Health : Hospital Plan Reduces Use of Cesareans

Reforms that could be put into place easily at almost any American hospital could halve the number of Cesarean section deliveries nationwide, two Chicago doctors report today.

The new protocol, developed at Chicago’s Mt. Sinai Hospital, is similar to an effort made to reduce the number of Cesareans at Kaiser Foundation hospitals in Southern California.

Both programs were prompted by a growing concern that too many surgical births occur in the United States and that the frequency of Cesarean deliveries has increased in the last 15 years despite intense efforts to control it.

The Chicago program, relying on tough hospital controls on physician behavior, could reduce by up to 450,000 the number of U.S. Cesarean births--a figure that would more than halve the 906,000 performed nationwide in 1986, the plan’s developers say. Nationally, Cesareans were performed in more than 24% of all deliveries.

Cesarean deliveries have been the subject of growing criticism because unnecessary use of the procedure subjects women and their babies to needless risks of major surgery. The procedure also has proven controversial because physicians have come to rely on it largely to protect against malpractice suits.

Increasing Proportion

Despite intense pressure to reduce the frequency of Cesareans, the proportion of such surgical deliveries has kept increasing. (It was 15.2% as recently as 1978.)

The situation has become such a concern that the nation’s largest obstetricians’ group, the American College of Obstetricians and Gynecologists, in late October called for a major effort to persuade women who have undergone Cesareans to deliver vaginally in subsequent births.

The latest Cesarean study, published today in the New England Journal of Medicine, is by Drs. Norbert Gleicher and Stephen Myers. Gleicher has long been a prominent advocate for reducing the number of C-sections.

“I think one very crucial point in our philosophy is that C-section is surgery,” he said, adding, “Vaginal delivery is the normal way babies should be delivered. It has been a major error in our profession that we automatically assume that C-section improves outcome. We have made our profession a victim of that philosophy.”

At Mt. Sinai, according to Gleicher, the percentage of C-sections declined from 17.5% in 1985 to 11.5% last year. The trend, he said, continued in 1988 and he hopes to reduce the percentage to 10% by year’s end and maintain it there.

The numbers fell after the hospital adopted a tough physician monitoring program, accepted after intense negotiations by the hospital’s full-time medical staff and the more numerous private physicians who admit patients to Mt. Sinai and other nearby institutions, Gleicher said.

Informal review found no change in the hospital’s lawsuit incidence as a result of the program, Gleicher said. But he cautioned that obstetrics malpractice cases often develop years after a delivery.

Program Outline

The Mt. Sinai rules apply equally to all doctors who admit obstetrics patients and specify that:

- Except in emergencies, a Cesarean patient must be evaluated by a second physician, who cannot be a practice associate of the patient’s primary doctor. Patients may not be charged for the second opinion and a report must appear in the official medical record.

- Any woman who has undergone a Cesarean must be allowed to try vaginal delivery. By the study’s second year, Gleicher said, 86% agreed to normal delivery. Labor was allowed in previous C-section patients, even those with old-style uterine incisions, which must be managed with great care. Despite the policy change, Gleicher and Myers reported only one maternal death in more than 6,200 deliveries; the woman in that case died of liver failure and acute infection.

- Fetuses in a breech presentation (in which a baby will be born other than head first) initially should undergo vaginal delivery, defying an unwritten, inflexible obstetric rule. “This is yet another holy cow, which, in our judgment, has corrupted obstetrical practice without any scientific evidence that doing Cesarean sections improves outcome,” Gleicher said.

In Anaheim, Dr. Bruce Flamm of the Kaiser Permanente Medical Center said doctors have prevented 60% of breech deliveries by non-invasive techniques--changing the fetus’ position from outside the mother’s body in her pregnancy’s final weeks. This technique, external version , has been tested successfully in 10 Southern California facilities and now is being introduced in Kaiser hospitals statewide, Flamm said.

- A diagnosis of failure to progress in labor--a common justification for a Cesarean--can be made only after a woman has made no progress for at least two hours, during which normal labor contractions have continued. The Chicago protocol permits liberal use of oxytocin, a drug that often can be effective in speeding up labor.

- A finding that a baby is in fetal distress--another common Cesarean justification--can be made only if the child’s heart rate and blood chemistry confirm the condition’s existence.

- All doctors using the hospital must participate in a peer review program, in which their individual C-section practices are monitored with a special computer program. Flamm said a similar Kaiser program enhanced attempts there to reduce the number of C-sections. “When the doctors know that every single C-section they do is going to be reviewed by their colleagues, it is very hard to be an out-lier,” Flamm said.

In the study to be published today, Gleicher and Myers concluded that since the new policy took effect, there were no significant differences between babies born vaginally and those delivered by Cesarean.

In the first one to 10 minutes after birth, there were slight differences in scores in one of two measures used to evaluate deliveries. But those differences, with Cesareans scoring higher than vaginal deliveries, may be tied to subtle scoring procedure changes made in the study period, Gleicher said.

He noted of the program: “This can be done at any hospital. That’s exactly the point. I think the most interesting part about our initiative is not that it was successful. The most interesting part is that the basic components are so simple. It just takes a bit of organization.”