The more a midwife speaks to a mother and spends quality time with her, the more likely a mother is to open up and reveal more of her daily routines and habits that can affect her pregnancy and birth.  For example, the midwife will ask a mother the most basic yet critical questions like what is she eating and follow up with nutritional counseling, a topic in which the midwife owns expertise. She’ll ask her what is occurring in her life today, yesterday, expecting for tomorrow. A mother’s every day peace and stress contributes to her body’s sense of well-being and reaching the point where mother and her body believe it is time now to give birth safely and securely.

The psychology of labor is addressed during the med school L&D rotation by incorporating finding other resources for emotional and mental support.  Subsequently we have a number of practitioners in all fields lacking in bedside manner today, but in birth this aspect has an impact intangible to the practitioner but very real to the mother and her family.  The average obstetrical course of education includes fewer than three credit hours in understanding nutrition.  The focus on prenatal nutrition is only a small portion of the syllabus (do your homework choosing a careprovider!).  The home birth midwife also follows the mother into the immediate postpartum and continues home visits to see how mother and baby function as a unit.

It is the midwife who is better versed in delivering babies in various but normal birth situations.  A breech baby can be birthed safer in the hands of a midwife than a hospital attendant.  She has not let her skills fall behind because medico-legal liability has dictated a breech birth to be enough of a risk as to deem a cesarean to be the required course of action; therefore, she continues to hone both her observational and palpating skills.

The American College of Obstetricians and Gynecologists (ACOG), America’s leading organization promoting the benefits of clinical obstetrics in the sterile rooms of trained physicians, has found itself in a dilemma.  The technology and protocols ACOG promotes are the very ones that directly influence our birth statistics negatively.  The birth technology ACOG promotes to prevent or lower risks in birth for both mothers and their babies has not been proven to be beneficial, yet it is used profusely.  Birth in America rarely includes the intimacy of the act that culminated in procreation.  Images of an infant gently caught into its own mother’s arms are so rare that they cause the general public to question the safety of such an event. Debate for and against the licensing of midwifery – and the definition of midwifery itself – is gaining momentum, because statistics for hands off care of normal, natural childbirth are far better than those of managed birth.

In fact, Rebecca Watson of the New Mexico Department of Health has stated, “I sometimes wonder why [we bother compiling statistics on midwives], since their statistics are so much better than everyone else’s.”

While home birth is stereotyped as dangerous because of the lack of medical supervision, it is the lack of that technology and medicine that actually makes birth at home safer than birth in a hospital under today’s protocols.

Studies have shown that once a technology is introduced and mandated, it is difficult to remove it from care practice despite being proven unsafe or unnecessary.  For instance, although the rates involving an episiotomy (cutting the perineum to create a larger opening for the baby to pass through) have dropped drastically since 1980, it is still a common practice.  Ironically, episiotomy rates today are justified as integral to the higher use of vacuum-assisted deliveries or unfounded fears that a baby is stuck because it is a large baby or presenting in a less than optimal position, (posteriors, for example, where a baby faces away from the mother’s back during labor).

America is one of the few nations where birth is managed more with technology than with the hands and eyes of the care provider, but other countries will soon catch up. In a country that boasts technology superior to other developed nations and is not known for undernourishing its citizens, our mothers and babies are faring no better at birth than underdeveloped nations such as Croatia. No improvements have been made in the maternal mortality rate in America since 1982, and  America’s infant mortality rate in the past two decades also has not improved. Our birth technology has increased and the number of routine prenatal screening tests have multiplied since the early 1960s, but our maternal and fetal outcomes have gone progressively backward.

“Despite a significant improvement in the U.S. maternal mortality ratio since the early 1900s, it still represents a substantial and frustrating burden, particularly given the fact that – essentially – no progress has been made in most U.S. states since 1982. Additionally, the U.S. Centers for Disease Control and Prevention has stated that most cases are probably preventable.” states C.T. Lang in a 2008 obstetrics and gynecology report.  Further, the Centers for Disease Control (CDC) reported in 1983 that the maternal mortality rate in the U.S. was 8.0 for every 100,000 live births (Monthly Vital Statistics Report).  In 1993, the rate was 12.0/100,000 live births (CDC).

Among the causal deaths that could be prevented were those that involve both underlying health issues such as poor nutrition and high blood pressure (World Health Organization) as well as those that are physician-caused including infection and hemorrhage.  Bacterium can be introduced first by the mother arriving in an environment where diseases are being treated as well as from infiltrating the natural barriers we have against infection through vaginal exams and, of course, surgical delivery. In addition, there are higher incidences of hemorrhage from forced delivery of the placenta as when a care provider intentionally pulls on an umbilical cord to tear the placenta away from the uterine wall of the mother’s womb. In all instances, normal birth evidence training of the professional birth attendant is critical.

