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Re: “Midwives seek autonomy in N.C.

JohnD--good questions!

Reference for the 10-15% optimal cesarean rate:

From Marsden Wagner's Born in the USA, pg47 "Through an exhaustive scientific process, WHO has calculated that the optimal rate of C-section for saving the most women and babies is 10-15%. There is no evidence that a rate of C-section over ten percent saves lives."

Reference: World Health Organization, "Appropriate Technology for Birth, " Lancet 2, no. 8452 (1985):436-37

Links for recent US perinatal mortality statistics:

CDC National Vital Statistics System perinatal mortality by state 2003-2004

With the definition of perinatal death as: Infant deaths of less than 7 days and fetal deaths with stated or presumed period of gestation of 28 weeks or more. Fetal deaths with not stated gestational age are proportionally distributed to 20-27 weeks and 28 weeks or more.

The most recent data (2004) puts NC in 47th position--

Average perinatal death rates for NC=8.41 per thousand live births (up from 7.91/1000 in 2003) US average is 6.69, and the best states have 4-5 deaths/1000

Interestingly, eight of the top ten states license CPMs.

The US is one of the countries with the lowest perinatal mortality rates. Infant mortality rates are a different measurement (death up to one year of age), and do not really reflect the quality of prenatal and intrapartum care, which is what we are evaluating. It is very difficult to compare numbers, however, because different groups and organizations use different definitions of the perinatal time period, among other confounding factors.

On the subject of the trade-off in risk of birthing at home vs birthing at a hospital.

With recent statistics stating that 31.1% of births in 2006 being performed by cesarean (approximately 20% of first time mothers), and the risk of maternal death by 2 fold higher for cesarean during labor and 2.3 fold higher for cesarean before onset of labor. Home birth midwives rates of cesarean section were reported to be 3.7% in the BMJ study. Mothers who have cesareans experience 5 fold higher risk of needing antibiotics, and experience increased risks for other types of morbidity. Because of the high percentage of cesarean births, risks associated with cesarean will account for some of the risk of maternal death and morbidity in planned hospital birth that is not present in home births.

Risks of postpartum hemmorhage are increased with interventions such as instrumental delivery (odds ratio 2.3), induction (OR 1.4), and use of pitocin to augment labor (OR 1.4). All of these interventions are used only at the hospital (in transfers for planned home births), at rates of 4 to 6 fold, 2 to 4 fold and 2 to 6 fold over planed home birth, respectively, and are not exclusive of one another.

Babies have an increased risk for neonatal death with cesarean, even when researchers exclude babies with fetal distress. Babies born by cesarean after labor experience 1.7 fold increase in neonatal death, and those born by cesarean before the onset of labor, a 1.9 fold increase. Instrumental and surgical birth also increase the possibility for birth trauma and breathing problems requiring time in the NICU.

Read the detailed report of all the intrapartum and neonatal deaths in the BMJ study. Determine for yourself which you think could have been prevented with standard obstetric care in the hospital.


Clin Perinatol. 2008 Jun;35(2):293-307. Cesarean birth in the United States: epidemiology, trends, and outcomes. Macdorman MF, Menacker F, Declercq E.

BMJ. 2007 Nov 17;335(7628):1025. Epub 2007 Oct 30.Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study. Villar J, Carroli G, Zavaleta N, Donner A, Wojdyla D, Faundes A, Velazco A, Bataglia V, Langer A, Narvez A, Valladares E, Shah A,Campodnico L, Romero M, Reynoso S, de Pdua KS, Giordano D, Kublickas M, Acosta A; World Health Organization 2005 Global Survey on Maternal and Perinatal Health Research Group.

J Matern Fetal Neonatal Med. 2005 Sep;18(3):149-54. Obstetric risk factors and outcome of pregnancies complicated with early postpartum hemorrhage: a population-based study. Sheiner E, Sarid L, Levy A, Seidman DS, Hallak M.

Posted by erin_ecmh on 06/01/2008 at 12:18 AM

Re: “Midwives seek autonomy in N.C.

My second child was born at home with a CPM. I felt that my baby and I were much safer and treated more gently at home than we would have been in the hospital. It was lot of hard work, but it was exhilarating and empowering. This article is a fantastic summary of why we need licensed CPMs in NC and where we are in the process of changing the laws! If you are interested in helping, or would like to learn more about this issue in NC and the US, visit:

Posted by erin_ecmh on 05/28/2008 at 9:01 PM

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