MotherBaby Network

advocacy and commentary with a focus on Lane County, Oregon

Tag Archives: VBAC

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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Stepping Toward A Baby-Friendlier Oregon

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The Breastfeeding Coalition of Oregon under the direction of Amelia Psmythe recently hosted its sold-out 5th annual two-day statewide conference – Stepping Toward A Baby-Friendlier Oregon. Supporters who made the conference possible include Oregon WIC, Oregon Public Health Institute, Hygeia, Limerick, and Medical International.

Anyone wanting to know what Oregon’s many infant-feeding stakeholder groups are up to should make a habit of attending. While there is still so much to be done to protect and promote breastfeeding, the following downloadable synopsis of conference presentations will give you a quick bird’s eye view of the excellent and diverse work already underway.

Oregon is fortunate to have an extraordinarily talented cadre of savvy, skilled and committed advocates for quality care. Throughout the state, these advocates promote and protect women’s health, well being and basic human rights spanning the entire arc of their reproductive lives whether at home, in the community, in the health care system, in the economy or as “subjects” of scientific research and inquiry. The BCO annual conference is a good opportunity to check in and rally for the difficult but critical work ahead to achieve breastfeeding’s full-spectrum benefits for the entire population.

Framing the discussion…Presentations and discussion were conceived of and organized to align with the Surgeon General’s Call to Action to Support Breastfeeding (SGCTA). The SGCTA is a federal tool to direct policy, fund activities and align stakeholders around important objectives outlined in Healthy People 2020. Federal, state and local grants and staffing resources are made available and prioritized based on alignment with SGCTA objectives.

The SGCTA to Support Breastfeeding is a ground-breaking document because it is a clear departure  from previous policy and political frameworks that define breastfeeding as an individual responsibility or lifestyle choice beyond the concern, responsibility and reach of government focus. Finally, breastfeeding behaviors and outcomes have been re-defined as the product of cultural norms and structures at all levels of society. Accordingly, public health workers, researchers, employers, health care systems, communities and families are “called to action” to better and more effectively support mothers and babies to breastfeed.

Presentation Synopses. Following is a list of presentations. It gives a wide-angle view of how individuals and institutions are aligning Oregon with the SGCTA. Click here for a version of this post that also includes a synopsis of each presentation.

The Role of Consumer Advocacy in Increasing E-B Infant Feeding Practices
Katharine Gallagher, MPP. Consumer advocate, blogger and independent childbirth educator.
slides
, talk

Let’s Talk! Breastfeeding Education Series Tear Sheet Project
Rachel Martinez, BA, IBCLC, RLC. New Member Training Coordinator at Nursing Mothers Counsel of Oregon, and Legacy Emmanuel Hospital lactation consultant.

The Oregon Black Women’s Birth Survey
Shafia Monroe, Midwife. Founder of the International Center for Traditional Childbearing

Supporting Families the Whole Way: Continuity Care Model
Debbie Alba, RN, IBCLC. Nurse and Lactation Consultant at Good Samaritan Regional Medical Center, currently serving as Western Region Steering Committee Chair

Angie Chisholm, CNM. Certified Nurse Midwife at Samaritan OB/GYN in Corvallis, with a long interest in lactation and evidence-based care.

Oregon WIC Peer Counseling: A Public Health Approach
Kelly Sibley, MPH, RD, IBCLC. Nutrition Consultant and Breastfeeding Coordinator with the Oregon State WIC Program. Coordinates WIC BF peer counselors.

Engaging Community Partners in Breastfeeding Support
Helen Bellanca, MD, MPH. Family physician who has worked with health policy and advocacy for four years, leading insurance collaborative and child care survey.

Lessons Learned on the Way to Baby-Friendly: Providence Newberg
Joanne Ransom, RN, IBCLC. Labor & delivery nurse and lactation consultant at Providence Newberg, former Vice-Chair of Northwest Mothers Milk Bank, new OEBIN co-lead

Redesignation with Baby-Friendly: Strategies for Success
Michelle Stevenson, RN. Perinatal Nurse and former La Leche League Leader, led two CA hospitals to Baby-Friendly designation, and now manages the Women and Newborn Care and Nursery at Kaiser Sunnyside Hospital.

Eliminating Elective Deliveries Prior to 39 Weeks Gestation: OR Challenge
Joanne Rogovoy, Executive Director of the Oregon March of Dimes, and leader of the workgroup that banned early c-sections on Portland area hospitals.

Donor human milk & Northwest Mothers Milk Bank
June Winfield, Board Chair / Director

Breaks for Nursing Mothers are Federally “Reasonable”
Amelia Psmythe, Director of the Breastfeeding Coalition of Oregon and West Region Coalition Representative to the United States Breastfeeding Committee.

Nursing Mothers Counsel Workplace Lactation Support Program
Marion Rice, Ed.D. 25 year educator, currently leads the Nursing Mothers Counsel of Oregon Worksite Lactation Support Program

What Do Women Really Want? A 21st Century Mother’s Movement
Andrea Paluso, MSW, MPH. Co-founder of Family Forward Oregon, The Mother PAC, and recent graduate of the Emerge Oregon legislative mentoring program.

