Patience: The answer to the cesarean epidemic

“The c-section you do today impacts the future health of the woman you’re caring for.” So said Aaron B. Caughey, MD, of Oregon Health & Science University, Portland, in his lunch-and-learn “The Cesarean Epidemic: Etiologies, Outcomes and Potential Solutions” on Monday, April 28 at the ACOG 2014 Annual Clinical Meeting in Chicago. What’s more, he pointed out, “the c-section you do today leads to the repeat … [which] leads to the repeat … [which] leads to the accreta in 8 years.” But Caughey did not place blame for the so-called epidemic with either doctors or patients.

Citing the well-known statistic that as of 2011, about 33% of all deliveries nationwide are cesarean deliveries, and pointing out that VBACs have plummeted since the mid 1990s, Caughey rejected the idea that maternal preference and physician convenience are driving these trends. “The environment in which we practice affects our decisions on cesarean delivery,” he said, although physicians may not be consciously aware of environmental pressures. People simply make decisions to maximize utility, he pointed out, and they follow established practices.

For instance, he said, despite much research, he could not determine the origin of the practice of considering cesarean delivery after only 2 hours of second-stage labor. With 2 additional hours of labor, he said, 60% of these women would go on to achieve vaginal delivery. This would take “a little more patience,” said Caughey, and there is no reimbursement for waiting. He noted that time is everything in running an ob/gyn practice, and said, “We should fight for better reimbursement for being patient.” Caughey encouraged the ob/gyns in the audience to fight for this and also to lobby for caps on malpractice awards, citing a study showing that malpractice award caps mean lower c-section rates. “If you have any sway in your state … [try to] get these caps in place,” he urged.

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