Through a comprehensive evaluation of the evidence from 21 studies of CNM care, the review concludes that there is high quality evidence that women cared for by CNMs are less likely to experience a cesarean delivery, episiotomy, or severe perineal trauma. Women cared for by CNMs are also more likely to choose non-pharmacologic approaches to manage pain, and they have higher breastfeeding rates.

Are you surprised?  I’m not surprised! I feel like this just confirms what we already knew: midwives establish better relationships, answer more questions, are more sensitive, check all the boxes on the customer satisfactions card…but more than that, they actually deliver better outcomes—fewer cesareans, fewer lacerations, increased rates of breasfeeding and natural delivery.  Of course!  It’s just very affirming to see it in writing.

To read the full review as a pdf file, follow this LINK!

A few weeks ago, during a prenatal visit, a woman pregnant with twins told me she would love to have a home birth, but did not have the $4,000 cash required upfront to do so. She was afraid of potential interventions in the hospital. After a discussion of her fears as well as potential complications that can abruptly occur in a twin birth, she admitted she would prefer a hospital birth if she could maintain some control over the situation. This is not a woman who cares more about the birth experience than the baby, but she was tempted, and in some ways I can understand her concerns. My cousin’s wife had her twin induction halted at 4 cm because the new obstetrician on call did not do breech extractions for second twins. Her only option became cesarean delivery.

I recently received a phone call from a woman 2 hours away who had planned a home birth for her second baby after having an easy first birth. When the fetus, which was anticipated to be a little smaller, was found to be a breech, the midwife sent the woman to the local obstetricians. They would only deliver the fetus by cesarean delivery. The midwife offered the woman a home breech birth, but admitted she had only delivered one breech (stillbirth) in her career. The woman appropriately questioned the safety of this, and was referred to us. She met the criteria for our vaginal breech protocol, and had an easy vaginal breech birth in our hospital. Unfortunately, this is becoming a rarity. A colleague of mine in another state watched the residents she was supervising emotionally bully a young woman and her mother into a cesarean delivery. The young woman had a rapidly progressing active labor with a normal-sized frank breech fetus. Had the residents been open to the idea, my colleague easily could have taught them how to deliver a vaginal breech.

The running joke in our community is that the only way to get a vaginal birth after cesarean delivery (VBAC) is to have the birth at home. Unfortunately, this is a reality rather than a joke. Our small community hospital, owing to regional liability insurance constraints, stopped allowing VBACs in 2002 after many years of  successfully offering them. This has led many women to risk home birth rather than travel to a tertiary care center to attempt VBAC. I recently counseled a woman against having a cesarean delivery who had a BMI of 52 and who arrived in active labor at over 35 weeks of gestation with two previous successful VBACs. I spent the following months defending that recommendation, despite her considerable operative risks and high likelihood of success.

Recent news and media excitement about the benefits and increased safety of home birth over hospital birth have made the former seem like a very attractive alternative. A growing notion among women in our region, and perhaps across the country, is that hospitals and obstetricians are a more risky option than lay-home midwives for birth. Although my initial reaction is disbelief, perhaps we should look at how we, the  obstetricians, contribute to this trend.

Each of these women deserves an honest discussion about the fetal and maternal risks of each birthing option. However, our lack of experience as obstetricians colored by our fear of liability is narrowing women’s choices, and sometimes motivating them to ignore fetal and maternal safety in an effort not to be coerced into unnecessary interventions. I sense a mounting tension, because many obstetricians do not have the willingness, time, or skills to provide maternal choices.

I believe we are at a crossroad in maternity care in this country, and I am saddened that obstetricians are considered the culprits. Our contracting skill set as obstetric providers, as well as the prevailing risk-adverse culture among physicians and hospitals, have given support to home birth. We can all agree that VBAC, twins, and breech should not be managed at home, yet we frequently demand complete control of the situation and eliminate some appropriate choices in the hospital. I understand that it can be very unnerving to be ultimately responsible for the outcome, as we are, and yet pushed into situations outside of our comfort zones. However, our unwillingness to budge in these situations is causing us to lose the battle regarding what is really important to most obstetricians: safety for mothers and babies.

Certainly, we can be proud of the dramatic decrease in maternal mortality in the last century. But, despite the highest per capita expenditure of health care in the world, infant and maternal mortality rates in the United States are higher than in all of western Europe. We have the third-highest cesarean delivery rate in the world.

