The National Center for Health Statistics released a new report Monday, Recent Trends in Cesarean Delivery in the United States. The report is most notable for a startling statistic: The C-section rate has reached the astronomical level of 32 percent, an increase of more than 50 percent since 1996. This is disturbing news.
As the authors explain:
Although there are often clear clinical indications for a cesarean delivery, the short- and long-term benefits and risks for both mother and infant have been the subject of intense debate for over 25 years. Cesarean delivery involves major abdominal surgery, and is associated with higher rates of surgical complications and maternal rehospitalization, as well as with complications requiring neonatal intensive care unit admission . In addition to health and safety risks for mothers and newborns, hospital charges for a cesarean delivery are almost double those for a vaginal delivery, imposing significant costs.
It’s not surprising news, though, since it is merely a continuation of a worrisome trend. As the graph demonstrates:
Why is the C-section rating sky high? The pervasive nature of the increase may hold some clues. The increase has been remarkably consistent across all possible variables. The C-section rate increased among all races. It increased in all maternal age groups. It increased at every gestational age, and it increased in all 50 states. The global nature of the increase suggests that it is due to a global factor, rather than the increase in a particular diagnosis a dramatic change in specific risk factors. Like many obstetricians, I suspect that the rising C-section rate is driven by liability concerns.
It’s true that there is no correlation between numbers of lawsuits and the C-section rate. In addition, there is no correlation between the size of monetary awards and the C-section rate. There is a correlation between malpractice premiums and the C-section rate, but the association is not dramatic. So how could the C-section rate be tied to liability concerns?
The assumption behind searching for a correlation between C-section rate and malpractice lawsuits or monetary awards is that as the rate or payout of lawsuits rises, obstetricians will be reminded that they are at risk of being sued. However, if every obstetrician expects to be sued, the increasing rate of suits or payouts will be irrelevant. At this point, every obstetrician expects to be sued at least once in a professional lifetime.
According to Victoria Green, MD, JD author of the chapter “Liability in Obstetrics and Gynecology” in the textbook “Legal Medicine”:
Nearly 77% of obstetrician/gynecologists have been sued at least once in their career and almost half have been sued three or more times. Moreover, virtually one-third of residents will be sued during their residency. Fear of malpractice, in general, may cause physicians to order more tests than medically necessary, refer patients to specialists, and suggest invasive procedures to confirm diagnoses more often than needed. Nearly 40% may prescribe more medications than medically necessary due to concerns of legal liability. The public has responded by escalating the “punishment” associated with malpractice claims where multimillion-dollar jury awards are commonplace.
When obstetricians expect to be sued, it no longer matters how many other suits are filed, how high the monetary judgments are, or even whether malpractice premiums are rising. The only consideration when a lawsuit is inevitable is how to successfully defend oneself.
Consider the most common reasons for an obstetrics lawsuit. The paper “Liability in High Risk Obstetrics” explains the most common causes. Although the paper concentrates on high risk obstetrics (perinatology), the results appear to be generalizable to obstetrics as a whole. According to the paper’s author James L. Schwayder, MD, JD, obstetric lawsuits center on errors of omission or commission. The most common alleged errors are:
1. Errors or omission in antenatal screening and diagnosis
2. Errors in ultrasound diagnosis
3. The neurologically impaired infant
4. Neonatal encephalopathy
5. Stillborn or neonatal death
6. Shoulder dystocia, with either brachial plexus injury or hypoxic injury
7. Vaginal birth after cesarean section
8. Operative vaginal delivery
9. Training programs (Resident supervision markedly impacts litigation exposure. Increased used of nurse midwives and nurse practitioners may increase ones liability exposure.)
Of the 9 most common reasons for obstetric malpractice suits, 6 (#3-#8) allege failure to perform a C-section or failure to perform a C-section sooner. In other words, performing a C-section when there is any doubt about the baby’s health, or even before there is any doubt, will virtually eliminate the chance of being sued successfully in connection with the delivery; it might even make a lawsuit less likely if the plaintiff cannot argue that a C-section should have been performed.
Most of these potential complications are equally distributed across maternal age, maternal race, gestational age, and state of residence, leading to a rising C-section rate across all demographics. The skyrocketing rate is being driven by an attempt to defend or potentially avoid lawsuits, since the majority of lawsuits allege failure to perform a C-section or to perform a C-section sooner. An ever increasing C-section rate is the inevitable result.
