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Why are so many Caesarean sections done on moms past 40?

Tuesday, February 05, 2002

By Patrick Thornton

Pregnant women over 40 are at higher risk for Caesarean sections, according to two recent studies. But the reasons may be far more complicated than age.

Not only did the two studies published in the October 2001 American Journal of Obstetrics and Gynecology confirm previous findings, they also failed, like earlier studies, to fully explain reasons for the increase.

The first study found older women had an increased rate of breech babies (in which the baby is turned around in the uterus to be delivered buttocks first) and previous uterine surgeries, which are both risk factors for Caesarean. The second study found infertility treatments associated with Caesareans.

In a Caesarean section, a doctor removes the baby through a horizontal incision made through the lower abdomen. These may be performed when labor fails to progress or a complication arises that can jeopardize the health of the infant or mother. The procedure is invasive and risky and is more expensive than a normal vaginal delivery.

The overall Caesarean rate nationally is 22 percent of all births. This rate has been on the rise since 1999 when it bottomed out at about 19 percent. But for older women the rate has been reported as high as 30 to 47 percent. (Some studies have shown these higher rates begin as early as age 35.) When other mechanical means of childbirth are included, such as forceps and vacuum extractions, the intervention rate for older women soars to more than 60 percent.

Nearly all studies over the past 15 years have acknowledged the lack of medical explanations for the disparity. While there are health differences in older and younger populations generally, the rate of interventions differs even when such disparities are controlled for statistically.

Yes, older women have higher rates of diabetes, obesity and high blood pressure, for example, which can lead to high-risk deliveries. But these conditions and others do not account for the big difference in Caesarean rates.

While researchers continue to search for medical explanations, they're also focusing attention on social factors, which are harder to track and quantify.

Many speculate that older first-time mothers are more likely to be employed, have higher incomes and private insurance, private attending physicians and to be white. These are all factors independently associated with higher rate of Caesareans. The question again is "Why?"

One possibility is that "elective" medical procedures are more common among these groups. One of the most common is induction (or chemical stimulation) of labor, which has been associated with increased Caesareans and other interventions. But medical records are often murky or incomplete when it comes to explaining why labor has been induced.

Researchers openly speculate that the pregnancies (especially first pregnancies) of older women may be valued more highly both by the women and their doctors. If this is true, physicians may attempt to limit risk by exercising maximum control over the birth. In some situations this may paradoxically expose women and their babies to surgical hazards while attempting to reduce overall risk. This could form a vicious circle where the inaccurate perception of risk actually creates it.

What can older women do to decrease the risk of Caesarean?

Here are some common sense strategies generally thought to support healthy and effective labors:

1. Stay fit. Labor is a demanding physical process. Maintain a balanced diet with adequate iron, calcium, fiber, fruits and vegetables. Exercise regularly. Don't smoke.

2. Learn about pregnancy and birth and your options for care. Being an educated consumer is the first step toward the outcome you want.

3. Develop a trusting relationship with a doctor who respects your feelings.

4. Plan on dealing with discomfort in labor. Explore effective strategies for coping with pain, even if you plan to use medications. Any one who promises you a pain-free labor is misleading you.

5. Minimize your exposure to unnecessary medical procedures. Virtually all carry some risk.

6. Ask your doctor about his or her Caesarean and labor induction rates. Most experts agree the average rates are too high. Look for rates well below average.

7. Contact the American College of Nurse Midwives and the American College of Obstetrician Gynecologists for advice.

Patrick Thornton is a Certified Nurse Midwife with a private practice in Regent Square

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