FAIRMONT - In 2010, the number of cesarean deliveries at the hospital in Fairmont was 33 percent. In 2011, it dropped to 29.6 percent. Then, last year, just 19 percent of 236 births were done by C-section.
Patient education is probably the main reason for the decline, according to Phyllis Hartwig, manager of the BirthPlace at Mayo Clinic Health System in Fairmont.
"We're doing a better job of letting women know we're not doing inductions until 40 weeks," she said.
Artificially inducing childbirth by administering the hormone oxytocin or puncturing the amniotic sac prior to 40 weeks has been shown to increase the risk of cesareans, one of the most common surgical procedures in the United States. If an induction is requested prior to 40 weeks, for instance if the birthing partner is being deployed for military service, the patient can appeal to the department head.
The medical center adopted new protocols three years ago, after the state started closely monitoring inductions, "and as you can see, our rates have gone down," Hartwig said.
The facility is also cautious about giving epidural anesthesia for pain relief. Give it too soon and the labor can stall out - the No. 1 reason for an unplanned C-section. While the patient is waiting through the contractions for active labor to begin, Hartwig said her staff tries to refocus the mom, using various means like massage or music.
"We try to make sure the patient is informed, so they know what's available to them," Hartwig said.
The pattern of declining cesarean rates at the Fairmont hospital is far from statewide, however, or nationwide.
At United Hospital District in Blue Earth, 38.7 percent of births were by cesarean in 2011. Dr. Terry Cahill, a physician at UHD, said the facility is generally at right around 30 percent, which reflects the national rate.
The mid-1990s is when cesarean deliveries started to climb in the United States, rising to an all-time high of 32 percent in 2007 and then plateauing, according to the National Center for Health Statistics. There were 1.31 million cesareans performed in 2010, or about a third of U.S. births. The World Health Organization recommends cesarean rates be no higher than 10 to 15 percent.
Reasons for reducing the cesarean rate are plentiful.
As explained by Hartwig, a cesarean is a major surgery, so following the procedure, the patient will be hooked up to an IV and a catheter. Also, she said, the risk of infection is higher, and the post-delivery pain is greater. Patients have to stay in the hospital longer, and the recovery time for the C-section incision is four to six weeks.
Bonding with baby also can be impacted, since the pain from a C-section can make breast-feeding more difficult, and women are advised once they return home to rest whenever possible. In Mayo Clinic's online article on C-sections, the author advises a woman to "consider recruiting help ahead of time for the weeks following the birth of your baby. This might include household help or child care for other children."
C-sections also increase the risk of lung problems in infants, since the fluid is naturally squeezed out of their lungs when they are delivered through the birth canal.
The topic of cesarean rates is a sensitive one, and the reactions to the statistics and the underlying causes vary.
"It's really a complicated thing, and it gets people's emotions high," said Dr. Steve Parnell at Dulcimer Medical Center in Fairmont. "Everybody wants a healthy baby and a healthy mom."
In Mayo's online article about C-sections, the author cites numerous reasons a health care provider might recommend a C-section, including:
o If labor isn't progressing.
o If the baby isn't getting enough oxygen.
o If the baby is in an abnormal position.
o If the mother is carrying multiple babies.
o If there's a problem with the placenta.
o If there's a problem with the umbilical cord.
o If the mother has a medical condition that could make labor dangerous, such as high blood pressure or HIV.
o If the baby has a health concern.
o If the mother had a previous C-section.
Parnell brought up a factor that wasn't mentioned in Mayo's list.
"Several things are driving the C-section rate. Some of it has to do with the whole malpractice climate and the concern about having a baby with any potential liability from a birth injury," he said.
The cesarean rates for Parnell's obstetrics patients is at 11 percent. Dulcimer utilizes Mayo's hospital in Fairmont for deliveries.
"There are some doctors who would do a C-section very easily, and others who will take the time to watch a patient and manage them through labor," he said, obviously putting himself into the latter category.
But patient preference is not to be slighted, since some women choose a cesarean over labor.
"If you look at trends, it's tough to say, 'This one thing is part of it,'" Cahill said. "Moms are older, babies are bigger, moms are bigger, liability, mom's choice. It's all played a role. And when do we say we don't want moms to have the choice; we don't want to factor in important considerations for women working who need to schedule some things. It's a balance in weighing patient choice and safety."
Talk to any rural provider and they'll tell you one factor that is definitely driving up cesarean rates at rural facilities are policies on VBACs - vaginal births after cesarean.
"There's a very rigid criteria for being able to do that, so lot of facilities backed away from VBACs," said Cahill.
The closest facilities that can do VBACs are in Mankato.
The main fear regarding VBACs is uterine rupture, if the scar from the previous C-section tears open during the delivery process. A uterine rupture is a life-threatening emergency, which is why hospitals that perform VBACs have staff on hand to respond quickly in a crisis.
"If you look at the total C-section rate, divided by total number of live births, that doesn't take into account the women who are just having a simple repeat C-section," Parnell said.
Some local providers counter that the risk of uterine rupture during a VBAC is extremely rare, especially if proper protocols are followed, but liability outweighs their arguments.
Just in the past year, Parnell has seen more women wanting to "forgo a lot of the intervention and to do things more naturally."
"Years ago, everyone went to Lamaze classes and worked on their breathing and that sort of thing, and they did very well," he said. "It's refreshing to see a bit of the renewed interest in doing more natural childbirth, but it takes a good labor nurse and a patient doctor and a supportive partner as well."
Concern about an epidural leading to a cesarean is one reason more women are choosing to go natural, but it's a trend Cahill says he hasn't seen. On the contrary, he has many more women come in and insist on an epidural.
"It's all about patient choice," he said. "If you said, I want a natural birth, then sure, that's great if we can provide that. ... The concept of having to experience pain during labor to appreciate the process? Ehhh ... " he said, indicating his disagreement. "You don't make people go through a painful procedure without offering pain management, and if women don't want to experience pain during labor, they should have that choice."