|Medical boon or lawsuit shield? Benefits, risks debated
Story By Mary Beth Pfeiffer
Two weeks before Kristi Ashley gave birth to a son in 2007, an ultrasound exam estimated the baby at a hefty 12 pounds, 10 ounces — too big, her doctor believed, for a safe vaginal delivery. After the child weighed in at 9 pounds, 4 ounces in the delivery room, Ashley came to believe that the planned cesarean section she had, with its attendant pain, long recovery and what she called “emotional damage,” may have been a rush to judgment.
“It’s very hard to go up against your physician, especially at the 12th hour,” said Ashley, 38, of Hopewell Junction. “I think doctors are very quick these days to get scared. They would rather opt for the surgical solution.”
Determined to avoid another surgical birth and aided by a supportive doctor, hospital and birthing coach, Ashley last month did something that has become increasingly rare for post-cesarean women today: She gave birth vaginally, to another son.
In an era of soaring malpractice premiums, technology that sometimes sets off false alarms, physicians pressed for time and mothers-to-be conflicted by fear, cesarean-section birth is soaring to its highest http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_12.pdf“>levels ever.
From 1999 to 2007, the proportion of New York babies born by cesarean section skyrocketed 42 percent. In 1999, just under 1 in 4 babies was born surgically. By 2007, the figure was 1 in 3 — or 34 percent of births — and there is nothing to suggest that the relentless uptick, evident locally as well, is showing any sign of slowing.
In Ulster and Dutchess counties, with cesarean rates in the top sixth of counties statewide, surgical birth rates increased from 1999 to 2007 by 64 percent and 36 percent respectively. Orange ranks in the middle of counties statewide but also saw its section rate rise by 36 percent in that time.
At Vassar Brothers Medical Center in Poughkeepsie, 1,072 babies were delivered via cesarean section in 2008 — two of every five births, for a rate of 40 percent. In Ulster County, Kingston Hospital had a cesarean rate of 40 percent in 2007, the latest figure available, while Benedictine Hospital’s was 35 percent, nearly double what it was in 1999.
Even Northern Dutchess Hospital in Rhinebeck, with a reputation for progressive natural-birthing practices, saw its surgical birth rate soar by 52 percent since 1999 — to 29 percent of all births in 2008.
The World Health Organization calls for a maximum cesarean section rate of http://www.unicef.org/sowc/“>15 percent in any nation in the world. Anything above that “seems to result in more harm than good,” according to a 2006 research summary in the British medical journal Lancet.
Factors hotly debated
Physicians, midwives, childbirth experts and researchers point to a confluence of factors behind the growing rate of cesarean section — factors that are hotly debated both in medical literature and hospital corridors. Some say that more mothers are older, obese, more prone to multiple births and, in particular at Kingston and Vassar Brothers hospitals, less healthy, increasing risks of surgical measures. Others contend that overused interventions to induce and augment labor, manage pain and monitor for fetal distress have driven cesarean rates to unnecessary heights.
All agree that fewer women are opting for once-popular vaginal birth after cesarean, or VBAC, as Ashley did. But some believe doctors emphasize its risk – that the scarred uterus could tear – while minimizing the drawbacks of surgery. VBACs have declined precipitously at five local maternity hospitals; at Northern Dutchess, 17 percent of women who had a previous cesarean gave birth vaginally in 2008, compared to 41 percent in 1999. In 2007, just 3 percent of post-cesarean women birthed vaginally at Kingston Hospital, where the procedure is officially banned. The figure was 33 percent in 1999.
Amid the debate, there is widespread agreement that medical factors are only a part of the story. Cesareans have become so common and accepted that first-time mothers – frightened by societal depictions of overwrought laboring women — sometimes request them simply to avoid labor; doctors, hospitals and insurance companies acquiesce. Moreover, obstetricians, who pay $84,500 a year for malpractice insurance in Ulster and Dutchess and $137,600 in Orange, may see cesareans as a way to avoid lawsuits over injuries to infants from vaginal birth — as well to manage precious time. Obstetricians must attend 54 births just to cover annual malpractice premiums in Westchester County, a medical society study showed; cesareans are undoubtedly quicker and more convenient.
“I see colleagues around me who seem to operate out of fear,” said Dr. Ira Jaffe, a Rhinebeck obstetrician who estimated his cesarean rate at less than 20 percent. “They always have in the back of their mind, ‘How is it going to look in court?’ It’s the defensive medicine.”
