Caesarean Birthrate Still Climbing, Report Says

Confounding all attempts to halt it, the nation’s Caesarean section birthrate is increasing--driven, doctors contend, by a fear of malpractice suits, but linked by critics to greed on the part of some physicians.

Between 1979 and 1984, figures to be released today by the American College of Obstetricians and Gynecologists and a federal agency show, the Caesarean rate increased from 14.1% of all births to 19%. This rise occurred even though a U.S. government task force called for major reform eight years ago.

And in step with the uninterrupted surge in Caesareans, the proportion of women who have had an initial Caesarean delivery but deliver subsequent babies vaginally has gone from 2.1% to 8% over the same period--but far less than what doctors had hoped.

Service Not Always Offered

While many large hospitals now attempt vaginal delivery in the cases of more than a quarter of women who had earlier Caesareans, 54% of all hospitals don’t offer the service. Attempts at normal labor and delivery after a Caesarean succeed in producing a normal delivery without surgical intervention more than half the time, the new report says.

One of the researchers said the increase in vaginal birth attempts was only a modest one since the proportion of non-Caesarean births after an initial section could potentially be far greater.

The findings of the report, published today in the Journal of the American Medical Assn., were quickly characterized by national medical experts as “depressing” and “disappointing.” Attempts to stem the increase in Caesareans have largely failed, these experts agree.

(In 1979, a federal task force estimated the national Caesarean rate had increased from 5.5% in 1970 to 15.2% in 1978--slightly higher than the newly published estimate for 1979--and called the 1978 results an example of medical excess.)

The new data appear to vindicate a leading critic of Caesarean practice who warned of a continuing surge in rates three years ago but was criticized by other doctors at the time as judging his colleagues prematurely.

The new Caesarean data was gathered by analysts at the American College of Obstetricians and Gynecologists and the government’s National Institute of Child Health and Human Development. The figures are based on a survey of delivery practices at 538 hospitals nationwide.

Caesarean rates were high in all areas of the country, with the South highest at 20.4% of all births, followed by the Northeast (20.2%), the West (18.9%) and the North-Central states (17.1%). In California, Caesareans account for 31% of all births, according to the Blue Shield health insurance plan.

Caesarean rates were highest--20.6%--among hospitals delivering 5,000 or more babies a year and lowest--18.5%--among health centers with 500 or fewer, but analysts noted that large hospitals often attempt the most difficult cases.

Small hospitals virtually never offered attempts at a vaginal delivery after an initial Caesarean in 1979, and did so in only 1.8% of potential cases in 1984. Large hospitals went up from 9.9% in 1979 to 25.4% in 1984. Larger hospitals had the greatest success rates in such cases--with women attempting vaginal birth after a Caesarean giving birth normally 62.8% of the time.

Requests for Caesareans

A majority of patients asked for Caesarean birth in 16.4% of the hospitals and 32.7% of the hospitals said a majority of the patients requested a trial of labor after an earlier Caesarean.

Hospital records said Caesarean births were undertaken because of indications of fetal distress in 21% of all cases, compared to 14% in 1979. But Dr. Warren Pearse, president of the American College of Obstetricians and Gynecologists, questioned whether the figures mean the number of babies with serious problems truly increased.

Instead, Pearse said, doctors may report fetal distress as a diagnosis more frequently to justify the Caesarean--while at the same time avoiding listing the diagnosis when a baby is delivered vaginally because physicians fear being sued if the vaginally delivered child subsequently develops such complications as learning disabilities.

“What it means is that if you (a doctor) make a judgment call and do a Caesarean, you write down fetal distress, but if you deliver vaginally, you don’t dare put that in the chart,” Pearse said.

The Malpractice Factor

Malpractice concerns have long been presumed to be at the heart of recent increases in Caesarean rates as doctors move to avert suits charging a physician failed to do a Caesarean when one was appropriate. Experts agree no comprehensive data have been developed to confirm this widely held belief, but physicians unquestionably believe malpractice risks to be real, Pearse and other doctors said.

Pearse said there is no agreement on what an acceptable Caesarean rate would be--only that what exists is far too high. Some radical observers have suggested that only 5% to 7% of births would be surgical if the only considerations were patient safety and medical need.

“These new findings are not a surprise to us,” Pearse said. “I think we can’t at this point identify what an optimal rate would be, but it is certainly lower than what exists. If you asked, ‘Has what has been done (already) stemmed the increase in Caesareans?’ the answer, of course, is ‘No.’ ”

In all, the new report concluded there is “no evidence that the Caesarean delivery rates are leveling off or decreasing” and that attempts to persuade physicians to cut down on unnecessary Caesareans “have not been sufficient to stem the rising . . . rates.” The report suggested that such steps as mandatory second opinions before a Caesarean can be done may be necessary to bring the situation under control.

The new figures coincided almost entirely with observations made in 1984 by Dr. Norbert Gleicher of Chicago’s Mount Sinai Medical Center and Rush Medical College, who is a leading critic of Caesarean practice. Gleicher suggested that because Caesarean delivery fees are higher than those for vaginal birth, doctors may gravitate to surgical delivery out of greed. His statistics and contentions were attacked widely at the time because, critics contended, Gleicher had not waited long enough for reforms called for in 1979 to be implemented.

