Lying in a hospital bed at Northwestern Memorial’s Prentice Women’s Hospital after giving birth in 2011, Erica Fleischer kept replaying what had just happened.
She had delivered her first child by cesarean section. Exhausted after 13 hours of labor, with the baby not yet descended, the Lakeview mom said she agreed to a C-section. But having encountered no major complications, she felt frustrated by the feeling that she might have been able to deliver vaginally.
“All that was in my mind was, ‘I don’t want this to happen again next time,'” said Fleischer, 39.
A Consumer Reports study to be released Tuesday analyzed more than 1,300 U.S. hospitals and found that more than half had C-section rates above the national target of 23.9 percent set by the U.S. Department of Health and Human Services for low-risk births.
Doctors are working to help decrease the rate of C-sections after the American Congress of Obstetricians and Gynecologists (ACOG) reported the procedure increased 60 percent from 1996 to 2011. Nationally, C-sections account for 32 percent of all births, according to the Centers for Disease Control and Prevention. Although ACOG has not designated a specific C-section rate each hospital should aim for, it suggests the national rate should be lower.
In Illinois, C-sections account for 27 percent of total births, according to 2015 data, the most recent available from the Illinois Department of Public Health. Overall the state’s rate is lower than the national average, but Chicago doctors say they hope to bring the number of C-sections at their hospitals even lower. The World Health Organization suggests aiming for 10 to 15 percent.
To reduce the number of C-sections statewide, the Illinois Perinatal Quality Collaborative, a CDC-funded group working to improve women’s and infants’ health, is considering C-section reduction as its main target for 2018. The group is working with hospital and health officials to finalize the goal, which it hopes to announce at its annual meeting in November.
“This is something where we know we can see a measurable difference,” said executive director and maternal-fetal medicine specialist Ann Borders.
Designating a target of fewer C-sections would mean the 100 hospitals in the Collaborative, including nearly all Chicago birthing centers, would use the same measures at the same time to scale back the surgery. Doctors from different hospitals could also compare their progress.
In January, ACOG issued new labor recommendations that might help lower cesarean rates. These build on guidelines issued in 2014, when ACOG and the Society for Maternal-Fetal Medicine jointly expressed “significant concern” that C-sections are “overused.”
In November, the Joint Commission, which accredits hospitals, launched a “Speak Up” campaign encouraging women to ask about C-section reasons and risks compared with vaginal delivery.
Chicago hospitals have been implementing many ACOG recommendations in recent years and noting results. Doctors at 10 Chicago area-hospitals said efforts include tracking the procedures among doctors and reconsidering how staffs manage labor.
Hospitals and health experts recognize the need for C-sections if the baby or mother’s life is at risk.
C-sections are performed for a wide variety of reasons, from stalled labor to pre-eclampsia, a life-threatening pregnancy complication, said Jeanne Mahoney, who leads an effort to scale back C-sections at the Alliance for Innovation on Maternal Health (AIM), a federally funded group promoting safe maternity care.
“When they’re necessary, they’re an important operation to have,” Mahoney said. “But they are not without consequences.”
C-sections, in general, carry more risk and have a longer recovery. Women are at risk for hemorrhages, for example. The surgeries can complicate future deliveries. Scars can rupture. Doctors also fear placenta accreta, a rare condition that can cause quick, fatal blood loss.
It is impossible to know whether an individual woman who had a cesarean birth could have otherwise safely and vaginally delivered, but health experts say implementing ACOG recommendations and rethinking labor can provide a better chance for patients to avoid a C-section.
“We have seen that even in the same hospital that we have great variability between providers as far as C-section rates,” Mahoney said. “There’s no blame here. It’s really about doing the best thing for everybody.”
ACOG recommends vaginal delivery for its lower infection rates, fewer anesthetic complications and shorter hospital stays.
Reducing a common surgery is a complex challenge. Each patient is unique; each birth is dynamic. Not every hospital has the same staff or resources. Each serves a different patient population. For all these reasons, many doctors said pursuing fewer procedures must be balanced with trusting their judgment.
Susan Veazie’s mother gave birth to her through C-section. Although Veazie didn’t want one herself, she didn’t fear the procedure, she said. Still, she hoped for a natural birth. But 20 hours after arriving at the hospital and with labor stalled, the River Forest mom requested a C-section. Throughout the process, she said it helped to feel involved in conversations and the final decision.
“I really felt supported,” Veazie said. With her second child, born in April, she again hoped to deliver without surgery but had a scheduled C-section 11 days after her due date.
Three years ago, Rush University Medical Center maternal-fetal medicine specialist Dr. Ramkrishna Mehendale took a hard look at hospital numbers. Digging through data for fiscal year 2014, he found that among low-risk patients, the C-section rate was 37 percent. He examined what preceded these surgeries. How long had the patient been laboring? Did some doctors perform C-sections more than others?
“We decided to focus really on the labor management because that could make the most difference,” said Mehendale, the hospital’s Patient Safety and Quality Improvement officer for Obstetrics.
Now, doctors check a flowchart that lists centimeters dilated and hours pushed and tells them when they can consider a cesarean. It also directs doctors to first consider alternatives, like using forceps.
