ACOG says labor should begin naturally—When will medical practice change?

In my latest column at RH Reality Check I talk about new guidelines issued by ACOG regarding scheduled c-sections. They were addressing the practice of scheduled c-sections that have been producing pre-term deliveries, with a particular push-back on the  reasoning of a baby being too large to be born vaginally.

For those of us who’ve been tuned into the maternity care debate, these kinds of change of practice or philosophy from a group like ACOG seem like a huge turn around. So huge, that at first I thought the whole thing was a hoax.

But, thankfully, it’s not. ACOG is actually urging providers to “let nature take it’s course.” Similarly, they just released new findings regarding the impact (potentially negative) of pitocin use on newborns.

For those of use who’ve been pushing back against rising c-section rates and pitocin use for a long time, this is a victory. But the challenge remains that history tells us it will likely take a long time for these recommendations to actually influence medical practice. In my column I use the example of episiotomy to illustrate this lag:

Unfortunately, it could take years for these changes to go into effect. Just look at the history of episiotomies. In the 1950s and ’60s, episiotomies, a cut in the perineum (the region between the anus and vagina), were recommended as routine practice during labor. At the time it was believed that an episiotomy was preferable to the natural tearing that is very common during vaginal delivery, and that the straight incision of an episiotomy was easier to repair. A 2012 Huffington Post article outlines this history, and how the practice came to dominate by the 1980s, occurring in more than 60 percent of deliveries.

It was only then that clinical trials were conducted to examine the impacts of episiotomy in comparison to natural tearing, and the results were staggering:

Clinical trials conducted in the ’80s and ’90s found that episiotomy cuts can, in fact, turn into even deeper lacerations during delivery, damaging the area around the rectum. Then, in 2005, a sweeping review published in the Journal of the American Medical Association found no benefits to routine episiotomy. A year later, the American Congress of Obstetricians and Gynecologists issued new guidelines, saying that episiotomy during labor should be restricted because doctors had previously underestimated the risk of bad outcomes later on, such as painful sex and possible incontinence.

Decades after those clinical trials, and seven years after the new ACOG recommendations, it’s unclear exactly how the new recommendations regarding episiotomy are being implemented. In 2005, the year before the ACOG recommendations, a study in the Journal of the American Medical Association (referenced in the Huffington Post article) estimated that 25 to 30 percent of vaginal deliveries still involved episiotomy. The 2010 National Hospital Discharge Survey reported that roughly 320,000 episiotomies were performed in the United States that year.

So this is both good news, and a call to action for all of us. As consumers, advocates and doulas our efforts have contributed to these recommendations, and we must remain vigilant to ensure that they get implemented. We can share these recommendations, coming from the Association tasked with governing Obstetricians, with providers who may be reluctant. And we can keep the pressure on. It’s a long battle, but I’m heartened by these incremental signs of progress.

Read the full column here.

The research is clear: Vaginal birth after c-section is safer and better

Highlighting something that we all already knew, the research is finally starting to come down in our favor on this issue of vaginal births after c-section (VBAC). Despite the frightening number of hospitals entirely banning VBACs, and an alarming number of providers refusing to do them, the research is showing that VBACs are the safer, better option for most moms and babies.

From the LA Times:

The first paper summarizes the findings of a government consensus conference that took place in March at the National Institutes of Health. Researchers concluded that vaginal birth after cesarean is “a reasonable choice for the majority of women.” The paper is based on a large database of births and finds that although both elective repeat cesarean section and VBAC are highly safe, maternal death was higher for elective repeat Cesarean sections (0.013% versus 0.004% for a trial of labor). The rates of hysterectomy, hemorrhage and transfusions did not differ between the two groups. Uterine rupture — the complication that is usually given for discouraging VBACs — was rare but higher in the trial of labor group (0.47% compared with 0.03% in the repeat C-section group). Infant death was higher in the trial of labor group (0.13% compared with 0.05% in the repeat C-section group).

How long do we think it will take medical practice to catch up to the research?

On Radio Bilingue this afternoon, 3:30 pm EST, talking about maternal health

I’ll be a guest on Radio Bilingue this afternoon, talking about maternal health and the situation for childbirth in the United States.

You can listen to the program here. It will be in Spanish! I’ll post the link to the interview after the show.

Update: You can listen to the recording from the program here.

Video and update about NYC midwives

Rachel, a doula from New Jersey, sent me this video she made about what she fears the birth future will be like.

So the situation with the NYC homebirth midwives has not been resolved, despite amazing advocacy and action on all your parts. The Department of Health told Choices in Childbirth they got more calls about this issue than any other, ever.

I’ll keep folks posted if I hear anything else about the situation in NYC.

UPDATE: Lauren at Birth and Bloom has an account of the press conference that happened on Friday.

