Patient choice cesarian

ACOG CLINICAL REVIEW March/April 2000

Volume 5 . Issue 2

W. Benson Harer, Jr, MD, FACOG

A

I rhe dawn of this century ccsarean delivery was a desperate operation to save a woman’s life. Ar midcentury, it became a low-risk procedure to save a fetus’ life.’ As the century ends, it is evolving into a lifeenhancing operarion for both mother and child. The continual advances of anesthesia, asepsis, neonatal care, and surgical techniques have reduced the risks of cesarean delivery. Perhaps rhe time has come when risks, benefits, and costs are so balanced between cesarean and vaginal delivery rhat chc deciding factor should simply be the mother’s preference for how her baby is to be delivered.

In America, women’s access to abortion and conrraception services has gone from being rightly restricted wirh criminal sanctions, to unrestricted access. This firs a pattern of restrictions by law and custom that limited women’s property rights, educarion, and voting thar has gradually given way to permitting them to make their own decisions. The role of physicians has concurrently shifted from dictating care to collaborating with the parienr who is rhe one to make final decisions about available options-except in the matter oftbe delivery of her baby. From earliest times to the dawn

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HISTORICAL-PERSPECTIVE

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EDITOR’S NOTE

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of this century, life expectancy for women was so low that few expected to live beyond the childbearing years. Today, the average woman can expect to live thirty years beyond menopause. Furthermore, prior to this century the average woman had to bear seven or more children to maintain a stable popularion but today that has fallen to only 2.1. Simultaneously, maternal mortality has dropped from approximately 1: 100 to I : 10,000. At the same time the possibilities of srerilization and effective contraception have provided options unavailable to women until the latter halfofthis century. With the increasing longevity of women, the preservation of sexual function and quality of life have more importance than ever before. Yet, the historical aversion to cesarean delivery and ignorance of the long-term consequences of vaginal delivery remain imbedded in both public and professional thinking. In discussions of risks and benefits rhe focus is overwhelmingly short term. Obsret-ricians routinely counsel patients regarding the risk of uterine rupture in a future pregnancy as a late consequence of cesarean delivery. Do they also counsel women regarding later sexual dysfuncrion, pelvic organ prolapse, urinary or fecal incontinence, or any other risks that are assoContinued on p. 13

PATIENT

CHOICE

CESAREAN

ciated with vaginal birth in much higher incidence than with cesarean delivery? If given the information regarding the greater length of life expectancy during which such morbidity increases and may be difficult and costly to alleviate, would more women request cesarean delivery? If the morbidity and cost of correcting these difficulties is included in the equation of risk versus benefit versus cost, the perceived advantage of vaginal birth is diminished or even eliminated. I have been unable to find an analysis which factors in the risks and costs of years-later pelvic reconstructive surgery and the morbidity and negative impacts on lifestyle that precede and accompany such procedures. A recent prospective study of urinary and anal incontinence associated with childbirth evaluated 949 women in five hospitals.2 At 3 months postpartum, fecal incontinence was found in 3%. Involuntary loss of flatus was reported by 25%. Fecal incontinence correlated with episiotomy and sphincter damage. Loss of flatus further correlated with maternal age, macrosomia, and use of forceps. Urinary incontinence (which was often pre-existing) was increased by 10%. Cesarean delivery was protective against these risks, that have enormous impact on quality of life, even if they do not shorten it. Use of ultrasound and an array of techniques to assess fetal lung maturity have minimized the risk ofprematurity when termination is scheduled electively. Furthermore, scheduling a cesarean permits assurance that needed support personnel for mother and baby are available. A small but significant morbidity is attendant to induction of labor and to use of forceps or vacuum extraction in order to achieve a vaginal birth. These risks particularly apply to the fetus, but are readily accepted to avoid a cesarean. Paradoxically, fetal risks of uncertain nature are often cited as the indications for cesarean. An insightful analysis by Sachs et al3 called for a revision of our view of vaginal birth after cesarean delivery (VBAC) and the Healthy Nation 2000 goal of a 15% cesarean delivery rste. No one knows what the best cesarean rate should be-or even what is a good range. Obstetricians are ob-

