PAULINE PELLEGRINO was expecting a big baby.
Ms. Pellegrino, a 37-year-old Leonia resident, said her doctor had estimated that her baby would weigh about 9 pounds. It was the day before Ms. Pellegrino's due date, and the baby showed no sign of being born soon. Big babies can often mean difficult deliveries and possible injury to both mother and child, so her doctor decided to try to induce labor with the drug Pitocin. It wasn't effective, so the dosage was increased, but then the baby's heartbeat became irregular; Ms. Pellegrino was then wheeled into the Englewood Hospital operating room for a swift Caesarean section. Her daughter weighed a normal 7 pounds 10 ounces.
Another day, another C-section in New Jersey.
New Jersey had the highest rate of C-sections in the country in 2003, 33.1 percent, according to recent preliminary data from the National Center for Health Statistics in Hyattsville, Md. The national rate is 27.6 percent, up 6 percent from 2002. While a few other states have rates of more than 30 percent, others, like Minnesota and Wisconsin, are in the low 20's. Nationally, the C-section rate has been growing since 1996, when they accounted for just 20.7 percent of all births.
New Jersey exemplifies many of the reasons C-sections are on the rise: the state has a large population of older mothers, and those women tend to have more risk factors during pregnancy, which leads to more C-sections. And with a vaginal birth, there is risk of damage to the muscles of the pelvic floor, which can lead to incontinence. There is also the growing number of women who opt for C-sections for the sake of convenience. And then there is the skyrocketing cost of malpractice liability insurance for obstetricians; many doctors fear being sued over the complications that can arise during vaginal childbirth and tend to recommend C-sections more quickly than in the past.
Birth rates for women over 30 are rising nationwide. New Jersey, however, ranks third in the rate of births to women over 35, according to government data for 2002. Older women are more likely to suffer from pregnancy-related hypertension or diabetes and to have problems during labor. They are also more likely to have multiple births because of fertility treatments. All those factors often lead to the operating table.
And once a woman has a C-section, she is more likely to need one for future deliveries. Attempting a vaginal birth after one Caesarean may cause a uterine rupture and subsequent brain damage to the baby, though the risk is small. The American College of Obstetricians and Gynecologists advises that such a vaginal birth be tried only when a doctor and anesthesiologist are available to offer emergency care. That's a standard difficult for many smaller hospitals to meet. Hundreds of hospitals throughout the country have even banned such attempts at a vaginal birth.
The threat of a malpractice suit weighs particularly heavy on a New Jersey obstetrician deciding whether to recommend a C-section. Annual malpractice insurance rates for the state's obstetricians -- ranging generally from $92,000 to $128,000 a year -- are among the highest in the nation. And just one claim, settled or not, can almost double a premium. Obstetricians are sued more often than any other type of doctor.
C-sections do reduce the risk of unexpected stillbirths and birth complications for the baby like injuries and neurological impairment, all leading reasons for obstetrics claims. But more women still die during C-sections than during vaginal births. According to a study published by Obstetrics and Gynecology in August 2003, the risk of maternal deaths with a C-section birth was 35.9 per 100,000 live births and 9.2 per 100,000 by vaginal birth. Fetal monitoring has become more sophisticated, yet any questionable situation that precedes a less-than-perfect outcome -- even a slightly abnormal heartbeat -- is grounds for a lawsuit. As one obstetrical saying goes, "You never regret the C-sections you've done, only the ones you haven't."
"Because of a threat of professional liability, doctors are under the gun so much they're more apt to do a Caesarean section, even an elective one, if the patient wants it, after presenting the pros and cons," said Dr. Thomas F. Purdon, a recent past president of the college of obstetricians.
A vaginal birth is still generally safer, Dr. Purdon said, as did all the doctors interviewed for this article. But even one negative court judgment can boost insurance premiums so high that a doctor is forced to stop practicing, or to drop the "ob" from his or her ob-gyn shingle. In fact, almost 23 percent of ob-gyns working in New Jersey stopped doing obstetrics between 1999 and 2003 because of the threat of lawsuits, according to a recent survey by the college of obstetricians. Dr. Francine Sinofsky, president of the New Jersey Obstetrical and Gynecological Society, estimates that the number is now closer to 40 percent, including doctors who have moved out of state. The college of obstetricians has designated New Jersey 1 of 15 states where the cost of liability insurance threatens the availability of doctors to deliver babies.
