Number of elective C-sections rising: study
By Joseph Conn
Nearly one woman in five who had a Caesarean delivery at a New York City hospital after being in labor either requested or were offered a C-section by their physician without a classic medical condition, according to a new study by researchers at New York-Presbyterian Hospital/Weill Cornell Medical Center.
Obstetricians at the unnamed hospital filled out questionnaires between May and November 2002 on 422 consecutive deliveries involving women who had been in labor prior to having a C-section. Questionnaires all were filled out within a week of delivery, most within 24 hours, said study co-author Robin Kalish, M.D., assistant professor of obstetrics and gynecology at Weill Cornell Medical College and an assistant attending obstetrician and gynecologist at New York-Presbyterian/Weill Cornell.
The surveys showed C-sections were offered by doctors in 13% of the cases prior to a clear medical indication and were requested by patients in another almost 9% of cases.
Duration of labor, use of epidural anesthesia and gestation age of the fetus apparently were not factors in the decisions. Neither, to Kalish's surprise, were "convenience factors" such as time of day or day of the week of the delivery.
The doctors, however, were a factor.
Older doctors, specialists in maternal-fetal medicine and full-time faculty members at the medical school affiliated with the hospital were more likely to offer women C-sections during labor than younger doctors and nonspecialists.
The data didn't say why, but Kalish theorizes that more communication between these physicians and patients is occurring in cases that are not black and white, where the evidence is building to a point where a C-section is justified by clinical guidelines, but that point has not been reached.
For instance, one guideline is to allow a first-time mother to push for three hours, Kalish said, "but if we're finding that after two hours, the patient is exhausted, the (fetus's) head is big, the pelvis seems small, someone will say, 'Hmm,' and will have a discussion with the mother, if you'd rather, we'll just go ahead with the C-section now. This is the gray zone."
But why certain groups of physicians respond to these situations differently than others is still a matter for conjecture, and possible a later study, Kalish said. For subspecialists in maternal-fetal medicine, training might be a factor, Kalish said.
"It's theorizing, but during the fellowship, most people get some formal ethics training and are more likely to encourage a patient's autonomy," she said.
More research is needed concerning patient choice and physician counseling, she said.
The National Center for Healthcare Statistics in December reported that 26.1% of all deliveries in the U.S. in 2002 were by C-section, the highest percentage in history and up 7% from the preceding year.
A study by HealthGrades of Lakewood, Colo., found that "patient choice" C-section deliveries rose 25% between 2000 and 2002, representing 2.21% of all U.S. deliveries in 2002. Kalish said that level of influence is being felt even both before and after labor begins.
"Women right now, it's been established -- even though we don't recommend elective C-section before the start of labor -- have a lot more say," Kalish said.