Sunday, March 26, 2006

Why is the C-section rate so high?

From Fixin' Healthcare:

For example, what is going on with care during pregnancy and delivery? This is a biological process that in the absence of complications cannot be improved upon with technology... Yet, beginning in the 1970s the incidence of C-sections rapidly increased.
As an obstetrician, there is very little that makes me angrier than attempts to blame the outrageous C-section rates on obstetricians.

First there is the pernicious blather about how pregnancy as a “natural condition”. Doctors, especially, should know better. Pregnancy is the single most dangerous phase of the average woman’s life, excluding old age. That’s despite the fact that modern obstetrics can successfully treat virtually all pregnancy complications. Historically, pregnancy was extremely dangerous. All you have to do is take a stroll though an old cemetery and see how many young women are buried there, victims of the “natural” state of pregnancy.

Complications in obstetrics are common, not rare. That’s in keeping with the fact that human reproduction on the whole is an extremely wasteful process. The gross excess of gametes, the high miscarriage rate, and the incidence of deadly pregnancy specific diseases like pre-eclampsia are just part of this.

Pregnancy is not “designed” to turn out fine; it is not “designed” at all. It is the results of millions of years of evolution balancing competing evolutionary benefits. For example, it is better for babies to be born with greater neurological competence (and therefore bigger heads), but it is harder for women to walk with a pelvis larger than certain dimensions. Those evolutionary needs have been in tension for millennia. The result is that often babies are too big to fit. In the good old days, women who could not accommodate a large baby died after an agonizing three days of obstructed labor. Or perhaps, they didn’t die, but the dead baby was removed in pieces and the woman suffered a recto-vaginal fistula that left her a pariah. Nowadays such women have a C-section and never stop to consider it a life saving procedure.

Before the advent of modern obstetrics, the most common causes of death in pregnancy were eclampsia, hemorrhage, infection, ectopic pregnancy, embolic phenomena and cephalo-pelvic disproportion. None of these are lifestyle issues. Many of these have benefited from the liberal use of C-sections.

Pregnancy demands a healthy diet.
No it doesn’t. More than 99.9% of all babies ever born were born to women who lived on subsistence diets. The impact of diet on pregnancy is minimal.

Yet beginning in 1970, the incidence of C-section rapidly increased.
You bet it did, and it had absolutely nothing to do with lifestyle. It’s because obstetricians are trying to prevent malpractice suits. It is virtually impossible to defend yourself in a “bad baby” case if the baby was born by vaginal delivery, even if C-section would not have made any difference at all. Pregnancy in its “natural” state results in many dead babies. Pregnancy in its modern state considers dead babies unacceptable and physically or mentally compromised babies are even worse.

Any risk of any kind is now unacceptable. The incidence of C-sections was rising in the 1990’s because of the safety of VBAC (vaginal birth after C-section). That was completely derailed when administrative organizations like ACOG announced that the risk of VBAC warranted in house anesthesia and 24 hour doctor attendance. For most small hospitals, it thereby rendered (unnecessary) repeat C-sections mandatory.

The role of lifestyle in health is grossly exaggerated (it’s wishful thinking more than anything), but the role of lifestyle in pregnancy is, if anything, even more grossly exaggerated. There are a lot of problems in modern obstetrics, and the outrageous C-section rate is indicative of this, but these are not lifestyle issues and these are not the fault of obstetricians.

13 Comments:

Blogger Flea said...

Most folks don't really understand risk. That's partly why OB's get blamed for the high rate of C/S.

Frankly, I don't think I could stand the risk of liability. A good OB friend of mine left the state because of inability to do enough deliveries to pay his premiums!

Just a question for you - does it bother you that residents aren't taught how to do versions and other complicated breech deliveries like they used to? Or is this a good thing?

best,

Flea

5:20 PM  
Blogger marcus said...

Did that statement blame obstetricians?

11:06 PM  
Blogger Amy Tuteur, MD said...

