Everyone's been through it. But for some reason, the topic of childbirth seems to get people awfully riled up.
Readers responded passionately to a story we posted earlier this week about the rate of cesarean deliveries in the U.S. creeping up to 50 percent. The comments section included some intense back-and-forth on how to fix things.
So here are 11 suggestions for lowering the c-section rate. The first six come from John Queenan, an emeritus professor at Georgetown University's department of obstetrics and gynecology and author of a recent editorial on the topic in the medical journal Obstetrics and Gynecology. The last batch are from readers.
1. Get a commitment from hospital obstetric departments to work on lowering the C-section rate and also cut down on the number of drug-based labor inductions. (See this related post on pregnant women inducing their own labor.)
2. Alert patients about the true risks of major abdominal (C-section) surgery, compared to normal vaginal deliveries.
3. Initiate tort reform to protect doctors from performing defensive c-sections. (This is controversial-- most docs support it, but will it really change practices?)
4. Use more nurse midwives, the ones that mostly work in hospitals (see also #11, about certified professional midwives).
5. Provide equal compensation for vaginal and C-section births; compensate Vaginal Births After Cesareans (VBACs) at a higher rate than normal delivery. (This is Queenan's idea but one reader, Denise, noted: "I do not agree that someone who is birthing in a Normal Biological State should be paying the same or more than the high rate of a major surgery.")
6. Re-establish teaching and training for breech deliveries. One reader also said medical students should have more exposure to normal deliveries and recounted this story:
My cousin did her med school OB rotation while I was pregnant with my daughter. She asked me at a holiday gathering if i had any questions for her. I had one - did you see any completely intervention-free births? Answer - nope.
7. The number one suggestion by readers for reducing the C-section rate is increasing the use of doulas, who provide continuous labor support, for women and their families. Multiple studies have found that having a doula present at birth can cut your chances in half for having major interventions, such as epidurals and C-sections. (Full disclosure, I have a dog in this race: I co-wrote a book on birth, with a doula, back in 2008.)
Reader KMB offered this quote from the venerable, pro-doula doctor and researcher John Kennell MD, who said: "If a doula were a drug, it would be unethical not to use [one]."
8. Provide more training and support for women giving birth to twins to do so vaginally.
9. Mobilize an effort to evaluate the effectiveness and need for labor induction, continuous fetal monitoring and epidurals because all of these procedures can lead to more C-sections.
10. Focus on the mothers. One reader noted that a mother's behavior truly impacts the way she gives birth:
...increasing numbers of pregnant women are overweight or obese, and are giving birth at an advanced maternal age. Blaming obstetricians, blaming inductions, blaming litigation, blaming hospital finances, blaming lack of training etc. will only get you so far. We also need to be honest with women about their individual risks, and their likelihood of achieving positive outcomes with different birth plans, by telling them how these can be affected by their personal circumstances too.
11. One popular suggestion — removing barriers so that more low-risk mothers can give birth at home, including more widespread use of certified professional midwives (the ones most likely to attend a home birth) — triggered the most controversy. In particular, Amy Tuteur, MD, came out swinging, writing:
As H.L. Mencken said: "For every complex problem there is an answer that is clear, simple, and wrong."
The rising C-section rate is a complex problem and the idea that it can be addressed by increasing CPMs and doulas is clear, simple and spectacularly wrong. CPMs are a second, inferior class of midwife that can't hold a candle to CNMs (certified nurse midwives). CPMs are grossly undereducated, grossly undertrained and don't meet the requirements for licensing of midwives in ANY first world country.
CPMs, and to a lesser extent doulas, privilege process over outcome. It is far more important to them how a baby is born than whether it is born healthy. Anybody can lower the C-section rate at the price of increasing the perinatal death rate. That's hardly a desirable solution.
The rising C-section rate is a result of a variety of factors, including societal expectations. Modern obstetrics has lowered the neonatal mortality rate 90% and the maternal mortality rate 99% in the past 100 years. As a result, Americans expect that every baby will be born perfect and want to punish someone if anything is less than perfect...
Which triggered this response from Ananda Lowe (my co-author on the birthing book):
Dr. Amy, I am not sure why you have made it your career to slander home birth practitioners. What do you get out of it? How many home births have you ever attended, and why do you claim to be an expert on home birth if you are not experienced with it? Parents who deliver with home birth practitioners generally express very high satisfaction with their care, and take on a high amount of personal responsibility for their decision to birth at home. The top reason parents give for making this choice is the increased safety and decreased risk of unnecessary intervention they will encounter at home. No one is insisting that all mothers birth at home, and no one is insisting that women birth at home without becoming educated about, and taking responsibility for, their care. The only mothers I know personally whose babies have died are those who birthed in hospitals, due to fetal distress after the use of epidurals or induction drugs. The field of obstetrics decreased maternal mortality in the past 100 years by finally admitting that lack of handwashing was killing mothers and babies, and by the development of antibiotics, when the cesarean rate was still BELOW 5 percent, not by increasing the rate of surgical births to unheard of proportions. As for whether the use of CPMs and doulas reduces the rate of cesareans, the scientific evidence is clear. There is no other intervention that has such a dramatic impact on the cesarean rate.
This program aired on October 7, 2011. The audio for this program is not available.