According to a recent study, nearly half of all primigravidas attempting vaginal delivery are induced, and half of cesarean deliveries for dystocia are done before 6 cm of dilation, presumably before active labor. It is amazing how many women begging for elective induction change their minds when told it doubles their cesarean  delivery risk.

We need to draw lines around patient safety, but must they be so rigid? Most midwives know from experience that Friedman’s curve is too strict. A recent study validates that knowledge. I sincerely hope it is taken seriously. Expectant management of ruptured membranes at term has been declared unsafe and of no benefit. The study that settled the question did not account for the number of vaginal examinations women received, and group B strep was not treated, both important variables. Most women do go into labor in 24 to 72 hours. The Cochrane systematic review concludes that, because the differences in outcome are not substantial, women need to be given the appropriate information to make a decision. This very rarely occurs in the hospital setting. The Term Breech Study closed the door on vaginal breech delivery even for the lowest-risk women in most obstetricians’ minds (including the residents I mentioned above). This, despite the opinion of the College that it may be appropriate in carefully selected situations. In any case, vaginal breech delivery is not completely avoidable, and should not be relegated to the history books with vaginal delivery for previa and high forceps.

Our mission has become more difficult in the last 20 years as mothers have become older, heavier, and of lower parity. Many women, admittedly, do have unrealistic expectations. Although I am eternally grateful for the obstetric skills I learned in residency, I have been amazed in my 14 years of practice to see much of the dogma I also absorbed disproven with experience and patience (both my own, my colleagues’, and the midwives I have worked with in the hospital setting). Collaborative practice with midwives is a good start, but in order for obstetricians to be more than providers of cesarean deliveries (a thankless and, in most cases, technically simple procedure) we need to have conversations with our patients that are not one sided and allow for true informed consent. Many of the obstetric disasters we have all seen and which color our  perspective (which David Grimes has called “numerators in search of denominators”) are at least in some part iatrogenic if examined deeply enough. That failed induction for convenience with early artificial rupture of  membranes and chorioamnionitis. The first cesarean delivery done at age 15 after 2 hours of pushing with an epidural that then leads to the fifth cesarean years later, and then accreta and life-threatening hemorrhage, are both typical examples. We need to recognize and own those aspects of obstetric management that are driving our skyrocketing cesarean delivery rate but having no positive effect on maternal or infant morbidity and mortality.

Admitting what is truly evidence based versus what is tradition and culture is a good start. It is essential that we offer real choices to our patients. We need to recover and disseminate the skills that make obstetrics an art and a privilege. Seek out mentors skilled in forceps, vaginal breeches, and breech extractions before it is too late. Then learn to be patient, so that you very rarely need to use them

I find this letter to be very brave and commendable, and while this may sound strange, I am actually really proud of ACOG for publishing it in the first place.  Kudos to Dr. Fineberg for writing this, especially given that she may very well experience a backlash from her colleagues for even suggesting that VBACs, vaginal breech deliveries and vaginal twin deliveries (with breech extraction for the second twin) are things which OBs should be offering their clients, let alone her suggestion that OBs may be partially responsible for driving women with complications to seek homebirth in the first place.

Even more fascinating to me, though, are the commentaries which are going up on The Unnecesarean right now, all written by a collection of different obstetricians who are willing to step forth and give their unvarnished opinion on the true state of things (and huge kudos to them, as well!).  Here are links to their articles:

Lamenting the System, by Dr. Jill Arnold

Lament in Stereo, by Dr. Lauren A. Plante

A Comeback for VBAC?, by Dr. Poppy Daniels

Another Obstetrician’s Lament, by Dr. Gustavo San Roman

An Obstetrician’s Hope, by Dr. David Hayes

The VBAC comments I found particularly compelling, given the sorry state of VBACs in this country right now (see my post below on the new NIH Consensus Guidelines).  The sad truth is, VBACs are no longer being offered as a viable option simply because of politics and a growing culture of fear (aided by our culture of litigation) which states that just because uterine rupture is (occasionally, super rarely) possible, there needs to be 24-hour on-call anesthesia, and an obstetrician on-call ready to brandish a knife at the drop of a hat…and because of this (occasional, super rare) risk, it’s better to not offer VBACs if you don’t have these emergency measures in place.  Nevermind the increasing risks associated with repeat cesareans, the growing rate of cesarean complications, placenta percreta/ acreta etc. etc.  But Dr. Poppy Daniels has addressed this on The Unecessarean more eloquently than I have time to right now, so I’ll let you follow the links.

