BIRTH STORY: Solstice, Bluegrass and Moonlight

(by Laura Gilkey, about the birth of Benjamin Wilson, born 12.22.07)

(December 22, 2007) It is 3:30 am, and I believe this solstice day may be your birthday! What a time for rebirth!

I was in Banyan’s room singing him to sleep when I felt a lot of wetness between my legs. I went to the bathroom and found I had lost my mucous plug, and since then I’ve had more show and some trickling water. I nested for a moment, emptying the dishwasher and folding laundry, then laid down with Papa and tried to rest. I’m awake now timing your squeezes…not quite time to let Harmony know yet. I’ll go back to bed and try to get as much sleep as possible. Who will you be? My eyes will know you!

It’s 9:30 am and my contractions have slowed to about once every 20 minutes, but super intense and short at each interval. Sweet Harmony is at a birth right now and will come and check things out on her way home. Banyan just woke up and gave me a big hug and whispered “happy birthday” to my belly. I LOVE YOU!

(December 26, 27 & 28, 2007) While it is still fresh in my madly-in-love mind, let me tell you the rest of the story of your birthday.

After speaking to Harmony Saturday morning, I decided to go ahead and make the kimbly, or ‘groaning cake,’ that I had read about in midwifery books. The story is that if a woman bakes this cake during labor, her pains will be short, and prosperity will come to the family. The scent of the cake baking throughout the home brings strength to the mother. The cake was beautiful and smelled of winter spices.

I stayed in a creating sort of space, brewing tea and preparing food for the day. We relaxed and played together throughout the morning. I wasn’t sure whether I was really in the thick of labor or not, because the contractions had slowed so much; so Papa and Banyan watched a mid-day movie and I took a glorious nap, waking only every half-hour or so for a contraction.

I was just waking up and planning to go in the kitchen and bake a blackberry crisp when Harmony arrived at our house, around 2:30 pm. We chatted, she told us about the birth she attended that morning, it was all very relaxed and casual. She decided to give me an impromptu prenatal checkup to see how we should proceed, expecting to go home and have us call her when things really progressed. I don’t think I’ll ever forget the look on her face when she said, “I want to be sure what I’m feeling here before I say anything….um, Laura? YOU ARE 8cm DILATED!” I felt elated, giddy, silly, and proud. I felt like Wonder Woman and like a little kid at the same time. We decided we’d better call Aunt Sarah and Mimi, and hope they made it in time, and Harmony decided she’d better not go anywhere! I told Harmony I didn’t know what to do with myself! She said, “if you were going to bake a blackberry crisp, go bake a blackberry crisp!” So I did, and the laughing and the baking and the happy day continued, right into the evening.

Aunt Gana arrived, Aunt Sarah arrived, and then Mimi arrived, and right on cue, my contractions started getting closer together. I stuck the chicken I had brined in the oven so my labor team would have something to eat for dinner. I was in a place of ecstasy, so happy I couldn’t stop smiling. Everyone was! At one point we all were sitting on the floor in Banyan’s room taking turns reading him stories. I was sitting on the birthing ball through those contractions, just happy to be in the room with everyone and not feeling reclusive at all, the way I remember feeling in labor with Banyan. I’d just have a contraction, open up, and it would be over, and I don’t think I ever stopped smiling! Banyan looked so beautiful to me as I was preparing to bring you into the world. He was absorbing the happiness of everyone around him.

As the evening progressed and my contractions became stronger and closer together, we put on some bluegrass music and started to move. With each contraction I would lean against Papa and have him press his strong hands into my back. Mimi made a salad and Harmony colored a mandala at the dining room table. We were still laughing, telling stories, and just busily creating our birthing space. Harmony called Jodi, our birth assistant, who arrived around 7:00. She was just lovely. She felt right at home in our space and said so, making me feel proud of my cozy nest. She was the last piece in the perfect group of attendants, waiting for you.

