Melissa Petrus always knew she wanted a big family, so when she became pregnant with her first child, she was determined to do all she could to have a vaginal delivery.
She said she knew that having a cesarean section the first time was likely to mean having another one in a future delivery. And C-sections carry risks that might limit how many children she could bear, she recalled thinking.
But when Petrus, who lives in Orange County, California, discovered that her first baby was in a breech position about a month before her March 2015 due date, she worried that a C-section was inevitable. For the next couple of weeks, she did some "hocus pocus tricks" to try to get the baby to move into the head-down position, including doing handstands in the pool, putting sage on her toes and lying facedown on the couch.
Then, her doctor at Providence St. Jude Medical Center in Fullerton tried a procedure to manually flip the baby.
"It worked, and I was able to deliver my daughter vaginally on her due date," she said. "It was awesome."
Petrus said she appreciated the support she got from her doctor and nurses to get through labor and delivery.
"Pushing was awful, because it was my first, but they were super encouraging — saying to just keep going, don't get tired, you can do it — and that was very helpful," said Petrus, 33, who now has five children, all born vaginally at the same hospital.
"If you had a C-section on your first birth, 90 percent-plus of all your future births are going to be a cesarean."
Providence St. Jude Medical Center is one of many California hospitals that in recent years have followed statewide initiatives and implemented interventions to reduce C-sections in low-risk first births — those involving single fetuses in the head-down position at 37 weeks or after.
The efforts are working: A recent study in the Journal of the American Medical Association found that the rate of cesareans in low-risk first births in California declined from 26 percent in 2014, before the coordinated efforts began, to 22.8 percent in 2019. By comparison, during the same period, the rate nationwide stayed the same, at 26 percent.
California's achievement puts it just below the national public health target of 23.9 percent that the Centers for Disease Control and Prevention set in its Healthy People 2020 goals. Medical experts became concerned when C-section rates began rising in the 1990s, and the country as a whole still hasn't met the goal. A CDC report released this month found that the nationwide rate last year was 25.9 percent.
"These were pretty dramatic results for a state," said an author of the new study, Dr. Elliott Main, a professor of obstetrics and gynecology at Stanford Medical School and medical director of the California Maternal Quality Care Collaborative. The group has been instrumental in California's multifaceted efforts to support vaginal birth, also working with state agencies, nonprofits and health plans. "And there was no harm to mothers or babies by having a lower C-section rate."
California aimed to reduce C-section rates in several ways, including by educating doctors and nurses about national guidelines for labor and ways to better support women in labor, along with informing doctors about how their C-section rates compared to those of other physicians. In some cases, there were incentives, such as honorary awards for hospitals that met the target. A quality improvement program that kicked off in 2016 was available to participating hospitals with elevated C-section rates.
There's no question that cesareans can be lifesaving for both mothers and babies when their health is endangered, Main said. C-sections also are often performed in other situations, such as to deliver multiples or in cases of breech positioning. But in recent years, there has been a growing realization of the downsides of cesareans when it's less clear that the surgery is absolutely necessary, said Main, who said doctors, for instance, are seeing more placental complications in pregnant women who have had previous C-sections. Cesareans also carry a risk of infection and hemorrhage, in addition to longer recovery, which can make it hard to care for a newborn.
California focused on first births because they generally involve more difficult labor and often determine the course of subsequent deliveries, he said. "We know that if you had a C-section on your first birth, 90 percent-plus of all your future births are going to be a cesarean," he said.
"Nobody ever says that they did an unnecessary cesarean."
C-section rates in low-risk first deliveries vary widely across the country, depending on the state, hospital and provider; some hospitals have rates as high as 50 percent or more, Main said.
"C-section rates shouldn't be dependent on which door the woman walks through," he said. "If she walks through one door, it's very low. With another door, it's very high, even with the same level of risk factors, and that's just not right."
Why such a wide variation?
It's not because so many women want to schedule their deliveries, Main said.
"There are always a few patients who want it, but it's less than 1 percent in most studies," he said. "Most of it has been driven by physician attitudes and nursing culture."
He said he thinks sentiment is rising that having a C-section is no different from having a vaginal delivery.
"There's a sort of loss of the value of having a normal birth," he said.
A co-author of the study, Dr. Melissa Rosenstein, an assistant professor of obstetrics, gynecology and reproductive sciences at the University of California, San Francisco, said that it's not that doctors have bad intentions "or that they are trying to do it just for convenience" but that it can be challenging to try to determine whether a patient who had a C-section would have been able to go on to deliver vaginally.
"Nobody ever says that they did an unnecessary cesarean," she said. "All the providers think that there's a reason. But I think that we were able to show that these reasons are fluid and there are ways you can be more patient with labor and end up with a vaginal birth."
Providence St. Jude Medical Center, where Petrus gave birth, started ramping up efforts to reduce first-time C-sections in January 2015, focusing at first on teaching nurses how to better support women in labor and encourage them to walk around more and change positions during labor, said Dawn Price, a nurse who is the hospital's executive director of women's and children's services, who helps oversee the program.
Then the hospital started providing educational sessions to physicians. A doctor from the California Maternal Quality Care Collaborative went out to talk about each physician's C-section rates and how everyone could get to the goal.
"It's that balance of monitoring the baby and observing the baby's tolerance of the labor, as well as giving Mom more support to have that labor and not rush to interventions," she said. The hospital also works to educate expectant women about why it's best to avoid first-time cesareans.
As at many other hospitals, its first-time C-section rate had climbed over the years.
"We got efficient at doing C-sections," Price said. "So it almost got normalized that that was OK."
But all that has changed significantly. The hospital's C-section rate in low-risk first births dropped from 34 percent when the program began to 19.9 percent last year, she said.
Dr. David Nelson, an assistant professor of obstetrics and gynecology at the University of Texas Southwestern Medical Center and chief of obstetrics at Parkland Health and Hospital System in Dallas, said the new study supports educating providers, standardizing labor management practices to promote consistency and tracking C-section rates among physicians, all to help other hospitals reduce their rates.
It's difficult for doctors to lower their cesarean rates without knowing what their rates are and how they compare to the target goal, said Nelson, who co-authored an editorial that accompanied the study. "For us to effect change on the cesarean rate, it's really important to measure and report the rate," he said.
Before the California program could be adopted in other states, it would be helpful to know which aspects of the big statewide effort had the greatest impact, Nelson said. That could allow other states to direct resources to the most effective and cost-efficient strategies.
"The findings from the California program offer hope for improvement," he said.
Experts also encourage women to talk with their doctors about any delivery concerns and ask about their C-section rates. In 2018, California launched the patient website MyBirthMatters.org, which includes a video and other materials to educate women.
Main said, "It's very important that women feel empowered and supported in labor."