At six hospitals in Massachusetts, forty percent of first-time mothers give birth by cesarean, according to this editorial in the Boston Globe, by Judy Norsigian (Our Bodies, Ourselves) and Timothy Johnson, MD (U Michigan). “Yet none of these hospitals is designated as a high-risk center. So much for the argument that high-risk pregnancies are the reason for these rates.” They also slash through other myths, like that more mothers are too old, too fat, or too posh to push. The C-section rate for women on Medicaid is rising faster than for women with private insurance, they report (which costs taxpayers more). “Considerable media attention has focused on how extreme obesity can raise the risk of having a caesarean, but more emphasis is needed on these system-based approaches,” they write, and go on to recommend that hospitals support vaginal birth after cesarean, restrict labor induction, and offer more nurse-midwifery.

They point out that in Boston, the two hospitals with no midwives had cesarean rates of 37% and 42%, while those with midwives had rates between 27%-35% (though they don’t say what rates the midwives alone achieved). “Enhancing access to midwifery care might well be the most effective approach to safely reducing the overall caesarean rate,” they write. “We must finally make midwives more central in maternity care — as do all other countries whose birth outcomes are superior to ours.” A true and brave statement from an obstetrician, but those numbers suggest that nurse-midwives can only do so much to mitigate a hospital culture that tends toward interventions and surgery. When midwives attend births autonomously outside the hospital setting, cesarean rates are closer to 5%.

Amnesty International minces no words in its new report on U.S. maternity care. Deadly Delivery: The Maternal Health Care Crisis in the U.S.A., reports that more than 2 women die per day in the United States from pregnancy- or childbirth-related complications, a rate that’s worse than in 40 other industrialized countries. “Preventable maternal mortality
is not just a public health issue, it is a human rights issue,” states Amnesty.

“Women in the USA face a range of obstacles in obtaining the services they need. The health care system suffers from multiple failures: discrimination; financial, bureaucratic and language barriers to care; lack of information about maternal care and family planning options; lack of active participation in care decisions; inadequate staffing and quality protocols; and a lack of accountability and oversight.”

The report profiles several women who died or nearly died because of inadequate, inappropriate, or discriminatory care: one woman dies of a blood clot following a cesarean section, which could have been prevented with simple circulation stockings (a standard prophylactic for other major surgeries); another woman bleeds to death following a C-section, even after she and her husband plead with medical staff to address her troubling symptoms; a high-risk woman experiencing complications late in pregnancy is turned away from a prenatal clinic because she can’t afford a $100 deposit; both she and her baby die after care is delayed.

Each death represents dozens of “near misses” that often leave women in worse health; of the 4 million American women who give birth each year, 1.7 million women experience complications that lead to adverse effects. “The US health care system is failing women,” says Amnesty. Read the full report here.

Investigative journalism lives at California Watch, which published this article about maternal mortality. An independent task force investigating the problem found “the most significant spike in pregnancy-related deaths since the 1930s…it’s more dangerous to give birth in California than it is in Kuwait or Bosnia.” But the state has yet to release a report.

This investigation is not the first to reveal higher than officially reported numbers of deaths, but it appears to have gone deeper than previous reviews in Virginia, New York, and Florida. “The group’s initial findings provide the first strong evidence that there is a true increase in deaths — not just the number of reported deaths.” And unlike previous reviews, it sought to determine causes, which are usually attributed to women: obesity, older mothers, and fertility treatments. The data, however, suggest otherwise, according to Elliot Main, MD, the task force’s lead investigator: “What I call the usual suspects are certainly there,” he told California Watch. “However, when we looked at those factors and the data analyzed so far, those only account for a modest amount of the increase.” What then is to blame for the increase?

Main said scientists have started to ask what doctors are doing differently. And, he added, 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.

While the findings appear to be languishing with the state department of public health, the Joint Commission, which certifies and accredits hospitals, is taking action. On January 26 it issued an alert, stating: “Unfortunately, current trends and evidence suggest that maternal mortality rates may be increasing in the U.S.”  After receiving the CA task force’s report, the Commission “issued incentives for hospitals to reduce inductions and fight what it called ‘the cesarean section epidemic.’”

With the historic news that a majority of the U.S. workforce is now female, it’s clear that American women have more power than ever before, says OB/GYN and bestselling author Christiane Northrup, MD. But is that power reflected in the healthcare available to women? No, she writes in an essay for Huffington Post, especially when it comes to childbirth:

“Our so-called healthcare system, which is a direct reflection of the beliefs of our culture, sees the female body and its processes (like labor) as an accident waiting to happen…The truth is that labor and birth need not be the emergencies we think they are. And the medicalization of birth actually does more harm than good.”

Northrup criticizes the rising rates of cesarean section and labor induction, and cites the rising maternal death rate. “Studies have repeatedly shown that in healthy mothers with no risk factors, home birth is as safe as hospital birth. Increasingly, savvy women who trust their ability to birth normally [and, we should add, who have the resources] are opting to avoid the hospital altogether.”

Northrup concludes the essay with a call to action: “When it comes to pregnancy and birth, we as a culture and as individuals need to wake up and claim our right to literally birth right!”

“Mention that you are planning a home birth and it might be as if you had just brought up Sarah Palin or Palestine: brace for family feuds, public denunciations, and offhand remarks that imply you are selfish and stupid, your midwife is a quack, and your unborn child is a victim already in need of social services…Such is the pitch of the ‘home birth debate’ in the United States. And yet, the the research evidence suggests a more nuanced conversation.”

Read more on Babble.com.

