Sunday, January 28, 2007

Cesarean rates and NYC

This is an opinion piece I wrote for the New York Times today

Cut and Run

LAST month, Betsy Gotbaum, New York City’s public advocate, issued a report noting that Caesarean section rates at some of the major hospitals in the city were nearly 40 percent, about 10 percentage points higher than the national average. The rates are probably even greater, given that the data — the most recent available — was from 2004 and the surgery’s popularity has only grown since then.

What gives? Have New York women been more susceptible to the Britney Spearsification of childbirth? That is: book an operating room reservation for delivery and then get a tummy tuck. Childbirth activists believe that the too-posh-to-push phenomenon, while tiny, may be part of the problem, especially in trend-conscious New York. But they say doctors are more to blame because they fear malpractice claims and want to control birth and their schedules as much as anyone, so they encourage women to have Caesareans that may not be necessary.

Obstetricians claim the rates are so high because professional women are becoming pregnant later in life, often with technological help, which makes labor and delivery riskier.

However, these truths don’t hold with all women. While New York-Presbyterian Hospital/Columbia had the highest Caesarean rate, at 39.6 percent, the hospital with the lowest, at 18.3 percent, was North Central Bronx Hospital, according to Ms. Gotbaum.

Which brings us to another angle to consider.

In 1908, Franklin Newell, a doctor affiliated with Harvard Medical School, said that moneyed urban women suffered more when having a baby, and he wanted to prevent them from having “nervous breakdowns” by offering Caesareans. This was a radical concept at the time. Caesareans were truly dangerous then. Antibiotics had not yet been invented. Anesthesia was in its infancy. But Newell still thought the surgery would be best for the mother.

“It seems to me that this overdevelopment of the nervous organization is responsible for the increased morbidity of pregnancy in the overcivilized class,” Newell said. “The advocacy of an elective Caesarean section for patients who have no pelvic obstruction will undoubtedly come as a shock to many members of the profession.”

Indeed it was. At the time, Caesarean rates were about 1 percent. (The World Health Organization today states that Caesarean rates in industrialized nations should be between 10 percent and 15 percent, beyond which, the risks and costs of the operation outweigh the benefits to mother and baby.)

But back to Newell. I believe he was on to something. New York women, stereotypically some of the most empowered and health conscious in the country, should not have any trouble giving birth, even if they are 38 years old and pregnant for the first time. Strength, both mental and physical, is all it usually takes to give birth (along with a lot of encouragement).

Yet if “overcivilized” is synonymous with “educated,” which could equal “having too much information,” which could make anyone neurotic, then it could also be said that city women are overcivilized. Thinking too much about everything that could go wrong during birth, instead of focusing on how it is a natural physiological process, is a recipe for surgery.

All a New York obstetrician has to do is introduce the concept of danger or inconvenience, and the expectant mother gets the vapors. Even some midwives, the guardians of natural birth, have admitted to me that they can tell by looking at a pregnant woman’s résumé whether she will be more prone to a Caesarean. Uptight? Check. M.B.A.? Check. Drives a Volvo? Check. If the city’s Caesarean trend keeps up, they can just skip to one simple question: From the Upper East Side? Check.

Although it is difficult to determine which belief came first, that upper-class women could not or would not handle childbirth or that doctors thought such delicate flowers could not or would not tolerate it, both, sadly, seem to be increasingly true today.

Although New York-Presbyterian Hospital/Columbia serves a diverse population, it also has many high-risk and affluent patients, as well as private-practice doctors who may be financially motivated to perform the surgery. (Nationwide, uncomplicated Caesareans cost almost two times as much as uncomplicated vaginal deliveries in the hospital.)

By contrast, North Central Bronx, a public hospital that serves a diverse population and doesn’t have the financial incentive to perform Caesareans, has the lowest procedure rate.

Or perhaps, doctors there aren’t inquiring about mothers’ résumés.


Tera said...

It seems to me there is a deep cultural divide between those who choose cesarean births and those who choose unmedicated births - and especially those who choose out of hospital births. There is a difference between being educated by a hospital birth class and an obstetrician and reading What to Expect When You are Expecting....and reading Henci Goer or Suzanne Arms and taking a Bradley or Birthing From Within class. Both sets of women are hyper-educated about birth and the process. However, the bias in their education leads them in different directions. What I wonder, though, is why the folks with the fancy resumes who choose their c-sections haven't stumbled upon things like the British Medical Journal's study that says home birth is safer than hospital births for American women....or The Thinking Woman's Guide to a Better Birth? I think it's culture, but I haven't yet figured out how or why or how a movement might help women be more fully informed of all of the perspectives before making their choices.

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