When trying to avoid c-sections, some mothers seek doulas for support

By Guimel Sibingo

Elisa Parsons-Facetti’s first birth was not the kind of the birth she had always imagined.

Due to a late diagnosis of pelvic girdle pain, a common condition in pregnant women, Parsons-Facetti’s doctor recommended a Cesarean section.

“It was my first pregnancy,” she said. “And I had to trust what the OBGYN was telling me.”

Elisa Pacetti in her office at Moberly Community College where she works. After a less than pleasant c-section she decided to get a VBAC and sought a doula to do so. Photo by Guimel Sibingo.

Elisa Parsons-Facetti in her office at Moberly Community College where she works. After a less than pleasant c-section she decided to get a VBAC and sought a doula to do so. Photo by Guimel Sibingo.

Because of the surgery, Parsons-Facetti wasn’t allowed to nurse her son right after the birth. By the time she could breastfeed him later, he had lost interest.

Parsons-Facetti wanted a different experience after she found out she was pregnant again. She wanted to avoid another C-section by using a process called VBAC, or Vaginal Birth After C-section. In order to make that process easier, she changed providers and decided to hire a personal birthing assistant called a doula.

“I discussed it with my husband,” she said. “And from the research, I thought it might be really beneficial.”

Parsons-Facetti is among the growing number of women rebelling against high C-section rates in the United States. About 1 in 3 women in the United States deliver via C-section, more than twice the rate called for by the U.S. Public Health Service.

Although C-sections are sometimes medically necessary, experts at the American Congress of Obstetricians and Gynecologists (ACOG) say the rate has mushroomed beyond reason since the 1970s. C-sections carry significant risks, including increased risk of death of the mother, a longer recovery time, risk of complications during surgery and major bleeding in future pregnancies.

VABCs (pronounced vee-backs) are one way to reduce the high C-section rate.

Although VBACs are considered a low-risk procedure recommended by national medical organizations including ACOG and the National Institute of Health, not every hospital or physician is willing to perform. The VBAC rate has actually decreased from 28 percent of all vaginal births in 1996 to just 8.5 percent in 2005.

The key question is choice: Does a woman have the right to have a sense of control over her birthing process? Evidence shows that in addition to choosing a supportive physician and good pre-natal care, having a doula provide trained birthing support results in better birth outcomes and fewer birth complications.

Determined to make a change, Parsons-Facetti signed up for a VBAC class given by a doula. Through the class she was encouraged to change providers. After finding a supportive physician, she decided to hire a doula and embarked on a journey to her first natural birth.

High C-section rates and the risks

The struggle to reduce C-sections has had little success. In the past 20 years, the C-section rate has increased from 19.7 percent in 1996 to 32.7 in 2013 according to the Centers for Disease Control. The United States’ rate puts it above other developed countries like Switzerland (28.9 percent), Canada (26.3 percent) and Ireland (26.2 percent) according to the World Health Organization. With a rate of 45.5 percent, Brazil takes first place as the country with the highest C-section rates.

Rates vary by state, with states like Florida and Mississippi nearly reaching the 40 percent mark. Missouri’s 2010 C-section rate is 31.9 percent, an increase from 21.4 percent in 2009, according to the CDC. In Columbia, about 32 percent of live births at MU Women and Children’s Hospital in 2014 were C-sections.  Boone Hospital did not respond to a request for information about its C-section rate.

State by state c-section rates vary. Rates go as high as 40% in some states. [C-section rate by state, 2010 courtesy of CDC]

State by state c-section rates vary. Rates go as high as 40% in some states. [C-section rate by state, 2010 courtesy of CDC]

C-sections can be important life-saving procedures. Situations requiring a C-section include when the cervix stops dilating and the fetus is in distress as a result, when the mother’s placenta is separated from the uterine lining causing bleeding and pain and interfering with the baby’s oxygen (placental abruption), if the uterus tears (uterine rupture), when the umbilical cord protrudes through the cervix before the baby is born, and when the placenta is low in the womb and blocking the baby’s exit.

However, C-sections cause many risks.

Dr. Michael Burks, Columbia OBGYN and owner of the Central Missouri Physicians For Women, is a long-time proponent for the reduction of the C-section rate.

Burks warns of the dangers with C-sections.

“C-section is a major surgery,” he said. “There is risk of infection, bleeding, and the recovery period is longer,” Dr. Burks said. “With any surgery, there can be complications.”

Health issues are not the only problem with C-sections; they can compromise a positive birth experience.

“Vaginal delivery offers more of an opportunity for bonding,” he said. “With a C-section, that is not usually the case.”

