Answers to why C-sections are on the rise

Why is the Cesarean rate so precipitously on the rise, from 21 percent of all American births in 1996 to 33.2 percent in 2007? The journal Obstetrics and Gynecology has the results of a new study that examines that question.

The Yale University Schools of Medicine and Public Health in New Haven, Conn., reacted to a spike in C-sections during births at Yale-New Haven Hospital between 2000 and 2002 by setting to work gathering comprehensive data on the 32,443 births that occurred there between 2003 and 2009, even while the hospital's C-section rate ballooned from 26 percent to 36.5 percent.

Not surprisingly, the study found that actual birth complications remained steady, while subjective judgments about the births changed.

The new study, presented at the February meeting of the Society for Maternal-Fetal Medicine, looks at the decision-making on the part of individual doctors that drove that increase.

"In this study, we examined physician-documented indications for Cesarean delivery at a major urban academic medical center in Connecticut, a state with one of the largest rate increases in the nation, to determine which specific indications contributed to the increase in our Cesarean delivery rate over a seven-year period," the researchers wrote.

First-time mothers accounted for half of C-sections during the study.

Indications for Cesarean delivery included "nonreassuring fetal heart tracing," an interruption in dilation, more than one fetus, pre-eclampsia, an especially large baby (which begins to be a concern just shy of nine pounds), and the mother's expressed desire for a Cesarean, the study's authors reported.

Complications like breech presentations, an interruption in the baby's progress into the birth canal and cord prolapse  did not increase significantly over time, the study found.

Slow dilation and those unsatisfactory fetal heart rate reports displayed only slight increases over time but contributed to an outsize degree to the increase in C-sections, the study showed. Concern for the baby's well-being, based on fetal-heart monitoring, was the top indicator for a Cesarean section at Yale-New Haven Hospital during the period studied.

Maternal request, suspected macrosomia (a large baby), more than one fetus and pre-eclampsia also showed big annual increases as indications for Cesareans.

Interestingly, the C-section rate among patients of physicians in private practice was 33.2 percent. For "university patients," who received care from the hospital service's residents and faculty midwives, supervised by attending physicians, the rate was 25.6 percent. The rate for "high-risk" patients (whose care was provided by some of the same maternal-fetal specialists who supervised in the "university" cases) was 44.6 percent.

Dads enter the American childbirth picture

American fathers began making their way into the childbirth picture in the 1950s, according to Make Room for Daddy: The Journey from Waiting Room to Birthing Room, historian Judith Walzer Leavitt's 2009 book. Birth had migrated from home to hospital by that time.Make Room for Daddy

Two developments helped bring dad into the birth process, Leavitt writes — the growing influence in this country of British obstetrician Grantly Dick-Read's 1933 book Childbirth Without Fear and the "natural birth" movement it helped launch; and the development of regional anesthesia for childbirth.

Dick-Read's book inspired couples to begin exploring ways to experience childbirth together. The introduction of regional anesthesia meant that women were conscious during birth, but often alone for long periods during labor.

Women asked for their husbands to be allowed to attend their births, and doctors and hospital officials eventually realized that the fathers' presence could make birth safer and more satisfying for mothers.

The phenomenon of fathers attending their children's birth was not just new, it was news. For the June 13, 1955 issue of Life magazine, photographer Burton Glinn snapped reporter John Stouffer gaping in amazement at the birth of his son at Virginia Mason Hospital in Seattle.

The birth of Prince William

Prince William, set to marry on Friday, was born in the private Lindo Wing of St. Mary's Hospital in London on June 21, 1982, more than a week before his due date.

He was the first male of the British royal family to be born in a hospital. Prince Charles also broke with tradition by attending the birth.

Prince William and parents leave the hospital

Prince William and his parents leave the hospital

Prince Charles and his first wife, Princess Diana, William's mother, arrived at the hospital very early on the morning of the day William was born.

George Pinker MD, the royal gynecologist, attended Diana. She had also been coached by Betty Parsons, a nurse and natural-birth advocate who had helped Queen Elizabeth with a couple of her births.

Many accounts present the birth as "natural" and drug-free, while at least one insider book holds that the princess had an epidural during her 16-hour labor.

William was born at 9:03 p.m., and weighed 7 lb. 2 oz. A 41-gun salute was fired off in his honor. Princess Diana was back home the next day.

Prince Charles, always restrained, was clearly thrilled. He wrote friends, "I can't tell you how excited and proud I am," adding that he found the newborn William "surprisingly appetising."

