Even as the proportion of births by caesarean section hovers at 32 percent in the U.S., new federal data show a decline in surgical births in Utah, which already had the lowest C-section rate in the nation.
In a report released Friday, the Centers for Disease Control and Prevention said 22.3 percent of Utah women who gave birth in 2016 had C-sections, down from 22.8 percent in 2015.
And Utah again had the lowest rate of C-sections in the nation. Nationwide, the C-section rate for 2016 was 31.9 percent, down a fraction from 2015’s 32 percent.
The new report, which contains provisional data compiled by the National Center for Health Statistics, also revealed that the number of births in the U.S. declined 1 percent and the fertility rate for American women between the ages of 15 and 44 is at a record low.
Utah is historically an outlier when it comes to the overall birthrate, too. In 2015, Utah had 78 births per 1,000 women, compared to the national average of 62.5.
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There were 50,464 babies born in Utah in 2016, but the state's overall ranking won't be known until the CDC releases its final report in the fall.
Meantime, the state can enjoy its top ranking in an important measure of women's health. While surgical births can save lives, unnecessary C-sections put both mothers and babies at risk for complications, not only in childbirth but later in life.
C-section babies are more likely to suffer respiratory distress and later have asthma, they miss the immune-boosting exposure to the mother’s microbiota during the journey through the birth canal, and, according to one Harvard University study, are more likely to be obese later in life.
Even when a C-section goes well, the procedure is major surgery from which the mother must recover, and her chance of having a vaginal birth with other children steeply declines.
In subsequent pregnancies, she is at risk for placenta problems (some of which can be fatal), uterine rupture and hysterectomy; in later years, she can develop abdominal adhesions. The World Health Organization says that C-sections should only be performed when medically necessary, and that too many are not. A C-section rate between 10 and 15 percent is widely considered optimal for the best birth outcomes in a society. Utah isn't there yet, but it's closer than any other state.
So what’s behind the Beehive State’s enviable C-section rate, and what can other states learn from Utah?
Although health officials everywhere agree that too many C-sections are taking place in the U.S., many are medically necessary — for example, if the child is in a breech position (feet-down) or in distress, if the mother has an active infection, or if labor has stalled or stopped altogether.
In developing nations, more mothers and babies die during childbirth when they don't have access to safe and sanitary surgical births. For this reason, health officials say a minimum number of C-sections is desirable. The World Health Organization sets that rate at between 10 and 15 percent, while noting that there is no evidence that mortality in childbirth decreases at rates higher than 10 percent.
In the U.S., the Department of Health and Human Services has set a goal of 23.9 percent for low-risk births. A pregnancy is considered low-risk if the woman is having a single child, is not obese, has no serious health issues, and the baby is positioned head-down.
In C-sections for low-risk pregnancies, Utah fares even better than in pregnancies overall. Utah's rate of C-sections among low-risk pregnant women was 16.8 percent in 2016, according to the CDC. The national average was 25.7.
In this category, as well, Utah's numbers declined while the national rate was stagnant. In 2015, Utah's C-section rate for low-risk pregnancies was 18 percent; the national rate was 25.8.
In an examination of C-section rates across the country, Consumer Reports said a woman's choice of hospital can affect whether or not she has a C-section. Hospitals that are actively trying to reduce their C-section rates may influence doctors in what they recommend to their patients; policies on when women may be induced may make a difference, too.
One Harvard researcher has posited that the physical design of hospitals may influence their C-section rates. When hospitals are designed in ways that encourage natural childbirth — for example, having rooms that allow laboring women to walk around instead of being confined to a bed — fewer C-sections take place.
"Even though mothers in labor are typically some of the healthiest patients in a hospital setting, they often are treated in intense treatment environments designed for the sickest," a report by Dr. Neel Shah, an assistant professor at Harvard Medical School, said.
Consumer Reports ranked major hospitals across the country by C-section rates. Two Intermountain hospitals in Utah had among the lowest: Utah Valley Regional Medical Center in Provo and Intermountain Medical Center in Murray. Hospital officials weren't immediately available to comment.
Intermountain has a policy that prohibits doctors from inducing labor before the 39th week of pregnancy, which may figure into its rates.
Induction increases the risk of having a C-section, said Theresa Morris, an associate professor at Texas A&M University and author of "Cut It Out: The C-Section Epidemic in America." Between 2006 and 2012, the rates of induced labor in Utah declined by more than 30 percent, according to the CDC.
Intermountain hospitals also allow women to have a vaginal birth after having had a C-section, a type of birth known as a vaginal birth after C-section, or VBAC. Many hospitals across the nation don't allow VBACs, Morris said. Utah is tied with Colorado for the highest rate of VBACs in the nation.
“It’s not just that Utah has healthy women, but providers are making better decisions,” Morris said.
What Utah women are doing right
Some women and their doctors want C-sections for the convenience of being able to schedule the birth. The American College of Obstetricians and Gynecologists estimates that about 3 percent of births in the U.S. are C-sections requested by the mother with no medical cause.
But the majority of C-sections are medically indicated, and often because of the health of the mother. A healthier population, therefore, is likely to have fewer C-sections, and this seems to play out in Utah.
Women who are overweight or obese, and women who gain a lot of weight during pregnancy, have larger babies. The larger the baby, the more likely the child will be delivered by C-section. Utah's obesity rate is 24.5 percent, 10 points less than the national average.
The presence of HIV, herpes or some other infection is another reason C-sections are sometimes necessary. Utah has some of the lowest rates of sexually transmitted infections in the nation.
Having a chronic health condition like diabetes and high blood pressure also raises the risk of a C-section. Utah is last among the states in the incidence of diabetes, with a rate of 7 percent. Utah is also last among the states and the District of Columbia in the prevalence of hypertension, with a 2015 rate of 23.6 percent. Nationwide, 1 in 3 Americans have high blood pressure.
Also, women who have prenatal care beginning in the first trimester are more likely to have healthier pregnancies overall.
In 2016, 82.1 percent of pregnant women in Utah were under a doctor's care beginning in the first trimester. Nationwide, the rate of prenatal care in all three trimesters was 77.2, according to the CDC.
Home versus hospital
According to Morris, the percentage of women who plan to deliver their babies at home, instead of in a hospital, also contribute to the C-section rate because an operating room isn't immediately accessible at home, and women laboring at home generally only go to the hospital when something goes wrong.
Utah ranks among the top 10 states of women who deliver at home, with roughly twice the national average of 1.36 births per 1,000 women, according to the CDC.
“Another interesting thing about Utah is that Utah has licensed certified professional midwives since 2005, so they’ve had a good 12 years of having licensure,” Morris said. “Women who attempt home births and birth-center births are less likely to have C-sections.”
Like the World Health Organization, the American College of Obstetricians and Gynecologists strongly discourages elective C-sections, especially among women who plan to have multiple children because the risk of complications increases with each surgery.
The group has issued guidelines intended to help reduce the incidence of surgical births, ranging from offering virus-suppressing medication to pregnant women with herpes in their ninth month, to advocating for tort reform so physicians aren't so worried about lawsuits if they allow labor to progress naturally.
Here, Utah has an edge, too. The state enacted limits on medical malpractice lawsuits in 2010.