"The Relentless Rise"
Friday, July 22, 2011 at 10:57AM
By ANaturalAdvocate
August’s issue of Obstetrics and Gynecology (The Green Journal) contains an editorial by Dr. John T. Queenan (Deputy Editor). Dr. Queenan’s article, titled “How to Stop the Relentless Rise in Cesarean Deliveries,” is notable not only for the admission of a problem with the increasing C-section rate, but also for the concern he describes for the profession of obstetrics itself.
He begins his editorial with a brief history of the rise in Cesarean deliveries in the US, stating “[i]t is unclear what an acceptable rate should be.” He continues with with a prediction that the increase in cesareans in nulliparous women, as well as the decrease in VBAC rate, will soon lead to an overall C-section rate of over 50%.
Dr. Queenan submits that there are two solutions, that must be applied together, to reduce the rate of cesarean deliveries:
- “make VBAC more accessible and more desirable”
He seems to be aware of the myriad reasons that a woman might have a repeat cesarean delivery, ranging from a difficult labor and/or recovery to financial and legal influences that may affect how a physician counsels a patient about her options. Dr. Queenan suggests that tort reform will make it easier for physicians to accept the “small but serious” risk involved in a VBAC, while “the hospital administrator makes a larger financial return on a cesarean delivery compared with a vaginal deliver.” He also recognizes that some women may desire a repeat cesarean after an easy recovery from their primary section, and making vaginal deliveries more attractive is a necessary part of reducing the repeat cesarean rate.
- “prevent primary cesarean deliveries in the first place”
Dr. Queenan describes this as the “more critical solution,” as clearly the first is less important if the second is working. He laments the more lax approval procedure, comparing it to when “obstetricians wishing to do cesarean deliveries were required to get consultation from a colleague.” Today, patient request cesareans are readily available (and sanctioned by ACOG as part of patient choice), and more complicated situations, once routinely taught to be handled vaginally, are virtually always delivered by cesarean. Dr. Queenan admits that cesareans are much safer than previously, and with shorter recovery times, but states that there is “significant risk for future pregnancies.” In addition, “the maternal mortality is higher in repeat cesarean deliveres than for VBAC.”
Dr. Queenan also addresses practice discrepancy, saying that it is important to discuss rates as they differ across the country - by state, by hospital, and even by physician - and that “reasons for these discrepancies could give some clues to lowering the rates.”
He then describes a few other suggestions for decreasing the rise in cesarean delivery rates:
- changing hospital policies, including “appropriate review of primary cesarean deliveries”
- decreasing inductions for laobr
- discontinuing the use of dystocia as an indication for C-section
- better patient education regarding “the risks and benefits of vaginal delivery and cesarean delivery”
- tort reform “either at the federal or state level” to prevent “costly defensive medicine”
- increase the use of nurse midwives
- provide equal compensation for vaginal and cesarean deliveries (“Vaginal birth after cesarean could be compensated higher than a normal vaginal delivery.”)
- “Re-establish teaching and training for breech and operative vaginal deliveries”
Dr. Queenan concludes with words of warning to his profession.
“What the appropriate rate should be for the United States is elusive, but a 50% rate seems too high and would draw common sense criticism from many areas. As of now the problem is ours to solve. If cesarean delivery rates spiral upward, our profession will lose both credibility and the opportunity to determine our direction, as third-party payers and the government will become involved. … The rising cesarean delivery rate is a threat to our profession. Remember that the official statistics on deliveries are always a year or two behind. There is no time for complacency. In my judgment, the best action for our profession is to commit to lower the primary cesarean delivery rate using every practical measure while we are still in control.”
Next, another article in the current issue, Dr. James Scott’s “Vaginal Birth After Cesarean Delivery: A Common-Sense Approach.”
Reader Comments (30)
Great post. Very refreshing. Home birth aside, I would love to hear this physicians stance on doulas, increasing access to child birth education, and true informed consent about any and all medical procedures/interventions during labor and birth. These are all things that can help change the tide on the rising cesarean rate.
