I was reading a Los Angeles Times article on the overuse of cesarean surgery when one quote leapt off the page at me. Said Dr. Elliot Main, chief of obstetrics of a California hospital chain, 'Cesarean birth ends up being a profit center in hospitals, so there's not a lot of incentive to reduce them.' This was not news to me. Some years ago, Susan Hodges of Citizens for Midwifery and I gave a joint talk on 'Economic Disincentives for Mother-Friendly Childbirth,' a talk Susan later expanded into an article, but I never thought I'd see the day when a system insider acknowledged this.

The L.A. Times article didn't elaborate on Dr. Main's statement, but let's take a cold blooded look at the business side of cesarean surgery: From the hospital's point of view, cesareans - especially scheduled cesareans - make staffing needs predictable and maximize patient throughput, essential elements of reducing costs. They also increase billing opportunities and lengthen postpartum stay, which enhance revenues. On the obstetrician's side, she or he may be paid more, although this isn't always the case, but the real savings is in time management - and time is money. Minimizing time spent in the hospital allows obstetricians to increase patient load and, what's more, deliver those patients at times that don't conflict with office hours or disrupt nights or weekends. And both hospital administrators and obstetricians believe that cesareans prevent malpractice suits. In short, cesareans are good for everybody, except, of course, mothers and babies.

When a system makes it financially disadvantageous to change obstetric practice, it is human nature to find reasons to maintain the status quo, which explains why we see so many obstetricians, prominent and otherwise, downplay or deny cesarean's harms, tout benefits that are minimal or nonexistent and generally frame cesarean surgery versus vaginal birth as 'chocolate versus vanilla.' According to the American College of Obstetricians and Gynecologists, all an ob/gyn has to do is 'believe' a cesarean is a good idea - never mind the reality - to make it ethical to perform one on a healthy woman. Small wonder that one in three U.S. women now has her baby via major abdominal surgery, a rate approaching three times what it should be, with no end in sight, and no one trying to do anything about it.

Well, that's not quite true. The L.A. Times article cites the Institute for Healthcare Improvement's Strategic Partners program. Despite the impressive title, it is merely a garden hose solution for putting out a forest fire. The best its program director could come up with from its clinical guidelines were recommendations to use oxytocin more carefully and hold off on elective deliveries until 39 weeks. The program director called the latter a 'tipping point' and 'culture change.' This would be funny if it weren't so pathetic. Even this feeble reform attempt hasn't generated much enthusiasm. In four years, only 60 hospitals have signed on, and the article didn't say whether the program has yielded any meaningful improvements.

It isn't as if we don't know what to do. We have Lamaze's Healthy Birth Practices, the Coalition for Improving Maternity Service's Ten Steps to Mother-Friendly Childbirth (PDF), and now, Childbirth Connection's Eight Steps to Reform Maternity Care. But as the maternity care system is currently organized and with the current reimbursement structure, a hospital would find it difficult to implement them and still keep its maternity unit open. If we hope to do anything meaningful about the cesarean rate, we need real culture change, and the tipping point will come when we somehow make vaginal birth an economically viable option. Change starts with understanding the barriers. In this case, it starts with not confusing cost-effective for the greater society with cost-effective for hospitals and doctors, much less with revenue generating.

For an excellent analysis of economic and other system barriers to maternity care reform, and recommendations for how to overcome them, download the report: Sakala, C., & Corry, M. P. (2008). Evidence-based maternity care: What it is and what it can achieve. New York: Milbank Memorial Fund.

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