In Cesarean Surgery

A study in the most recent issue of Birth provides eye-opening illumination on non-medical reasons for high cesarean rates (Kennedy 2016). Investigators at Yale’s med-school affiliated hospital conducted in-depth interviews eliciting opinions on how the institution could do better at promoting vaginal birth with 79 caregivers (obstetricians, pediatricians, anesthesiologists, anesthetists, midwives, nurses, doulas, and childbirth educators), 2 administrators, and 24 1st-time mothers. As background, the hospital’s cesarean rate had risen from 22% in 1997 to 38% in 2009, which was attributed mainly to a rise in 1st deliveries by cesarean. This tells us that the high cesarean rate can’t be attributed to the hospital’s having more high-risk maternity cases since that was also true in 1997.

Four themes emerged from the interviews:

  • the woman’s preparation for childbirth
  • early labor management
  • clinician knowledge and practice style
  • birth environment (physical, emotional, and hospital culture)

While the various constituencies shared these concerns, differences in their understanding of the issues and how they might be addressed brought “fish swimming in water don’t notice the water” to mind. I’ll be providing a narrative, but really, to appropriate the latest catchphrase, “The tweets,”—or in this case, the quotes—“speak for themselves.”

Preparation for Childbirth

Caregivers felt that childbirth education helped women be better prepared and more confident, but views differed on how to accomplish this. Doulas and childbirth educators saw education as critical to a woman choosing her care provider and making informed decisions:

I think education is probably the biggest piece of it, so that they can make informed decisions, not just in labor, but in pregnancy . . . choosing the care provider that works best. (doula)

Nurses, on the other hand, “believed that the education program should involve their participation to help prepare women for birth in the specific institution,” which sounds more like preparing them to be compliant patients.

Women, too, thought that childbirth education helped, but some felt insufficiently prepared for interventions or knowledgeable about the side effects of epidurals. One wished her nurse had reminded her of coping strategies learned in her classes. Reading between the lines, women may not be given the information they need to make an informed decision about epidurals, and nurses may not assist women wishing to avoid one in applying what they had learned.

Hospital Admission in Early Labor

Caregivers agreed that admission in early labor increased the unnecessary use of interventions, including cesarean surgery, which is, I should add, an accurate perception (Kauffman 2016; Tilden 2015). Think about that for a moment. Caregivers agreed that checking into the hospital could be hazardous to a woman’s health because medical staff would likely mismanage her. Their solution was access to phone support to keep women home until active labor, about which study authors write: “Several obstetricians described overhearing midwives counsel women over the phone in a way that they did not learn during their education.” So OBs at a teaching hospital acknowledge that they haven’t been taught what they need to know to keep women in early labor out of the operating room. Caregivers also agreed that women in early labor should be sent home with guidelines for when to return, but, as the study authors diplomatically put it, “This practice was not consistent across caregivers”:

Like women come in at, you know, 1 to 2 centimeters [dilation] and they admit them very early and give them epidurals right off the bat. I feel like they’re not really in good labor on their own, and that kind of impedes the process. (nurse)

Meanwhile, women document the “traumatizing and demoralizing” effects of insensitive counseling:

I was only 1 centimeter dilated, and she [caregiver] said, “I . . . know you think this hurts, but you’re not actually in real labor. Go home, have a Benadryl, and take a nap . . . I can tell you for sure this baby is not coming today” . . . I’d already been in labor for 12 hours. And I just went home and cried. (mother)

Women also wondered why they couldn’t be at the hospital in early labor but not admitted. Why not, indeed. Almost certainly because, changing the culture aside, setting aside a space to accommodate them, their labor companions, and their needs would be a money loser, which would trump the clear potential to reduce cesarean surgeries.

Clinician Knowledge and Practice Style

Issues raised mostly by caregivers as barriers to promoting vaginal birth were:

  • Fear of litigation
  • Rigid interpretation of protocols, unwillingness to individualize care
  • Knowledge and clinical skills (forceps, vaginal breech birth, care that supports physiologic birth)
  • Impatience (mostly raised by nurses)
  • Labor Inductions for non-medical reasons

Some obstetric practice groups were “perceived to have a practice of ‘cleaning up’ for the next shift with an expectation to not leave a potential cesarean for the person coming on duty”:

I’ll come in and the C-section fairy is on . . . and all of a sudden the board goes pink [the nursery census board lists babies delivered by cesarean in pink], and I think to myself, somebody was on who just wasn’t comfortable waiting. (pediatrician)

Some caregivers commented on the importance of their role in helping women advocate for themselves:

My job is to empower them. I don’t need to feel powerful . . . it’s all about them, and putting the confidence back in them. I try to find out what their hopes and goals are for the birth, and support them in their goal. (nurse)

However, women reported that staff didn’t necessarily listen to what they had to say about their perceptions of the labor and that their wishes might not be accommodated and their decisions respected.

