'Normal Labor' And Why C-Section Rates Climbed So High
Public health officials across the U.S. say the number of cesarean sections being performed has gotten way out of hand. It's a life-saving surgery for complicated births, but today nearly a third of pregnancies end up as a C-section.
And everyone agrees that’s just too high.
“We've seen the cesarean rate rise over the last 15 to 20 years for no good medical reason,” said Dr. Aaron Caughey, chair of obstetrics and gynecology at Oregon Health and Science University. That includes Washington state.
Caughey said there is one particular factor that makes a huge difference: How you define a normal labor.
It turns out our modern standard for labor dates back to the 1950s. That’s when a physician named Dr. Emanuel Friedman tracked the labors of hundreds of women and came up with a spectrum for length of labor. It’s known as the Friedman curve, and Caughey said, it stuck.
“The Friedman curve is still the curve that is in every textbook on the planet today,” Caughey said.
National OBGYN groups say the Friedman curve is why the C-section rate has risen so dramatically. Earlier this year, the groups released guidelines that said women should be allowed to labor longer to lessen the chance of a C-section.
‘You’ve Had Enough Time’
Emily Cameron, an attorney in downtown Seattle, might have benefited from these new guidelines.
As a 24-year-old pregnant woman in Boulder, Colorado, Cameron chose a group of female doctors who said they had a low C-section rate.
Her pregnancy was going along fine until she hit 37 weeks. That’s when she learned she had slightly elevated blood pressure. Her doctor also worried that her baby would be too big when he reached 40 weeks, so she said a cesarean section might be necessary.
At first, Cameron was induced using a gel and a synthetic drip that triggers contractions. But after 20 hours, her contractions slowed.
“They said, ‘You’ve had enough time. If you’re not dilated anymore in an hour, noon or 1 p.m., we’re just going to do a C-section,’” Cameron said.
“I feel like as an overweight woman, I was already treated differently,” she recalled. “I felt like people were not showing me the same kind of respect for my own choices.”
When she returned home from the hospital, her stitches ruptured. A nurse was dispatched to tend to her every day.
And her baby nursed non-stop. When he wasn’t nursing, he cried.
“He seemed like he was really not ready to be out here,” Cameron said. “He had a strong startle reflex. He just needed to nurse. He was not ready to be disconnected from the placenta. I thought, ‘You just need to crawl back in.’”
Thirty-seven weeks used to be considered full-term. But Washington state officials have found that children delivered earlier than 39 weeks are more likely to have problems with writing and reading in elementary school.
Cameron said her son Jack, now 10, has grown up to be an exceptional artist. He does Math Olympiad, reads and writes at an advanced level.
“He seems like he’s on the young end of things in terms of development, but he’s an amazing kid,” she said. Occasionally she wonders if being born early hindered his development. “He does have a speech impediment and some core strength issues,” she said.
Now 35, Cameron wishes she had pushed back and asked, “What’s the harm in waiting?”
Caughey sits on a panel that explored potential causes of the high C-section rate for the American College of Obstetricians and Gynecologists.
He said the Friedman curve isn’t the only reason why the C-section rate has increased.
Older women get pregnant, fertility treatments have increased and doctors are scared of being sued.
But Caughey said one thing is certain:
Friedman's studies were not rigorous by today's standards. For one thing, he excluded some data that seemed outside the norm. As a result, the Friedman Curve shows labor starting earlier and progressing faster. Caughey said when you restrict the definition of normal, you get to abnormal much quicker, and that has contributed to doctors jumping in sooner.
“And all data since then points to a longer length of time and a much wider range of normal. In other words, there are women who take a lot longer in labor, and that's OK,” he said.
Caughey helped write a new set of C-section guidelines released earlier this year by the American College of Obstetricians and Gynecologists. The basic message: Be patient.
But that might be easier said than done.
Every doctor and nurse interviewed said another reason for higher C-section rates is that moms are more sick and overweight than even a decade ago.
Sorensen at Swedish said that older women typically have more complications and therefore a higher risk of C-section.
“I also think that for women who are obese – the whole population is more obese – there’s a higher risk for diabetes,” she said. “It leads to more complications later on and a higher risk of C-section.”
