Ob-gyns address pressure to lower cesarean section rates

Delivery decisions should be made based on the individual patient, not numbers, say doctors.

By Victoria Stagg Elliott, amednews staff. May 28, 2001.

When Michael L. Socol, MD, took over as chief of obstetrics at Northwestern Memorial Hospital in Chicago in 1987, the cesarean section rate at the private teaching hospital was 27.3%. By 1996, it had dropped to 15.4%.

He achieved this decrease by instituting a protocol of active management of labor and circulating physicians' C-section rates among their peers rather than allowing them to remain private.

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Northwestern was one of many institutions to react to the high cesarean rates of the 1980s and attempt to increase the rate of vaginal birth -- considered more safe and less of a strain on the health care system. "Pregnancy is a healthy time frame, and as a society we have to realize that the overuse of any of our interventions threatens the larger community as resources are limited," Dr. Socol said.

Reducing cesarean rates has its advantages, including lowered mortality and morbidity, reduced costs and shorter hospital stays. In addition, they have long been used as a measure of quality of care by insurers, managed care organizations and other agencies.

Ob-gyns complain, however, that this approach represents a disconnect. What should be a decision made based on a patient's choice, individual physiology and circumstances is too often being influenced by pressure to get the numbers down, according to attendees at the American College of Obstetricians and Gynecologists annual meeting in April.

"Personally, I wouldn't do a VBAC [vaginal birth after cesarean] on someone with four previous cesareans or someone whose last baby was 12 pounds, but that's what we're seeing," said Stanley Zinberg, MD, vice president of practice activities with ACOG. "The pendulum always swings a little too far."

Cesareans dipped in the early '90s in response to pressure to lower the national overall rate from a high of 23.5% in 1990. To get the rates down, some institutions refused to offer elective C-sections or vigorously encouraged VBAC. Others tightened the criteria that would indicate a medically necessary C-section and required a second opinion before one could be carried out.

The overall rates, however, are starting to rise again, hitting 22% in 1999, according to figures from the Center for Disease Control and Prevention's National Center for Health Statistics, but some say the initial push to lower rates was misguided.

"We need to take another look. Clearly, earlier in the last decade we were overly aggressive about VBAC," said Robert Gherman, MD, head of maternal-fetal medicine at the Naval Medical Center in Portsmouth, Va. "We were VBACing everybody. Now that we've had a chance to look back at that data, we know that there are some patients who we should probably not VBAC. But the old, 'Once a cesarean, always a cesarean,' didn't really work out either."

But the pressure is still there to get the rates down.

The government's Healthy People 2010 calls for the rate of C-sections among low-risk women to be lowered to 15% from its current rate of 18% and for those with prior cesareans to be lowered to 63% from 72%.

A measure of quality?

The question of the numbers, how they are decided and what goes into them is highly controversial. There is, for example, no agreement on what the ideal C-section rate should be. Some ob-gyns say that the Healthy People 2010 goals have more to do with chance than with science.

"We use cesarean rates as a measure of quality," Dr. Zinberg said. "But we don't know what the ideal cesarean delivery rate should be."

The numbers also never tell the full story. Some ob-gyns have more patients with complicated pregnancies. "It depends on the population mix and the kind of patients an institution treats," Dr. Zinberg said. "What we're always striving for is to find a system of measurement where we can compare appropriately one institution to another, one individual to another."

But many experts say a C-section rate is not a valid indicator of care quality in the first place.

"Using C-section numbers as an indication of quality of care is misleading," said Linda Brubaker, MD, professor of ob-gyn and urology with the Loyola University Health System in Maywood, Ill. "Think about our colleagues in Nigeria, where the cesarean section rate is profoundly low, yet we do not consider their obstetrical care to be optimal."

The pressure to reduce the cesarean rates comes primarily because the procedure is viewed as more expensive and involves longer hospital stays. There is also a higher rate of mortality and morbidity. But some feel that those numbers do not include all the conditions that they should.

According to data presented by Dr. Brubaker, the morbidity and expenses associated with C-sections would be lower if conditions that may appear years after a vaginal birth such as those caused by pelvic floor injuries were considered.

"We need to resist the financial quotas that managed care companies are putting on us and encourage them to broaden their window to look at the entire woman's lifespan and include pelvic morbidity and cost of treatment in their financial analysis," Dr. Brubaker said.

Others, however, called these sorts of data inconclusive because there is no clear research showing whether it is caused by pregnancy itself or the means of delivery. "If you look at questionnaire studies, a fair number of women have fecal and urinary incontinence just from being pregnant," Dr. Gherman said.