Mother-Baby Friendly Care is evidence-based, high quality maternity care which can improve health outcomes for mothers and babies, reduce costs of maternity care, and help achieve public health objectives for maternal and infant health. Mother-Baby Friendly Care combines the “Ten Steps of the Mother-Friendly Childbirth Initiative for Mother-Friendly Hospitals, Birth Centers and Home Birth Services and the “Ten Steps of the Baby Friendly Hospital Initiative (BFHI) developed by the WHO and UNICEF to promote a breastfeeding supportive hospital environment.

“Heart and Hands The Art and Science of Mother-Baby Friendly Nursing, A Proposal for High Quality Maternity Care,” a training for hospital labor and delivery nurses and nurse-managers will be offered in Los Angeles May 22, 23, 24, 2012. To learn about the health benefits and potential health care cost reductions of Mother-Baby Friendly Nursing, maternity care nurses, nurse managers, and hospital administrators are invited to attend a free Introduction and Information Session to Mother-Baby Friendly Nursing on Thursday, February 23, 2012 from 2:00pm-5:00 pm at the California Endowment Center for Healthy Communities, Sierra 2 Room, 1000 N. Alameda Street, Los Angeles, California, 90012. The Information session will be simultaneously offered as a webinar and will be available for future viewing on the Coalition for Improving Maternity Services website.

The training is co-sponsored by The Association for Wholistic Maternal and Newborn Health in collaboration with the Coalition for Improving Maternity Services, and Educate. Simplify. Creative Resolve Healthcare Training Company.

Representative Lucille Roybal-Allard (CA-34) will be recognized at the event with the Champion for the Mother-Friendly Childbirth Initiative Award for her legislative initiative, the MOMS for the 21st Century Act (HR 2141, 112th Congress) by the project’s collaborating organizations. The Maximizing Optimal Maternity Services for the 21st Century Act  places a national focus on evidence-based maternity care practices to help achieve the best possible maternity outcomes for mothers and babies.

In a press release, Congresswoman Lucille Roybal-Allard stated, “Despite the vast body of knowledge regarding best evidence-based maternity care, current maternity practice does not follow that research. For example, the widespread over-use of maternity procedures including Cesarean sections and scheduled inductions, which credible evidence tells us are beneficial only in limited situations, has resulted in longer maternity hospital stays and multiple costly procedures…sadly, despite our exorbitant expenditures on maternity care, childbirth continues to carry significant risks for mothers and babies, especially in communities of color.”

In its report, The Future of Nursing: Leading Change, Advancing Health, the Institute of Medicine (IOM) concluded that nurses can play a vital role in helping to transform the health care system and can and should play a fundamental role in its transformation. The role, responsibilities and education of nurses will need to change to meet the increasing demand for safe, high-quality, and effective health care services.

Maternity care nurses are on the front lines, and the Mother-Baby Friendly Nursing educational program can serve as an evidence-based guide to assist labor, delivery and neonatal nurses provide safe, high-quality and effective care.

To register for the free February 23rd Introduction and Information session link to http://mother-baby-friendly-nursing-training.eventbrite.com/ .

To register for the free webinar that will be available from 2pm to 5pm that day link to https://www4.gotomeeting.com/register/852801407 .

To find out more about the Mother-Baby Friendly Nursing or to bring the training to your community, please contact Cordelia Hanna-Cheruiyot by phone at 626-388-2191 or Email: cordeliahc@socalbirth.com .

blog post updated, 2/19/2012, 5 pm

The report also confirmed that there are psychological costs that are often overlooked. Postpartum anxiety, depression,  and post-traumatic stress disorder (PTSD). Cesareans affect maternal-infant attachment and breastfeeding as well.  The cesarean rate in California and the United States increased by 50 percent between 1998 and 2008. It rose from 22 percent to 33 percent in ten years. Researchers found no data to document any population-level benefit to mothers or newborns associated with the  increased rate of cesareans.

The authors state, “Today providers seem to see no ‘downside’ to a high cesarean rate; and women seem increasingly accepting of the prospect of a cesarean.”

California healthcare payers pay hospital charges of $24,700 for a cesarean compared to $14,500 for a vaginal birth. The authors state physicians, healthcare payers, employers who pay for childbirth costs, and public health officials are not aware of the “disconnect” between the amount of dollars spent and the health outcomes in U.S. maternity care.

The authors of  Cesarean Deliveries, Outcomes, and Opportunity for Change in California: Towards a Public Agenda for Maternity Care Safety and Quality found that the increasing cesarean rates can be attributed to two main reasons: cesareans performed on mothers having their first baby and the dramatic decline in VBACs.

