The Coalition for Improving Maternity Services (CIMS) latest project, available only in New York until this week, has now launched nationwide. From their website:

“For years, consumers have enthusiastically shared online reviews of movies, restaurants, products and services, but readily available information about maternity care providers and birth settings was nearly unattainable-no longer. As part of the Transparency in Maternity Care Project, CIMS developed The Birth Survey as an online resource for new mothers to share their consumer reviews of doctors, midwives, hospitals, and birth centers, learn about the choices and birth experiences of others, and view data on hospital and birth center standard practices and intervention rates. The Birth Survey is now accessible throughout the United States.

“The Birth Survey is an on-going online consumer survey that asks women to provide feedback about their birth experiences. Women’s responses about specific providers and facilities will be available online to other women in their communities to help them decide where and with whom to birth. As they become available, the official facility-level intervention rates gathered from the state departments of health will be paired with the women’s survey responses to help families make their birthing decisions.”

If you’ve given birth in the past three years, help improve this resource by taking the survey here.

The “BirthTrack System” for continuous labor monitoring has been approved by the FDA, and its manufacturer, Barnev Inc., wants you to know it is the greatest thing to happen to birth since the electronic fetal monitor.

The system goes a step beyond the fetal scalp electrode which is “already standard practice at most hospitals.” In addition to the sensor on the fetal scalp, the BirthTrack System places two more sensors on the mother’s cervix to continuously monitor dilation and fetal descent in real-time on the nearby monitor.

It’s sure to be universally popular with maternity patients and their partners. As the Barnev website says, “Limiting the number of intrusive, vaginal examinations provides the mother-to-be with the comfort and privacy she desires. The partner becomes an informed participant. The displayed data allows them to follow the labor process together minimizing anxiety and contributing to a relaxed atmosphere in the labor room.” What could be cozier than watching your real-time cervical dilation on a bedside monitor together? The partner can “participate”! Just like he does in the Sunday afternoon football game!

Barnev can’t prove that the Birth Track System will reduce Cesarean section rates - not “yet,” anyway. They think it might, though, pointing out that the “continuous, real-time data” will allow obstetricians to identify non-progressing labor sooner and facilitate “early decision-making.” Doesn’t sound terribly compatible with cesarean reduction, but Barnev can promise a lower risk of malpractice, and that’s what’s really important. One of BirthTrack’s benefits is “full documentation” of the labor process, which can be used as a “support tool during litigation.” This innovative new device, Barnev promises, “holds potential to become the Standard Method of Care in Women’s Healthcare.” Just like the electronic fetal monitor, a handy “support tool during litigation” which just happens to increase cesarean sections and instrumental deliveries without improving neonatal outcomes.

Hat tip: Rixa at The True Face of Birth

If you’re going to the hospital for the birth of your choice, you’re going to  the wrong place… they don’t sell that there.
Carla Hartley (HT: Hathor the Cow Goddess)

This clickable chart from the New Jersey Star-Ledger is great, and I hope it will be imitated in other places. While not as detailed as the data from the Birth Survey will eventually be, it is a valuable tool that lets women quickly and easily compare different hospital’s cesarean rates — and those rates have incredible variation, with some hospitals near or even over 50% surgical births and others closer to 20%. By clicking on a hospital’s name, you get the cesarean and VBAC rates for ten years past; it is rather chilling to see the Cesareans swiftly climbing while the number of VBACs drops.

At a party yesterday, a co-worker of my husband’s admired my new baby, who was peacefully sleeping in a sling. “I became a great-aunt this morning,” my acquaintance informed me. “My niece had her first baby.”

She continued, “It was very ironic — a few weeks ago she was in the hospital to keep the baby from coming early. But when he was allowed to come, she didn’t go into labor, so she had to be induced. And then he didn’t come in 24 hours, so she needed a Cesarean.” She added, “Of course, she was very happy to be done!”

Stories like this are as common as baby announcements. This article looks at studies and statistics from the U.S. and Europe and comes to some troubling conclusions. In most developed nations, the combined total of cesarean deliveries and induced labors ending in vaginal birth outnumber vaginal births after spontaneous labor.

