C-sections increasing infant mortality

In the June entry, we examined how c-sections could be increasing maternal mortality in the United States. Now let’s examine the other half of the equation – the baby. As of 2006 our infant mortality rates fall all the way to the second worst in the modern world, according to reports published in an article by CNN (www.cnn.co m/2006/HEALTH/parenting/05/08/mothers.index./). Most of the European nations rank better, and several studies and reports have noted that the United States offers inferior health care regardless seemingly better supply of medical resources. It is also noted that those same countries regularly employ midwives as care providers while our society seems to shun these women – treating them as nothing more than relics. However, midwives are excellent assets to good prenatal care and have lower rates of c-sections.

Studies have shown that c-section babies have poorer outcomes than their vaginally born peers. One such study published in Birth looked at a group of babies born in uncomplicated vaginal births and a group of babies born by planned, uncomplicated c-section births (www3.interscience.wiley.com/cgi-bin/fulltext/118622106/HTMLSTART). When the two groups were compared, it was found that babies born via c-section had higher mortality rates. Another such study published in BMJ also concluded that infants in the occipital anterior position faired better during vaginal delivery than a c-section – either planned or not (www.reuters.com/article/healthNews/idUSSAT17412420071031). Why would this be? As previously discussed, there are risks involved with a c-section, such as a potential for injury to the baby during the incision process. Also, babies born via c-section do not have the benefit of passing through the birth canal where some of the fluid in their lungs is pushed out, leading to higher rates of respiratory distress. Of course, there are many more risks involved, but these are just two examples of what could go wrong during a c-section.

Another factor in this epidemic would be the number of elective c-sections being performed prior to 40 weeks. Because each baby is different, we run the risk of extracting a baby from=2 0the womb before s/he is fully developed and ready to be born. The March of Dimes discusses the risks associated with being born prematurely as difficulties in breathing, feeding, temperature regulation, and jaundice (www.marchofdimes.com/pnhec/240_19673.asp). With the increase of non-medically needed, elective c-sections comes the increase of babies being born prematurely. Prematurity increases mortality. The CDC lists prematurity as being the second leading cause of death in infants (www.cdc.gov/MMWR/preview/mmwrhtml/mm5642a8.htm). A study published in Pediatrics also found that preterm births account for a little over one third of infant deaths. This is alarming in a country where we seem to have so many neonatal intensive care units.

So what should we do to decrease the infant mortality rate? First of all, we should look to our peers in Europe and Japan to see what type of care they provide. As previously stated, those countries tend to treat midwives more like competent care providers and trust the thousands of years of collective experience midwives have accumulated throughout the history of humankind. Secondly, we should seek to increase educational outlets for women aspiring to become midwives and teach our doctors, doctoral students, patients, and others involved in patient care about the risks involved with ro utine medical interventions. We want healthy families – that means both healthy mothers AND healthy babies!

Florida Friends of Midwives Responds to the Closure of Miami Dade College's Midwifery Program

Despite strong opposition from the community, Miami Dade College's Midwifery Program to close indefinitely

MIAMI, FL (August 14, 2008) – Florida Friends of Midwives (FFOM), a non-profit grassroots organization dedicated to promoting and supporting the practice of midwifery in Florida is disappointed and concerned with the indefinite closure of Miami Dade College's Midwifery Program, a vital program to the local community and to communities statewide. Despite strong opposition expressed by students, mothers, midwives and concerned members of the community, the College cited tough economic times as the reason for their decision.

On Friday August 8, 2008, the College held a meeting at the Medical Campus to formally announce the closure of the program and return prepaid tuition to currently enrolled students. At that meeting, members of the public showed up to express their disappointment and dissatisfaction with the closure of the program. The College claims tough economic times have caused them to close programs with low enrollment and high costs. However, Midwifery is the first and only one out of over 200 degree-granting programs offered at Miami-Dade College to be eliminated as a result of those cuts.

Students, who had already completed all course requirements to be admitted into the program, were devastated. Some students had relocated to South Florida, and many had already taken out loans to cover tuition costs. "Miami Dade College doesn't understand that we didn't choose to be in this career program just to have any degree – this is our passion," said Melissa Chin Casey, who was set to start the Midwifery Program in the Fall 2008 semester. "It's insulting and cruel for the administrators to say the program was cut because of low enrollment, when we are practically beating down the door for them to let us in. As a public education institution, they have failed this community."

MDC's accredited Direct-Entry Midwifery Program was the first in the country to be offered at a public institution, offering students a more affordable option compared to the programs offered at private colleges and universities. Since it's inception in 1994, over 80 midwives have been trained and graduated the program.

"This community has endured a great loss with the closing of this program," said Tamara Taitt, president for Florida Friends of Midwives. "Many of the women who have graduated from this program have become indispensable to our community by providing quality and personalized pre- and post-natal care."