We continued dancing right on through the contractions. Everyone ate dinner while Papa and I danced our labor dance. Things began to intensify yet again, and at around 8:30 we decided to take a moonlight walk. What a great idea that was. All of us went, even Banyan, the lightkeeper, who thought it was terrific fun. It was the most gorgeous winter solstice night, two away from a full moon, cool and crisp and clear. I looked at that moon and those bright stars and felt surrounded by the energy and wisdom of the universe. I felt like a miracle.When our walk was over, things changed in my body. My amazing birth team sensed that and even as I walked in the house, the bluegrass had been turned off, the lights turned down, and the mood much calmer. I needed all of those things to have happened and I didn’t even know it, much less voice it. I was only in the house a few minutes and a few contractions before I decided it was time to get into the birth pool. Harmony and Jodi filled the pool; Banyan helped, then went with Aunt Sarah to his room to read stories. I was a bit saddened by this. I really wanted him to see your birth, but I knew he was exhausted and would fall into the rhythm that was right for him. And of course, everything happens for a reason. I just missed him a little.

When the pool was full I took off my clothes and got in. The water felt amazing. The birth altar which had been set up since my Blessingway was alive with candlelight, and I chose an angle to labor that would allow me to look right at all of those symbols of support. Papa knelt right beside me, giving me that same strength that he had given me through Banyan’s birth, the strength that was the most important element of my birthing ability. I enjoyed very much the time we had alone together in that small space, while the rest of the birth team waited to come and watch your arrival. Kissing him felt so good, I didn’t want to stop doing it. I was still riding a wave of ecstasy I couldn’t believe.

I had several contractions in the pool before my water broke. I kept feeling an urge to push, and kept feeling to see if your head was within reach, even though I knew it wasn’t time yet. Now I know that feeling was because of the bag of waters bulging in front of you. Suddenly, with one strong contraction it was like a cannon shot out of my body, making everyone in the room jump. It burst forth in huge white ripples through the water. Harmony said in her sweet voice, “the next contraction is going to feel a little different.” I braced myself. I was given one contraction to prepare, one final moment of ecstasy.

Then came the next contraction, and I felt my body being tunneled down by a freight train, ripping through me faster than I felt ready for. I remember asking my body out loud to “slow down.” You crowned immediately and stayed that way for four or five minutes. I felt your sweet head and heard everyone say they could see your nose, your ear. With one more contraction your head was out. Papa was behind me and I knew he wanted to catch you, but he stayed by my side, because Harmony needed to work her magic. She spoke those unbelievable words I had never expected to hear again: “Laura, you need to get out of the tub now.”

I gathered the strength to stand up and held onto Papa with everything I had. That is when I felt a bit of fear. I knew it would be over soon and you would be in my arms; it was this singular thought that gave me comfort. This cannot possibly last more than a few moments. Breathe. Breathe. Breathe. But I know on the outside I was screaming. What I didn’t know then was that you had shoulder dystocia, where your little shoulder was stuck behind my pelvic bone. It had caused the cord to be wrapped around your body like a harness, and Harmony couldn’t free your shoulder or the cord with me in the tub. So I stood, clinging to Papa, trying with all my might not to bite him as I pushed your body out with Harmony’s hands inside me, tumbling you over so the cord would free you. And there you were, my little bird, on the floor beneath me, with Harmony above you giving you oxygen. I felt helpless at that point because I couldn’t hold you, I couldn’t turn my body around without pulling on our cord and Harmony needed to be with you. She abandoned the oxygen mask and knelt down to you, giving you a breath of her life and speaking sweet welcoming words into your heart. I saw that you were a boy and announced it joyously, then said to you as closely as our still-joined bodies would allow, “we’re not going anywhere. This is our home.” And we didn’t. You breathed, you cried, we cried, and just like that, our family became a foursome.

Harmony suggested we move into bed. I found it a difficult task, but you were in my arms at last and my liquid insides didn’t seem to matter much. Because of the crazy push through the birth canal and the extra oxygen you needed, Harmony really wanted you nursing well right away. It took you a while to get the hang of it. It finally happened after I delivered your placenta, which we left you attached to as long as possible; then Papa cut the cord and you were free, your own little bird. Everyone was at the foot of the bed checking out the placenta and making prints of it (that turned out beautifully) when you latched on perfectly and never looked back.

