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cesarean birth

An Open Letter to ACOG

Posted by MANA Community Manager on April 10th, 2014

The American Congress of Obstetricians and Gynecologists recently released a joint statement with the Society of Maternal-Fetal Medicine on ways to reduce primary cesareans. As a part of our Cesarean Awareness Month efforts, we wanted to share with the MANA community our open letter to ACOG. We welcome your comments.

Dr. Jeanne Conry, President
Dr. Hal Lawrence, Executive Director
American Congress of Obstetricians and Gynecologists

Dear Drs. Conry and Lawrence,

On behalf of the Midwives Alliance, I am writing to congratulate you for the strong commitment to high quality maternity care that ACOG has demonstrated by developing and disseminating the Joint Statement by the American Congress of Obstetricians and Gynecologists and the Society of Maternal-Fetal Medicine, Safe Prevention of the Primary Cesarean Delivery.

In recent studies and commentaries regarding causes for the escalating rate among low-risk patients, experts suggested the increase in cesarean sections was due to maternal health issues, such as gestational diabetes and obesity, fetal issues, such as malpresentation and multiple gestation, as well as malpractice concerns affecting hospital policies and practitioners. However, this new position statement by the nation's maternal and fetal health experts suggests that modification of certain maternity care practices could in fact reduce primary surgical deliveries. The World Health Organization called for the elimination of unnecessary cesarean sections as early as 1996, yet until recently there were few resources to assist maternity care providers in achieving this goal. This new joint statement provides a critical, evidence-based and actionable guideline for both health care providers and consumers. The emphasis placed on accounting for patient preference when making these complex decisions is reflective of the value that ACOG places on patient oriented outcomes.

As you may be aware, in May 2012, MANA, ACNM, and NACPM issued a joint statement entitled Supporting Healthy Normal Physiologic Birth That statement provides a complementary evidence-based guideline for practitioners who seek to facilitate normal physiologic birth and limit obstetric interventions to those that are necessary and evidence-based. We look forward to future opportunities to collaborate across disciplines to endorse evidence-based best practices in maternity care.

I wanted you to know that MANA publicly endorses the Joint Statement on the Safe Prevention of the Primary Cesarean. We are committed to working together—physicians, nurses, midwives, hospital personnel—to strive for an integrated maternal and child health system that provides high quality care for all women and infants in the U.S.

Thank you again for your leadership and vision.

Marinah V. Farrell, President
Midwives Alliance

Marinah V. Farrell is the president of the Midwives Alliance of North America. Politics and traditional medicine is what led Marinah to midwifery, and she has a firm commitment to both political activism and birth work. Marinah has been the president of various non-profit boards, has worked in waterbirth centers and medical facilities for international NGOs, free-standing birth centers in the U.S, and has been the owner of a long standing homebirth practice. Marinah also works with various local grassroots organizations in Arizona such as the Phoenix Allies for Community Health, a free clinic in downtown Phoenix, and assists in collective endeavors with other grassroots groups. Marinah is focused on the issue of lack of access to midwives and the profession of midwifery in communities where health disparities are overwhelming, as well as training in cultural safety.

Thoughts? Comments? Please add them here.

What We Know - And What We Can Change - About Cesarean Birth in the U.S.

Posted by Midwives Alliance on April 9th, 2014

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When three women in early labor walk into a hospital in the United States, we know that one of them will have her baby by cesarean section. Why is the surgical birth rate so high, and what can we do about it? We know that full term vaginal birth with mother and baby enjoying skin to skin during the first hour, with baby at the breast, and an environment filled with love and familiar voices is what both science and instinct tell us is best for mother, baby, and family. How do we make this a reality for more women in the U.S.? Identifying the issues can help us develop the best solutions through education and implementation of what we learn.

What are some of the challenges women face in achieving normal physiologic birth?

1. Hospital birth procedures. Time limits on stages of labor, interventive or interruptive hospital routines, and lack of support for women with challenging labors and longer labors may all contribute to high c-section rates. Experience shows us that:

  • Each woman's labor has its own rhythm that works well for her and her baby.
  • Even minor interventions,  procedures, and interruptions can distract, slow down or even stop labor and can impact the progress.
  • Fetal heart monitors can restrict a woman's ability to move during labor and distract her and her team from the work at hand.
  • Continuity of care, even having one person such as a doula or midwife stay with a woman throughout her labor and birth can help her cope, decreasing the need for pain medication and increasing her confidence and ability to birth without intervention.

