Friday, July 1, 2011

Reducing the cesarean rate for first-time moms

A new study from researchers at the Yale University of Medicine pinpoints two primary reasons for the skyrocketing cesarean rate in the United States: more c-sections in first-time mothers and decreasing rates of VBAC (vaginal birth after cesarean). Having a cesarean for your first baby changes your choices and increases risk for future pregnancies and births. It can be life-saving surgery, when used appropriately, of course. But with vaginal birth after cesarean (VBAC) increasingly harder to access in hospitals nationwide, it’s critical that birth activists work to get mothers the information they need to avoid an unnecessary first cesarean.

So how can a first-time mom maximize her chances for a vaginal birth in a culture where a third or more of all women are giving birth via major abdominal surgery? We’ve identified 10 key points that can help a woman stack the deck in her favor.

1) Hire your provider with extreme care. This point is number one for a reason – it’s absolutely critical. You need to know your provider’s cesarean rate, and the overall rate of the practice. Group practices typically share call time, and while an individual midwife or doctor may have a lower cesarean rate, unless that person is guaranteed to be at your birth, you must consider the cesarean rates of everyone in the practice. Does this provider practice in the medical model or in more of a midwifery model of care? The labels “obstetrician,” “family doctor” and “midwife” sometimes tell you surprisingly little about philosophy. We have worked with midwives who practice in an extremely medical model, essentially practicing as “junior OBs.” Conversely, we have seen physicians who will go the extra mile to support a woman and patiently give her body all the time it needs to work. To make it all that much more complex, it can be hard sometimes to get straight answers or sort out lip service from genuine information. Not sure how to scope out the real deal on docs and midwives? Ask a doula. We see a wide variety of practices, and know those providers who will go the extra mile to help a woman avoid a cesarean, as well as those who might have a woman-friendly reputation but will throw in the towel on a vaginal birth much more quickly. Doulas see the women seeking VBAC who were traumatized by their first birth experience, and those VBAC mamas who felt their cesareans were necessary and that they were treated with kindness and respect. Your first birth (or any birth) is far too important to blindly trust to the kindly OB who has been doing your pap smears since high school, but whose birth philosophy you know nothing about. Or that midwife your friend had a great birth with? Maybe your friend got lucky, or maybe the midwife’s philosophy and approach have shifted in recent years. And the flashy high-volume hospital with a big NICU might not actually be the best place to have a normal, low-risk birth. Who has the skills to help you find natural alternatives for a complex labor, and who has only a medical/surgical toolbox? Ask a doula. Trust me, they will be delighted to offer a recommendation and it’s your best bet for locating a truly woman-friendly provider. If it becomes clear that you are not with a supportive provider, it is never too late to switch – never.

2) Hire a doula. This isn’t self promotion, it’s evidence-based care. A meta-analysis of studies (thanks to DONA International for the data) shows that women who use a doula are 26 percent less likely to have a cesarean birth, among other dramatic benefits. Continuous support of any kind is helpful, but the best outcomes are doula-specific. That is, according to a recent Cochrane Review, having continuous support during your birth from a doula improves outcomes significantly more than continuous support from family members, friends or medical staff. The Lamaze International blog, Science and Sensibility, offers a wonderful overview of the best research. What exactly is the doula magic? The research hasn't pinpointed that, but I believe the unique combination of physical, emotional and informational support, plus gentle advocacy makes a huge difference. Doula care helps women to feel safe and comfortable so the hormones of labor can work at optimal levels, positioning ideas and tricks can help babies work their way out, and evidence-based information and advocacy can help women maximize their chances within a system that doesn’t necessarily support normal, natural birth.

3) Take an independent natural childbirth class. It’s not so much that you need to know a lot about giving birth, but rather that many women (and men) need to undo what society has taught them about birth. Independent classes tend to be longer and more in-depth, with an interactive rather than lecture-based format. A good instructor can help increase your confidence in your body and instill some trust in the normal birth process. She’ll teach you the tools you need to let your body do its work, and reinforce the value of avoiding unnecessary interventions and keeping your body moving throughout the birth journey. Breech baby? Your instructor can tell you about ways to help a breech baby turn, and maybe even point you to providers who will attend vaginal breech births if that is an option you want to pursue. Hospital classes often stress compliance with routine procedures – “This is what we will do to you, trust your provider.” In an independent class, it helps that your instructor works for you, not the hospital. If you hope to successfully navigate a system that finds surgery necessary for a full third of all births, it’s a huge advantage to have someone who can give you the straight scoop on advocating within that system. Did you know that in low risk births, continuous electronic fetal monitoring increases your chances for a cesarean as compared to intermittent monitoring with a Doppler, but doesn’t improve outcomes for moms and babies? Your independent instructor will tell you all about this research, but you’re not likely to hear it in a hospital-based class. An independent instructor is not bound by hospital politics or policies, and she can tell you about all of your options and rights without worrying about repercussions from administrators or providers. An independent Lamaze-certified instructor will base her class on the six Lamaze Healthy Birth Practices, an amazing resource that lays the groundwork for the best possible birth. (And no, Lamaze doesn’t teach “the breathing” anymore. This isn’t your mother’s Lamaze!) An independent instructor can reassure you that although you hire your provider and birthplace for their expertise and recommendations, and you should take those recommendations seriously, in the end it is your body, your baby and your birth.

