Increasing C-section rates has mothers, doctors concerned

SACRAMENTO, Calif. -- Elizabeth Avery-Hammond did her homework.

She read books, talked to lots of moms and attended 18 hours of "Ready, Set, Deliver!" classes to prepare for childbirth at Sutter Memorial Hospital in Sacramento.

"I was really hoping for a natural, no-medication, short birth," Avery-Hammond said. "I'm a naturalist at heart, and really wanted to experience the whole thing."

But the first-time Sacramento mother would go on to endure marathon labor in a hospital involving a cascade of medical interventions and ending in the operating room with a Caesarean-section delivery.

The 32-year-old is one of a growing number of women who have C-sections, a surgery that requires a 4- to 6-inch abdominal incision and, on top of an already draining postpartum period, several weeks of recovery.

The C-section rate in the United States has increased more than 40 percent since 1996 and has never been higher than it is today, representing more than 29 percent of births, according to the National Center for Health Statistics.

That's almost double the rate -- at least for low-risk pregnancies -- that the U.S. Department of Health and Human Services had set as a national goal for 2010.

Despite arguments that C-sections are easier on babies and result in fewer pelvic problems for women later in life, most experts agree that surgery generally increases complication risks for mother and baby.

The higher surgery rates have many doctors and hospitals re-examining their approaches to managing one of life's most fundamental processes: childbirth.

C-sections occur for many reasons, said Dr. Robert Azevedo, who oversees obstetrics and gynecology at two Kaiser Permanente hospitals in the Sacramento region.

He said women are postponing childbirth until they are older or using reproductive technologies that increase their chances of having more than one baby -- and thus of having a C-section delivery.

"Obesity is a risk factor, as well," Azevedo said. "Obese women have bigger babies, are at higher risk for diabetes and that can be an indication for a C-section."

In addition, fewer women who had C-sections for their first pregnancies are opting for vaginal births for their subsequent deliveries. Vaginal birth after Caesareans poses a small risk of uterine rupture.

Finally, more women are electing C-sections because they don't want to suffer active labor and natural delivery or because they want to the eliminate guesswork involved in delivery time.

But what about mothers such as Avery-Hammond, who prepared for an old-fashioned delivery, but whose uncomplicated first pregnancy wound up in a C-section anyway?

Dr. Elliott Main, chief of obstetrics and gynecology at California Pacific Medical Center in San Francisco, explored the phenomenon. He reviewed 41,000 births among first-time mothers at 20 Sutter hospitals in California between 2001 and 2003. All of the subjects studied were pregnant with a single baby in a headfirst position at the time of delivery.

Main found a range of C-section rates at the different hospitals, from 10 percent to 30 percent of all births. And, contrary to what some might suspect, he determined that infants born vaginally fared no worse than those born surgically.

After examining the data, Main found a direct correlation between high C-section rates and women choosing to have labor induced -- as well as of women admitted to the hospital at very early stages of labor (less than 3 centimeters dilated).

"What appears to be going on is that there are a number of practices that women and obstetricians are doing that lead to poor labor progress and the development of a reason to do a C-section," said Main.

Main said hospitals with high induction rates or early labor admissions have C-section rates 50 percent to 100 percent higher than hospitals with low induction and early labor admission rates.

Avery-Hammond's complicated childbirth began when her pregnancy stretched into its 41st week. "I was huge, uncomfortable, swollen," she said. "I couldn't sleep. All I could do is lay on the couch."

Her parents, who live in Modesto, hoped to be with her for the birth, she added, and she wanted to be sure that her husband could arrange time off from his job as a schoolteacher.

"I liked the idea of knowing," she said. "To have control over it. I was afraid of the unknown."

Although there is no firm guideline on when to induce labor, doctors generally agree that pregnancies should not go on longer than 42 weeks, and that induction is a reasonable approach if labor hasn't started by the end of the 41st week.

So, with the blessing of her doctor, Avery-Hammond scheduled an induction at 7:30 a.m. Jan. 27, exactly seven days after her due date. While she hoped for a quick and efficient childbirth, she knew deep down that the induction drug, Pitocin, could promote a more painful experience and maybe even a C-section.

In cases where the woman has high blood pressure or diabetes, or the fetus has stopped growing, inductions may be medically necessary, said Dr. William Gilbert, Sutter Health's medical director for women's services.

"But your chance of a C-section is two times higher (for first-time moms) and you have a higher chance of complications" if induced, he said.

Main explained that induction adds up to "artificial or forced labor" in which the uterine muscle may not contract in an organized way, making it harder for labor to progress.

Avery-Hammond's cervix was dilated 1 centimeter when she arrived at the hospital, and she was put on Pitocin. She was fine until 10 that night, when the contractions were coming at a rapid-fire pace.

But after 34 hours of labor, at 4 p.m. Saturday, the doctor suggested a C-section. Avery-Hammond agreed. Ivy Hammond was born at 5:12 p.m. She weighed 8 pounds, 15 ounces, and was 20 inches long.

"Things happen when you are admitted to the hospital," said Main, whose study appeared in this month's American Journal of Obstetrics and Gynecology. "You want to be there when you are in active labor, but you want to be at home ... where you can walk ...

if you're not."

Regina Nelson, 27, hired a "doula" to help with her first birth experience. Doulas are specially trained to support women in labor, but unlike certified nurse midwives, they are not credentialed to deliver babies.

Nelson called upon her doula only after she had labored for six hours and her own relaxation techniques were failing to help her cope with pain.

"If I hadn't had her, I would have told my husband, 'OK, let's go to the hospital' after six hours," Nelson said. "She helped me to trust the process and my body."

Nelson labored another six hours at home. After she was admitted to Sutter Davis Hospital, she delivered her son, Isaiah, five hours later.

Dr. Bruce Flamm, an obstetrician-gynecologist at Kaiser Permanente in Riverside, said while Main's study doesn't settle the debate over C-section rates, it does offer guidance on how to reduce the number of unnecessary ones.

c.2006 The Sacramento Bee