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Cesareans Are Increasingly Being Questioned

14 Mar

In a video address to the Coalition for Improving Maternity Services (CIMS) Forum participants on March 1, Michael C. Lu, MD, MS, MPH, Director of the U.S. Maternal and Child Bureau, stated, “Cesarean has its place, but given the real risks associated with cesarean it should not be performed without clear maternal, fetal or obstetrical indication…Cesarean delivery increases the risk of placenta accreta which intern increases the risk of postpartum hemorrhage and cesarean hysterectomy.“

Michael C. Lu, MD, MS, MPH, Director U.S. Maternal and Child Health Bureau

Michael C. Lu, MD, MS, MPH, Director U.S. Maternal and Child Health Bureau

In an interview with Rebecca Dekker, Ph.D., RN, of, Celeste G. Milton, MPH, BSN, of the Joint Commission expressed her concern about preventable cesareans,  “When medications are used to force labor, a first-time mom doubles her chance of having an unplanned C-section…A substantial number of unplanned C-sections are due to physicians mislabeling a woman’s labor as ‘failure to progress’- a term that research says is more aptly named ‘failure to wait.’“ The Joint Commission which accredits and certifies health care organizations wants hospitals to perform fewer early elective cesarean deliveries (before 39 weeks) and fewer cesareans on low-risk first-time mothers.

Milton stated that “physician and hospital practice patterns-not pregnant women’s conditions or their diagnoses- are the major reason for differences in C-section rates among hospitals.”  The Joint Commission has made it mandatory, as of January 2014, for hospitals with more than 1,100 births a year to publicly report on their elective cesarean rates and rates for low-risk first-time mothers.

In a recently published White Paper on cesarean section in the U.S. the California Maternal Quality Care Collaborative recently concluded:

Cesarean delivery has come to be regarded as the safer option, when in fact it has greater risks and complications than vaginal birth. Higher cesarean delivery rates have brought higher economic costs and greater health complications for mother and baby, with little demonstrable benefit for the large majority of cases. With the marked decline in vaginal births after cesarean, cesarean deliveries have become self-perpetuating; and every subsequent cesarean brings even higher risks…

Some women prefer cesarean birth, or view it as a positive experience. However, there is growing evidence that for the majority of women, having a cesarean (compared with giving birth vaginally) is associated with greater psychological distress and illness, including postpartum anxiety, depression, and post-traumatic stress disorder. Cesarean deliveries can have an adverse influence on maternal-infant contact at birth, women’s satisfaction with and feelings about the birth, their babies’ experiences, and their success with breastfeeding.

In its recent systematic review comparing harms of cesarean with vaginal birth, Childbirth Connection cautioned, “Overuse of cesarean delivery in low-risk women exposes more women and babies to potential harms of cesarean with minimal likelihood of benefit. Of particular consequence are downstream effects including childhood chronic illness and placental complications in any subsequent pregnancies. These include life-threatening complications that occur more frequently with accumulating surgeries.”

In Dr. Michael C. Lu’s video address he also emphasized that “…no woman should be subjected to unnecessary interventions and… every woman should be cared for in a system that respects her autonomy and upholds the principles of Empowerment, Do No Harm, and Responsibility (principles of the Mother-Friendly Childbirth Initiative) and be given the choice of mother-friendly maternity services…”

Caring for childbearing women according to the recommendations of the evidence-based Ten Steps of the Mother-Friendly Childbirth Initiative can effectively reduce exposure to unnecessary interventions that can lead to avoidable cesareans.





Physicians and Midwives Working Together: An Option for Mothers Seeking a Woman-Centered Birth in a Traditional Setting

4 Feb

Evidence shows that a collaborative model of care that includes physicians and midwives working together can lower interventions, the use of drugs for pain relief in labor, induction and cesarean rates and improve health outcomes for mothers and babies. Brigid Maher, a documentary filmmaker, Associate Professor of Film and Media Arts in the School of Communication at American University (Washington, D.C.) and a VBAC mother herself, wants more women to know that. In fact, in The Mama Sherpas, a full-length documentary about four physicians and nurse-midwives collaborative models of care which Maher is currently producing and directing, she seeks to educate women about birth options they may not know exist.

A Sherpa refers to a member of a Tibetan people living on the high southern slopes of the Himalayas in eastern Nepal and known for providing support for foreign trekkers and mountain climbers.

