Part 2 ~ by FG:
Perhaps the most damning and depressing comment about this issues comes from the Medical Leadership Council (an association of US hospitals) which concluded in1996 that the ever-escalating cesarean rate in the US (at that time only 20%) was:
“…medicine’s equivalent of the federal budget deficit; long recognized as [an] abstract national problem, yet beyond any individual’s power, purview or interest to correct”.
Note that last phrase – “beyond any individual’s INTEREST to correct”.
The Joint Commission’s report originally issued on April 1st, 2010, referenced in the part 1 (the Scrippt’s report), also did not mince words about the extremely problematic nature of our sky-rocketing Cesarean section rate:
“… removal of any pressure to not perform a cesarean birth has led to a skyrocketing of hospital, state and national cesarean section (CS) rates. Some hospitals now have CS rates over 50%. Hospitals with CS rates at 15-20% have infant outcomes that are just as good, and better maternal outcomes (Gould et al., 2004).
There are no data that higher rates improve any outcomes, yet the Cesarean rates continue to rise.”
When mothers have normal vaginal births instead of surgery, the direct expense of surgical delivery (with prolonged hospital stay higher rate of re-hospitalization) is eliminated, along with the additional cost of delayed post-operative complications, secondary infertility (6%) and downstream complications that includes an a 5-fold increase in fetal demise in subsequent pregnancies and up to 13-fold increase in emergency hysterectomies from abnormal placental implementation and hemorrhage at delivery.
Recent surveys of birth practices in the U.S. identified a 99% medicalization rate, with an average of seven medical and surgical interventions per new mother. For seven out of new mothers, childbirth included a major or minor surgical procedure – episiotomy, instrumental delivery or Cesarean section. [Listening to Mothers Survey, 2002, 2006, www.ChildbirthConnection.org, formally known as the Maternity Center Association of NYC, est. 1918].
According to research published by this same group (, there are 33 route-of-delivery complications associated with Cesarean surgery, compared with only 3 for spontaneous vaginal birth.
The economic impact of maternity care for healthy women with normal pregnancies (70-80% of total childbearing population) accounts for 25% of our entire national health care budget or 4% of the GDP. The US is currently spending 3% of its total GDP to unnecessarily medicalize a healthy population, while life-threatening medical needs of the ill and injured continue to go untreated.
Maternity care is the #1 occasion for hospitalization and the largest category of expense for both private insurers and the federal Medicaid programs. Hospital charges for mothers and babies far exceed any other single condition. [Milbank Report: Evidence-Based Maternity Care, 2008] This money is mainly spent on the routine use of obstetrical intervention on healthy women. Cesarean surgery is the number one operating room procedure in American hospitals – 1.3 million a year – equal to the number of students that graduate from American colleges every year.
Today’s Cesarean surgery rate in the US — 32.8% — is triple the evidence-based rate and this has not been associated with any additional reduction cerebral palsy or in maternal or newborn mortality. Because of this or in spite of it, maternal death rates in the U.S. were higher than in 33 other countries in 2005 and have risen the last 3 years in a row.
In 1977, the maternal mortality rate (MMR) was 10 deaths per 100,000; in 2007, MMR was 14. The rise in MMR is directly and indirectly associated increasing level of Cesarean delivery with the medical intervention of induction and the surgical intervention of operative delivery, most particularly, Cesarean section.
Identifying ’cause & effect’ — replacing harmful policies with with “Best Practices”
The JC’s recommendation spoke forcefully about the need to the “change practices” that result in the dramatic overuse of operative delivery. It also indirectly acknowledged the role played by the obstetrical “culture” of customary practices that define the standard care for obstetrical practice as whatever a majority of obstetricians do. While the public assumes that everything in ‘modern’ medicine is based strictly (and exclusively) on scientific evidence and “best practices”, setting hospital policies is not and in fact is more often driven by legal or economic benefit to the institution.
In all too many, communities, the ‘standard’ practice of obstetrics is a combination of “physician preference” at the individual level with a no external oversight and internal accountability for outcomes other than mortality. As long as no one dies, whatever drastic measures an obstetrician employs are assumed to reflect his or her superior clinical judgement. the cost of these highly interruptive and disruptive practices to others — economic and human — simply didn’t matter as determined by the system itself, as long as they function for the system.
While the JC’s recommendations strongly condemn the status quo and identify practices such as early-labor hospitalization and elective induction that should be eliminated, they don’t do an equally good job at naming what is missing from the current medicalized system. Every practice, custom, protocol or policy that is eliminated must be replaced with something that provides safe and cost-effective care.
So far, the bold talk about the cost and harm of our over-the-moon Cesarean rate is NOT accompanied by similarly boldly honest recommendation based on both the evidence-based science of spontaneous biology — the principles of physiological management of labor and birth in healthy women with normal pregnancies. Physiological: “..in accord with, or characteristic of, the normal functioning of a living organism (Stedman’s Medical Dictionary – 1995)
Physiological management of labor and birth is associated with a substantial increase in reduction in the number of operative deliveries, these skills are an important contribution to childbearing women and reducing the cost of health care.