The C-section rate is skyrocketing primarily for non-medical reasons. While doctors blame the tort system as the proximate cause, the fundamental cause rests with patients, not lawyers or insurance companies. The fundamental cause is an inability to tolerate any risk to a newborn. In the current legal climate, there is no possible justification for not doing a C-section, regardless of how tiny the risk posed by vaginal delivery may be. Unless and until people stop penalizing doctors for not doing C-sections, they will continue to do them in ever increasing numbers. They really have no choice. You cannot say to obstetricians, “Give me a perfect baby or I will sue you for failure to perform a C-section” and then express shock and dismay that obstetricians will perform C-sections in order to guarantee that you will have a perfect baby.
The sky high C-section rate is the all too predictable result of parental expectations. As long as parents continue to sue for failure to perform a C-section, the C-section rate will continue to rise.
In breathless language, Amnesty International urges the US to confront its “shocking maternal mortality rate.” Entitled Deadly Delivery: The Maternal Healthcare Crisis in the USA, the report observes:
The total amount spent on health care in the USA is greater than in any other country in the world … Despite this, women in the USA have a greater lifetime risk of dying of pregnancy-related complications than women in 40 other countries … Amnesty International is sure that this increase is due to lack of access to medical care. The US government’s failure to ensure that women have guaranteed lifelong access to quality health care, including reproductive health services, has a significant impact on the likelihood of having a healthy pregnancy and delivery.
Natural childbirth advocates, meanwhile, are sure that the rising rate of C-sections and other interventions is contributing to the rising maternal mortality rate. Amnesty International agrees, citing a “lack of information and autonomy” as the cause.
The report has made for frightening headlines: “Too Many Women in US Dying While Having Babies,” reported Time, while CNN’s headline called it “scandalous.” However, it is not clear that maternal mortality is even rising, let alone rising because of decreased access to care or increases in the C-section rate. Review of the data suggests that changes in the way that maternal mortality is assessed may be leading to a spurious “increase” in maternal mortality. Moreover, a detailed analysis of the causes of maternal mortality casts serious doubt on either access or interventions as the reason for any rise. And while the statistics for African-American women truly are horrific (three and a half times the rate of white women) — this disparity has existed almost since the statistics were first recorded 80 years ago.
In the last two decades, awareness that maternal mortality is underreported has grown. Vigorous efforts have been made to correct that problem. The CDC report Maternal Mortality and Related Concepts (2007) explains these changes:
In 1999, the coding guidelines used in the United States were expanded … Along with the new definitions, the [new coding guidelines] introduced new details and categories in the cause-of-death titles associated with pregnancy, childbirth, and the puerperium … Furthermore, in 2003, the US Standard Certificate of Death was revised to ask explicitly whether any female death was associated with pregnancy, instead of relying on the person filling out the form to voluntarily provide that information.
The results of these changes are captured by the following graph.
The 1999 and 2003 changes in reporting of maternal mortality resulted in large “increases” that are not actual increases at all. They reflect the more accurate measurement of maternal mortality just as they were designed to do.
Yet some of the increase may be real. What about possible causes?
Curiously, the Amnesty International report provides no evidence that there has been a decrease in access to maternity services. Almost all states provide public health insurance for the duration of pregnancy in any woman who needs it. Indeed, 99+ percent of births take place in hospitals, so there is certainly no decrease in access to hospital care.
If decreased access to healthcare were responsible for an increase in maternal mortality, we would expect that the increase would be spread evenly among all possible causes of maternal mortality, but that’s not what we find. The following chart shows maternal death rates from pre-eclampsia/eclampsia, hemorrhage, embolism (the three most common causes of maternal death) as well as other direct causes (all other obstetric complications) and indirect causes (from other medical conditions).
The most common causes of maternal mortality remained flat. In contrast, the categories expanded in the new reporting guidelines contributed almost all of the observed increase. This suggests that the “increase” reflects more comprehensive reporting, not an actual increase in maternal mortality.
What about an association between the rising C-section rate and rising maternal mortality? A graph comparing the maternal mortality rate and the C-section rate certainly shows a correlation.
But correlation is not causation. If the rising C-section rate were leading to an increased maternal mortality rate, we would expect to see C-section complications, such as hemorrhage and embolism increasing disproportionately. But as we saw above, both hemorrhage and embolism death rates remained flat.
What can we conclude about the observed rise in maternal mortality? First, we can see that the 1999 coding revision and the 2003 birth certificate revision captured more maternal deaths, as they were designed to do. Together they account for 80 percent of the observed increase since 1998 (5/100,000 out of a total change of 6.2/100,000).
