Once again, my hopes are raised that we may turn the corner and reverse our skyrocketing cesarean rate. The reason for my optimism is the increasing concern I am seeing in medical journals about the risks associated with common obstetric interventions. In the April 2011 edition of The Journal of Maternal-Fetal and Neonatal Medicine, Dr. J. Christopher Glantz of the University of Rochester School of Medicine looked at the relationship between rates of labor induction and primary cesarean delivery and rates of adverse neonatal outcomes. “If labor induction and cesarean section are beneficial in terms of improving neonatal outcome, then higher rates of intervention should be associated with lower frequency of risk-adjusted adverse neonatal outcomes.” Right?
Wrong. Dr. Glantz analyzed records from the Statewide Perinatal Data System, a validated electronic birth certificate database available for analysis though the New York Department of Health. The study used data from January 2004 through December 2008. In the labor induction group, Dr. Glantz analyzed 28,883 records and in the primary cesarean delivery group, he analyzed 29,764 records. A little over 80% of patients were common to both groups. In order to reduce variance caused by women with high-risk conditions during pregnancy, Dr. Glantz only looked at data from level I (low-risk, no NICU) hospitals. He also used risk adjustment to further reduce variance caused by differences in risk and patient demographics among the patients giving birth at the ten hospitals included in the study. He concluded that differences in rates of labor induction and primary cesarean delivery were due to differences in practice styles rather than differences in risk status and patient demographics. Not surprisingly, he found a positive association between induced labor and primary cesarean delivery. But most importantly, he found that hospitals who had the highest rate of labor induction and primary cesarean delivery did NOT have better neonatal outcomes. (Neonatal outcomes were defined as 1) neonatal transfer, 2) immediate assisted ventilation, and 3) low 5 minute Apgar score, <5.) There was no correlation at all between labor induction and/or primary cesarean delivery and neonatal outcomes.
“Medical and surgical interventions are supposed to improve outcomes. Certainly some labor inductions and cesarean sections – presumably those done for specific, established indications – lead to improved outcomes, but hospitals in this study with high intervention rates had outcomes indistinguishable from hospitals with low rates, before and after risk adjustment.”
Dr. Glantz goes on to say, “A corollary to the medical dictum ‘First do no harm’ might be ‘Second, do some good.’ In obstetrics, this applies to the mother and also to the infant. It is difficult to justify high rates of obstetrical interventions (especially elective) in a low-risk population of pregnant women in the absence of demonstrable neonatal benefits, given that these interventions have finite maternal risks.”
Certainly, there is no question about the increased risks associated with a surgical rather than a vaginal delivery and the increasing risks for the mother with each subsequent cesarean delivery. Kudos to Dr. Glantz for asking the question, “Are increased rates of labor induction and primary cesarean section improving outcomes for babies?”