One of the first to question Gleicher’s original criticisms was Dr. Mortimer Rosen, head of the department of obstetrics and gynecology at New York’s Columbia University College of Physicians and Surgeons. But in a telephone interview earlier this week, Rosen, who chaired the federal government’s 1979 task force, said the new figures, in which he said he was “disappointed,” clearly “confirm Dr. Gleicher’s earlier suggestions.

“Unfortunately, the (Caesarean) birthrate continues to go up about a percent a year. The major causes are the repeat Caesarean and the rising incidence of fetal distress. But it is hard to believe there is an increased number of (actually) sick babies.

“This is not a physician problem alone. It is a patient problem and a societal problem. Society expects us to deliver perfect babies and we don’t have the answer to the perfect baby, but it is demanded. It (the increase in rates) is the patient’s fault as much as it’s the physician’s fault. (But) physicians must practice medicine.

“I couldn’t help but be disappointed that change hasn’t occurred. I’m more disappointed in the (implied) application of poor patient care practices.”

Dr. Robert Cefalo, director of the maternal-fetal medicine program at the University of North Carolina School of Medicine in Chapel Hill, questioned whether findings of the new survey were accurate--saying hospitals may have underreported the rate of vaginal births after Caesareans. But Cefalo, who served on the 1979 task force and has consistently said increases in Caesarean rates may be overstated, conceded there is a problem.

“There is no question what it is now,” he said. “The problem is directly proportional to the increase in (malpractice litigation). In 1979 and 1980 (when the initial study was done) this was not a problem. In 1986 and 1987, it is.”

Delivery Fees

Other critics have suggested the higher fees common for surgical delivery attract physicians and that some obstetricians do Caesareans for their own convenience to avoid devoting long periods to difficult vaginal deliveries. Such practices, critics contend, increase doctors’ incomes by permitting them to complete more deliveries in a given period.

Rosen warned that doctors may soon find the choice of how to resolve the problem taken out of their hands. Already, mandatory second-opinion programs have been put into place in some areas and insurance carriers have instituted controls. In California, the state Blue Shield plan is close to an announcement of a new Caesarean-control policy in which the difference in fees between vaginal and Caesarean delivery will be abolished and replaced by a new one that is somewhere between the state average of $1,600 for vaginal delivery and $2,000 for Caesarean.

“We had to reach a formula that would not increase (the total money spent on deliveries) but remove the incentive to do a Caesarean,” said Dr. Ralph Schaffarzick, Blue Shield’s San Francisco-based senior vice president and medical director. “Now we are at the point where we think we have the formula.”

In Chicago, Gleicher said his own hospital began a program in 1986 that features far more vigorous review of individual physicians’ Caesarean rates and a “stringent” second-opinion requirement. The program, he said, produced a 5% reduction in Caesareans at Mount Sinai in its first year.

Gleicher said he has no sense of personal victory in the wake of the new confirmation of his 1984 observations. “Dr. Rosen and I agreed something had to be done,” Gleicher said of the earlier conflict. “I felt we had to speak out (forcefully) in order to achieve progress. He felt quiet diplomacy would work.”

He emphasized that the question of vaginal birth after a Caesarean is also a major concern since childbirth experts have been trying for more than 10 years to do away with the dictum, “Once a Caesarean, always a Caesarean.” In recent years, changes in surgical technique have made it often possible for a woman to give birth normally after she has had one Caesarean--or more.

Rosen said vaginal birth is preferred if it can be safely accomplished because it carries none of the risks of surgical delivery. “It’s inconceivable how someone could consider an operation that loses two to three times the amount of blood comparable to vaginal delivery,” Rosen said. “I wouldn’t let anyone do that to me (if I didn’t need it), yet, in obstetrics, that’s what’s happening.

“The far more morbid (dangerous) procedure shows no benefit to mother or fetus, yet everyone is still doing it.”

Birth Practices by Region

Percent of attempted vaginal deliveries Percent of subsequent to Region of Cesarean Cesaerean country deliveries deliveries. Northeast 20.2 9.5 South 20.4 3.9 North Central 17.1 9.5 West 18.9 9.9

RATES OF CESAREAN DELIVERIES AND SUBSEQUENT VAGINAL DELIVERIES

Trends in Birth Practices

Hospitals’ annual Percent of Percent of vag no. of deliveries Caesarean deliveries subsequent to Ca 1979 1984 1979 less than 500 12.3 18.5 n/a 500-599 14.6 19.3 1.1 1,000-1,999 16.0 20.3 0.9 2,000-4,999 16.0 20.4 2.3 more than 5,000 17.1 20.6 5.3 Total percent 14.1 19.0 1.3

Hospitals’ annualinal deliveries no. of deliveriesesarean deliveries 1984 less than 500 2.4 500-599 4.1 1,000-1,999 9.0 2,000-4,999 13.1 more than 5,000 16.4 Total percent 4.8

Information from the National Institute of Child Health and Human Development and the American College of Obstetricians and Gynecologists.

*Not available

Caesarean birthrates rose in hospitals of all sizes between 1979 and 1984, above, along with vaginal births after Caesareans. Regional trends in such rates, right, were similar.