Dear Marcus,

You are absolutely right that the statement did not blame obstetricians specifically, and I thought about that before (and especially after) I wrote my rant. I concluded that the mention of the preterm and post term deliveries, the inductions, the issues of decisions that require "no harm" were allusions to obstetricians since I did not think you meant to saddle patients with the blame for these decisions. If I over-interpreted, please accept my apologies.

This issue is especially close to my heart because I participated in a think tank study in the late 1990's about how to achieve the goal of a national C-section rate of 15%. We spent a long time talking about the factors involved (most of which having nothing to do with obstetricians) and made a variety of recommedations about how to achieve the goal. No one paid any attention. The biggest blow of all was the law suits about VBAC resulting in administrative decisions that essentially force many women to have unnecessary repeat C-sections.

As regards the corollary issue, I do think that the role of lifestyle in health is vastly overblown and in the area of pregnancy particularly. There is very little evidence that any lifestyle measures have any impact on pregnancy (with the exception of substance abuse). The food fascists have no evidence to show that diet has much of an impact on pregnancy, and those who prescribe exercise as an antidote to CPD are completely wrong.

My C-section rate in a low risk population was 10% and rose to 15% in a mixed population. I have the highest respect for the natural process of birth and most of the time I just watch it. Yet I never forget that labor and delivery are quite dangerous, and complications occur quite often. I suspect that this is because of the complex interplay between various evolutionary imperatives and, in addition, the high level of wastage in the reproductive process.

7:14 AM  
Blogger Amy Tuteur, MD said...

Dear flea,

It is certainly true that younger physicians possess very little experience in versions, breech deliveries, etc. My opinion about it varies from procedure to procedure. For example, version is an excellent skill and involves very little risk. It would be a terrible shame if we lost it.

Breech delivery is much trickier. I certainly regret the fact that I have very little experience with breech delivery. On the other hand, those who have witnessed a breech with a trapped head describe it as a horrifying experience and would do anything to avoid it.

Then there are some procedures that I would not miss, like forceps. The potential for damaging the baby is so high and I have seen some terrible outcomes. To me it hardly seems worth the risk, medical or legal.

7:22 AM  
Blogger marcus said...

Dear Amy,

I do believe that patients are the ones driving the excess in medical care. Their expectations and demands are high.

I will have to respectfully disagree with you about obesity. You should spend some time in my practice to see the association of obesity with diabetes and hypertension. Most of my pateints are referred by physicians on medications for those problems. About 40% of the diabetics and half of the hypertensives who are on medications don't need medications within 4 to 6 months. Whole foods over highly processed food - I hope that is not food facisism.

Thank you for your comments.

5:51 PM  
Blogger Amy Tuteur, MD said...

Dear Marcus,

I'm not trying to say that obesity isn't a problem; it's the problem that's left after you control most infectious diseases and once you develop sustained adequate food supplies. As such, it is a sign of progress.

"Whole foods vs. highly processed foods".

That's an excellent place to start a discussion about the relative role of diet in health. What scientific evidence is there to show that processed foods are in any way inferior to whole foods? Personally, I'd rather have real cheese than Velveeta, but that's a taste preference. What would be the mechanism whereby processed foods would affect health? What is the evidence that these effects (if there are any) make a meaningful contribution to the health or sickness of the individual? I doubt, for example, that there is any scientific evidence that "processed" sugar is different in any meaningful way from raw sugar.

6:20 PM  
Blogger marcus said...

Dear Amy,

I'll not argue the point on processed vs raw sugar or even on cheeses. But, vegetables and fruits vs French fies and chips are another matter.

11:18 PM  
Blogger Amy Tuteur, MD said...

Dear Marcus,

That's not an issue of raw vs. processed; it's about a particular mode of preparation: frying. There are other ways to prepare potatoes.

I'm interested in whether there is a difference between raw vs. processed per se. There are a variety of claims that processed foods are somehow inferior from a health point of view. I've just never seen any evidence that this is true. Furthermore, there are some forms of processing such as pasteurization which are distinctly beneficial.