The number of cesarean performed during labor vary widely and reflect individual physician discretion rather than clear medical indications.  In fact researchers found that 90 percent of the variation in cesarean rates during labor is due to only two indications: failure to progress and non-reassuring fetal heart tones (fetal distress).  The number of cesareans performed for these two indications vary widely and depend on the physicians’ individual response to these two conditions.  Attitudes of physicians and nurses on the labor and delivery unit also play a part.

The White Paper showed that overall, hospital cesarean rates in California varied from 18 percent to over 50 percent of all births. Hospital cesarean rates for low-risk mothers giving birth for the first time varied from 9 percent to 51 percent. More recent data showed that in 2009 hospital cesarean rates in California varied from 16 percent at Sutter Davis Hospital in Davis to 68 percent at Los Angeles Community Hospital.

The Joint Commission, an independent, not-for-profit organization that accredits and certifies more than 19,000 health care organizations and programs in the United States, states, “Hospitals with CS rates at 15-20% have infant outcomes that are just as good and better maternal outcomes. There are no data that higher rates improve any outcomes, yet the CS rates continue to rise.” 

The argument has often been made that hospitals with high cesarean rates have a higher proportion of high-risk births and that rising cesarean rates are due to “maternal request.” This report clearly shows that there is no foundation to these arguments.

With regard to the decline of  VBACs, researchers say it will take persistent pressure from childbearing women and advocates for evidence-based practice in childbirth, public reporting of  hospitals who support VBAC and increased awareness by childbearing women about the safety and benefits of VBAC. Citing a national survey  of women’s experience of childbirth, the authors found that reality-based television shows on childbirth and many websites send an incorrect message that cesareans are easy, pain-free, and risk-free. Most women have very little knowledge of  common hospital procedures and their impact on the normal progress of labor.

Based on interviews of California careproviders, the report found that VBAC is also “not popular” with physicians due to the longer time commitment needed for a vaginal birth and their perception of increased liability.

“Whatever the motivation for today’s more ‘defensive’ approach to delivery,” the authors state, ” it is not resulting in better outcomes for babies or their mothers.”

The White Paper is an extensive and insightful study of the rising cesarean rate in California, the health risks of surgical birth, the medical factors driving the trend, and the socio-cultural factors that keep cesarean rates high. It also dispells several myths about cesarean section.

The report includes a valuable, multi-faceted response to reducing cesareans. Strategies include, quality improvement measures, examining hospital practices that lead to cesareans, public reporting of hospital cesarean and VBAC rates, payment reform, and an education campaign to increase awareness about the short- and long-term health risks of cesareans for mothers and babies.

The authors make a  strong recommendation to use several facility-appropriate approaches at the same time since many of  “these interventions interact positively with and reinforce each other, making the whole greater than the sum of its parts.”

The White Paper is a collaborative report by researchers from the California Maternal Quality Care Collaborative, the Pacific Business Group on Health, and the California Perinatal Quality Care Collaborative.

Resources

To find out more about reducing the odds for “failure to progress,” during labor, see

Six Lamaze Healthy Birth Practices

To see how Contra Costa Regional Medical Center in California made changes to support women who want to plan a VBAC, see the video

The Birth After Cesarean Improvement Project

To find out more about what some hospitals are doing to reduce cesareans, see

Michigan Health & Hospital Association Keystone Center- Obstetrics

Sutter Health, California,

West Virginia Perinatal Partnership- First Baby Clinical Initiative

For a list of support groups for mothers who experience psychological stress after a cesarean see,

Support Groups 

To find out more about hospital intervention rates and what mothers think of their careproviders, see

The Birth Survey

Recently, there has been a long-awaited call by academics, healthcare quality improvement groups, business groups, hospital associations and state lawmakers to bring down the number of cesareans. To reduce the number of maternal and newborn complications associated with the surgical procedure as well  reduce healthcare costs.

Some in the medical community are also trying to increase access to VBAC by redefining ACOG’s restrictive recommendation to have a surgical team “immediately available” for all women laboring for a VBAC regardless of their risk status. Although there is nowhere near agreement about what the ideal cesarean rate should be, there is an increasing awareness that mothers and newborns should not be subjected to unnecessary health risks associated with the operation when health outcomes are not improved.

More than 4 out of 10 births in the U.S. are paid for by Medicaid  and shrinking state budgets make cesarean section, a high-ticket item,  a logical focus of expense cuts. In 2009 the average cost of a cesarean section ranged from $13,000 to $20,000 compared to $11,400 for a vaginal birth.

Research has shown that non-medically indicated early elective deliveries (between 37 and 39 weeks gestational age)  are associated with short and long-term neonatal morbidities,  increased neonatal deaths and no health benefits for  mothers. Repeat cesarean sections puts mothers at increased risk for death.  There is now a nation-wide focus on reducing elective (medically unnecessary) cesareans before 39 completed weeks of gestation. Elective inductions before 39 completed weeks are also associated with poor birth outcomes.

