The birth of a trend? C-sections rise 55 percent statewide

Is it fear of malpractice or is it becoming common practice? Is it medically necessary or a matter of convenience?

Perhaps it's just patient impatience?

Whatever the cause, the Caesarean section (C-section) birth rate in Minnesota rose 55 percent from 1996 to 2007, according to the most recent statistics available from the Centers for Disease Control and Prevention (CDC).

A C-section is the method of delivering a baby by surgically removing it by cutting through the walls of the abdomen and the uterus. It is performed when complications prevent a vaginal delivery (see related sidebar).

In 1996, 16.9 percent of babies in Minnesota were delivered by C-section. By 2007, that number rose to 26.2 percent.

Nationwide, nearly one in three women now have babies by C-section. Is it an epidemic?

Why the big hurry?

"It's alarming," said Jeanne Howell, a nurse/midwife at Broadway Medical Center in Alexandria. "I think everyone is concerned about it."

Howell has worked in obstetrics for 36 years - 16 as a nurse and Lamaze coach, and the past 20 as a nurse midwife. She has seen a steadily growing number of C-sections being performed through the last three decades.

From her perspective, one of the major contributing factors to that trend is the increasing number of inductions, which she sometimes attributes to impatience.

"There is a higher C-section rate with inductions. I am real concerned about the induction rate," she explained. "Sometimes, rather than a failure to progress, it amounts to a failure to wait. Why are we in such a hurry?"

Howell also points to the following factors to the increase in surgical deliveries - fear of lawsuits, the tendency to automatically perform a repeat C-section on a woman whose first child was delivered via C-section, and increased fetal monitoring.

"Fetal monitoring has had a huge impact on C-section rates. It's one more thing to tie them to the bed," she said. "Moving around is helpful."

Howell stressed that there are certainly medical indications necessitating a C-section, most notably failure for a woman to progress in labor and fetal distress.

"If there is an issue with the baby that I am concerned about, that baby has to come out now," Howell said.

Despite the increasing C-section trend, within Howell's practice, it has remained fairly steady - she refers about 11 to 15 percent of her patients for surgical deliveries, less than half the national rate.

"I think one of the reasons is that I really talk to them about labor," she surmised. "I think we need to help patients understand the process of labor, how to deal with it and how to work with it. And make them more aware that there are things they might want to do to learn the process and make it work better for them."

While there are often risks with allowing a woman to proceed with a vaginal delivery, Howell stressed that C-sections are not without their own risks, including a higher infection fate, blood loss, and maternal recovery issues. C-sections are also much more costly.

"The C-section rate is not reducing our health care dollars," she said.

Howell is hopeful that instead of increasing, the C-section rate takes a downward turn.

"It's going to involve a lot of educating, not only of providers but of our society," she concluded. "I think we need to educate our patients about the risks and benefits of childbirth and what options you have."

Safer surgery?

"We try to do everything we can to do a vaginal birth," said Erika Johnson, an obstetrician/gynecologist at the Alexandria Clinic since 2003. "I don't think any C-section I have done was not justified on some level."

When Johnson began her residency at Regions Hospital in St. Paul in 1983, she recalls the C-section rate being around 9 percent. About 1990, she noticed it starting to rise.

Johnson points to several factors that have precipitated the growing percentage, including the switch in the early 2000s to discouraging vaginal births after a previous C-section (VBAC). Many hospitals will no longer perform VBACs.

"We now have a rule that if you are going to do a VBAC in Alexandria, the patient has to sign a permit," Johnson said.

Like Howell, Johnson also surmises that fetal well-being and fear of lawsuits prompt doctors to opt for a C-section.

"We tend to do them sooner if there are fetal heart rate abnormalities," she said. "If the baby shows any sign of a problem, we don't have the luxury of waiting for true distress. We have to call in the crew."

Johnson also cites the following circumstances that may indicate more frequent surgical deliveries: More multiple births and doctors' reluctance to deliver them vaginally; no longer delivering breech babies vaginally; an alarming increase in the number of patients with gestational diabetes; a growing rate of maternal obesity; and the fact that as technology improves, surgery has become much safer.

"We tried so hard 30 years ago to deliver vaginally because C-sections were more risky," Johnson explained. "All in all, everything has gotten safer in surgery. We are not as highly incentivized."

Johnson also says that patients have gotten more "savvy" and know that they can ask to have a C-section, although she will not perform one simply for convenience sake.

While Johnson realizes that there are risks to having a C-section, she also points out that any medical procedure is not without risk, including a vaginal delivery for a woman who may have difficulty.

"Yes, C-sections have gotten a bad rap," she concluded. "The fact of the matter is, women don't understand that sometimes, there are risks to vaginal deliveries as well."

And both Howell and Johnson agree. No matter what the trend, the safety and health of both mother and child is ultimately what is the most important.

Why a C-section?

A doctor might recommend a C-section if he or she thinks it may be safer for the mother or baby. Some C-sections are planned, but most are done when unexpected problems occur during delivery. Although there are risks with a C-section, the benefits outweigh the risks when:

•  The mother is carrying more than one baby.

•  The mother has health problems, including HIV infection, herpes and heart disease.

•  The mother has dangerously high blood pressure.

•  There are problems with the shape of the mother's pelvis.

•  There are problems with the placenta.

•  There are problems with the umbilical cord.

•  There are problems with the position of the baby, such as breech.

•  The baby shows signs of distress, such as a slowed heart rate.

•  The mother has had a previous C-section.

•  The baby is too large.

•  There is a history of shoulder dystocia (shoulders are bigger than head and get "stuck").

•  Failure to progress.

Why the trend?

•  Technology such as ultrasound, fetal monitoring and other medical interventions.

•  Fear of malpractice lawsuits.

•  Patient preference.

•  Convenience - doctor and patient schedules; or just to avoid lengthy labor.

•  Repeat C-sections to prevent rupture of scar from the first delivery. Many hospitals will not deliver vaginally after a previous C-section.

•  Increased safety of surgical procedures.