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Guide to Avoiding Unnecessary Cesarean Sections in New York – Driving

April 21, 2010

Sidney Wolfe, M.D.
Public Citizen Health Research Group

Full report as a pdf
Statements from press conference

About New York
Variations in Cesarean Sections, VBACs, and Midwife Availability by County and by Hospital Within Each County
Healthy Outliers: Two New York Hospitals that Have Bucked the Trend
Factors Possibly Associated with Variation in Rates
What is Driving Cesareans in New York?
How a Woman Can Avoid an Unnecessary Cesarean in New York State
What Health Departments and Hospitals Can Do to Reduce Unnecessary Cesareans
New York Hospital Birth Statistics by County

What is Driving Cesareans in New York?

Despite the large unexplained variation, there are a number of factors that are driving cesareans in New York. These include patient factors, physician factors, and an array in the medical and legal environment affecting birthing practices.

Patient Factors

The patient population has undergone significant changes in the past 20 years. These include an increase in the numbers and proportions of older mothers,[1] a rise in the incidence of obesity,[2] and diabetes,[3] and a greater reliance on fertility-enhancing therapies and a consequent rise in multiple pregnancies.[4] While all of these have been associated with the rise in cesarean sections, the increase in surgical delivery has affected most groups of women, regardless of age, parity, health status, race/ethnicity or other demographic variables.[5] As stated previously, although “more than half (53%) of the recent increase in overall cesarean rates resulted from rising primary cesarean rates… [the increases] were not related to shifts in maternal risk profiles.”[6]

The matter of patient preference has received greater attention in recent years. As a result, the phrase of “cesarean delivery upon maternal request” (CDMR) was the subject of a National Institutes of Health (NIH) State-of-the-Science conference in 2006. At the time of the conference, “estimates of [CDMR ranged] from 4 to 18% of all cesarean deliveries; however there [was] little confidence in the validity of this estimate.”[7] Nevertheless, the factors that may lead women to opt for a cesarean section include “a desire for sterilization at the time of delivery, scheduling convenience, the desire to avoid labor pain,… a fear of an unsuccessful [trial of labor]”[7] and perceived concerns with uterine rupture.[8]

As mentioned before, in the context of non-medically necessary elective induction or elective cesarean in women without a previous cesarean, “Given that the advantages of elective delivery are primarily social or logistical and not medical, an argument could be made not to offer an elective delivery at all given the maternal risks. At minimum, patients should be well informed of the fetal and maternal risks of elective delivery.”[9]

Physician Factors

Physicians, like some of their patients, may find it advantageous to schedule deliveries; this in turn may be driving the rise in cesareans. A planned cesarean reduces the physician’s time: An average cesarean-section delivery takes only a fraction of the time that the average vaginal birth does. Additionally, physicians and hospitals may have a financial incentive to perform cesareans. When payment is global and providers receive a fixed fee regardless of type of delivery, they may have an incentive to intervene surgically to avoid a longer procedure.[10] And fee schedules favor cesareans: Nationally, they average approximately $10,958 while vaginal deliveries average $7,737.[11]

Physician practices have also varied over time. New entrants into obstetrics have been exposed to different training and use of technology and are likely to have different clinical norms and practices than their older peers. A recent survey of practitioners in the Dallas-Fort Worth area of Texas found that those “physicians practicing less than 10 years were significantly less likely to perform VBACS compared to physicians in practice more than 10 years.”[12] This suggests that the trend is self-reinforcing, as younger entrants replace older cohorts of practitioners.

Physicians also respond to peer pressure and to environmental influences, including the technological and legal changes that shape medical practice.