Obstetrical care in South Florida has come under scrutiny in recent years as the rate of caesarean sections in the state of Florida has increased to an all-time high of 36.6% in 2006 which is well above the World Health Organization and Healthy People 2010's recommendations of 15%. Specifically, Palm Beach County had a cesarean section rate of 39.3%, Broward was 41.2%, and Miami-Dade was 45.5%. According to the Florida Council of Licensed Midwives, Florida Licensed Midwives had a cesarean section rate of 6.3% in 2006. There is also expected to be a significant shortage of Obstetricians in the tri-county area within the next three years.

Miami Dade College is a public institution and has an obligation to the public it serves. FFOM believes it is unjust to close a program that is crucial on a number of levels. To take away this program is to take away one of the only affordable opportunities in this country for women to become Licensed Midwives through an accredited program.

FFOM urges the College to reconsider the closure of the Midwifery Program and also ask for continued support from the community in our efforts to keep this program open.

About Florida Friends of Midwives
Florida Friends of Midwives is a non-profit grassroots organization dedicated to promoting the Midwives Model of Care and supporting the practice of midwifery in Florida. Florida Friends of Midwives was formed to support midwives who offer safe, cost-effective, evidence based care to Florida's families. For more information, please visit www.flmidwifery.org.

# # #

Response to AMA Resolution 205

Recently, the American Medical Association (AMA) released a resolution in favor of lobbying for legislation stating that hospitals are the safest place to birth:

RESOLVED, That our AMA develop model legislation in support of the concept that the safest setting for labor, delivery, and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex, that meets standards jointly outlined by the AAP and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers.” (Directive to Take Action) (http://www.ama-assn.org/ama1/pub/upload/mm/471/205.doc)

While this does not blatantly state the AMA will seek to outlaw home birth, one can imagine that legislation dictating that women should give birth in a hospital or birthing center within a hospital would imply women will forfeit the right to give birth at home. The AMA makes this resolution based upon issues of safety. However, safety may not be the true issue behind this resolution.

According to a study published in the British Medical Journal by Kenneth C. Johnson and Betty-Anne Davis, home birth is just as safe as giving birth in the hospital and associated with lower instances of intervention in low-risk pregnancies (http://www.bmj.com/cgi/content/full/330/7505/1416?ehom). In fact, the ratio of women undergoing continuous electronic fetal monitoring (EFM) is remarkably lower at home than in the hospital.. From my personal experience, the belts for the EFM were uncomfortable and easily moved by my unborn children. Isn’t it obvious that you wouldn’t receive accurate readings of the baby’s vital signs if s/he kicks it away? Moreover, a study published in The Journal of Perinatal Education shows that routine interventions do not improve maternal and infant outcomes (http://www.lamaze.org/Default.aspx?tabid=461, http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1905822). In fact, these routine interventions – which are more often than not performed in hospitals20– cause more harm than good in low-risk pregnancies and lead to unnecessary c-sections. The World Health Organization (WHO) actually recommends the midwifery model of care for the majority of pregnancies and seeks to lower the number of unnecessary c-sections being performed (www.who.int/entity/making_pregnancy_safer/documents/newsletter/mps_newsletter_issue5.pdf). It would seem the medical model of care in this country is currently failing us in that c-section rates have sky-rocketed, along with the rates of interventions.

I suggest instead of lobbying for legislation stating what setting is best for childbirth we review the United States Constitution, the Bill of Rights, and the Patients’ Bill of Rights. Passing any legislation that would define where a woman could give birth is a blatant violation of our rights as citizens of this country. We should also review studies from all ends of the spectrum to make informed choices.

Could C-sections Be Increasing Maternal Mortality?

The adage “healthy baby, healthy mother” is touted by people everywhere. One half of that equation – the mother – must provide care for herself and her newborn for at least a couple of decades. However, we have seen a rise in the maternal mortality rates here in this country. In 2003 and 2004, the maternal mortality rates rose to 12 per 100,000 and 13 per 100,000 respectively (http://www.kaisernetwork.org/Daily_Reports/rep.index.cfm?DR_ID=47116). To make that easier to understand, 1 in 7692.31 women will die during childbirth or the six week post-partum period. The United States of America boasts advanced technology, state-of-the-art gadgets, and renowned research facilities. Why then are we experiencing a surge in what was once thought of as a third-world country issue? Perhaps we need to look no further than the rising c-section rates.

