City of Sarasota, State of Florida Proclaim October 4-8 Licensed Midwives Week

At next week’s City Commission meeting (Monday, October 4, 6:00pm), Sarasota Mayor Kelly Kirschner will proclaim October 4th through 8th as Sarasota Licensed Midwives Week. Mayor Kirschner’s recognition will pay tribute to the skilled, individualized care that Sarasota’s licensed midwives offer women and their families throughout the childbearing cycle. It will signify the strong contribution licensed midwives make to the health and well-being of our community's mothers and babies through appropriate care and treatment in all phases of childbirth.

The week has also been proclaimed Florida Licensed Midwives Week by the office of Florida Governor Charlie Crist, coinciding with National Midwifery Week, a time to recognize the contributions of Certified Nurse Midwives (CNMs), Certified Midwives (CMs) and Certified Professional Midwives (CPMs) nationwide. The American College of Nurse Midwives (ACNM) publicly announces the week with an introduction to midwifery. "The heart of midwifery care for women and newborns lies more in the nature of that care than in its specific components. Midwifery practice has a firm foundation in the critical thought process and is focused on the prevention of disease and the promotion of health, taking the best from the disciplines of midwifery, nursing, public health and medicine to provide safe, holistic care."

HISTORY OF MIDWIFERY IN FLORIDA: Midwives have a long and valued history in Florida. The state first passed legislation to license direct-entry midwives in 1931. In the 79 years since, Florida’s licensed midwives have continued to tirelessly serve the families of Florida and to ensure the continued availability of safe, evidence-based birthing options for Florida’s families. In 1992, Governor Lawton Chiles declared the first-ever Licensed Midwives Week. More women than ever before are seeking out licensed midwives for maternity care.

ABOUT MIDWIFERY IN FLORIDA: In Florida, two types of midwives are allowed to practice: Certified Nurse-Midwives and Licensed Midwives (a Florida state licensure), also known as direct-entry midwives. Throughout the state, about 11.2 percent of births are estimated to be managed by midwives, rather than by OB-GYNs. Many birth centers and midwives have reported a significant increase in business in the past year. This increase is believed to be a result of various factors, primarily a greater number of women seeking alternative birthing choices due to an unhealthy increase in caesarean sections and other unnecessary interventions that frequently occur in hospital settings. In a 2006 report on Florida Licensed Midwives, midwives had a caesarean section rate of 6.3 percent compared to a 36.64 percent statewide average in hospitals the same year.

In honor of this week, Florida Friends of Midwives (FFOM), a non-profit grassroots organization dedicated to promoting and supporting the practice of midwifery in Florida, will be hosting various community events throughout the state this week and during October to celebrate the more than 110 currently practicing licensed midwives. For more information of midwifery in Florida, please visit www.flmidwifery.org.

“We are humbled by the dedication of the mothers who worked so hard to have this week declared licensed midwifery week,” says licensed midwife Miriam Pearson-Martinez. “We hope that the events happening all over the state this week serve to raise awareness regarding the benefits of midwifery care.”

The proclamation in Sarasota will be read by Mayor Kirschner at the beginning of the City Commission meeting, Monday, October 4th, at 6:00 pm in Sarasota’s City Hall. Florida Friends of Midwives encourages all families who have benefited from the care of licensed midwives to attend this special recognition.

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 the July AJOG Meta-Analysis Against Homebirth

Florida Friends of Midwives supports and aligns ourselves with the efforts of The Midwives Alliance of North America (MANA) and The Big Push for Midwives. In July's American Journal of Obstetrics and Gynecology, an article denounced homebirth for increased neonatal mortality. This conclusion was based on a study that our allied organizations have proven misleading. Florida Friends of Midwives endorses the following responses to the study from both MANA and The Big Push.

Response from the Midwives Alliance of North America:

A new meta-analysis rushed to on-line publication well before its availability in print, concluded that less medical intervention, which is a characteristic feature of planned home birth, is associated with a tripling of the neonatal mortality rate compared with planned hospital births. In a study published online on July 1, 2010 in the American Journal of Obstetrics and Gynecology (AJOG), researchers at Maine Medical Center in Portland, Maine analyzed the results of multiple studies from around the world. The lead investigator, Joseph R. Wax, MD, Department of Obstetrics and Gynecology, Maine Medical Center, stated, “Our findings raise the question of a link between the increased neonatal mortality among planned home births and the decreased obstetric intervention in this group.”

However, Canadian researchers whose data showing the safety of home birth in a well-organized and regulated system, were used in the meta-analysis, are sharply critical of the study. Dr. Michael C. Klein, a senior scientist at the Child and Family Research Institute in Vancouver and emeritus professor of family practice and pediatrics at the University of British Columbia said the U.S. conclusions did not consider the facts. “A meta-analysis is only as good as the articles entered into the meta-analysis—garbage in, garbage out. Moreover, within the article, Wax et al did their own sub-analysis of the studies in the meta-analysis, after removing out-of-date and low quality studies, and found no difference between home and hospital births for perinatal or neonatal mortality. Yet in the conclusion, they choose to report the results of the flawed total meta-analysis, which showed the increased neonatal mortality rate.” Klein said that this is apparently a “politically motivated study in line with the policy of the American College of Obstetricians and Gynecolgists (ACOG) who is unalterably opposed to homebirth.”

