Belly Tales

Sometimes, briefly, you feel like you’re making progress, that midwifery outreach is making a difference, that people are becoming more educated and informed, and then you read an article like this one, over at Time Magazine, and you realize that you exist in a small bubble where your philosophy on birth is far different than the majority of the country, and no matter how much you talk yourself hoarse educating people about the issues, they’re still going to buy into the myths of birth, hook, line and sinker.

Cesarean births are not “safer”. Numerous studies have demonstrated, again and again, that cesarean births carry more risks than vaginal delivery, and these risks multiply with each cesarean birth. Sure, the woman in this article had a “safe” and uncomplicated primary cesarean, but no attention is given to what happens when this same woman comes back for her second or third repeat cesarean—how difficult it is to perform surgery on the same site, to cut through scar tissue, how the risks for abnormal placentation such as placenta previa or placenta acreta increase exponentially with each cesarean, how the risk of hemorrhage increases dramatically. There’s also no discussion about how painful recovery from a cesarean is compared to recovery from a vaginal delivery, and how statistics have shown that this poorly affects bonding and breastfeeding rates in women who’ve given birth by cesarean. (Not to mention the fact that the motivation for elective cesareans for many women is a fear of pain, and in fact, the entire process is often much more painful, for a much longer period of time, post cesarean).

Vaginal delivery can, for example, lead to future incontinence and pelvic damage, while babies born by C-section may suffer from respiratory problems because of not being exposed to certain hormones during the birthing process.

Where is the author, Alice Park, getting this information from? How come there are no articles or references cited? I thought we were well beyond the argument that cesareans prevent pelvic floor damage. While injury to the pelvic floor can and does occur during vaginal delivery, it’s often caused by practices such as episiotomy, vacuum-extraction, forceful pushing and lithotomy position during deliveyr, all of which can be (and are being) minimized during vaginal birth. Routine episiotomy, for example, is now by and large a thing of the past. Furthermore, there is no conclusive evidence which demonstrates that cesarean section prevents pelvic floor damage. To quote from What Every Pregnant Woman Needs to Know About Cesarean Section (2006), published by the Maternity Center Association:

Is vaginal birth in and of itself harmful? It is common to hear that “vaginal birth” causes pelvic floor problems. Of hundreds of studies examined, however, not one attempted to avoid or limit the use of practices that can injure a woman’s pelvic floor to try to determine whetehr vaginal birth itself plays a role. It is wrong to conclude at this time t hat the cause of pelvic floor problems is giving birth through the vagina….

Is “vaginal birth” the culprit in the high levels of incontinence that women experience later in life? Studies that take a longer view find that new problems with urinary incontinence that appear after birth lessen over time. These problems tend to completely disappear by the time of menopause. Older women experience high rates of incontinence, but this appears to be due to other factors. For example, excess weight and smoking play a role.

Does cesarean section prevent incontinence? Routine cesarean section would only prevent continuing symptoms of incontinence in a small portion of birthing women. For most women, it would pose numerous risks without benefit. And it would offer no protection against experience incontinence in later years. As no research has found that vaginal birth itself causes incontinence, there are more sensible ways to prevent these problemss: 1) avoid when possible the use of birth interventions that can injure the pelvice floor, and 2) focus on keeping a healthy weight, avoid smoking and other risk factors.

(Still not convinced? Check out the following studies:

[1] Shorten, A, Donsante, J. & Shorten, B. (2002) Birth position, accoucheur and perineual outcomes: Informing women about choices for vaginal birth. Birth, 29(1), 19-27.

[2] Terry, R, Westcott, J, O’Shea, L., & Kelly, F. (2006). Postpartum outcomes in supine delivery by physicians versus nonsupine delivery by midwives. The Journal of the American Osteopathic Association, 106(4), 199-202.

[3] Soong, B., & Barnes, M. (2005) Maternal position at midwife attended birth and perineuam trauma: Is there an association? Birth, 32(3), 164-169.)

The point being, I can’t believe such a mainstream publication could write such an imbalanced, one-sided and poorly researched article. I think I feel a letter to the editor coming on!

So, not the most pleasant way to start out our new year, but our national Cesarean Section rate is somewhere around 29%, possibly even higher now, given that this data was from 2004, and we’re still awaiting the final tallies from 2005 at this point. To quote Marion Toepke McLean from her article Cesarean on Maternal Request in this month’s issue of Midwifery Today: “For the woman with complete placenta previa, or the woman who, for whatever reason, needs to give birth abdominally as the lifesaving or safer course, I can recommend cesarean. But 29% of birthing women do not fall into this category”. (emphasis mine…and speaking of doctors opinions and policies…or lack thereof…on cesareans on maternal request, check out Womens Health News.)