While I was pregnant with you, I was unsure of your gender. But when I was in labor, especially as you were traveling through me, I was picturing you: a boy, clear as day. And the second I saw your face, I knew your name. Benjamin. Once you were free of the placenta, Harmony measured and weighed you, and you took after your big brother and tipped the scale at ten pounds even, 22 and a half inches long. I wanted to get into a nice herbal bath (even though I didn’t tear, my bottom half was rather sore!) so Papa proudly carried you into the living room to announce your name, your weight and your length to Grammy and Papu under the twinkling lights of the Christmas tree.

After getting dressed we snuggled down together in bed, nursing, smiling, and drifting into a blissful sleep. While everyone was still sleeping, Banyan woke up at about 5 am. He sleepily crawled into bed with us and said hello to you for the first time. It was beautiful to watch him look at your face for the first time, kiss your sweet blond hair, clutch your tiny fingers.

Welcome, little bird. Thank you for choosing me to give you the grand tour!*edited to add: Re-reading this story makes it even more clear to me why I have chosen to advocate choices in childbirth so passionately. Because of the midwives' model of care, I was able to have the most supportive labor team and most comfortable setting imaginable. Thank you Michael, Harmony, Jodi, Mama, Sarah, Gana, Kathy and Mic for your unbelievable support.

Born in Sarasota Post in Midwifery Today

I was honored to receive the winter quarterly issue of Midwifery Today and find a Born in Sarasota post in their Networking section! Managing Editor Teri Myers saw the post immediately following Florida's 2nd national ranking in c-section rates, and asked me to resubmit it for the magazine's audience. The article follows in its entirety.

Florida Ranks 2nd Nationally for C-Sections

A June 8, 2009 article in the South Florida Sun-Sentinel reveals that the most recent Florida Agency for Health Care Administration data, from July 2007 through June 2008, shows Florida ranking second in cesarean section rates, just behind New Jersey. Florida rates are now 39%, far exceeding the national average of 31.8%. According to the researchers’ data from 2007, Sarasota County ranks 4th of all reporting counties in Florida, delivering over 41% of our babies surgically. The consumer data from the same year puts this number at an even higher 44%, almost tripling the World Health Organization’s recommended 15%.

In sharp contrast, the most recently available Licensed Midwives Annual Report, collected from 34 practicing Florida Licensed Midwives in 2006, reveals a C-section rate of just 6.3% (92 surgeries out of 1454 births).

Something isn't adding up.

The Sun-Sentinel article, like many other writings on the subject, cites "medical malpractice fears" as a big part of the problem. "Obstetricians and hospitals in litigious South Florida order C-sections for any irregularity before or during labor," doctors and researchers said. "Doctors contend they are under pressure to deliver surgically. If they don't and something goes wrong, they are sued." Yet based on my own research, I have yet to discover a single medical malpractice suit awarded to a client of a Florida Licensed Midwife.

So midwives aren't getting sued, yet they aren't performing the high volume of C-sections that many obstetricians credit as their saving grace from malpractice litigation. What is at the root of this anomaly?

I understand that the current C-section rates take into account those high-risk women and pregnancies that actually require them, and once again, I cannot extend enough gratitude to the obstetricians that skillfully and appropriately perform this surgery. Yet according to the World Health Organization, as well as recent research supporting its recommendation, the best outcomes for mothers and babies are congruent with cesarean section rates of 5% to 10%. High-risk hospitals (such as Sarasota Memorial, the only provider of obstetrical services and Level III neonatal intensive care in Sarasota County) have the best outcomes with C-section rates of 15% or less. The combined evidence I've seen over the last five years, including the most recent issue of Obstetrics and Gynecology, indicates that cesarean rates above 15% are simply medically irresponsible, and are directly contributing to the high maternal mortality rates in our country (1 in 4800).

According to research from the Childbirth Connection, the following seven evidence-based factors are contributing to the rising C-section rates in America:

1. Low priority of enhancing women’s own abilities to give birth.
2. Side effects of common labor interventions
3. Refusal to offer the informed choice of vaginal birth.
4. Casual attitudes about surgery and C-sections in particular.
5. Limited awareness of harms that are more likely with C-sections.
6. Providers’ fears of malpractice claims and lawsuits.
7. Incentives to practice in a manner that is efficient for providers.

