•Almost half of women wanting vaginal births were induced.
•Women who were induced were twice as likely to have a cesarean birth as moms whose labor starts spontaneously.
•Of the c-sections done after induction, half were performed before the cervix had dilated to six centimeters, “suggesting that clinical impatience may play a role.”
•A third of first time mothers had c-sections.
•C-sections upon maternal request (those done for non-medical reasons) account for only 9% of c-sections.
•Attempts at VBAC are less likely to result in vaginal birth than previously thought. Few women are offered the option of VBAC.

… what can you do about all this if you are pregnant and want a vaginal birth? Here are a few ideas:

A startling number of first-time mothers – 92 percent — believe it’s safe to deliver a baby before 39 weeks, according to a recent UnitedHealthcare survey of 650 insured, first-time mothers …

… “Unfortunately, many expectant mothers are not aware of the risks associated with early elective C-sections and induced labor. Expectant mothers may believe that at 36 weeks they have completed their nine months of pregnancy, but Mother Nature’s formula for healthy babies is actually 40 weeks,” Dr. Groat says.

… babies born electively by C-section at 37 weeks were twice as likely to have health problems, usually respiratory in nature, than babies born at 39 weeks or later. Infants delivered preterm are at an increased risk of developing chronic lung disease, cerebral palsy, learning disabilities and behavioral problems.

Researchers have established that when high levels of lactic acid are measured in the amniotic fluid, it is unlikely the mother will deliver vaginally.

Measuring this acid could help decide whether to end a difficult labour and opt for a Caesarean earlier.

The test is being rolled out in a number of European hospitals.

Prolonged labours which end up in a Caesarean section are seen by many as the worst of all worlds.

In the UK, despite the mantra “too posh to push” more than half of Caesareans are emergency rather than elective procedures, in which the mother frequently undergoes a long and painful labour before an urgent operation is deemed necessary to protect the health of both her and her baby.

… the uterus produces lactic acid as other muscles do when they work hard, but that when it reaches a certain level the substance starts to inhibit contractions.

… The hormone oxytocin is usually administered in cases of slow labours to stimulate the uterus into contracting, but not all labouring women respond to it.

… the test should help doctors establish which women may go on to deliver vaginally, as low levels of lactic acid suggest the uterus could still produce the contractions needed to push out the baby.

“But a high level of lactic acid in the amniotic fluid indicates that the uterus is exhausted. To stimulate this kind of labour with an oxytocin infusion would be like asking a marathon runner to run an extra 10,000 metres after he or she has passed the finish line.”

Currently, women who undergo caesareans often receive antibiotics as a precaution against infection to the abdomen and uterus—but usually only after the delivery, when the umbilical cord is clamped, because of concern for the baby’s safety.

Some pediatricians worry that antibiotics administered to the mother will reach the newborn and suppress the baby’s blood bacterial count, potentially masking a serious infection in the baby unrelated to the caesarean section.

The American Congress of Obstetricians and Gynecologists examined several large, recent studies that administered antibiotics to mothers before and after caesarean deliveries. The group concluded there was no evidence of greater risk to the babies when mothers received antibiotics before surgery. Yet there was an increased benefit for the mothers in receiving the antibiotics before surgery.

… Some 8% to 10% of women who have a scheduled caesarean will acquire an infection, as will about 30% of women who have a caesarean delivery after labor has begun, because of greater exposure of the inside of the uterus to bacteria from the vagina …

In newborns, the prevalence rates for sepsis … is estimated at less than 1% of live births.

While the maternal antibiotic appears to neither help nor hinder a newborn’s chances of getting sepsis, doctors have worried that in babies who have the bacterial infection, antibiotics administered to the mother before the c-section will suppress bacteria in the babies’ blood test, resulting in a failure to detect the sepsis infection.

Some doctors, however, question whether the existing research adequately addresses the question of harm to the baby.

