ICAN of Somerset County, NJ

The reason we lost 2 NJ moms in childbirth....

Amnesty International issues scathing report on pregnancy and childbirth care in U.S.

By Susan Perry | Published Tue, Mar 16 2010 9:28 am

With so many young women I personally know having babies this year, I read with both anger and dismay Amnesty International’s damning report about pregnancy and childbirth care in the United States.

Released last Friday, the report, aptly titled “Deadly Delivery,” notes that deaths from pregnancy and childbirth in the United States have doubled in the past 20 years (from 6.6 per 100,000 live births in 1987 to 13.3 deaths per 100,000 live births in 2006).

That’s two to three women dying daily in the United States from pregnancy-related complications.

Some of that increase may be due to better reporting, but it’s more likely that the figures may actually understate the problem, for, as the Amnesty International report points out, there are no federal requirements to report maternal deaths.

American women are now at greater risk of dying from pregnancy-related causes than women in 40 other countries — five times greater than Greek women, for example, and four times greater than German women.

And another 1.7 million American women — a third of all women who become pregnant in the United States — experience some kind of pregnancy-related complication that adversely affects their health. Severe pregnancy-related complications (known as “near misses” because the woman comes close to death) have increased 25 percent since 1998.

Yet, as the Amnesty International report notes, the United States spends $86 billion annually on hospitalization related to pregnancy and childbirth — more than on any other area of medicine.

Preventable deaths

According to the Centers for Disease Control and Prevention (CDC), about half of all maternal deaths in the U.S. are preventable. Pregnant women and new mothers are dying because of “systemic failures” in our current health system, the Amnesty International report says. Those failures include non-existent or inadequate health care coverage (13 million American women, or one in five of reproductive age, have no health insurance), financial and physical barriers to accessing care (including a lack of physicians in rural areas), and an overuse of risky interventions, such as inducing labor and delivering via cesarean section.

African-American women are almost four times as likely as white women to die from pregnancy-related causes, according to the report.

Minnesota scores better than most states

There’s some good news for Minnesota women in the report’s appendix. We’re one of only five states that met the Healthy People 2010 goal (set in 1998) of reducing maternal deaths to 4.3 per 100,000 live births. Our current maternal mortality ratio is 3.7.

Still, 13.9 percent of Minnesota women receive delayed or no prenatal care. And for women of color, that percentage jumps to 27.9.

Behind the statistics

Interspersed among the appalling statistics in the Amnesty International report are truly heartbreaking stories of individual women who died or nearly died as a result of inadequate pre-natal or post-natal care. Here’s just one of those stories:

In 2007, Valerie Scythes, a 35-year-old teacher in a New Jersey elementary school, died after giving birth to a healthy baby, Isabella Rose. The cause of death was a blood clot (embolism). She had had a scheduled c-section and an ovarian cyst was removed at the same time. Despite her heightened risk of developing a blood clot, because of her age, weight and surgery, she received no preventative care. She was not provided with compression stockings or a blood-thinning drug and staff failed to ensure that she walked around as soon as possible – she had been in bed more than a day following her c-section when she died. Valerie Scythes’ attorney told Amnesty International, “I would like to see a national standard of care implemented, similar to what they have in place in England.”…

In an unrelated and tragic coincidence, Valerie Scythes’ close friend and teacher at the same elementary school, Melissa Farah, died following a c-section at the same hospital two weeks later. The cause of her death was shock as a result of hemorrhage. A hospital spokesman stated: “Our treatment protocols seem to be well in line with or consistent with what I’ll call appropriate treatment care.”

http://www.minnpost.com/healthblog/2010/03/16/16685/amnesty_international_issues_scathing_report_on_pregnancy_and_childbirth_care_in_us

The Amnesty report:  http://www.amnestyusa.org/dignity/pdf/DeadlyDeliverySummary.pdf

Rising C-section rate in N.J. raises concerns

By ANDREA CLURFELD and LAVINIA DECASTRO • Gannett New Jersey • May 23, 2010

It's not nice to fool with Mother Nature, say medical professionals and mothers railing against New Jersey's rising Cesarean section rate and the state's status as No. 1 in the nation for birth by surgery.

Federal data released in March show the national Cesarean rate for 2007 to be the highest ever reported, at 31.8 percent of all births, an increase of 54 percent from 1996.

In top-ranking New Jersey, Cesarean sections accounted for 38.3 percent of all births, a jump of 60 percent from 1996 to 2007. More recent data from the New Jersey Center for Health Statistics show in 2009, 40 percent of all hospital births in the state were by Cesarean section and that close to half the hospitals -- 26 of 54 -- had C-section rates of more than 40 percent.

"It's not possible to ascribe the rise in C-sections to medical reasons," said Dr. Charles Denk, a research scientist with the Maternal and Child Health Unit in the state Department of Health and Senior Services' epidemiology program.

"It's not the way it should be."

The ebb and flow of C-sections has been studied and argued since the 1970s and '80s, when results from electronic fetal monitors were misinterpreted by some in delivery rooms as signals of fetal distress, with C-sections deemed the necessary course of action. The latest rise in C-sections, obstetricians say, can be traced in part to a report in 1996 in the New England Journal of Medicine citing complications from vaginal births after Cesareans, known as VBACs.

Some of those same specialists who are not inclined to favor surgical intervention over nature cite a follow-up study from 2004 in the same journal concluding that "absolute risks are low."

Others note a report from 2006 in the British medical journal Lancet that says unless strictly indicated, C-sections may be harmful to the health of both mothers and newborns.

Yet the rise in C-section rates has not subsided, a fact that has both mothers and some in the medical community raising questions about unnecessary surgeries and reasons behind the high rate of C-sections in the state and nation.

(2 of 5)

"New Jersey is on the crest of a wave sweeping everywhere," Denk said. "It's happening everywhere -- all across the country, all over the world."

But why?

Dr. Richard L. Fischer, head of Cooper University Hospital's Division of Maternal-Fetal Medicine, lists some of the most discussed reasons: medical climate, professional women wanting planned deliveries, obesity, more induced labors, medical and legal complications.

"There are many issues that are driving the C-section rate increase in New Jersey," Fischer said.

When Fischer first came to Cooper 21 years ago, the hospital's C-section rate was 18 percent. Last year, that number climbed to 27.9 percent. But Cooper nonetheless maintains one of the lowest C-section rates in the state.

Fischer said the same has happened to the rate of labor inductions, which is now 22 percent of the 2,200 deliveries performed at Cooper every year. An induced labor doubles the chances C-section will be needed, Fischer said.

"The induction rate has been rising and it mirrors the rate of C-sections," Fischer said.

Maternal obesity can lead to more birth complications and larger infants, Fischer said. Doctors also rely on a fetal heart rate monitor to determine if the fetus is in distress.

"We're relying on a very imprecise tool, but it leads to an increase in C-section rates," Fischer said. He added that before the monitor was widely used, the C-section rate was only 5 percent. But it is currently the only viable tool available.

Dr. Eric Lehnes, president of the medical staff at Kimball Medical Center, Lakewood, and former chairman of the hospital's Department of Obstetrics and Gynecology, says the climbing C-section rate in the country is all about doctors' fears of malpractice lawsuits.

"Defensive medicine is why C-section rates are so high in New Jersey," Lehnes said.

Kimball's rate is the lowest of any hospital with a maternity ward in New Jersey: 20.8 percent.

"That's because we have chosen not to practice defensive medicine here," Lehnes said. "If I'm going to practice medicine, I'm going to practice it the way I was taught."

(3 of 5)

Cooper's low C-section rate is laudable when you consider it is one of only two designated perinatal centers in South Jersey capable of handling high-risk pregnancies and deliveries. Fischer estimates that between 40 and 50 percent of deliveries at Cooper come from high-risk pregnancies. Last year, 150 deliveries were women transferred from other hospitals.

Our Lady of Lourdes Hospital in Camden is the other designated perinatal center in the area.

"We're always looking at ways to improve our C-section rates," Fischer said. That means, among other options, attempting to turn a breached baby before considering a C-section, something that is now seldom done.

Fischer said many doctors are quick to turn to C-sections, rather than risk a lawsuit, because they are a relatively safe procedure.

"Obstetrics has a high litigation rate and more doctors are sued for not doing a C-section than for doing it," Fischer said.

But C-sections are not risk free. The blood loss is higher than that of a vaginal birth, there is a five-fold increase in the risk of blood clots, recovery is longer and the risk to future pregnancies increases with each C-section, Fischer added.

At Community Medical Center in Toms River, where the C-section rate in 2009 was 44.6 percent, the prevailing philosophy in the Obstetrics and Gynecology Department is "non-directional counseling," according to department chair Dr. John Sutherland.

Community's C-section rate, 11th highest in the state, is attributable to several factors, Sutherland said.

