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“No evidence supports the idea that cesareans are as safe as vaginal birth for mother or baby. In fact, the increase in cesarean births risks the health and well-being of childbearing women and their babies.”1
Years ago, I attended a childbirth educators’ conference session on elective repeat cesarean delivery and vaginal birth after cesarean (VBAC). The speaker was a published expert on the subject and a practicing obstetrician-gynecologist affiliated with a highly ranked medical school. At the beginning of his presentation, as he adjusted his microphone, he asked, half joking, “Are there any physicians in the audience?” When no hands went up, he took a deep breath. “Alright, I can speak freely now.”
Recently, a physician contacted me to ask if I knew of an attorney who represented women who were denied medical care for a planned VBAC. He said that his wife, an obstetrician-gynecologist, was planning to labor for a fourth VBAC but, due to the no-VBACs policies of local hospitals, the closest VBAC-friendly provider she could find was 70 miles away. His was not the first request for legal representation in this matter.
The controversy over cesareans and VBACs is not new. However, unprecedented are: the current promotion by the media and some physicians of elective primary cesarean delivery as a low-risk procedure, inappropriate use of medical interventions that increase the odds for cesarean (see sidebar, “Care Practices That Increase the Odds for a Cesarean Delivery”), the denial of medical care for women who want to labor for a VBAC, and the grab bag of current justifications for performing a cesarean section.
In 2002, 26.1 percent of US women gave birth by cesarean. The majority of these were elective repeat operations and first cesareans for dystocia, or failure of labor to progress, a highly variable diagnosis. The cesarean rate is the highest ever for this country. Eighteen percent of women had a primary cesarean, a rate also unprecedented.2 Of concern is the fact that young women between the ages of 18 and 24 have the highest number of first cesareans.3 A cesarean rate of no more than 15 percent is recommended by the World Health Organization,4 and a goal of the US National Health Service is a cesarean rate of 15 percent for first-time mothers by the year 2010.5
In the US, a woman is likely to have a cesarean, says Diony Young, editor of Birth: Issues in Perinatal Care, if “she’s too big or too small; too early or too late; too old or too fearful; too tired of being pregnant or too tired of being in labor; if she’s having twins, if she’s breech, if she’s previously had a cesarean; or if she’s due and so is the weekend, Christmas, Thanksgiving, or New Year’s Eve. Then again, she’s also at risk if her doctor is in doubt, scared of a lawsuit, too busy, going out of town, or convinced that a cesarean is always safer . . . the reasons go on.”6
Cesarean Section is Major Abdominal Surgery
Dangers for the Mother: Although cesarean section is safer than ever before, it is still major abdominal surgery with inherent risks. A woman who has one cesarean will always be at risk for a uterine rupture in a subsequent pregnancy, whether she labors for a VBAC or has an elective repeat cesarean delivery.
With one prior uterine scar, the risk of a uterine rupture is 1 in 500, compared to 1 in 10,000 for a woman without a cesarean scar. Each additional cesarean increases that risk. Postoperative complications include risk of injury to other organs (2 percent), hemorrhage (1 to 6 percent of women will need a blood transfusion), blood clots in the legs (0.06 to 2 percent), pulmonary embolism (0.01 to 2 percent), infection (up to 50 times higher), and complications from anesthesia. A woman is four times as likely to have a placenta previa (low-lying placenta) in her next pregnancy, putting her at risk for miscarriage, bleeding during pregnancy and labor, placental abruption, and premature delivery. One birth by cesarean puts a mother at 10 times the risk for placenta accreta (placenta grows into or through the uterus), for which women often require a hysterectomy to stop the hemorrhaging. The incidence of placenta accreta has increased tenfold in the last 50 years.7
A US study found that mothers are four times more likely to die from a cesarean unrelated to health problems, compared with women who have vaginal births.8
Emotional Scars of Cesareans: Personal accounts from women who have had a cesarean, as well as emerging research, suggest that despite a healthy baby and a timely physical recovery, some women experience cesarean birth as a traumatic event. An unanticipated cesarean is more likely to increase the risk for postpartum depression and post-traumatic stress disorder (PTSD). As in other traumatic human experiences, the symptoms of birth-related PTSD may emerge weeks, months, or years after the event.9–11 Women re-experience the birth and the emotions associated with it in dreams or thought intrusions. They avoid places or people that remind them of the event. Some mothers have difficulty relating to their infants, and some will avoid sexual contact that may result in pregnancy. They will also exhibit symptoms of hyperarousal, such as difficulty sleeping or concentrating, irritability, and an excessive startle response. Untreated post-traumatic stress often leads to clinical depression.12
A traumatic birth of any kind can leave a woman feeling disempowered, violated, or betrayed. Unless she has had the opportunity to process the event, in her next pregnancy a woman who has no way of controlling what she perceives as events that are likely to reoccur will sometimes choose to repeat a cesarean with a known physician in a more controlled environment.