We kind of sit there waiting for the next step or for them to tell us what’s going on; and I think if we could change that culture, so that we feel empowered when we’re there, then we could tell them what we’re experiencing and feel confident in that. (mother)

Birth Environment

Birth environment issues included: physical and emotional aspects and the work culture. Caregivers brought up insufficient space, inadequate staffing (mostly nurses), the lack of birthing tubs and other alternatives for coping with labor, and that women weren’t allowed to eat or drink (at the time of the survey). They emphasized the importance of continuity of care and of physical presence in the labor room, as opposed to labor management via chart from a central monitoring station, which, one would assume, must have been common practice or survey participants wouldn’t have mentioned it. Caregivers also united in stressing the need for collaboration, teamwork, communication, and mutual respect, but as with childbirth preparation, staff members differed from non-staff members on what this might mean. An obstetrician thought team relationships should be top down:

So I think the more people who collaborate as a team when they’re in labor . . . on the same page, we say the same things to the patients . . . [but] sometimes if you have a nurse that says one thing, the doc says another, this person says another—it just instills fear. (obstetrician)

In other words, team members should speak with one voice: the doctors’.

Women found it difficult when caregivers were at odds, but they attributed this to power imbalances between them:

. . . to have the hierarchy of the doctors and nurses be less pronounced . . . every time a doctor—even the nurse-midwives—every time they came into the room they [nurses] all just clammed up and they would no longer help me advocate for myself. (mother)

Relationships among caregivers weren’t always hierarchical:

In this practice I have appropriate professional autonomy and respect . . . so I trust that my consultants are available and . . . otherwise in a normal situation appropriately disinterested. (midwife)

However, when they are, this is by nature antithetical to collaboration, communication, and mutual respect.

Can These Problems Be Fixed?

The intent of the researchers was to gather data that could inform strategies to improve care. As much as I wish them success, the odds are against it. For one thing, the people causing the problems aren’t likely to think so. For another, the problems are embedded in the hierarchical social structure and hospital culture, which means the structure and culture would require reform for solutions to work; and for a third, as study authors put it, obstetricians “lack meaningful incentives to go the extra mile to help a woman achieve a vaginal birth and avoid a cesarean”:

People are starting to think; are we really doing the right thing? And I think the answer is clearly no . . . I can’t believe that evolution is pushing us into the operating room. I think we’re pushing ourselves into the operating room. . . . it’s almost like the perfect storm. You’re going to pay me more, I get to worry less, you’re not going to sue me, and I’ll be done in an hour. (obstetrician)

The solution is quite simple: put the woman at the center. Do that, and everything falls into place, but this last quote tells us just how broken the system is. It’s hard to say which is worse: that the system incentivizes flouting the primary ethical imperative “First, do no harm,” and its corollary, “Second, do some good” or that doctors need incentives to adhere to those principles. The two together, though, tell us just how difficult true reform would be.

The Take-Away

What can we conclude from this study?

  • Even a prestigious university hospital, training not only physicians, but midwives, fails to provide optimal care because barriers to its provision are embedded in the social structure and culture of institutionalized medical care.
  • The overall institutional culture influences care quality, but it also varies widely by individual caregiver.
  • Hospital admission in early labor is harmful, and caregivers may lack the skills and knowledge to help couples cope with early labor at home and time their admission appropriately.
  • Supportive care in labor is likely to be inadequate.
  • Caregivers may impede informed decision making, and some may not respect a woman’s right to do so.

In light of this, what can you do to prevent a preventable cesarean?

  • Learn what policies and practices best promote safe, vaginal birth so you can choose a place of birth and care providers accordingly. Develop a birth plan in collaboration with your care providers to ensure that whichever of them ends up attending you in labor, you will be on the same page. Tip: Hostility to a birth plan is a red flag.
  • Take a set of quality childbirth preparation classes. Quality characteristics include:
    • Taught by a certified* educator.
    • Lengthy enough to allow for in-depth coverage of the knowledge and skills you and your partner need to cope with labor, breastfeeding, and new parenthood. Tip: One-shot or two-day classes aren’t.
    • Prepares you to make informed choices.
    • Uses a variety of teaching techniques, not just lecture/discussion, and includes opportunity to practice labor-coping techniques.
  • Hire a certified* doula. Doulas provide one-on-one supportive care throughout labor not only to you, but to your partner and any other labor companions. Doulas are also in your corner and can help you advocate for yourself should that become necessary. Tips: Make sure her philosophy lines up with yours, especially as regards epidurals. Caregiver hostility to your having a doula is also a red flag.

*Certification doesn’t guarantee excellence, but it ensures that she has achieved at least some level of knowledge and skill.

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