Concerns about masking babies’ infections are largely theoretical … While the antibiotic does cross over from the mother to the baby through the placenta, and while it could mask the blood culture, there are usually other clinical signs that a baby is sick …

But C-section carries all the attendant risks of major surgery; and data show that compared with vaginal birth, cesarean delivery increases the odds that a mother will end up back in the hospital after birth with complications …

Now obstetrics experts are actively seeking ways to drive down the number of C-sections … the ACOG issued new guidelines recommending that hospitals allow most mothers who desire vaginal birth after cesarean … to attempt a trial of labor, including … mothers who are carrying twins or have had two prior C-sections. Despite studies showing VBAC to be safe for most women — ACOG data suggests that 60% to 80% of women who attempt VBAC will succeed — many hospitals have urged women to undergo a repeat cesarean over the past decade, largely to avoid medical risks and malpractice suits.

Another factor contributing to high C-section rates is the increase in induced labor, especially between 37 weeks and 38 weeks … The use of labor induction in the U.S. has risen from less than 10% of deliveries to more than 22%, between 1990 and 2006 … research suggests that induced labor results in C-sections more often than natural labor … those whose labor was induced were twice as likely to have a C-section delivery as those who experienced spontaneous labor.

… previous studies had come to the same conclusion. In her study of … mothers delivering before 41 weeks’ gestation … 44% of women had their labor induced.

… after 41 weeks’ gestation, at which point it is standard policy to induce labor, it may lower the risk of medical complications for mother and baby — including the risk of stillbirth — and even decrease the likelihood of C-section delivery, but those same effects are not seen in women who induce labor before the 41-week mark.

… Among the women whose labor was induced in Ehrenthal’s study, nearly 40% of cases were categorized as elective. In other words, there was no pressing medical indication for induction. Extrapolating from the study findings, Ehrenthal suggests reducing the use of elective labor induction could lower the national C-section rate by as much as 20%.

Several hospitals have already begun reducing medically unnecessary induction as a way to lower the rate of cesareans …

… under the new policy the overall induction rate dropped 33% and the rate of elective inductions fell by roughly the same amount … the total number of C-sections among first-time mothers who underwent elective induction dropped 60% …

If a relatively simple policy shift based on medical evidence can successfully cut the rate of induced labor and C-sections at a single hospital, experts say similar changes applied broadly may help lower the rate of C-sections on a national level.

VBAC is known to increase the risk that the scar left in the womb from a previous cesarean will tear during labor, leading to massive bleeding that can threaten the baby’s life. That has led to previous guidelines urging caution for women who have had cesarean sections.

But recent research shows so-called uterine rupture occurs in less than one percent of women who opt for vaginal birth, and that between 60 and 80 percent of VBACs are completed successfully.

While the new guidelines from the American College of Obstetricians and Gynecologists (ACOG) still say a full surgical team should be present in case an emergency cesarean is required, they now put a bigger emphasis on the woman’s decision.

“Respect for patient autonomy supports that patients should be allowed to accept increased levels of risk; however, patients should be clearly informed of such potential increase in risk and management alternatives,” they say.

“For most women with a previous cesarean delivery, a trial of labor is a safe and appropriate option,” …

… Even women who’ve had two prior cesareans might be good candidates for vaginal birth …

… Today, about nine in 10 pregnant women … end up with a repeat cesarean if they’ve already had one. By comparison about a third of all women who give birth have cesareans.

… between 1932 and 1946, … only 2,273 (1.4 per cent) Caesareans were performed and 61 (3 per cent) of these were associated with maternal death.

By the end of the 20th century Caesarean births had become much safer for the mother. In 1985, the World Health Organisation concluded: “There is no justification for any region to have CS rates higher than 10-15 per cent”. Yet, in the generation since remarkable differences in global, regional, national and hospital CS rates have evolved. In underdeveloped countries, particularly African, CS rates remain around 2-3 per cent, in part because there is often no obstetrician available to do the operation.

Maternal mortality rates in these countries remain stubbornly high due to the lack of resources. In a report from 119 countries between 1991 and 2003, only 3.4 per cent of high-income countries had a CS rate of less than 10 per cent compared with 76.3 per cent of low-income countries. The maternal mortality rate per 100,000 live births was 630 deaths in the low-income countries compared with 54 in the high- income countries.

