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More Information on Quality of Care

Guide to Avoiding Unnecessary Cesarean Sections in New York State

April 21, 2010

Sidney Wolfe, M.D.
Public Citizen Health Research Group

Full report as a pdf
Statements from press conference

Introduction
Objectives
Methods
About New York
Variations in Cesarean Sections, VBACs, and Midwife Availability by County and by Hospital Within Each County
Healthy Outliers: Two New York Hospitals that Have Bucked the Trend
Factors Possibly Associated with Variation in Rates
What is Driving Cesareans in New York?
How a Woman Can Avoid an Unnecessary Cesarean in New York State
What Health Departments and Hospitals Can Do to Reduce Unnecessary Cesareans
New York Hospital Birth Statistics by County

How a Woman Can Avoid an Unnecessary Cesarean Section in New York State

The Story of Rachel and Donald vs. the Obstetrician-Gynecologist Establishment: Midwife to the Rescue

Although woman’s choice of prenatal care may be a decision with far-reaching consequences, it is a decision often made with limited information. Women often rely on word-of-mouth or convenience, giving limited attention to other factors. The following vignette summarizes how choices can be framed, with cesarean section being the default for some practitioners. But it also suggests the pressing need to explore other birthing alternatives.

The following true story did not occur in New York State but it is included to illustrate the extent to which some obstetricians and their staffs are attempting to push unnecessary cesarean sections.

Rachel and Donald were expecting their first child. Rachel chose her obstetrician-gynecologists on the recommendation of her sister-in-law, who had had four cesarean sections with the same obstetrician-gynecologists, a father-daughter team. When Rachel was 31-33 weeks into her pregnancy, she was asked, during an office visit, if she wanted to schedule her cesarean section. She said that she wanted to give birth vaginally if possible, and was told by the receptionist that “nothing is ever the same down there” if she delivered vaginally.

At Don’s instigation, Rachel scheduled a special appointment with her physician so that the three of them could discuss her delivery. When Don expressed his concern concerning a surgical delivery, the doctor got very defensive and aggressive. She scared Rachel by describing the potential side-effects of vaginal birth as if they were very common: vaginal tears, uterine rupture, incontinence, loss of sexual satisfaction. Rachel ended up in tears and Don was very upset. They resolved to find a different practitioner, one more attuned to their needs and expectations concerning delivery.

Because it was a late switch, and Rachel had been told that she was 3 centimeters dilated and 75 percent effaced at 34 weeks, there was some urgency in finding another practitioner. Rachel and Don reached out to a midwife who was recommended as being ethical, trustworthy and good. By then Rachel was 36 or 37 weeks into her pregnancy, and had found out that the baby was an “oblique breech.” If that was the case and Rachel was therefore going to undergo a cesarean anyway, she was inclined to stay with her original doctor. But an ultrasound confirmed that the baby was okay, so she elected to have the midwife deliver her baby.

The midwife said that there was no way Rachel could have been as dilated or effaced as she had been told. Indeed, Rachel had to be induced just short of 42 weeks. The midwife attended her birth of a health baby boy, 7lbs, 7oz.

Although this actual case demonstrates the extremes to which some obstetricians will go to convince women to have unnecessary cesareans, there are many less extreme cases in which obstetricians are also performing unnecessary cesareans.


There are some things a woman can do to avoid an unnecessary cesarean section in New York State.

1. Talk to your doctor or midwife early about your preferences. Do not hesitate to let either know what you want and expect. She/he should hear you out and discuss what is best for you, based on your individual circumstances and those of your baby. If there are any major discrepancies concerning your respective perceptions of risks and benefits, these should be fully aired. If you are not satisfied that you have been provided with complete and accurate information, you should consider finding another provider.

2. Use the data in this report to find the overall, primary and VBAC rates in the hospitals you are considering using for your pregnancy (See Table 2). In addition, it is important to also ask for information specific to the obstetrician(s) or midwife you are considering using because there may be considerable variation within hospitals among obstetricians or between obstetricians and midwives. A hospital with a relatively low cesarean rate may have obstetricians with high rates and vice versa.

Fortunately, New Yorkers have a valuable source of information that is not available to women in other states. NYS Public Health Law section 2803 requires that every hospital and birth center provide each prospective maternity patient and the general public an informational leaflet with data on maternity care and insurance coverage. The hospital and birth center must also provide statistics on its maternity-related procedures. These include data on cesarean rates, successful VBACs, midwife-attended births, use of fetal monitoring, use of forceps and analgesia, anesthesia, births delivered vaginally, induced deliveries, use of augmentation of labor and episiotomies, availability of birthing rooms and  facilities for rooming-in. This report uses these data to make comparisons not otherwise available to women in New York State.

3. Consider using a certified nurse-midwife or certified midwife. From 1981 to 2006, there was a 5.6-fold increase in the number of midwife-attended births, from 56,000 a year to 311,000 a year in the United States. The percentage of all hospital births attended by midwives rose from 1.53 percent in 1981 to 7.46 percent in 2006, a 4.9-fold increase in the percent of deliveries by midwives.[1]

Of the 143 hospitals listed in this report, 99 have midwives doing deliveries, ranging from 0.1 percent of births at St. Catherine of Siena Hospital and North Shore University Hospital to 79.8 percent of births at North Central Bronx Hospital (See Table 2 to find out if your nearby hospital has midwife deliveries). In New York State in 2007, there were 23,968 midwife-assisted births. Out of a total of 250,780 births that year, the percentage delivered by midwives was 9.6 percent. Even in hospitals with high overall cesarean rates, choosing a midwife will very likely decrease the chance of an unnecessary cesarean section since the likelihood that a cesarean will be needed is generally less with midwives than with obstetricians.