Injuries and deaths related to the physician’s care range from the off-label use of medicine such as Cytotec (also known as Misoprostol) for the inducing of labor as well as the sanctified use of surgical delivery, which gives us embolism, one of the leading causes of maternal mortality and a risk directly associated with cesareans.  Cesarean rates for delivery rose by 46 percent from 1995 to 2006.

Women around the world, the time to look again at the image of women birthing with women versus a medical obstetrical group in normal birth is now. WE can improve global maternal and newborn birth outcomes and experiences. WE know birth. WE know women’s hopes and fears.  A new generation of birth wisdom and experiences is here!

Wishing you a truly happy Mother’s Day secure in the knowledge of your body’s innate wisdom!

Learn more about the wisdom of utilizing your best resource: an Independent Childbirth member led birth education class like Dorene Vaughn’s All Natural Baby!

Visit our comments section (this post) to find some of the most awesome birth wisdom posts our readers have found on the web and to add the ones you’ve found!

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There are many variations on the only thesis available to opponents of home birth: What do the statistics say? Despite the enticement of a warm, peaceful and private birth that a home birth offers, the perceived importance of missing technology lingers like impending doom. In America, less than 1% of births takes place in homes. It is difficult for the other 99% of Americans to make the transition from technology as the benchmark for establishing worldwide leadership to the reality that the human body is designed to give birth and it has evolved to make many variations in labor and birth look so easy.

The Stockholm Birth Center Study followed one birth center’s outcomes over a ten-year period culminating in 2000 and comparing the outcomes to the associated hospital’s birth outcomes. The one strong observation in this study is the truism that many women will choose a birth center because of the perceived safety in having a hospital nearby. However, it is a mistake to conclude the birth center is free of institutional intervention. The study’s results are negated because of the influence of the obstetrical backup. Every woman who chose the birth center for her birth location was still subjected to the institutional care package. This is the most influential determinant in whether or not a woman is “risked out” of laboring and ultimately delivering in the birth center.

A birth center so closely associated with a hospital is not autonomous and must operate under strict supervision by institutional birth practitioners. The authors themselves state they did not study the effect of individual labor and delivery protocols, but rather the care documented in each case as a “package.” In addition, they have correctly remarked standards of maternity care do not exist, but they have again missed the mark on the importance of this statement. This is critical to interpreting the outcomes, because one solitary intervention can turn out to be the predictor of a birth outcome. For example, every care provider practices according to their comfort level; although every care provider will monitor a baby’s heart tones in labor, how the monitoring is done varies by care provider. Continuous electronic fetal monitoring (EFM) can range in definition from ten minutes hooked up to a monitor every hour on the hour to a handheld doppler check through a contraction every few hours to a telemetry unit (a girdlelike band outfitted to wirelessly transmit fetal monitoring data) that allows the mother walk more freely.

The ability to walk freely even under continuous monitoring allows the mother greater mobility for finding a position that increases her ability to cope with her contractions. Setting aside the U.S. Preventative Service’s Task Force’s findings and stance that continuous fetal monitoring provides no benefit at all – and the data showing that continuous EFM results in more cesareans – it can be argued that fetal monitoring that limits a mother’s mobility is therefore more likely to result in more intervention as the mother shows signs of distress and therefore the baby does as well.

The authors of the Stockholm Birth Center study argue that many other studies have reached conclusions similar to theirs. In the same publication we are offered a Cochrane Systematic Review of Home-Like versus Conventional Institutional Settings for Birth. Here the reviewers concluded births in home-like settings compared to purely hospital settings “provided only modest benefits including reduced medical interventions and increased maternal satisfaction.”

A hasty read of this data by institutional birth practitioners correctly supports their ingrained training that routine intervention is acceptable and “safe.” However, the paper actually clearly demonstrates that all births taking place in a hospital are going to meet up with interventions at some point during labor, and it is the overuse of technology that needs to be analyzed. Indeed that message is there somewhat cryptically as the authors instead hinder the possibility of improving on the scope of research by advising “caregivers and clients should be vigilant for signs of complications.” It is difficult for any woman who has given birth or who respects her body to hear such little value placed on the differences the studies do reveal, such as the “modest benefits” of “reduced medical interventions” and “increased maternal satisfaction.” Surely even one avoided episiotomy would be appreciated by the woman whose perineum would have been cut and would find several women healing from receiving an unnecessary episiotomy envious.

In 1998, a study of infant mortality in planned home births was conducted in Australia. Author Hilda Bastion reviewed these outcomes as neither hospital nor home births have defined what constitutes standard care. She reviewed both midwives and medical practitioners, registered and unregistered, minimal experience and heavy case load. Also included in the study were births that would be deemed risky by virtue of poor health in the mothers or other underlying health conditions. This is crucial to understanding the bias of many hospital birth proponents: It is not the intent of home birth advocates to claim home birth is best for everyone, but rather a viable option for low-risk and otherwise healthy women. The author goes so far as to note it is a disturbing trend that midwives may be encouraging and willing to take high-risk births because of the high number of low birth-weight infants counted in the statistics. In fact, it is quite possible that a woman who cannot afford good nutrition may also not be able to afford hospital birth care, and perhaps a midwife is her better choice than no care at all.

