Just “Reducing C-Sections” shouldn’t be a goal

The Pediatric Insider

© 2017 Roy Benaroch, MD

Consumer Reports today released a report critical of the c-section rates of many US hospitals. Titled “Your biggest c-section risk may be your hospital”, the article encourages parents to choose a hospital based on c-section rates. The lower, the better.

That’s misguided advice, and focuses attention on the wrong parameter. Parents should concentrate on improving their odds of a healthy and safe delivery for mom and baby. Knowing the overall c-section rate of a hospital doesn’t tell you anything at all about whether the babies born there are healthy.

In an ideal world, we would easily be able to tell exactly which mom-baby pairs need a c-section. Sometimes, it is easy to tell – mom’s past medical history, or something about the baby, makes a c-section very clearly necessary. But most of the time, c-sections are a decision made based on “risk reduction”. And that’s not an exact science. We know that some babies with a certain kind of fetal heart tracing may be headed for trouble – they’re at an “increased risk” of problems with delivery (and those problems can be devastating, leading to death or permanent neurologic disability.) But most of the time, even these “higher risk” babies can probably labor longer, and could probably be born vaginally and do fine. But what’s probably? What if you were told your baby had a 1 in 3 chance of severe complications? Or a 1 in 50 chance of having brain damage, and never being able to walk? Would 1 in 100 be a reasonable risk, or 1 in 500? We do c-sections to mitigate, or reduce, those risks. It’s up to midwives and moms and obstetricians to discuss these risks and decide on the best course of action for each individual mom in labor.

The article points out that over half of the hospitals surveyed – or “nearly 6 in 10” — have a c-section rate above the rate of 23.9% established as a goal by the US Department of Health and Human Services. But that means that close to half of the hospitals actually had a c-section rate somewhat less than the government target. But the CR headline doesn’t read “Nearly half of hospitals aren’t doing enough c-sections.”

By the way, I have no idea where that 23.9% goal comes from. I know of no data that explicitly determines the percentage of c-sections that is ideal for health. I don’t think any such data exist, or that there even could be “one number” that’s perfect for every community.

Although the survey did try to look at the reasons behind c-section variability at hospitals, those can be difficult numbers to quantify. We know older moms, and overweight moms, are more likely to need a c-section – so hospitals catering to those groups are being unfairly targeted for their high c-section rates. (One reason why c-section rates have crept up over the last few decades is the changing demographics of pregnancy in the US. There are more twins, too.) In fact, if I were a hospital administrator who wanted to brag about my low c-section rates, I’d just drop out of the business of seeing high-risk pregnancies, or catering to older or obese women. That hospital would “win” the low c-section sweepstakes! But is that the best way to take care of women – to neglect the ones that make our hospital numbers look bad?

Also – and I know I’m going to lose some of you with this – I’m not entirely comfortable with the overall message here that even elective, non-medical c-sections are bad and should be discouraged. Moms deserve honest, science-based advice on the pros and cons of both vaginal and c-section delivery, tailored to their own circumstances and health histories. If a mom, given good information, decides that even without a specific medical indication she’d prefer to get a c-section, is that wrong? Aren’t we past the point where doctors are supposed to tell their patients what to do? And aren’t we past the point where women should be told what to do by their man-doctors? (Parenthetically, all of the MDs interviewed for the CR story were men*. I’m sure that’s just a coincidence.)

C-section rates are one measure of a hospital – and for women who put a top priority on having a vaginal delivery, this Consumer Reports article gives some helpful information. But I don’t think most women ought to focus on that one parameter, or worry about taking steps to avoid a c-section. That’s my judgement, but you pregnant women should make up your own minds. I don’t think the “23.9 percenters” ought to try to take that decision away from you.

 

*Neel, Elliott, Aaron, Gilad, Robert – I’m assuming these are all male first names.

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