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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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.

One thing we loved about the documentary Orgasmic Birth, is how it complements Business of Being Born’s consumerism awareness and vice versa because the woman herself was the focus.  Her power.  Her ability to birth.  No focus on who is catching the baby.  AND…the births take place in America in the mother’s own time and her space.  A Disney film attempted to show waterbirth with dolphins and took place in scenery meant to be exotic and far away, but took a toll on both the dolphins and the women and families birthing in the name of cinematography in the process instead.  Disney, we don’t need to sell birth in an infomercial, but birth is of global interest.

Practitioners are selling fear of birth.  The truth is birth is simple and we do more harm just by using words to put a fear of the unknown in place rather than the empowerment of experiencing the new.  Birth is not an unknown UNLESS you throw interventions into the mix.  Then you’re on a whole ‘nother flowchart.

I think we, natural childbirth educators and advocates, are accused of “selling” natural childbirth by careproviders annoyed that they’ve lost another customer. 

When birth is allowed to just happen it is not only an experience of wonderment for all in its presence it is also an experience in appreciation for a woman to be “a” woman, one not one of many.  For a baby to be the individual human welcomed, not one of many.

I loved “Kerstin’s Birth Story” which is the birth story of our own Olivia Sporinsky now living in Texas with her husband and family on his military base.  Olivia tells us of her birth experience in Germany where the careproviders believed something definite about American women.  Still, they were open to allowing Olivia to birth her way even though it differed from what they believed to be true about American women and how they birthed.

I recalled Henci Goer during the NIH conference on elective cesarean.  The panel was quick to say “more research is needed”, the typical wishy-washy answer so as not raise the ire of an industry that has a heavy interest in the public perception of cesareans.  However, Henci, in her usual to the point manner, asked, “What are careproviders telling women about labor, birth?”  Her viewpoint being if we only look at “elective” cesarean as a “whatever you’d like” versus talking to women about labor as a healthy and safe process; VBAC labor as one where we support natural labor as the healthiest route even more so; talking to women about how normal it is to have trepidation about natural birth and recommend resources for them to learn more about the birth process, well then, of course you breed more fear of birth.  Careproviders themselves are actually talking themselves into being afraid of the laboring woman as pure risk.

Here’s to you Olivia and Kerstin.  May the international birth community and women around the world know that technology is good to have but do not attach technology as a necessity for American women, for any woman.  America’s maternity care has misplaced faith in technology and other countries need not follow.  There are American women who are not afraid of birth and every day these women are a hands-on lesson for society and practitioners every day.  Humble and wiser is the practitioner who gives the mother her due for a most satisfying labor only she can do.

In January 2005 I found out that I was expecting my 3rd child.  Being stationed in Germany with my husband I was excited about giving birth outside of the US.  I was assigned a German OB and also sought out a midwife.  Home birth was finally an option with my insurance.  The funny thing was that the insurance insisted that I continue to see the OB even though I was seeing a midwife.  I eventually stopped seeing the OB because it was a waste of my time to go to 2 appointments for the exact same thing. 
 
In my 8th month the midwife informed me that due to some legal technicalities she could not attend my birth on the Army base.  It is considered US soil, and there was some question about whether she could lose her license if she attended a birth there.  I would have been the first home birth on the base.  I then returned to the OB who sent me to register at my choice of hospitals.  I chose St Hildegardis-Krankenhaus I would be attended by midwives at the hospital and an OB would only be called in if there were a problem.
 
On September 8th I drove a friend home, about 20 minutes from my home.  On the way back I had a strong contraction.  I thought to myself, “if I have many more like this before I get home I won’t be able to drive”.  I returned home, climbed the 3 flights to my apartment and sat down on the couch.  A couple minutes later I had another contraction that made me jump off of the couch.  I said to my husband that that was the 2nd strong contraction like that I had had.  It was now about 9:45 in the evening.  He asked if we should call the neighbor to come take our other 2 for the night and I said no, it will probably be a while yet.  The first 2 contractions were about 20 minutes apart and the next few were strong, not painful and about 10 minutes apart.  I spent my time sitting on the toilet, the most comfortable position for me, but also a good position since it opened the pelvis.  I prayed that this labor, which felt so different from my 2 previous, would go quickly.  God granted my prayer request.  Around 10:20 or so I said he needed to call the neighbors and let them know he would be bringing the kids over.  When he asked for the number, and wanted me to call, I couldn’t form a complete thought.  I pointed him to the list of emergency numbers to call.  After he carried our second child over, I realized I could not wait for him to come back upstairs to get me.  I gathered my bag, his wallet and the keys and was waiting in the parking lot for him.  He looked at me as if I’d lost my mind, but I knew we needed to leave then.  The normally 26 minute drive took 45 minutes that night, and the car ride through the country to the “big city” was painful.  Every bump in the road hurt. 
 
