Rise in California Maternal Death Rate Linked to Cesarean Sections: Why Aren't They Telling Us?

My brother, Richard, alerted me to an article in the San Francisco Chronicle yesterday with the head line "Pregnancy Related Death Rate on the Rise". It turns out a task force headed up by a scientist in the California Department of Public Health started a study back in 2006. There were gasps from the audience and basic disbelief when they reported their findings at an American College of Obstetricians and Gynecologists' conference in 2007. The attending doctors seemed to think it was implausible that in this day and age with all our current technology we could possibly be getting worse outcomes for mothers. (A side note is that we are also getting worse outcomes for our babies. The rate of "premature" babies that end up in our neonatal intensive care units is growing too!) They don't seem to see or perhaps they don't want to see that there is actually a link between the increase in technological birth and the bad outcomes. In 2008 a second study confirmed the initial study's findings.

And here it is 2010 and the California Department of Public Health has still not released this study to the public. In other words the very people, who most need to know about this study, the women every day who are getting cut open to give birth in our country, are being kept in the dark. We continue to be sold the myth that a cesarean birth is completely safe, even in some ways preferable to a vaginal birth. Our culture continues to promote the idea of choosing dates and scheduling inductions or cesareans without even any labor at all. Women continue to think this is a safe way to escape the pain of labor. Do you think this would be happening if women were advised by their doctors that their chance of DYING while giving birth would more than DOUBLE if they are induced or schedule a cesarean?

Although the study's findings have still not been released, a California Task Force has begun pilot projects to bring down the death rate. What are they doing? Encouraging the reduction of the induction rate! Why? Because studies show that an induction DOUBLES your chances of "needing" to have your baby come by major abdominal surgery.

In 2002 the Medical Director at one Orange County hospital instituted new guidelines for elective inductions; no inductions before 41 weeks of pregnancy. That means no scheduling an induction because that’s when Grandma will be in town or because the next week your O.B. is going on vacation. It also means women don't get to their 39 week prenatal visit and have the doctor cheerily inform them that they will put them on the schedule to be induced if they haven't had their baby by week 40. From my own experience I can tell you how critical that last week is for moms' bodies to prepare for labor. Their body chemistry is slowly building toward a perfect hormonal balance to begin and support a labor that will progress until their baby is born.

And what has happened at the Orange County hospital? They have fewer babies who need to spend their first days in a neonatal intensive care unit separated from their parents instead of bonding and breastfeeding at home. They have fewer maternal hemorrhages which is the leading cause of death for mothers during the birth process. And they have fewer emergency hysterectomies which is what they have to do to save her life if a woman is bleeding to death. The hospital has also seen its profits go down. Full O.R.s and neonatal units, and longer hospital stays for recovering moms equal big bucks. Remember having a baby by cesarean surgery is at a minimum twice as expensive.

Here it is by the numbers ladies:
California Maternal Death Rate 1996: 5.6 mothers die per 100,000 live births.
2006: 16.9 mothers die per 100,000 live births.
California's rate is even worse than the national rate which is 13.3. My guess as to why we are higher is a deadly combination of cultural factors, fear of liability by doctors and Hollywood stars fueling a "too posh to push" mentality.

Here is a question I would like answered. Where does the fact that we have gone back to the “once a cesarean always a cesarean” policy fit into this picture? How can a woman be an informed consumer when choosing between the risks of having a repeat cesarean versus the risks of trying for a vaginal birth after a cesarean if they are keeping the facts about the risks from us?

So if someone is recommending to you to schedule an induction simply because you are at week 40, or you are thinking about just picking a day for your baby's birth by signing up for a trip to the Operating Room, don't make your decision lightly because your life may depend on the decision you make. Consider first do you have any other indications that your health or your baby's health needs you to take this risky step? Is your blood pressure too high? Is your baby no longer growing or showing other clear signs of being in distress? Women will often be frightened by stories of healthy placentas magically turning into degrading placentas the moment they are at 40 weeks plus 1 day. Yes, all placentas will begin to break down at some point. For some women it will start at week 38 and for others at week 43. The only way to know about your placenta is to monitor the health of your baby through nonstress tests and ultrasound. Remember there are times when the very best choice for you and your baby is an induction or cesarean surgery but only if there are clear indications of current risk.

Read "Bodie's Birth" to hear a couples' story of a necessary cesarean section and how our system should work.

Bodie's Birth: An Example of How Our System Should Work

I am going to tell you the story of Bodie's birth because it is a good example of how I wish our system always worked. When I first spoke to Bodie's Mom she was looking for childbirth classes with someone who believed in natural childbirth and would be supportive of her choice to birth at home with a Licensed Midwife. We started the group classes at the end of October and I quickly learned what a sweet, intelligent woman she is.