The risk of maternal death per million births has been estimated at 17-20 for a vaginal delivery, 59 for an elective CS and 182 for an emergency CS. Mortality risks of CS are low, but they are dependant on the healthcare setting and are higher in resource-poor countries.

Rising CS rates increase foetal risks. Elective Caesarean births increase the risk of transient tachypnoea of the newborn and respiratory disease syndrome …

In developed countries, however, Caesarean birth has become so safe that rates have soared as women and their obstetricians strive to avoid the perceived risks and traumas of vaginal birth …

Similar increases have been reported in other developed countries and there is no evidence that CS rates have reached a plateau.

In many developing countries, Caesarean section rates are too low, resulting in preventable adverse outcomes for mothers and their babies. In developed countries, there are growing concerns that CS rates are too high, particularly in circumstances where there is little medical justification for the operation.

A Caesarean delivery in the current pregnancy also has long-term implications … it increases the need for either emergency or elective Caesareans for future babies. It increases the future risk of catastrophic obstetric complications such as uterine rupture or peripartum hysterectomy …

Another concern about the rising CS rates is the impact on healthcare budgets with resources becoming more limited in the face of the economic recession … costs for Caesarean delivery were twice those for spontaneous vaginal delivery … for each 1 per cent reduction in the CS rate in England, the health services would save £8.8 million annually. Avoiding a first Caesarean delivery will also reduce economic costs in the longer term by decreasing repeat Caesareans.

The main reasons for the rise in CS rates in developed countries are the safety of the procedure and the perceived risks of labour. It has been fuelled by the carpe diem mentality of modern life where women and their doctors focus on the short-term outcomes of the current pregnancy without considering the long-term consequences for a woman’s health. This short-termism is more likely in circumstances where a woman is planning to have a small family.

Policymakers … have suggested target CS rates, for example … a CS rate of 20 per cent. However, such targets, including the WHO target, may be unrealistic. The optimum CS depends on local healthcare resources and service quality, and not on national or international recommendations. There is also a danger that, in attempting to meet hospital targets a Caesarean is not done in individual cases when it should have been done. This may have serious adverse consequences clinically and subsequent high financial costs medically and legally.

Optimising CS rates … needs to start with improvements in data collection and analysis to identify why Caesarean sections are done, and whether the results in some hospitals are outside an acceptable norm …

What happened is this: In my 39th week, I am induced because of high blood pressure. At the hospital, I am given Pitocin, a synthetic form of the labor-inducing hormone oxytocin, and Cervidil, a vaginal insert used to dilate the cervix. Within two hours, my contractions are one minute apart. I had lasted as long as I could without an epidural because I had read that they sometimes slow dilation. That’s the last thing I need: I’m at a pathetic 2 centimeters. My doctor comes up with a solution for the pain: a syringe full of a narcotic called Stadol.

“I have a history of anxiety,” I tell the nurse who has brought in the syringe, as I always warn any medical professional who wants to give me drugs. “Is this drug OK for me?” “It sure is,” she says.

It is not. Within 10 seconds, I begin hallucinating. For five hours, I hallucinate that I’m on a swing that’s soaring too high, that houses are flying at my face. My husband has fallen asleep on the cot next to me, and I’m convinced that if awakened, he will turn into a monster — literally. I’m aware this notion is irrational, that these images are hallucinations. But they are terrifying. I buzz the nurse. “Sometimes that happens,” she says …

By noon the next day, 24 hours after I had arrived, I am only 3 centimeters dilated. The new nurse, a nice lady, tells me the induction isn’t working. “Your blood pressure isn’t even high anymore,” she says. “Tell the doctor you want to go home.”

When my OB comes in, I say, “I’d like to stop this induction, if that’s possible. I’m worn out. I hallucinated all night … I just don’t think this is working out.”

“OK,” he says. “Let me examine you. If you’re still not dilating, we’ll talk about going home.”

