Variation in Caesarian section deliveries

I would expect that some sort of cultural determination is going on here.

Is there any correlation with availability and usage of non-hospital birthing facilities (home birth / midwife-led birthing centres etc)?

I would anticipate that where delivery in a less medicalised environment is encouraged and properly supported there would be a lower likelihood of all interventions not just C-section.

My best guess (and completely ignorant, no less!) is that it's a phenomenon related to differences in fertility rate, coupled with standard medical practice. In the United States, it's pretty standard practice to deliver a mother's subsequent children by C-section if she had one previously.
But that's an 8:19 am, off-the-top-of-my-head idea. And the fertility rates ain't that different between the U.S. & the Nordic countries. So who knows?

Yes, cultural dimension, which cuts many ways.

C sections are profitable, let us not forget that.

In some countries one relies on docs / surgery / etc. more, including body modifications (plastic surgery, etc.) The knife and the men in white are the tops, upper class, aspired-to-way. Expert and expensive is better than natural, slow, dopey, poor (crouching in the favela, the jungle, the rotten suburbs, etc.)

C sections are also prevalent where mothers work and get little time off - plan the birth is best, or even just bloody essential - it must be during Xmas hols, etc. or on X date, so as to fit into the manager-s scheme.

Nordic countries have a tradition of "naturalism"..and pay for it thru taxes and then offered time off, med care, etc.

Low nitric oxide.

Pregnancy is a high NO state, with the first trimester being a very high NO state. I think that is what causes the nausea of morning sickness, and why high nausea correlates with better pregnancy outcomes. That high NO in the first trimester is important for proper fetal differentiation and epigenetic programming as well as mitochondria biogenesis in the placenta and maternal liver. It is also important in increasing hematocrit to counter later blood loss. That high NO is why some disorders get better during pregnancy.

NO is also one of the main regulators of angiogenesis, which is important in achieving the proper vascularization of the placenta to support sufficient exchange capacity. The response to insufficient supply of O2 is hypoxia, which causes acute oxidative stress, which acutely lowers NO levels, which makes correcting the insufficient vascularization more difficult. It is low NO that leads to preeclampsia, and very low NO leads to eclampsia.

Low NO leads to insufficient mitochondria and insufficient capacity for oxidative phosphorylation. This is compensated for by glycolysis, but that requires 19x more glucose. When the maternal liver supplies more glucose, there is gestational diabetes. That tends to cause elevated birth size which can require more C-sections. It is probably more glycolysis in the mother, not in the fetus that leads to this. The O2 level in the fetus is pretty low and most ATP probably does come from glycolysis anyway. The fetus needs lots of substrate for growth, not so much for just ATP. Fetal lactate may be used for cell growth and not recycled back to glucose.

NO is what regulates synthesis of androgenic steroids. Low NO leads to higher levels of androgens, which accelerate growth and lead to larger infants. This also leads to hyperandrogenic infertility, such as polycystic ovarian syndrome.

NO is the generic signal that indicates "stress". Low NO comes from high stress and signals many of the physiological compensatory responses to high stress. Those responses may be adaptive under conditions of high stress, they are not adaptive under non-stress conditions. I think this also causes preterm birth, but not necessarily via CS.

A large change in economic circumstances in a single generation will likely cause increased CS rates too, as women who are small due to conditions during their gestation and childhood attempt to give birth to infants conceived under much better economic circumstances. I suspect this relates to the high CS rate in Korea.

Why the lowest CS rates are in the Nordic countries? My guess would be good prenatal care, fairly homogeneous population and gene pool, low stress environment, and the practice of sauna, which raises NO levels. Also, as Nordic countries, they have cold winters, where sweating is greatly reduced. The lack of sweating during winter would have prevented the formation of NO/NOx from skin bacteria, which they have partially compensated for via the cultural practice of sauna. I suspect that the Nordic gene pool contains other compensatory factors for dealing with the loss of NO from skin bacteria. These genetic factors are less frequent in warmer climates, which is why I think there is a higher CS rate in Italy and Mexico.

If you want to do an interesting bit of research, look at the variation of C-section rates between regions of just the U.S. It'll boggle your mind.

This isn't the only procedure for which there are fairly wide variations of usage, either. Understanding these differences and disparities is very important, because a lot of the difference is clearly not related to science-based medicine.

If I was doing serious research on this, the first thing I'd do is covary out age of mother. If mothers are older. I'm fairly sure some parts of Caesarian risk increase with age.

The two social constructs are the general acceptability of Caesarians as an elective procedure and the interaction between the legal and healthcare systems.

For the legal issues, it is also vital to also look at fetal death and injury rates. In the US, when there is a risk of limb displacement, Caesarians are very common. Other countries with less agressive lawyers might take more risks have have a more children with minor injuries.

