Star Tribune Features Low-tech Birth & Midwives in MN

The Star Tribune recently published two stories highlighting one Minnesota woman's journey to VBAC despite many roadblocks and St. Joe's Hospital's extraordinarily low cesarean rate. Both articles are valuable in what they have to say about birth in our area.

The first article by Josephine Marcotty tells Danette Lund's search for a care provider to support her desire for VBAC.

Because she had delivered her first child by Caesarean section, a hospital birth would almost certainly mean surgery again. Home birth? Her midwife refused, saying it was too risky. A birth center outside a hospital? She'd have to shell out $7,000 because her insurance wouldn't cover it.

"I felt like I had no options," said Lund, 36, who lives near Waconia. "I was so frustrated."

Lund and other women have discovered that birth in America is rarely the natural event they long to experience.

The article goes on to highlight the overuse of cesareans, the risks involved, and the barriers that so many of us face to having a safe, healthy birth. Marcotty uses Lund's story to illustrate how, despite what media stories and even doctors sometimes say, women are fighting to avoid unnecessary interventions in childbirth. Lund's story will sound familiar to many of us:

"There is nobody advocating for lower C-section rates," Peaceman said. "It's not insurance companies. Not doctors and not women."

Except, perhaps, for women like Lund.

Last year, when she became pregnant for the second time, she knew she was likely to have a C-section again. The surgery has become standard for women like her because there is a small chance that a prior C-section scar will rupture during contractions....

Lund's hospital, Ridgeview in Waconia, will consider a vaginal birth after a C-section. Many hospitals won't because of stringent national medical guidelines for the procedure...

After weighing her options, Lund asked a midwife to deliver her baby at home, but the midwife said it was too risky. She called a St. Louis Park birthing center run by midwives. Although such centers are common in some states, they are new to Minnesota, and Lund's health plan wouldn't pay.

By that point she was 30 weeks pregnant and out of options, she said.

Lund, an attorney and trained litigator, is the first to admit she is not typical of most pregnant women. She's comfortable with confrontation and decided to take matters into her own hands.

Three months ago her labor started at 1:30 a.m. She and her husband waited. And waited. They counted the minutes between contractions, then waited some more. Finally, when she was far enough, she hoped, that it would be too late for a C-section, she went to the hospital.

As soon as she arrived, her water broke. Her cervix was 9 1/2 centimeters dilated. She was ready to deliver her daughter.

"I said: 'Yay, there is nothing they can do to me now,'" Lund said.

The second article by Chen May Yee profiles St. Joe's Hospital in St. Paul, which boasts an incredibly low cesarean rate of around 12%, far lower than Minnesota's 26% rate and the nation's 32.3% rate.  The story tells of St. Joe's long history of supporting natural childbirth, especially with its emphasis on midwifery care.

Kara Sime, 38, a first-time mother from St. Paul, arrived one recent Thursday morning, her contractions five minutes apart. By Friday morning, her labor still wasn't progressing. Exhausted, Sime asked for an epidural, a powerful painkiller, and got one. She also got Pitocin, a synthetic hormone to induce labor.

But there was a problem. Her baby was facing backward, increasing the diameter of the head going through the pelvis. Such cases usually require a C-section or a vacuum.

Instead, the midwife and nurse helped Sime onto all fours -- no small feat since her legs were numb from the epidural. With Sime's belly hanging down, the baby turned.

Three pushes later, Catherine Julia was born at 6 pounds 10 ounces.

"I don't have surgical skills," said the midwife, Melissa Hasler. "I'm motivated to get the baby out vaginally."

Gail Tully, on her Spinning Babies Blog, also shared her own experience with the care providers at St. Joes:

A long time ago, I was at a posterior birth with Deb Monson in which the mom was working hard but staying at 7 cm for 3 hours. Deb's simple trick of 3 pushes against her fingers as they created a false pelvic floor quickly turned the baby and let the labor proceed. Doctors at St. Joe's (I don't know if the Midwives do this) will also occasionally reach in and manually rotate the posterior baby's head to anterior so the birth can finish vaginally. Not all posterior births need any of these interventions, but some do and I believe these skills are a big part of why St. Joe's has a low rate of cesarean section. Plus, the community midwives and doulas have long referred to St. Joe's for their quiet, kind nurses, and mother-centered birthing practices. 

With such a low cesarean rate and a practice culture that supports non-interventive birth, St. Joe's may be the best hospital in the Twin Cities for women hoping to avoid a cesarean. Sadly, however, St. Joe's is the only hospital in the Twin Cities metro area that does not allow VBACs.

This means that St. Joe's rich tradition and practice culture described by Yee and Gail are not available to women like Danette Lund who, for whatever reason, did not avoid that first cut. In a conversation I once had with a representative from St. Joe's administration, I was told that this is because HealthEast "cannot afford" the medical malpractice insurance fees involved in supporting VBAC. This stands in stark contrast to St. Joe's reputation for supporting evidence-based childbirth. And, unfortunately, it shuts out women seeking VBAC who could perhaps most benefit from the kind of support and quality care that St. Joe's provides.

Many thanks to Marcotty, Yee and the Star Tribune for writing and publishing these stories on a very important topic for birthing women in Minnesota.

