C-sections - why are so many NJ women getting them?
By ANDREA CLURFELD
May 27, 2010 05:51 AM
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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.
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."