Dangers for the Baby: Healthy babies born by cesarean are more likely to have breathing problems and to need admission to intensive-care units. The odds of developing persistent pulmonary hypertension, a life-threatening complication, are higher. Mothers who give birth by cesarean are more likely to have difficulty with establishing and maintaining breastfeeding.13 Breastfeeding, which offers optimal long-term health benefits for mothers and their children, is more likely to be compromised with a cesarean birth.14
“Elective Primary Cesarean Delivery: What’s the Big Deal?”
The argument for giving women the choice to have an elective cesarean has become commonplace among US physicians. At a recent annual clinical meeting of the American College of Obstetricians and Gynecologists (ACOG), a physician argued, “If patients can choose to have . . . rhinoplasty [cosmetic surgery on the nose], a breast enlargement and reduction, abdominoplasty [tummy tuck], liposuction . . . why can’t the same patient choose to have a primary elective cesarean section?”15
ACOG’s Ethics Committee recently framed the issue of elective cesareans as a “debate.” Although it cautioned against actively promoting elective cesareans, the committee’s opinion has given physicians virtual carte blanche to perform major surgery when no specific medical indications exist. ACOG’s press release states that “evidence to support the benefit of elective cesarean is still incomplete and that there are not yet extensive morbidity and mortality data to compare elective cesarean delivery with vaginal birth in healthy women.” If “the physician believes that cesarean delivery promotes the overall health and welfare of the woman and her fetus more than vaginal birth, then he or she is ethically justified in performing a cesarean delivery.”16 The committee’s opinion is puzzling, given the evidence against elective cesareans,17 and given that the risks associated with cesareans are clearly outlined in Evaluation of Cesarean Delivery, an ACOG publication.18
Many physicians have said that it is their patients who “demand” cesareans without medical justification. Although that may be the case, reports from several studies concluded that women are choosing cesareans based on incomplete information about the risks, or because they were persuaded by their physicians over the course of the pregnancy.19–21
Cesarean Delivery and the Pelvic Floor
A “hot” indication for elective primary cesareans is protection of the pelvic floor. Despite inconclusive evidence, primary cesarean delivery is being widely promoted as a protective measure against pelvic-floor disorders in later life.22, 23
Proponents of “protective” cesareans argue that urinary and anal incontinence and uterine prolapse result from pressure on the pelvic floor when a woman pushes her baby out. Researchers and women’s advocates say that recommending cesarean section to prevent future pelvic-floor damage is premature and extreme. Carol Sakala, PhD, director of programs at the Maternity Center Association in New York, feels strongly that “warnings linking vaginal birth to future pelvic floor problems are inappropriate, arouse undue fear, and oversimplify a complex matter.” She argues that we need better research to sort out effects of normal aging, a woman’s gynecologic history (such as hysterectomy and hormone replacement therapy), and the type of births she has had—including the risks of major abdominal surgery and of episiotomy, vacuum extraction or forceps, and other common interventions. It is also important for women to understand and consider the many drawbacks of cesareans in the weeks and months after birth, and for future pregnancy and birth experiences.24, 25
Cesareans and the Media
The media has framed the issue of elective cesareans as a “popular” alternative procedure to “natural childbirth.”26 The proliferation of incomplete, inaccurate, or biased information about cesarean delivery and VBAC is easily spread by the media,27 but the issue is rarely investigated independently. Rather, canned press releases, unexamined conclusions of studies in medical journals, and opinions from “experts” in high places generate sensational headlines.
