Once again Consumer Reports deserves a big fat “F” for its series on C-sections.
Why? Because it starts with a conclusion and works backward to support it.
“Everybody knows” that the C-section rate is too high, and Consumer Reports is no different, but as is the case with many pieces of conventional wisdom, what “everybody knows” is not necessarily true.
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]We should use metrics to evaluate the quality of healthcare, but our metrics should be OUTCOMES not processes.[/pullquote]
To hear Consumer Reports tell it, obstetric care begins and ends with C-sections and our priority should be reducing their number. But C-sections are a procedure, not an outcome, and our focus should always be on outcomes. Curiously while the Consumer Reports series on C-section focuses a great deal on variation in C-section rates between hospitals, it utterly ignores the real metric by which we should judge hospital quality — perinatal mortality.
One of the reasons I left the practice of medicine is because of short sighted, simplistic views of patient care beloved on large healthcare organizations and healthcare journalists. I once was notified that my rate of ordering ultrasounds the previous month was higher than average. When I asked the executives in charge of compiling such statistics whether any of the ultrasounds I had ordered that month were unnecessary, they couldn’t tell me and seemed shocked that I even bothered to ask.
I was once notified that my forceps rate was “too low.” That was truly mystifying since my C-section rate was low also (16%) and I hadn’t left a single baby inside a single woman. Instead of being lauded for a vaginal delivery rate of 84%, I was chastised for an operative delivery rate of nearly 0%. That doesn’t make any sense at all.
Of course we need to use metrics to evaluate the quality of healthcare, but our metrics should be OUTCOMES not processes. When we look at the C-section rate and ask if it is too high, what we OUGHT to be asking is whether any C-sections were recognized as unnecessary in advance not whether they were recognized as unnecessary in hindsight.
To understand what I mean, consider biopsies for breast lumps. We know that 80% of breast lumps are benign, but we biopsy 100% of breast lumps. In other words, we have an “unnecessary” breast biopsy rate of 80% … or do we? The fact that 80% are “unnecessary” can only be known in hindsight; it is impossible to say beforehand which biopsies are safe to skip. We don’t don’t judge breast cancer care by the breast biopsy rate and we shouldn’t. We judge breast cancer care by the survival rate.
Just as we should never judge breast cancer care by how many biopsies were actually cancerous, we should never judge obstetric care by the C-section rate. We should judge obstetric care by the survival rate, but obstetrics has become such a victim of its own success that Consumer Reports starts with the completely irresponsible assumption that all hospitals have the same perinatal mortality rates and therefore, we don’t even need to check them. And that is very, very wrong.
When you choose a hospital for obstetric care, you should choose based on which hospital will give your baby and you the best chances of coming through the process of childbirth without injury or death. For better or for worse, there is no consistent relationship between C-section rates and outcomes. While that may mean that higher C-section rates are not better, it ALSO means that lower C-section rates aren’t better, either. Why? Because the ideal C-section rate is the one where all women and babies who NEED a C-section get one, and not too many women and babies who don’t need a C-section end up with one anyway. Notice that I did not say that there would be NO unnecessary C-sections. Given the current state of technology that can only imperfectly tell us in advance which C-sections are necessary, it is better to do many unnecessary C-sections in order not to miss any necessary ones.
When it comes to C-sections, the current Demonizer-in-Chief is Dr. Neel Shah, who practices in the same place where I trained and practiced, Boston’s Beth Israel Deaconess Medical Center.
While a number of factors can increase the chance of having a C-section—being older or heavier or having diabetes, for example—the biggest risk “may simply be which hospital a mother walks into to deliver her baby,” says Neel Shah, M.D., an assistant professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School, who has studied C-section rates in this country and around the world.
His private remarks to me on the topic of C-sections were particularly irresponsible.
Shah responded on Twitter to a piece I wrote for TIME questioning his sloppy, poorly sourced support for homebirths published in the New England Journal of Medicine. He appeared to be entirely unaware of the published literature on the dramatically increased death rate at American homebirth, and equally unaware that homebirth in the US is typically attended by a second, inferior class of midwife, one who does not meet the basic education and training standards in any other industrialized country. The analogy I used in my TIME piece is that hospitals are like seat belts; most of the time you aren’t going to get into an accident, but if you do, seat belts saved lives.
Shah, clearly stung by my criticism, had this to say:
[H]ospitals are not seatbelts; they are airbags that explode in your face 1 out of every 3 times you get in the car.
Holy hyperbole! Shah implies that 100% of C-sections are unnecessary, and are performed merely because the system is malfunctioning spectacularly. At a MINIMUM, fully half of those C-sections he derides are medically necessary and a substantial proportion are literally life saving. Yet Dr. Shah implies that obstetricians are performing C-sections for reasons that aren’t merely illegitimate, but are a travesty exploding in the face of unsuspecting mothers.
It makes for good copy, but it is irresponsible medicine.
Dr. Shah knows as well as I do that the increase in C-section rates have been driven by the fact that our knowledge has eclipsed our technology. We know that vaginal birth can be dangerous and even deadly to a substantial proportion of infants. Indeed, Dr. Shah was a co-author on a recent paper that showed that a MINIMUM C-section rate of 19% is needed to be sure that rates of perinatal and neonatal mortality are low. That means that in order to ENSURE that all babies are born healthy, nearly 1 in 5 MUST be delivered by C-section.
Which 1 in 5 babies needs a C-section to be born safely? We can’t always tell in advance because the things that we need to know are inaccessible to us. To reduce C-sections for fetal distress we need to know the oxygen content of a fetus’ blood during labor, but we don’t have the technology to determine that. To reduce C-sections for breech, we need to know which babies’ heads will get trapped by their mothers’ pelvis, killing them, but we don’t have any technology to determine that. To reduce C-sections for cephalo-pelvic disproportion (a baby too big to fit) we need to know whether the diameter of a baby’s head can mold enough to fit through his mother’s pelvis, but we don’t have the technology to determine that, either. When we have those technologies, we will reliably be able to reduce the percentage of unnecessary C-sections to zero.
In the meantime, we do the best with what we have. Obstetricians perform unnecessary (in retrospect) C-sections because we often CAN’T tell in advance the difference between the necessary C-sections and the unnecessary ones. Not surprisingly, we try to err on the side of caution. The Consumer Reports C-section series deserves a big fat “F” because it is utterly irreponsible. It insists that there are too many C-sections being done but offers NO GUIDANCE on how to determine in advance which C-sections are the unnecessary ones. It presumes that the C-section rate is a quality metric when it is anything but. And it is based on the premise that our goal should be a reduction of the C-section rate when our goal ought to be the best possible rates of perinatal and maternal mortality.
The series doesn’t help mothers, doesn’t help babies, doesn’t help obstetricians, but does sell magazines. I guess that’s the point.
