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Giving moms-to-be control of birthing process

After giving birth to her second child by cesarean section in 2010 at Newport Beach's Hoag Hospital, Kimberlee Streiff felt something wasn't right.

She and baby Rhone, now a curly-headed 3-year-old, were fine; it was the process, and her sense that the birth was out of her hands, that had unsettled her.

Streiff, whose oldest son was also born by cesarean, had hoped to attempt a vaginal birth after C-section, or VBAC, she said.

But when her labor didn't progress fast enough, her doctor quickly ushered her into surgery.

"There's so much focus on this worst-case scenario," the trim West Newport mom said recently. "It creates the impression that doctors are more worried about their liability and their schedule than they are about reaching the best possible outcome."

Now, doctors are sifting through mountains of data in search of ways to avoid unnecessary C-sections, which during the last several decades had become a reliable — though much less desirable — default for women and doctors facing birthing complications.

Last month, the American College of Obstetrician-Gynecologists released new guidelines recommending that women be allowed to stay in the early stages of labor for longer before they're diverted into surgery, a move aimed at curbing rising C-section rates.

According to an ACOG statement related to the new findings, a 60% increase in C-sections between 1996 and 2011 raised "significant concern that cesarean delivery is overused without clear evidence" that it's better for moms or babies in most situations.

At Hoag, where C-section rates had climbed almost 10% higher than the national average, leaders of the hospital's obstetrics unit are working to rein in the practice by stepping up data analysis and patient education.

The result, they say, has been a shift from the type of prescribed childbirth, which has frustrated women like Streiff, to a model of care that factors in safety, but gives moms the tools they need to decide what kind of birth fits them best.

"We just have more evidence available to us," said Dr. Allyson Brooks, executive medical director of the Hoag Women's Health Institute. "Women need to have a variety of options available to them, and that's where the data helps."

Experts say that ability to track even minute differences among patient outcomes and standardize recommended practices paradoxically lets doctors present women with a more personalized picture of risks involved with various birthing options.

And being able to weigh those risks for themselves, in turn, helps moms-to-be feel more in control.

"We need to be consistent among ourselves about how we're describing and assessing the baby," said Dr. Jeanne A. Conry, ACOG's president. "Standardization actually improves our communication between ourselves and our patients."

Dr. Patrick D. Roth, who heads Kaiser Permanente's obstetrics practice in Orange County, added that the Joint Commission, a group that accredits hospitals, has started closely tracking C-section rates through data that's publicly reported and shared among institutions quarterly.

"This is new," he said. "That's a much bigger incentive for hospitals to curtail their C-section rates."

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Vaginal births are preferable

Experts have always recommended natural childbirth whenever possible. It's healthier for the baby, for one thing, and because C-sections are major surgery, they typically require a longer, more expensive in-hospital recovery period than natural births.

But starting about 40 years ago, C-sections — easy to pencil in for doctors and emergency staff and less likely to result in potentially life-threatening complications, such as uterine rupture — steadily gained ground. Surgical births became common practice, even in cases when they were not medically necessary.

In 1970, C-sections accounted for about 5% of births nationwide. By 2007, that number had jumped to more than 31%. Variations among hospitals have been attributed to a litany of factors, including that hospitals stand to make more money by steering women toward surgical births, though direct causes of a particular facility's higher-than-average C-section rate can be tough to pin down.

For example, Northern California hospitals, by and large, have lower C-section rates than hospitals in Southern California, Conry said.

That regional difference holds true among both nonprofit and for-profit hospitals, even while a Center for Investigative Reporting analysis found that women giving birth at for-profit hospitals are much more likely to do so by cesarean, no matter where in California they live.

"There's more variation than we should see," Conry said. "Why? There are patterns that [financial factors] can't explain."

Roth said it could be a societal thing. Sometimes patients are concerned about longer-term effects of labor, such as bladder or sexual problems sometimes associated with vaginal births.

"We occasionally have a woman who just comes in and says, 'I don't want to labor,'" he said. "We really do everything we can to encourage women that natural childbirth is the best."

At Hoag, which serves a wealthy community where women often take time to pursue education or develop careers before starting their families, new moms tend to be older — a potential "risk factor" for C-sections.

That means that they may come into the birthing process with worries about trying to give birth vaginally — and doctors may have been too quick to recommend surgery, rather than carefully monitor a longer delivery. That, coupled with a larger number of births by women who have given birth surgically before, can contribute to a higher C-section rate.

But as a state-of-the-art facility— where patients can give birth in a private suite with a serene harbor view — Hoag likely has a greater capacity than, say, a more rural hospital in a lower-income neighborhood to deal with unexpected complications during labor.

