MotherBaby Network

advocacy and commentary with a focus on Lane County, Oregon

Tag Archives: March of Dimes

Cesarean Awareness Month – April 2012

For the first time in 14 years, the 2010 US C-section rate of 32.8% is down slightly from the 2009 rate of 32.9%. This is excellent news but it is too early to celebrate. A quick look at the US Cesarean Rates from 1970 to 2010 depicts the long history of a negative trend. It will take some time to bend it positively.

How does Oregon compare with other states?

For years, cesarean section rates in Oregon hospitals and counties have far exceeded the 15% limit recommended by the World Health Organization. Oregon Public Health Authority (OPHA) data for 2011 indicates a state rate of 28.94% – down slightly from 29.45% in 2010. Unfortunately, Lane County’s Sacred Heart Medical Center RiverBend (35.18%) and McKenzie-Willamette Medical Center (29.71%) are above the state average and well beyond recommended rates.

The State of Oregon proclaims April Cesarean Awareness Month.

State of Oregon Proclamation: April is Cesarean Awareness Month

OPHA collects birth certificate statistics for vaginal, VBAC and cesarean section deliveries by county, facility and out of hospital settings. Cesarean sections resulting from birth center, home birth or inter-hospital transfer are not disaggregated. Using 2011 data, the following tables were created by MotherBaby Network. Download the OPHA document

Tables for Oregon 2011 using OPHA Data (download tables)

  1. Hospital Rates for –C-Section and VBAC
  2. C-Sec and VBAC Rates for Hospitals with more than 1000 births
  3. County C-Sec Rates
  4. County Out-of-Hospitals Births (Birth Center and Planned Home Births)
  5. Lane County Vaginal, VBAC and C-Sec Rates by Facility

Cesarean section can be a lifesaving technique for both mother and infant. When practiced in the absence of medical benefits, however, the risks outweigh the benefits of vaginal birth. Potential risks to babies include: low birth weight, prematurity, respiratory problems, and lacerations. Potential risks to women include: hemorrhage, infection, hysterectomy, surgical mistakes, re-hospitalization, placental abnormalities in future pregnancies, unexplained stillbirth in future pregnancies and increased maternal mortality.

The California Maternal Quality Care Collaborative (CMQCC) recently published a comprehensive White Paper on the state’s cesarean section rates. In addition to confirming higher costs and more complications for mothers and babies, the paper reports growing evidence of greater psychological distress and illness including postpartum anxiety, depression, and post-traumatic stress disorder associated with cesarean birth as compared to vaginal.

…the widespread over-use of maternity procedures including Cesarean sections and scheduled inductions, which credible evidence tells us are beneficial only in limited situations, has resulted in longer maternity hospital stays and multiple costly procedures…sadly, despite our exorbitant expenditures on maternity care, childbirth continues to carry significant risks for mothers and babies, especially in communities of color.
– Congresswoman Lucille Roybal-Allard

To stop exposing women and babies to cesarean risk in the absence of real medical benefit, the multiple perverse incentives driving its misuse must be addressed. Provider convenience and changes in obstetric practice, misguided insurance policies, defensive medicine and financial incentives are a few needing correction. Debunking the myths of maternal request for cesarean section is also important.

Although there are undoubtedly some women who do seek elective Caesareans, they are hardly enough to increase the number of Caesareans by 400,000 nationally since 1996.
Declercq & Norsigian

As cesarean section rates increased by sixty percent over the past 15 years, access to VBAC (vaginal birth after cesarean) has diminished. In 2008, less than 13% of Oregon births after cesarean were vaginal. Most women have no choice but to have a repeat cesarean. Despite the lack of choice, this is called “elective” surgery.

Wondering if your hospital allows or bans VBAC? Find out at cesareanrates.com.

Barring women from VBAC drives today’s cesarean section epidemic by fulfilling the prophecy “once a cesarean, always a cesarean.” Interestingly, this saying was originally uttered as a precaution against over use. A cursory look at Childbirth Connection’s graph of 1989 -2010 federal data for primary, elective and VBAC births shows the down-ward trend of VBAC reflecting its absence as a choice in the reproductive lives of women. Seeking to correct this barrier, the National Institutes of Health and the American Congress of Obstetricians and Gynecologists have both recently taken positions supporting VBAC as a safe option for most women.

 “… needless cesarean sections are actually harming women and babies alike. California Watch found that hemorrhaging from C-sections “is one of several possible factors in the state’s increased maternal death rate,” with the main risk coming in women who have multiple c-sections.”
The Atlantic Monthly

Since MotherBaby Network’s 2010 cesarean awareness post, four developments are positively influencing cesarean reduction in Oregon:

  • Oregon Health Sciences University Center for Women’s Health is reducing c-section by changing provider practice. How? Weekly provider reviews to discuss decisions leading to c-section and consistent counseling for women following cesarean surgery about VBAC in the future. Reviewing practices leading to cesarean section encourages a more measured, patient approach that slows the tendency to abandon vaginal birth for non-medical reasons. OHSU Center for Women’s Health director Dr. Aaron Caughey is to be commended for correctly describing the  majority of circumstances resulting in repeat cesarean section as coercive due to the fact women lack access to VBAC.

