Lessons from Cesarean Section Rates

Evidence-based (data-driven) medicine, or EBM, is gaining momentum as an antidote to the perils of of groupthink in medicine. Just because something has "always been done this way" doesn't mean it is right; EBM argues that research data should better inform how medicine is practiced day-to-day.

It's interesting to apply EBM principles to cesarean surgery rates in this country. Far more women deliver by cesarean section now than in the past. Why? Some researchers, such as Dr. Frederic Frigoletto, Jr. at Harvard Medical School, argue that the increased rate is primarily due to complications caused by increased obesity rates and advanced maternal age. Some women also choose elective cesareans in order to control the timing and nature of the birth, he explained in a 2006 WebMD article.

Although cesarean rates have increased across the country, not every area has the same rate. Rates are generally higher in more conservative areas of the country and lower in more liberal areas. A study of California cesarean rates presented at a health policy meeting in 2000 found that the cesarean rate was up to 2.5 times higher in some regions of the state than in others. These facts have made cesarean rates a political and feminist issue as well as a medical one.

Cesarean sections are also extremely profitable for hospitals. The California study noted that cesareans are more common among for-profit hospitals than not-for-profit and teaching hospitals, which suggests a profit motive behind the surgeries as well.

On the other hand, are obesity rates (and/or maternal age) simply higher than average in some areas, potentially leading to a local increase in medically-necessary cesarean sections? If this is true, does a hospital with high cesarean rates have an ethical obligation to put some of these surgical revenues toward programs to decrease the obesity rates in its community? (Trying to decrease maternal age in a community is a thornier issue, I think). And how would this ethical obligation undermine a hospital's bottom line? A decrease in cesareans, after all, means a decrease in revenue.

Medical data is a starting point for these discussions, not an end point. All data needs some context. It's good to remember this as the presidential elections approach and the candidates try to summarize their views on the health care system into marketable sound bites. A few sentences, or a single anecdote, rarely tell the whole story.