Very happy to hear this being spoken out loud by a member of the Obstetric community. I only hope there are enough providers around still practicing real Obstetrics who are willing to teach those not educated in the finer points of vaginal deliveries in non straight forward cases. And I hope that there will be a willingness to learn.
Thanks for restoring the full feed!
I look forward to reading the full editorial and I'm grateful for the recommendations that are made. There are, however, six little words that really stand out to me: "while we are still in control." That little phrase says a lot about the defensive stance that obstetrics is taking, despite its relative monopoly in childbirth care in the United States.
Regardless, it should always be the mother's choice. Provide as much education as possible and leave the choice up to her.
Adriana, I think the "while we are still in control" statement has more to do with autonomy within their practice and the fear of becoming heavily regulated by, as he mentioned, both the law and insurance providers.
I get excited when I read something like this and then I remember how little the indivdual OBs who I come in contact with (as a doula and in my own personal care) seem to be affected by ACOG. So how can the field be reached while still young, impressionable and in training?
"I get excited when I read something like this and then I remember how little the indivdual OBs who I come in contact with (as a doula and in my own personal care) seem to be affected by ACOG. So how can the field be reached while still young, impressionable and in training?"
They need to do rotations in midwifery run practices,free standing birth centers, and be trained in normal deliveries by midwives. I would hope it would lessen the view that birth is pathological for them and for us.
I know there is a OB/GYN here in the los angeles area who's Csection rates are 13%! she is highly recommended by the doula/midwives here as a transfer OB. I know it can be done even in a medical setting...
Love the article, but twice they mention that we don't know what an acceptable rate is. We do though. The World Health Organization recommends a 10-15% C-section rate.
Jill - It is nice to read that someone other than myself in the obstetrical community feels the way that I do. Unfortunately, I am finding it nearly impossible to get fellow obstetricians to care about the cesarean delivery rate. Rachel is correct in assuming that ACOG may not provide much influence in this situation and I agree with the editorial in that if obstetricians don't step up to address the problem that third party payers will intervene in a way that obstetricians will come to regret.
I presented my software tools to the ACOG District ii Patient Safety Committee this week in hopes of getting them to use my software tools as a means of safely lowering the cesarean delivery rate. I can only hope that they will take advantage of my tools.
Mercy, the WHO has acknowledged that the 10-15% recommendation that it made in the 1980s was not based on any actual data. In its 2009 Monitoring Emergency Obstetric Care: A Handbook, the WHO states that, "Earlier editions of this handbook set a minimum (5%) and a maximum (15%) acceptable level for caesarean section. Although WHO has recommended since 1985 that the rate not exceed 10-15%, there is no empirical evidence for an optimum percentage or range of percentages, despite a growing body of research that shows a negative effect of high rates."
Further, the research on which it based its comment about the negative effects of high rates is problematic when considering planned elective CS instead of emergency CS, which is riskier.
As someone who wants a small family and is considering elective CS for my births, I have to speak out against any arbitrary cap placed on CS in the name of lowering rates that are "too high." I'm all for research into how to make fetal monitoring a more reliable indicator of fetal distress, but trying to get the CS rate below an arbitrary number could very well have the effect of denying me the birth that is best for me and my family.
Alexis, even though a medical culture that shrugs off a rising percentage of c/sections might, in your opinion, benefit you, that doesn't make it healthy for the majority of women. C-sections are surgery and carry the risks of surgery; reducing the need for them is a straightforwardly beneficial step, in the same way that making sure women who need them have access to them is beneficial.
Women with genuine medical and/or psychological needs will still be able to have them. If that doesn't describe you, you may have to work harder to find someone to do one for you, though probably only if you're talking a decade or more from now--this isn't going to change overnight.