Besides, I have much more exciting news to share! Stay tuned for a very personal birth story, coming up next!

I’ve been meaning to post this post for ages, but was never able to finish it during the school year last year. All of this comes from the research project that I worked on last year for 2 semesters as part of my research class, and even though I had to radically alter the goal and purpose of my research proposal in the end, along the way I had the opportunity to do some of the research I was really interested in doing in the first place, and it definitely needs to be shared. This is rather a long post, and it gets somewhat technical in places, but bear with me; a lot of the information here can help you fend off an unnecessary induction or cesarean, so it’s well worth reading. And with that, here we go:

Premature rupture of membranes (or prelabor rupture of membranes, aka PROM) occurs when a woman’s water breaks before she actually goes into active labor. It can happen to women at any point in their pregnancy, and when it happens to women who are still preterm, the danger to herself and her baby is much higher, as are the risks of infection (and many studies have demonstrated that in fact, preterm PROM, aka PPROM, is often caused by infection in the first place). However, the majority of PROM occurs in women who are at term gestation (37+ weeks)—90% of all cases, in fact (Zamzami, 2005), and it’s pretty common, too: PROM at term occurs in 8% of all births. (Hannah et. al., 1996)

In our hospitals today, there is sort of an unspoken rule—let’s call it the 24-Hour Rule. It goes something like this: if you haven’t delivered your baby within 24 hours of breaking your water, something is going to have to be done. In many cases, this something is induction, and in many cases, waiting a full 24 hours before inducing is something that never happens. Providers are often way too impatient and antsy for that, and will generally talk a woman into induction long before the 24 hours has passed. Many providers have the policy of immediately inducing a woman with PROM, either by using prostaglandin gels like cervadil followed by IV oxytocin (pitocin), or by just starting on the pit right away. The rationale for this type of management (often called active management) stems from research that was done in the 1960s (Shubeck, 1966; Rusell & Anderson, 1962) which found that the longer a woman was ruptured, the greater the chance of infection, chorioamnionitis (an acute infection of the chorion, which is part of the placenta), and maternal and/or fetal sepsis.

These early studies advocated immediate induction, and were the beginning of active management. The idea that the length of PROM is responsible for maternal infection is something which has sort of been hard-wired into modern obstetrical practice right now, and in my own experience, I have seen the 24-Hour Rule in effect many a time. Providers often use it to justify the need for an induction or augmentation, i.e. “we need to get your labor moving along, because you’ve been ruptured now for 8 hours…12 hours…18 hours…and you’re still not in active labor”, and as studies have shown, inductions and augmentations, especially for PROM, often lead to cesarean (Mozurkewich & Wolf, 1997; Grant et. al., 1992; Tan & Hannah, 2001). I have seen this deadline held over women’s heads before, and in my most humble opinion, it does absolutely NOTHING to help a woman relax, labor effectively, and have a vaginal delivery. (What’s that old Bradley joke about telling a man he better orgasm soon or else his penis will have to be cut apart to get to the sperm? No pressure, now!)

The thing is…the research from the ’60s, which forms the basis of the 24-Hour Rule, has more holes in it than swiss cheese. For one thing, these studies were retrospective, instead of prospective, which means that they relied on going back and looking at records after the births had already occurred, and never tried to control for any of the gazillion variables that might have affected these birth outcomes other than PROM. Similarly, these early studies were non-randomized, meaning that there might have been selection bias at play which could have muddied the findings. Additionally, both term and preterm pregnancies were mixed together when examining the effects of PROM, which seriously confounds results since preterm infants are much more susceptible to infection, and as I mentioned above, preterm PROM often occurs because of infection in the first place (McGregor & French, 1997). These studies had very imprecise definitions for infection, and the management protocols used were neither uniform or clearly discussed. And of course, NICUs and antibiotic therapy have improved so much in the past 40 years that many of the babies that died of infection in these early studies probably wouldn’t have died if they had been born today. So, as you can see, the studies from the 1960s had a lot of problems, and the fact that modern obstetrical practices are still based in part on the findings in these studies is an even BIGGER problem.

