On October 13, 2018, The Lancet, one of most prestigious journals in the medical world published a staggering series on the use of c-sections by OB/Gyns delivering babies.
You may read this series HERE.
This historic collage of scientific articles and editorials points to an astonishing rise in the rate of c-section deliveries. It’s important to know that c-sections are one of the most, if not THE most, common surgical operation in the world.
The punch line of the Lancet series is that over the period between 2000 and 2015, the global number of c-sections has gone from 16 million (12% all births) to 30 million (21% of all births). An INCREDIBLE doubling in the absolute number of operations.
The rates of c-sections is so staggering today that global experts at the World Health Organization (WHO) and expert editorials in The Lancet are calling it an “EPIDEMIC”.
In the United States alone, 32% of deliveries were by c-section in 2015, up from 23% percent in 2000. That’s ONE out of every THREE American babies!
Now, there is no question that there are pregnancies in which saving the mother’s or child’s life REQUIRES a c-section — conditions such as breach pregnancies, pre-eclampsia, intractable bleeding, or trauma.
But the trouble is that an increasing number these operations are NOT being performed out of medical necessity.
What does this mean?
It means that an increasing number of OB/Gyns either: 1) have a very low threshold for taking pregnant women to the operating room for a c-section, or 2) believe that it’s appropriate to offer pregnant women a medically unnecessary, elective c-section, so long as the patient asks for it and consents to the operation.
But neither of these two reasons are sufficient medical justification for performing what is a sizable, but medically unnecessary, surgical operation on millions of women across the world every year.
The first reason listed above usually has to do with surgeons’ convenience and his/her need to “get through the shift” in as predictable and “smooth” a pace as possible. Thus many gynecologists develop a low threshold for putting knife-to-skin to “get it over with”. For the OB/Gyn, a c-section is a lot more predictable (and faster) than waiting around for a vaginal delivery — every one of which is different depending on the patient, her personality and her anatomy.
The second reason listed above has to do with a system of thinking in contemporary medicine that says “whatever the patient wants” — so long as it pays, that is. This kind of thinking seems to be especially prevalent in Gynecology (and in Plastic Surgery). But while it’s true that patient autonomy and collaborative decision making is of critical importance in the practice of medicine, it is no substitute for sound clinical and ethical judgment by the physician.
In a moment of honest reflection, most OB/Gyns reading this know exactly what I’m talking about.
But, both of these reasons have to do with a compromised medical ethical compass in the Gynecology specialty— where the patient’s health and safety do NOT seem to be the primary driving forces motivating these physicians’ behavior. And this compromised standard of ethical thinking has led to the evolution of yet another iatrogenic epidemic in Gynecology.
When it comes to c-sections it’s important to say that anyone who has ever witnessed or taken part in one knows that it is a big abdominal operation. Certainly, from a technical perspective, it’s not an elegant surgical procedure. And it affords a lot of opportunity for technical mishaps — because it requires speed.
C-sections are done through large abdominal incisions, anywhere from 5–10 inches long. There’s usually a good amount of blood loss. And like any other large abdominal surgery c-sections have their share of tough recovery — and, of course, complications.
You might be asking why I’m harping on this disturbing epidemic of medically unnecessary c-sections in gynecology — what business or qualification does a cardiothoracic surgeon and women’s health advocate have meddling in this issue?
Let me explain.
The reasons I’m writing here is that starting a few years ago my wife, Dr. Amy Josephine Reed, and I got into a pretty ugly fight with the gynecological specialty over a medical device, called a Laparoscopic Power Morcellator. They were using this machine to perform an operation known as a “hysterectomy”, where a woman’s uterus is removed.
The gynecologists’ laparoscopic Power Morcellator shreds up enlarged uterine tissue/tumors for the purpose of getting big masses out of small skin incisions. But the trouble is that if these masses are carrying a cancer, the machine spreads and upstages the cancer with deadly results. This is the tragedy that took my wife from our family when her cancer was spread in 2013 at the Brigham and Women’s Hospital in Boston — using a Laparoscopic Power Morcellator made and distributed by the German company STORZ.
Until 2014 when Amy engaged the Gyneoclogy specialty, literally, hundreds of thousands of women’s uteri were being morcellated using this device across the world — and many were having their cancers spread and upstaged with deadly results.
Though it might seem clear-cut to most other medical professionals, and even to informed lay-persons, that no one in their right mind should shred potentially cancerous tissues/tumors inside a woman’s abdominal cavity, the gynecological specialty and its advocates vigorously defended the practice. Some even did so to the point of belligerence towards my wife and me — people like Dr. William Parker of UCLA, and the husband and wife team of fertitlity specialists, Drs. David Olive and Elizabeth Pritts, among others.
