19. Cesarean Sections Epidemic

Source: HEALTH LETTER, Date: June 1994, Title: "Unnecessary Cesarean Sections: Curing a National Epidemic," Author: Public Citizen Health Research Group

SSU Censored Researcher: Jennifer Bums

SYNOPSIS: While the U.S. cesarean (c) section rate, which skyrocketed during the 1980s, has plateaued and begun a very slow reversal, nearly one in four pregnant women still have a c-section. While often considered a routine procedure, the c-section is major surgery that involves entering the abdominal cavity and surgically modifying an organ. At times a c-section can be a life-saving intervention for both mother and child; however, at other times, it can do significant harm to mothers without providing additional benefits to infants when performed outside of certain well-defined medical situations.

There are only four indications for which a c-section is commonly performed. In order of frequency of diagnosis, these categories are 1) previous cesarean, 2) dystocia (abnormal progress of labor), 3) breech presentation, and 4) fetal distress.

Today the traditional "once a cesarean always a cesarean" thesis is being widely challenged, with the American College of Obstetricians and Gynecologists (ACOG), and others, recommending that women with a previous c-section be given a chance to deliver naturally if possible.

Dr. Emanuel A. Friedman, Professor of Obstetrics and Gynecology at Beth Israel Hospital in Boston, and a recognized authority, suggests that about 50 percent of cesareans for arrest disorders, the second leading reason for c-sections, are unnecessary.

The "obstetrician impatience factor" is also cited for the increased incidence of cesareans. The impatience factor, speeding up normal labor through aggressive use of drugs and other interventions, has been seen in studies demonstrating that c-sections are performed more frequently in the evening or when there are fewer obstetricians to share round-the-clock availability for labor and delivery.

The economic factor also may influence cesarean rates. An analysis of hospitals grouped by ownership revealed that of the four categories, federal government hospitals have the lowest cesarean rate, at 17.0 percent; state and local government hospitals at 21.1 percent; not-for-profit hospitals at 22.4 percent; and for-profit hospitals at 25.3 percent. The for-profit's cesarean rate was almost 49 percent higher than that of federal government hospitals.

Further, the increased costs associated with unnecessary c-sections are passed on to a society already suffering from grossly inflated health expenditures. Former ACOG President Dr. Richard Schwarz has estimated that a drop of only one percent in the national cesarean rate would save $115 million annually.

Finally, it is commonly believed that concern about malpractice is a major cause of the high cesarean section rate. Avoidance of malpractice suits has served as one of several impediments that prevent physicians from heeding the results of research and the recommendations of their own professional leadership urging fewer cesareans.

However, the Public Citizen Health Research Group charges that "concern for legal issues cannot be allowed to cover up for, or even cause, bad medical practice."

COMMENTS: Responding on behalf of the Public Citizen Research Health Group, Mary Gabay said the release of the group's report, "Unnecessary CSection," initially received a substantial amount of mass media coverage. However, she attributed the media's interest to the attention being given health care reform at the time and the report's estimate that the cost of unnecessary c-sections was over $1.3 billion, a figure which seemed to play a central role in the stories reported by the mass media.

Gabay noted that "While the issue of the cost of all this unnecessary surgery is an important one, our own focus for this story centered on what the variation in cesarean rates says about the quality of medical care women receive during labor and delivery and on how women can avoid an unnecessary c-section. These issues appear to be of secondary importance, if they are discussed at all, in stories that appear in the mass media."

On the other hand, "In-depth coverage of this story by the mass media might have done more to: increase women's awareness of the risks associated with cesarean surgery and of the steps they can take to avoid an unnecessary c-section; and encourage women to take an active interest in the care they will receive during labor and delivery. Women need to know that discussing with their doctors their concerns about cesarean section and other forms of medical intervention that may occur during labor and delivery is not only appropriate, it can ensure that women choose an obstetrician (or midwife) whose philosophy of obstetric care compares favorably with their own, leading to better childbirth experiences for women."

Gabay feels that certain physicians and hospitals have most to gain from the limited coverage given the subject. "Certainly, those physicians who don't want to be questioned by their patients about treatment decisions or held accountable for their over-utilization of this major surgery benefit most by limiting coverage of this story.

"Hospitals also benefit from the limited coverage. The medical literature includes several examples of how hospitals have addressed the problem of high cesarean rates by instituting one or more measures designed to reduce the use of cesarean surgery. However, rather than take responsibility for unnecessary surgery taking place within their walls, some hospitals may instead continue allowing the performance of unnecessary surgery, due to the strong pull of financial incentives. Media coverage can increase the pressure on those hospitals named as having high c-section rates to pursue changes that can result in lower cesarean rates." Gabay notes that the Florida legislature has taken steps to reduce the number of unnecessary cesareans and hopes that other state legislatures will follow Florida's lead and take a more proactive role toward ending the costly and dangerous epidemic of unnecessary cesarean surgery.