For her first baby, Naomi Laguana tried - with her doctor's encouragement - to give birth naturally. But after hours of anxiety-ridden labor, she ended up in the operating room, undergoing a cesarean section.
So when baby No. 2 came along, six months ago, she decided to short-cut the process and scheduled a C-section at 39 weeks.
"I really did it for pure convenience. I liked having a scheduled date, I liked not having anxiety," the 41-year-old mother said.
Increasingly, American mothers are opting to give birth by cesarean section - commonly known as a C-section - a week or more before their due dates. It is a decades-long trend, but some doctors are beginning to worry it's gone too far.
"I think unfortunately what we are seeing is ... people becoming more and more cavalier of the outcomes," said Dr. Aaron Caughey, an associate professor in the Department of Obstetrics, Gynecology and Reproductive Sciences at UCSF.
The March of Dimes today released a nationwide report card evaluating the states' progress toward reaching a national goal of a preterm birthrate of 7.6 percent. The nation as a whole, with a preterm birthrate of 12.7 percent, rated a D. California scored a C, with a rate of 10.7 percent, and some individual counties - including most of the Bay Area - scored better still.
Higher infant mortalityThe Centers for Disease Control and Prevention have tracked an increase in preterm births for decades, with the percentage of births delivered before 37 weeks of gestation rising 21 percent between 1990 and 2006. That increase is the main reason the nation's infant mortality rate has stubbornly refused to decline, remaining higher than most other developed nations.
Some preterm births were linked to mothers' smoking, and others to the mothers' lacking insurance. But more than 90 percent of the increase in preterm, nonmultiple births is attributable to an increase in babies being delivered by C-section at 34 to 36 weeks gestation, according to the March of Dimes.
"It comes from a general change in obstetric practice in our society," said Dr. Alan Fleischman, medical director of the March of Dimes Foundation. "The doctors and the women are intervening in a much more aggressive style toward the end of pregnancy."
Fleischman and other medical experts say there are a number of reasons doctors and mothers are choosing C-section delivery - and not all of them stem from medical necessity, the health of the mother or infant.
One reason is legal, said Dr. Mitch Katz, director of the San Francisco Department of Public Health. Some doctors are recommending a C-section at the first hint of problems, seeing early surgical delivery as a safer bet than waiting for natural labor.
"Almost any negative outcome of a baby is cause for malpractice, whether or not the doctor has done everything right," Katz said. "If our medical system punishes physicians for not doing a C-section ... then doctors are going to do more C-sections."
In other cases, doctors and mothers are choosing a C-section for scheduling - to make sure the baby is born while the mother's family is in town to help care for the newborn, or even to avoid conflicting with the doctor's planned Thanksgiving celebration.
"I'm not saying that's pervasive," Fleischman said. "But I am saying that there are times when convenience is part of the decision-making process, and that really shouldn't be."
Cavalier about C-sectionsUnfortunately, Caughey said, some medical professionals have become "cavalier" about C-sections. Many may be unlikely to deliver a baby at 36 weeks, he said, but some may see little problem in delivering at 37 weeks - short of the 39 weeks recommended by the American College of Obstetricians and Gynecologists.
"Thirty-nine weeks is a really good gestational age to achieve," Caughey said. "At 37 weeks the outcomes were worse than 39 weeks. They both were considered term births, but it's better to be a 39-week baby than a 37-week baby."
About 30 percent of fetal brain growth happens in the last five weeks of pregnancy, Fleischman said, and babies born preterm are more likely to die in the first week or year and may have trouble with breathing or feeding. Studies suggest that babies delivered in late preterm suffer consequences in the form of poor math and English performance, have increased need for special education and - according to one study in Sweden - may earn less later in life.
"Every baby should be born at the right time," he said. "We don't know how many cesarean sections are the right number. But we do know that every induced and cesarean (birth) should be done for the right reason."
The March of Dimes has begun a petition drive pushing for more federal support for prematurity-related research, for expanded access to health care and smoking cessation programs for expectant mothers, and for encouraging hospitals to assess C-sections that occur before 39 weeks.
But one of the main goals of the organization's ongoing campaign, Fleischman said, is to make sure doctors and mothers are having detailed and informed conversations about delivery options well before the baby is born.
"Women are also part of this equation, and we're trying to empower women with information," he said.
Laguana, whose 6-month-old baby is thriving, said she has no regrets about her choice and believes the final decision of how to deliver should remain firmly with mothers. But she said that she would encourage many women to deliver vaginally, and that it is important for mothers to know enough to make the right decisions.
"I feel like moms need to choose what the right route is, but obviously not all moms are well read or well educated, so they look to the medical world for advice," she said. "The most important thing, in my opinion, is the baby comes out happy and healthy."
Online resource For more information: Marchofdimes.com
Copyright 2008 San Francisco Chronicle