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Hospitals trying to halt rise in C-sections

Now encourage going into labor naturally

After her water had broken last month and her contractions hadn’t yet begun, Melissa Turner (with baby Emma Rose) jumped at the chance to see if labor would begin on its own.
After her water had broken last month and her contractions hadn’t yet begun, Melissa Turner (with baby Emma Rose) jumped at the chance to see if labor would begin on its own.Wendy Maeda/Globe Staff/Globe Staff

Modern childbirth is a far cry from when our grandmothers delivered at home, and few women would want to return to those days. But as the number of cesarean sections has risen sharply, with no clear evidence that they improve the health of mothers or babies, experts say that childbirth has become overly medicalized and overly expensive. Now some hospitals are making an effort to reduce those trends.

Massachusetts General Hospital has phased in several new initiatives during the past few months designed to encourage pregnant women to go into labor naturally with fewer medical interventions and, hopefully, lower costs and fewer C-sections. The labor and delivery unit's obstetricians, nurses, and midwives — all on staff at the hospital — have agreed to end elective inductions, which are usually scheduled ahead of time for the convenience of doctor or patient and without a medical reason. Medical reasons to induce childbirth include high blood pressure or diabetes in the mother or a growth problem in the baby.


Women whose water has broken but who haven't started contractions have recently been given the option to return home to get another night of rest — rather than being given drugs to induce contractions— to see if labor will start naturally.

"We've pulled out all the stops to try to decrease our induction rate to only when it's a medical necessity," said Dr. Laura Riley, Mass. General's medical director of labor and delivery, though the hospital still schedules a handful of inductions for nonmedical reasons each month. The new policy could help lower the hospital's 30 percent C-section rate, since studies suggest that scheduled inductions sometimes lead to prolonged, nonprogressing labors that necessitate surgery. But other factors contributing to the steady C-section rise —older mothers with riskier pregnancies, multiple births, and bigger babies — might be impossible to reduce.


Another aim of the hospital's new rules, Riley said, is to shorten the time a pregnant woman spends laboring in the hospital, which can free up beds and save on health care costs. Women who go into labor naturally tend to spend about 10.5 hours in the labor and delivery unit compared with 22 hours for women whose labor is induced.

After Melissa Turner's water had broken last month and her contractions hadn't yet started, she jumped at the chance to return home to see if her labor would start on its own. When Turner, 37, returned to Mass. General the next morning, she still wasn't in labor. The mother now of a healthy 4- week-old daughter said she doesn't regret waiting.

"I had the opportunity to see if my labor would begin naturally," Turner said, "so when I did get the pitocin [a hormone to trigger contractions] I felt more peaceful about it."

While it's too soon to say whether the hospital's new policies will lower the rate of C-sections, free up beds in the labor and delivery unit, and save on health care costs, similar efforts have produced striking results when implemented elsewhere.

At Intermountain Healthcare, a system of 22 hospitals based mainly in Utah, policies banning elective inductions have been in place for more than a decade, leading to a drop in the rate of C-sections from 28 percent to about 21 percent and a cost savings of $50 million a year to Utah, according to chief quality officer Dr. Brent James.


Hospitals earn more for C-sections; in Massachusetts, they charge an average of $13,400 compared with $9,700 for an uncomplicated vaginal delivery.

The Intermountain hospital system, which handles 34,000 deliveries a year, experienced no rise in death rates or serious complications in mothers or babies after putting its policies into effect. "In most cases, we've found that when you improve the quality of care," said James, "the costs also decline." He conceded that Intermountain sees a high percentage of young mothers who are in good health.

Mt. Auburn Hospital in Cambridge has a C-section rate of about 23 percent, one of the lowest in the state, and a few years ago implemented many of the same policies Mass. General is now trying. Much of Mt. Auburn's success can be attributed to the patients, said Dr. Ed Huang, chair of obstetrics- gynecology at the hospital. "We have patients who don't want an operative intervention. Fewer than half get epidurals for pain relief compared to 70 to 80 percent at other hospitals."

Health policy experts point out that the reasons for the rapid increase in C-sections both statewide and nationally are varied and complex, and reversing the trend will involve an overall culture change at many hospitals. Many community hospitals in the state, for example, don't allow women to attempt vaginal births after they've had a C-section because there is a small increased risk of uterine rupture, which could expose the hospitals to lawsuits.


Hospitals in the state, however, are starting to band together to implement practices that have been shown to benefit birth outcomes. The majority of the state's birth centers recently moved to ban elective C-sections and inductions before 39 weeks except when there is a clear medical need. The move was based on a spate of studies that found that such policies led to reductions in admissions to neonatal intensive care units at several hospitals across the country without an increase in stillbirths.

Brigham and Women's Hospital in January began encouraging more women to have vaginal deliveries after C-sections to nudge down its C-section rate, which is slightly below the state average. "To my great happiness," said Dr. David Acker, chief of obstetrics at Brigham and Women's, "about 26 to 27 percent of women who've had previous cesareans now deliver vaginally compared to 21 or 22 percent a year ago."

While certain birth centers like Tufts Medical Center argue that their C-section rates, which are well above the state average, can be attributed to serving more pregnant women who have complications, many community hospitals including Newton- Wellesley Hospital also have higherthan- average rates.

"I don't think anyone's arguing that Newton-Wellesley serves as high a risk population as Boston Medical Center, which has a large low-income population," said Eugene R. Declercq, a professor of community health sciences at Boston University School of Public Health. Yet Newton- Wellesley's C-section rate was nearly 38 percent in 2009 compared with 30 percent at Boston Medical Center, according to the latest state data.


What's more, a Department of Public Health report released last year showed that the cesarean rates for first-time mothers with low-risk pregnancies ranged from 10 percent to 35 percent among the various state birth centers, which suggests that some hospitals are clearly performing too many surgeries.

"We track our C-section rate and are always making efforts to keep a handle on it," said Dr. Sabrina Craigo, chief of maternalfetal medicine at Tufts Medical Center. The rate declined from a peak of nearly 39 percent in 2009 to 35 percent in 2011, which Craigo attributed to the hospital's recent addition of two nurse midwives who handle lower-risk pregnancies and favor fewer medical interventions.

Thomas Beatty, chair of obstetrics-gynecology at Newton-Wellesley, said his hospital's C-section rate is now in the 33 to 34 percent range after the hospital's midwives and physicians adopted new policies.

But, Beatty said, it's been difficult for staff to pinpoint why their C-section rates were higher than average in the first place. "There are so many factors that play into it."

Deborah Kotz can be reached at dkotz
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