Turning the Tide for Birth

Abstract

In this column, the editor of The Journal of Perinatal Education discusses the escalating cesarean surgery rate and the need for evidence-based practice changes that support vaginal birth after cesarean. The editor also describes the contents of this issue, which offer a broad range of resources, research, and inspiration for childbirth educators in their efforts to promote natural, safe, and healthy birth practices.

Wendy C. Budin

Editor

In the past 6 months, 6 out of 6 women who I know gave birth to their first baby, all by cesarean. That translates to a cesarean rate of 100% for this small subset of the population. What is going on? All of these women were young, healthy, well prepared, and hoped to have a natural birth. If one was to ask the reason for their cesarean, I am sure that each woman would say it was due to medical indications. One cesarean was scheduled because of a breech presentation, three were due to failed inductions, and two were because of failure to progress during labor and the physicians' expressed concerns about the babies' well-being.

Chances are pretty good that, if things don't change in the current health-care system, each of these women will have repeat cesarean surgery for future pregnancies despite evidence that, when properly managed, a vaginal birth after a cesarean (VBAC) is no more dangerous than a repeat cesarean (Guise et al., 2004). In fact, although many cling to the long-held belief that “once a cesarean, always a cesarean” because of fears that the uterine scar might rupture in a subsequent labor, an expert panel in 1980 declared that it is safe for many women to give birth vaginally after a cesarean (National Institutes of Health, 1980). Consequently, the VBAC rates reached a high of 28% in 1996. However, since 1996, for reasons that are not entirely clear, VBAC rates in the United States have consistently declined, while cesarean rates have been steadily rising (Agency for Healthcare Research and Quality, 2010). Many critics say doctors perform too many unnecessary cesareans, exposing women and babies to surgical risks. The current national cesarean rate of 31.8% (Menacker & Hamilton, 2010) is thought to be fueled in part by repeat patients. Although there is no consensus on what the cesarean rate should be, the World Health Organization (1985) still suggests a goal of 15% in low-risk women.

As I write this editorial, the National Institutes of Health is preparing for a consensus development conference in Bethesda, Maryland, about the country's dismal VBAC rates. The purpose of this conference is to evaluate the available scientific information on VBAC and to develop a statement that advances understanding of the issue under consideration and will be useful to health professionals and the public. The goal is to come to consensus about what the rates and patterns should be for trial labors, VBACs, and repeat cesarean surgeries as well as the short- and long-term benefits and harms to the baby and mother who attempt a trial of labor after a prior cesarean versus elective repeat cesarean surgery, and relevant factors influencing each. By the time this issue of The Journal of Perinatal Education is published, we hope we will have some answers to these questions, and perhaps we can begin to turn the tide for birth.

IN THIS ISSUE

We are excited to carry over the theme of cesarean surgery and VBACs into this issue's “Celebrate Birth!” column and our guest editorial. Continuing the practice of advancing Lamaze International's mission to promote, support, and protect natural, safe, and healthy birth by sharing birth stories, this issue's “Celebrate Birth!” column features two birth stories. The first story is about a new mother who chose to have a planned home birth. With the support of her husband, her midwife, and her doula, Katherine Taylor labored at home for 48 hours before transferring to the hospital where her baby was born by cesarean about 20 hours later. Confident and supported, Taylor and her husband were able to make informed decisions and have a positive birth experience, although it was not what they had planned. In the second “Celebrate Birth!” story, Stephanie Berger, a second-time mother, describes how she used a combination of comfort measures and hypnosis for childbirth to achieve a medication-free birth. Throughout the birth, this mother remained calm and did not experience pain, thanks to her practice with perinatal yoga and the Hypnobabies method of childbirth.

In this issue's guest editorial, Desirre Andrews and Gretchen Humphries discuss how the discrepancy between the evidence supporting VBAC and actual medical practice illuminates the larger issues of evidence-based care versus current obstetrical practice. Andrews and Humphries suggest that although the reasons for the disconnect between what we know to be healthy birth practices and what women actually experience are multiple and complex, a commitment to providing accurate education, truly client-centered support, and active patient advocacy will give women the ability to insist on best practice care for themselves and their babies.