With C-sections, depending on the hospital, mothers may not get to have immediate skin-to-skin contact with their child for initiation of breastfeeding. The mode of delivery can also affect the development of microbiota, microorganisms that can help fight disease. Vaginal delivery passes on vaginal microbiota to the child, allowing for a better development of the immune system while C-sections prevent the child from having that early exposure.

Both national and international health organizations have encouraged hospitals worldwide to practice methods that would reduce the rate. The World Health Organization (WHO) recently released a statement urging hospitals worldwide to avoid unnecessary C-sections as much as possible.

National advocacy groups like Improving BirthInternational Cesarean Awareness Network, and Childbirth Connection  urge mothers to explore their options and resources for the best birth plan.

The American College of Obstetrics and Gynecology periodically publishes guidelines for maternity care to decrease C-section rates. One of them is allowing women to push for a longer period of time, 2 hours if it is their second birth, 3 hours if its their first, and even longer if they opted for an epidural. Other guidelines include avoiding excessive weight gain during pregnancy, manual turning of the baby if it is breech (feet first), and maternal support like the use of a doula.

“Once A C-section always a C-section”

Parsons-Facetti had done her homework on VBACs but for a moment became concerned about the risks. She had heard that it is best to have a VBAC at least 18 months after a C-section. Parsons-Facetti, however, had gotten pregnant four months after the birth of her son. She found support in stories of women in the online maternal health community.

“I had read about women in my same situation that had successful VBACs,” she said. “So I decided to talk to my physician about it.”

It turns out that evidence works in Parsons-Facetti’s favor.

Vaginal Birth after C-section rates declined sharply by 2006.  Graph courtesy of National Center for Health Statistics.

Vaginal Birth after C-section rates declined sharply by 2006. Graph courtesy of National Center for Health Statistics.

The American College of Obstetrics and Gynecology has stated that VBACS are a key way to reduce the C-section rates. In the 70’s, common practice was that mothers who had previous C-sections would continue to have C-sections for following births, hence the old saying “once a C-section, always a C-section.” The main concern was that if mothers delivered vaginally, the uterus or the incision from a past cesarean could tear.

Thanks to newer evidence, leading experts agree that “once a C-section, always a C-section” no longer applies.

A 2004 study conducted by the National Institute of Child Health and Human Development of the National Institutes of Health determined that vaginal delivery after a C-section does pose slightly more risks than a repeat C-section from issues like infection of the uterine lining or tearing of the uterus; however, those risks are very low. Uterine rupture, for example, only occurs in 0.5 percent to 0.9 percent of VBAC cases.

The ACOG reports that 60 to 80 percent of VBACs will be successful, meaning they will not result in a repeat C-section. Benefits of VBACs include avoiding major surgery, lowering risk of bleeding and infection, and avoiding an extensive recovery period.

It can also improve a woman’s future by avoiding issues commonly associated with multiple C-sections, such as hysterectomies, bladder injuries, and adverse placenta conditions. It can also help reduce the C-section rate.

ACOG advises physicians to choose VBACs on a case-by-case basis.

“Each individual is different,” Dr. Burks said. “It is important to look at why the mother had a previous C-section.”

Finding Support

Parsons-Facetti’s VBAC class was taught by Katy Miller, a doula that for the past two years has helped coordinate a local rally for Improving Birth, a California-based national health organization that seeks to provide women with evidence to help them make better decisions about their maternal care. In the class, Parsons-Facetti learned a little bit more about VBACs , what happens in a hospital setting, and the benefits of having support during labor. She also learned about the importance of finding a supportive physician.

“I started panicking,” Parsons-Facetti said. “I began thinking my physician probably was not going to let a VBAC happen and that I was going to have another C-section.”

Out of a list of doctors suggested in the class, Parsons-Facetti chose to go with Dr. Burks, the leading VBAC expert physician in Columbia.

Parsons-Facetti sensed Dr. Burks was supportive of a VBAC from the beginning. Parsons-Facetti said that on her first meeting with him, he gave her more information on VBACS, spending almost an hour and half with her and her husband.

“When I had doubts,” she said, “he was positive and championing me through the pregnancy. He took his time and answered every question I had. It was a really wonderful experience.”

Parsons-Facetti had been considering hiring a doula for some time. She discussed it with Dr. Burks, who was supportive of the idea.

After doing her research and much consideration, Parsons-Facetti decided to hire Miller as her doula.

Miller is one of many doulas in Columbia. She has been working as one for 11 years. She said doulas serve many purposes during the labor process. In addition to providing encouragement and comfort, they also keep mothers informed about their options and evidence-based care.

“It is a dynamic relationship that varies from client to client,” Miller said. “But it always includes providing evidence-based information about labor and birth, observing and helping (without intruding) during labor and birth, and offering advice during labor and the postpartum period.”

