In the United States, approximately 1.3 million women undergo a cesarean section every year, making it the most common surgery done in the US. Yes, cesarean sections are commonplace, (32.1% of all births in 2022), but they continue to put healthy women at higher risk for serious complications and death. April is Cesarean Awareness Month, an initiative of the International Cesarean Awareness Network designed to bring attention to the risks associated with cesarean surgery and to educate expectant parents about their birth options. If a cesarean can be avoided mothers would suffer fewer short- and long-term complications. Cesareans are associated with a higher risk of severe acute maternal morbidity than vaginal delivery — particularly in women aged 35 years and older. Healthy babies are also at greater risk if born by cesarean.

The number of cesareans has increased 500% in the last 40 years, but maternal and newborn health has not improved. Women are more likely to die in childbirth today than a generation ago. Maternity care experts see “unnecessary cesarean birth as a preventable cause of maternal morbidity and mortality and reduction of cesarean birth rates as an important strategy to improve women’s health,” So it seems that we still need to be reminded that performing an avoidable cesarean puts mothers and babies at risk.

What Is the Impact of a Cesarean Section Compared to a Vaginal Birth?

According to the California Maternal Quality Care Collaborative, “For most low-risk NTSV women, cesarean birth creates more risk – more hemorrhage, uterine rupture, abnormal placentation, and cardiac events… The biggest risk of the first cesarean may very well be the next and subsequent cesareans.” NTSV refers to Nulliparous, Term, Singleton, Vertex. The lowest risk for childbearing women with a first pregnancy and one fetus with a head-down position at term.

The CMQCC adds, “Women also suffer from less acute but nonetheless significant other consequences: longer hospital stays, increased pain and fatigue, slower return to normal activities and productivity, and delayed and difficult breastfeeding.” They are also more likely to experience post-partum anxiety, depression, and post-traumatic stress.

In the United States the majority of women and birthing people with a prior cesarean undergo a routine repeat operation despite the fact that the overwhelming majority who labor for a VBAC do have a safe vaginal birth. In 2022 only 14.6% of mothers with a prior cesarean had a VBAC although about 70% of those who labor after a cesarean do have a safe vaginal birth.

• Uterine rupture.
• Blood transfusion.
• The formation of a blood clot in the legs or lungs can be life-threatening.
• Cardiac arrest.
• Hemorrhage requiring hysterectomy.
• Acute renal failure.
• Needing assistance with breathing.
• Intubation.
• Major infection.
• Surgical injuries to internal organs.
• Admission to an intensive care unit.
• Ileus (bowel obstruction).
• Chronic pain.
• Sexual dysfunction.
• Adhesions (internal scar tissue that forms between tissues and organs that can complicate cesarean surgery).
  

The likelihood of adhesions is increased with multiple cesareans. The surgery becomes more complicated. More time is needed to complete the operation, which increases the risk of infection and bleeding for the mother.  After a second cesarean, the odds of developing adhesions can be as high as 46% and 75% after a third cesarean.

The Risks for Placental Problems Have Dramatically Increased

Repeat cesareans increase the risk of placental problems in a subsequent pregnancy. The risk for placenta accreta, a life-threatening condition, increases with each additional cesarean. Normally, the placenta detaches easily from the uterine wall after the baby is born. With placenta accreta, the placenta growns into the uterine wall putting the mother at risk for hemorrhage and a hysterectomy.

The increasing rate of placenta accreta over the past four decades is likely due to the increased rate of cesarean delivery. Studies from the 1970s and 1980s suggested the accreta rate was 1 / 2,510 to 1 / 4,017. More recent published rates reflect an occurrence of 1 / 272.

The risk for accreta increases with a placenta previa in a current pregnancy and a prior cesarean setion.  More than two-thirds of mothers with five or more prior cesarean births and a current diagnosis of placenta previa are at risk for placenta accreta. Babies whose mothers are diagnosed with placenta accreta are at risk for premature birth, breathing problems, and extended stays in a neonatal intensive care unit (NICU). Placenta accreta is difficult to diagnose and cannot be prevented.

What Are the Risks of Repeat Cesareans in a Future Pregnancy?

The American College of Obstetrics and Gynecology and the Society for Maternal-Fetal Medicine caution:

“Placenta accreta spectrum is becoming increasingly common and is associated with significant morbidity and mortality … It is worth noting that even in the most optimal setting, substantial maternal morbidity and, occasionally, mortality occurs.”

The odds that a mother will lose her uterus while giving birth get higher with each additional cesarean.  A pregnant person without a prior cesarean birth has a 1 in 25,000 chance of having a hysterectomy. With one previous cesarean, the odds are 1 in 500 and increase to 1 in 20 for mothers with 3 or more prior cesarean sections.  

With a prior cesarean birth, mothers are more likely to have difficulty becoming pregnant again. The embryo can implant itself in the uterine scar (cesarean scar ectopic pregnancy), which is a life-threatening condition, and there is a higher occurrence of fetal malformations, preterm birth, and low-birth weight.

