One-third of New York's cesarean sections are unnecessary and represent, in essence, "acts of violence against women," says Public Citizen director Sidney Wolfe, MD, who released a report yesterday showing how high and low rates of the procedure vary in New York hospitals.
What this means, he said, "is that the health of the mothers and babies is being needlessly jeopardized because mothers go under the knife instead of delivering vaginally."
The great variation provides ammunition for concern, Wolfe said. Public Citizen's report gleaned statistics from New York State health records for 143 hospitals in 2007 showing that the weighted average of the 10 hospitals with the lowest cesarean rates is 20.8%, with the lowest being 16.6% at Auburn Memorial Hospital in Auburn.
Nationally, C-section rates are the highest they've ever been, at 31.8%, and about one-third of those he says are unnecessary.
In New York, on the high end, however, St. Anthony Community Hospital in Warwick and Lawrence Hospital Center in Bronxville had cesarean rates of 53.3% and 52.7%. "The weighted average for the 10 hospitals with the highest overall cesarean rates is 48.3%, he says.
The report is entitled "Guide to Avoiding Unnecessary cesarean sections In New York State."
As more evidence, Wolfe's report points to a 2.5-fold variation in cesarean rates by county, with a low of 16.6% in Cayuga County to a high of 43.1% in Westchester.
Rates for primary cesarean procedures, that is those in women who delivered their first birth by cesarean, also vary by county by 3.5 fold. Rates for VBACs, or vaginal births after cesareans, were actually higher than the national average, 9.3% as opposed to 8%. However, these rates varied more than 19-fold by county and 900-fold, from .03% to 28.13%, by hospital.
Echoing recommendations from others, Wolfe suggests that far more women who previously gave birth through cesarean should be allowed to deliver subsequent babies vaginally, an issue that is complicated because many hospitals do not have required emergency staff such as anesthesiologists standing by in case of a rupture.
According to Howard Minkoff, chairman of the Obstetrics and gynecology department at Maimonides Medical Center in Brooklyn, the national VBAC rate should be increased from its current 9.6% to 28.1%, and that women without clear contraindications should be given the opportunity.
The report suggests a number of reasons for the increase in cesareans.
To a great extent, the report says, the increase is attributable to women who are higher risk because they are older, are obese or have diabetes, or took fertility-enhancing drugs that make multiple births more likely.
However, Wolfe's report says a predominant reason for the increase is due to physicians who "may find it advantageous to schedule deliveries," and cesareans take "a fraction of the time that the average vaginal birth does."
Also, he says, "Physicians and hospitals may have a financial incentive to perform cesareans. When payment is global and providers receive a fixed fee regardless of type of delivery, they may have an incentive to intervene surgically to avoid a longer procedure.
"Fee schedules favor cesareans: Nationally they average approximately $10,958 while vaginal deliveries average $7,737."
Another reason is technological, because now physicians have more ways to screen for problems and to intervene. And risks of anesthesia have diminished so doctors are less reluctant to use sedation.
Wolfe says that 50 years ago when he was in medical school, the cesarean rate of 5% was acknowledged as way too low because women who should have had them were not given the opportunity. The percentage moved up to 20% over the years, "but then it kept rising, to 25 and 30%."