Too Late for Natural Birth?

In my google alerts today, one headline stuck out: “Too late to reverse rise in c-sections?” from the Boston Globe.  It is a letter to the editor from Lois Shaevel, co-author of “Silent Knife.

Shaevel states:

For eons we females had been capable of giving birth with very little medical intervention. Then childbirth went into the hospital, and the process became a medical and increasingly surgical event.

It’s sad really.  I’m not saying that all women don’t need a hospital and that all births can be achieved non-medically, but what makes me sad is the shift in how pregnancy and childbirth are viewed by our society.  Pregnancy and birth used to be normal and expected events in a woman’s life.  Now when you tell someone that you are pregnant they ask you if you have a first trimester ultrasound scheduled yet.  When you respond by saying that you don’t plan to utilize ultrasound technology unless it becomes medically necessary, they cock their heads, look at you funny, and respond with a suspicious “huh!”

Shaevel continues: 

When Nancy Wainer and I wrote “Silent Knife” in 1983, we hoped our work would reverse the trend and give women confidence in their bodies’ innate ability to birth their babies. If this trend of surgical intervention in the natural process of childbirth continues, the only women who will birth their babies naturally 50 years from now will be those who don’t make it to the hospital in time for their caesareans.

Some women are finding ways to become more confident in their bodies.  I joined the International Cesarean Awareness Network (ICAN) which greatly increased my confidence and understanding that a repeat cesarean would likely be unnecessary.  However, the doctors will always find a way to rob us of our confidence.  One ICAN list member was told early on in her pregnancy that s/he was supportive of her choice to VBAC.  Now at 36 weeks she’s been told to schedule a repeat cesarean.  This is not an uncommon story.

Here are my thoughts on how/why this keeps happening to women who desire vaginal birth after a cesarean (VBAC).  Perhaps the doctor just wants the business and thinks s/he will be able to change the patient’s mind along the way?  Perhaps the doctor believes in a woman’s choice but loses confidence along the way?  Perhaps in losing confidence in the mother along the way, the doctor is thinking about the legal consequences of not performing an elective repeat cesarean?  Perhaps the doctor, losing confidence along the way or thinking s/he can coerce the patient into surgery, also has the $$ in his/her eyes since surgical birth costs so much more than vaginal birth?  Perhaps the doctor knows that VBAC labor can take longer, and since s/he will have to be more readily accessible thanks to ACOG directives, s/he pushes for the quicker solution – major abdominal surgery?  Perhaps the doctor is more afraid of the uncertainty of normal (as in natural) birth because s/he is not familiar with it versus that which s/he is trained to do – perform surgery?

Shaevel’s letter was formed in response to this recent Boston Globe article.  Here are a couple of important points to consider from the article:

“It’s important for us to step back and say, ‘Why is this happening, and is it in the best interest of the public?’ ” said [the state's secretary of health and human services, Dr. JudyAnn] Bigby, whose research before entering state government had focused on women’s health issues at Brigham and Women’s Hospital. “This is not a minor surgical procedure; it’s a big deal. We need to understand why this trend continues.” [emphasis mine]

She is “sufficiently alarmed” that her state’s cesarean rate now eclipses the national average of 31.1%.

Obstetricians’ fears of lawsuits may also fuel some of the increase.

“There’s no doubt about the medical-legal burden; the litigious nature of society has an impact on this,” said Dr. Fred Frigoletto, chief of obstetrics at Massachusetts General Hospital. “Very few obstetricians have been litigated because they did a C-section. But they’re always litigated because they didn’t do one.”

Fear of litigation is NEVER an appropriate motivator for medicalized childbirth.  Interventive practices are only appropriate when there is sound evidence of need.  Basing medical opinion, advice, and practices on a fear of litigation is unethical and violates the oath and creed to “first do no harm” that all doctors agree to when they become registered practitioners.

It once was popular to deliver subsequent babies [following a cesarean] by vaginal birth, but by the late 1990s the practice began to fall out of favor because of potential risks.

Potential risks – yes, it is possible that a woman’s uterus may rupture during labor.  The risk of rupture may be as low as .5%, and any doctor who puts forward a rate of greater than 1% should be asked for the research to support such a statistic.  Avoiding induction and augmentation of labor and having continuous labor support (an experienced doula and/or midwife) will help VBAC moms achieve their goals.

Anyone who doubts the importance of natural childbirth for both mother and child should register for the “What Would Mammals Do” webinar through Conscious Woman

Contrast these homebirth news stories!

I have followed homebirth legislation news in Utah and South Dakota with interest and concern.  I don’t want Montana getting any stupid ideas. 

UtahI blogged about their nonsense recently.  Yesterday, the Utah Senate voted to restrict homebirth practices.  The bill was supposed to have been a compromise, but what resulted was something restrictive and punitive.  Women will be forced to attempt VBACs in hospitals or on their own.  Were this the case in my state, I would have an overwhelminly large chance at “failure” since my hospital’s VBAC rate is a pitiful <1%.  They only had 16 successful VBACs at the hospital in 2006.  Utah legislators have chosen a path that makes homebirth less safe.  To search for Senate Bill 93, click here.

