International Cesarean Awareness Network

Education, Support, & Advocacy for Birth Justice & Healing

Only 2% of cesareans requested by moms

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A new study in British Columbia has found that, contrary to what some doctors and media reports might contend, the growing cesarean rate is not driven by maternal demand. This is similar to previous findings from the Listening to Mothers study in which only one out of over 1,300 mothers in the study reported requesting her cesarean without medical indication.

As reported in the Vancouver Sun:

The study, which examined all deliveries in B.C. between 2004 and 2007, suggests regional disparities are due to differences in doctors’ approaches and lack of resources — not because women are requesting them or their medical conditions require them more in certain communities.

Researchers at the University of British Columbia’s School of Population and Public Health, found that the number of caesarean births ranged from a high of 27.5 per cent in South Vancouver Island, to 22.1 per cent in Vancouver, to a low of 16.1 per cent in East Kootenay.

Only a small proportion of C-sections — two per cent — were performed because mothers requested them. The wide variation remained even after researchers accounted for medical conditions and maternal characteristics that could necessitate an assisted birth, such as smoking, weight gain, diabetes and high blood pressure.

ICAN of Lower Mainland co-leaders Mieke Bray and Elodie Jacquet were quoted in the news article.

Mieke Bray had a caesarean last May due to a complicated birth. She was two weeks overdue, and tried a synthetic hormone to induce labour at B.C Women’s Hospital.

Shortly after, Bray’s placenta detached from her uterine wall. Bleeding excessively, she was rushed to the operating room for an emergency C-section. Fifteen minutes later, her second son, Tait, was born.

“It never occurred to me that I would get a C-section,” said Bray, 34, whose first child was born naturally. “I do yoga, I’m a vegetarian, so I’ve always lived a naturopathic lifestyle.”

Bray admits that the C-section saved her life, but she still found the experience traumatic.

Elodie Jacquet, 28, also had a caesarean last July. She had planned a home birth, but as she went into labour, her baby’s heartbeat began decelerating. After being induced, Jacquet’s baby got stuck in her pelvis and could not turn.

“They said, ‘I’m sorry but we’re going to have to give you a C-section,'” said Jacquet. “I didn’t want one, but I wanted whatever’s best for my baby.”

Soon after, baby Liam was born. Seeing that he was healthy, Jacquet wondered if the induction and the following caesarean was really necessary.

Dr. Friedman on "The peril of multiple c-sections"

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Dr. Alex Friedman from the Hospital of the University of Pennsylvania published an article in yesterday’s Philadelphia Inquirer detailing his own experience with the serious risks of multiple cesareans:

The worst surgical case of my residency came when we delivered my patient’s baby by cesarean – her ninth cesarean birth.

The baby came out fine, but for the mother we suspected one of most feared complications in obstetrics – that her placenta had burrowed deep into the muscle of the uterus.

To get oxygen and nutrients to the fetus, the placenta needs to attach just a few millimeters deep into the uterus. We worried that hers had gone much farther and might eat through the entire thickness of the uterus, keeping it from shrinking back to its normal size after delivery and causing a massive hemorrhage.

We gave a gentle tug on the umbilical cord. Usually the placenta peels off with such gentle pulling, but hers remained stuck – an ominous sign.

Importantly, Friedman notes:

The case points out a fundamental truth about surgical delivery: a first cesarean for most women leads to a cesarean with every pregnancy. And while a first section is quick, easy to perform, and rarely complicated, each repeat surgery carries greater risk.

Why the greater risk? Friedman explains:

Repeat C-sections pose more risk than a first section for many reasons. One factor concerns anatomy. When a doctor performs a first cesarean, the layers of tissue look and feel very different from each other. These visual cues and textures guide the surgeon, indicating exactly where to cut…

The surgeon loses the advantage of good anatomy after the first section. The tissue undergoes scarring, toughens, and blends together as it heals. The variations in color and texture disappear. The intestines and bowel sometimes stick to the healing wound, putting them in harm’s way the next time surgery is performed.

These changes in anatomy due to previous cesarean surgery can lead to serious complications.