According to the Leapfrog Group, a leading national non-profit organization that helps employers with value-based purchasing of healthcare, several hospital associations and state health departments have been actively working to  lower their elective delivery rates.

In an editorial in the August 2011 issue of Obstetrics & Gynecology Dr. John T. Queenan’s commentary, How to Stop the Relentless Rise in Cesarean Deliveries, warns colleagues that the U.S. cesarean rate is likely to reach 50% unless cesarean rates are reduced and access to VBAC is increased. Dr. Queenan’s recommendations for lowering cesarean rates include evidence-based patient education on the benefits and risks of cesareans, increasing the number of midwives who attend low-risk women, paying physicians a higher reimbursement rate for supporting VBAC and retraining physicians in the art of vaginal breech birth.

Despite a recommendation by the National Institutes of Health Consensus Development Conference on VBAC that ACOG should reconsider its controversial and confusing guidelines that call for an “immediately available” surgical team for all women who labor for a VBAC, current guidelines have not changed. However, some physicians are looking for ways to increase access to VBAC.

In an article by James R. Scott, MD, titled, Vaginal Birth After Cesarean: A Common-Sense Approach, also published in the August 2011 issue Obstetrics & Gynecology, Scott presents a positive and flexible approach to support women who want to labor for a VBAC without increasing providers’ exposure to malpractice suits. “We need to do what is best for the patient,” he writes despite fear of malpractice suits. This is an ethical approach to caring for women with a previous cesarean that has not been considered for more than a decade.

Scott refers physicians to the evidence-based protocols of the Northern New England Perinatal Quality Improvement Network (NNEPQIN) VBAC Project risk stratification method that hospitals can use to provide care for women who labor for a VBAC in community hospitals, dismissing the assumption that only facilities that care for high-risk childbearing women can provide safe care for VBAC.

In the September 2011 issue of Obstetrics and Gynecology Dr. Howard Blanchette of New York Medical College argues that contrary to common belief, the rise in cesarean sections has led to increased adverse health outcomes for mothers and newborns.”  In his commentary, The Rising Cesarean Delivery Rate in America: What Are the Consequences?, he urges physicians to “reduce the primary cesarean delivery rate and avoid the performance of a uterine incision unless absolutely necessary.” His recommendations for reducing the cesarean rate include promoting support for women who want to plan a VBAC and refraining from performing a cesarean on first-time mothers for failure to progress (dystocia) until they are in the active phase of labor (4 or more centimeters of dilation).  A recent Yale University study found that primary cesarean births (first cesarean) accounted for 50 percent of the increasing cesarean rate in the U.S. and that non-progressive labor was a subjective indication for performing a cesarean which contributed more than other more objective indications (such as placental problems and  malpresentation) to the increase in cesareans.

A one tenth of one percent decrease in the U.S. cesarean rate, an increased awareness of the health implications of a surgical birth and a call for fewer cesareans and more VBACs is a trend we have not seen in decades. Whether or not this trend will continue and how many years it will take to make a significant dent in the cesarean rate is yet to be seen.

The project creators of One World Birth are Toni Harman and Alex Wakeford. Their mission is to make birth better and safer around the world and to empower women to make informed choices about childbirth.

The documentary film begins with a quote from Thomas Jefferson. “Every generation needs a new revolution.”

One World Birth is a global cross-media film project that is also building a community of birth professionals to connect, inspire and to help deliver change. Featured in the film are world renowned birth professionals, researchers and maternity care academics including Sarah Buckley, Michel Odent, Sheila Kitzinger, Debra Pascali-Bonaro, Ina May Gaskin, Soo Downe, and Elizabeth Davis.

Using social media, the producers aim to encourage local action, campaign for policy change, press for media coverage and when the time comes seize the moment.  The trailer of One World Birth which has been on their website for several weeks has already fired up birth activists around the world to create sub-titles for the film in more than seven languages.

Co-creator Toni Harman makes the important point that; “One World Birth is also about YOU! Everyone loves hearing from the leading experts, but what makes this site even more exciting is that we want to include the midwives, doulas and campaigners who are at the front line of birth as your stories are vital to the bigger global picture!”

One World Birth gives everyone around the world who believes that change in childbirth is long overdue the opportunity to get involved and make changes in their own communities.

If given the option to labor for a VBAC, about 75 percent of women would give birth normally and avoid exposure to the risks of a surgical delivery.

