"The Relentless Rise"
August’s issue of Obstetrics and Gynecology (The Green Journal) contains an editorial by Dr. John T. Queenan (Deputy Editor). Dr. Queenan’s article, titled “How to Stop the Relentless Rise in Cesarean Deliveries,” is notable not only for the admission of a problem with the increasing C-section rate, but also for the concern he describes for the profession of obstetrics itself.
He begins his editorial with a brief history of the rise in Cesarean deliveries in the US, stating “[i]t is unclear what an acceptable rate should be.” He continues with with a prediction that the increase in cesareans in nulliparous women, as well as the decrease in VBAC rate, will soon lead to an overall C-section rate of over 50%.
Dr. Queenan submits that there are two solutions, that must be applied together, to reduce the rate of cesarean deliveries:
- “make VBAC more accessible and more desirable”
He seems to be aware of the myriad reasons that a woman might have a repeat cesarean delivery, ranging from a difficult labor and/or recovery to financial and legal influences that may affect how a physician counsels a patient about her options. Dr. Queenan suggests that tort reform will make it easier for physicians to accept the “small but serious” risk involved in a VBAC, while “the hospital administrator makes a larger financial return on a cesarean delivery compared with a vaginal deliver.” He also recognizes that some women may desire a repeat cesarean after an easy recovery from their primary section, and making vaginal deliveries more attractive is a necessary part of reducing the repeat cesarean rate.
- “prevent primary cesarean deliveries in the first place”
Dr. Queenan describes this as the “more critical solution,” as clearly the first is less important if the second is working. He laments the more lax approval procedure, comparing it to when “obstetricians wishing to do cesarean deliveries were required to get consultation from a colleague.” Today, patient request cesareans are readily available (and sanctioned by ACOG as part of patient choice), and more complicated situations, once routinely taught to be handled vaginally, are virtually always delivered by cesarean. Dr. Queenan admits that cesareans are much safer than previously, and with shorter recovery times, but states that there is “significant risk for future pregnancies.” In addition, “the maternal mortality is higher in repeat cesarean deliveres than for VBAC.”
Dr. Queenan also addresses practice discrepancy, saying that it is important to discuss rates as they differ across the country - by state, by hospital, and even by physician - and that “reasons for these discrepancies could give some clues to lowering the rates.”
He then describes a few other suggestions for decreasing the rise in cesarean delivery rates:
- changing hospital policies, including “appropriate review of primary cesarean deliveries”
- decreasing inductions for laobr
- discontinuing the use of dystocia as an indication for C-section
- better patient education regarding “the risks and benefits of vaginal delivery and cesarean delivery”
- tort reform “either at the federal or state level” to prevent “costly defensive medicine”
- increase the use of nurse midwives
- provide equal compensation for vaginal and cesarean deliveries (“Vaginal birth after cesarean could be compensated higher than a normal vaginal delivery.”)
- “Re-establish teaching and training for breech and operative vaginal deliveries”
Dr. Queenan concludes with words of warning to his profession.
“What the appropriate rate should be for the United States is elusive, but a 50% rate seems too high and would draw common sense criticism from many areas. As of now the problem is ours to solve. If cesarean delivery rates spiral upward, our profession will lose both credibility and the opportunity to determine our direction, as third-party payers and the government will become involved. … The rising cesarean delivery rate is a threat to our profession. Remember that the official statistics on deliveries are always a year or two behind. There is no time for complacency. In my judgment, the best action for our profession is to commit to lower the primary cesarean delivery rate using every practical measure while we are still in control.”
Next, another article in the current issue, Dr. James Scott’s “Vaginal Birth After Cesarean Delivery: A Common-Sense Approach.”