A study from 2006 published in the journal Obstetrics and Gynecology compared C-section complications in more than 30,000 patients. Risks of requiring a large blood transfusion, incurring a bladder injury, needing to be on a ventilator, and ending up in intensive care all increased significantly with the number of sections after the first.

The study also showed greater risk for my patient’s complication. Scarring on the inside of the uterus after a cesarean causes the placenta to attach abnormally in future pregnancies. During a first section, the risk of this complication was less than 1 in 400. After a sixth section, the risk ballooned to more than 1 in 15.

Ultimately, Dr. Friedman’s patient survived, but only after a risky hysterectomy that left the OR awash in blood and the mother in the ICU for several days.

My patient lost three times the entire blood volume of a normal person, sixteen liters in all. Only a massive transfusion kept her alive. Anesthesiologists pumped in 51 units of red blood cells and seven six-packs of platelets.

Sadly, Friedman notes what so many of us cesarean moms know:

More and more women are finding themselves on the C-section path. Almost one in three babies was delivered by cesarean in 2007, the most recent year for which data are available, an increase of more than 50 percent from a decade earlier.

At the same time, it’s becoming harder for mothers to avoid repeat surgery. The number of vaginal births after a C-section fell by two-thirds, to fewer than 10 percent, over the same time period. This year, the National Institutes of Health estimated that since 1996, one-third of hospitals and one-half of doctors who offered vaginal births after a C-section no longer do so.

As Friedman’s experience demonstrates, the stakes in this quandary are incredibly high:

With a first cesarean, the up-front costs – a few more days in the hospital, a longer recovery – may seem reasonable. Only in retrospect can the true costs become apparent.

Childbirth Professionals: A Call to Advocacy

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jpeICAN President Desirre Andrews and Advocacy Director Gretchen Humphries have recently published an article in the Journal of Perinatal Education. Desirre and Gretchen call for childbirth professionals to work together with advocates to promote change so that childbearing women can be empowered to seek the best care for themselves and their babies.

Tackling the topics of cesarean surgery and vaginal birth after cesarean (VBAC) is an increasing challenge  for  the  birth  professional  even  though  scientific   evidence   clearly   supports   reducing  the skyrocketing cesarean rate and increasing the support for and availability of VBACs for childbearing women. We need to ask why this is so…

Using  RCS  and  VBAC  as  an  example  of  the broader issues within the current maternity care system, we can identify some of the issues facing both the birth professional and the consumer. Looking at the published evidence about cesarean and VBAC is  both  heartening  and  disheartening:  heartening because the evidence is that, although cesareans are safer than ever before, they should be used in a judicious manner (not prophylactically), and VBAC is a safe, viable option for most women who have had a  previous  cesarean;  disheartening  because,  even with  tens  of  thousands  of  research dollars having been spent in the past two decades to define the risks and benefits of VBAC and RCS, the evidence has not translated into education and medical practice. We maintain that the failure to accurately communicate  the  risks  and  benefits  of  RCS  versus VBAC  is  a  stumbling  block  that  needs  to  be addressed in order to apply the gathered evidence to  good  practice.

Desirre and Gretchen suggest several ways that childbirth professionals can help overcome this stumbling block.

  • Childbirth educators:

Many   couples   attend   a   childbirth   preparation course.  Within  the  curriculum,  there  is  usually some  discussion  of  cesarean  surgery.  Research has shown that if a woman is told about the option of VBAC at the time of her cesarean, she is more likely to have a VBAC. A discussion of the realities of  post-cesarean  pregnancy  and  the  validity  of VBAC  as  a  choice  would  also  serve  this  purpose… Childbirth  educators  have  the  opportunity  and ethical  requirement  to  give  the  most  accurate and up-to-date information about birth practices, even when it does not reflect current practice on the labor and delivery floor.

