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VOL. 6 | NO. 25 | Saturday, June 15, 2013

Birthrights

Rise of C-sections has mothers, hospitals examining delivery processes

By Jennifer Johnson Backer

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As Deidra Stephens Clark’s due date approached, she made a straightforward birth plan that included a vaginal birth, an epidural for pain relief and her desire to breastfeed immediately after birth.

A soaring number of first-time, low-risk mothers, in Memphis and across the nation, are delivering their babies by cesarean section. And that has some concerned.

(Photo: Shutterstock)

But as Clark, 33, neared her 41st week of pregnancy, her obstetrician told her she would need to be induced to prevent complications.

While some physicians allow patients to go two weeks after their estimated due date, the medical definition of a post-term pregnancy, others opt to induce earlier. A full-term pregnancy lasts 40 weeks, but babies born after 42 weeks can be at risk for complications.

Last February, Clark was induced with synthetic oxytocin, a medication widely used in U.S. hospitals to induce and manage labor. By late in the day, she still hadn’t progressed and delivered her first child, a daughter, by cesarean section.

“I believe that my obstetrician was acting in my and the baby’s best interest,” she said. “(But) I wish I had been more assertive in waiting at least another week for induction.”

Clark is part of a soaring number of first-time, low-risk mothers delivering their first babies by C-section both in Memphis and across the nation. From 1998 to 2008, U.S. cesarean delivery rates climbed by 50 percent, gaining from 22 percent to 33 percent of all births in just a decade, data from the Centers for Disease Control and Prevention and the National Center for Health Statistics show.

In Tennessee, the cesarean rate for the 69 hospitals that delivered babies in 2011 averaged 34.3 percent, up 4.3 percent from 32.9 percent in 2006, according to data from the Tennessee Department of Health.

C-section rates have continued to rise for every type of woman regardless of race, ethnicity, age, weight or the gestational age of the pregnancy, according to a white paper authored in 2011 by researchers from the California Maternal Quality Care Collaborative. CMQCC researchers also found cesarean rates vary widely between geographic regions, cities, hospitals and providers for reasons that go beyond payment contracts and liability laws, suggesting that cultural factors and labor management practices play a key role.

The total cesarean rate at The Regional Medical Center at Memphis was 31.6 percent in 2011, while Saint Francis Hospital-Bartlett averaged 41.3 percent, Methodist Le Bonheur Germantown Hospital was 41.1 percent and Baptist Memorial Hospital for Women was 39.4 percent, according to the Tennessee Department of Health.

Memphis-area obstetricians and gynecologists said the C-section rate includes women who are more likely to need cesareans, including mothers who have had prior cesareans, those who are delivering multiples, and babies who are feet-first at term – also known as breech babies.

As cesarean sections continue to climb in the U.S., there is growing concern that many C-sections have greater risks and complications than vaginal birth, without any clear benefits for the mother or the baby.

“… Because major complications are rare with a first (cesarean) birth, the risks of primary cesarean are not visible to practicing obstetricians,” CMQCC researchers wrote. “However, repeat cesareans, in particular, carry significant risks and complications that are not well appreciated by either obstetricians or the public.”

According to the Joint Commission, the accrediting body for more than 19,000 health care organizations, there is no data that higher cesarean rates improve any outcomes. Hospitals with cesarean rates of 15 to 20 percent have infant and maternal outcomes that are as good, and often better than those with much higher rates.

“C-sections are incredibly safe, however, if you compare them to a vaginal delivery, they are a little bit higher risk,” said Dr. Mel Blackett, an obstetrician and gynecologist affiliated with Baptist Memorial Hospital for Women in Memphis. “When you have things that are very safe, people tend to minimize the risk.”

Besides short-term risks like obstetric hemorrhaging and infections, cesareans – especially repeat cesareans – can have significant long-term consequences for women’s reproductive health, including fertility issues and complications in future pregnancies. Experts also say C-sections can have a negative impact on women’s satisfaction and feelings about maternal-infant contact at birth and their success with breastfeeding. After Stephens Clark delivered her daughter by cesarean last February, she didn’t hold her daughter until four hours after birth.