“It’s not in the best interest of women and babies to do this many C-sections,” he said.
And the more common cesareans become, the more accepted they are as an alternative way to have a baby. “When you talk to co-workers and friends, so many people have had C-sections,” said Kimberly Revak, 37, of Fishkill, who has had two cesareans, the last with twins in February. “We’re kind of losing that experience” of vaginal birth.
As in Ashley’s case, an ultrasound overestimated the size of Revak’s first baby, putting her at 12 pounds while she delivered at under 9. “It’s easier to go along than to choose the other way and have a problem,” she said.
Telling both sides
For a community of activists who say the cesarean section rate is out of control, the question is whether women like Revak are getting both sides of the story – on one hand that cesarean sections no doubt save lives in high-risk circumstances and are generally safe, but that they contribute in other cases to prematurity, cause respiratory problems in babies and increase maternal bleeding and infection.
“Women are getting cheated by not being encouraged to believe both in their ability to birth and that birth can be a positive experience,” said Christie Craigie-Carter, Hudson Valley coordinator of the International Cesarean Awareness Network, or ICAN, who echoes other mothers who believe they’ve had needless or questionable cesareans at the expense of a core maternal experience: vaginal birth.
Assemblywoman Amy Paulin, a Democrat from Scarsdale in Westchester County, said she is “very alarmed” by the rising cesarean rate.
A Paulin http://www.amypaulin.com/press_rel_detl.asp?id=50“>bill, signed into law last year, requires the state to educate women on birthing procedures, such as the induction of labor and use of pain-numbing techniques like epidurals, that increase risk of cesarean section. Paulin, a three-time mother who had two midwife-attended babies at home, believes that cesareans are often performed for reasons of convenience, fear and liability. “We have a huge problem,” she said.
But while physicians acknowledge room for debate, many accept and even embrace rising cesarean rates, in particular for women having just one or two children, when cesareans are safest. Some noted that planned cesareans generally produced better outcomes than emergency procedures performed after problems arise.
“Is it wrong?” asked Dr. Carla Eng, an obstetrician who delivers babies at Vassar Brothers Medical Center. “It’s hard for me to answer that. The final outcome is to have a healthy baby and a healthy mom.”
“It’s not necessarily a bad trend,” said Dr. Cornelius Verhoest, an obstetrician for 25 years who practices in Fishkill and Poughkeepsie and specializes in urinary disorders. Verhoest, who recently married and is considering fatherhood, said he would encourage his wife to have a cesarean section. He and other obstetricians said the procedure helps avoid potential “pelvic floor disorders” such as urinary incontinence that sometimes follows vaginal childbirth.
“There’s more fevers, wound infections associated with C-section,” acknowledged Dr. John McAndrew, chairman of obstetrics and gynecology at Kingston Hospital, where the cesarean rate hit 43 percent in 2006. “However, it’s safer for the baby.”
Weighing surgical risks
Physicians and researchers concerned with rising cesarean rates take issue with that assertion, which they say fails to weigh the risk that a baby will be damaged or die in vaginal delivery – what drives many decisions to operate – against surgical risks to mother and child.
“In low-risk or no-risk mothers, studies have consistently shown higher morbidity (illness) in infants delivered by cesarean section,” said Dr. Lucky Jain, a pediatrics professor at Emory University School of Medicine in Atlanta who has studied respiratory problems in C-section http://www.ncbi.nlm.nih.gov/pubmed/16549212“>babies. “We have created a monster here without knowing what the long-term impact is.”
“There is no evidence that cesarean is safer for the baby,” said Dr. Jed Turk, newly appointed obstetrics and gynecology chairman at Vassar Brothers Medical Center and a proponent of lower cesarean rates. “It is not a good trend.”
To be sure, every obstetrician knows of or has experienced a vaginal birth gone bad; some said that they and other colleagues had been sued more than once. “If anything goes wrong, the first question you’re asked is, ‘Why wasn’t a C-section done?’ ” said Dr. Scott Hayworth, chairman of the New York district of the American College of Obstetricians and Gynecologists, who calls lawsuit fears “the leading cause” of rising cesareans.