  • Doulas:

Although  a  doula  cannot  speak  for  her  client,  she can be a force for best practice if she has adequately prepared her client for the realities of the labor and delivery floor and is not afraid to speak the truth when the client is buffeted by conflicting information. ‘‘Preserving the experience’’ is a false positive outcome when ultimately the experience has negative repercussions in the months and years to follow, no matter what the client may describe in the hours and  days  after  giving  birth.  ICAN  knows  that women appreciate honesty, even honesty that is difficult  to  hear.  This  is  truth  that  doulas  are  well equipped to speak.

  • Labor and delivery nurses:

A  supportive   nurse   can   make   the   difference   when a woman seeks a low-intervention labor or wavers in the face of the difficulties of labor. And there is no doubt that the nurse is also often caught in the middle of the conflict between the patient and the machinery   of   institutionalized   maternity   care…Nevertheless, nurses are called to advocate for their patients, and this is no less true on the labor and delivery floor than in the cardiac wing…A commitment to staying current with the evidence for best practice through continuing education and working as a profession to support best practice is required to effect any real change within the hospital system. To do anything less is to compromise the very principles of nursing.

To summarize, Desirre and Gretchen point to ICAN as an example for all childbirth professionals:

More often than not, ICAN is the only source   of   evidence-based   information   on   the risks  and  benefits  of  RCS  and  VBAC  and  the only  source  of  support  for  a  decision  to  choose VBAC. If we have any hope of derailing the juggernaut of worsening maternal and fetal outcomes in the United States, the wider worldwide childbirth community  must  begin  to  support  and  educate as ICAN does.

Cesarean & VBAC in Syracuse, NY

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ICAN’s own Lauren Cooper and Lisa Carguello from ICAN of Syracuse were featured on their local TV evening news talking about the rising cesarean rate and availability of VBACs. Says Lauren, “I was terrified but it was an amazing opportunity to help spread the word about the kind of support and information ICAN has to offer. This channel has done a great job of bringing attention to local cesarean/VBAC issues lately and I am ecstatic that they finally highlighted our chapter so that we can help reach more women.” Check it out!

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Erin's Cesarean

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Erin sent in this birth story to share. Would you like to have yours posted here? Send it to: blog@ican-online.org. If you are looking for more birth stories, click here.

I had a perfect pregnancy.  I had no heartburn, no hemorrhoids, no morning sickness, no back pain, nothing. I sailed through pregnancy with such ease and happiness I thought my labor would be the same way. I chose an OB with a midwife in her office, thinking that would be the best because I knew I wanted a natural birth. I did what what i thought was the right thing and I took my hospital “birthing class.”  My husband and I laughed through the whole thing, and felt we gained nothing from it but I thought I was doing all I could to prepare myself for my perfect natural birth.

When I was 34 weeks along the midwife started checking me at my prenatal appointments and each visit she would say “Nope, nothing.” Each visit I left the office feeling a little disappointed that nothing was going on, but I didn’t worry too much. When I was 35 weeks she palpated my stomach and told me I had a big baby coming. I thought nothing of it even though she sent me for an ultrasound to estimate the size.  The ultrasound technician told me these ultrasounds could be either a pound small or a pound heavy. They told me he was 8 lb 12 oz.  I still thought nothing of it, I am not a size 0 by any means and I felt in my head my body was made to birth this baby and I was going to be fine. I wasn’t scared at all.

When my due date passed and I still wasn’t effaced or dilated the OB ordered a non stress test.  She was worried because I had gained 9 lbs in one week and I was swelling.  Never once did she do a blood test to test my liver and my blood pressure had remained a constant 120/60.  The non stress test  came back fine (reactive) but she told me this baby had to come out because he was big and I was retaining fluid.

I got induced April 8, 2009.  At 6:30 am they put Cytotec in me.  They used one dose of it and it didn’t work. I was still 0% effaced and 0cm dilated. They started the Pitocin.  I had heard so many stories about Pitocin and when they hooked the IV up was when I got scared.  Each time they upped the Pitocin, they asked me “can you feel pain yet?”  almost as if they were waiting for me to say “YES!”  I told the nurses that I didn’t want an epidural and each time I said that the nurse replied ” In a little while you will screaming for one. I usually give new moms to about a 3.”  The nurse must have asked me 3 more times if I wanted an epidural and each time I told her no.

