Thirty-nine weeks and two days into her second pregnancy, Kimberly Heiner, 35, checked into the labor and delivery unit at Morristown Medical Center, where her labor was induced. Her baby was surrounded by excess amniotic fluid and in an abnormal position—presenting brow first, with the baby’s head extending backward, instead of head first with its chin tucked to its chest, the preferred position for a safe vaginal delivery. Her doctor was concerned that if Heiner pushed, it could injure the baby’s neck.
Heiner had planned to give birth naturally, as she’d done with her first child. Instead, she learned it would be necessary to give birth via c-section, or cesarean section, a surgery that involves cutting through the wall of the mother’s abdomen and uterus to deliver a baby.
“I always had it in the back of my mind that things could happen and it would be a possibility,” says the Jefferson Township resident, “but I never thought it would happen to me.”
Cases like Heiner’s are why doctors perform c-sections: to protect the health of mother and baby during the delivery. But while cesarean birth is safer than vaginal birth in certain high-risk situations—such as when there are signs of fetal distress, a baby is in a breech (feet first) position, or when a mother develops preeclampsia—the surgery can pose risks of its own.
“Having a cesarean section is major surgery,” says Linda Schwimmer, CEO of the New Jersey Health Care Quality Institute (NJHCQI). “As with every surgery, there are complications and risks, and so you want to make sure that every c-section is necessary.”
It’s an especially pressing issue in New Jersey, where the state’s unusually high c-section rate has received scrutiny and debate in recent years. According to many organizations and physicians, New Jersey doctors perform too many—but steps are being taken to drive the number down.
Following a national trend, the total c-section rate has risen dramatically in New Jersey since 1995, when the state’s rate was 22.1 percent. The surge peaked in 2009, when 38.1 percent of all live births in New Jersey were cesarean.
Although there has been some improvement, New Jersey still has some of the highest c-section rates in the country, accounting for upwards of 40,000 surgeries each year. In 2016, the state ranked fourth in the nation, behind only Mississippi, Louisiana and Florida, with a total cesarean rate of 36.2 percent compared to the national average of 31.9 percent, according to the Centers for Disease Control and Prevention.
Similar to the total cesarean rate, the primary cesarean rate—defined as the percentage of cesarean deliveries out of all births to women who have not had a previous c-section—has also increased. In 1995, the primary c-section rate in New Jersey was 16.7 percent. By 2009, it had risen to 28.7 percent. It has been slowly falling since, but it’s still a concern. In 2016, the most recent data the state provides, the primary c-section rate was 25.2 percent.
“It’s not a good thing,” says Dr. Matthew Iammatteo of the Morristown-based Madison Avenue OB/GYN practice. “We’d like to see our rates lower, as they should be. We are certainly taking steps to move in that direction.”
The first step was acknowledging the problem. “One of the hardest [discussions] was actually owning up to the fact that there is an issue here in New Jersey with the c-section rate being high,” says Cathy Bennett, president and CEO of the New Jersey Hospital Association (NJHA).
Pinpointing what, exactly, is behind the rise in c-sections is another story. “There’s never one specific reason why the rates are high,” says Iammatteo. “It’s a multitude of reasons.”
Typical factors blamed for the higher rate include fear of malpractice suits and financial incentives for doctors and hospitals, though several doctors we spoke to deny that is the case. Other reasoning points to the fact that American women are having babies later in life, and both advanced maternal age and the use of in vitro fertilization (IVF), which has risen in recent years, can lead to high-risk pregnancies that are likelier to result in a cesarean birth. Women over 40 are more than twice as likely to deliver by cesarean than women under 20. Complications such as excessive maternal weight gain, diabetes and hypertension can also contribute to a higher probability of c-section. But these do not add up to a complete explanation.
“It’s a very complicated topic to have a global discussion about because it’s not always clear cut,” says Dr. Robert Rubino of the Rubino OB/GYN Group in West Orange.
It turns out that one of the biggest factors for whether a woman will get a c-section is not her health record or personal preferences, but what hospital she goes to. One working theory, described last year in a study published in the medical journal Obstetrics & Gynecology, suggests that a hospital’s labor team and protocols contribute to a significantly higher risk of primary cesarean delivery in low-risk patients. For example, hospitals with midwives on staff tend to have lower c-section rates.
