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June 15, 2016 Central Massachusetts Health

C-sections on trial

Jennifer Kenney, an expectant mother from Milford, is examined by Dr. Fae Nason at Milford Regional Medical Center at a 40-week prenatal visit.

On July 7, 2015, Laura Croteau gave birth to her second child, Zachary, safely and the old-fashioned way.

This, of course is nothing unusual, but because Croteau had delivered her first child via scheduled cesarean section nearly two years earlier, Zachary’s birth was a bit of an outlier as far as hospital births in the United States go.

Until recently, vaginal birth after cesarean, or VBAC, was rare, but as pressure to reduce cesarean section rates in U.S. hospitals mounts, more mothers are being encouraged to attempt labor the second time around.

At age 30, Croteau, a Medway resident, was a prime candidate to attempt VBAC. Her first c-section was scheduled only because her baby was in the breech position -- not because of a medical condition or complication that put her or her son at risk.

With a team of doctors who were knowledgeable and supportive of VBAC, Croteau said she felt at ease about the process. It might sound corny, Croteau said, but she wanted to know that she could deliver a baby naturally.“I was very happy I chose it,” Croteau said.

But it wasn’t just the validation that made the VBAC worth it to Croteau. The recovery was far easier, she said, and she was able to drive and to lift her toddler, who was 22 months old at the time. Those things would have been impossible had Croteau undergone another c-section.

This easier recovery period is among a host of reasons that health care advocates and the U.S. government have raised a red flag over the high rate of c-sections in the U.S., setting a new goal that proponents say will make birth safer for mothers and babies while also reducing the cost of childbirth in hospital settings.

The health implications of c-sections are clear. According to the American Congress of Obstetricians and Gynecologists, cesarean sections are associated with an increased risk of complications in mothers, from infections to blood loss and clots, and even injury to internal organs. Babies can suffer from breathing problems after birth because they haven’t been squeezed through the birth canal, a process that helps clear out newborn lungs before they take their first breath.

The rise of the cesarean

At the end of 2014, c-sections accounted for 32.2 percent of all deliveries, according to the U.S. Centers for Disease Control. And while this type of surgery is undoubtedly necessary to protect the health, and indeed life, of mothers and babies, there are many c-sections that are performed without necessity, according to Erica Mobley, director of communications and development at The Leapfrog Group, a nonprofit watchdog organization that provides quality and safety information on U.S. hospitals.

“C-sections are performed at an alarmingly high rate in the U.S.,” Mobley said. “It’s beginning to level off, but year to year, it had been increasingly exponentially.”

The Leapfrog Group reported that the U.S. c-section rate was 4.5 percent when first measured in 1965 and hovered in the single digits for many years until rates started to increase in the 1990s and 2000s, eventually peaking at 32.9 percent in 2009. This, according to The Leapfrog Group, is attributed to many factors, from an increase in maternal age and multiple births, to more relaxed attitudes about surgery in general, and an increase in interventions such as labor induction that have proven to lead to higher c-section rates.

In 2015, The Leapfrog Group included in its annual hospital survey measuring quality and safety in U.S. hospitals rates of primary cesarean sections, a measure which refers to those c-sections performed on first-time mothers at low-risk for cesarean delivery. Leapfrog found that more than half of hospitals surveyed reported rates that exceeded Leapfrog’s target rate of 23.9 percent for pregnancies identified as unlikely to require surgical intervention during labor. That target rate was derived from Healthy People 2020, a federally-backed initiative aimed at improving overall health in America through a number of proposed goals, including cutting the c-section rate.

Dr. Fae Nason, a laborist who practices at the Maternity Center at Milford Regional Medical Center, has seen c-section rates go from arguably too low (around six percent, nationally, when she began working as a doctor at Fallon Clinic in 1993) to too high (peaking around 30 percent).

Nason said when c-section rates were very low in the early 1990s, there were bad outcomes for mothers and babies that caused the obstetrics field and healthcare policy makers to ease up on a drive to keep the rates very low.

But then, the trend reversed and rates skyrocketed. Nason said more c-sections were performed without necessity. And Nason, who performs relatively few c-sections (around nine percent of her deliveries are primary c-sections), said that’s nothing to brush off.

“It’s major abdominal surgery and women can die. And the recovery is much longer,” Nason said.

