The Unnecesarean & it's Impact on the United States Today
The Unnecessary Cesarean Section & it’s Impact on the United States Today
Allowing most women with low-risk pregnancies to spend more time in the first stage of labor may avoid unnecessary cesareans (9). The first stage of labor is defined as when a woman is less than 4 centimeters dilated. Considering cervical dilation of 6 centimeters (instead of 4 centimeters) as the start of active phase labor (9) can give her more time to progress. The first stage of labor can be the longest, and some providers will only allow a woman to be in this stage of labor for a certain amount of time before recommending a cesarean, or that she be discharged to continue her labor at home. Labor stalling is relatively normal, and as long as mother and baby are not in danger, no interventions should be taken. Nowadays, however, if labor stalls while at the hospital, a c-section is one of the few things an OB will suggest to hurry the process along.
Allowing women to push for at least two hours if they have delivered before, three hours if it’s their first delivery, and even longer in some situations, for example, with an epidural (9), can help reduce the cesarean section rate. If a woman receives an epidural, it can be harder for her to feel the need to push, hence the need for extra time spent in the pushing stage. Mothers can become frustrated when the pushing phase lasts too long, and the thought of a c-section can seem like sweet relief. But with the right support and encouragement, any woman can achieve a vaginal birth barring any serious complications.
The pushing stage, and most often the labor stage in a hospital, is usually done with the mother lying on her back. When women labor and birth lying down, their pelvis cannot physically open as wide, resulting in the birth canal being up to 30% smaller (3). That also means pushing baby against gravity, and this can cause more pain (3). With support from her provider, there are ways to push that will increase the chance of a vaginal delivery. For instance, delivering in a birthing pool, squatting, or even standing up. These positions, however, are not common practice in the hospital, and are readily done more so at birthing centers and home births.
A normal pregnancy can last up to 42 weeks (13), and the myth of a “due date” puts pressure on the mother, making her due date seem more like an “expiration date”. The idea that pregnancy lasts 40 weeks comes from Franz Carl Naegele (8). He proposed that human gestation was ten menstrual cycles in duration (8), but not every woman’s body is the same. Dating to the last menstrual period can be inaccurate, since many women ovulate at different times in their cycle. If a woman ovulates late in her cycle, her pregnancy could be as much as two weeks off. So, in reality, when she is told she’s 39 weeks, she could actually be 37 weeks. The evidence of her baby seeming smaller for it’s gestational age can arise and start the intervention process.
There are procedures that some providers routinely do which are not medically required, and actually increase the chance of surgery (3). Some of these procedures are continuous electronic fetal monitoring, artificial rupture of membranes (breaking water), and induction of labor (3).
Besides the procedures that are sometimes done that are not medically required, obstetricians are making it easier for women to schedule their cesarean sections. The ease of this scheduling can come from the doctors’ need for him or her to have their own set schedule, so they might push patients to have their baby on a certain day, at a specific time. We are taught to trust our doctors and believe that they know best, but sometimes the woman knows her body best. And once she’s educated about her choices, she is able to make the right decision regarding her body and child.
A lot of first-time mothers are unaware of their options as far as birth goes. A birth can be accompanied by an obstetrician or a midwife, or both. Usually obstetricians only attend hospital births, and midwives attend both hospital and home births. Obstetricians are the main physicians in the United States who are supposed to guide and nurture a woman during her pregnancy and birth. Obstetricians (OB), however, are trained as surgeons to deal with illness and emergencies (10). Most pregnancies are low-risk, but the need to treat more and more pregnancies as high-risk is becoming more prevalent today. In the online video, “Debunking The Myth: The US has the Best Birth Outcomes and the Best Medical Care in the World”, Briget Lynch, the President of the International Confederation of Midwives, states:
. . . As we put all of our money and research into high-risk care, we haven’t been paying enough attention to normal birth. We haven’t been paying enough attention to reassuring women that birth is normal. That they can go through birth and actually have an experience that is a fulfilling experience.
A low-risk pregnancy, barring any complications, is sometimes better handled with minimal interventions, if any at all. A trained individual to handle this type of pregnancy is a midwife. A midwife is different than an OB in many ways. Although they both are trained to care for a pregnant woman during her pregnancy and delivery, OB’s are trained to handle complications that might arise, and are also qualified surgeons (10). Midwives take a gentler approach to pregnancy and birth, and are more hands-on (10). Pregnancy should be treated with the utmost care, and a midwife can be the leading example of a true supporter for a woman during this special time. There is a worldwide need for midwifery coverage, and there are several beneficial effects on clinical and health outcomes for women and babies (14).
