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Unnecessary Cesarean Sections: Curing A National Epidemic

-How to Help Yourself or Your Friends/Family to Avoid an Unnecessary C-section

The United States cesarean section rate, which skyrocketed during the 1980s, has plateaued and begun a very slow reversal of this earlier dangerous trend. It appears that increased use of vaginal birth after cesarean section (VBAC) has been a major factor in bringing the increase in c-section rates to an end. This is the main conclusion of a report by Public Citizen’s Health Research Group on the use of cesarean section in U.S. hospitals, findings of which are summarized here. According to the National Center for Health Statistics (NCHS), the c-section rate nationwide increased more than four-fold in a little less than 20 years, rising from 5.5 percent in 1970 to 24.7 percent in 1988. Since then the rate has varied only slightly, actually decreasing modestly after 1990. Meanwhile, between 1985 and 1992, the VBAC rate (the proportion of women with a previous c-section who deliver vaginally) has steadily risen from 6.6 to 25.4 percent. Our own data, collected mainly from state vital records offices, show a nationwide cesarean rate of 22.6 percent for 1992, slightly lower than the 1990 rate of 22.7 percent presented in our previous c-section report. Because of the large number of births used to calculate these cesarean rates, even this small decline was statistically significant. The challenge now is to encourage a much sharper reversal of the earlier trend and work toward a less extensive, more rational use of cesarean surgery.

The upward cesarean surgery trend has been of concern to the Health Research Group for several years. In 1988, we published our first report on this issue, for the first time making data on hospital and physician cesarean rates widely available. Since then, we have continued to expand the size of our state and hospital databases. The current report includes statewide c-section rates from all 50 states and the District of Columbia, statewide VBAC rates from 49 states (only Connecticut is missing) and the District of Columbia, and hospital-specific cesarean rates and VBAC rates from 3,159 hospitals in 41 states. These statistics are calculated from data on the method of delivery used in almost 4 million births occurring in U.S. hospitals in 1992, making our report the most comprehensive source of information on hospital and state cesarean section and VBAC rates available.

Delivery by Cesarean Section

Over most of the past 25 years, the average American woman expecting a child has been increasingly unlikely to deliver her baby vaginally. Nearly one in four pregnant women now have a cesarean section. This operation is similar in scope to an appendix or gall bladder removal in that it involves entering the abdominal cavity and surgically modifying an organ.

For years controversy raged in the United States over whether increased c-section use represented a gross and excessive danger to mothers, a new and more convenient way of delivering normal babies, the guarantee of a perfect baby, the root of the decline in infant deaths, or a knee-jerk response by physicians to problems of malpractice, or a source of added income for doctors and hospitals. At one point, an academic article went so far as to suggest that all women be offered a cesarean at their due date. The answers to most of these questions have become increasingly clear as research accumulates. C-section, while at times a life-saving intervention for both mother and child, can do significant harm to mothers without providing additional benefits to infants when performed outside of certain well-defined medical situations. We are beginning the long road back from an epidemic of unnecessary surgery.

Curing the Cesarean Epidemic

There are many strategies that hospitals, insurers and consumers can pursue in lowering cesarean section rates. Hospitals can address the problem by putting one or more of the following measures in place:

Develop and enforce clinical standards for obstetric care;

Require second opinions for all but emergency cesareans;

Audit and peer-review cesarean operations;

Develop mandatory, hospital-wide information forms which explain to women with previous cesarean sections why VBAC is recommended as the safest course for most women;

Use trained labor companions;

Incorporate midwives and their philosophy of care into labor and delivery care programs; and

Develop a perinatal database to track patient care and clinical outcomes.

Financial incentives driving our current insurance system favor cesarean surgery over vaginal delivery. There are six actions we feel insurance companies should take to correct this situation:

1. Equalize physician fees for c-section and vaginal delivery;
2. Pay hospitals through a refined “diagnostic related group” (DRG) compensation system that more closely reflects true cost differences among various types of deliveries;
3. Use such cost control tools as preadmission certification of elective repeat cesareans and retrospective review;
4. Select physicians and hospitals with low cesarean section rates as preferred providers;
5. Provide financial incentives for women to attempt VBAC; and
6. Use insurance coverage to promote less costly and less technology-driven forms of care.

The most important people to stop this epidemic are those who must undergo and live with the effects of unnecessary cesarean surgery — women. We suggest three steps women can take to lower the risk of unnecessary cesarean surgery:

Determine the cesarean section “track record” of available doctors and hospitals;

Discuss concerns about cesarean section and other forms of medical intervention during labor and delivery with their doctor;

Consider choosing a midwife for prenatal care and as the birth attendant.

In these ways, hospitals, insurers, and consumers can all take action to lower the incidence of expensive and dangerous unnecessary cesarean sections being performed today. This is truly an issue where the interests of good health and cost-containment coincide, creating common ground between health-care consumers and the insurers and employers who pay for this care. With regard to cesarean section, physicians have adopted a style of practice that is in the best interest of neither society nor the individual woman. By taking actions described above, those with a stake in this issue can be instrumental in reversing the 20-year trend that has caused “the c-section epidemic.”

Unnecessary Cesarean Sections: Curing A National Epidemic

Published: May 1994

Cost: $15 state report or $60 for the national report

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