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
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the
American College of Obstetricians and Gynecologists released a formal
opinion that supported elective C-sections with the informed
consent of the patient.
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In your voice|