"Perception of risks on the part of the patient" is one factor, Sutherland explained. "If a mother believes it's safer and more convenient to have a C-section, she may choose a C-section. The perception on the part of the obstetrician who believes one mode of delivery may be safer than another in terms of liability - that plays a role."

At Monmouth Medical Center in Long Branch, which also has one of the lowest C-section rates in the state - 27.6 percent, according to the 2009 state report - the push to reduce medically unnecessary C-sections and raise the rate of vaginal births after Cesareans is seen as critical. It will better serve mothers and their babies and, ultimately, reduce both legal risks and insurance premiums.

(4 of 5)

"I'm passionate about getting it (C-section rate) reduced," said Dr. Robert A. Graebe, chairman of the Department of Obstetrics and Gynecology. To that end, Monmouth Medical Center has two delivery teams on duty at all times - "24/7," Graebe said. Emergency drills involving the entire obstetrics staff on such procedures as vaginal breech delivery are conducted routinely, and updated education and training efforts are ongoing.

The overarching philosophy at the hospital?

"Nature does a better job of it than we can," Graebe said. And, he added, "legal risks decrease when quality increases."

Department Vice Chairman Dr. Robert A. Massaro says it's not unusual for an obstetrician to pay annual insurance premiums of around $125,000 to $135,000. In 1987, he said, during his first year out of residency, Massaro paid a $25,000 insurance premium. Those coming out of residencies today, he said, will pay at least $60,000 to be insured in 2010.

Lehner, whose private practice Ocean Obstetrics and Gynecology is based in Lakewood, says obstetricians are paid about $2,000 to $2,400 to deliver a baby. "Most insurance companies today are paying the same for vaginal deliveries and C-sections," he added.

"There used to be higher pay for C-sections, but not any more."

Mothers who want vaginal delivery and obstetricians who would prefer to let nature take its course agree there's too much talk about blaming people, when policies are the obstacles to the preferred outcome.

Denk, the research scientist for the Department of Health, says "it's important not to jump to the conclusion that high rates of C-sections are all about women getting what they want."

In fact, Denk says, the extensive data he's compiled from reviewing years of electronic birth certificates doesn't support claims that C-section rates are on the rise because mothers want to set their due dates or there's an increase in medically warranted Cesareans.

"The argument that it's medically motivated doesn't stand up," Denk said. "Blaming it on the patient's desire to deliver at a certain time seems to be the norm. But the data doesn't support that."

(5 of 5)

Nor does the data show a disproportionate increase in C-sections for any one category of mother, he added. In a report on C-sections released in November 2009, Denk said an analysis of New Jersey birth records showed the rate of Cesarean delivery increased from 26.5 percent in 1999 to 35.3 percent in 2004.

The average annual rate of increase in Cesarean delivery - 6 percent per year - was fairly uniform across most obstetric and sociodemographic categories, including the mother's age and pre-existing medical conditions.

Cooper's Fischer agrees. He estimated only 2.5 percent of mothers who deliver at the hospital choose to have a C-section.

Women who are bucking the trend and raising questions about C-sections have other theories about the Cesarean rate.

"Ob-gyns are surgeons," says Rosemarie DeMarie, a birth doula from Old Bridge whose client base is in Monmouth and Ocean counties. "They are trained to cut. And a Cesarean is major abdominal surgery."

So why are there no current standards on a state or federal level for maternity care? Riverview's Loh Collado has advice for expectant mothers.

"Have a dialogue with your doctor about what you want and what you feel comfortable with," he advised. "If you're not, go elsewhere."

"New Jersey is on the crest of a wave sweeping everywhere," Denk said. "It's happening everywhere -- all across the country, all over the world."

But why?

Dr. Richard L. Fischer, head of Cooper University Hospital's Division of Maternal-Fetal Medicine, lists some of the most discussed reasons: medical climate, professional women wanting planned deliveries, obesity, more induced labors, medical and legal complications.

"There are many issues that are driving the C-section rate increase in New Jersey," Fischer said.

When Fischer first came to Cooper 21 years ago, the hospital's C-section rate was 18 percent. Last year, that number climbed to 27.9 percent. But Cooper nonetheless maintains one of the lowest C-section rates in the state.

Fischer said the same has happened to the rate of labor inductions, which is now 22 percent of the 2,200 deliveries performed at Cooper every year. An induced labor doubles the chances C-section will be needed, Fischer said.

"The induction rate has been rising and it mirrors the rate of C-sections," Fischer said.

Maternal obesity can lead to more birth complications and larger infants, Fischer said. Doctors also rely on a fetal heart rate monitor to determine if the fetus is in distress.

"We're relying on a very imprecise tool, but it leads to an increase in C-section rates," Fischer said. He added that before the monitor was widely used, the C-section rate was only 5 percent. But it is currently the only viable tool available.

Dr. Eric Lehnes, president of the medical staff at Kimball Medical Center, Lakewood, and former chairman of the hospital's Department of Obstetrics and Gynecology, says the climbing C-section rate in the country is all about doctors' fears of malpractice lawsuits.

"Defensive medicine is why C-section rates are so high in New Jersey," Lehnes said.

Kimball's rate is the lowest of any hospital with a maternity ward in New Jersey: 20.8 percent.

"That's because we have chosen not to practice defensive medicine here," Lehnes said. "If I'm going to practice medicine, I'm going to practice it the way I was taught."

(3 of 5)

Cooper's low C-section rate is laudable when you consider it is one of only two designated perinatal centers in South Jersey capable of handling high-risk pregnancies and deliveries. Fischer estimates that between 40 and 50 percent of deliveries at Cooper come from high-risk pregnancies. Last year, 150 deliveries were women transferred from other hospitals.

Our Lady of Lourdes Hospital in Camden is the other designated perinatal center in the area.

"We're always looking at ways to improve our C-section rates," Fischer said. That means, among other options, attempting to turn a breached baby before considering a C-section, something that is now seldom done.

Fischer said many doctors are quick to turn to C-sections, rather than risk a lawsuit, because they are a relatively safe procedure.

"Obstetrics has a high litigation rate and more doctors are sued for not doing a C-section than for doing it," Fischer said.

But C-sections are not risk free. The blood loss is higher than that of a vaginal birth, there is a five-fold increase in the risk of blood clots, recovery is longer and the risk to future pregnancies increases with each C-section, Fischer added.

At Community Medical Center in Toms River, where the C-section rate in 2009 was 44.6 percent, the prevailing philosophy in the Obstetrics and Gynecology Department is "non-directional counseling," according to department chair Dr. John Sutherland.

Community's C-section rate, 11th highest in the state, is attributable to several factors, Sutherland said.

"Perception of risks on the part of the patient" is one factor, Sutherland explained. "If a mother believes it's safer and more convenient to have a C-section, she may choose a C-section. The perception on the part of the obstetrician who believes one mode of delivery may be safer than another in terms of liability - that plays a role."

At Monmouth Medical Center in Long Branch, which also has one of the lowest C-section rates in the state - 27.6 percent, according to the 2009 state report - the push to reduce medically unnecessary C-sections and raise the rate of vaginal births after Cesareans is seen as critical. It will better serve mothers and their babies and, ultimately, reduce both legal risks and insurance premiums.

(4 of 5)

"I'm passionate about getting it (C-section rate) reduced," said Dr. Robert A. Graebe, chairman of the Department of Obstetrics and Gynecology. To that end, Monmouth Medical Center has two delivery teams on duty at all times - "24/7," Graebe said. Emergency drills involving the entire obstetrics staff on such procedures as vaginal breech delivery are conducted routinely, and updated education and training efforts are ongoing.

The overarching philosophy at the hospital?

"Nature does a better job of it than we can," Graebe said. And, he added, "legal risks decrease when quality increases."

Department Vice Chairman Dr. Robert A. Massaro says it's not unusual for an obstetrician to pay annual insurance premiums of around $125,000 to $135,000. In 1987, he said, during his first year out of residency, Massaro paid a $25,000 insurance premium. Those coming out of residencies today, he said, will pay at least $60,000 to be insured in 2010.

Lehner, whose private practice Ocean Obstetrics and Gynecology is based in Lakewood, says obstetricians are paid about $2,000 to $2,400 to deliver a baby. "Most insurance companies today are paying the same for vaginal deliveries and C-sections," he added.

"There used to be higher pay for C-sections, but not any more."

Mothers who want vaginal delivery and obstetricians who would prefer to let nature take its course agree there's too much talk about blaming people, when policies are the obstacles to the preferred outcome.

Denk, the research scientist for the Department of Health, says "it's important not to jump to the conclusion that high rates of C-sections are all about women getting what they want."

In fact, Denk says, the extensive data he's compiled from reviewing years of electronic birth certificates doesn't support claims that C-section rates are on the rise because mothers want to set their due dates or there's an increase in medically warranted Cesareans.

"The argument that it's medically motivated doesn't stand up," Denk said. "Blaming it on the patient's desire to deliver at a certain time seems to be the norm. But the data doesn't support that."

