Public Citizen Spotlights Unnecessary Cesarean Sections in New York State

by Melissa Garvey, ACNM Writer and Editor

Some of you may remember Public Citizen’s 1997 report “Nurse-Midwifery: The Beneficial Alternative.” Yesterday, the group released a new report called “Guide to Avoiding Unnecessary Cesarean Sections in New York State.”

They chose to spotlight New York not because of its high rate of cesarean births (At 33.7%, only nine states have higher rates than NY), but because it is one of only two states that tallies intervention rates for obstetric procedures all the way down to the facility level.

What they found is that the cesarean section rates vary widely throughout the state and nearly a third of cesarean sections may be unnecessary. That estimate is based on the fact that the state’s 10 hospitals with the lowest cesarean rates had an average rate of 20.8%—more than one third lower than the average rate for all New York hospitals.

The report contains a myriad of useful information, including birth statistics by county, tips for women who want to avoid an unnecessary cesarean section, and even guidelines for health departments and hospitals seeking to reduce unnecessary cesarean sections. Before you dive in, I’d like to highlight one of my favorite quotes from the Public Citizen press conference, which was held yesterday morning. This comes from Dr. Jacques Moritz, an obstetrician at St. Luke’s-Roosevelt, Roosevelt Division:

“The model of obstetrical care in this country is all wrong. The model of an overtrained obstetrician attending to a normal birth is all wrong. The proper model is for all low-risk mothers to be managed by a certified midwife with a midwife-friendly obstetrician as back-up. This works in other industrialized countries, but not in ours.”

Susannah Donahue-Negbaur, CNM, MPH, a midwife at Roosevelt Hospital, New York City, drove the issue home:

“Choosing a midwife is one good way a woman can reduce her chance of a cesarean section. Research shows that low-risk women who use midwives are more likely to have a safe and healthy birth for themselves and their babies, and are less likely to undergo an induction of labor, cesarean or episiotomy than low-risk women who use doctors.”

Read more of Susannah’s comments about how maternity care works best as a partnership between midwives, physicians, and families here.

What do you like most about Public Citizen’s latest report?

Washington State Stacks Financial Incentives in Favor of Vaginal Birth

The state of Washington is taking an innovative step toward tackling rising cesarean section rates by eliminating the profit motive. Beginning this month, the state’s Medicaid reimbursement for uncomplicated cesarean sections dropped from approximately $3,600 to about $1,000—the same reimbursement provided for complicated vaginal birth.

Because the cost of vaginal birth is lower than the cost of c-section, the new payment structure rewards health care providers for supporting vaginal birth rather than for performing c-sections. Nearly half of all births in Washington are reimbursed through Medicaid, so the change is expected to have far-reaching effects. In fact, the state has already received calls from hospitals requesting assistance to revise the protocols they use to decide when a cesarean section is necessary.

A recent Crosscut.com article by Carolyn McConnell explains why this is an excellent way to improve maternal and infant health. It’s also in line with #5 and #7 of ACNM’s Seven Key Principles for Health Reform.

What do you think? Would you like to see the rest of the country adopt Washington’s new strategy?

Denis Walsh, mommy wars, and coming together On Common Ground

Originally published on Science and Sensibility by Amy Romano, CNM, for Lamaze International

Last week, I was thrilled and humbled to be asked to contribute to the On Common Ground collection at RH Reality Check. My assignment was to write a piece from the maternity care perspective that represents common ground for people on opposing sides of the abortion debate. I was asked to help readers who cannot agree even on the basic precepts of an issue discover concerns and beliefs held in common. I hope I succeeded. But I may have stepped from one divisive debate right into another. In my article, Improving Maternity Care: A Mother and Child Reunion, I discuss how what happens in birth can affect a woman’s transition to motherhood, and even her biological bond with her baby. Sound familiar? This is a bit like what midwife and researcher Denis Walsh is reported to have said in a recent article. The article, published in the Daily Mail’s Online Edition, ignited a storm of attacks against Dr. Walsh, who is a man, for allegedly saying that epidurals can complicate maternal-infant attachment and breastfeeding. A look at the hundreds of comments on the feminist site Jezebel will give you a sense of how unpopular his remarks are.