More women are simply choosing to have C-sections, too. A study published in The British Medical Journal in November showed the rate of C-sections for no indicated medical reason rose by 67 percent between 1991 and 2001 in the United States. In a 2003 survey, Health Grades, a Lakewood, Colo., health care research company, found an increase of 20 percent in such operations from 1999 through 2001. New Jersey had the third-highest rate.
Mothers over 35 are more likely to have planned C-sections, the Health Grades study reported, possibly because they want more control over the birth process. More women are also being induced to labor now, sometimes to accommodate their own or doctors' schedules; inducing itself increases the possibility of a C-section. But a scheduled delivery has the benefit of preparation.
"I begged for a C-section with my twins," said Liz Newell, of Ridgewood, whose doctor eventually recommended a C-section for medical reasons. "With another child already at home, at least I could plan for the day."
Dr. Ruth Schulze, an ob-gyn practicing in Ridgewood and secretary of the Medical Society of New Jersey, said: "There are some very educated women who put forth their agenda. And if you can say you've appropriately counseled the person and they're requesting something, you had better do it. Because if you don't do that and you have a complication, you're going to come back and sue me."
Though doctors still debate it, an opinion from the college of obstetricians' ethics committee states that an elective C-section is medically ethical, provided that the patient wants it and the doctor feels it is in her best interest. But potential complications are grave. A Caesarean can cause infection, hemorrhaging and deep-vein blood clots. It carries a higher risk of death for the mother, and can lead to placental problems that can cause major bleeding or premature delivery in future births. Babies born by C-section are more likely to suffer from respiratory distress and need oxygen therapy, and a German study published this year indicated that children born by C-section are twice as likely to develop food allergies. And it takes six to eight weeks for the mother to recover from what is, after all, major abdominal surgery.
"It was really months before I felt normal again," said Elisha Charles, of Bloomingdale, who had a C-section with her first daughter. "I couldn't wear pants that put any pressure on my midsection."
Many advocates of vaginal birth say it is a meaningful rite of passage that's psychologically better for the mother. A range of studies show that women are more likely to have a negative perception of their delivery with either an elective or emergency C-section. Ms. Charles had a vaginal birth for her second baby, and said she preferred that experience.
The C-section "was more a matter of being robbed of the whole experience of giving birth," she said. "You kind of feel like your baby is taken."
Debra Pascali-Bonaro, founder and president of MotherLove, which is based in River Vale, said: "Giving birth naturally empowers women. You're going through this range of emotions, and at the moment you give birth these elevated oxytocin levels and endorphins give you this sense of euphoria and well-being and actually facilitate the bonding that needs to take place between mother and baby." Her company trains doulas, birth coaches who offer continuous emotional support as well as massage, counseling, therapeutic touch and postpartum help.
Yet outside of home birth, the state has no options for delivering in a nonmedical setting. The last independent birth center, the Childbirth Center in Englewood, can no longer accommodate on-site births because malpractice insurance became unaffordable, even without a single claim, said Lonnie Morris, the director of the center.
Hospitals are filling a small part of the gap with natural birth aids. Pascack Valley Hospital in Westwood is constructing a new building, set to open this spring, that will included an expanded area for its Childbirth and Women's Wellness Center. The center has a self-described holistic environment for births, including a labor tub, and its staff includes certified nurse-midwives. Hackettstown Community Hospital's Childbirth Family Center began offering water births in 2000. Valley Hospital in Ridgewood has started a doula training program and encourages their participation in births, which studies show can lower the C-section rate by 10 to 15 percent.
"We wanted to be the compromise between the natural childbirth option and the high C-section rate," said Cindy Ferestien, the center's coordinator of parent education.
These efforts, though, will probably have little impact on the state's C-section rate, which will keep rising, doctors say. "As far back as I can track, the rates nationally have been going up, so maybe New Jersey is ahead of the curve," said Dr. Paul Stumpf, director of reproductive endocrinology at Newark Beth Israel Medical Center and the college of obstetricians New Jersey section chairman. "At some point in time, it's got no further to go."