In general, birth care is divided into either purely institutional care or modified institutional care. No research exists on pure, spontaneous vaginal birth over an intact perineum without induction agents, drugs, surgery and instruments. What is available is mounds of research on what a mother or baby can “tolerate” in labor and what interventions have achieved an acceptable degree of risk. The acceptable degree of risk is not defined by an independent counsel but often influenced by the strongest or loudest lobbying effort, as witnessed by the American College of Obstetricians and Gynecologists’ (ACOG) August 2007 statement on the advance of midwifery options for consumers. ACOG’s bottom line is midwifery options must be controlled and home birth as an option must be eliminated. The average consumer misses the bias and conflict of interest: A rise in home births means a decrease in income for a field already plagued by the reality that there is no money to be made in natural childbirth.

In addition to a lack of studies of organic birth as defined above, there are no long-term, randomized longitudinal studies to confirm or deny the correlation of many interventions. For example, the impact of a mother’s drug use in labor on emotional bonding, breast-feeding, postpartum depression, later drug abuse (baby as a young adult), etc. In the 1970s, Doris Haire, the President of the American Foundation for Maternal and Child Health, said, “No drug has been proven safe and effective for use during pregnancy or childbirth.” Considering that 25% of drugs introduced in the market today are recalled or pulled off the market in 1 to 5 years, this statement has never been more true. Until such time that midwifery care can be studied with a critical but appreciative eye, we will find only the weakest of studies boxed in by outdated beliefs that American women cannot afford to birth outside of a medical institution. In fact, it is our country that cannot afford to NOT offer free standing birth centers as a birth care option for American women.

Works Cited
Bastian, Hilda, “Perinatal Death Associated with Planned Home Birth in Australia Population Based Study”: BMJ 1998; 317: 384-8

Hodnett, E.D and S. Downe and N. Edwards and D. Walsh, “Selected Cochrane Systematic Reviews: Home-like versus Conventional Institutional Settings for Birth”; BIRTH Issue 32:2; June 2005

Waldenstrom, Ulla and Charlotta Grunewald, “The Safety of Birth Centers Responses to a
Critique of the Stockholm Birth Center Study”; BIRTH Issue 32:2; June 2005

Just a quick look at the birth outcomes for Independent Childbirth educator led birth classes led by Sheridan Ripley, Gretchen Vetter, Olivia Sporinsky, Molly Remer, Aimee Crane, Joni Nichols, Ruth Trode, Dale Bernucca, Brandy Segin, Helen Loucado, Sara Wallbaum and Dorene Vaughn.

PLANNED OUT OF HOSPITAL BIRTHS  (132)

Free Standing Birth Center = 45; Planned Home Birth = 55; Planned Unassisted Birth = 4; Unplanned Unassisted Birth = 3; Transfers = 25

Combined Spontaneous, Unmedicated, Unmanaged Vaginal Births = 107

Combined Transfer Medicated, Vaginal Births = 8

Combined Transfer Medicated, Cesarean Births = 2

Combined Transfer Unmedicated then OR for Cesarean = 13

Combined Transfer Unmedicated, Vaginal Births = 2

  C/S Rate for all OOH Births:  11.36%

  Transfer Rate for all OOH Births :  19%

  C/S Rate for Transfers of OOH Births:  60%

 

PLANNED HOSPITAL BIRTHS  (101)

OB Attended = 75; Family Physician Attended = 6; CNM Attended = 19; Other = 1

Combined Spontaneous, Unmedicated, Unmanaged Vaginal Births = 57

Combined Managed, Unmedicated, Vaginal births (i.e. AROM) = 6

Combined Managed (includes pitocin/induction only) Vaginal Births = 25**

Combined Managed Resulting in Cesarean Births = 11**

Combined Spontaneous, Unmedicated, Unmanaged Resulting in C/S = 2

   C/S Rate for all Planned Hospital Births: 12.88%

   C/S Rate for all Managed Hospital Births**:  26.19%

   Percentage of Hospital Births Managed**:  41.58%

 

We did not penalize hospitals by including cesareans from homebirth transfers in their statistics.  We did however include c/s for breech in their statistics because medical training trends have forced those cesareans by no longer training medical practitioners to catch breech babies.

Amber Marlowe anticipated an easy delivery when she went into labor on January 14, 2004. But after a routine ultrasound, doctors at Wilkes-Barre General Hospital, in Pennsylvania, decided that the baby–at what looked like 13 pounds–was too big to deliver vaginally and told her that she needed to have a cesarean. The mom-to-be, however, wasn’t convinced: After all, she’d given birth to her six previous kids the natural way, including other large babies. And monitoring showed that the fetus was in no apparent distress.