To the extent that there has been a real increase, is decreased access or the increased C-section rate the causes of this increase? That seems unlikely since the increase was not distributed evenly among all causes (as would be expected if decreased access were to blame) nor is the increase predominantly distributed among common C-section complications (if the increased C-section rate were to blame).
Despite the rhetoric of Amnesty International, it is unclear whether we are experiencing an increase in maternal mortality rate or a crisis of any kind.
Amy Tuteur is a retired OB/GYN who also blogs for Open Salon.
The NIH Consensus Conference on Vaginal Birth After Cesarean has just released its findings offering strong support for a far more liberal policy regarding vaginal birth after C-section (VBAC).
The NIH conference on VBAC was convened because doctors, patients, and policy makers believe that the current VBAC policy is misguided and potentially harmful. As the statement (PDF) explains:
Vaginal birth after cesarean (VBAC) describes vaginal delivery by a woman who has had a previous cesarean delivery… In 1980, a National Institutes of Health (NIH) Consensus Development Conference Panel questioned the necessity of routine repeat cesarean deliveries and outlined situations in which VBAC could be considered. The option for a woman with a previous cesarean delivery to attempt a trial of labor (TOL) was offered and exercised more often in the 1980s through 1996. Beginning in 1996, however, the number of VBACs has declined, contributing to the overall increase in cesarean delivery …
Although the number of women … faced with the question of whether to attempt TOL has markedly increased, there has been a concurrent, dramatic drop in VBAC. Yet cesarean and VBAC rates are identified as quality indicators for maternal health by policymakers, insurance providers, and health care quality monitoring groups. Success of TOL is consistently high (60 to 80 percent), whereas the risk of uterine rupture is low (less than 1 percent)…
In other words, in 1980, after reviewing the scientific literature, an NIH panel recommended offering a trial of labor to women who had had a previous C-section. As a result, VBAC became popular. Many women had successful vaginal deliveries. Only a very small proportion of women had serious complications, almost exactly what was predicted. Yet the VBAC rate peaked in 1997 and has declined precipitously since, as the following graph shows.
Open Salon/AmyTuteurMD
Decline in vaginal births after cesarean
Why did VBACs decline despite the fact that the benefits and risks were exactly as predicted? The answer can be summed up in one word: lawsuits. Although women offered VBAC were counseled about the small risk of uterine rupture (opening of the uterine scar during labor) and the attendant risk that the baby might die in the event of a rupture. Nonetheless, when a baby died after a uterine rupture, many mothers sued, and claimed that they had not “understood” the risks even though those risks were clearly explained. Juries were moved by these emotional appeals, and large judgments were paid out.
What did everyone learn from these lawsuits? Doctors learned that patients maintained that they could not “understand” risks no matter how carefully explained, patients learned that they did not have to take responsibility for their decisions, and lawyers learned that VBAC complications represented a bonanza.
The American College of Obstetricians (ACOG) stepped into the breach and, attempting to make things better, made them far worse. ACOG likes to remind its members that doctors have never lost a lawsuit in which they followed ACOG guidelines. Therefore, ACOG decided to promulgate guidelines that doctors could use in their legal defense. Unfortunately, the ACOG guidelines were so strict (unreasonably strict in the eyes of most obstetricians) that most obstetricians could not meet them. ACOG mandated that VBAC should only be attempted when both an anesthesiologist and obstetrician were present so that anyone who experienced a uterine rupture could be treated immediately. Most medium sized and small hospitals cannot afford to have an anesthesiologist in the hospital around the clock. Most obstetricians cannot afford to sit for hours while a patient labors. Therefore, many hospitals and anesthesiologists stopped offering VBAC.
Simply put, lawyers have sharply restricted the availability of VBAC.
The latest NIH panel reviewed the scientific literature and confirmed their earlier stance. VBAC should be offered to eligible women because the chance of success is high and the risk of complications is low. Furthermore, the conference report urged ACOG to re-evaluate their VBAC guidelines, presumably to eliminate the need for continuous presence of both anesthesiologist and obstetricians. In addition, the panel recommended that policy makers review the medico-legal strictures on VBAC, since liability concerns are driving the restriction of VBACs.
So doctors, patients and NIH are in agreement that VBAC should be offered to many more women. Too bad the lawyers don’t agree, since they seem to be in charge of making the decision, and they recommend C-section.
Continue Reading
Close
Judith Warner's brave new book upends the myth that our children are being overmedicated
By Amy Tuteur, M.d.