The CDC statistics have shown a continued increase in the c-section rates here in this country to the tune of 50% in the last ten years (www.int.com/articles/2008/04/22/opinion/edlanger.php). The truth is that 1 out of every 3 pregnant women will undergo a c-section. A c-section is a major abdominal surgery that carries the same risks as any other abdominal surgery, yet women are increasingly being convinced of all the benefits involved in a c-section. “You won’t have bladder dysfunction.” “You’ll avoid vaginal tearing.” “You can schedule your baby’s birthday!” All of these so-called benefits are given much more emphasis than the risks: injury to intestines or bladder (still think you can avoid that bladder dysfunction?), injury to the baby, post-partum hemorrhage, infertility, death. In fact, women are 3 times more likely to die during a c-section than a vaginal birth according to a large study published in the Lancet (http://www.wddty.com/03363800369784516151/c-section-aftershocks.html, Lancet, 1999; 354: 776). I would like to assert the clear correlation between the rising c-section and maternal mortality rates and make the case women everywhere to be on high alert.

Let’s examine some probable causes as to how the c-section rate is affecting the maternal mortality rate. In the United States, we have seen a rise in obesity, which seemingly sets up pregnant women for a c-section. Speculation and early research claims obese women have weaker contractions due to obesity-related health problems (http://www.medicineonline.com/news/12/8821/Obese-pregnant-women-may-have-weaker-contractions.html). “Fetal distress” may also be cited as a reason for c-section in obese women when, in fact, the monitors are simply not working through the mother’s fat tissues. Another cause of the rising c-section rate is the increasing number of older first-time mothers. It would seem that many women delay having families in order to complete higher education and start careers. Older women are much more likely to end up with a c-section regardless of whether they are high risk or low risk (http://www.webmd.com/baby/news/20070312/older-moms-have-more-c-sections). Furthermore, hemorrhage and sepsis are the leading causes of maternal mortality throughout the world – both of which are risk factors in c-sections (www.who.int/reproductive-health/publications/interagency_manual_on_RH_in_refugee_situations/ch3.pdf). While we could discuss all of these causes in further depth, I trust that my assertation that the rising c-section rate is increasing the maternal mortality rate has been made clear.

I’m a believer in the saying that “prevention is the best medicine,” and I would like to further assert that simple preventative measures can both lower the c-section rates and the maternal mortality rates. First of all, I suggest every single pregnant woman learn as much as she can about the pros and cons of c-sections and other medical interventions. Perhaps with more knowledge, women wouldn’t be so apt to choose an elective c-section. Secondly, eat a healthy, balanced diet and get plenty of exercise. No one can go wrong with that recommendation, whether young, old, male, female, white, black, green, or polka-dotted. Thirdly, seek consultation from a midwife. Midwives have lower rates of c-sections and can provide excellent prenatal care for most pregnant women. Finally, know your rights as a patient and exercise your right to refuse treatments. If no medical indications show a necessity for c-section, simply repeat these words: “I do not consent.” Your doctor may not like hearing those words, but it is his or her responsibility to respect your wishes as his or her patient. You are the boss, you are paying them for their services, and you certainly wouldn’t take insubordination from an employee.

Need More Midwives

Recently, Florida’s birthing atmosphere has experienced a major epidemic. Due to the rising costs of medical malpractice, OBGYNs are increasingly nitpicking patients in order to decrease their chances of litigation and maximize their profits. Some OBGYNs are even discontinuing practicing obstetrics simply because it carries too many risks of litigation and not enough compensation. Medical students are afraid to go into the obstetric field because they’ve heard all the bad stories surrounding medical malpractice suits and insurance premiums. For more details on this issue, you may read the article “More S. Florida obstetricians stop delivering babies” in the Sun Sentinel (http://www.sun-sentinel.com/news/local/palmbeach/sfl-flpobgynpnapr14,0,6542600.story).

Enter midwifery. Two midwifery schools here in Florida are the Florida School of Traditional Midwifery in Gainesville and the International School of Midwifery in Miami. However, more programs are being offered in other locations around Florida as the need arises for more midwives. For starters, did you know that midwives can offer care to many patients who currently see OBGYNs? If patients began seeing midwives, more OBGYNs could get back to their basis of their practice – caring for high-risk pregnancies. Not only would this take pressure off of the obstetricians, but this would also offer many women the wonderful opportunity to experience the midwifery model of care. You can read more about the midwifery model of care at the Citizens for Midwifery website (http://cfmidwifery.org/mmoc/index.aspx).

Midwives come in a variety of settings and types. To start with, midwives practice in hospitals, birthing centers, and even your own home. Depending on your wants and needs, a midwife can definitely accommodate your desired location. Next, midwives in Florida practice as either Licensed Midwives (LMs) or Certified Nurse Midwives (CNMs). Much in the way you would choose among a Family Practitioner, Obstetrician, Perinatalogist, or Maternal-Fetal Specialist, you have a choice of what type of midwife you’d like to attend your birth. An excellent explanation of the differences among these types of midwives can be found here (http://www.naturalbirthandbabycare.com/midwives.html). This source also cites the wonderful fact that midwives can care for more than just low-risk patients. Even women with prior c-section deliveries can receive care from a midwife.

