Sunday, December 17, 2006

Too Posh to Push? A Critique of the Role of Public Health in the Increasing Cesarean Section Rate- Cynthia Johnson

The cesarean section (C-section) rate in the US rose to an all-time high of 29.1% in 2004. This represents a dramatic increase from 4-6% in the 1930’s that tripled to 15.2% between 1968 and 1978. In 1981 a National Institutes of Health commissioned report brought the concern about the rising rate to the public and strongly supported vaginal birth after cesarean (VBAC). Ten years later, in 1991, the Healthy People 2000 initiative advocated for a cesarean rate of 15%. (1) A small percentage of the current cesareans are due to demand C-sections, but the health policies regarding demand C-sections have undoubtedly contributed to the increasing rate. I will define demand C-section and the scope of its impact on the C-section rate. I will make three arguments to support my thesis that the approach to demand C-sections has unwittingly reinforced the high C-section rate. The first argument is that, based on framing theory, public health has framed demand C-sections such that benefits are exaggerated and costs are minimized. The second argument, based on the dissonance theory, is that physicians and patients, at an individual level, have been complicit in the crisis of the rising C-section rate. The third argument, based on the theory of reasoned action, is that public health has been unable to present a clear message for society. Finally I will propose strategies for reframing the issue of demand C-sections.

There are many types and definitions of C-sections. A primary, or first C-section is done for a medical indication such as serious bleeding. A demand C-section is done for a first time mother with no medical indication. An elective repeat C-section is done for a patient who declines a vaginal birth after cesarean (VBAC). If there is a medical indication for repeat C-section then it is simply called a repeat C-section. The primary C-section rate clearly can drive up the repeat C-section rate since many women are not candidates for, or decline, a VBAC.

A demand C-section is also called cesarean delivery on maternal request. The National Institutes of Health (NIH) convened a conference in March 2006 to look at the issue of Cesarean Delivery on Maternal Request. The conference conclusions highlighted the medical complications of C-sections and determined that the decision to have maternal request C-sections should be individualized. Another conclusion was that the magnitude of the problem could not be determined. (2) In fact, there are some data to show the magnitude of the problem. Dr Declercq from the BU School of Public Health is one of the researchers involved in a national survey of women’s birth experiences called “Listening to Mothers.” This 2005 study of 1573 participants showed one in 252 women had requested their first C-section with no medical indication. (3)

Framing theory suggests that a behavior is determined by the way that behavior is framed by society. This supports my first argument that benefits of demand C-sections are exaggerated and costs are minimized. How the issue of elective C-section is framed becomes a public health problem because there are diametrically opposed perspectives regarding the benefits and risks of C-sections. I present two opposing views of C-sections. It is confusing for women to decide which authority to believe, and furthermore, there are clear risks that are not publicized as broadly.

Some articles emphasize the potential benefit of C-sections. In the American College of Obstetrics and Gynecology Clinical Review of March-April 2005 the editors list the maternal and fetal risks of both C-sections and vaginal deliveries. They write, “Vaginal birth may be nature’s way, but nature’s way has always been hazardous and still is in nations where cesarean delivery is not a readily available option.” Furthermore, they point out that there is no evidence to show that C-section is detrimental. There are studies that conclude elective C-section is safe and psychologically well tolerated with comparable results to an uncomplicated vaginal delivery. (4)

Other articles present C-sections from a critical point of view. The November 16, 2005 Boston Globe article describing the record high number of cesarean sections highlighted the quote “Many (women)…have to submit to major surgery in order to get medical care.” In a world where independence and taking charge are considered survival tactics of the fittest, submitting to major surgery is not considered a benefit. Many women use the book Our Bodies Ourselves as a guide for woman care. In a chapter about cesarean sections in the 2005-2006 edition, the statement is made that “Surgical deliveries have increased alarmingly over the past thirty years.” Should we be alarmed? In the December 15, 2005 issue of Ob.Gyn. News, a newspaper for obstetricians and gynecologists, Bruce L. Flamm, MD suggests that the all-time high C-section rate in 2004 is a “perfect storm” of medical, legal, and personal choice issues. A “perfect storm” is not what we aim for in medicine or in life.