Saraswathi Vedam, a nurse midwife and researcher at the University of British Columbia who is considered to be an expert on assessing the quality of literature related to homebirth, states that the study is deeply flawed for several reasons, particularly, “the authors’ conclusions are not supported by their own statistical analysis.” Vedam states that Dr. Wax et al acknowledges the consistent findings of low perinatal and neonatal mortality in planned home births across the best quality studies they reviewed “but amazingly Wax does not emphasize or even mention this in his sole conclusion.” This begs the question of whether the author’s analysis and reporting of reviewed articles on homebirth do not support his foregone conclusion about the safety of homebirth.

The Midwives Alliance of North America, a professional organization of over 1200 members, believes childbearing women and those involved in maternal and child health policy should be made aware of the flaws and erroneous claims in the Wax et al study. There is a substantial body of evidence-based literature from well-designed studies that establishes the safety of planned homebirth with a skilled birth attendant. The fact that the American College of Obstetricians and Gynecologists maintains its position in opposition to homebirth, despite the evidence of its safety and efficacy, makes one question ACOG’s motive in publishing Wax’s substandard study.

Midwives are the primary care providers in out of hospital settings. Whether their work is studied and scrutinized here in the US or abroad the findings are consistent. Trained midwives are qualified health professionals with the requisite expertise to provide mothers and newborns with outstanding care, using less intervention, resulting in maternal and infant outcomes as good as those in hospital settings under the care of obstetricians.

The American public, particularly women in the childbearing years and those who care for them, have a right to high quality research on childbirth. Research literature should not be used to cause undue alarm or limit a woman’s choice regarding care providers, including skilled midwives, and place of birth.

Response from The Big Push for Midwives Campaign:

As New York and Massachusetts moved to pass pro-midwife bills in the final weeks of their legislative sessions, the American Journal of Obstetrics and Gynecology fast-tracked publicity surrounding the results of an anti-home birth study that is not scheduled for publication until September. Described as unscientific and politically motivated, the study draws conclusions about home birth that stand in direct contradiction to the large body of research establishing the safety of home birth for low-risk women whose babies are delivered by professional midwives.

“Many of the studies from which the author’s conclusions are drawn are poor quality, out-of-date, and based on discredited methodology. Garbage in, garbage out.” said Michael C. Klein, MD, a University of British Columbia emeritus professor and senior scientist at The Child and Family Research Institute. “The conclusion that this study somehow confirms an increased risk for home birth is pure fiction. In fact, the study is so deeply flawed that the only real conclusion to draw is that the motive behind its publication has more to do with politics than with science.”

Advocates working to expand access to out-of-hospital maternity care questioned the timing of AJOG’s public relations efforts on behalf of a study that won’t be published until next fall.

“Given the fact that New York just passed a bill providing autonomous practice for all licensed midwives working in all settings, while Massachusetts is poised to do the same, the timing of this study could not be better for the physician groups that have been fighting so hard to defeat pro-midwife bills there and in other states,” said Susan M. Jenkins, Legal Counsel for The Big Push for Midwives Campaign. “Clearly the intent is to fuel fear-based myths about the safety of professional midwifery care in out-of-hospital settings. Their ultimate goal is obviously to defeat legislation that would both increase access to out-of-hospital maternity care for women and their families and increase competition for obstetricians.”

The United States recognizes two categories of midwives: Certified Nurse-Midwives, who are trained to practice in hospital settings and who also provide primary and well-woman care, and Certified Professional Midwives, who undergo specialized clinical training to provide maternity care in out-of-hospital settings. Research consistently shows that midwife outcomes in all settings are equivalent to those of physicians, but with far fewer costly and preventable interventions, including a significant reduction in pre-term and low birth weight births, and as much as a five-fold decrease in cesarean surgeries.

The Big Push for Midwives Campaign represents thousands of grassroots advocates in the United States who support expanding access to Certified Professional Midwives and out-of-hospital maternity care. The mission of The Big Push for Midwives includes educating state and national policymakers about the reduced costs and improved outcomes associated with births managed by CPMs in private homes and freestanding birth centers.

Action Alert: VBAC Ban in Florida Birth Centers

On Wednesday, March 24th, the State of Florida's Agency for Health Care Administration will move to permanently ban Vaginal Birth after Cesarean (VBAC) in Florida birth centers. Currently, women who choose to give birth normally after surgery must do so in a hospital that will allow it, which encompasses only half of those in the state, or at home with a Licensed Midwife and physician consult sign-off. VBAC's are currently not permitted in birth centers, but only because of a 'de facto ban' due to outdated language in the regulations. After a request that the language be updated to include legalized VBAC's at birth centers with Licensed Midwives and physician consultation, the State used the opening to move to make VBAC's illegal in state licensed birth facilities.

Allowing the pursuit of VBAC at home or at a state licensed birth center with a Florida Licensed Midwife will keep healthy, safe options open for Florida's families, and will dramatically reduce taxpayers' investment in unnecessary surgery.

