C-sections could put mother and child at risk

I recently saw a 4-year-old obese boy at St. Christopher's Hospital for Children in North Philadelphia for an asthma follow-up. He was born via C-section because of non-reassuring fetal heart tones, a marker of potential fetal distress.

Could his obesity and asthma be related to the method of his birth? Possibly.

In 1965, the C-section rate in the United States was 4.5 percent. In the late 1990s, when I was in medical school watching deliveries, the rate had soared to 23 percent.

Today the C-section rate in the U.S. is 33 percent of births - 1.3 million children.

Of course, C-sections can be lifesaving. But the World Health Organization estimates that C-sections should involve just 10 percent to 15 percent of all pregnancies. This means up to 800,000 are unwarranted C-sections.

Recent statistics also point to alarming variations in C-section rates among hospitals and even among providers in the same hospital.

A recent 2014 Consumer Reports article found that rates of low-risk C-sections, in hospitals a few miles apart, may be worlds apart.

In Los Angeles Community Hospital, which serves a low-income population, nonemergency C-section rates are 55 percent. In California Hospital Medical Center, 5.3 miles away, the rate is 15 percent.

The demographics of women who have a C-section also show some disturbing trends. If you are African American, you have a 3 percent higher chance of having a C-section, at 35.5 percent.

If you are a single mother, C-section rates are even higher.

Do these mothers have more indications for C-sections, or does it have more to do with disparities in care? Research has shown both to be true.

Once you have a C-section, you have a 90 percent chance of having a repeat procedure with later pregnancies and increasing risks to both mother and children, even though most of those births could happen vaginally. Many hospitals make it hard for women to have a vaginal birth after a cesarean, despite high rates of success when it is supported.

Responding to the rise in C-sections, the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine announced new guidelines in March 2014.

They noted "significant concern that cesarean delivery is overused," and said providers should have more patience with labor.

The risks to the mother of having a C-section include blood clots, pulmonary embolisms, infection, emergency hysterectomies, postpartum depression, and a major rise in maternal mortality. Preventable and unnecessary C-sections cost over $5 billion a year in the United States.

The immediate risks to the infant include more admissions to the neonatal intensive care unit, more respiratory emergencies, and less breast-feeding.

C-sections bypass the physiological process of labor, limiting the baby's exposure to positive labor-related hormones. The infant also misses exposure to vaginal flora when it does not make the trip through the birth canal. New studies have shown the importance of labor to infants' long-term health.

A mammoth study in the journalPediatrics looked over a 35-year period between 1977 and 2012 in Denmark, at almost two million children born during that time. Results confirmed past work and found an association that children born via C-section had a 20 percent higher risk of asthma; 11 percent higher risk of connective tissue diseases such as lupus; 10 percent increased risk of juvenile arthritis; and 20 percent higher risk of inflammatory bowel disease.

This study also showed that children born via C-section were 46 percent more likely to develop an immune deficiency and 17 percent more likely to develop leukemia.

With all this information, how does one ensure an optimal outcome for mothers and newborns?

Parents should become familiar with the spectrum of birth options available, combined with optimal prenatal care by either a midwife or obstetrician. Options range from home births to birthing suites and a hospital birth.

Choose your provider carefully. It's good to know the C-section rates of your doctor, midwife, and hospital. Find out your provider's philosophy on supporting vaginal births if you already had a C-section.

Watch your weight and stay fit. Both will reduce the possibility of having a C-section.

Get support during labor. Consider hiring a doula, a trained birth assistant who can provide physical and emotional support throughout labor and delivery. Research shows that women who have continuous support from someone who is not a friend, family member, or a hospital staff member have a 28 percent lower chance of C-section and shorter labors. Ask the insurer if it will cover doula and midwife care.

Know local resources that support and empower pregnant and parenting families such as the Nurse Family Partnership, the MOMobile, or the Healthy Start Program. Identify informed family members or friends to be your pregnancy advocate.

Ignore the clock. The new expert guidelines call for allowing more time in each phase of labor and delivery. In general, decisions to intervene should be based on how well mothers and babies are doing, not how much time has passed.

Reverse the clock. Reverse decades of escalating C-section rates. Get back to the beauty of childbirth.