It seems to me that perhaps the root of the malpractice anomaly lies within the patient's basic rights to informed consent and refusal. An excerpt from The Florida Patient's Bill of Rights:

"A patient has the right to be given by his or her health care provider information concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis, unless it is medically inadvisable or impossible to give this information to the patient, in which case the information must be given to the patient's guardian or a person designated as the patient's representative. A patient has the right to refuse this information.

"A patient has the right to refuse any treatment based on information required by this paragraph, except as otherwise provided by law."

Improving American birth culture and reducing egregious C-section rates absolutely must be the result of a combined effort among legislators, policy makers, public health officials, hospitals, maternity care providers, and us, the consumers, who have the right and responsibility to the best evidence and information about our maternity care choices.

Download Ina May Gaskin's Presentation to SMH

On Friday, October 30th, Ina May Gaskin presented a closed clinical conference to the medical staff of Sarasota Memorial Hospital. Her presentation was entitled "Combining the Best of Modern Obstetrics with Respect for Nature and Traditional Midwifery Approaches." Ms. Gaskin has been internationally credited with reintroducing legalized direct-entry midwifery in the United States. The presentation is available via podcast on the SMH Continuing Education website. View a PDF of the accompanying power point presentation, in both English and Spanish, here.

Her objectives were threefold: to explore the knowledge base and skills common to traditional midwifery; to understand the need for both modern obstetrics and (authentic) midwifery; and to build positive relationships between the two professions (especially with regard to home birth midwives). Present at the conference were SMH Director of Maternal-Fetal Medicine Dr. Washington Hill; Sarasota County Health Department OB/GYN Dr. John Abu; Licensed Midwives Christina Holmes and Alina Vogelhut; and several members of the hospital staff and the community, including childbirth educators, nurses and retired physicians.

In her introduction, Ms. Gaskin told attendees "I just want to show what someone who births at home teaches us," and proceeded to show still images of the dancing birth of her own grandchild. She then discussed everything from her world-famous Gaskin maneuver for delivering babies with shoulder dystocia, to the rapid decline in vaginal breech birth, to the benefits of allowing the baby to clear his or her own air waves. She talked about the 1-2% c-section rate at her renowned midwifery center, The Farm, in Summertown, Tennessee. "We did allow eating and drinking during labor; we never would have had such a low c-section rate had we not." When discussing positive, unmedicated, ecstatic birth experiences, Ms. Gaskin said, "We can only achieve that if we keep the labor room calm and sweet...because we find the mother's feelings really do matter a lot."

Ina May Gaskin then gave those present a brief history of American midwifery and its resurgence, and talked about her own tutelage from a family physician, and subsequent collaboration with several obstetricians. She asked the question, "How do we then lower a c-section rate when it is up so high?" She suggested alternative methods for labor induction, specifically discussing her concerns about the use of misoprostol for induction, a drug which has never been approved by the FDA for this purpose and has been directly linked to an increase in amniotic fluid embolism, a potentially fatal condition for both mother and baby. She also discussed alternatives to medical pain relief, different positioning and movement, and the need to reverse an overall "cultural unfamiliarity" with unmedicated birth.

In conclusion, Ina May Gaskin talked about the need for healthy relationships when transferring patients from midwifery care to the hospital. "Above all, what the women who come to us (midwives) want, if we have to take them to hospital, is that they don't want to be punished or judged for having made that choice. That's probably the number one thing that needs to be conveyed."

Dr. Washington Hill, Medical Director, Labor & Delivery, SMH with Ina May Gaskin

MHC Panel Wrap-Up from Sonia Fuentes

It was an absolute joy to co-plan Maternal Health Care in the 21st Century: Sarasota and Beyond with Sonia Pressman Fuentes, the co-founder of the National Organization for Women (NOW). Here is the letter she is sending to the editor of the Sarasota Herald-Tribune about the event.

On Sunday afternoon, Nov. 1, Sarasotans had a unique opportunity to learn about maternal health care issues and available resources in Sarasota County, Florida, and the U.S.—and about 250 of them took advantage of that opportunity.