Maher’s film, scheduled to be released for festivals and broadcast in the Spring of 2015, follows the lives of several expectant mothers through the course of their pregnancies and the four different types of collaborative practices that care for them. The documentary follows expectant mothers who plan to give birth in four U.S. communities: Alexandria, Virginia; Arnold, Maryland; Springfield, Massachusetts; and the Sacramento area of California. Mothers can give birth in a hospital or a birth center.

The Mama Sherpas investigates how midwifery care, if mainstreamed into current medical practices can improve health outcomes and reduce costs. In March of 2011 the American College of Obstetrics and Gynecology and the American College of Nurse-Midwives issued a joint Collaborative Practice Statement affirming  that “quality of care is enhanced by collegial relationships characterized by mutual respect and trust, as well as professional responsibility and accountability.”

“I have two objectives for this documentary,” states Professor Maher. “The first is for general audiences who will watch the long format documentary and hopefully recognize that integrating a nurse-midwife into the prenatal experience is not and either or paradigm. You can have a collaborative experience with midwives and doctors in a hospital. What the documentary explores is what that can look like.  The second objective is for this project to be useful for care providers, NGOs and maternity care non-profits who work within a collaborative-care model or similar style of care. If for instance, a woman is going for a VBAC, what can that look like?  Following and observing a woman’s story can help women gain a better understanding of what to expect beyond a text book or a traditional info-birth video. This is where the web component- short, weekly released scenes (we have filmed) – becomes critical.”

Rather than the traditional method of releasing a trailer in advance of the completed film, Maher, Program Director of the Digital Media Skills Graduate Certificate Program at American University has chosen to begin educating women and the medical community about this collaborative model of care early on by posting weekly short scenes from what will eventually become a full-length documentary. Maher has posted scenes from the mothers they are following on vimeo.

Professor Maher has partnered with the American College of Nurse-Midwives and the Birth Options Alliance  to extend her outreach efforts. She plans to post several educational materials on the film’s website that can be used to develop a curriculum and encourage conversations to take place about the benefits of mainstreaming midwifery care into current medical practice.

To find out more about the upcoming documentary visit The Mama Sherpas  webpage  and the following social media links:


Pinterest and
















The Latest Best Evidence on the Safety of VBAC

13 Dec

Henci Goer and Amy Romano have recently published their much awaited book, Optimal Care in Childbirth: The Case for a Physiologic Approach. Their research, based on the best available evidence, makes a strong case for supporting women who want to plan a VBAC.

The most valuable aspect of their book is the fact that they have selected high quality studies that truly compare the benefits and risks of elective repeat cesarean (not medically necessary) with planned VBAC. They have only included well-designed studies that took into account confounding factors, that is, factors that can lead to a misinterpretation of results.  Optimal Care in Childbirth

The authors clearly show that some studies published in respected journals may in fact reach mistaken conclusions and confirm that the current, restrictive guidelines for VBAC  are not based on sound evidence.

In the interest of clarifying some of the confusion and misinformation regarding VBAC, here are the facts regarding VBAC based on Goer’s and Romano’s research in Chapter 6 of their book.

Who Can Labor for a VBAC?

Over 95% of women with a prior cesarean can labor safely for a VBAC without any uterine scar problems.

  • Women with more than one prior cesarean
  • Women with a single layer uterine closure
  • Women with a low vertical uterine scar
  • Women with a prior pre-term cesarean.
  • Women with a short inter-delivery interval (< 18 months since the prior birth)
  • Women of older maternal age.
  • Women with an anticipated macrosomic (more than 4000g) baby
  • Women whose pregnancy is past their due date

What are the odds that a woman who wants to labor after a prior cesarean will actually have a VBAC? 

On average the VBAC rate is 74%, but care during labor makes a difference. With usual management, studies report VBAC rates in women with no prior vaginal births ranging from 61% to 72%. With physiologic care, that is, care that supports the natural unfolding of the labor process, a study reported a VBAC rate of 81%. This means that somewhere between 9 and 20 more women with no prior vaginal births will have a VBAC with physiologic care than with usual management.