A published comment from an obstetrician puts this issue of physiological management vs. the obstetrical model in perspective very succinctly for the obstetrical profession as a whole: “It is no longer feasible for individual physicians who have invested 12 years in training at a cost of hundreds of thousands of dollars to dedicate extended periods to observing one normal woman in labor.” [Macer JA et al; Am J Obstet Gynecol 1992:166:1690-7].
Obviously from the above comment, the current training of obstetricians is too lengthy and costly for OBs to provide physiological care. However, the good news is that many types of non-obstetrician birth attendants did not “invested 12 years in training at a cost of hundreds of thousands of dollars”.
This is to the great advantage of women and society.Because family practice physicians and midwives do not provide a surgical form of care, they are by training and temperament able to provide physiological forms of care, including the extend time commitment that such care innately requires.
ACTION PLAN by FG:
As a consumer activist, you should freely share this information broadly and frequently.
As a pregnant woman, ask your OB for his or her C-section and induction rate are. If not promptly and happily supplied, find another doctor or consider a non-physician practitioner provider of physiologically-based care, such as a nurse-midwife (CNM) or physician-assistant (PA) with obstetrical practice privileges at your hospital.
If your OB provides his or her C-section and induction rates and both are under 15%, ask if they are familiar with and trained in the use of physiological management for normal labor and birth.
If not, consider changing care providers OR planning to have your baby in a free-standing birth center under the care of a family practice physician, a nurse midwife or a direct-entry licensed midwife.
The likelihood of having a C-section goes from over 20% to under 10% simply by choosing a professional birth attendant and planned place-of-birth that is compatible with the science-based care for healthy women with normal pregnancies — which is the routine use of physiological management.
This includes the freedom to walk and move about at will, one-on-one emotional and physical support, patience with nature, non-drug methods of pain-relief, judicious use of pharmaceutical pain relief as needed, and upright and mobile mother during second stage, right use of gravity, and absence of artificial time-limits as long as mom and baby are OK and there is progress (even if slow).
Physiological: “..in accord with, or characteristic of, the normal functioning of a living organism (Stedman’s Medical Dictionary – 1995)
1. Continuity of care
2. Patience with nature
3. Social and emotional support
4. Full-time presence / availablity of the primary caregiver during active labor
5. Mother-controlled environment (place + policies) for labor and birth
6. Provision for appropriate psychological privacy (persons present)
7. Mother-directed activities, positions & postures for labor & birth
8. Opportunity for an upright and mobile mother during active labor
9. Recognition of the non-erotic but none-the-less sexual nature of spontaneous labor & normal birth
10. Non-pharmaceutical pain management such as walking, one-to-one care, touch relaxation, showers & deep water tubs, other time-tested strategies
11. Judicious use of drugs and anesthesia when needed (for hospitalized women)
12. Absence of arbitrary time limits as long adequate progress, mom & babe OK
13. Vertical postures, pelvic mobility and the right use of gravity for pushing
14. Birth position by maternal choice unless medical factors require otherwise
15. Mother-Directed Pushing – NO prolonged breath-holding (Valsalva Maneuver)
16. Physiological clamping/cutting of umbilical cord – after circulation between baby and placenta has stopped (average 3-6 minutes)
17. Immediate possession and control of healthy newborn by mother and father
18. On-going & unified maternity care and support of the mother-baby during the postpartum/postnatal period
Physiological management is the science-based model of normal maternity care. The principles of physiologic management are based on supporting normal biology of childbirth and supporting the psychology of the mother as she copes with these biological imperatives. It includes a body of knowledge and the technical skills to detect abnormalities and complications and initiate appropriate medical interventions when needed. This perspective is both time-tested and scientific. It can be used by all birth attendants (obstetricians, family practice physicians and all types of midwives) and in all birth settings.
In the developed world, the principles of physiological management for normal birth have been integrated with the best advances in obstetrical medicine to create an evidence-based standard for healthy women with normal pregnancies.
Mastery in normal childbirth services means bringing about a good outcome without introducing any unnecessary harm or unproductive expense. For an essentially healthy population, the most efficacious form of maternity care (safety plus cost-effectiveness) is the method that provides “maximal results with minimal interventions”.
Physiologically-based childbirth practices should be the foremost standard of care for all healthy women with normal pregnancies, regardless of the category of maternity care provider (physician or midwife) and regardless of the setting for labor and birth (hospital, home or birth center).
In practical and political terms, the controversy over childbirth practices should not pit midwives against obstetricians. There also is no reason why an evidenced-based system of care cannot be a profitable part of the mainstream healthcare system. This is not a ‘place-of-birth’ issue, as no healthy childbearing woman should ever be forced to choose between a midwife and an obstetrician or between a hospital or OOH birth in order to have a physiologically-managed normal birth.
At the present time, OOH childbirth services are almost exclusively provided by professional midwives. Midwifery is health care at its very best, as it provides relationship-based and time-intensive style that provides health education and emotional support based on the best of the art and science of our time.
While place-of-birth is very controversial, numerous peer-reviewed studies comparing OOH births in healthy women with standard hospital-based care document childbirth in an non-medical setting to be associated with fewer maternal interventions including epidural analgesia, electronic fetal heart rate monitoring, episiotomy, operative delivery, lacerations, postpartum hemorrhage and infections. Neonatal outcomes include less frequent prematurity, low birth-weight, and assisted newborn ventilation.