Evidence suggests that birth assistance, particularly from doulas, helps mothers in labor and produces better birth outcomes. In a study led by University of North Carolina’s Kenneth J. Gruber, researchers studied 226 women with high-risk birth outcomes and separated them into two groups.

One of the groups received assistance from a doula and the other group did not. The researchers found that mothers that had received assistance from doulas had better birth outcomes in terms of baby weight, fewer birth complications, and better breastfeeding initiation.

In another study led by University of Toronto’s Ellen D. Hodnett, researchers conducted 22 trials with more than 15,000 women, some of them who had continuous support during birth and others who did not. The women who did have continuous support were not only more satisfied but had shorter labors and were less likely to have a C-section.

Doulas have helped many mothers forego epidural use, which can make the time to push much longer and complicated and which can lead to the decision to perform a C-section. They can also help decrease the stress related to birth.

Through doulas, many women have had positive birthing experiences whether those were in a traditional hospital setting or at home.

Birth at a Hospital

Parsons-Facetti’s second birth didn’t go perfectly either. She went into labor at 39 weeks and 6 days.  Miller was delayed and missed the first few hours of labor, which was a disappointment for Parsons-Facetti who had expected her to be there sooner.

Miller was sorry to hear that Elisa was disappointed by her late arrival.

“I do not ever want a mom to feel that she needs doula support from me and isn’t getting it,” she said. “Very rarely, I cannot get to a birth as soon as someone calls me, but most times I am ready and waiting for a client to say, ‘Ok, now I need you,” she said.

For the first few hours, Parsons-Facetti felt alone and found the hospital nurse to be unhelpful. In intense pain and a bit of self-described hysteria, she was offered an epidural but refused. Her husband did not know what to do; this was his first time at a vaginal birth as well. She ended up consenting to receive an IV of stadol, a narcotic.

“That didn’t do anything,” she said. “I kept feeling high and it wore off pretty quickly.”

Dr. Burks arrived first, three hours before pushing. Miller arrived later. Once they arrived, Parsons-Facetti was able to calm down. This was her first time going through a natural birth and the pain made it very difficult for her to stay calm.

“I was not in my right mind,” she said. “I don’t think any woman is on her right mind at that point. That’s why I really believe you need to have someone else to vie for you, be it a doula or your husband, because even the strongest woman loses it at that point. It is really painful.”

Thanks to Dr. Burk’s and Miller’s support, Parsons-Facetti was able to resist the temptation for an epidural, which helped make the birth easier.

Although Parsons-Facetti opted for a birth at a hospital, Miller said that some women feel they are not in control of their birth experience and options in a hospital setting. For this reason they opt for home births. They do so to have as much control as possible over their birth experience, from the choice of a primary care giver like a midwife, down to whom they can have in the delivery room. However, home births are not without risk either. Although the majority of births are successful, some have not ended well.

For all its high-tech care, the United States has one of the highest maternal mortality rates among other developed countries. It is ranked significantly higher than countries like Canada, France, Portugal, Italy, and Greece. C-sections have been linked to maternal mortality rates.

“The U.S. maternity care system is pretty broken,” Miller said

In Columbia, MU Women and Children’s Hospital encourages women to work with their own doctor as part of the birthing plan. If a doctor is not in place, an attending physician is assigned to the case. Hospital personnel said that they are supportive of doulas and try to accommodate them.

“MU Health Care has a close relationship with the doulas and midwives in the community,” said Stephanie Baehman, the MU Health Care spokeswoman. “We encourage patients to have the support that they believe will be best for them during their delivery.”

Mothers are allowed to have up to one hour of skin-to-skin contact with the baby after a C-section unless there is a medical emergency. Boone Hospital did not respond to request for interview in time for publication.

Successful and Satisfying Birth

Parsons-Facetti’s daughter was born at 1:30 p.m. The baby was immediately placed on Parsons-Facetti’s chest and started to breast-feed.

Although Miller’s late arrival made the doula experience less than ideal, Parsons-Facetti said that using one took the load off her husband and gave him the opportunity to enjoy the birth.

“Doulas have experienced several births, they can read the mom and know when to comfort and how to comfort,” she said.

Parsons-Facetti was also very pleased with Dr. Burks who was like a coach, helping and encouraging her during the pushing phase.

She said she would work with a doula again, and that one of the best parts of hiring her doula was that it led her to Dr. Burks.

“I am really grateful that she pointed me in the right direction, when she suggested a list of VBAC supportive providers, among which Dr. Burks was the one I decided to transfer my care to,” she said.

Parsons-Facetti considers it important that women have gained more autonomy and can research their options, both in terms of the physicians they hire or the support they employ.

“That’s not necessarily how mothers experienced birth 30 years ago,” she said. “We have options now, and we would like for births to be special moments, because it is a special moment.”

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