Correspondence

The Risks of Lowering the Cesarean-Delivery Rate

N Engl J Med 1999; 341:53-55July 1, 1999

Article

To the Editor:

Sachs et al. (Jan. 7 issue)1 are incorrect in their assumption that programs designed to reduce the rate of cesarean delivery center on increasing the number of operative vaginal deliveries (the use of forceps and vacuum extractors). Quite to the contrary, we have found that physicians who perform fewer cesarean sections tend to perform fewer operative vaginal deliveries (14.9 percent, as compared with a rate of 20.7 percent among those who perform more cesarean sections).2 These same physicians also have lower rates of use of epidural analgesia and induction of labor, but they more often monitor the fetal heart rate and encourage ambulation during labor.

The goal of recent programs, such as the “breakthrough series” collaborative,3 has been to help all clinicians involved in perinatal care to learn the techniques of providers who are able to deliver obstetrical care safely without resorting to unnecessary interventions. The ultimate intervention is cesarean delivery. Thus, learning to improve obstetrical care leads to lower rates of cesarean delivery as a secondary effect.

Robert K. DeMott, M.D.
Herbert F. Sandmire, M.D.
Ob–Gyn Associates of Green Bay, Green Bay, WI 54301

3 References

1
Sachs BP, Kobelin C, Castro MA, Frigoletto F. The risks of lowering the cesarean-delivery rate. N Engl J Med 1999;340:54-57
Full Text | Web of Science | Medline

2
Sandmire HF, DeMott RK. The Green Bay Cesarean Section Study IV: the physician factor as a determinant of cesarean birth rates for the large fetus. Am J Obstet Gynecol 1996;174:1557-1564
CrossRef | Web of Science | Medline

3
Flamm BL, Berwick DM, Kabcenell A. Reducing cesarean section rates safely: lessons from a “breakthrough series“ collaborative. Birth 1998;25:117-124
CrossRef | Web of Science | Medline

To the Editor:

The increased use of epidural analgesia during labor is not one of the explanations for the recent increase in the rate of cesarean delivery in the United States, in contrast to the statement made by Sachs et al. Although the results of two randomized trials that they cited support this contention,1,2 newer studies suggest that this is not the case. A meta-analysis of prospective trials in which women were randomly assigned to receive either epidural analgesia or parenteral opioid analgesia revealed no increase in the rate of cesarean delivery among the women who received epidural analgesia.3 Furthermore, when the use of epidural analgesia is introduced in a hospital, the rate of cesarean delivery does not increase.4

Stephen H. Halpern, M.D.
Women's College Hospital, Toronto, ON M5S 1B2, Canada

Barbara L. Leighton, M.D.
Medical College of Pennsylvania–Hahnemann University, Philadelphia, PA 19102

4 References

1
Thorp JA, Hu DH, Albin RM, et al. The effect of intrapartum epidural analgesia on nulliparous labor: a randomized, controlled, prospective trial. Am J Obstet Gynecol 1993;169:851-858
Web of Science | Medline

2
Ramin SM, Gambling DR, Lucas MJ, Sharma SK, Sidawi JE, Leveno KJ. Randomized trial of epidural versus intravenous analgesia during labor. Obstet Gynecol 1995;86:783-789
CrossRef | Web of Science | Medline

3
Halpern SH, Leighton BL, Ohlsson A, Barrett JF, Rice A. The effect of epidural vs parenteral opioid analgesia on the progress of labor: a meta-analysis. JAMA 1998;280:2105-2110
CrossRef | Web of Science | Medline

4
Fogel ST, Shyken JM, Leighton BL, Mormol JS, Smeltzer JS. Epidural labor analgesia and the incidence of cesarean delivery for dystocia. Anesth Analg 1998;87:119-123
CrossRef | Web of Science | Medline

To the Editor:

Because of reports suggesting increased maternal and fetal risk with the use of trials of labor and vaginal delivery in women who have had cesarean deliveries, we have been working with a statewide group to review the complications of this method of delivery. As part of that effort, we conducted a five-year chart review of matched maternal and neonatal records at Baystate Medical Center that were coded at discharge as uterine rupture (665.0 or 665.1), according to the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM).1 We discovered that such data are not specific for uterine rupture. The code is generic and therefore may include not only cases of true uterine rupture but also cases of incidental wound dehiscence as well as intraoperative extensions of cesarean-delivery wounds. As a result, many other institutions in the state have conducted similar reviews.

We found that only approximately 50 percent of the ICD-9-CM codes that were assigned represent cases of any degree of uterine rupture or preoperative dehiscence of uterine wounds. Many cases were not associated with a trial of labor or previous cesarean section. Furthermore, less than half the cases of true uterine rupture involved any degree of severity. On the basis of these preliminary data, we caution against the use of data derived from ICD-9-CM codes to estimate rates of uterine rupture.

Susan DeJoy, C.N.M., M.S.N.
John Patrick O'Grady, M.D.
Ronald T. Burkman, M.D.
Baystate Medical Center, Springfield, MA 01199

1 References

1
Department of Health and Human Services. The international classification of diseases. 9th rev. Clinical modification: ICD-9-CM. Vol. 1. Diseases: tabular list. Washington, D.C.: Government Printing Office, 1980. (DHHS publication no. (PHS) 80-1260.)

To the Editor:

The article by Sachs et al. was timely and germane to the ongoing discussion of the best way to evaluate the use of cesarean section. When attempting to apply the information in this article to regional projects related to the use and outcome of cesarean sections, however, I found a shortcoming.

I had difficulty securing four references.1-4 Contacts at the departments of health in Florida, Pennsylvania, and New York and at the Massachusetts Rate Setting Commission were unable to substantiate the references, and no comparable data could be found on the organizations' Web sites. Consequently, these data cannot be replicated, and the analyses cannot be readily confirmed or reproduced.