Obviously, other people feel similarly, and in a landmark case decided in Massachusetts, a court ruled in favor of the plaintiff, Mary Meador, a woman who gave birth via cesarean section and claimed that the risks of VBAC were misrepresented to her and that she was coerced and misled into having a cesarean—so, basically suing for receiving an unecessary cesarean section. (Editor’s note 1/6/07: It has come to my attention that this case is from 1993, so not really landmark these days, although it’s nice to know a precedent like this exists. I wish it had made more of an impact.)

One has only to look at womens’ responses to cesareans that they know are unecessary to see how destructive and devastating this practice can be. How can anyone think that coercion qualifies as informed consent? What amount of pain and anguish can lead to art like this?

In my practice as a nurse, I cannot tell you how many times I’ve seen a cesarean performed for no good reason at all: for provider preference, because he or she wanted to go to sleep, or get to their office hours on time, or because of provider ignorance. Just last night at work, I was with a woman who was moderately preeclamptic with increasing amounts of protein in her urine (an ominous sign). I agreed with the obstetrician’s decision to deliver this baby immediately, but because her baby was breech, she was told that cesarean was her only option, end of story, sign on the dotted line, please. No informed consent, no weighing of the benefits and risks of induction and breech delivery versus cesarean. Forget the fact that this was her fourth baby, and that her first three babies were all uncomplicated vaginal deliveries. Forget the fact that she had a “tested” pelvis that was more than adequate to accomodate her baby (a tiny little peanut that ended up weighing 6 lbs. 8 oz.). Because of lack of provider skill, because of lack of provider education, because breech deliveries are so rarely performed any more, by any one, this woman had a primary cesarean.

Cesarean is increasingly becoming the correct response to any birth that deviates even slightly from “normal”. Cesarean is nine times out of ten (the Meador v. Stahler and Gheridian case aside) the trump card that will stand up to court scrutiny. Doctors are so concerned about not doing a cesaeran that it’s very easy to forget the other angle to it: cesareans are major abdominal surgery, with more risks associated with it than vaginal birth. Imagine what our world would be like if doctors felt more strongly about the possibility of being sued not for failing to do a cesarean, but for performing a cesarean that was unecessary? Imagine how much longer trials of labor would last, how much higher our VBAC rate would be, how much more time women who are being induced would be given to allow their bodies to go into labor. Imagine the increased time and attention that would be spent with true informed consent, and the weighing of options? Imagine how much lower our cesarean section rate would be.

Well, huh, this isn’t really news, but better late than never: a very well balanced article from the New York Times examines many of the issues which contribute to the declining rate of VBACs in this country, including doctors’ rising fear of uterine rupture, hospitals’ difficultly in staffing the necessary number of qualified doctors to support and provide VBACS, women who are more than happy to schedule their second, third and fourth (and primary!) cesarean, and women who desire a VBAC and feel betrayed by the lack of options available to them in their area.

Many women are willing to take the risk [of having a VBAC], and the hospitals’ stance has become a charged issue, part of a larger battle over who controls childbirth. Some women say their freedom of choice is being steamrolled by obstetricians who find Caesareans more lucrative and convenient than waiting out the normal course of labor. Doctors say their position is based on concern for patients’ safety.

Meanwhile, a story from yesterday’s New York Daily News charts the rising cesarean rate in hospitals, citing which five hospitals in New York city have the hightest rates: New York-Presbyterian Hospital Columbia (a whopping 39.6%, which still seems monumental even when you factor in that NY Presb handles many of the highest risk births in this city—the method of handling them is obviously cesarean), St. Vincent’s Hospital Staten Island (39.5%), Brooklyn Hospital Center (38.5%), New York Presbyterian Weill Cornell (37.1%) and finally, Flushing Hospital (37%).

Powerful numbers, indeed. If this continues, the Healthy People 2010 goal of a 15% cesarean rate for first time mothers and an increase the VBAC rate to 63% will seem laughable, rather than even remotely attainable.