We arrived at the hospital, around 11:20, and he dropped me at the door and then went to park the car.  I rang the bell for the night watchman (not all German hospitals have “emergency” rooms, we went to a private hospital that handled scheduled procedures and birth), told him in my very broken German that I was in labor.  As he went to get a wheelchair I waved him off and said I couldn’t sit anymore.  We made our way slowly upstairs, pausing every 2 minutes or so for a contraction.  When we arrived in the labor area, I rang the bell and told the midwife I was American.  She returned with an English speaking midwife who watched me through one contraction and said we needed to be in the birth room.  The next words she said shocked me.  She said, “we should call the anesthesiologist, yes?”  I responded with “No, please don’t”  She then said, “you are American, yes?”.  I said that I was but I really preferred to do this without any drugs.  It wasn’t until later that I realized the full implication of what she had asked me.  She asked if they could check to see how far I was dilated, and I agreed, again, curiosity getting the better of me.  I think I was 6 or 7.  I requested that they break my waters, my other 2 had come so quickly after the release.  She grudgingly agreed and did it the German way–no amniohook, just pinched the bag during a contraction and popped it–never again will I request that!  They wanted to get a good read on the baby, so I allowed them to hook up the EFM.  The room (at the hospital) was wonderful.  I had all the tools at my fingertips that I needed.  The midwives then left me to labor quietly, peacefully.  I spent most of my time swaying, doing the belly dance, and chanting “baby out, baby out”.  My husband wonderful as he is, is not a great labor companion.  He kept saying that he wished he could get the baby out.  I didn’t want him to do anything, I just needed to say it.  Suddenly there was a flurry of activity in the room and I realized that they were pulling out the internal monitor.  I couldn’t verbalize that I knew where the baby was, that all was ok with her/him.  There was no way that I was letting them screw that electrode into my baby’s head.  I knew it meant that my 4 hour recovery stay would turn into 24.  All I could say was that I would have 1 more contraction and push.  I climbed on the bed on all fours, had one contraction, rolled over and in a half-sitting position pushed before the midwife knew what was happening.  My husband was frantically ringing for the other midwife to come in.  She ran in just as my baby’s head was born.  They all stood there and stared at me.  After a short time, 2 minutes, she that I needed to push again to birth the body.  I’m not sure if she was concerned that the shoulders were stuck, or what, but when I felt the urge, I birthed the body.  They allowed me to reach down and pick up the baby, who was a girl.  She was born at 12:28 am.  They nestled us skin to skin and covered us with warm blankets.  Then came the next crazy (in my opinion) question:  “did you remember to bring your own formula?”  I pointed at my breasts and said “I have 2 of these and they work great!”  The lights were turned up a bit when they took baby Kerstin across the room to weigh her and do her exams.  They dressed her and brought her back where she happily nursed away.  They continued to bring us warm blankets until about 5:30 when they took me to my room, holding the baby in my bed.  I then had the option to take her to the nursery while I showered.  I shared a room with 2 other women, neither of whom had her baby in the room and both were sleeping.  I showered, got my baby, and ate breakfast.  While I waited for  my husband to come pick us up, I noticed that there were several nurses who kept pausing at our door.  I started listening to their conversations (oh, the joy of understanding a foreign language) and realized they were all talking about me–the American who didn’t have drugs and was breastfeeding.  I also insisted on leaving that morning, 9 hours after her birth, we left for home.  The Germans typically stay for a week until the birth certificate is ready, they leave rested, and prepared to care for a baby. 
 
I finally understood understood why the midwives were so surprised that I refused the drugs.  Most of the American spouses who deliver there demand drugs, the German women don’t.  I started asking all the Germans I knew, they all had home births, or non-medicated hospital births.  It also made me so sad that American women are seen as weak, not able to handle labor.  The Germans don’t see it as painful, just a necessary process to have a baby.  So what if it hurts a little?  They accomplished it.  I’ve often said if I were to have another baby I would hop a flight across the Atlantic if I could not have a home birth. 

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.