Breastfeeding Outcomes in Women with a Prior History of Cesarean Section
Cathy Emeis, PhD, CNM. A nurse-midwife and researcher at OHSU, Cathy’s current research examines the impact of birth interventions and c-section on breastfeeding.

Breastfeeding Coalition of Oregon: Northwest Edge of the Wave of Change
Amelia Psmythe, Director of the Breastfeeding Coalition of Oregon and West Region Coalition Representative to the United States Breastfeeding Committee

US Breastfeeding Committee Annual Report
Robin Stanton, MA, RD, LD. USBC Past-Chair and Nutrition Consultant with OR Department of Human Services, Public Health Division

Collaboration for Collective Impact
Amelia Psmythe and Robin Stanton, MA, RD, LD

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Part 1: Consumer Advocacy & Evidence-Based Infant Feeding Practices

Here’s the first “installment” for my upcoming presentation at the March 2-3 Breastfeeding Coalition 5h Annual Meeting. Blue text indicates information that will be placed on PowerPoint slides, black text indicates what will be said. I’d love your feedback either here or via email at motherbabynetwork@gmail.com.

This installment covers introductory info, background on me and why thinking of women as consumers rather than patients can be productive. The next installment will go into consumer demand, the Baby Friendly Hospital Initiative and the increasing support for Baby Friendly at all levels of government and among accrediting bodies.

The Role of Consumer Advocacy in Increasing Evidence-Based Infant Feeding Practice

“Mothers are acutely aware of and devoted to their responsibilities when it comes to feeding their children, but the responsibilities of others must be identified so that all mothers can obtain the information, help, and support they deserve when they breastfeed their infants.” (Surgeon 2011: v)

Good morning. My name is Katharine Gallagher. I have been invited to speak with you today about the role consumer advocacy plays in increasing evidence-based infant feeding practice. My objective is to outline how responding to consumer demand and encouraging and engaging consumer advocacy encourages hospitals and providers toward practices that effectively support women in making sound infant feeding decisions.

The framework for this year’s annual meeting is the Surgeon General’s 2011 Call to Action to Support Breastfeeding. The fundamental assertion made in this call to action is that a woman’s ability to initiate and sustain breastfeeding is influenced by a host of variables and factors. These include an individual woman, her partner, extended family, healthcare providers and employer. Public health and social service agencies as well as community-based programs also influence breastfeeding decisions as do schools, child care centers, houses of worship, business and industry, and, let’s not forget…the media.

In other words, decisions and outcomes related to infant feeding occur in a multi-layered and dynamic environment. The manner in which these multiple factors support or thwart a woman’s ability to make and follow through on infant-care decisions has a very fast-acting and mostly permanent impact on the trajectory of decisions to breastfeed.

Each of us comes to this meeting with a particular role to play in curbing the discord of the aforementioned factors that influence individual-level decisions. We are here to develop meaningful social supports to ensure women can follow through on the decision to breastfeed their babies. My focus this morning is on the inter-play between women as the consumers of infant feeding services and health care facilities – hospitals – and  providers.

Responding to demand and partnering with consumers fosters improved maternity care. It moves us closer to a model that consistently educates and supports women, families and communities to make choices supported by sound scientific research, good judgment and individual preferences and values. Once engaged, consumers provide an invaluable feedback loop to support and inform policy, practice and outcome analysis. As system users, consumers have a unique perspective. They know from experience how well a particular system is or is not working. Frequently, they know what is needed.  When this information is regularly sought and acted upon, we have a culture of consumer engagement.

About Me

Before getting started, I’d like to share a little about myself and how I came to be involved with maternity care reform as a consumer advocate.

I am the mother of two boys – ages four and six. My professional background is in public policy. My experiences over the past six years with both evidence-based and non-evidence-based maternity care have profoundly influenced me as a person, a mother and a citizen. The result is a deeply-held conviction that we must transform maternity care in this country. This is not solely a women’s issue. We are talking about reforming policies and practices as well as behaviors and decision-making approaches with major physical, emotional, social and financial implications for the economic health and security of this generation and those to come. This is an “everyone” issue.

My first pregnancy was a healthy, low-risk experience that resulted unexpectedly in what I believe to have been an unnecessary and entirely avoidable cesarean section. Hindsight is 20/20. Only in retrospect could I see the signs pointing to and hinting at the impatience and aggressive management my Ob/Gyn employed during my labor and birth. My postpartum trajectory continued south as my son and I had extreme difficulties establishing breastfeeding. However, because he was such a determined latcher, we were considered to be doing fine and encouraged to skip our lactation consultation before discharge from the hospital. This decision was made despite the telltale signs of chewing on my nipples and my too-shyly stated observations that “things didn’t feel right.” At home with a chomper-latch baby and reeling from the shock of an unanticipated surgery, hazy from painkillers, things got worse and worse still.

A long story short, my pleas for help from the medical practice I was using and a willingness to pay out of pocket failed to secure the assistance we needed. In serious need of help, during an appointment for my baby, I asked the pediatrician to look at my breasts to confirm that I had a problem. He would not, and no referral was made. A desperate late-night call to La Leche League and another pediatrician’s gentle support resulted in our finally finding someone to help. We found an independent lactation consultant who works outside the healthcare system.

