C-section complications: Increasing with the growing c-section rate

It is undeniable that the c-section rate in the US and most developed countries is only rising. In the US, the rate is now up to about 1/3 of all deliveries. In some countries, like Brazil and China, the c-section rate has risen to astronomical proportions, often driven by patient or provider preference and not medical necessity. (See this interesting article on the topic from The Economist.) A group of researchers from the National Center for Chronic Disease Prevention and Health Promotion, led by Dr. Creanga, Harvard University, and Stanford University published their study on the complications from cesarean sections in the September 2015 Grey Journal. 

The authors analyzed a large collection of data from the Nationwide Inpatient Sample from 2000-2011. They extracted the ICD-9 billing codes from all the deliveries to identify cesarean deliveries and 12 complications that are known to result from c-sections. The complications included injury to the bladder, death, complications from anesthesia, placenta accreta (the placenta growing into the uterine muscles in the next pregnancy), shock, sepsis (bloodstream infection), kidney failure, ventilation support (respiratory collapse that requires a breathing tube to keep breathing), bladder operation, obstetric wound complication (such as a wound infection or break-down), blood transfusion, and hospital stay greater than 5 days.

As we might expect, the authors showed that the rate of c-sections rose significantly from the start of the study to the end. 22.8% of babies were born by c-section in 2000, and 33.3% of babies were born by c-section in 2011. That's a huge increase! Many of these new c-sections were the result of repeat c-sections, or women who have a second or third c-section after they've had their first.

Now on to the complication rates: About 10% of women having their first c-section (primary cesarean) had one or more of the complications studied. The most common complication was a prolonged hospital stay, but a significant number of women had worse or multiple complications. About 2% of women had more than 1 complication. For women having a repeat c-section, the rate of complications was lower, about 5%. However, certain risks, likely connected with multiple surgeries, were higher in repeat c-section patients, including the risk of injury to the bladder and placenta accreta. Women who had a repeat c-section were 2 times more likely to have a placenta accreta diagnosis than women with one c-section.

How does the increasing rate of c-sections affect these complications and risks? The authors showed that the rate of complications from c-sections rose by about 1% every year from 2000 to 2011.  The authors highlight the issue of the increasing incidence of placenta accreta, which can have dramatic effects on subsequent pregnancies, including increasing the risk of needing a hysterectomy or blood transfusions. They warn that providers performing repeat c-sections should always keep in mind that the placenta could have an abnormal attachment (placenta accreta) and to be ready to cope with this complication if it comes up. 

With the media highlighting the increasing popularity of c-sections, which some women view as safer, easier, and more cosmetically appealing, it's important that we remember the downsides of this major surgery. Although most women will not experience a complication, the incidence of c-section complications is only growing as the number of c-sections performed grows.