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ORIGINAL RESEARCH |
From the 1Battelle Centers for Public Health Research and Evaluation, Seattle, Washington.
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ABSTRACT |
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 ABSTRACT MATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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METHODS: National Hospital Discharge Survey data 1991–2004 (N=458,767) were used to identify maternal request cesarean deliveries. After excluding women with a history of cesarean delivery, women who labored, and women with indicated risks against labor, 2,394 potential maternal request cesarean deliveries remained. Indicated risks were identified with a recognized protocol.
RESULTS: Maternal request cesarean deliveries have two properties: 1) cesarean delivery before labor and 2) cesarean delivery in the absence of medical conditions presenting a risk for labor. Risk is either absolutely absent or it is relatively absent. In 1991–2004, 0.20% of women who delivered live infants and 1.34% of women who delivered by primary cesarean delivery did so without any medical conditions listed on their hospital discharge record. Estimates for maternal request cesarean deliveries without certain indicated risks were 0.75% for women who delivered live infants and 5.03% for women who delivered by primary cesarean delivery. Maternal request cesarean deliveries without any indicated risk peaked in 1999 for women who delivered live infants. Maternal request cesarean deliveries without certain indicated risks crested in 2004.
CONCLUSION: Our estimates were affected by three factors: 1) lack of agreement on a definition of maternal request cesarean deliveries, 2) changes in medical coding practices, and 3) changes in physician response to medical conditions. To validly and reliably estimate maternal request cesarean deliveries requires an empirically tractable, standard definition.
LEVEL OF EVIDENCE: III
In the past, the relationship between physician and patient was largely paternalistic or authoritarian and patient autonomy was not thought to include a patient's right to select route of delivery.8,12 Recently, however, the American College of Obstetricians and Gynecologists (ACOG) argued that requests for any surgery should be carefully negotiated between physician and patient and should incorporate the major tenets of ethical medical practice: beneficence, nonmaleficence, patient autonomy (including informed consent and informed refusal), justice, and veracity.4 Essentially, ACOG argues patient choice should be respected and supported so long as it does not negate ethical medical treatment for both mother and fetus.6
The American College of Obstetricians and Gynecologists' view on maternal request cesareans is contrary to recommendations by other organizations. For instance, the International Federation of Obstetrics and Gynecology states "performing cesarean section for non-medical reasons is ethically not justified."13,14 Despite the controversy on maternal request cesareans, there is currently little information on how common such procedures are in the United States. Obtaining valid estimates is hampered by the lack of a consistent vocabulary and definition for maternal request cesareans. Accordingly, the work presented here has two goals: 1) to review the definitions and terminology used to identify maternal request cesareans, and 2) to provide estimates for maternal request cesareans among primary cesareans, per year from 1991 to 2004 using nationally representative data on deliveries. The second goal will be accomplished by using the terminology found in current literature as a basis for our analyses.
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MATERIALS AND METHODS |
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ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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To achieve our second goal, we extracted data on women who delivered live births from the National Hospital Discharge Survey public use files. For each patient, the National Hospital Discharge Survey listed a maximum of seven diagnostic codes and four procedure codes. The diagnostic codes were from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM).15 The National Hospital Discharge Survey has been conducted continuously by the National Center for Health Statistics (NCHS) since 1965. The National Hospital Discharge Survey is the principal source for national data on patient discharges from nonfederal, short-stay hospitals. Since 1988, the survey included hospitals whose specialty is either general medical, general surgical, or children's general regardless of average length of stay. The hospitals in the sample were selected using a stratified three-stage probability design using primary sampling units used in the National Health Interview Surveys, then hospitals within those primary sampling units, then discharges within those hospitals. The hospital sample was updated in 1988, 1991, 1994, 1997, 2000, and 2003. We were unable to include sampling design effect variables in our analyses because such variables were not contained in the National Hospital Discharge Survey public-use data files for confidentiality reasons. To account for the complex sampling design we calculated adjusted standard errors using the formulas and parameters provided by NCHS, which are based on a method using generalized variance curves. These calculations were a cost-effective alternative to accessing restricted data.