What have more recent studies shown? Well, many studies have shown that strict adherence to active management is often unnecessary, and in some cases, does more harm than good (seems to be a repeating theme when you start to look at obstetrical research—funny, that. And here is where it gets very technical. I’m putting the rest of this behind a cut, for those of you who are interested.)

Kappy et. al. (1979) challenged the 24-Hour Rule, asserting that active management unnecessarily increased the cesarean section (CS) rate, and that expectant management of PROM could reduce the rising CS rate while at the same time keep infection to a minimum. Using a prospective, nonrandomized, observational design, the rates of infection were studied in 110 women with preterm PROM and 78 women with term PROM. In both groups, patients were managed expectantly until they either delivered or signs and symptoms of infection appeared, at which point the patients were induced. No digital examinations were performed on patients until they were in active labor, and no tocolytic agents or prophylactic antibiotics were given unless a patient showed signs and symptoms of infection, at which point the patient was induced. Kappy et. al. found that only 13% of all term women had clinical signs of infection at delivery, and only 3% had chorioamnionitis. There were no maternal deaths, and no neonatal deaths attributed to sepsis. Unlike earlier studies, Kappy et. al. separated preterm and term births, used standardized and clearly defined indicators of PROM (sterile speculum exam to detect vaginal pooling, followed by positive nitrazine tests and microscopic ferning to confirm rupture) and standardized and precise definitions of infection (clinical signs confirmed by positive blood, sputum, spinal or placental cultures). The weaknesses of this study included its nonrandomized design, the fact that no effort was made to control for infectious risk factors such as GBS, and only infants showing clinical signs of infection were cultured. Nevertheless, Kappy et. al. were able to conclude that “the conservative approach in the term pregnancy with PROM…seems to decrease the incidence of cesarean sections without an appropriate increase in the infectious morbidity”.

Duff et. al. (Duff, Huff & Gibbs, 1984) supported these results with a randomized control trial that demonstrated that “expectant management resulted in a lower frequency of both cesarean delivery and intrapartum infection than…the practice of immediately inducing labor”. In this study, 134 women with PROM were assigned either to an oxytocin induction group or to an expectant management group where they were observed as inpatients until the onset of labor. The researchers found a statistically significant increase in the number of cesarean deliveries and intra-amniotic infections in the induction group versus the expectant group—20% versus 7%, p<0.05, for cesarean deliveries, and 17% versus 4%, p <0.05, for intra-amniotic infections. This study used a non-blinded, randomized, prospective design (in other words, one of the strongest study designs you can use, and the “gold standard” for research), standardized definitions for maternal and neonatal infection, and uniform and clearly defined indications for cesarean section. Women participating in the study were from a homogenous population of carefully screened low-risk women at term without complicating risk factors such as diabetes, postdates pregnancy, meconium-stained fluid, hypertensive disorders, intraamniotic infection or malpresentation. However, again no mention was made of GBS status, potential bias could have occurred in the use of two distinct management teams, not all neonates were screened for sepsis, and the use of antibiotics during management was not specified.

A study conducted by Grant et. al. (1992) also found that expectant management significantly lowered the cesarean rate while at the same time posing no additional infectious risk to women or infants. In this study, 444 term primigravidas with PROM were blindly randomized to either an immediate induction group or induction the following morning (9-33 hours later, depending on when the woman arrived on the unit). It was found that there were fewer cesareans in the group that was allowed to wait 9-33 hours before induction (11.1% versus 17.4%, p = 0.06) with no significant increase in the rates of neonatal or maternal infection. It’s also interesting to note that women in the immediate induction group were more likely to ask for epidural anesthesia (70.3% versus 57.3%, p < 0.005), which supports the idea that induction leads to increased demand for epidurals, and that epidurals lead to increased cesarean rates.

The largest study to date, the TERM PROM study (Hannah et. al., 1996), examined 5041 women from 72 centers throughout Canada, Israel, Australia and the UK with PROM at term who were randomized to one of four groups: immediate induction with oxytocin (induction-oxytocin); immediate induction with vaginal prostaglandin gel first, followed by oxytocin if active labor had not started (induction-prostaglandin gel); expectant management for up to 4 days unless signs of infection or fetal distress were noted, followed by oxytocin induction if labor had not started after four days (expectant-oxytocin); and expectant management for up to 4 days, followed by induction with prostaglandin gel (expectant-prostaglandin). The study protocol was standardized and well-defined, and the randomization process was blinded (i.e. a very rigorous study design). Vaginal exams were discouraged; however, approximately one third of the women, equally divided among all four groups, received vaginal exams during the initial cervical assessment. Approximately 78% of the women in both expectant management groups went into labor spontaneously within 4 days of PROM and did not require induction. The researchers found no differences in the rate of neonatal infections or cesareans, but an increase in maternal infectious morbidity was noted in the women of the expectant management groups, with 8.6% of the expectant groups developing clinical chorioamnionitis versus 4% in the immediate induction groups.