A hundred years ago it was rarely diagnosed in children. In the intervening timespan the number and type of diagnoses have exploded. Moreover, the number and type of treatments have also exploded. The favored treatment usually involves powerful medications with serious side effects. Big Pharma has made a fortune from these medications and is constantly searching for new variations to patent and sell.
I’m talking about childhood cancer, but I bet you thought I was talking about childhood mental illness. After all, everyone in contemporary society knows that childhood mental illness is over-diagnosed, that drugging children is the preferred method for dealing with the normal problems of childhood, and that normal children are being treated with powerful psychotropic medications simply because they are quirky and authentic.
That’s what Judith Warner (author of “Perfect Madness”) thought, too, when she sold a proposal back in 2004 for a book that would explore the over-diagnosis of mental illness and over-treatment of children with psychiatric medication. She knew it for all the reasons listed above: Childhood mental illness was rarely diagnosed in children 100 years ago; since then the number and type of diagnoses have exploded; the number and type of treatments have also exploded; the medications used to treat childhood mental illness are powerful and can have serious side effects; Big Pharma has made a fortune from these medications and is constantly searching for new variations to patent and sell.
But the same things apply to childhood cancer, and no one is suggesting that childhood cancer is over-diagnosed, that chemotherapy is the preferred method for dealing with the normal problems of childhood, and that normal children are being treated with chemotherapy simply because they are quirky and authentic. The conclusions we have drawn from the dramatic increase in the diagnosis of childhood mental illness are wrong. Though childhood cancer was rarely diagnosed 100 years ago, that’s not because it didn’t exist. It’s because we didn’t have the tools to recognize it or any effective medications to treat it. Similarly, we need to consider the fact that childhood mental illness is not new, just as childhood cancer is not new; we just lacked the tools to recognize it and any effective medications to treat it.
In “We’ve Got Issues: Children and Parents in the Age of Medication,” Judith Warner has written a brilliant and compelling book, a must-read for any parent who has a child who is miserable and struggling. It is also a must-read for anyone who thinks he knows that childhood mental illness is over-diagnosed and over-treated. Parents who have dealt with mental illness in a child will find solace here, because someone has finally acknowledged that their child’s “issues” are not the normal problems of childhood, that they struggled for years against putting their child on medication, and that their most fervent wishes are not that their child will get A’s in order to get into a competitive college, but merely that he or she will be able to live outside an institution without hurting anyone.
Warner details how she came to write a book that is 180 degrees opposite of what she initially intended. It happened because she talked to parents and psychiatrists and looked at what the medical literature actually shows. And Warner details how she and many others came to believe that childhood mental illness is a fraud perpetrated on society by Big Pharma:
The web of belief — let’s call it the “naysayer” position … is the new face of mental health stigma in our time. It is voiced as concern, as a desire to save children, as a wish to give childhood back to kids, but what it really is, most of the time, is prejudice. And it’s a poison.
People who share the views I used to espouse don’t see themselves as prejudiced. They believe they are raising their voices in protest of a world that’s gone mad, and, in particular, providing necessary pushback against a pharmaceutical industry that’s grown way too powerful, with the collusion of our government and far too many research scientists and clinical practitioners.
Warner is not naive:
I want to say here as strongly as I can that I agree that many aspects of today’s world of childhood are toxic and that I deplore both the irresponsible marketing practices of Big Pharma and the failure of our government and research institutions to stand up against it.
But we must not confuse one issue with another:
That said, I also fiercely believe that the social climate of family life, the machinations of the pharmaceutical industry, and the lives of children and parents dealing with mental health issues have to be viewed as separate phenomena. Not because they aren’t interconnected, but because if you let your feelings about industry and society cloud your vision of parents and children, you run the risk of not seeing them at all. (Emphasis mine)
We have used the wrong measurements to determine whether childhood mental illness is real (the rise in diagnoses, the rise in medications, the profitability of the treatment), and therefore we have reached the wrong conclusions. Children with mental illness always existed; we just never saw them because of prejudice, labeling (“mentally defective”) and institutionalization. It would be a terrible sin if we continue not to “see” them today because of our feelings about contemporary society or our feelings about the pharmaceutical industry. Warner points out that real children and real parents are suffering terribly. We should not compound their suffering by pretending that childhood mental illness does not exist.
[url=file_search.php?action=file&lightboxID=312777][img]http://www.pascalgenest.com/istock/seriesImages/banners_featuredImages.gif[/img][/url]
[url=file_search.php?action=file&lightboxID=312798][img]http://www.pascalgenest.com/istock/seriesImages/banners_women.jpg[/img][/url]
abdomen of a pregnant woman 