Whether Denis Walsh said what was reported or not (there’s a good chance he didn’t), this isn’t the first time any of us have heard the claim – and even the science behind the claim – that epidurals disrupt the biological processes of maternal-infant attachment and breastfeeding. These claims are made about cesareans, too. But clearly, even the most eloquent and informed among us (for example, Denis Walsh) are unable to talk about these effects in language that resonates with the majority of women.

Is there a better way we can talk about the impact of maternity care practices on mother-infant attachment? I think so.

In my article at On Common Ground, I discuss the beneficial effects on maternal-infant attachment of two practices: continuous support in labor and skin-to-skin contact between mothers and newborns after birth. I give an example from a randomized controlled trial comparing women who had continuous support from friends or family members trained as “lay doulas” with other women who labored without such support. I also discussed the findings of a Cochrane systematic review of studies of skin-to-skin contact. In both cases, beneficial effects included easier transitions to motherhood and improved maternal-infant attachment.

These are practices we can offer women whether or not they have epidurals, and regardless of how they give birth. More importantly, they improve mother-infant attachment whether or not women have epidurals and regardless of how they give birth.

In the doula study, postpartum effects were profound. Women who had continuous support were more likely to describe their babies as “very easy” and to believe that their babies cried less often than other babies. They were more likely to pick up their babies when they cried and to report that they were able to sense their babies’ needs “very well.” Regarding their own postpartum experience, they were more likely to say that the transition to motherhood had been “very easy” and to report that they had received support from others in the previous week. Women assigned to the doula group also scored more favorably on measures of self-worth including sense of self as a woman, sense of their bodies’ physical strength, and ability to be a good mother. Do you want to know what did not differ? The rates of epidural use (85% doula group vs. 88% no doula group) and cesarean surgery (19% doula group vs. 18% no doula group).

The systematic review of skin-to-skin contact included mostly studies of vaginal births in women without epidurals, but one study included in the review looked only at women who had scheduled repeat cesareans under spinal anesthesia. This study in fact yielded some of the most impressive differences in maternal-infant attachment behaviors of all of the studies included in the review. Some of the differences in maternal attachment behaviors persisted an entire month after giving birth.

I believe that mothers and babies experience physiological and emotional benefits when the woman has an unmedicated vaginal birth. But in our culture, women are not given a fair shake to achieve unmedicated vaginal births, and are fed messages that they shouldn’t care how they give birth as long as there’s a healthy baby. Even when care is top-notch, some women will still need epidurals or cesareans. Do we really want to tell these women that they might not be able to parent effectively?

The Healthy Birth Practices that Lamaze International has been championing for years allow us to have our cake and eat it too. Taken together as a package of care, they decrease the need for cesarean surgery and pharmacologic pain management. As we have seen in the two examples here (which represent two of the six Healthy Birth Practices), they may also mitigate or even overcome the effects of epidurals and cesareans on maternal-infant attachment. How’s that for a win-win?

We need to find common ground with women when it comes to talking about birth and bonding. Focusing on outcomes, which can result from choices, circumstances, or system effects, dooms us to alienate some women and ultimately fail to reach them with information that matters. Let’s instead advocate for better, safer care in labor – The Healthy Birth Practices – and fight to make sure no woman is denied access.

SOGC Says No More Automatic Cesareans for Breech Babies

Whether you’re aiming for a hospital, birth center, or home delivery, if you get the news that your baby is in the breech position, chances are you’ll be advised to have a cesarean section. But on Wednesday, the Society of Obstetricians and Gynaecologists of Canada (SOGC) released new guidelines for health professionals that turn the breech issue upside down. They state that health professionals should not automatically recommend cesarean sections for women carrying breech babies.

After a comprehensive review of research, SOGC concluded that vaginal breech birth is a safe option in some cases:

“The evidence is clear that attempting a vaginal delivery is a legitimate option in some breech pregnancies,” said Dr. André Lalonde, Executive Vice-President of the Society of Obstetricians and Gynaecologists of Canada. “The onus is now on us as a profession to ensure that Canadian obstetricians have the necessary training to offer women the choice to deliver vaginally when possible.”