WASHINGTON -- Caesarean sections were performed on a smaller percentage of U.S. women in 1990 than the year before, apparently halting two decades of growing reliance on the surgery, a health advocacy group reported yesterday.
But Dr. Sidney M. Wolfe, director of Public Citizen's Health Research Group, estimated that nearly half the 982,000 Caesareans performed in 1990 were still unnecessary, endangering the health of both mother and child and wasting $1.3 billion in doctor and hospital fees.
"We are optimistic enough to believe that this signals the beginning of the end of this terrible, violent epidemic of Caesarean sections," Dr. Wolfe told reporters at the National Press Club. "But there is a long way to go."
Dr. Wolfe's group released a 48-state survey reporting that between 1989 and 1990 use of the surgical procedure, where the baby is delivered through incisions in the abdomen and uterus or womb, dropped from 23 percent of all deliveries to 22.7 percent.
That rate began soaring in the United States after 1970, when only 5.5 percent of deliveries were Caesarean.
Dr. Wolfe and Ingrid VanTuinen, a Public Citizen researcher who wrote yesterday's study, estimated that the procedure should be used in only 12 percent of deliveries, based on the experience of many hospitals that have worked to reduce them, the rates in some other industrialized countries and the judgment of some prominent obstetricians.
They noted that Japan, which has the lowest infant mortality rates in the world, has a Caesarean rate of only 7 percent.
Comparing the surgery to an assault on the body, Dr. Wolfe charged that overuse "represents a major example of violence ++ against women, in this case perpetrated by physicians." And he asserted that "any hospital that wants to lower its Caesarean section rate can do it very easily, and can do it in ways that save money and improve the quality of health care."
Ms. VanTuinen said Maryland's 1989 rate was 24.5 percent, while yesterday's study reported a 1990 statewide rate of 24.4 percent.
But she cautioned against drawing any conclusions on the state figures because of the small number of births studied. "It may be a fluctuation and not an indication of a trend," she said.
The study found the highest Caesarean rates in Nevada, Arkansas, Louisiana and New Jersey. The states with the lowest rates include Minnesota, Wisconsin and Alaska.
Kate Ruddon, a spokesman for the American College of Obstetricians and Gynecologists, agreed that the rate of Caesareans seems to be dropping nationwide.
But she said there is no evidence that doctors perform the procedure twice as often as it's needed. "There's just not good data for that kind of claim," Ms. Ruddon said.
She said Caesarean rates soared over the past two decades for several reasons. Physicians believed that women who had the procedure once needed it on all subsequent births, and they feared malpractice suits if they hesitated to order surgery in any difficult birth, Ms. Ruddon said.
Several physicians also said that the widespread use of fetal monitors triggered some questionable Caesareans because the devices would often falsely signal trouble.
Ms. VanTuinen added that economics may also have encouraged surgical intervention. The average vaginal birth costs $4,334 in doctor and hospital fees, the report noted, while the average Caesarean birth costs $7,186.
"I don't know if I would say a physician consciously decides to perform a Caesarean for the money," Ms. VanTuinen said. But she added that the higher fees and the pressure to fill hospital beds may have helped create a climate in hospitals that encouraged use of the surgery.
Ms. Ruddon of the obstetrics groups said the Caesarean rate is probably declining because of publicity about its overuse, more judicious use of fetal monitoring equipment and her group's 1988 decision to advise physicians to urge women who previously had Caesareans to try vaginal delivery.
Dr. Carlyle Crenshaw, chairman of obstetrics and gynecology at the University of Maryland Medical Systems, added that in recent years physicians have returned to using forceps and vaginal suction techniques to assist in difficult births -- mechanical methods that fell out of vogue beginning in the late 1960s.
Dr. Crenshaw agreed with Dr. Wolfe that there is still plenty of room for improvement. "I would have no qualms about saying nationwide, taking all populations into account, that 12 percent would be very reasonable," he said.
Dr. Crenshaw predicted that, despite growing pressures against Caesareans, use of the procedure will "slowly drift down" in coming years as doctors unlearn old habits.
To speed the process, the Public Citizen study included a list of 104 hospitals with rates above 37 percent.
Only one was in Maryland -- the Kent and Queen Anne's Hospital in Chestertown, which had a 1990 rate of 42.1, the 34th highest among 2,657 hospitals listed in the report.
Kent and Queen Anne's president William R. Kirk Jr. said concern about that rate prompted hospital officials to ask an outside physician to review every Caesarean birth there in 1989 and 1990.
The physician found in each case that the procedure was needed, he said. Another researcher was recently hired to determine whether the population served by the Eastern Shore hospital has special medical problems that make deliveries more difficult.
Garrett County Memorial Hospital in Oakland, meanwhile, had a rate of 10.4 percent in 1990, the lowest in the state and one of the lowest in the nation.
Dr. Karl E. Schwalm, head of obstertics and gynecology at the Garrett hospital, said hospital's physicians actively encourage patients who previously had Caesareans to have vaginal delivery.
The hospital, he said, also emphasizes prenatal care, the presence of coaches and family members during labor and the avoidance, if possible, of painkillers that can slow down the delivery process.
Dr. Schwalm suggested that the absence of any obstetricians on staff may also promote low-technology deliveries.
But he said he was not blaming his fellow physicians. "It's not just the doctors, it's what women demand too," Dr. Schwalm added. "Society wants perfection. Society wants no pain in labor . . . If society demands lower [Caesarean] rates, we'll have to go along."