Currently, Swedish is building operating and labor rooms for women who are extremely obese.
At Whidbey General, nurse manager Trish Nilsen said that the toilets have had to be reinforced because of increasing obesity.
“The biggest issue is that women are sicker,” Nilsen said. “They’re not as healthy as they were. I see women who would never have been able to carry a pregnancy. Women with cancer, women with diabetes. It’s miracle by miracle.”
Whidbey recently had its first case of a woman who was too heavy to be carried by helicopter. Now the hospital asks moms for their BMI so they can plan on having an ambulance on hand in case of emergency.
Dr. Tom Benedetti of the University of Washington said doctors face a tough decision. A C-section could save a life. It could also lead to complications years down the road.
“There’s this nasty thing called abnormal placentation,” Benedetti said. “The more times you cut the uterus, the more likely the placenta is to grow into the scar. If the placenta grows into the scar, it can be a disaster.”
The placenta is the organ that feeds and protects the baby after about week 12 of the pregnancy. It detaches from the uterus and is pushed out after the baby is delivered.
“Sometimes the placenta doesn’t just grow out of the uterus, it grows through the uterus, into the bladder or it grows into the bowel,” Benedetti continued. “When it does those kind of things, people lose their lives. You can’t stop the bleeding.”
The chance of this occurring is rare, but some moms in Washington state have died because of it.
Map: Click on the map to see how C-section rates at hospitals in Washington state. The red dots are indicates hospitals where the rate for low-risk, first time moms exceeds 20 percent -- about what the World Health Organization recommended in a 2010 report.
Reversing The Trend
Seventeen hospitals in the state are participating in a pilot program aimed at lowering their C-section rates. At Providence Sacred Heart Medical Center in Spokane, physicians are regularly given a report of their personal rate and their group’s rate.
“It's peer pressure – when you have doctor say, 'Holy cow, why is our group's rate higher than this other group?'” said Dr. Steven Brisbois of Sacred Heart. “Initially they're resistant when you say, 'You're doing too many C-sections.' But once you bring them through this process and start sharing data, it causes an internal process to re-assess.”
Swedish hospital in Seattle is one of 17 hospitals involved in a pilot program aimed at reducing unnecessary C-sections. One big push is to track data and get doctors to rethink that Friedman labor curve they learned about in school. And also to re-educate mothers and their partners that it’s OK to be patient with labor.
The rate for C-sections on low-risk pregnancies there has declined to 26 percent from 31 percent in just six months.
Dr. Tanya Sorensen, who specializes in maternal fetal medicine, cautions that the end goal of reducing C-sections shouldn't be a number, it should be patient health.
“One thing we are absolutely not wanting to do is reduce the C-section rate at the risk of mother or baby safety.”
‘My Heart Sank’
Cameron has since had four other children vaginally. But the C-section she had in Boulder has haunted her medical records.
When she moved to Washington state, she learned some hospitals would not allow her to attempt a vaginal birth.
After moving to Seattle, Cameron delivered her fourth child at home. She then delivered her fifth at Group Health Medical Center. It was there, during a prenatal visit, that she learned that her first child’s delivery by C-section may have been unnecessary.
“Group Health ordered the report, and I asked to read it,” she said. “As I read, I kept looking for the reason for the C-section. Somebody is in distress. That the C-section was indicated. That I couldn’t have fought harder, it was necessary. I couldn’t find it. There was nothing in there.”
Her mildly elevated blood pressure wasn’t even noted.
“My heart sank. I cried,” she said. “I told the midwife, ‘There’s nothing in here that says it was necessary, and I am so angry.’ She couldn’t explicitly agree with me. She was not there. And I would never expect her to do that. She can’t say they were wrong. But she expressed she understood how I was feeling. She was also perplexed.”
Under the new guidelines, Cameron might have been allowed to push longer. Or perhaps another nurse or doctor would have stepped in and questioned the decision to deliver her baby by C-section.
This series on cesarean sections in Washington state is a collaboration between KUOW Public Radio in Seattle and the Northwest News Network. Jessica Robinson of the Northwest News Network reported from Spokane; Isolde Raftery of KUOW reported from Seattle.
Isolde Raftery can be reached at firstname.lastname@example.org or 206-616-2035.