Most women with a prior cesarean will give birth vaginally, including women with the following conditions:

  • More than one prior cesarean
  • Having had a prior cesarean for:
    • Dystocia (delay in progress)
    • Macrosomia, a baby weighing more than 4000g ( 8lb. 13oz)
    • Older age
    • High body mass index (BMI)
    • Longer pregnancy duration

Women are more likely to have a VBAC if:

  • They have had a prior vaginal birth either before or after the cesarean.
  • Labor begins on its own. One reason heavier women, women carrying bigger babies, and women who are past their due date are more likely to have a repeat cesarean is that they are more likely to have labor induced.
  • They are given physiologic care-supportive of the normal process of labor with minimal use of interventions.

With proper care the risk for a scar rupture can be as low as 0.5% or 1 in 200 healthy women laboring for a VBAC.

The likelihood of a symptomatic scar separation during labor is dependent on the type of care provided to women during surgery and when laboring for a VBAC. To lower the risk for a potential scar rupture:

  • Physicians should use double-, not single–layer, suturing when closing the uterine incision.
  • Avoid inducing or augmenting labor.
  • Misoprostol should not be used for inducing labor in women with a prior cesarean scar.
  • Oxytocin should not be given to induce labor with an unripe cervix.
  • Women undergoing cervical ripening before induction should be given sufficient time for this process (longer than 40 hours).
  • Labor should not be augmented unless the fetal head is engaged in the pelvis and the cervix is dilated 3 or more centimeters.
  • Allow 12 hours between doses of PGE2 (dinoprostone) for cervical ripening and induction.
  • Women with more than one prior cesarean should not be given PGE2.
  • Allow 40 minutes before increasing the oxytocin dose.

No evidence establishes benefits in VBAC labors for the following practices, but they introduce potential harms.

  • Early admission to the labor and delivery unit
  • Routine use of I.V.s
  • Use of an intra-uterine pressure catheter
  • Forbidding food and water (NPO)
  • Establishing a time limit for women to reach full dilation and complete second stage
  • Manually exploring the uterus for scar separation after a vaginal birth

However, electronic fetal monitoring is a reliable indicator of a uterine scar rupture. Over 90% of the time a uterine scar rupture is detected by abnormal fetal heart tones (bradycardia) as documented by electronic fetal monitoring.

What are the advantages for mothers of planning a VBAC?

Accumulating cesarean surgeries increases the likelihood of:

  • Placenta previa, placenta accreta, and having the two in combination
  • Severe bleeding
  • Hysterectomy
  • Maternal admission to ICU
  • Maternal need for postoperative assistance with breathing
  • Thromboembolism
  • Ileus
  • Operative injuries
  • Adhesions

In contrast, having a VBAC decreases the risk of uterine rupture in future VBACs and increases the odds of having another vaginal birth thereby avoiding the risks of additional surgery.

For babies, accumulating cesarean surgeries increases the likelihood of:

  • Preterm birth and subsequent complications
  • Breathing difficulties
  • Admission to NICU

What are the trade-offs between having a VBAC and an elective repeat cesarean?

Although the rates are low, elective repeat cesarean increases the odds of maternal mortality. Twenty-one more women per 100,000 having elective repeat cesareans die than women planning a VBAC.

The differences is small, but 4 more perinatal deaths (deaths during labor or in the days after birth) per 10,000 occur with planned VBAC than with planned repeat cesarean. However, looking at neonatal deaths (deaths in the first four weeks after birth), studies disagree. One study reported rates of 11 per 10,000 with planned VBAC versus 5 per 10,000 with planned repeat cesarean but two others reported identical or nearly identical rates of 7 to 8 per 10,000.

Goer and Romano are optimistic that women have an excellent chance of having a VBAC when given proper care.

…a woman laboring in a low-stress environment surrounded by care providers who are relaxed and confident of her ability to give birth, who make decisions collaboratively with her, and who help her deal with any fears and anxieties is more likely to do well in labor and progress to vaginal birth than a woman who feels she needs to be in defensive mode or who feels unsafe, doubtful, or frightened.

* The information provided in this blog post is based on Chapter 6, “The Case Against Elective Repeat Cesarean,” of Goer’s and Romano’s book, Optimal Care in Childbirth: The Case for a Physiologic Approach (p 95-128).


For additional evidence-based information on the impact of cesarean section see Childbirth Connection’s just published report, Vaginal or Cesarean Birth: What Is At Stake for Mothers and Babies? A Best Evidence Review.


