In the Health Affairs article (see post below), one of the strategies recommended to reduce cesarean rates (and thus healthcare costs) is to establish more birth centers which focus on physiologic childbirth for low-risk women. The Health Affairs article comes on the heels of the publication of a large prospective cohort study looking at outcomes at 70 midwifery-led birth centers in 33 states from 2007 to 2010. Most birth centers in the study were freestanding; a few were physically located inside a hospital building, but met AABC (American Association of Birth Centers) standards for autonomy and were separate from the hospital’s acute care obstetric care. Analysis was by intention to treat so that statistics for women requiring transfer to the hospital either before, during or after labor were included.

As with previous studies looking at birth centers, the outcomes were more than impressive. Most importantly, of the 15, 574 women planning and eligible for a birth center birth at the onset of labor, 93% experienced a spontaneous vaginal birth regardless of where they ultimately gave birth, whereas only 6% had a cesarean birth. There were no maternal deaths and both the intrapartum fetal mortality rate and neonatal mortality rates were comparable to those reported in many studies of low-risk women. Since low-risk women make up approximately 85% of the pregnant women in the United States, switching the usual place of birth from the typical hospital model with frequent unnecessary and sometimes harmful interventions to a birth center model could result in savings in the billions of dollars and improved outcomes for mothers and babies. At the very least, we need to learn from the birth center model strategies to promote healthy, safe and physiological birth.

It is one thing for birth advocates to lament the state of maternity care in the U.S. (and many other countries around the world). It is another thing when health policy experts start questioning the status quo. In an article in the March 2013 edition of Health Affairs, researchers examined the variation in cesarean rates for over 800,000 births at 593 hospitals across the country. They excluded hospitals with less than 100 births per year, but otherwise examined a wide variety of hospitals: teaching, non-teaching, rural, urban, large, and small. Acknowledging that some differences in cesarean rates may be due to risk factors in the patient population, they examined both overall cesarean rates and the cesarean rate for low-risk women. They were surprised to find a ten-fold variation in overall cesarean rates among hospitals from 7.1 percent to 69.9 percent. Expecting to find a much smaller variation in low-risk cesarean rates, they were astonished to find a fifteen- fold difference from 2.4 percent to 36.5 percent. Such findings lead to tough questions and the inevitable conclusion that much of the variation is likely due to obstetric care practice patterns.

Not only does cesarean delivery increase risks for both mother and baby, but unnecessary cesarean surgery has a huge impact on our healthcare budget. Government money pays for almost half of the births in the U.S.; indeed, in 2009, state Medicaid programs paid over 3 billion dollars for cesarean surgery. Clearly, it is time to focus attention on maternity care practices that not only improve outcomes for mothers and babies, but also cost less. Childbirth educators are in an ideal position to work with other team members in the hospital to develop policies to promote and support normal, physiological birth; and to educate parents on how to plan for normal birth and avoid unnecessary interventions which lead to unnecessary cesarean surgery.

Last night I watched the premiere on TV of a new medical drama, Monday Mornings. I have always been fascinated by any entertainment genre featuring medicine – books, movies, TV shows. While my husband fondly remembers watching Matt Dillon (Gunsmoke) and Wyatt Earp as a child, I remember Ben Casey and Marcus Welby. Dr. Casey and Dr. Welby were never wrong and certainly never caused the deaths of their patients. It was the times I grew up in – doctors were placed on pedestals and revered. In contrast, last night on Monday Mornings, two doctors were called to task for making mistakes that caused the deaths of their patients. It is a sober reminder that doctors are human and make mistakes like everyone else. I think it is a good thing that we have taken doctors off the pedestal. But, it is a fine line. Doctors sometimes have to make life and death decisions  – we want them to have confidence in their knowledge, skills, and “gut.” On the other hand, we want them to listen to us (consumers), provide the information we need to make fully informed decisions, and “allow” us to make our own decisions. I’m glad that the students in our childbirth classes are seeing in the media more realistic portrayals of doctors. I hope that will help them feel more comfortable talking with their physicians on a more equal basis. But, I also hope that Monday Mornings will celebrate more successes and the good that physicians do as well as the tragic mistakes.