It’s a decision that’s on the rise. 15 years ago only about 20 percent of women had c-sections. Now, 32 percent give birth this way. The reasons are varied … some doctors worry about law suits after vaginal birth complications … sometimes the reason is cosmetic for women ….

“‘Is having a vaginal birth going to damage me and then I’ll need cosmetic surgery? Maybe if I do c-section I’ll avoid that,” Dr. Melhem proposed a hypothetical. “Again, misconception.” …

“… convenience plays a big part of it. I think doctors want the baby born on his time schedule and I think moms play a part in it. They want the convenience of deciding what day and time they want their babies to be born,” …

The whole trend raises concerns … with every c-section there’s more risk for complications like uterine rupture and infection.

The ban aims to close the loop on what is already a stringent policy on VBACs in Florida. To have a non-surgical birth after a C-section, women are compelled to go to hospitals that permit it (which are not accessible throughout the state), or, if a physician signs off on the procedure, they can have one at home with the guidance of a licensed midwife. VBACs currently don’t occur in Florida birthing centers because of what is being a called a “de facto ban” due to outdated language in the state regulations. The language, which will be updated this week, will turn the ban from de facto to explicit—making VBACs illegal in all of Florida licensed birthing facilities.

Miriam Pearson-Martinez, a licensed midwife who serves on the Pushing for VBAC committee of BirthGirlz, said that the organization has hired an attorney and will file a legal challenge to the ban when the AHCA moves to amend its regulatory language.

“We believe that the role of our law, and the agency’s duty, is to provide access to birth centers, not limit access, and that this ban is outside the scope of its role,” Pearson-Martinez said.

She noted that licensed Florida midwives are legally permitted to oversee VBACs, so long as a physician signs off on it, and that not all birth centers are owned by midwives—marking the ban as a move that conflicts with legal activities.

The AHCA contends that this week’s adjustment is merely cleaning up its language, rather than an attempt to make any new restrictions on VBACs, birthing centers, or midwives …

“I might be able to believe that, but at the same time … the AHCA intends to reduce the maximum number of births a woman can have before she is allowed to use a birth center. While before a woman who had seven births can have her eighth child at a birth center, she now will not be able to do so if she’s had more than five births.

… the ban is troubling, especially given recent statistics that reveal a 12% chance of something going wrong with a VBAC in a hospital setting, compared to a 4% chance in a birth center.

“There’s not a single statistic that justifies this (ban),” …by restricting women’s ability to give birth where she chooses, the Florida policy will lead to dangerous consequences—including women having unassisted births at home or the prosecution of licensed midwives.

“Throughout history, the traditional medical field has frowned upon midwives, and this (ban) seems to be taking another step to maintain the power of their industry,” … “It seems like a ploy for doctors to say this is one more thing midwives can’t do, one more thing to have control over.”

Nationally, VBAC rates have declined since 1996, while the delivery rates for cesareans are increasing … cesarean deliveries in 2005 are at the fourth highest rate of the world’s developed nations, behind Italy, Mexico, and Korea. This rate is exacerbated by the American College of Obstetricians and Gynecologists 2004 recommendation that women not attempt a normal birth after a C-section if a hospital does not have round-the-clock obstetrics and anesthesia backup. Likewise, medical practitioners’ fear of being sued if something goes wrong with the procedure has also discouraged VBACs.

… about 45% of hospitals in the United States formally ban VBACs either explicitly or through unsupportive policies and procedures.

… the rate of C-sections has been increasing out of proportion to their need. In 1965, when the C-section rate of delivery was first measured, it weighed in at 4.5 percent; in 1996, the rate was 20.7 percent, and the provisional 2006 rate was 31.1 percent of all births – representing a 50 percent increase over fifty years. Meanwhile, VBACs have declined by 72 percent in less than a decade – 28 percent in 1996 to eight percent in 2005.

The World Health Organization recommends that … cesarean rates … above 15 percent are likely to do more harm than good.

… While the deadliest risks of VBAC, including uterine rupture, are possible, the risk is limited—impacting less than one percent of patients. Seventy-four percent of VBACs are successful …

“… VBAC is a reasonable option for most women. Over 75% of women who attempt VBAC will be successful,” “Currently less than 10% of women who have had previous cesareans deliver vaginally in subsequent pregnancies, leading to significant and preventable illness and death.”

… the NIH panel urged ACOG to reassess its guidelines on VBACs, noting that large swaths of the nation don’t have the resources for hospitals with obstetrics and anesthetics back-up teams.

Jane Peterson, a certified professional midwife in Wisconsin and a member of the Big Push for Midwives, said that while there are health risks in VBACs, as there is in any birthing experience, it has been shown that the risk increases with more labor interventions, such as induction.

“Births in birth centers under the midwifery model of care don’t have interventions, and so they have a greater opportunity for success,” Peterson said.

She added that birth centers screen very carefully for VBACs, ensuring that candidates are healthy. They also make plans to move to traditional facilities if anything occurs that is not reassuring.

Peterson said she advocates for “complete informed consent” from mothers about the risks and benefits of VBACs—a conversation that is most likely to happen outside a hectic hospital setting.

“The fix (for poor maternity care in the United States) is to increase access to midwives, not decrease them,” Peterson said …

The Netherlands has one of the highest rates of home births in the developed world. Around a third of all births take place at home. A similar proportion of pregnant women plan to give birth at home if all goes well, but on the basis of the midwife’s risk assessment they transfer to hospital during labour.

