High c-section rates draw concerns

Pregnant women entering almost every other hospital in the state last year also faced higher odds of delivering by c-section than women did in the past, the AJC found. Statewide, the percentage of births by c-section increased from about 1 in 4 in 2000 to 1 in 3 last year.

The rates have increased so steeply in recent years that experts in obstetrics believe c-sections are now being overused. The American College of Obstetricians and Gynecologists this year raised a red flag and asked doctors delivering babies across the country to take a more cautious approach.

While it’s a routine procedure, mothers whose babies are delivered by c-section face risks inherent in surgery, including infections, significant blood loss and blood clots. Plus, the recovery is much tougher, and one c-section usually leads to another.

“Those risks matter,” said Dr. Aaron B. Caughey, a member of the committee that developed new c-section standards for The American College.

The recommendations call for doctors to allow women to labor a bit longer and to redefine the active phase of labor as cervical dilation of 6 centimeters instead of 4 centimeters. The recommendations are based on evidence that labor progresses slower than previously thought, Caughey said.

While there’s been an upward trend statewide, c-section rates vary significantly from one hospital to the next. North Fulton Hospital in Roswell had one of the lowest rates in the state last year at 18 percent, the AJC found. John D. Archbold Memorial Hospital in Thomasville topped the charts with a c-section rate of 50 percent.

Doctors and midwives who deliver babies make the call on when a c-section is necessary. So the rates are generally a reflection of the providers who practice in each hospital, as well as the health of the pregnant women in that hospital’s community.

Northside Hospital said its vast obstetrics facility attracts many women with complicated pregnancies who are more likely to need a c-section.

“Women who experience difficult or high-risk pregnancies often come to Northside because we are so well-equipped to support them,” said Melissa Sisson, Northside Hospital’s director of women’s services. “We have sophisticated early warning systems designed to manage maternal complications, and our staff is remarkable in the care they provide.”

Northside also said its c-section rate is now on the decline; the reports studied by the AJC show that Northside’s rate hit a high of 40.8 percent in 2010 and dropped to 39.2 percent last year. Northside attributed the decline to its new guidelines which no longer allow inductions and c-sections before the 39th week of pregnancy, unless they are medically necessary.

Georgia’s c-section leader, Thomasville’s John D. Archbold Memorial Hospital, said it sees a significant number of high-risk pregnancies, and its highest priority is providing the safest care possible for women and babies.

“We work with our patients in deciding the best option for their care, and sometimes there are circumstances that make c-section the best option,” said Dr. Melissa Bruhn, Archbold’s ob-gyn. “Because we have a higher rate of obesity and disease than other areas of the state, we see more high-risk patients than other hospitals.”

Bruhn said the best opportunity to lower the rate at Archbold is through improving women’s health.

Allowing time to labor

Caughey, of The American College of Obstetricians and Gynecologists, said there are a lot of theories about what has pushed the c-section rate up so steadily.

Some attribute it to an increase in high-risk pregnancies tied to women delivering babies at older ages. Also a factor: higher obesity rates among pregnant women. Obesity can cause a range of complications that can make c-sections necessary.

Caughey and other doctors also said growing concerns about malpractice lawsuits may also be driving doctors to order more c-sections.

The new guidelines for c-sections from The American College have prompted those delivering babies across the country to start having conversations about their practices, Caughey said.

Dr. Hughan Frederick, an ob-gyn who delivers babies at North Fulton Hospital, said he was gratified when reviewing the guidelines. “When I was reading that it was like, ‘This is what we do in our practice now,’ ” he said.

North Fulton has metro Atlanta’s lowest c-section rate at 18 percent. Unlike the trend statewide, its rate has remained fairly flat since 2000, usually between 18 and 20 percent.

Both Frederick and Nancy Melcher, the hospital’s chief nursing officer, attributed the low rate to the fact that midwives handle many of the deliveries at North Fulton.

Frederick’s practice has more midwives than doctors. While doctors are always available should a c-section become necessary, Frederick said his practice tends to give women more time to labor. He also said that midwives have the time and skill to help women feel comfortable and safe through the delivery process, even if it does drag on.

“We really want to keep those c-section rates as low as possible, and the hospital knows that by allowing the patient to labor a little bit longer, it really is going to be the best outcome for the patient and the baby,” said Debbie Bobb, clinical manager of women’s health at North Fulton. “We’re very fortunate to have providers who are supportive of having patients labor for a longer period of time.”

Atlanta Medical Center, another hospital that embraces midwives in the maternity ward, also posted a relatively low c-section rate, at 25.8 percent last year. Dr. Lathan Overstreet, at ob-gyn at Atlanta Medical, said doctors delivering babies at the hospital started working to combat the upward trend about a decade ago.

“We realized that these national averages were just a little too high, especially when you compare it to 1971, when the rate was 5 percent,” Overstreet said.

Today, midwives handle more deliveries than doctors at the hospital, which attracts patients from across Atlanta with its water birth option and professionals who support natural childbirth.

When Lorena Wargo became pregnant with her second child, she started searching for a practice that she hoped would allow her to have a different birthing experience.

Wargo delivered her first baby, a daughter who is now 3, at Northside Hospital. She said her labor was progressing well until she got an epidural and the process slowed. “After many hours, a total of 18 hours of labor, they said they baby did not drop and they decided the baby had to come out.”

She wasn’t prepared for a c-section and said it was difficult — and disappointing.

“It’s surgery,” she said. “The recovery was very painful and slow. It affected everything, my breastfeeding, my mind, my body, my spirit.”

For her second baby, Wargo wanted to avoid another c-section. She turned to Intown Midwifery, whose patients deliver primarily at Atlanta Medical Center. The practice said its c-section rate averages about 15 percent.

“I was determined that I was going to be able to do this, and I went to the right place,” Wargo said.

Most doctors recommend that women who have had a c-section deliver that way for subsequent births. That’s because they are at higher risk of significant complications if they deliver vaginally.

But Intown’s midwives supported Wargo’s desire for natural childbirth, and Wargo got just what she wanted. Her new daughter, Mary Annabelle, arrived at the end of October through a smooth, natural delivery.

Wargo’s midwife and her husband were at her side during the whole process.

Wargo said her recovery this time was almost immediate. “I could not be any more thrilled.”

While doctors and midwives may approach labor differently, pregnant women also have different expectations — with some treasuring the experience of natural childbirth, others asking for a c-section to avoid it all, and many more just hoping for a great outcome no matter how the baby arrives.

Katy Thurow of Marietta was planning on a natural birth for her first baby, a daughter who is now 2 ½. But her doctor discovered late in her pregnancy that the baby was 9 pounds, breech and wasn’t going to flip.

Thurow said she was initially disappointed, but accepted the c-section as a gift. “We probably wouldn’t have both made it, had we not taken that option,” said Thurow, who delivered at Northside Hospital.

She researched a natural delivery for her second baby, Josie, who was born one month ago. But after looking at all the factors, Thurow decided it was too risky. She went back to Northside for her second c-section, and Josie arrived safely.

“I have two beautiful healthy children,” she said. “How I got them, at this point, to me is not as important as my two beautiful healthy children!”