Healthcare coverage is limited for some in the U.S. Some have medical coverage that only allows them to see certain providers. Even if a woman desires a certain birth, or outcome during her pregnancy, her choices might be limited due to the fact that insurance only allows her to see certain physicians. Doctors can be intimidating, but are still necessary for high-risk situations. Despite doctors being the sole provider for a woman during her pregnancy, the U.S. has one of the highest infant mortality rates among industrialized nations (15). How can this be? Aren’t we supposed to be the greatest country in the world? We are in some aspects, but when it comes to pregnancy and birth, we are lacking in proper prevention of unnecessary surgery.
In a Canadian study, Patricia Janssen states, “Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician”. These findings also concluded that women in the planned home birth group were significantly less likely than those who planned a midwife-attended hospital birth to have obstetric interventions (e.g., electronic fetal monitoring, assisted vaginal delivery) or adverse maternal outcomes (e.g., third- or fourth-degree perineal tear, postpartum hemorrhage) (5).
Home birth can be joyous, and allows a woman to move freely and labor at her own pace. Some have regarded home birth as like riding a motorcycle without a helmet (6). Sadly, many view home birth as a sure way of either maternal or child death, which is why in the U.S. it is more likely a woman will choose a hospital birth.
Despite home birth being regarded as dangerous to some, hospital birth can lead to more interventions, increasing the risk of complications and a woman having a cesarean section. It is like a domino effect (2). Once a women is induced, her contractions become exceedingly painful. The need for an epidural arises, and that slows her labor (2). Once her labor is slowed, the baby could become distressed. Suddenly the need for a c-section is imminent (2). Why treat a pregnant woman like a sick patient? When in the hospital, it is inevitable that a pregnant mother will be treated as such.
Evidence-based maternity care is practices that have been shown by the highest quality, most current medical evidence to be most beneficial to mothers and babies (reducing incidences of injuries, complications, and death), with care tailored to the individual (16). “Standard” care (the care that the vast majority of women receive) in most hospitals in the U.S. is not evidence-based (16). The United States is seen as this sort-of “power country” that can do no wrong. But, as evidence shows, the U.S. is nowhere near invincible. It’s actually a myth that the U.S. has one of the best medical systems in the world (2). In the online video, “Debunking The Myth: The US has the Best Birth Outcomes and the Best Medical Care in the World”, Ina May Gaskin, a notable and successful midwife, states:
. . . One would believe that this country has the best birth outcomes both for mother and child, but that is not the case. The U.S. follows 40 other countries in maternal mortality rate - including Bulgaria, Slovania, Croatia, Cuba, Costa Rica - they all do better than we do, and they don’t spend anywhere near the amount of money we do. All of those countries use midwives way more than we do.
There seems to be a correlation with low maternal mortality rate, low cesarean section rate, and the use of midwives.
After a woman has a cesarean section, the likelihood that she will have another one increases. Many providers will not perform a VBAC (vaginal birth after cesarean) (12), so it is up to the mother to find a provider who will allow her to try for a vaginal birth. A study discussing contemporary cesarean delivery in the U.S. indicates that pre-labor repeat cesarean sections currently have a profound impact on the overall cesarean rate (17). Only 10% of American women give birth vaginally after a previous cesarean (12). Women who have already had a cesarean might think that they have no other choice for subsequent pregnancies, when in fact delivering vaginally after a c-section is safer for mother and baby. The risk of death is three times greater with a secondary c-section than with a VBAC (12). Too many women choose cesarean birth because of fear, lack of information, and improper guidance by their care providers (4).
All of these issues go hand in hand, with decreasing the risk of c-sections in the U.S., to allowing midwives to be the sole provider for low-risk pregnant women. Pregnancy can be a scary time for a woman. Doctors have the ability to make it less stressful, but they aren’t trained to have the necessary, compassionate side. Midwives, however, are more inapt to handle the emotional, scary part of pregnancy and birth, and can put a mother’s mind at ease. Every pregnancy and woman is different, which is why each individual should not be treated the same, especially when it comes to labor and birth. Women have the power to become educated about their choices and what is done to their bodies and babies. Decreasing the nation’s cesarean section rate is possible. By allowing more time to labor while decreasing the amount of unnecessary interventions, it can be done.