In one case reported on VerdictSearch.com, a legal research service, a Suffolk County jury awarded $212 million in 2005 to a boy born in 1998 with brain damage after a delayed cesarean section (the award was later reduced to $10.6 million). In another, a Bronx jury awarded $64 million in 2002 to an 18-year-old woman who suffered cerebral palsy during her vaginal birth.
Locally, an Ulster County case was settled for $3 million in 2006 after a baby boy allegedly suffered brain damage during a vacuum extraction birth in 2001 at the former Mid-Hudson Family Health Institute in Kingston, which had been licensed to perform births.
“Physicians are less risk-tolerant,” said Dr. Michael Rosenberg, president of the 25,000-member Medical Society of the State of New York, echoing several local obstetricians who acknowledged the role of litigation fear. “When a physician is forced to make clinical decisions influenced by the threat of lawsuits, they are not rendering the best medical care to their patients.”
Vaginal birth undoubtedly has risks. One in 5,000 to 10,000 babies suffers permanent shoulder damage, and one in 1,000 suffers moderate to severe brain damage, according to a 2006 http://cat.inist.fr/?aModele=afficheN=18208466“>article in the professional journal Seminars in Perinatology. These injuries, as well as 6,000 stillbirths, could be avoided nationwide if the nation’s 3 million annual vaginal births were performed surgically at term — but that would mean additional costs and maternal and infant complications.
While researchers do not suggest universal cesarean section, momentum currently favors surgical birth – with troubling implications. At least two of New York’s 146 maternity hospitals have rates above 50 percent, and 23 are in the 40s; the state’s rising rates worry health officials.
“C-section is major surgery, which involves a longer recovery time for the mother and can have other significant consequences,” said Barbara McTague, family health director for the state Health Department.
The cost of cesareans in a cash-starved health-care system is just one consequence. A cesarean birth cost the state Medicaid program $7,200 on average for hospital care in 2007 – 49 percent more than a vaginal delivery. The state’s cesarean price tag was $189 million.
Of greater concern may be the effect of cesareans on babies that are increasingly being delivered early. Thirty-six percent of elective cesareans were performed before 38 weeks, according to a http://content.nejm.org/cgi/content/short/360/2/111“>study published in January in the New England Journal of Medicine, producing infants who had high rates of breathing problems, prolonged hospitalization and sepsis, a severe bacterial infection.
As significant, the study found that 10.2 percent of all cesarean-born babies were admitted to neonatal intensive care units, and 4.4 percent suffered from respiratory distress syndrome caused by fluids that are normally wrung from infant lungs during labor and vaginal delivery. Twenty-thousand babies delivered near-term by cesarean section suffer respiratory distress each year, according to a 2006 http://www.ncbi.nlm.nih.gov/pubmed/16549212“>article in Seminars in Perinatology, while death rates of C-section babies before 28 days were nearly triple those of vaginal deliveries, according to a 2006 http://www.ncbi.nlm.nih.gov/pubmed/16948717“>study by researchers at the U.S. Centers for Disease Control in Birth: Issues in Perinatal Care.
Studies have also found 20 percent higher incidence in both childhood-onset http://www.ncbi.nlm.nih.gov/pubmed/18292986“>diabetes and http://www.ncbi.nlm.nih.gov/pubmed/18352976“>asthma among cesarean babies, who have one-third to three-quarters the level of healthy http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1774211“>bacteria in their intestines as vaginally born babies.
“When a baby comes out the normal way, they swallow vaginal mucus en route and get a nice dose of healthy bacteria to jump start their digestion,” said Dr. Joseph Malak, a Poughkeepsie pediatrician who called “surreal” the number of cesarean babies he sees on hospital rounds. “This doesn’t happen when babies come out through an abdominal incision.”
Malak believes that the rising cesarean rate may be linked to “a dramatic increase” in recent years in infants with colic, acid reflux, eczema and milk allergies – effects that, some say, obstetricians do not consider when weighing vaginal versus cesarean birth.
“You hand the baby to the pediatrician and you release the mother from your care,” said Dr. Carol Sakala, who has a doctorate degree in public health and is program director for the research and advocacy group Childbirth Connection, based in New York City. “There’s very little thought to the ongoing consequences.”
