C-section goal delivers critics; Births: Government's push to lower rate ignores factors that bring many women into the operating room, doctors say.


Despite years of effort to curb the number of babies delivered surgically, the nation's Caesarean-section rate has nudged down only slightly. Now, many doctors say it is unrealistic to expect the rate to drop much further and some predict it could even rise.

Today, one out of five deliveries in the United States is a C-section, compared to one out of four when the rate peaked in the late 1980s.

Obstetricians say the rate remains high for several reasons, including an epidemic of multiple births and an increase in the number of premature and large babies. Fearing uterine ruptures, many doctors are also reluctant to encourage women to try labor if they had Caesareans before.

Many are harshly critical of a federal report, issued in 1990, that called upon doctors to lower the national rate to 15 percent by 2000. With the decade drawing to a close and the goal far from met, the government has proposed the same target for 2010.

That, doctors say, ignores the factors that bring women to the operating room.

"The goals are arbitrary and capricious," said Dr. David Nagey, an expert on high-risk pregnancies at the Johns Hopkins School of Medicine. "What's right for one hospital is not right for another."

From 1970 to 1988, the nation's Caesarean rate soared from 5 percent to 25 percent. The jump was blamed on many factors, including larger babies and the tendency for many women, especially those with careers, to start their families at a later age when pregnancies can become more complicated.

The increase also came at a time when obstetricians began to routinely use monitors that recorded fetal heart rate and breathing. According to some critics, doctors overused the monitors and rushed many women into operating rooms when the babies weren't in distress.

Some doctors also blamed the increase on defensive medicine: the fear of being sued if a normal delivery went bad. Lawyers were winning multimillion-dollar judgments on behalf of parents whose children died or suffered brain damage or other injuries after being delivered through the birth canal.

Caesarean sections were viewed as safer for the child, though for the mother they posed a much higher risk of infection and other complications. Caesareans were also helping to drive up the cost of health care, costing about twice as much as the average vaginal delivery.

As Caesareans soared, professional groups waged a vigorous educational campaign to reduce their number.

But now, many doctors say the rate has probably dipped as much as it ever will. Some even predict the rate will climb again.

"Just from talking to doctors around the country, my gut feeling is that the rates will start going up again," said Dr. Bruce Flamm of Riverside, Calif., a regional research director for Kaiser Permanente. Many doctors, he said, still fear being sued. Also, some obstetricians argue that vaginal deliveries can damage nerves and tissues that cause women to lose urinary control.

The U.S. Public Health Service and the World Health Organization joined in setting a goal of 15 percent, figuring the rate could be lowered to that point without causing any increase in fetal injury.

Nagey said the federal goal of 15 percent was based on an unfair comparison to Ireland, where the rate stood at 5 percent in the 1980s. But even there, he said, the rate tripled after a highly publicized malpractice suit.

Debate over the goal has intensified since Dr. Benjamin Sachs and three other specialists from Boston published a report earlier this year in the New England Journal of Medicine. They charged that the federal goal was "authoritarian" and "implies that women should have no say in their own care."

Maryland's rates have tracked very closely to the nation's, dropping from 25 percent in 1988 to 21 percent last year. Practices vary widely from hospital to hospital. At 27 percent, the Greater Baltimore Medical Center in Towson had the highest rate in the metropolitan area last year.

The University of Maryland Medical Center had the lowest -- 14 percent. Hopkins is closer to the average, at 22 percent.

Dr. Lindsay Alger, director of labor and delivery at UM Medical Center, said the hospital has been able to achieve a low rate, in part, by having surgeons and anesthesiologists who can assemble at a moment's notice so doctors can push labor further than they otherwise might, knowing they can order an emergency C-section if problems develop. This is possible mainly at teaching hospitals and urban hospitals with busy obstetric practices.

A decade ago, the Caesarean rate at Maryland Medical Center was just as low. According to Alger, this was due in part to the department's philosophical bent. Doctors deliver a majority of twins and many triplets vaginally. They also assume that most women who have had Caesareans in the past can attempt a vaginal birth the next time around.

"We feel that the risk of getting a complication with a C-section is far greater than the risks" of vaginal birth after Caesarean (VBAC), Alger said.

Nationally, more than a third of all C-sections are repeat Caesareans. Doctors agree that Caesarean rates cannot be lowered without increasing the number of VBACs, but the practice remains controversial.

Many doctors perform repeat Caesareans as a matter of course because they fear the patient's surgical scar will rupture during labor, an emergency that in rare cases could cause severe problems. Others insist the benefits far outweigh the risks and that most ruptures can be safely repaired in the operating room.

In recent years, clusters of uterine ruptures in California and Utah have caused doctors elsewhere to turn away from VBAC. Doctors who perform them say they are more careful than ever to inform their patients of the risks.

"Up to a couple years ago, I wouldn't offer a repeat Caesarean," Nagey said. Now, he offers both, carefully explaining the risks and benefits of each procedure.

Nagey said he hasn't seen a uterine rupture since he started his residency in 1975, but acknowledges that there is some evidence that ruptures are more common now that more VBACs are done. At the same time, he said there is really no evidence that more women have been harmed.

Dr. Frank Witter, head of labor and delivery at Hopkins, said the United States has more premature babies and more large babies than many countries in Western Europe. For different reasons, he said, both can be hard to deliver safely through the birth canal.

"People looked at European countries that have very homogenous populations," Witter said. "They failed to take into account the differences."

In Maryland, some of the highest rates are in the affluent suburbs. Dr. Victor Khouzami, obstetrics chief at Greater Baltimore Medical Center, said many of his patients are having babies later in life when the placenta is more vulnerable to the strains of labor. Also, women taking fertility treatments -- a GBMC specialty -- are more likely to have multiple births.

Not surprisingly, midwives are among the strongest advocates to avoid surgery. Hilles Whedbee, a midwife at Union Memorial, said only 8 percent of her patients end up in the operating room. But she admits she attracts patients who are philosophically in sync with her.

Despite this, Whedbee said she can sense that attitudes toward C-sections are softening. And the change, she says, comes not only from what she calls Baltimore's conservative medical community.

"There is more demand from women," she said. "Maybe because they are working and don't have as much time off, they seem less inclined to even push for a nonmedicated birth. They want to know that they are coming in on a certain date and having the baby."

Pub Date: 9/14/99

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