Unlike earlier studies, a similar number of babies in all four groups were sampled and cultured for neonatal sepsis, regardless of what management group their mothers had been assigned to. Overall, this study presented a very strong case for arguing that immediate induction does not increase the cesarean rate, and that expectant management may increase maternal infection rates. Nevertheless, it still had a few weaknesses. For one thing, multiparas were pooled with nulliparas, and there was no standardization of Bishop’s score (cervical ripeness); 6-15% of the women had ripe cervices, versus 29-54% which were considered unripe, and in 33-65% of the women, the cervical status was unknown. Additionally, the researchers stated that “digital vaginal examinations were avoided,” but the expectant management groups had considerably more digital vaginal exams than the immediate induction groups. This is very important to note, given that digital vaginal exam after PROM has been found to be an independent risk factor for maternal and fetal infection.(Shutte et. al., 1983; Lenihan, 1984)

Even more recent studies (Zanzami, 2005) have found that in the absence of other obstetric and maternal or fetal risk factors, PROM at term is not an additional risk factor on its own. “Expectant management of PROM at term enhances a patient’s chance of normal delivery without an incrase in fatal and/or maternal morbidity.”

Now, this is not to say that other studies haven’t found the contrary to be the case. For example, Wagner et. al. (1989) found an increase in infection rates in babies born to women with PROM who had been managed expectantly versus actively, although this study also found that the number of vaginal exams performed increased the infection rate (which other studies have confirmed). Rydhstrom & Ingemarsson (1991) found no difference in the cesarean rates in a randomized trial between active management and expectatant management, and Akyol et. al. (1999) actually found that the cesarean rate was lower in the immediate induction group of their study when compared to the expectant management group who were randomized to induction after 24 hours had passed. However, it’s important to note that this increase in cesarean rate was in a group of women who had already failed to go into spontaneous labor within 24 hours. The majority of women will go into labor within 24 hours, so inducing those who didn’t might imply other variables at work which would make induction particularly unsuccessful.

My thoughts on the subject? If your water breaks and your labor doesn’t start right away, that’s fine: 8-12% of all women experience this problem, and it happens most often at term. If the fluid is clear and you can feel the baby moving, call your provider by all means and discuss your options with her, but try to stay home for as long as possible! Go for a walk, bake some cookies, scrub out the bathtub, do some yoga, try to get those contractions to kick in (just don’t have sex, now that your membranes are ruptured). Most women will go into labor on their own within 24 hours, and so long as NO digital vaginal exams are performed (i.e. using fingers; a sterile speculum exam is somewhat better, but still isn’t 100% risk-free), the risks of infection are low. If your provider urges an induction, ask for more time; studies have shown that inductions for PROM often don’t work that well, and women who are induced have a higher risk for developing an infection or having a cesarean (Zanzami, 2005; Hannah et. al., 1996), in part because once the induction process begins, vaginal exams and other interventions which increase the rate of infection, like internal monitoring, are often done.

Talk with your provider about giving your body AT LEAST 12 (and preferably 24) hours to get going on its own, and chances are very good that it will. If, after 24 hours you’re still not in active labor, don’t panic; about 15-20% will not do so within 24 hours (Kappy et. al. 1979). In a clinical trial that measured a 12-hour expectant management regimen versus a 72-hour regimen, the rates of infection, chorioamnionitis and neonatal morbidity were the same in both groups. (Shalev et. al, 1995) In other words, you can probably wait up until 72 hours, so long as no signs and symptoms of infection occur (although your risk of infection does marginally increase the longer you’re ruptured, especially after 24 hours). Also, keep in mind that one of the side effects of an epidural is fever! One of the warning signs of infection is a rising temperature, but if you’ve just had an epidural, it could be from the epidural, and not really an infection at all—especially if your provider has kept his/her fingers out of your vagina! (Goetzl, et. al. 2001)

(Having just issued all of this advice, though, please go read my Quick Disclaimer before you go forth holding my word as gospel. I’m not a midwife! I’m a student, and I have NO idea what your personal situation might be. Each labor and birth is unique, full of a million and one variables, and needs to be handled individually by a health care provider you trust.)