On August 22nd ACOG issued this press release to raise awareness about the risk of pulmonary embolism related to cesarean section and published Practice Bulletin #123 “Thromboembolism in Pregnancy” in the September 2011 issue of Obstetrics & Gynecology.

New Recommendations to Prevent Blood Clots
During Cesarean Deliveries Issued

Washington, DC — In an effort to reduce maternal mortality due to blood clots—a leading cause of maternal death in the US—The American College of Obstetricians and Gynecologists (The College) now recommends that all women having a cesarean delivery receive preventive intervention at the time of delivery. The new recommendation was released today along with updated guidance for the prevention, management, and treatment of blood clots during pregnancy.

Thromboembolism—blood clots which can potentially block blood flow and damage the organs—is a leading cause of maternal morbidity and mortality in the US. The majority of blood clots in pregnant women are venous thromboembolism (VTE), usually occurring within the deep veins of the left leg. “Cesarean delivery is an independent risk factor for thromboembolic events—it nearly doubles a woman’s risk,” said Andra H. James, MD, who helped develop the guidelines. Most women who develop clots in the lower extremities will have pain or swelling in the leg. Sometimes, clots travel to the lungs causing a life-threatening condition known as pulmonary embolism. Symptoms include sudden shortness of breath, chest pain, and coughing.

“Fitting inflatable compression devices on a woman’s legs before cesarean delivery is a safe, potentially cost-effective preventive intervention,” said Dr. James. “Inflatable compression sleeves should be left in place until a woman is able to walk after delivery or—in women who had been on blood thinners during pregnancy—until anticoagulation medication is resumed.” The College notes, however, that an emergency cesarean delivery should not be delayed for the placement of compression devices.

Pregnancy is associated with a four-fold increase in the risk of thromboembolism. Clotting problems are more common among pregnant women because of the physiological changes that accompany pregnancy, such as blood that clots more easily, slower blood flow, compression of pelvic and other veins, and decreased mobility. Other risk factors include a personal history of VTE, an increased tendency for excessive clotting (thrombophilia), and medical factors such as obesity, hypertension, and smoking.

“VTE is a major contributor to maternal mortality in this country. The risk of VTE is increased during pregnancy and the consequences can be severe,” said Dr. James. The recommendations explain how to monitor women for these events, address certain risk factors, and treat suspected or acute cases of VTE. “It’s important for ob-gyns to adopt these recommendations to help reduce maternal deaths.”

The College recommends preventive treatment with anticoagulant medication for women who have had an acute VTE during pregnancy, a history of thrombosis, or those at significant risk for VTE during pregnancy and postpartum, such as women with high-risk acquired or inherited thrombophilias. Women with a history of thrombosis should be evaluated for underlying causes to determine whether anticoagulation medication is appropriate during pregnancy. Most women who take anticoagulation medications before pregnancy will need to continue during pregnancy and postpartum.

“Because half of VTE-related maternal deaths occur during pregnancy and the rest during the postpartum period, ongoing patient assessment is imperative,” Dr. James noted. “While warning signs in some women may be evident early in pregnancy, others will develop symptoms that manifest later in pregnancy or after the baby is born.”

# # #

According to a World Health Organization report on maternal mortality, in 2010 the United States ranked 50th among 59 developed countries.

In the September issue of Obstetrics & Gynecology, Howard Blanchette, MD of New York Medical College wrote an article entitled, The Rising Cesarean Delivery Rate in America, What Are the Consequences?

He writes, “In 1998 when the cesarean delivery rate was 21.2% in the United States, the maternal mortality rate was 10 per 100,000. In 2004, with a cesarean delivery rate of 29.1%, the maternal mortality rate increased to 14 per 100,000…To reverse the trend of the rising cesarean delivery rate in America, we as obstetricians must reduce the primary cesarean delivery rate, and avoid the performance of a uterine incision unless absolutely necessary for fetal or maternal indications. For women with one previous low transverse cesarean delivery we must promote a trial of labor after previous cesarean delivery…We must constantly remind ourselves, Primum non nocerum (First do no harm).

Dr. Vadeboncoeur searched long and hard through her personal journey to better understand what led to the cesarean birth of her first child and why that experience impacted her life so profoundly. Her pursuit of a Ph.D. after the birth of her children was in great part a means to conduct research into the maternity care system and the high rate of cesareans .  Although it was challenging for her to find a care provider to support her wish for a normal birth in her second pregnancy, she found that experience to be transformational. That is why she wants women to know that it’s possible for them to avoid a routine repeat cesarean and have a safe normal birth.

The book begins with an assessment of the historical and current perspective on cesarean and VBAC. How the beliefs of the day regarding the safety and indications for cesareans have changed in the last three decades and how widespread non-medical indications for cesarean have increased the cesarean rate. Cesarean section, the most common major operation in the world is examined within the current climate of fear of childbirth, the undervalued process of normal birth and the highly charged medico-legal climate in the United States.