(5 of 5)

Nor does the data show a disproportionate increase in C-sections for any one category of mother, he added. In a report on C-sections released in November 2009, Denk said an analysis of New Jersey birth records showed the rate of Cesarean delivery increased from 26.5 percent in 1999 to 35.3 percent in 2004.

The average annual rate of increase in Cesarean delivery - 6 percent per year - was fairly uniform across most obstetric and sociodemographic categories, including the mother's age and pre-existing medical conditions.

Cooper's Fischer agrees. He estimated only 2.5 percent of mothers who deliver at the hospital choose to have a C-section.

Women who are bucking the trend and raising questions about C-sections have other theories about the Cesarean rate.

"Ob-gyns are surgeons," says Rosemarie DeMarie, a birth doula from Old Bridge whose client base is in Monmouth and Ocean counties. "They are trained to cut. And a Cesarean is major abdominal surgery."

So why are there no current standards on a state or federal level for maternity care? Riverview's Loh Collado has advice for expectant mothers.

"Have a dialogue with your doctor about what you want and what you feel comfortable with," he advised. "If you're not, go elsewhere."

Cooper's low C-section rate is laudable when you consider it is one of only two designated perinatal centers in South Jersey capable of handling high-risk pregnancies and deliveries. Fischer estimates that between 40 and 50 percent of deliveries at Cooper come from high-risk pregnancies. Last year, 150 deliveries were women transferred from other hospitals.

Our Lady of Lourdes Hospital in Camden is the other designated perinatal center in the area.

"We're always looking at ways to improve our C-section rates," Fischer said. That means, among other options, attempting to turn a breached baby before considering a C-section, something that is now seldom done.

Fischer said many doctors are quick to turn to C-sections, rather than risk a lawsuit, because they are a relatively safe procedure.

"Obstetrics has a high litigation rate and more doctors are sued for not doing a C-section than for doing it," Fischer said.

But C-sections are not risk free. The blood loss is higher than that of a vaginal birth, there is a five-fold increase in the risk of blood clots, recovery is longer and the risk to future pregnancies increases with each C-section, Fischer added.

At Community Medical Center in Toms River, where the C-section rate in 2009 was 44.6 percent, the prevailing philosophy in the Obstetrics and Gynecology Department is "non-directional counseling," according to department chair Dr. John Sutherland.

Community's C-section rate, 11th highest in the state, is attributable to several factors, Sutherland said.

"Perception of risks on the part of the patient" is one factor, Sutherland explained. "If a mother believes it's safer and more convenient to have a C-section, she may choose a C-section. The perception on the part of the obstetrician who believes one mode of delivery may be safer than another in terms of liability - that plays a role."

At Monmouth Medical Center in Long Branch, which also has one of the lowest C-section rates in the state - 27.6 percent, according to the 2009 state report - the push to reduce medically unnecessary C-sections and raise the rate of vaginal births after Cesareans is seen as critical. It will better serve mothers and their babies and, ultimately, reduce both legal risks and insurance premiums.

"I'm passionate about getting it (C-section rate) reduced," said Dr. Robert A. Graebe, chairman of the Department of Obstetrics and Gynecology. To that end, Monmouth Medical Center has two delivery teams on duty at all times - "24/7," Graebe said. Emergency drills involving the entire obstetrics staff on such procedures as vaginal breech delivery are conducted routinely, and updated education and training efforts are ongoing.

The overarching philosophy at the hospital?

"Nature does a better job of it than we can," Graebe said. And, he added, "legal risks decrease when quality increases."

Department Vice Chairman Dr. Robert A. Massaro says it's not unusual for an obstetrician to pay annual insurance premiums of around $125,000 to $135,000. In 1987, he said, during his first year out of residency, Massaro paid a $25,000 insurance premium. Those coming out of residencies today, he said, will pay at least $60,000 to be insured in 2010.

Lehner, whose private practice Ocean Obstetrics and Gynecology is based in Lakewood, says obstetricians are paid about $2,000 to $2,400 to deliver a baby. "Most insurance companies today are paying the same for vaginal deliveries and C-sections," he added.

"There used to be higher pay for C-sections, but not any more."

Mothers who want vaginal delivery and obstetricians who would prefer to let nature take its course agree there's too much talk about blaming people, when policies are the obstacles to the preferred outcome.

Denk, the research scientist for the Department of Health, says "it's important not to jump to the conclusion that high rates of C-sections are all about women getting what they want."

In fact, Denk says, the extensive data he's compiled from reviewing years of electronic birth certificates doesn't support claims that C-section rates are on the rise because mothers want to set their due dates or there's an increase in medically warranted Cesareans.

"The argument that it's medically motivated doesn't stand up," Denk said. "Blaming it on the patient's desire to deliver at a certain time seems to be the norm. But the data doesn't support that."

Nor does the data show a disproportionate increase in C-sections for any one category of mother, he added. In a report on C-sections released in November 2009, Denk said an analysis of New Jersey birth records showed the rate of Cesarean delivery increased from 26.5 percent in 1999 to 35.3 percent in 2004.

The average annual rate of increase in Cesarean delivery - 6 percent per year - was fairly uniform across most obstetric and sociodemographic categories, including the mother's age and pre-existing medical conditions.

Cooper's Fischer agrees. He estimated only 2.5 percent of mothers who deliver at the hospital choose to have a C-section.

Women who are bucking the trend and raising questions about C-sections have other theories about the Cesarean rate.

"Ob-gyns are surgeons," says Rosemarie DeMarie, a birth doula from Old Bridge whose client base is in Monmouth and Ocean counties. "They are trained to cut. And a Cesarean is major abdominal surgery."

So why are there no current standards on a state or federal level for maternity care? Riverview's Loh Collado has advice for expectant mothers.

"Have a dialogue with your doctor about what you want and what you feel comfortable with," he advised. "If you're not, go elsewhere."

Previous Page

Analysis needed of state's high C-section rates

May 30, 2010

Ultimately, anecdotal conjecture must give way to scientific research. And when it comes to analyzing New Jersey's highest-in-the-nation rates of births by Cesarean section, that research is sorely needed.

As Staff Writer Andrea Clurfeld reported in last Sunday's article "C-sections — why are so many NJ women getting them?" 40 percent of all hospital births in the state last year were by Cesarean section and close to half the hospitals that deliver babies — 26 of 54 — had C-section rates of more than 40 percent.

In addition, the rates varied widely among local hospitals, from 48.9 percent at Centra-State Medical Center in Freehold Township — third-highest in the state — to 20.8 percent at Kimball Medical Center in Lakewood, the lowest in New Jersey.

Given that medical research has shown that C-sections are absolutely necessary in only about 15 percent of the cases, and that C-sections carry more risks for the mother, including infection, other complications common to surgery and longer recovery times, there is something going on in New Jersey that warrants close scrutiny.

Various reasons are offered for the rising rate of C-sections in New Jersey and nationally. Obstetricians often say that unnecessary C-sections are a result of the fear of lawsuits and the costs of malpractice insurance. Some mothers say their physicians prefer the ease of a scheduled birth to potentially protracted labor. Some doctors say older moms, obese moms and career moms increasingly dictate delivery modes.

In New Jersey, specifically, there are two other questions that require detailed analysis: Why is New Jersey's rate the highest in the nation? And why is there such variability in rates from one hospital to the next?

Fortunately, finding answers to those questions will be one of the goals of a statewide quality improvement initiative launched last year by the state Department of Health and Senior Services and the Institute for Quality and Patient Safety at the New Jersey Hospital Association.

The primary focus of the two-year study is to reduce the number of deliveries before the full-term pregnancy benchmark of 39 weeks. But, Aline Holmes, director of the Institute for Quality and Patient Safety at the New Jersey Hospital Association, said a parallel track includes developing recommendations for reducing the volume of Cesarean deliveries overall, as well as shedding light on why New Jersey's C-section rates are so high and why the rates differ so dramatically at various hospitals.

Dr. Eric Lehnes, president of the medical staff at Kimball and former chairman of the hospital's Department of Obstetrics and Gynecology, believes the threat of a lawsuit is one of the most important factors in New Jersey's high C-section rates: "Do you think it's a coincidence that New Jersey has the highest per-capita number of C-sections in the country and the highest number of lawyers per capita?" he asks. "Vaginal birth is safer for the mother; a C-section is slightly safer for the child, and it's definitely safer for the doctor."

Doctors, he says, have to worry about lawsuits for 21 years following a delivery. Sometimes, a lawyer will claim that trauma resulted from a vaginal delivery that could have been avoided if a C-section had been performed earlier in labor. For many physicians, C-sections are defensive medicine.

Some hospitals are trying to reverse the trend. Monmouth Medical Center in Long Branch has one of the lowest C-section rates in the state at 27.6 percent. The hospital has at least two delivery teams on duty around the clock. Emergency drills involving the entire obstetrics staff on such procedures as vaginal breech delivery are conducted routinely, and education and training efforts are ongoing.