References:

Akyol, D., Mungan, T., Unsal, A. & Yuksel, K. (1999) Prelabour Rupture of the Mmebranes at Term—No advantage of Delaying Induction for 24 Hours. Australia and NZ Journal of Obstetrics & Gynecology, 39(3): 291-295.

Duff, P., Huff, R.W. & Gibbs, R. (1984) Management of Premature rupture of Membranes and Unfovarable Cervix in Term Pregnancy. Obstetrics & Gynecology 63(5): 697-702.

Duncan, S.L.B & Beckley, S. (1992) Prelabour rupture of the membranes—why hurry? British Journal of Obstetrics and Gynaecology, 99: 543-545.

Ezra, Y., Michaelson-Cohen, R., Abramov, Y. & Rojansky, N. (2004) Prelabor rupture of the membranes at term: when to induce labor? European Journal of Obstetrics & Gynecology and Reproductive Biology, 115:23-27.

Grant, J.M., Serle, E., Mahmood, T., Sarmandal, P., & Conway, D.I. (1992). Management of prelabour rupture of membranes in term primigravidae: a report of a randomized prospective trial. British Journal of Obstetrics & Gynaecology, 99(7): 557-562.

Goetzl, L., Cohen, A., Frigoletto, F., Ringer, S.A., Lang, J., & Lieberman, E. (2001). Maternal Epidural Use and Neonatal Sepsis Evaluation in Afebrile Mothers. Pediatrics, 108(5): 1099-1102.

Hannah, M.E., Ohlsson, A., Farine, D., Hewson, S.A., Hodnett, E.D., Myhr, T.L. et. al. (1996). Induction of Labor Compared with Expectant Management for Prelabor Rupture of the Membranes at Term (TERM PROM study). New England Journal of Medicine, 334(16), 1005-1010.

Kappy A.K. et. al. (1979) Premature Rupture of Membranes: A conservative approach. American Journal of Obstetrics & Gynecology 134(6): 655-661.

Lenihan, J.P. (1984) Relationship of Antepartum Pelvic Examinations to Premature Rupture of the Membranes. Obstetrics & Gynecology, 83(1): 33-37.

Marshall, V.A. (1993) Management of premature rupture of membranes at or near term. Journal of Nurse-Midiwfery, 38(3): 140-145.

McGregor, JA, French, JI. (1997) Evidence-based prevention of preterm birth and rupture of membranes: infection and inflammation. Journal of the Society of Obstetricians and Gynaecologists of Canada, 13: 835-852.

Mozurkewich, E.L. & Wolf, F.M. (1997) Premature rupture of membranes at term: a meta-analysis of three management schemes. Obstetrics & Gynecology, 89(6):1035-1043.

Rhdhstrom, H & Ingemarsson, I. (1991) No Benefit from consevative management in nulliparous women with premature rupture of membranes (PROM) at term. Acta Obstetrica Gynecologica Scandinavia, 70: 543-547.

Russell, K., & Anderson, G. (1962) The aggressive management of ruptured membranes. American Journal of Obstetrics and Gynecology, 83(7): 930-937.

Shalev, E., Peleg, D., Eliyahu, S. & Nahum, Z. (1995). Comparison of 12- and 72- hour Expectant Management of Premature Rupture of Membranes in Term Pregnancies. Obstetrics & Gynecology, 85(5): 766-768.

Shetty, A., Burt, R. Rice, P & Templeton, A. (2005) Women’s perceptions, expectations and satisfaction with induced labour—A quastionnaire-based study. European Journal of Obstetrics & Gynecology and Reproductive Health.

Shubeck, F., Benson, RC., Clark Jr, WW., Berendes, H., Weiss, W., & Deutschberger, R. (1966). Fetal hazard after rupture of membranes. A report from the Collaborative Project. Obstetrics & Gynecology, 28(1), 22-31.

Shutte, M.F., Treffers, P.E., Kloostermoan, G.J. & Soepatmis, S. (1983) Management of premature rupture of membranes: The risk of vaginal examination to the infant. American Journal of Obstetrics & Gynecology, 146(4): 395-400.