By this point, all of us were in pretty wretched shape. My nipples were chewed to shreds, my son was far from content and my husband was worried. Getting back on track required weeks of pumping and syringe feeding until my breasts healed. We then slowly re-introduced my baby to the breast. This was a team effort. My husband and I both took unpaid maternity leave and my mother moved in and  took care of all of us. Weeks of perseverance paid off and eventually we were where we needed to be to continue breastfeeding. Clearly this experience is and would be the exception, not the rule for most women and families.

Pregnant again and much better informed the second time, I knew I wanted to have a different birth and postpartum experience – one that would allow me to hold and hug my two-year old and tend to a newborn without the physical and emotional challenges of cesarean recovery. I selected the Baby-Friendly designated PeaceHealth Nurse Midwifery Birth Center for my care. My prenatal experience exhibited the hallmarks of optimal healthcare – individualized care, personal responsibility, shared decision making and informed consent. Attended by a midwife at the hospital, I had an un-medicated VBAC. My second son was born content and alert and eased peacefully into life outside the womb beginning with the glorious and inordinately important but yet to be fully understood skin-to-skin time. My delight and amazement in seeing a baby so alert and present was shared by the many Labor and Delivery nurses who came in to see an “un-medicated baby.”

Consistent with Baby Friendly, I had been counseled and educated prenatally about breastfeeding. I had the knowledge and support to confidently continue nursing my first son through my second pregnancy. Per my wishes, I was also able to tandem nurse until my oldest son weaned at 3 yrs old. Furthermore, along the way I connected with other new mothers using the Nurse Midwifery Birth Center. These women became an invaluable source of support for breastfeeding and just about everything else – pumping, returning to work, not returning to work, how to take a shower, the best places in town to change diapers and the lists goes on.

Tops on our personal lists for breastfeeding success? The weekly drop-in baby clinic and 24-hour phone support for lactation. We had a  lactation safety net and while many of us had not realized it would so critical before birth, we soon discovered how necessary it is to getting breastfeeding started and maintained. We did not yet know this lactation support was the outcome of evidence-based practice or that it had a name –the Baby Friendly Hospital Initiative. What we did know was that it worked. This was a most welcome change from my first breastfeeding experience and I was continually struck by the way in which new mothers were seamlessly supported in learning to breastfeed and to solve problems and overcome challenges that are part of life with a new baby.

Consumer or Patient?

“Empowered, informed, engaged consumers, individually or collectively, can be effective at overcoming barriers to safe, effective care.” (Romano, 53) 

Just as communities, healthcare systems, government and employers must re-tool or re-orient themselves to support evidence-based infant feeding decision making, so too must those who consume maternity services – women. Seeing oneself as a consumer rather than as a patient can provoke a radically different set of perspectives and actions that positively influence individual and system-wide care.

Pregnancy is a gateway experience into the health care system for many women. For most, pregnancy is a time of health, discovery and a renewed commitment to well-being. Women’s experience shapes their behaviors and expectations for future interactions with healthcare throughout the life cycle. Add to this that women frequently take the lead in heath care decision making for nuclear and extended family members and their initial experiences via maternity care have multiple ripple effects. Accordingly, the manner in and degree to which they participate in decision making during pregnancy, birth and the postpartum period has significant social, health and economic implications in the lives of women, families and communities that reach well beyond today’s topic of infant feeding.

Re-conceiving of the users of the maternity care system as consumers rather than patients promotes productive ideas and behaviors by providers and users. Consumers are associated with:

  • Knowledge
  • Choice
  • Purchasing Power
  • Autonomy
  • Responsibility

As a consumer advocate and childbirth educator, I encourage women to take an active role in their care. I encourage them to use their purchasing power and autonomy to shop around and ask questions in order to identify facilities and practices with the best reputations for thorough lactation support with excellent post-birth outcomes. I remind them that it is okay to change hospitals, birth centers and providers, too.

When women are seen as and view themselves as consumers with the attributes of knowledge, choice, purchasing power and autonomy, it is much easier to develop and benefit from the resulting personal responsibility, mutuality, partnership, collaboration and trust when they engage care in a particular setting. This beginning orientation lays the groundwork for developing the expectation for and demand for consistent evidence-based practices. It lays the anticipatory groundwork on the part of the user for share decision making and informed consent across the life cycle.

These assertions have yet to be borne out by research. The majority of current maternal and child health research focuses on interventions fully within the realm of providers with little to no consumer participation. Cesarean surgical techniques or intensive care treatments are examples of “provider realm” interventions. Research into consumer-realm interventions would invert institutional paradigms to elevate women receiving care to the position of  a “positive” and “powerful” actor capable of moving maternal and child health outcomes in a positive direction. In this era of health reform in which we appear to be searching for meaningful ways to move toward a preventive model with the associated reduced costs, increased positive outcomes and great consumer satisfaction, this type of inquiry is much needed.