Prima Non Nocere: Iatrogenic Cesareans
When used inappropriately, medical interventions interfere with the normal process of birth and increase the risk of complications and cesarean deliveries.28, 29 A US national survey of birth practices revealed that 93 percent of women had electronic fetal monitoring, 86 percent had intravenous fluids administered through a blood vessel in their arm (an IV), 55 percent had their amniotic sac membranes artificially ruptured, 53 percent had oxytocin to strengthen contractions, and 63 percent had epidurals for pain relief. More than a third of labors were artificially induced. Almost three quarters of the women were restricted to bed, and three out of four were on their backs while pushing their babies out.30
A colleague of mine, Dora, a certified nurse midwife on staff at a large maternity hospital in the Midwest, told me, “The hospital treats every woman as fragile and high-risk, which results in interventions being used that interfere with the normal process of birth. With continuous electronic fetal monitoring, women are confined to bed. IVs are hooked up on admission. Food and fluids are withheld. Our women-to-nurse ratio is usually 2 to 1 or 3 to 1, which essentially eliminates any support for walking in labor, or changing positions. Non-drug pain-relieving options like back rubs, emotional support, or use of hot or cold packs take too much time to prepare. . . . Our physicians actively resist the implementation of evidence-based practice and don’t believe a cesarean rate in the low twenties is a problem.”31
With appropriate care, 70 to 80 percent of women who labor for a VBAC will have an uncomplicated vaginal birth. With a planned VBAC, the risk of uterine rupture with one low-transverse scar is 5 per 1,000. Five to ten babies out of every 10,000 planned VBACs will be severely affected by a uterine rupture.32
In 2002, however, less than 13 percent of US mothers with a prior cesarean gave birth vaginally—a 55 percent drop from its highest recorded rate of 28.3 percent.33 “The decline,” say pro-VBAC maternity-care providers in Vermont and New Hampshire, “is due to the lack of clear national standards, negative press coverage and excessive medical malpractice awards.”34
Current (1999) controversial ACOG guidelines recommend that anesthesia and personnel for emergency cesarean delivery should be “immediately” available when women labor for a VBAC.35 Previous guidelines stated that these should be “readily” available, which often meant within 30 minutes of the decision to perform a cesarean. Most facilities interpret “immediately” to mean in-house availability. Large tertiary-care centers have 24-hour in-house availability for any obstetric emergency including a cesarean section, but most US hospitals do not. Facilities that no longer support VBACs say it is too costly for them to comply with current ACOG recommendations.36
Ruth Guin, a mother in Ohio, contacted several providers who she hoped would support her wish for a VBAC, one located two hours away from her home, but was unsuccessful in finding one. A nearby hospital stated that, officially, they didn’t do VBACs, but if she came in at 8 centimeters or more they would probably let her labor.37
Several times a week, women who can’t find VBAC-friendly providers in their communities contact Tonya Jamois, president of the International Cesarean Awareness Network (ICAN). Jamois says that “most of them are frightened, upset, and angry. The problem is particularly pronounced in rural areas, where choice of care providers and larger hospitals are limited. For these women, their choice is to submit to unnecessary major abdominal surgery, attempt to find a willing midwife, or go it alone at home, unassisted. The latter choice is what I’m hearing about more and more.”38
Organizations that had been recommending safe alternatives to cesareans have also been impacted by the revised ACOG guidelines. Andrea Kabcenell, RN, MPH, former director of the Institute of Healthcare Improvement’s Cesarean Section Collaboratives, stated, “We were making tremendous progress among a small group of hospitals, but then were slowed down by a series of widely publicized research reports on the ‘dangers’ of VBAC and a coming change in the ACOG guidelines.”39
Experts state that any laboring woman faces unpredictable complications—such as umbilical cord prolapse, acute fetal distress, or hemorrhage from a placental abruption—that might require an emergency cesarean. The odds of these complications are 2.7 percent, or 30 times higher than the risk of a uterine rupture with one prior low-horizontal uterine scar. If a hospital cannot respond quickly enough to the less than 1 percent occurrence for a uterine rupture, the experts reason, they cannot respond quickly enough to other obstetric emergencies.40
To those who have been critical of the ACOG guidelines, Dr. Stanley Zinberg, vice president of practice activities at ACOG, stated that “patient outcomes may benefit from the immediate availability of a physician who can perform c-sections,” and that “defendant physicians are in a better position from a liability perspective if they were present at the time of the complication.”41
