At the end of 2015, the Journal of American Medical Association (JAMA) published a study indicating the ideal cesarean delivery (C-section) rate the World Health Organization has established, of 10 to 15 percent of all baby deliveries, may be too low.
After analyzing data from 23 million C-sections performed during 2012 in 54 countries, the study found that maternal and fetal mortality declined as the C-section rate approached 19 percent, indicating a more optimal lifesaving rate. The survival benefits of delivering via C-section versus vaginally leveled off after 19 percent.
While many foreign countries performed C-sections well below this rate, the C-section rate in the United States is almost 33 percent. Given that the United States has one of the highest maternal mortality rates among developed nations, why does its C-section rate so far exceed the ideal rate of reducing mortality? And why do doctors seem so overly eager to cut these days, rather than to wait out the natural labor process?
Private Insurance Pays More for C-Sections
Although I suspect the answer to this question is rather complex, NPR’s Shankar Vedantam provides a simple answer: “Obstetricians perform more cesarean sections when there are financial incentives to do so,” citing a study conducted by the National Bureau of Economic Research (NBER), which analyzed the links between “economic incentives and medical decision-making during childbirth.”
NBER is not the first to suggest that money motivates the rise in C-sections. Over 20 years ago, the National Center for Biotechnology Information noted this alarming trend: “Providers who encounter higher opportunity costs while attending to mothers in prolonged labor can reduce these costs by operating . . .” Delivering via C-section costs the physician less than delivering naturally, particularly when the patient is covered by private insurance: “Mothers with private, fee-for-service insurance have higher C-section rates than mothers who are covered by staff-model HMOs, who are uninsured, or who are publicly insured.”
That’s rather discouraging news for mothers with private insurance who want to deliver the way God intended (like me), particularly for those who have had a previous C-section and hope to have a vaginal birth after C-section (VBAC) (again, me!). Since “the Physician has to devote considerable more time in the labor suite for a VBAC (vaginal birth after cesarean) than for a scheduled repeat caesarean delivery . . . the hospital administrator makes a larger financial return on a cesarean delivery compared with a vaginal delivery,” writes the deputy editor of the medical journal Obstetrics and Gynecology, Dr. John T. Queenan.
A Doctor Pushed Me Into a C-Section
If only I had known the odds were stacked against me, perhaps I wouldn’t have been quite so heartbroken when an impatient obstetrician cast aside my VBAC plans. My first C-section was an emergency, caused by a random complication that wasn’t likely to occur again, so I very much hoped to avoid having another C-section.
Although exceptionally grateful for the lifesaving intervention, I did not want to go through the hideous recovery process. C-sections are serious surgeries with serious complications, (several of which I experienced). These include risk of blood clots, blood loss, adhesions or serious infection, and more specific complications including risk of uterine rupture, complications with future pregnancies, or reducing the number of pregnancies a woman can have. So no one should treat C-sections lightly.
Call me old-fashioned, but I also really wanted to experience natural childbirth. So, when I became pregnant again, I began the tedious process of finding a doctor who was committed to helping me have a VBAC. Find her I did: together we wrote pages of brilliant birthing plans.
But those plans were damned, because my doctor was out of town when my labor commenced early on Father’s Day weekend. Instead, I was left with a doctor who took one look at my previous C-section and began scrubbing in for surgery. I was given no chance to labor. I was bullied and told that even though my child wasn’t in distress, the doctor would rather not wait for distress to occur (as if distress was inevitable).
I was in and out of surgery within an hour of being admitted. As the doctor was stitching me up, he smiled at me and said, “Thanks for making that so quick. Now I can get home to my own Father’s Day celebration.” Despite my wishes, I went through a major unwanted and, I believe, unnecessary surgery. For what—a little extra cash and a little more time at home for the doctor?
