The Town Business

Caesarian sections in the U.S. hit a record high for the eleventh year in a row –averaging about one-third of births nationally, up from 26 percent in 2002 and 5 percent in 1970. The rate is 36 percent in New York (45 percent at Albany Medical Center) and 39 percent in Florida (50 percent in Miami Dade County).

Some argue the high statistics are due to older, overweight mothers, larger babies, and multiple births, but statistics don’t validate this. Another reason is the risk of malpractice claims prompting doctors to make decisions for non-medical reasons. C-section rates are higher for women who have private medical insurance and deliver in a private hospital, suggesting financial incentives may play a role. Doctors now perform caesarean sections rather than use forceps or deliver a baby in breech position (feet first). Predicting the due date is not an exact science, and doctors worry if a baby is overdue. They’re anxious and they’re making their already anxious patients unnecessarily fearful about nature’s natural process – a vaginal birth. Dr. Alan Fleischman, medical director of the March of Dimes Foundation thinks, “. . . convenience is sometimes part of the decision-making process, and that really shouldn’t be.” (“Trend to C-Section Births Worry Some Doctors,” Matthew C. Stannard, 11/12/08, SFGate.com)

Whether because of doctor’s anxieties or hospital and doctors’ schedules, doctors often induce labor and/or recommend C-sections. A troubling and prevalent reason derives from the increased use of technology and use of labor inducing drugs. One example was a caesarean on a woman whose ultrasound showed the fetus to appear larger (12 lbs. 10 oz.) than it actually was (9 lbs. 4 oz.). Ultrasound is not a reliable method for determining the baby’s weight. In another case, a young woman believes that the crowded hospital facilities in New York City prompted her doctor to induce labor. A Belgian study revealed that induced labors involves significantly more pain medication and leads to more cesarean births due to both fetal distress and stalled labors. Once there is induction, the baby must be monitored. The drugs administered to this New York mother affected the baby’s heartbeat (fetal distress), necessitating a C-section. There is also a risk that the baby will be in the wrong position because it’s not ready to be born, or that the induction will not work.  If the mother’s water has broken, the baby must be born by C-section for its safety.

Some doctors base their decision on a standardized labor curve developed by Emanuel Friedman forty years ago. Newer research has shown a “wide range of normal,” with a curve that differed markedly from the Friedman curve. (“Reassessing the Labor Curve in Nulliparous Women,” by Zhang, Troendle, &Yancey, American Journal of Obstetrics and Gynecology, 10/2002, Vol. 187, No. 4) One doctor at Cedars-Sinai Hospital in Los Angeles told his patient (who requested anonymity), “If you’re not progressing in labor according to the Friedman scale, we have to do what’s best for the baby,” and, “If you’re not dilated at a certain point, we have to intervene.”  When asked if there were any possible side effects from a C-section, he replied, “Absolutely not.” The patient told me that he made it seem as if natural childbirth was a risk. This mother did some investigation on her own.  She learned that the Cedars’ rate of C-sections was 20 percent higher among PPO patients than HMO patients. She ultimately elected to have a natural delivery at a birthing center.

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Doctors argue that C-sections are safer for the baby, but the statistics are otherwise in low or no risk mothers. Research also shows that these babies stand a 20 percent greater risk of getting childhood diabetes, and a 50 percent increased risk of developing asthma. For the mother, there’s scar tissue, possible surgical complications, and a ten times greater risk of death. Christie Craigie-Carter, Hudson Valley coordinator of the International Caesarean Awareness Network, thinks, “Women are getting cheated by not being encouraged to believe both in their ability to birth and that birth can be a positive experience.” (“Birth by Surgery: The Skyrocketing Caesarean Rate,” Mary Beth Pfeiffer, Poughkeepsie Journal.com, 3/29/09)

Dr. Marsden Wagner, former director of women’s and children’s health for the World Health Organization, admits, “There is an awful lot of lying to women about cesarean….All of those thousands of women who are getting unnecessary cesareans in New York state are at double or more risk of dying and the babies are at risk of dying.” (“Birth by Surgery,” supra)

The U.S. ranks number 33rd in infant mortality behind most Western countries and Cuba, Slovenia and the Czech Republic. The leading cause is that elective caesareans increasingly are being performed late pre-term (34-37 weeks). A survey revealed 36 percent of women who had elected to have a second C-section (before entering labor), elected to deliver before 39 weeks. Another reason electing a C-section prior to onset of labor is that due dates are often miscalculated, and doctors think the baby is overdue. Babies delivered by C-section at 37 weeks are twice as likely to experience bloodstream infections and other complications, and have a four times greater risk of breathing problems. Those born just one week shy of the recommended 39 weeks of gestation have a 50 percent greater chance of suffering such problems. (“Early Repeat C-Sections Increase Risks, Study Finds Babies More Likely to Have Breathing, Blood Complications,” Rob Stein, The Washington Post, 1/8/09) Studies also suggest that late pre-term babies suffer consequences in school performance. (“Trend to C-Section Births,” supra) Interestingly, one survey revealed female women doctors perform fewer patient-requested caesareans.

In contrast, at a small Navajo hospital in Tuba City, only 13.5 percent of first-time mothers have caesareans, and 32 percent of mothers have vaginal birth after caesarean (VBAC) – over three times the national average. The reason is that nurse-midwives deliver most babies, with a doctor on-call if necessary. Midwives are more patient and specialize in coaching women through labor and are less likely to induce it before the due date. They don’t have to rush home to a golf game. Of her prior job in North Carolina, Nurse Rackley at the Navajo hospital said that if doctors didn’t want to work late, they’d set an arbitrary deadline for delivery, and if nature didn’t meet it, the mother had to have a caesarean. Another difference in Tuba is that the staff doctors are paid and insured by the federal government, so there’s no financial incentive to perform C-sections, nor are VBAC’s banned as they are by some hospitals or insurers who either deny coverage or charge much higher premiums. (“Lessons at Indian Hospital About Births,” Denise Grady, The New York Times, 5/6/10).

As the use of midwives at home births and birthing centers is growing, the American Medical Association has begun lobbying Congress and each state to eliminate deliveries by midwives requiring hospital births by doctors.

The March of Dimes is campaigning to empower women with information so that they can have informed discussions with their obstetricians well before delivery. This is also my purpose. There are cases where caesarean is the wisest and safest choice for both mother and child, but expectant mothers should be informed of their options, question their doctors and feel comfortable with a mutually agreed-upon plan long before labor begins. My concern is that decisions are being made for women that aren’t in their best interest, and that technology is alienating us from their own bodies. Women need to be reminded that our bodies are designed to deliver a baby – to conceive it, grow it, and birth it when it is ready to survive outside the womb.

 

Copyright Darlene Lancer, MFT 2010