For the elective Caesarian issues, the # of Caesarians after labor begins is a better metric. (It also removes things like placenta praevia, but that should be a fairly constant rate across countries). The only thing this doesn't cover is induced pregnancies. those rates might be higher in some countries and they do lead to more unplanned Caesarian sections.

The comment about sauna's is way off. Dutch hardly ever go to a sauna. But perhaps you should look at the percentage of home births, it is way higher in the Netherlands than most other countries, so there is no doctor to perform a needless c-section. So, it is mostly a cultural issue, giving birth has been succesfully medicalised in several countries.

Brian, that is a very astute observation. I think you are correct, they are both related, and via the final common pathway of nitric oxide. However it is the lowest birth rate that correlates with the most C-sections (with Mexico being a big outlier, the US and Australia outliers too). Italy and Korea have very low birth rates (~1.3, not even replacement levels). With most women having only a single birth, repeat C-sections can't be the main driver of high C-section rates.

A time of high stress is a bad time to get pregnant. If NO is one of the signals of high stress (which it is through multiple pathways), it would make sense that low NO would cause infertility.

There is a downloadable file (1.5 MB) that has much of this data over multiple years.

http://www.irdes.fr/EcoSante/DownLoad/OECDHealthData_FrequentlyRequeste…

Italy shared the highest rate with the US in 1991, 22.6%. The Italian rate has gone up ever since, the US rate went down and then went up. The rate in Finland went up a little, but hasn't changed in the last 10 years. None of the Nordic countries have changed much during that time.

wilfred, you may be correct. When C-sections are not available, the rate of C-sections can only go down. Maternal and neonatal mortality go up.

There is a very nice paper on historical trends in maternal, neonatal and post-neonatal mortality in the developed world and comparisons to undeveloped regions.

http://www.ajcn.org/cgi/content/full/72/1/212S

Before the modern era (post 1937), maternal mortality was on the order of a few tenths of a percent per birth.

On page 214S, he discusses the experience of a modern religious cult that avoids all medical care including medical treatment during delivery. They had a maternal death rate ~ 0.87%, about 100 times higher than the death rate for women in the surrounding community. The perinatal death rate was only 2.7 times higher.

He also discusses cephalopelvic disproportion which becomes much more frequent in women of smaller stature. If competent obstetrical care is not available, a baby that is too large is a dire problem. If competent obstetrical care is not available, nutritional supplementation during pregnancy for small stature women needs to be considered very carefully due to the risk of cephalopelvic disproportion.

In that issue of American Journal of Clinical Nutrition, there are a number of papers on maternal nutrition, with some that more specifically discuss obstructed birth and cephalopelvic disproportion. One of the papers does have a table (table 1) showing differences between maternal mortality in hospital births and those delivered by midwives associated with the Kentucky Frontier Nursing Service.

http://www.ajcn.org/cgi/content/full/72/1/241S

My mother happened to be a nurse midwife who worked in Frontier Nursing in Kentucky and rode her horse to deliver babies. She was an RN, CNM with degrees from Johns Hopkins. She completely embraced SBM, though it wasn't called that then. All of her children were born in a hospital, and I don't think she would have considered a home birth were a hospital birth available. I suspect that the very low rate of maternal mortality that the FNS had was due in part to the rural nature of the women and (I speculate), their surface biofilms of ammonia oxidizing bacteria.

What is it with all the remarks about NO and other such nonsense? People should really just research the culture around giving birth in the various countries involved. I can assure you that they are quite different. Ah, nevermind.

I think this is a fascinating subject. I think the relative placement of the US in a cross-section of countriesis interesting, but I think it is more fascinating that the rate is increasing so much over time (seemingly everywhere). Are we really getting that much better outcomes (reduced maternal and infant mortality as well as fewer problems) for all this increase?

It's my belief that this is primarily related to the culture of medicine and the culture of pregnancy. Childbirth has become overly medicalized in the US. Most US physicians tend to view pregnant women as an accident waiting to happen; at the first sign of any deviation from the mean a c-section is suggested. Women are not encouraged to trust their bodies, so most are open to high levels of intervention. I understand that complications do arise that result in the need for medical intervention but there is no good reason for a national c-section rate of close to 30%. The following study suggest that a less medicalized standard of care for low-risk women is safe: http://www.bmj.com/cgi/content/full/330/7505/1416?ehom

There is a good analysis that debunks the BMJ Johnson and Daviss study. The neonatal death rate at home births is more than twice that in the corresponding low risk group in hospital births. If you think more than twice the risk is ok, that is an opinion that many do not share.

http://homebirthdebate.blogspot.com/2007/01/johnson-and-daviss-study-sh…

I highly recomment this website, Homebirthdebate. The author Dr Amy Tuteur is quite knowledgable and has a very extensive discussion of many issues surrounding home birth and C-sections with many links to the literature.

