Is the 33 % C-section Rate the New 10 %?
There is nothing mysterious or magical about how to reduce the c-section rate in the U.S. The question is whether we just want to talk about it or whether we want to dig in our heels and actually do something to bring that 33 percent rate down to what used to be the norm—10 percent. Or stated another way, follow the money to find out why the c-section rate is so high in the U.S. Our healthcare system is currently running full bore after the money, and that includes too many c-sections. In the U.S., c-sections account for more surgeries than any other operation.
When I was in residency, the general c-section rate for the country was 10 percent. I have practiced obstetrics with a 10 percent c-section rate and I know how it can be done. Even though it’s possible to reduce the c-section rate, there are many people involved in the current high rate problem who will not take any responsibility for their part in the problem, so the high c-section rate is likely to remain a significant problem for the American patient.
How to Decrease the C-section Rate
1. Decrease the payment for c-sections
Medicaid and Health insurance companies pay twice the reimbursement for a c-section than they do for a vaginal birth or a vaginal birth after cesarean (VBAC). The payment schedule for various forms of delivery greatly increases the incentive to do c-sections because the pay is high for a procedure which takes relatively little time. The payment for a natural delivery is half what it is for a c-section, even though monitoring a natural labor and delivery can take hours. And worst of all, the VBAC, a good way to reduce the c-section rate, is reimbursed at the same rate as a natural delivery. Yet it’s the most complex delivery procedure, requiring more time, better informed-consent, more anxiety, and a very calm and confident group of labor and delivery nurses and doctors. A VBAC should be reimbursed at more than the current c-section rate.
2. Increase VBACs
With the American College of Obstetricians and Gynecologists (ACOG), their attitude toward doing or not doing sVBACS come and goes. There was a time when ACOG for all intents and purposes banned VBACs. Today ACOG accepts VBACs, but limits VBACs to certain patient ages, certain places, and does not approve VBACs for multiple births such as twins.
None of my VBAC patients ever had a blood transfusion and I had only one infection after a VBAC delivery. One patient, a nurse practitioner, had four previous c-sections and a successful VBAC with her fifth child. She did well without any morbidity for either herself or her baby.
3. Deliver breech babies vaginally
Most breech babies can be delivered vaginally. I’ve done dozens of vaginal breeches and vaginal multiples without any incident. One patient who had had a very successful vaginal breech birth told me later the wife of one of the other obstetricians said vaginal breech births were dangerous and carried a risk for complications of the offspring later on. In my experience, there isn’t good evidence for such a statement. I am aware of the present literature indicating lower Apgars in up to 50 percent of breech vaginal births.
We can choose to do breech births well or we can by default do them badly. I believe that the lower Apgar scores for vaginal breeches are not necessarily due to the vaginal breech, but rather to doing the vaginal breech with insufficient skill.
I’ve most often done vaginal breech delivery under a double set up, meaning having everything ready in case a c-section is needed, but I’ve never needed the backup. Vaginal breech babies should be allowed to deliver spontaneously to their umbilicus, (belly button). Then the legs and the arms should be delivered.
The most important thing to remember about delivering breech babies is to flex (chin tuck) the baby’s neck. You do this by putting suprapubic pressure on the mother’s abdomen externally with your hand. The baby’s face needs to be looking backward, at mom’s sacrum (tail bone) and the baby’s head needs to be pushed out with the physician’s left hand on the mother’s abdomen.
Flexing the baby’s neck by suprapubic pressure is the key to a successful and uneventful vaginal breech birth. This flexing of the baby’s head presents the smallest diameter of the baby’s head to the mother’s pelvis. Extending the baby’s neck (star gazing pose) as a result of pulling on the baby’s arms or legs which have already delivered creates the largest circumference of the baby’s head to the mother’s pelvis. This makes the baby’s head and, therefore, the remainder of the baby, impossible to deliver vaginally. This may be where the low Apgars come from.
The problems caused by lack of flexion of the baby’s neck exists for c-section breech birth deliveries as well as vaginal breech births. So, one way or another, the delivering doctor needs to remember to avoid neck extension and to produce neck flexion. Whether the breech is delivered vaginally or by c-section, the baby must be facing the mother’s spine. If the breech baby is facing the front of the mother instead of towards the mother’s spine, this breech position which must turned or be delivered by c-section
4. Eliminate the C-section of Convenience
Individual obstetricians often prefer c-sections to vaginal breeches or vaginal birth of multiples. I believe one of the problems we have today is that many of the professors or residency instructors don’t feel confident themselves in doing a vaginal breech, vaginal birth of multiples, or even VBACs.
Doing a 20-minute surgery at a scheduled time is easier than wondering about trying to work through an unscheduled vaginal birth, breech birth, multiple birth, or VBAC. However, with a c-section, the hospital stay is three times longer. So not only is the cost of the c-section twice the cost of a natural delivery, but there will be the additional cost for more days in the hospital.
Third-party payers could simply decide to decrease the amount of money that they pay for c-section surgery. There would probably need to be some negotiating with ACOG and the AMA, but reducing the rate of reimbursement for c-sections should be possible. I would also increase the reimbursement for VBACs because those actually require much more skill, time, attention, and commitment than a cesarean section or the usual vaginal birth.
Two Good Reasons to Decrease the C-section Rate
1. Patient morbidity would be reduced
C-sections are major surgery. Complications can include making a hole in the bladder or bowel, tying off a ureter (the tube that goes from the kidney to the bladder), or even the loss of the uterus to stop hemorrhaging.
Even with the best c-sections, there’s always an increase in time to recover from the surgery.
2. Decreasing maternal mortality
Today maternal mortality in the United States is increasing, not decreasing. Presently we rank 33rd among other countries in our maternal mortality rate, worse than any other developed country in the world. At 33rd, the U.S. is on a par with Iran’s maternal mortality rate. The Scandinavian countries have a maternal mortality rate of 2 deaths per 100,000 births, not 21 maternal mortalities per 100,000 births. Some critics claim other countries don’t record all of their maternal mortalities in the ways the U.S. does, but that shouldn’t be an excuse to avoid addressing the inordinately high rate of maternal mortalities in the U.S.
We CAN Decrease the C-section Rate
It is possible to reduce the c-section rate, but it will take some major alteration in the mindset of insurance companies, Medicaid, and ACOG obstetricians. It’s time to stop complaining about how the data for c-sections and maternal mortalities are collected and start taking positive steps to decrease the financial incentives for c-sections and make the delivery playing field even. Unfortunately, those following the money will be very reluctant to accept change.
On the other hand, without the commitment of the obstetric profession, it may be that 33 percent is the new 10 percent. And the next year it’ll be 35 percent, then 40 percent, ad infinitum.