Kentucky has one of the highest Caesarean section rates in the country at nearly 40 percent, but some local mothers and the nation's obstetricians are working to change that.
"That 40 percent rate is a real problem," said Cristen Pascucci, a Lexington mom and vice-president of ImprovingBirth.org, an educational organization aimed at helping women make informed birthing decisions.
Pascucci is concerned that many doctors and hospitals focus too much on getting mothers in and out of the hospital rather than letting nature take its course with a birth, potentially creating risk for mother and child.
The concerns expressed by the volunteers at ImprovingBirth.org have recently been echoed by two national physicians groups who produced a report last month calling for a shift in how babies are born.
Kentucky is part of a national trend that has seen C-section rates increase dramatically over the last 20 years, according to the recent report by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine.
In 2011, one in three women in the United States gave birth by Caesarean delivery. That's a 60 percent increase since 1996. The induction of labor also increased to about 23 percent in 2008, compared with 9.5 percent in 1990.
"There are just too many C-sections," said Dr. Aaron Caughey, who helped write the report for the American College of Obstetricians and Gynecologists.
While Caesarean deliveries can be necessary for high-risk pregnancies, for other, low-risk, pregnancies, a Caesarean delivery may pose a greater risk to the mother, causing infections and blood clots, said Caughey.
Also, it can lead to the need for C-sections for subsequent births and requires a longer recovery time for the mother. Babies born via C-section have higher rates of respiratory problems, he said.
That trend is having a toll on mothers, said Pascucci, who got involved in ImprovingBirth.org after she felt so pressured to have what she considered an unneeded induction of labor at 41 weeks she switched doctors. Since then, she said, she has heard from hundreds of women who felt pressured to have labor induced or have a Caesarean delivery often while they are in the midst of labor.
"I talk to people all the time who say that doctors are talking to them (about decisions such as Caesarean or induction) while they are in contractions," said Sarah Wylie VanMeter, another Lexington mom who works with ImprovingBirth.org.
Pascucci blames the hospitals.
"It's a system that has perverse incentives. The fewer interventions you have, the less money you are worth" as a patient, she said.
There are other factors, Caughey said. The spike in C-sections is tied to decades-old efforts to get doctors to consider them as an option with high-risk births. More recently, he said, there is pressure on doctors to avoid lawsuits by performing C-sections.
"I've heard a lawyer say he's never heard of a doctor being sued for doing a C-section too early," he said.
Also, the rise is tied to an increase in the number of women designated as "high risk." Pregnant women who are obese or who have chronic illnesses such as hypertension are considered high risk, he said. Plus, the average age of first-time mothers is increasing, which can also increase risk, he added.
"All of those things come into play" in pushing up the number of C-sections, Caughey said
Until recently, there hasn't been any sustained effort to curtail C-sections. But the American College of Obstetricians and Gynecologists is trying to get the word out that C-sections aren't always the answer.
"Evidence now shows that labor actually progresses slower than we thought in the past, so many women might just need a little more time to labor and deliver vaginally instead of moving to a Caesarean delivery," Caughey said.
Educating doctors about this evidence can lead to a more uniform standard of when to opt for a C-section over vaginal birth, he added.
Currently, the amount of time doctors consider appropriate for "active labor" before a C-section is considered can vary from practice to practice or even doctor to doctor, he explained.
Still, reducing the number of C-sections will require a cultural shift among medical providers, he said. One of the key suggestions in the report is providing more direct support for mothers giving birth. For example, it suggests that hospitals consider some non-traditional patient support such as doulas, who are trained to offer comfort and aid to mothers before, during and after labor and delivery.
Those are efforts that ImprovingBirth.org can get behind, said Pascucci. The organization is also hoping that Kentucky hospitals and physicians will be more open about their policies for C-sections, she said. Often it can be hard to determine whether a hospital has written guidelines and what those might be, she added. Having such guidelines would help mothers make an informed choice about where they want to deliver.
'Right now," Pascucci said, "families are shopping blind when they are shopping for maternity care."
Pascucci and VanMeter encourage mothers to create a birth plan and to discuss it with their doctor; it's also helpful to have advocates on hand during labor to make sure the plan is followed, because during labor it can be tough to say no when a doctor tells a woman that she must have a C-section or induced labor in order to protect the health of her child.
Caughey said he hopes mothers, doctors and hospitals can work together to improve the C-section rates.
In some states coalitions are being formed to do just that. In Oregon, where he is based, the effort is being pushed by the state's hospital association.
Communication between patient and doctor is key to having a successful birth experience, he said. Families should start talking with their doctor early in a pregnancy about the use of induction and C-sections. If the doctor and patient aren't on the same page, they should part ways long before birth, he said.
But, it's also important for mothers to understand nature is in control when dealing with birth. The birth experience, Caughey said, can be unpredictable, and even the best-laid plans can go awry.