How a baby is brought into this world is, fundamentally, a decision between a woman and her doctor. But women need to be given all the facts to ensure their decision is fully informed and free of any considerations other than what is best for mother and baby. The state and its research partners must make certain those facts are readily available.

Retrieved July 9, 2010 from http://webcache.googleusercontent.com/search?q=cache:YCYS6fkcU94J:www.dailyrecord.com/article/B3/20100530/OPINION01/5300323/Analysis-needed-of-state-s-high-C-section-rates+why+are+so+many+NJ+moms+getting+c-sections+dailyrecord&cd=1&hl=en&ct=clnk&gl=us

C-sections - why are so many NJ women getting them?

Asbury Park Press



C-sections - why are so many NJ women getting them?


By ANDREA CLURFELD
STAFF WRITER
May 27, 2010 05:51 AM
img
View Full Story

Ten weeks pregnant and thrilled at the prospect of experiencing the birth of her second child as nature intended, Kate Schorr was floored when her obstetrician tried to put the brakes on her plans by talking about scheduling another Cesarean section. She hadn't wanted a C-section two years earlier when she had her first child. She'd felt pressured during labor and regretted her decision to give birth surgically. "It left me sick. I couldn't get out of bed," the 30-year-old mother from Manalapan said. "My ob-gyn told me that a (traditional birth after Cesarean) was a thing of the past." Schorr put her future into the hands of another obstetrician, one who supported her desire for a VBAC - vaginal birth after Cesarean - and left the hospital she terms "big on C-sections." Last fall she had her second child at Monmouth Medical Center in Long Branch. "After my VBAC, I had energy," Schorr said. "I had my husband order me a chicken burrito."

Highest percentage of births by surgery

The push for C-sections has given New Jersey the dubious distinction of being the state with the highest percentage of births by abdominal surgery. Last year, the rate was four out of every 10 births - an eightfold increase from 1970. Why New Jersey leads the nation is a question with no definitive scientific answer. It's not because of medical emergencies. It's not due to race, age of the mother or size of the baby. Mothers and medical professionals offer a stew of largely anecdotal reasons why knife prevails over nature in the maternity ward. Obstetricians interviewed say it's mostly about a fear of lawsuits and the costs of malpractice insurance. Moms say ob-gyns prefer the ease of a scheduled birth to potentially protracted labor. The doctors say older moms, obese moms and career moms increasingly dictate delivery modes, while mothers claim obstetricians are surgeons trained to cut. Meanwhile, one respected medical journal reported that C-sections in nonmedical emergencies can end up harming the mother, the child or both. Both sides agree, however, that if health issues warrant a C-section, it should be done. Medical research shows that C-sections are absolutely necessary in about 15 percent of the cases.

Necessary C-section

Hypertension led Jodi Rudolph of Ocean Township to have an emergency C-section with her first daughter in 2006. For her second child, she scheduled a C-section at Monmouth Medical Center and delivered a baby girl on May 14. "I was awake through the whole thing," Rudolph said. "I don't feel like I missed out on the birthing process. I don't want to come down on either side of the issue. It's OK either way." Medical concerns do dictate some Cesareans. But a state health professional who has reviewed years of birth data says that only a small proportion of babies in New Jersey are being delivered by C-section due to health issues. Dr. Charles Denk, research scientist with the Maternal & Child Health Unit in the Epidemiology Program of the state Department of Health and Senior Services, Trenton, has reviewed years of New Jersey birth records. The rise in C-sections exists across all categories, he says. In other words, everybody's doing it. They've been doing it since the 1970s and '80s, when results from electronic fetal monitors were misinterpreted by some in delivery rooms as signals of fetal distress. More recently, they've been doing it in the wake of a report in 1996 in the New England Journal of Medicine citing complications from VBACs. But even as subsequent reports diffused some of those concerns, C-section rates did not markedly decline. And after a report in 2006 in the British medical journal The Lancet stated that "Cesarean sections, unless strictly indicated, may be harmful to the health of the mothers and their newborn babies," C-section rates still climbed. Some 1.4 million women in the United States had a Cesarean birth in 2007, according to the latest federal data. New Jersey's most recent data, from 2009, show 42,545 women having a C-section. "New Jersey is on the crest of a wave sweeping everywhere .?.?. all across the country, all over the world," Denk said. Some obstetricians would prefer to defy that trend. They'd prefer nature over knife. Dr. Marilyn Loh Collado, chairwoman of the Obstetrics and Gynecology Department at Riverview Medical Center in Red Bank, would like to see the hospital's C-section rate come down. According to the 2009 state statistics, Riverview's rate is 46.3 percent, seventh highest out of the 54 hospitals in New Jersey that deliver babies. But, she says, more women are choosing to have repeat C-sections as well as elective C-sections the first time. "Sometimes, I can't even sell it (vaginal birth)," Loh Collado said. "Everything is going right. I say, 'Let's go for it!' But the patient says, 'No more.' I've seen things swing back and forth. .?.?. It's customer service." CentraState Medical Center in Freehold Township has the highest rate of C-sections - 48.9 percent - of any hospital at the Shore and ranks third in New Jersey. "My personal bias? I think the rate is too high," said Dr. Norman Back, chairman of the Department of Obstetrics and Gynecology at CentraState. To find ways to slow or reduce the rate, Back this spring formed a committee of ob-gyns to review the hospital's policies and procedures. What does Back think is needed? A state-sanctioned "team of doctors available 24/7 to review, in real time, ongoing labors and advise physicians." Why the need for a review team? Because of heightened concerns about malpractice, "now there actually are three people in the delivery room - the doctor, the patient and the lawyer," Back said.

Practicing 'defensive' medicine

Dr. Eric Lehnes, president of the medical staff at Kimball Medical Center, Lakewood, and former chairman of the hospital's Department of Obstetrics and Gynecology, says the climbing C-section rate is about doctors' fears of malpractice lawsuits. "Defensive medicine is why C-section rates are so high in New Jersey," Lehnes said. Doctors, in other words, prefer to cut and deliver the baby immediately, rather than risk answering an attorney's questions about why they chose to wait out a vaginal birth should anything go wrong. A settlement for a birth injury can reach into the millions of dollars, especially if the child needs lifetime care. Kimball's C-section rate is the lowest of any hospital in New Jersey with a maternity ward: 20.8 percent. "That's because we have chosen not to practice defensive medicine here," Lehnes said. Dr. Anu Chakraborty, the obstetrician who delivered both Jodi Rudolph's babies via C-section at Monmouth Medical Center, believes birth by abdominal surgery is a trend that will continue for another reason. "The doctors who are coming out (of medical school) now have been training in an environment of rising C-sections," said Chakraborty, whose practice is based in Eatontown. She and her medical partner, Dr. Andrea Price, have a low rate of C-section delivery between them - "of 15 babies we deliver a month, maybe three or four are C-sections." At Community Medical Center in Toms River, the prevailing philosophy in the Obstetrics and Gynecology Department is "nondirectional counseling," according to department chair Dr. John Sutherland. Doctors lay out the options for parents and allow them to decide the course of delivery. Community's C-section rate, 11th highest out of 54 hospitals in the state, is attributable to several factors, Sutherland said. "Perception of risks on the part of the patient" is one factor, Sutherland said. "If a mother believes it's safer and more convenient to have a C-section, she may choose a C-section. The perception on the part of the obstetrician who believes one mode of delivery may be safer than another in terms of liability - that plays a role." At Monmouth Medical Center, which has one of the lowest C-section rates in the state at 27.6 percent, the push to reduce medically unnecessary C-sections and raise the rate of VBACs is seen as critical not only to better serving mothers and their babies but, ultimately, to reducing both legal risks and insurance premiums. "I'm passionate about getting it (the C-section rate) reduced," said Dr. Robert A. Graebe, chairman of the Department of Obstetrics and Gynecology. To that end, Monmouth Medical Center has at least two delivery teams on duty "24/7," Graebe said. Emergency drills involving the entire obstetrics staff on such procedures as vaginal breech delivery are conducted routinely, and education and training efforts are ongoing. The overarching philosophy at the hospital? "Nature does a better job of it than we can," Graebe said. And "legal risks decrease when quality increases." Department Vice Chair Dr. Robert A. Massaro says it's not unusual for an obstetrician to pay annual insurance premiums of around $125,000 to $135,000. In 1987, he said, during his first year out of residency, Massaro paid a $25,000 insurance premium. Those coming out of residencies today, he said, will pay at least $60,000. Lehner says obstetricians are paid about $2,000 to $2,400 to deliver a baby. "Most insurance companies today are paying the same for vaginal deliveries and C-sections," he added. "There used to be higher pay for C-sections, but not any more."