The author believes that birthing decisions  should be made by women and their partners and writes in her Introduction, “We women need to have our say because we’re the people most immediately affected by birth.” Vadeboncoeur’s respect for women’s autonomy and empathy for each woman’s  personal journey towards making a decision about how she wants to give birth is reflected throughout the book.

She presents factual information and her personal point of view without judgement. Her guide offers women a balanced view of the benefits and risks of repeat cesarean and VBAC. Even women who decide that a repeat cesarean is best for them can benefit from the advice given about how to have a satisfying cesarean birth.

Mothers considering a VBAC will get an honest estimate of the level of risk  that they are likely to face and how likely they are to give birth on their own.  The author also covers a wide range of issues that are likely to affect a VBAC – having had one or more cesareans, the time interval between the current pregnancy and the prior cesarean, whether or not labor is induced, having had a vaginal birth and if single or double layer sutures were used to close the cesarean incision.

Dr. Vadeboncoeur makes a convincing case  for why it’s worth the effort to consider a normal birth after a prior cesarean. Overall, VBAC is safer for women than major abdominal surgery especially if they are considering having several children. Normal birth makes it easier for babies to adapt to extra-uterine life, breath on their own and begin breastfeeding. Mother-infant attachment is more likely to be successful.  Emerging research is also helping us to understand the complex science of hormones and the significant part they play for mothers and babies during the process of normal birth.

Throughout the book Vadeboncoeur shares with women that giving birth normally can be an empowering, transformative and fulfilling experience when they work together with their care provider to plan the birth experience they want. Women considering a VBAC will find useful and realistic information about how best to prepare for a VBAC- before and during pregnancy as well as during labor and birth.

Given how difficult it is in North America today to have access to caregivers and hospitals who support vaginal birth after cesarean the author also provides her readers with advice about how to increase their odds of finding a supportive provider and how to reassess the need for medical interventions proven to reduce their chances of having a normal birth.

Birth is a powerful emotional and psychological experience that impacts women’s well being, their self-confidence and self-esteem and their capacity for early parenting. To help women explore and understand how their cesarean  may have impacted them and to help them heal from a traumatic birth Vadeboncouer writes  with compassion and wisdom about the value of revisiting their experience so as to better prepare for a normal birth. “It is possible that some of this book will shock you,” she writes. “That emotions about your previous cesarean(s) will resurface for the first time, or that they will re-emerge, even if you think you’ve put those feelings behind you. Don’t let that stop you. As you will see when you read the birth stories in this book…this is perfectly normal.”

The book is enriched by many  birth stories of women who have had a wide range of birth experiences. Personal accounts of women who began searching for a VBAC-friendly provider soon after their first cesarean as well as of women who, reluctant at first eventually did labor for a  VBAC. We also read about the women who labored for a VBAC but ended up needing a cesarean. Vadeboncoeur’s own personal birth experience and the stories that are weaved throughout the book give an honest account of what women experience when seeking providers, a safe place for birth, and support for labor.  Above all, the stories are testimony to what women can accomplish despite the many obstacles they find in a health care system that stacks the odds against them.

Fathers as well as mothers will also find Vadeboncoeur’s partner’s honest account of his experience of the birth of his two children very valuable. Although both children are now adults, it is revealing to find out how birth is also vividly remembered by fathers. Although Steve was a constant companion throughout both of  Hélène’s pregnancies and births he admits that during the first long birth that ended with a cesarean under general anesthesia he at times felt “a sense of impotence.”  When finally the couple found a supportive provider that would “allow” laboring for a VBAC  the conditions at the hospital were not quite as expected. The staff reflected anxiety and fear. “We did not experience this VBAC in peace and harmony,” Steve writes. “It was almost as if we felt that having a VBAC was a sin.”

This valuable book is available in both an American and a British edition. My only reservation is that having read Vadeboncoeur’s book in French, as originally published in Canada, occasionally I found myself, while reading the American translation, occasionally stumbling over a sentence or two that lacks the natural flow and cadence of the English language.  Overall, this comprehensive, well-researched and sensitively written book is a real find.

To find out more about Hélène Vadeboncoeur’s book and her  perspective on normal birth and cesareans, read her Three-Part Interview on Lamaze International’s Science & Sensibility blog.

The number of women who do give birth vaginally after a prior cesarean vary widely among providers, hospitals, states, and countries.  To better understand the non-clinical factors that encourage women to labor after a prior cesarean and which models of care influence physicians and hospitals to support VBACs, researchers from Australia conducted a systematic review of 700,000 births in studies published up to 2008 that included data from several countries.  The review was published in the August 2011 issue of the Journal of Advanced Nursing.