With less than half of all babies “coming in their own good time”, births drop dramatically on weekends and holidays, and fewer births happen at night — even though, as the article notes, “many studies have shown that women’s natural hormonal cycles tend toward labor starting at night.”

Despite the risks of inductions and cesareans, the article finds a way to put a positive spin on obstetric convenience. Having babies during “banker’s hours”, the article tells us, is actually safer. According to a recent Texas study, “Particularly among hospitals that delivered about 4,000 to 7,700 babies [in a 3-year-period], there was a 51 percent greater risk of death for a baby born on a weekend than on a weekday.”

Sounds alarming, doesn’t it? The Texas study article advises parents to be to “shop” for their hospital, choosing one that delivers more babies and has a better-staffed neonatal nursery just in case their baby needs special care.

At least parents weren’t advised to schedule their birth during the week to avoid weekend staff shortages. Induction increases the already high risk of Cesarean section, and non-emergency Cesareans increase neonatal mortality by 70 - 90%.

The issue of increased neonatal mortality on weekends has been debated for years, with conflicting findings in different studies. Reduced staffing on weekends is generally blamed for the “weekend effect”. However, some of these studies have noted that pre-term and low-birth weight births are over-represented in weekend births — probably because preterm births are least likely to be affected by obstetric practices which lead to the higher rate of births on weekdays. A 2003 study found that after adjusting for birth weight, the weekend increase in neonatal mortality was no longer statistically significant.

Expectant parents need more options than shopping for the best neonatal intensive care nursery and scheduling their induction for the most convenient weekday. In the hospital setting, the Midwives Model of Care has been shown to reduce inductions, cesareans, and preterm and low-birth-weight babies. As for me, I’ll stick with a CPM who makes house calls — even on weekends and holidays.

The National Center for Health Statistics released the birth data for 2006 today. Their press release focuses on the increase in births to teens and unmarried mothers, but buried near the bottom is this nugget of information:

“The cesarean delivery rate rose again in 2006, to 31.1 percent of all births, a 3 percent increase from 2005 and a new record high. The percentage of all births delivered by cesarean has climbed 50 percent over the last decade.”

At this link, you can access state-by-state preliminary data in pdf format. Ohio, Kentucky, and Indiana all experienced an increase in their cesarean rate. Ohio now stands at 29.3%, Kentucky at 34.5%, and Indiana at 29%.

In an emergency, Cesarean delivery can be life-saving. But in the United States today, the Cesarean rate is almost one in every three births — despite the overwhelming evidence that such high rates of surgical birth actually exposes mothers and babies to unnecessary risk of complications. This article cites a recent British Medical Journal study that warns of the risks inherent in non-emergency Cesareans.

“Overall, Caesarean delivery doubles the risk of severe maternal morbidity, and elective procedures add another 30% to the risk, they said. Caesarean delivery also doubles an infant’s risk of a prolonged stay in the ICU.”

“Any net benefit from the liberal use of Caesarean delivery on maternal and neonatal outcomes. . .remains to be demonstrated,” according to the study’s authors.

I recently heard from some newly-married friends who have just learned they are expecting their first baby. They wrote asking for advice in planning for a safe hospital birth:

It doesn’t look like a home birth will be possible because there is no available midwife, so we’ll be having the baby in the hospital. I don’t want to be pressured into a C-section because we hope to have many more children in the future.

So my questions for you are:
1) What would you consider a necessary reason to have a C-section? (Breech? 36-hour labor? Placenta previa? Fetal heart decels or failed nonstress test?)
2) What would you consider a necessary reason to have an episiotomy?
3) What would you consider a necessary reason to have an epidural?
4) What should we look for in a doula?
5) Any other advice?

You’re wise to be thinking about this now. With Cesarean rates approaching 30% in most of the U.S. (Ohio included), the vast majority are not medically necessary and as you probably know, the risks of Cesarean compared to vaginal birth increase significantly with additional pregnancies. Also, one Cesarean will make it much more difficult to find a practitioner willing to work with you for a vaginal birth in future pregnancies.

In my experience having babies, talking to other people about their births, and providing labor support, the most important factor in your birth experience is actually only indirectly related to how well-informed and prepared you are and what plans you make for the birth. I believe that being extremely careful in selecting your primary caregiver for the birth is more important than anything else you do to prepare for your baby’s birth. (But be sure to find out whether the person you’ve chosen will actually be there for your birth. Some practices rotate who is on-call.)