Starting at 3:00 p.m. and for two hours afterwards, Laura Gilkey, vice-president, Florida Friends of Midwives, and I presented a top-notch panel of experts on Maternal Health Care in the 21st Century: Sarasota and Beyond in the ballroom of the Sarasota Hyatt Regency. Our panelists were: Ina May Gaskin, the most renowned midwife in the United States; Dr. Washington Hill, Maternal-Fetal Medicine Director, Sarasota Memorial Hospital; Jennifer Highland, executive director, Healthy Start Coalition of Sarasota County; and Representative Keith Fitzgerald, who represents Sarasota in the Florida House of Representatives. The panel was moderated by Kelly Kirschner, vice-mayor of Sarasota.

After the formal presentations, there was a question-and-answer period followed by refreshments. Available to all attendees was a 28-page Program and Resource Guide containing a glossary of terms, a listing of resources available in Sarasota, a list of people with expertise available at the program, and a list of recommended readings. Our program was sponsored by the Sarasota-Manatee chapter of NOW (National Organization for Women), SCSW (Sarasota Commission on the Status of Women), and FFOM (Florida Friends of Midwives). All at no cost to the attendees. That was made possible by the generous donations in money and in-kind by Sarasota businesses, organizations, and individuals.

Laura and I made this educational program available because the U.S. ranks 35th in maternal mortality and 33rd in infant mortality in the world. The U.S. spends more money on mothers’ health than any other nation in the world, yet in America women are more likely to die during childbirth than they are in most other developed countries.

We learned a great deal from our panelists. We learned about the problems caused by women in poor health, and those who are smokers, alcoholics, and drug addicts, becoming pregnant. We learned about the problems caused by induced labor and the performance of unnecessary Cesarean sections. We learned that statistics and other information on the incidence of induced labor, the rate of Cesareans, and maternal deaths in our community by obstetrician and hospital are not readily available. We learned about the success of special interest groups in preventing the passage of needed legislation in the Florida Legislature and the U.S. Congress. We learned about the system of postnatal care in The Netherlands where every new mother in the first eight to ten days after the birth of her baby is entitled to the services of an assistant, who will aid in the recovery of the mother and provide her with advice and assistance to care for her newborn. We learned that the maternal death rate in the US has not gone down since 1982 and the rate for African-American women has been three to four times higher than for whites since 1940.

As if to point up the timeliness of our program, two days later, on November 3, The New York Times published an article entitled “Premature Births Worsen US Infant Death Rate.” The article referred to the fact that about 1 in 8 U.S. births are premature and that early births are much less common in most of Europe. Among the reasons given for the high rate of prematurity in the U.S. were some of the very reasons discussed by our panelists, including the induction of labor and the overuse of C-sections.

Because of what we’ve learned, Laura and I now plan to build on this panel discussion and form an advocacy group to address these issues for Sarasota County, Florida, and the U.S. We welcome participation by anyone interested in working with us to achieve the goal of a healthy mother and a healthy baby in the case of every pregnancy.

The Safe Motherhood Quilt on SNN6

Ina May Gaskin presented three panels of The Safe Motherhood Quilt Project on Saturday at the Selby Public Library. About fifty people attended the leading midwife as she explained why it is so important for the United States to begin accurately counting and accounting for the rising maternal deaths in our country.

Please watch the video of Ina May's interview with Sarasota's own SNN News Channel 6.

If you would like to sew a quilt square for a mother who has died of pregnancy or childbirth related causes in America since 1982, please email me. Sadly, there are many women still to be honored.

My Guest Column in Today's Herald Tribune

On Sunday, the Sarasota community has an opportunity to improve the health of our pregnant women. "Maternal Health Care in the 21st Century: Sarasota and Beyond" is a free discussion featuring leaders in the fields of obstetrics, midwifery, public health and public policy. This balanced panel will create a forum for much-needed dialogue about the state of maternity care in Sarasota.

The distinguished panelists for Sunday's program are Dr. Washington Hill, M.D., FACOG, medical director of labor and delivery at Sarasota Memorial Hospital; Ina May Gaskin, CPM, founder and director of The Farm Midwifery Center; Jennifer Highland, executive director of the Healthy Start Coalition of Sarasota County; and Rep. Keith Fitzgerald, District 69, Florida House of Representatives. The discussion will be moderated by Sarasota Vice Mayor Kelly Kirschner.