We are seeing hints of this forward-thinking inversion here in Oregon. During the last legislative session, a law was passed directing the Oregon Health Authority to investigate how doulas (labor companions) improve birth outcomes for women at disproportionate risk. Doulas provide emotional, non-medical support associated with positive outcomes. Doulas are a well documented evidence based and non-medical intervention with a proven track record for positively influencing the social, physical and emotional outcomes of the perinatal period. Rep. Tina Kotek (D-N and NE Portland) and Rep. Lew Frederick (D-NE Portland) sponsored the bill. Portland-based International Center for Traditional Childbearing played a critical role in the introduction of the bill.

Fortunately, there is one very important “consumer realm” intervention for infant feeding services that has already clearly demonstrated massive maternal and child health benefits.. It is the Baby Friendly Hospital Initiative’s Ten Steps to Successful Breastfeeding. From start to finish, consumers are educated, engaged in decision making with the necessary evidence-based information about infant feeding and provided with full-spectrum perinatal support for making breastfeeding work. This intervention can be summarized in two words: “It works!” It works for mothers, families, employers, communities, economies and, well, everyone. Baby Friendly figures greatly into any discussion, including this one, of policy development and implementation for heeding the Surgeon General’s Call to Action to Support Breastfeeding.

End of installment #1…..

Oregon c-section rates for state, counties, hospitals

  April is Cesarean Awareness Month:

What are the cesarean section rates for local hospitals, Lane County and Oregon?


In 2009, the US cesarean section rate rose from 32.3 percent in 2008 to 32.9 percent. This was the 13th consecutive year of increase. Since 1996, the rate at which U.S. cesarean sections are performed increased by 60%. Cesarean section is increasing among women of all age and all race and ethnicity groups. For detailed information, consult the National Vital Statistics Report Births: Preliminary Data for 2009.

The following graph from The Unnecesarean illustrates the cesarean section rate from 1970 to 2009. Cesarean section rates in the United States and Lane County are well beyond recommendations that they not exceed 15%. Tables 1 through 8 below provide 2010 cesarean section rates for Oregon hospitals, counties and the state. 

Exceptionally high rates continue despite the evidence that this practice places women and babies at increased risk for morbidity and mortality immediately following birth and in the long term. 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, dangerous placental abnormalities in future pregnancies, unexplained stillbirth in future pregnancies and increased percentage of maternal death.

As cesarean section rates have risen, access to VBAC (vaginal birth after cesarean) has diminished in spite of the 2010 statements from the National Institutes of Health and the American Congress of Obstetricians and Gynecologists supporting it as a safe option. 

Despite the prevalence of cesarean section being performed, women, particularly “low risk” pregnant women, are frequently un- or under-informed about the risks they face for having a one. Gaining insight into their providers’ and hospitals’ philosophies, practices and outcomes is important information that can help a woman decide where and with whom she will give birth. Yet, this information is hard to come by as it is not made readily available or generally offered upon individual request.

Yesterday, the California Department of Public Health released a much-anticipated report on maternal deaths. In addition to race/ethnicity, poverty, education and access to healthcare, medical problems from cesarean sections were reported to have contributed to an increase in maternal deaths. Regarding cesarean section, California Watch reports that it contributed to 15 of 98 maternal mortalities between 2002 and 2003. While women who do not need cesarean section are getting them, other women, for whom the benefits would actually outweigh the risks, are not. The Los Angeles Times’ coverage of the rise in maternal mortality specifically notes the role of cesarean section: Caesarean sections are a major factor in pregnancy-related deaths, report finds

A closer look at Oregon and Lane County

The Oregon Public Health Authority collects statistics for cesarean section by county and facility in a document titled “Oregon Occurrence Births by Final Method of Delivery by County, 2010.” The following tables and graphs were created by MotherBaby Network using the OPHA document statistics. For each Oregon facility, this document lists three methods of delivery: (1) total, (2) cesarean and (3) “other method or unknown.” MotherBaby Network calculated the percentages communicated in Tables 2 – 8. Cesarean section is only performed in hospitals. Accordingly, a  “O %” statistic appears beside non-hospital facilities.

Lane County residents will be interested to know that:

  • Lane County’s 2010 cesarean section rate of 32.33% is slightly below the 2009 national rate of 32.9%. While lower than the national rate, it is more than twice the recommended rate. Table 4 contains statistics for Lane County.
  • Among Oregon hospitals with the ten highest total 2010 births, Sacred Heart River Bend has the third highest cesarean rate, 35.18%, (Table 6). This rate is well above the state and national averages.

Oregonians will be interested to see the greater than 20% variation in cesarean section rates among the state’s hospitals with the ten highest total births in 2010. (Table 6) Within the Portland metro area, Legacy Emmanuel Hospital & Health Center has a rate of 42.34 for 1809 births while Kaiser Sunnyside Medical Center has a rate of 21.39% for 1725 births. For an interesting discussion of cesarean section rate variation among “low risk” pregnant women accessing hospitals located just miles apart, read For-profit hospitals performing more C-sections.

Something to ponder

Relative to other states, Oregon has a higher rate of out-of-hospital births. It is also comprised of many rural counties and communities. It would be interesting to explore how these two characteristics may contribute to the state cesarean section rate being considerably lower than the national average as well as the rates of thirty others states in the union. Were Oregon out-of-hospital birth rates similar to most other states, would the statewide cesarean section rate increase?

How does Oregon compare with other states?

Oregon’s 2009 cesarean section rate was 29.4. According to OPHA, the 2010 rate is now 29.45.