Standards for maternity care

If C-sections have become the presumed antidote to matters pertaining to birth complications and patient/doctor convenience, what's the real harm? A leader of the state chapter of the advocacy group International Cesarean Awareness Network (ICAN), says the underlying cause of the rising C-section rate is "a lack of respect for women." "There's no one looking out on behalf of women on a federal level, on a state level. Why are there no standards on a state or federal level for maternity care?" said Stacey Gregg of Rockaway, ICAN's New Jersey spokeswoman. "The C-section rate is a crisis, almost an epidemic, and there's a lack of uniformity among hospitals. What's happening in one hospital isn't happening in another. What's needed is a maternal review board." That might serve to allay concerns such as the ones raised by VBAC advocate Dana Roberts of Manville, also a member of ICAN, about exactly why the C-section rate continues to rise. "Cesareans are doctor-friendly; it's less than a half hour," Roberts said, echoing the sentiments of a number of women interviewed. "There seems to be a push to make obstetrics a 9-to-5 profession." Riverview's Loh Collado has advice for expectant mothers who want to buck the trend toward Cesarean delivery. "Have a dialogue with your doctor about what you want and what you feel comfortable with," Loh Collado said. "If you're not, go elsewhere."

Why are so many NJ moms having c-sections?

Why are so many Jersey moms having C-sections?

Nationwide leader: 4 out of every 10 births in New Jersey are C-sections

By LORRAINE ASH and ANDREA CLURFELD • STAFF WRITERS • May 25, 2010

s Page

This article first appeared in the Sunday print edition of the Daily Record and is appearing online for the first time today.

Ten weeks pregnant and thrilled at the prospect of experiencing the birth of her
second child as nature intended, Kate Schorr was floored when her obstetrician tried to put the brakes on her plans by talking about scheduling another Cesarean section.

She hadn't wanted a C-section two years ago when she had her first child. She'd felt pressured during labor and regretted her decision to give birth surgically.

"It left me sick. I couldn't get out of bed," the 30-year-old mother from Manalapan
said. "My ob-gyn told me that a (traditional birth after Cesarean) was a thing of the
past."

So Schorr put her future into the hands of another obstetrician, one who supported her desire for a VBAC — vaginal birth after Cesarean — and left the hospital she terms "big on C-sections." Last fall she had her second child at Monmouth Medical Center in Long Branch.

"After my VBAC, I had energy," Schorr said. "I had my husband order me a chicken
burrito."

The push for C-sections has given New Jersey the dubious distinction of being the state with the highest percentage of births by abdominal surgery. Last year, the rate was four out of every 10 births — an eightfold increase from 1970.

Those figures disturbed pregnancy rights advocates on the New Jersey Maternity Care Worst to First 2010 Campaign. So did the reported rates at Morris County hospitals, which last year hit 45.8 percent at St. Clare's Health System and 42.7 percent at Morristown Memorial Hospital, according to the New Jersey Center for Health Statistics.

The goal of the maternity campaign is a 10 to 15 percent C-section rate at each
hospital in the state by the end of the year, according to Stacey Gregg of Rockaway
Township, a co-founder.

"Investigations show the percentage of women who even bring up C-sections as an option is less than 3 percent," said Gregg, adding that women's care is dependent on the hospital and doctors they choose.

Why New Jersey leads the nation is a question with no definitive scientific answer. It's not because of medical emergencies. It's not due to race, age of the mother or size of the baby. Mothers and medical professionals offer a stew of
largely anecdotal reasons why knife prevails over nature in the maternity ward.

Moms say ob-gyns prefer the ease of a scheduled birth to potentially protracted labor.

But obstetricians interviewed say it's partially about a fear of lawsuits and the costs of malpractice insurance. Some doctors say older moms, obese moms and career moms increasingly dictate delivery modes.

Necessary C-sections

Everyone agrees, however, that a C-section should be done if health issues, such as fetal distress or an abnormal presentation of the baby, warrant one. Medical research shows that C-sections are absolutely necessary in about 15 percent of cases.

Hypertension led Jodi Rudolph of Ocean Township to have an emergency C-section with her first daughter in 2006. For her second child, she scheduled a C-section at Monmouth Medical Center and delivered a baby girl on May 14.

"I was awake through the whole thing," Rudolph said. "I don't feel like I missed out on the birthing process. I don't want to come down on either side of the issue. It's OK either way."

But the deeper question is why some women get C-sections without medical necessity. A state health professional says only a small proportion of babies in New Jersey are being delivered by C-section because of health issues.

Dr. Charles Denk, research scientist with the Maternal & Child Health Unit in the Epidemiology Program of the state Department of Health and Senior Services, has reviewed years of New Jersey birth records. The rise in C-sections exists across all categories, he says.

In other words, everybody's doing it.

They've been doing it since the 1970s and '80s, when results from electronic fetal monitors were misinterpreted by some in delivery rooms as signals of fetal distress. More recently, they've been doing it in the wake of a report in 1996 in the
New England Journal of Medicine citing complications from VBACs.

But as subsequent reports diffused some of those concerns, C-section rates did not markedly decline. Even after a report in 2006 in The Lancet, the British medical journal, stated that "Cesarean sections, unless strictly indicated, may be harmful to the health of the mothers and their newborn babies." C-section rates still climbed.

Some 1.4 million women in the United States had a Cesarean birth in 2007, according to the latest federal data. New Jersey's most recent data, from 2009, show 42,545 women having a C-section.

"New Jersey is on the crest of a wave sweeping everywhere ... all across the country, all over the world," Denk said.

The heads of the obstetrics and gynecology departments at two Morris County hospitals say the issue of C-sections is more complex than the public realizes.

For starters, a higher rate doesn't necessarily mean more C-sections, according to Dr. Richard Rothenberg of St. Clare's, where the rate rose from 41.4 percent in 2008 to 45.8 percent last year.

Local hospital rates, he said, also reflect a steady decline in the number of deliveries in Morris County, where many young people cannot afford to live. The number of babies delivered at St. Clare's, for instance, decreased from 2,144 in
2000 to 1,583 last year.

The number of births throughout Morris County dipped from 6,438 in 2000 to 5,748 in 2006, the last year for which statistics are available, according to the state Department of Health and Senior Services.

Changes in medicine

Rothenberg and Dr. Joseph Ramieri, who chairs the obstetrics, gynecology and women's health department at Morristown Memorial Hospital, point to three factors to account for a rise in C-sections.

First is a lack of training in medical schools, which haven't taught midforceps delivery techniques or other vaginal maneuvers since the 1970s.

"When I was a resident, our C-section rate was 5 percent," Ramieri said. "Now if a patient doesn't deliver spontaneously, most often she has a C-section because obstetricians are more confident in themselves doing a C-section.

That's because they haven't been trained as well."

At 66, he said, he is one of a few obstetricians at Morristown Memorial who does midforceps deliveries.

Second is a rising number of patient requests for elective Cesareans since 2003, when the American College of Obstetricians and Gynecologists released a formal opinion that supported elective C-sections with the informed consent of the patient.

"In my practice five years ago no woman asked for a Cesarean," Rothenberg said. "Now, with increased public awareness, there are five women a year who do. If you do 100 deliveries a year, that's 5 percent of your patients right there."

Indeed elective C-sections are becoming more popular worldwide. A 2007/2008 World Health Organization global survey showed a 46 percent C-section rate in China. The highest rates reflected in media reports are at private clinics in Brazil — 90 percent.

Practicing defensive medicine

The third reason for rising C-section rates, doctors say, is the malpractice liability climate in the state.

Dr. Eric Lehnes is president of the medical staff and former chair of the Department of Obstetrics and Gynecology at Kimball Medical Center, Lakewood, where the C-section rate is the lowest of any hospital in New Jersey with a maternity ward: 20.8 percent. He says the climbing C-section rate is about doctors' fears of malpractice lawsuits.

"Defensive medicine is why C-section rates are so high in New Jersey," Lehnes said. Doctors, in other words, prefer to cut and deliver the baby immediately, rather than risk answering an attorney's questions about why they chose to wait out a vaginal birth should anything go wrong.

A settlement for a birth injury can reach into the millions of dollars, especially if the child needs lifetime care.

Lehnes also says obstetricians are paid about $2,000 to $2,400 to deliver a baby.

"Most insurance companies today are paying the same for vaginal deliveries and C-sections," he added. "There used to be higher pay for C-sections, but not anymore."

Dr. Robert A. Massaro, vice chair of the Department of Obstetrics and Gynecology at Monmouth Medical Center, says it's not unusual for an obstetrician to pay annual insurance premiums of around $125,000 to $135,000.

In 1987, during his first year out of residency, he paid a $25,000 insurance premium. Those coming out of residencies today, he said, will pay at least $60,000.

Cesarean hysterectomies

Yet having too many C-sections creates risks, according to Ramieri of Morristown Memorial Hospital, who doesn't recommend a C-section for a woman delivering her first baby but planning on having three or four. Why? Because the placenta
in subsequent pregnancies tends to adhere itself to the uterine scars created by C-sections.

