- Associated Press - Sunday, September 7, 2014

MOUNTAIN HOME, Ark. (AP) - Vicki Southard accompanied her husband to Bamberg, Germany, where he was stationed with the U.S. military in 1994. Southard was pregnant with their first baby, a son, who “by God’s grace and a very heavy nurse” is alive today after a traumatic birth in a strange country.

Southard, who was 22 at the time, had been pushing in labor for three hours, The Baxter Bulletin reported (https://bit.ly/1w1fjHA ). She was under the care of a German doctor, who did not order a cesarean delivery until it was too late.

Her son was stuck on an inverted pelvic bone. The doctor lost his heartbeat and proclaimed the baby dead. Southard’s heart was ready to give out as a medical team gathered the tools to “cut him into pieces.”

That’s when the nurse stepped in. She strapped herself down and looked Southard in the eye for one last try.

“Next contraction, push,” she said. “Don’t breathe, just push.”



With two broken clavicles and nonstop bleeding, the baby came out - and he was alive.

“They waited too long,” Southard said. “I almost lost my life, and they almost hacked my son up to get him unstuck.”

Southard walked away with Posttraumatic Stress Disorder and was on medication for 9 months to help cope with the horrifying memory.

Had she been in the U.S. for the birth, this event, almost turned tragic, may not have occurred.

When Southard returned to Arkansas, she had three more babies - two healthy, born through an opted cesarean section, and one came naturally, but was premature and lost at 19 weeks.

Not all mothers, though, initially want a C-section during birth.

Hilary Garrison, 23, recalls feeling devastated when she found out her firstborn daughter was in breech position and required a C-section.

“With my first daughter, I had a really rough time. I did not want a C-section,” Garrison said. “It threw me into postpartum even before I had her. I didn’t want a C-section, I didn’t want surgery. I wanted to be able to deliver her naturally, because here you’re stripped of so much.”

But when Garrison was expecting her second child in July, she scheduled her second C-section. Knowing what to expect, she decided it would be the safest route of delivery.

Since the 1990s, cesarean section delivery has become a more common procedure in U.S. hospitals - much more common than countries in Europe or Asia. In the U.S., C-section rates have increased nearly 60 percent since 1996. The most recent figure from the Centers for Disease Control and Prevention cites a 32.8 percent C-section rate for the nation.

There is no singular explanation for the rise, but some health care professionals argue the rate is too high and worry that this procedure, which can be lifesaving in cases like Southard’s, may be overused in low-risk, first-time pregnancies.

In Arkansas, the rate is higher than the national average. The Department of Health cites an overall C-section rate of 35.3 percent for Arkansas in 2012. Baxter County data shows an even higher rate than the state at 45.9 percent for 2012.

Overall rates have always been publicly available through the Department of Health, but in 2012, health care officials began paying close attention to a subset of data: Primary C-section rates.

“A primary C-section rate is the first time C-section rate,” Arkansas Medicaid Director Dr. William Golden said.

This includes first-time mothers and mothers who had a C-section after having a vaginal birth after a C-section.

In an effort to safely lower rates, Arkansas Medicaid and Department of Human Services came up with an idea to use its Inpatient Quality Incentive program for hospitals to decrease the number of patients needing a second C-section by avoiding the first C-section. The idea is to reduce preventable C-sections in first-time, low-risk pregnancies, or the “nulliparous, term, singleton, vertex patient population,” and to encourage natural or vaginal births.

In an article co-authored by Golden, vaginal births tend to be healthier for the baby’s immune system.

“Once you have a C-section in Arkansas, you tend to get them going forward,” Golden said. “That’s why we’re targeting the first-time C-section, because any subsequent pregnancies, increasingly, doctors are reluctant to allow you to have a vaginal birth.”

According to the Department of Health, financial benefits are involved as well.

“C-section deliveries cost more than a natural delivery,” spokeswoman Kerry Krell said. “There’s also risks involved, so from the health care savings standpoint, it’s much more beneficial to have a natural birth than a C-section birth.”