For these reasons, I urge you to sign this petition and make your voices heard in support of legalizing VBAC's in Florida's licensed birth centers:

To: Florida Agency Health Care Administration

While we recognize the need to change outdated language in the rule, it is our position that the state consider similar language to that of F.S. 467. Such language would work to insure the patient received competent care from a licensed practitioner and respects the right of the patient to make an informed decision. We ask the State of Florida to remain a regulatory body and not take on the role of medical surrogate. (Sign here)

For more information, please visit http://www.vbacsummit.org/VBACBAN.html.

A Letter from the MAMA Campaign

Dear Florida Supporters of Midwifery--

As Florida constituents you all are in a unique and special position to help encourage federal recognition of CPMs by helping The MAMA Campaign.

The MAMA Campaign is an effort by six national organizations to include CPMs as Medicaid providers in the evolving healthcare reform legislation currently under consideration. Visit www.mamacampaign.org for more information about the campaign and to signup for news and alerts.

This week, the MAMA Campaign is trying to get letters from constituents sent to the offices of Senator Nelson and/or Congresswoman Kathy Castor of the 11th district in Florida. Anyone who lives in Florida can write as a constituent to Senator Nelson. We only need people who are constituent’s of Congresswoman Kathy Castor to write to her. To find out if you or someone you know lives in Castor’s Tampa Bay area district, visit http://www.govtrack.us/congress/findyourreps.xpd?state=FL&district=11.

Congresswoman Castor is on the House Energy and Commerce committee and Senator Nelson sits on the Senate Finance Committee. These committees will make decisions about changes to Medicaid in the current health care reform efforts, including whether or not CPMs will be added to the list of approved Medicaid providers. Hence, as Floridians, you are in a special position to help influence these critical legislators. This inclusion of CPMS as federal Medicaid providers would be an important step in increasing access to CPMs across the country.

Both Congresswoman Kathy Castor and Senator Bill Nelson have indicated some support for our amendment. But ours is only one of many potential amendments to the health care bills, all demanding their attention. We need you to write a letter of encouragement to Senator Nelson and/or Congresswoman Castor, telling them to take action on this issue.

Please forward this letter writing request to other Floridians who support midwifery. If you have clients, friends, relatives or ANYONE who is a constituent who will write a letter to Representative Castor and/or Senator Nelson please ask them to do so. It is important to send letters as soon as possible! These personal letters from constituents are critical and make a huge impact. Please write and fax or email a short letter TODAY!

MAMA CAMPAIGN INSTRUCTIONS AND TALKING POINTS FOR E-MAILED OR FAXED LETTERS FROM CONSTITUENTS OF SENATOR NELSON OR REPRESENTATIVE CASTOR

1. Handwritten or typed letters may be faxed to the number provided below.

2. Please fax your letter to the legislator’s Washington, D.C. office. This is the best way to get the letters to them quickly and effectively. If you are unable to send a fax, the next best thing is to send your letter by using the legislator’s web-based e-mail form. If you would like to help but can’t fax a letter, or send an email, a phone call to their Washington, D.C. office, is also helpful.

Rep. Kathy Castor (FL-11th)(Tampa): Visit http://www.govtrack.us/congress/findyourreps.xpd?state=FL&district=11 to see if you are a constituent.

DC Fax: (202)225-5652
DC Phone: 202-225-3376
Web Email Form: https://writerep.house.gov/writerep/welcome.shtml

Sen. Bill Nelson (FL)
DC Fax: 202-228-2183
DC Phone: 202-224-5274
Web Email: http://billnelson.senate.gov/contact/email.cfm

3. Please include the following crucial language in your letter; this is what you are asking your legislator to do:

FOR REP. CASTOR: "I am a constituent and I ask that the Congresswoman support efforts to improve the maternity care system by adding Certified Professional Midwives to the list of providers covered by Medicaid. Will Congresswoman Castor raise this issue with Energy & Commerce Chairman Henry Waxman as a priority for her, to see if we can get this important provision in the final House bill? It’s so crucial that we expand access to maternity care as a component of health reform.”

FOR SEN. NELSON "I am a constituent and I ask that the Senator support efforts to improve the maternity care system by adding Certified Professional Midwives to the list of providers covered by Medicaid. Will Senator Nelson please raise this issue with Finance Committee Chairman Max Baucus as a priority for him, to see if we can get this important provision in the final Senate bill? It’s so crucial that we expand access to maternity care as a component of health reform.”

4. A short letter is sufficient. But, if you wish to write an expanded, more personalized letter, at the end of this document are a list of talking points to help you explain why Senator Nelson or Representative Castor should ask their appropriate chairman to add this amendment to the bill. You do not need to use all the talking points. We encourage you to make this a personal letter from you. We do not want these to look like form letters. We do suggest, because the chairmen are looking for cost-savings wherever they can find them, that you might want to emphasize the second and fourth bulleted points in the list of talking points below.

Note: For clarity’s sake, please be sure to write out “Certified Professional Midwife” rather than “CPM”.

5. Share a brief personal detail if possible and relevant, for example: “Two of my children were born at home attended by Certified Professional Midwives. I believe all women regardless of their income should have access to the safe, high-quality, cost-effective care provided by Certified Professional Midwives.”