Its good to see that Obstetricians are understanding that they actually DO NEED TO DO SOMETHING ABOUT THE RISE. What confuses me is the disregard for the acceptable level's of cesarean (in any World region) stated by the WHO, which i'm sure is quoted to be 10-14%. So why is it so unclear to Dr Queenan "What an acceptable rate should be for the U.S"????!!!!
Andrea, again, the WHO does NOT recommend an "acceptable level of cesarean." It does NOT. I really wish people would stop propagating that 15% number as if it were the answer to all things obstetric.
And Emjaybee, I don't think that the medical culture is at all "shrugging off a rising percentage of c/sections." If it were, there wouldn't be so much research geared toward finding the optimal dates for inductions, and towards reducing the false positive rate of electronic fetal monitoring. While "reducing the need for them is a straightforwardly beneficial step," there is nothing straightforward about figuring out exactly which CS are safe to reduce, unless you eliminate the elective planned CS first. Hence my speaking out against arbitrary caps.
Would it be a good thing, in your opinion, if only women with "genuine medical and/or psychological needs" had access to CS? Who decides whose needs are genuine? That sentence was very chilling to me, but I understand that the ideology of this blog is very much toward promoting vaginal birth.
Patrice: In the editorial, Dr. Queenan appears to give great weight to *true* informed consent, stating that many women are not aware of the risks and benefits connected to their choices (often through no fault of their own). While I cannot state his position on the other matters, that seemed like a clear answer to that to me.
Adriana: I admit that that statement seemed a little chilling to me at first, but I think it was pretty much a reference to being in control of their own career, and not of the women who see out their care. The editorial overall seemed very concerned with the well-being of women and their babies with no real controlling tone - I'm sorry if that did not come across in my brief about it. :)
my3girls: Agreed. Dr. Queenan did state that it was the choice of the woman, although I think he believes that many women are not given accurate information.
Rachel: I'm not sure, really. I like SaneenMother's suggestion, but I'm not sure how practical it is. It would be nice if they had at least a small observation requirement in an OOH center, or at least under CNMs.
Mollie: That's great to hear!
Mercy: I think there are some questions about the 10-15% rate, and how applicable that may be, especially since it's been a while since the number came up and the complication rate may have changed significantly (due to a number of reasons).
Alexis: I don't see how a cap on the number of sections would be appropriate at all, despite my instinct that the current level is too high. Obviously, complication rates can vary widely, and expecting all hospitals to hold at, say, 10% would be ridiculous and require bargaining as to who is "most worthy" to receive intervention. However, I think that perhaps a second-look, and a much improved informed consent process would be very beneficial. Also, while many of the authors presented here believe that a vaginal birth is best for mother and baby on a population-level scale, I can state definitively that my goal is more and better education AND autonomy. Also, insofar as emjaybee's comment, I believe (please correct me if I'm wrong, emjaybee) that the need for a cesarean would be determined by the woman and her provider (along with an oversight board if necessary). I also think that she was stating that the current culture would not pose many (any?) barriers to your wish for an elective section, and that it would take many years before any such barriers were placed (assuming the above recommendations go into place now).
With all due respect to the WHO, their target of a 10-15% cesarean birth rate is irresponsible. Before you start throwing tomatoes, please view the two minute video at http://www.youtube.com/watch?v=TAEsEswfrgE . If you think that I am wrong then please note that I am still waiting for ANYONE to provide data that the physical characteristics of their patients DOESN’T affect their outcome.
Not until all parties involved begin to understand that the only way to find the unnecesareans is by using a measure and not a rate will we be able to significantly decrease the number of cesarean births. For example, currently, cesareans ARE decided by the woman and her doctor therefore, a review board will deem the cesarean necessary because the guidelines used to manage labor are being set by that same board and it is THEIR guidelines that are leading to the unnecesareans. For example, I am the only obstetrician in my county (20,000 births per year in the county) that waits until at least two weeks past a woman’s due date to induce labor for postdates. The guideline is that it is reasonable to induce at 41 weeks, so when Mary has a cesarean birth during her 41 week induction for “postdates”, the review board will deem that it was necessary.