Data were collected using one of two procedures, manual or automated. There is an ongoing quality control program for the National Hospital Discharge Survey manual data collection. Approximately 10% of manually collected abstracts were independently recoded, with discrepancies resolved by a chief coder.21 The overall error rate for records manually coded for the 2003 data were 0.1% for demographic and medical coding and data entry.17
The current study used weighted data from 1991 through 2004, the most recent National Hospital Discharge Survey data available. The weights for the National Hospital Discharge Survey data are complex and have changed over time. Starting in 1988, weights for hospitals similar to nonresponding hospitals were inflated annually to account for nonresponding hospitals. For partially responding hospitals, discharges received from that hospital were weighted to account for missing discharges from that hospital. For 1991–2004, the National Hospital Discharge Survey included records from 458,767 women who delivered live infants (ICD-9-CM code V27.0,2,3,5,6,9). This analysis was exempt from the Battelle Internal Review Board because this was a secondary data analysis and there were no identifiers in the National Hospital Discharge Survey public-use data.
Analysis data were extracted in three stages to capture potential maternal request cesareans (Fig. 1). First, we excluded women who delivered with a history of cesarean (identified with ICD-9-CM code 654.2 for previous uterine scar). Second, we excluded women who labored. Trial of labor was identified with ICD-9-CM codes 652.1, 653.X, 656.3, 659.0, 659.1, 660.X, 661.X, 662.X, and 663.0.22 Dr. Kimberly Gregory confirmed that Henry et al23 validated the ICD-9 codes for labor using abstracted medical records in their 1995 study (first author personal communication with K. Gregory, October 28, 2005).
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We added ICD-9-CM codes 656.8 and 659.7 to this list to incorporate changes in the coding for fetal distress.24 In 1998, ICD-9-CM code 656.3 was reassigned to three separate codes. Code 656.3 (fetal distress) was delegated to represent fetal metabolic acidemia; code 656.8 (other specified fetal and placental problems) was revised to represent abnormal acid-base balance, intrauterine acidoses, lithopedion, and meconium in liquor; and a new code 659.7 (abnormality in fetal heart rate or rhythm) was created to represent depressed fetal heart tones, fetal bradycardia, fetal tachycardia, fetal heart rate decelerations, and nonreassuring fetal heart rate or rhythm.
Third, we excluded women with certain maternal, fetal, or placental pregnancy complications identified as risks that indicate against labor. To identify pregnancy complications, we used an established and published list of complications developed by Gregory et al.22 This list consisted of 12 maternal, fetal, and placental pregnancy complications.22 These complications accounted for 93% of all primary cesareans without a trial of labor in California in 1995. No other list has been validated in the literature to identify complications that present a risk for labor, making this the best choice for our analyses. This list was recently tested in the Healthcare Cost and Utilization Project, with 1994 to 2001 data from California by Meikle et al25 who obtained the same results as Gregory et al.22 The complications are: malpresentation (ICD-9-CM code 652.X, except 652.1,5); antepartum hemorrhage, abruption placentae, placenta previa (641.X, 656.0); herpes simplex (054.X, 647.6); severe pre-eclampsia and eclampsia (642.5,6); uterine scar not elsewhere classified (654.9); multiple gestation (651.X); macrosomia (656.6); unengaged fetal head (652.5); abnormality of organs and soft tissues of pelvis (654.X, except 654.2,3,8); other hypertension complicating pregnancy (642.x, except 642.5,6); preterm gestation (644.2); and central nervous system malformation in fetus or chromosomal abnormality (655.0,1). We tested these conditions by applying them to weighted 1995 National Hospital Discharge Survey data using the original labor codes established by Gregory et al.22 The National Hospital Discharge Survey data do not contain state identifiers, thus we were unable to isolate California, to replicate previous research. Instead, we limited the data to the "West" region which contains 13 states, including California. Our findings were similar to those of Gregory et al.22 and Meikle et al.25 The 12 complications accounted for just over 86% (confidence interval [CI] 86.12 – 86.26) of all primary cesareans before labor.