“Everything happened so quickly,” she said. “She was out before I really had time to register, and it never even occurred to me to ask for her in the operating room to take with me to recovery. I saw her briefly when my husband held her next to me, touched her briefly, and she was off to the nursery.”

Her recovery also was difficult.

“I bled constantly from the incision site because the glue came loose,” Stephens Clark said. “I couldn’t do anything, including lean over to get my daughter out of her bassinet. If I hadn’t had the support of my husband and family, I think my maternity leave would have been much more difficult and less enjoyable.”

Memphis obstetricians and gynecologists interviewed say the reasons for soaring cesarean rates are complex and multifaceted – but the need to practice defensive medicine because of legal concerns overwhelmingly topped the list.

CMQCC found that rising cesarean delivery rates can mostly be attributed to two factors: a decline in vaginal births after a prior cesarean and a gain in the number of first-birth cesareans done during labor. While most medical experts agree that the vast majority of women can safely attempt a vaginal birth after a cesarean, local doctors said medical malpractice carriers strongly discourage the practice.

“It’s a self-perpetuating problem, and that’s a real problem,” said Dr. Aric Giddens, a partner and physician with the Memphis Obstetrics and Gynecological Association. “The pendulum – and I’ve been in practice over 18 years – has kind of swung back and forth over the years, but it’s as far on the conservative side as it has ever been.”

Blackett says there is a less than 1 percent risk that a woman who delivers vaginally after a C-section could face severe complications if the prior incision reopens in labor. About one third of those cases also can have fetal damage, he said.

“But, it’s enough to make people pause and ask, ‘Do I want to have that risk?’ ” Blackett said. “If you happen to have that one-third of 1 percent – it’s a real disaster.”

Doctors also attribute rising cesarean rates to increased use of technology like continuous fetal monitoring, physician and staff practice patterns, older mothers, more multiple births, the removal of pressure not to perform a cesarean, more obese and hypertensive mothers, and economic and time constraints. But overwhelmingly, they say the medical legal climate adds to the pressure.

“It’s not just a doctor phenomenon, it’s a hospital, nurse, system phenomena, too,” Giddens said. “They have similar pressures on them legally. And I think all of those things add up to bumping up the cesarean rate.”

Several studies have found that 90 percent of the variation in cesarean rates done in the course of labor can be accounted for by two medical indications: failure to progress and fetal intolerance to contractions. Both are largely situations where doctors have to make subjective judgment calls.

“There is no well-defined moment where it’s going to be too early or too late,” Blackett said.

While the reasons for soaring C-sections are complex, there are growing efforts to bring down the cesarean rates for low-risk, first-time mothers with a baby in a head down position at the time of birth.

Citing concerns that cesareans do not improve infant or maternal outcomes, The Joint Commission will begin requiring accredited hospitals that deliver at least 1,100 babies or more per year to begin reporting on a set of measures known as the perinatal core: decreasing the early elective birth rate before 39 weeks, decreasing the cesarean rate in first-time mothers with a single baby who is head down at term, increasing the use of steroids for babies who are born pre-term, reducing acquired bloodstream infections in newborns and increasing the exclusive breast-feeding rates during hospitalization.

Celeste Milton, associated project director in the Center for Performance Measurement in the Division of Healthcare Quality Evaluation at The Joint Commission, says the new data will allow hospitals to establish a baseline and compare how they are doing relative to other facilities.

“We are really trying to get hospitals to understand what their baselines are, and what kind of performance improvement efforts they might undertake to improve,” she said. What we are looking for in terms of improvement would be a lower rate, but we aren’t setting any specific benchmark.”

Most Memphis hospitals have established policies that discourage or ban elective inductions before 39 weeks. Dr. Arthur Townsend, an obstetrician hospitalist at Methodist Le Bonheur Germantown Hospital, says the hospital holds meetings to discuss cesarean data each month and provides physicians how their rate compares to that of their peers.

Townsend says Methodist Le Bonheur also provides physicians with educational materials designed to increase awareness and education of physician practice patterns that might increase their cesarean rates with no added benefit to patients.

“At the end of the day, the mother and babies’ health is the primary concern,” he said. “We want to decrease or eliminate those practice patterns that don’t provide any benefit to mothers and babies and increase risk.”

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