The number of cesarean sections has risen by 50 percent over the last decade without any medical or cost-benefits to patients. Tina Rosenberg discusses in her NYTimes article In Delivery Rooms, Reducing Births of Convenience, a healthcare infrastructure that encourages C-sections despite its risks and harms. In doing so, she highlights lessons medical care providers can glean from the exception to the rule: San Francisco General Hospital.
San Francisco General is a public hospital serving a largely lower income population. With few luxuries and baby swag to provide to its mothers, the hospital excels in exercising evidence-based medicine, thereby protecting the health of mothers and their newborns. The evidence, according to the American College of Obstetricians and Gynecologists, suggests doctors should be performing few C-sections--setting a target rate of 15.5 percent for first-birth low-risk C sections.
The recommendation should not be taken lightly, as Rosenberg expounds: Having a C- section puts a woman at increased risk for hysterectomy, hemorrhage, infection and deep vein thrombosis, and the risk rises with each subsequent C-section. They are also more expensive. The California Maternal Quality Care Collaborative, a group that works to improve birth outcomes, said commercial insurers pay 60 percent more for a C-section than a vaginal delivery and this is the most commonly performed surgery in America. She reasons that with limited health or financial benefits, another factor is driving the increase in C-sections. Indeed, these factors motivating C-sections in most hospital wards are absent at San Francisco General, where C-section rates among the lowest risk patients are 10.1 percent compared to rates of 62.7 at neighboring hospitals.
Rosenberg asserts, Probably the single most important factor is that doctors at General are salaried and on shifts. Their pay doesn t vary by the number of patients they see or tests they order. Perhaps more important is the fact that most of what a private-practice ob-gyn doctor earns from taking care of a pregnant woman comes from the delivery. That means doctors have a strong financial incentive to deliver their patients babies themselves.
If private practice OB-Gyns receive more compensation for the delivery itself, this boils down to a timing and scheduling matter, which C-sections accommodate much better than vaginal deliveries. Unlike doctors at San Francisco General, private practice physicians are not available at any moment. Chief of Obstetrics at General, Juan Vargas, comments, We re here no matter what. There s no time that a woman needs to be delivered by.
The solution to decreasing C-section rates may therefore originate from switching from fee-for service medicine to salaried doctors, says Rosenberg. In addition, nurse-midwives are another way San Francisco General allows labor to take its course and reduce C-sections. Vargas adds, A lot of us recognize that midwives are the real experts in labor. I trained as a high-risk obstetrician. I m best at dealing with complications. So I stand by and try to be patient.
Similarly, Obstetric hospitalists also discourage C-sections, allowing labor to enfold naturally. Hospitalists are salaried doctors that monitor mothers throughout labor and call to private practice physicians if needed during delivery. These professionals are dedicated exclusively to labor and delivery, providing not only patient attention, but also expertise in vaginal delivery such as operative deliveries with forceps and vacuum. Dr. Brian Iriye, managing partner of the Las Vegas High Risk Pregnancy Center, evaluated the impact of hospitalists at a Las Vegas facility, concluding that they reduced C-section rates by 27 percent. Moreover, Iriye s study, and those alike, found hospitalists not only reduced adverse events, but also were associated with a 90 percent reduction in malpractice payouts. Thus, patience during labor may benefit even the hurried doctors.
ACSH s Dr. Gilbert Ross had this comment: C-sections done just for the convenience of doctors should never be done. Delivery even one of two weeks before full-term can have serious adverse effects. Delivering by C-section should be avoided unless absolutely necessary.