Although studies have shown that clinical factors such as induction of labor, use of labor epidurals, and x-ray pelvimetry can impact VBAC success, the authors of this study focused on non-clinical, system-led interventions such as practice guidelines and physician characteristics that promote VBAC and increase the number of women who do end up having a normal birth.

Researchers found several non-clinical interventions that had a significant impact on increasing VBAC rates.

Provider Guidelines, Policies, and Programs for Cesarean or VBAC

After the publication of the first U.S. National Institutes of Health Consensus Development Conference on VBAC in 1980, the VBAC rate in ten hospitals increased from 11% to 29% and the overall VBAC rate rose from 6% to 16%.  When in 1992 Florida state legislation mandated the distribution of cesarean practice guidelines to all obstetricians the state VBAC rate increased from 22% to 31%. A 1996 study showed that across 55 U.S. hospitals VBAC rates increased from 12.6% to 18.5% when the then current ACOG guidelines were widely distributed. (The ACOG recommendation that emergency services be “immediately available” for all women laboring for a VBAC in hospital was first introduced in 1999 and has led to the most recently reported 8.4% national VBAC rate.)

When a small Canadian community hospital changed its practices following the National Canadian Consensus Conference on Aspects of Cesarean Birth (1985) the number of women who labored for a VBAC increased from 7% to 79%.

Local guidelines developed by individual U.S. hospitals also had an impact. When clinicians were encouraged to take a more conservative approach to cesareans, the number of women who labored for a VBAC increased from 32% to 84% and the number of women who did have a vaginal birth increased from 65% to 84%.

The successful approach to increasing VBAC in two studies (published in 2006 and 2008) had a long-term impact. After six years, despite the fact that the number of women with a prior cesarean doubled (7-14%) the number of women who labored for a VBAC remained high and VBAC births increased from 53% to 70%.  Only one study published in 2001 reported negative results, a 7% decline in VBACs despite hospital and management policies that encouraged physicians to support VBAC. This study reflected the national trend of declining VBACs following the 1999 ACOG guidelines.

Audit and Feedback

The audit and feedback approach establishes regular audits of individual physicians’  cesarean rates and the results are reported back to the physicians with the expectation that the high cesarean rate physicians would change their practice patterns and support VBAC.  Researchers found that in the three studies they reviewed, this approach was not very successful.  However, in one study in which physicians were audited and asked to defend their decisions to perform cesareans, over a 10-year period the cesarean rate decreased and the number of women who labored for a VBAC increased from 35.6% to 54.5%.

Style of Care

Researchers also looked at how VBAC attempts and rates differed with different hospital characteristics (size, tertiary or non-tertiary), physician practice style and women’s insurance status. Two studies showed that VBAC was more likely to occur in university/teaching hospitals but one study showed no difference. One study found that although VBAC rates varied from hospital to hospital, hospitals where women were allowed to labor longer had higher rates of successful VBACs regardless of the number of women who labored after a cesarean.

When looking at hospital characteristics researchers found that women were more likely to have a VBAC in hospitals with intermediate or high obstetric resources including a higher number of beds, births, and obstetricians. Women were also more likely to have a VBAC with a female physician, with an obstetrician rather than with a GP and in hospitals with an overall lower cesarean rate. In contrast, one study reported women under the care of a family physician  (81%) were much more likely to labor for a VBAC than women under the care of an obstetrician (51%) and were more likely to actually have a vaginal birth (76% vs. 64%).  In one study published in 1998, women were more likely to try for a VBAC (76%) when their obstetrician’s cesarean rate was below 15% compared to those whose overall rate was greater than 15% (45%).  Women cared for by the low cesarean rate physicians were also more likely to end up with a VBAC (83% vs. 66%).

With regard to insurance status, researchers found inconclusive results. When comparing women with private health insurance with women covered by the public health system, two studies found no difference between the groups. One reported that privately insured women were less likely to attempt a VBAC (50% vs. 64%), another showed a significantly lower VBAC rate in privately insured women (8.1%) than in women insured by the public health system (25%) and one reported a seven times higher repeat cesarean rate for women who were privately insured.

Information Provided To Expectant Mothers

Does providing information about elective repeat cesarean and VBAC during the prenatal period make a difference on women’s choice of birth after a prior cesarean? In a Canadian study of 11 hospitals where women were randomized to either receive an educational pamphlet or to have an individual discussion with a professional, slightly more women (53%) chose to labor for a VBAC after a discussion than after having received a pamphlet (49%).  A U.K. study looked at the effects of   two computer-based decision aids on decisional conflicts compared to usual care. Women who received usual care were somewhat less likely to have a VBAC  (30%) than women who were given the computer-based decision aids ((37%).  In one study a significantly higher number of women ((63%) who participated in a prenatal educational counseling program on choice of birth after a cesarean chose to labor compared with only 38% in the control group.

