Preserving Vaginal Birth: A Call to Action
The longstanding commitment by midwives and many physicians to offer healthy women the best vaginal birth possible was transformed to a campaign to protect access to vaginal birth 6 years ago.1–3 The very public conversation occurring today regarding cesarean delivery on maternal request can be traced to the appearance of then American College of Obstetricians and Gynecologists (ACOG) President Benson Harer, Jr., in 2000, on Good Morning America, where he stated, “For the baby the risks are far higher for vaginal delivery than for an elective cesarean section at term. For the mother, the immediate risks for a cesarean section are a little higher, but the longer term risks of pelvic dysfunction, urinary incontinence, anal incontinence, pelvic dysfunction—those risks are higher for vaginal birth. …”4
Although strong evidence demonstrating that a cesarean section prevents pelvic dysfunction is lacking, some physicians welcomed the opportunity to point to vaginal birth as the cause of loss of bowel/bladder control and sexual pleasure. Understandably, some women welcomed the offer to control the timing of their delivery, avoid the discomforts of late pregnancy, and/or relieve their fears about vaginal birth. This approach, which plays into the fears of many women, has the potential to dramatically change the culture of childbirth.
Proponents of elective cesarean delivery were further empowered by the 2003 ACOG Ethics Committee statement Surgery and Patient Choice: The Ethics of Decision Making.5 While concluding that the relative risks and benefits of elective caesarean versus vaginal delivery remain unclear, and cautioning against actively advocating surgical deliveries, the ethics committee stated, “If the physician believes that [caesarean] delivery promotes the overall health and welfare of the woman and her fetus more than vaginal birth, he or she is ethically justified in performing the procedure.”5
As midwives are aware, the 2004 ACOG statement on Vaginal Birth after Previous Cesarean Delivery (VBAC),6 which required a physician to be “immediately” available during an attempted VBAC, eliminated access to VBAC in many communities. Following this revival of the previous “once a cesarean section, always a cesarean section” approach, one might have predicted a greater respect for the importance of avoiding unnecessary primary cesarean deliveries to reduce the incidence of uterine rupture, abnormal placentation,7 and hysterectomy in women who have subsequent pregnancies.8 However, by 2004, the national rate of cesarean section reached an all time high of 29%,9,10 with some hospitals reporting a 44% rate. Although the rise in cesarean deliveries is partially explained by a decline in the number of VBACs, the increase in the number of primary cesareans has continued to rise, reaching 20.6% in 2004.10 The increase in primary elective or no medical indication cesarean deliveries is a source of significant concern to many midwives, physicians, and consumers.
The Maternity Center Association (now Childbirth Connection) systematic review of the literature11 concluded that spontaneous vaginal birth involves fewer risks overall than either cesarean section or assisted vaginal birth.
WHAT DO MOTHERS HAVE TO SAY?
The media have featured mothers who are happy with their scheduled surgeries. Casual conversations with midwives reveal a sense that more women are asking for elective cesareans. The first national data about maternal request cesareans, Listening to Mothers, conducted by Harris Interactive among US women who gave birth in 2005, reported that just one of the 1574 (0.06%) women surveyed said that she had a planned initial cesarean by her own choice with the understanding that there was no medical reason to do so.12Listening to Mothers results also revealed that 9% of the mothers reported feeling pressure from a health professional to have a cesarean. Interestingly, 42% of participants believed that the current malpractice environment leads maternity care providers to perform cesareans that are not really necessary.
ACNM REDUCE CAMPAIGN
To challenge the rapidly increasing number of cesarean deliveries in the United States, ACNM launched the Research and Education to Decrease Unnecessary Cesarean Sections Campaign (REDUCE), calling on Congress to explore the alarming increases in the rate of cesarean births performed in this country, and the long-term implications of major abdominal surgery on women's health and the costs of obstetric care. On March 20, 2006, ACNM, in partnership with Lamaze International, Citizens for Midwifery, the Coalition for Improving Maternity Services (CIMS), and the International Cesarean Awareness Network (ICAN) held a media briefing in Washington, DC, to call attention to the fact that the risks of cesarean delivery are largely misunderstood and underreported, and any benefits are often overstated. Women undergoing the procedure are doing so without being properly informed and are placing their future ability to have a normal delivery in serious jeopardy.
