Two years after a much-heralded drop in the skyrocketing number of American babies born by Cesarean section, the Cesarean rate has leveled off nationally and risen slightly in California--news that some experts fear indicates that the nation will not meet its goal of reducing surgical deliveries to 15% by 2000.
In a report released Wednesday, the Washington-based Public Citizen's Health Research Group estimated that nearly half of the 421,000 Cesarean sections in 1992 should not have been done. The report further says that in 1991 unnecessary C-sections added $1.3 billion to the nation's annual health care bill at a time when the government was clamoring for cost containment.
For the Record
Los Angeles Times Friday May 20, 1994 Home Edition Metro Part B Page 3 Column 1 Metro Desk 2 inches; 64 words Type of Material: Correction
Cesarean births--Because of an editing error, a story in Thursday's Times incorrectly reported the number of babies born by Cesarean section in the United States in 1992. The correct figure is 896,289, according to a report by Public Citizen's Health Research Group. In addition, state health officials dispute the Public Citizen report's finding that 21.8% of all California babies were born by Cesarean section in 1992. The state puts the figure at 21.6%
"Its discouraging," said Nancy Theriault, president of the International Cesarean Awareness Network, a consumer activist group. "I think we have a long way to go."
Public Citizen found that the national Cesarean rate remained essentially the same between 1990--when 22.7% of all babies were delivered surgically--and 1992, when the figure stood at 22.6%. In California, the rate went up slightly, from 21.4% in 1990 to 21.8% in 1992.
The national rate peaked at 24.7% in 1988 and the California rate hit a high of 24.5% in 1986.
Although the report said the numbers mark "a very slow reversal of the earlier dangerous trend," Dr. Sidney Wolfe, executive director of Public Citizen, said Cesareans are still performed nearly twice as often as they should be.
The Public Citizen study found that 106 U.S. hospitals delivered more than 37% of all infants surgically--including four hospitals in Southern California. In California, Los Angeles Community Hospital had the highest Cesarean rate in the state, 43.8%
"We think that this is a very well-orchestrated form of violence against women," Wolfe said in a telephone interview. He said that even though patients consent to the surgery, they may do so on the basis of incomplete information "that is tilted toward the obstetrician doing a C-section."
Wolfe and his group maintain that the national rate should be 12%--a figure that drew protest Wednesday from the American College of Obstetricians and Gynecologists, which said there is "not adequate science upon which to recommend an ideal" rate. The U.S. Public Health Service has set a target rate of 15% by the turn of the century.
Whatever the optimal rate, most experts agree that too many American infants are being delivered in the operating room. But they disagree as to why.
Wolfe, who for years has been crusading against unnecessary Cesareans, blames the phenomenon on greedy physicians and hospitals hungry to fill beds.
Most obstetricians, however, say factors beyond money are at work--most important, doctors' fears of being sued for malpractice if something goes awry during vaginal birth.
"I honestly don't believe that money is the issue here," said Dr. Bruce Flamm, a nationally regarded expert on Cesareans who has been instrumental in lowering C-section rates at Kaiser Permanente hospitals in Southern California. "Day after day I talk to doctors around the country who are continuously burdened by this fear that they will be sued."
According to the report, Cesarean section is the most common major operation in the United States. During the surgery, the abdomen and uterus are cut open to deliver the baby. The operation can in some instances save the life of the mother and fetus.
There are four main reasons to perform a Cesarean: previous Cesarean; the failure of a woman to progress into full labor; breech position (feet- or rump-first), and fetal distress, such as abnormal heartbeat. Repeats account for about a third of all C-sections, despite a growing trend toward what is known as VBAC--vaginal birth after Cesarean. Many hospitals are trying to bring down their C-section rates by promoting subsequent vaginal births, which carry a small risk that the previous incision will rupture during birth. But these education efforts have not always been successful, particularly in affluent areas, where experts say patients and doctors are unwilling to accept even the most minimal risk.
"One reason for the Cesarean rate has to do with the demands of private patients not to tolerate too long a labor, or even abnormalities that potentially suggest harm to the fetus," said Dr. Ezra Davidson, chief of obstetrics at at Los Angeles County's Martin Luther King Jr./Drew Medical Center. At King/Drew, where most patients are poor, the Cesarean rate for 1992 was just 13.9%--1,068 out of 7,700 births. Davidson attributes the low rate to the hospital's enforcement of very strict guidelines about when to perform Cesareans
Across the city, at Cedars-Sinai Medical Center, the C-section rate for 1992 was 29.4%--2,031 out of 6,907 births. About a third of those were repeat Cesareans, according to Dr. Kimberly Gregory of the obstetrics department. She said records showed that 45% of the repeat C-sections were elective.