Streamlining these standards created a common baseline, Mehendale said. The hospital has since lowered the rate of C-sections among low-risk mothers to 24 percent.
Like Rush, other hospitals similarly track their progress in reducing C-sections.
Area hospitals including NorthShore Evanston Hospital, for example, monitor how often each physician performs C-sections, distributing an internal list by doctor within departments. Administrators hope letting physicians see how they match up with colleagues will encourage conversation.
Although using data helps, it has limits.
“I’m quite proud to say that we try not to provide unnecessary sections,” said Dr. Dimitrios Mastrogiannis, director of obstetrics services in the University of Illinois Hospital & Health Sciences System. The hospital monitors C-section data, but specialists handle high-risk cases and complicated deliveries. So there’s a limit, he said, to how low numbers can go while protecting patients.
Presence Saint Joseph Hospital, where Health Department data show the highest percentage of 2015 total C-sections at 32 percent, regularly reviews procedures, according to regional chief medical officer Dr. Joel Spear. But he noted that the hospital treats complicated cases because of its Level III Neonatal Intensive Care Unit, which offers specialized care for newborns.
Experts agree that scaling back cesareans is a difficult task. Safely reducing the procedure will require different approaches, ACOG noted.
Many hospitals are trying to target prevention at a woman’s first birth.
“I think the big thing is to be patient with labor,” said Dr. Whitney You, a maternal-fetal medicine doctor at Prentice Women’s Hospital. “My job is to think in the long term.”
In the last year, doctors delivered 12,000 babies at Prentice, the busiest birthing center in Chicago. Specialists also handle many high-risk cases. Northwestern was highlighted as one of the largest hospitals with a low C-section rate, at 17 percent of low-risk deliveries, by Consumer Reports.
To limit cesareans among low-risk, first-time moms, Northwestern does not permit cesareans for nonmedical reasons before 39 weeks. And like other hospitals in Chicago, it follows ACOG guidelines surrounding labor, which emphasize that time in labor alone should not be a reason for a C-section.
ACOG does not specify an exact number of laboring hours before or after which a C-section should or should not happen — doctors say births are so individual that such a strict standard is impossible. But being more patient during labor, while monitoring a woman’s risk factors and the baby’s condition, is something experts agree on.
“The longer you wait, the more chances that the woman has of being able to push the baby out on her own,” Mahoney said.
ACOG recommends incorporating doulas and midwives as a way to support women in labor and potentially avoid C-sections. Some hospitals employ midwives. A patient can also hire her own midwife or doula, someone trained to assist pregnant women. Because midwives do not operate, their instincts lean toward patience. When a labor is stalled, they might suggest a change in position to stave off surgery.
St. Anthony Hospital has the lowest percentage of total C-sections in the city at 14 percent.
“I think the biggest factor is our midwifery program,” said Dr. Eden Takhsh, chairman of obstetrics and gynecology, and the hospital’s chief quality officer.
Although treating a smaller population, it faced some similar challenges as bigger city hospitals. Straddling Lawndale and Little Village, patients tend to be low-income and high-risk, Takhsh said. The 14 midwives rotate, with a doctor always available in case of complications. The most complicated cases, about three to four patients a month, are sent to larger hospitals such as the University of Chicago.
Midwives were key to the September opening of the University of Chicago Medicine’s Family Birth Center in Comer Children’s Hospital, said Dr. Kenneth Nunes, obstetrician and chief of General Obstetrics and Gynecology.
Previously, he said, the hospital built a reputation for treating high-risk cases, resulting in more interventions and C-sections. It also meant some patients avoided the hospital, he said, assuming a better chance elsewhere of vaginal delivery.
“Our priority was, how do we get people back to the University of Chicago to have good, normal laboring experiences?” he said.
In 2015 he hired certified nurse midwife Erin Irwin, who leads a team of five midwives. On a recent morning just after delivering a baby — without surgery, he noted — Nunes gave a tour of the new center, where all nine labor rooms were occupied.
Ideally, Nunes said, women meet their children in one of the rooms labeled “Natural Birth” — not on an operating table. The rooms have birthing tubs, which ACOG recommends for comfort during labor, and peanut balls, popular as a support to lie on or sit in a different position.
Some hospitals in Chicago allow women to try to labor after a previous cesarean. ACOG guidelines say some women who have had a cesarean may consider delivering vaginally, depending on risk factors such as incision type and number of previous deliveries.
After her C-section, Fleischer connected with the International Cesarean Awareness Network and now co-leads its Chicago chapter. When she was pregnant with her second child, she switched to a medical practice that included midwives. She said she felt empowered by learning her options. Her midwife supported her through labor, she said, and this time, about 45 minutes after she was told to push, she delivered her daughter, now 2.
“She was on my chest right away,” she said. “It was a really powerful experience.”
Fleischer keeps a photo of when she met her first daughter, who is now 6. But she doesn’t remember those few seconds after surgery. The memory remains hazed by drugs and her distress.
“This is just another day for my OB,” she said. “But for me, this is how I became a mom.”
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