In New York State, all midwives must meet certain criteria in order to practice. These are:

  • A bachelor’s degree (in any subject)
  • Midwifery education at a NYS-approved midwifery school
  • Demonstrated competency in particular areas related to well-woman care and pharmacology
  • Passing the American Midwifery Certification Board (AMCB) examination.

In a study we did surveying national hospital-based midwife deliveries and reviewing the published literature, we found that, in hospitals with both obstetrician and midwife deliveries, the following practices were much more likely to occur with midwife-assisted deliveries than with obstetrician-attended deliveries:

  • Oral fluids during labor
  • Room to ambulate during labor
  • Use of shower, bath, or hot tub
  • Encouragement of alternate positions for delivery
  • Use of intermittent, not continuous fetal monitoring (less chance of false signals of fetal distress)
  • Shorter stay and early (24 hours or less) discharge[2]

These factors contribute to the findings in multiple studies showing that the likelihood of induction, episiotomy, or a cesarean section is generally lower with midwife-attended deliveries than with obstetrician-attended deliveries.

A recent study involved women with pregnancies that were considered low-risk enough to qualify for a home delivery but all of whom delivered in the hospital. Four hundred eighty-eight of these women had hospital midwife deliveries, and 572 had hospital physician deliveries. The decreased risks in the midwife group included a 42 percent reduction in cesarean sections and a 38 percent decrease in episiotomies. There was also an 81 percent decrease in the use of drugs for resuscitation at birth. The authors concluded that: “A shift toward greater proportions of midwife-attended births in hospitals could result in reduced rates of obstetric interventions, with similar rates of neonatal morbidity.”[3]

4. Consider using a doula. If a certified nurse-midwife or certified midwife is not available in the hospital(s) you are considering using, think seriously about using the services of a doula (continuous labor support by an experienced woman) in conjunction with your doctor. A published study evaluated the positive effects of doulas on childbirth. Among 224 women with an uncomplicated pregnancy who took a childbirth education class, half were randomized, after admission for labor, to doulas, who provided close physical proximity, touch, and eye contact with the laboring woman, and teaching, reassurance, and encouragement of the woman and her male partner. The other half of the women served as a control group. “The doula group had a significantly lower cesarean delivery rate than the control group (13.4 percent vs. 25.0 percent). Among women with induced labor, those supported by a doula had a lower rate of cesarean delivery than those in the control group (12.5 percent vs. 58.8 percent).”[4]

Finding a Midwife in New York State

The following sources may be useful in providing background information and locating midwifery services*:

www.midwife.org/find.cfm
This will take you to the website for the American College of Nurse-Midwives, which represents all certified nurse-midwives (CNMs) and certified midwives (CMs). The organization is divided into regions; Region II includes New York State. Inserting your location (zip code) will provide you with a list of sites that provide midwifery services, including information on how they may be reached. You can also indicate the type of birthing site you prefer, and the list will be restricted to that category.

www.childbirthconnection.org
Childbirth Connection (formerly the Maternity Center Association) is a not-for-profit organization dedicated to improving the quality of maternity care through research, education, advocacy, and policy. Its website has a lot of information on pregnancy and childbearing, including different modalities of maternity care. It also has useful summaries of the risks and benefits of different types of delivery.

www.mana.org/memberlist.html
This is the website for the Midwives Alliance of North America, an organization of midwives and midwifery advocates. It will provide a state-specific list of its members upon request.

www.birthpartners.com
This site seeks to provide information on “natural childbirth options in your area.” This commercial site advertises a variety of practitioners and includes listings of midwives, doulas, childbirth educators, breastfeeding support, and other services

Four universities offer midwifery training in New York State. These are Columbia University, New York University, Stonybrook University, and State University of New York (SUNY) Downstate Medical Center (in Brooklyn). 

Fifty-one (51) cities in New York have midwifery services available. These include persons who provide home, birth center, or hospital births.

* Public Citizen is not responsible for the content of the listed websites.



[1] "Table 1-24. Live Births by Place of Delivery, and Attendant, According to Race and Hispanic Origin: United States, Selected Years, 1975-2003." CDC. Web. <http://www.cdc.gov/nchs/data/statab/natfinal2003.annual1_24.pdf>.

[2] Gabay, Mary, and Sidney M. Wolfe. "Nurse-Midwifery. The Beneficial Alternative." Public Health Reports 112 (1997): 386-94. Print

[3] Janssen, Patricia A., Elizabeth M. Ryan, Duncan J. Etches, Michael C. Klein, and Birgit Reime. "Outcomes of Planned Hospital Birth Attended by Midwives Compared with Physicians in British Columbia." Birth 34:2 (2007): 140-47. Print.

[4] McGrath, Susan K., and John H. Kennell. "A Randomized Controlled Trial of Continuous Labor Support for Middle-Class Couples: Effect on Cesarean Delivery Rates." Birth 35.2 (2008): 92-97. Print.

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