Every Cesarean Delivery Should Be Justified. No Exception. Here Is How to Make That Happen.
A lesson from surgical peer review that obstetrics has refused to learn.
Every Tuesday at noon, the chief residents stood up and presented every cesarean delivery performed that week. Not just the complicated cases. Every single one. The attending who ordered it sat in the room. So did the department chair. So did everyone else on the service.
Nobody wanted to stand up in front of that room without a solid answer.
I remember because I was there.
The cesarean rate at that time was well below 20%.
Today the cesarean delivery rate in the United States is approximately 1 in 3 births. In England, it recently crossed 40%.
Committees have convened.
Guidelines have been written.
Quality metrics have been introduced.
The rate continues to stay high or rise.
More patients are being induced but the cesarean delivery rate hasn’t dropped much or at all.
Meanwhile, there is a model from a different surgical specialty that demonstrated something important: when every procedure is reviewed, discussed, and publicly justified, the rate of unnecessary procedures falls. Without harming patients.
This is a direct call to ACOG and to hospital leadership: mandate cesarean case review.
Not as a quality metric buried in a dashboard.
Not as “NSTV” reporting.
As a standing requirement, presented by the attending, in front of the department. If we are serious about reducing unnecessary cesareans, accountability is where we start.
In the 1980s and 1990s, studies examined what happened when hospital pathology departments reviewed every appendectomy specimen and reported the results back to the surgical team. When surgeons knew their negative appendectomy rate was being tracked and publicly discussed, the proportion of normal appendixes being removed fell. Patients were not harmed. In fact, outcomes improved. [CITATION NEEDED — appendectomy audit studies demonstrating reduction in negative appendectomy rates following mandatory histopathology review and peer discussion]
The mechanism is not mysterious. Accountability changes behavior.
What I Am Proposing
Every cesarean delivery should be presented by the attending physician who performed it. Not a resident summarizing the case. Not a monthly aggregate in a quality report. The attending who made the decision stands up and explains it. The indication. The alternatives considered. The reasoning at the time of decision.
This is not a new idea. During my training, we called it noon conference. It ran every week without exception. Cases were presented whether they were straightforward or difficult, whether the outcome was good or bad. The expectation was that every cesarean delivery was a decision that deserved to be examined.
I am proposing we bring it back.
What the Current System Is Missing
Cesarean delivery rates are currently measured by hospital and by system. They appear in quality dashboards. They are sometimes tied to reimbursement. But individual physician accountability is largely absent from this picture. A clinician can perform cesarean deliveries at twice the rate of a colleague seeing the same patient population, with no formal mechanism for case-by-case review.
This is not how medicine handles other high-stakes surgical decisions. Tumor boards review cancer treatment plans. Morbidity and mortality conferences examine adverse outcomes. Cardiac surgery programs review every in-hospital death. Why is the most commonly performed surgical procedure in American obstetrics operating under a lower standard of professional review than any of those?
The cesarean rate varies widely between hospitals with comparable patient populations.
That variation cannot be explained by clinical indication alone.
Some of it reflects culture, habit, convenience, or the absence of accountability.
Black patients have higher cesarean delivery rates than white patients. An nobody can reasonably explain why.
Mandatory peer review addresses exactly that portion.
What Patients Should And Deserve To Know
If you are pregnant and your doctor recommends a cesarean delivery, you are entitled to a clear explanation of why. Not a general statement about fetal well-being or a reference to policy. A specific clinical justification for why vaginal delivery is no longer the safer choice for you and your baby at this moment.
You should also know that the hospital where you give birth matters. Cesarean rates vary between hospitals by more than most patients realize. Asking your hospital’s cesarean rate is a reasonable question. So is asking about your individual doctor’s rate.
My Take
I am not arguing that every cesarean is wrong. Many are lifesaving decisions made under genuine time pressure. But the data on variation in cesarean rates, the international comparisons, and the historical record all point in the same direction: a meaningful proportion of cesarean deliveries are performed without strict clinical necessity, and that proportion responds to accountability.
The intervention required is not a new guideline, a task force, or a quality metric. It is a meeting.
Several times a week.
Every case.
No exception.
Every attending at the table, presenting their own decisions.
We did this. The rate was below 20%. We stopped doing it. The rate is now above 30% in the United States and above 40% in England. I am not claiming that one caused the other.
I am saying that we have not seriously tried the most obvious intervention available.
We know what accountability looks like in obstetrics. We built it once. We can build it again.
There are so many factors that enter into this topic. I'm not sure where I would really start. I was trained as a Resident 1973-1977 and once I settled down into the full time practice of OB/Gyne, it was 1978, late in the year. I came to a large cllinic practice in Central WI. which had a Level 3 or Level 4 NICU and received a lot of referals from the northern half of the state. We hired the first Parinatologist shortly after I arrived and at one time had 3 in our practice. Our C-section rate was at the most in the low teen's. One of the issues that changed starting in the late 60's or so was the issue of Malpractice and litigation that complicated the decision making process. I have special feelings in that area. The training received in those years was changing because of the advent of Fetal-Maternal monitoring and that coupled with the rapidily improving Ultrasound equipment and the ability to use it was moving rapidly. In the large residency programs the use of alternative methods of delivery assistance was taught, Forceps, Vacuum assistance and methods of determining fetal well being. I remember that I was at the bedside of many patients that needed support. The use of Epidurals and othat forms of pain relief were starting to be used. I, personally, persued the use of these methods when I was a Senior Med student. I was fortunate enough to have made contact with the Head of Anesthesia at Lying-In Hospital at the University of Chicago and get exposed to many methods of dealing with the issue of pain during labor. It was about that time that the Lamase method of tolerating labor came into vogue and that method of "Self-Hypnosis" was a good tool to add to the many learned. This can look more like a second article on the topic so we should move to today. We have NOT solved all the problems in Medicine and particularly child birth. There are several factors that play a role, in my opinion. A serious problem is the establishment of rapport with any patient. What follows is the confidence that what is going to happen in a situation that is filled with fear and mystery has been lost and the mechanistic approach has taken hold. Enter the Hospitalist and the disconnection of the patient from their trusted Physician. This problem needs to be reversed and the suggestions of the author would be a good start. Corporate Medicine (Socialized Medicine) is NOT the answer.
When I complete my operative report, I review the indications for the procedure. In it, I detail all methods used for induction or augmentation of labor, any resuscitative measures, and why the decision was made to move to cesarean delivery. This is also helpful because it helps me advise patients for their next delivery- are they a good TOLAC candidate?