Each speaker will offer his or her unique expertise with regard to the current condition of maternal health care and what we can do to improve it. Attendees will have the opportunity to ask the panelists questions immediately following the discussion. There will also be several guests in attendance with expertise in different areas of maternal health care, to whom questions can be directed as well.

The American obstetric model is being replicated worldwide, yet we are failing our pregnant women. According to a World Health Organization report released this July, America ranks 35th in maternal mortality and 33rd in infant mortality, two widely recognized barometers of public health.

We cannot improve America's maternal and child health status without making changes in our own community that ensure that prenatal care is available for all of our women and families, and that modern medicine and technology are being used appropriately.

While obstetric interventions like labor induction and cesarean section surgery are absolutely necessary and even lifesaving for some, they can be detrimental and life-threatening for others, and are extremely costly for taxpayers (Medicaid covers about half of all births).

It is our responsibility as maternity-care consumers to become educated about all options available to us. This education is a key objective for the planners of "Maternal Health Care in the 21st Century: Sarasota and Beyond." Each attendee will leave the program with a resource guide outlining available prenatal and maternity-care services in Sarasota, a glossary of terms and explanations of different models of care.

One possible way to improve outcomes for mothers and babies is to increase access to, and education about, midwifery care for low-risk, healthy pregnant women, and to encourage a collaborative model of care, whereby midwives and obstetricians work together to give each woman the most appropriate care for her specific set of risk factors.

Pregnant women in our community are very fortunate to have options within both the obstetric and midwifery models of care. Sarasota is home to two free-standing birth centers, four licensed midwives, several certified nurse midwives, many obstetricians, perinatologists and a hospital with the only Level III intensive- care nursery in this four-county region. There are options for low-income and uninsured families to receive quality prenatal, childbirth and postpartum care, regardless of income.

Improving Sarasota's maternal health care will take a collaborative effort by individuals and organizations in many disciplines working together to provide affordable care based on the best evidence available.

However, no advances can be made without the effort and participation of concerned and informed consumers. By attending "Maternal Health Care in the 21st Century: Sarasota and Beyond," Sarasota's women, families and maternity-care practitioners will be on their way to positive change in our community.

Laura Gilkey, vice president of Florida Friends of Midwives, is co-planning "Maternal Health Care in the 21st Century: Sarasota and Beyond" with Sonia Pressman Fuentes, co-founder of the National Organization for Women.

Sarasota Health News on MHC in 21st Century

Florida's high c-section rates, midwifery among topics of Sarasota conference seeking to improve community's maternal healthcare

by David Gulliver (Sarasota Health News)

When Jennifer Petroskey was planning for the birth of her third child, she hoped she would be able to have a natural delivery. Her twins, born four years earlier, had to be delivered by Cesarean section.

Her doctor, however, ruled out the natural birth, following a widely-held view among obstetricians: “Once a c-section, always a c-section.” Her doctor cited the potential for complications -- primarily, uterine rupture, resulting from pressure where her uterus had healed.

“I was basically told that this was how it was going to be,” the North Port mother said, “although I wanted the experience of a vaginal birth.”

Petroskey’s experience is the norm, and illustrates a significant trend in how babies are delivered. C-sections accounted for 38.2 percent of all births in Florida in 2008 -- up almost 50 percent from the rate in 2000 and the second-highest rate in the country.

It also highlights how rifts can develop between women, their doctors and other providers of maternal health care. In this case, obstetricians are following their profession’s guidelines for minimizing risk, while more women are embracing the trend of less invasive medical care.

Those are the issues behind a conference Sunday in Sarasota, titled “Maternal Health Care in the 21st Century: Sarasota and Beyond.”

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The conference was born out of a presentation by Laura Gilkey, who delivered her two children at her Sarasota home with the aid of midwives. She is vice president of the Florida Friends of Midwives.

In July, she spoke before the Sarasota Memorial Hospital Board, laying out a slew of statistics in her six-minute talk -- such as Florida’s high c-section rate, studies showing higher neonatal ICU (or NICU) admissions and death rates for babies delivered by c-section, and that c-sections cost nearly twice as much as a vaginal birth.