Dr. Tuteur fails to mention that the study with the 0.9/1000 mortality rate excludes low birth weight infants, a subset of infants that have a high risk of mortality. Low birth weight infants were not excluded from the Johnson and Daviss study. If you read the comments to the blog you will find that Dr. Tuteur's analysis is far from perfect. I'm not saying the J&D study is perfect and I agree that there are problems with the comparison groups, but I think the study provides useful information on the safety of homebirth.

I am familiar with Dr. Tuteur's site and I find her to be extermely biased. As a medical professional (MPH, physician in training) it's not too difficult to conclude that there is another side of the story that she is not presenting.

Could the use of Pitocin (?) to hurry birth along have something to do with it? (As I understand it, it is often applied without the woman's knowledge or consent under the guise of "checking you".)

I don't know the answer to why the variations in c-sections, but everything I've read about how women are commonly treated when they're in labor (disregarded, lied to, bullied, threatened, and belittled seem to be recurrent themes) makes me very glad I plan never to have children.

caia: I doubt "Pit" use has anything to do with it. A pitocin drip doesn't go unnoticed. It produces fierce contractions (it is a natural hormone). It is often used, when the progress of labor pauses, to accelerate evolution of labor. C-section is only done when despite the very powerful contractions it produces, labor doesn't progress. This was the case with our first child and I have vivid memories of it.

The suggestions that the section rates should be adjusted for maternal age makes a lot of sense, but I'm not sure it could account for the difference between Italy and The Netherlands.

Hmm, I must have the wrong drug name then... it was something applied internally that I read about. I also don't remember the web site I read it at, so.

Don't forget the cases where the contractions that pit causes send the baby down fast but in a bad position. I came close to a C-section after getting pitocin and ending up with baby having shoulder dystocia. It seems to be a common issue with pitocin. In fact as soon as I was given pit, I was considered high risk for a C-section and treated as if I WAS going to have one.

Why'd I have the pit? The docs changed my due date after a late ultrasound showed a big baby - ignoring the earlier and undoubtedly more accurate very early ultrasound I'd had. They decided I was "officially late". I was with a combined practice - the NMW wanted to do a trial of prostaglandin gel. Unfortunately, 15 minutes after she admitted me, an OB in the practice took over and was very aggressive. He didn't bother to inform her of any changes either. I'm still sorry I didn't have a better support system with me - given the treatment I got, I really needed a patient advocate. My alleged informed consent information was cursory and biased; my questions and concerns were summarily dismissed. Walking out AMA while in labor without a good support network is a limited option.

With kiddo #2, a new doc started planning a C-section 5 minutes into my first appointment since I'd had a big baby with #1. I found another provider and delivered a 10 lb 7 oz baby on her own schedule, without surgery.

I learned a lot about hospitals with baby #1. Enough to arm myself with printouts of research for #2. Unfortunately, I know more than a few mothers who have had essentially the same experience as my first. Educated consumers are NOT very welcome in the OB world IME.

From talking to others and my own experience, it's clear that for many medicos, the woman is of little importance in the delivery room. We are merely delivery devices who should do as we're told. True informed consent seems a rare commodity, and medical personal have and do threaten women who don't want to "follow the program" with DCF referrals.

I've talked to many first time pregnant women who have docs who have planned an induction - I wonder how many of them end up C-section? It reduces the number of planned C-sections, but since induction seems to be a risk factor, it almost seems to be statistical shifting if true. "We're not planning sections. We're just ready if the induction goes wrong." Failure to progress from the induction or shoulder dystocia - same probable outcome - an unplanned, but perhaps predictable, C-section.

I suspect the drug Caia was mentioning is prostaglandin gel. It is used to start up labor, and could easily be applied under the guise of an exam. It doesn't give tectonic contractions, but could still start things before mom and baby are really ready.

Pitocin also increases the risk of fetal distress which may lead to a c-section. The whole point of pit is to create long and strong contractions, which may or may not be tolerated by the infant. Like all medical interventions there are approapriate times to use it, but the risks of the intervention need to be weighed against the risks of not using it.

I've also heard that induction has a 50% failure rate (sorry, I don't have the research to support this claim). This means that 50% of inductions result in a c-section.

Thanks, Karen. Ashley, too.

I do know that some hospitals have C-section policies that would inflate the number of "repeat" C-sections. For example, our local hospital will not allow a mother to go through natural childbirth if she has previously had a C-section. Not sure exactly why. In any case, a person may want to look into "first time" births...?