Nurse midwife standing by couple after birth

To increase your chance of having a vaginal delivery, do some homework before you write your birth plan.

A birth plan is (ideally) a concise little document that tells your doctors and nurses exactly what kind of birth you desire. It explains your philosophy on pain relief, interventions and early newborn care. Personally, I like to frame it as a set of preferences, rather than a plan- but that’s for another day.

Whether you call it a “plan” or a “set of preferences”, by the time most people put together this document, they’ve already overlooked a crucial step: their choice of birth team and birthing location.

More important that laying it out in the birth plan, you need to choose a provider and a birthing location that aligns with the type of birth you want.

If you want a vaginal birth, choose a provider and a birthing location that excel at supporting vaginal births.

If you desire a vaginal birth (medicated or unmedicted), increase your odds of having this birth by choosing a birth team and birth location that have great success at supporting vaginal birth.

You have the data you need to make this choice.

The data tell us that for low-risk pregnancies delivered in hospitals, midwifery-attended births are 30 % less likely to result in C-section (1). And that’s just for in-hopital births.

Of course, not all pregnancies are low-risk, and some parents may still desire to work with an MD. No problem. In this case, your choice of hospital becomes the crucial variable.

The data show that there is a vast difference hospital-to-hospital when it comes to the rates of primary cesareans (2). The same is true for trial of labor after cesarean (TOLAC).

Cesarean rates for Seattle-area hospitals

Here are some data from a few hospitals that are local to me in vicinity of Seattle, WA:

C-section rates of King County Hospitals, including Evergreen, Overlake, Swedish First Hill, Swedish Issaquah, UW-Montlake and UW-Northwest.
2019 C-section rates (for first time birthing parents, single fetus, head-down presentation) for Seattle area hospitals. Data are taken from the Washington State HealthCare Authority website. Purple shading indicates the World Health Organizations target cesarean rate. The red dashed line indicates the target Cesarean rate proposed by the Healthy People 2020 report, the product of a US federal initiative to identify nationwide health improvement priorities. The blue dash line indicates Washington State’s average C-section rate in 2019. All of our local hospitals perform C-sections at a rate higher than the WHO recommendation. Many of them perform the procedures at a rate lower than the state average. There is an almost 15% range in the rates of primary Cesarean’s performed in our regions hospitals.

Let’s break this down a little bit.

Starting with our reach goal: The World Health Organization (WHO) recommends a Cesarean rate of 10-15% (5). Through extensive research, the WHO arrived at this recommendation by determining that when Cesarean rates exceed this threshold, on a population level, there is no additional benefit with respect to reductions in maternal and newborn mortality. The WHO rate is clearly much lower than our local C-section rate or the rate of any other American state.

A more realistic goal for my community is that set by Healthy People 2030. Healthy People 2030 is the United States’ 10-year plan for addressing critical public health priorities and it recommends a target C-section rate of 23.6 % for low-risk, first time births (6).

In 2019 Washington State’s primary cesarean section rate is 23.8% (7). So on average, Washington State is not doing so bad.

You can see from the cute little graph, the range in primary Cesarean rates for my local hospitals is roughly 15 percentage points. Take a look at the next graph and you’ll see the range in vaginal births after Cesarean (VBAC) is 14.8% to 64.1%. (If you’re hoping for a VBAC, which hospital would you choose?!)

C-section rates of King County Hospitals, including Evergreen, Overlake, Swedish First Hill, Swedish Issaquah, UW-Montlake and UW-Northwest.
2019 VBAC for Seattle area hospitals. Data are taken from the Washington State HealthCare Authority website. The blue dash line indicates Washington State’s average VBAC rate in 2019. There is a 49.3% range in the rates of VBAC performed in our regions hospitals.

There is a vast difference in the rates of primary C-section and VBAC among my local hospitals. While I can’t tell you exactly WHY that difference exists, it’s important for the consumer (that’s YOU, the pregnant person!) to know that it does.The difference likely doesn’t stem from vastly different different patient risk profiles (at least, that’s what the data tell me) (2,3). Unfortunately, it tends to correlate to how the hospital is funded (2). And it has a lot to do with the culture among the hospital staff (3, 4). If you decide to work with an obstetrician, it turns out the cesearean rate of the hospital is MORE important than the cesarean rate of your OB (3, 4).

I’m going to be a broken record: If you want to avoid a Cesarean, please research your hospital or birthing center. They aren’t all equivalent with respect to their track records around birth.

Don’t forget, you are the customer.

You are a consumer- and in most cases you can choose where you give birth. You are allowed to shop around. It behooves you to choose a provider and a hospital with the best track record of delivering the type of birth you desire.

It is important to point out, there are reasons to choose a hospital with a high Cesarean rate. Great reasons, in fact. For example, if you are carrying a high risk pregnancy, you’ll likely benefit from being in a Level 4 maternal care facility (the hospitals best equipped for dealing with high risk deliveries). In this case, choose your hospital for it’s speciality as opposed to it’s C-section rate.

But for the low-risk pregnancy and the parent desiring a low-intervention birth, think early and think critically about WHERE and WITH WHOM you deliver your sweet babe.

References:

(1) Souter, Vivienne, et al. “Comparison of Midwifery and Obstetric Care in Low-Risk Hospital Births.” Obstetrics & Gynecology, vol. 134, no. 5, Nov. 2019, pp. 1056–65.

(2) McKenzie, L., and P. A. Stephenson. “Variation in Cesarean Section Rates among Hospitals in Washington State.” American Journal of Public Health, vol. 83, no. 8, Aug. 1993, pp. 1109–12.

(3) https://www.kuow.org/stories/why-some-washington-hospitals-have-such-high-c-section-rates Accessed 3 May 2021.

(4) Plough, Avery C., et al. “Relationship Between Labor and Delivery Unit Management Practices and Maternal Outcomes.” Obstetrics & Gynecology, vol. 130, no. 2, Aug. 2017, pp. 358–65.

(5) “WHO | WHO Statement on Caesarean Section Rates.” WHO, http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/cs-statement/en/. Accessed 28 Apr. 2021.

(6) Reduce Cesarean Births among Low-Risk Women with No Prior Births — MICH‑06 – Healthy People 2030 | Health.Gov. https://health.gov/healthypeople/objectives-and-data/browse-objectives/pregnancy-and-childbirth/reduce-cesarean-births-among-low-risk-women-no-prior-births-mich-06. Accessed 3 May 2021.

(7) https://www.hca.wa.gov/assets/program/delivery-statistics-WashingtonStateNonMilitaryHospitals.pdf Accessed 3 May 2021.

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