In Florida, a c-section cost about $14,458, compared to about $7,533 for a vaginal birth, according to the most recent state figures. With more than 40 percent of c-sections being performed on Medicaid or charity cases, the trend also has implications for both the state’s Medicaid spending and Sarasota County’s hospital tax, Gilkey said.

She called on Sarasota Memorial to take steps to lower its c-section rate -- in 2008, it was 41.7 percent, ranking 22nd among the 115 Florida hospitals delivering babies, and about 10 points higher than the 2000 rate.

“Our medical model is not as great as everyone thinks it is,” Gilkey said in a later interview.

She summarized her points in a letter published in the Sarasota Herald-Tribune. It caught the eye of Sonia Pressman Fuentes, a longtime women’s rights activist, who said she was amazed at the findings. Pressman Fuentes, a member of the local National Organization for Women chapter, pulled together support for the conference.

The conference’s purpose, Gilkey said, is to provide better education about childbirth risks and about the full spectrum of maternal healthcare.

“If we move toward a collaborative model, doctors and women working together based on risk levels, our VBAC would rise, there would be fewer pre-term babies, NICU admission would decline and our overall health barometer would rise,” she said.

Panelists include Jennifer Highland, executive director of the Healthy Start Coalition of Sarasota; Ina May Gaskin, a national expert on midwifery; Florida Rep. Keith Fitzgerald, who serves on a House health care planning committee; and Dr. Washington Hill, medical director of labor and delivery and director of maternal-fetal medicine at Sarasota Memorial and a nationally-known expert in his field. Vice-Mayor Kelly Kirschner is the moderator.

At the July hospital board meeting, Hill said it was more important to look at the end result. “When I was a medical student in 1965, we all looked at c-section delivery rates,” he said. “I think now what we look at is the quality of that patient and the quality of that outcome.”

“There is no single c-section delivery rate that can be said to be ideal or correct for either the physician or the hospital or the county or the state,” he said.

But the rise of Cesarean section deliveries demonstrates what happens when some of the most powerful trends in medicine interact.

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In 1990, the U.S. Dept. of Health and Human Services set a national goal of reducing c-sections to 15 percent of births. After some initial gains, rates have steadily risen to a national average of about 32 percent. In some Florida hospitals, c-sections account for more than half of all births.

In his talk to the hospital board, Hill pointed to a number of reasons behind the trend.

There are more mothers over age 35, who tend to develop more complications. More mothers of all ages are obese, another complication. More women are concerned about preserving their pelvic floor. Some women elect c-sections for convenience and for a desire to have a “perfect” baby.

And hospitals are trying to respect patients’ decisions. “We’ve made a decision at this hospital that if a patient is well counseled and says she wants a primary elective cesarean delivery or induction, then she can have that done,” Hill said.

One of the most important factors, he said, is fear of a malpractice suit. “The physicians themselves say very clearly that malpractice litigation concerns and the risk of litigation is going to increase their decision to do a cesarean delivery,” Hill told the board.

C-sections are quicker and more predictable, less prone to sudden or unforeseen complications, obstetricians say.

And as more patients and doctors opt for the surgical deliveries, it starts a cycle. If a woman who delivered by c-section is having another baby, her doctor is likely to recommend another c-section. National studies show about 90 percent of women who deliver a baby after a c-section do so by another c-section.
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Jennifer Petroskey’s four-year-old twins, Alex and Kailin, are happy, healthy kids now. But at birth, one was in breech position, the other transverse, indicating a c-section was the safest course.

Six-month old Jackson presented no such problems, but her obstetrician insisted on a c-section, saying the risk were too great. Petroskey likes and respects her doctor, so she agreed.

“I wasn’t really given a choice. I was told that was what was going to happen,” she said.

The doctor’s advice reflected the evolution of the field’s position on vaginal birth after Cesarean, or VBAC. The long-held dictum was challenged in the 1980s and doctors again began accepting the procedure, with it peaking in the late 1990s.

But the studies reaffirmed the initial position, and doctors again shied away from VBAC. In Sarasota, Dr. Michael Shroder is one of the small handful of obstetricians will perform the deliveries.

He understands his colleagues’ reluctance about the VBAC. "There is a real risk of complications,” said Shroder, who, like Hill, is a member of the First Physicians Group practice.