They continued to up the Pitocin and still I felt nothing.  The doctor on call decided I wasn’t moving along fast enough so he broke my water.  When he broke my water, nothing came out. The young doctor looked around and said “where is the fluid?”  I was getting more and more nervous….The contractions became worse but still tolerable.  My worst complaint was that I was starving and pretty tired. I hadn’t eaten since 6pm the previous night and it must have been about 7:30 because I remember Jeopardy was on.  After Jeopardy was over the nurses walked in with the anesthesia cart and said “Your epidural is here.”  At that point I was so tired and exhausted and it was right there, I caved in and said ok.

I didn’t really feel the epidural being put in but I remember thinking, I thought it would take the pain away more than this.  I kept telling everyone that the epidural wasn’t working.  I could still feel the contractions, which were coming right after another with no break in between because the Pitocin was now maxed out. The nurse kept telling me she could tell I was getting pain relief by the look on my face.  I was getting mad because i knew what i was feeling and it was EVERYTHING.  Another nurse said to me “honey imagine what it would be like without the epidural.”

At about midnight the doctor came in and told the baby was big and wasn’t moving and I could be in labor for days.  After 18 hours I had only dilated to a 3 and this wasn’t fast enough for him I guess. I asked him if it was his wife what he would do and he told me he would tell her to have a c-section. I had never wanted a c-section and somewhere in the back of my mind I had anticipated this happening.  A week before I had told my mom, “I know I’m going to labor for 24 hours and then they are going to call a c-section”  and I had turned out to be right, except I had only been in labor for 18 hours……

So in my moment of weakness, my tired, hot, beaten body told my brain “yes, have a c-section, it will all be over with” and I did. As they were wheeling me to the operating room i told them I could feel the medication going down my spine and it was cold.  They finally realized that the epidural hadn’t’ been working this whole time. They had told my husband Krystopher to go scrub up and they would come get him when I was ready.  Since the epidural hadn’t worked they decided to do a spinal block.  It seemed like it took forever for them to stick all those needles in my spine.  When they were done the doctor asked if I could move my feet and legs, and I could.  They had me lay down and poked me with toothpicks and asked which leg and if i could feel it.  I could.  The anesthesiologist was standing behind me and when he found out I wasn’t numb he said, “Shit, we are going to have to knock her out.”  I looked at him and said “Shit what!?!? Why did you say shit?”  The doc told one of the nurses to get the intubation cart and I busted out crying. I did not want a tube down my throat and I did not want to be knocked out and I was scared.  They tied me down to the table as I sobbed and bawled, “I never thought it would be like this.” I kept saying over and over.  No one had gone to tell Krystopher what was going on.  Little did I know he was in a panic too.  The doc told me to stop crying and just breathe as he he put the mask over my face.  That was the last thing I remember before I was cut open.

When i woke up i was in excruciating pain…..They couldn’t give me any pain medication until I woke up from the anesthesia.  My son was born at 1:11 am april 9, 2009 and the first time I held him was 5am.  I had missed his birth and so had his father.  Bonding was hard. Breastfeeding was harder. No one ever tells you how hard it is. It took me a long time not to be angry about my birth, not to feel like a failure and not to be mad at myself for giving in, for letting all the interventions that I did NOT want happen.  People tell you “be happy, you have a healthy son”  but who is to say that there are no long term effects on his health? and what about my health?  My body looked like an alien being the first weeks after surgery.  I hated it….I couldn’t birth a baby and now here I was with these awful stretch marks and this scar that was a reminder of that traumatic event.

Its now a year later and I still am haunted by the memories of that experience but I am also more knowledgeable. I know what happened to me has happened to so many other women and that it was totally unnecessary. I know I can have the birth I want and I know that I can stand up for what I want. I plan on having more children, not in a hospital if possible. I know my c-section was unnecessary because my son wasn’t ready to come out. If he would have been able to progress as he wanted, I think wholeheartedly I could have birthed him naturally, even though he was 10 lbs.