"The more sections a woman has, the higher the chances of placental implantation abnormalities," he said. "Sometimes the placenta will actually grow through the uterus so that it becomes one with the uterus and cannot be removed."

The result: cesarean hysterectomies, in which a baby is delivered and the uterus is removed. There have been 20 such operations at Morristown Memorial in the past five years — more than Ramieri has seen in the rest of his career.

On the other hand, he said, the vaginal stretching and tearing that occurs in multiple vaginal deliveries are linked to the need for pelvic reconstructive surgeries for women in later life. So prevalent are these problems that urogynecology has emerged as a medical specialty of its own.

"Is it better to do a section? Is it better to do a vaginal birth?" he asked. "That depends very much on what long-term studies are going to show. The field of obstetrics currently is in a quandary."

In the meantime, Gregg said, women need to take on a "buyer beware" attitude when approaching a hospital or a doctor and educate themselves

the American College of Obstetricians and Gynecologists released a formal opinion that supported elective C-sections with the informed consent of the patient. "In my practice five years ago no woman asked for a Cesarean," Rothenberg said. "Now, with increased public awareness, there are five women a year who do. If you do 100 deliveries a year, that's 5 percent of your patients right there." Indeed elective C-sections are becoming more popular worldwide. A 2007/2008 World Health Organization global survey showed a 46 percent C-section rate in China. The highest rates reflected in media reports are at private clinics in Brazil — 90 percent. Practicing defensive medicine The third reason for rising C-section rates, doctors say, is the malpractice liability climate in the state. Dr. Eric Lehnes is president of the medical staff and former chair of the Department of Obstetrics and Gynecology at Kimball Medical Center, Lakewood, where the C-section rate is the lowest of any hospital in New Jersey with a maternity ward: 20.8 percent. He says the climbing C-section rate is about doctors' fears of malpractice lawsuits. "Defensive medicine is why C-section rates are so high in New Jersey," Lehnes said. Doctors, in other words, prefer to cut and deliver the baby immediately, rather than risk answering an attorney's questions about why they chose to wait out a vaginal birth should anything go wrong. A settlement for a birth injury can reach into the millions of dollars, especially if the child needs lifetime care. Lehnes also says obstetricians are paid about $2,000 to $2,400 to deliver a baby. "Most insurance companies today are paying the same for vaginal deliveries and C-sections," he added. "There used to be higher pay for C-sections, but not anymore." Del.icio.us Facebook Digg Reddit Newsvine Buzz up! Twitter FarkIt That's because they haven't been trained as well." Type Size A A A Next Page 1 | 2 | 3 | 4 | 5 Previous Page This article first appeared in the Sunday print edition of the Daily Record and is appearing online for the first time today. Ten weeks pregnant and thrilled at the prospect of experiencing the birth of her second child as nature intended, Kate Schorr was floored when her obstetrician tried to put the brakes on her plans by talking about scheduling another Cesarean section. She hadn't wanted a C-section two years ago when she had her first child. She'd felt pressured during labor and regretted her decision to give birth surgically. "It left me sick. I couldn't get out of bed," the 30-year-old mother from Manalapan said. "My ob-gyn told me that a (traditional birth after Cesarean) was a thing of the past." So Schorr put her future into the hands of another obstetrician, one who supported her desire for a VBAC — vaginal birth after Cesarean — and left the hospital she terms "big on C-sections." Last fall she had her second child at Monmouth Medical Center in Long Branch. "After my VBAC, I had energy," Schorr said. "I had my husband order me a chicken burrito." The push for C-sections has given New Jersey the dubious distinction of being the state with the highest percentage of births by abdominal surgery. Last year, the rate was four out of every 10 births — an eightfold increase from 1970. Those figures disturbed pregnancy rights advocates on the New Jersey Maternity Care Worst to First 2010 Campaign. So did the reported rates at Morris County hospitals, which last year hit 45.8 percent at St. Clare's Health System and 42.7 percent at Morristown Memorial Hospital, according to the New Jersey Center for Health Statistics. The goal of the maternity campaign is a 10 to 15 percent C-section rate at each hospital in the state by the end of the year, according to Stacey Gregg of Rockaway Township, a co-founder. "Investigations show the percentage of women who even bring up C-sections as an option is less than 3 percent," said Gregg, adding that women's care is dependent on the hospital and doctors they choose. (2 of 5) Why New Jersey leads the nation is a question with no definitive scientific answer. It's not because of medical emergencies. It's not due to race, age of the mother or size of the baby. Mothers and medical professionals offer a stew of largely anecdotal reasons why knife prevails over nature in the maternity ward. Moms say ob-gyns prefer the ease of a scheduled birth to potentially protracted labor. But obstetricians interviewed say it's partially about a fear of lawsuits and the costs of malpractice insurance. Some doctors say older moms, obese moms and career moms increasingly dictate delivery modes. Necessary C-sections Everyone agrees, however, that a C-section should be done if health issues, such as fetal distress or an abnormal presentation of the baby, warrant one. Medical research shows that C-sections are absolutely necessary in about 15 percent of cases. Hypertension led Jodi Rudolph of Ocean Township to have an emergency C-section with her first daughter in 2006. For her second child, she scheduled a C-section at Monmouth Medical Center and delivered a baby girl on May 14. "I was awake through the whole thing," Rudolph said. "I don't feel like I missed out on the birthing process. I don't want to come down on either side of the issue. It's OK either way." But the deeper question is why some women get C-sections without medical necessity. A state health professional says only a small proportion of babies in New Jersey are being delivered by C-section because of health issues. Dr. Charles Denk, research scientist with the Maternal & Child Health Unit in the Epidemiology Program of the state Department of Health and Senior Services, has reviewed years of New Jersey birth records. The rise in C-sections exists across all categories, he says. In other words, everybody's doing it. They've been doing it since the 1970s and '80s, when results from electronic fetal monitors were misinterpreted by some in delivery rooms as signals of fetal distress. More recently, they've been doing it in the wake of a report in 1996 in the New England Journal of Medicine citing complications from VBACs. (3 of 5) But as subsequent reports diffused some of those concerns, C-section rates did not markedly decline. Even after a report in 2006 in The Lancet, the British medical journal, stated that "Cesarean sections, unless strictly indicated, may be harmful to the health of the mothers and their newborn babies." C-section rates still climbed. Some 1.4 million women in the United States had a Cesarean birth in 2007, according to the latest federal data. New Jersey's most recent data, from 2009, show 42,545 women having a C-section. "New Jersey is on the crest of a wave sweeping everywhere ... all across the country, all over the world," Denk said. The heads of the obstetrics and gynecology departments at two Morris County hospitals say the issue of C-sections is more complex than the public realizes. For starters, a higher rate doesn't necessarily mean more C-sections, according to Dr. Richard Rothenberg of St. Clare's, where the rate rose from 41.4 percent in 2008 to 45.8 percent last year. Local hospital rates, he said, also reflect a steady decline in the number of deliveries in Morris County, where many young people cannot afford to live. The number of babies delivered at St. Clare's, for instance, decreased from 2,144 in 2000 to 1,583 last year. The number of births throughout Morris County dipped from 6,438 in 2000 to 5,748 in 2006, the last year for which statistics are available, according to the state Department of Health and Senior Services. Changes in medicine Rothenberg and Dr. Joseph Ramieri, who chairs the obstetrics, gynecology and women's health department at Morristown Memorial Hospital, point to three factors to account for a rise in C-sections. First is a lack of training in medical schools, which haven't taught midforceps delivery techniques or other vaginal maneuvers since the 1970s. "When I was a resident, our C-section rate was 5 percent," Ramieri said. "Now if a patient doesn't deliver spontaneously, most often she has a C-section because obstetricians are more confident in themselves doing a C-section. (4 of 5) That's because they haven't been trained as well." At 66, he said, he is one of a few obstetricians at Morristown Memorial who does midforceps deliveries. Second is a rising number of patient requests for elective Cesareans since 2003, when the American College of Obstetricians and Gynecologists released a formal opinion that supported elective C-sections with the informed consent of the patient. "In my practice five years ago no woman asked for a Cesarean," Rothenberg said. "Now, with increased public awareness, there are five women a year who do. If you do 100 deliveries a year, that's 5 percent of your patients right there." Indeed elective C-sections are becoming more popular worldwide. A 2007/2008 World Health Organization global survey showed a 46 percent C-section rate in China. The highest rates reflected in media reports are at private clinics in Brazil — 90 percent. Practicing defensive medicine The third reason for rising C-section rates, doctors say, is the malpractice liability climate in the state. Dr. Eric Lehnes is president of the medical staff and former chair of the Department of Obstetrics and Gynecology at Kimball Medical Center, Lakewood, where the C-section rate is the lowest of any hospital in New Jersey with a maternity ward: 20.8 percent. He says the climbing C-section rate is about doctors' fears of malpractice lawsuits. "Defensive medicine is why C-section rates are so high in New Jersey," Lehnes said. Doctors, in other words, prefer to cut and deliver the baby immediately, rather than risk answering an attorney's questions about why they chose to wait out a vaginal birth should anything go wrong. A settlement for a birth injury can reach into the millions of dollars, especially if the child needs lifetime care. Lehnes also says obstetricians are paid about $2,000 to $2,400 to deliver a baby. "Most insurance companies today are paying the same for vaginal deliveries and C-sections," he added. "There used to be higher pay for C-sections, but not anymore." (5 of 5) Dr. Robert A. Massaro, vice chair of the Department of Obstetrics and Gynecology at Monmouth Medical Center, says it's not unusual for an obstetrician to pay annual insurance premiums of around $125,000 to $135,000. In 1987, during his first year out of residency, he paid a $25,000 insurance premium. Those coming out of residencies today, he said, will pay at least $60,000. Cesarean hysterectomies Yet having too many C-sections creates risks, according to Ramieri of Morristown Memorial Hospital, who doesn't recommend a C-section for a woman delivering her first baby but planning on having three or four. Why? Because the placenta in subsequent pregnancies tends to adhere itself to the uterine scars created by C-sections. "The more sections a woman has, the higher the chances of placental implantation abnormalities," he said. "Sometimes the placenta will actually grow through the uterus so that it becomes one with the uterus and cannot be removed." The result: cesarean hysterectomies, in which a baby is delivered and the uterus is removed. There have been 20 such operations at Morristown Memorial in the past five years — more than Ramieri has seen in the rest of his career. On the other hand, he said, the vaginal stretching and tearing that occurs in multiple vaginal deliveries are linked to the need for pelvic reconstructive surgeries for women in later life. So prevalent are these problems that urogynecology has emerged as a medical specialty of its own. "Is it better to do a section? Is it better to do a vaginal birth?" he asked. "That depends very much on what long-term studies are going to show. The field of obstetrics currently is in a quandary." In the meantime, Gregg said, women need to take on a "buyer beware" attitude when approaching a hospital or a doctor and educate themselves. Next Page 1 | 2 | 3 | 4 | 5 Previous Page That's because they haven't been trained as well." At 66, he said, he is one of a few obstetricians at Morristown Memorial who does midforceps deliveries. Second is a rising number of patient requests for elective Cesareans since 2003, when the American College of Obstetricians and Gynecologists released a formal opinion that supported elective C-sections with the informed consent of the patient. "In my practice five years ago no woman asked for a Cesarean," Rothenberg said. "Now, with increased public awareness, there are five women a year who do. If you do 100 deliveries a year, that's 5 percent of your patients right there." Indeed elective C-sections are becoming more popular worldwide. A 2007/2008 World Health Organization global survey showed a 46 percent C-section rate in China. The highest rates reflected in media reports are at private clinics in Brazil — 90 percent. Practicing defensive medicine The third reason for rising C-section rates, doctors say, is the malpractice liability climate in the state. Dr. Eric Lehnes is president of the medical staff and former chair of the Department of Obstetrics and Gynecology at Kimball Medical Center, Lakewood, where the C-section rate is the lowest of any hospital in New Jersey with a maternity ward: 20.8 percent. He says the climbing C-section rate is about doctors' fears of malpractice lawsuits. "Defensive medicine is why C-section rates are so high in New Jersey," Lehnes said. Doctors, in other words, prefer to cut and deliver the baby immediately, rather than risk answering an attorney's questions about why they chose to wait out a vaginal birth should anything go wrong. A settlement for a birth injury can reach into the millions of dollars, especially if the child needs lifetime care. Lehnes also says obstetricians are paid about $2,000 to $2,400 to deliver a baby. "Most insurance companies today are paying the same for vaginal deliveries and C-sections," he added. "There used to be higher pay for C-sections, but not anymore." Lorraine Ash: 973-428-6660; lvash@gannett.com In your voice| 1000 characters left {staffMark} {authorIcon} {authorHandle} wrote: {commentBody} {commentTimestamp} {commentBody} {authorNameHandle} {recommendLink} {newpostLink} {replylink} {reportAbuseLink} Report item as: (required) X Obscenity/vulgarity Hate speech Personal attack Advertising/Spam Copyright/Plagiarism Other Comment: (optional) Missing input fields. You must fill out the comment body in order to submit a comment. Comment too long. The comment you have entered is too long. Please limit your post to {maxchars} characters or less.