ligated to recommend cesarean delivery in any given case based on the best available evidence of the balance of riskand benefits for mother and child. If the mother agrees, a cesarean is performed. The statistics shouldn’t matter. In recent decades, the mere presence of breech presentation has been recognized as indication for cesarean delivery. This reflects the fact that despite all of our efforts to minimize risk to the fetus, a tiny percent of babies will suffer massive morbidity. Those few cases blight the life of the babies, destroy the tranquility of their families, and place a financial burden on insurance carriers (both health and liability) and the public, which massively outweigh any short-term cost savings. The role of cesarean delivery in Brazil demonstrates the ultimate contrast to the United States. The overall cesarean delivery rate is 50 - 60% and goes to 90% in the higher educated, middle-upper class population. In an insightful article intended to disgrace these statistics, Pinotti and Knotti observe this is “a cultural phenomenon that surpasses strictly medical considerations. It’s popularity among women is incontestable.” In consulting women regarding this preference “there seems to be no doubt that the most important factors for them are the preservation of the perineal and perivulvar musculature as well as fear of labor pain.” A woman’s choice of elective cesarean is generally honored. It is simplistic to blame the rise on physician economic benefit since any compensation differential for vaginal versus abdominal delivery was eliminated in 1980. In fact, that act had no impact on the steady rise of cesareans in that country.5 Health care financing managers in the United States have been afflicted with a shortterm, profit-driven, cost-cutting mania in recent years. The goal of immediate savings has placed great pressure on physicians to carry out VBAC as the easiest way to reduce the cesarean delivery rate. Unfortunately, many physicians (with the managed care concurrence) have refused to grant patients the option of elective repeat cesarean. Enough VBAC disasters have occurred that ACOG has declared it should be the woman’s choice. Public revulsion of such policy has forced the managed care organizations to agree with the ACOG position in the hope of

avoiding legislative restriction of their activities and ultimately their profits. The once significant differences in cost between cesarean and vaginal delivery are close to disappearing. To eliminate any economic incentive, many physicians charge the same fee for obstetric care regardless of method of delivery. Hospitals and anesthesiologists could easily do the same. Timebased anesthesia charges for epidural anesthesia in labor typically exceed those for cesarean alone. The safety of modern anesthesia (particularly epidural) is such that it is considered the right of women in labor to demand it and inappropriate for it to be withheld without good cause. Saigal et a16 studied diff&ences in preferences of neonatal care outcomes between parents and health care professionals that confirm the current shift to patient-centered care. In assessing various models of physician/ patient relationships, they cite Emanuel and Emanuel’: the “deliberative model in which the patient’s perspective is incorporated when determining the choice of therapy is considered the optimal.” This trend towards patient autonomy is reflected in rates of induction of labor that increased from 9% in 1989 to 18.4% in 1997.* Our local experience shows this as driven primarily by patient demand. Others might argue socioeconomic pressure on busy obstetricians as a cofactor. Laine and David” surveyed the evolution of patient-centered medicine and its further relationships to law, education, research, and quality of care assessment. In supporting the deliberative model of care they say: “Autonomy requires that individuals critically assess their own values and preferences; determine whether they are desirable; affirm upon reflection those values as ones that should justify their actions; and then be free to initiate action to realize the values.” The role of the physician is clearly one of informing the patient. Ideally, the patient will integrate the information so that both will be satisfied with the ultimate decision. In real life, it often does not work that way, in which case the patient’s choice should prevail. If that choice is sufficiently contrary to the physician’s values, the physician should withdraw from the case. Nevertheless, women have been legally compelled to undergo unwanted cesarContinued on p. 15

PATIENT CHOICE CESAREAN Conthued from p. 13 ean deliveries’” and been denied cesarean deliveries they have requested. ’ ’ Physician paternalism has dictated choice of care until recent years. The public has clearly rebelled in favor of patient autonomy. A new managed care paternalism has arisen to impose its own profit-driven control on both doctor and patient. Fortunately, we are slowly overcoming managed care tyranny. Nevertheless, cesarean delivery remains a major example of both managed care and physician paternalism. The ACOG Committee on Ethics states, “the role of the obstetrician should be one of an informed educator and counselor.“12 Furthermore, “the obstetrician should refrain from performing procedures that are unwanted by a pregnant woman.” Even in cases of perceived conflict of maternal and fetal interests, “the pregnant woman’s autonomy should be respected.” Traditional paternalistic medicine held that therapeutic choice is dictated by the “doctor knows best” theory, and therefore the paternalistic choice prevailed. The time is coming-if not already here-for “maternal-choice cesarean.” Perhaps unwittingly the Health Care Financing Administration agrees. Their interim final rule published in the Federal Register July 2, 1999, requires hospitals to give patients the right to participate in the development and implementation of their plan of care and to request or refuse treatment. It would seem to follow that a woman’s right to participate in the decision and to choose to deliver her child by cesarean delivery will be respected.