It is difficult to study the risks of C-sections since the risk for each individual woman and her baby is small. To comprehend the risks of C-sections we need to look at world literature on large populations of women. First let’s look at the problems for the babies. In a recent ecological study, Villar et al looked at the WHO global survey on maternal and perinatal health in Latin America and found a threshold rate of C-section associated with negative outcomes. The risk of preterm delivery and neonatal death rose at C-section rates of between 10% and 20%. An increase in fetal death was associated with cesarean delivery, especially elective cesarean delivery. (5) The New York Times published an article on September 5, 2006 with the headline “Voluntary C-sections Result in More Baby Deaths,” based on an article by MacDorman, Declercq, Menacker, and Malloy from a national linked birth and infant death database. (6) Both international and national data show an increased risk of death for babies after C-section.

Now let’s look at the risk of death for the mothers. Deneux-Tharaux et al from France showed that cesarean delivery is associated with a three-fold increase in the risk of postpartum maternal death as compared with vaginal delivery. (7) US women have a 1 in 3500 chance of a pregnancy-related death. However, maternal mortality in developed countries has not significantly decreased in the last 20 years. The American College of Obstetrics and Gynecology (ACOG) News Release in August 2006 suggests that choosing vaginal delivery over demand C-section could help lower maternal mortality rates. ( 8) A study by Silver et al showed serious maternal problems with an increasing number of C-sections. Most of the problems are from the placenta growing into the uterine muscle causing significant bleeding and often leading to hysterectomy. (9)

On the one hand there are clear risks to demand C-sections. There are, on the other hand, medical journals that frame demand C-sections as safe and appealing. The power of the public health establishment represented in the major medical journals has led to a situation where the debate is framed in a manner that is deleterious to women’s health.

The dissonance theory suggests that individuals selectively attend to information that matches their position while systematically filtering out contradictory information. This theory supports my second argument that physicians and patients have been complicit in promoting the crisis of the increasing C-section rate. Both physicians and patients, based on their self-interest, screen out contradictory information. As we noted with framing, there is conflicting evidence in both the popular press and the medical literature regarding the benefits and risks of C-section.

Most physicians find it easier to schedule C-sections rather than wait for a woman to come to the hospital in spontaneous labor because it makes life more predictable and can be scheduled during the day. Whereas C-sections generally take about one hour, spontaneous labor can take hours to days. Since there is no consensus from NIH regarding the risks and advantages of demand C-section there is no limit to the number of C-sections that can be scheduled. Every physician can choose the body of literature that supports his/her view of what the C-section rate should be.

A woman can also selectively choose the information that supports her view of whether a demand C-section is appropriate for her. A paper by Lucas from Scotland, where the national rate of C-section is 30% (close to the US rate of 29%), discussed the role for repeat elective C-section in the rising rate of C-sections in Scotland. His questionnaire showed the majority of women made their decision to have a repeat C-section instead of a vaginal birth after cesarean based on non-clinical and personal issues. (10) The reasons that US women give for a maternal request C-section are also personal. It is the path of least resistance for many women and lends some control to an emotional experience over which they may feel they have very little control.

Here is a list of the personal issues that a woman could invoke to demand a C-section. Having a definite date and time for delivery is a compelling reason to schedule surgery, especially when there are other children for whom to find care. One can choose a “designer date”, such as the birthday of a family member or a special anniversary date. Scheduling a C-section is more convenient for the patient and the physician. Some patients feel it is safer to have surgery, especially if they buy into the lure of technology. After a C-section women may stay longer in the hospital where meals are provided on a regular basis. Some women are afraid of the pain of labor. Most are not thinking about the postoperative pain or they feel they can use more medication for pain after the baby is born. Some women are concerned about pelvic floor damage after a vaginal delivery and are worried about urinary or bowel problems or pain with intercourse in the future. Some women prefer to have a spinal anesthesia for surgery with a single dose of medication instead of an epidural catheter in their backs for labor. Women may know that disability claims usually cover 8 weeks of maternity leave after a cesarean and 6 weeks after a vaginal delivery so you get more covered time at home with your baby. Obstetrical practices are larger than in the past due to increased demands for hospital coverage and paperwork, so the chance of having your own doctor or midwife at the birth is less frequent. With a planned C-section you know who will deliver the baby. Any one or combination of these reasons could be enough to demand a C-section and ignore any risks associated with major surgery.

The perceived self-interest of woman to choose C-section is influenced by the framing of C-sections by society. They are getting incomplete information. Physicians also screen out the risks in the self-interest of convenience and financial gain. The end result is that women and doctors choose C-section more frequently than is warranted by an objective consideration of the risks.