Two studies have recently come out which highlight the risks of cesarean birth for both mothers and babies, particularly primary cesareans with no medical indication. A recent study printed in Birth: Issues in Perinatal Care found that neonatal mortality rates were higher in babies born by cesarean, even after the statistics had been adjusted for congenital malformations, socioeconomic and medical risk factors. This is especially significant given that the focus of the study was on low-risk mothers who had no medical indication for cesarean, and the sample size was quite large (311,927 low risk women were analyzed). The NY Times picked up the story in last Tuesday’s paper (Voluntary C-sections Result in More Baby Deaths).

And then, it never rains but it pours: Nabbed from Milliner’s Dream, who saw it first, a recent French study also found that having a cesarean more than triples a woman’s risk of death when compared to the risks associated with a vaginal birth. (Postpartum Maternal Mortality and Cesarean Delivery) The increased risk of death was found to stem from complications from anesthesia, puerperal infection and venous thromboembolism, all of which are risks associated with surgery.

So, how…vindicating. There is now a sudden spurt of evidence which suggests that cesareans aren’t nearly as safe or benign as common practice would indicate. Now the question is: how long will it take for the medical community to absorb this new information and begin to cite the risks involved to the women trying to schedule a primary cesarean when there is absolutely no medical indication for one? It took years for the medical community to acknowledge that routine episiotomy can cause more harm than good, but practic is finally beginning to change. And, I wonder who will be the first to try to refute these findings?

(By the way, have you noticed how chock-full of good stuff the September issue of Obstetrics & Gynecology is? In addition to the above French study on maternal mortality and c-sections, check out ACOG’s Committee Opinion on the HPV vaccine).

ADDENDUM:

ACOG’s press release on the results of the French study in this month’s Obstetrics & Gynecology :

Though rates of maternal death in most developed countries are relatively low—US women have a 1 in 3,500 chance of pregnancy-related death—incidences of maternal mortality have not significantly decreased in the last two decades. These study results suggest that mode of delivery may be a modifiable risk factor, and in some cases, choosing vaginal delivery over non-medically indicated cesarean delivery could help lower maternal mortality rates.

This is a fantastic article from Parenting.com, which was brought to my attention in one of the natural birth online communities I frequent. I am posting it in its entirety here, so that everyone can read it, even if you’re not subscribed to Parenting (although it’s well worth subscribing to). Can you imagine being prosecuted for first degree murder, just by refusing a cesarean? Scary scary article, just in time for Halloween. (Read on …)

Last night at work was the night of six minute bradycardias. Scary scary night. (Read on …)

I’ll grant you a terse congratulations, but that’s it. Britney Spears had a healthy baby boy today, via primary cesarean section. To quote the Reuters article: “Spears…had been previously reported as saying she planned to have the baby by Caesarean section to avoid the pain of a natural birth.” In other words, too posh to push.

Now, I have two conflicting thoughts here. On the one hand, it’s her body, her choice, she’s a woman, and I have to respect her decision, even if I would have counselled her otherwise, or made a different decision myself. On the other hand, she’s an icon with a huge following and therefore an untold amount of influence and power, and therefore an extraordinary opportunity to create positive change and lead by example. Some celebrities use this power to its utmost (just look at Sean Penn in New Orleans in his own boat, doing what he personally could to save lives and ease suffering); others fritter it away and could care less, and still others abuse their power and influence to terrible ends.

Britney had an opportunity to educate herself about birth. Britney’s family had an opportunity to edcuate themselves about birth. Britney’s health care providers had an opportunity to educate her about birth. Her fans were watching her pregnancy and the decisions she made very closely. She could have created far-reaching positive change in the way young women in this country view birth. Instead, she upheld the status quo, and embraced the idea that childbirth is painful, not something a woman can or should go through, if she can afford not to, and cesarean birth is an easier and safer ideal. Why did she have to go to the far extreme of technological intervention? Why not show instead that women’s bodies are strong, capable of birth, and that babies don’t need an exit through the abdomen when one has already been so perfectly designed for them? I mean, c’mon…if she really wanted to avoid the pain of natural childbirth, why didn’t she just have an epidural? Then she could have still delivered vaginally, at least.

Golden opporunity pissed down the drain.

I guess while we’re at it, we can always encourage Britney to breastfeed.

Public Advocate and outraged citizen Betsy Gotbaum released a report on Wednesday (7.13.05) about the soaring Cesarean Section (CS) rate in New York City, which she called “alarmingly high”, noting that in some hospitals the number was nearly twice the rate recommended by the World Heath Organization and the CDC.