“The C-section rate in your first pregnancy matters a ton,” Caughey said. “The C-section rate is only about five percent of women with a previous (vaginal) delivery.” – The Lund Report

  • The March of Dimes’s “Eliminating Elective Deliveries Prior to 39 Weeks Gestation: OR Challenge” spurred 17 Portland- metro hospitals to implement policies eliminating non‐medically indicated deliveries before 39 weeks. This policy results in fewer failed inductions, meaning fewer cesarean sections. The Atlantic Monthly covered this important shift in community norms in Why Hospitals in Portland Are Banning Early Births. 34 of 53 Oregon hospitals have since joined the challenge to stop elective deliveries before 39 weeks.
  • The Oregon Public Health Authority collects “mode of delivery” statistics from birth certificates at facility and county levels. Beginning with 2011 data, OPHA now reports VBACs as a mode of delivery. This is key as it provides information about which facilities actually support VBAC and the number occurring on an annual basis. We should see these numbers increasing every year as hospitals and physicians return to patient-centered evidenced-based care.
  • Oregon state health care reform has the potential to transform the current model of care into one in which patient / consumer experience and community health outcomes replace billable procedures as the metric by which hospitals determine best practices.

CostCo is raising cesarean awareness and encouraging prevention in CostCo Connection magazine.

Despite these positive developments, the deck is still stacked for women seeking to maximize individual and infant health and well-being. Gaining insight into the opaque world of provider and hospital philosophies, practices and outcomes is nearly impossible. Even when women ask the right questions, the answers they receive are often unfounded, fuzzy and vague. Consequently, most  remain unaware of the real risks of being subjected to unnecessary primary- and repeat-cesarean section.

Learn more about cesarean section

Learn more about VBAC

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March of Dimes: Empower Women, Decrease Disparities

Finishing my childbirth education certification means I can start combing through several maternal and infant health reports I’ve been collecting. What can I say? In addition to providing childbirth education, I like to read wonky reports.

First up is the March of Dimes’ December 2010 Toward Improving the Outcome of Pregnancy III (TIOP III). For the short version, check out this video clip and summary. TIOP III focuses on five themes or action items to improve overall quality of outcomes for the entire perinatal period (preconception, pregnancy, birth and postpartum):

1.       Pursue quality improvement and safety initiatives

2.       Decrease disparities, increase equity

3.       Empower women, encourage shared decision making

4.       Standardize regionalization of services

5.       Improve data collection

I know what you’re thinking. Won’t this report be more likely to collect dust on shelves across the land than affect real change? No, not necessarily. TIOP III hints at where maternal and infant care ought to be going in the next decade or so.

TIOP I (1976) and II (1993) continue to influence the delivery of motherbaby services today. The emergence of neonatal intensive care unit centers can be traced to the TIOP I recommendation that more of these resources be made available. Interestingly, TIOP III now suggests an oversupply of NICUs exist today relative to total annual births. This oversupply has been described as playing an unfortunate role in the dangerous trend of non-medical inductions. The babies who are born too early to thrive outside the womb create an unnecessary demand for NICU care.

As a consumer advocate and childbirth educator, I especially like TIOP III’s first three objectives for improving overall care and outcomes. Here are a few thoughts on each…

Perinatal quality improvement and safety initiatives

TIOP III supports quality improvement efforts like those underway by The Joint Commission on Accreditation of Hospitals, the primary accrediting body for most health care facilities. The Joint Commission is now including new performance measurements for accreditation including tracking for elective delivery, cesarean section, and exclusive breastmilk feeding.

The decision by The Joint Commission, an influential and powerful organization, to monitor infant feeding, no doubt, plays a role locally. Sacred Heart Medical Center plans to pursue the Baby Friendly designation for evidence-based infant feeding.

Pursuit of this designation is an important development for mothers, babies and the community because facility-based practices play a critical role in supporting families to initiate, establish and maintain exclusive breastfeeding after they leave the hospital or birth center. I’ve posted extensively on the importance of local hospitals becoming designated Baby Friendly providers of evidence-based infant feeding care.

Decrease disparities, increase equity

Addressing disparities in access to perinatal services is of critical importance to local families and communities. Lane County’s fetal-infant mortality rates are the highest in the state (among the highest in the nation?). Maternal and infant mortality are long-accepted markers for community wellbeing and potential. Lane County outcomes for all demographic groups lag. While lack of healthcare access is a problem throughout Oregon, our fetal-infant mortality rate means local communities suffer even more than similar communities from disparities in access and a lack of general healthcare equity. That Lane County is also home to the University of Oregon and Sacred Heart Medical Center, a major regional hospital, is incredible. Sadly, and despite the efforts of the Healthy Babies, Healthy Communities coalition, there has been an impressive lack of civic leadership / engagement devoted to closing these gaps.

Empowering women and families for full partnership with providers and shared decision-making

TIOP III provides organizations and individuals committed to excellent motherbaby outcomes with an updated mission statement:

Empowering women and families with information to enable the development of full partnerships between health care providers and patients and shared decision-making in perinatal care

These are more than nice words. They describe practices that are increasingly associated with desirable outcomes. Here’s what TIOP III goes on to say:

… evidence-based practices — CenteringPregnancy®, Kangaroo Care and exclusive breastmilk feeding — have been shown to improve perinatal health outcomes by empowering patients: positioning them, their newborns and their families at the center of their care and making them an integral part of their health care decision making team.

The PeaceHealth Nurse Midwifery Birth Center is the only Lane County provider of Centering Pregnancy. It is a recipient of March of Dimes funding for this evidence-based prenatal care.

Looking to the future, TIOP III goes on to acknowledge the Institute for Healthcare Improvement for being on the right track where empowerment and decision making are concerned. IHI develops various care models to describe the future direction of healthcare excellence – its perinatal model of the future puts women and families at the center of future care structures as the source of control – IHI’s ideal model of perinatal care. As a childbirth educator and motherbaby advocate, I am fully on board with this!

That’s all for now…..

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