After she said no to surgery, doctors spent hours trying to change her mind. When that didn’t work, the hospital went to court, seeking an order to become her unborn baby’s legal guardian. A judge ruled that the doctors could perform a “medically necessary” c-section against the mom’s will, if she returned to that hospital. Meanwhile, she and her husband checked out against the doctors’ advice and went to another hospital, where she later gave birth vaginally to a healthy 11-pound girl. “When I found out about the court order, I couldn’t believe the hospital would do something like that. It was scary and very shocking,” says Marlowe. “All this just because I didn’t want a c-section.” ~ Could You Be Forced To Have A C-Section?, Lisa Collier Cool, Baby Talk Magazine

Although the c-section rate for planned out of hospital births appears to be the same as that for planned hospital births here is the difference:  the c-section rate for planned hospital births doubles when the labors are managed (ANY intervention is used).

The possibility of a cesarean section should be discussed with every patient as part of the patient’s birth plan, with contingent consent for a cesarean section obtained early in the woman’s pregnancy. The woman must sign the consent form herself; her husband should not be asked to sign it. At the time the cesarean section becomes necessary, the woman should be asked to resign the original consent form, indicating that the conditions for needing a cesarean section have now occurred. The fact that the mother may have had some pain-relieving drugs does not render her legally incompetent to acknowledge the need for the procedure. Her husband has no authority to sign the consent to her surgery unless she has given him this right in a power of attorney. If the mother is medically unable to consent because she is psychotic or comatose, the surgery may go forward based on the consent signed as part of the birth plan. – Excerpted from LSU’s Law Center Medical and Public Health Law Site

Practitioners presenting the information for acquiring a mother’s informed consent are not always comfortable with how to explain the procedure they want to do and why they want to do said procedure.

It isn’t always easy for birth practitioners to call their colleagues’ errors to public attention and in the process perhaps admit that they themselves crave a better quality of training.  

It is necessary to call attention to and demand spontaneous, normal, unmedicated, vaginal birth over an intact perineum be the gold standard for birth care.  We do so for the greater benefit to global maternity care.  Independent Childbirth educator members are at the forefront of making a difference.  When women are educated as to all of their birth care choices including planned out of hospital birth our combined c-section rate is 12.02%. The World Health Organization declares no region in the world should have a c-section rate greater than 10% to 15%; based on the cesarean rate for managed births we know our combined cesarean rate could be improved dramatically with increased use of better birth care practices by medically trained personnel.

*In our statistics there were 7 successful VBACs and 2 successful VBA2C; 2 VBACs became repeat CS for a successful VBAC rate of 81.82%.  There were 29 waterbirths.  There was one vaginal breech birth while 5 other breech presentations were automatic cesareans.  All 7 unassisted births were successful, healthy outcomes.  There were four sets of twin births, two with both vaginal but very managed labor, one scheduled c/s for breech at 31 weeks, one singleton born vaginally at term with sibling stillborn vaginally and it was known sibling had died inutero but mother chose to continue pregnancy for her other daughter’s health.  Learn more about gentle stillbirths and remembrance at Now I Lay Me Down To Sleep.

As a group whose every day bears witness to the entry into this world of many a newborn we enjoy hearing women’s descriptions of all things birth.  We tend to cringe hearing harsh language surrounding birth.  An irritable uterus?  What is that, a belly with angry eyes???

I remember Laura describing her daughter’s entry into the world as one where her cord was “creatively wrapped.”  What a difference it makes to view each birth with wonder, not as a risk.  I believe it is in the documentary by Patchwork Films called “Born In The USA” where Dr. Joanne Armstrong admits hospitals have low tolerance for viewing laboring women as anything but risk.

We spent a good portion of last year bringing awareness to the misleading presentations on technology in birth.  We will continue to do so as new “turf battles” with ACOG arise, but it’s time now to see the beauty of labor and birth as it really exists.  I know many believe “orgasmic birth an old midwive’s tale” or simply too extreme a description for what is otherwise only a reverential experience.  I have to smile to myself and just state the obvious: birth is personal and some take their personal view as the only view and are taken aback when their view isn’t just like someone else’s is.  Perhaps that’s why Ms. Moore fails to mention that Orgasmic Birth also contains the story of a mother who labored and labored and labored.  It wasn’t orgasmic in the sexual sense.  It was sexual as in liberating.  Had this woman labored in a hospital she would have been sectioned.  The only real point of discussion is that whether or not any of us feels she should have been sectioned is a matter of personal choice.  And that’s what we here at Independent Childbirth see as the reason why globally maternal care is so faulty: it does not have choice at the foundation.