My previous dilation exams had been quick and painless, if not entirely pleasant. This one takes a long time. Suddenly, it hurts. “What are you doing?” I scream. “Why does it hurt?”

No answer.

“He’s not examining me,” I scream at my husband. “He’s doing something!” My husband grips my hand, frozen, unsure.

I scream to the nurse, the nice one who had suggested I go home. “What is he doing?” She doesn’t answer me, either. I writhe under the doctor’s grasp. The pain is excruciating.

The first sound I hear is the doctor’s directive to the nurse, in a low voice: “Get me the hook.”

I know the hook is for breaking my water, to speed my delivery by force. I scream, “Get off of me!” He looks up at me, as if annoyed that the specimen is talking. I imagine him thinking of the cadavers he worked on in medical school, how they didn’t scream, how they let him do whatever he wanted.

“You’re not going anywhere,” he says. He breaks my water and leaves. The nurse never looks me in the eye again.

Eleven more futile hours of labor later, I am exhausted and terrified when the doctor comes in and claps his hands together. “Time for a C-section,” he says. I consider not signing the consent form, ripping off these tubes and monitors, and running. But the epidural I’d finally gotten won’t allow me to stand up.

It’s nearly midnight when I hear a cry. My first emotion is surprise; I had almost forgotten I was there to have a baby.

I was desperate to find someone who could tell me what had happened to me was normal. To say, “You hallucinated? Oh, me, too.” Or “My doctor broke my water when I wasn’t looking. Isn’t that the worst?” Nothing …

Now, I’d never loved my doctor … I’d found him patronizing — “Normal!” he’d shout at me, when I asked a question — I thought his assuredness might be a good antidote to my anxiousness. It seemed to work, until it didn’t.

… I also didn’t have a birth plan … Sure, I had a plan for the birth: Have a baby using whatever breathing method I’d learned in the hospital’s birth-preparedness class, maybe get an epidural. But I didn’t have the piece of paper that so many of my friends have brought to the hospital with them … in my opinion, the very act of creating such a contract was to ignore what labor is: something unpredictable that you are in no way qualified to dictate.

… people who hear my story ask … Did I consider a home birth? A midwife instead of an obstetrician? … The answer is no. I am not holistically minded. My philosophy was simple: Everyone I know has been born. It can’t be that complicated.

The women who ask me about my preparations for my first son’s birth — who imply with these questions that I could have prevented what happened to me if I’d been more diligent — are part of an informal movement of women who are trying to “take back” their birth — take it back from the hospital, the insurers and anyone else who thinks he can call the shots.

But hospitals aren’t so interested in giving women back their birth … stipulations dealing with labor and delivery (“I want only one medical professional in the room at a time”) garner barely a glance. University OB/GYN in Provo, Utah, even has a sign that reads, “…we will not participate in: a ‘Birth Contract’, a Doulah [sic] Assisted, or a Bradley Method delivery. For those patients who are interested in such methods, please notify the nurse so we may arrange transfer of your care.”

… This question of whether I could have prevented my trauma has lingered in my mind since that day; now that I am pregnant again, it has become deafening. I have a chance to do it all over. Would I benefit from thinking more holistically? Should I bother taking back my birth?

During my pregnancies, friends gave me two books; their spines are still barely cracked. The first is called “Ina May’s Guide to Childbirth.” … The other book is “Your Best Birth” by Ricki Lake and Abby Epstein; it’s an offshoot of their 2008 documentary, “The Business of Being Born.” Their urgent message is that women who want to deliver vaginally can do so if no one intervenes. Instead, doctors and hospitals are doing all they can to “help” the laboring woman along … and failing. Inductions like mine, epidurals given early in labor, continuous fetal-heart monitoring — all of them have been associated with a higher risk for cesarean section. The result is an epidemic — 32 percent of U.S. births were C-sections at last count, the highest rate in our history. Individual surgeries may be medically necessary, but as a matter of public health, the best outcomes for mothers and babies come with a rate of no more than 15 percent, according to the World Health Organization.

