Eight Reasons The Cesarean Rate is Too High

From the Midwife Nextdoor blog
http://www.themidwifenextdoor.com/?p=1254


The October edition of ObGyn News featured a commentary entitled: The Cesarean Section: A View From The Trenches. David Priver, MD, described himself as “nothing more than an everyday ob.gyn who has written no papers nor taught many residents”, yet he has crystallized many of the primary reasons we have not made progress in reducing our c-section rate. Dr. Priver states that over his 36 years of practice, his c-section rate never exceeded 10%. He modestly describes himself as having “no extraordinary wisdom, skills or dexterity” but offers points that he believes, if taken into consideration by OBs, could successfully decrease the c-section rate.

* The c-section rate has increased costs but hasn’t improved outcomes.
* As the incidence of c-section increases, so does the incidence of placenta accreta. This often requires hysterectomy and blood transfusions. OBs need to take seriously the future risk they are creating for women each time they make a decision for c-section.
* OBs are paid more for doing c-sections than vaginal deliveries. Dr. Priver suggests that “guiding a woman through a labor and vaginal delivery” takes more skill and judgement than doing a c-section. He recommends paying OBs up to $1000 more for accomplishing a vaginal delivery in a first-time mother or a woman desiring VBAC.
* We must change a system that nearly ensures an OB will be sued if the outcome if not perfect, even if s/he did nothing wrong.
* OBs today are too impatient. Dr. Priver points out that women and their physicians used to wait until 42 weeks before inducing labor. He believes that oligohydramnios (low amniotic fluid) is a “pseudo-issue” that is used to expedite delivery, although evidence does not show benefit of induction.
* In the case of VBAC, women should be allowed to begin labor before a decision about type of delivery is made. When the woman starts spontaneous labor, she should be assessed and a decision made regarding whether or not to attempt VBAC. Dr. Priver is strongly against use of Pitocin augmentation during a VBAC, believing that a stalled labor may be a warning not to “push the process”.
* Vaginal birth when baby is in a frank breech position should be the rule, not the exception. Dr. Priver uses the rule of “watchful waiting” in these cases, and as long as progress is being made and baby is doing well, labor may continue.
* Breech delivery techniques and skillful use of forceps are rapidly becoming a lost art, which will further drive up the cesarean section rate–unnecessarily.

Next Meeting

The next meeting will be May 4th in Brandon, MS at 6:30PM. Email me at icanofjacksonms@gmail.com if you are interested in attending and I will send you directions.

Legislature labors over birthing option

From MS Digital Daily
By Natalie West
Melissa Barlow and husband Jerry had a difficult experience with their first daughter’s Cesarean birth, so bad, in fact that the couple waited ten years before deciding to have a second child. When they learned they were expecting last summer, Melissa and Jerry made a concerted effort to educate themselves and explore options in hopes of facilitating a smoother, less traumatic birth.

On February 16, surrounded by friends and family in a cozy, welcoming environment, Melissa was allowed to walk around freely, listen to meditative music, labor in various positions both in bed and in water, and have the natural labor and delivery she’d always wanted and had a healthy, 8 pound 1 ounce little girl. Shortly after baby Caroline was born, big sister Desi cut the umbilical cord.

Where did she find this accommodating birthing suite and supportive, staff? In her home. Assisted by a lay midwife, a doula, her husband and her young daughter, Melissa delivered a healthy baby girl at her family’s house on Dogwood Lane in Florence.

“This birth was everything I wanted it to be,” says Melissa. “And the people who helped me were friends and family, not strangers, who honored my wishes and let me know that I was in control. I wouldn’t change anything about this experience.”

If the Mississippi Board of Nursing has its way, as of July 1, home birth with the assistance of a certified, direct-entry midwife in Mississippi will not be a legal option for expectant mothers. House Bill 695, which passed the house on February 9, will effectively repeal a provision that currently protects lay midwives, whose education does not necessarily include a medical license, from prosecution. Not only would HB 695 limit the practice of midwifery to certified nurse midwives (CNMs), it would criminalize lay midwifery.

Many argue that home birth without an attending physician or nurse is risky, that it is a crude and archaic practice that has no place in modern American society. House Representative Stephen Holland, chair of the Public Health and Welfare committee, says, “We’ve had midwives. It’s an old cultural experience. All my parents and grandparents were delivered by midwives, so I understand the experience. But,” he continues, “I would hope that anybody, if they’re going to deliver at home, would want a medical presence or someone who has had a wealth of experience delivering babies, to be there… not just someone random person who says, ‘Hey, I know how to deliver a baby.’"

Home birth advocates say there is nothing random about home birth.

Melissa, a registered intensive care nurse at a local hospital, assessed the health risks and benefits to both her and the baby and chose home birth when her options were narrowed by her OB/GYN.

“We did not initially set out to have a home birth,” she explains. “I originally wanted to have a VBAC [or Vaginal Birth After Cesarean] in a hospital. As a nurse, I already knew that VBAC was considered too risky by some physicians, so I was reluctant to bring it up to my first obstetrician. When I finally did, he basically told me that if I wanted to continue our doctor-patient relationship, I’d have to change my mind and have a C-section.