As part of the IQI program, Baxter Regional Medical Center reported its data to the state, specifically focused on Medicaid deliveries. Medicaid funds roughly two-thirds of births in Arkansas.

In one year, the health center saw a significant increase in its C-section rate for first-time, low-risk mothers. In 2012, it had a 23 percent rate, and in 2013, it was at 40 percent.

For this specific subset, the state’s goal is 24 percent.

“Twenty-four percent as a state goal for that program is actually pretty reasonable,” Golden said. “The state average, a year ago, was 28 percent. For whatever reason, the hospital in your area went from 23 percent, which would be an OK rate, to 40 percent last year.”

Though the hospital’s rates are higher than the state average in overall and primary C-sections, it raises no concern in health care quality or patient safety.

The hospital receives quality and patient safety measures from the American Data Network, which allows for a comparison between Baxter Regional Medical Center and other hospitals. Tammy Penka, who works with Quality Assessment and Improvement for Baxter Regional Medical Center, says the hospital is within where it wants to be.

“What we see currently is that we’re within 1 to 2 percent of how the state of Arkansas is doing, in general, on average,” Penka said. “We haven’t seen internally a big spike in the data that would cause concern for us.”

Some mothers, like Kassie Green, on the other hand, find the rates from the state to be alarming.

“If I had known the C-section rates were that high, I would have gone to a birthing center, whose rates are considerably lower,” Green said.

Green, 25, and her husband were curious about C-section rates after having their first daughter, who was delivered via C-section. Green says she had a good pregnancy experience until she reached 39 weeks. She hoped to have a vaginal birth, but ended up having a C-section at Baxter Regional Medical Center.

“At that point, I developed a mild case of preeclampsia. I had one high blood pressure reading and a little bit of protein in my urine,” Green said. “I understand doctors have to take precaution, but I felt very pressured into being induced.

“I saw the doctor and was scheduled two days later. I even asked if he could wait a few more days to induce, but he said I might have seizures or worse. I left the office very upset. I was induced at 4 a.m. and progressed to a 7 (centimeters), then stayed at a 7 up until the C-section. I truly believe my body was not ready.”

Around 12 hours later, Green’s doctor told her she was not progressing and ordered a C-section.

“There was no encouragement and absolutely no risks given about what could happen if I had a C-section,” Green added.

Green said she consented to having the procedure after she learned from her doctor that she needed to make a decision before the anesthesiologist left for the night. After the surgery, her newborn turned out healthy, other than having a high respiratory rate.

“The most important thing is that she is here and healthy,” Green said. “It’s easy to be upset about the experience I had getting her here, but in the end, I am so glad she is here.”

Green’s doctor labeled the pregnancy as one that was failing to progress. According to the American College of Obstetricians and Gynecologists, this is one common reason why unplanned C-sections occur.

Dr. Harley Barrow, a gynecologist at Baxter Regional Medical Center, estimates he has delivered 3,000 babies in his career. He looks for medical indicators that call for the surgery to be done.

“If a patient is going through labor, things are looking good, the baby is looking reassuring, but they’re only getting to 5 or 6 centimeters and don’t change for two, three, four hours, then obviously there’s a point at which we decide that the baby’s head is not fitting as it should, and you give it some time because a baby has a capability of molding and shaping,” Barrow said. “But in many cases with those efforts, and with an adequate evidence of labor, if they don’t progress, that would be another reason for C-section.”

From Golden’s research for Arkansas Medicaid, preventable C-sections happen for other reasons. When first-time mothers have their labor induced, it can double the chance of having a C-section.

Ultimately, when it comes time to make a decision, Barrow says it’s about the well-being of the patient and the baby. An unhealthy baby, from his experience, can be “catastrophic.”

“We have to guide our patients, but we don’t want to manipulate our patients, and we don’t want to be paternal with our patients,” he said. “We want to educate our patients and make a decision as a team - the patient and me.”

To see complete birth data for all 75 counties in the state, visit the Arkansas Department of Health website.

___

Information from: The Baxter Bulletin, https://www.baxterbulletin.com

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