PUBLIC CITIZEN HEALTH RESEARCH GROUP SIDNEY M. WOLFE, M.D., EDITOR September 2006 N VOL. 22, NO.9 The Changing Dynamics of C-Sections in the United States: Cesarean Delivery on Maternal Request Part 2 Last month in Health Letter, we over time, the focus was on cesareans usually constrained by physician prac- described recent trends in cesarean on maternal request. Over the course tices and preferences, and the informa- sections in the United States. Here, we of two days, however, it became tion women receive. The National summarize the major findings of an evident that the data are spotty, many Center for Health Statistics uses the NIH conference on the topic. This arti- studies are not amenable to compar- term “cesarean with no medical indica- cle is the second in a two-part series. isons, and there are no easy algorithms tion,” thereby focusing on the apparent or decision trees to provide reliable lack of a health rationale rather than on ast March, the National Institute guidance to patients and physicians. the women’s choice; others use “no of Child Health and Human Although The Washington Post’s report medical risk cesarean” for the same LDevelopment (NICHD) and the reason. But the acronym CDMR on the conference was headlined “NIH Office of Medical Applications of panel finds no extra risk in cesarean (cesarean delivery on maternal Research convened a panel of experts section,” the discussions reflected a request) has already entered the and held a State-of-the-Science more complicated reality. medical literature, and the conference’s Conference on “Cesarean Delivery on The idea of “maternal request” is title and the ensuing report may give Maternal Request” to look into the actually misleading. Despite a few additional legitimacy to this nomencla- following questions: high profile celebrities who have said ture. Although the final report states they want to deliver by cesarean that CDMR “is not readily identifiable in 1. What is the trend and incidence of section, there is limited evidence that any existing studies or U.S. national cesarean delivery over time in the women actually request a particular databases, either currently or historical- United States and other countries? type of delivery. Instead, their choice is continued on page 2 2. What are the short-term (under one year) and long-term benefits and C O N T E N T S harms to mother and baby associat- ed with cesarean by request versus Patients Without Borders, Part 2 attempted vaginal delivery? Health Letter takes a second look at medical tourism.........................3 3. What factors influence benefits The “Utimate Prize” for Big Tobacco and harms? Cigarette smuggling in China opens the doors to 4. What future research directions need a massive Chinese smoking market......................................................5 to be considered to get evidence for making appropriate decisions Recalls regarding cesarean on request or July 19, 2006 – August 21, 2006 attempted vaginal delivery? This month, Synthroid tablets and coffemakers are on the list................6 Although the initial question Outrage of the Month Fairness creams in South Asia — a case of disease mongering?......12 referred to overall c-section trends VISIT HEALTH RESEARCH GROUP’S WEB SITE AT WWW.CITIZEN.ORG/HRG/ C-SECTIONS, from page 1 ture found only three instances in babies delivered prior to 39 or 40 ly,” and that there is “little confidence which there was at least moderate weeks of gestation. As a result, one of in the validity of estimates” suggesting evidence of maternal and neonatal only two practice guidelines included that CDMRs represent four to 18 outcomes favoring one modality over in the report’s conclusions state that percent of all c-sections, the report the other. There was a lower frequen- “cesarean delivery upon maternal assumes that a growing proportion of cy of postpartum hemorrhage with request should not be performed prior c-sections are driven by medical need. planned cesarean delivery than with to 39 weeks of gestation or without The only survey to directly gauge the planned vaginal delivery or unplanned verification of lung maturity, because incidence of CDMR was sponsored by cesarean delivery. But two other of the significant danger of neonatal Childbirth Connections and conducted respiratory complications.” by Harris Interactive. This study, which There is a reluctance to adopt interviewed women who gave birth in any “ideal rate” of cesarean deliv- 2005, found that less than 0.4 percent ery as a goal. The conference panel (1/252) of the respondents who had a There is limited evidence rejected that option, which the World primary cesarean initiated a planned Health Organization and other organ- cesarean without medical reason. Two that women actually izations have espoused. In the other women with a primary c-section absence of benchmarks, women and said that the procedure was scheduled request a particular type practitioners will therefore lack a ahead of time without medical reason of delivery. Instead, their legitimate yardstick to assess the and initiated by a health