South DakotaI also blogged about their homebirth “situation,” and it appears that both the SD House and Senate have approved a homebirth bill. 

The bill would require midwives to become registered nurses, get master’s degrees in nursing, and pass additional tests. Certified nurse midwives wanting to attend home births would need approval of both the Nursing board and the Board of Medical Examiners.

Allowing certified nurse midwives to attend home births in South Dakota would be allowed on a trial basis until 2013.  (click here for source article)

My concern is that CNMs were previously required to have OB back-up, and evidently no OBs were agreeing to provide back-up services.  What will be different?  And I’m not sure that having a Masters Degree makes anyone particularly qualified to attend labor.  Shouldn’t these homebirth midwives have assisted on “x” number of births before they become licensed?  Why is it always about the piece of paper??

Also, the bill states that CNMs will be able to attend homebirths “under certain circumstances” but doesn’t clarify what those circumstances may be.  I suppose we must find the Board guidelines to find more clear language.  To read the bill, click here.

2006 Cesarean Statistics Released – it ain’t good

Today I was informed that the CDC released preliminary vital statistics for 2006 which includes state-by-state cesarean birth information.  Here in Montana the 2006 cesarean rate was 28%, earning us a rank of number 37 (of 51).  The national cesarean rate was 31.1%, an all-time high.  Although Montana was 3 percentage points below the national average, the rate still exceeded World Health Organization (WHO) recommendations by 13-18%!  The WHO determined that when cesarean rates exceed 10-15%, the risks of the surgery outweigh the benefits.  It is my understanding from a recent discussion with a hospital administrator that Community Hospital’s (Missoula) cesarean rate exceeded 30% in 2006.  Missoula’s cesarean rate is headed in the wrong direction. 

As a woman with one cesarean scar, these statistics are frightening.  Is cesarean birth becoming “normal” birth?  If one out of three babies is born through major abdominal surgery, then yes, I’d say the norm is swinging that direction.  You need to know that the percentage of birth by cesarean has risen 50% in the past decade.  This is straight from the horse’s mouth!  You also need to know that Montana’s VBAC (vaginal birth after cesarean) rate in 2005 was only 1%. 

For the second year in a row, ICAN has compiled a list of research from the past year that shows cesarean surgery should be used more judiciously and that VBACs should be routine/normal.  Currently, more than 300 hospitals across the U.S. ban women from having a VBAC, essentially coercing them into unnecessary surgery and feeding the growing rate of cesarean.  Very few Montana women have access to vaginal births after cesarean sections.  Only a handful of hospitals across the state allow VBACs – one of those hospitals is Community Hospital in Missoula

In August, the Centers for Disease Control released a report showing that, for the first time in decades, the number of women dying in childbirth has increased.  Experts note that the increase may be due to better reporting of deaths but that it coincides with dramatically increased use of cesarean.  The latest national data on infant mortality rates in the United States also show an increase in 2005 and no improvement since 2000.  “At a time when maternal and infant mortality rates are decreasing throughout the industrialized world, the United States is in the unique position of having both a rapidly increasing cesarean rate and no improvement in these basic measures of maternal and infant health.” says Eugene Declercq, Ph.D., Professor of Maternal and Child Health at Boston University School of Public Health.

Another report released in October by the World Health Organization, the United Nations Population Fund, the U.N. Children’s Fund, the U.N. Population Division and The World Bank, and published in the Lancet shows that the U.S. has a higher maternal death rate than 40 other countries.  “Women in the U.S. think they’re getting top notch care, but our death rate for mothers shows otherwise,” says ICAN’s President, Pamela Udy.  The U.S.’s maternal death rate tied with that of Belarus, and narrowly beat out Bosnia and Herzogovena.

Research from 2007 also shows that VBAC continues to be a reasonably safe birthing choice for mothers. “The research continues to reinforce that cesareans should only be used when there is a true threat to the mother or baby,” said Udy. “Casual use of surgery on otherwise healthy women and babies can mean short-term and long-term problems.” For women who encounter VBAC bans, ICAN has developed a guide to help them understand their rights as patients. The resource discusses the principles of informed consent and the right of every patient to refuse an unwanted medical procedure. Click here for a pdf copy of this important resource.

Women who are seeking information about how to avoid a cesarean, have a VBAC, or are recovering from a cesarean can visit www.ican-online.org for more information, to find a local chapter, and to receive support.

About Cesareans: ICAN recognizes that when a cesarean is medically necessary, it can be a lifesaving technique for both mother and baby, and worth the risks involved. Potential risks to babies include: low birth weight, prematurity, respiratory problems, and lacerations. Potential risks to women include: hemorrhage, infection, hysterectomy, surgical mistakes, re-hospitalization, dangerous placental abnormalities in future pregnancies, unexplained stillbirth in future pregnancies and increased percentage of maternal death. http://www.ican-online.org/resources/white_papers/index.html Mission statement: ICAN is a nonprofit organization whose mission is to improve maternal-child health by preventing unnecessary cesareans through education, providing support for cesarean recovery and promoting vaginal birth after cesarean. There are 94 ICAN Chapters across North America, which hold educational and support meetings for people interested in cesarean prevention and recovery.