What Is the Impact of a Cesarean Birth on Babies?

A cesarean can be a life-saving procedure and is beneficial for babies in a breech presentation at birth.  One would also expect a significant improvement in newborn health given the steady increase in cesareans these last decades, but the infant mortality rate in the United States is one of the highest in developed countries and the number of babies with cerebral palsy (a condition that cesareans were supposed to avoid) has not changed in the last 15 years.

Babies born by cesarean are more likely to experience significant health consequences. They are more likely to suffer from serious respiratory complications, be admitted to a Neonatal Intensive Care Unit (NICU), and develop childhood asthma.

Birth by Cesarean Can Affect Breastfeeding

During the “golden hour” immediately after birth when the baby is alert, active, and moving towards the breast mother and baby should not be separated.  With skin-to-skin contact, babies are more likely to breastfeed early and longer. Birth by cesarean can interfere with early skin-to-skin contact and affect a mother’s ability to initiate early breastfeeding. Having a cesarean makes a mother’s skin-to-skin contact with her baby less likely.  

With proper support, pregnant people who have a cesarean can experience skin-to-skin contact with their babies immediately after birth. Many hospitals are now making an effort to encourage breastfeeding as soon as possible after a cesarean birth.

A Cesarean Can Affect a Baby’s Immune System

Emerging evidence suggests that experiencing labor and passing through the birth canal prepares babies for receiving beneficial microorganisms from their mothers. These play a key role in the development of the immune system. Babies born by cesarean are exposed to a different physical, hormonal, bacterial, and medical environment, which can modify neonatal physiology.

Altered immune development increases the probability of allergies, and asthma, and lessens the body’s ability to respond to pathogens. The reduced exposure to the mother’s microorganisms may affect the child’s risk for obesity, metabolic disease, asthma, increased blood pressure, Type 1 diabetes, and stress-related issues.

National Efforts to Reduce Unnecessary Cesareans

The Alliance for Innovation on Maternal Health works to reduce maternal mortality and severe maternal morbidity (SMM) within the United States. One of its main initiatives is to train clinicians and healthcare teams to avoid the very first cesarean section and to educate expectant parents about their options for labor and birth throughout their pregnancy. AIM also actively promotes the benefits of vaginal birth and provides guidance about how to promote progress in labor and  how to cope with the pain of childbirth. It also educates expectant parents about the benefits of doula care.  

Childbirth Connection’s work to reduce unnecessary cesareans puts a strong focus on relying on evidence-based resources to help make informed decisions and emphasizes the importance of every expectant parent’s rights in childbirth. The right to choose where and with whom they want to give birth.  The website includes information on the benefits and risks of both cesarean section and vaginal birth.

The National Accreta Foundation educates consumers and maternity care professionals alike about the risks of developing accreta and the need to reduce unnecessary cesareans. The Foundation includes extensive guidance about how to find the appropriate care team required to deal with the complications of placenta accreta and provides a space where women who experienced placenta accrete can access the emotional support that they need.

These efforts will go a long way to reduce unnecessary cesareans if expectant parents also take the time to learn about their birth options and discuss their concerns with their care providers before making informed decisions about the birth that is right for them.

For additional information on the benefits and risks of repeat cesareans download Module 4 of the VBAC Education Project. You will find it on vbac.com. It’s free.

References

American College of Obstetricians and Gynecologists. (2018). Obstetric care consensus No. 7: Placenta accreta spectrum. Obstetrics and Gynecology, 134(2), e164–e173. doi: 10.1016/j.ajog.2018.09.042

California Maternal Quality Care Consensus. (2022). Toolkit to support vaginal birth and reduce primary cesareans. A Quality Improvement Toolkit Addended Part V. https://www.cmqcc.org/VBirthToolkit

Dy, J., DeMeester, S., Lipworth, H., & Barrett, J. (2019). No. 382-Trial of labour after caesarean. Journal of Obstetrics and Gynaecology Canada, 41(7), 992–1011. doi: 10.1016/j.jogc.2018.11.008

Korb, D., Goffinet, F., Seco, A., Chevret, S., & Deneux-Tharaux, C. (2019). Risk of severe maternal
morbidity associated with cesarean delivery and the role of maternal age: a population-based propensity score analysis. Canadian Medical Association Journal, 191(13), E352–E360. https://www.cmaj.ca/content/191/13/E352

Rottenstreich, M., et al. (2018). Prolonged operative time of repeat cesarean is a risk marker for post-operative maternal complications. BMC Pregnancy and Childbirth, 18(1), 1–6. doi: 10.1186/s12884-018-2111-8

Sandall, J., et al. (2018). Short-term and long-term effects of caesarean section on the health of women and children. The Lancet, 392(10155), 1349–1357. doi: 10.1016/S0140-6736(18)31930-5