6. Sign off with your name, address, and contact information.

7. If Senator Nelson’s or Representative Castor’s office would like more information about our efforts to pursue this important Medicaid improvement, they may contact Mary Lawlor with the National Association of Certified Professional Midwives at president@nacpm.org or on her cell phone at 917-453-6780. She and other Campaign members will be in D.C. during the next few weeks and may be available to meet his/her staff.

8. Please send the MAMA Campaign a copy of your letter. Email it to info@mamacampaign.org or FAX to 802-536-4142.

Again, anyone who lives in Florida can write as a constituent to Senator Nelson. We only need people who live in Congresswoman Kathy Castor’s district to write to her. To find out if you or someone you know lives in Rep. Castor’s district which includes: Tampa and St. Petersburg and parts of Hillsborough, Pinellas and Manatee counties, visit http://www.govtrack.us/congress/findyourreps.xpd?state=FL&district=11. PLEASE forward this writing request to other Floridian’s who support midwifery. These letters are incredibly important.

If you haven’t already, please sign up with the MAMA Campaign at www.mamacampaign.org to get e-alerts and find more information and handouts. Please donate to the campaign at www.mamacampaign.org. Thanks so much for all you are already doing and for all you will do this week!

THANK YOU!

Nasima Pfaffl
Citizens for Midwifery/MAMA Campaign
321-733-6156
nasima@cfmidwifery.org

Talking Points :

CPMs are highly-trained, credentialed clinicians who provide effective, evidence-based maternity care. They are the only maternity care providers specifically trained in attending births outside the hospital and, by assisting in births at home and in birthing centers, offer women an important choice in how their babies are delivered.

I support the basic principal that health reform should make obtaining care MORE AFFORDABLE for all American. Adding Certified Professional Midwives to the Medicaid list would SAVE MONEY by reducing health care costs immediately.

Each mother on Medicaid who chooses an out-of-hospital birth with a Certified Professional Midwife would lower Medicaid costs, since Medicaid would otherwise be paying for a hospital birth at greater cost and with much greater likelihood of an expensive cesarean section.

Research demonstrates that midwives who attend births outside the hospital (at home or in a birth center) have much lower rates of unnecessary and potentially dangerous medical interventions such as inductions and cesarean-sections with at least as good outcomes in terms of maternal and infant mortality, at substantially lower costs.

Because Certified Professional Midwives provide thorough individualized care that promotes healthy pregnancies, the babies are healthier – more are full term and full weight, avoiding costly health problems.

Of the twenty-five states that now provide a path to licensure for Certified Professional Midwives, only 9 include CPMs in their state Medicaid programs, so low-income women on Medicaid have difficulty obtaining services. This falls short of genuine and consistent patient choice and access. Certified Professional Midwives and women who want access to them are seeking federal Medicaid reimbursement for their services as one important step to increase access to this kind of maternity care.

All women deserve to have access to quality, comprehensive maternity care, in the communities where they live, with a choice of qualified provider and services that are fully recognized and reimbursed by both private and public payers.

As the #1 reason for hospitalization, but with declining quality outcomes in the U.S., it is essential for health care reform to include maternity care.

FFOM Welcomes Ina May Gaskin to Sarasota

Sarasota, FL (July 31, 2009) -- On November 1, 2009, Sarasota will host a discussion entitled 'Maternal Health Care in the 21st Century: Sarasota and Beyond.' The program will feature a distinguished panel of internationally recognized speakers. The Sarasota-Manatee Chapter of the National Organization for Women (NOW) is sponsoring the event, along with co-sponsors Florida Friends of Midwives and the Sarasota Commission on the Status of Women. The discussion will take place at the Hyatt Regency Sarasota. The public is welcome to attend at no cost.

The panelists for this discussion are:
--Dr. Washington Hill, MD, FACOG, Labor and Delivery Medical Director and Maternal-Fetal Medicine Director at Sarasota Memorial Hospital;
--Ina May Gaskin, MA, CPM, Founder and Director of The Farm Midwifery Center;
--Rep. Keith Fitzgerald, PhD, Florida House of Representatives, District 69; and
--Jennifer Highland, MPH, Executive Director of the Healthy Start Coalition of Sarasota County.

The discussion will be moderated by Kelly Kirschner, MA, Sarasota City Commissioner and Vice Mayor, and will last approximately an hour and a half. Time will be allotted for audience questions and answers, as well as refreshments following the program.

This panel will review current trends in maternity care in Sarasota within the context of the U.S. and the world and target paths to improving maternity care locally and nationwide. Topics for discussion include:

• maternal mortality,
• obstetric intervention rates and risks,
• legislation,
• legal reform and malpractice concerns,
• insurance coverage,
• community education and awareness,
• the midwifery model of care,
• informed consent and refusal,
• transparency in maternity care,
• the availability of prenatal care (including education, counseling, and doulas), and
• the upcoming expansion of Sarasota Memorial Hospital to include new labor and delivery rooms.

