Do You Know What Reduces the Cesarean Rate? Birth Doulas Reduce the Cesarean Rate!

By Sharon Muza, BS, CD(DONA), BDT(DONA), LCCE, FACCE, CLE

A new study, well, the abstract at least, the ARRIVE Trial, was released on February 1, 2018. The study findings indicated that healthy low-risk pregnant people who were induced at 39 weeks of pregnancy had lower maternal and neonatal morbidity and a reduced cesarean rate. The study results had been expected and were released at the Society for Maternal-Fetal Medicine‘s annual meeting. According to the press release from the SMFM website:

In a study with more than 6,100 pregnant women across the country, researchers randomly assigned half of the women to an expectant management group (waiting for labor to begin on its own and intervening only if problems occur) and the other half to a group that would undergo an elective induction (inducing labor without a medical reason) at 39 weeks of gestation.

Results include:

• Lower rates of cesarean birth among the elective induction group (19%) as compared to the expectant management group (22%)
• Lower rates of preeclampsia and gestational hypertension in the elective induction group (9%) as compared to the expectant management group (14%)
• Lower rates of respiratory support among newborns in the induction group (3%) as compared to the expectant management group (4%)

When I read this abstract and much of the press (both opposed to and in favor of) surrounding the results that healthy low-risk pregnant people might consider being induced at 39 weeks, my head started to spin. My thoughts went in so many directions:

• What if the due date is off?
• What if the family has a history of “growing their babies long”?
• What if the baby is not “ready”?
• Isn’t it the baby that starts labor when their lungs are mature?
• Inductions can often take a long time and exhaust the birthing person and the birth team.
• Inductions are expensive and this will raise the cost of having a baby.
• Inductions occupy an L&D room and a lot of nursing staff for a long period of time.
• What if the cervix isn’t ready and the Bishop’s score is low?
• What does this mean to doulas who attend births and support families?
• What does this mean for healthcare providers and facilities – especially labor and birth units?
• If all the L&D rooms are booked with inductions, how is there any space for spontaneous labors?
• How will this affect out of hospital midwives and home or birth center births?

I am sure that many of you reading this have supported clients who needed to be induced. Inductions can often be a long slow process that starts with cervical ripening agents (misoprostol, Cervidil, Cook’s/Foley catheter or other medication) applied to the cervix the evening before and then Pitocin via IV the next morning. Sometimes providers begin Pitocin, then stop, and then communicate that the induction can possibly last two or three days before the birth occurs. I simply cannot imagine the additional financial costs, logistics and staffing needs if every pregnant person was induced at 39 weeks. These variables do not take into account the emotional and physical burden on the person being induced or their family and support team. By the time a family is holding their baby in their arms, after a three-day induction, they are simply exhausted, and recovery and establishing breastfeeding can be more difficult.

As I was reading the study abstract, Henci Goer’s review of the research and other online discussions and commentary, I couldn’t help but think that there has to be a better way. Something just does not seem right. Does reducing the cesarean rate really mean we need to make birth more medicalized? How can that be? Maybe conclusions will change when the entire study is published, and we can examine the methods more closely, but the final numbers won’t change.

How can often painful and long inductions reduce the cesarean rate? Aren’t they going to lead to more requests for epidurals? There is nothing wrong with birthing with an epidural, but if someone was hoping to birth without pain medications, induction often makes it more difficult. When a person is induced, they require continuous electronic fetal monitoring which has a high false positive rate. There are more vaginal exams to track progress, which increases the risk of infection. Epidurals mean someone is confined to bed, which may make it more difficult for the baby to descend and rotate. The second stage (pushing) may take longer and more often results in an operative vaginal delivery (vacuum or forceps). Food and drink are often withheld in labor, especially with an epidural. There is more of a risk of an “epidural fever” which causes concern for healthcare providers and family alike. The list of potential interventions that can interfere with a spontaneous vaginal delivery and result in a cesarean section is long.

You know what is an easy solution to immediately bring down the cesarean rate? A DOULA!  Having a doula attended birth has been proven to lower someone’s risk of cesarean. Instead of going down the path of a medicalized induction simply to reduce the cesarean rate, why not establish doula programs everywhere and make doulas available and accessible to everyone who is birthing and wants one? In addition to lowering the cesarean rate, there are many other benefits of having a doula attend a birth. Only six (6) percent of birthing people had a doula accompany them in labor, according to the Listening to Mothers survey. There are some situations that require a cesarean, and there always will be. I am by no means anti-cesarean and I am glad that we have the ability to provide this surgery when it is appropriate. Many places around the world are not able to perform cesareans safely and lives are lost.

Doulas are a low tech solution and affordable solution to a highly medicalized and expensive problem. What are the risks of providing doulas to all birthing families? To my knowledge, there are none. Simply put, birth outcomes all around are better with a doula.

Everyone agrees that the cesarean rate in the USA and many other developed nations is unnecessarily high. Medical costs are skyrocketing. The downstream effects of too many cesareans are playing out daily with observable complications in future pregnancies and births. Why is it necessary to throw millions (billions?) of dollars and intensive medicalized treatments at the problem when doulas could be the simple solution?

What is preventing the implementation of this doula solution? Why is this not an obvious answer to every researcher working to define exactly what can be done to make a big impact on our unhealthy cesarean rate? I am dumbfounded that this is not being sung from every rooftop. What are we missing?

Doulas make a difference. Doulas lower the cesarean rate. Doulas can help. The research has supported this for years. We don’t need fancy and expensive medical models to make an impact. We are ready and willing to be recognized as a valuable member of the team. Things can start to change now.

Rebecca Dekker from Evidence Based Birth shared in her discussion of the ARRIVE trial that the number of people who needed to be induced at 39 weeks to prevent one cesarean at the end of 40 completed weeks was 28. (This is referred to as the number needed to treat, or NNT). Dr. Dekker also went on to state that based on existing research, the number of people who needed to have a doula attended birth to prevent one cesarean is nine. That’s a big difference that is so much more cost-effective, and I can only assume more emotionally and physically satisfying for the birthing family.

Sometimes the answer is right in front of our nose if we would only look. The doula solution may be simpler, less expensive, better and completely do-able. Why do we look for complicated answers when a simple one may result in better outcomes? Hello (waves hands in air) everyone! Doulas are ready to step in and do what we do best. We can help reduce cesarean rates.  Please, invite us in.