Dr. Barbara Harbor Evert, vice president and chief medical officer at Upper Valley Medical Center and a member of the board of the Ohio Hospital Insurance Company, explained: “Obstetricians want their patients to have the best care possible while allowing for personal choice in the method of delivery. However, obstetricians are paying extremely large malpractice insurance premiums, and are increasingly hesitant to perform procedures that put themselves at even higher risk of lawsuit. Bad outcomes from VBACs frequently result in lawsuits, and some awards have been very large. . . . Some medical malpractice insurance carriers are refusing to insure healthcare organizations who provide VBACs.”42
The reality of impending malpractice lawsuits is reflected in the advertisements of attorneys who specialize in birth injuries.43 Some have “educational” web pages that state, “We are admittedly and unashamedly anti-VBAC.”44
VBAC-Friendly Providers Few and Far Between
Although many hospitals across the nation are denying women care for VBAC, maternity-care providers who want to support women’s choice to labor have found creative ways to provide this service while lowering their risk for medical malpractice. The Vermont/New Hampshire VBAC Project, a collaborative effort of the Dartmouth-Hitchcock Medical Center and Fletcher Allen Health Care, in alliance with the University of Vermont, fine-tuned ACOG’s guidelines for VBAC so as not to categorize all women laboring for a VBAC as “high-risk.” They also developed a research-based consent form and patient information pamphlet to help women make informed decisions about an elective repeat cesarean or labor for a VBAC. 45 Although some VBAC advocates may find the basic interventions for all VBAC patients restrictive (such as continuous fetal monitoring after 4 to 5 centimeters dilation), many women welcome the opportunity to avoid an unnecessary operation.
Tanja Johnson, MSN, ARNP, CNM, clinical manager of the Family Birth Center of the Three Rivers Community Hospital in Grants Pass, Oregon, explained: “To honor a mom’s choice to VBAC and uphold patient rights as discussed in the American Hospital Association patient rights booklet, we state on our consent form that we do not officially offer VBAC services due to limited medical personnel, as recommended by ACOG. However, a patient who refuses/declines a cesarean and elects a trial of labor is supported in her decision. . . . All of our providers have agreed to remain in-house for VBACs in active labor, and our anesthesia service is available Monday to Friday, 6 a.m. to 2 p.m., then on-call from 2 p.m. to 6 a.m. There is on-call coverage 24/7 on the weekends.” Johnson believes the Family Birth Center at Three Rivers can be “used as a model which works in complying with ACOG and supporting informed choice for mothers.”46 The Family Birth Center at Three Rivers is the first hospital in the US to be designated as a Mother-Friendly birth facility by the Coalition for Improving Maternity Services (CIMS), a United Nations–recognized NGO. CIMS’ “Mother-Friendly Birth Initiative,” a consensus document, has been recognized as an important wellness model of maternity care that can improve birth outcomes and substantially reduce their costs.
Maternity Care Professionals Alarmed by the High Number of Cesareans
Midwives and nurses are also very concerned about the escalating number of cesareans and the impact of surgical deliveries on the health and quality of life of childbearing women and their infants. Deanne Williams, executive director of the American College of Nurse-Midwives (ACNM), and Mary Ann Shah, president of ACNM’s board of directors, stated that the cesarean rates “are off the charts, and women are being duped into thinking that this is alright.”47 “The belief that a major surgical procedure is preferable to a normal vaginal birth is used to justify an assault on women and a total disregard for normal physiology,” writes Nancy Lowe, editor of the Journal of Obstetrics, Gynecologic, and Neonatal Nursing. “The distressing social reality is that a number of women seem to accept and even welcome the assault.”48
Is Anyone Accountable?
The rise in cesarean deliveries has not substantially improved outcomes for mothers or babies.49 At the end of the 1970s, when the US cesarean rate was 16 percent, the benefits of a surgical delivery no longer seemed to outweigh the risks. Dr. Mortimer Rosen, who chaired the National Institute of Child Health and Human Development Consensus Panel on Cesarean Childbirth in 1979, wrote, “We were delivering more and more babies by cesarean, but about the same percentage of them died and about the same percentage were born with brain damage or other problems.”50
In today’s disjointed, economically strapped, and liability-burdened healthcare system, it is difficult to know who is ultimately accountable for the thousands of women every year who needlessly go under the knife to have a baby. Susan Hodges, president of Citizens for Midwifery, a nonprofit advocacy group, and a member of the Consumer Panel for the Cochrane Collaboration’s Pregnancy and Childbirth Group, cannot see an immediate solution to the high rate of cesareans.
