International Cesarean Awareness Network

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More evidence that less is more

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Evidence continues to mount that increased use of interventions in childbirth, such as induction and cesarean, are not necessarily beneficial to mothers OR babies.

In a study published this month in the Journal Maternal-Fetal and Neonatal Medicine, researchers found no evidence that higher rates of cesarean benefit babies. According to the study’s author Dr. Christopher Glantz, “Like virtually all medical therapies and procedures, these interventions entail some risk for the mother, and there is no evidence in this study that they benefit the baby…In my mind, if you are getting the same outcome with high and low rates of intervention, I say ‘Do no harm’ and go with fewer interventions.”

Here is a description of the study:

In the study, Glantz focused on pregnant women delivering in level I hospitals – those lacking a Neonatal Intensive Care Unit or NICU – because they care primarily for low-risk women who do not have major complications, such as diabetes, high blood pressure or other severe disease. The majority of women in the United States deliver in level I hospitals.

Through a birth certificate database, Glantz obtained and analyzed data from 10 level I hospitals in the Finger Lakes Region of upstate New York and calculated the rates of induction and cesarean delivery at each between 2004 and 2008. Not surprisingly, the rates varied widely.

To determine the health of newborns delivered at these hospitals, he looked at three outcomes: transfer of the newborn to a hospital with a NICU (signifying the presence of complications that required a higher level of care); immediate ventilation or breathing assistance; and a low 5-minute Apgar score (a quick assessment of the overall wellbeing of a newborn).

Using statistical models, Glantz assessed the relationship between rates of induction and cesarean delivery and rates of the three neonatal outcomes. He found intervention rates had no consistent effect on newborns: Whether a hospital did a lot or very few interventions, there was no association with how sick or healthy the infants were.

Even after a second round of analysis that accounted for differences among pregnant women that could potentially impact the results, the finding was the same – hospitals with high intervention rates had newborn outcomes indistinguishable from hospitals with low rates.

CAM Birth Story: Katharine's necessary cesarean

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This birth story, in honor of Cesarean Awareness Month (CAM), comes from Katharine Evaul. Katharine says, “I was suggested to send this to you because while many c-sections are unneeded, sometimes they are. At the same time complications because it is major surgery arise.” To have your birth story posted on this blog, email it to: blog@ican-online.org

I was hospitalized for pre-eclampsia and developing HELLP syndrome on the 3rd of August 2009. The only reason I did not have Liam taken out on the 3rd off August was because of just HOW early he was – by my last period he was 28 wk and 6 days but as I knew when I ovulated I knew I was only 28 weeks and 2 days pregnant. Regardless we expected an October baby – NOT an August baby. My stay at the first hospital was fine – lots of regular BP checks and non-stress tests for Liam which he passed with flying colors. They also injected me on Monday and Tuesday with betamethasone which is a steroid that can increase lung development in premature babies. Unfortunately I was not outputting what I was inputting and very swollen. The doctors were not particularly optimistic about my medical condition. Friday – 8/7 – my OB came to me and said that while she hoped I would stay more or less how I had been the previous few days (stable, not great), she also knew that this hospital did NOT have room in their NICU for another baby. At that time hospital #1 had 53 NICU babies – and only 48 beds. She wanted me to ok a transfer to a different hospital – just in case. Unfortunately right about the time she arrived (about 3pm) I was already feeling worse. I called Mark regarding the hospital transfer and he came over. Throughout the evening I continued to get sicker – vomiting and other symptoms – so the OB resident expedited my transfer to hospital #2 an hour away as it was the only nearest hospital with NICU beds. Another hospital would have been closer for us – but like hospital #1 they too were overflowing. I was transported by ambulance at about 11pm finally. I was checked into Labor and Delivery – the nurse is asking all of these questions regarding my birth plan and if I wanted a natural childbirth and so on. I finally said to her that if this baby is coming out – it’s by a section as the one thing I did know was that an induction would fail. Unfortunately an induction was so far out of the cards by morning.