Data records containing only ICD-9-CM codes that did not match these 12 conditions constituted potential maternal request cesareans. This sample consisted of records from 2,394 women who delivered by primary cesarean without a trial of labor and without any of the 12 maternal, fetal, or placental pregnancy complications. Women who delivered by primary cesarean were identified with procedure codes 74.0,1,2,4,99 (in conjunction with no previous cesarean).
We estimated maternal request cesareans using the definitions of maternal request cesarean found in the literature. In addition, we provided context by offering estimates of maternal request cesareans in five different populations 1): women who delivered live infants, 2) women who delivered by cesarean, 3) women who delivered by cesarean with no trial of labor, 4) women who delivered by primary cesarean, and 5) women who delivered by primary cesarean with no trial of labor. To demonstrate trends over the study time line, 1991–2004, we illustrated yearly estimates in several figures. These trends were validated using the Cochran-Armitage Test for Trend.26,27 All trends reported here are significantly different from zero (P<.001). All confidence intervals are 95% CI and were calculated using the adjusted standard errors. Analyses were conducted using SAS 9.1 (SAS Institute Inc., Cary, NC).
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RESULTS |
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ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Based on our review of the remaining 105 articles, we conclude that maternal request cesareans have two properties: they are performed before onset of labor (timing) and in the absence of medical conditions presenting a risk to the pregnant woman or the fetus for labor (absence of risk). Those who offer a definition of maternal request cesareans agree on the timing component.5,11,23,25 One exception is Kalish et al28 who suggest it is also important to investigate cesareans requested by patients after labor has begun.
The second property, absence of risk, is defined less consistently in the literature. There are two approaches to defining absence of risk: 1) the absence of any medical condition, or 2) the absence of certain medical conditions indicating risk. In other words, risk is either absolutely absent or it is relatively absent. An example of the absolute absence of risk is found in the work of Gregory et al22 in which maternal request cesareans are described as "cases associated with no medical condition" (p.1396). An example of the relative absence of risk is provided by ACOG,4 which infers maternal request cesareans are those "in the absence of an accepted medical indication" (p.24). The American College of Obstetricians and Gynecologists does not expound on what is and is not regarded as accepted.
In addition to variations in definitions, maternal request cesareans have several aliases. These include: maternal request,29,30 patient-choice (hyphen optional),1,3,4,8,31–33 cesarean on demand,2,5 elective cesarean,28,34–36 and prophylactic cesarean.3 The American College of Obstetricians and Gynecologists suggests, however, that some of these terms are not simply aliases, but refer to different circumstances. In "Surgery and Patient Choice,"4 ACOG differentiates between a cesarean on demand and an elective cesarean, using physician–patient discourse as a distinguishing factor.4 To complicate matters, recent studies have used the term elective cesarean, such that it includes maternal request cesareans as a subset of elective cesareans.29 This presents a logistical problem for measuring maternal request cesareans, because there is no consistent definition for an elective cesarean in medical literature.29,30
It is also important to address the difference between primary and repeat cesareans. This is important not only for determining a single definition but also for providing estimates of maternal request cesareans.4,8,11,37 For the most part, the literature on maternal request cesareans suggests this concept is applicable to both primary and repeat cesareans. However, recognizing maternal request cesareans among women with a history of cesarean implies the patient has a choice between vaginal or operative delivery. The American College of Obstetricians and Gynecologists' stance on vaginal birth after cesarean (VBAC) has varied over time. Their most recent recommendation (Practice Bulletin 54)38 is that VBAC should be attempted with caution. With VBAC rates in decline and clinical practice reconverging toward "once a cesarean, always a cesarean," it is no longer clear whether maternal request cesareans occur for women with a history of cesarean. At the very least, the algorithm used to decide route of delivery varies for primary and repeat cesareans.37 In response, HealthGrades defines maternal request cesareans as "a first-time, pre-planned C-section for which there is no medical necessity" (p.1). Thus far, others have not offered a definition for maternal request that either distinguishes primary cesareans from repeat cesareans, or combines primary and repeat cesareans.
