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.

In today’s New York Times, Section A, a story about a tiny, impoverished Navajo hospital in Tuba City, AZ, doing birth better than anyone: “this small hospital in a dusty desert town on an Indian reservation, showing its age and struggling to make ends meet, somehow manages to outperform richer, more prestigious institutions when it comes to keeping Caesarean rates down, which saves money and is better for many mothers and infants.”

How do they do it? Midwives attend the majority of births; obstetricians are available if needed. All the providers are on salary, so the profit motive is gone. And the hospital is federally insured, so it hasn’t been bullied into banning VBAC like so many others around the country. Even though the patient population has risk factors like hypertension and diabetes, the cesarean rate is a mere 13.5%.

“Tuba City…could probably teach the rest of the country a few things about obstetrical care,” writes the Times. “But matching its success would require sweeping, fundamental changes in medical practice, like allowing midwives to handle more deliveries and removing the profit motive for performing surgery.”

The Big Push for Midwives campaign — 10,000 Facebook members strong — is taking their message to Congress this week with a Capitol Hill Issue briefing “on how out-of-hospital maternity care reduces costs and improves outcomes,” writes the group. “Studies show low-risk women who plan their births with out-of-hospital midwives have outcomes equal to low-risk women who deliver in the hospital, but with far fewer costly and preventable interventions.” Not to mention unnecessary and harmful interventions! Increasing women’s access to midwives and birth centers should be a no-brainer, but so far, nobody at the healm of health care reform is talking about the need for maternity care reform, which could save the country billions of dollars a year. (Read more about the potential cost savings in the L.A. Times.)

You can help out the Big Push by spreading the word about the briefing, scheduled for this Thursday, May 21, and urging your representatives to attend.

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.

Woah, Florida dept. of health officials really need a childbirth ed. class. Twenty — yes, 20 — state and federal law enforcement and government agents RAIDED the Miami Maternity Center on December 24, Christmas Eve, based on allegations that the center was baking their clients’ placentas together in a single batch and grinding them up into pills for distribution. The midwives deny any wrongdoing. ”They charged in here as if I were making crack cocaine,” said one midwife. Or maybe a witch’s brew…. Read more about it in the Miami Herald.

Some healthcare trivia: In the United States, what is the No. 1 reason people are admitted to the hospital? Not diabetes, not heart attack, not stroke. The answer is something that isn’t even a disease: childbirth. It costs the country far more than any other health condition. But cost hasn’t translated into quality…

[Read the op-ed, “Midwives Deliver,” in the Los Angeles Times]

Mr. Daschle,

It’s true, those insurance execs who are coopting your call for “community” health reform discussions this week and next will probably have the higher-end rum in their eggnog, but don’t drink it. They want to keep profiteering off the very communities you and President-elect Obama asked to come together, share stories, and brainstorm for better health care.

If you really want to hear it from the heartland, decline those invitations, and may I suggest that you head to Kansas City tomorrow, December 20, where leaders of the maternity care reform movement will be hosting THE house party of the health care reform season. You want stories? These families have stories. Looking for fresh ideas about how the system needs to be reformed? These women will tell you how the U.S. could save billions by overhauling birth care. (In short, we’re overspending and underserving women and families. See this report for details.)

The “Maternity Care Community Discussion in the Heartland” starts at 2 pm in Lees Summit, MO. You should be there.

 http://www.ipetitions.com/petition/birthathome/index.html

382 2,451 4,899 signatures and counting..