Friday, April 30, 2010

Introducing: 20% by 2020

The preliminary data for births in 2008 has been released by the CDC's National Center for Healthcare Statistics. Florida has risen to an all-time high 38.2% cesarean section rate. Sarasota Memorial Hospital's c-section rate for the same year was 41.7%, a slight increase from their 2007 reported data of 41.3%.

These numbers are simply dangerous. As they continue to increase (up over 50% in the last decade), so do our maternal mortality rates. These are a few facts taken from the Independent Childbirth Education Association:

-The World Health Organization (WHO) states that no region in the world is justified in having a cesarean rate greater than 10 to 15 percent.

-A cesarean section poses documented medical risks to the mother's health, including infections, hemorrhage, transfusion, injury to other organs, anesthesia complications, psychological complications, and a maternal mortality two to four times greater than that for a vaginal birth.

-An elective cesarean section increases the risk to the infant of premature birth and respiratory distress syndrome, both of which are associated with multiple complications, intensive care and burdensome financial costs. Even mature babies, the absences of labor increases the risk of breathing problems and other complications.

-Cesareans can delay the opportunity for early mother-newborn interaction, breastfeeding and the establishment of family bonds.

-The four most common medical causes contributing to the increase in cesarean section rates in North America are: routine repeat cesareans; dystocia (non-progressive labor); breech presentation; and fetal distress. Some reports suggest that more careful diagnosis and management of dystocia could halve the primary section rate. Combined with fewer cesareans for breech presentation (along with more cephalic versions), careful diagnosis of fetal distress and active encouragement of VBAC, these efforts have resulted in lowering cesarean rates to less than 12% in various parts of the world.

-Cesarean rates are influenced by non-medical factors. Rates are higher for women who have private medical insurance, are private rather than public clinic patients, are older, are married, have higher levels of education and are in a higher socio-economic bracket.

-Cesarean sections are sometimes performed for other than maternal or fetal well-being, such as avoidance of patient pain, patient or provider convenience, provider legal concerns or provider financial incentives.

What if instead of a slight increase each year in c-section rates, Sarasota Memorial Hospital and our community worked toward a slight decrease?

With only a reduction of 2.2% per year, we can put our obstetric community at the forefront of health care reform by achieving a very healthy model, saving taxpayers literally millions of dollars, and educating women and families in the process.

It has been done, and it is being done right now in other parts of the country. New Jersey, the only state in the nation with a higher c-section rate than Florida, is launching the "Worst to First 2010" campaign, in which seven hospitals have agreed to re-educate their staffs to achieve 10%-15% c-section rates. And on Staten Island, one hospital is taking powerful measures to create drastically different outcomes than its nearest competitor. The two New York hospitals sit just five miles apart and serve an almost identical demographic, yet one has the highest c-section rate in the city, and the other, the fourth lowest. Why? Because Staten Island University Hospital does not allow unnecessary inductions for first-time pregnancies at any point before the 41st week, since they are a main cause of c-sections. They also do not allow elective cesarean deliveries upon maternal request.

Therefore, it is with great hope, excitement and the vision of a long journey ahead, that Born in Sarasota introduces 20% / 2020, an initiative to encourage elected officials, hospital staff, maternity care practitioners and consumers to reduce Sarasota's epidemic cesarean section rates to 20% by the year 2020.

How can we expect obstetricians, our hospital, and our consumers to undergo this change?

1 : Engage our community in an educational campaign about the benefits of spontaneous labor and the risks of cesarean sections that are not medically necessary, to mothers, to babies, and to future pregnancies.

2 : Explicitly describe the difference between maternal request elective cesarean section, physician ordered elective cesarean section, and true emergency surgery. Increase transparency in billing codes so that maternal request elective cesareans are accurately reflected in medical billing.

3 : Increase access to Vaginal Birth After Cesarean. Arm consumers and practitioners with the latest evidence and legislation.