To examine whether there are maternal request cesareans in the National Hospital Discharge Survey data, we must first conceptualize these cesareans. We do so by using the definitions of timing and absence of risk found in the literature just reviewed. The timing component in our analysis is consistent with the literature in that maternal request cesareans occur before onset of labor. With respect to the absence of risk, we use both approaches found in the literature: 1) the absolute absence of risk (absence of any medical conditions), and 2) the relative absence of risk (absence of certain medical conditions). Table 1 provides a demographic overview of the analysis sample, as well as of all women who delivered by primary cesarean and did not labor (the analysis sample is a subsample of such women).
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We first examined what ICD-9-CM codes appear in the analysis sample. Each hospital discharge record in the sample contains at least one ICD-9-CM code. Not all ICD-9-CM codes, however, correspond to a medical condition. Of all records in the analysis sample, 29.55% (CI 29.43–29.67) include the code for "cesarean without mention of indication"; 16.93% (CI 16.77–17.09) include the code for "sterilization"; 11.40% (CI 11.16–11.64) include the code for "other current conditions classifiable elsewhere"; 9.13% (CI 8.88–9.38) include the code for "pregnancy-related anemia"; and 8.20% (CI 7.94–8.46) include the codes for "pregnancy-related diabetes." These were the five ICD-9-CM codes most common in the analysis sample. The trend for the ICD-9-CM code for "cesarean without mention of indication" in the analysis sample varies widely over time, from 17.73% (CI 17.64–17.82) in 1991 to 50.96% (CI 50.86–51.06) in 1997 to 21.37% (CI 21.30–21.44) in 2004.
Of the hundreds of codes listed in the sample, only three potentially represent an absolute absence of a medical condition: 669.7 "cesarean delivery, without mention of indication," 650.x "normal delivery," and V25.2 "sterilization." Sterilization is defined as an "encounter for contraceptive management" and is not considered a medical condition.39 More than 26% (CI 26.55–26.79) of the weighted analysis sample contains only these three codes. That is, no medical condition precluding labor is recorded, suggesting that over one fourth of the cases in the analysis sample are maternal request cesareans with an absolute absence of risk. This is equivalent to 0.20% of all women who delivered live infants in 1991 through 2004 (pooled years) or to 1.34% of women who delivered by primary cesarean during these 14 years (CIs in Table 2). The equivalent figures for 2000 through 2004 are 0.17% of all women who delivered live infants and 1.05% of women who delivered by primary cesarean. We provide estimates for both periods as maternal request cesareans began to garner public attention around 2000.
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Figure 2 illustrates the trend of maternal request cesareans, with an absolute absence of risk, from 1991 to 2004. The figure shows centered moving averages (calculated as [(PYEAR 1+PYEAR 2+PYEAR 3)/3)*100], where P=percent), whereas the percentages reported in the text are yearly estimates. For example, maternal request cesareans without any indicated risk peaked in 1999 for women who delivered live infants. Figure 2, however, places the peak at 1998. This discrepancy is due to the use of centered moving averages. Between 1991 and 1999, there was a steady increase in maternal request cesareans with an absolute absence of risk. By 2004, the estimates of maternal request cesarean with an absolute absence of risk had declined to mirror those of the early 1990s.