Mankato malpractice case: A dangerous verdict

This week, a jury in Mankato, MN brought back a verdict in a malpractice case that may very well fuel the already skyrocketing cesarean rate. The Mankato Free Press summarizes the verdict saying, "Jurors finished deliberating Friday afternoon and determined the clinic and obstetrician Carla Goerish were negligent by not recognizing the fetus was so large it should have been delivered by Caesarean section."

The situation is a sad one. No parent could help but sympathize with the couple who sued Dr. Goerish. Their beautiful baby daughter suffered nerve damage in the course of her birth. Who wouldn't want someone to be held responsible? We all do when something goes wrong, especially with our children.

However, this verdict sets a very dangerous precedent for birthing women everywhere. We just recently posted here about a recent study demonstrating a link between malpractice lawsuits and the rising cesarean rate. This case will no doubt contribute to more unnecessary cesareans being performed on the basis of a suspected macrosomic (large) fetus.

The plaintiff's lawyer argued that a radiologic report that "suggested a macrosomic fetus," combined with "accepted, published medical standards (that) suggest a C-section be done with macrosomic fetuses" meant that the OB was negligent in this case. Apparently, the jury believed this evidence. Unfortunately, while some studies and standards my "suggest" a cesarean in such cases, there is far from a solid consensus in the medical literature regarding the use of cesarean for suspected large babies. The truth is, radiologic measurements are notoriously unreliable. Estimated weights can be off by more than a pound in either direction. As Dr. Goerish's lawyer argued, there is simply no way to know if a baby it "too large" based on such evidence. See Kmom's excellent discussion of the medical evidence here.

Not to mention that women's pelvises are made to flex and expand to allow babies to move through during birth; a process that is hindered by standard hospital practice of birthing while lying in bed (usually with an epidural). Babies heads are also made to mold, if given time and opportunity to do so, to fit through the pelvis. See ICAN's White Paper on Cephalopelvic Distortion (CPD) for more information. Gloria LeMay's Pelvises I Have Known and Loved is also instructive.

In reality, things can happen in birth. The temptation to say that a surgical procedure may have prevented a poor outcome is alway strong in hindsight. Perhaps it would have in this case. It seems we expect our doctors to be nearly omniscient when it comes to this. It's no wonder many OBs practice "defensive medicine" out of fear of being sued.

But performing cesareans for suspected large babies is NOT the answer, as this video from ICAN Voices illustrates so well. Women of all sizes CAN birth babies of all sizes. No technology to date can accurately predict this, as much as we might like it to.

C-section & malpractice suits - some evidence for a link

Researcher studies rates of cesarean sections, malpractice suits
by Kristina Goodnough - September 2, 2008

There may be a relationship between cesarean delivery rates and medical malpractice rates, according to research by Dr. Jeffrey Spencer, a fellow in maternal fetal medicine at the Health Center.

As the state’s medical malpractice premiums increased, the number of cesarean deliveries also rose, according to Spencer, who reviewed the deliveries at Hartford Hospital from 1991 to 2005.

During that time, there were 64,767 deliveries, of which 15,021 (23 percent) were cesarean deliveries. Of the 15,021 cesarean deliveries, 8,045 (59.5 percent) were primary or first-time cesarean deliveries, while 6,076 (40.5 percent) were repeat cesarean deliveries.

During the same time period, medical malpractice rates increased substantially. Spencer obtained mean malpractice premiums for obstetricians from the hospital’s major medical malpractice provider and adjusted them for inflation.

The mean premiums for medical malpractice insurance for obstetricians increased from less than $80,000 for an individual physician to more than $120,000.

“When I compared the malpractice rates to cesarean delivery rates prior to 1999, both were declining at a similar rate,” says Spencer. From 1999 to 2005, however, both were increasing. “I can’t say one led to the other or visa versa,” he says, but he speculates that rising medical malpractice rates are driving up cesarean delivery rates.

Normal vaginal delivery is considered safer than a cesarean delivery for both mother and baby if the birth is uncomplicated. Cesarean deliveries are recommended for complications, such as slow or long labor or indications of fetal distress during labor.

Maternal fetal medicine specialist Dr. Jeffrey Spencer of the UConn Health Center performs an ultrasound.

Photo by Lanny Nagler

“Most of the large malpractice cases result from a poor fetal outcome, that is, an expected ‘normal’ baby is born with health problems or has a bad outcome for whatever reason,” says Spencer. “The MDs get sued because they didn’t do all that was possible for the baby – meaning perform a cesarean.”

“Malpractice premiums are a huge expense for physicians,” says Spencer. “It’s difficult for them not to practice defensive medicine. But although cesarean deliveries are less risky for the baby, they are more risky for the mom, with longer recovery times, generally, than vaginal deliveries. It’s important to consider whether every cesarean delivery is truly necessary.”

It’s possible that there are other factors that may also account for the association,” says Spencer, who presented his research at the American College of Obstetricians and Gynecologists annual meeting last spring. “With our data, we cannot prove a causation but only suggest an association.”

Nationwide, cesarean deliveries accounted for 30.2 percent of all deliveries in 2005, compared to 20.7 percent of deliveries in 1996. The rising rate of cesarean deliveries has triggered a debate over whether the increase can be attributed to medical necessity.

Source