4 : Make informed consent and informed refusal a respected right of the maternity care consumer. Make the public acutely aware of the Patients' Bill of Rights.

5 : Develop a localized cost-savings analysis that will illustrate to the Sarasota County Public Hospital Board and to the taxpayer that a reduction in c-section will not only improve outcomes but save millions of dollars and reduce readmission rates.

6 : Encourage independent childbirth education classes regardless of maternity care provider. Aside from good health and low risk assessment, prenatal education (including includes thorough education of the childbirth process, inspiring real-life examples, pain-coping mechanisms that do not require medical intervention, and hands-on labor preparation techniques) is the most critical element to avoiding surgical birth. These classes also explore in full detail the risks and benefits of common obstetric interventions such as c-section, labor induction, episiotomy and epidural anesthesia.

7 : Reduce the high-risk population by engaging the childbearing public in a campaign about pre-pregnancy and prenatal nutrition, including the risks of obesity and high blood pressure at birth.

8 : Maintain continued demand for transparency in statistics, at the provider and facility levels. Encourage and advertise The Birth Survey at all maternity care provider offices and facilities in our community.

9 : Increase access and use of Licensed Midwives for low-risk, healthy pregnant women. Using midwives at homes and in Birth Centers safely and cost-effectively reduces intervention rates.

10 : Introduce a feedback system by which physicians receive detailed information about the c-sections they have performed, coupled with voluntary adoption of more aggressive protocols for inducing and augmenting labor. In one California hospital, this measure alone HALVED the c-section rate.

Born in Sarasota would appreciate your feedback on how to best execute this ten-step model toward healthier birth outcomes. It will take the entire community of consumers, physicians, midwives, doulas, hospital administrators, legislators, insurance agents and policy makers to make this happen. But we can save mothers and babies in the process. We want to hear from you!


  1. Laura do you have a link to the 2008 CDC statistics? Thanks!

  2. Thanks Misty--not sure what happened to my hyperlink there! Should be all fixed.

  3. May I ask what practical measures are going to be taken to reduce the high levels of obesity in pregnant women - and what targets/ expectations you have for reducing obesity rates in your area?
    Also, how will you address the issue of increasing maternal age (since we know that this is a factor in cesarean rates)?
    Finally, in the context of birth autonomy and informed decision making, are you committed to only reducing unwanted cesarean rates in Sarasota and not those (maternal request) cesareans that are WANTED by women?
    Thank you.

  4. Thanks for your comment, cesarean debate--these are great questions.

    The American obesity epidemic (see item #7 on my list) must be addressed in this context through increased emphasis on preconception nutrition. In our own community, counseling in this area is offered through Healthy Start. I would love to see a campaign illustrating the risks of poor nutrition choices on future babies (something like "They are what you eat.")

    Advanced maternal age in and of itself does not predict risk nor indicate the need for cesarean delivery. Rather, other risk factors tend to be higher in women in these groups (high blood pressure, diabetes, etc.). On the flip side, women over 35 also have a tendency to have achieved more socioeconomic and marital stability. So I'm not convinced that advanced maternal age is an issue that needs addressing, but rather further emphasis on prenatal and preconception health and nutrition.

    As for the question of maternal request cesarean sections, there is a chasm of discrepancy in data that boggles my mind. I absolutely believe in patient autonomy and decision making, provided informed consent is appropriately achieved, and women are told the risks and benefits of both vaginal and cesarean birth in a way that they understand. A woman should be comfortable with her decision after knowing that she, her baby, and her future pregnancies are at a MUCH higher risk of complications (including death) than with vaginal birth. But what boggles my mind, what REALLY gets me in this whole conversation, is that the medical community touts patient choice--that women are requesting c-sections and have the right to do so (and they do)--but the data simply doesn't show it. In the top ten list of physician diagnoses for c-sections in my home state of Florida, neither physician ordered elective c-section nor maternal request elective c-section made the 'cut' (no pun intended). WHY? Because these surgeries are not reimbursable by Medicaid. So on the one hand, we have doctors telling us that women are choosing c-sections, but on the other hand, providing medical diagnoses for them. Are the women really choosing them? Why is their choice not reflected in the data? In the Childbirth Connection's Listening to Mothers Survey, 98% of women who had primary c-sections believed there was a medically necessary reason for them.

