[ozmidwifery] interesting article 2

[Mary Murphy]

CLINICAL OPINION  American Journal of Obstetrics and Gynecology (2006) 194, 932–6   Myth of the ideal cesarean section rate: Commentary and historic perspective Ronald M. Cyr, MD* Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI Received for publication July 10, 2005; revised September 12, 2005; accepted October 8, 2005 KEY WORDS Cesarean section rate Myth History of cesarean section John Whitridge Williams Evidence-based medicine Attempts to define, or enforce, an ‘‘ideal’’ cesarean section rate are futile, and should be abandoned. The cesarean rate is a consequence of individual value-laden clinical decisions, and is not amenable to the methods of evidence-based medicine. The influence of academic authority figures on the cesarean rate in the US is placed in historic context. Like other population health indices, the cesarean section rate is an indirect result of American public policy during the last century. Without major changes in the way health and maternity care are delivered in the US, the rate will continue to increase without improving population outcomes. _ 2006 Mosby, Inc. All rights reserved. Since the earliest days of the modern cesarean sectiondthe 1880sdthere has raged within the profession a debate about the appropriate indications for this operation.1,2 For several decades after the availability of antibiotics and blood banking, the cesarean section rate in the US remained in the 4% to 6% range. Between 1968 and 1978, the rate tripled to 15.2%, and discussion of cesarean section moved permanently into the public domain. A 1981 report commissioned by the National Institutes of Health (NIH) expressed concern about the rising rate, and its recommendations for reducing cesareans included qualified support for VBAC.3 By the 1990s, individual hospital cesarean section and VBAC rates were being published, and interpreted by consumer groups as indicators of obstetric care quality. In 1991, the Healthy People 2000 initiative advocated a 15% cesarean rate as a US health promotion objective by the year 2000.4 Despite expert and lay opinion that many cesareans are unnecessary, the rate continues to increase in the USdexceeding 27% in 2004dand shows no sign of abating.5,6 Indeed, there is growing discussion and acceptance of patient-choice cesarean section as a legitimate birth option.7,8 A recent editorial opined that ‘‘It’s time to target a new cesarean delivery rate.’’9 It is the premise of this essay that attempts to define, or enforce, an ‘‘ideal’’ cesarean section rate are futile, and should be abandoned. It will be argued that the cesarean rate is a consequence of individual value-laden clinical decisions, and that it is not amenable to the methods of evidence-based medicine. The influence of academic authority figures on the cesarean rate in the US will be placed in historic context. Like other population health indices, the cesarean section rate is an indirect result of American public policy during the last century. Without Dr Cyr is the 2003 ACOG/ORTHO-McNEIL Fellow in the History of American Obstetrics and Gynecology. * Reprint requests: Ronald M. Cyr, MD, Department of Obstetrics and Gynecology, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI 48109-0276. E-mail: [EMAIL PROTECTED] 0002-9378/$ - see front matter _ 2006 Mosby, Inc. All rights reserved. doi:10.1016/j.ajog.2005.10.199