain is treatable and should be treated as you need it treated.

Some women are also faced with the cultural norms of choosing a C-section, and I hear this quite a bit. My mother had C-section, so I'm going to have one. I might as well choose it. They also think that this leads to a quicker recovery because their friends and family members have told them that and we would like to educate patients and change that narrative as well.

Host: Definitely. Well, Dr. Fallah, how can providers integrate shared decision making into labor decisions with their patients?

Maheen Fallah, MD: At EvergreenHealth, we are actually working to adapt the clinical environment and all the resources the patient has or think they have. We integrate that with patient engagement and shared decision making, and this starts really early on during their pregnancy. We don't wait for labor. This is very dear to my heart. I talk a lot about this with my patients at every visit, address their concern, address the concern about labor, how can we help them with pain control and so on. Most patients are very appreciative of this, and we continue to do this and change the narrative.

We also have a wonderful and dedicated childbirth education department. They host their detailed classes. They also delineate the expectations very well, so we are hopeful that going forward, all of this is going to help patients, especially with the shared decision making.

Host: Wonderful. Well, thank you so much to both of you, Dr. Swords and Dr. Fallah for this great discussion.

Maheen Fallah, MD: Thanks for having us.

Lauren Swords, MD, FACOG: Thank you so much.

Host: That's it for another episode of Checkup Chat. EvergreenHealth Partners with you and your family from the moment you begin considering pregnancy to the months and years after you give birth. For more information, visit evergreenhealth.com/pregnancy.