THE NIH STATE-OF-THE-SCIENCE CONFERENCE
The most recent damaging rhetoric followed the March 2006 National Institutes of Health (NIH) State-of-the-Science Conference on Cesarean Delivery on Maternal Request (CDMR). After two days of meetings and review of the published research, the panel released a draft report addressing 24 health outcomes for mothers and babies.9 In the case of 21 outcomes (e.g., infection rates, anesthesia complications, and fetal mortality), the available evidence for planned cesarean delivery or planned vaginal birth was labeled as weak-quality or absent. In the case of three of the outcomes (i.e., hemorrhage, maternal length of hospital stay, and respiratory morbidity), the evidence in favor of planned vaginal birth was labeled as moderate-quality. There was no evidence regarding maternal or neonatal outcomes following either planned vaginal birth or elective cesarean delivery that was deemed to be strong. The NIH panel report found only weak-quality evidence to support cesarean delivery as an appropriate approach to avoid urinary incontinence or other complications related to sexual function or bowel/bladder control. The call for future research included “strategies to predict and influence the likelihood of successful vaginal birth, particularly in the first pregnancy”9 and “modifiable factors in the management of labor that can decrease maternal and newborn complications.”9 The panel made two important clinical recommendations:
- 1Cesarean delivery on maternal request is not recommended for women desiring several children; and
- 2Surgery should not be performed before 39 weeks, or without verification of fetal lung maturity.
Members of the panel stated repeatedly that because the evidence on the risks and benefits is so weak, physicians should not be asking women if they want this surgery.
Within 48 hours of the conclusion of the NIH conference, more than 118 references to articles on the findings were found on a Google search. Thankfully, the majority of the articles got the message right, with titles such as NIH Panel Urges Caution on Cesarean Delivery, Unnecessary C Sections Discouraged, and NIH Panel: No Final Word on Cesareans; but the Washington Post titled its article NIH Panel Finds No Extra Risk in Caesarean Section,13 and quoted Dr. Harer as follows: “This really does validate the elective cesarean section as a mainstream obstetrical procedure.”13
CALL TO ACTION
Midwives and our colleagues who understand the risks involved with this rush to cut must be united and unrelenting in our efforts to provide women with the best information about the risks and benefits of cesarean delivery. We must offer women real choices regarding how their birth is managed, and we must take the lead on conducting research to validate “best practices” for vaginal birth. Efforts must be renewed to decrease the apparent culture of fear surrounding childbirth and return to a time when more women can experience the joy and satisfaction of giving birth. There is much work to be done and each of us must commit to taking action.
- •Copies of the publication What Every Pregnant Woman Needs to Know about Cesarean Section4 should be available in every waiting room, prenatal education class, and labor and delivery unit, and linked to all women's health Web sites.
- •Working in collaboration with women and physicians, we need to teach women how to give birth vaginally while minimizing the risks of pelvic floor damage. ACOG has a new guideline that discourages the use of episiotomy14; midwives can teach physicians the techniques that decrease the need to use scissors in the birthing room!
- •Midwives must also utilize the best evidence in managing labor and birth by encouraging ambulation, mother-directed pushing, and Kegel exercises, while avoiding fundal pressure. Vacuum or forceps extraction should be used infrequently and very cautiously.
- •Lobbying efforts need to focus on spending less money studying surgical interventions during normal pregnancy and spending more money on how to assure safe and satisfying vaginal birth for the majority of women.
- •Conduct research that supports best practices in vaginal birth and reduces the occurrence of cesarean delivery.
- •Ask yourself if you need to change your practice. Although midwives are supporters of vaginal birth and usually avoid unnecessary interventions, a policy of vaginal birth at all costs may be harmful. Is it possible to push too long? Do you have the proper education and experience to perform a vacuum extraction? Are you sometimes tempted by interventions like induction of labor and rupture of membranes that, when not used judiciously, may increase the chance of having an operative birth?
- •Call attention to the economic impact of a rising cesarean delivery rate: bigger hospitals, more operating rooms, more equipment, more staff to take care of mom and baby. Imagine the day a woman who needs an emergency cesarean delivery can't get it because the operating rooms are full of women who just wanted to have a baby that day or nurseries that are filled with newborns experiencing respiratory complications following a cesarean birth, leaving no room for a premature baby.
- •Become a spokesperson for the ACNM REDUCE Campaign. All the information you need can be found on the ACNM Web site: www.midwife.org