While cesarean delivery is safer than ever for the mother, it is not risk-free. According to a 2008 http://www.ajog.org/article/S0002-9378(08)00268-8/abstract”>report in the American Journal of Obstetrics and Gynecology, 2.2 women died for every 100,000 cesarean births – 10 times higher than for vaginal births. “Cesarean delivery is associated with an increased risk of postpartum maternal death,” concluded a 2006 http://journals.lww.com/greenjournal/Abstract/2006/09000/Postpartum_Maternal_Mortality_and_Cesarean.12.aspx“>report in the same journal.
In New York, the rate of maternal mortality rose 70 percent from 1997 to 2007, when 40 women died as a consequence of pregnancy. Researchers say the rise, seen nationally as well, may be related in part to better reporting as well as to rising rates of obesity; one http://www.childbirthconnection.org/pdf.asp?PDFDownload=LTMII_report“>survey found that a quarter of pregnant women were obese. While no link has been proven between rising maternal deaths and rising cesarean rates, a state-sponsored study in 2004 identified three of the major causes of maternal death as embolism, hemorrhage and infection – all of which occur at higher rates in cesarean section.
Indeed, serious obstetrical complications increased by 27 percent from 1998-99 to 2004-05, according to a 2008 report in http://www.ncbi.nlm.nih.gov/pubmed/19155897“>Obstetrics and Gynecology. These included renal failure, pulmonary blood clots, shock, blood transfusion and ventilation — upticks that parallel rising cesarean rates.
“It looks like there’s an association,” said the study’s author, Dr. Susan Meikle, an obstetrician and medical officer at the National Institutes of Child Health and Human Development. She and others argue that indicators like maternal mortality and illness should be dropping if, indeed, more cesareans are a good thing. “Where’s the benefit from the increase?” she asked.
In its 2006 review of optimal cesarean rates, the British medical journal Lancet, for one, showed “no reductions” in mother or child illness or death in populations with cesarean rates above 15 percent.
“There is an awful lot of lying to women about cesarean,” said Dr. Marsden Wagner, former director of women’s and children’s health for the World Health Organization and author of several books on childbirth. “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.”
The argument over cesarean’s benefits is perhaps most pointed when it comes to vaginal birth after cesarean; many doctors fear that the scarred uterus will tear, resulting in hemorrhage and loss of oxygen to the infant.
“There’s a real risk,” said Dr. Maureen Terranova, obstetrics chief at Northern Dutchess Hospital. “They have to be willing to accept that 1 percent risk of uterine rupture.”
“When it occurs, it can be catastrophic,” said Kingston Hospital’s McAndrew, who has seen uteruses so thin in surgery that the baby is visible. “That’s the thing that makes us reluctant to tread in that water.”
Melissa Ptacek, 47, of Garrison in Putnam County, said it took her years to recover from a uterine rupture from which her daughter – now a normal 11-year-old – had to be resuscitated. “I wouldn’t want anyone to go through what I had to go through,” she said.
In a study published in the http://content.nejm.org/cgi/content/abstract/351/25/2581“>New England Journal of Medicine in 2004, 124 women suffered uterine rupture among 17,898 who attempted vaginal birth after cesarean — a rate of 0.7 percent. Seven babies suffered brain damage, including two who died. A 2000 research http://www.google.com/search?hl=en&q=%22Evaluation+of+Cesarean+Delivery%22&b”>summary by the American College of Obstetricians and Gynecologists put the risk of rupture in vaginal birth at 0.2 to 1.5 percent for most women with one prior cesarean. In an advisory that subsequently sent cesarean rates climbing, the organization recommended that post-cesarean vaginal births only be attempted in hospitals “with physicians immediately available to provide emergency care.”
Proponents of vaginal birth after cesarean say the risks of rupture must be balanced against the downsides of surgical birth. “The conversation about VBAC doesn’t touch on dozens of other concerning outcomes that favor vaginal birth,” said Sakala of Childbirth Connection, noting that cesareans make breastfeeding difficult, lead to adhesions and cause significant pain for up to six months. More than 7,000 repeat cesareans would be needed to save the life of one baby from a ruptured uterus, she said, citing a 2004 British Medical Journal http://www.bmj.com/cgi/content/abstract/bmj.38160.634352.55v1“>study.
Other proponents argue that not all ruptures are catastrophic and some have actually been caused by labor-enhancing medications, called http://content.nejm.org/cgi/content/abstract/345/1/3“>prostaglandins, whose dangers for post-cesarean women are now recognized.