C-section numbers are up on OBX. But why?

NAGS HEAD, N.C.

Amanda Finchem had planned a natural birth - no drugs or interventions - with her first child, but after a long labor she said she was diagnosed with "failure to progress" and underwent a cesarean section at The Outer Banks Hospital. She said it has gnawed at her ever since.

"I just wasn't sure it was necessary," she said.

Finchem, who leads the Outer Banks chapter of the nonprofit International Cesarean Awareness Network, said the procedure has become too common.

At the network's urging, Gov. Beverly Perdue proclaimed April Cesarean Awareness Month" to bring attention to unnecessary use of the major abdominal surgery, which involves cutting into the abdomen and uterus to deliver a baby.

When Finchem gave birth in 2004, the hospital's C-section rate was 36.1 percent and the statewide rate was 28.8 percent, according to the state Division of Public Health. By 2008, the hospital's C-section rate was 40.4 percent - the highest in the state. North Carolina's rate that year was 31.3 percent, and the national rate had climbed to 32.3 percent.

The Centers for Disease Control and Prevention report that C-sections in North Carolina increased 45 percent between 1996 and 2007, from 21.1 percent to 30.7 percent. New Jersey had the highest rate in the nation, 38.3 percent, and Utah had the lowest, 22.2 percent. The World Health Organization recommends that the C-section rate be about 12 percent.

The Outer Banks Hospital has eight obstetrical physicians with privileges on staff - three of them full-time. Van Smith, president of the hospital, said it has no policies on C-sections. "The physicians and the patients are the ones who make that decision. "

Smith said that the hospital's rate is one of the highest in the state mostly because of its location. Also, it has no neo-natal unit, he said, which makes a doctor less likely to chance a potential problem with a delivery.

"We are one of the smallest hospitals in one of the most remote areas of the state," he said. "If there's an abnormal indicator for the mother or the child, often a C-section is less risky."

Smith cited a survey that placed the hospital's birth-unit patient satisfaction in 2009 in the top 10 percent of the 183 hospitals surveyed by an outside market research group.

Eugene Declercq, a professor of community health sciences at the Boston University School of Public Health, attributes the steady rise in the use of C-sections to "practice changes" by medical providers who plan for the worst-case scenario rather than the more likely normal birth.

Declercq said that very few women schedule C-sections simply for their convenience. It is more common, he said, that women are not provided with information about other options or the potential harm from the surgery.

C-sections can be a life-saving operation, he said, and doctors may prefer them because they can be more efficient and predictable than vaginal births. They are also less likely to expose doctors to malpractice lawsuits.

But a C-section can make nursing and caring for the baby more difficult and cause post-surgical complications. It is also at least twice as expensive as a vaginal birth, Declercq said.

"Part of the challenge here is there are a lot of clinicians who are not at all bothered by this," he said. Even insurance companies, he said, are not complaining. But consumers are getting louder. "Now that we're talking about one out of every three, people are getting more alarmed about it."

Critics of C-sections say routine obstetrical practices such as induction of labor; lack of labor support from midwives; use of movement-restricting monitoring equipment; an unwillingness to let normal labor continue beyond a set parameter; and fear of malpractice lawsuits can all lead to a decision to section. Many doctors also do not allow vaginal births after a previous C-section, because of a small risk of uterine rupture, according to the National Institutes of Health.

At an NIH conference in March on the low national rate - 10 percent - of vaginal birth after cesarean, or VBAC, medical experts urged practitioners to reassess guidelines that have discouraged such births.

Finchem said that the goal of the International Cesarean Awareness Network is to help prevent unnecessary C-sections through a combination of education and support. The local chapter, with six members, has been meeting for about a year, she said.

Brandi Miss, a massage therapist and certified doula - someone who provides nonmedical support before, during and after birth - said she plans to open a nonprofit educational and support center in Nags Head for expectant and new parents. Miss said she has been hired to serve as a doula during a birth at The Outer Banks Hospital in July. It will offer a doula training course in September.

She said some pregnant women on the barrier islands have chosen to give birth in Elizabeth City or Virginia rather than give birth where the C-section rate is so high and no nurse-midwives or certified professional midwives are available. And there is no longer a birthing center on the Outer Banks.

"We're really the only culture where women birth alone," Miss said. "In this country, because we're so medicalized and industrialized, we've really taken out that 'miracle of life' part."

Catherine Kozak, (252) 441-1711, cate.kozak@pilotonline.com