Responce by California College of Midwives
to the Good Morning America’s
Tues. June 20
program with Diane Sawyer
"Patient Choice" (medically unnecessary) elective c-sections
avoid the infrequent and non-fatal complications
of normal childbirth
with Dr. Marsden Wagner and Dr. Benson Harer,
president of the American College of Obstetricians and Gynecologists

California College of Midwives

June 22, 2000

Faith Gibson, LM, CPM
Director, ACDM/CCM

Dear Ms Sawyer,

As director of the California College of Midwives, former labor and delivery room nurse, mother of three, grandmother and a personal acquaintance of Marsden Wagner’s, it was with great interest that I watched the segment on the elective use of cesarean as a surgical method to avoid the infrequent and non-fatal complications of normal childbirth. The following numbers are perhaps the best over-all commentary of the merits of this idea. Mortality for women of childbearing age per 100,000 are:

vaginal birth > 6; [citation # 1]

auto accidents > 20,

cab driver > 22, (most dangerous occupation)

breast cancer > 26,

Cesarean surgeries > 31 deaths [citation # 1]

This is a ratio of 1 death per 3,225 Cesarean surgeries versus 1 in 16,666 for vaginal birth (including high risk pregnancies, women with no prenatal care and use of forceps)

Perhaps the potential problem of pelvic floor relaxation is not so important when contrasted to an increased maternal deaths of five times that of normal birth. The suggestion by this male obstetrician that "excess maternal mortality" is offset by advantages to the baby is either a perverse form of sexism or a blind spot of monumental proportion. According to estimates by the CDC over 100,00 American die each year due to the complications of medical or surgical treatments. [2] Obstetrician David Lawrence, in a guest editorial for Ob.Gyn.News (Jan 15, 2000, p. 8) voiced the opinion that "Quality of care -- not managed care -- is the problem. ... Extrapolating from these hospital studies to health care in general, one can conclude that the 3rd leading case of deaths in the US is fatal (medical) mistakes". Such accidents account for 400,00 death annually and that number doesn’t include ... the impact of overzealous care". Cesarean on demand is "overzealous care" in the extreme!

I also could not help but wonder that something which effects childbearing women so personally and so profoundly as Cesarean surgery be argued for and against by two men, neither of whom have even given birth or been the recipient of this operation. Perhaps the next episode in this on-going saga could feature women who have had both a normal vaginal and cesarean operation and who could report their experiences (relative pain and recovery time, long term effect on newborn bonding, etc) and the women’s own preferences. You can contact the cesarean prevention movement (ICAN).

As for the statistical evidence of increased hazard from elective surgical births I would like to cite just one study which compared normal vaginal birth with a breech baby with elective cesarean for breech position [3]. The outcome for the baby was the same in both arms of the study (same number of babies with good outcomes and no signs of long term disability) so obviously cesarean surgery is not "safer" or better for babies. However there was a maternal complication rate of 13% follwoing CSs while there was no significant maternal morbidity among the 104 women who had a normal childbirth. Of the 104 women assigned to the elective cesarean arm of the study two developed uterine wound infections requiring prolonged hospitalization and a hysterectomy, another mother was in intensive care with pneumonia and a forth required an emergency hysterectomy and massive blood transfusions (with risk of AIDS and hepatitis) as the result of a nicked uterine artery which was an accident (and well known hazard) of this surgery.

Promoting unnecessary medical procedures during childbirth means less money for the necessary care of the ill, injured and elderly. Since 66% of all babies world wide are delivered by midwives in jurisdictions which enjoy the cost-effective midwifery model of care as the norm for healthy women, the US is put at an competitive disadvantage in our current global economy. In the US Medicaid (i.e. the tax payers) pay for 40% of all birth services, the rest coming from employers who must factor high health insurance expenses into the cost of doing business. Jobs are being shipped off shore to countries that spend far less and have far better outcomes and which, unlike the US, do not have to inflate the price of goods and services to cover the cost of unnecessary surgical interventions during childbirth.

For example, a well known side effect of epidural anesthesia is maternal fever which necessitates the baby being admitted to the neonatal intensive care nursery for a septic workup (which often includes a spinal tap) and the administration of IV antibiotics for several days. According to a peer review article on infectious diseases, 86 % of all septic workups are on term babies whose mothers had epidural anesthesia; 87% of all antibiotics given in the NICU are to babies whose mothers had epidural induced fevers. [4] The cost of this, both human and economic, is staggering. However when professional midwives provide care in hospitals, epidurals, episiotomies, induction, operative deliveries and NICU admissions are reduced 2 to 6 times. [5]

I believe the more important line of inquiry is why America seems to embrace such an expensive and unsatisfactory system of high-tech obstetrical care for healthy women with normal pregnancies while the rest of the world enjoys the safer and more "mother-friendly" system know as the "Midwifery Model of Care" with its higher maternal satisfaction, lower perinatal mortality rate and 1/2 to 1/5 the cost to health insurance companies and tax payers. [6]

faith gibson, Licensed Community Midwife #41
Nationally Certified Professional Midwife # 96050001
Director, American College of Domiciliary Midwives / California College of Midwives

 1. Liliford, RJ et al The Relative Risks of Cesarean section (intrapartum and elective); Br J Obstetrics Gyn 1990;97:883-892

2. Dr. Lucien Leape et al N. England J Med 324 [6]:370-76, 1991

3. Collea JV et al The Randomized management of term frank breech presentation: a study of 208 cases, Am J Obstetics Gynecol 1980; 137 (2):235-244

4. Liebermann E, et al Epidural, maternal fever and neonatal sepsis evaluation Pediactrics 1997; 99:415-420

5. Dr Roger Rosenblatt,et al Differences in the obstetric care of low-risk women, Am J Public Health 87(#):334-351, 1997

6. Anderson, et al The Cost effectiveness of Home Birth, J Nurse Midwifery. Vol 44 Jan/Feb 99

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