    So the shorter answer to your last question would be that I am committed to reducing the c-section rates because evidence shows that they are being performed in such high numbers that they pose a public health problem for our mothers and babies. With the rise in c-sections comes the rise in maternal and infant mortality, premature birth and NICU admissions, plus a host of other complications. I just am not seeing evidence that women are really and truly being informed of these risks (see #1, #2, #4, #6 and #8 on the list).

    Again, thank you for your comment. It is such a huge and multi-disciplinary burden that must be looked at from all angles.

  5. Finally, with regard to obesity: I like your slogan name of ‘They are what you eat’, and I genuinely hope that you have success in reducing maternal obesity in Sarasota. However, you must recognize that unless you’re successful in a rate reduction in this area, you will not achieve a safe rate reduction in cesarean delivery either. And on the subject of maternal age, I’m not sure I understand what you’re saying. I wasn’t suggesting that age itself is an issue, but rather (as you listed) all the complications that arise as a result. Again, I just don’t think that this is an easily solved issue. Do you encourage mothers to have their babies sooner (to put their careers on hold earlier or to meet Mr Right in a timely fashion)? Or are you saying that if older mothers ensure that they are healthy before and during their pregnancy, that they will have a successful spontaneous delivery? If the latter is true, then I’m afraid I simply don’t see the data supporting this view.

    Personally, I would like to see us working towards different goals than simply ‘rate reductions’. That is, to set goals of positive physical and psychological birth outcomes – regardless of delivery type. A happy and healthy mum is what’s best for any baby, and while I agree that for some women, the chance to have (for example) a VBAC trial of labor would help ensure this, it needs to be recognized that for many other women, a planned cesarean is what’s best for them. It’s not an issue of numbers or percentages – it’s an issue of safest birth outcomes and maternal satisfaction.

  6. One of the problems we face when debating this topic is that there is a great deal of bias and prejudice in the presentation of cesarean data – and in particular, cesarean delivery on maternal request.
    For example, when the WHO published its latest findings on cesarean delivery in January 2010 (Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007-08), its own data highlighted very positive birth outcomes with planned cesarean delivery, and yet the authors final conclusion was in complete contradiction to these facts. Here are some examples of criticism of the WHO’s conclusions:

    30 Jan 10 Nigel Hawkes: A bad case of bias against Caesareans, Independent
    26 Jan 10 Funny Figures from WHO on Caesareans, Straight Statistics
    12 Jan 10 Study advises against non-medial cesareans but how accurate is the advice?

    You say that aspects of maternal request cesarean boggle your mind, but fundamentally, it seems that you are guilty of supporting ‘informed decision-making’ as long as that decision is one that you agree with or would choose yourself. So often, I read vaginal birth advocates stating that VBAC (which has a greater risk of death – for the baby and for the mother – than maternal request cesarean in a healthy pregnancy) is an issue of choice. Women should be allowed a VBAC as long as they recognize the risks, which include death.

    Yet your appraisal of maternal cesarean risks is completely incorrect. A woman (like myself) is NOT more likely to die following a maternal request cesarean than a PLANNED vaginal birth. The latest maternal mortality data in the UK (where we separate elective and emergency outcomes) shows that women are less likely to die as a result of an elective cesarean than any other delivery type. If you insist on only comparing ALL cesarean outcomes with ONLY vaginal delivery outcomes, then you are not truly informing a woman at the birth PLAN stage.

    I agree that an uncomplicated spontaneous vaginal delivery – in hindsight – has fewer risks than cesarean surgery, but the whole point is that no one knows if they’ll have a spontaneous vaginal delivery until after they’ve had one. Also, there are a number of studies that show that the safest way to deliver a baby is by planned cesarean at 39 weeks. This is the number one reason I chose a cesarean, but other reasons included avoiding the unpredictability of labor and reducing my risk of pelvic floor damage.