Hosting a panel discussion about maternal health care issues was the brainchild of Sonia Pressman Fuentes, co-founder of the National Organization for Women (NOW). “After spending a lifetime improving the legal status of women and fighting gender discrimination in the US and the world, it is exciting for me to be involved in a field new to me, that of improving maternal health care options for women in Sarasota, the US, and the world,” says Fuentes. Joining her in planning the event is Laura Gilkey, local childbirth advocate and board member of Florida Friends of Midwives. "With a panel representative of obstetrics, midwifery, legislature and public health, perhaps Sarasota can begin a conversation that will pave the way toward becoming a national model of community healthcare reform through improved maternity care," says Gilkey.

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For more information, please contact Laura Gilkey at laura@kangaroopromotions.net / (941) 915-8115. Interviews are available at the request of the press. Planning and agenda updates for the panel will be posted on the website www.borninsarasota.blogspot.com.

About the National Organization for Women (NOW): The National Organization for Women (NOW) is the largest organization of feminist activists in the United States. NOW has 500,000 contributing members and 550 chapters in all 50 states and the District of Columbia. Since its founding in 1966, NOW's goal has been to take action to bring about equality for all women. NOW works to eliminate discrimination and harassment in the workplace, schools, the justice system, and all other sectors of society; secure abortion, birth control and reproductive rights for all women; end all forms of violence against women; eradicate racism, sexism and homophobia; and promote equality and justice in our society.

About Florida Friends of Midwives (FFOM): Florida Friends of Midwives (FFOM) 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. Our members are consumers and birth advocates with a common goal: to preserve the legal protection afforded to Florida's midwives and birth centers. We are committed to organizing the community to support midwives and to assure the continued availability of midwifery care in the State of Florida.

About the Sarasota Commission on the Status of Women (SCSW): The Sarasota Commission on the Status of Women (SCSW) was re-established in Sarasota County to empower women through education, research, and advocacy.

ABOUT THE PANELISTS:

Dr. Washington Hill, M.D., FACOG
Labor and Delivery Medical Director / Maternal-Fetal Medicine Director, Sarasota Memorial Hospital
B.A., Rutgers University, College of South Jersey, Camden, New Jersey, 1961
M.D., Temple University School of Medicine, 1965
Obstetrics and Gynecology Residency, William Beaumont General Hospital, 1970
Post Graduate, Maternal-Fetal Medicine Fellowship, University of California, San Francisco, 1984
Board Certification, American Board of Obstetrics and Gynecology with Special Competence in Maternal-Fetal Medicine, 1989 with Recertification 1978, 1993 and 1998

Dr. Hill is the Past President of the Medical Staff and Chairman of the Department of Obstetrics and Gynecology at Sarasota Memorial Hospital, Sarasota, Florida. He is currently Director of Maternal-Fetal Medicine. He is also Clinical Professor Department of Obstetrics and Gynecology at University South Florida College of Medicine, Tampa Florida and Clinical Professor Department of Clinical Sciences OB/GYN Clerkship Director-Sarasota Campus Florida State University College of Medicine Tallahassee Florida. After earning his medical degree at Temple University and interning at Walter Reed General Hospital in Washington, D.C., Dr. Hill spent the next nine years as a Medical Officer in the United States Army. During this time, he conducted his residency training in Obstetrics and Gynecology at William Beaumont General Hospital in El Paso, Texas. Upon finishing his residency, he was an Obstetrician and Gynecologist in Germany for three years. After twelve years of private practice in Obstetrics and Gynecology, Dr. Hill completed a fellowship in Maternal-Medicine at the University of California, San Francisco and Children’s Hospital of San Francisco in 1984. While there, he was also a Research Fellow at the Cardiovascular Research Institute. Following completion of his fellowship in Maternal-Fetal Medicine, he has practiced this subspecialty for over 20 years first at the Sutter Perinatal Center and the University of California-Davis School of Medicine, Sacramento, California, and then at Creighton University, School of Medicine, Omaha, Nebraska; Meharry Medical College, and Vanderbilt University School of Medicine, Nashville, Tennessee. He served as Chairman of the Department of Obstetrics and Gynecology at Meharry Medical College, School of Medicine, educating minority medical students and residents from 1990 until 1992, when he took his current position as Director of Maternal-Fetal Medicine and the Perinatal Center of Sarasota Memorial Hospital in Sarasota, Florida. Dr. Hill is a leader in Maternal-Fetal Medicine. He has a strong interest in education, patient care, teaching and clinical practice. He is a regular participant at conferences which teach perinatal healthcare providers management and use of research in caring for high risk pregnancies. He has been a leader in the development of a center of excellence known throughout the nation for the care of high risk pregnant patients. Dr. Hill is a frequently sought after speaker in the community and at medical centers around the nation in high risk pregnancy management. He is Board Certified in Maternal Fetal Medicine and Obstetrics and Gynecology. He also serves around the country as a consultant for maternal-fetal medicine and medical legal issues. In his “spare time,” he likes to travel, especially to Africa on medical missions and will be happy to recruit to go also. He also enjoys sports, music and collecting African artifacts when not engaged in his teaching duties. Dr. Hill is the author of at least 60 articles in refereed journals and the book, “Ambulatory Obstetrics.” He contributes regularly to the medical literature and provider education. A native of Camden, New Jersey, Dr. Hill is married to Pauline Hill.

