Jan. 11, 1999 Four Harvard physicians are strongly recommending a moratorium on efforts to further reduce the national cesarean section delivery rate until the safety of mothers and babies can be assured. The four obstetricians suggest that economic forces, rather than the well-being of patients, may be driving the US government's goal of reducing the cesarean section rate. One of the aims of the "Healthy People 2000 Project" of the Department of Health and Human Services is to reduce the cesarean rate to 15 percent, down from the current 22 percent, by the year 2000. The viewpoint of these four Harvard doctors has been published in the January 7, 1999 issue of the New England Journal of Medicine.
"There is no evidence to support the Healthy People 2000 target," says author Dr. Benjamin Sachs, chief of obstetrics and gynecology at Beth Israel Deaconess Medical Center. He calls the setting of such a goal "a paternalistic approach to health care delivery. Research into maternal and infant safety issues and a true cost-benefits analysis are needed to define the optimal cesarean delivery rate," Sachs adds.
Although vaginal deliveries are associated with better birth outcomes and lower costs, the authors strongly contend that such results apply only to safe vaginal deliveries. They believe that two of the proposed strategies for lowering the rate outlined in the Healthy People 2000 Project may carry increased risks of harm to mothers and newborns, as well as increased costs. Those two strategies call for increasing vaginal deliveries in women with previous cesarean sections and increasing vaginal deliveries assisted by vacuum extractors or forceps.
While vaginal delivery after previous cesarean delivery and vacuum-assisted deliveries are relatively safe, all medical procedures are associated with risk, the authors say. As the numbers of vaginal delivery after cesarean and vacuum-assisted deliveries increase, so will the number of reported complications. "These need to be weighed against the risks of cesarean delivery," says co-author Dr. Fredric Frigoletto, chief of obstetrics at Massachusetts General Hospital.
The authors cite data showing an increase in the number of women that rupture their uteruses in labor, which they believe is associated with an increase in the number of trials of labor after prior cesarean and an expansion in the indications for women undergoing a trial of labor.
In the US, the vacuum instrument is replacing forceps for assisting vaginal deliveries. Performed correctly, it is a safe method and is also much easier to use than forceps. The authors believe, however, that the rise in numbers of vacuum-assisted deliveries -- because of the instrument's ease of use and because of expanded indications for its use -- has caused increased injuries to infants.
According to the authors, insurance companies are trying to reduce the cesarean delivery rate because they assume that a lower rate is safer and cheaper. Under managed care, obstetricians who have cesarean section rates perceived to be too high may find that their patients are directed to other obstetricians. As a result, doctors are pressured to expand the indications for vacuum-assisted deliveries and trials of labor for women with a history of prior cesarean. While the authors believe that "section rates above the current national rate of 22 percent are probably too high," they also say, "We believe that the current approach results in increased complications for mothers and children and is more costly."
There are a number of medical conditions that require a cesarean delivery. The authors suggest one alternative would be to set rates for each indication, based on risks, rather than shooting for one raw number. "A cesarean section is a procedure. We should focus more on improving our ability to diagnose these conditions (the diagnostics) before we operate," says Frigoletto. Indications for cesarean deliveries include previous cesarean (35%), failure to progress in labor (cephalo-pelvic disproportion 30%), fetal distress (9%), and breech presentation (12%).
The doctors also suggest focusing on lowering the primary cesarean delivery rate rather than on pushing for vaginal deliveries in women who have had previous cesarean sections. They strongly recommend against trials of labor for women who have had prior cesarean delivery unless the hospital where they are delivering has the resources readily available to perform an emergency cesarean delivery.
Finally, the authors suggest that careful monitoring systems need to be in place if we are to further reduce the cesarean section rate.
"We should take pride in the incredible childbirth safety record that we have in this country," says Sachs, who describes it as one of the best in the world. "Childbirth has become very safe for both mothers and babies, and the option of cesarean delivery has no doubt contributed to that safety. So we need to address this issue with great care."
Both Beth Israel Deaconess Medical Center and Massachusetts General Hospital are major clinical, research and teaching affiliates of Harvard Medical School.
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