Bodie's parents were seeing Edana Hall, L.M. for their prenatal care and planning a beautiful and peaceful birth at their home in Pismo Beach. Being a medical professional herself she was very clear on her reasons for wanting a homebirth. She explained, "Having worked in hospitals I can tell you they are a great place for sick people but if you aren't sick you don't want to go there. I'm not sick. I'm just pregnant."

As time passed I secretly began to hope I would be invited to their birth. I love going to homebirths. With all the hospital births I do, homebirths help me stay grounded to how women really birth. Even the "natural" births I help create at the hospital are not as empowering for the birthing women. I was sure this couple was preparing for a really special birth.

The first sign that everything might need to go a different direction was just over the horizon. Both her midwife and I had some concern about the baby's size and growth rate. We both had done the right thing and counseled the mom on her diet and she conscientiously made changes in her eating patterns. Her midwife also encouraged her to slow down at work and in life and focus on growing a healthy baby and Bodie's Mom did the right thing and followed her advice.

Eventually as the weeks passed and the baby's growth seemed to be slowing down in spite of the Mom's diligence her midwife did the right thing and sent her to Dr. Cedars, a local perinatologist, for testing. He discovered that the baby was in an alarmingly low birth weight percentile for the number of weeks gestation. Could her dates be wrong? No, Bodie's Mom was sure of her dates.

When the Midwife was told what the tests revealed she immediately did the right thing and told Bodie's Mom she was no longer a good "candidate" for a homebirth. Only healthy women with healthy babies should be giving birth at home. Bodie was no longer considered healthy. She gave the Mom the name of an O.B. for her to get in touch with right away.

Bodie's Mom chose to work with Dr. Yin. At her first appointment Dr. Yin did the right thing and explained to the parents about the need to monitor Bodie much more closely than another baby from now until he was born. Although understandably frightened they agreed that careful watching was necessary.

Putting aside her dreams of a homebirth was difficult even though she completely understood the gravity of the situation. Transitioning to the idea of a hospital birth was also scary. Her Midwife recommended she hire a Doula to guide her through this changing landscape and stand by her side. Bodie's Mom called me. I was invited to her birth but it wasn't going to be the birth I had been wishing for her.

Dr. Yin did the right thing when she advised Bodie's Mom to take it one week at a time. Perhaps things would turn around and the baby would do ok until closer to her due date. She might then be taken out of the high risk category. We hoped it would work out this way and Bodie could be born at French Hospital.

We worked together on things she could do safely and naturally at home to promote her body to move towards an inducible state. It began working and she began off and on to have mild contractions. But there came a day when through the appropriate use of technology it became clear it was riskier for Bodie to continue inside the womb than outside.

So Bodie's Parents did the right thing and checked into Sierra Vista Hospital where they have a Neonatal Intensive Care Unit at the level that Bodie might need. Mom was already having mild contractions. Her Doctor did the right thing by trying a different approach to the induction than simply hooking her up right away to pitocin. I worked with the parents and we did lots of walking the halls together.

At one point I stopped by the nurses' station to speak to their nurse. I explained I wanted her to know that once Bodie's Mom was in a more active labor I knew she was going to need to be monitored much more frequently than usual. The nurse was pleasantly surprised I felt that way. I expressed my concern about Bodie and my understanding that I knew he might not deal with the stress of real labor well.

Unfortunately that is exactly what happened. Shortly after starting into a more active labor pattern Bodie's heart rate was alarmingly up. This is a clear indication of stress. Our nurse hurried into the room and gave Mom oxygen, had her lie on her left side which is a position that is easier for the Mom to get oxygenated blood through to her baby, and called Dr. Yin. I explained what was going on to Bodie's parents and tried to began to prepare them for the emotional transition that their son might need to be born surgically. Lots of healthy babies have "funny" heart tones at times during labor and are born just fine vaginally but we all knew Bodie wasn't a healthy baby.

By the time the Doctor arrived the heart rate was back in the normal range. She wasn't alarmist and instead did the right thing by taking a let's wait and see approach. She stayed close by at the nurses' station where she could watch Bodie on the heart monitor. But it wasn't long before Bodie's heart rate began to climb again and it was clear how he needed to be born. I explained again to Bodie's Parents why this was now the safest option for their baby. Dr. Yin seemed surprised I was supportive of a cesarean.

What the medical staff didn't seem to realize is that an experienced Doula should know the difference between how healthy babies respond to labor and a compromised baby. A good Doula should champion staying the low tech natural path as long as the mom and baby are healthy. If mom or baby aren't healthy a Doula's role changes. She becomes a conduit for information about what is going on around the couple, since often the staff need to act quickly and don't have time to fill in all the details for the parents. The staff also doesn't have time to deal with the parents emotions but a good Doula meets that need as well. When plans change their is always fear mixed with grief that needs to be addressed. Life changes very quickly at that point.