“To my knowledge, there is no economic or other incentive to hold back interventions, including cesareans, or to support normal birth. If a woman comes in and labors normally, in her own time,” says Hodges, “the hospital isn’t going to make much money on the birth. Hospitals bill for interventions, and when midwives do not use interventions, then hospitals do not make as much money.”51
Guidelines and recommendations to safely reduce cesarean deliveries have been available to medical care providers, hospital administrators, health-policy makers, employers, and healthcare insurance payers for more than 20 years.52–56 The Medical Leadership Council, an association of more than 2,000 US hospitals, concluded in its report on cesarean deliveries in 1996 that the US cesarean rate was “medicine’s equivalent of the federal budget deficit; long recognized as [an] abstract national problem, yet beyond any individual’s power, purview or interest to correct.”57 If physicians are expected to perform fewer cesareans, it is childbearing women themselves who must make their voices heard, and heard loudly.
1. Coalition for Improving Maternity Services (CIMS) Fact Sheet, “The Risks of Cesarean Delivery to Mother and Baby” (2003):
www.motherfriendly.org , click on “Resources.”
2. Centers for Disease Control, National Center for Health Statistics, “Births: Preliminary Data for 2002,” National Vital Statistics Report 51, no.11 (25 June 2003): 1–5.
3. Agency for Healthcare Quality and Research, Care of Women in U.S. Hospitals, 2000, Healthcare Cost and Utilization Project (HCUP) Fact Book No. 3, AHRQ Publication No. 02-004 (Rockville, MD: Agency for Healthcare Research and Quality, 2000):
4. World Health Organization, “Appropriate Technology for Birth,” Lancet 2, no. 8452 (Aug 1985): 436–437.
5. Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services, Healthy People 2010 (Washington, DC): 16–30; www.healthypeople.gov .
6. Diony Young, “The Push against Vaginal Birth,” Birth: Issues in Perinatal Care 30, no. 3 (September 2003): 149–152.
7. See Note 1.
8. M. A. Harper et al., “Pregnancy-Related Death and Health Care Services,” Obstetrics & Gynecology 102, no. 2 (2003): 273–278.
9. D. Bailham, S. Joseph, “Post-Traumatic Stress Following Childbirth: A Review of the Emerging Literature and Directions for Research and Practice,” Psychology, Health & Medicine 8, no. 2 (2003): 159–168.
10. Nicette Jukelevics, Ruth Ancheta, VBAC Sourcebook and Teaching Kit (Minneapolis: International Childbirth Education Association, 2000): Chapter 2, 1–16.
11. Nicette Jukelevics, “The Emotional Scars of Cesarean Birth,”
12. See Note 9.
13. See Note 1: www.motherfriendly.org .
14. Coalition for Improving Maternity Services (CIMS) Fact Sheet, “Breastfeeding Is Priceless” (2003): www.motherfriendly.org , click on “Resources.”
15. D. S. Cole, MD, “Elective Primary Cesarean Delivery: What’s the Big Deal?,” Highlights in Obstetrics from the 50th Annual Meeting of the American College of Obstetricians and Gynecologists (4–8 May 2002, Los Angeles, CA):
16. “New ACOG Opinion Addresses Elective Cesarean Controversy,” ACOG News Release (31 October 2003):
17. Henci Goer, “The Case against Elective Cesarean,” Journal of Perinatal & Neonatal Nursing 15, no. 3 (2001): 23–26.
18. American College of Obstetricians and Gynecologists, Evaluation of Cesarean Delivery (Washington, DC: ACOG, 2000): 5–6.
19. S. Donati et al., “Do Italian Mothers Prefer Cesarean Delivery?,” Birth: Issues in Perinatal Care 30, no. 2 (June 2003): 89–93.
20. J. A. Gamble, D. K. Creedy, “Women’s Request for Cesarean Section: A Critique of the Literature,” Birth: Issues in Perinatal Care 27, no. 4 (December 2000): 256–263.
21. K. Hopkins, “Are Brazilian Women Really Choosing to Deliver by Cesarean?,” Social Science and Medicine 51, no. 5 (September 2000):725–740.
22. Sandy Doughton, “More Moms Seek C-sections as Preventive Medicine,”
23. M. Murphy, MD, C. L. Wasson, Pelvic Health & Childbirth: What Every Woman Needs to Know (Amherst, MA: Prometheus Books, 2003).