Tan, BP & Hannah, M.E. (2001) Oxytocin for prelabour rupture of membranes at or near term (Cochrane Review). In: The Cochrane Library, No. 2., Oxford: Update Software, 2001.

Wagner, M.V., Chin, V.P., Peters, C.J., Drexler, B., & Newman, L.A. (1989) A Comparison of Early and Delayed Induction of Labor with Spontaneous Rupture of Membranes at Term. Obstetrics & Gynecology, 74(1):93-97.

Zamzami, Y. (2005) Prelabor Rupture of membranes at term in low-risk women: induce or wait? Achives of Gynecology and Obstetrics, Oct. 6: 1-5 [e-pub. ahead of print.]

Obstetrical interventions pass for science, even though their use in normal pregnancy is irrational. According to anthropologist Robbie Davis-Floyd, obstetrical interventions fulfill a rational societal function by diminishing our high-tech society’s extreme fear of birth. Specific cultural services are performed when obstetricians “bring forth a new social member through a maze of wires and electronic bleeps.” Obstetrical rituals convey core values that center around science and technology. Belief in them as “necessary” sustains patriarchal institutional management. We let monitors, intravenous devices, and drugs give birth instead of women, turning the bodies of women who give birth into “machines.” Faith in technology provides a comfortable refuge from the unknown.

Even though this article was written in 1993, almost everything it discusses is still true, or even more true. The c-section rate is no longer 23%, it’s a whopping 29%. Things keep getting worse, not better. No joke. This article is AMAZING, complete with references! Go read it IMMEDIATELY! I cannot stress this enough. We should print out copies of this and tape it to the walls of hospitals, or hand it out on the street, or just randomly place it in mailboxes. This article needs to become public knowledge, ASAP. The time to rediscover midwifery is NOW.

This study was published in June and is a welcome addition to the homebirth v. hospitals debate which has been raging in this country for years. Some of the biggest arguments against homebirth studies so far have been that they’ve been predominantly retrospective, which brings up issues of selective reporting and potential bias, and few studies can distinguish between planned and unplanned home births. Well, no longer! This study measures only planned homebirths, and is prospective in nature, which provides a rather conclusive wallop to the ongoing debate.

In a large, prospective cohort study carried out with assitance from the North American Registry of Midwives (NARM), the outcomes of low risk women giving birth in hospitals were compared with those giving birth at home under the care of a CPM. 409 practicing CPMs agreed to take place in this study, enrolling all of their patients with an expectant date of delivery in the year of 2000. Overall, 7623 women were registered, although several women were eliminated from the data pool for multiple reasons (such as medical problems removing them from the low risk category, deciding to deliver in a hospital instead of at home, declined participation, etc. etc.); the study group was eventually nailed down to 5418 women who intended to give birth at home at the start of their labor. This number was then compared to all the women who gave birth to singleton, vertex babies of at least 37 weeks gestation in a hospital in 2000, after determining that they were low risk through a screening tool consisting of 13 personal and behavioral variables associated with perinatal risk. The data for this control group was provided by the National Center for Health Statistics.

It was found that the intrapartum and neonatal mortality rate for homebirths was on par with what other studies have shown for hospital births, while the rate for medical inverventions was much lower for the homebirth group as compared to the hospital birth group. In other words, for low risk women, homebirth is just as safe as hospital birth, and hospital birth is just as safe as homebirth, from a statistical standpoint. Of the 5418 women, 655 (12.1%) were transferred to the hospital, mostly for epidural medication (4.7%) or cesarean delivery (3.7%), indicating medical intervention rates astoundingly lower than the national average (19% in 2000 for low risk women). The intrapartum and neonatal mortality rate was calculated at 1.7 deaths for every 1000 planned home births, after breech and twin deliveries were excluded (since they don’t qualify as low risk). This is consistent with the findings of other studies of planned home births and low risk hospital births. No maternal deaths occurred.

In general, this study is very strong. It’s prospective and limited to planned homebirths, the data is clearly presented and easy to understand, and the results are consistent with other findings. The weaknesses of this study lie in the fact that the control group was not prospective as well, but the authors addressed this in the discussion, pointing out the difficulties in trying to create a workable design for low risk hospital births. Vital statistics forms do not accurately collect information on medical risk factors, either, so it was difficult to create a retrospective low risk hospital group as well. Additionally, there may always be confounding factors, such as some unidentified difference between women who select home birth as their method, when compared to women who choose to give birth in a hospital.