Birth is.  Period.  That’s the true beautiful secret of birth.  Each birth is unique as well as being unique to the mother at that moment in time.  When she first birthed she was not the same woman that she is giving birth the following year or years later.  She is not the same woman giving birth two, three, four births later.  None of those babies are the same as the ones before.

When women fail to honor the different choices we each make we tear each other down.  Why else are the mommy wars the fodder of many a journalistic piece?  It makes for entertainment: judging each other for the decision to breastfeed even when it means dealing with people who cannot see breasts as anything other than sexual; judging each other for a mom who wants to both be a mother and have a successful career.

We need more appreciation for the turtle women.  Yes, turtle women.  There are turtle women specific to the birth world but I think turtle women abound in all aspects of our life.  They are the women who support, not criticize, our choices.  It does not mean they agree with every choice we make.  It does mean that they are wise enough to recognize the value of stirring every woman to think about her choices, why she made them and most importantly be confident in her own wisdom to adjust or make different choices because she has learned something new.

“Orgasmic Birth” is scheduled to be reviewed in a segment by ABC’s 20/20 tonight at long last.  Unfortunately it may be viewed as a part of a theme called “extreme mothering.”  Today’s journalism just isn’t journalism unless it’s sensationalist.  Sigh.

No matter.  Turtle women all the way down … enjoy!

What does Dr. Helen Sandland have to do with our goal to help you be an educated health care consumer?  For the most part we all tend to be interested only in what affects us at the moment so for those women new to the birth scene and just reading our most recent posts we include here the story of a doctor who quit rather than be fired for refusing to adhere to her hospital’s medicolegal requirement to do more cesareans.  In continuing the struggle to give American women the best maternal care: the midwifery gold standard.:

Doctor Won’t Make The Cut:
Feeling pressure from hospital for more c-sections, she leaves

Wilmington Star Newspaper, 5 June 2005

Surrounded by a house full of cardboard boxes, Wilmington obstetrician Helen Sandland discussed how giving birth Mother Nature’s way is in jeopardy.

Dr. Sandland – known for the past decade as the doctor local women went to if they desired natural, vaginal deliveries – moved to Mississippi last week after being told by New Hanover Regional Medical Center administrators to do more c-sections.

She refused.

“I leave NHRMC with my morals and backbone absolutely uncorrupted,” Dr. Sandland wrote in her resignation letter dated May 15. “I am going to practice with a long-time friend, whose scruples I admire, and in a place where unnecessary surgery is not encouraged.”

During a time when national health officials have sounded the alarm that the cesarean section rate is at an all-time high and needs to be sliced, Dr. Sandland’s case raises questions about what factors are pushing the numbers higher.

Since history has been recorded, cesarean sections have always been a procedure used on mothers. The procedure was given its current name when, under Julius Caesar’s reign, Roman law decreed that all women dead or dying from childbirth were to be cut open to try to save the baby.

Until the 1800s, when formal anatomy education arose, the procedure rarely saved the mother’s life. It was used as a last resort until the 1940s, when antibiotics became available, and into the 1950s, when most women switched to giving birth in hospitals instead of at home.

Considered major abdominal surgery with complications that can lead to death, c-sections became used more commonly for abnormally positioned babies or when the mother or baby is in distress. During a c-section, mothers are given anesthesia, an incision is made through muscles of the abdomen, organs are moved aside and the baby is pulled from a cut in the uterus.

By 1970, 5.5 percent of babies were delivered through c-sections.

The rate doubled in five years and continued to increase until 1990, when it peaked at 22.7 percent. It held steady and slightly declined through the 1990s before picking up again in 1998. The rate now sits at 26.1 percent of 4,021,726 births nationally. North Carolina’s rate is 26.4 percent.

“I don’t see any end in sight right now,” said Dr. Bruce Flamm, regional chairman of The American College of Obstetricians and Gynecologists, saying there’s little concrete data on how many c-sections are unnecessary. “All of the current pressures seem to be going in the direction of more c-sections, not less.”

He and other national medical experts are concerned with the trend; a trend they believe is pushed by medical liability issues, convenience for both doctors and patients, and perhaps hospitals’ financial and staffing pressures.

“There are some doctors who say the only cesarean section I have ever been sued for is the one I didn’t do,” Dr. Flamm said. “It’s a sad but \true situation.” Not only is there a decreased chance of getting sued if a c-section is performed, but it’s less time consuming to perform c-sections instead of waiting out long and sometimes difficult labor.

“It’s a very vulnerable time,” said Deanne Williams, executive director of the American College of Nurse Midwives. “The increased demand is really a reflection of being told this is a quick fix, there’s no risk, why wouldn’t you? And that’s by the medical community.”

But, as many obstetricians will point out, pressure by doctors or hospitals is only part of the equation. Some women, they say, really are looking for a c-section because they fear the pains of labor or want to schedule it when grandparents are in town or around holidays.