As far as becoming a medium or high risk patient, it is still very possible to receive both prenatal care from a midwife and visit a specialist for whatever may ail you. For example, having gestational diabetes does not necessarily risk you out of a midwife’s care – she can simply send you for visits with a perinatalogist from time to time while still maintaining you as a patient. Women with prior c-sections generally do not need a repeat c-section as most causes for the previous c-section do not reoccur in subsequent pregnancies. Many women have gone onto have success homebirth deliveries after a c-section with both mother and baby turning out happy and healthy.

A Reflection on the ACOG Statement on Homebirths

By: Misty M. McGovern, Student Midwife

Much has been said in my community in the few weeks about the recent ACOG (American College of Obstetricians and Gynecologists) anti-homebirth anti-midwifery press release. If you are a member of even just one natural parenting, natural birthing, midwifery or attachment parenting group, you have probably heard plenty of outrage about it. I find this subject to be of the utmost importance to myself and to all other women in this place we call "home". We must assure that women's rights, not doctor's pocketbooks, are protected first and foremost. As women, we have a responsibility to ourselves, and to our sisters and daughters, mothers and aunts, to make our voices heard and to speak up for ourselves and all women in this country and worldwide.

The German philosopher Arthur Schopenhauer (1788 - 1860) once said: "All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident." I love this quote, and used it as a tag line in all of my signatures for a very long time. It can be tested against so many things and found to be true. I think back to acupuncture. Not all that long ago, in my lifetime, acupuncture was considered irrational, illogical and irresponsible. Then, it was considered down right *dangerous* by western society. If you used it in place of allopathic medications, you were basically considered to be writing your own death certificate.

Thousands of years of predictable results, even documented results, were not good enough to convince our doctors of the safety and efficacy of the treatment, even when our western lab-made medicines could do nothing more. However, now that the gold standard of double blind studies have "proven" that acupuncture indeed does work, and quite well, attitudes are changing! Now, the acupuncturists, and those who had been "sold" on acupuncture already knew this, they didn't need double blind studies to tell them, just age old experience. Acupuncture is now more accepted in our society, and you can find an acupuncturist almost as easily as you could find a McDonald's! Acupuncture has even been incorporated into nursing textbooks and has turned into a viable (though, granted, not ideal in the eyes of western medicine) alternative or adjunct to western treatments.

The same can be said about homebirth, and midwifery. For thousands of years women relied on other women to help them through their labors and births. It was a sacred event into which men were not welcomed in most societies. Women were empowered with the task of bringing forth life, and allowing the human species to continue on. But at some point in history we relinquished our power to the doctors. Even in the early obstetrical years, properly trained midwives consistently had better maternal and fetal outcomes than did doctors. This fact, though often overlooked by the "professionals", still holds true today.





This brings me back to Arthur Schopenhauer. First, midwifery and homebirth were ridiculed. This began in the late 1840's (possibly quite a bit sooner, depending on who you ask!) when midwifery was looked at as second class care for poor people. When I was in high school in the 1990's, my best friend's aunt had a baby using a midwife. I asked my mother what a midwife was exactly and she replied, "Oh, that's what poor people use to deliver babies when they can't afford a doctor. It's quite irresponsible!" That was all I knew of midwifery until researching it on my own after deciding to have children. Midwives of today continue to battle ridicule!

"...Second, it is violently opposed." This is where I really think we are now. This is part of the reason that I think midwives, midwifery advocates, and women as a whole should both rejoice, and scream even louder in protest as a result of the recent ACOG statement! We are making a difference, and we are causing change. This change is evident in the fact that ACOG and its members feel attacked by midwifery. They feel like midwifery is a threat to their pocket books, and this has them all in a bunch! We must keep them backed into a corner with our superior care of women; our superior maternal/fetal outcomes; our superior cesarean section rates; and our superior breastfeeding rates! We should continue to make them shake in their boots about us, until they finally realize that which we all already know: that competent midwifery care is ideal for the normal, healthy, low risk pregnant woman's care.

Eventually, this will be "accepted as self-evident." To quote ACOG, "The main goal should be a healthy and safe outcome for both mother and baby." We already know that in low risk, normal pregnancy, women that birth with midwives who maintain non-interventive policies fare far better statistically than induction, epidural, lithotomy position, cesarean section happy OBGYNs. We don't need their "scientifically rigorous" studies to prove it to us. The ACOG statement just brings us one step closer to our ultimate goal, which is a total reintegration of the midwifery model of care for women and babies throughout the country, and the world. Let’s take the outrage that we feel boil up from deep in our bellies upon reading the statement and turn it into energy to create positive change. After all, women are strong, and tired of being bullied. We're ready to take back what is ours, one empowered birth at a time.

