Medical Professional Liability and the Delivery of Obstetrical Care Volume II, An Interdisciplinary Review (1989) / Chapter Skim
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Is the Rising Rate of Cesarean Sections a Result of More Defensive Medicine?
Is the Rising Rate of Cesarean Sections a Result of More Defensive Medicine?
Pages 27-40
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From page 27... ...
To address this difficult question, ~ review the epidemiology of cesarean sections, discuss the causes for the rise in the rate, and examine the possible relationship of that rise to the practice of defensive medicine. HISTORICAL PERSPECTIVE Cesarean deliveries were rarely performed in the United States and Europe prior to the end of the nineteenth century.)
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From page 28... ...
However, this report stressed that the high mortality was due as much to preexisting conditions as to the procedure itself EPIDEMIOLOGY OF CESAREAN SECTIONS There has been a dramatic rise in the rate of cesarean delivery, from less than 5 percent before 1965 to 24.1 percent in 1986.~: The primary cesarean section rate appears to be leveling off at 17.4 percent, having risen from 4.2 percent in 1970.~2 If the current rate of increase continues, by the year 2000 the total cesarean section rate will be 40 percent; for women aged 35 years and older, it may reach 50 percent.~3 A National Institutes of Health (NIH) task force examined the reasons for the increase in the cesarean section rate between 1970 and 1978 (Table 1~.~4 It reported that 30 percent of the rise was due to a diagnosis of dystocia,25 to 30 percent to repeat cesarean sections, 10 to 25 percent to breech presentation, and 10 to 15 percent to fetal distress.
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From page 29... ...
Liss.1987.1Yends in the United States cesarean section rate and reasons for the 1980-85 rise.
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From page 30... ...
Comparison of National Cesarean Section Rates There has been a marked rise in the frequency of cesarean deliveries in Europe and in Australia and New Zealand (Table 2) , but the highest rates are found in the United States.27 National differences are related to differences in obstetrical practice with regard to complications in pregnancy and delivery and the frequency of vaginal deliveries following a cesarean section.
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From page 31... ...
Originally intended for the management of high-risk obstetrical cases, electronic fetal monitoring (EFM) has become almost routine for deliveries in the United States respite a number of recent reports that routine fetal monitoring does not improve the outcome in Tow-risk obstetrical patients.28 29 The widespread use of EFM has lead to a marked increase in the cesarean section rate, for a number of reasons.
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From page 32... ...
In contrast, most patients today have a low transverse incision, which has been shown in many studies to allow for safe vaginal delivery in a subsequent pregnancy.35 In a review of vaginal deliveries following prior cesarean sections the incidence of uterine rupture was 0.7 percent; the incidence of perinatal death (fetal
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From page 33... ...
The maternal mortality rate is defined as the number of maternal deaths during pregnancy and within a set time postpartum per 100,000 live births.38 For deaths directly related to the cesarean section, the rate in five American and two European studies ranged from 0 to 60.7 per 100,000 cesarean sections.39 40 The mean was 27 deaths per 100,000 cesarean sections (with a 95 percent confidence limit, + 15.11. It is difficult to compare these seven studies as two were hospital based, three were statewide reviews, and two dealt with national statistics.
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From page 34... ...
HAS THE INCREASED RATE OF CESAREAN SECTIONS LOWERED PERINATAL MORTALITY? Is there a cause-and-effect relationship between the dramatic rise in the number of cesarean sections performed in the United States over the last decade and the simultaneous decline in neonatal mortality?
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From page 35... ...
The contrary point of view was put forth by Williams and Chen in a study in California in which they showed that there was a reduction in perinatal mortality in infants weighing less than 2,000 grams as a result of the advent of neonatal intensive care units and an increase in the cesarean delivery rate.46 ~ examined the effects of cesarean section on neonatal mortality rates for breech and low-birthweight vertex infants in Georgia between 1974 and 1978.47 For 229,241 singleton deliveries, cesarean section improved the neonatal outcome for breech infants and high-risk low-birthweight infants presenting by the vertex. COST OF CESAREAN SECTIONS In 1984 health care costs represented 10.6 percent of the gross national product (GNP)
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From page 36... ...
If the cesarean section rate could be reduced by 5 percent, it would represent a savings of between $700 and $900 million per annum. HEALTH POLICY A 1987 survey of practicing obstetricians by the American College of Obstetricians and Gynecologists found that 46 percent were performing routine fetal monitoring, 41 percent reported a change in their clinical practice because of the medical-legal environment, 33 percent cared for fewer or no high-risk patients at all, and 12 percent were no longer practicing obstetrics.48 The widespread use of routine EFM is a form of defensive medicine: it reflects the perception among many clinicians that fetal monitoring and a timely cesarean section can keep them out of court.
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From page 37... ...
Arguments that the rise in the cesarean section rate is a result of defensive medicine include 1. the widespread use of fetal monitoring (because of the medicallegal environment, fetal monitoring is widely used, even though its poor predictive value for detecting perinatal asphyxia in low-risk patients results in more cesarean sections)
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From page 38... ...
dystocia and repeat cesarean sections as important reasons for the rise in the cesarean section rat~they are probably only in part a result of the medical-legal environment.59 The high cesarean section rate in the United States is a major public health problem, one that is having and will continue to have a major impact on health care delivery. If the $800 million that could be saved by reducing the cesarean section rate by 5 percent were spent instead on prenatal care and preventive programs, dramatic effects on maternal and child health would be seen.
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From page 39... ...
1987. Itends in the United States cesarean section rate and reasons for the 1980-85 rise.
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From page 40... ...
Electronic fetal monitoring and clinical practice. A survey of obstetric opinion.
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