References
1. American Journal of Obstetrics and Gynecology, 1. Retrieved April 30, 2014, from http://www.acog.org/Resources_And_Publications/Obstetric_Care_Consensus_Series/Safe_Prevention_of_the_Primary_Cesarean_Delivery
2. Debunking The Myth: The US has the Best Birth Outcomes and the Best Medical Care in the World [Youtube Video]. (2011). Retrieved from https://www.youtube.com/watch?v=52zteu7my7w#t=65
3. Evidence Based Maternity Care | What is Evidence Based Maternity Care & What everyone ought to know.. (n.d.). Your Baby Booty RSS. Retrieved May 6, 2014, from http://yourbabybooty.com/resources-101/evidence-based-maternity-care-what-is-evidence-based-maternity-care/
4. Hotelling, B. A. (2007). The Coalition For Improving Maternity Services: Evidence Basis For The Ten Steps Of Mother-Friendly Care. Journal of Perinatal Education, 16(2), 38-43.
5. Janssen, P., Saxell, L., Page, L., Klein, M., & Liston, R. (2009). Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. Canadian Medical Association, 181. Retrieved May 6, 2014, from http://search.proquest.com.ezproxy.library
6. Keane, D. (2014, May 5). Hospital consultant says Caesarean rates ‘almost a national crisis’. Irish Times. Retrieved May 7, 2014, from http://www.irishtimes.com/life-and-style/health-family/hospital-consultant-says-caesarean-rates-almost-a-national-crisis-1.1783616
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7. Lombroso, L. (2014, April 4). Report: Longer labor leads to fewer C-sections. Report: Longer labor leads to fewer C-sections. Retrieved May 7, 2014, from http://www.lohud.com/story/news/health/2014/03/31/maternal-health-new-labor-guidelines/7115743/
8. Mittendorf, R., Williams, M., Berkey, C., & Cotter, P. (1990). The Length of Uncomplicated Human Gestation. Obstetrics & Gynecology, 75. Retrieved May 6, 2014, from http://journals.lww.com/greenjournal/Abstract/1990/06000/The_Length_of_Uncomplicated_Human_Gestation.8.aspx
9. Nation’s Ob-Gyns take Aim at Preventing Cesareans. February, 19, 2014. Retrieved from http://www.acog.org/About_ACOG/News_Room/News_Releases/2014/Nations_Ob-Gyns_Take_Aim_at_Preventing_Cesareans
10. Northside Women's Specialists. (n.d.). Northside Women's Specialists. Retrieved May 6, 2014, from http://www.nws-obgyn.com/body.cfm?xyzpdqabc=0&id=8&action=detail&ref=12
11. Osterman, M., & Martin, J. (2014, January 23). National Vital Statistics Reports Primary Cesarean Delivery Rates, by State: Results From the Revised Birth Certificate, 2006–2012. Centers for Disease Control. Retrieved May 6, 2014, from http://www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_01.pdf
12. Pascucci, C. (2014, April 14). VBAC Bans: The Insanity of Mandatory Surgery - Improving Birth. Improving Birth RSS. Retrieved May 7, 2014, from http://www.improvingbirth.org/2014/04/bans/
13. Safranski, M. (2008, September 24). The Lie of the EDD: Why Your Due Date Isn't when You Think. Yahoo Contributor Network. Retrieved May 7, 2014, from http://voices.yahoo.com/the-lie-edd-why-due-date-isnt-you-1958162.html
14. Sandall, J. (2012). Every Woman Needs a Midwife, and Some Women Need a Doctor Too. Birth: Issues In Perinatal Care, 39(4), 323-326. doi:10.1111/birt.12010
15. W.K. Kellogg Foundation. (n.d.). Maternal & Child Health American Journal of Public Health publishes special issue on improving birth outcomes. Retrieved May 7, 2014, from http://www2.wkkf.org/webmail /17412/134091149/2395670a2db4548127339d0d03c197bf
16. What is Evidence-based Maternity Care? - Improving Birth. (n.d.). Improving Birth RSS. Retrieved May 7, 2014, from http://www.improvingbirth.org/the-evidence-shows/
17. Zhang, J. et al. (2010). Contemporary Cesarean Delivery Practice in the United States. National Institute of Health, 203. Retrieved April 30, 2014, from http://www.ajog.org/article/S0002-9378(10)00838-0/abstract
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