Ina May Gaskin, M.A., C.P.M.
Founder / Director, The Farm Midwifery Center
State University of Iowa, Iowa City, Iowa, B.A., English, Summa cum laude, Highest honors
Northern Illinois University, DeKalb, Illinois, M.A., English
North American Registry of Midwives
Certified Professional Midwife
Tennessee Licensed Certified Professional Midwife

Ina May Gaskin, MA, CPM, is founder and director of the Farm Midwifery Center, located near Summertown, Tennessee. Founded in 1971, by 1996, the Farm Midwifery Center had handled more than 2200 births, with remarkably good outcomes. Ms. Gaskin herself has attended more than 1200 births. She is author of Spiritual Midwifery, now in its fourth edition. For twenty-two years she published Birth Gazette, a quarterly covering health care, childbirth and midwifery issues. Her most recent book, Ina May’s Guide to Childbirth was released in 2003 by Bantam/Dell, a division of Random House. She has lectured all over the world at midwifery conferences and at medical schools, both to students and to faculty. She was President of Midwives' Alliance of North America from 1996 to 2002. In 1997, she received the ASPO/Lamaze Irwin Chabon Award and the Tennessee Perinatal Association Recognition Award. In 2003 she was chosen as Visiting Fellow of Morse College, Yale University. Ms. Gaskin has lectured widely to midwives and physicians throughout the world. Her promotion of a low-intervention but extremely effective method for dealing with one of the most-feared birth complications, shoulder dystocia, has resulted in that method being adopted by a growing number of practitioners. The Gaskin maneuver is the first obstetrical procedure to be named for a midwife. Her statistics for breech deliveries and her teaching video on the subject have helped to spark a reappraisal of the policy of automatically performing cesarean section for all breech babies. As the occurrence of vaginal breech births has declined over the last 25 years, the knowledge and skill required for such births have come close to extinction. Ms. Gaskin’s center is noted for its low rates of intervention, morbidity and mortality despite the inclusion of many vaginally delivered breeches, twin and grand multiparas. Their statistics were published in “The Safety of Home Birth: The Farm Study,” authored by A. Mark Durand, American Journal of Public Health, March, 1992, Vol. 82, 450-452. Ms. Gaskin was featured in Salon magazine’s feature “Brilliant Careers” in the June 1, 1999 edition. She is the originator and coordinator of The Safe Motherhood Quilt Project, a national effort developed to draw public attention to the current maternal death rates, as well as to the gross underreporting of maternal deaths in the United States, and to honor those women who have died of pregnancy-related causes since 1982. Her newest book, Ina May's Guide to Breastfeeding, will be released October 1st, 2009.

Rep. Keith Fitzgerald, Ph.D.
Florida House of Representatives, District 69
University of Louisville, B.A., 1979
Indiana University, Ph.D., 1987

Representative Keith Fitzgerald was elected to represent State House District 69 in 2006. His district includes the northern part of Sarasota County and a small portion of Manatee County. Representative Fitzgerald was born in Springfield, OH and grew up in Louisville, KY. He holds a B.A. from the University of Louisville, and a Ph.D. from Indiana University. Representative Fitzgerald has lived in Sarasota and taught political science at New College of Florida since 1994. He and his wife, Angela Baker, have nine-year-old twins. Representative Fitzgerald is a lifelong public servant. From the time when he worked in high school and college as a reading tutor for dyslexic children until his present job as a college professor at New College of Florida, he has been an educator. As a Ph.D. in political science, he has studied politics his whole life, taught at colleges and universities and conducted scholarly research. Representative Fitzgerald serves as the Democratic Ranking Member on the Policy Council and as a member of the Finance and Tax Council, Health and Family Services Policy Council, Select Policy Council on Strategic & Economic Planning and the Military and Local Affairs Policy Committee. Representative Fitzgerald also serves as Policy Chair for the House Democratic Caucus. His prior leadership positions include service on the Advisory Council of Faculty Senates, the Board of Trustees at New College of Florida and the Sarasota City Charter Review Board.

Jennifer Highland, M.P.H.
Executive Director, Healthy Start Coalition of Sarasota County
University of South Florida, M.P.H. Public Health, 1995

Jennifer’s passion for helping mothers and infants began, of course, with the birth of her children. Most of her early career in Louisiana, Georgia and Texas was as a registered nurse working in hospital settings, in clinical nursing and staff development. Her education positions allowed her to utilize her graphic art skills in the development of printed educational materials and newsletters for hospital staff and nurses. After she moved to Florida and became a mother, Jennifer volunteered for the Breastfeeding Advocates of Sarasota County and completed her Master of Public Health Degree from USF, graduating in 1995. Jennifer was the Project Coordinator for the first and on-going national breastfeeding promotion campaign, “Loving Support Makes Breastfeeding Work,” through her employment with Best Start, Inc., in Tampa. She then became trained as a Childbirth Educator and taught at Sarasota Memorial Hospital. Her work at Healthy Start began in 2001 as the Contract/Quality Manager. Her role expanded to include professional education. In 2006 she became the Executive Director.