Table 1

What are the cesarean section rates for each of Oregon’s counties? (Click on table to enlarge)

Table 2

By descending order of total births (highest to lowest), what are the cesarean section rates for each of Oregon’s counties? (Click on table to enlarge)

Table 3

What are the rates for Lane County and its hospitals? (Click on table to enlarge)

Table 4

What are the rates for Oregon hospitals? (Click on table to enlarge)

Table 5a

Table 5b

What are the rates for Oregon’s hospitals with the top ten total births in 2010? (Click on table to enlarge)

Table 6

How many of Oregon’s hospitals have cesarean section rates consistent with the World Health Organization recommendation of 10 to 15%? (Click on table to enlarge)

Table 7

Which of Oregon’s hospitals have the ten lowest cesarean section rates?(Click on table to enlarge)

Table 8

Where can women and families learn more about cesarean section?

MotherBaby Network recommends visiting Childbirth Connection’s cesarean section information page. Childbirth Connection is a respected source for up-to-date, evidence-based information and resources on planning for pregnancy, labor and birth, and the postpartum period. The following questions can be addressed there.

  • How can I make sense of what I hear about c-section and vaginal birth?
  • Why should I learn about how cesarean section compares with vaginal birth?
  • Is cesarean section a special concern for certain women?
  • Will c-section protect my pelvic floor from weakness or injury?
  • What if I have already had a cesarean section?
Providers, hospitals and communities are well served to use the March of Dimes new “toolkit” for eliminating elective delivery.

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Latest on Midwifery Board rules / Shout Out to Midwifery Supporters

Latest development in OARS

The Oregon Board of Direct Entry Midwifery is near the end of a yearlong process of revising the Oregon Administrative Rules (draft rules) that govern licensed direct-entry midwives (LDMs). With a few exceptions, LDMs are the sole providers of home birth services in Oregon. In September, draft rules developed by the “Rules Advisory Committee” received seven-to-one support from the Midwifery Board. (Read earlier post and reference the Guide to Midwifery Credentials and Terms in Oregon)

Following a subsequent month of written public comments and an October 28 public hearing, the Oregon Health Licensing Agency (OHLA) —oversight agency for the Midwifery Board— extended the written public comment period by 30 days. OHLA cites the “high volume of public comment and diverse nature of topics” for the extension.

Consumers underrepresented at public hearing

Advocates for choice in maternity care have expressed concern over so few consumers and supporters of LDM care attending the hearing. Consumer Minna Pavulans offered the only such perspective. (Read a consensus letter Pavulans helped draft earlier this year.) The small showing contrasts with a large Spring 2010 convergence in Salem of the many women, partners and babies registering demands for continued access to LDMs.

In contrast, LDM opponents were in high attendance at the recent public hearing, achieving the strategic benefit of over-representation for their views. Requests included altering the draft rules to forbid LDMs from serving women with the following kinds of pregnancies:

  • Vaginal birth after cesarean (VBAC)
  • Breech
  • Twin.

The proposed draft rules permit LDMs to serve women with most of these kinds of pregnancies. This is a major victory for maternity choice advocates and likely an choice in care unique to Oregon. LDM opponents also asked that practicing LDMs be required to secure $1 million liability insurance. Obtaining this level of coverage is almost certainly impossible.

Within the licensed direct-entry midwifery community, a lack of basic accord on the draft rules exists. Discerning if the LDM community generally views the rules as mostly okay with a few exceptions or mostly unacceptable is difficult. In contrast to LDM opponents, it is proving hard for this constituency to convey a consistent, strong message to the Midwifery Board.

Ironically, as midwives debate the impact of the draft rules on choice in maternity care, the position of individuals and groups pushing for additional restrictions improves. For good or bad, boards respond most to constituencies with clear and consistently conveyed demands.

What does freedom of choice mean in the context of licensure?

In Oregon, direct-entry midwives may practice with or without a license. Women select licensed or unlicensed direct-entry midwives for numerous reasons. Three common reasons for selecting a licensed midwife include:

  • Insurance reimbursement. Some health insurance plans, including that of the Oregon Public Employee Benefit Board and Oregon Health Plan, reimburse for LDM care.
  • Professional standards. To gain licensure, midwives demonstrate evidence of core competencies and pass written exams.
  • Legend Drugs and Devices. LDMs legally carry and administer anti-hemorrhagics, medical oxygen, IV fluids, anaphylactic treatment and local anesthetics among other items.

In selecting a LDM, a woman opts into a model of care in which state-endorsed rules govern the terms of licensure. Rules for who midwives may serve, when additional consultations are required and consumer recourse in the event of a complaint are just a few of the many areas in which the midwife-client relationship is shaped by codified guidelines.

However a woman defines the benefits of licensed direct-entry midwifery, they are gained in the context of the rules of licensure. Rules, by their very nature, infer limits. The Midwifery Board’s most pressing task right now is to determine what those limits on scope of practice should be and how to articulate them in the new set of rules.

Support for imperfection?

Are the draft rules perfect? Must they be to garner general consumer support? The answer is “no” on both accounts.

