C-sections on trial

Jennifer Kenney, an expectant mother from Milford, is examined by Dr. Fae Nason at Milford Regional Medical Center at a 40-week prenatal visit.

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By Emily Micucci

On July 7, 2015, Laura Croteau gave birth to her second child, Zachary, safely and the old-fashioned way.

This, of course is nothing unusual, but because Croteau had delivered her first child via scheduled cesarean section nearly two years earlier, Zachary’s birth was a bit of an outlier as far as hospital births in the United States go.

Until recently, vaginal birth after cesarean, or VBAC, was rare, but as pressure to reduce cesarean section rates in U.S. hospitals mounts, more mothers are being encouraged to attempt labor the second time around.

At age 30, Croteau, a Medway resident, was a prime candidate to attempt VBAC. Her first c-section was scheduled only because her baby was in the breech position -- not because of a medical condition or complication that put her or her son at risk.

With a team of doctors who were knowledgeable and supportive of VBAC, Croteau said she felt at ease about the process. It might sound corny, Croteau said, but she wanted to know that she could deliver a baby naturally.“I was very happy I chose it,” Croteau said.

But it wasn’t just the validation that made the VBAC worth it to Croteau. The recovery was far easier, she said, and she was able to drive and to lift her toddler, who was 22 months old at the time. Those things would have been impossible had Croteau undergone another c-section.

This easier recovery period is among a host of reasons that health care advocates and the U.S. government have raised a red flag over the high rate of c-sections in the U.S., setting a new goal that proponents say will make birth safer for mothers and babies while also reducing the cost of childbirth in hospital settings.

The health implications of c-sections are clear. According to the American Congress of Obstetricians and Gynecologists, cesarean sections are associated with an increased risk of complications in mothers, from infections to blood loss and clots, and even injury to internal organs. Babies can suffer from breathing problems after birth because they haven’t been squeezed through the birth canal, a process that helps clear out newborn lungs before they take their first breath.

The rise of the cesarean

At the end of 2014, c-sections accounted for 32.2 percent of all deliveries, according to the U.S. Centers for Disease Control. And while this type of surgery is undoubtedly necessary to protect the health, and indeed life, of mothers and babies, there are many c-sections that are performed without necessity, according to Erica Mobley, director of communications and development at The Leapfrog Group, a nonprofit watchdog organization that provides quality and safety information on U.S. hospitals.

“C-sections are performed at an alarmingly high rate in the U.S.,” Mobley said. “It’s beginning to level off, but year to year, it had been increasingly exponentially.”

The Leapfrog Group reported that the U.S. c-section rate was 4.5 percent when first measured in 1965 and hovered in the single digits for many years until rates started to increase in the 1990s and 2000s, eventually peaking at 32.9 percent in 2009. This, according to The Leapfrog Group, is attributed to many factors, from an increase in maternal age and multiple births, to more relaxed attitudes about surgery in general, and an increase in interventions such as labor induction that have proven to lead to higher c-section rates.

In 2015, The Leapfrog Group included in its annual hospital survey measuring quality and safety in U.S. hospitals rates of primary cesarean sections, a measure which refers to those c-sections performed on first-time mothers at low-risk for cesarean delivery. Leapfrog found that more than half of hospitals surveyed reported rates that exceeded Leapfrog’s target rate of 23.9 percent for pregnancies identified as unlikely to require surgical intervention during labor. That target rate was derived from Healthy People 2020, a federally-backed initiative aimed at improving overall health in America through a number of proposed goals, including cutting the c-section rate.

Dr. Fae Nason, a laborist who practices at the Maternity Center at Milford Regional Medical Center, has seen c-section rates go from arguably too low (around six percent, nationally, when she began working as a doctor at Fallon Clinic in 1993) to too high (peaking around 30 percent).

Nason said when c-section rates were very low in the early 1990s, there were bad outcomes for mothers and babies that caused the obstetrics field and healthcare policy makers to ease up on a drive to keep the rates very low.

But then, the trend reversed and rates skyrocketed. Nason said more c-sections were performed without necessity. And Nason, who performs relatively few c-sections (around nine percent of her deliveries are primary c-sections), said that’s nothing to brush off.

“It’s major abdominal surgery and women can die. And the recovery is much longer,” Nason said.