Choosing A Care Provider

When choosing a primary care provider, we don't ordinarily rush to hire a surgeon to handle our every need. A sneeze does not indicate a necessity for rhinoplasty, nor does a headache always require brain surgery. So why then is it that women are rushing into the arms of surgeons to give birth? Obstetricians are surgeons who go to medical school to specialize in surgical techniques for labors and deliveries gone wrong. It wasn't until the late 19th century that the practice of routine intervention became commonplace, more than likely due to the advent of antiseptics, antibiotics, and anesthesia. Before the popularization of obstetrics, midwives cared for most pregnant women during labor and delivery. Thousands of years of history and experience refined their skills and abilities into what we now know as modern midwifery. The scope of midwifery covers much of the natural processes of pregnancy and childbirth, yielding only to complications in which medical intervention becomes necessary and life saving. Midwives are trained to minimize interventions and respect the natural birth process, which yields better outcomes for mothers and babies.

Midwives practice evidence-based care. "Evidence-based" means using results of the best research about the safety and effectiveness of specific tests, treatments, and other interventions to help guide maternity care decisions. You may be surprised to learn that most maternity care in the United States is NOT evidence-based. Midwives receive training in labor and delivery just as an obstetrician does; however, the midwife is more akin to your primary care physician who refers to a specialist – for complications outside of the general practice scope. In some states, including Florida, midwives receive licensure as well. While we are more likely to hear about cases in which bad outcome are associated with midwife-attended births, those situations most certainly do not represent the majority of such births. The National Birth Center Study (Rooks et al., 1989) found that birth centers were a safe alternative to hospitals for women at low-risk of birth outcomes, and used fewer resources than hospitals did. A systematic review of midwife-led birth centers reached the same conclusion (Walsh & Downe, 2004). Similarly, a recent study of more than 5000 women intending to birth at home attended by Certified Professional Midwives found a similar rate of intrapartum and neonatal mortality rates as in low risk hospital births, but with lower medical intervention rates (Johnson & Daviss, 2005).

Midwife means "with woman." Midwives provide personalized care that respects individual and cultural differences. With a midwife, you become an active partner in your care working with your midwife to decide the course of your pregnancy and birth. Whether you are a first-time mom or a fifth-time mom, a new baby will change your life in wonderful and unpredictable ways. The outcome of a birth is more than a healthy mom and baby – it’s a family. Midwives treat you as a whole person while addressing your physical, emotional, psychological, and spiritual needs throughout pregnancy, birth, and the postpartum period. Remember midwives when you think of pregnancy and childbirth. Healthy, low-risk women have the option of hiring a midwife to care for them during pregnancy. Women have the right to choose what type of practitioner will provide their prenatal care.

The Cesarean Epidemic

The most common operating room procedure in U.S. hospitals, c-section involves considerable morbidity in women and babies and considerable expense for private payers/employers and Medicaid/taxpayers. - Childbirth Connection

The percentage of United States’ births delivered by cesarean section has increased substantially in recent years, climbing 50 percent over the last decade from 20.7 percent of all births in 1996 to a new record high of 31.1 percent in 2006 (1,2). These statistics are featured in a new report released in December 2007 by U.S. Centers for Disease Control and Prevention (CDC) National Center for Health Statistics, and are based on data from over 99 percent of all births for the United States in 2006. Consistent with the rise in the national rate, the 2006 C-section delivery rate was 36.0% of all deliveries in Florida up from 22.6% in 1997. In a 2006 report from the Agency for Health Care Administration (AHCA) Center for Health Statistics C-section rates were found to be higher among women of Hispanic ethnicity and among women ages 30 years and older in 2004. South Florida had the highest rate of any region. Of the ten facilities statewide who had the highest cesarean rate six were located in Miami-Dade County. (9) In 2006, the C-section rate for Miami-Dade was a staggering 44.8%. While many experts contend that there is no “ideal” cesarean rate, the World Health Organization (WHO) maintains that in a developed country, the proportion of cesareans should not exceed 15%; beyond that, the maternal injury and death consequent to major abdominal surgery being to eclipse the lives and health saved.(3) More women suffer from infection, hemorrhage and death, and babies are more likely to be born prematurely or die.

