Susan Frank has one main concern for young mothers, many of them giving birth for the first time.

The public health nurse worries that their fear of the pain and duration of labor prompts them to have a Caesarean section, and that they believe it will be as simple as unzipping their tummies and having their baby come out. Frank worries young first-time mothers discount their bodies' ability to endure and sustain childbirth.

“Women and girls don't have a lot of confidence in their bodies and themselves,” Frank said. “The body is meant to have babies.”

Frank knows a lot about what pregnant moms think. She is the public health nurse for a program for income-qualifying pregnant women seeking medical care, the Cayuga County Health and Human Services Department's Medicaid Obstetrical Maternal Service (MOMS) program. She was a maternity nurse at the hospital in Sodus for several years and still actively helps delivers babies.

It is a confidence-building measure for young moms to successfully take care of themselves during pregnancy, to make it through labor without a lot of medical interference, and to give birth to a healthy, normal-sized baby. That's why Frank is an advocate of vaginal childbirth, even as more and more healthy women - one in five nationally - are electing Caesarean sections.

“Nowadays, you have women, not so much in this area, who come in and demand a Caesarean delivery,” said Auburn obstetrician Dr. Kenneth Palmer.

But what is happening on a national level isn't what occurs in Cayuga County - at least not yet. Auburn Memorial Hospital had a 14.6-percent rate of Caesarean deliveries in 2003, second lowest in the state.

Local health professionals attribute those figures to the county's C-section rate to a commitment by area obstetricians and midwives to deliver vaginally whenever possible, and to the referrals of high-risk pregnancies in need of C-section deliveries to secondary care and tertiary care hospitals outside the county with more specialized treatment capabilities.

The county's C-section rate is considered a success story. The World Health Organization has long recommended no more than a 15 percent Caesarean rate, and the U.S. Health and Human Services Department has made it a goal to reduce the country's rate of Caesarean births over the last two decades. Its goal is that by 2010, only 15 percent of first-time, low-risk mothers will choose to have C-sections, and for only 63 percent of low-risk mothers with a succeeding pregnancy to have another Caesarean delivery.

“We have doctors and medical staff committed to keeping things normal,” said Marge Tracy, who has been a licensed midwife for seven years and was previously a childbirth educator and a public health nurse for 30 years. “We've worked very hard to not do unnecessary C-sections.”

Tracy is in an Auburn practice with Palmer. They started delivering babies in October at Community General Hospital in Syracuse. There are two obstetricians - Dr. William Bock and Dr. Ayodeji E. Lukula - who currently deliver babies at AMH.

“We have physicians and midwives that really support vaginal delivery,” Frank said. “They're not too quick to do C-sections.”

The less intensive nature of a maternity ward at a hospital like Auburn Memorial may be more conducive to the promotion of vaginal deliveries over Caesarean deliveries, said Palmer, who came to the area 3 1/2 years ago after practicing obstetrics at a New Jersey hospital that sees higher-risk pregnancies.

Palmer suspects that with a lower patient load “you don't have to push to get them dilated to 10 centimeters and into another room. There's less intervention at (Auburn).”

Plus, central New York women are less likely to choose regional anesthesia like epidurals and spinals and the use of pitocin, a drug used to induce labor, Palmer and Tracy said.

“This is a more rural community,” Tracy said. “Women tend to be less inclined to want a C-section.”

The difference in C-section rates by region has a lot to do with influences of other women and their expectations for delivery of their babies, Palmer said.

“What women expect, what women want, at least with obstetrics and probably other areas of life ... a lot of it has to do with their peers, their mothers and their girlfriends, who have more an influence on what they think than we do,” Palmer said. Palmer had only one patient in the last two years who desired an elective Caesarean.

Skaneateles obstetrician Dr. James Alexander prepares all of his patients for vaginal delivery, but is supportive of women using medical technology to control the pregnancy and labor process to meet their needs. Alexander moved his office from Auburn to Route 20 in Skaneateles in July and delivers babies at Community General Hospital.

It is a rare for his patients to request a Caesarean section, Alexander said, but he accommodates those requests because he believes scientific research shows that C-sections are getting safer and safer all the time. He also will induce labor to meet the scheduling needs of patients.

“I don't think we're going to minimize or cheapen the birth experience by offering women what they want. We're relying on women to know that they want. Who are we to impose our opinions on someone else's experience?” he said.

Elective or medically necessary C-sections can help women schedule their childbirth, avoid the pain of labor, and potentially reduce fear they may have over their body's ability to give birth.

But blithe attitudes toward Caesarean deliveries must be avoided, local health professionals said, because there are risks.

A C-section is a major surgery involving a 6- to 7-inch cut through the skin and muscle of the abdomen and a 5- to 6-inch cut in the uterus. There is a higher risk of bleeding and infection for women who have C-sections, and there is some risk from having anesthesia, including an increased risk of developing blood clots. The bowel organs can be damaged during the surgery. The recovery time is longer with Caesarean deliveries, and the incision can be very painful. It takes several weeks or even months for the abdominal tissue to heal.

Death during delivery is five to 10 times greater for C-sections than vaginal deliveries, and there is a higher chance of stillbirth. There is also a higher chance of placenta previa (the nourishing tissue for babies partially or completely covering the cervix) and placenta accreta (the placenta pushing too deeply into the uterus' wall). Both conditions can result in severe bleeding.

But the biggest risk comes for women who try to have a vaginal birth for their later pregnancies after having a C-section; they have a higher chance of uterine rupture during delivery. Some studies have shown that C-sections can lead to respiratory problems for babies.

The risks of vaginal deliveries also involve serious medical concerns. Research indicates that labor can weaken the tissues that support the uterus, leading the uterus to drop down into the vaginal canal. Caucasian women most often experience what is called vaginal prolapse, and it must be fixed by major surgery; they often require a hysterectomy.

Vaginal birth is also thought to cause problems with incontinence, usually beginning in middle age, including increased risk of leaking both urine or fecal matter. A difficult labor can leave women with extensive tears in their flesh, which can take as long as six months to heal.

Proponents of Caesarean deliveries will also point out that vaginal deliveries can be emotionally traumatic if a labor is difficult or involves a large baby. Vaginal delivery advocates counter that women lose out from the pride in making it through delivery and lose out from immediately connecting with their newborn being placed at their breast or stomach. Bonding and, if desired, breast-feeding, does not begin immediately after Caesarean deliveries.

“Somewhere in the middle lies the truth,” said midwife Tracy. “Caesarean sections are a wonderful, wonderful tool that have saved many mothers and babies. I wouldn't want to be without one. Does everyone need one? Like an epidural, does everyone need one? No.”

In the end, it is up to expectant mothers, their partners and their families to decide what is best.

“Bottom line, it's their baby, their birth, their experience,” Alexander said.

Staff writer Amaris Elliott-Engel can be reached at 253-5311 ext. 282 or at amaris.elliot-engel@lee.net