“I didn’t want that,” she continues, “so I found another doctor who was more supportive of VBAC, but only under one condition—that I agree to be induced using pitocin. According to my research, pitocin-induced labors carry an increased risk of complications, including uterine rupture in VBAC patients. I felt that the risk was too great to me and my unborn daughter. Plus, according to some studies, pitocin-induced women are more likely to end up delivering with a C-section anyway. That was exactly what I didn’t want, so this option didn’t appeal to me, either.” Given these choices and based on their research, Melissa and Jerry decided that home birth was their safest option.

According to a 2000 study of planned home births in North America, home birth under the supervision of an experienced, non-nurse midwife is a safe alternative for low risk pregnancies. The study finds that low risk mothers delivering at home experienced lower rates of medical intervention when transferred to a hospital. Results of the study also show that both low risk home births and low risk hospital births are associated with similar infant mortality rates, indicating that assisted home birth is no less safe that hospital delivery.

Although the medical establishment considers expectant mothers with gestational diabetes to be high risk, Melissa insists that it did not exclude her as a candidate for home birth with a lay midwife. After her OB/GYN’s initial diagnosis, Melissa credits medical awareness and vigilant attention to nutrition with keeping her healthy enough for home birth. “The only time my blood glucose level was elevated was during the oral glucose tolerance test,” she states. “After that, my blood glucose levels stayed within normal range throughout my pregnancy.”

Nancy White, another Jackson mother and home birth advocate, delivered the last of her four children at home three years ago. “I was diagnosed with gestational diabetes by my OB/GYN,” she says. “Once under the care of my midwife, I had to turn in weekly food logs and continue to monitor my blood sugar with a glucometer,” she explains. Like Melissa, Nancy was successful in controlling her gestational diabetes through diet and delivered a healthy baby girl with the assistance of a non-nurse midwife and experienced no complications.

In addition to healthier mothers, newborns reap health benefits when born at home under the guidance of an experienced midwife. A Canadian study published in 2009 demonstrated that babies born at home were less likely “to require resuscitation at birth or oxygen therapy beyond 24 hours” and less likely to experience meconium aspiration, which can be a sign of fetal distress.

Healthy mothers and healthy babies are top priorities of both health care providers and the families involved. Out of pocket cost is another consideration. The average home birth in Mississippi costs $1500 to $2000 compared to approximately $5000-8000 for a natural vaginal delivery in a hospital and $8000-12,000 for a C-section without complications. If Nancy had utilized her midwife for the entire pregnancy, prenatal care, home birth and postpartum care would have cost less than $1500 total. Since she began using a midwife later in her pregnancy, Nancy’s family ended up paying about half that, “which was nearly equal to our insurance deductible,” she recalls, “so, we basically broke even.”

Melissa’s case was different. “Because I have insurance through the hospital where I work, our out of pocket cost for a home birth was higher than it would have been for a C-section in a hospital,” she explains. “It was worth it to me and my family to pay outright for home birth.”

While Melissa and Nancy both had insurance that would have covered all or most of the cost for hospital delivery, this is not the case for the many uninsured and under-insured expectant mothers in Mississippi. Home birth and midwifery advocates insist that assisted, planned home birth is a safe, affordable alternative for women with low-risk pregnancies, particularly in low income areas of the state.

While safety, health and cost are major concerns for any expectant mother and her family, lay midwifery and home birth advocates believe that freedom of birthing choice is an oft overlooked consideration. If home birth is removed from the list of legal options, many fear that midwifery will go underground and mothers—particularly those in low-income areas or with cultural or religious objections—may attempt unassisted home births, thus increasing the risk to these women and their unborn babies.

Rep. Holland understands this. “If you want to deliver unassisted birth, quite frankly, the bill doesn’t do anything about that,” he acknowledges. “People are thinking their rights are being violated because they want to deliver their baby with their neighbors and everyone standing around in the bedroom. Well, this doesn’t prevent that.

What HB 695 prevents is assisted home births supervised and attended by non-nurse midwives. "[Criminal prosecution} is only for people who hold themselves out to be midwives," Holland explains. "If you don’t hold yourself out to be a midwife, this bill don’t [sic] apply to you. And if you want to have your preacher or your significant other deliver your baby, this bill doesn’t apply to that, either.”

Unnecessary medical intervention is another concern. “If I had gotten pregnant later and had to deliver my baby in a hospital after July 1 because of HB 695,” Melissa concludes, “my choices would have been limited and I would have likely ended up having an unnecessary Cesarean section.”

If HB 695 is passed, the Mississippi Board of Nursing will be responsible for formulating the rules and regulations for certified nurse midwives. Although Dr. Melinda Rush, Executive Director for the MSBN, agreed to an interview for this article, she was not made available for comment.

HB 695 has passed the House of Representatives and is now before the Senate Public Health and Welfare Committee where it was expected to die. However, sources say that the bill has picked up momentum and may, indeed, come to a vote later today.

“I urge all women of child-bearing age to contact their state legislators to preserve our child-bearing rights in Mississippi,” says Nancy.

MS Digital Daily

ICAN 2010

We are planning an ICAN meeting for February. It will probably be on a Tuesday night. Please contact icanofjacksonms@gmail.com if you are interested in meeting with us for our first meeting of 2010. Also, let us know if you know of any birth related expos where we can set up a booth for ICAN.