HMS Affiliates Criticize Move to Limit Caesareans

In one of the first reports to question the prevailing medical wisdom, four prominent doctors at Harvard Medical School (HMS) concluded that decreasing the percentage of caesarean deliveries may lead to greater risk for mothers and babies and higher costs for hospitals and patients.

After a year of gathering statistics and data from around the country, the four concluded that two of the major strategies used to increase normal deliveries are not always safe alternatives to the caesarean method. Their findings were published last week as part of an opinion piece in the New England Journal of Medicine.

The four doctors called on the Department of Health and Human Services (DHHS) to suspend efforts to reduce the percentage of caesarean births until the medical community can further monitor and evaluate the births.

The authors of the study are Benjamin P. Sachs, chief of obstetrics and gynecology at Beth Israel Deaconess Medical Center and professor of obstetrics, gynecology and reproductive biology: Fredric D. Frigoletto Jr., chief of obstetrics at Masschusetts General Hospital and Green professor of obstretrics and gynecology; Mary B. Ames Castro, a doctor at MGH and instructor in obstetric, gynecology and reproductive biology, and Cindy Kobelin, a doctor at Beth Israel.

In 1988 and 1989, DHHS set an objective of decreasing the percentage of caesarean deliveries to 15 percent by 2000 after it hit a peak of 25 percent. Currently, about 21 percent of births are casearean deliveries.

Sachs said the target is "arbitrary" and "not supported by scientific evidence."

According to Sachs, the current attitudes in the medical community are misguided.

"The previous sentiment in the country is the lower the caesarean section rate, the better the quality of care and the lower the cost," Sachs said.

To reduce the number of caesarean deliveries, hospitals often increase the number of vaginal deliveries among women who have already had one or more caesarean sections-a process known as a trial of labor. Thirty-five percent of all caesareans are performed on patients who have previously had at least one caesarean delivery.

The article reports that, although "uncontrolled" studies have shown vaginal delivery after a caesarean section to be safer for the mother and baby, the evidence has not been confirmed by randomized trials.

"A major risk of a trial of labor after caesarean delivery is that uterus may rupture during labor, which may result in substantial hemorrhage and require hysterectomy," the article said.

According to data compiled for the article, the incidence of uterine rupture in Massachusetts tripled from 1985 to 1995.

An alternative to a caesarean section, employed in an attempt to reduce the number of these births, is removing the fetus from the mother's body with forceps or by means of a suction cup or vacuum extractor. These procedures, the article reported, can be traumatic for the fetus and cause skull fractures, shoulder injuries, retinal hemorrhages and bleeding in the brain.

"Clearly the safety of vacuum extraction depends on the proper selection of patients, the experience of the operators and a continuous commitment to teaching, research and quality assurance at all levels," the article said.

"The article also said caesarean delivery may not cost more for a hospital than vaginal births.

Professor of Obstetrics and Gynecology at the University of North Carolina Robert C. Cefalo, another expert in the field, said he disagrees with maintaining high rates of caesarean sections, although he said he is skeptical that the percentage could drop to 15 percent.

"Mothers are mortal," he said. "A caesarean delivery is a major surgical operation. There are mothers who die from caesareans."

Cefalo urged hospitals to reduce the number of caesarean sections by better monitoring the labor process and by not rushing to perform the procedure.

In 1994, the American College of Obstetricians and Gynecologists released a statement saying the number of caesarean deliveries in the U.S. is higher than it should be. The College declined, however, to recommend an ideal rate. This October, in a move Sachs said was a step in the right direction, the college published guidelines to aid doctors in determining when to perform vaginal births after a prior caesarean section.

Sachs said managed care companies often provide incentives for hospitals and doctors to perform fewer caesarean sections. Physicians sometimes do not get referrals if their caesarean section rates are too high.

Sachs said he plans to continue his work, performing more studies and compiling more research.

"I think it's an important public health issue," he said. "I think we will see more changes."

The DHHS declined comment yesterday.