I am proud to have worked in a hospital that was level 3, had high risk patients and a C Section rate that was always at that 20% rate. We were doing VBACS even in the early 90’s. However, there were still physicians who were known for doing C sections after office hours or because they were going out of town. As a nurse manager I brought these cases forward to our OB chair but of course no reviews were done. Every physician needs to have his/her cases reviewed and appropriate action taken to decrease those unnecessary c section
I'm so disturbed by the Cesarean you mentioned that was for breech and then it was found that the baby was actually head down. Yikes—that's chilling.
For me, integrating midwives fully into US maternity care is the answer to so many of the problems we have, including and perhaps most especially the Cesarean rate. I've been a doula for 13 years and practiced for 5 years in Albuquerque, NM, where it was more rare for my clients to have a physician as a provider than not. CNMs were in many ways the norm there— at every hospital and with full practice authority. As a state, NM has a higher percentage of births attended by midwives, and a (no surprise!) 27% Cesarean rate. Plus, UNM has one of the oldest and most well-known midwifery programs for CNMs (although they just changed it to a DNP and people have opinions on that!). And of course, CPMs are also licensed and have been able to practice for decades (although the level at which they are integrated into the system varies, and people have opinions on that, too).
I've also practiced in Washington DC and in New Orleans. I now live in Austin, TX, where the sole hospital midwifery practice is turning away patients because they can't serve everyone who wants midwifery care.
By far, the biggest difference I have seen in care across time and location is access to midwives. I'm curious about whether or not the efforts to increase access in states like AL will eventually make a difference in care and Cesarean rates—I believe there's now a midwifery program at the University of Alabama Birmingham and there's one at LSU in New Orleans now, too. Will having these programs be a small part of the culture shift? Could that eventually mean fewer Cesareans?
Anyway, after typing all of this, I realize I don't have to convince a midwife that midwifery matters :) But thanks for opening this space to chat! Appreciating your work!
Yes! I am very hopeful for the future of midwifery. I think that integrating it will be a huge part of combating the high CS rate. Even though I'm sad to hear a midwifery practice in TX is having to send women away, it makes me hopeful that as more women demand midwives, the system will change. I've heard really good things about NM for midwifery as well!
Thank you so much for sharing your perspective, I really appreciate it. From a public health lens, it’s troubling to see how OBGYNs are being trained in ways that prioritize risk management over patient centered care. Medical education often conditions providers to be defensive in their practice, with the goal of minimizing liability rather than supporting physiological birth. But risk is an inherent part of childbirth, and efforts to eliminate it entirely often come at the expense of the birthing person’s experience and autonomy. There are also structural issues at play. Insurance reimbursement models frequently undervalue vaginal births, while cesareans being surgical and billable at a higher rate are more financially incentivized. Add to that the fact that many OBGYNs are trained primarily as surgeons, and it becomes clear why cesareans are often favored, even when not medically necessary. It’s less about patient need and more about comfort, control, and institutional profit. I do believe cesarean rates could be lowered, but that would require a significant shift in how we approach maternal care, starting with informed, community based education that helps healthy families understand they may have better outcomes by not beginning their care in a hospital setting. For many, that’s the only way to truly preserve the possibility of a physiological, undisturbed vaginal birth. This is also part of why I’ve chosen to focus on education rather than becoming a provider myself, the constraints of liability and institutional pressure too often stand in the way of true, respectful care. Thank you again for your thoughtful writing; these conversations are essential.
"There are also structural issues at play. Insurance reimbursement models frequently undervalue vaginal births, while cesareans being surgical and billable at a higher rate are more financially incentivized." For sure this is part of the problem. But beyond money, I think we have to acknowledge the time required to support vaginal birth. We're talking about a process than can take hours or days, vs a surgery that takes 40 min. So even if there were not financial incentives, there would still be time incentives for doctors trying to have any kind of work/life balance. Personally, as someone who attends hospital births, I don't think it's impossible to have high quality, supportive, evidence-based care. I also think there are just a lot of people not willing/able to do out of hospital birth because they have serious risk factors that make it unsafe, or because they want an epidural. I hope to get into this in a later post, but I do not think hospital birth has to be horrible.
Great post! I am in NJ, home of some seriously crappy maternity care, and had an NTSV cesarean for a “big” 8lb2oz baby. Then I had a VBAC with a bigger baby. I remember studying the ACOG VBAC bulletin like it was a religious text then being kind of taken aback that the OBs in the hospital were saying stuff that was not in the bulletin! “Wait a minute - ACOG says epidural is neither required nor contraindicated during a VBAC and my OB said it was my choice… so why isn’t it my choice again?”
And then the RN tried to lie to me “we don’t have mobile monitoring.” “But my OB said you did.” “No we don’t.” “But he said you did and I could use it.” “Oh, well we have it but it doesn’t work” - said as she pulled open the drawer next to my bed to reveal… the mobile monitoring.