The theory of reasoned action suggests that attitudes toward a behavior and perceived expectations regarding a behavior determine a person’s intention to perform that behavior. Intentions then cause the actual behavior. This theory includes both social and individual factors. Framing theory describes behavior of society and dissonance theory describes behavior of individuals. These are the roots for this third theory and for my third argument that public health has been unable to present a clear message for society. Organizations like medical groups and hospitals are biased toward C-sections because C-sections give them more control and profit. Hospitals get more money for C-section deliveries that keep their beds filled more frequently. Society has made C-sections not only accepted, but also expected and even preferred. Women perceive C-sections as safe and normal. They may not even realize that it is major abdominal surgery.

Public health has not taken a strong stance in dispelling myths about C-sections. Some professionals believe Hollywood celebrities and super models have spawned the current trend for C-section on demand. (11) There is an implicit understanding that you will look like a model after a C-section. The literature shows that women in higher socioeconomic strata find it easier to choose to have a C-section. C-section rates are higher for women who have medical insurance, who are older, more educated, and wealthier. These are factors that may be related to having more control. The women who have C-sections tend to be private and not public clinic patients. (12) Some classes of women may have access to hospitals and doctors who perform more C-sections. A study of female obstetricians in England showed that one third of them would opt for a C-section for their first delivery if given the choice. In Latin America too, it has been noted that the rates of elective C-section in private hospitals reflect a complex social process. Victora and Barros report that women from poor families in Brazil were inspired by trends in the rich families and subsequently demanded C-sections. (13) Brazil now has the second highest C-section rate in the world.

Public health policy has at times attempted to determine the ideal C-section rate and imposed guidelines to reach or maintain those goals. One of the methods in the past was to require obstetricians to have a second opinion from another obstetrician before doing a C-section. That policy no longer exists. Insurance companies in the past would not pay for a repeat cesarean until a woman had attempted a vaginal birth after cesarean (VBAC). Large studies then showed the risk of a VBAC delivery and now some insurance companies will not cover a VBAC. It is pointed out in an article by Cyr, titled “Myth of the ideal cesarean section rate: Commentary and historic perspective”, that the US lags behind other developed countries in every measure of health care quality. (1) Better perinatal outcomes are achieved with lower cesarean rates and less spending on health care in Europe. So public health in the US not only has no recommendation for C-section rate, but also gets poor grades on the world health report card in this regard.

Is the C-section rate spiraling up because of a backlash to policies in the past? Is it because people, and women in particular, want to have a modicum of control over the complexity of life in the US? Is it because some in the generation of women in the childbearing age are used to getting what they want and/or are fearful of the pain of childbirth? Is it because medical groups and hospitals are getting financial rewards?

How can we get the message of the risks of surgery out to women and reframe the issue of demand C-section? According to Aiken consumers will devalue the credibility of sources of health recommendation that are at variance with their own practice. (14) What source would women trust to get more information regarding demand C-sections?

The diffusion theory might help with the task of reframing demand C-section. It focuses on social networks, opinion leaders, and change agents. I suggest six strategies that fit this model.

One strategy is to assemble opinion leaders to look at the issue of demand C-section. Although that is what NIH did in 2006, they seem to have raised more questions than arriving at a consensus regarding solutions. An editorial from Ireland recommended that the NIH consensus conference be reconvened because “American obstetricians overreacted to publications that were alarmist and limited.” (15)

A second strategy is to publish a strong editorial about the risks of demand C-section. There are several examples of dramatic trends noted in response to an editorial in a prominent journal. For example, the VBAC rate dropped precipitously after articles about uterine rupture and an editorial were published in the New England Journal of Medicine in 2001. A similar trend was noted in the number of articles about counting fetal kicks to evaluate fetal health after an editorial in The Lancet in 1987. I think we need a high profile champion to write an editorial about the risks of C-section to the mother and the baby. The importance of MD attitude in making decisions has been studied in other areas and cannot be overemphasized for the decision about delivery mode.

A third strategy is to collect timely data. We need US data similar to the WHO global data from Latin America to determine the risk of C-section in the US. We need to have population studies that fairly compare the risks and benefits of demand C-sections and C-sections with medical indications. The studies should look at which classes of women are getting C-sections. It is beyond the scope of this paper, but the change model used in international health and in corporate circles could be used to bring the data and ideas into mainstream thought and practice.

A fourth strategy is to use the media. Presenting the issue of demand C-section on Oprah or 20/20 or a show like Grey’s Anatomy, House, or ER could be an additional way to get the message out into the realm of public awareness.

Some opinion leaders have suggested a fifth strategy. They suggest that we should let the C-section rate float and self adjust. I am skeptical about a system that is the path of least resistance for both physicians and patients. For all of the reasons that I have pointed out in this paper, there is reason to believe the C-section rate would keep increasing. It is difficult to take away a covered benefit and people react to a forced specific C-section rate because it means cost control to them. Women do not want to hear about the risks that are meaningless to one individual.