Ultimately, Brooks said, the hospital is finding answers in numbers.

"Each hospital has its own culture and things that contribute to its C-section rate," Brooks said. "What we found was we were able to share the data with the physicians and create a climate of continuous improvement."

To that end, Hoag joined the California Maternal Quality Care Collaborative in late 2012, which looks at "hot topics" in obstetrics using real-time data from hospitals around the state.

Brooks credited that move with helping her doctors see beyond their "personal preferences," and fears of liability, should something go wrong.

Hoag has also implemented of a 24-hour laborist program, and has added extra steps into its elective C-section and inducement scheduling process to help ensure that expectant mothers are well-informed of the risks and benefits of those procedures.

And a "VBAC success calculator" is available to moms who have previously given birth by C-section.

Those efforts contributed to a drop in Hoag's C-section rate, from 39.7% in 2012 to 37.3% in 2013, Brooks wrote in an email. Cesareans among first-time mothers at the hospital, meanwhile, dropped from 31.5% in 2012 to 24.3% in 2013.

Brooks said that the hospital hopes to continue the downward trend. More importantly, though, the hospital wants to see the healthiest possible deliveries — whatever that might entail.

"There's not a one-size-fits-all," she said.

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What drove up C-section rates?

One factor in rising C-section rates, doctors have found in recent years, was a low percentage of vaginal births after a first, or even second, cesarean delivery.

Kaiser Permanente's Roth said VBACs have fallen in and out of favor with the medical community over the years, but are now firmly considered preferable for many healthy patients.

"VBACs have kind of come full circle," he said. "Actually, like twice."

He said that in the 1980s and 1990s, doctors were "really going gung-ho with the VBACs," and the national rate climbed to about more than a quarter of births to moms who had already had cesareans.

Then, horror stories about incidents of uterine rupture, hemorrhaging or even maternal death emerged, which put doctors on edge about liability for VBACs gone wrong and left moms asking for C-sections.

With the advent of detailed fetal monitoring, though, the actual risks of such complications for most women are rendered almost insignificant.

"I honestly didn't know much about VBACs, because you don't hear a lot about it," said Megan Rosenberry, a Huntington Beach resident who delivered a daughter at Hoag in November. "Everyone assumes if you've had one C-section, it's what you're going to do next time,"

In 2010, ACOG loosened recommended restrictions on allowing women who had given birth by cesarean to try to give birth vaginally, finding that with proper planning and emergency help on-hand, the practice is safe.

At Hoag, Dr. Jeffrey Illeck has made educating women about the VBAC process a kind of personal crusade.

"When he talked to me about the VBAC, I was like, 'Oh, I can do that?' " said Dianne Mayne, who gave birth to a son in December at age 35, after delivering by emergency C-section about two years before.

This time, the Tustin resident said, "I actually had a really good experience, though I would have to put credit toward, you know, the drugs," referring to an epidural.

She let out a hearty laugh.

"I was in labor for 12 or 13 hours, and I didn't really feel a thing," Mayne said.

Illeck said that Hoag has a bit of a reputation for having a high C-section rate, which is one of many reasons he stresses to his patients that, even in a hospital setting, moms have choices.

Plus, he said, there's no need to rush.

"When I was trained, the typical labor curve was different from what we're looking at now," he said. "We're giving Mom more time."

"[Brooks] calls me the VBAC King," Illeck joked.

Illeck, who's worked at Hoag since the mid-1990s, said he's seen the rising tide of C-sections — and has noticed the growing backlash, with some women foregoing hospital births altogether in favor of home births or birthing centers.

And just as detailed data has become a resource for hospitals, it's also made their processes more transparent.

Streiff said that, for her, an informed approach made all the difference.

Before having her first baby in 2008, Streiff — at the time a bi-coastal mergers and acquisitions attorney — had looked at childbirth as one more task to tackle. She said she hadn't given much thought to the importance of a natural delivery.

"I thought, 'Women have been doing this for thousands of years. How hard can it be?'" she recalled with a wry laugh.

Two C-sections later, and pregnant with her third child, she decided she wanted something different: a natural birth.

A friend pointed her in Illeck's direction.

"I almost fell off the table when he said these words: It's up to you," she said.

In October, Streiff, then 39, gave birth to Elize Lorraine. No epidural, no surgery — though she did have a doula.

"Not to take anything away from my two sons, but it's so far above and beyond to catch that baby and immediately bring that baby to your chest," she said. "It's as close as you get to just you and your child.

"Don't be afraid to go for that."

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