Many N.J. babies are born by a procedure that is often medically unnecessary and carries risks for mother and child.
Published by Lindy Washburn on NorthJersey.com
By most measures, New Jersey’s mothers-to-be are the same as those around the country. The state’s obstetricians, likewise, are as dedicated and competent as their peers around the country.
So why are a higher percentage of babies here than in almost any other state born by cesarean section, a surgical procedure that often is medically unnecessary?
Nearly 40 percent of the births in New Jersey occur via C-section, an operation that costs more than normal childbirth and creates extra risks for mothers and babies. That ranks the state among the highest in the nation for use of the procedure.“Women’s pelvises can’t be that different from Ohio to New Jersey,” said Dr. Jack Feltz, founder of one of the state’s largest OB/GYN practices, Lifeline Medical Associates, with 125 physicians in 11 New Jersey counties. Nor do they vary from one part of the state to the other.
Childbearing women in New Jersey are not older, fatter, less likely to have prenatal care or more likely to demand a birth scheduled for their own convenience, said Charles Denk, a health statistician who analyzed birth trends in his former position as a research scientist at the state Health Department.
Yet the state tied with Louisiana last year for the third-highest C-section rate among low-risk mothers, behind Mississippi and Florida — not usually New Jersey’s peers in health care. The year before, the C-section rate among low-risk mothers, who are least likely to need such a delivery, was the highest in the country.
But that’s not the only surprise: Hospital by hospital, rates of C-section delivery vary almost threefold across the state. Medical facilities separated by less than five miles can be worlds apart.
The C-section rate for low-risk first-time mothers at Hackensack University Medical Center, the state’s busiest maternity hospital, is the highest in the state — and nearly 2½ times higher than at Holy Name Medical Center in Teaneck, according to data reported by the hospitals themselves to a non-profit group.
Hackensack made Consumer Reports’ national list in June of “11 Hospitals to Avoid if You Don’t Want a C-Section Birth.”
Other North Jersey hospitals are close behind. Nine of the 10 hospitals with the highest rates of cesarean births in New Jersey are in the north, including St. Joseph’s Regional Medical Center in Paterson, HackensackUMC Palisades in North Bergen, St. Mary’s General Hospital in Passaic, The Valley Hospital in Ridgewood and Meadowlands Hospital Medical Center in Secaucus.
The reasons are complex, and include at least three theories:
- Doctors’ fear of malpractice lawsuits. In dollars and cents, a lawsuit over harm to a baby settles for more than a suit over harm to a mother. Cesarean delivery reduces the chance of injury to the baby during childbirth — or at least shows the doctor tried everything to limit risk. “Doctors are scared,” said Dr. Abdulla Al-Khan, Hackensack’s director of maternal-fetal medicine. “If you want a drastic decline in C-sections, stop frivolous lawsuits.”
- Labor inductions, or the use of drugs to start uterine contractions before they start on their own. “For women who are otherwise at lowest risk, It virtually doubles your chance of having a [C-]section,” said Denk.
- Avoidance of overtime. Small or cash-strapped hospitals may prefer to schedule births — by induction or cesarean — to avoid calling in nurses and other staff at unpredictable hours.
“I don’t think we have the answer at this point,” said Linda Schwimmer, president and CEO of the New Jersey Health Care Quality Institute. “We’re trying to figure out the tools to work with this and drive these numbers down.”
Some women who experience an unexpected C-section find the emotional and physical toll lingers. A network of activists has grown to support them, promote vaginal birth after cesarean and use education to prevent unnecessary cesareans and improve maternal and child health.
‘It was traumatizing’
Jessica Williams, who is 35, described her first child’s birth at a monthly meeting in Westwood of the International Cesarean Awareness Network of Bergen County. Her labor was induced after her obstetrician told her that an ultrasound showed the amniotic fluid in her uterus was low and the baby was big. The baby was a day past 40 weeks’ gestation.
