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US effort to cut caesarean section rate may be harmful

Scott Gottlieb , New York

Efforts to reduce the number of caesarean births in the United States may be leading to an increased number of serious injuries to newborn infants and putting some mothers at risk, according to four obstetricians at Harvard Medical School.

The doctors, who voice their concern in an editorial in the New England Journal of Medicine (1999;340:54-7), call for a moratorium on efforts to reduce the number of caesarean sections performed in the United Statesat least until better systems are in place to monitor the safety consequences of such a policy.

About 21% of newborn infants in the United States are delivered by caesarean section, a lower rate than the record high of nearly 25% reached in 1988, but far higher than the 5% of 1965.

Ten years ago, responding to concerns by health insurers and politicians that too many caesarean sections were being performed in the United States as a result of so called "defensive medicine," a federally sponsored public health initiative known as Healthy People 2000 set a goal to reduce the number of caesarean sections to 15% of all deliveries.

"It's fine to have a target, but let's make sure it's safe," says Dr Benjamin Sachs, chief of obstetrics and gynaecology at Beth Israel Deaconess Medical Center in Boston and an author of the article. Dr Sachs says that he and his colleagues are not advocating an increase in the rate of caesarean sections but are expressing concern about problems that are associated, they say, with pursuing an aggressive goal based on economic considerations rather than sound medical science.

The doctors say that evidence they have gathered from around the United States suggests that incidence of uterine rupture during delivery, and some injuries to infants, increased during the mid-1990sa consequence that they attribute to the less frequent use of caesarean deliveries during that time.

Many of the problems, they say, have occurred among women who have previously undergone a caesarean section and then attempted a vaginal delivery for a subsequent birth.

The US Food and Drug Administration has reported a fivefold rise in serious complications to newborn infants, including skull fractures.

Caesarean births: is cutting the rate leading to injury?