Natural Delivery Takes a Lot More Time
It made me wonder just how much time a physician saves performing a C-section instead of attending to a vaginal birth. A non-emergent C-section take 10 to 15 minutes, with an additional 45 minutes for delivering the placenta and suturing the incisions. Allotting an additional hour for pre and post-surgical procedure, the average C-section takes approximately two hours of the surgeon’s time.
The average labor and delivery time of a vaginal birth for a first-time mother lasts about 16 hours, with that time decreasing with subsequent births, per the Cleveland Clinic. So, a doctor could deliver eight babies via C-section in the time it takes to attend to and deliver one baby vaginally.
Let’s do the very simple math: if the average insurance payout for a vaginal delivery is $18,329, while the average insurance payout for a C-section is $27,866, then it costs $9,537, or 34 percent more, to have a C-section. Given that physicians could theoretically perform eight C-sections in the time it takes to attend to one vaginal delivery, providers could rake in an additional $76,296 during that 16-hour time frame! Based on that rather elementary math, it’s easy to see why motivations behind performing C-sections could be financial.
Our Legal Climate Is Rotten, Too
Obstetrician Amy Tuteur believes the financial motivations behind C-sections are more closely tied to physicians’ fear of being sued than their ability to make more money. Citing a study analyzing the most common causes for obstetrics lawsuits, Tuteur states: “Of the 9 most common reasons for obstetric practice, 6 allege the failure to perform a c-section or perform a c-section sooner. In other words, performing a C-section when there is any doubt about the baby’s health, or even before there is any doubt, will virtually eliminate the chance of being sued successfully in connection with the delivery; it might even make a lawsuit less likely if the plaintiff cannot argue that a C-section should have been performed.”
Because we live in a litigious society, where parents have “an inability to tolerate any risk to a newborn,” Tuteur believes the rate will continue to rise. But I believe the responsibility lies more with physicians than with patients, as fear of litigation cannot be a legitimate excuse to perform unnecessary and unwanted surgery. Yes, medical malpractice tort reform is grossly needed, but if obstetricians faced an equal risk of lawsuits from mothers who did not want or need C-sections, I highly doubt the C-section rate would be so high.
Whether the increase in C-sections is due to time, money, or litigation, one thing is certain to associate professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School Dr. Hope Ricciotti: “There’s a basic, irreducible number of C-sections we need to do for women’s health. But there’s also no question that we’re doing too many in the United States.”
Also Consider the Gray Zone
So, how do we address which C-sections should be eliminated? In attempts to address this question, Dr. George Macones, chairman of the department of obstetrics and gynecology at the Washington University in St. Louis School of Medicine, expounds: “When the procedure is needed — when the mother or baby is in distress or other factors make a vaginal delivery hazardous — it can be a lifesaver. But only about 5 percent of C-sections are true emergencies. Around 3 percent are completely elective, meaning there’s no medical reason whatsoever, but the vast majority of C-sections actually fall into a gray zone: the baby looks big, mom is past her due date, labor isn’t progressing well.”
In addition to addressing the unbalanced financial incentives for performing C-sections, this “gray” area must also be addressed, through reevaluating which complications are truly emergent and which are manageable. Queenan points to breech babies (buttocks or legs first in the birthing canal, instead of head first) as an example. Once considered a manageable complication of natural delivery, breech babies now almost always indicate the need for a C-section, because “vaginal delivery of breech fetuses is no longer taught in many training programs.”
Limited physician training does not constitute an emergency: it is just plain irresponsible, and should not be allowed to become the norm. The “gray” area will never be black or white, cut or don’t, but the female body is made to deliver babies: doctors should be trained to afford women every opportunity to do so.
By providing compelling financial incentives to medical providers, we have allowed doctors to use a major, and often unnecessary, surgical procedure to become the default method of delivering babies when natural delivery conditions are less than ideal. Until we equalize those financial incentives through compensation and tort reform, the medical community will continue to lean towards increased C-sections, rather than find innovative ways to enable natural delivery.