Sadly, I’m not sure how much a study like this is going to change current attitudes towards homebirth, despite it’s strong design and clear findings. On the BMJ website, several practitioners wrote comments in response to this study which pretty much flat-out stated that it wouldn’t change their practice in any way. Another practioner commented about the 1.3% of all babies born in the homebirth group who had five minute Apgar scores below 7; this statistic is very small, and in line with hospital statistics, but the practioner honed in on it as if any home without an on-site NICU is inadequate, and as if the CPMs were not prepared to resuscitate the babies properly (they are, and babies are usually stable before being transferred to the hospital). Even so, the majority of the comments were resoundingly positive, and I should take this opportunity to remind my impatient, idealistic self that change is slow, and is often a long time in coming. It was nearly 20 years, after all, before the medical community came to accept handwashing between patient visits as a common practice. Our country is slowly, slowly moving away from technocratic birth, and coming to a larger acceptance of homebirth and midwifery. We’ll get there eventually.

Attention all doulas out there: this is something you really need to read. It’s one of my favorite studies of all time, actually. I discovered it in Nursing School when I was writing a report on health care policy measures which could be used to lower our abysmally high c-section rate. This study found that the importance of continuous emotional support during labor cannot be overemphasized, which isn’t really news to a midwife or doula, but is something that many doctors tend to overlook, not to mention many of our hospitals, and the field of obstetrics in general. We have whole systems devoted to the get ‘em in, get ‘em delivered, get ‘em out approach, with a lot of time and attention spent on interventions which allegedly speed up birth, such as inductions and the judicious use of pitocin, and of course, there’s the misguided idea that a cesarean is actually a safer, faster, healthier option than a vaginal birth (as our growing elective primary c-section rate would attest). What this study found was that continuous emotional support during labor not only lowered the c-section rate, but also shortened the length of labor, and even lowered the epidural rate. Pretty powerful stuff!

In this remarkable study performed at Jefferson Davis Hospital in Houston, TX, researchers paired women in labor with either a doula or a non-interactive observer, and compared the cesarean section (CS) rates of both groups to a control group which received no outside support other than the hospital staff. The doulas had all experienced a normal labor and vaginal delivery, were fluent in English and Spanish, had been trained in labor support techniques during a three week intensive, and were comfortable dealing with both patients and medical staff. During labor, the doulas offered continuous hands-on support, often holding, massaging and verbally reassuring the woman in labor, as well as explaining what was happening during labor and what would likely happen next. In contrast, the non-interactive observer, while also continuously present, maintained an inconspicuous role and never spoke with the patient. The results of this study revealed that doulas had a profound effect on the CS rate: women with doula support had an 8% CS rate as compared to a 13% CS rate for the observed group and an 18% CS rate for the control group. Doula supported women also had a lower rate of epidural use (7.8% vs. 22.6% and 55.3% for the observer and control groups, respectively) a shorter labor (an average of 7.4 hours v. 8.4 and 9.4 hours for the observer and control groups) and a reduced rate of oxytocin use, maternal fever and prolonged infant hospitalization. Although they were unable to draw any conclusive reasons for these striking differences, the researchers did conjecture that reduced maternal anxiety in the doula-supported group could have been responsible. The authors also indicated that the support given by doulas was different from the support given by male partners, and that the doulas tended to provide more physical reassurance than the male partners, perhaps because they were more familiar and comfortable with the labor process.

There you have it. The benefits of this study are self-evident: even simply having someone in the room on a continual basis proved effective in lowering the CS rate (even if they weren’t saying a word). Midwife means “with woman”, and to my way of thinking, any decent midwife worth his or her salt rarely leaves his or her patient’s side. Similarly, this might help explain why midwives, using the Midwifery Model of Care, which emphasizes a hands-on approach, have a much lower c-section rate, a lower epidural rate, and shorter, less-complicated labors in general. Or why having a doula is the next best thing, if you don’t have a midwife. Or, have a midwife *and* a doula, and amaze all your friends with the brevity and ease of your birth story! Well, that might be pushing it slightly, but you see the point. A trained labor companion, by reducing maternal anxiety, educating the patient and providing continuous support, can not only expedite delivery but also produce a better outcome. It’s really validating when you find a study that supports what you’ve known and believed all along.