The Medical Environment

Changes in technology account for some of the trends. Health professionals have adopted an expanding array of tools to screen for and detect more potential problems, and to intervene in order to avert them. Physicians and midwives are better able to gauge accurately the size and gestation of the fetus, and women are more closely monitored during pregnancy and labor. The introduction of electronic fetal monitoring more than three decades ago exacerbated the propensity to intervene surgically. An early study (1979) found that, in upstate New York, monitored women were more than twice as likely to undergo a primary cesarean than those who were not monitored.[13] Another major technological change has occurred in anesthesia: As the risks of anesthetics have diminished, health practitioners are less reluctant to sedate the patient. In addition, practices that were once used in delivery have now been discontinued. “Better data concerning complications associated with the use of forceps or vacuum extraction have led to a decrease the number of in operative vaginal deliveries that parallels… the increase in cesarean deliveries.”[14]

Changing guidelines have also triggered significant changes in the practice of obstetrics. As described earlier, ACOG requirements that the hospital be “immediately available” to provide emergency care in the event of a failed trial of labor after cesarean has led VBAC rates to plummet. This has limited the number of hospitals that do this procedure, as well as the number of practitioners who perform it. And as the number of VBACs goes down, some practitioners grow less comfortable with the procedure, thereby reinforcing the downward trend. The fact that many hospitals in New York do not perform VBACs has narrowed the options available to many women. These policies need to be reversed.

The Legal Environment

The legal climate has also had an impact on cesarean delivery. Some procedures that are termed “defensive medicine” have been encoded in medical practices, even when they may be at odds with good medical care and may even worsen patient safety and well-being. “Action bias” – a propensity to intervene – may be reinforced by fear of lawsuits: Doctors are more likely to be sued for not having performed a cesarean, or for intervening too late, than for having performed a cesarean unnecessarily.[15] Physicians concerned with a potential lawsuit if a vaginal delivery goes awry may therefore opt for a cesarean if there is no clear indication against it. In this case, the question “How will this stand up in court?” may take precedence over the question “Is this appropriate care?” 

Fear of lawsuits is a concern for obstetrician-gynecologists practicing in New York State. According to ACOG’s 2006 Survey of Professional Liability, 61 percent of New York State respondents (compared with 47.5 percent of national respondents) reported having experienced three or more medical liability claims filed against them during their careers.[16]

Medical liability insurance premiums vary geographically. In New York, the medical liability carrier that insures about 60 percent of physicians divides its clients into six premium “territories.” In 2007-08 annual premiums for obstetrician-gynecologists in these territories varied more than 4.7-fold: from $37,384 to $177,880.[17] It is clear, however, that within these premium territories, there is enormous variation in the cesarean section rate, among counties with the same premium rate and within counties for different hospitals.

The fact that there are hospitals that keep their cesarean rates lower, despite the higher premiums, in order to practice better medicine should be instructive to those hospitals and physicians whose defensively and dangerously high cesarean rates need to be reduced.

Among the 10 hospitals with the lowest cesarean rates in New York are five hospitals with malpractice premium rates in the highest three brackets. Conversely, among the 10 hospitals with the highest cesarean rates, there is one hospital with premiums in the lowest three brackets.

[1] The rate of cesarean section rises with the age of the mother. In 2005 the rate of cesareans among mothers 40 years of age and older was more than twice that of mothers under 20 (46.2 vs. 21.5 percent, respectively). U.S.A. U.S. Department of Health and Human Services. National Center for Health Statistics. Births: Final Data for 2005. Joyce A. Martin, Brady E. Hamilton, Paul D. Sutton, Stephanie J. Ventura, Joyce Menacker, Sharon Kirmeyer, Martha Munson, and Division of Vital Statistics. Vol. 56. 2007: 19. Hyattsville, MD. Print.

[2] A study carried out at the University College of London Hospitals found that a body mass index of over 30 increased sixfold the likelihood that a woman would undergo an unplanned cesarean section delivery after starting labor. Four factors tied to need for cesarean delivery. “Four Factors Tied to Need for Cesarean Delivery.” MedlinePlus. Reuters, 13 Mar. 2006. Web. <http://www.nlm.nih.gov/medlineplus/news/fullstory_30927.html>.

