Thesis Proposal: Mia DeSimone '09

Medicalized Birth in A Small Town: A Case Study of North Adams Regional Hospital


My fieldwork research will encompass a case study of North Adams Regional Hospital (NARH) with a primary focus on the processes of reproduction, maternity, and childbirth as perceived by and experienced within the hospital and larger community. I am interested in studying how a major institution (in this case a rural hospital) functions within a small town and how it develops, packages, and delivers its services. With respect to my specific focus on the process of childbirth, I would like to consider the national increase in medicalized births and NARH’s response to that trend. I became interested in this thesis topic because of the 10 % lower cesarean section rate at NARH compared with the Massachusetts state average.

If I gain access to the Labor and Delivery ward (as of May 18, 2009, I had not yet received endorsement from the hospital to conduct my fieldwork), I hope to develop a qualitative understanding through observation and interviews with nurses and physicians of the obstetric ward that will supplement the quantitative data published by the Massachusetts Department of Health in the 2008 Hospital Feedback Report. I intend to look for the human stories that underlie the seeming inconsistencies among the raw data: although the statistics reveal comparatively few cesarean sections (18 %) and labor and delivery complications, the sociological data indicate that the region exhibits low levels of educational achievement, large populations of unwed mothers and Medicaid patients, and a high incidence of tobacco use. Explain why these pieces of information are incongruent with each other.

I intend my research to shed more light on the social fabric that has created these incongruities, working to relate the sociological data to patient outcomes at NARH and to elucidate the labor and delivery complications and the maternal and neonatal morbidities and mortalities. In addition, I hope to develop my own understanding of the hospital’s role within the community and influence on the culture and society around it. And finally, I will present the hospital with a broader perspective on the issues they face as they work to better serve their community.

Research Background:

1. Medicalized birth

Over time, childbirth in the United States has moved from the home to the hospital, from a natural, female-oriented and female-dominated process to a medicalized, physician-oriented and physician-dominated procedure. As our society became more modernized and industrialized, with an increased reliance on science and technology, so too did medicine and its application to the human body, and more specifically, to childbirth. Women began to instill more trust in doctors and hospitals instead of in their own bodies, as society reinforced this shift by viewing the human body as a machine—a machine that should be controlled, predictable, and superior over nature (Davis-Floyd, 1990: 177, 182). Promoters of science and technology, obstetricians dominated childbirth in the United States and began championing hospital births with medical interventions. Institutional organizations developed, like the American College of Obstetricians and Gynecologists (ACOG), to protect the interests of the American obstetricians. In opposition, birth advocates emerged, standing up for the rights of women to regain control over their own bodies. Soon, childbirth became a divisive subject creating one major schism in our society that subsequently instigated cascades of other major disparities—hospital versus home, cesarean versus vaginal delivery, obstetrician versus midwife, intervention versus natural, dangerous versus safe. Through a close analysis of the obstetric literature, the ACOG principles and recommendations, and the scholarly work of birth advocates, I hope to begin to understand the medicalization of birth in the United States and to form the foundation for my study of childbirth in a small town hospital, North Adams Regional Hospital (NARH).

Birth is an American rite of passage that unites most women through the universality of stories and experiences (Davis-Floyd, 1992: 1). For many women, pregnancy is an overwhelming, all-encompassing journey that climaxes with childbirth. During natural childbirth, the woman disengages her mind and surrenders herself to her own body. In a society where we feel divorced from our own bodies, no other experience or human process except natural childbirth embodies this same connection between mind and body where the instincts are supposed to be in control. Childbirth is no longer revered as a rite of passage. Instead, we have moved toward the medicalization of birth where we adopt and accept medical interventions to mediate the seeming disconnect between the woman’s mind and body. Now when a woman enters a hospital to give birth, she becomes a patient, a consumer, and a subject all at the same time. Robbie Davis-Floyd (1990: 175), a cultural anthropologist who is an expert on childbirth and midwifery, outlines important questions to consider in order to help frame my analysis of modern childbirth:

How to make birth, a powerfully female phenomenon, reinforce, instead of undermine, the patriarchal system upon which American society is still based? How to turn the natural and individual birth process into a cultural rite of passage which successfully inculcates the dominant core value system into the initiates? In the absence of universal baptism, how to enculturate a non-cultural baby?

