CESAREANS: Obstetricians Criticize Goal To Reduce Rate

      The "Healthy People 2000 goal of reducing the cesarean-delivery rates to 15% may have a detrimental effect on maternal and infant health," four leading obstetricians charge in today's New England Journal of Medicine. They contend "[t]here is no evidence to support this target," and that "[s]etting a target rate is an authoritarian approach to health care delivery" that "implies that women should have no say in their own care" (Sachs et al., NEJM, 1/7 issue). The New York Times reports that the Department of Health and Human Services set the 15% goal in 1990 out of concern that unnecessary C-sections were driving up health costs. In 1988, the C-section rate was 25.5% of deliveries up from only 5% in 1970; it dropped to 23.5% in 1990 and "hovers around 21%" today (Brody, New York Times, 1/7).

Taking A Chance?
      Dr. Benjamin Sachs, chair of obstetrics as Beth Israel Deaconess Medical Center and lead author, said, "We think the current push to reduce the C-section rate is increasing complications to mothers and infants." He said pressure to reduce rates was "coming from many sources, including the managed care companies. They believe that lower C-section rates mean better care and lower costs. We think they are wrong on both counts." Sachs and his co-authors charge that these pressures lead doctors "to encourage women to try vaginal delivery even when risks are higher than those of a C-section," particularly when a woman has had a previous C-section. The result is higher rates of uterine rupture, "as well as injuries to babies caused by vacuum devices and forceps." Sachs commented, "In some parts of the country, some people have tried to mandate a trial of labor and not give the women the option of a repeat caesarean delivery. There is enormous apprehension in the medical community about these mandates and approaches" (Lasalandra, Boston Herald, 1/7). Sachs and his colleagues note that a repeat caesarean delivery at their Boston hospital costs approximately $7,700 -- only $900 more than a normal vaginal delivery. However, a failed vaginal delivery followed by a caesarean drives up the cost by $3,000 more than a normal vaginal delivery, and complications stemming from a botched procedure can add an additional $6,000 to the total bill (NEJM, 1/7). Co-author Dr. Frederic Frigoletto, chief of obstetrics at Massachusetts General Hospital, concluded, "We should begin by identifying what the rate should be for given conditions: multiple births, breech presentation, diabetes in the mother, etc. We need data to determine this so we can establish rates based on the best outcomes, not rates set by bureaucrats with economically driven motives" (New York Times, 1/7). Click here for recent Daily Report coverage of caesareans.