By virtue of having been drafted by a group of individuals —each with a unique set of convictions, beliefs and biases— the rules are necessarily imperfect. This is not the same as saying they are unworthy of support. Another litmus test is to assess to what extent the divergent views have been transparently negotiated with evidence-based findings setting the standard for debate.

Consumers can also assess their personal level of support or opposition for the draft rules by asking two questions:

  1. Are the flaws fundamental enough to preclude one’s overall support?
  2. Is a better outcome possible given current political realities?

Consumers, make your thoughts known

Having dominated the public hearing, LDM opponents have everything to gain by redoubling their efforts. Despite a poor showing at the public hearing, it’s not too late for consumer feedback to stabilize what is turning out to be an unpredictable conclusion to a yearlong revision. Consumer participation earlier in the process is credited for strengthening the position of advocates for choice in maternity care. To the degree that the rules protect those choices, consumers deserve credit. To get the job done, more letters (yes, another letter!) are needed to empower the Midwifery Board to resist yielding to extreme positions.

Supporters (and opponents) of the LDM model of care have through Sunday, November 28 at 5pm to weigh in. Email or mail your letter here:

Samie Patnode, Policy Analyst
Oregon Health Licensing Agency

700 Summer St NE, Suite 320
Salem, OR 97301-1287
samie.patnode@state.or.us
Work: (503) 373-1917
Fax: (503) 585-9114

Send it to your elected representatives and post it on your personal Facebook pages. Send it to Oregon Midwifery Council at info@oregonmidwiferycouncil.org.

Invite partners, family and friends who support choice in maternity care to write letters, too. Share your letter with them to help them get started. Offer to send it in for them.

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New rules for the Oregon Midwifery Board?

Last month, the Oregon Board of Direct Entry Midwifery (Midwifery Board) voted seven to one to submit revised administrative rules to the Oregon Health Licensing Agency (OHLA).

This is the latest development in a nearly ten-month process of literature review, expert testimony and public comment. Not altered since 1993, the administrative rules regulate licensed direct entry midwifery. They include definitions for certain births that may not be attended by the state’s 65 licensed direct-entry midwives (LDM). Click here for a definition of LDM.

Proposed rules: http://www.oregon.gov/OHLA/DEM/Midwifery_Laws_Rules.shtml.

What should consumers know?

The draft rules are evidence based and serve the vast majority of practicing LDMs and Oregon women desiring their care. They identify three new types of high or absolute-risk birth that may not be attended by a LDM:

  1. Three cesarean sections unless previous successful vaginal birth
  2. Monochorionic, monoamniotic twins
  3. Breech where feet or knees are presenting and fetal hips are extended (Proposed Div 25 & 30 – p. 7)

Additionally, there is a new non-absolute risk requiring consultation with another Oregon licensed health care provider, including an LDM, with appropriate experience. Here is the new non-absolute risk:

Lack of adequate progress in vertex presentation is when there is no progress after a maximum of three hours in cases with full dilation, ruptured membranes, strong contractions and sufficient maternal effort; (Proposed Div 25 & 30 – p. 14)

Following is the definition of consultation:

For the purpose of this rule “Consultation” means a dialogue for the purpose of obtaining information or advice from an Oregon licensed health care provider who has direct experience handling complications of the risk(s) present, as well as the ability to confirm the non-absolute risk, which may include but is not limited to confirmation of a diagnosis and recommendation regarding management of a medical, obstetric, or fetal problems and condition. (Proposed Div 25 & 30 – p. 16)

Time to wrap it up

The revision process has been a long, fraught one. There are individuals and organizations that no doubt view the draft rules as granting too much or too little scope of practice for LDMs. It is critical for consumers in support of the Midwifery Board’s more than ten-month effort to balance these views by publicly supporting its recommended rules.

Consumer voices make a significant difference. Letters and public testimony make an impression on elected officials and appointees. Earlier in the revision phase, letters and public testimony demanding continued access to LDMs most certainly strengthened the position of like-minded members on the Midwifery Board. As a result of public accountability, these members were better able to counter efforts to impose unwarranted restrictions on individual choice in maternity care and to instead press for governing rules that are in step with consumer preference and evidence-base care.

Consumer power works

Earlier this year, state employees and dependents petitioned the Public Employees Benefit Board to restore access to maternity care with LDMs after it erroneously denied claims and gave incorrect benefit information to individuals desiring this benefit. And, just last month, PEBB stated it would defer to the Midwifery Board when determining coverage for LDM-attended births.

More than 140,000 Oregonian are covered by PEBB. This makes the recent decisions a significant and positive development for choice in maternity care.

Grab your pen

Write a letter of support to the Oregon Board of Direct Entry Midwifery and send it to:

Samie Patnode, Policy Analyst
700 Summer St NE, Suite 320
Salem, OR 97301-1287
samie.patnode@state.or.us
Work: (503) 373-1917
Fax: (503) 585-9114

Send it to your elected representatives and post it on your personal Facebook pages. Send it to Oregon Midwifery Council at info@oregonmidwiferycouncil.org.

Come to Salem

On October 28, 2010, the agency and the board will hold a public hearing where a contracted hearings officer will receive oral testimony. More info here.