“It’s called doctor shopping,” Dr. Flamm said, discussing how women will go from one doctor to another until they get what they want. “You have to be responsive, within reason, to the desires of the patient.”

Regardless of the reason, health officials across the country are concerned with the rates.

Leading medical groups such as the Centers for Disease Control and Prevention, National Institutes of Health and the World Health Organization have all spoken out against the increase, demanding the medical community investigate ways to lower the rate to 15 percent or below. C-section culture Dr. Sandland thought she was doing just that. 

In the decade she has delivered babies and cared for their mothers in New Hanover County, she has always had a rate below 10 percent.

“I’ve always maintained I’m a midwife with a MD behind my name,” she said from her two-story Pine Valley home last week while preparing to move. “It’s better for Mother Nature to decide when it’s time, not the doctor. My philosophy is you don’t interfere unless you really have to.” 

Her philosophy, admittedly different from the mainstream, attracted many patients who wanted the best chance of having a vaginal delivery.  Dr. Sandland became known as one of the few doctors in the area who would try to deliver breech babies naturally or pursue a vaginal birth with a woman who already had one child with a c-section. Her solo practice boomed.

If her lack of medical malpractice lawsuits and gratitude of patients are of any account, she was not only popular, but also successful.

Fellow Wilmington obstetrician Dr. Joshua Vogel said though she was considered too set in her ways or a renegade by some doctors, he admired her talents to deliver naturally in situations when other doctors would have automatically pushed for a c-section. “She was a valuable asset for patients,” he said.

Dr. Sandland said she became the target of the hospital’s professional review and credentials committees. Because it is confidential by law, she could not legally discuss the peer review process.

But the Star-News viewed two letters addressed to her from committee members. Written on New Hanover Regional letterhead dated July 6 and July 7, 2004, the letters discuss the conversation committee members had with her.

The first letter, written by Dr. Cobern Peterson, chairman of the Professional Review Committee, stated “concerns” regarding her practice. They include higher than average infant birth weights, much lower than average c-section rates and later than average gestational age of neonates at delivery.

The letter states “the main concern reiterated several times was an overall practice attitude rather than any individual case.”

The next letter, written by Dr. Janelle Rhyne, acting chairman of the Credentials Committee, states Dr. Sandland’s privileges at the hospital would be reappointed for a period of six months but monitoring would continue.

It reads, “Your c-section rate is to be within an acceptable range as determined by the NHRMC OB/GYN Department with a plus or minus deviation of two.”

No reason was given in the letters, other than adding the committee would be watching other outcomes like collarbone fractures – something experts say is a minor, common complication of vaginal deliveries.

New Hanover Regional spokeswoman Kendra Gerlach said two standard deviations equates to five or six percentage points above or below the average.

The c-section rate at New Hanover Regional is 27.9 percent. At the time, Dr.. Sandland said, it was about 26 percent. That meant the committee was requiring her to reach at least a 20 percent c-section rate. To do so, she’d have to more than double her current rate.

“It’s just not something I could see happening,” she said. “You just don’t change your practices overnight. I certainly wasn’t going to change them to meet some arbitrary quota.”

Jack Barto, chief executive officer of New Hanover Regional, said he was not familiar with the letters but that it sounded to him more like a “guideline” than a “quota.”

“To me, a quota is, ‘You will be at X percent,'” he said. “I think it gives a range to allow physicians to have discretion.”

When asked if other doctors who deliver patients at the hospital are given the same guideline, he would not answer the question. He did not say why a guideline would be necessary.

But Dr. Sandland said that in a March conversation with Mr. Barto, part of the reason became clear.

“Barto said in a separate meeting that a c-section rate of 25 percent would reduce the likelihood of getting sued,” she recalled.

Mr. Barto confirms he had a meeting with Dr. Sandland but would not discuss the conversation.

“I had a private conversation with one of my physicians,” he said, asserting he did not recall discussing liability issues. “I talked with her about a variety of topics.”

Dr. Sandland also said the decree put a “seed of doubt” about other things going on during labor and delivery.

One time, she said a fellow physician called her to tell her she had a woman who was attempting to vaginally deliver a breech baby and, when Dr. Sandland explained the patient was aware of the risks and wanted to at least try, he said maybe he should go talk to the mother and try to “bully her” into a c-section.

Other times, especially when the unit was overrun with laboring moms, she said, there was pressure from department heads to speed up labor or consider a c-section.

“Quite a lot of c-sections are being done for so-called failure to progress,” Dr. Sandland said. “If you haven’t progressed in a couple of hours, a c-section’s waiting. There’s certainly a pressure to keep patients moving on through.”

Fellow obstetrician Dr. Vogel said he never felt pressured by New Hanover Regional administrators but he knows it goes on from time to time, mostly at for-profit hospitals for financial reasons.

The hospital’s chairman of the OB/GYN department, Dr. Bora Duruman, declined to comment on Dr. Sandland but said doctors are not pressured to do c-sections nor do they pressure patients toward c-sections unless the procedure is medically necessary.