I am in a handful of cesarean support groups and there was recently an OB who does VBA2C and breech, works with midwives, etc. She was called out for giving medical advice (the group’s rules forbid it). She said it was OK because she was an OB and also she was one of the good OBs who tried to do the right thing, unlike “most” other OBs. She then concluded she was being “bullied” and it wasn’t worth sticking around or trying to help us ungrateful women anymore.
I have noticed this real, I guess, brittleness, this real emotional fragility and reactivity, in the dispositions of the OBs I’ve met with in person and honestly, most of my friends who work in health care. Most recently, in a friend who became an EMT. I really have to wonder if industrial birth care harms providers as much as it harms birthing people - because they don’t seem to be doing well, at all. Perhaps if you are effectively treading water day to day, the idea that you need to improve the quality of your patient care strikes you as somewhat insane.
The culture of medicine today does not support people to provide true individualized care—or, maybe more importantly, for people to practice in a way that also honors their own humanity, including their own mental and emotional processing when things get scary and hard. I think the entire system of learning to become a doctor is dehumanizing from the very beginning—so what happens as a career progresses, when it's rotten at the root?
To provide a different type of care consciously, it seems physicians *really* have to work to go against the grain, their training, possibly their colleagues/the people on their unit/hospital admin....there's just so many factors that make it incredibly difficult for physicians to be the providers they can and very likely want to be. I believe that people get into obstetrics because they want to do good in the world. We need a system that actually makes it possible for them do that.
Yes, NJ stats are a little concerning. My sister did have 5 hospital births with a group of CNMs (2 of them water births!) and had a good experience. But your experience of having to fight for yourself to get the birth you wanted (one which was very evidence-based, by the way!) is really disappointing/concerning to me. Sadly I think it happens all over the country, and I think it can occasionally push women into bad situations. Regarding "fragile" healthcare providers, yeah, they're out that. Not sure what always causes it-a bad lawsuit, lack of time to really provide personalized care...there could be a lot of reasons. Thankfully I have been blessed to work with many wonderful doctors who deeply care about women's experiences and outcomes, so they're out there as well.
Tell your sister to bug her reps about sponsoring the midwifery licensing act! The governor has said he will sign it if it is on his desk. There is an assembly version and a senate version. https://www.instagram.com/gardenstatebirthcoalition/ They have a call on Monday to discuss strategy.
And yeah I did find a kind OB to support me for my VBAC. He was visibly annoyed I’d had a section in the first place, and told me “what they did to you was wrong.” He trained overseas (I think Syria?) and managed to keep calm about everything, whereas the other OBs I saw treated my body like a ticking time bomb about to explode in their faces.
I am proud to have worked in a hospital that was level 3, had high risk patients and a C Section rate that was always at that 20% rate. We were doing VBACS even in the early 90’s. However, there were still physicians who were known for doing C sections after office hours or because they were going out of town. As a nurse manager I brought these cases forward to our OB chair but of course no reviews were done. Every physician needs to have his/her cases reviewed and appropriate action taken to decrease those unnecessary c section
Thank you for all your advocacy over the years. It made a big difference!
I'm so disturbed by the Cesarean you mentioned that was for breech and then it was found that the baby was actually head down. Yikes—that's chilling.
For me, integrating midwives fully into US maternity care is the answer to so many of the problems we have, including and perhaps most especially the Cesarean rate. I've been a doula for 13 years and practiced for 5 years in Albuquerque, NM, where it was more rare for my clients to have a physician as a provider than not. CNMs were in many ways the norm there— at every hospital and with full practice authority. As a state, NM has a higher percentage of births attended by midwives, and a (no surprise!) 27% Cesarean rate. Plus, UNM has one of the oldest and most well-known midwifery programs for CNMs (although they just changed it to a DNP and people have opinions on that!). And of course, CPMs are also licensed and have been able to practice for decades (although the level at which they are integrated into the system varies, and people have opinions on that, too).
I've also practiced in Washington DC and in New Orleans. I now live in Austin, TX, where the sole hospital midwifery practice is turning away patients because they can't serve everyone who wants midwifery care.
By far, the biggest difference I have seen in care across time and location is access to midwives. I'm curious about whether or not the efforts to increase access in states like AL will eventually make a difference in care and Cesarean rates—I believe there's now a midwifery program at the University of Alabama Birmingham and there's one at LSU in New Orleans now, too. Will having these programs be a small part of the culture shift? Could that eventually mean fewer Cesareans?
Anyway, after typing all of this, I realize I don't have to convince a midwife that midwifery matters :) But thanks for opening this space to chat! Appreciating your work!
Yes! I am very hopeful for the future of midwifery. I think that integrating it will be a huge part of combating the high CS rate. Even though I'm sad to hear a midwifery practice in TX is having to send women away, it makes me hopeful that as more women demand midwives, the system will change. I've heard really good things about NM for midwifery as well!
