Sunday, January 20, 2013

My Birth Statistics: 2010 through 2012

Statistics are an interesting animal. You can shape them or skew them various ways. They are used by many people to prove points or to motivate or even manipulate people into taking an action they desire. When asked about statistics on issues such as risks associated with a possible course of action doctors often answer with non-answers. Many times I have heard doctors say, "if it is your baby that dies the risk was 100% not worth taking" or "I only recommend this or do this procedure when it is necessary." They rarely give couples what percentage of their clients do they deem it necessary to do the procedure on, or how that compares to a local, national or global average. They certainly don't offer the parents what studies have proven the statistic should be based on best outcomes for mothers and babies. Those studies weigh the risks of both doing and not doing any given procedure.


For cesarean section the World Health Organization took a global look. Because they are a world-wide organization they looked at poor countries with low access to cesareans and wealthy countries with lots of access to cesareans. Their studies say a cesarean rate of between 5 to 10% of births is ideal and further when you get beyond 15% you are now doing more harm than good to mothers and babies. My total rate has increased from 15% to 17%. My rate in the last 3 years alone, when calculated as I believe WHO intended: total number of births and number of cesareans for any reason, is a depressing 22%. My numbers prove to me what my gut had been sadly telling me for a while; it has gotten harder to keep women out of the operating room. When looking at my statistics is important to remember how few births I attend; 27 since 2009. An individual birth has the ability to shift my rates wildly. But let's put my numbers into context.

Here is the national trend.

Here is the state trend.

But as I said numbers can be shaped many ways. Let's compare my section rate not using WHO's way of compiling statistics. Instead let's use the way California compiles their stats. They choose to not include breech babies, twins, premies and abnormal presentation. Abnormal presentation seems so vague to me it could include posterior babies (facing the wrong way), babies with a hand coming beside their faces (compound presentation) and babies that don't get their heads lined up just right (acenclytic). I have had all of these over the years and most but not all of them came through their mama's pelvis just fine. Using this system of exclusion my rate for the last 3 years plummets to 7% while California's is shocking.

OK now I'm not feeling so bad and a lot less frustrated. But wait! Maybe this doesn't reflect me at all. Maybe we just have really great providers and hospitals? Using identical parameters of exclusion in the statistics here are our local hospitals 2011 rates:

 French 21%
Sierra Vista 32%
Twin Cities 22%
Marian 30%

Now I'm definitely feeling better about my 7%! Let's not forget that I have done births at all of these hospitals in the last 3 years interacting with the staff and working within their individual medical establishment cultures. Don't forget to factor in that my clients use a variety of care providers, 15 in the last 3 years; from the ones who never saw an intervention they didn't like to the most
hands-off low-tech midwives. I've supported high risk moms and teen moms. I've had women hire me 1 week before their birth, 1 day before their birth and 2 this year during their births! Fifty-six percent of my moms were having their first babies and only one of them ended up having a section because of failure to progress.
Now let's compare my primary (first time) cesarean section rate to our hospitals rates. Using their compilation methods I have a 4% rate. The local hospitals 2011 rates:

French 12% 

Sierra Vista 18%

Twin Cities 10%

Marian 16%

Because I go to whichever hospital my client's choose for a birth place, 41% of my births took place in the 2 hospitals with the highest surgical birth rates.

But numbers are just a snap shot. They certainly don't tell the whole story. Let's look back at my true total of 17%. Ten percent of those aren't included in the numbers above. What are their stories? Some moms had a herpes outbreak and felt it was safest for their baby to be born via surgery. A small number were failed v-bacs. About 1% were failed inductions for one reason or another. In the last 3 years I had 2 un-diagnosed breech babies. Both moms labored great but when their baby's position was discovered a cesarean was performed. I had a high risk mom go into labor with her premie baby the day after we first met. Another was a mom trying for a vaginal birth after her first child was a cesarean baby. After laboring at  home and in the hospital for a long time she ultimately had a second section. This time I was able to explain to her exactly what was going on inside her pelvis which made her babies need to come through an incision in her belly.