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The proportion of maternal request cesareans with a relative absence of medical conditions is considerably greater than the proportion with an absolute absence of conditions for each denominator reported (Table 3 versus Table 2). Unlike estimates for the absolute absence of risk, the estimates for the relative absence of risk increased in the last few years of the analysis (Fig. 3). Maternal request cesareans with a relative absence of risk among women who delivered by cesarean or by primary cesarean peaked in 1998. Maternal request cesareans with a relative absence of risk among women who delivered live infants crested in 2004, suggesting this population is still experiencing an incline in maternal request cesareans.
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DISCUSSION |
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ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Our findings suggest the rate of maternal request cesareans across time lies somewhere between the estimates presented by HealthGrades and Childbirth Connections. Where risk is absolutely absent, maternal request cesareans have decreased since 1998. This is the very time frame in which maternal request cesareans have become controversial. This is a salient finding considering primary cesareans have increased over this same time period. According to the National Hospital Discharge Survey data, primary cesareans have risen from 17.21% (CI 17.20–17.22) in 1991 to 20.67% (CI 20.66–20.68) in 2004. How is it that maternal request primary cesareans have declined as primary cesareans have increased? There are three possible explanations. First, the availability of ICD-9-CM codes on hospital discharge records has improved over time. This is likely a result of increased requirements for documentation that may have changed the clinical practice of providing ICD-9-CM codes on patient charts. Second, advances in diagnostic procedures enable health care providers to identify complications earlier than in the past. Third, physicians may have changed their response to certain diagnoses over time. All of these factors could affect the number of women delivering without mention of complications and hence contribute to observing fewer maternal request cesareans in recent years. Diagnosis rates for the 12 pregnancy complications used in this study indeed have increased over time for women with no previous cesarean deliveries (Joesch JM, Gossman GL, Tanfer K, 2006; manuscript under review). As the proportion of women with at least one of the 12 pregnancy complications increases, the number of women with an absence of risk decreases. Thus, our estimates of maternal request cesarean deliveries in the absence of risk may be an artifact of coding.
However, maternal request cesareans in the absence of certain medical risks demonstrate a different trend. These cesareans have ebbed and surged across time, with a minor crest in 1994, a major crest in 1998, and a tertiary crest in 2004. The pronouncement of these swells varies, depending on the denominator. This finding underscores the necessity for the medical community to determine a singular definition for a maternal request cesarean. It seems this definition, the absence of certain medical conditions, better reflects the debate in current literature in that it demonstrates a recent increase in maternal request cesareans.
The pregnancy complications used in this study were identified with an established research protocol. However, they do not necessarily capture all situations in which cesarean delivery before onset of labor may be indicated. For instance, gestational diabetes mellitus (GDM) is not included in the list of pregnancy complications used here. At this time, the appropriate route of delivery for women with GDM remains contested. If GDM were added to our list of medical indications against labor, our estimates for maternal request cesareans would decrease. On the other hand, it is possible the conceptualization of "relative absence of risk" used here may be too broad. Gregory et al's22 approach, which is followed in this research, is based on the premise that women who deliver by cesarean before labor "represent a ‘high-risk’ group for whom there would be relative consensus about the clinical conditions mitigating against allowing labor to proceed" (p.1,389). Nevertheless, the authors conclude "that there are very few absolute indications" for cesarean delivery before labor (p.1,396).22 Thus, we provide a starting point for deriving accurate estimates of the extent of maternal request cesareans based on a methodology that can be reproduced and refined by others, as the discussion on this little-understood phenomenon progresses.
A further limitation of our estimates of maternal request cesareans is that they are based on administrative data. For instance, the National Hospital Discharge Survey data include up to seven diagnostic codes per hospital discharge record. In contrast, Gregory and colleagues22 had up to 25 diagnostic codes per case, creating more "opportunity" for a medical condition to emerge. Nearly 7% (CI 6.55–7.39) of our weighted analysis sample contained seven diagnosis codes. If additional diagnosis codes were available in the National Hospital Discharge Survey data, perhaps we could identify more women with an indicated risk listed on their discharge records. This would improve our estimates of maternal request cesareans with a relative absence of risk. Finally, the labor codes used in this analysis have not been validated since 1995. These codes need to be validated using a recent data set. This is especially true for fetal distress, one of the indications used to measure labor. The 1998 change in this code may affect estimates of maternal request cesareans.