“There’s no guideline at New Hanover Regional,” he said. “I take that back. There’s absolutely a guideline at New Hanover Regional. The guideline is healthy mother, healthy baby. The c-section rate then falls where it falls to achieve that.” Concerns for future Emily Lanier’s greatest fear when she went into labor Mother’s Day with her first child was of getting a c-section.

“My main thing was c-sections are not natural, and I wanted to experience natural delivery and I did not want to go through the recovery time,” the 29-year-old said.

But when her son’s head got stuck in her pelvis, her blood pressure shot up and his heart rate plummeted, she understood the necessity of the operation. 

Nearly a month later, she said she’s saddened New Hanover Regional has put a c-section “guideline” on at least one doctor.

“Something like that really doesn’t surprise me,” she said. “Kind of like at the end of the month, a cop has to give more tickets.

Everybody has quotas. I feel like if it happens at one hospital, it’s going to happen everywhere, so there’s really no escaping something like this.” 

Ms. Williams said members of her nurse midwives organization have long suspected hospital administrators may be driving the c-section rates behind the scenes, but she was shocked to hear a hospital actually put a quota in black and white.

“It’s likely happening,” she said. “If one person has the guts to come forward and say this has happened to me, it means it is happening a lot.”

Ms. Williams said hospital administrators would probably be happy to schedule all c-sections because it would control costs of staffing a labor and delivery unit around the clock.

“They want to put women on the conveyor belt,” she said. “They could save tremendous amounts of money.”

New Hanover Regional administrators said there’s no such movement at their hospital.

“For most people, this is the most amazing, wonderful moment of their lives,” Dr. Duruman said, also denying the hospital is out to make more money by doing c-sections. “What crosses your mind the whole time is healthy mom, healthy baby.”

Mrs. Gerlach said the hospital charges $4,700 on average for noncomplicated vaginal deliveries and $14,200 for noncomplicated c-sections. Those amounts do not include doctor fees.

Consumer watch dog group Public Citizen has estimated that half of cesarean sections are unnecessary and result in 25,000 serious infections, 1.1 million extra hospital days and cost more than $1 billion each year.

Meanwhile, the procedures don’t seem to be making a difference, noted Dr. Flamm, explaining that while the c-section rate continues to climb, the number of fetal deaths remains steady.

Legally it’s safer, he said, but not necessarily safer medically. He added that he and other physicians debate constantly and can’t come to a conclusion of what the correct c-section rate should be.

Ms. Williams is concerned that the more c-sections become the norm, the riskier giving birth will be. 

“We are going to see an increase in morbidity and mortality for the mothers,” she said, explaining how the first and even second c-sections are fairly risk-free but then scar tissue builds up and increases the surgery’s risk.

“Every subsequent cesarean section, the risk of a woman ending up with a severe hemorrhage, losing her uterus or ending up dying goes up,” she said. “By the time women figure that out, we’re going to be long
gone.”

If you’re thinking of having a baby soon, have a friend, daughter, sister planning to have a baby: please take the time to learn what gives in America.

This movie, Orgasmic Birth, focuses on the women giving birth, and that’s something the public has been waiting for a long time!! Every woman you’ve ever shared birth with is in this film. There is the mother who believes you trust doctors for everything and she ends up with an induction, epidural and baby finally born after two vacuum attempts … and she believes the doc saved her. You see the mom who also believes the same, is induced, and has a cesarean. However, the movie starts and ends with the mothers who have believed in the birth process, their bodies and that how they birth matters to their babies. You hear from fathers who love that their babies were born surrounded by their home and loved ones…their natural environment to begin life in.

Instead of the black/white contrast of The Business of Being Born, you have a sophisticated segue in the sense that the commentator’s information is presented around the story told so the dots are connected fully because these women tell their own story and the commentator fills in the ‘real’ story. It’s not told fear based, it’s told from a know natural birth perspective. No rant. It just is.

We believe that it is also the intent to interview everyone in a home or home-like atmosphere, with the exception of hospital footage for those two moms with routine medicalized birth … and that’s a smooth, thinking contrast. Every person is speaking softly even when venting on medical birth. Love the moment that Dr. Northrup tells us with medical intervention we “screw it up” — “it” being normal birth.

It is also one of the first films presented to the public to show a wonderful birth class outside of the hospital. We don’t know if it is the producer’s intent but perhaps the film is trying to turn Lamaze around and portray Lamaze in the Institute for Normal Birth light. We say this because the producers limited themselves to Lamaze. They did also keep footage of someone mentioning a Lamaze in-hospital class that they didn’t like.