This is evident in New Jersey, where the primary c-section rate for low-risk, first-time mothers varies widely by hospital. According to 2016 data compiled by the Washington, D.C.-based Leapfrog Group, CentraState Medical Center in Freehold, at 42.1 percent, has the highest primary c-section rate in the state—more than three times higher than CarePoint Health’s Christ Hospital in Bayonne, with the lowest rate of 14 percent. Other hospitals with above state average c-sections rates include Hackensack University Medical Center (41 percent); Jersey Shore University Medical Center (39.3 percent); and Robert Wood Johnson University Hospital (38.6 percent). Notably, unlike some smaller, local hospitals, all three have Neonatal Intensive Care Units, or NICUs, and receive transfer patients with high-risk deliveries, which have a higher likelihood of resulting in a c-section. [Editor’s note: Since the deadline for this story, more recent data has been made available through the Leapfrog Group 2018 survey, which indicates decreasing primary c-section rates for low-risk, first-time mothers at CentraState Medical Centre in Freehold (new rate 39.4 percent); Hackensack University Medical Center (34 percent); Jersey Shore University Medical Center (30.7 percent); and Robert Wood Johnson University Hospital (29 percent).]
So what’s the right rate? The answer remains unclear.
“One may argue that 100-plus years ago we didn’t do enough c-sections,” says Rubino. “You don’t want to be too low, because then you’re going to see complications from prolonged childbirth, such as hemorrhage, infection, or babies being born with brain damage or shoulder dystocia.”
Yet unwarranted cesarean births come with risks, too, including conditions mothers wouldn’t have otherwise been exposed to, such as uterine rupture, pulmonary embolisms and cardiac events, as well as a longer recovery time after giving birth. Mothers who deliver via c-section can expect to stay in the hospital three to four days after the delivery, and longer if there are complications.
Standards for the ideal rate vary. The World Health Organization has suggested no more than 15 percent. Objectives defined by Healthy People 2020, a federal project launched in 2010 to improve the health of Americans, suggest a goal of 23.9 percent among low-risk women.
Earlier this year, NJHA and the N.J. Department of Health launched a statewide initiative to reduce unnecessary primary cesarean sections as part of the New Jersey Perinatal Quality Collaborative. The goal is to achieve a 10 percent reduction in New Jersey’s c-section rate among low-risk pregnancies by January 2020.
“It’s a very aggressive goal,” says NJHA’s Bennett, “and it’s one that only happens if we get everyone working together collaboratively on this.”
All 49 birthing hospitals in the state have committed to the program, which includes adopting evidence-based best practices such as increased education for nurses and staff on how to support mothers in labor; the integration of trained labor coaches, called doulas, into the birth-care team; more education and guidance for parents about what to expect during delivery; and counseling for women about the benefits of riding out the early part of labor at home.
NJHA’s program is specifically targeting unnecessary primary c-sections. The thinking: If you can change the trajectory of the women having first-time cesareans, you can increase their likelihood of delivering vaginally in future pregnancies.
“Once a woman has a cesarean birth, there’s a 90 percent likelihood thereafter that all her births will be cesarean births,” says NJHCQI’s Schwimmer. “We want to give women all possible chance of having a vaginal birth, and the potential of avoiding a surgery.”
Efforts to reduce the total cesarean rate include doctors offering the option of a VBAC (Vaginal Birth After Cesarean) to women who have previously delivered by c-section. After a brief surge in the late 1990s and early 2000s, VBACs have become less common—around 2,000 out of more than 100,000 births in New Jersey in 2016 were VBACs. With a 60 to 80 percent success rate, there are no guarantees, and VBACs come with their own risks, like uterine rupture. But in recent years, more obstetricians are recommending and encouraging their patients who are good candidates to attempt a VBAC.
“If you don’t have to do a cesarean, don’t do it,” says Dr. Lidia Vitale, a partner at Advanced Obstetrics and Gynecology in Flemington. “If patients are properly selected [for a VBAC], we can see great outcomes.”
Reducing c-section rates in New Jersey is still a work in progress, but it’s promising that various organizations, physicians and hospitals are making a collaborative effort.
“We all play a role in promoting a successful pregnancy and making sure that, where appropriate, we have a vaginal delivery,” says Bennett. “We’ve got to encourage everyone to sign on, to engage and to take ownership to help drive down the c-section rate.”
Under the NJHA initiative, it is recommended that every hospital have a team working to try to reduce their c-section rates. At Morristown Medical Center, Iammatteo serves as chairman of the care-review committee, and oversees the efforts being made to lower the hospital’s c-section rates. “We want to be consistent with the national average, and to even go below the national average if we can,” says Iammatteo. “We’re all working together as a department and as a team to do what we can to help each other.”
Of course, at no point do those efforts cancel c-sections that are medically necessary. “Once you even suspect that a baby is in any kind of jeopardy, you don’t even look at your cesarean section rate,” says Iammatteo, “because all you care about is a good baby and a good mother.”