During the night they continued to do lab work and my platelets kept falling (one of the main symptoms of HELLP). At 8am the doctors came and said that they needed to take Liam out NOW. During the following hour Mark called family while I had to sign papers and then I was off to an crash emergency c-section. They had to do general anesthesia so Mark wasn’t allowed into the room. Liam came out at 9:31am. He was exactly 29 weeks gestation, 2 pounds 10oz and 15 inches long.

Liam was taken to the NICU – but fortunately Mark got to see him – even trim his umbilical cord but Liam was off. On that Saturday they did intubate him for a brief period to give him surfactant and then they placed him on a C-PAP machine. Sometime between Saturday and Sunday they put him on room air – but the CPAP helped it into his lungs.

As for myself – I was placed on magnesium sulfate to treat the pre-eclampsia and prevent seizures. It’s a horrible drug – it makes you feel absolutely awful. Most of Saturday is a blur – my best friend stayed Saturday night with me which was wonderful (Mark was able to crash and I had help to turn over and various things).

On Sunday at about 12pm I finally got to see my son. I can’t describe how tiny he was – even with pictures. Also on Sunday they discontinued the magnesium. By Sunday I realized I had a complication from the anesthesia – the tube irritated my uvula (that thing in the back of your throat) so it was hugely swollen. It was causing me to wheeze. Unfortunately the doctors all thought it was a result of my asthma – even when I said it wasn’t. This created a less than ideal situation. The doctors kept giving me breathing treatments – inhaled steroids – every 4 hours and checking my oxygen every 2 hours and I was placed on oxygen by nasal canula. By Monday (8/10) I had had it – and was very upset and anxious. So the docs give me a sedative (which didn’t help matters). This was doubly frustrating as late Sunday an anesthesiologist had come, looked at my throat, and concurred that my uvula was HUGE. But the doctors continued to wake me up and give me steroids every 4 hours. Finally the respiratory therapist realized mid-Monday that I was oxygenating the same on room air as I was on oxygen. This was because – oh wait – the uvula was huge so the oxygen couldn’t even get to my lungs to improve my stats. So ultimately they discontinued the treatments. My twin sister Sarah kindly stayed with me Sunday night – again it was great having help turning over and tucking my 800 pillows around me 😀 ok just 4 – but it was a huge help.

Monday family left – I had people visiting but one thing I haven’t mentioned is on Saturday due to my high BP I developed a spot in my left eye. Basically this made it impossible to see out of my left eye. This created its own set of problems as I had people visiting and I couldn’t see. I know all parental units appeared as did my siblings. I felt really horrible when I realized that my older sister Anna and her husband kids were all in the hospital and didn’t see me as they had been told I was resting so I could see Liam on Sunday. Which is true – the nurses said I had to be rested to visit and I had yet to see him…I just felt bad as they finally wheel me to the NICU and there they were in the waiting area. Oh well.

So Monday was a rough day but I can’t remember all of it. I rather lost it Monday night – Mark stayed with me and I to say I was emotional was an understatement. I couldn’t see, I couldn’t hold my son, I was in pain from surgery.

Tuesday I do know the social worker came to visit. Mostly the interesting thing I learned was the docs had put down that I had a history of anxiety – which I don’t. Fortunately the worker took that off.

Late afternoon on Tuesday my incision had a burst of blood. However it stopped and I agreed with the intern that it was likely a small hematoma that just broke through the incision. Then Wednesday morning – more blood. When the upper level resident came to see me she realized that I had a HUGE hematoma and they had to reopen my incision and drain it. A very unpleasant experience that involved morphine to give you an idea of how unpleasant… Originally I was to be discharged but that got nixed. The doctor wanted to attach me to a Wound Vac machine to help my incision heal. On Wednesday it was 19 cm long, 3 cm deep and 2.5 cm wide. I also had approximately 28 staples. I asked if the interns went a little staple crazy but oh well.

Thursday I was hooked up to the Wound Vac – again not a pleasant experience but none of the dressing changes and all are so just keep that in mind. However Thursday was a big day – I finally was allowed to hold Liam for the first time! I still don’t comprehend how small he is – but that’s all I see when I see him – this tiny little person who is not even the length of my entire arm. The weight seems so insignificant – he was smaller than a sack of flour.

