“Inne-CESAREA”: A Spanish language campaign against unnecessary cesareans

6 Mar

Our thanks to Ana M. Parrilla-Rodríguez, MD, MPH, FABM, LCCE, professor of Maternal and Child Health, Graduate School of Public Health, Medical Sciences Campus, University of Puerto Rico for contributing this blog post.

Statistics show that Puerto Rico continues with one of the highest cesarean section rates in the world. During the last thirty years the percentage of cesarean deliveries on the island has increased drastically from 18.2% in 1980 to 46.3% in 2010. For the last five years we have annually tripled the World Health Organization (WHO) statement that there is no reason for any country to have a cesarean section rate over 15%. This is a significant public health problem which affects, among other things, the health of Puerto Rican mothers and their babies.

In the face of this reality, the inne-CESAREA campaign has been launched. It is an initiative of the Association of Students of Maternal and Child Health at the Graduate School of Public Health, University of Puerto Rico Medical Sciences Campus. It strives to promote the empowerment of Puerto Rican women through an educational campaign for the prevention of unnecessary cesarean sections. The multi-media educational campaign is appealing, up- to-date and approved by public health experts. It  promotes the humanization of childbirth and its benefits for the health of mothers and babies. It means to address a severe public health problem represented by the unacceptably high cesarean section rates and unnecessary interventions used during labor and birth on mothers and babies.

Campaign director Javier Morales-Nazario, student in the Maternal and Child Health Program, states, “We invite mothers, their partners and relatives to embrace a different experience, where childbirth is seen as a natural process which is beautiful and full of energy.”

“A new chapter has begun in the struggle for humanized childbirth in Puerto Rico. We hope to see changes in maternal and child health care. It is time for women to be the principal decision-makers in what really belongs to them-childbirth,” adds Morales-Nazario.

This public education project encourages women to make their own decisions for themselves and  their babies. Its motto reads: “Decide for yourself, be the protagonist, take control. It includes a theme song and Hip-Hop video, a web page, presence in the social networks Facebook and Twitter, as well as educational posters and fliers. It has been endorsed and supported by over twenty local and international organizations in an effort named “inne-CESAREA Alliance”. It has received support from many people in other Spanish-speaking countries and Amnesty International is working to unite its affiliates in Latin America to join the campaign. Work is being done to caption the video in Portuguese, French, English and sign language.

To view the campaign materials in Spanish visit www.inne-CESAREA.org.

To view the campaign materials in English (a Google translation) visit www.inne-CESAREA.org.

California Community Foundation Funds a Grant for Hospital Improvements and Nursing Education

19 Feb

The California Community Foundation has awarded a grant to the Association for Wholistic Maternal and Newborn Health of Los Angeles for hospital improvements and nursing education. The Association is taking advantage of this opportunity and has developed a program to educate maternity care nurses in Mother-Baby Friendly Care.

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-Baby Friendly Maternity Care 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, 2/29/2012, 1:20 pm

California Reseachers Call For Fewer Cesareans and More VBACs

30 Jan

In a recently published White Paper by the California Maternal Quality Care Collaborative researchers in California confirmed that the high number of cesarean sections performed in the United States and in California put mothers and babies at increased risks and add significantly to healthcare costs with little evidence of health benefits.

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.



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

U.S. Cesarean Rate Dips Slightly: Is There Hope for More VBACs?

19 Nov

This week the Centers for Disease Control and Prevention released their report  on preliminary data for 2010 births in the United States. There were 4,000,279 births in 2010, 3 percent less than the year before. The cesarean section rate declined slightly from 32.9 percent to 32.8 percent, the first decline in cesareans since rates started climbing in 1996. Seventeen states and the District of Columbia however, had a higher cesarean rate in 2010 than in 2009.

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.

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