Given the nature of this article and the views expressed, it would be valuable to have the ability to scrutinize the foundation on which the conclusions are based. This is especially true for those of us attempting to delve into the central question raised in this article: What is the actual rate of cesarean section?

Carl A. Sirio, M.D.
University of Pittsburgh Medical Center, Pittsburgh, PA 15261

4 References

1
ICD-9 codes V30-V39, 665.0, 665.2. Hospital discharge data set (FY 1985-1996). Boston: Massachusetts Rate Setting Commission, 1996.

2
Pennsylvania State inpatient data. Monthly state statistics report. Vol. 44. No. 12. July 1996. Harrisburg, Pa.: Department of Health, 1996.

3
New York State Department of Public Health/SPARCS and Monthly Vital Statistics Report. Vol. 46. No. 1. Suppl.

4
Florida Vital Statistics: annual report 1996. Jacksonville: Florida Department of Health, 1996.

To the Editor:

The article by Sachs et al. raised some important questions about the Healthy People 2000 initiative. The authors specifically objected to the goal of this initiative to reduce the rate of cesarean delivery to 15 percent of live births by the year 2000.1 The rate in 1987 was 24.4 percent. They contend that “setting a target rate is an authoritarian approach to health care delivery” and that it “implies that women should have no say in their own care.”

The objectives of Healthy People 2000 are national targets derived from biomedical and public health data and expert and public opinion. These targets are for the U.S. population as a whole and are not intended to be clinical guidelines for individual physicians or their patients. Healthy People represents a combined effort of the public and private sectors in which more than 350 nonfederal partner organizations and state public health leaders from around the country helped craft the health objectives; ultimately, more than 10,000 people were involved.

Sachs et al. also call for “a reevaluation of the goal to reduce the cesarean-delivery rate in the United States.” The Department of Health and Human Services is now coordinating the development of Healthy People 2010. The 1998 public consultation on this next set of national objectives included public hearings at five regional meetings and at the national Healthy People Consortium in Washington, D.C. In addition to the 2000 persons who participated in these sessions, more than 2000 people and organizations provided comments. All this information is publicly available.2 These comments will receive careful consideration as we lay the foundation for the next set of Healthy People objectives to improve the health of our nation's mothers and infants.

David Satcher, M.D., Ph.D.
Department of Health and Human Services, Washington, DC 20201

2 References

1
Healthy People 2000: national health promotion and disease prevention objectives: full report, with commentary. Washington, D.C.: Government Printing Office, 1990:378. (DHHS publication no. (PHS) 91-50212.)

2
Healthy People 2010 Web site (http://www.health.gov/healthypeople). (Also available from NAPS, c/o Microfiche Publications, 248 Hempstead Tpke., West Hempstead, NY 11552.)

Author/Editor Response

The authors reply:

To the Editor: In response to Drs. DeMott and Sandmire: we hope that the rate of cesarean delivery can be safely lowered. However, there are instances in which this has occurred but fetal mortality was increased, perhaps because the use of acceptable indications for operative vaginal delivery was abandoned.

The increased use of epidural analgesia has been cited as being responsible for the increased rate of cesarean deliveries, but it was not the focus of our paper. We agree with Drs. Halpern and Leighton that it is unlikely to be a major factor.

DeJoy and her colleagues question the incidence of uterine rupture associated with trials of labor and vaginal delivery after cesarean section in Massachusetts. We agree, as we stated in our paper, that there are problems of overcoding and undercoding for uterine rupture. Data from other states have also revealed an increased incidence of uterine rupture. However, without an in-depth study it is difficult to determine the exact incidence.

Dr. Sirio raises an interesting question regarding the use of a proprietary data base as a reference in an article in a peer-reviewed journal. The data base we used was compiled by Sachs Group (Evanston, Ill.) from data published by the states. We had no alternative but to pay for this information.

Dr. Satcher explains the process and the value of setting health targets. However, in the current health care environment, when the federal government sets a target of a 15 percent rate of cesarean delivery, it is readily translated into a standard of care. We do not believe that this was ever the intention of the Public Health Service. Our article was motivated by the concern that the rate of complications among women and their infants may increase as the cesarean-delivery rate is reduced below the current national level of 21 percent, especially if the intervention is focused on a single approach, such as increasing the number of vaginal births after cesarean sections or increased use of operative vaginal delivery. Unfortunately, the Healthy People 2000 objectives and national targets were long in terms of their derivation from “expert and public opinion” but short on biomedical and public health data because few data were available at the time the objectives were determined.

We support a national target of a 15 percent rate of cesarean delivery; however, we urge the Public Health Service to establish systems to monitor complication rates and to fund research on the appropriate identification of safe interventions to lower the cesarean-delivery rate.

Benjamin P. Sachs, M.B., B.S., D.P.H.
Cindy Kobelin, M.D.
Beth Israel Deaconess Medical Center, Boston, MA 02215

Fredric Frigoletto, M.D.
Massachusetts General Hospital, Boston, MA 02114

Citing Articles (3)

Citing Articles

1
Kuang-Hung Hsu, Pei-Ju Liao, Chorng-Jer Hwang. (2008) Factors affecting Taiwanese women's choice of cesarean section. Social Science & Medicine 66:1, 201-209
CrossRef
2
Kimberly D Gregory. (2000) Monitoring, risk adjustment and strategies to decrease cesarean rates. Current Opinion in Obstetrics and Gynecology 12:6, 481-486
CrossRef
3
C. Stone, J. Halliday, J. Lumley, S. Brennecke. (2000) Vaginal births after Caesarean (VBAC): a population study. Paediatric and Perinatal Epidemiology 14:4, 340-348
CrossRef