At the end of 2014, c-sections accounted for 32.2 percent of all deliveries, according to the U.S. Centers for Disease Control. And while this type of surgery is undoubtedly necessary to protect the health, and indeed life, of mothers and babies, there are many c-sections that are performed without necessity, according to Erica Mobley, director of communications and development at The Leapfrog Group, a nonprofit watchdog organization that provides quality and safety information on U.S. hospitals.

“C-sections are performed at an alarmingly high rate  in the U.S.,” Mobley said. “It’s beginning to level off, but year to year, it had been increasingly exponentially.”

The Leapfrog Group reported that the U.S. c-section rate was 4.5 percent when first measured in 1965 and hovered in the single digits for many years until rates started to increase in the 1990s and 2000s, eventually peaking at 32.9 percent in 2009. This, according to The Leapfrog Group, is attributed to many factors, from an increase in maternal age and multiple births, to more relaxed attitudes about surgery in general, and an increase in interventions such as labor induction that have proven to lead to higher c-section rates.

In 2015, The Leapfrog Group included in its annual hospital survey measuring quality and safety in U.S. hospitals rates of primary cesarean sections, a measure which refers to those c-sections performed on first-time mothers at low-risk for cesarean delivery. Leapfrog found that more than half of hospitals surveyed reported rates that exceeded Leapfrog’s target rate of 23.9 percent for pregnancies identified as unlikely to require surgical intervention during labor. That target rate was derived from Healthy People 2020, a federally-backed initiative aimed at improving overall health in America through a number of proposed goals, including cutting the c-section rate.

Dr. Fae Nason, a laborist who practices at the Maternity Center at Milford Regional Medical Center, has seen c-section rates go from arguably too low (around six percent, nationally, when she began working as a doctor at Fallon Clinic in 1993) to too high (peaking around 30 percent).

Nason said when c-section rates were very low in the early 1990s, there were bad outcomes for mothers and babies that caused the obstetrics field and healthcare policy makers to ease up on a drive to keep the rates very low.

But then, the trend reversed and rates skyrocketed. Nason said more c-sections were performed without necessity. And Nason, who performs relatively few c-sections (around nine percent of her deliveries are primary c-sections), said that’s nothing to brush off.

“It’s major abdominal surgery and women can die. And the recovery is much longer,” Nason said.

Practical problems

While the risk of death due to c-section is minute -- according to the National Institutes of Health, rates of zero have been achieved in some settings -- c-sections do prove impractical for many mothers, especially those in the U.S. where family medical leave policies are generally not as robust as those found in other developed countries. Some women must return to work just six weeks after delivery, and many don’t have a spouse who can take more than a week or two off of work when a baby is born.

Jessica Castillo, a Blackstone mother who delivered her only child, Jaden, via cesarean section when she was 26 years old, said the recovery was “a nightmare.” She couldn’t drive due to the pain medication she was taking after the surgery. She also couldn’t carry her baby up and down the stairs and had to sleep on the first floor as she recovered.

Castillo’s c-section was unplanned, and was performed because she had reached the pushing stage of labor and wasn’t making progress. If given the chance to do it again, she said she would have asked the medical staff to turn down her epidural so she could attempt delivery with lighter anesthesia. The experience has made Castillo wary of having another child, she said.

Better for baby?

Castillo is not alone in her wariness. Dr. Diana Rabkina, a pediatrician with Harrington HealthCare System based in Southbridge, added that it was much more common to see women opt for an elective c-section 15 years ago than it is today. And for babies, Rabkina thinks that’s best. As c-section rates have declined and VBACs become routine practice at some hospitals, Rabkina said she sees fewer newborns with jaundice, a condition where newborns have trouble eliminating bilirubin because they aren’t getting enough to eat. This is more common when mothers have had c-sections because milk production is delayed, Rabkina said.

Cost consideration

C-sections are also more expensive than vaginal births, another aspect of cesarean birth that The Leapfrog Group explored in its report. Dr. Ellen Delpapa, chief of the maternal-fetal medicine division within UMass Memorial Medical Group, said there was pressure from insurance companies in the 1990s to reduce c-section rates. That could happen again as insurers collect data on c-sections to try to measure and predict the cost of covering birth expenses for members.

For her part, Delpapa considers a c-section a “neutral outcome,” and is most concerned with ensuring the health of both mother and baby. She is uncomfortable about allowing the national c-section rate become a major factor in her every day treatment of patients.

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