MODERATOR: Kelly Kirschner, M.A.
Sarasota City Commission (District 3 Commissioner / Vice Mayor)
B.S. Foreign Service, Georgetown University
M.A. Latin American Studies, Georgetown University

Kelly is a lifelong Sarasotan. He has served the Sarasota community as President of the Alta Vista Neighborhood Association as well as having been an active member of the Coalition of City Neighborhood Associations. Believing strongly in public service, Kelly has worked for the White House Office of Public Liaison; served as a Peace Corps Volunteer; and led a USAID community conservation project in rural Guatemala. Kelly lives with his wife, Tracy, son, Bodhi, and daughter, Selby, in District 3.

EVENT SPONSOR: Sonia Pressman Fuentes, JD
The National Organization for Women (NOW)
B.A. Cornell University 1950
J.D. University of Miami School of Law 1957

Sonia Pressman Fuentes, who was born in Berlin, Germany, of Polish parents, came to the U.S. with her immediate family in 1934 to escape the Holocaust. She graduated as valedictorian of her high school in Monticello, New York, Phil Beta Kappa from Cornell University, and first in her class at the University of Miami (FL) School of Law. She was an attorney for the U.S. Department of Justice, the National Labor Relations Board, the Equal Employment Opportunity Commission (EEOC), and the U.S. Department of Housing & Urban Development in Washington, D.C. She was the first woman attorney in the Office of the General Counsel at the EEOC and drafted a number of the Commission’s landmark guidelines and decisions. She was a co-founder of NOW, WEAL (the Women’s Equity Action League), and FEW (Federally Employed Women) and a charter member of VFA. She was the longest-serving board member in the history of NWP (National Woman’s Party). She also served as an attorney and executive, respectively, at the headquarters of GTE Service Corporation and TRW Inc., and was the highest-paid woman employee at each of those headquarters. In 1993, she retired from the federal government, thereafter wrote her memoir, Eat First—You Don’t Know What They’ll Give You, The Adventures of an Immigrant Family and Their Feminist Daughter, and embarked on new careers as a writer and public speaker. For further information, see her website.

EVENT COORDINATOR: Laura H. Gilkey, BLA
Florida Friends of Midwives (FFOM)
B.L.A. Landscape Architecture, University of Florida, 2000

Laura Gilkey serves on the Board of Directors for Florida Friends of Midwives, and is the Florida Coordinating Ambassador for The Birth Survey: The Transparency in Maternity Care Project. Laura is an endorser of The Mother-Friendly Childbirth Initiative and a member of the Coalition for Improving Maternity Care Services. She is a project coordinator and quilter for Ina May Gaskin's Safe Motherhood Quilt Project, intended to raise awareness about American maternal mortality. Laura has recently joined the Planning and Evaluation Committee for the Healthy Start Coalition of Sarasota County, whose mission is to improve the health and well-being of Sarasota's pregnant women, infants, and small children. Professionally, she is the marketing manager for Michael A. Gilkey, Inc., landscape architecture studio, and is the owner of Kangaroo Promotions, Inc., a creative marketing firm in Sarasota.

Fight Florida's Ban on VBACs in Birthing Centers!

Join the fight to change the State of Florida's ban on Vaginal Births After Cesarean (VBAC) in birthing centers.

Currently the State of Florida's legislative rule governing birth centers is written in a manner which has now been used to restrict women from choosing VBACs with any licensed practitioner in a free standing birth center.


The Florida Alliance of Birth Centers has retained an attorney to challenge the legislative rule banning a woman from attempting a vaginal birth after c-section in a birth center. With c-section rates in some Florida hospitals topping 70%, women's choices are being limited.

PUSH BACK for VBAC's.

Visit the Birthgirlz website for more details and please donate today.

Until midnight tonight, any donation made to this worthy cause will be matched.

ACTION ALERT: Health Care Reform

Dear Midwifery Supporters,

Florida Friends of Midwives supports The Big Push for Midwives in their current federal legislative efforts. They have been hard at work presenting evidence in Washington that access to Certified Professional Midwives and out-of-hospital maternity care would save billions of US healthcare dollars while simultaneously improving birth outcomes.

Now, it's Florida's turn to show our support. Please read the following ACTION ALERT carefully, and take few moments to let our current administration know that this issue is important to you and your family.

Thank you,
Board of Directors
Florida Friends of Midwives
_____________________________________________________________________________________

As many of you may know, the White House issued a call this week asking citizens from across the country to send emails about what they would like to see in health care reform. Not long afterwards, the server accepting the emails crashed.

Why? Because it got flooded with emails about the President's birth certificate!

Now the press is reporting about it, just as they did when grassroots organizers for the legalization of marijuana set the record for the most number of emails sent during the transition-a mere 6000. We can top that!

It turns out there is another, lesser-known online form for submitting comments about health care reform. Let's use it!

If we top 6000 emails-and I know we can-we will set a new record and get the White House's attention on how strong support for out-of-hospital maternity care and Certified Professional Midwives is.

So please go to the following link and fill out the form with a short, simple message about why you want all women, including those on Medicaid, to have access to out-of-hospital maternity care and Certified Professional Midwives who are specially trained to provide it.

http://www.healthreform.gov/communityreports/comments.html

Pick one or two points to include in your own words: And always use the title, Certified Professional Midwives, spelled out.