Overall Conclusions

The researchers who  reviewed these studies that covered a span of 20 years concluded that non-clinical factors do have a significant impact on women’s choice for VBAC and the number of women who subsequently do have a vaginal birth. The most significant difference seems to be local “ownership of the desire to reduce CS rates or increase VBAC rates.”  Also, individual physician characteristics may impact the number of women whose choose to labor for a VBAC and have a normal birth. The study also concluded that involving women more fully in decision-making and providing evidence-based information about their options should be incorporated into the care of all women with a previous cesarean section.

She writes, “I am impressed with your website and the support that you provide new mothers. Your message of support is similar to my passion for the psychological care of women during and following childbirth, which is reflected in my primary line of research.  My interest evolved out of my clinical work with postpartum women who often reported disappointment and stress reactions related to their birth experience. There is empirical evidence that the optimal psychological functioning of new mothers has  important implications for their relationships, their personal functioning, and their children’s developmental trajectory.  However, there are few models of intervention available. I hope that through the results of my research I can gain information that can be used to develop a preventive model of intervention for women experiencing one of the most significant events in their lives.”

To participate in this study, new mothers can go online and complete an anonymous survey at https://www.psychsurveys.org/lauren/childbirth.

For additional information about the study you can contact Lauren at spoonerwl@windstream.net.

The number of women who are having an elective primary cesarean (with no medical indication)  is increasing. For a woman to make a truly informed decision about whether or not to choose a cesarean she needs access to the full range of potential risks for herself and her baby. She also needs to have the opportunity to discuss her fear of childbirth with a health professional.

This proposed Informed Consent/Refusal form for elective primary cesarean was first published in Birth: Issues in Perinatal Care, Putting Mothers and Babies At Risk: Promoting the Illusive “Cesarean Delivery On Maternal Request.” The form reflects the potential risks of a cesarean section with no medical indication. Expectant mothers may want to discuss these risks with their careprovider.

INFORMED CONSENT-REFUSAL

FOR ELECTIVE PRIMARY CESAREAN SECTION

WITH NO INDICATED MEDICAL RISKS*

I have never had a cesarean. I had a healthy pregnancy and my baby is in excellent health. I told my physician, Dr._______ that I wanted to schedule a cesarean section because_________. My physician gave me a comprehensive patient education pamphlet to read and took at least 15 minutes to speak with me and explain the possible health risks for my baby and me associated with cesarean surgery. He/she also explained the average cost difference between a vaginal birth and a cesarean section and the potential cost of NICU (neonatal intensive care unit) services if my baby developed serious complications as a result of the cesarean section.

I am afraid of the physical pain and suffering I may have if I labor. I am also afraid that I may hurt by baby while giving birth. Other reasons are_______. My physician has referred me for psychological counseling to help me work through my fears and asked that we talk about these issues again after I have completed counseling.

I understand that a cesarean section is major abdominal surgery and compared with a vaginal birth, my baby and I will be exposed to additional risks. I understand that the following physical complications from surgery are more likely:

• The doctor can cause unintended surgical injury to my internal organs, including my gastrointestinal tract, bladder, and urinary tract.

• I am at higher risk for wound, uterine, pulmonary, and bladder infection. Infection can develop within a couple of days of surgery or up to 6 weeks after the birth. Although all women who have a cesarean should be given antibiotics before the procedure, there is no guarantee that they will be available to me before my cesarean and antibiotic-resistant infections are not uncommon in hospitals.

• I am obese (or I am diabetic) and therefore more susceptible to infection.

• I will lose about twice as much blood and may need a blood transfusion.

• I am more likely to be admitted to intensive care.

• I am more likely to suffer complications from anesthesia.

• I am more likely to be readmitted to the hospital days or weeks after the birth for complications directly related to the cesarean.

• I am more likely to develop a blood clot that can travel to my lungs and cause my death.

• I am more likely to experience significant pain 2 to 6 months after the surgery.

• I am significantly more likely to suffer complications, such as increased hemorrhage and injury to my bladder or intestines, if I have a vaginal hysterectomy in the future.

• I am likely to develop pelvic adhesions (scar tissue) that will cause me abdominal pain later in life and complicate any future abdominal surgery that I may need, including another cesarean section.

• I am more likely to suffer from intestinal or bowel obstruction months or years after the cesarean section.

• I am twice as likely to die from a cesarean as from a vaginal birth.

• If I choose to become pregnant again, I am more likely to have fertility problems.