Williams, a nurse herself, wishes now that labor had been allowed to start on its own. The Pompton Lakes woman had run marathons before becoming pregnant and trained mentally and physically to give birth naturally, she said.
The induction caused her contractions to quickly overwhelm her, but her cervix did not dilate, she said. “At first, they were like waves,” she said. “Then forget the waves, it was a tsunami, and nothing was stopping. They kept coming and coming.” When the baby’s heart decelerated with each contraction, the attending nurse called the obstetrician and told Williams they would need to operate. “I was so scared,” Williams said.
Williams’ baby, Bradley, was born more than 14 hours after her labor began, healthy at 7 pounds. Yet Williams still cries as she talks about her experience at Hackensack. “It was traumatizing. I felt out of control,” she said. “It was nothing for which I had prepared.”
She awaits the birth of her second child in January, and has changed hospitals and doctors in hopes of having a vaginal birth. For mothers like Williams, the chances of a repeat C-section are great. VBACs, as vaginal births after C-section are known, have become more uncommon after a brief surge in the 1990s.
Another mother who had an unexpected C-section at Hackensack has also switched doctors and hospitals. A Hoboken resident after growing up in Ridgewood, she is early in her second pregnancy and asked that her name not be used.
In May 2014, when her son was born, she received medicine to induce labor after her water broke but she didn’t feel the urge to push the baby out, she said. She was given three hours to try, under the protocol her obstetrician followed, but nothing happened. “I really felt like they were watching the clock,” she said.
Only when she was being wheeled into the operating room did she feel the baby shift, causing her to think, “So that’s what it’s like to push.” But her time was up. The delivery was uncomfortable, with the doctor “really wrestling to get him out. … It felt so awful, I just had to go someplace else in my head” to keep calm.
The following day, the doctor told her that having her second child would be easy — with a C-section, “We’ll just schedule it!”
It wasn’t what the new mother wanted to hear. She recalled how her “birth plan,” expressing her preferences for what medical interventions to use, had been dismissed by her obstetrician. “I wish I had chosen a doctor who would be there for me,” she said. “Doctor choice and hospital choice are really important.”
Obstetricians vary in their reactions to women who bring up birth plans. Feltz uses them to launch a conversation about their expectations: “My job is primarily to get you and the baby out of the hospital healthily and safely,” he said he tells them. “My secondary goal, which is high on the list, is to give you the best experience possible. … When it comes to safety, you have to give me ownership of things, because that’s why you hired me.”
N.J. death rate high
No one says the C-section rate should be zero. And some say the focus on comparing C-section rates is misplaced.
“Bad things can happen in obstetrics,” said Al-Khan, the maternal-fetal medicine director at Hackensack. Better to look at the big picture — the health and safety of the mother and baby.
“I need to know what [a hospital’s] risk of maternal death is,” said Al-Khan, or how often a mother hemorrhages or a newborn goes to the intensive-care nursery.
Unfortunately, the death rate for new mothers, like the C-section rate, is comparatively high in New Jersey: The state ranks 35th among the 50 states, according to Amnesty International. Postpartum hemorrhaging is known to be the leading cause of such deaths nationally. But hospital-by-hospital information for New Jersey is not publicly available.
Surgery to get the baby out is sometimes necessary to protect the health of the mom and the baby. The mother’s uterus can rupture, or the baby’s shoulder catch after its head has emerged — emergency situations doctors want to avoid at all costs.
But the risks of medically unnecessary C-sections for mothers and babies prompted the federal government to set a goal of reducing their use by 2020 to less than one in four births — 23.9 percent.
The World Health Organization reached an even stronger conclusion: No reduction in death rates among mothers and their newborns is achieved when cesarean deliveries among low-risk moms exceed 10 percent, the organization said.
Only one New Jersey hospital in four met the national goal. And just one hospital in New Jersey had a C-section rate below 15 percent.