There is little evidence that a vast, growing segment of the female population wants or needs major abdominal surgery to give birth. (5) Until the 1940’s, cesarean delivery was rare and only utilized as a last resort to save the baby, many times at the cost of the mother’s life. One in 16 women died. Advances in surgery, antibiotics, transfusions and anesthesia have made an operation that was nearly always fatal as recently as the mid-19th century routine 150 years later. Despite these advances, serious consideration should be given to the risks involved in cesarean surgery. Recent mortality figures from a large study of over 150,000 elective Cesarean operations in Britain show that mothers run nearly three times the risk of dying from a Cesarean section than from a natural delivery. Additionally a woman having a repeat C-section is twice as likely to die during delivery and twice as many women require re-hospitalization after a C-section than after a vaginal birth. (6)

Not only is the health of the mother impacted. Since vital statistics data on cesarean sections was first collected in 1989, the infant mortality in the United States for total cesarean deliveries has consistently been about 1½ times that of vaginal delivery. (7) It had long been assumed that the difference was due to the higher risk profile of mothers who undergo the operation. Many have pointed to changes in the population of childbearing women, such as more older women who have developed medical conditions and more women with extra challenges of multiple births. While there are some overall changes in this population, researchers have found that cesarean section rates are going up for all groups of birthing women, regardless of age, the number of babies they are having, the extent of health problems, their race/ethnicity, or other breakdowns (7). A study of almost six million births published in the September 2006 found that the risk of death to newborns delivered by voluntary Cesarean section is much higher than previously believed. This study, according to the researchers, is the first to examine the risk of Cesarean delivery among low-risk mothers who have no known medical reason for the operation. Study authors used the Healthy People 2010 criteria for low-risk (women with a full-term, singleton infant in head down presentation) and included only women who had no reported risk factors or complications of labor and delivery identified on the birth certificate. (14) Among this group there was a 49% increase in odds of cesarean delivery from 1996 to 2001, after statistical adjustment for maternal age, race, education, birth weight and parity. Researchers found that the neonatal mortality rate for Cesarean delivery among low-risk women was 1.77 deaths per 1,000 live births, while the rate for vaginal delivery was 0.62 deaths per 1,000. The risk in first Cesarean deliveries persisted even when deaths from congenital malformation were excluded from the calculation. (7) In other words, there is a change in practice standards that reflects an increasing willingness on the part of professionals to follow the cesarean path under all conditions.

Despite these cautionary statistics the rising trend of surgical birth persists. The overall increase in cesarean sections is due in large part to a notable rise in primary section rates, from 14.6 percent in 1996 to 29.0% in 2004. This increase is also partly attributable to the decline in Vaginal Birth After Cesarean (usually abbreviated VBAC) at an all-time low of 9.2 percent in 2004. (13)A woman who has a primary cesarean section has a greater than 90 percent chance of having a subsequent cesarean delivery. A policy statement published by The American College of Obstetricians and Gynecologists (ACOG) in 1998 recommended a surgical team and anesthesiologist must be available twenty-four hours a day in order for VBAC to be safe. Many hospitals who fall short of this criteria have been choosing not to allow women to attempt VBACs within their facilities because they cannot provide 'immediate' surgery if needed. A large number of physicians feel that the risks of uterine rupture (developing a tear in the wall of the uterus) that accompany VBAC are too high and that an elective or scheduled c-section is the best option for a mother who had the surgery for a prior pregnancy. Yet evidence is growing that scars in the uterus which accompany cesarean surgery can cause placental abnormalities that endanger both mother and baby in future pregnancies, and that the risk of these abnormalities increases dramatically with a subsequent cesarean. (8) Cesareans are inherently riskier than normal vaginal birth, but repeat cesareans carry even higher risks.

Today, more than ever physicians may be turning to Cesareans sections in order to avoid potential litigation. Under the specter of lawsuits C-sections have gradually become more about caution and convenience than life or death. Many obstetricians contend that patients are driving this trend with their almost unreasonable aversion to even the smallest risk. (4) The tragedy behind this phenomenon is that a cesarean is not a guarantee of a happy outcome. In comparison with other industrialized nations, the United States ranks second-to-last in infant survival and for the first time in decades the number of women dying in childbirth has increased. (10) Some experts cite consumer demand as a contributing factor in the rising cesarean rate. A New York Times article published December, 2007 noted that there was some evidence that a growing number of women were requesting Cesareans. (4) Yet, findings from the large and well-designed United States national study, Listening to Mothers, reported that less than 1 percent of mothers (only 1 of 1,300 women surveyed) who had a first cesarean actually requested one. The survey, conducted by the Childbirth Connection (a leading nonprofit organization that works to improve maternity care), also noted that, in contrast, nearly 10 percent of those surveyed reported feeling pressure by a health professional to have a cesarean delivery, and 42 percent believed that fear of being sued leads physicians to perform unnecessary cesareans (9).

