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Half the Cesarean Operations in U.S. Called Unnecessary

Times Medical Writer

About half the Cesarean section surgeries in the United States in 1987 should not have been performed, according to a new report designed to focus attention on what it terms “an onslaught of unnecessary and dangerous surgery.”

The strongly worded report released today by the Washington-based Public Citizen Health Research Group is likely to fuel the national debate over when the surgeries should be performed. The report’s authors said it was the most extensive compilation of Cesarean statistics “ever compiled.”

The report by the consumer advocate group includes Cesarean rates for about 2,400 hospitals in 30 states, including 1986 statistics for California hospitals, and statewide figures for an additional 11 states. Cesarean rates varied from a high of 30.3% in the District of Columbia to a low of 17.9% in Alabama. In California, the rate for 1986 was 24.5%.

‘Extraordinary Variations’

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The report’s list of 106 hospitals with the highest Cesarean rates--35% and higher--included 22 California hospitals, 18 Florida hospitals and eight New York hospitals.

Cesarean section rates show “extraordinary variations between states and between hospitals within states,” according to Dr. Sidney M. Wolfe, director of the Health Research Group and one of the authors of study. “The national rate is twice as high as it should be.”

The Cesarean rate nationally--the percentage of all deliveries performed by Cesarean section--has increased steadily over the last two decades--from 5.5% in 1970 to 24.4% in 1987. Cesareans are now the most common major operation in the United States.

The study said the 475,000 “unnecessary” Cesareans performed in 1987 resulted in 25,000 serious infections, 1.1 million extra hospital days and a cost of more than $1 billion. These conclusions were based on an analysis of data obtained from 41 states, a review of studies published in medical journals and other publicly available data.

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Cesareans are considered necessary in certain instances to safeguard the mother’s or baby’s health, such as when the fetus has an abnormal heartbeat or when there is a clear inability to deliver the baby through the vagina. But there is disagreement over how to apply these criteria in individual cases.

The major piece of “good news,” according to Wolfe, are tentative indications that the national Cesarean rate may have reached a plateau. Between 1986 and 1987, the increase was only 0.3%, and preliminary 1988 data for some states, such as Arizona, Maryland and Washington, show a decreased rate, according to the report. “I am reasonably optimistic, although there is a long way to go,” Wolfe said.

But the report said voluntary efforts by physicians to control their “own excesses have had no effect whatsoever” on the number of Cesareans and calls upon women, hospital administrators, state legislators and insurance providers “to fill the leadership vacuum.”

The report was sharply criticized by a spokesman for the Washington-based American College of Obstetrics and Gynecology, whose members include most practicing obstetricians.

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The spokesman, Dr. Harold Kaminetzky, said there is little information “one way or the other . . . to confirm a proper Cesarean rate.” He also said the report did not adequately account for “the extraordinarily difficult” medical malpractice environment for obstetricians, many of whom fear they will be sued anytime a baby has a bad outcome and a Cesarean was not performed.

Report Criticized

The Health Research Group is “making the presumption that there is an excess (of Cesareans),” Kaminetzky said. “That argument is specious. There is no proof there is an excess. (Wolfe) simply says that there is an excess.”

Last October, the American College of Obstetrics and Gynecology called upon its members to perform more vaginal deliveries for women who have had Cesarean births, although it did not set specific numerical guidelines. According to the Health Research Group, repeat Cesareans account for about one-third of all such operations and about half of the “unnecessary” Cesareans. At present, only about 10% of women with a previous Cesarean have vaginal deliveries.

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According to the report, Hialeah Hospital in Florida’s Dade County had the highest Cesarean rate, 53.1%, based on 2,239 births. Three other Florida hospitals had rates greater than 45%. Some Florida obstetricians have been particularly outspoken about the effects of medical malpractice claims on their practices.

Southern California hospitals with high Cesarean rates included AMI Tarzana Regional Medical Center; Huntington Memorial Hospital, Pasadena; Northridge Hospital Medical Center and Scripps Memorial Hospital, La Jolla. The rates for these hospitals were between 36% and 39%.

Malpractice Concerns

The Times published the Cesarean rates for 140 Southern California hospitals with more than 400 deliveries on Aug. 21, 1988, as part of an analysis by the newspaper of similar statewide data. At the time, many physicians acknowledged that the rates at their hospitals were too high, but they said substantial decreases were unrealistic. This was primarily because of concerns over malpractice suits and what the physicians said were the preferences of many women for Cesarean deliveries.

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The Health Research Group said that Cesarean rates of 10% to 12% would be appropriate for “average” hospitals and that rates up to 17% would be appropriate for referral hospitals with neonatal intensive care units, that treat more complicated cases. Leading obstetricians contacted by The Times have said the desirable range is somewhat higher, between 15% and 20%.

The report specifically pointed out that the Kaiser Permanente hospitals in California had an average Cesarean rate in 1986 of 19.4%, compared to the statewide average rate of 24.5%. It called this rate “still too high, but markedly better than other hospitals.” Kaiser Foundation Hospital Anaheim, a hospital with an intermediate level neonatal intensive care unit, was praised for its particularly low rates--14.6% in 1986 and 13.8% in 1988.

In addition to fear of malpractice suits, inadequate attempts by physicians at vaginal deliveries and financial incentives that favor surgical deliveries contribute to the escalating Cesarean rate, the report said.

Among the suggested remedies are hospital policies to encourage vaginal births after Cesareans, legislation to require disclosure to maternity patients of Cesarean section statistics for individual doctors and hospitals, wider use of second opinions before non-emergency Cesareans are performed and changes in insurance reimbursement policies to eliminate incentives favoring surgical deliveries.

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CESAREAN SECTIONS: THE U.S. AND CALIFORNIA

These are recent Cesarean section statistics for the United States and California, as compiled by the Washington-based Public Citizen Health Research Group. The Health Research Group contends that about 50% of the Cesareans performed in the United States are unnecessary.

TOTAL CESAREAN TOTAL UNNECESSARY BIRTHS RATE CESAREANS CESAREANS United States: 1987 3,829,000 24.4% 934,000 475,000 1986 3,757,000 24.1% 905,000 455,000 California: 1986 461,000 24.5% 113,000 58,000

Between 1980 and 1987 the national Cesarean section rate increased by about 50%--from 16.5% of deliveries to 24.4% of deliveries. Four situations account for most of this increase: repeat Cesarean sections, difficult or abnormally progressing labor known as “dystocia,” fetal distress, and the positioning of the baby to come out with buttocks or feet first rather than head first, known as “breech.” According to Public Citizen, a policy of encouraging vaginal births after Cesarean sections, more appropriate diagnosis of fetal distress and dystocia, and increased use of a technique to manually turn babies from the breech position to the head-first position could help lower the national Cesarean rate toward the 1980 level.

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TOTAL UNNECESSARY Cesarean deliveries in 1987 934,000 475,000 Repeat Cesareans 330,000 237,000 Fetal distress and dystocia 355,000 142,000 Cesareans for “breech” position 90,000 65,000

Numbers have been rounded to the nearest thousand


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