Friday I was so ready to go home. To make a long story short – insurance initially denied the wound care – with the machine I need 3 times a week for a nurse to come to my house to change the dressing and monitor the machine. Finally after the docs wrote letters including that I would not be released and after getting denied and taking it up to the medical director of the insurance company they let me LEAVE. The machine and care was not approved until 5pm on Friday. I had actually given up on the idea that I was going to leave and was begging for visitors since Mark really needed to be at home.

Still – leaving was bittersweet. I did not get to take Liam with me and will not be able to bring him home for months. He stayed in the NICU for 81 days until October 24th.

No One Truly Benefits from Defensive Medicine

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This is a cross-post from The Unnecesarean, which is in the midst of a fantastic series on defensive medicine. If you haven’t been reading the posts in this series, you can get caught up here.

By Desirre Andrews, President of ICAN

A woman’s pregnancy should be a positive time as she prepares for the birth of her baby.  Unfortunately, in this age of defensive medicine, a pregnant woman must arm herself with evidence-based information and self-advocacy skills.  She must be willing to act in a self-protective way to be certain she is getting individualized patient care versus the cookie cutter care modern medical practice normally affords.

This phenomenon of defensive medicine may largely be born out a very human response to the expectation of perfection we have in society today, especially with care providers.  We have developed a willingness to hand personal authority over to our care providers.

For years, doctors have been deified, treated as being better than everyone else.  Perhaps it is in their ability to save lives. We simply expect them to be able to do everything, but they can’t.  They are human.

Doctors and patients might be able to see the human face of medicine if the traditional practice style that valued provider-patient relationship came back into use.

Today, with OB appointments being no more than ten minutes each visit, how can a personal, trusting relationship build between the two parties? It cannot.  A woman can not be sure she can fully rely on her provider to know her well and help her make decisions that are in the best interest of her and her baby.  The provider must rely on what he or she is comfortable with offering and doing to patients instead of taking each mother and baby into consideration individually.  It is no surprise the circle of distrust and fear is palpable by all sides.

Prior to ever practicing medicine, the defensive attitude comes with the education a physician receives in medical school and the training in residency.  The lesson is that your patients are not as educated as you are, always practice to defend yourself and get the patient to agree to the course of action you want no matter what.

With this attitude, what sort of “care” practices is a woman facing? Higher induction rates to lessen the rare fetal demise that can occur “post dates”.  Higher cesarean rates because a physician does not want to incur risk of a VBAC mother going for a vaginal birth, even though catastrophic uterine ruptures are not common place.  Viewing all OB patients through a lens of high risk or as an emergency waiting to happen.

All aspects of managed and medicalized birth occur because a physician is not comfortable, has fears, has worries and/or is not willing to practice outside of that mode because tolerate risk has been depleted.  The physician desires to create a zero risk environment because of a lowered risk threshold either by training or by an adverse outcome in the years of practice.  The humanness of the mother has been left out of the equation, while the ideal of a “healthy” baby is elevated in this physician centered point of view.

We as ICAN believe that every mother has the ability, responsibility and intrinsic right to make medical care decisions for her pregnancy, labor birth and baby.  She should be able to obtain true and complete informed consent from her provider. We believe it is unethical for a physician to recommend and/or perform non-medically indicated cesareans (elective), to refuse to support VBAC (vaginal birth after cesarean) across the board without individualized assessment, or to skew cesarean as the easier, safer choice as a standard course of practice.

In the big picture no one truly benefits from a defensive medicine practice style. Providers and patients all lose.

Cesareans 17% more likely at for-profit hospitals

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California Watch, a nonpartisan investigative reporting initiative, has released a study showing that for-profit hospitals in California are performing cesareans at higher rates than non-profits, even in low-risk pregnancies.

A database  compiled from state birthing records revealed that, all factors considered, women are at least 17 percent more likely to have a cesarean section at a for-profit hospital than at one that operates as a non-profit. A surgical birth can bring in twice the revenue of a vaginal delivery.