My Birthrisk Cesarean Birth Measure adjusts a cesarean delivery rate to account for the physical characteristics of the women who are giving birth so that we can find which management strategies will result in less cesarean births. Get informed at Birthrisk.com and then help me to get the word out.
Alexis, I am not proposing any kind of arbitrary cap, so you should not feel "chilled" and I would appreciate you not jumping to that conclusion.
If a given hospital or doctor is actively trying to reduce its c-section rate, then the chances are that a woman may have to appeal, or possibly change doctors, if her reason for having a c-section falls outside their standard guidelines. But those guidelines are at the moment fairly wide open, and are likely to stay that way in the immediate future.
And quite frankly, this all smells of a straw-argument to me. If you are truly worried about being refused your c/section, then you should be discussing it with your OB or their hospital, not with me.
Dr. San Roman: I thank you for your work, although I think the suggestion of Dr. Queenan is more that cesareans are reviewed *before* they are performed, and under much stricter criteria. As helpful as it may be, I don't think that your measure will stop maternal request (either actually elective or through subtle pressure) and I think that it is imperative that we also look at other ways to decrease the rate.
Emjaybee, I'm sorry that I jumped to the wrong conclusion. When you said, "Women with genuine medical and/or psychological needs will still be able to have them. If that doesn't describe you, you may have to work harder to find someone to do one for you," I took that to mean that in this future you're predicting, women who don't have those genuine medical and/or psychological needs could effectively be denied CS in the name of reducing the CS rate. I find thoughts of such a future chilling. YMMV
And I'm not particularly worried about myself, as I hope to begin my family next year. However, I can still worry about how access to CS may be affected in the future by policies put in place today. I don't find it to be a straw-man argument to consider the future consequences of today's actions.
Alexis – I don’t think that you have anything to worry about. Since there are risks and benefits to both vaginal and cesarean births, a well-informed woman who believes that a cesarean birth is a better choice for her or her baby will always be able to choose a cesarean birth on maternal request. These are not the cesareans that are driving up the rate as these represent a very small percentage of our cesareans.
However, the reasons behind this request must be explored by the physician in order to best inform the patient. For example, I had a first time mother who requested a cesarean because she had a medical condition that would not allow her to have an epidural for labor. Half of her friends had a cesarean birth after a long labor and the other half told her that there is no way that they would labor without an epidural. This woman was convinced that she had a 50% chance of having a painful labor which would eventually result in a cesarean birth anyway.
With my software I was able to show her that only 8% of the last 100 women with similar physical characteristics had a labor that ended in a cesarean. With this information and the promise of IV Demerol I was able to convince her to wait until 41 weeks for her scheduled cesarean. She went into labor at 40 weeks and arrived at the hospital 3 cm dilated, received one dose of Demerol and was holding her baby in her arms 3 hours later. She was very grateful that I talked her out of a 39 week scheduled cesarean. Now don’t get me wrong, if my software revealed that 80% of the last 100 similar women had a cesarean in labor, she would have had a 39 week scheduled cesarean.
With knowledge comes power and my software provides knowledge. Without this knowledge ALL of the women who requested a cesarean for the wrong reasons would go ahead with their requested cesareans and the review panels will find that these cesareans were necessary due to patient request.
As for review boards reviewing decisions "before" labor there is a very large logistical problem with this concept. My hospital has over 2,000 births per year and it is not unusual to be the only obstetrician on labor and delivery at any given time. Who is going to review my decision at 2 am? Will this review include a vaginal examiniation to confirm my findings? If I feel that there could be fetal distress, how long should I wait for the review board to arrive before starting the cesarean?
Looking at each individual labor is not the best way to affect change. Looking at an obstetrician's results over time with a method that accounts for the physical characteristics of their patients will expose those obstetricians who are performing the unnecesareans. Once we know this information, we can decrease the number of cesarean deliveries over night. To see how, watch a 40 second video at http://www.youtube.com/watch?v=tG4qNWo6M_o