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Unneeded cesareans are risky and expensive

Cesarean deliveries are over-used in California, and reducing the number of surgical births would save health-care dollars and protect women's health. Those are the conclusions of a new white paper issued today by the California Maternal Quality Care Collaborative.

The paper's authors, including Stanford professor and Packard Children's neonatologist Jeffrey Gould, MD, agree that cesareans can be necessary and lifesaving. But in the last 15 years, the rate of surgical birth has increased from 22 to 32 percent of California deliveries with no measurable benefits for new mothers or their babies.

This is a concern because cesareans aren't risk-free. After surgical delivery, women experience more pain, infection and hemorrhage than women who give birth vaginally. Women who have had a prior cesarean also have more problems with subsequent pregnancies. The placenta can become deeply implanted in scar tissue from the old incision, causing hemorrhage at the second delivery, for example.

The white paper, which was funded by the California HealthCare Foundation, uncovered striking evidence for over-use of cesarean: Among low-risk women having their first baby, the rate of the surgery varies from nine percent to 51 percent of births based on the mother's geographic location within California. As a press release about the paper says:

This large variation among California regions and hospitals cannot be explained by medical factors alone and therefore suggests that labor management practices and local attitudes help drive the use of cesareans during labor.

Reasons for the increase also include: physicians’ concerns about medical liability and avoidance of risk, as well as specific labor practices such as the increased reliance on labor induction, early labor admission, lack of patience in labor, and the virtual disappearance of vaginal birth after a prior cesarean, the report found.

“Over the last 15 years, cesarean deliveries have become so common that in some hospitals and communities they are considered ‘normal births’ despite the increased risks,” said Dr. Elliott Main, medical director of the CMQCC and a practicing obstetrician.

The white paper makes several recommendations for how to reduce unnecessary cesareans, including removing perverse financial incentives that may prompt obstetricians to over-perform the surgery, encouraging VBACs for women who have already had a cesarean, improving public education about the risks of cesarean delivery, and implementing statewide quality-improvement activities for better labor practices.

The payoff of these changes could be substantial. Not only would women avoid needless medical risk, the state could save between $80 million and $441.5 million a year, depending on the number of surgical deliveries averted.

Previously: NIH panel weighs in on vaginal birth after cesarean
Photo by Gilberto Santa Rosa

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