Sam … was five months pregnant when watching “The Business of Being Born” convinced her that hospitals could be dangerous and a home birth would be more meaningful. She and her husband found a midwife … and spent the rest of the pregnancy preparing.

After 24 hours of labor, Sam’s contractions were two or three minutes apart, yet when her midwife examined her, she was only 3 centimeters dilated. The midwife gently told her that she was nowhere close to delivering, despite her contractions, exhaustion and pain. Sam asked to be taken to the hospital.

The change of scenery did her good. “At that point, I had been in labor for 40 hours,” she says. “I entered the relaxed zone. The epidural took the edge off … It was a sacred space.”

After her son’s delivery, Sam passed out, having lost 50 percent of her blood volume in a postpartum hemorrhage. Needless to say, she was relieved that she was in a place where blood transfusions were readily available … she believes she will want midwife care at a hospital next time.

… Bialik’s first birth didn’t go the way she wanted. After three days of labor at home, she stalled at 9 centimeters, one short of the goal. Her midwife suggested they go to the hospital, where after a natural childbirth, Bialik’s son spent four days in the neonatal intensive-care unit. “My son was born with a low temperature and low blood sugar, which isn’t unusual in light of the fact that I had gestational diabetes,” she explains. “I understand doctors need to err on the side of caution, but there was nothing wrong with my child. All of our plans for bed sharing, nursing on demand, bathing him — gone.”

The experience was scarring. “I felt a sense of failure that I had to call my parents from the hospital,” Bialik continues. “Yes, I know vaginal birth in the hospital is the next best thing to a home birth.” …

I point out that natural childbirth in the hospital — her “failure” — was my best-case scenario. But I also understand when she says, “Everyone is allowed her own sense of loss.” She realized her vision when her second son was born at home.

The second time around
I don’t consider myself a candidate for a home birth. The risk of uterine rupture from an attempt at vaginal birth after cesarean (VBAC) makes it unthinkable … I’m also not really interested in a home birth … But I’m also not interested in another C-section …

So I’d like to attempt a VBAC, but I know that it doesn’t always succeed. I have a new doctor — the 10th I interviewed following my son’s birth — at a new hospital, and he has agreed to help me try. But my primary goal is more modest: not to be retraumatized. Even now, my heart pounds at the sight of hospital receiving blankets, the antiseptic smell of the maternity ward.

The common thread in Bialik’s and Sam’s stories that impressed me was how supported and safe they felt with their midwife …

In an e-mail Bialik sends after our meeting, she goes back to my idea that some women weren’t meant to have babies the holistic way. “There are those among us who believe that if the baby can’t survive a home labor, it is OK for it to pass peacefully,” she writes. “I do not subscribe to this, but I know that some feel that … if a baby cannot make it through birth, it is not favored evolutionarily.”

I think about my appendectomy, back in 2003. Had I not made it to the hospital in time, I would be dead. What would it be like to refuse medical intervention? I’d call my family, say my good-byes. “I’m sorry,” I’d say. “But I’m not evolutionarily favored. It’s time for me to go.”

This attitude, that everything was better back when there were no doctors, seems strange to me. C-sections, although certainly done too often, can save lives. Orthodox Jews still say the same prayer after childbirth that those who have been in near-death experiences say — and with good reason. A birth that leaves mother and child healthy may be commonplace, but it’s also a miracle every time.

As the weeks pass and my belly grows, I can’t stop thinking about Sam. Her pregnancy was a sacred time, and she had truly looked forward to labor. Is that what I should try for — a meaningful birth, as well as an untraumatic one? At what point had people like Sam and me learned to feel entitled to a meaningful birth?

“I think that birth should be a beautiful experience,” says obstetrician Kimberly D. Gregory, M.D. She’s the vice chair of women’s health care quality and performance improvement at Cedars-Sinai Medical Center in L.A. “It should be exactly the way you want it, and doctors should intervene only to preserve the health or life of you or your baby.”