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April is Cesarean Awareness Month

Sponsored by International Cesarean Awareness Network (ICAN), April is Cesarean Awareness Month. It is an opportunity for raising awareness about this over-used surgery and for making information about resources and support available.

Cesarean section rates continue to rise

For the 12th consecutive year, the national cesarean section rate increased in 2008, even as total births dropped two percent. According to preliminary data from the Centers for Disease Control and Prevention’s National Center for Health Statistics (NCHS), the 2008 rate reached 32.3 percent, up from 31.8 percent in 2007.  Of the more than 4.25 million births in 2008, approximately 1.37 women underwent surgical birth. The 2008 total is equivalent to the population of Philadelphia or the combined populations of Alaska and Washington, D.C.

Cesarean section stats / characteristics from a recent 2007 NCHS report:

  • Cesarean section is the most performed surgery in the United States
  • Cesareans are up for all women irrespective of age, race, state of residence or gestational age of infant(s) at birth
  • Women under age 25 experienced the greatest increase in cesarean deliveries from 2000 to 2007
  • Cesareans are up for infants of all gestational ages
  • Repeat cesarean rate exceeds 90% (not in NCHS report)

Oregon and Lane County Cesarean Rates

2007 cesarean rates increased in all states, and by more than 70% in six. Oregon’s cesarean rate increased 67% from 16.9% in 1996 to 28.2% in 2007. 2009 data reported in Summary of Birth Statistics of Oregon indicates a Lane County cesarean rate of 34%.

What’s the problem?

If cesarean section has the potential to save life, why should women and families be concerned about the current rate? Because cesarean section, never intended for routine use, is over-employed in Lane County and elsewhere.  The World Health Organization recommends a rate no higher than 15%. Past this point, preventable deaths and complications occur. In other words, we’re not solving problems – we’re making them.

Risks for babies include low birth weight, prematurity, respiratory problems, lacerations and breastfeeding complications. Risks for women include hemorrhage, infection, hysterectomy, re-hospitalization and placental abnormalities in future pregnancies.

Women’s choices for subsequent births are deeply constrained by providers, facilities and insurers that formally or informally ban vaginal birth after cesarean (VBAC). Fortunately, neither Sacred Heart Medical Center nor McKenzie-Willamette has formal VBAC bans, though women encounter informal barriers beginning with inaccurate information and spotty provider support. For more information on bans, see VBAC Policies in US Hospitals.

A 1996 New England Journal of Medicine editorial describes the unending complexity an initial cesarean introduces into women’s reproductive lives:

It is, after all, the initial procedure that scars the uterus, and it is this scar that raises the specter of morbidity throughout a woman’s later reproductive years. In turn, this concern has led to the policy of encouraging elective cesarean section in subsequent pregnancies, which, as noted earlier, accounts for so many of the cesarean sections performed today.

In short, cesarean section ought not be taken lightly.

Scrutiny on the Rise

A recent National Institutes of Health (NIH) panel concluded scientific evidence does not support banning VBAC. (Read my blog post on the NIH VBAC panel here.) The panel unfolded against a backdrop of growing concern about the connection between over-use of cesarean section and maternal mortality. The Joint Commission, the leading health care accreditation body, recently issued Preventing Maternal Death highlighting preventable errors specific to cesarean section: (1) failure to pay attention to vital signs following cesarean section and (2) hemorrhage following cesarean section.

On the heels of the Joint Commission alert, news broke that a special California task force found mortality rates for California women dying from causes directly related to pregnancy tripled in the past decade. (ABC News coverage) According to task force investigator Elliott Main, MD as reported to California Watch:

it’s hard to ignore the fact that C-sections have increased 50 percent in the same decade that maternal mortality increased. The task force has found that changing clinical practice could prevent a significant number of these deaths.

What’s the “take away”?

Increased scrutiny does not translate into provider- and facility-level reform. Consumer awareness is necessary for protecting normal birth for low-risk, healthy women.

Despite the frequency of cesarean section, most women are uninformed until presented with a provider recommendation during labor. This is a poor time for discussion. Making an informed decision is quite difficult, if not impossible, under these circumstances. Learning about cesarean section before pregnancy and as a part of childbirth preparation is ideal. Having this awareness will help women ensure surgical birth is reserved for appropriate, medical indication.

Women are well served to use prenatal appointments to learn more about their provider’s cesarean section rate and philosophy. It’s important to have this conversation early in pregnancy.

Birth after cesarean resources

VBAC.com

International Cesarean Awareness Network

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U.S. Cesarean Sections at an All-Time High

Weeks after the NIH statement encouraging increased access to vaginal birth after cesarean, the CDC National Center for Health Statistics released Recent Trends in Cesarean Delivery in the United States. The 2007 national cesarean section rate reached 32%, the highest U.S. rate ever recorded and higher than most other industrialized countries.

Findings

  • The 2007 rate of 32% is more than double what it was in 1996 at 21%. The number of cesarean births increased 71% from 1996 (797,119) to 2007 (1,367,049).
  • Cesareans are up for all women irrespective of age, race, state of residence or gestational age of infant(s) at birth.
  • Cesarean rates increased in all U.S. states, and by more than 70% in six states. Oregon’s cesarean rate increased 67% from 16.9% in 1996 to 28.2 in 2007.
  • Women under age 25 experienced the greatest increase in cesarean deliveries from 2000 to 2007.
  • Cesarean rates increased for infants of all gestational ages.