24. Carol Sakala, PhD, MSPH, personal communication (24 September 2003).
25. Carol Sakala, PhD, MSPH, Maureen P. Cory, MPH, “Much Research Is Needed to Provide Fully Informed Consent about Mode of Delivery,” letter to the editor, American Journal of Obstetrics and Gynecology 188, no.5 (May 2003): 1380.
26. Rob Stein, “Elective Caesareans Judged Ethical; Doctors Group Issues Statement on Popular Procedure,” Washington Post: Final Edition (31 October 2003): A.02.
27. Nicette Jukelevics, “Cesareans, VBACs and the Media”:
28. Coalition for Improving Maternity Services, Mother-Friendly Childbirth Initiative (MFCI):
29. Lamaze International, “Care Practices that Promote Normal Birth #4: No Routine Interventions” (Lamaze Institute for Normal Birth, 2003):
30. E. D. Declercq et al., Listening to Mothers: Report of the First National U.S. Survey of Women’s Childbearing Experiences (New York: Maternity Center Association, October 2002):
31. Personal communication (18 September 2003).
32. Vermont/New Hampshire VBAC Project, “Birth Choices after a Cesarean Section” (3 October 2002). Available from Northern New England Network: www.nneob.org .
33. See Note 2.
34. Vermont/New Hampshire VBAC Project, “Overview” (3 October 2002): Available from Northern New England OB Network: www.nneob.org/vbac.html .
35. American College of Obstetricians and Gynecologists Practice Bulletin, “Vaginal Birth after Previous Cesarean Delivery” (Washington, DC: ACOG, July 1999).
36. Nicette Jukelevics, “A Ban on VBACs Puts Mothers and Babies at Increased Risks for Complications” (2003): www.vbac.com/hottopic/banonvbacs.html .
37. Personal communication (23 October 2003).
38. Personal communication (9 October 2003).
39. Personal communication (8 October 2003).
40. Murray Enkin et al., A Guide to Effective Care in Pregnancy and Childbirth, 3rd ed. (Oxford University Press, 2000): 368.
41. Stanley Zinberg, MD, “College Recommendation on VBAC Based on Risk of Uterine Rupture,” ACOG Today (Washington, DC: ACOG, April 2000): 2.
42. Personal communication (14 November 2003).
43. Dov Apel et al., “A Legal Discussion on Medical Malpractice: Is Vaginal Birth after Cesarean Safe”: www.birthinjuryinfo.com , click on “Press Releases.”
44. McMillan, Reinhart, and Voight, “Why Does a Law Firm Have a VBAC Web Site?”:
45. See Notes 32 and 34.
46. Personal communication (11 December 2003).
47. D. R., M. A. Shah, “Soaring Cesarean Section Rates: A Cause for Alarm,” Journal of Obstetric, Gynecological, and Neonatal Nursing 32, no. 3 (May/June 2003): 283–284.
48. N. K. Lowe, “Amazed or Appalled, Apathy or Action?” Journal of Obstetric, Gynecological, and Neonatal Nursing 32, no.3 (2003): 281–282.
49. Marsden Wagner, MD, “Technology in Birth: First Do No Harm”:
50. Mortimer Rosen, Lillian Thomas, The Cesarean Myth: Choosing the Best Way to Have Your Baby (New York: Penguin Books, 1989): ix.
51. Personal communication (17 October 2003).
52. U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, Cesarean Childbirth: Report of a Consensus Development Conference, Publication No. 82-2067 (Washington, DC: National Institutes of Health 1981).
53. M. Gabay, S. Wolfe, MD, Unnecessary Cesarean Sections: Curing a National Epidemic (Washington, DC: Public Citizen’s Research Group, 1994).
54. B. L. Flamm, MD, E. J. Quilligan, eds., Cesarean Section: Guidelines for Appropriate Utilization (New York: Springer-Verlag, 1995).
55. Medical Leadership Council (MLC), Coming to Term: Innovations in Safely Reducing Cesarean Rates (Washington, DC: The Advisory Board Company, 1996).
56. B. L. Flamm, MD, et al., Reducing Cesarean Section Rates While Maintaining Maternal and Infant Outcomes (Boston: Institute for Healthcare Improvement, 1997).
57. See Note 55: 3.
Nicette Jukelevics is a childbirth educator, author, and speaker on VBAC and cesarean issues. She is the publisher and editor of www.VBAC.com , the highest-ranked website on the subject by major English-language search engines.