Health

HEALTH • Summer 2016 19 Those things would have been impossible had Croteau undergone another c-section. This easier recovery period is among a host of rea- sons that health care advocates and the U.S. govern- ment have raised a red flag over the high rate of c-sections in the U.S., setting a new goal that propo- nents 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 communica- tions and development at The Leapfrog Group, a nonprofit watchdog organization that provides qual- ity 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-sec- tion 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, even- tually peaking at 32.9 percent in 2009. This, accord- ing to The Leapfrog Group, is attributed to many factors, from an increase in maternal age and multi- ple 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 per- formed on first-time mothers at low-risk for cesar- ean 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 interven- tion 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 cut- ting 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 U.S. c-section rates have begun to level off, according to the latest data from the U.S. Centers for Disease Control, but they are still well above the target rate of 23.9 percent NATIONAL TRENDS and babies that caused the obstetrics field and health- care 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. 15% 20% 25% 30% 35% '91 '13 '93 '95 '97 '99 '01 '03 '05 '07 '11 '09 32.7% "It's major abdominal surgery and women can die. And the recovery is much longer," Nason said. Practical problems While the risk of death due to c-section is minute -- according to the National Institutes of Health, rates of zero have been achieved in some settings -- c-sections do prove impractical for many mothers, especially those in the U.S. where family medical leave policies are generally not as robust as those found in other developed countries. Some women must return to work just six weeks after delivery, and many don't have a spouse who can take more than a week or two off of work when a baby is born. Jessica Castillo, a Blackstone mother who deliv- ered her only child, Jaden, via cesarean section when she was 26 years old, said the recovery was "a night- mare." She couldn't drive due to the pain medication she was taking after the surgery. She also couldn't carry her baby up and down the stairs and had to sleep on the first floor as she recovered. Castillo's c-section was unplanned, and was per- formed because she had reached the pushing stage of labor and wasn't making prog- ress. If given the chance to do it again, she said she would have asked the medical staff to turn down her epidural so she could attempt delivery with lighter anesthesia. The experience has made Castillo wary of having another child, she said. Better for baby? Castillo is not alone in her wariness. Dr. Diana Rabkina, a pediatrician with Harrington HealthCare System based in Southbridge, added that it was much more common to see women opt for an elec- tive c-section 15 years ago than it is today. And for babies, Rabkina thinks that's best. As c-section rates have declined and VBACs become routine practice at some hospitals, Rabkina said she sees fewer new- borns with jaundice, a condition where newborns have trouble eliminating bilirubin because they aren't getting enough to eat. This is more common when mothers have had c-sections because milk production is delayed, Rabkina said. Cost consideration C-sections are also more expensive than vaginal births, another aspect of cesarean birth that The Leapfrog Group explored in its report. Dr. Ellen Delpapa, chief of the maternal-fetal medicine divi- sion within UMass Memorial Medical Group, said there was pressure from insurance companies in the 1990s to reduce c-section rates. That could happen again as insurers collect data on c-sections to try to measure and predict the cost of covering birth expenses for members. For her part, Delpapa considers a c-section a "neutral outcome," and is most concerned with ensuring the health of both mother and baby. She is uncomfortable about allowing the national c-sec- tion rate become a major factor in her every day treatment of patients. Dr. Ellen Delpapa chief of maternal- fetal medicine, Umass Memorial Medical Group There's significant variation in hospital c-section rates. Find out where your local hospital stands. Source: The Leapfrog Group 2015 hospital ratings MetroWest Medical Center, Framingham ..................... 27.4% Saint Vincent Hospital, Worcester ...................... 27.4% Milford Regional Medical Center ............................. 21.5% Umass Memorial Medical Center, Worcester ......................... 21.5% Heywood Hospital, Gardner .......................................... 19.4% Athol Memorial Hospital ................... Declined to respond HealthAlliance Hospital ................... Declined to respond U.S. .............................................. 32.2% Target .......................................... 23.9% Hospitals ranked from highest primary cesarean delivery rate* Hospital Rate LOCAL C-SECTION RATES

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