Maternal mortality and c-sections on the rise

Cross-posted from

This is a post I wrote for Feministing that I wanted to cross-post here. It’s a bit broader (and less political!) than what I write for Radical Doula because of the audience there.

Birth has been making national news lately because of the release of recent data indicating continuing upward trends in maternal mortality and c-section rates.

Jessica mentioned the recent California report that exposed the rise in maternal morality in the state. But this problem isn’t just in CA, it’s national.

The New York Times reported this week that the US c-section rate has reached an all-time high of 32%. That’s more than 1 in 3 women giving birth via surgery. C-section has been the most common surgical procedure in US hospitals for a while now, and the increases don’t seem to be slowing down.

I often get flack for being anti-doctor when I write about birth politics here, but pretty much everyone can get behind a concern about this rate of surgical birth.

The increases — documented in a report published Tuesday — have caused debate and concern for years. When needed, a Caesarean can save the mother and her child from injury or death, but most experts doubt that one in three women need surgery to give birth. Critics say the operation is being performed too often, needlessly exposing women and babies to the risks of major surgery. The ideal rate is not known, but the World Health Organization and health agencies in the United States have suggested 15 percent.

The risks to c-sections are numerous. It’s major abdominal surgery, with it’s resulting possibilities for complications. It presents problems for subsequent pregnancies, and it can be really difficult to find a hospital that will allow you to try a vaginal birth after a c-section (VBAC), meaning once a c-section, always a c-section.

Amnesty International recently released a report entitled Deadly Delivery: The Maternal Health Care Crisis in the US. Amnesty, an organization often focused on highlighting the stark situation of countries around the world, found itself examining what is a crisis among maternal health in the US.

The report exposes the fact that the risk of dying during childbirth is greater here than in 40 other countries, putting us at the bottom of the developing world when it comes to maternal mortality.

Continue reading

Midwives banned from California hospital

Jos at Feministing has the full story, but it deserves mention here as well.

Basically, midwives who were practicing at St. John’s Pleasant Valley Hospital received a letter in the mail telling them they could no longer deliver there, and instead had to deliver at a facility 11 miles away. The reason cited was the lack of NICU at the Valley Hospital.  More details here.

It’s such a shame that the few midwives that do practice in the US (and put up with the challenges of being in a hospital run by OB-GYNs) have to deal with crap like this.

Also,a related side note/rant. On Jos’ post at Feministing, all the comments decided to attack my assertion that the increased rate of maternal mortality in California might just have something to do with the double in the number of c-sections.

It amazes me that even the readers of a feminist website would go to such lengths to defend c-sections. I’m not anti c-section. But 30% and rising is way too much. Also, apparently, only “self-serving doulas” think that elective, non-emergency c-sections are not the best way to give birth.

If you’re feeling feisty, head over to the post and join in the comment conversation.

California pregnancy-related deaths triple in the last decade

A new investigative report released by California Watch reports that maternal mortality rates in California have seen a spike in recent years, almost tripling in the last ten years.

To me, there is one clear cause of this kind of increase, and that’s the c-section rate, which according to California Watch have increased 50% in the same decade in CA.

The World Health Organization recommends a c-section rate of about 10%. We currently have a national average of 30%. In some hospitals it’s as high as 90%.

C-sections are major abdominal surgery. There are risks involved, and with so many c-sections, you’re going to start having deaths as a result.

We need less c-sections. Period.

The other thing this report revealed was that there was significant increase in maternal mortality among non-Hispanic whites, a group traditionally excluded from maternal mortality and low infant birth weights. Well again, this is probably because of the c-section rates, which might even be higher among this group than women of color.

The idea that increases in technology use could actually harm women, rather than help them, is impossible to believe for the OB-GYN community:

When researchers unveiled their initial findings to a conference of the American College of Obstetricians and Gynecologists in 2007, there were gasps from the audience, according to participants at the San Diego event. The idea that California was moving backward even in an era of high-tech birthing was implausible to some.

This is exactly the point. Overusing technology it’s just as harmful as under-utilizing it. The bottom line is that OB-GYNs are trained as surgeons, and their dominance of maternity care is proof of that–they are performing more and more surgeries than ever.

We need practitioners who are trained to care for women birthing without technology, namely midwives. Technology has a role, but it should be the exception not the rule. And let’s be clear here. It’s not just c-sections that are to blame. It’s also increasing induction rates, epidurals and other medical interventions that disrupt the process and are more likely to cause interventions.

“For every maternal death, there are 10 near misses; for every near miss, there are 10 severe morbidity cases (such as hysterectomy, hemorrhage, or infection), and for every severe morbidity case, there is another 10 morbidity cases related to childbirth,” Camacho wrote in an e-mail.