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More Information on Quality of Care

Statements Concerning Guide to Avoiding Unnecessary Cesarean Sections in New York State

April 21, 2010

Howard Minkoff, M.D., Chief of Obstetrics and Gynecology, Maimonides Medical Center 
Jacques Moritz, M.D., Obstetrician, Gynecologist, St. Luke’s- Roosevelt, Roosevelt Hospital Division
Susannah Donahue-Negbaur, CNM, M.P.H, Midwife, Roosevelt Hospital, New York City

Howard Minkoff, M.D., Chief of Obstetrics and Gynecology, Maimonides Medical Center 

There is little question that many women, if fully informed, want to have vaginal deliveries, including after a previous cesarean (VBAC), whenever safely possible. However, the statistics in today’s report testify to a different reality, one in which choice around both VBAC and vaginal delivery in general has become highly circumscribed for too many women.

Risks related to VBACs, which were understated in the 1980s, are now more often overstated. Standards promulgated for the purpose of making VBACs as safe as possible have been almost impossible to achieve in many of a variety of healthcare settings with wildly disparate resources. 

Listing factors, including the fear of litigation, that contribute to the foreclosure of pregnant women’s reproductive options is important. Today’s report is eloquent in describing additional patient and provider factors. The challenge is in trying to reverse a decades-old and accelerating trend. Recommending changes in obstetrical standards is just one step. (Other steps include more versions for breech and revising ACOG (American College of Obstetrics and Gynecology) standards to offer more full-throated support for VBAC.) Pregnant women can follow the report’s advice to educate themselves about their provider’s track record. Equally important is for providers to act in accordance with the core tenets of obstetrical ethics, i.e., maternal autonomy should never be breached, and patients require informed consent. Informed consent in turn requires voluntariness and information — information that should be tailored to the woman’s clinical circumstances, not proffered as an act of suasion to move someone to the operating room when labor is still a reasonable option.

Perhaps the most important step in reducing cesarean section rates is embracing a philosophy that defines a successful hospital stay as the discharge of a healthy mom who delivered a healthy baby vaginally. No one would argue that the mode of delivery should trump health considerations of the mother or child, but there are no data demonstrating that ever better health outcomes have been achieved by ever higher operative delivery rates. If physicians and pregnant women can embrace safe vaginal delivery as a mission (midwifes already have), then strategic and tactical approaches to achieve that goal will fall into place.

Jacques Moritz, M.D., Obstetrician, Gynecologist, St. Luke’s- Roosevelt, Roosevelt Hospital Division

The reason midwives have lower C-section rates is that they offer a high-touch versus high-tech approach to delivery. The model of obstetrical care in this country is all wrong. The model of an overtrained obstetrician attending to a normal birth is all wrong. The proper model is that all low-risk mothers be managed by a certified midwife with a midwife-friendly obstetrician as back-up. This works in other industrialized countries but not in ours. The possible shortage of obstetricians in the next few years is another reason why this model will have to be implemented.

Susannah Donahue-Negbaur, CNM, M.P.H, Midwife, Roosevelt Hospital, New York City

It’s great that Jacques, Shiri and I are here together because I think the best maternity care is a partnership between doctors, midwives and families. If you are pregnant, healthy and low-risk, you are in very good hands with a midwife. You probably don’t even need to cross paths with a doctor during your pregnancy, labor and delivery. I tell our patients that they might say “Hi” to Dr. Moritz in the hall, and that he’s here if we need a consult or more, but he’s happy to stay out of their way. If you are a high-risk pregnant woman, that’s when you need an obstetrician.

Choosing a midwife is one good way a woman can reduce her chance of a cesarean section. Research shows that low-risk women who use midwives are more likely to have a safe and healthy births for themselves and their babies, and are less likely to undergo an induction of labor, cesarean or episiotomy than low-risk women who use doctors.

As a midwife, I have a chance to get to know my patients. I work closely with them to try to prevent problems before they happen. Our visits tend to be longer than doctor visits; we can spend time listening and teaching, which I really enjoy. We make time to talk about things like nutrition, exercise, preparation for labor and emotional well-being.  

During labor and through the birth, midwives will stay at the patient’s side to provide her with support and guidance. In itself, good labor support can reduce a woman’s risk of needing a cesarean section. 

My focus is on normal, healthy pregnancy, labor and birth, and that applies to the vast majority of women. Should any complications pop up, I am trained to recognize them and deal with them, and that may be when we need to bring an obstetrician into the mix. Maybe a cesarean section is what’s needed – the procedure can be a lifesaver when it is necessary. But one thing about midwives: If problems occur, we make every effort to try other solutions before recommending surgery. We may know of other options besides surgery. 

Women in labor can do amazing things – it’s miraculous every time. As a midwife, I try to remember what the women I care for are capable of when given patience, support and a watchful eye.   

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