4) Avoid induction unless clearly medically necessary. As a first-time mom, some studies show that simply walking in the door for an induction of labor doubles your risk of a cesarean. Doubles it. That’s huge! Avoiding induction is never more important than with a first baby. But if you must be induced, call on your natural childbirth instructor and your doula (remember them?) to help you with tips to keep it as normal and natural an experience as possible, given the unexpected circumstances. If mom and baby are not in imminent danger, low-and-slow inductions can result in a better chance of a vaginal birth, but you’ll need great support on the journey.

5) If birthing in the hospital, stay home at least until strong, active labor. Your independent childbirth instructor will help you understand the signposts to watch for. If you follow the common hospital recommendation to “come in when contractions are five minutes apart, at least a minute long, for at least an hour,” most women having their first baby will be very early in labor. The signposts of intensity are your guide, not the contraction timing. Minimizing the number of hours spent in the hospital can also help minimize the number of interventions and potentially lower your risk of cesarean. In her book “Pushed: The Painful Truth About Childbirth and Modern Maternity Care,” Jennifer Block tells the story of a hospital in Florida that lost power after a major hurricane. The generator kept the essentials running, but there was not enough power for air conditioning. In an effort to maximize their resources and keep laboring women reasonable comfortable and cool, for a full week they turned away any woman who was not in full-blown, active labor. Their emergency cesarean rates during that week plummeted.

6) Avoid an epidural, at least in early labor. Research is a bit mixed, and the quality of studies is often tainted by comparisons of epidural births with those in which the women had IV narcotics, rather than comparing women with epidurals to those who birth naturally. But still, the best evidence available does seem to show that epidurals, especially those administered early in labor, do increase the cesarean rate in first-time mothers. Childbirth Connection is a great resource for benefit/risk information about epidural analgesia. There are rare times, of course, when getting an epidural can actually help a woman have a vaginal birth, if she simply doesn’t have the strength to go on. Each labor is unique, and must be evaluated in the moment. But an epidural also makes it harder for a malpositioned baby to reposition, limits the mother’s mobility, and introduces a host of other interventions (IV, continuous monitoring, bladder catheter, etc.). Your doula and your independent childbirth class may give you enough natural tools so that you won’t even need the drugs. Most women don’t.

7) Read only the best in childbirth books. Get these books, and devour them cover-to-cover. Seriously, throw away “What to Expect When You’re Expecting,” and dive into these gems instead.

• “Ina May’s Guide to Childbirth,” by Ina May Gaskin

• “The Thinking Woman’s Guide to a Better Birth,” by Henci Goer (Written in 1999, this book is getting a little long in the tooth, but it’s still excellent information and routine procedures and hospital technology have not changed significantly since that time. Henci also runs a helpful Q&A forum on the Lamaze International web site.)

• “Your Best Birth: Know All Your Options, Discover the Natural Choices, and Take Back the Birth Experience,” by Ricki Lake and Abby Epstein (they also offer a great web site and community)

• “The Official Lamaze Guide: Giving Birth with Confidence,” by Judith Lothian and Charlotte Devries (check out their "Giving Birth with Confidence" blog)

And while you’re at it, buy the DVDsThe Business of Being Born” and “Orgasmic Birth” – they're even on Netflix. That’s right, “Orgasmic Birth.” Stretch yourself, sister.

8) Get your partner on board. It's tough to do this alone, you need support! Even with the best doula, your partner is still an integral part of your birth journey. Penny Simkin’s book “The Birth Partner: A Complete Guide to Childbirth for Dads, Doulas and All Other Labor Companions” is a wonderful place to start. Be sure your partner attends that independent childbirth class with you – sometimes partners benefit even more than moms from that information and support.

9) Consider an out-of-hospital birth. It’s certainly possible, with the right support, to have a great first birth in the hospital – vaginal and unmedicated, even. We see them all the time, and the hospital is the perfect choice for women who feel safest and most comfortable there. We also see women who were deeply traumatized by their first hospital birth and find out-of-hospital options for their second child because they simply can’t bear the thought of going back to the hospital. The best research is quite clear that your odds of a vaginal birth are better outside those sterile walls, at home or in a birth center. In 2005 the British Medical Journal published a large prospective study investigating home births in the United States attended by Certified Professional Midwives. The women who birthed at home had similar outcomes to low-risk hospital birthers in terms of safety for moms and babies, but with a cesarean rate of 3.7 percent for the home birth women and 19 percent for their low-risk counterparts in the hospital. The current cesarean rate in the United States is 32.9 percent, according to the Centers for Disease Control. Study after study shows the same positive outcomes and low cesarean rates for planned out-of-hospitals births attended by a qualified midwife (as opposed to unassisted and/or unplanned home births, which are statistically not as safe). Sometimes women say, “I’m interested in home birth, but for this first baby we’ll stick with the hospital, just in case.” Just in case of what? If there’s any birth for which it’s most important to maximize your chances of a healthy vaginal birth, isn’t it your first? The research shows that out-of-hospital birth maximizes your chances of a positive outcome and is equally safe for moms and babies. Given that data, I'll reiterate that women should birth wherever they feel safest and most comfortable. At the very least, out-of-hospital birth is worth considering.