Thank you so much for sharing your perspective, I really appreciate it. From a public health lens, it’s troubling to see how OBGYNs are being trained in ways that prioritize risk management over patient centered care. Medical education often conditions providers to be defensive in their practice, with the goal of minimizing liability rather than supporting physiological birth. But risk is an inherent part of childbirth, and efforts to eliminate it entirely often come at the expense of the birthing person’s experience and autonomy. There are also structural issues at play. Insurance reimbursement models frequently undervalue vaginal births, while cesareans being surgical and billable at a higher rate are more financially incentivized. Add to that the fact that many OBGYNs are trained primarily as surgeons, and it becomes clear why cesareans are often favored, even when not medically necessary. It’s less about patient need and more about comfort, control, and institutional profit. I do believe cesarean rates could be lowered, but that would require a significant shift in how we approach maternal care, starting with informed, community based education that helps healthy families understand they may have better outcomes by not beginning their care in a hospital setting. For many, that’s the only way to truly preserve the possibility of a physiological, undisturbed vaginal birth. This is also part of why I’ve chosen to focus on education rather than becoming a provider myself, the constraints of liability and institutional pressure too often stand in the way of true, respectful care. Thank you again for your thoughtful writing; these conversations are essential.
Thanks for reading!
"There are also structural issues at play. Insurance reimbursement models frequently undervalue vaginal births, while cesareans being surgical and billable at a higher rate are more financially incentivized." For sure this is part of the problem. But beyond money, I think we have to acknowledge the time required to support vaginal birth. We're talking about a process than can take hours or days, vs a surgery that takes 40 min. So even if there were not financial incentives, there would still be time incentives for doctors trying to have any kind of work/life balance. Personally, as someone who attends hospital births, I don't think it's impossible to have high quality, supportive, evidence-based care. I also think there are just a lot of people not willing/able to do out of hospital birth because they have serious risk factors that make it unsafe, or because they want an epidural. I hope to get into this in a later post, but I do not think hospital birth has to be horrible.
Great post! I am in NJ, home of some seriously crappy maternity care, and had an NTSV cesarean for a “big” 8lb2oz baby. Then I had a VBAC with a bigger baby. I remember studying the ACOG VBAC bulletin like it was a religious text then being kind of taken aback that the OBs in the hospital were saying stuff that was not in the bulletin! “Wait a minute - ACOG says epidural is neither required nor contraindicated during a VBAC and my OB said it was my choice… so why isn’t it my choice again?”
And then the RN tried to lie to me “we don’t have mobile monitoring.” “But my OB said you did.” “No we don’t.” “But he said you did and I could use it.” “Oh, well we have it but it doesn’t work” - said as she pulled open the drawer next to my bed to reveal… the mobile monitoring.
I am in a handful of cesarean support groups and there was recently an OB who does VBA2C and breech, works with midwives, etc. She was called out for giving medical advice (the group’s rules forbid it). She said it was OK because she was an OB and also she was one of the good OBs who tried to do the right thing, unlike “most” other OBs. She then concluded she was being “bullied” and it wasn’t worth sticking around or trying to help us ungrateful women anymore.
I have noticed this real, I guess, brittleness, this real emotional fragility and reactivity, in the dispositions of the OBs I’ve met with in person and honestly, most of my friends who work in health care. Most recently, in a friend who became an EMT. I really have to wonder if industrial birth care harms providers as much as it harms birthing people - because they don’t seem to be doing well, at all. Perhaps if you are effectively treading water day to day, the idea that you need to improve the quality of your patient care strikes you as somewhat insane.
The culture of medicine today does not support people to provide true individualized care—or, maybe more importantly, for people to practice in a way that also honors their own humanity, including their own mental and emotional processing when things get scary and hard. I think the entire system of learning to become a doctor is dehumanizing from the very beginning—so what happens as a career progresses, when it's rotten at the root?
To provide a different type of care consciously, it seems physicians *really* have to work to go against the grain, their training, possibly their colleagues/the people on their unit/hospital admin....there's just so many factors that make it incredibly difficult for physicians to be the providers they can and very likely want to be. I believe that people get into obstetrics because they want to do good in the world. We need a system that actually makes it possible for them do that.
Yes, NJ stats are a little concerning. My sister did have 5 hospital births with a group of CNMs (2 of them water births!) and had a good experience. But your experience of having to fight for yourself to get the birth you wanted (one which was very evidence-based, by the way!) is really disappointing/concerning to me. Sadly I think it happens all over the country, and I think it can occasionally push women into bad situations. Regarding "fragile" healthcare providers, yeah, they're out that. Not sure what always causes it-a bad lawsuit, lack of time to really provide personalized care...there could be a lot of reasons. Thankfully I have been blessed to work with many wonderful doctors who deeply care about women's experiences and outcomes, so they're out there as well.
Tell your sister to bug her reps about sponsoring the midwifery licensing act! The governor has said he will sign it if it is on his desk. There is an assembly version and a senate version. https://www.instagram.com/gardenstatebirthcoalition/ They have a call on Monday to discuss strategy.
And yeah I did find a kind OB to support me for my VBAC. He was visibly annoyed I’d had a section in the first place, and told me “what they did to you was wrong.” He trained overseas (I think Syria?) and managed to keep calm about everything, whereas the other OBs I saw treated my body like a ticking time bomb about to explode in their faces.
All great points. 👍
Absolutely correct and beautifully done. Thx!!