The Dutch home birth system isn’t the product of any recent move towards de-medicalisation and natural birth – it’s simply that many Dutch women still give birth at home the way their grandmothers did …

The Dutch midwives association argues in favour of seeing childbirth as a natural process rather than a medical condition. It points out that home births result in a much lower rate of unnecessary medical intervention, which is safer for both mother and child. However, in recent years the Dutch system has increasingly come under attack. Critics claim it is old-fashioned, and women are being denied proper access to pain relief.

“Inadequate reimbursement for midwifery services has been a significant barrier to women’s access to the valuable services of CNMs and certified midwives (CMs),” … “This legislation not only improves Medicare for women, but will encourage Medicaid plans and third-party payers to adopt equitable reimbursement policies for midwifery services.”

CNMs and CMs provide health care services to women of all ages and stand to play a vital role in increasing access to quality, affordable primary care, gynecology, family planning, and maternity care services. Equitable reimbursement will enhance the viability of midwifery practices as well as increase the incentive for hospital and physician practices to employ CNMs and CMs. In addition, CNM- and CM-attended births-which occur primarily in hospitals, but also in birth centers and private residences-are associated with high-quality outcomes and fewer cesarean sections … cesarean section has been identified as an overused maternity care intervention by the National Priorities Partnership, an influential multi-stakeholder coalition working to identify top priorities for improving the quality and affordability of health care in the US.

A birthing pool

The tub, which looks much like a regular bathtub, but is deeper and has a larger water spout, was installed just in time for Gage’s arrival …

Gentler entry

… The main objective of water births is to provide a gentler delivery process for mother and baby. The baby goes from the warmth of the mother’s body to the warmth of the water to the warmth of her arms, … “For the baby it’s … such a gentle entrance into the world. There is no screaming or crying.” And, for the mother, she says, there is less discomfort. Soothing water … is sprayed on the woman’s … back and stomach. “It’s a nice way to labor, really decreases pain,” …

That is what attracted Jacobsen to water birth … she had a more typical birth at Cooley Dickinson 21/2 years ago for her first child … While she describes that delivery as a great experience, she says she is not tolerant of pain and had … an epidural … This time … she was looking for a natural alternative to that.

Gage, who weighed 10 pounds, 4 ounces, began nursing right away …

… Cooley Dickinson Hospital began making arrangements to add water births after women expressed interest [in forums] held by the hospital to discuss restoring its midwifery services … Those services had been discontinued in 2007 when Hampshire Obstretrical and Gynecological Associates stopped having its midwives deliver babies at the hospital. Not only was there was a high volume of women interested in receiving midwifery care, says Kueny, but many wanted access to water births …

Obstetric care in Hungary is indeed excellent today. It is tightly run by skilled doctors, with low mortality rates. But those who challenge the medical profession still face problems. Agnes Gereb, a pioneer of home births, is facing up to eight years in jail. Prosecutors are going after her over one fatality in childbirth, one case in which a baby died some months after birth and two births that ended up as emergency hospital admissions. In the eyes of many Hungarians, such incidents show that home births are insanely risky and that those who promote them are little more than irresponsible cranks.

That view may seem outdated in the West, but not in the ex-communist East, where birth is a medical problem not a natural process … Such procedures as episiotomy (cutting the vulva) are standard, whereas Ms Gereb says she has performed it in just ten out of 3,000 home births …

Mrs Roche … gave birth to her son Dylan at home two years ago under the supervision of a registered midwife.

“It was very important to me to have the continuity of care that a private midwife provides, from when conception has occurred, right throughout the pregnancy, the birth and beyond,” she said.

“You’ve got a relationship with your midwife that you would never find in the public or private health system,” she said.

But now, Mrs Roche said, women’s choices would be limited by legislation.

“People are faced with a choice: to have their baby in a hospital, or to use midwives who are unprotected and unregistered.

“It really is devastating. It means there’s less opportunity for people like me to make choices about how to deliver their own babies.”

Mrs Roche said the first birth she ever attended was that of a friend who home-birthed.

“Her experience was wonderful,” she said.

She said other friends had ‘diverse’ birth experiences at hospitals.

Mrs Roche said the negative experiences were usually the result of ‘highly medicalised births’.

With this in mind, Mrs Roche felt she would have ‘more control’ giving birth at home.

“I felt my choices would be respected, but I also knew that if I needed medical help, it was readily available.”

… “My midwife had established protocols with the hospital so that if I needed, she could contact them and they would be expecting me.”

Now pregnant with her second child, Mrs Roche had ‘no hesitation’ in choosing the same process again …

Midwife laws

*  Midwives will be able to provide Medicare-funded care for the first time …
*  Indemnity insurance will be a registration pre-requisite.
*  … New laws fail to provide for midwives offering home births.
*  Framework includes a request for midwives to form a collaborative relationship with a doctor.
*  Midwives will require doctor to sign-off to access Medicare insurance and pharmaceutical benefits.

… The new laws will provide midwives the ability to provide Medicare-funded care – but only if they are registered, and to be registered, they must be indemnified.

… To be eligible for a Medicare provider number, midwives will need the sign-off of an obstetrician.

… Margaret … said she would recommend home-birthing to other mums and dads-to-be.

“I felt that being in our own home, comfortable, with our own belongings, and access to food and private spaces, would help me to feel relaxed and less frightened, which in turn would help make the experience less painful,” she said.

“I also really liked the idea of having my own bedroom and bathroom and the peace and quiet, without other mums, babies, visitors and hospital staff.

“I think privacy was important to me as a first time mum, I felt daunted by how ‘exposing’ childbirth might be.”

When the day came … she said everything went to plan: “When the baby was ready to be born I was able to use gas and air to help keep me relaxed and Arlo was born in just a few pushes, and passed straight into my arms by a midwife I’d had the chance to form a trusting bond with.