She also noted that only 1 hospital out of the 44 contacted could provide current statistics and information about their CS rate, even though all hospitals are required by law, under the Maternity Information Act (MIA), to not only provide this data but also make it publicly accessible in the form of a pamphlet, or on their website. As Gotbaum succinclty put it: “The City’s hospitals should be recommending what is best for the health of the mother and newborn, so when 43 of 44 hospitals surveyed by my office fail to provide this data, we have to ask ‘What are they trying to hide.’” It’s also sad to note that the material provided by the lone hospital that complied with the request was dated from 1998.

C-sections are major abdominal surgery, a fact which is often overlooked in our country; a woman undergoing a c-section is at risk for many of the same complications which attend any surgery, such as increased risk of infection, damage to internal organs, hemorrhage and anesthesia complications—risks which are often downplayed in the hospital, or not even discussed at all. Gotbaum also added infertility and psychological trauma to the list of potential health risks associated with c-sections, as well as an increased risk of respiratory distress and premature birth in infants. C-sections are sadly the most commonly performed surgery in America right now, but for some reason, c-section surgery is not treated with the same gravity as other surgeries. Could you imagine a man four days after obstructive bowel surgery to be up at all hours of the night and on his feet and taking care of a newborn? It’s unthinkable. I’ve never understood why c-sections are often thought of as if they’re minor surgery (they’re not!). Maybe the fact that c-sections are done under epidural or spinal anesthesia (where the patient is awake and alert during the procedure), instead of general (where the patient is completely out), makes it seem less serious? Who knows.

The CS rate in NYC right now is 26.4%. To quote Gotbaum again: “This is unacceptable. We’ve got hospitals all over the city that are delivering a third of their babies by c-section. The Department of Health has to get to the bottom of why this is the case. I also want to know why not one hospital out of 44 could provide the information they are required by law to provide.” Pithy, blunt, and to the point.

Whenever news abour labor and birth hits the mainstream media, I sit up and take notice. The fold-out section on Women’s Health in this sunday’s New York Times certainly caught my attention, and while perusing it, I read the following tidbit in Eric Nagourney’s article about shifting health guidelines for women:

Caesarean Birth

There was a time when women who had already given birth by Caesarean section would never be allowed to have their next child naturally. Doctors considered the practice too dangerous.

That thinking changed about two decades ago. Doctors are now taught that in most cases, vaginal birth after Caesarean - often referred to as VBAC (commonly pronounced VEE-back) - is only slightly less safe than having another Caesarean.

But try getting a hospital to allow it. After years in which the number of VBAC’s went up, many hospitals, concerned about medical complications and legal liability, have begun forbidding the practice.

Part of the concern is that the stresses of labor may put so much pressure on the old incision site that the uterus can rupture, putting baby and mother at serious risk. Even advocates of VBAC say that it should be done in hospitals that are equipped to deal with a problem.

The American College of Obstetricians and Gynecologists counsels that most women who have had what is known as a low-transverse incision Caesarean should be offered a chance to give birth vaginally. (The group advises against it with women who have had a “classical” Caesarean incision.) Epidural anesthesia is fine, the group says, but inducing labor should be discouraged.

According to the preliminary birth data for 2003, the cearean section rate is at an all time high in this country, coming in at a whopping 27.6%. Meanwhile, the report issued by the CDC noted that the VBAC rate has fallen abysmally from it’s high of 31% in 1998, and is now down to 10.6%. What I want to know is: what’s happening here? Why is the VBAC rate falling so precipitously?

The overall risks of a VBAC are low, but there is always the possiblity of uterine rupture, which occurs in approximately 1 out of every 2,000 births, and is pretty serious, of course, since it puts both the mother and baby at risk, depending on the severity of the rupture. However, a repeat cesarean is hardly risk free: not only does it bring with it the usual risks associated with abdominal surgery (risk of infection, anesthesia complications etc.), but the risks of infection and surgical complication are higher with a repeat, and the chance of incorrect placental implantation or placental accreta with future pregnancies is much higher as well. If a woman has one repeat cesarean, she will almost unequivocably be having a cesarean with her third child and fourth child too, and the risks associated with those cesareans will just keep rising each time.

I do wonder how much fear of litigation is affecting this. When a cesarean is viewed as the “safer” option, the consevative approach, the correct course of action and the solid defense that will hold up in court, then of course a nice, clean, quick cesarean would seem much more preferable to a long, drawn out (i.e. normal vaginal birth) VBAC, with its inherent risk of uterine rupture and potential malpractice claim. Even though the chance of uterine rupture is very low, when the cost of defending a malpractice claim is so high, I wonder if a lot of doctors just don’t think it’s worth it anymore?

