Sociologist and college professor Theresa Morris claims in her introduction (and throughout her excellent new book) that she does not blame maternity health care providers for sky-rocketing cesarean section rates in the U.S. However, this claim rings hollow when you read actual quotes from maternity providers who share that they can talk any woman into a cesarean surgery. In addition, two of the organizations that Morris does blame – hospital protocol-creating committees and ACOG (the American College of Obstetricians and Gynecologists) – are largely made up of maternity care providers. Nonetheless, Cut It Out is a compelling examination of the risks associated with cesarean surgery, the reasons for the rise in the cesarean surgery rate, and solutions to address the problem. For me, the key takeaway from this book is that pregnant women do not know that cesarean surgery is associated with increased risks for both mother and baby. Instead, they too often are told that cesarean surgery is the safest “option” by caregivers who feel forced to choose reducing liability exposure over the welfare of the mother and baby. Morris does a good job of explaining the unfair assumption that all bad outcomes are caused by malpractice and the financial and emotional repercussions of malpractice lawsuits from the maternity care provider’s point of view. But she also highlights the paradox that although some hospitals, insurance companies, and many health care providers believe that more cesarean sections are the appropriate response to the malpractice crisis, that more cesarean sections are actually driving up maternal mortality. Morris does an excellent job of providing extensive references for the information that she includes. Quotes from postpartum women and maternity caregivers (with names changed to protect their identities) interviewed both by herself and her college students help to drive home her points. As life-threatening complications from primary and especially repeat cesareans continue to climb due to an almost 33% cesarean rate and underutilization of VBAC, we, as a society, must address the cesarean epidemic. The first solution that Morris lists under “Immediate Solutions for Women Who Plan to Give Birth” is that “women should take independent childbirth education classes.” We (childbirth educators) need to make sure that women have the information they need to make informed decisions about cesarean surgery and about common interventions that increase the risk for cesarean surgery. We can make a difference, but we need to stay update-to-date with valuable resources such as this book.
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I picked up this book to read a chapter or two. The next thing I knew several hours had passed by and I had finished the book. Roanna Rosewood is an excellent writer and she certainly hooked me from the beginning of the book. I had expected another book focusing on the anger and disappointment that many women feel after a cesarean birth. (That’s not to say that those books are not valuable; but I’ve already read more than one.) This book is so much more – a celebration of womanhood, female friendships, and yes, pregnancy and birth. I can’t say whether her first two cesarean births were necessary or not. She planned home births with midwives. She labored for many, many hours and went reluctantly to the hospital upon the advice of her midwives. I don’t want to say too much more because I don’t want to spoil the suspense (yes, suspense) in the book. Although I am about as left-brain as they come, I loved her descriptions of the many alternative practitioners and therapies that she tried. Her descriptions of her relationships with her husband and children were funny and heartwarming. I applauded her stories and attitude towards their family bed. The only people who I think may not like her book are those mothers who have to have cesarean births because of physical and medical problems. But I hope that those mothers will understand that Roanna was at peace with the idea of a third cesarean when she was pregnant for the third time. She had arrived at a place in her life where the mode of birth no longer defined her. I am grateful that she shared her story in this wonderfully entertaining and powerful book. And, if I am ever in Ashland, Oregon, I look forward to having lunch at the family’s restaurant.
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.