Tag Archives: cesarean

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.

 

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

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.

A California Non-Profit Helps Mothers Reduce Their Odds for Cesarean By Helping To Pay For Doulas, Midwives, and Birth Center Births

2 Dec

As with many other communities in the United States, in South Orange County, California expectant mothers have unlimited access to high intervention hospital options for childbirth, including an elective cesarean section, but restricted access to a midwifery model of care in or out of the hospital. However, the Community Alliance for Birth Options (CABO), a non-profit group dedicated to helping families access non-interventive care believes that all expectant mothers should have access to birth options that meet their needs. CABO awards women, with financial hardships or lack of insurance coverage, scholarships to help pay for non-interventive maternity care services of their choice. Research shows that by giving birth with a midwife, having a doula, and giving birth at home or in a birth center women are much less likely to be exposed to the harms of routine medical interventions and less likely to have a cesarean.

In May 2008 the only hospital-based nurse-midwifery service in the community was disbanded when the OB services at South Coast Medical Center closed its doors. However, through donations and by sponsoring annual fundraisers and silent auctions CABO has found a way to provide families with the financial support they need to pay for a doula, choose a certified nurse-midwife as a primary care provider, or give birth in a birth center. Often, health insurance coverage does not include reimbursement for these services.

On December 10, 2010 CABO will hold its Holiday Evening Fundraiser at the Coto De Caza Golf & Racquet Club. Last May CABO awarded three scholarships of up to $3500. All awards are kept confidential.

CABO also provides outreach and education on alternative and complementary maternity services for women. The non-profit’s goals include advocating for evidence-based care, educating the community about the safety of low-interventive birth options, promoting collaborative practice of nurse-midwives and physicians, and advocating for change in the current health care system.

CABO and other birth activist groups who support the midwifery model of care are actively pushing back the medical establishement and insurance companies who control access to and reimbursement for midwifery care, birth centers, doulas, VBAC, and home births.

Watch a video about Beach Cities Midwifery, one option available to families in South Orange County.

http://www.youtube.com/watch?v=At65_ekEZM0

Resources For Non-Interventive Care

American Association of Birth Centers

BirthNetwork National

Citizens For Midwifery

Dona International

Mothers Naturally

My Midwife

The Big Push for Midwives

Where’s My Midwife?

What if it is a cesarean birth?

26 Oct

Although a cesarean is major surgery, it is also the birth of your baby. Find out what options are available if a cesarean section becomes necessary. This advance planning may make even an unexpected cesarean section a better experience.

  • If you have a planned cesarean, ask to have the cesarean after labor begins to reduce the baby’s risk of being born too early and having breathing problems.
  • Ask that your partner and/or labor assistant accompany you in the surgical suite.
  • Ask to  have a spinal or an epidural to allow you to be awake during the birth. This would allow you to hear your baby’s first cry, to see your baby’s face, and to breastfeed sooner.
  • Ask the anesthesiologist to avoid giving you sedatives or other drugs that might make you forget your time in the recovery room.  This way you can be alert to spend time with the baby in the recovery room, and you won’t forget that experience later.
  • Ask to hold the baby while the team completes the surgery.  For the baby to have its first exam in the operating room instead of going to the nursery.
  • Ask the anesthesiologist to give you epidural medication to extend comfort during the first 24 hours after the baby is born.
  • Take pictures, videotape the birth,  or record your baby’s first cry.
  • Ask the staff  to place your baby on your chest for a few minutes so that you can feel, see, and speak to your newborn while the physicians complete the surgery.
  • Ask to  have warm blankets after the surgery.
  • Ask that your partner go to the nursery with the baby during observation.
  • Ask that  your family and friends visit you and the baby in the recovery area.
  • Ask to have the baby with you in your room when you’re ready.
  • Ask if  your partner can stay overnight with you in your postpartum room. Is there a cot or bed for him/her  to sleep on?
  • Find out if  a lactation consultant is available to help you with breastfeeding.

Find out more about planning a cesarean from:

ICAN, Family Centered Cesarean

Penny Simkin, The Best Cesarean Possible

Mother’s Advocate video, skin-to-skin contact at the moment of birth


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