To the Editor:-Dr. Hawkins and colleagues have to be congratulated on their task. To provide comparative information for Germany, we used the data contained in the Rhineland Perinatal Survey at the Chamber of Physicians of Northrhine/Germany (Rheinische Perinatal-Erhebung bei der Arztekammer Nordrhein/RPE). Our goal was to evaluate the distribution of births among hospitals of different sizes and to define the use of regional and general anesthesia. 
Note that it is mandatory to report perinatal data to the Perinatal Survey at the Chamber of Physicians of Northrhine. The collected data regarding number of births were compared with the data supplied by the State Office of Statistics. This verified the completeness of the data (99.3%).
The survey monitored 890,422 births between 1988 and 1996.
Of these, 654,308 were spontaneous deliveries. The number of all labor epidurals increased from 22,355 (24.3%) in 1988 to 24,095 (24.4%) in 1996.
In 1988, 15,038 patients underwent cesarean sections. In 1996, the number had risen to 19,767 patients, which constitutes 20.1% of all deliveries. This is an increase of 4,729 deliveries or 3.7%. The increase in cesarean sections was caused by concerns about medicolegal liability and the increasing average age of the parturient patients. 
The maternal mortality rate related to pregnancy, birth, and confinement decreased from 8.9 per 100,000 pregnancies during this period in 1988 to 5.2 per 100,000 in 1996.
The Commission on Medical Malpractice at the Chamber of Physicians of Northrhine did not record any maternal deaths attributed to obstetric anesthesia in their closed-claim database (1988-1996).
All 119 obstetric units in the Rhineland participate in this program. They provide different facilities by category. There are Perinatal Centers that serve as referral centers for high-risk obstetrics, i.e., hospitals capable of caring for women in premature labor before the 28th week of gestation on a 24-h basis. There are hospitals with obstetric and neonatal units (level III), hospitals with obstetric and pediatric units (level II), and stand-alone obstetric units in community hospitals (level I). A small reduction in the number of hospitals providing obstetric care has been taking place during these years.
General anesthesia was administered between 1988 and 1996 in 60.8% of the cesarean sections. Only 39.2% of the patients received regional anesthesia, i.e., primarily epidural anesthesia (36.1%) for cesarean section delivery. The remaining 3.1% were recorded on the data form as local anesthesia without differentiation between spinal and epidural anesthesia.
In 1996, regional anesthesia rates for cesarean section delivery were similar in all hospital groups stratified by facilities (Table 3). Differences between the strata were caused by the variation of risk groups of women admitted for delivery.
Anesthesiologists or physicians in training under supervision or direction of an anesthesiologists administer most anesthesia for cesarean sections in Germany, there are no nurse anesthesists. Pediatricians were present in the labor ward or operating room in 15.4% of the deliveries. 
The number of certified anesthesiologists working in hospitals has increased from 744 in 1987 to 1,335 in 1996 within the area covered by the Perinatal Survey.
Hospitals can charge only a procedure-related lump sum (in some aspects comparable with the diagnosis-related groups in the United States) for most cesarean sections irrespective of the kind of anesthesia administered.
Hospitals with an obstetric unit are within fairly easy reach (10-15 km) of 95% of the parturient patients in the Rhineland/Germany. This enhances competition between the hospitals providing obstetric care and gives mothers-to-be a choice about where to be delivered of a baby and how. Lay publications related to pregnancy, delivery, and confinement and antenatal classes are easily available. Figure 1
The discussion about whether epidural analgesia for labor increases the risk of cesarean section [1,3,4]is not confined to the United States. We cannot answer the question whether labor epidural increases cesarean section rates in general. The Survey is applied in an unselected population with an observed variability in practice pattern of the obstetricians. This makes it difficult to study one intervention (labor epidural analgesia). We can state, however, that a high epidural analgesia rate does not imply a high cesarean section rate in an obstetric unit. Obviously, the practice patterns described differ from those seen in the United States and in other countries. The data presented do not provide any information about the reasons underlying those differences. However, proper assessment of this comprehensive data base may permit the evaluation of important issues in the future.
Klaus U. Josten, M.D.
Abteilung fur Anaesthesiologie Johanniter-Krankenhaus; Bonn, Germany; Chairman of the Committee on Quality Assurance; Arztekammer Nordrhein; Dusseldorf, Germany;firstname.lastname@example.org
Hannes Wolf, M.D.
Projektgeschaftsstelle Perinatologie/RPE bei der Arztekammer; Nordrhein; Dusseldorf, Germany
Robert Dietrich Schafer, M.D.
Geschaftsfuhrender Arzt der Arztekammer Nordrhein; Dusseldorf, Germany
The data submitted have been in part presented in a lecture at the European Academy of Anaesthesiology Meeting September 4, 1997-the data have not been published in whole or part elsewhere.
The Rheinische Perinatalerhebung is a joint endeavor of the Health Insurance Agencies, the Hospital Association and the Chamber of Physicians. There are no other sources of financial support for the work.
(Accepted for publication June 11, 1998.)