2. Inductions. The increasing rates of inductions may be a contributing factor in the high c-section rate.

  • Inductions with an unripe cervix or undescended fetal presenting part (the baby's head in a vertex presentation if well-flexed and low in the pelvis will work with the contractions to promote efficient labor and dilation of the cervix) may result in cesarean section.
  • The use of pitocin increases the need for pain medication, both of which may not be well tolerated by the baby and may lead to cesarean due to fetal distress - a classic snowball effect of one intervention leading to another. A new study also suggests that term newborns exposed to pitocin in labor have a higher rate of admission to Intensive Care than those who are not.

3. "Normal" pregnancy. Many "variations of normal" that used to be considered reasonable for vaginal delivery, such as breech and twins, are now candidates for routine cesarean section. Physicians may not have the training or skills to adequately assist due to inexperience in these types of vaginal births.

4. Restricted access to Vaginal Birth After Cesarean. Although we no longer believe "once a cesarean, always a cesarean," it has become harder and harder for women to find care providers to help them achieve a vaginal birth after cesarean. Although ACOG has modified its position on limiting VBACs to advanced care centers with 24 hour in-house operating room staff, liability insurance providers have been much slower to reinstate coverage to smaller hospitals who may have had excellent VBAC success rates 10 years ago but were forced to discontinue offering VBACs because of policy. Even large hospitals who have numerous providers in their on-call list may find it unrealistic to offer VBACs when all their providers are not on the same page. A woman may have to travel hours to find a provider and a hospital who will support her goal of normal physiologic birth after a previous C-section.

5. Birth culture. A cultural attitude that does not value normal labor and birth, does not believe in women's abilities to birth, and does not believe in pain as a positive force, does not foster a woman's confidence in herself, her body or her connection to her baby during labor and birth. Just recently, we saw a very public example of the devaluation of physiologic birth when a national sports commentator criticized a major league baseball player for missing the season's opening game in order to be at the birth of his child, and suggested the player and his wife should've opted for a scheduled a C-section.

Paving the Way for Change

We know that cesarean section, now considered "routine" surgery, has risks for both mother and baby, including infection, adhesions, anesthesia complications, unintended damage to mother's organs, unintended damage to baby, and respiratory compromise for baby. Repeated cesarean sections with subsequent pregnancies carry greater risks for mom with each surgical delivery. Also, delayed bonding and breastfeeding are often consequences of operating room and recovery room routines and incapacitation of mom.

Education and the implementation of our learnings are key to decreasing cesarean sections and making the benefits of normal physiologic birth available to more women and babies. Thankfully, more and more resources are available for women to get the information they need for the birth they want, including consumer organizations such as ICAN, Homebirth Cesarean International, and websites like MothersNaturally.org. For mothers who do have a cesarean delivery, they can minimize separation and delayed bonding by requesting support for skin-to-skin with baby in the operating room, breastfeeding with the help of a Certified Lactation Counselor (CLC) or International Board Certified Lactation Consultant (IBCLC) in the recovery room, and having a "mommy" surrogate (partner, family member, or friend) stay with baby for all necessary procedures and when mother is unavailable.

There are many ways we can work to make hospitals and surgical experiences more mommy, baby, and family friendly. Midwifery care in all settings, including birth centers and homebirth, is linked to lower C-section rates. Hospitals that achieve Baby Friendly certification focus on natural birth and breastfeeding. In May 2012, MANA, ACNM, and NACPM released a Joint Statement entitled Supporting Healthy Normal Physiologic Birth to provide guidance for the birth community in how we can change the culture of birth in the U.S. We are now encouraged by the recent Joint Statement for the Safe Prevention of the Primary Cesarean Delivery released last month by the American Congress of Obstetricians and Gynecologists and the Society of Maternal-Fetal Medicine as another impetus for finding solutions to the cesarean epidemic. 

This month is Cesarean Awareness Month. We have been - and will continue to - highlight stories, images, and research about cesarean birth, prevention, and VBAC all month long on Facebook and Twitter. We hope you will join the conversation with us there, and add your comments here on the blog.

Author Jill Breen, CPM, CLC, has been serving women, babies and families for 36 years as a homebirth midwife and natural family health consultant in central Maine. She has 6 children and 8 grandchildren, all born into the hands of midwives including her own. She is working on Best Practices Guidelines with several state and national task forces. She served on the MANA Board, most recently as President, and is currently Communications Chair.

 

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