In addition, some hospitals appear to be performing more C-sections for non-medical reasons – including an individual doctor’s level of patience and the staffing schedules in maternity wards, according to interviews with health professionals…

…California Watch examined the births least likely to require C-sections, those in which mothers without prior C-sections carry a single fetus – positioned head down – at full term, and found that, after adjusting for the age of the mothers, the average weighted C-section rate for nonprofit hospitals was 16 percent, while for-profit hospitals had a rate of 19 percent.

That may seem like a small percentage gap to the casual observer, but medical experts consider it a significant difference. It means women are 17 percent more likely to have a C-section if they give birth at a for-profit hospital. (When calculated without weighting averages by number of patients, the difference is slightly larger.)

This analysis provides evidence of what many have long suspected – that profit drives cesarean rates. As ICAN President Desiree Andrews comments:

“This data is compelling and strongly suggests, as many childbirth advocates currently suspect, that there may be a provable connection between profit and the cesarean rate,” said Desirre Andrews, president of the International Cesarean Awareness Network, a nonprofit group that would like to see C-sections only in cases of medical need.

Eugene Declerq weighs in on the study, noting that while profit motives may not be explicit, other factors such as efficiency can result in the same effect:

Gene Declercq, professor of community health sciences at the Boston University School of Public Health, agrees that hospitals would not explicitly push C-sections for profit. But subtle incentives to increase efficiency could have the same effect.

“There are factors that are attractive to hospitals in terms of training and staff and facilities,” he said. “It’s a lot easier if you can do all your births between seven and 10 in the morning and know exactly how many operating rooms and beds you need.” Vaginal births are unpredictable, creating inefficiencies that can hurt the bottom line.

Two ICAN mamas are also quoted in the report, citing their own experiences at California hospitals.

Even at nonprofit hospitals, some women say they felt pressured to have a C-section.

Rebecca Zavala, 29, a teacher and makeup artist in Ventura, was one.

Zavala consented to have her delivery induced a week early because the baby’s head seemed large and because the doctor was about to leave for vacation.

Zavala went to the nonprofit Santa Monica-UCLA Medical Center, where nurses gave her drugs to dilate her cervix and start the contractions. After four hours, in which labor progressed slowly, Zavala’s doctor broke her water and turned up the drug, stimulating contractions.

“It felt like there was this monster on top of me all of a sudden,” Zavala said. “It was terrifying. I was totally unprepared for anything like that.”

Shortly thereafter, her doctor informed Zavala that her baby was showing signs of distress and recommended a C-section. Zavala agreed. Nurses congratulated Zavala on being an accommodating patient.

But Zavala said she felt manipulated. Her doctor hadn’t told her that induction increased the likelihood that she’d have a C-section, and that C-sections came with health risks, she said. Now that she is pregnant again, she has learned that most hospitals are unlikely to allow a woman with a prior C-section to give birth naturally.

“She told me nothing,” Zavala said of her doctor, noting that the doctor left for her vacation shortly after the delivery.

And…

For some, a C-section can have devastating consequences.

After Heather Kirwan had been in labor for a few hours her doctor at Rancho Springs Medical Center in Murrieta urged her to have a C-section, warning that the baby was too big for her birth canal. She reluctantly agreed to the procedure, but now questions that decision.

“She ended up being a 5-pound, 12-ounce baby,” said Kirwan, 26, a manager for The Home Depot who lives in Murrieta. “So that was obviously a lie.”

A year and a half later, Kirwan was pregnant again, but the doctors found that the embryo was developing outside the uterus. Before her C-section, Kirwan said no one had warned her that C-sections increase the risk of this life-threatening condition, called ectopic pregnancy. And if it were listed in her lengthy consent form at the time of her first delivery, Kirwan said, no one bothered to point it out.

The doctors removed the embryo, along with one of Kirwan’s ovaries and fallopian tubes. She has been unable to conceive since.

“I’ve been trying for years and years, and I still can’t get pregnant. It’s very heartbreaking,” Kirwan said. “I just want people to know the risks.”

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