Hitting the Right Notes... from the Journal of Perinatal Medicine

Two-tim VBAC mom and ICAN member, Berna Diehl explains her personal birth stories, including her 3rd VBAC, in a major medical journal. 

http://www.scribd.com/doc/21368378/Hitting-the-Right-Notes

Cesarean surgery carries risks; worries MDs

Complications worry MDs
 
Surgery carries risks, doctors say
 
By Sharon Kirkey, Canwest News Service

August 1, 2009 

 
Dr. Jan Christilaw, president of the B.C. Women's Hospital and Health Centre in Vancouver, says she is concerned about the number of caesarean sections being performed in the province.
Photograph by: Jenelle Schneider, Canwest News Service, Canwest News Service

Dr. Jan Christilaw was in the operating room the day a routine incision was made into a young mother's abdomen to deliver her baby.

 

What happened next, Christilaw says, "is something we never want to see."

 

Normally, the placenta separates from the wall of the uterus after birth. It's lacy almost, and not like solid tissue. "You can take your hands and sort of scoop it up, it's like breaking cobwebs as you go," says Christilaw, an obstetrician and president of B.C. Women's Hospital and Health Centre in Vancouver.

But the placenta had eroded through the wall of the uterus, a condition known as placenta accreta. As soon as they stretched the opening of the uterus to deliver the baby, "the placenta started bleeding everywhere," Christilaw says.

 

They couldn't get the bleeding to stop. The woman was losing two cups of blood every 30 seconds.

The only way to stop the bleeding was an emergency hysterectomy. The woman was in the operating room for eight hours and lost 15 litres of blood.

 

It used to be that obstetricians might only ever see one or two cases of placenta accreta in their lifetime. Although still rare, obstetricians across Canada say one of the most feared complications of pregnancy is increasing as a direct consequence of the nation's rising cesarean section rate.

 

Virtually all placenta accretas occur in women who have had a previous C-section, and the risk increases with each additional surgical delivery. The placenta attaches to the old C-section scar. Scars don't have a proper blood supply to feed a placenta, so it keeps burrowing into the uterus until it finds one, sometimes pushing through the uterus completely and into the bladder or other organs.

 

The condition can be detected by ultrasound, but not always. "You almost never see it in a woman who has not had a C-section," Christilaw says.

 

Today, about 28 per cent of babies born in Canada are delivered by caesarean. In 1969, Canada's rate was five per cent.

 

More than 78,000 caesarean sections were performed in Canada last year, making it the single most frequently performed surgery on Canadian women.

 

"We don't know what the ideal rate is," says Dr. Mark Walker, a high-risk obstetrician at the Ottawa Hospital and senior scientist with the Ottawa Hospital Research Institute. "I think it's fair to assume it's lower than where we are now."

 

Walker says changing demographics -- older first-time mothers, more multiple births from fertility treatments, more mothers with hypertension, diabetes, obesity and other health problems -- are not enough to explain an almost doubling in the C-section rate since the early 1990s.

 

Neither is there evidence to support the idea that women are seeking C-sections on demand. Studies from Ontario suggest less than one per cent of caesareans are for "maternal request."

 

The Society of Obstetricians and Gynaecologists of Canada says the vast majority of caesareans are done for medically valid reasons. But there are concerns that too many are being ordered because labour isn't progressing quickly enough, and that thousands of "routine" interventions are now being done that increase the odds of a woman needing a surgical birth.

 

What's more, the number of women who give birth vaginally after a previous C-section is dropping dramatically, meaning more and more women are having repeat C-sections.

 

Dr. Michael Klein calls it the industrialization of childbirth, where, in today's risk-averse society, women in labour are being treated "as an accident waiting to happen" and where doing something is always better than doing nothing.

 

"Physicians and society have helped women basically believe that childbirth is no longer a natural phenomenon, but an opportunity for things to go wrong," says Klein, emeritus professor in the departments of family practice and pediatrics at the University of British Columbia.

 

"But the fundamental issue is, we aren't improving outcomes by doing more C-sections. For the first time in Canada, we are seeing the key indicators for mothers and babies going in the wrong direction."

 

Risks to babies range from accidental lacerations when the surgeon cuts into the uterus, to neonatal respiratory distress. Research suggests two times as many babies born via C-section will end up in an incubator with water on their lungs, or with serious respiratory problems compared to babies delivered vaginally, because a C-section interferes with the normal hormonal and physiological changes associated with labour that prepare a baby to take its first breath.

