American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Cesareans, Foreign Medical Graduates

Baby_1Cesarean rates have been on the rise in the U.S. for years. Over 30 percent of American births are currently done by c-section. And it’s a number that isn’t likely to drop any time soon. Once a woman gets a cesarean, she’ll almost always have another when she gives birth again. Recent revisions to guidelines for VBACs – or “vaginal birth after cesarean” – are intended to reduce multiple c-sections. On today’s show, why those guideline revisions may have less impact than intended and just how concerned we should be about the rising cesarean rate. And later in the show, how foreign medical grads are contributing to U.S. health care.

Listen to this episode.

Segment 1: Cesareans (00:00-13:40)
Guest: Dr. Bill Grobman, co-author of revised VBAC ("vaginal birth after cesarean") guidelines for College of Obstetricians and Gynecologists


Since 1970, the cesarean delivery rate in the U.S. has jumped from 5 percent to more than 30 percent. (The rate recommended by the World Health Organization is 15 percent.) A lot of factors have contributed to the increase: more women are giving birth at an advanced age and more are having multiple births - twins and triplets - some as a result of fertility treatments. Doctors' fears of litigation have contributed, as well; as could have the fact that cesareans pay doctors more - on average, almost twice as more - as a vaginal birth.

Another factor: electronic fetal monitoring. Introduced in the '70s, it's now become standard in most births. Changes in the baby's heart rate - a possible sign of too little oxygen - will often result in a c-section; but there's little proof that the test actually saves lives.

And despite the fact that most women who've had a c-section can safely give birth vaginally, less than 10 percent are having VBACs - or "vaginal birth after cesarean." VBAC rates have fluctuated over the years largely in response to shifting guidelines. A 1999 revision stated that hospitals had to have surgery and anesthesia teams "immediately available" - that is, on site - in the case of a woman requesting a VBAC. The costs of this recommendation lead many hospitals - especially smaller and rural hospitals - to ban the practice.

Just last month, the college of Obstetricians & Gynecologists revised its guidelines again. The new guidelines reaffirm the safety of VBAC for most women. But they also retain the "immediately available" language regarding emergency care. A recommendation that women be allowed to accept "increased levels of risk" has also been added. The question remains whether this will have the hoped-for outcome - that is, an increase in VBACs and a decrease in the overall cesarean numbers.

Segment 2: Foreign Medical Graduates (13:43-28:00)
Guest: James Hallock, former president of the Educational Commission for Foreign Medical Graduates


One of the biggest problems facing the health care industry today is a shortage of primary-care physicians. As U.S. med school grads choose specialization over general medicine, foreign medical graduates are coming to the U.S. for residency programs, and many are sticking around and helping to fill primary-care vacancies.

By a wide margin, the largest number of foreign medical graduates have come from India, but significant numbers have also come from Pakistan, the Philippines, China, Egypt, and the Dominican Republic. But how comparable is medical education in these countries? And how equipped are these international doctors to care for sick Americans?

Since 1956, the Educational Commission for Foreign Medical Graduates has evaluated and certified foreign medical grads for U.S. residency programs. In 2008, the commission issued over 10,000 certificates. If the commission's previous statistics apply, about 7,000 will end up practicing medicine here in the States.