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 
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
"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.
"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
"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."
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."
"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
"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."
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."
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."
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