In the US, the profit motive explains may explain rising rates of Cesarean. According to the HealthCare Cost and Utilization Project (HCUP), a 2000 study conducted by the U.S. Department of Health and Human Services Agency for Healthcare Research and Quality, childbirth accounts for more than four million hospitals stays annually and over $33 billion dollars in aggregate charges in 2003 alone. Many health professionals are feeling squeezed by tightened payments for services and increasing practice expenses. The flat "global fee" method of paying for childbirth does not provide any extra pay for providers who patiently support a longer vaginal birth. Some payment schedules pay more for cesarean than vaginal birth. A planned cesarean section is an especially efficient way for professionals to organize hospital work, office work and personal life. Average hospital charges are much greater for cesarean than vaginal birth, and may offer hospitals greater scope for profit. (11) In the private American healthcare system, doctors and hospitals find cesarean sections more profitable than natural births.

There is no denying that cesareans save lives when performed as an emergency intervention. Many cesareans are the clear result of medical necessity, but others occur in circumstances where there are other options available including many which are medically appropriate. A great majority are performed as a result of a labor that has gone on too long or at the first deviation from the norm, such as a “non-reassuring” fetal heart rate on a monitor. There is an overall lack of support for normal physiological birth evidenced by the dwindling number of women who labor without the assistance of induction or augmentation. A rising number of women are being pushed into the operating room after failed inductions and fetal distress caused by augmentation. (12) The practice of “defensive” medicine, heightened by rising malpractice premiums has created a climate of fear which not only affects the care providers, but the clients they serve. The escalating C-section rate in the U.S. should be a major public health concern. It represents a complex and difficult problem whose solution demands strategies that are multifaceted and comprehensive. Although doctors, hospital, and insurance companies (who often represent warring interests), do contribute to the high rate of cesareans, it is not only with them that blame should be placed. These facts point to a failure in the United States’ system of maternity care. Yet this is not the only issue. The increased rate of cesarean deliveries nationwide may be partly due to a lack of consumer knowledge. Most mothers are healthy and have good reason to anticipate uncomplicated childbirth. Cesarean section is major surgery and increases the likelihood of many short- and longer-term adverse effects for mothers and babies.(1) One primary influence in determining routine care regardless of its proven risks and benefits lies in the perception of birth as a dangerous and life threatening event. Consumers must take a proactive approach to educating themselves about the physiological process of natural birth and the impact of interventions on a woman's ability to birth normally. (15) Education is the key word in preventing unnecessary cesareans and having a safe birth experience. When a cesarean section is necessary, it can be truly life-saving, but birth is a safe and natural process that generally succeeds without intervention.



(1). Childbirth Connection. New National Survey Results from Mothers Refute Belief That Women Are Requesting Cesarean Sections Without Medical Reason. Press release. March 20, 2006.

(2). Declercq E, Norsigian J. Mothers aren’t behind vogue for Cesareans. Boston Globe April 3, 2006.

(3) WHO, Appropriate Technology for Birth; Jose Villar et al., Caesarean Delivery Rates and Pregnancy Outcomes: The 2005 WHO Global Survey on Maternal and Perinatal Health in Latin America, Lancet 367 (2006): 1819-29.

(4). Bakalar, N. Voluntary C-Sections Result in More Baby Deaths. New York Times Sept 6, 2006.

(5). McCullough, M. C is for caution: C-sections on the rise. Philadelphia Inquirer June, 10, 2007

(6) Hall MH, Bewley S. Maternal mortality and mode of delivery [letter]. Lancet, 1999; 354: 776

(7) Declercq, E, Menacker F, MacDorman MF, Malloy, M, Infant and Neonatal Mortality for Primary Cesarean and Vaginal Births to Women with “No Indicated Risk, United States, 1998-2001 Birth Cohorts, Birth: Issues in Perinatal Care 33:3 2006 175-182

(8) Health Outcome Series: Cesarean Deliveries in Florida Hospitals, AHCA State Center for Health Statistics May 2006

(9) Declercq, E. et al., Listening to Mothers II: Report of the Second National U.S. Survey of Women’s Childbearing Experiences (New York: Childbirth Connection, 2006)

(10) Organisation for Economic Co-operation and Development (OECD) Health Data 2007: Statistics and Indicators for 30 Countries July 18, 2007

(11) Why Does the National U.S. Cesarean Section Rate Keep Going Up? (New York: Childbirth Connection, 2007)

(12) Block, J. The C-section epidemic. Los Angeles Times September, 24, 2007.

(13). Declercq, E, Menacker F, MacDorman MF, Rise in “no indicated risk” primary cesareans in the United States, 1991-2001: Cross sectional analysis, BMJ 2005; 330:71-72.

(14) U.S. Department of Health and Human Services. Maternal, infant and child health. In: Healthy People 2010, 2nd ed. Washington DC: U.S. Government Printing Office, November 2000, pp. 16-30-31.

(15) The Cesarean Epidemic - A Response, Independent Childbirth, 2007

Announcing the Florida Friends of Midwives Website!!!

