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.
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