Is Goldberg’s Prentice Hospital terminal?

The days may be numbered for the quatrefoil building at 333 E. Superior in Chicago, the old Prentice Women's Hospital, where both my children were born.

Northwestern Memorial Hospital, which opened a shiny new Prentice in 2007, plans to tear down the old building to put up a new research center. Preservationists are gearing up for a fight to preserve Bertrand Goldberg's 1975 design, which echoed some elements of his hugely successful Marina City downtown residential development, finished in 1964.

Bertrand Goldberg's Prentice Hospital
Bertrand Goldberg's Prentice Hospital

Hospital buildings don't have long lives; indeed, they are often obsolescent soon after they are built.

That was certainly true of NMH's Gothic-style Wesley Hospital, so impressive it was subtitled the "cathedral of healing." Wesley opened on Dec. 6, 1941, literally on the eve of U.S. involvement in World War II, which changed everything, as wars so often do.

The new Prentice now stands at 250 E. Superior, on precisely the spot Wesley once occupied on the NMH campus.

NMH's first women's hospital shared space at 333 E. Superior with the Stone Institute of Psychiatry, which stayed after labor and delivery et al. moved from the poured-cement structure into the new Prentice. The psychiatry department will move out in September, and the building will then be torn down, according to Northwestern University spokesman Al Cubbage.

The university explored and rejected the idea of recycling the existing building for another use, Cubbage says.

"At this point, the university’s plans are to take that building down and use that area for additional research facilities that would be constructed in the future,” Cubbage told the Chicago Tribune's Blair Kamin.

The "old" Prentice has many detractors who believe the building is ugly. Even when my younger daughter was born there 13 years ago, mothers (and doctors) were complaining the facility was outdated.

Prentice was built to last 30 to 40 years; however, the services it offered were so popular it barely made it past 20 years. Planned for 5,000 annual births, it was handling more than 10,000 a year at the end.

And, things changed. The obstetric anesthesiology department, which by 2007 was hugely important, was not on the drawing board when the facility was built.

I loved the old Prentice — its pie-shaped rooms, the intimacy of its floors, the stunning views of Lake Michigan and the city.

Preservationists are understandably upset about the building's impending demise, and are hoping to succeed with an end-run around NMH. Goldberg historically is an important Chicago architect, but his work isn't old enough to have gained the gravitas it deserves, or the protection it needs in terms of landmark status on a local or national basis — and that includes Marina City.

The local alderman, Brendan Reilly, has secured a 60-day delay, which might give friends of "old" Prentice a chance to organize.

Personally, I would bet on the hospital getting its way on the "old" Prentice. As Mark Twain said, they aren't making any more land these days.

Northwestern University/NMH, a major medical school/hospital/research complex, is likely to prevail in doing what it has done for decades on its lakefront campus — raze an old hospital building to create a new facility that reflects the latest knowledge, technology and priorities.

I'll be very sad to see the old girl go, if indeed that is how this story ends.

Here's a bit of irony: “Bertrand Goldberg: Architecture of Invention," opens September 10 at the Art Institute of Chicago.

Photo by Delia O'Hara

Leapfrog: Early elective births are common

The Leapfrog Group, a 10-year-old hospital monitoring group, has found that doctors and hospitals are commonly scheduling women for elective deliveries before 39 weeks of gestation, even though studies have established a bright arrow that shows that babies are at risk of death or serious health problems if they are born before then.

A survey of 773 hospitals released this week shows that these institutions performed more than 57,000 inductions and Cesarean sections before 39 weeks just in the last year. The hospitals displayed a wide range of rates for early elective deliveries, from less than 5% to more than 40%.

"Leapfrog’s release of 2010 data is the first real evidence that the practice of scheduling newborn deliveries before 39 weeks without a medical reason is common and varied among hospitals even in the same state or community," the report stated.

The brain and lungs aren't fully developed until the very last weeks of pregnancy, said Alan R. Fleischman MD, senior vice president and medical director of the March of Dimes, a group that works to prevent birth defects, and is working with Leapfrog to cut the numbers of early births.

“Women need to protect themselves by refusing to schedule their deliveries before 39 weeks without a sound medical reason, and by knowing the facts about the hospitals they plan to deliver in,” said Leapfrog CEO Leah Binder.

Some hospitals, notably Hospital Corporation of America, have programs in place to encourage doctors to refrain from scheduling Cesarean sections and elective inductions for nonmedical reason, Leapfrog officials said.