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HISTORICAL PERSPECTIVE Continuedfrom p. 12 septic was applied to the wound. Ferdowsi, the renowned epic poet of ancient Persia, has illustrated this epic episode in his poem. The translation into English is as follows: He (high priest) slit the flank of the Goddess of beauty (Roudabeh) and the head of a boy came into view. The boy, “Rostam,” was brought out of the womb magnificently without harm; no one had seen this wonder up to that time. The icon-like child entered this world and flank of that Goddess was filled with blood. High priest said the agony and ordeal is over, and the boy was named Rostam (the Her-

culean) In this epic and legendary poem of ancient Persian history, the Iranian folk hero Rostam was delivered by the high priest. The boy became the pro-

tagonist of Persian epic poems as well as the Iha& and Odyssey5by Homer, the great epic poet of ancient Greece. The description of anesthesia, surgery, antiseptic, procedures, and suturing is real enough to persuade one that this was the first ever recorded delivery of an infant via an opening in the abdomen. I, therefore, propose that cesarean section should be known as “rostam section.”

1. Sedwell JE. Cesarean Section-a Brief History; a brochure to accompany an exhibition. Nat Lib Med April 30August 31, 1993. ACOG, Washington DC. 2. Reza F. A Search Into Ferdowsi’s ‘Book of Kings’. 3. Hillman M. Personal communication. September 14, 1998. 4. Lang A. Iliad. Oxford: MacMillan and Co. Limited; 1929. 5 Lattimore The Odyssey of Homer. New York: Harper and Row; 1965. PII 11085.6862(00)00027-3

he reader will note that over the past few years it has become almost routine to report results of studies in statistical terms. As the editor reviews these articles, an attempt is made to include the statistical summary in the synopsis and comment. In the past, several of our readers have raised questions regarding these reports and on the basis of these questions, it appears that some are unfamiliar with or confused by the reports. In this issue of ACOG Clinical Review there are again papers that rely upon statistical terms to explain their findings. As a result, I would like to take this opportunity to simply explain the meaning of the terms. I am not a statistician and I rely on experts such as Leon Burmeister, PhD, Assistant Editor of Statistics for Obstetrics & Gynecology, for detailed analysis. If the reader wishes to have a more thorough review, The American College of Physicians in Philadelphia has published an excellent book by Thomas A. Lang and Michelle Secic titled, How to Report Statistics in Medicine. * The terms most commonly referred to in the reviews are listed:

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REFERENCES

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PATIENT

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zonte, Brazil: social and economic determinants. Reprod Health Matters 1998;6:115-21. Saigal S, Stoskopf RI, Feeny D, Furlong W, Burrows E, Rosenbaum PI, et al. Differences in preferences for neonatal outcomes among health care professionals, parents and adolescents. JAMA 1999;28 1: 1931-7. Emanuel EJ, Emanuel LL. Four models of the doctor-patient relationship. JAMA 1992;267:2221-6. Analysis of Birth Certificates. Nat Centcr for Health Statistics. 1999. I;aine C, Davidoff F. Patient centered medicine.JAMA 1996;278: 152-6. Bowes WA, Selgestad B. Fetal versus maternal rights: Medical and legal perspectives. Obstet Gynecol 1981;58:209-14. Abramo PC. Intrapartum c/s requests trigger informed consent duty. OBG Mgmt 1999:36-42. ACOG Committee on Ethics. Patient Choice and the Maternal-Fetal Relationship Committee Opinion #2 14. 1999 PII II 081.686WXWC130-3

NOTE

Prevalence: The percentage of individuals in a specified population grouping who have the disease. Sensitivity: The number of true positives that are identified by a test. It identifies those with the disease. A sensitivity of 85% means that 85 out of 100 people with the disease will be identified. However, 15 will not, so it can also be said that they represent a falsenegative rate. Sometimes sensitivity is actually reported as falsenegative identification test. This may lead to confusion if not understood. Sensitivity rests are usually screening tests. Specificity: The number of true negatives. It identifies those who do not have the disease. A specificity of 85% means that 85 out of 100 individuals will be shown to be free of disease. However, 15 will not be proved disease free so they represent a false-positive result and this may be the way the information is presented. This, too, may lead to some confusion if it is not understood. Specificity tests are usually diagnostic tests. Predictive value: By use of specificity and sensitivity, researchers attempt to predict the disease occur-

rence rate. They are usually divided into positive predictive value and/or negative predictive value. A positive predictive value is used to tell you how likely it is that a patient with a positive test will actually have the disease while a negative predictive value is used to explain the likelihood that a negative test means the patient does not have the disease. For an ideal test, both numbers should be 100%. In practice, however, we rarely see an ideal test so what we find reported are values of lesser percent. The higher this percentage the more valuable the test. In future issues of ACOG Clinical Review, other aspects of common statistical reporting methods will be explained. If the reader has a specific question, please write to the Editor and we will attempt to respond. Ralph W. Hale, MD, Editor PII 11085-6862~00J00031-5

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