Maternity Care in America — Empowering Women for Their First Birth

Over at the Independent Childbirth site, “Birth Wisdom Week” is being celebrated.  I was supposed to write a post as part of this, but I’ve been a bit tied up planning some activism related to the situation with The Midwives, so I apologize profusely about how late this post is!

As a childbirth educator and doula, I have to admit, one of my greatest frustrations is that many women don’t even really seem to be bothered by the rising cesarean rate in America.  If I thought that it was that the women didn’t care if they had a vaginal vs. cesarean birth, I’d be able to accept that.  But I really don’t think that is the case  I think that the majority of women in their first pregnancy really would prefer to avoid birthing by cesarean, and if they are low risk, they really think that will pretty much happen on its own. 

Laura Lund says of this kind of thinking “I’m most frustrated by [women] … thinking that while their doctor might do x, y, z a lot of the time, he’s going to act differently for *them*.”

I know that when I was pregnant with my first baby, I never even really thought a cesarean was a possibility for me–of COURSE I would have a vaginal birth.  What I did to avoid a cesarean was done more by luck than by any active effort–I took an independent childbirth class because it was reccommended to me by a friend who was pregnant at the same time. 

When I was expecting my first baby, the cesarean information I had available indicated that rates were dropping to their lowest levels in over a decade (1996 and that is the latest information I had in mid-1998).   I’d like to say that I considered those rates in my niave belief that I didn’t need to worry about cesarean–but I didn’t–I didn’t even know what the cesarean rate was until I was well into my 3rd trimester.  Yes, I was niave to not even really consider Cesarean since my odds of having one, even as a low risk first time mother was about 1 in 5.  

By 2002 a first time mother had a 1 in 4 chance of having a cesarean…and by 2007 the rate had risen to 1 in 3 first time mothers birthing via cesarean.

1 in 3.  Wow.  Some media reports have tried to place the blame for this rising cesarean rate on the demographic profile of birthing women becoming “higher risk.”  Older moms, more twins, more big babies…you name it…the births are becoming riskier, so of course the cesarean rate is rising.

Except that it isn’t true.  As early as 2005 the American Journal of Public Health reported that after extensive analysis, there was no increasing risk profile seen, if anything, the level of risk had DECLINED!

So why the increased cesarean rate?  Well looking back at that American Journal of Public Health report, they dance all around it…but then finally state: 

The present results suggest the need for further studies focusing on nonclinical reasons for shifts in cesarean delivery rates. It has been suggested that some of the growth in primary cesareans has resulted from “patient choice” cesareans, although evidence of such a trend is not based on systematic surveys of mothers. A current debate in the obstetrical literature, with more published editorials calling for elective cesareans,33 indicates that there may be a shift in obstetricians’ attitudes,34 but again the data are anecdotal.

In addition, there have been suggestions that “defensive” medicine associated with fear of malpractice awards might cause shifts in clinicians’ behavior.35 More research is needed on the causes of such trends, given that the increase in primary cesareans combined with growing restrictions on VBACs will lead to a continuation—and, in all likelihood, acceleration—of the current growth in overall cesarean rates in the United States.

This article suggests that the only reasons left to explain the rising cesarean rate are either maternal choice, or care provider attitudes.  The Listening to Mothers II Survey found that “maternal choice” only contributes a miniscule amount to the total cesarean rate, so that leaves care provider attitudes.

So what attitudes are problematic?  Well it isn’t as simple as simply a preference toward vaginal birth or cesarean, although that certainly is a part of it!  But it is much further reaching.  Since utilizing interventions such as induction of labor, augmentation of labor with Pitocin, breaking the amniotic sack to speed up labor, restriction of positions for labor and/or pushing all introduce risks that increase the odds of developing a need for cesarean, a care providers attitude about when to use those interventions is important.  Childbirth Connection has this to say about interventions:

Childbearing women need to understand that maternity care that is routinely available often is not in the best interest of themselves and their babies. Pregnant women have the right and responsibility to become informed and make wise choices — for example, their choice of caregiver, birth setting and specific procedures, drugs and tests. Becoming informed and taking responsibility can be a big task — and can have very big pay-offs.

I was lucky.  I had a vaginal birth with my first baby even though my labor could have been managed in a way that would have led to cesarean.  Unfortunately, I’ve talked to too many women who aren’t so lucky.  In fact, if the “Healthy People 2010″ goal of having a 15% cesarean rate for first time mothers is appropriate, over 15% of first time mothers who give birth this year–that is, about 1 in 8–will not be so lucky, as they will have cesareans that were unnecessary.*
 
If you don’t want to be that 1 in 8, please, take the time to learn about different types of care providers, interview several different care providers, even some that you really don’t think you would consider such as a home birth midwife.  Remember, 

… “this” is the only chance you’re going to get to birth this baby.  Sure you may go on to have other babies, but you only get THIS chance to birth THIS baby.  … because of this fact, the significance of this birth is infinitely greater than the significance of this birth is to your nurse, OB, midwife, etc.  Don’t just do what “Dr. So-and-so wants” because s/he is the doctor.  You’re the one who has to go home and live with your birth experience - good, bad, indifferent - for the rest of your life.  Louise E. DeLaney, CCCE, CLD

To read more on this topic, head over to “The first birth is HERstory”
 
*Many of the cesareans will be necessary in the moment.  The issue is…interventions were used when they were not needed…and all interventions have a certain amount of possible negative side effects, which result in the need for a cesarean.

Tags: Birth Wisdom Week, Childbirth Connection, Induction