When interviewing possible providers, ask for their specific Cesarean rate. Most hospital-based midwives (CNMs) have a rate of 10% or less, out-of-hospital midwives (CNM or CPM) tend to be even lower (3-7%). 10-15% is great for a ob/gyn. If your ob is performing surgery on one in every three or four of their patients, that’s not very good odds for you. Ask about their suture rate for vaginal births, not just their episiotomy rate (if they can’t, or won’t, give you an actual number, that is probably a bad sign). Some practitioners will agree not to do an episiotomy but really have no idea how to avoid tears. (My own opinion, not backed up by any studies, is that your best bet is a waterbirth with the mother’s hands only guiding the birth of the head, but that’s probably not possible in the hospital; your second best bet is finding a practitioner — usually a midwife — who takes pride in an intact perineum and rarely needs to suture.) If you possibly can, ask the labor and delivery nurses about the ob or CNM you are considering. They know which ob is “the episiotomy queen” and which doctor’s arrival prompts cracks of “Elvis has entered the building”.

If you have a CNM or ob who you can trust, then you will not need your doula to be “second-line defense” against procedures that you don’t want. If your goal is an unmedicated birth, you need a doula who can be focused on non-pharmacological pain relief and physical / emotional support, because most hospitals are not set up to facilitate the parents who don’t want an epidural and the labor and delivery nurses don’t have much to offer besides pain meds (or time to do the one-on-one, ongoing labor support that is needed).

There’s a tendency in some natural-childbirth books and childbirth education classes to really emphasize the husband / father’s role in labor support and I have seen some men who because of this feel left out or inadequate by their wife’s desire for another woman’s support in labor. A good doula will help the husband effectively help his wife rather than coming between them, but from my perspective after 6 births, the labor support provided by a midwife or doula is very different and not to be confused with the husband’s participation in childbirth. Not all men are naturally good at labor support or naturally inclined to a particular interest in it. I love my husband and I do like to have him there when our babies are born, but his presence is honestly as much for him as for me; I “need” my midwife there much more than I “need” my husband. Not everyone feels this way of course and some husbands are much more “into” the process of their childrens’ births than mine is but there aren’t a lot of voices out there saying that you can still have a great marriage and a lovely natural birth even if the husband is not the ideal Bradley coach, so I thought I’d mention it.

There are a very limited number of “absolute indications” for C-section — placenta previa or abruption, cord prolapse, shoulder presentation. But that doesn’t mean that every C-section that is not done for one of those reasons is therefore unnecessary or preventable. There are so many factors in an individual situation that you can’t always come up with a protocol that will guarantee the right decision. For instance, I would not consider a breech presentation an indication for a C-section — UNLESS I was absolutely unable to find a practitioner who was experienced and comfortable with doing a breech birth. Having a breech baby with an inexperienced doctor or midwife who was nervous about doing a vaginal breech birth might be a lot more risky (for that birth and that baby) than a well-planned C-section. (So you see, again it comes down to trusting your caregiver.) Prolonged labor is a common justification for Cesareans. I would tell you that as long as baby’s heart tones are good and mother is able to eat, drink, and rest, labor can continue as long as it needs to (and I’ve had some long ones… grand multips often tend to have long start-and-stop labors.) Once you go to the hospital, however, your ability to eat, drink, and rest is often severely restricted, and there can be a lot of pressure to have the baby within a certain time frame.

The same is true for other interventions: there are occasions when, used appropriately, they are extremely helpful; they all tend to be grossly overused in modern obstetrics; figuring out when they are appropriate is not always a matter of applying a cut-and-dried formula; and medical management of labor can frequently create the necessity for the intervention. Your birth is not necessarily going to follow the textbook and determining if, when, and how it is appropriate to intervene in a particular labor is not always a straightforward matter. If anything unexpected arises, you are ultimately dependent on the wisdom and experience of your care provider, and if having a birth with only the minimum necessary intervention is important to you, your first concern should be finding a doctor or midwife who shares that motivation.

What advice would you share with first-time expectant parents? Have your say in the comments.