Elective C-Sections Stir Up Controversy

OB/GYN News, Oct 1, 2000 by Greg Borzo

Some experts attribute the recent rise in the cesarean rate to a decrease in the frequency of vaginal birth after cesarean section, but others say more women are choosing cesarean delivery even when it is not medically indicated.

The cesarean rate rose in 1999 for the third year in a row to 22%, after falling continuously for nearly 10 years. (See box on next page.) This reversal shines a spotlight on the increasingly open discussion of C-sections on demand.

Dr. Brent W. Bost created a stir at the American College of Obstetricians and Gynecologists annual meeting earlier this year by recommending elective C-sections for women with a fetus weighing more than 4,000 g, which includes about 13% of all pregnant women.

ACOG president Dr. W. Benson Harer Jr. has suggested that the deciding factor for a C-section should be the mother's preference. If the morbidity and cost of correcting the difficulties often associated with vaginal birth--sexual dysfunction, pelvic organ prolapse, and urinary or fecal incontinence-are considered, "the perceived advantage of vaginal birth is diminished or even eliminated," he Wrote in an AGOG Clinical Review article last spring (5[2]:1-16, 2000).

Other physicians, however, insist that C-sections should be limited to cases of medical necessity. "Patients are being hoodwinked into choosing cesareans by overblown fears of incontinence and other risks associated with trial by labor," said Dr. Robert K. DeMott, chief of staff at Bellin Memorial Hospital, Green Bay, Wis.

For Dr. DeMott, the bottom line is that more women die undergoing cesareans than giving birth vaginally. While that number is hard to pin down, "Evaluation of Cesarean Delivery" a new AGOG report, says the maternal mortality rate for C-sections is three to seven times higher than for vaginal delivery This estimate covers both scheduled and emergent Csections. Nevertheless, Dr. DeMott maintains that since there are relatively few truly emergent cesareans, a scheduled, elective C-section is far riskier than a vaginal birth.

"Putting it bluntly," he said, "it's unethical to recommend a practice that leads to more patient deaths."

By performing elective cesarean sections, physicians are giving in to consumer demand as they have done with other things, such as antibiotics, fetal ultrasound, and elective scheduling of induction, he added.

Dr. Bost, who practices in Beaumont, Tex., does not agree that the death rate is significantly higher for C-section than it is for vaginal delivery although he admits to a dearth of data on the subject. But, he added, a comprehensive look at the issue would have to include deaths from hysterectomies, bladder suspensions, prolapse of the uterus, and other procedures that can result from vaginal delivery.

The real problem is that ob.gyn. is divided between those who practice maternal-fetal medicine and those who practice urogynecology, he said. "One side wants happy moms and happy babies and takes a short-term view The other side treats women who suffer from long-term effects of vaginal deliveries."

The interest in elective C-sections comes on the heals of a major push to lower the cesarean rate. In the 1980s, medical and patient advocacy groups began to criticize the relatively high level of cesareans, which peaked at 24.7% in 1989. The following year, the U.S. Department of Health and Human Services Healthy People 2000 report called for reducing that rate to 15%. That seemed possible as the cesarean rate fell to 20.7% in 1996, but then the rate reversed course.

Much of the decline in cesareans from 1988 to 1996 has been attributed to the increased frequency of vaginal birth after cesarean (VBAC), which rose from 12.6% in 1988 to a high of 28.3% in 1996. Since then, however, there have been questions about VBAC, and growth of this practice reversed course, too.

"As we did more, catastrophes occurred and concern about uterine rupture increased," said Dr. Roger K. Freeman, chair of the AGOG task force that produced "Evaluation of Cesarean Delivery" "Now physicians are less willing to do them."

Still, the report urges that more VBACs he attempted to lower the C-section rate. Two types of patients account for two-thirds of all U.S. cesareans: nulliparous women delivering a single fetus in the vertex position at 37 weeks of gestation or higher without other complications and women with one prior low-transverse cesarean, delivering a single fetus at 37 weeks of gestation or higher without other complications.

These two types of patients also account for the most dramatic variations in cesarean rates by region, group model, type and volume of hospital, source of payment, and physician coverage. The report recommends that providers compare their rates to benchmarks of 15.5% for first-time cesareans and 37% for repeat cesareans. "If they are off the mark, they should review how they practice," said Dr. Freeman, who practices in Long Beach, Calif.

The report concludes that although current research on pelvic floor injury from vaginal delivery does not offer sufficient evidence to mandate a change in standard clinical management of labor and birth, patients at high risk of incontinence and genital prolapse after vaginal delivery should be offered an elective C-section.