    As for physician diagnoses, I don’t know if this is the same reason in Florida, but in the UK, where many hospital trusts are also trying to reduce the number of cesareans, doctors will write a ‘medical reason’ on the paperwork – not because there IS a medical reason, but because they don’t want to highlight the ‘maternal request’ status of the surgery. To do so could be career damaging and may affect the chances of subsequent pregnant women having access to this birth plan. I don’t know, but I would guess that some doctors in the U.S. may be willing to note a ‘medical reason’ in order to ensure that the woman’s medical insurance company covers the birth. Until we stop demonizing and refusing what is a perfectly legitimate birth choice, we simply won’t know the true numbers. Meanwhile, it may be of interest that a recent UK survey found that 5.8% of women said that access to maternal request cesarean delivery was the ‘most important’ aspect of their birth.

  7. I support informed decision making whether the decision is one I would make myself or not. My point is that most women are not being given adequate information upon which to base their decision, neither about the risks of unnecessary surgery to themselves and their babies, nor about the benefits of vaginal birth for themselves and their babies.

    My appraisal of maternal request cesarean risks is thoroughly evidence based:


    The most reliable maternal mortality data come from the UK Confidential Enquiries into Maternal Deaths. While it may have been obstetric politics which promoted the omission of the usual chapter on maternal mortality with CS from the latest report (1998) two scientists calculated the rate from data in the report. An elective CS with no emergency present had a 2·84 fold greater chance of the woman's death than if she had a vaginal birth. Since a randomised controlled trial is not ethically possible, the UK data on 153,929 elective procedures give powerful enough evidence of the increased risk of maternal mortality with women's choice elective CS.


    The risks of severe maternal morbidity associated with planned cesarean delivery are higher than those associated with planned vaginal delivery. These risks should be considered by women contemplating an elective cesarean delivery and by their physicians.


    Maternal mortality, while a rare event in developed nations, is 2 to 3 times higher in elective cesarean delivery than in vaginal delivery, although there are no large studies of maternal mortality risk for primary elective cesarean delivery.

    I'd love to see your pelvic floor research for my own oedification. The studies I've read in this area are highly inconclusive, and may be more accurately attributed to pregnancy itself (rather than delivery) and certainly are exacerbated by high rates of episiotomy and hyperstimulated uterine contractions due to induction. I'd love to see studies that follow women without these interventions vs. those who have them and measure their pelvic floor damage. So far so good here, and I've had two ten pound boys. Granted, I had little orange KEGEL stickers everywhere as reminders during my pregnancies... :)

    As for the fabricated medical diagnoses for maternal request c-sections, this is insurance fraud and should NOT be tolerated by us as consumers. This is contradictory to transparency in medicine. How can we make informed decisions if the data shows that higher percentages of women are having certain complications than are actually having them? Making up phony medical conditions is a self-fulfilling prophecy that only serves to feed the fear-fueled fire surrounding childbirth.

    On to your second comment, improving prenatal and preconception nutrition (read: reduce obesity and high blood pressure) is one of the ten steps in our campaign. I don't think advanced maternal age should be "addressed." If older mothers are healthy and do not screen positively for risk factors, there is absolutely no reason for them to be discouraged from pursuing a vaginal delivery.

    I agree that we should be working toward healthier birth rather than a specific number, but we've got to start somewhere, and our numbers must be reduced to achieve this healthier birth. Yes, it's an issue of safest birth outcomes and maternal satisfaction... both of which are higher with vaginal birth than cesarean section.

    You did your research, you were informed, you made a choice, you're happy with your choice. That's terrific. I did my research, I was informed, I made a choice, and I was--and still am--ecstatic with my choice. And that's terrific too.