We wish more had been done to represent other independent birth ed options as independent childbirth educators are among the most deeply anchored normal birth supporters in America and have always known that hospital preferred birth classes are a disservice to women, hindering their access to unbiased information and, many argue, used only for props to keep women birthing in hospitals. Around the world, normal birth education may not be done in the traditional setting that we in America are accustomed to but it is still independent of medical fear and bias, with knowledge transfer occurring rather as a woman to woman knowledge share with midwives as the informational conduit.

We do wish the film included reflection on mothers who are second or even third generation homebirthers as well. These women kept normal birth in America from completely fading away. There really needs to be a film as a tribute to these women pioneers. In other words, it is important that nations, especially America, fully recognize that home birth, normal birth is not something new; that women have believed in and enjoyed their normal births before 2008.

The births shown are wonderful. One of the best births is the mom who talks about childbirth as a mother’s sacrifice. You might cringe because you start thinking here we go… “Birth is painful. Birth is a sacrifice. Birth is about a medal.” However, to our delight, this mother delivers within a pretty normal window for active labor, 26 hours, she’s birthing at home and the midwife says outright in a hospital she would have been given pitocin and c-sectioned by now. The great thing is the mom talking afterwards about enjoying that birth for its own challenge for her if not for any great spiritual or relaxing birth story.

This is a great contrast to the mom who I mentioned above with the vacuum baby who says not until closer to her due date and hiring a doula did she hear anyone talk about embracing contractions. Until then everyone talked about labor as a difficult thing. You really do get the full connection of the contrast between the two women’s births… some of the responsibility lies with women doing the work to face and/or overcome fears… some of the responsibility lies with careproviders’ attitudes about birth and their inability to provide humanized birth. It’s not only about medical vs. normal birth. It’s also about what women are told, have been told and how it’s still quite accidental for women to hear about birth as an enjoyable event in their lives.

The abuse survivor’s birth and another homebirth will make you cry. The very personalized births will leave you smiling and swaying with the moms. Very cool.

We can’t wait to share it with you and we hope to see you at our screenings!! Just check our “Birth Events Near You” page on this blog.

The cause of rising malpractice insurance for obstetricians is NOT that birth is risky. It’s that the medical model for birth care, also known as managed birth, is dangerous. We are not a nation of women and babies who need saving from labor. According to ACOG’s greatest supporter, Dr. Amy’s latest responses on who deserves to decide who is licensed to be a midwife in America, she considers anything less than a medical model midwife ~ highly managed by an obstetrician ~ a “second class” of midwife.

Let’s consider this: the average American believes primitive homes with dirt floors are unsanitary places to give birth, a clean source of water is vital for our health for consumption and bathing, a nation ought to have good farmland for producing healthy foods organic or otherwise, a nation ought to have cutting edge physician care options and everyone has the right to a free public education to the high school level.

If we are a nation of women for whom the majority live in clean homes with clean drinking water, are able to purchase nutritious foods and supplement with container gardening if not a full garden, are educated to a high school level minimum then why does America’s infant mortality rate rank only 0.19% better than Croatia? The American government is spending millions on health care and technology aimed at the minority and lower income population to close the disparity in maternal outcomes. American health insurance companies spend millions reimbursing for ultrasounds, screenings and diagnostic tests for genetic counseling and detecting babies with anomalies while they are in utero.

Setting aside some of the possible causes for the disparities in the IMR (i.e. nations that allow for abortion, nations which use a different cut-off date for considering a death to fall under the Infant Mortality category, etc.) we still have what it takes to rank higher as a nation of healthy mothers and infants. If our government truly wishes to rest on its laurels for providing what our citizens need for whole, physical health then, yes, our country is poised for what Dr. Amy considers a “second class of midwives.”

Our country should be strong and proud to say we are a nation of healthy, low risk mothers and we have earned the right to be the first to recognize that non-intervention trained women may serve these mothers, and these non-intervention trained women are intelligent and can recognize through simple measures how to recognize the mother who must be transferred over to a next level of clinical care. That level of care can be the CNM who is the expert in navigating the halls of medical protocol and hospital policies in addition to the CNM having the board certification to enact ‘medicine.’ The next level after that should be the medical specialist who also has surgical skills.

Our front line for our nation of healthy women preparing to give birth should be the midwife who is the expert in normal birth as well as the expert regarding her community and its affect on the mothers seeking her birth expertise. She can be the dialogue bridge between the medical experts who are willing and available to provide specialized services and the woman who truly needs them.

When choosing [representatives] for your committee, please include midwives who still do 70% of the births in the world and are experts not only at ‘normal’ birth but at keeping infants normal around the birthing process. ~ MacDorman and Singh, 1998

Were it not for the 1% of women in America who continue to choose homebirth with normal birth experts, the public would never have access to experiencing normal birth and using spontaneous, vaginal birth over an intact perineum as the gold standard for which to measure all birth policy.

I sometimes wonder why [we bother compiling statistics on midwives], since their statistics are so much better than everyone else’s. ~ Rebecca Watson, New Mexico Department of Health