As a separate issue, I have noticed recently a spate of scientific papers debunking claims that specific foods are uniquely beneficial to health, or have disease preventing properties (aside from preventing dietary deficiencies). I'm not surprised since there is really no reason to think that vitamins, minerals, etc. have any role beyond that of fitting into the metabolic cascade. Since virtually all humans who have ever lived have survived on a subsistence diet, it is hardly likely that an "ideal" diet of some kind could possibly be needed for human growth and flourishing. Of course, that would mean that the $40 billion dollar supplement industry is one giant con.

Don't get me wrong, I'm not suggesting that food intake is irrelevant. It's just that it has a minimal impact on health. Most people who are ill in this country are ill because of bad luck, not dietary lapses or indiscretions.

7:07 AM  
Blogger marcus said...

Dear Amy,

I want to pick up on your last comment after I get back from the clinic.

We got off to a start with nutrition but I consider that last in lifestyle. Organization (planning), dealing with stress, bad habits (smoking, etc.) and physical activity are major aspects of the equation.

I'll be baaaaack this evening.

7:25 AM  
Anonymous Anonymous said...

"More than 99.9% of all babies ever born were born to women who lived on subsistence diets. "

you could also say

"More than 99.9% of all babies ever born were born through vaginal birth delivery"

8:42 PM  
Blogger marcus said...

Dear Amy,

Well, frying potatoes is processing of French fries and the fats have a negative influence on metabolism. Potatoe is the most commonly consumed vegetable in America because of French fries. It is impressive that in Supersize Me a healthy person can have elevated liver enzymes by the third week.

The human body is a marvelous biological "machine" with amazing manufacturing capability. The buffering, feedback and crossover pathways keep the need for specific items in the diet to a minimum.

Food provides fuel and "building materials". You are correct that for the most part the American diet provides everything the human body needs. Fiber is low and deficiency of some of the phytochemicals might have long-term impact, but that is conjecture.

The most significant aspect of the American diet is excess and calories rank at the top. Processing of food concentrates calories into small volumes. Appetite and satiety are problems and there may be some aspects of processed food and drinks that aggravate appetite, artificial sweeteners for example.

As you know, nutrition does not lend itself to the types of clinical trials that we would consider scientific evidence or proof. Much of the evidence comes from identification of biochemical pathways and non-rigorous epidemiological observations.

The supplement industry is unregulated and open to all sorts of wild marketing. Most, if not all of it, is unnecessary.

The inflammatory agents from fat cells could be a major contributor to disease precesses.

10:03 PM  
Anonymous Anonymous said...

I know you won't post this but I will write you anyway. What is most bothersome about OBs like yourself is your unwillingness to accept ANY responsibility for the C-section rate. Any doctor who will perform or be a member of an organization that does not repudiate maternal requested c-sections does deserve some blame for the c-section rate. And there is no question that certian standard interventions (e.g., get in bed on your back upon admission) do slow labor, which can increase risk and necessitate additional interventions. The never ending OB cycle. And I don't understand how you can advocate evidenced based medicine when so many common OB practices - like mother baby separation after birth - have NO evidence base. Finally, your rant would be better received if you were not so harsh and jusgemental about others "food fascists".

7:17 PM  
Blogger jenne.heise said...

As an pregnant obese woman with a 'morbid obesity' BMI range (though before my pregnancy I *experienced* no morbidity), I have to say that doctor's response to the fear of medical malpractice suits does appear to be driving the craze for c-sections, especially in obese patients.

Unfortunately, such a reaction in the medical profession is unlikely to protect the doctors, if my response is any guide. Being treated as a statistic instead of a patient makes me want to say "I understand that if I refuse any interventions and something goes wrong, I am to blame. But if any of the interventions you are pushing on me go wrong, I will be looking for a lawyer."

Perhaps someone should break down and do a study on the relation between maternal obesity and malpractice suits. A followup study might ask whether doctors who interact with the maternal patient as a person rather than as a BMI measure have more or less malpractice claims.

3:55 PM  

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