Most moms are worried when they’re pregnant, whether it’s a high-risk pregnancy or not.
There’s a child in your body and you can’t necessarily control what will happen the next day, said Mikki Salisbury, who has undergone four cesarean section operations and is the mother of four boys.
“You are worried every single day of that pregnancy,‘ she said.
That’s why it’s important to have good prenatal care, which can help ease a mother’s fears, and why she thinks a new initiative Munson Healthcare Cadillac Hospital has joined is “amazing.‘
The hospital recently joined 72 other Michigan hospitals participating in a Blue Cross Blue Shield of Michigan initiative to safely reduce non-medically necessary, low-risk C-sections statewide.
Of Salisbury’s C-sections, two were medically necessary and two were not.
If she could go back, knowing the risks like she does now, she probably would have made different choices, she said.
The risks of a C-section
C-section delivery rates have been increasing in the United States since the 1970s and today, one in three births are by C-section. To date, Michigan has a higher rate of low-risk C-sections than the national average, according to a Blue Cross Blue Shield press release.
Sometimes the C-section is necessary for the life or health of the baby or mother.
During Salisbury’s first delivery, her labor failed to progress and her son’s heart rate dropped so she had to get a C-section, she said.
But C-sections do carry risks and are associated with an increased risk of hemorrhage, hysterectomy, infection and other complications for both mother and infant.
Salisbury chose to have her second and third deliveries be C-sections. What she didn’t know was that with each additional C-section, she was increasing her risk of having a cesarean scar pregnancy, where the pregnancy implants into the scar left from a previous cesarean section.
The muscle is very thin there compared to a normal pregnancy and the placenta can grow to invade the muscle and can even start invading organs in the pelvis, such as the bladder. By the time the mother undergoes the C-section, the placenta can be so tightly bound to the organs and uterine muscle it can put the mother’s life in danger removing it.
Her fourth pregnancy was such a pregnancy and there was a very real possibility that both she and her child could die due to a much higher risk of hemorrhaging, premature birth or the risk of the placenta growth. Luckily, both Salisbury and her son, Tyler, came out healthy.
In general getting pregnant and having a baby is a risky process, said Munson Healthcare Cadillac Hospital Vice President of Medical Affairs and pediatrician Joe Santangelo.
That’s why they are trying to improve the care for the process and reduce the risks involved.
They do C-sections at the hospital and have been working for a long time to reduce the number they perform.
It’s “a major operation on a mom’s belly‘ when her body is already on a lot of stress after being pregnant for nine months, he said.
C-sections are big operations, but they have become more routine, so many women have had them.
In some places it is preferred, but it is not as healthy to do it that way unless it’s medically necessary, he said.
The hospital wants to try not doing C-sections unless they are absolutely necessary for the health of the mom and the baby.
The worry after a C-section is that there is a big cut in the uterus and will create problems with later deliveries, like Salisbury’s.
The importance of preventing the first C-section
What Cadillac hospital is targeting is preventing moms from having that first C-section.
When they prevent that first C-section they reduce the complications with that pregnancy and for future ones, Santangelo said.
C-sections are increasing across the country and one of the biggest reasons is because once a woman has a C-section she is more likely to opt to do that delivery method the second time around.
So if they can stop the first C-section, they can stop the repeat ones, he said.
The number of vaginal births after a C-section is also decreasing, said Dr. Faris Ahmad, medical director at Blue Cross Blue Shield of Michigan.
Michigan has a higher rate of C-sections, but he’s not sure why. It could probably partly be due to the population that can now have babies that couldn’t before, like those with diabetes and hypertension.
With the initiative they are looking at low-risk pregnancies, so looking at the pathways to reduce C-sections.
If we can stop the C-sections the first time around and increase the amount of vaginal births, that will increase the health of the mother and child exponentially and long-term, Salisbury said.
Preventing the first C-section is the most important “because that’s when all your odds start to increase," she said.
The increased risk to the mother and child is not worth it after that first C-section.
“There is nothing like having to go through a high-risk pregnancy," she said.
What the Blue Cross Blue Shield of Michigan initiative does
There is great variation in cesarean delivery throughout the state and the goal of the initiative is to learn why some areas of the state have rates as high as 44% while others are only at 9%.
The initiative collects data from multiple sources including the participating hospitals, Blue Cross and state birth certificate data, all to help shed light on situations that lead to a C-section.
A coordinating center at the University of Michigan manages the data. The coordinating center, in collaboration with the participating hospital, will work together to examine the data and identify opportunities for improvement.
For example, project participants looked at research that showed women who are admitted to the hospital during the early stages of labor have a significantly higher risk of delivering by cesarean than women who are admitted during active labor.
Researchers then developed an admission checklist that labor and delivery triage staff can use to assess patient readiness for admission.
This tool promotes shared decision-making between the hospital team and the patient. Not being admitted during this phase of labor has been linked to reduced cesarean deliveries, reduced use of epidurals, and lower rates of maternal death.
“Hospital staff are using the checklist to help them identify who could spend this labor period outside of the hospital and helps them work together with the mother to provide appropriate support,‘ said program director Daniel Morgan. “So, mothers-to-be know what to expect and what to look for and work together with the maternity team to be safely admitted when they reach active labor, or before that if the maternity team thinks it’s best.‘
Ahmed said a third of C-sections, or 34%, are because of labor arrest. A quarter are for non-reassuring fetal tracing, or when the baby’s heartbeat isn’t acting normally.
And then 15 to 17% are done for malpresentation, or “breach babies‘ that don’t have the head first but rather a arm or foot.
Instead of promoting that C-sections are bad they are trying to promote how healthy natural vaginal births are, he said.
They aren’t trying to change physicians’ practice patterns, but educate doctors and patients and let them know these other options are possible.
Santangelo said Munson Healthcare Cadillac Hospital’s role in the initiative is to participate in educating people about the guidelines for the first C-section and when they should and shouldn’t get them.
They will submit data on the number of births they have, the number of C-sections they perform and the reasons why.
The data has always been gathered but they are excited to share it with other health systems so they can learn how they can improve, he said.
It’s really to improve the quality of care delivered to moms in Michigan, he said.
The importance of having good maternity health care
Santangelo said they know there are problems that can happen during pregnancy and delivery, so they want to reduce the risks so the mom feels more comfortable and can go home and enjoy having a new baby.
“We want to provide excellent care to pregnant moms,‘ he said.
Getting good prenatal care is the most important part. If there is a complication then it can be discovered, treated, and everyone can end up fine, he said.
Salisbury said improving maternal care is important because confidence in the doctors is such a big deal.
If the woman doesn’t trust what the doctor is saying, “that’s going to hinder everything,‘ she said.
The worst thing in the world is to lose a mother trying to bring a new person into this world, so it’s important that doctors are staying up-to-date and can safely deliver mothers and children into this world.
Hopefully more hospitals will become involved in the initiative and doctors and hospitals should not push C-sections, she said.
The least amount of unnecessary C-sections done will help save more lives.
“We’ve got to kind of weigh our odds better than we are,‘ she said.