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An Update on C-Sections

December 04, 1987

The recent article "C-Sections: Are There Too Many?" purports to analyze hospital records but does little analysis. Rather it primarily attempts to legitimize a supposed "health care consumer group" which apparently has determined what the "necessary" number of C-sections should be and has decided that by printing a list of raw data, 3 years old, the "unnecessary" C-section rate will be reduced. Indications for Caesarean section as a medical procedure, however, should be defined by physicians and not by Ralph Nader and his colleagues.

The article is limited in scope and invites several dangerous inferences, to wit: 1--the Caesarean-section rate can be related to, and is a measure of, the quality of care; 2--the Caesarean-section rate determines to any significant degree the costs of obstetrical and neonatal care; 3--patients can or should consider the C-section rate in deciding upon an obstetrician. There is clearly a need for the evaluation of Caesarean sections, but it should not focus on whether they are "necessary." Rather the proper question to ask is "Is each individual C-section appropriate and reasonable?"

The reasonableness of a C-section is best determined by a physician who is evaluating the patient while caring for her during her pregnancy. Individual physicians have, as their responsibility, to help conclude the pregnancy with the healthiest possible mother and baby without benefit of hindsight or clairvoyance. What is certain is that if one waits for a procedure to become unequivocally necessary, then one has waited too long.

The modern practice of obstetrics requires constant study and re-evaluation based on the latest clinical literature. At the Tarzana Regional Medical Center, we review each and every C-section performed at our hospital. Our Chart and Peer Review Committee meets twice monthly and has as one of its aims the improvement of our perinatal morbidity and mortality and the propriety of each C-section. In 1987, the Joint Commission on Hospital Accreditation cited as exemplary the quality assurance activities of our Department of Obstetrics and Gynecology. We have an active Division of Maternal Fetal Medicine and a Level Two Neonatal Intensive Care Unit which accept high-risk mothers and distressed newborns from other institutions (facts which were left out of your story).

For patients who are presently pregnant or are contemplating pregnancy, you have provided no useful information but rather only fostered fear and apprehension. Further, you have insinuated into the current doctor-patient relationship much distrust by not properly examining the reasons for the increased C-section rate and not concomitantly including the facts that we presently have a vastly improved perinatal outcome.

If, due to the hysteria created by an article such as this, an appropriate C-section is not performed for fear of exceeding an allowable rate or because the patient is improperly educated, and the newborn is consequently damaged, the cost to society for the remedial care of such an infant will be much greater than the cost of the operation.

Patients must choose their physicians with great care and obstetricians must guard their patients' well-being with skill, integrity, compassion, and their best personal efforts. It is with this spirit that our community of doctors and patients needs to rise above your dangerous half-critique to pursue the best possible maternal and child health care.

ALLAN S. LICHTMAN MD, F.A.C.O.G.

Tarzana Regional Medical Center

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