April 21, 2010
Sidney Wolfe, M.D.
Public Citizen Health Research Group
About New York
Variations in Cesarean Sections, VBACs, and Midwife Availability by County and by Hospital Within Each County
Healthy Outliers: Two New York Hospitals that Have Bucked the Trend
Factors Possibly Associated with Variation in Rates
What is Driving Cesareans in New York?
How a Woman Can Avoid an Unnecessary Cesarean in New York State
What Health Departments and Hospitals Can Do to Reduce Unnecessary Cesareans
New York Hospital Birth Statistics by County
How a Woman Can Avoid an Unnecessary Cesarean Section in New York State
There are some things a woman can do to avoid an unnecessary cesarean section in New York State.
1. Talk to your doctor or midwife early about your preferences. Do not hesitate to let either know what you want and expect. She/he should hear you out and discuss what is best for you, based on your individual circumstances and those of your baby. If there are any major discrepancies concerning your respective perceptions of risks and benefits, these should be fully aired. If you are not satisfied that you have been provided with complete and accurate information, you should consider finding another provider.
2. Use the data in this report to find the overall, primary and VBAC rates in the hospitals you are considering using for your pregnancy (See Table 2). In addition, it is important to also ask for information specific to the obstetrician(s) or midwife you are considering using because there may be considerable variation within hospitals among obstetricians or between obstetricians and midwives. A hospital with a relatively low cesarean rate may have obstetricians with high rates and vice versa.
Fortunately, New Yorkers have a valuable source of information that is not available to women in other states. NYS Public Health Law section 2803 requires that every hospital and birth center provide each prospective maternity patient and the general public an informational leaflet with data on maternity care and insurance coverage. The hospital and birth center must also provide statistics on its maternity-related procedures. These include data on cesarean rates, successful VBACs, midwife-attended births, use of fetal monitoring, use of forceps and analgesia, anesthesia, births delivered vaginally, induced deliveries, use of augmentation of labor and episiotomies, availability of birthing rooms and facilities for rooming-in. This report uses these data to make comparisons not otherwise available to women in New York State.
3. Consider using a certified nurse-midwife or certified midwife. From 1981 to 2006, there was a 5.6-fold increase in the number of midwife-attended births, from 56,000 a year to 311,000 a year in the United States. The percentage of all hospital births attended by midwives rose from 1.53 percent in 1981 to 7.46 percent in 2006, a 4.9-fold increase in the percent of deliveries by midwives.
Of the 143 hospitals listed in this report, 99 have midwives doing deliveries, ranging from 0.1 percent of births at St. Catherine of Siena Hospital and North Shore University Hospital to 79.8 percent of births at North Central Bronx Hospital (See Table 2 to find out if your nearby hospital has midwife deliveries). In New York State in 2007, there were 23,968 midwife-assisted births. Out of a total of 250,780 births that year, the percentage delivered by midwives was 9.6 percent. Even in hospitals with high overall cesarean rates, choosing a midwife will very likely decrease the chance of an unnecessary cesarean section since the likelihood that a cesarean will be needed is generally less with midwives than with obstetricians.
In New York State, all midwives must meet certain criteria in order to practice. These are:
- A bachelor’s degree (in any subject)
- Midwifery education at a NYS-approved midwifery school
- Demonstrated competency in particular areas related to well-woman care and pharmacology
- Passing the American Midwifery Certification Board (AMCB) examination.
In a study we did surveying national hospital-based midwife deliveries and reviewing the published literature, we found that, in hospitals with both obstetrician and midwife deliveries, the following practices were much more likely to occur with midwife-assisted deliveries than with obstetrician-attended deliveries:
- Oral fluids during labor
- Room to ambulate during labor
- Use of shower, bath, or hot tub
- Encouragement of alternate positions for delivery
- Use of intermittent, not continuous fetal monitoring (less chance of false signals of fetal distress)
- Shorter stay and early (24 hours or less) discharge
These factors contribute to the findings in multiple studies showing that the likelihood of induction, episiotomy, or a cesarean section is generally lower with midwife-attended deliveries than with obstetrician-attended deliveries.
A recent study involved women with pregnancies that were considered low-risk enough to qualify for a home delivery but all of whom delivered in the hospital. Four hundred eighty-eight of these women had hospital midwife deliveries, and 572 had hospital physician deliveries. The decreased risks in the midwife group included a 42 percent reduction in cesarean sections and a 38 percent decrease in episiotomies. There was also an 81 percent decrease in the use of drugs for resuscitation at birth. The authors concluded that: “A shift toward greater proportions of midwife-attended births in hospitals could result in reduced rates of obstetric interventions, with similar rates of neonatal morbidity.”
4. Consider using a doula. If a certified nurse-midwife or certified midwife is not available in the hospital(s) you are considering using, think seriously about using the services of a doula (continuous labor support by an experienced woman) in conjunction with your doctor. A published study evaluated the positive effects of doulas on childbirth. Among 224 women with an uncomplicated pregnancy who took a childbirth education class, half were randomized, after admission for labor, to doulas, who provided close physical proximity, touch, and eye contact with the laboring woman, and teaching, reassurance, and encouragement of the woman and her male partner. The other half of the women served as a control group. “The doula group had a significantly lower cesarean delivery rate than the control group (13.4 percent vs. 25.0 percent). Among women with induced labor, those supported by a doula had a lower rate of cesarean delivery than those in the control group (12.5 percent vs. 58.8 percent).”
 “Table 1-24. Live Births by Place of Delivery, and Attendant, According to Race and Hispanic Origin: United States, Selected Years, 1975-2003.” CDC. Web. <https://www.citizen.org/sites/default/files/natfinal2003.annual1_24.pdf>.
 Gabay, Mary, and Sidney M. Wolfe. “Nurse-Midwifery. The Beneficial Alternative.” Public Health Reports 112 (1997): 386-94. Print
 Janssen, Patricia A., Elizabeth M. Ryan, Duncan J. Etches, Michael C. Klein, and Birgit Reime. “Outcomes of Planned Hospital Birth Attended by Midwives Compared with Physicians in British Columbia.” Birth 34:2 (2007): 140-47. Print.
 McGrath, Susan K., and John H. Kennell. “A Randomized Controlled Trial of Continuous Labor Support for Middle-Class Couples: Effect on Cesarean Delivery Rates.” Birth 35.2 (2008): 92-97. Print.