Affluent Women Twice as Likely as Poor to Have Cesarean Births
Affluent women are nearly twice as likely to have their babies delivered by Cesarean section than are poor women, a study of 245,854 births in Los Angeles County has found.
Women whose median household income was greater than $30,000 had a 22.9% rate of first-time Cesarean sections, compared to 13.2% among women whose household income was less than $11,000, the study reported today in the New England Journal of Medicine. Overall, the rate was 17.8%.
The discrepancy in part reflects doctors’ fears that affluent patients will sue them if there are problems involving vaginal deliveries, according to one of the UC Berkeley researchers who conducted the study. “I think that physicians are under tremendous pressure from very articulate patients and also from the threat of litigation,” said Dr. Jeffrey B. Gould, professor and chairman of maternal and child health at UC Berkeley’s School of Public Health.
The disparity held up even when the researchers took into account age, ethnicity, race, previous pregnancies, the baby’s birth weight and whether there were complications reported during labor. Indeed, a third of the Cesarean births occurred in women whose doctors reported no complications at all, the study found.
The report represents another indicator of what has been a widely acknowledged problem in recent years, unnecessary Cesarean sections in the United States. The rate skyrocketed from 5.5% in 1970 to 24.1% by 1986. In California, it was 24.5% in 1986.
Ralph Nader’s Public Citizen Health Research Group, which has studied the issue in depth, estimates an optimal Cesarean rate at 12%.
The latest study was done to try to shed light on “this topsy-turvy result of affluent women who are supposed to be more healthy requiring more in the way of medical intervention,” Gould said.
Not Specific on Reasons
Gould and co-authors Becky Davey and Randall S. Stafford were not specific in their report about possible reasons for the socioeconomic differences in Cesarean rates. In an interview, however, Gould suggested that the primary reasons are doctors’ fear of malpractice suits and delayed childbearing by “yuppie” patients who are more inclined to sue if a birth goes wrong.
Although Cesarean operations increase the chance of infection and death in the mother, in some situations they reduce the chance of damage to the baby during birth.
“The norm among affluent women is to have as good a baby as possible, not to take any risks. You wait this long to have a baby, you want the best possible outcome,” Gould said.
In addition, poor patients are more likely to deliver at a teaching hospital or at a hospital with few resources, he said. Both are environments with positive reinforcement for avoiding unnecessary surgeries.
A Times analysis last year found that 41 hospitals in California had Cesarean rates higher than 30%, with these high rates more likely at hospitals serving affluent patients. The lowest rates were at teaching hospitals, which often employ second opinions, and in health maintenance organization hospitals. For example, County-USC Medical Center had a 13.6% rate in 1986 and Kaiser Foundation hospitals had rates ranging from 14% to 24%.
Dr. Sidney M. Wolfe of the Public Interest Health Research Group said he lays more blame on the fact that, except in a situation such as Kaiser’s, Cesareans make more money for both physicians and hospitals.
Wolfe said he has confidence in the Gould study’s results, but said he wishes the researchers had used other available data to point out specific reasons for the socioeconomic differences in Cesarean rates and to recommend remedial action.
Gould does have advice for women who want to avoid unnecessary Cesarean sections: “You should go deliver at a facility, or engage an obstetrician, who requires a second opinion prior to a Cesarean section; where there is a very clearly defined set of criteria for those circumstances that require a Cesarean section, and where every case is reviewed by a panel of nurses and physicians.”
These measures have been shown to reduce a hospital’s excess Cesarean rate, he and Wolfe agreed.
CESAREAN RATES
Rates of primary Cesarean section among women 18-34 years old in Los Angeles County from 1982-83 according to race or ethnicity and median family income: ALL INCOMES
RACE OR ETHNIC GROUP No. of women Rate* Anglo 79,692 20.6 Asian 17,104 19.2 Black 31,564 18.9 Latino 86,428 13.9
* Per 100 deliveries
MEDIAN FAMILY INCOME
Less than $11,000 More than $30,000 RACE OR ETHNIC GROUP No. of women Rate* No. of women Rate* Anglo 756 17.9 10,200 23.4 Asian 739 16.5 1,663 20.9 Black 7,257 16.3 433 25.6 Latino 9,811 9.6 1,528 16.7
* Per 100 deliveries