Several aspects of maternal request cesareans require more attention before it will be possible to estimate validly, reliably, and accurately how many cesareans in the United States are performed at the behest of patients. The only way to truly monitor maternal request cesareans in the future is to 1) agree on a definition and 2) measure these events empirically in a consistent manner. Ideally, a new ICD-9-CM code would capture maternal request cesareans as a subset of cesarean deliveries performed before labor. Such a code would need to describe both timing and absence of risk, as well as a recording of patient choice to deliver vaginally or by cesarean. Although there is consensus in the literature that timing of maternal request cesareans is before onset of labor, practitioners and policy-makers may also be interested in cesareans requested during labor.28
Developing a new code will be challenging, particularly in regard to capturing risk, because a comprehensive list of accepted medical conditions is required. The scheme presented by Gregory et al22 is an excellent start, but requires more attention. These authors did not design their list to identify maternal request cesareans. They developed the scheme to create a standardized methodology using administrative data to identify indications for cesareans without a trial of labor and to provide estimates for these indications (p.1,394).22
An additional challenge will be to clarify cesarean for nonmedical reasons. For example, if a woman desires a cesarean to avoid future medical complications, such as pelvic organ prolapse or sexual dysfunction, would it be considered a cesarean for nonmedical reasons? Finally, developing an ICD-9-CM code to identify maternal request cesareans will be challenging if such a code is to incorporate ACOG's definition(s). In their publication "Surgery and Patient Choice,"4 ACOG introduces a third dimension (in addition to timing and absence of risk), a dimension of discourse between provider and patient. Operationalizing this dimension to measure it empirically and consistently will be challenging. However, measuring the physician's role in the route-of-delivery decision process is critical to understanding the increasing rates of cesarean delivery. According to Childbirth Connections, nearly 10% of respondents to their national survey felt pressure from a health professional to deliver by cesarean.40 The physician–patient discourse is also important because this is where and when a patient will request a cesarean. Patient intent is vital to understanding trends in primary cesareans before labor.29
There may be resistance to a new code for maternal request cesarean, however, from both physicians and patients. Past president of ACOG, W. Benson Harer Jr, suggested that coding practices in the United States may be skewed to secure payment from the patient's insurance company. In 2002 Harer wrote, "physicians and patients often creatively find a "medical" indication to placate payers or quality-assurance committees" (p.42).6 If this is the case, we may never be able to truly measure the phenomenon of maternal request cesareans.
In conclusion, we provide two alternative estimates for maternal request cesarean in the United States for 1991 to 2004 using nationally representative hospital discharge records. While there do seem to be cases of maternal request cesarean without any medical conditions, the coding of the conditions is not consistent over time. There are also cases of primary cesarean delivery before labor performed in the absence of specific pregnancy complications indicating cesarean delivery. However, the concept of relative absence of risk requires additional scrutiny. Whether medical indications for cesarean delivery are present or absent, the current conceptualization of so-called maternal request cesareans in the literature lacks empirical utility.
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Footnotes |
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Supported by grant number 1 R01 HD045819 from the National Institute of Child Health and Human Development.
The authors thank Elizabeth A. Strickland, MD, for her consultation on numerous medical issues.
Corresponding author: Ginger L. Gossman, Battelle Centers for Public Health Research and Evaluation, 1100 Dexter Avenue North, Suite 400, Seattle, WA 98109-3598; e-mail: gossmang{at}battelle.org.
doi:10.1097/01.AOG.0000242564.79349.b7
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REFERENCES |
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