Naturally, one would assume that Dr. Gregory advocates birth plans. When I ask her this, she laughs. “We always say, ‘If you show up with a birth plan, just get the C-section room ready,’” she says. “You get everything on that list that you don’t want. It’s like a self-fulfilling prophecy.” Dr. Gregory led an unpublished study that compared women who took traditional hospital birth classes with those who employed Bradley-like training and a birth plan. The birth-plan group trended toward a higher C-section rate and more interventions. “There’s a certain personality type that tends to be more anxious. Maybe the anxiety hormones themselves put them at risk,” Dr. Gregory theorizes. “It seems that being open and honest and choosing the right doctor is probably a better option than writing everything down. Walking in with this list appears to set up an antagonistic relationship.” …

… In the past three weeks, I’ve had the same dream. I’m in a field (I believe at Ina May Gaskin’s Farm), and women in braids are dancing around me as my baby is born, painlessly, joyously. As I reach down, I notice my C-section scar is gone.

I wake up upset. Am I truly under the impression, subconscious though it may be, that taking back this birth will undo the damage of the last one?

“I don’t understand this phrase ‘take back your birth,’” nurse-midwife Pam England, creator of “Birthing From Within,” … tells me. “Who took it? What would a woman tell herself it meant about her if she failed to meet the criteria she made up for ‘taking back’ her birth? I am concerned that this phrase, meant to generate action and a feeling of empowerment, may actually be generated by or feeding the victim part of her.”

England is right: Having a childbirth that I deem successful this time will not change what I haven’t overcome from the first. I try to find a way to make what my doctor and nurses did to me OK, but my mind rebels. I feel loss — no, theft — of an opportunity for me to have a baby the way so many other women do: a carefree pregnancy, a labor that could still go any way.

Maybe I’m not so different from the women I spoke with, after all. Bialik had a successful natural childbirth but felt like a failure because it was in the hospital. Women who had a C-section also used words like failure. Perhaps part of the problem is that our generation of women is so ambitious, so driven, that we don’t know how to do anything without quantifying it as a success or failure.

According to Dr. Gregory, women are now requesting a C-section for their first birth, even without indication. “A lot of people are uncomfortable with the unknown,” she says. Plenty of people are wary of C-sections by choice, from holistic moms to obstetricians. But isn’t this, too, taking back your birth? Refusing to be out of control seems to me the epitome of taking it back. You don’t have to have an unattended birth in the woods to be considered a real woman.

Deciding that you can’t control the uncontrollable — and committing to that decision when you are, in fact, out of control — is also taking back your birth. It’s what your grandmothers did. It’s what their grandmothers did.

With this, I realize that I have already taken back my birth, but not as part of any movement. I have stopped judging women who take extra precautions as defensive and started to understand that everyone has to find her way.

I don’t know how this story ends. I’m still not convinced my body was made to deliver vaginally. But here’s what I do know: I will insist on kindness. I will insist on care. And I hope I will be open to being treated kindly. It’s harder than it seems.

The proportion of surgical births should be reduced to 20 per cent by 2015, from 30 per cent now, and first-time mothers would be attended by the same midwife throughout labour.

The Minister for Health, Carmel Tebbutt, said the directive was ”designed to support women to have a birth that is as free as possible from invasive medical intervention, while also recognising that labour occurs across a wide spectrum … The safety of mother and child are, of course, paramount.”

The president of the Australian College of Midwives, Hannah Dahlen, said: ”For the last 15 to 20 years [birth interventions] have just gone up and up and up. At some point we have to start coming down again. The policy says, ‘Let’s stop, let’s regroup and try to get a balance.’ ”

She emphasised it would remain ”the safest option for some women to have a caesarean section, and women should not feel lesser because they had to have an intervention”.

Only about 13 per cent of women now achieved a vaginal birth after a caesarean, while up to 80 per cent could do so if properly supported. The NSW targets specify a 30 per cent rate by 2012 and 50 per cent by 2015.

Dr Weaver said the appropriate caesarean rate was about 25 per cent of all births, because the current generation of women represented ”an older population, a fatter population, and a lot of first-time mothers”, Factors which raised their risk.