Tuesday, February 17, 2009

UK hospitals restrict cesareans based on inaccurate cost calculations

The weekend's Sunday's Times article, 'Hospitals curb caesarean births' (by Health Editor, Sarah-Kate Templeton) was just one of many to report on the decision by hospitals in the Greater Manchester area to "ration" cesarean deliveries so that only "women with specific medical conditions" are eligible to deliver their babies via this method.

The Daily Mail's Daniel Martin's report, 'Caesareans rationed: Women denied procedure on safety grounds - and because it's too dear', and The Telegraph's Sarah Knapton's report, 'Caesarean births rationed by hospitals in order to cut costs' were two others.

Personally, I think that this decision is a national disgrace, and I can only hope that there are more doctors in the UK that will ignore such irresponsible guidelines and support the views of Doctor Christoph Lees, an obstetrician and gynaecologist at Addenbrooke's hospital in Cambridge, who is quoted in these stories saying:

"I strongly disagree with this prescriptive condition setting. Sometimes well-informed women, often older and very unlikely to have further children, do request caesarean sections and it is unreasonable to refuse if they are fully informed."

Some reasons why COST is not a valid reason for cesarean rationing
The main issue is the inaccurate cost comparison between PLANNED vaginal delivery (PVD) and PLANNED cesarean delivery. I highlight the word planned because it is no use in comparing spontaneous delivery outcomes with cesarean delivery outcomes alone. The fact is that a PVD can have many different outcomes for mother and baby - regardless of how much a spontaneous delivery is desired or encouraged - such as instrumental delivery and most importantly, emergency cesarean delivery. The cost of the latter in particular is rarely, if ever, factored into the cost of a PVD, yet it should be.

Worse still, traditional cost comparisons actually take these PVD emergency cesarean outcomes and add them to all planned cesarean costs in order to demonstrate 'hospital cesarean costs'. More recent studies have at least separated emergency and planned cesarean costs, but even then, in the argument against healthy women being able to choose a planned cesarean delivery, they do not recognize that the vast majority of these planned cesareans were for medical reasons and were therefore likely to have extra costs associated with them that would not be the case in a healthy pregnancy. The best example of this is studies that look at the NICU costs of babies born at 38 weeks gestation and earlier - obviously these costs are high, but in a healthy pregnancy where a woman delivers at 39 weeks gestation (repeatedly shown to reduce respiratory distress - see ACOG and NIH statements and others), these costs are not applicable.

The truth about birth costs
No one wants to do the study that needs to be done - an analysis of cost of women who plan a vaginal delivery (and all their actual outcomes - short and long-term) and women who plan a cesarean delivery. Doctors in Australia in 2003 looked into whether such a study would be a good idea and raised concerns that one of the biggest dangers would be the fact that planned cesarean delivery may be proven to be safer than PVD - "what a disaster" that would be, they said.

It's also worth looking at Appendix C of the NICE 2004 Clinical Guideline on Caesarean Delivery - they actually admit that it is possible to take current cesarean cost data and demonstrate that
planned cesarean delivery can be cheaper than vaginal delivery, but in the very next sentence, they dismiss it as being an 'unrealistic conclusion' to draw. It is not referred to again.

When vaginal deliveries go wrong
The cost of obstetrics litigation in the NHS is enormous and yet this is also not accounted for in any cost analysis of PVD. When a cesarean is not done in time or is not done at all, and the baby dies or is severely injured, there is a financial cost associated with that - as well as a psychological cost.

When women suffer severe pelvic floor injuries, there is a financial cost associated with post-birth surgical repair, and even more minor injuries can result in long-term damage such as incontinence or pelvic organ prolapse. Again, not to mention the psychological trauma and need for post-birth counselling that many women experience.

Perhaps hospitals would do better to concentrate on supporting positive birth experiences, and rationing negative ones - and believe me, research shows that this is not achieved by forcing all women to have a vaginal delivery.


Elisa said...

Appendix C of NICE 2004 does not contain the information you mention.

cesarean debate said...

Appendix C of the 2004 NICE guideline reads:

‘The estimated cost of maternal request can change depending on the cost value entered in the model... If the lowest vaginal birth costs reported in the review and highest caesarean cost reported in the view are used, the additional cost for accepting 8,747 maternal requests for caesarean is around £21.2m. [But] since the highest cost for vaginal birth in the review is higher than the lowest cost for caesarean, if these values were entered into the model, the model would show that increasing planned caesarean due to maternal request would lead to savings, which is not a realistic conclusion.’