What was their reasoning?
Well, they claimed that because this device made small incision surgery possible it is advantageous to the majority of women. They claimed that making a larger incision to remove the enlarged uterus without shredding it would cause unacceptable harm and even mortality to women undergoing elective hysterectomies.
So, the defense of Power Morcellation by Gynecologists was basically centered on the small size of the abdominal incision the Laparoscopic Power Morcellator makes possible.
Of course, this defense was an incredible red herring — for the Gynecologists, clearly, it’s not about the size of the incision as the epidemic of medically unnecessary c-sections is demonstrating.
Let me explain.
As I came across the Lancet studies and editorials about this epidemic of unnecessary c-sections, with their characteristic LARGE abdominal incisions, it dawned on me that it’s not really the size of the incision that matters to these physicians. It’s the economics of the practice and surgeon convenience that are driving the whole “business model”.
C-sections make the surgeons’ schedule more predictable — and, at least in the US, every operation pays pretty well. Additionally, with so many women wishing to make a lifestyle choice (i.e., a lack of desire to undergo a vaginal delivery or desire to control the timing of a birth), c-sections sell well! So a large incision size becomes ACCEPTABLE to the gynecologist when offering women “routine” medically unnecessary c-sections.
Likewise, Power Morcellation makes the surgeon’s job convenient (Same day surgery and a faster operation), and it pays pretty well. Not to mention, many women make the decision based on real or perceived cosmetic advantage (i.e., small incision) and faster recovery times. “Minimally invasive” surgery sells well! So, a larger incision size becomes UNACCEPTABLE to the gynecologist when offering women “routine” Laparoscopic or Robotic “Hyster-”ectomies or Myomectomies.
But gynecologists can’t have it both ways. If it’s about preserving women’s health and defending their safety, especially from avoidable iatrogenic complications and mortality, large incisions are either acceptable or they are not! But what’s actually driving the gynecologists in what size incision they deem acceptable is economics. So what they accept is a function of business directives and revenue.
Certainly, in the fight over Power Morcellation, it was never about the size of the incision for the Gynecologists like William Parker and his crew— or the large number of other GYNs who pushed back against my wife and me. Because if gynecologists really cared about what a large incision does to women, they’d never be offering elective and medically unnecessary c-sections to the women who trust their professional acumen.
Instead, the gynecologists’ defense of Power Morcellators was about preserving an economically lubricated practice. Likewise, in the epidemic of medically unnecessary c-sections, it’s not about what’s best for the patient, it’s about convenience and a lucrative business.
It’s hard to escape the conclusion that the gynecologists who are still defending Power Morcellation on the basis of the size of incisions are terrible hypocrites — they are either brainwashed by their teachers and mentors, or they are nothing more than business-men and -women in white coats. Because many of the same surgeons who vigorously defended the Laparoscopic Power Morcellator on the basis of incision size, have no problem offering medically unnecessary elective c-sections with massive skin incisions to otherwise young and healthy women.
The scary bottom line is that Gynecology, as the medical specialty charged with the care of women, seems to have lost its ethical and leadership compass somewhere along the way. The specialty seems more moved by economic considerations than it is by the safety and health of the women it’s charged with protecting.
Of course, some say this pattern is pervasive in all of medicine, as business considerations and revenue increasingly drive innovation and physician practice patterns in America and across the world— but my contention is that Gynecology (and likely Plastic Surgery) is particularly susceptible to the profit motive.
But, it’s not good enough to do things that are efficient, lucrative, convenient for the surgeon, or preferred by a majority of patients, when minority subsets of patients can be irreversibly and unreasonably harmed or killed. That’s just not how we should be practicing medicine in the 21st century.
Certainly, patient consent, though necessary for the ethical practice of medicine, should never be allowed to replace good clinical judgment geared towards protecting every patient from harm— both medically unnecessary c-sections and UNCONTAINED Laparoscopic Power Morcellation in women are truly unnecessary and avoidable, but lucrative and high volume practices.
Women beware, Gynecology has strayed quite far from where it ought to be, ethically — and it will take some real leadership and, likely, serious external guidance and restraints to get these doctors back on track.
Perhaps a few good gynecologists out there see my point and will step up to lead and repair their badly broken professional compass.
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Hooman Noorchashm
Hooman Noorchashm MD, PhD is a physician-scientist. He is an advocate for ethics, patient safety and women’s health. He and his 6 children live in Pennsylvania.
Het bericht The Gynecologists’ Hypocrisy: It’s Neither About the Size of their Incisions Nor About Keeping Women Safe. verscheen eerst op SIN-NL.