Here's what I'm talking about

Seems that Florida's Miami-Dade County is the first locality to achieve a dubious distinction: in 2008, more babies in Miami-Dade were delivered by cesarean than vaginally.

It had to happen sooner or later. In 1970, the cesarean delivery rate in the US was around 5%. By 2007, that number had reached 31.8%. If these trends continue, soon the whole US may look like Miami-Dade.

By way of reality check, the World Health Organization targets a cesarean rate of around 5-10% to correspond with optimal maternal-child health, and a 2006 study published in the Lancet suggested that when the cesarean rate exceeds 15%, cesareans are causing more harm than they prevent.

What's driving this change? A number of factors are commonly cited: providers' fear of malpractice litigation, their desire to manage their workloads and hours, cost incentives for hospitals, some women's preference for cesarean delivery, and a recent ACOG opinion supporting a woman's right to choose a cesarean even in the absence of any medical reason for it.

A rising cesarean rate entails higher costs. According to this analysis of 2003 data, a cesarean delivery was about two times the cost of a vaginal delivery. I guarantee you they haven't gotten any cheaper since then, but the relative cost of vaginal vs. c-section probably hasn't changed much.

This is a perfect example of why I say we do not currently have a free market health care system. There's no way, in a free market, that the lower cost option - and the option that's healthier for most women - gets gradually driven out of the market.

It's also a great example of what happens when users are separated from costs. Let's say you were planning to go grocery shopping sometime this weekend. Your grocer comes to you on Thursday and says, "I'm going out of town this weekend. How about I go ahead and sell you some groceries today that could endanger your health, and charge you two times what you'd pay for normal groceries?" I think you'd be looking for a new grocer. However, thousands of women accept precisely the same offer from their obstetricians every day. If they actually had to pay the cost of the cesarean out of their own pockets, I think the picture would be a bit different.

I'm not advocating a pure fee-for-service health care system where everyone pays cash for everything. Even if it would work optimally, you'd never get people on board. Also, I think there are some practical problems. Health care bills are just too big and too unpredictable for most folks to be able to budget for them.

What I am saying is that whatever "reformed" health care system we come up with, it better include some form of cost control incentive that is felt where it counts: with the patient. Right now we as patients have none of the consumer power we have when we shop for all the other goods and services we buy. Instead, we have a system analagous to people making purchasing decisions, the charges for which wind up on someone else's credit card statement. I see little chance of costs coming down in a system that works like this.