My sixth and final strategy relates to delivery support. Throughout history it has been midwives who delivered babies and made birth a woman-centered event. They were well known in their communities and respected for their medical knowledge and skills. Birth became “medicalized” as the numbers of physicians increased and the field of Obstetrics and Gynecology came into its own as it evolved out of the surgical field and focused on women. There is no question that giving birth is safer in hospitals, but midwives are well suited for doing normal deliveries. Since one of the reasons for demanding a C-section is to have your own doctor at the delivery, there might be a place for certified nurse midwives to do more than the 9-11% of deliveries in the US that they do today. Women want to have emotional support in labor. Obstetricians by training do not spend as much time with women as women might like and need. Obstetricians would be involved for high risk pregnancies and to do C-sections for patients who cannot have a vaginal delivery, but midwives could give women the emotional support they need at an important time in their lives, just as they have throughout history. Reversing the trend toward more C-sections would decrease the risk of women dying from the complications of placental problems that are inevitable after multiple C-sections.

Society and individuals have the same goal of healthy mothers and healthy babies. Public health has contributed to the highest C-section rate in US history by, first, exaggerating benefits and minimizing cost with a lack of clear framing; second, presenting conflicting information to individuals; and, third, making C-sections seem a reasonable option for delivery in our society. Demand C-sections are a relatively small percentage of the C-sections done, but the philosophy of surgery with no medical indication pervades the mindset for both society and individuals. The costs are minimized and the benefits are exaggerated. Women and their babies are experiencing unnecessary risk.

Cyr R. Myth of the ideal cesarean section rate: Commentary and historic perspective. American Journal of Obstetrics and Gynecology 2006 June;194(4):932-936.

National Institutes of Health State-of-the-Science Conference Statement. Obstetrics and Gynecology, 2006 June;107(6):1386-1397.

Declercq E, Sakala C, Corry M, Applebaum S. Listening to Mothers II Executive Summary. October 2006.

Schindl M, Birner P, Reingrabner M, Joura E, Husslein P, Langer M. Elective cesarean section vs. spontaneous delivery: a comparative study of birth experience. Acta Obstet Gynecol Scand, 2003 Sep;82(9):834-40.

Villar J, Valladares E, Wojdyla D, Carroli G, Velazco A, Shah A, Campodonico L, Bataglia V, Faundes A, Langer A, Narvaez A, Donner A, Romero M, Reynoso S, Dimonia de Padua K, Giordano D, Kublickas M, Acosta A. Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America. The Lancet 2006 June;367:1819-1829.

MacDorman M, Declercq E, Menacker F, Malloy M. Infant and Neonatal Mortality for Primary Cesarean and Vaginal Births to Women with “No Indicated Risk,” United States, 1998-2001 Birth Cohorts. Birth 2006;33(3)175-182.

Deneux-Tharaux C, Carmona E, Bouvier-Colle M, Breart G. Postpartum Maternal Mortality and Cesarean Delivery. Obstetrics and Gynecology 2006;108:541-548.

ACOG News Release

Silver R, Landon M, Rouse D, Leveno K, Spong G, Thom E, Moawad A, Caritis S, Harper M, Wapner R, Sorokin Y, Miodovnik M, Carpenter M, Peaceman A, O’Sullivan M, Sibai B, Langer O, Thorp J, Ramin S, Mercer B. Maternal Morbidity Associated With Multiple Repeat Cesarean Deliveries. Obstetrics and Gynecology 2006;107:1226-1232.

Lucas A. Information for women after CS: are they getting enough? RCM Midwives, 2004 Nov;7(11): 472-5.

Victora C, Barros F. Beware: unnecessary caesarean sections may be hazardous. The Lancet 2006;367:1796-1797.

Ailen L, Jackson K, Lapin A. Mammography screening for women under 50: Women’s response to medical controversy and changing practice guidelines. Wom Health 1998;4:169-197.

Agnew G and Turner M. Letter to the Editor. Can a 29% Cesarean Delivery Rate Possibly Be Justified? Obstetrics and Gynecology 2006;108:452.


Anonymous Casandra A said...

I really enjoyed reading your paper Cynthia and I learned so much! I didn't really know much about the C-section rate and didn't realize that it's so high. I think your work highlights the importance of this issue and really advocates for a better understanding among both patients and providers.

12:57 PM  

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