This last mom called me because her doctor had said her baby was too large and scheduled her for a section for the next day. She was in a panic. We both worked very hard for a week trying to find a care provider willing to take her and let her try for a vaginal birth whom her insurance would cover. We couldn't find one and after an exhausting week of discussions with her doctor she ultimately chose to have a scheduled cesarean. I was with her as much as Marian Hospital would allow and helped her become one of the first moms to latch her baby on in the recovery room immediately after her surgery. 
But women have lots of worries about more than just cesareans. Here are my statistics which speak to those issues; the dreaded pitocin, its connection with induction and the need for pain medications!


Since 2010 I have had 22% of my mamas use pitocin at some point during their birth process; either to induce labor (7%) or to move a labor along (15%). This represents a significant increase from my past 14% rate. On closer inspection I see the change has come in my use of pitocin to augment or move a labor forward. 


My induction rate has held steady since 1993; 7%. The only reason for induction in the last 3 years has been because their water had broken and we couldn't get labor rolling with natural methods. All of these women were able to labor without resorting to pain medication and birthed vaginally. 


Between 1993 and 2009 7% of my clients opted to use pitocin to augment their labors. But in the last 3 years 15% utilized pitocin to try to make progress during a stalled labor. Half of the stalled labors, or 7.4%, were transferred into the hospital after a planned out-of-hospital birth. Fifty percent of those transfers ended with a vaginal birth. 

Pitocin plus Pain Medication

The other 7.4% who augmented their labor with pitocin had chosen to take pain medication and then their labor stalled. Ultimately all of these women birthed vaginally. My hat is off to the 33% of my moms who labored on pitocin without pain medication. I am in awe.

This amazing mama successfully navigated a high risk pregnancy, a pitocin induction for broken waters and a vaginal birth in the operating room; all without pain medication!

Pain Medication 

Speaking of pain medication... let's see what my numbers say about the issue. Since 2010 I have had 19% of my moms choose to use pain medication of some sort during their labor. This is up from my 1993-2009 rate of 11%. Not what I had hoped for but to put it into perspective I looked up the official epidural rate in California in 2012. Turns out it was 42%. It is hard for me to believe this is an accurate number considering how ubiquitous epidural use has become in our culture. Digging into it further I see that in 100% of the cases my moms chose pain meds, pitocin was involved; either before or after. It turns out 10% of my moms opted for pain medication and then ended up on pitocin and 10% of my moms needed pitocin and then chose an epidural to  help them cope or as part of an over-all strategy to make forward progress during their birth. I don't know how that compares with the rates for California or our individual hospitals. They don't break their rates down this way.   

Speaking of a doula I am always pushing the boundaries of the places and providers that my clients have chosen. This usually involves giving moms the information they need to confidently say no to routine policies that are not based in evidence-based practices, such as the 40 week automatic induction or rigid guidelines on fetal heart monitoring. One of the areas my clients and I have been pushing is gravity enhanced non-traditional pushing positions, i.e. birthing on hands and knees, in a squat and standing. I have felt that I wasn't getting anywhere with this issue but the numbers tell a different story. I am happy to say 15% of my moms in the last 3 years have birthed within a traditional setting using a non-traditional position. This is a testament to the strength of will and confidence of those mamas. If I was at all instrumental in creating that to happen I am satisfied.    

This beautiful 9 pound 4 ounce baby boy was born quickly and easily as his mother stood beside her hospital bed.

By the Numbers
27 births
55% first time mothers 

Total Vaginal Birth Rate: 78%

Adjusted Vaginal Birth Rate: 93%
        (See above story for explanation of adjustment)

Adjusted Vaginal Birth Rate First Babies: 96%

Spontaneous Start of Labor: 93%

Total without Pain Medication: 81%

Pain Medication after Pitocin: 10%

Labor without Pitocin Augmentation: 85%

Labor without any Pitocin: 78%

Successful VBAC Rate: 50%

Looking at it another way...

Total C-section Rate: 22%

Adjusted C-section Rate: 7%
    (See above story for explanation of adjustment)

Adjusted Vaginal Birth Rate First Babies: 4%

Total Pitocin Rate: 22%

Pitocin Induction Rate: 7%

Pitocin Augmentation Rate: 15%

Total Pain Medication Rate: 19%

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