Born in the USA (10 page)

This is why the International Federation of Gynecology and Obstetrics (FIGO), the umbrella organization of national obstetric organizations (including ACOG), issued a statement in 1999: “Because hard evidence of net benefit does not exist, performing cesarean section for non-medical reasons is ethically not justified.”
²⁹

Currently more than one million C-sections are done in the United States every year, which amounts to more than 29 percent of all births.
³⁰
Through an exhaustive scientific process, WHO has calculated that the optimal rate of C-section for saving the most women and babies is 10 to 15 percent.
³¹
There is no evidence that a rate of C-section over 10 percent saves lives.
³²
All attempts to show fewer babies dying in highly developed countries when there are more obstetric interventions, such as C-sections, have failed. A U.S. National Center for Health Statistics study comments, “The comparisons of perinatal mortality ratios with cesarean section and with operative vaginal rates finds no consistent correlations across countries.”
³³
A review of the scientific literature on this issue by the Oxford National Perinatal Epidemiology Unit found that a number of studies had failed to detect any relation between crude perinatal mortality rates and the level of operative deliveries.
³⁴
In other words, scientific evidence shows that increased rates of C-sections are not saving more lives of either women or babies.

The WHO's optimal C-section rate was challenged and called “arbitrary” by American obstetricians in a 1999 article in the
New England Journal of Medicine
.
³⁵
The authors of the article are not connected with the WHO and, to judge from their position, it appears that they did not take the time to learn how optimal C-section rates are determined.

The figure was ascertained during a WHO consensus conference attended by sixty-two participants from more than twenty countries, including representation from U.S. obstetrics.
³⁶
Participants began with a thorough review of the scientific literature on the risks of C-section to women and babies and concluded that the optimal rate must be the minimal optimal rate. Then they studied variations in C-section rates across countries. As several countries that had low rates of maternal and infant mortality were found to have national C-section rates close to 10 percent of live births, this appeared to be a minimal optimal rate. Coupled with this, studies sponsored by the WHO that span many countries have found no evidence that C-section rates above this level decrease mortality rates. The overall recommendation was then modified from 10 percent to a rate of 10 to 15 percent because some hospitals have higher-risk populations, especially referral hospitals to which general hospitals send difficult or complicated cases. Participants concluded by consensus that a rate of 10 percent is optimal for hospitals serving the general population, and up to 15 percent is optimal for hospitals serving high-risk populations.

In 2004, twenty years after the WHO announced its recommendation regarding optimal C-section rates, the organization undertook a study to look at C-section rates in all countries and compare them with maternal mortality rates.
³⁷
This study found that countries that have a C-section rate below 10 percent (as do most poor countries) have higher maternal mortality rates, and countries that have a C-section rate above 15 percent (as do some highly industrialized countries) also have higher maternal mortality rates. Thus the study confirmed the earlier WHO recommendation. Apparently, women's bodies and reproductive capacities do not change over twenty years. The study goes on to urge countries with C-section rates above 15 percent, such as the United States, to carefully evaluate their
maternal mortality rates, including the contribution of C-section to maternal mortality. We can hope that this will raise awareness of the fact that the current C-section rate in the United States is double the optimal rate and the current U.S. maternal mortality rate is double that found in a number of other countries.

Interestingly, there is a small group in the United States that has a rate of C-section far below the national rate, with excellent results: the Zuni-Ramah Native American population. A study found a 7.3 percent C-section rate among this population in 1996.
³⁸
And although many members of this group live in poverty and have a higher than average incidence of obstetric risk factors (such as many pregnancies and poor general health), no adverse outcomes were found from the low C-section rate. Researchers attribute the low C-section rate among the Zuni-Ramah to the “prominent involvement of family physicians and nurse-midwives, who have a significantly lower cesarean delivery rate and intervention rate,” and to “almost universal acceptance of trial of labor after cesarean,” and to “a cultural attitude toward childbirth and increased social support within the community.” These are elements in maternity care that can be seen as more modern and advanced than the obstetric-based maternity care in the United States today. In
chapters 8
and
9
, we will look at how we can make all maternity care in the United States more like this group's.

Another important aspect of the debate surrounding C-section rates is cost. First, to say that vaginal birth is nearly as expensive as C-section, as some obstetricians have done, is absurd.
³⁹
Although it is true that the practice style of many obstetricians in the United States results in vaginal births that are needlessly expensive owing to unnecessary interventions, a C-section has many associated costs that must be factored in. These include the cost of maintaining the operating room; fees for surgeons, assisting surgeons, and surgical nurses; and the costs of anesthesia, the anesthesiologist's services, surgical instruments, blood for transfusion, and a longer postbirth hospital stay.