The potential problems include uterine rupture, hysterectomy, blood clots, infection, maternal mortality. Uterine rupture, tear in the wall of the organ, occurs in about 1 percent of VBACs, but of that 1 percent, few are catastrophic ruptures and can be treated easily.

He cited a Dec. 2004 study in the New England Journal of Medicine, which examined nearly 34,000 cases of mothers carrying a single baby and who had a previous c-section. About half had another c-section, while half had a traditional labor and delivery.

In the labor and delivery group, there were 124 uterine ruptures, about 0.7 percent, and 12 cases of where the infant suffered complications from a lack of oxygen during delivery. There was no difference in maternal death rate.
Overall, the researchers found a 1 in 2,000 chance of of an adverse complications for the infant. Echoing the authors, Shroder termed it a "a small but significantly higher risk."

But, he notes, in some cases there are “significant benefits." In addition to avoiding a longer hospital stay, the major advantage is avoiding another scar in the uterus, which could complicate a future pregnancy. Those complications include placenta previa (separating and bleeding), or placenta accreta (intruding into the muscle of the uterus.)

He bases his decisions on the patient’s history -- has the patient had more than one previous c-section, or if the c-section was other than a low transverse incision -- and on the presence of other conditions, like placenta previa, that would indicate a c-section.

And it depends largely on the patient’s plans. A c-section might be indicated for 40-year-old woman planning no future pregnancies. “A 20-year-old who plans two more children has a lot to gain from a VBAC," he said.

“It’s incumbent on me to look at the facts and risks and benefits and help the patient make a informed decision.”

In addition to potential complications and liability, he said, some obstetricians avoid VBAC because of hospital policies. Sarasota Memorial’s policy, which he said is common, requires the obstetrician to be present for entire labor, a major time commitment that can take them away from other patients.

That reluctance of doctors and hospitals may send women to midwives, generally more accepting of the mother’s wishes. But that raises some concerns for doctors.

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“Having a baby at home is a risk. Having a baby at a birthing center is a risk,” Hill said. “If they have a decline of the fetal heart rate, by the time the baby gets here it could be a catastrophe.”

But he also sees the value of midwives in maternal health care, noting the non-profit Genesis Newtown Medical Group’s team approach to reducing fetal death rate, premature births and low birthweight babies. It employs community volunteers, midwives and an obstetrician to provide prenatal care for the low-income community.

Similar programs have a track record of success. In 2002, Florida Hospital Waterman, in Lake County, noted an alarming trend: More and more pregnant women were showing up in its emergency room, some about to deliver, with no prenatal care.

It meant complicated, often premature births, and longer hospital stays for both mother and child. It meant financial losses for the hospital, because most of the mothers were uninsured. Meanwhile, obstetricians were leaving the county, over the rising cost of malpractice insurance -- to some extent because of the more precarious deliveries.

The hospital met with Lake County officials and together they developed a strategy to hire four midwives and two OB/GYNS midwives to provide prenatal care. The midwives also care for the mothers in the early stages of labor.

The result: in 2007-08, the program handled some 700 deliveries and saved the hospital an estimated $1 million.

Lake County saw its Cesarean delivers drop from almost 51 percent in 2006 to 36 percent in 2008, a 14-point drop -- double the reduction of the next-best Florida hospital over that time, and only 11 hospitals reduces Cesarean deliveries by 2 percentage points or more.

County officials attributed the improvements to the work of the midwives. “If you didn’t have a team program that saw the uninsured in the community, what you would have is the patients reporting to the ER with no prenatal care,” said Donna Gregory, a Lake County Health Department administrator, in an interview this spring.

The Sarasota conference planners say they hope to foster similar partnerships and more unified maternal care with the best possible outcomes.

“There are many pieces needed to make this happen -- licensed midwives, hospitals, the community, government. Each piece has some work to do,” Hill said.

“The licensed midwives need to communicate better with the doctors. We need to communicate better with the licensed midwives. We all need to work together. If we don’t communicate with each other, the whole thing breaks down.”

“We should do whatever we can in the community to have a healthy mother and a healthy baby,” he said.

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The conference is free and open to the public, and will be at 3 p.m. Sunday, Nov. 1., at the Hyatt Regency of Sarasota. Call 915-8115 for more information.