The website for Florida Friends of Midwives is finally finished! Words cannot express how happy I am.

You may visit the site at - www.flmidwifery.org

We have some Phase 2 and Phase 3 updates planned for early March and April, but for now, the site is done.

MANY MANY MANY MANY MANY MANY thanks to Lori Manning, my best friend of almost 15 years, who is a professional web designer and donated her time to designing the FFOM website. She really came through for me and us and put in over 100 wo-man hours into making the FFOM site fabulous. Lori has been pregnant during this whole process and lives in New York City. She literally worked on the site right up until she was 41 weeks pregnant. I can't put a price on the value of what she has done for the Florida Midwifery community by gifting us her amazing skills to create this site, but the proof is there on the site for all to see. I shall be eternally grateful to her for putting up with my demands these last few months. Thank you Lori :-)

MANY MANY thanks to FFOMer Angela Bailey who has agreed to be our Assistant Webmaster and who really really come through in the final hours with her HTML and coding skills to help us get to the finish line. Her ongoing assistance has been invaluable.

For all others who helped - Sandi Blakenship, Sharon Dejoy, Heidi Dahlborg, Rebekah Finklea. Thanks for your kind words, your writing skills, your time. I/We couldn't have done it without you!

Join FFOM Today!

As we move forward with Florida Friends of Midwives and begin to craft a future for the group, one of the most important steps is to establish FFOM as an official legal not-for-profit entity and formally solicit membership. We need your help! Efforts great and small are needed to help this organization grow and to spread the word about midwifery care in Florida. FFOM welcomes as members all individuals, families, businesses, and organizations who want to support and
promote midwife-attended births in Florida. Membership fees support the ongoing work of FFOM in its educational, informational and future legislative efforts .

Become a “Supporter”. Joining Florida Friends of Midwives can cost as little as $1 for one year of membership.

Our membership categories were developed with working, growing families in mind. We want you to contribute as much as you are able. Whether you join at the $1 or $150 level, you are demonstrating your commitment to the future of midwifery in Florida. As a member of FFOM you become part of a growing movement of mothers and families committed to preserving and protecting midwifery in our State.

Not a member yet?

Follow these simple steps.

1. Join the FFOM Yahoogroup!

2. Download the membership form in the files section.

3. Mail in your membership form today.

Its time to organize to support normal birth in Florida!

At the 2007 Midwives Alliance of North America (MANA) Conference in Clearwater, Florida we decided to restablish the long silent Florida Friends of Midwives. We had no idea the response from consumers would be so great. We are so excited to note the amount of interest in FFOM and how our Yahoogroup has expanded in just three short months. WELCOME and thank you for your interest in this important cause.

This group has re-formed to discuss ways of organizing to cultivate a strong consumer voice in support of midwifery our State. It is our hope that FFOM will not only be a great place to support midwifery, but also for you all to support each other and educate other women about birth!

In Florida:

• Licensed Midwives can attend homebirths legally.
  
• 16 birth centers are owned and operated by Licensed and Certified Nurse Midwives (www.birthcenters.org).
  
• Two midwifery schools accredited by MEAC (www.www.meacschools.org)
  
• Medicaid and insurance coverage of licensed and nurse midwifery care is mandated by state law.
  
• Over 1500 babies are born into the arms of licesned midwives each year and that number is climbing.

What's the bottom line? Women have easy access to birth centers and homebirth midwifery care. In Georgia, one State away, there is one birth center and home birth (direct-entry) midwifery is illegal. Midwives can actually get arrested for attending home births there, and mothers looking for midwives have to find an "outlaw" midwife to attend them! In Alabama and North Carolina the story is much the same. Families who desire the care of midwives for homebirth, must seek that care without the networks and resources the women of Florida enjoy.

It is easy to forget just how good we have it here. The great conditions Florida's residents enjoy are due to political organizing done in the 80's and 90's by many - including crucial grassroots efforts by the Florida Friends of Midwives. Consumers and advocates of midwifery care lobbied our state government and succeeded in getting mother friendly laws passed in our State.

Political circumstances over the next few years are going to require a really strong family-mother/consumer voice in support of midwifery. Yes, homebirth midwifery is in danger of becoming illegal again in Florida if we do not organize to protect it.

Let's work hard as guardians of birth choices for ourselves, our sisters, our friends and perhaps most importantly - our daughters!

Heidi Dahlborg, LM
Midwife, Sarasota

Tamara Taitt
Region 3 Representative
Midwives Alliance of North America (MANA)

Shannon Mitchell
Information Services Director
International Cesarean Awareness Network (ICAN)

To join the FFOM Yahoo group visit:

http://health.groups.yahoo.com/group/FloridaFriendsofMidwives/