professional. labor practices of particular physi- The medical literature, though choice is usually cians and hospitals. This may eventu- growing, does not provide much ally be reflected in the nation’s guidance for practitioners. In constrained by physician Healthy People objectives when they preparation for the conference, are revised. NICHD commissioned a literature practices and The data may very well become review comparing cesarean delivery more muddled over time. Despite on maternal request with planned preferences, and by the calls for more targeted, better- vaginal delivery. The review found designed studies and more funding that the existing studies lack consis- information women for research, it is unlikely that any tent definitions of routes of delivery clear guidance will come from this and are therefore difficult to compare. receive. source. The gold standard for In addition, most focus on the actual medical evidence — the randomized route of delivery rather than on what clinical study — presents a number was planned. Not surprisingly, the of difficulties. First, it would probably final conference report concludes that outcomes — maternal length of hospi- be unethical to randomize women to “there is insufficient evidence to eval- tal stay and neonatal respiratory a planned cesarean delivery versus a uate fully the benefits and risks of morbidity — favored planned vaginal planned vaginal birth, nor would cesarean delivery on maternal request delivery over c-section. Evidence many women be willing to consent as compared to planned vaginal deliv- concerning the association of neonatal to such randomization. In addition, ery, and more research is needed.” respiratory morbidity with c-section is the study would have to be very large In fact, those reviewing the litera- particularly strong and consistent for continued on page 3 Editor..................................Sidney M.Wolfe, MD The Health Research Group was co-founded in 1971 by Ralph Nader and Sidney Wolfe in Managing Editor........................Kate Resnevic Washington, D.C. to fight for the public’s Contributor ......................Annette Ramírez de health, and to give consumers more control Arellano, DrPH over decisions that affect their health. Proofreader......................................Shiloh Stark Copyright © Health Letter, 2006 Published Monthly by Material in the Health Letter may not be Production Mgr.......................Kristy I. Jackson Public Citizen Health Research Group re-printed without permission from the Editor. All rights reserved. ISSN 0882-598X Send letters and requests to HEALTH LETTER, President....................................Joan Claybrook Editor, 1600 20th St., NW, Washington, D.C., 20009. Annual subscription price is $18.00 (12 is- sues). Mail subscriptions and address changes to Health Letter, Circulation Department, 1600 20th St., NW, Washington, D.C., 20009. Our Web site address is www.citizen.org/hrg. 2 N September 2006 Patients without Borders: The Emergence of Medical Tourism Part 2 In the July issue of Health Letter, involved. Here, we will present some surprising that hospitals seeking to Public Citizen wrote about the rapid- of the trade-offs the U.S. consumer is attract foreign patients have taken ly emerging phenomenon of medical making when opting for medical pains to provide the amenities that tourism. The article described a kind tourism, and some of the issues that ensure patient approval. Many have of “patients without borders” whereby should inform this decision. therefore invested an inordinate more and more Americans are travel- amount of resources to create posh ing beyond national boundaries to How good is the care? facilities combining high-technology receive medical care. Here, Public For Americans going abroad, the medicine with resort attractions. Citizen expands on this topic. This possibility of trading off quality care In addition, some hospitals designed article is the second in a two-part for affordability may be of vital impor- for a foreign clientele have adopted series. tance. And the choice consumers face Western standards of care, and sought between “suffering with a health prob- and obtained accreditation from the growing number of U.S. lem or facing significant damage to international arm of the Joint patients are turning to other their finances” may not be easy. Commission for the Accreditation of Acountries for surgical and The short answer to the question Healthcare Organizations. They also other care. The lure of “first-class concerning quality is: it depends. As capitalize on the fact that some of their services at third-world prices,” as with health services in the United physicians were trained in the West. tantalizingly portrayed in the elec- States, the quality of the product can And, because they are in the hospitali- tronic and other media, is attracting vary widely, and patients are often ty business, they tend to have a high those who want to combine their not in a position to judge what they staff-to-patient ratio and stress gracious care with a vacation, are seeking are getting.