• With my next pregnancy I am more likely to have problems with the location of the placenta, and more likely to have bleeding problems, a miscarriage, and give birth preterm.

• With my next pregnancy I will be at risk for a placental abruption and a uterine rupture.

• If I give birth in the United States, I am highly likely to have no other option than a repeat operation with my next pregnancy.

• Complications from a cesarean delivery increase progressively with each additional operation.

Compared with a vaginal delivery, I understand that the following risks to my baby are more likely with a cesarean section:

• With a scheduled cesarean section my baby is more likely to be born preterm and to be physiologically and metabolically less mature, and may have difficulties with digestion, dehydration, infection, regulating his/her blood glucose level and body temperature.

• A preterm baby is more likely to have breathing difficulties when breathing on his/her own. Respiratory complications can be serious enough to require admission to a special care nursery. My baby is more likely to be at higher risk for persistent pulmonary hypertension, a potentially life-threatening condition.

• With immature liver function my baby may accumulate high levels of bilirubin (a neural toxin) and become jaundiced.

• If my baby is born preterm, he/she is more likely to have learning and behavior problems at school age.

• Being born only 1 week earlier can make a difference to my baby’s health.

• My baby and I are less likely to have skin-to-skin contact immediately after birth, an important factor for maternal-infant attachment and the initiation of breastfeeding.

• Anesthetic drugs used during surgery cross the placenta and can make it more difficult for a baby to breastfeed.

• With a scheduled cesarean section my baby is more likely to die in the first 4 weeks of life and in the first year of life.

I have discussed these risks from cesarean section for my baby and me with my physician, and at this time:

____I want to think more about having a scheduled cesarean.

____I no longer choose to have a scheduled cesarean

____I choose to have a scheduled cesarean.

Patient’s Name_______________________________________

Physician’s Name_____________________________________

*Informed Consent/Refusal form, modified from Jukelevics N. Understanding the Dangers of Cesarean Birth: Making Informed Decisions. Westport, Connecticut: Prager, 2008:53–76.

Labor anesthesia rates ranged from 21.9 percent in New Mexico and 42.5 in California to 78.2 percent in Kentucky. Women who received epidural/spinal anesthesia during labor but ultimately had a cesarean delivery were excluded and according to the study’s authors the data likely underestimates the proportion of all labors that involve epidural/spinal anesthesia.

More than three out of five women (63.4 percent) whose births were attended by a medical doctor or a doctor of osteopathic medicine (62.5 percent) received epidural/spinal anesthesia compared with less than one in two women attended by a certified nurse midwife (49.8 percent).

Although the use of epidural or spinal anesthesia is very effective at reducing labor pain, the report acknowledges that women who use this form of pain relief are more likely to be at risk for several complications:

• Increased risk of instrumental delivery (forceps or vacuum)
• Fetal malposition
• A longer second stage of labor
• Fetal distress (compared with women who receive opiates intravenously or by injection)
• Severe headache
• Maternal hypotension
• Maternal fever, and
• Urinary retention

Women in the U.S. have limited access to other non-pharmacological methods of pain relief that are not associated with these risks.

Among the three different types of vaginal delivery (spontaneous, forceps, and vacuum), more than one-half of women (60.0 percent) who had spontaneous vaginal births received epidural/spinal anesthesia during labor, compared with 83.8 percent of women who had a forceps delivery and 77.3 percent with a vacuum extraction.

The use of anesthesia for labor varied by age, race, educational level, and parity. Women under age 20 (nearly 64 percent) were more likely to have anesthesia than women 35-39 years of age (59 percent). Women over 40 were least likely (55.3 percent) to receive epidural/spinal anesthesia. Use of anesthesia for labor also differed by race. Non-Hispanic White women were the most likely to received epidural/spinal anesthesia (68.6 percent) compared with 62.1 percent of black women and 61.8 percent of Asian women.

Women with at least a master’s or doctoral degree (70.1 percent) were twice as likely to receive epidural/spinal anesthesia as women with an 8th grade education (33.8 percent). Women who gave birth for the first time (68.1 percent) were more likely to receive regional anesthesia than women giving birth to their second or higher child (57.3 percent).

The CDC reports large state differences in the percentage of mothers who receive epidural/spinal anesthesia. The differences may be influenced by  a state’s demographics as well as local, and physician practices, and hospital policies on the use of epidural/spinal anesthesia.

Resources

For additional information on the use of epidurals and risk factors associated with the procedure, see

Michael C. Klein, MD.  Epidural Analgesia—a delicate dance between its positive role and unwanted side effects in  Science & Sensibility, Part One,  Part Two, and  Part Three .

For information on coping with labor pain, see

Childbirth Connection,  Labor Pain, What You Need To Know