When might a high C-section rate be a good thing?

The World Health Organization has said (and since reiterated — despite the latest spin-doctoring, which Science and Sensibility exposes) that no country or region should have more than 10-15% C-section rate, and that once above that rate, more mothers and babies are harmed rather than helped by this intervention. The rising maternal mortality rates in the United States (and perhaps other countries) seems to be corroborative evidence of that. So, when might it be a good thing? I can envision one scenario.

If an obstetrician were in practice with several midwives, and the midwives took care of all the normal (low-risk) women, while the high-risk cases were referred out to him, that might be an ideal situation. Assuming the midwives are not “medwives,” they should have low rates of interventions, including C-sections. However, the doctor, having a clientele composed strictly of high-risk women, would have a much higher rate of interventions. Of course, not all “high-risk” women will need C-sections, but the 10-15% figure of ideal C-section rate includes the normal mix of all risk levels of women — so low-risk women would probably need C-sections in the range of 2-5% (which is probably the rate among intended home-birthers), whereas higher-risk women may need C-sections higher than 15% of the time — perhaps 30%? Maybe higher, depending on the particular type of risk.

I have a hard time believing any obstetrician, except perhaps one who has only an ultra-high-risk clientele (and maybe not even then), can justify a C-section rate of 70%, but there are doctors who do have rates that high. Let’s see.

Let’s assume that it is our goal to have a 10-15% C-section rate across a normal mix of risk levels, and there are four midwives and one obstetrician in the practice, with the midwives seeing all the low-risk clients, and transferring all the high-risk ones to the OB. We’ll also assume that the patients are equally divided, so that all providers see the same percentage of clients — that would put the “high-risk” group at 20% of the average population. Assuming the midwives had a 5% C-section rate, the OB would have to have a 55% C-section rate for the practice average to be 15%; if the practice average were at 10%, then the doctor’s C-section rate would need to be 30%. [Out of 100 clients, 80 would be low-risk and see midwives, and for a 5% C-section rate would have 4 total C-sections; so 10% total C-section rate would be 10 women, and 15% would be 15; 10-4=6, 15-4=11. The OB would see 20 women, and would section 6-11 of them for 10-15% total.]

There is no single definition of “high risk,” however, and different providers might use different criteria; and some midwives may continue caring for some women who move into a “high risk category,” while other women may be transferred to doctors. The University of California at San Francisco said that only 6-8% of all pregnancies will have high risk complications, so I’ll use those numbers. [The numbers seem a little low — perhaps they’re only looking at women who ultimately have complications, not just those who are at higher risk of complications.] We’ll assume that instead of an even mix, the OB only sees 10% of all patients (perhaps some low-risk women just want an obstetrician, or they transfer some that they didn’t truly need to), while the midwives (with their 5% C-section rate) would see the remaining 90% — oddly enough, that’s about the reverse of the actual situation in the United States, with midwives seeing about 10% or less of all pregnant women, and obstetricians seeing about 90%. With a 5% C-section rate, 4.5 clients of midwives would have their baby through an abdominal incision (I’ll round it up to 5), so of the doctor’s 10 clients, he would have to have a C-section rate of 50-100%, in order to have a 10-15% C-section rate across the entire practice.

So, it could be possible for a doctor to have an ultra-high C-section rate, while still practicing evidence-based medicine. It’s just not very likely.

The figures I’ve played with above are, of course, only estimates and best guesses. Most obstetricians are not in the idealistic situation described above. (I know of none — do any of you know of such a practice, or such an obstetrician, who sees only high-risk women?) With 90% of the pregnant population seeing obstetricians, the average doctor is going to be seeing primarily low-risk clients. So why are their C-section rates so dad-blame high?? There are 4 millions live births in the United States every year, with a 31.7% C-section rate, or 1,268,000 babies born by C-section. Assuming there to be a “normal” mix of low- and high-risk patients (say, 92% and 8% respectively), and all high-risk patients have C-sections, that still only accounts for 320,000 births, with 948,000 C-sections being performed on low-risk patients. Even subtracting 5% low-risk women (200,000) who will end up with a necessary C-section, that still leaves about 750,000 C-sections to be accounted for. Somehow, I don’t think “maternal request C-sections” can account for all of that.

So, if your obstetrician has a clientele composed of primarily high-risk patients, and he has a high C-section rate, that might be understandable. But for the average obstetrician… not so much.

4 Responses

  1. I think we cannot reduce the c-section rate without tort reform. When Doctors are no longer practicing defensive medicine and are not tied to using the efm as the sole predictor of outcomes, then we can decrease c-section rates. I heard that Obama plan is not looking at that. They need to.

    ANytime there is a blip in the screen (EFM) we now immediately think C-section. 5 years ago we watched and watched some more. Only after it stayed nonreassuring did we do a c-section. Now Docs will section first ask questions later. And they do it because they have been sued. All of them! every single one of the Doctors I know who have practiced over 10 years have had legal problems. Most of those Doctors are very good Doctors. Many have left the profession. Something has got to give.

    Women should not have to have a homebirth to have a non-interventive birth. That is totally screwed up! No one should have to risk safety on either side of the equation. The more I think of it, the more I think free standing birth centers across the street from a major hospital are a good idea. I think the closest Birth center in my area is 1.5 hours away from me and I would have to drive through city traffic to get there. I would like to see the Obama plan invest in more birth centers.

  2. The reason there are so many c-sections is due to the fact OB’s and even midwifes pay outragous amounts in malpractice. No one wants to be sued, but I have been doing alot of reading since I am TTCing and OB’s will opt for a c-section just because their malpractice insurance has informed them of what they can win if they do get sued and what they can’t. There are situations where even if it’s not the doctors fault, they won’t win, such as shoulder dystocia. It’s not the doctor’s fault, it’s the baby’s anatomy…Mother’s are quick to sue at the drop of a hat over their babies and rightfully so, but that’s just hogwash to sue a doctor over something they have nothing to do with!
    As a woman I feel we need to stop being babies and suck it up and let our bodies do what they were made to do..have babies naturally! I am an extremely high risk patient for any OB due to me being diabetic, having high blood pressure, polycystic ovarian syndrome, and high cholestrol and I was told that c-section is my only option followed by a hysterectomy. I am going to atleast try to push for a vaginal birth because I think my body can do it! If not…c-section it is…either way I have to get a hysterectomy…We have all just accepted this is the way things are and we aren’t truly fighting for what is the best and that’s not being so drugged up and cut open!

  3. Thanks for your post–when I read the title, I thought “how could there ever be a good reason for a high c-section rate?” However, the situation you described is exactly the situation in which I work.

    We have three midwives and one OB. The midwives see almost all the clients–only if a woman specifically wants an OB does she see him. He does about 5 births/month compared to our 35. We even manage the higher-risk pregnancies, with consultation from our OB, of course.

    The midwives’ primary c-section rate is about 5%. I’m not sure what the OB’s rate is, but it would be high since most of the deliveries he does are the ones that require surgery. This would include breeches where the mother does not want to try a vaginal delivery, twins where the mom decides for a c-section or her babies’ positions are unfavorable for a vaginal delivery, scheduled repeat c-sections, and births where the midwives need to call the OB because of complications. We are fortunate that our OB is not hasty to decide upon c-section as a solution, and really tries to give the woman every opportunity for a vaginal delivery.

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