The C-section rate in 2004 in the United States was 29 percent, which means there were approximately one million C-sections that year. If the rate had been 12 percent, the evidence-based rate found in those countries that have the lowest mortality rates for women and babies around the time of birth, there would have been only about a half-million C-sections that year, which leaves a half-million
unnecessary
C-sections. Since each C-section costs at least $5,000 more than a vaginal birth, we see that the United States spent approximately $2.5
billion
more than necessary on births in 2004 because of uncalled-for C-sections.

Those are just direct costs. That $2.5 billion does not include the long-term costs of nonemergency C-section, which are huge. More C-sections mean more babies in intensive care with respiratory distress, more emergency surgeries for pregnancies outside the uterus, more emergency surgeries due to detached placentas and hemorrhaging, and more emergency surgery for ruptured uteruses. The true amount wasted on unnecessary C-sections is probably closer to twice the $2.5 billion figure.

The concept of women choosing C-section raises further questions. If surgery is done only because the woman requests it, who pays for it? If a woman decides to have cosmetic surgery, such as breast augmentation, most insurance companies and HMOs will not cover the cost. However, while it is next to impossible for a surgeon to find a medical reason to do breast augmentation, it's easy for an obstetrician to cover up an elective C-section with a medical justification. This is insurance fraud, and it happens frequently. When insurance companies unwittingly pay for elective C-sections, this inevitably causes insurance premiums to go up. So the cost of all those unnecessary C-sections is borne by the public, or by everyone who pays for health insurance. And even if a woman pays for an elective C-section performed by her private obstetrician in a private hospital, the public is still paying as well, because public funds helped pay for the education and training of her doctor and for the construction and running of the private hospital.

Some of these same issues regarding risks, information disclosure, ethics, and unnecessary costs apply to other invasive obstetrics interventions as well. When lecturing to a roomful of obstetricians, I often show a slide (see
table 2
) that lists common obstetric procedures and policies and shows how often they occur in the United States and how often they should occur based on scientific evidence.

Usually, quite a few obstetricians in the room become defensive when I present this table because it makes clear that their practice is a long way from the stated goal of obstetric textbooks: evidence-based practice. Every leading obstetric textbook today makes repeated strong statements about the importance of coming as close as possible to the scientific data. Obstetricians like to say they are scientific, but clearly many of them are anything but. Such a large gap between what obstetricians are doing and what science says they should be doing could not exist if many, if not most, obstetricians were not ignoring science and ignoring their own textbooks.

Now let's look at obstetric intervention rates in one metropolitan area—Seattle, Washington.
Table 3
demonstrates the gap between obstetric practices
and scientific evidence at nineteen Seattle hospitals in the year 2000. In nearly every hospital in Seattle there is a big gap between what obstetricians do during labor and birth and what they should be doing, according to scientific evidence. Note specifically their practices with regard to the routine use of intravenous drip, drug induction of labor, routine electronic monitoring of the baby, and C-section. A woman in Seattle would be hard pressed to find a hospital where she could have a birth that is not high-tech and full of unnecessary invasive interventions.

One can see at a glance in both these charts that the big gap is the result of obstetricians doing too much, or intervening when it is not necessary and can even be dangerous. To understand why so much unnecessary technology is used during pregnancy and birth, it is instructive to understand how technology comes to be used in obstetrics in the first place. One might expect that the use of a new technology or drug would be preceded by careful scientific
evaluation, followed by official approval and thoughtful requirements for educating doctors in its use. Sadly, the truth is something else entirely.

While I was attending a conference in Chicago in the mid-1990s, an anesthesiologist from Boston told the audience how she first heard the idea of using epidural block for normal labor pain. She said that a colleague called her one night and told her that he had tried it on ten women, it was fantastic, and she should try it too. So, as she proudly told the audience, the next day she tried it. During the discussion, I challenged her, saying that it appeared she was doing experiments on women without their permission. Confused and angry, she replied, “But that's how we make progress in medical care.” She was clearly using the anti-precautionary approach to the introduction of new interventions—assumed safe until proven unsafe (see
chapter 4
). Still today, experimentation in the technique of epidural block is going on all across the United States on the bodies of women who are rarely told that they are experimental subjects.