It’s 7 p.m. on a Thursday at Valley Hospital and Medical Center in Spokane, and Dr. Nathan Meltzer has already had a very long day.
He has one mother in labor. She’s been there for more than 12 hours.
“It would be very easy to encourage her to say, ‘We gave it a good try.' It's 7 o'clock and I could do a C-section right now and be home with my family in time for dinner,” Meltzer says, standing outside her room. “It's tempting, but it's not the right thing. The right thing is to wait and see how this turns out.”
The patient, Kelly, sits on the bed, propped up by pillows. It’s her second pregnancy – the first time, she had a C-section.
This time, she wants to give birth vaginally. Some doctors and hospitals in Washington state would discourage her from trying a vaginal birth after a previous caesarian, but Valley supports moms like her.
Washington, like the rest of the country, has seen a dramatic increase in C-sections since 1996.
KUOW examined rates at hospitals throughout the state and found that the rates vary dramatically, from 6 percent at Othello Community Hospital in eastern Washington to 41.8 percent at Whidbey General. On average, about one-quarter of first-time, low-risk moms get C-sections.
Dots denote hospitals; click for the C-section rate. Red dot = hospital where rate for low-risk moms exceeds 20 percent -- about what the World Health Organization recommended in a 2010 report. (KUOW/Kara McDermott)
“It was scary,” Kelly recalled of her C-section. “When they pulled my daughter out – all I could do was reach for her hand.”
“No,” the nurses told her. “Not yet.”
Doctors and nurses at hospitals throughout the state gave many reasons for the variability: Older patients and an increase in fertility treatments around Seattle, rise of obesity statewide, low rates of vaginal births after C-section, fear of being sued.
But many say another reason prevails: hospital culture.
“When you see all that variation, you always wonder, what is going on? Because you cannot explain all that kind of variation by biologic variation,” said Dr. Tom Benedetti of UW Medical Center. “We’re learning that there are different cultures in different hospitals.”
Hospital culture in Washington state just started to change, Benedetti said. At EvergreenHealth in Kirkland, Benedetti said the nurses "started buying into giving the patients more time.”
“The doctors aren’t there, they’re not sitting there and watching the labor,” he said.
The benefits and risks of cesarean sections have been long debated. Often, C-sections save lives. But they also involve major abdominal surgery – incisions into the muscle and the uterus – and can result in long-term complications. The question in the medical community has become: What’s the right number? And how do we get there without risking lives?
Swedish Hospital: Tackling High Rates
When Dr. Dale Reisner went through her residency in the 1980s, she said doctors and nurses “had more confidence in how we watched labors.”
“We may have pushed it too far in some circumstances. There were some complications that we rarely see now that we did see then,” said Reisner, who specializes in maternal fetal medicine at Swedish First Hill.
“But I’ve also seen vaginal breech deliveries go away” – deliveries of babies coming out feet first – “which I was very comfortable doing.”
Over the years, Reisner, who specializes in maternal-fetal medicine, watched C-section rates rise at Swedish.
“We’ve been puzzling over why. We’ve looked at reasons why for a number of years,” Reisner said.
Reisner said that until this year, there were few protocols for doctors delivering babies. Doctors are trained in their residency programs, “but once you start practicing, you develop these little quirks that help the art of how you practice medicine,” Reisner said.
Reisner and her colleague Dr. Tanya Sorensen have considered how other factors might affect the C-section rate, such as fetal heart rate monitoring and hiring doulas. Electronic fetal heart monitoring sometimes results in a false sense of urgency, which could contribute to more C-sections, Sorensen said.
In contrast, Reisner said the presence of midwives and doulas, or birth coaches, has reduced the odds of a C-section. But doulas are expensive, typically between $800 and $1,500, and their services are not covered by insurance.
“Can we try doulas in support in the hospital?” Reisner said. “Can we try a program that might be able to provide that support to anyone who might need it, rather than the people who can financially afford it?”
‘The Hard Stop’
Last year, 8.7 percent of women at Mason General in Shelton, Washington, got C-sections. Mason is one of the few hospitals in the state where the rate has declined since 2000 -- by 50 percent.
Marcia Rohlik, the nurse manager of obstetrics there, said that’s because providers are encouraged to question each other. Before, a doctor might have called the hospital to schedule a C-section or an induction, even if moms weren’t yet 39 weeks pregnant – considered full term.
“But now,” Rohlik said, “the nurse is going to say, ‘Why are we doing this? She’s not 39 weeks.’”
Patients had asked for C-sections because their husbands are in the military are about to be deployed overseas, or because their moms are in town.
At some hospitals, administrators have started to get involved in that discussion. Or they ban it completely, which is called a “hard stop.” Rohlik said the physicians keep each other in check, too.
Some doctors say fear of being sued has resulted in a higher C-section rate.
“The saying in medicine has been, ‘I have never been sued for doing a section too early,’” said Benedetti of the UW Hospital.
But there’s more to it than fear of the legal system, he said.
“Everybody is practicing in the same liability environment, so that can’t be the only thing,” he said. “Then you have to look at the complications and the ages of patients coming in. And even after you account for all of that, there’s still variation. That’s called unexplained variation, and so then you have to look at culture.”
Benedetti said there has been a cultural shift at EvergreenHealth in Kirkland. In 2011, Evergreen had a 35 percent C-section rate, one of the highest in the state. The hospital started talking about reducing its C-section rate, which has since declined to 27 percent.
Benedetti noted a concern as C-section rates decline across the state: “It remains to be seen whether they have had an increase in adverse outcomes in the babies.”
“Is it OK to do 10 fewer C-sections and hurt one baby?” he asked. “I’m not sure you’d pick that choice. But if it’s a thousand to one, is it OK? Well, we haven’t had those conversations. And people don’t think about things like that.
“Some people say, ‘Oh, you shouldn’t worry about that.’ But I worry about it a lot.”
Officials at Evergreen say there haven't been more complications for babies or mothers.
“We certainly want to be sure we are not damaging babies or mothers by changing how we are managing labor,” said Dr. Angela Chien, who oversees quality monitoring in Evergreen's OBGYN department. “If anything, our adverse outcome index is trending downward.”
At Valley Hospital in Spokane, the chances were quite good that Kelly would give birth vaginally.
First of all, Valley has one of the lowest C-section rates in the state – 12.4 percent for low risk, first-time moms.
And about half the women who have previously had C-sections end up delivering vaginally – the highest rate for any hospital in the state.
About 20 minutes before midnight, Kelly found the waiting paid off. After pushing for a little over an hour, baby Colton was born.
No C-section required.
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.