Only Women Have the Legal Authority to Decide How, Where and With Whom They Want to Give Birth

19 Sep

With thanks to Hermine Hayes-Klein, U.S. attorney for her assistance with this article.

On September 20th over 1,000 individuals, health professionals, and birth advocates groups will be screening the one hour campaigning documentary Freedom For Birth: The Mothers’ Revolution in over fifty countries worldwide.  This global call-to-action video directed and produced by two British film makers was inspired by and reports on the ruling of the European Court of Human Rights who in December 2010 stated that childbirth is a fundamental human right. Women have the human right to choose how, where, and with whom they want to give birth. The Court held that governments cannot use the force of law to take away their options.

On May 31 and June 1, 2012, over 300 men and women gathered at The Hague University in The Hague, The Netherlands, for a conference on Human Rights in Childbirth to discuss what it means for childbirth to be a human right and what conditions are necessary that can truly give women the right to control their own bodies. The film includes interviews with over forty birth experts from four continents and with civil rights attorneys who spoke about the new context in which the violation of women’s rights in childbirth can now be framed. Human rights are universal rights.

Hermine Hayes-Klein, the American attorney who spearheaded the Human Rights in Childbirth Conference while serving as Director of the Byrkenshoek Center for Reproductive Rights in The Hague stated,

“More than anything, the film seems to be a call to women to stand up for themselves,  for their rights around birth.  It’s also a call to lawyers, and an offer from the lawyers in the movie, to help and support women in that process. It’s essentially a kind of reframing of the birth-care conversation, isn’t it—it’s no longer just about, ‘please give us evidence-based care, and ‘joint decision-making,’ but, ‘We own these bodies, these are our babies, and the provider role is simply, only, to advise and support us on our terms.”

In Ternovszky v. Hungary, the European Court  handed down a judgment in favor of Anna Ternovszky, a Hungarian mother who brought her case to the court. She wanted to give birth at home with her midwife, Dr. Ágnes Geréb, formerly an obstetrician/gynecologist, but could not do so because it was not clear whether home birth was “legal” under Hungarian law, and midwives who agreed to attend a home birth risked being convicted.  In fact  Dr. Geréb was convicted and initially sentenced to prison and later to house arrest.

The European Court of Human Rights ruled that birthing women have the right to choose the circumstances in which they give birth, including the choice for home birth, and that their government must enable that choice as legitimate. When the state prevents a woman from being free to choose the circumstances of the birth of her children it is violating her right to privacy, her right to autonomy and her right to control her own body.

The European Court’s ruling is binding on all members of the European Union. But is the ruling of the European Court useful for those concerned with women’s birth rights in the United States or indeed other countries?, the website created to facilitate and encourage the much needed revolution for birthing women suggests that the fundamental human right recognized in the Ternovszky case is relevant in any constitutional democracy with a meaningful right to privacy and right to physical autonomy. Anna Ternovszky stood up for her rights, and so those rights were enshrined in law; her example could be followed in other courts around the world.

“As a birthing woman, you have the right to meaningful choice and genuine support for your personal needs around and during childbirth.  Nobody can tell you that you “must” do anything.  Nobody can “let you” or “not let you” do anything.  Nobody can pressure or force you into a cesarean section that you do not believe is in the interest of yourself and your baby.  Nobody can cut an episiotomy if you do not consent to one.  Nobody can do anything to your body or your baby without discussing it with you first and asking for your consent.  You have the right to be the ultimate authority over everything that occurs around your body’s birth of your baby.”

The documentary producers, Toni Harman and Alex Wakeford, parents of a four year-old daughter, organized this event to be the kick-off of what they hope will be a global  “Mothers’ Revolution,” because only mothers or expectant mothers can really bring about the change.  Following the September 20th  Premier Screening,  a 20 minute version of the documentary will be available for free download from the Freedom For Birth website. The video is available with sub-titles in 17 languages.

The producers hope to keep the momentum going and ask that those hosting the attending the screenings, please take photos and post them on their Facebook pages and on Twitter to build up a global buzz:

Women and birth advocates interested in finding out more about the Human Rights in Childbirth Conference can view a webinar, visit the conference Facebook page,  or may be able to get a copy of the conference proceedings.