  8. My evidence in relation to maternal request cesarean delivery is all outlined on my main website ( and also written about on my blog (cesareandebate.blogspot). Unfortunately, I do not have the time today to write it all here.

    I guess we will have to wait until 2020 to find out whether you achieve your 20% goal, but in the meantime, this is what concerns me from what you've written:

    "My point is that most women are not being given adequate information upon which to base their decision, neither about the risks of unnecessary surgery to themselves and their babies, nor about the benefits of vaginal birth for themselves and their babies."

    What about being informed about the risks of vaginal birth and the benefits of surgery? Wouldn't this have made your statement more balanced?

    We also need to agree to disagree for now on your other point:

    "Yes, it's an issue of safest birth outcomes and maternal satisfaction... both of which are higher with vaginal birth than cesarean section."

    First of all - as so many people do - you refer to 'cesarean section' in your summary as though all cesareans are the same (they're not). And secondly, when it comes to maternal satisfaction, maternal request cesarean delivery wins hands down when compared to women planning a vaginal delivery (shown in research but also evident on any birth trauma website).

    Finally, you did not reply to my comment about 'planned' vaginal delivery being a different birth type to compare with maternal request cesarean than an actual vaginal delivery outcome (unknown until it happens). You insist on comparing births in hindsight rather than at the planning stage (which would include an assessment of ALL actual outcomes). Remember that in planning a cesarean, many women are seeking to avoid unpredictability and a possible emergency cesarean. You also did not comment on the examples I gave about the WHO research in January (for example) when I was trying to illustrate how data is being misrepresented.

    I wish you luck with your efforts to safely reduce unwanted cesarean deliveries, but I hope you do not seek to achieve this by under-estimating the risks of a planned vaginal delivery and over-estimating the risks of a planned cesarean when you are informing women...

  9. I am hopeful and optimistic, yet this campaign realistically will only reach consumers...and as we know, the responsibility of this health crisis is also shouldered by care providers, hospitals, insurance commissions, medical schools, litigators, legislators, policy makers and the media. It will take a cultural shift to see this goal achieved. Not an easy feat, but I still believe in my deepest heart, a necessary one.

    Of course, in the interest of informed decision making, I would demand that consumers be informed of the risks of vaginal births and benefits of surgery as well. Those are just much, much, much shorter lists than their counterparts. Like you, I won't rehash all of the statistics I've compiled over the years, but here's a great overview comparing risk:

    I think it's also important to remember that so much of birth trauma from planned vaginal delivery occurs when women aren't being granted informed consent. They aren't told what will realistically happen if induced prior to spontaneous labor, or when only 2 cm and in the hospital. They don't know that Cytotec can and has killed women. They don't know the cascade effect that starts with induction, leads to anesthesia and often ends in assisted delivery...a VERY traumatic event.

    I do not intend to under- or over-estimate anything. I carefully read the studies I quote. I just feel so much pain for women who are robbed (not by their own choosing) of the chance to feel, firsthand, the benefits of spontaneous labor, of the natural hormonal sequence, of that MOMENT of birth.

    I am grateful for all of your comments. It is very interesting and educational for me to understand that there are people in the world that are advocating just as strongly as I am, although our platforms vary greatly. What it boils down to is that women have the right to choose how, where and with whom they give birth, and should not be manipulated or forced otherwise by lack of informed consent.

  10. I am an obstetrician with over twenty years of experience who is trying to decrease the number of cesarean deliveries. I believe that you will not be able to reduce the number of unnecessary cesarean deliveries until you take the time to better understand the statistics. Once you better understand the statistics you will realize that what we need is a cesarean birth measure not a cesarean delivery rate. A cesarean birth measure corrects a cesarean delivery rate using the main risk factors that increase a woman’s chance of having a cesarean delivery. With this correction we can find the labor management strategies that will result in the fewest number of cesarean deliveries. You can find information on the pitfalls of the current way that we report cesarean delivery rates as well as the answer to why is the cesarean rate increasing on my website