Similarly, a prospective cohort study conducted in Seattle, Washington, found that obese women experienced a threefold increase in the risk of cesarean delivery compared to their lean counterparts. Dempsey, J., Z. Ashiny, C. Qiu, R. Miller, T. Sorensen, and M. Williams. “Maternal Pre-Pregnancy Overweight Status and Obesity as Risk Factors for Cesarean Delivery.” Journal of Maternal-Fetal and Neonatal Medicine 17.3 (2005): 179-85. Web.

[3] A survey of women with gestational diabetes found that the odds ratio of such women reporting at least one of six non-routine medical complications during pregnancy after adjusting for age at pregnancy and non-gestational hypertension was 4.3. Saydah, S., A. Chandra, and M. Eberhardt. “Pregnancy Experience Among Women With and Without Gestational Diabetes in the U.S., 1995 National Survey of Family Growth.” Diabetes Care 28.5 (2005): 1035-40. Web.

[4] The twin birth rate in the U.S. rose 70 percent between 1980 and 2005. In addition to being associated with the greater use of assisted reproductive technologies, the upsurge in multiple births has also been attributed to older age at childbearing. Between 1980 and 2006, twin birth rates rose 27 percent for mothers under age 20, compared with 190 percent for mothers aged 40 years and over. In 2006, 20 percent of births to women 45-54 years of age was a twin, compared with about 2 percent of births to women aged 20-24.  U.S.A. U.S. Department of Health and Human Services. National Center for Health Statistics. Births: Final Data for 2006. Joyce A. Martin et al. Vol. 57. 2009: 20-21. Print.

[5] Declercq, Eugene, Fay Menacker, and Marian MacDorman. “Maternal Risk Profiles and the Primary Cesarean Rate in the United States, 1991-2002.” American Journal of Public Health 96.5 (2006): 867-72. Web.

[6] Declercq, Eugene, Fay Menacker, and Marian MacDorman. “Maternal Risk Profiles and the Primary Cesarean Rate in the United States, 1991-2002.” American Journal of Public Health 96.5 (2006): 867-72. Web.

[7] National Institutes of Health State-of-the-Science Conference Statement on Cesarean Delivery on Maternal Request. Rep. 1st ed. Vol. 23. 2006. Print.

[8] Ibid.

[9] Bailit, Jennifer L., Kimberly D. Gregory, Uma M. Reddy, et al. “Maternal and Neonatal Outcomes by Labor Onset Type and Gestational Age.” American Journal of Obstretics and Gynecology 202.245 (2010): 1-12. Print.

[10] “Why Does the National U.S. Cesarean Section Rate Keep Going Up?” Childbirth Connection. Web. 4 January 2010. <www.childbirthconnection.org/printerfriendly.asp?ck=10456>.

[11] Thomson Healthcare. The Healthcare Costs of Having a Baby. For the March of Dimes. Rep. 2007. Print.

[12] Chet Edward Wells. “VBAC: Views from the Private Practitioner.” National Institutes of Health Consensus Development Conference: Vaginal Birth After Cesarean: Program and Abstracts. 2010:105. Print.

[13] Zdeb, Michael S., and Vito M. Logrillo. “Prenatal Monitoring in Upstate New York.” American Journal of Public Health 69.5 (1979): 499-501.

[14] Ecker, Jeffrey L., and Fredric D. Frigoletto, Jr. “Cesarean Delivery and the Risk-Benefit Calculus.” New England Journal of Medicine 356.9 (2007): 885-88. Web.

[15] Viniker, David A. “Answers to Frequently Asked Questions. Cesarean Rates in the Region of 30% Are Becoming the Norm – Is This Appropriate?” 2 Women’s Health. Web. <www.2womenshealth.com/cesarean-section-rate.htm>.

[16] American College of Obstetricians and Gynecologists. Analysis of the Current Medical Liability Climate in New York State. Rep. 2008: 2. Print.

[17] Ibid.: 5.