Understanding the factors increasing cesarean delivery and impacting quality care

Cesarean Sections (c-sections) are the most common surgery in the U.S. In 2010, the national rate declined to 32.8% from 32.9% (2009). The Los Angeles County (LAC) rate increased to 37.7% from 37.2% (2009). Multiple reasons have been attributed for the increasing rate.

Methods: Obstetrician/gynecologists in LAC completed a self-administered questionnaire to assess their practices and attitudes related to c-sections.

Results: 117 obstetrician/gynecologists responded. The practice types were 37.4% (44/117) solo practice, 33% (39/117) group and 16.5% (19/117) university/teaching practices. Medicaid was the primary method of payment accepted, followed by private PPO, private HMO and other. Reasons cited for performing c-sections the month prior were failure to progress, fetal distress, failed induction, cephalo-pelvic disproportion and maternal complications (pre-eclampsia). 55% stated the threat of litigation drove them to recommend a cesarean delivery and 45% to discourage a VBAC. 53% stated their hospital c-section rate was too high. Although providers delivered at several hospitals, 98% of their primary affiliation had 24-hour in-house anesthesia. 95% stated they follow the ACOG recommendation of no elective delivery less than 39 weeks gestation. Email (85%) and medical conferences (33%) were the preferred methods of obtaining medical information.

Conclusion: The threat of litigation was cited as reason to perform a cesarean and not recommend a VBAC. In-house anesthesia was cited as important to have in their primary delivery hospital. ACOG practice recommendations were followed by participants. E-mail was the preferred method of obtaining medical information/recommendations. Patient quality of care and delivery of care is influenced by provider threat of litigation. A multi-pronged approach, working with providers, hospitals, malpractice companies and patients, is needed to address the most common cesarean section drivers.