The risks of unnecessary C-sections include higher rates of infection and blood clots for the mother. Her recovery will take longer, and she will be less likely to rely on breast milk, which is better for infants, to feed her baby when she leaves the hospital, studies have shown. Most importantly, any children she has in the future also are much more likely to be born via C-section — causing her a greater risk of hemorrhage or uterine rupture because of the surgical scar in the uterus.
Babies that aren’t squeezed through the birth canal are more prone to respiratory problems, and don’t benefit from exposure to the mother’s healthy bacteria. They are more likely to grow into obese children, and may also have higher rates of asthma, diabetes and allergies, research has shown.
Hospital report cards
The public now has access to timely hospital-by-hospital comparisons of C-section rates from The Leapfrog Group, which issued its first “maternity care report card” last year. The report includes other markers useful in evaluating maternity care, such as early elective deliveries; use of episiotomies, incisions to widen the birth canal; and a hospital’s ability to handle high-risk deliveries.
Leapfrog based its comparisons on first-time low-risk moms — those giving birth to a single child who was in the head-down (rather than breech) position. It updates the data monthly from hospital reports; all but six New Jersey hospitals with maternity services participate. The most recent comparisons, with a single exception, cover the first nine months of 2015.
The bright light of publicity makes hospitals take notice.
For example, St. Mary’s in Passaic had the highest C-section rate in the metropolitan area when the first report card came out in 2015. More babies there were delivered surgically — 54 percent — than vaginally. But the 2016 report shows a steep drop, to 37 percent. The hospital declined to comment.
Shore Medical Center in Atlantic County succeeded St. Mary’s in the hot seat, with the highest C-section rate in the state — 54 percent — earlier this year. But it provided updated information to Leapfrog this fall — the only New Jersey hospital to do so — showing the rate had plummeted to 33 percent.
Now Hackensack occupies the unwanted top spot.
“We’re tracking it on a weekly basis,” said Al-Khan. The majority of the doctors who deliver babies at the hospital are in private practice, he said, which means that inducing them to change their habits requires diplomacy. “We’re micromanaging, watching OBs, having discussions in a positive way — not a destructive way, not a militant way — to encourage that things should done the right way,” he said.
The effort has paid off with a significant reduction in C-sections, he said.
In public eye
The power of sunshine has been amply demonstrated, experts say, in the stunning drop in early elective deliveries nationwide in the past few years. These are C-sections or inductions without medical justification before the 39th week of pregnancy, for the convenience of the mother or doctor or in the mistaken belief that it is safe to deliver. A lot of fetal brain development occurs in the final weeks of pregnancy. Babies born before the 39th week were more likely to weigh less, and be admitted to intensive care.
After hospital comparisons were first reported, many hospitals put a hard stop on births scheduled before 39 weeks for non-medical reasons. The New Jersey Hospital Association and other groups launched a campaign, “Baby is Worth the Wait,” said Aline Holmes of the association. Hackensack went a step further this year, with a hard stop on elective births before 40 weeks, said Al-Khan.
After eight years, the national rate of early elective deliveries has dropped to a record low — 2.8 percent — from 17 percent.
“Once there was public reporting of these rates, people started really paying attention,” said Erica Mobley, of Leapfrog. “We hope that will be the case with C-sections.”
The challenge of improving maternity care is a microcosm of efforts to transform the health-care system. Big data, financial incentives and changes in the organization of hospitals and the physicians who practice at them will all be part of the effort, say those involved.
The savings that result from such efforts would help drive health care costs down. Labor and delivery account for almost a quarter of all hospitalizations. Payments from insurance companies for C-section births for mother and baby are 50 percent higher than for a vaginal birth. In New Jersey, Medicaid — fully funded by taxpayers — pays for 42,000 births a year.
Childbirth is one area of medicine where health care may be overused. “In most cases, you can have a delivery that does not involve surgery, and in so doing, it’s better for you and better for the baby,” said Schwimmer, of the Health Care Quality institute.
“Less can be more.”