Key Take Away

In every state of the union, women of all ages and ethnic groups are affected by the increasing rate of cesarean section birth. Accordingly, all women need to know about cesarean section.

Why are cesarean sections cause for concern?

The most frequently performed surgical procedure in U.S. hospitals, cesarean section is major abdominal surgery. When medically necessary, it can be a lifesaving intervention for both mother and baby.

However, cesarean section is increasingly under scrutiny for overuse. When performed as a non-medically indicated intervention, it is associated with surgical complications including maternal re-hospitalization and newborn complications requiring NICU care.

Cesareans also introduce long-term risks to future fertility and subsequent pregnancies. Furthermore, women’s choices for subsequent births are deeply constrained by providers, facilities and insurers that formally or informally ban vaginal birth after cesarean (VBAC) for non-medical reasons. For more information, see VBAC Policies in US Hospitals. In short, unnecessary cesarean introduces considerable complexity into a woman’s future reproductive life.

Press coverage following release of the CDC report

The New York Times

National Public Radio

Birth after cesarean resources

International Cesarean Awareness Network

VBAC.com

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VBAC: generally safe but inaccessible

In early March, the National Institutes of Health convened a special consensus conference panel to craft an official statement reflecting expert assessment of current data on and access to vaginal birth after cesarean (VBAC). The panel concluded that VBAC is a safe alternative to repeat cesarean for most women and that most women opting for one do so successfully. It also acknowledged that women face unacceptable, non-medical obstacles to avoiding repeat cesarean surgery.

Background

The panel explored causes for the plummeting VBAC rate since the first 1980 NIH VBAC panel recommended providing women with access to a trial of labor (TOL) after a previous cesarean. Beginning in 1996, VBAC rates started and have continued to decline to fewer than one in ten women.

Given cesarean section has the potential to save a woman and / or baby’s life, why are VBAC rates of interest? Because cesarean section is over-employed – meaning the risks are too often greater than the perceived potential benefits. These risks increase with each surgery and stretch beyond postpartum recovery.

After eleven consecutive years of growth, the national rate for cesarean section reached 31.8% in 2007, double what it was a decade ago. These outcomes run counter to national and international health guidelines recommending a rate of 15%. While primary cesareans drive the growth, repeat cesareans and the lack of alternatives play a significant role. Inaccessibility to VBAC also has significant but generally unacknowledged implications for women’s reproductive rights.

Access to VBAC is critical to restoring cesarean section to its role as an intervention of medical necessity. Fortunately, Lane County women have access to providers and locations in which VBAC receives proper support.

Backdrop

The second NIH VBAC panel unfolded against a backdrop of growing concern about the connection between over-use of cesarean section and maternal mortality. The Joint Commission, the leading health care accreditation body, recently issued Preventing Maternal Death highlighting preventable errors specific to cesarean section: (1) failure to pay attention to vital sings following Cesarean section and (2) hemorrhage following Cesarean section.

On the heels of the Joint Commission alert, news broke that a special California task force found mortality rates for California women dying from causes directly related to pregnancy tripled in the past decade. (ABC News coverage) According to task force investigator Elliott Main, MD as reported to California Watch:

it’s hard to ignore the fact that C-sections have increased 50 percent in the same decade that maternal mortality increased. The task force has found that changing clinical practice could prevent a significant number of these deaths.

So, why the VBAC slump?

In the past decade, at least a third of hospitals have implemented official policies banning VBAC. Additional hospitals have no specific ban but also have no physicians willing to attend one. Official and de facto bans are generally attributed to legal, non-medical concerns:

  • Hospitals desire to avoid high-dollar lawsuits in the event of a catastrophic uterine rupture. (Uterine rupture has been found to occur at a rate of less than one percent.)
  • Insurers raise malpractice premiums for providers offering VBAC.
  • Health care facilities are incapable of adhering to the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists 2008 recommendation that VBAC occur only in facilities capable of maintaining an emergency response team. Obstetric procedures with comparable risk regularly occur in facilities incapable of retaining such a team.

What should be done?

The NIH recommends that hospitals, maternity care providers, liability insurers, consumers and policymakers collaborate to remove barriers to VBAC as follows:

  • Medical providers should reconsider the litigation-wary policies blocking women from a real choice between vaginal and cesarean birth
  • Doctors are encouraged to facilitate informed consent through the provision of unbiased, evidence-based information about the risks and benefits of repeat cesarean and VBAC
  • The American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists are encouraged to reassess the requirement for emergency responses teams
  • Healthcare organizations and providers ought to make transparent their TOL policy and VBAC rates
  • Policymakers and liability insurers must develop pathways to eliminate the damaging effect of the medical-legal environment on access to care

As mentioned in the “about” section, I am working toward a childbirth educator credential. As I fulfill written requirements, I will post them here. Up next? Analyses of VBAC research. These write-ups might be useful to women beginning to contemplate the path to birth following cesarean.

In the meantime, you might peruse NIH panel coverage in the mainstream coverage:

Associated Press

National Public Radio

The Los Angeles Times

The New York Times