Mothers, experts seek ways to lower C-section rate

Capital JournalJuly 13, 2014 

— Before Dawn Reum, of Fort Pierre, gave birth to her twins, Gage and Gunner, in June 2011, she was adamant about her wish to have a natural birth. But when doctors informed her she had a placenta previa — the placenta had grown too low in the womb, creating a barrier for the babies' exit — a decision was made to perform a cesarean section.

"I fought tooth and nail till the end because I wanted a natural birth but they weren't having it," Reum told the Capital Journal (http://bit.ly/1m7yz2X ). "I guess the doctor knows best."

Prior to having a cesarean section, Reum had natural deliveries for her two other children.

Reum's latest delivery experience is part of an ongoing trend that medical professionals are continually working to reduce. In fact, although it is performed only on women, the incision into a woman's abdomen and uterus to deliver a child — the cesarean, or C-section — has become the most common surgery in the United States.

In addition to placenta previa, surgical birth can be necessary for a variety of reasons. Cesarean deliveries have been established as the safest route of delivery for certain clinical conditions such as a uterine rupture, which can interfere with a baby's oxygen supply.

Though cesarean deliveries can often be life-saving for the baby and mother, some experts and mothers say the practice, which includes significant health risks and increased labor costs, has become all too common.

Research shows mothers that have cesarean deliveries face a greater risk of disease and death than vaginal deliveries, as well as significant financial burdens. For example, the average expense for a cesarean birth at Sanford Medical Center in Sioux Falls was $12,000 more than the average vaginal birth in 2012.

The United States saw a 60 percent rise in the use of cesarean delivery between 1996 and 2009. Today, about 32.7 percent of births nationwide will happen via C-section, or nearly one 1 of 3.

Things are better in South Dakota, which has an average cesarean section rate of 25.5 percent. That ranks the state 46th in the country since 2012. But that is still 1 of every 4 births.

Although the state has had one of the lowest rankings in the country for several years, experts like Marilyn Hildreth, CEO of JM Birth Consultants, believe South Dakota's hospitals need to continue to improve. Hildreth's consulting company offers professional maternity care training to nurses, midwives and other health professionals.

Hildreth says through education and attempts to reduce elective inductions — when labor is induced out of convenience or preference — the cesarean section rate at hospitals can begin to fall.

"If you wait to induce babies, you won't have the C-section rates that we have now," Hildreth said.

Hildreth says it is equally important to educate nurses on how to provide support for women who want to have a non-medicated birth.

"All hospitals can give epidurals, but there are very few hospitals in the state of South Dakota where the nurses have been specifically trained to provide labor support for a non-medicated birth," Hildreth said. Brookings Hospital is a notable exception, she said.

Hildreth said nurses in most other hospitals in the state have never been specifically trained in labor support.

"The Brookings staff is very respectful of the mother and the family," she said.

Every year since 2010, Brookings has one of the lowest C-section rates in South Dakota's hospitals. In 2011, the hospital had a 10 percent C-section rate. The next year it was 11 percent. In 2013, the total jumped to 16.9 percent, yet Brookings still had one of the lowest cesarean rates in the state.

"We try to follow American Congress of Obstetricians and Gynecologists' guidelines to decrease cesarean rate by allowing adequate time for the second stage of labor," said Brookings Hospital Obstetrics Director Mary Schwaegerl.

When asked what Brookings does differently than other hospitals, Schwaegerl said, "We offer vaginal births after cesarean deliveries, do versions, and some vaginal breech deliveries. We also provide a free labor doula service to our patients."

A version is the manual turning of the baby in the womb to aid delivery.

Many hospitals in South Dakota do not offer vaginal births after cesarean deliveries, or VBACs, including St. Mary's in Pierre.

Mikel Holland, a family medicine doctor for St. Mary's, said the American Congress of Obstetricians and Gynecologists guidelines would require the hospital to employ year-round anesthesiologists, obstetricians, gynecologists and surgical staff 24-hours-a-day. That makes large tertiary care organizations like Avera McKennan ideal locations for VBACs, he said.

"In small rural community hospitals that can be a challenge, if not a logistical impossibility," Holland said.

But some rural hospitals such as Brookings Hospital make arrangements for VBACs on a case-by-case basis.

"As soon as they present labor we call the on-call staff and they stay until she's out of labor," Schwaegerl said.

St. Mary's does not offer similar arrangements for VBACs.

That has been a frustration for Shannon Zeeb, of Pierre, who has had three vaginal births after two cesarean sections.

Zeeb said after two C-section births and a horrific VBAC in a hospital, she searched for someone that would support her to give decision to birth her child the way she wanted.

In 2008, after interviewing 11 different health care providers, Zeeb traveled to Minnesota to birth her fourth child, Bryant, outside a hospital setting with a certified professional midwife.

"The midwife supported me the whole labor and delivery. She allowed me to labor at my pace and without fear and pressure to use any type of intervention," she recalls.

Midwifery does not come without complications — Bryant was born with his arm up by his face and he was over 10 pounds — but it was possible because of the knowledge of the midwife, Zeeb says.

Zeeb had her fifth child in her home in Pierre with a certified nurse midwife. Comparing her experiences, research and the fact that St. Mary's does not allow VBACs, Zeeb felt the homebirth was the only choice for her.

"One of the biggest things that you have is support and somebody telling you that you can do it," she said.

Aided by her husband and doulas — a non-medical person who assists a woman during labor — Zeeb said the midwife did not pressure her to have interventions like the scraping of membranes, breaking of water, too soon or too many cervical checks, labor inducing medication and epidurals.

Zeeb says the reasons C-sections are so common is because of overuse of interventions, lack of patience and experience in natural childbirth, liability and money, in addition to the installation of fear on moms, unsupportive staff and mothers' complete trust in their care provider.

"They act like it's not a big deal but it's a huge deal," she said.

Zeeb said it's a human right issue because women that have C-sections don't have much choice without access to a natural birth-friendly hospital that offers VBACs or the ability to make arrangements with one of only four midwives that practice out of hospital births in the state.

Like Zeeb, Reum felt like her options were limited while delivering her twins. But today she says natural birth is the best option.

"If I were to ever have children again, I would do anything I could to have a natural birth," she said. "There's nothing like it."

Information from: Pierre Capital Journal, http://www.capjournal.com

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