Why are so many Jersey moms having C-sections?
Nationwide leader: 4 out of every 10 births in New Jersey are C-sections
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.
This article first appeared in the Sunday print
edition of the Daily Record and is appearing online for the first time
today. 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 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 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 "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 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-sectionsEveryone 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 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 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 (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 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 medicineRothenberg 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 Practicing defensive medicineThe 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 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 hysterectomiesYet 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 "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 "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. 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 Practicing defensive medicineThe 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 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 |
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