“The worldwide ‘Baby Friendly Hospital Initiative‘ is a great campaign — get the baby skin-to-skin with mom first thing after birth, leave them be for an hour to start nursing, and basically phase out the nursery. A centerpiece of the initiative is to ban formula companies from giving out free samples in maternity wards. But perhaps calling it ‘baby friendly’ was a bad idea. Perhaps it sends the message that breastfeeding is somehow not ‘mother friendly.’

That’s essentially what Hannah Rosin argues in an article in this month’s Atlantic, ‘The Case Against Breastfeeding’…”

[Read more and add your $.02 on Babble.com]

You’d think that between Erykah Badu’s home-birth twitter and Ricki Lake’s film success and the New York Times coverage that we’d moved beyond dissing home birth as fringe — “extreme.” Apparently not. The current New York magazine titles a feature about it “Extreme Birth.” The piece, by Andrew Goldman, tries to be a character study of Cara Muhlhahn, the home-birth midwife and now memoirist featured in Lake’s film The Business of Being Born. But after raising her to a teetering pedestal, crowning her “the fearless — some say too fearless — new leader of the home-birth movement,” Goldman shoots her down. It feels more like a character assassination — of both her and the movement.

This is unfortunate for many reasons. As Goldman himself admits, routine maternity ward monitoring, inducing, and anesthetizing have added up to millions of unnecessary cesarean sections (latest CDC rate: 31.8%) — a “hospital childbirth system gone insane.” Midwives who attend home birth provide a much needed, safe alternative. But Goldman can’t quite buy that (or manage to cite any research one way or another). He claims that Lake’s movie “de-radicalized home birth, conflating it with garden-variety natural childbirth and allowing Muhlhahn, largely unchallenged, to argue for its safety.”

Here’s the deal on safety: The American College of Obstetricians and Gynecologists claims that it isn’t safe; the American College of Nurse Midwives and the American Public Health Association claim that it is. The research evidence clearly demonstrates that birth outside the hospital with a trained midwife is not only as safe for the baby, but safer for the mother, provided she is considered “low risk” — a healthy woman carrying one full-term, head-down baby.

What does Goldman mean by “garden variety natural birth” and where can you get one? The “painful truth” is that it’s an uphill battle to avoid unnecessary intervention once you check yourself into a garden variety U.S. maternity ward (these “pushed births” are epidemic). In many places, like NYC, there is very little gray area between the extremes, if you will, of home and hospital. And freestanding birth centers are great if you can find one, but there’s no real clinical difference between there and at home: every piece of equipment at a birth center a midwife can bring to a home birth. If labor isn’t progressing normally or a complication develops in either location, you transfer care to the hospital.

This concept of transporting a birth from home to hospital is a toughy, especially for reporters — it looks like failure. The anonymous OBs quoted in New York magazine call transports “dumps” and “train wrecks.” In reality, transports are normal and appropriate. These are the women who actually need advanced medical intervention; most just need pain relief or antibiotics (the C-section rate for planned home birthers is under 5%). The option of transport to a fully equipped hospital is what keeps home birth safe. Supportive physicians embrace the role of providing appropriate medical intervention and emergency care, rather than demanding that every woman give birth in the hospital and be treated as if she’s an emergency.

Several times in the NY piece, Goldman thinks he’s catching Muhlhahn in flagrant malpractice, but this is because midwifery standards and obstetric standards differ so, and because Goldman is relying on a cultural bias that obstetrics is more scientific. But it’s not.

Yes, hospitals and physicians restrict women to 24 hours of labor after their waters have broken (many providers want you induced with Pitocin immediately after membrane rupture), but that’s just standard protocol, not science. The best, largest study actually showed that a woman can labor four days without risk to the baby. Goldman also sanctions Muhlhahn for underestimating a baby’s weight, and quotes an OB who claims she should have known the baby was “too big.” But again, the evidence shows that even the highest-tech ultrasounds can be off by two pounds, and that it’s impossible to predict which babies’ shoulders will get stuck. Even ACOG doesn’t recommend inducing or sectioning based on size guesstimates.

The truth is, standard maternity care is not evidence-based care (see this recent report.) And this is why more women are interested in giving birth at home. Not just so they can have candles and music and a better “experience,” but because they know that checking into a hospital means exposure to preventable risks.

Which is really the shame in all this. Because most Americans are skittish about home birth, and no woman should feel it is her only option for that garden variety, supported, physiological birth.

As for the higher-risk births (twins and breeches for instance), the ideal setting is a hospital in theory, but some midwives agree to attend them at home because they know that their clients have zero chance of a vaginal birth otherwise. They feel an obligation to support women’s choices and help them avoid unnecessary surgery. And they have the skills to do it (the current obstetric training for breech delivery is a cesarean section!). The system is shameful to an extreme.

Consumer Reports named this true/false quiz, “Matertnity Care, Beware.” Take it here. CR writes, “Despite growing evidence of harm, many obstetricians and maternity hospitals still overuse high-tech procedures that can mean poorer outcomes for baby and Mom.” Also, check out their October ‘08 report, “Back to Basics for Safer Childbirth.”

Most of us learn the word “elective” in high school, when we find ourselves with the newfound freedom to take a course like AP music theory, or advanced sculpture, or yoga. Elective implies freely chosen, life-enhancing. Laser eye surgery is elective. Tattoos are elective. But the vast majority of so-called “elective” cesarean sections are not, and it is inappropriate and disingenuous to call them so in the medical literature, as did a recent study… (Read the the entire commentary at RH Reality Check.)