Abiola Adeoti wanted to push her baby out herself.

A cesarean delivery for her first child was never an option for Adeoti, a patient at Texas Health Harris Methodist Hospital Hurst-Euless-Bedford. She knew the procedure’s risks because her mother is a nurse. 

“The incision is very deep, and it takes a (longer) while for you to recover from than natural birth,” said Adiola. “I was like, I’m going to go for a vaginal birth.”

An increasing number of first-time mothers are delivering babies through C-sections. The federal government set a national goal to lower the numbers, and Tarrant County hospitals are working toward it. However, the solution is more complex than just determining to perform fewer C-sections, health professionals told the Fort Worth Report.

The rise in C-section rate is minimal, but the number has consistently made up a third of all births in the U.S. for over a decade, according to the Centers for Disease Control and Prevention. 

The problem dates back to the 1970s, when the overall C-section rate increased from 5% to peaking at 24.7% in 1988. Since then, the rate has fluctuated but reached an all-time high of 32.9% in 2009. 

Low-risk pregnancies make up 26.3% of all C-sections — the highest number since 2013. In February, the U.S. Department of Health and Human Services called for the number to be reduced to 23.6% over the next year.

The “low-risk” pregnancies targeted under the national goal are a first-time, full-term pregnancy with a single baby that is positioned head down. 

One set of rates may appear higher than they really are, said Dr. Meaghan Nelsen, assistant professor at The University of North Texas Health Science Center’s Texas College of Osteopathic Medicine. 

A mother may have a first-time, full-term pregnancy with a single baby that is positioned down, Dr. Nelsen explained, but “also be 41 years old with hypertension and poorly controlled diabetes.” In such a case, a mother may have a C-section because of these other issues, she said.

What are the risks that come with C-sections?

The national C-section rate started to get higher than what physicians are comfortable with, said Cari Kemp, manager of the labor and delivery unit at Texas Health Hurst-Euless-Bedford.

The numbers were alarming because of the risks of the procedure, which include:

  • Weakening of the uterus, increasing the chances that it tears during future deliveries. 
  • Bleeding and infection of the uterus.
  • Damage to other organs like the bowel, bladder and uterine arteries.

The risks created by the initial C-section can require patients to continue repeating the procedure for future pregnancies.

A path to a smooth delivery 

Texas Health resources has reduced its NTSV C-section rates by 25% since the national goal was announced, according to officials. Texas Health did not disclose more detailed data to the Report.

The Hurst-Euless-Bedford location acted quickly after high C-section rates were brought to its attention, said Cari Kemp, labor and delivery unit manager.

The hospital created a walking path in the labor and delivery unit in March to encourage movement for pregnant moms while they are in labor. Stopping points include activities like slow dancing with a partner as well as squatting and sitting on exercise balls.

A sign instructs pregnant mothers in labor to slow dance at a station along the walking path located in the labor and delivery unit at Texas Health Hurst-Euless-Bedford. (Sara Honda | Fort Worth Report)

Walking and movement help the baby settle into the pelvis and improve blood circulation to help the uterus squeeze during labor, Kemp said. 

“We knew that the C-section rate was on our radar of something that we needed to work on, and Texas Health made it a key performance indicator for this year,” she said. 

Why C-section rates are high 

The factors that make up the C-section numbers are complex, Nelsen, the HSC professor, said. 

Nelsen, who practices obstetrics and gynecology, says the numbers can differ based on location, the type of patients served, demographics as well as access and quality of care.

Maternal insurance coverage and socioeconomic status play a significant role in varying rates, according to the National Health Institute. Research found the NTSV C-section rate is higher for those covered by commercial, private insurance than those covered by public insurance.

Medical City Healthcare sees higher C-sections rates because of a treatment program that specifically cares for mothers who are at risk for complications. 

“The Maternal Fetal Institute is one of a handful of highly specialized centers in the country that offer life-saving care to high-risk moms and babies,” said Laura Swaney, division vice president of women services at Medical City. 

Medical City does not perform any elective deliveries, including C-sections, unless medically necessary, Swaney said. 

Nelsen agrees reducing the frequency of C-sections is a complex matter. 

“Obstetricians can be concerned about a suboptimal outcome, or they’re concerned about whether a vaginal delivery will occur without harm to mom and the baby,”  she said. “When they want to intervene, the intervention is a C-section.”

Labor and delivery is overall an unpredictable process that calls for interventions at times, Nelsen said. But, any time physicians intervene with nature, the risk for a C-section rises. 

Regardless of the procedure, there is no way to know beforehand how the patient’s body will react, Nelsen said. C-sections are hard to reduce because of the complications that may call for one to save a patient’s life. 

“What we have with the information in front of us, we do what we think is right,” she said. “That’s why lengthy training, preceptorship and mentorship is so important on the field.”

A safe intervention

Erin Peterson, a labor and delivery nurse at Texas Health Arlington Memorial, participated in an eight-hour class hosted by Bundle Birth, a California-based nursing corporation.

Possible interventions during labor complications 

Labor may be induced or augmented when patients experience complications.

  • Inductions can help trigger labor if the patient has trouble going into labor naturally, if their blood pressure is high or if the baby is too big. 
  • Augmentations help the labor process progress towards delivery by stimulating the uterus to increase contractions when they have slowed or stalled. 

The interventions can be procedures like giving the patient an IV drip of a labor stimulating hormone, artificially breaking their water or asking them to participate in movement activities.

She learned how to help patients have a safe delivery and avoid complications that could call for a C-section and how to identify factors in the delivery room that may interfere with the birthing process, such as bright lights.

“One of the quotes they had was ‘motion is lotion,’” Peterson said. “Just keep turning, keep positioning, alter those hips.”

A couple of weeks after the training session, Peterson noticed abnormalities in the positioning of a first-time mother’s baby. She guided the patient in a positioning adjustment activity. 

“And then she just rapidly dilated, and she actually had a very, very smooth birth,” Peterson said. 

The training and education of nurses and physicians makes a difference, she said. She plans to attend more training sessions in the future to create low stress and natural deliveries. 

“We cannot control every situation, but we do have a small amount of control in doing the best we can,” Peterson said. “If we can just try to make the path the best we can, then we’re just giving that baby the best chance to come vaginally.”

Physicians and nurses successfully helped Adeoti, the Texas Health patient, accomplish her goal. 

She gave birth — naturally — to a baby boy on July 23.

Editors note: This story was updated on Sept. 6 to correct a quote regarding C-section numbers at Medical City Healthcare. The statement originally referenced Medical City Fort Worth, which does not perform deliveries.

Disclosure: Texas Health Resources is a financial supporter of the Fort Worth Report. At the Fort Worth Report, news decisions are made independently of our board members and financial supporters. Read more about our editorial independence policy here.

Sara Honda is the audience engagement and social media fellow for the Fort Worth Report. Contact her at sara.honda@fortworthreport.org.

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Sara Honda is the 2023 fall fellow focusing on social media and audience engagement. She is currently a senior at Texas Christian University, with a major in news and media and minor in criminal justice....