Confounding all attempts to halt it, the nation's Caesarean section birthrate is increasing--driven, doctors contend, by a fear of malpractice suits, but linked by critics to greed on the part of some physicians.
Between 1979 and 1984, figures to be released today by the American College of Obstetricians and Gynecologists and a federal agency show, the Caesarean rate increased from 14.1% of all births to 19%. This rise occurred even though a U.S. government task force called for major reform eight years ago.
And in step with the uninterrupted surge in Caesareans, the proportion of women who have had an initial Caesarean delivery but deliver subsequent babies vaginally has gone from 2.1% to 8% over the same period--but far less than what doctors had hoped.
Service Not Always Offered
While many large hospitals now attempt vaginal delivery in the cases of more than a quarter of women who had earlier Caesareans, 54% of all hospitals don't offer the service. Attempts at normal labor and delivery after a Caesarean succeed in producing a normal delivery without surgical intervention more than half the time, the new report says.
One of the researchers said the increase in vaginal birth attempts was only a modest one since the proportion of non-Caesarean births after an initial section could potentially be far greater.
The findings of the report, published today in the Journal of the American Medical Assn., were quickly characterized by national medical experts as "depressing" and "disappointing." Attempts to stem the increase in Caesareans have largely failed, these experts agree.
(In 1979, a federal task force estimated the national Caesarean rate had increased from 5.5% in 1970 to 15.2% in 1978--slightly higher than the newly published estimate for 1979--and called the 1978 results an example of medical excess.)
The new data appear to vindicate a leading critic of Caesarean practice who warned of a continuing surge in rates three years ago but was criticized by other doctors at the time as judging his colleagues prematurely.
The new Caesarean data was gathered by analysts at the American College of Obstetricians and Gynecologists and the government's National Institute of Child Health and Human Development. The figures are based on a survey of delivery practices at 538 hospitals nationwide.
Caesarean rates were high in all areas of the country, with the South highest at 20.4% of all births, followed by the Northeast (20.2%), the West (18.9%) and the North-Central states (17.1%). In California, Caesareans account for 31% of all births, according to the Blue Shield health insurance plan.
Caesarean rates were highest--20.6%--among hospitals delivering 5,000 or more babies a year and lowest--18.5%--among health centers with 500 or fewer, but analysts noted that large hospitals often attempt the most difficult cases.
Small hospitals virtually never offered attempts at a vaginal delivery after an initial Caesarean in 1979, and did so in only 1.8% of potential cases in 1984. Large hospitals went up from 9.9% in 1979 to 25.4% in 1984. Larger hospitals had the greatest success rates in such cases--with women attempting vaginal birth after a Caesarean giving birth normally 62.8% of the time.
Requests for Caesareans
A majority of patients asked for Caesarean birth in 16.4% of the hospitals and 32.7% of the hospitals said a majority of the patients requested a trial of labor after an earlier Caesarean.
Hospital records said Caesarean births were undertaken because of indications of fetal distress in 21% of all cases, compared to 14% in 1979. But Dr. Warren Pearse, president of the American College of Obstetricians and Gynecologists, questioned whether the figures mean the number of babies with serious problems truly increased.
Instead, Pearse said, doctors may report fetal distress as a diagnosis more frequently to justify the Caesarean--while at the same time avoiding listing the diagnosis when a baby is delivered vaginally because physicians fear being sued if the vaginally delivered child subsequently develops such complications as learning disabilities.
"What it means is that if you (a doctor) make a judgment call and do a Caesarean, you write down fetal distress, but if you deliver vaginally, you don't dare put that in the chart," Pearse said.
The Malpractice Factor
Malpractice concerns have long been presumed to be at the heart of recent increases in Caesarean rates as doctors move to avert suits charging a physician failed to do a Caesarean when one was appropriate. Experts agree no comprehensive data have been developed to confirm this widely held belief, but physicians unquestionably believe malpractice risks to be real, Pearse and other doctors said.
Pearse said there is no agreement on what an acceptable Caesarean rate would be--only that what exists is far too high. Some radical observers have suggested that only 5% to 7% of births would be surgical if the only considerations were patient safety and medical need.