The cesarean section is the most common surgery performed both globally and here in the United States. Nationally, one in three people who gave birth in 2016 did so by an incision through their abdomen. It is estimated that almost 20 percent of all births around the world are cesarean births. Many developed countries have a higher cesarean rate than is believed to be necessary. There has been much discussion about what an "appropriate" cesarean rate might be in developed nations and Science & Sensibility has covered that topic here and here before.

Developing nations still struggle with maternal and neonatal mortality and morbidity due to lack of access to safe and timely cesarean surgeries. For the people giving birth in those countries, the low rate of cesarean is not improving the health of birthing people and their babies.

The impact of giving birth by cesarean has come under increasing scrutiny, especially in the past few years, as researchers recognize that maternal and neonatal complications and deaths are not declining as a result of all these surgical births. In fact, outcomes are worse than ever in many places.

Additionally, it is clear that further obstetrical complications are likely in the postpartum period and during future pregnancies and births after someone has given birth by cesarean section. These morbidities include the increased risk of hysterectomy, need for blood transfusions, intensive care unit admission, wound infection, readmission to the hospital, along with placenta previa, placenta accrete, and uterine rupture in future pregnancies. The downstream effects increase as the number of cesarean births a person experiences goes up.

Now, new research has come to light that the impact of giving birth by cesarean section can also create gynecological problems long after a person's reproductive years are completed. A new study just published last week in JAMA Surgery, Association of Previous Cesarean Delivery with Surgical Complications after a Hysterectomy Later in Life, indicates that people who have had previous cesarean sections are more likely to have complications during or after their hysterectomies, should they have one at a later point in time. Cesarean surgery can create adhesions between the uterus and other pelvic and abdominal organs that increase the risk of surgical complications later, such as during a hysterectomy. "This study is the first to estimate the potential population-wide harms of this trend to mothers over the long term." according to Neel Shah, MD, MPP, one of the authors of the study. This research was done by researchers at Aalborg University in Denmark and at Ariadne Labs in Boston, here in the U.S.

The research was conducted in Denmark, a country ideally suited for longitudinal research due to their comprehensive national data set that contains relevant clinical and sociodemographic information. It appears from this new research that a person who had at least one birth and a hysterectomy, were 50 percent more likely to have delivered their baby by cesarean section than the general population, suggesting that birthing by a cesarean section may increase a person's risk of needing a hysterectomy later in life.

Furthermore, compared to people who gave birth vaginally, those who had a surgical birth and later needed a hysterectomy were more than 16 percent more likely to experience postoperative complications such as bleeding or infection. They were also 30 percent more likely to require reoperation after the initial hysterectomy. People who had two or more cesarean births were 96 percent more likely to require blood transfusions during the hysterectomy.

The research excluded people who required a hysterectomy within 42 days of giving birth. Denmark began to track mode of birth after 1992, so the study population required people to have given birth after 1992 and then had a hysterectomy. 7685 people were included in the dataset, having given birth between January 1, 1993, and December 31, 2012, and underwent a benign, nongravid hysterectomy between January 1, 1996, and December 31, 2012. The rate of benign hysterectomy in Denmark during the study period was approximately 10 percent.

The study concluded that reoperation, perioperative and postoperative complications, and blood transfusion within 30 days of a hysterectomy are all more common if a person has previously given birth by cesarean. It is estimated that in the United States, approximately 50 percent of the cesareans that are done are avoidable. There is a connection with giving birth by cesarean and future complications during a hysterectomy. It continues to be imperative that we reduce the number of cesarean surgeries that are done so that the complications from hysterectomy patients who had cesareans are reduced.

Families need to be informed of all the downstream effects of giving birth by cesarean, with the immediate birth, future pregnancies, and births and on the possible hysterectomy that may be decades down the road. The choices we are given and make now are not without serious impact and this impact must be considered.

When you discuss cesarean sections with your students, clients, and patients, do you feel that it is important to share this new research? What are your thoughts?

References

Lindquist SAI, Shah N, Overgaard C, Torp-Pedersen C, Glavind K, Larsen T, Plough A, Galvin G, Knudsen A. Association of Previous Cesarean Delivery With Surgical Complications After a Hysterectomy Later in Life.JAMA Surg. Published online August 09, 2017. doi:10.1001/jamasurg.2017.2825

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