So we all went to the O.R., Bodie's Mom first to be "prepped" while I waited behind with Bodie's Dad. This is a particularly difficult time for fathers. Very soon Bodie was out and it became clear there had been multiple issues contributing to Bodie's tiny size, none of which could have been prevented by anything his Mom could have done. There is nothing different that would have happened if she had chosen to see a Doctor for prenatal care or planned a birth in a hospital. Ultimately no matter what path she chose it would have lead her to that moment.

I am happy to report that beautiful Bodie has doubled in size in the few weeks since his birth. He is healthy and getting stronger everyday and so is his Mom.

This is how I wish our system always worked. This is how it is done in the Netherlands and they consistently have better outcomes than the U.S. All women are initially seen by Midwives. They assess them and determine if they need to plan a hospital birth with an O.B. or with a Midwife, or if they will be birthing at home with a Midwife. Each time prenatal care is given they are re-evaluating. Is she still a homebirth "candidate". If at anytime leading up to the birth or during the birth she is no longer a "candidate" they turn care over to the appropriate care provider. This care provider continues to work with the midwife and accords her the professional respect she deserves. After all she did the right thing.

Thank yous to Edana Hall, L.M., Dr. Cedars, Perinatalogist, and Dr. Elain Yin, O.B. for their quality care of Bodie and his Mother. I want to say an individual thank you to Dr. Yinn who took the time to get me re-connected with my mom down in the Recovery Room.

Diane's Poem

December 25, 1997

Jennifer,

When I try to put into words what we have achieved together, it seems so simple that the intensity is lost. I am left with emotions and the process which words can not recreate. Metaphors and poetry will have to suffice. . .

Thank you for offering your strength,

you became a safe harbor in a storm.

Thank you for seeing my vision

and allowing me to face my dragon

and ride it through the fire.

Thank you for sharing my excitement,

the magic of anticipation as the journey began.

Thank you for understanding each transformation,

as I became a person I did not know,

in a body no longer mine.

Thank you for cleansing my spirit,

as my body flowed from every pore.

Thank you for singing my song with me

and guiding it's harmony to follow nature's melody.

Wishing you love and peace this Christmas & New Year,

Diane

Lisa Ann & Tracy's Gift

November 13, 2004

Dear Jennifer,

Over the past few months, we have tried to think of some gift that would precisely express our deep appreciation for your part in our son's birth. Any item we could think of minimized this expression. We would like instead, for this letter, a gift of the heart, to serve our purpose.

The work you did with us prior to Grant's arrival was an important part of our journey. You partnered with us in structuring our dream by getting us ready for the most monumental event of our lives. In the birthing classes we learned valuable information, imparted to us with tender care. Our personal meetings with you brought all three of us closer. The teaching we received about what to expect, how to prepare, how to ready ourselves as a couple, was invaluable. Though our birthing experience was surprising, we were as well prepared as possible thanks to your excellent instruction. But the word "instruction" doesn't speak to the heart you put into your work. You are so much more than a teacher and coach.

Our birthing experience was powerful and precipitous. We know it would have gone much differently had you not been a part. You kept us on track, you remembered our requests, and you honored the reality of what we were experiencing. We couldn't have asked for anything more than what you gave. You gave of yourself Jennifer and we can never equally repay you.

We believe that when we look into our son's bright, alert, attentive eyes-that you are partly responsible for that look. You kept us drug free! That is true even before the delivery as you worked with Lisa Ann on some health issues. You gave us an honorable birth. You walked with Lisa Ann into an inferno and helped her find a place she could survive. You steadied Tracy as he looked on as his son tore into the world much more frighteningly than we could have imagined. You maintained our dignity as you worked with us to create the birth you rememberd we wanted. In your own words, you gave us as much of our dream as you could.

You have become much more than a birthing coach. You are a friend. whatever paths our lives take, you will always have a special place in ours. How can we look at our son without remembering you? You have a gift and what you do is an artform. We know you put your heart and soul; into it and we want to recognize you for this immense effort.

Thank you Jennifer, for your part in Grant's arrival. Thank you for your care in the hospital and in the days afterward. Thank you for your continued presence in our lives. You are an angel.

With loving gratitude,
Lisa Ann & Tracy

Birth & Baby Resource Network’s Parenting Night

Confused by all the conflicting advice in baby books and parenting manuals? Looking for a way to raise children with close family ties while nurturing their independence? Come learn how to integrate the principles of Attachment Parenting into the current American family culture. This will be an informal evening of sharing and discussion with other parents giving practical advice and common sense tips. Hear about the why, how, and how did that work out for you on these topics: family bed, baby wearing, pediatric alternative health care, baby led weaning, elimination communication, breastfeeding beyond a year, homeschooling, positive discipline and more. Do you need support for making any of these “different” choices for your children? Join BBRN on Tuesday February 23 at 7 p.m. at the San Luis Obispo YMCA, 1020 Southwood Blvd. This event is part of BBRN’s free monthly education nights. Go to www.bbrn.org to find the month’s topic. Babies and children are always welcome!