Certified Professional Midwives are specially trained as experts in out-of-hospital maternity care and deliver babies in private homes and in freestanding birth centers.

Research consistently shows that low-risk women planning to deliver their babies at home under the care of Certified Professional Midwives experience outcomes equal to low-risk women who deliver in the hospital, but with far fewer costly and preventable interventions, including a five-fold decrease in cesarean section.

Babies delivered under the care of Certified Professional Midwives have significantly reduced rates of prematurity and low-birth weight, two of the leading contributing factors to racial and ethnic disparities in birth outcomes and to the costs associated with long-term care.

David Anderson, Professor of Economics at Center College with a specialization in the costs of out-of-hospital maternity care, calculates that increasing use of Certified Professional Midwives and of out-of-hospital maternity care by less than 10% would result in savings of $9.1 billion annually, while actually improving outcomes.

The state of Washington reports a savings of $3.1 million dollars over a period of two years to the state Medicaid system when women experiencing healthy, low-risk pregnancies give birth with licensed midwives instead of in the hospital.

The recent Milbank Report conservatively estimates savings of $2.5 billion dollars a year if the cesarean surgery rate is brought down to 15% in the U.S.

Certified Professional Midwives are the only providers specially trained in out-of-hospital birth in the event that hospitals become unsafe for healthy pregnant women during a disaster.

Thank you to everyone who is reaching out-it only takes a few minutes but it is so very helpful. We are making amazing progress in DC and now is not the time to let up! So please forward this to family and friends who can help, and thank you for doing your part to get Certified Professional Midwives and out-of-hospital maternity care included in health care reform.

ATTENTION MIDWIVES! Yes, we are shouting at you! Please send this action alert with a personal appeal to your networks of clients-it only takes a few minutes, and people are especially motivated to act when they get a personal request from their midwife.

STATE GROUPS! Please be sure to post this alert to your state lists!

Katherine Prown, PhD
Campaign Manager
TheBigPushForMidwives.org
414.550.8025
Envisioning a safer, less-costly model of maternity care in the United States.

Transparency Needed as C-Section Rates Rise

CIMS, the Coalition for Improving Maternity Services, a group working toward transparency in maternity care, announced last week that the 2007 US birth statistics, just released, show that 31.8% of births are via cesarean section. The percentage of cesarean deliveries has increased by 50% since 1996 and is more than double the World Health Organization’s recommended rate of 15%.

Currently, cesarean rates vary widely across the US. The 2007 birth data highlight this variation; for instance, a woman giving birth in New Jersey has a 73% higher chance of having a cesarean than a woman in Utah.

This strong variation in rates isn’t only geographic; it is also seen among individual hospitals in a community. For example, in 2006, New York City, one of the few places facility-level rates are available, St. Vincent’s Staten Island Hospital had a rate of 44.5% compared to 17.2% at North Central Bronx Hospital. Many believe that this variation is due to high risk sicker mothers and babies that these hospitals serve; however, that is only part of the story. Extensive research has shown that these huge variations are strongly linked to the practices and policies of individual hospitals and providers not just the health status of mothers and babies.

“Most women believe that they will only have a cesarean section if they experience complications in pregnancy or labor. But research tells us that most of the factors affecting a woman’s risk of a cesarean have nothing to do with her health or that of her baby. One of the most effective strategies for avoiding a preventable cesarean is choosing a provider and birth setting with a low cesarean rate. In the United States, we are seeing increased public reporting of outcomes and procedure rates for facilities in surgical and cardiac care, but, access to maternity care data remains almost non-existent,” says Amy Romano, MSN, CNM, a transparency expert for CIMS.

C-section can be a life-saving procedure, but it is a major surgery that carries extensive risks for both mother and baby, risks that are not present in a vaginal birth. Research conducted by the World Health Organization shows that these risks of cesarean outweigh the benefits when the c-section rate exceeds 15%. Currently, women have no way of knowing if their local hospitals exceed this recommended rate.

“Women can unknowingly increase their risk of unnecessary surgery based on their selection of where and with whom to birth. To enable women to make informed choices, maternity care data must be available at the facility level. Whether requiring a c-section or planning a natural birth, women need data in order to choose the facility that most closely matches their needs,” said Elan McAllister, Founder of New York’s Choices in Childbirth and Co-chair of the Transparency in Maternity Care Project.

Transparency empowers consumers, and studies have shown that public reporting of intervention rates and outcomes leads to better healthcare. New York and Massachusetts are the only states with legal mandates to require release of facility-level maternity care obstetrical intervention statistics such as cesarean sections. Unfortunately, such information remains unavailable in most parts of the country, but a CIMS project is working to change this fact.

To help expectant parents to make informed health care decisions about where and with whom to birth, CIMS developed the Transparency in Maternity Care Project: The Birth Survey. CIMS has trained local level ambassadors across the US to interface with their state departments of health to work to make facility-level intervention rates available to the public. As intervention rates are obtained, including the rate for c-sections, they will be included in publicly accessible free reports.

Transparency of health care information is increasing across the US and maternity care must be included in this movement. Otherwise, women are choosing their place of birth blindfolded and potentially increasing their chances of having an unnecessary cesarean section as rates across the country continue to rise above recommended levels.

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!

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.

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