10) Believe in your body! The cesarean rate for women who birth at The Farm in Tennessee is less than 2 percent. The World Health Organization recommends a cesarean rate of 10 percent or less, and says no country in the world is justified in a cesarean rate of more than 15 percent. Women have been doing this for millions of years! Your body works. Birth works, in all its complex and amazing variations. Surround yourself with knowledgeable support, of course, in case of rare and unexpected complications. But truly… trust birth.

Written by Jessica English, CD(DONA), LCCE, owner of Birth Kalamazoo.


  1. What do you suggest, under #1 for those women who don't have much choice of who their OB is. With fewer and fewer OBs practicing (especially in small towns) because of malpractice lawsuits and malpractice insurance costs and health insurance companies being more tight leashed over who is "in-network" many women don't have options. And dishing out $7,000 or more for an out of network doctor isn't an option for most people either.

    I'm not asking this to be a pain or a bitch, but so many articles I see on avoiding cesareans and increasing breastfeeding work on the assumption that women have a wealth of options in this area. I know I had the option of 3 hospitals, all in the same hospital network (main hospital and 2 off-shoots), all with the same internal policies and I live in a huge city, but my (popular) insurance limited my options. Thankfully I found an OB I love and trusted and who trusted me in my network, but that was by chance that she was part of the GYN office I'd been seeing since I'd moved to Giant City.

    I am truly interested in what your thoughts are for women in that situation (women who might already feel disenfranchised by the health system as a result of archaic practices and limiting insurance policies)

  2. This is a wonderful article! I would like to point out though, that that avoiding AROM (artificial rupture of the membranes), is super important when avoiding a c-section. It can cause the baby to enter the pelvis in a poor position and also puts you in a bit of a time crunch for delivery (depending on where you deliver).

    Kristen Elliott LM, CPM

  3. Laura, you make a good point about options being limited by insurance. It can be a big problem. A few thoughts... 1) Make a fuss through your HR department, they are there to serve and advocate for YOU. 2) Some insurances have out-of-network coverage, e.g. 80% for someone out of network - still a cost, but at least a feasible option. 3) Consider home birth or a birth center, in most places it will not cost anywhere near $7K and you might even get much of it reimbursed as an out-of-network expense. 4) consider driving to a neighboring city. I have a student who is driving over an hour because she wants to birth at a birth center and there are none in our area. Women in the upper peninsula of Michigan must drive hours to have a VBAC, and many of them do. 5) Still consult a doula to find out which is the best of your (not great) options, and make sure you have her with you at the birth ~ stay home a long time if you feel comfortable doing that, and know that you can legally refuse anything you do not want.

    Kristen, that is a good point about AROM! It's mentioned in the Lamaze Healthy Birth practices, and would hopefully be covered by the independent CBE. Thanks for the addition!

  4. "The World Health Organization recommends a cesarean rate of 10 percent or less, and says no country in the world is justified in a cesarean rate of more than 15 percent."

    This is incorrect. The WHO used to state that that cesarean rates should not exceed 15%, and a minimum rate should be about 5%. They now say, "Both very low and very high rates of caesarean section can be dangerous, but the optimum rate is unknown. Pending further research, users of this handbook might want to continue to use a range of 5–15% or set their own standards." They actually state that there is "no empirical evidence" supporting their previous recommendation of 5-15%.

    So they say both high and low levels of Cesarean delivery are a problem, but admit that there is actually no evidence on what is a good range, and what is too high of a range. They do state, "Ultimately, what matters most is that all women who need caesarean sections actually receive them."

    Even the European countries with the best perinatal and maternal mortality stats, such as Norway and Sweden, have rates or 15% of more. Italy, in particular, has great stats and the lowest maternal mortality rate in Europe, but has a cesarean rate of nearly 40%. I wonder if part of the reason the high cesarean rate does not affect their maternal mortality rate is because of the low birth rate, so most women having cesareans are likely to have no or only one more pregnancy and birth?

    I do agree that we need to lower our cesarean rate, as there doesn't seem to be a correlation between cesarean rates and reduction in perinatal mortality after about 15-20%. I don't think aiming at admittedly baseless goals is the answer, though, but rather we should find evidence based protocols to help insure that cesareans are used only when truly indicated.