The featured articles in this issue span topics that include spirituality in childbirth, adolescent pregnancy, and a lesson from Lamaze's history. In their article “Spirituality in Childbearing Women,” Lynn Clark Callister and Inaam Khalaf describe how childbearing is the ideal context within which to enrich spirituality. The purpose of their study was to generate themes regarding spirituality and religiosity among culturally diverse childbearing women. The following themes emerged from the data: childbirth as a time to grow closer to God, the use of religious beliefs and rituals as powerful coping mechanisms, childbirth as a time to make religiosity more meaningful, the significance of a Higher Power in influencing birth outcomes, and childbirth as a spiritually transforming experience.

Josephine DeVito presents findings from a secondary content analysis of data from a study on how first-time adolescent mothers feel about becoming a parent. The purpose was to explore and, in turn, better understand first-time adolescent mothers' meaning and experience of parenting during the 4-to-6-week postpartum period. Three themes emerged: “Being Caught Between Two Worlds,” “Feeling Alone and Desperate,” and “If I Knew Then What I Know Now.” Findings revealed many adolescent mothers are unprepared to take on the demands of parenthood and, so, need extra guidance, instruction, and support.

In the article “A Chapter From Lamaze History: Birth Narratives and Authoritative Knowledge in France, 1952–1957,” Paula Michaels analyzes birth narratives gathered during what can be considered a formative period of the Lamaze movement in the West: from 1952 through Fernand Lamaze's death in early 1957. The use of women's birth narratives as an assessment tool is one of Dr. Lamaze's most enduring contributions to obstetric pain management. The early work of Lamaze and his collaborator Pierre Vellay provided a template for studies conducted elsewhere for decades to come. Michaels explains that by examining expectations in another time and place, our own standards, so often normalized to the point of invisibility, are thrown into sharp relief. Her article addresses the conflicting and contested nature of authoritative knowledge surrounding parturition.

In this issue's “Tools for Teaching” column, Barbara Hotelling describes how collaborative efforts and coalitions have replaced exclusivity as birth organizations and individuals unite to humanize birth and provide women with transparency of information about maternity care providers and facilities and about access to the midwifery model of care. Hotelling highlights two excellent examples of collaborative efforts to support natural, safe, and healthy birth practices as well as women's choices in childbirth: the Coalition for Improving Maternity Services and the upcoming 2010 “Mega Conference” to jointly celebrate the 50th anniversaries of Lamaze International and the International Childbirth Education Association. Hotelling makes a case for childbirth educators to learn from and support national coalitions devoted to improving maternity care and to use local resources to develop their own collaborative efforts on behalf of childbearing families.

In the column “Ask an Expert,” Nayna Philipsen explains how protecting the confidentiality of the personal information that childbirth educators receive from their clients is crucial. Without this respect for privacy, educators will not be able to get the information essential to meeting their objectives. Childbirth educators who work in schools or are employed in a health-care facility may come under federal law that protects individuals' personal or health information. All childbirth educators must be thoughtful advocates of the rights to privacy and self-determination of expectant parents.

Author Amy Romano reprises recent selections from Lamaze International's research blog, Science & Sensibility, in her column “Creating a Culture of Consumer Engagement in Maternity Care.” Each selection discusses opportunities to establish a culture of consumer engagement in maternity care. Romano demonstrates how improving health literacy, ensuring multi-stakeholder participation in the development of clinical guidelines, and supporting comparative effectiveness research of woman- and family-centered care practices may improve maternity care.

In this issue of the journal, instead of our usual “Media Reviews” column coordinated by Teri Shilling and Stacie Bingham, we are excited to share a review by Tamara Kaufman, “Use of Big-Screen Films in Multiple Childbirth Education Classroom Settings.” Kaufman gives examples of how two recent films, Orgasmic Birth and Pregnant in America, can serve as valuable teaching resources in multiple childbirth education settings, even though the films were intended for the big screen.