Midwives question the rise of c-sections



Debates have been roiling in health care circles nationwide over the standard of care for delivering babies.

“Surgery can save the lives of mothers and babies, but it is by no means the safest mode of delivery.” — Linda Robinson, certified nurse/midwife
“Surgery can save the lives of mothers and babies, but it is by no means the safest mode of delivery.” — Linda Robinson, certified nurse/midwife

In eastern Maine earlier this year, Bar Harbor-based certified nurse/midwife Linda Robinson got lots of Mainers talking about the issue as a result of her letter to the editor in the Mount Desert Islander that was printed following her departure from Mount Desert Island Hospital.

“I was not ready to retire, but I can’t accept the direction women’s health is heading. There is temptation to expedite births with intervention, creating risk and consequences…,” she wrote. “Surgery can save the lives of mothers and babies, but it is by no means the safest mode of delivery.”

In the United States, about a third of all babies are now delivered by surgical cesarean section, compared with 5 percent in 1970. In the medical field, the dramatic rise in cesareans results from the drive to standardize care, increase efficiency and minimize risk. Natural births, critics note, lower medical costs and result in better health to babies and mothers.

“I decided to become a midwife when I was working with midwives in Malawi, Africa, when I was a Peace Corps volunteer there in the ’70s,” Robinson told Health Quarterly. “I saw what great care they gave to women and how much less invasive the deliveries were. It was so different from my OB experience in the states I wanted to emulate that here.”

Certified nurse/midwife Renata Moise delivered this baby last spring at Maine Coast Women Care in Ellsworth.
Certified nurse/midwife Renata Moise delivered this baby last spring at Maine Coast Women Care in Ellsworth.

The World Health Organization (WHO) and the American Congress of Obstetricians and Gynecologists (ACOG) have both revised their recommendations regarding C-sections in recent years, according to a 2012 Harvard magazine article by Nell Lake.

In 1985, WHO set an ideal cesarean rate of 15 percent, about half the current rate in the United States. In 2009, it modified that position, saying no optimum rate is known but that “both very high and very low rates of cesarean section can be dangerous.”

In the 1990s, the ACOG issued a recommendation against vaginal births after c-section. As a result, a mother whose first child is born by c-section was virtually guaranteed to have any subsequent children by cesarean as well. ACOG officials also said that hospitals offering vaginal births as an option needed to have a surgeon and anesthesiologist immediately on hand for emergency surgery — a high bar for small and rural hospitals. The group revised its position in 2010, with guidelines saying vaginal births and a trial of labor after a C-section are appropriate in many cases.

Risks associated with C-sections include infection, chronic pain, difficulty breast feeding, depression and blood clots that can lead to death, Robinson said. Of course, natural births have risks too. Providers worry about uterine rupture, a tear in the uterine wall, often at the site of a previous C-section scar. The rupture causes severe bleeding for the mother and oxygen loss for the baby, creating risk of brain damage.

“If the result is life-long brain damage to a child, who is willing to take that risk?” Dr. Barbara Levy, vice president of health policy at ACOG, told The Atlantic magazine last year. “Can we —knowing that that is a risk — put policies and procedures in place that don’t obviate that risk? And I think that’s the fundamental issue. Who is going to take the liability?”

C-sections are sometimes performed when, in a vaginal birth, a “failure to progress” or “obstructed labor” is determined. Midwives are more likely to be willing to wait out a longer labor and less likely to recommend interventions such as inducing labor. They’re trained in non-surgical interventions and non-cesarean rescues with which obstetricians have become less familiar as C-sections became more common.

“Cesareans have increased because in some cases they were essential for preventing the worst outcomes, because they followed other interventions, were relatively easy to teach and perform, and were unlikely to provoke lawsuits,” Lake wrote in the Harvard magazine article. “Attaining an optimal C-section rate may be a matter of finding a middle ground between two approaches to bir

Certified nurse/midwife Lauren Hunter
Certified nurse/midwife Lauren Hunter

th and risk —between vigilance toward the ‘disaster waiting to happen’ and support for the ‘physiologically sound process.’ That way, surgery happens when necessary, but is avoided in many cases when it’s not.”

MDI Hospital plans to hire another Certified Nurse Midwife to join the team at the Women’s Health Center in Bar Harbor following Robinson’s departure. In the Maine Coast Memorial Hospital system, smaller facilities such as the Blue Hill Memorial Hospital no longer offer birthing services.

“It’s expensive to pay a staffer when the census is low and there isn’t a big population of childbearing women,” Robinson said. “The larger hospitals still provide care but women have to travel long distances to get there.”

Maine Coast Women Care at MCMH in Ellsworth is a Level 2 birthing facility. Four midwives are on staff there and each attends a significant number of the deliveries, Certified nurse/midwife Lauren Hunter says. They also teach birthing classes and provide other support.

“That’s the great thing about being a midwife,” she wrote. “You actually get to spend more time with patients and work with them to make their birth a great experience. It’s a special event in their life and we intend to make it the best it can be.”

First Light Community Midwives offers home-birth options in Hancock County and beyond. First Light’s Certified Professional Midwives Chris Yentes and Julie Havener report very low C-section rates.

 

Liz Graves

Liz Graves

Reporter at Mount Desert Islander
Former Islander reporter and editor Liz Graves grew up in California and came to Maine as a schooner sailor.
Liz Graves

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