A very large and comprehensive study of the risks of VBAC versus elective repeat cesarean was published in December, 2004 in the New England Journal of Medicine. This study found that the overall risk in having a VBAC was low, but nevertheless, slightly higher than the risks involved in having an elective repeat cesarean. Hospitals have been limiting the number of VBACs for several years now, and there are several hospitals which flat-out refuse to do VBACs, even if their attending doctors (not to mention the women giving birth) are willing. If a hospital was on the brink, perhaps this study has just offered up the unequivocal proof they were looking for, and tipped them over the edge, into the No VBAC zone.

ACOG still recommends that women with low-transverse incisions and no other obvious risks attempt a VBAC before having a repeat cesarean. The Healthy People 2010 guideline is recommending a 37% percent VBAC rate by 2010, so we’ve got a long ways to go to reach that, in not a lot of time. However, as Eric Nagourney’s article in the New York Times pointed out, guidelines keep changing, and what was seen as sound, incontrovertible medical practice now is often found to be questionable 10 years down the road. VBACs changed the landscape, challenging the old medical idea of “once a cesarean, always a cesarean”, but now perhaps we’re in the middle of a cesarean backlash, as the VBAC rate keeps plummeting. We can only hope that 10 years down the road, VBACs will be on the rise again, and the notion of “once a cesarean, always a cesarean” will be something relegated to history books.

It’s summertime! The weather is warm, the t-shirts and skirts have been dragged out of the depths of my closet, and school is officially on hold for the next three months, which means I have a lot more time to play around on the internet, and go for walks, and eat ice cream, and most importantly, write tons of posts for this website! Aren’t you all in luck? (Granted, I’m not entirely sure that anyone is reading this website yet, but hey, it’s fun to have an imaginary audience.)

Anyway, amid all my ice cream eating and internet-surfing, I stumbled upon the 2002 labor intervention statistics for hospitals in the New York metropolitan area, courtesy of the New York State Dept. of Health, and nicely summarized on the Choices in Childbirth website. So, without further ado, here are the 2002 cesarean section rates for the major NYC hospitals we all know and love:

Allen Pavillion… 28% (16% Primary, 12% Repeat)
Bellevue Hospital… 19.8% (13% Primary, 6.8% Repeat)
Beth Israel… 22.4% (15.1% Primary, 7.4% Repeat)
Columbia Presbyterian… 33.8% (22.5% Primary, 11.3% Repeat)
Harlem Hospital… 24.9% (15.1% Primary, 9.8% Repeat)
Jamaica Hospital… 25.3% (16.5% Primary, 8.8% Repeat)
King’s County… 23% (17.9% Primary, 5.9% Repeat)
Lenox Hill… 31.5% (21% Primary, 10.5% Repeat)
Maimonides… 18.9% (12% Primary, 6.8% Repeat)
Metropolitan Hosp… 22.8% (11.9% Primary, 10.9% Repeat)
Mt. Sinai Hospital… 26.9% (18.1% Primary, 8.8% Repeat)
NY Downtown… 13.3% (9.0% Primary, 3.3% Repeat)
NYU Medical Center… 26.4% (19.1% Primary, 7.3% Repeat)
Roosevelt Hospital… 27.0% (19.4% Primary, 7.6% Repeat)
St. Vincent’s… 26.1% (19.7% Primary, 6.5% Repeat)

These statistics usually aren’t that easy to find—it’s a pain in the ass to look them up or request them from the Dept. of Health, and few (if any) hospitals will volunteer their own cesarean section rates during the hospital tour for expectant families. Why? Because these CS rates are all embarassingly high. According to the World Health Organization, “countries with some of the lowest perinatal mortality rates in the world have cesarean section rates of less than 10%. There is no justification for any region to have a rate higher than 10-15%.” (see below for full citation¹).

Most hospitals in NYC are averaging 22-25%. Some hospitals even go as high as 31-33%. That means that more than 1 in 4 women at those hospitals end up with a cearean. Those are terrible odds. Cesarean delivery is the most common surgery performed in the US right now. Is anyone else distressed by this? Can’t we do better than this?

¹WHO, 1985. Appropriate Technology for Birth. Lancet, 2(8452), 436-437).