 

Risks to women include higher risks of hemorrhage requiring a hysterectomy, major infections including blood infections, wound infections and bladder infections, and blood clots in the lungs -- and every C-section increases the risk for another.

 

"If you have a caesarean section for the first birth, the probability of having one the second time around is huge, because of the difficulty women have in getting a doctor to look after them once they have a uterine scar," Klein says.

 

The worry is that the scar will pull apart during labour, causing a uterine rupture.

"If you have a catastrophic rupture, you can get into big trouble," Christilaw says. "You can have a negative outcome for mom or baby. In severe situations, the baby can die or become damaged -- but that's a very rare outcome."

 

Her hospital is encouraging more VBACs -- vaginal births after caesarean -- in carefully selected women. "In those women who attempt a VBAC, our success rate is well over 80 per cent."

But less than one in five women in Canada with a previous C-section delivered vaginally in 2007-08. Eighty-two per cent had a subsequent C-section.

 

Christilaw says the only thing preventing Canada from seeing "horrific" complication rates from C-sections is the fact women are not having as many babies as they once did.

 

"A C-section can be a life-saving manoeuvre for a mother or baby. Nobody is saying differently," she says. "What we're trying to say to people is, a C-section is not a benign thing. If you need one, that's different. But you should not be doing this unless you absolutely have to."

 

C-sections are frequently the end result of a cascade of interventions that often starts with inductions.

Tens of thousands of women in Canada have their labours artificially induced every year, often via intravenous infusion of artificial oxytocin. Oxytocin is naturally produced by the human body. It's what creates contractions in labour. Today in Canada, one in five women who gives birth in hospital is induced.

What doctors fear are stillbirths. But alarmed by the rising rates of inductions, the Society of Obstetricians and Gynecologists of Canada recently urged doctors not to consider an induction until a woman is at least one week past her due date.

 

Claudia Villeneuve says that women are getting induced "if they're two, three, four days overdue."

"Inductions are rampant," says Villeneuve, president of the International Cesarean Awareness Network of Canada. "You have a perfectly normal mom who comes in with a perfectly normal baby, and now you put these powerful drugs into her system to force labour to start."

 

The "humane" thing is to offer an epidural, she says. With an epidural, a woman can't feel pain in the lower half of her body. But epidurals slow labour, sometimes so much that labour stops. "Now you have to get this baby out," Villeneuve says. Two-thirds of first-time C-sections are done for "failure to progress."

 

Klein says epidurals are too often given before active labour is established.

 

"The majority of women today get their epidurals in the parking lot."

 

Kayla Soares had been in mild labour at home for 24 hours when her contractions suddenly stopped. Doctors told the Edmonton mother she would have to be induced. She was three centimetres dilated when they started the oxytocin drip.

 

"It was the worst pain I've ever felt in the world," she remembers. "I wasn't having contractions at all and then they put me on the oxytocin and every half-hour they would boost it up, so the contractions were coming every minute, pretty much. It was like going from nothing to being in crazy, absolute labour, and in so much pain." Eleven hours later, she was still just three centimetres dilated. "That's when they said it was enough, and they were doing a C-section.

 

"I didn't want to do it. I was asking, could we just have more time?"

 

Three weeks later, she still couldn't get out of bed without help. Her incision had become infected. "It felt like I was ripping apart every time I moved. It was a pretty brutal recovery."

 

Soares had her second baby in June. "I was dead set on having a VBAC," a vaginal delivery after cesarean. "It was a fight, an uphill battle the whole time with doctors." One obstetrician asked her her shoe size. "She said that because I was a size five and smaller framed that I definitely was going to have another caesarean and that a VBAC wouldn't happen. She said that because I was a 'failure to progress' the first time I'll be a 'failure to progress again.'"

 

Two weeks before her daughter was born, Soares started going in and out of labour. "They had me convinced it was causing stress to the baby even though the tests said everything was fine. They had me convinced it was enough, because I was overdue and they said my incision was going to rupture," she says.

 

"They just kind of scared me into having another C-section."

 

© Copyright (c) The Windsor Star
http://www.windsorstar.com/health/Complications+worry/1852860/story.html
 

 

   
 
 

UPDATE on the case where NJ DYFS removed child from a mom who refused a cesarean

I spoke with "V" the other day and the appellate court reached a decision against her.  They decided to confirm that abuse and neglect had been committed against the child over V's refusal of a cesarean during labor.  The following document was released by the NJ courts  and should dispel any rumors about the actuality of this case. 

http://www.judiciary.state.nj.us/opinions/a4627-06.pdf

The story is a bit mixed in the report above.  They wanted her to sign a blanket consent form upon arrival at the hospital for a cesarean. She refused and they got mad stressing the importance of their ability to do a cesarean quickly if necessary.   Later, the baby was "showing signs of distress."  So what did they do?  They tried even harder to push the potential need for a cesarean.

The fact is that cesareans are seldom so emergent that there is no time for consent.  St Barnabas has a nearly 50% cesarean rate.  Why couldn't they do something else to relieve the alleged "stress" on the baby before yelling at this women about a cesarean?  Why not try repositioning her?  They were upset about how V acted in labor.  That's why it's called labor!  It doesn't tickle!  The report claims the nurses were trying to restrain her.  V claims they bruised her because they were so rough.  Baby was born at 35 weeks and was in good health for being slightly premature and doesn't seem to have suffered distress during labor (of course "distress" in labor is NOT easily defined, especially when diagnosed by looking at fetal monitors). 

As far as the custodial issue goes, DYFS psychiatrists don't believe that V is capable of caring for a child.  They stressed to her that it is a 24 hour job.  They don't think she could feed or diaper a baby.  They are concerned because she has had psychiatric problems in the past. 

I'm not trying to preach a belief that V would be mother of the year.  But the custodial issue only came up because she delivered at St Barnabas and they wanted the freedom to do a c-section at will.  DYFS always seems to be willing to work with illegal drug addicted mothers and return their children after a working with them.  I personally know of a case where the mom went back on drugs and moved.  DYFS and CPS of the particular state haven't acted very quickly trying to remove that child from the situation. 

A judge told V in one of her hearings that he felt she would be too argumentative and that would wind up hurting her child.  For instance, she would argue with teachers and receptionists at the dentist office.  Well, I'm sure all NJ teachers and receptionists are breathing a sigh of relief since parents so seldom aruge with them. 

They call V paranoid and claim there is something wrong with her.  I think I'd be paranoid too if someone took my baby away from me.  Physically and emotionally, that has to take an incredible toll on a woman who is not expecting that.  V wishes the doctors had told they didn't believe she was fit to be a mother so she could have made arrangements to have her child cared for by someone she knew.  V is being told that doctors can decide which people are fit to be parents. 

This is a tough case.  It was all instigated over a cesarean that was not ultimately needed.  How much time and money are being invested into keeping V's child away from her rather than trying to work with her and help her learn whatever parenting skills they feel she needs?

Lawsuit... over a cesarean?!

THURSDAY, JULY 09, 2009 3:30:00 PM
Michigan Supreme Court: Family can sue for loss of services BY CHRIS RIZO Michigan Supreme Court building LANSING, Mich. (Legal Newsline)-A dead mother's family can sue for damages for loss of household services, a divided Michigan state Supreme Court ruled this week. The court's majority said Laurie Ann Greene's family can sue Mercy Memorial Hospital in Monroe, Mich., for $1.4 million for a loss of household services. The family alleges Greene died because she bled to death from the site of a Cesarean section. They allege medical malpractice in the case. Last year, the state appeals court ruled that household services such as caring for children are not subject to caps on medical malpractice damages related to pain and suffering. The hospital appealed the decision to the state Supreme Court, arguing that the loss of household service is noneconomic and subject to a damage cap. In a 4-3 vote, the high court's justices said they would not hear the hospital's appeal. From Legal Newsline: Reach staff reporter Chris Rizo at chrisrizo@legalnewsline.com. Filed Under: State Supreme Courts http://www.legalnewsline.com/news/221916-michigan-supreme-court-family-can-sue-for-loss-of-services

NJ midwifery laws in legislation to recognize midwifery as independent practicioners

http://www.nj.gov/oag/ca/proposal/bmepro_060109.htm

Please go to this website and submit your comments in favor of this legislation by July 31, 2009.  NJ needs more midwives and we should recognize them as an independent practice without the need for a doctor to dictate how they can practice:

NEW JERSEY REGISTER
VOLUME 41, ISSUE 11
ISSUE DATE: JUNE 1, 2009
RULE PROPOSALS
LAW AND PUBLIC SAFETY
DIVISION OF CONSUMER AFFAIRS
STATE BOARD OF MEDICAL EXAMINERS

Proposed Amendments: N.J.A.C. 13:35-2A.2, 2A.5 and 2A.6

Certified Midwives
Definitions; Independent Practice; Affiliated Physicians; Clinical Guidelines