Childbirth, which has historically been a rite of passage imbued with mystery, superstition, and taboo, is now de-mystified, de-ritualized, de-sexualized, and humanized (Davis-Floyd, 1990: 182, 185). The customs of obstetrics have stripped away the power, the obscurity, the ceremony, and the sexuality of the birth experience by forcing women onto their backs in the lithotomy position, controlling their bodies and the environment around them, and masking all things inhuman. There have been appeals from physicians and mothers, midwives and nurses alike to return birth to its roots as a rite of passage, as a female phenomenon that cannot be taken away—her fantastic ability to bring another life into this world. Michel Odent (2004: 17), a progressive obstetrician in France, claims that with the medicalization of birth and industrialization of obstetrics, we have failed to remember the basic needs of women, especially the basic needs of laboring women. How can we liberate childbirth from unnecessary and harmful technology? What role do the obstetricians and nurses play in reinforcing the trend toward medicalization of birth? Why do mothers continue to perpetuate this cycle as well by trusting obstetricians as the absolute authority and instilling total faith in science over nature? When we rediscover the respect women deserve and the knowledge of birth physiology, we can begin to break out of the vicious cycle.

2. Cesarean section

In order to study the medicalization of birth, I will focus on cesarean sections because those rates are good indicators of the extent to which medical interventions have penetrated a given hospital. Cesarean sections were actually performed in ancient times, but only in the late-nineteenth century did the cesarean become an alternative to vaginal delivery. With more advanced antiseptic, antibiotic, and anesthesia techniques, this type of surgery has become safer than in ancient times when the operation always resulted in the death of the mother (Rosen & Thomas, 1989: 13-15). Before I delve into the reasons to perform a cesarean, I will briefly illuminate the classifications according to two experts in the field of obstetrics, Mary Vadnais and Benjamin Sachs, (2006: 245), which will enable me to better understand the context that necessitates a cesarean:

  1. Emergent: instant danger to the woman and/or fetus
  2. Urgent: not immediate threat to the woman and/or fetus
  3. Scheduled: necessary early delivery with no risk to the woman or fetus
  4. Elective: maternal request then scheduled for convenience
  5. Perimortem: performed while the woman is actively resuscitated to save the woman and/or fetus
  6. 6. Postmortem: performed after death of the woman to save the fetus

From these classifications, I see distinctions formulated based on urgency (dangerous or fatal for the woman and/or fetus) and choice (physician or maternal). Ultimately, the obstetrician is held accountable for the classification because of his/her liability to the insurance companies. This issue elucidates the first conflict of interest between the obstetrician and the mother: how can a system guarantee the best interests of individual patients and individual obstetricians when a system of power is embedded in the society where patients are under physicians and physicians are under insurance companies? Can an obstetrician provide unbiased information to assist the patient in making a fully informed decision when childbirth has become a business for both the insurance companies and hospitals? Do women have the right to request a cesarean section and do physicians have the right to recommend one even when the surgical procedure itself is dangerous and typically unnecessary? With these questions in mind, I will next explore the medical reasons obstetricians assert to justify cesarean delivery.

There are several medically motivated reasons for performing a cesarean section: dystocia, repeat cesarean, fetal distress, and breech. There is evidence that cesarean delivery does improve the outcomes of these various complications of pregnancy, as reported by the National Institute of Health Consensus Development Program on Cesarean Childbirth in 1980. However, this same panel discussed the concerning rise in the cesarean birth rate, which had increased three-fold during the 1970s from 5.5 % to 15.2 %. The rate has since almost doubled. The complications that precipitate a cesarean demand an explanation in hopes of understanding how the cesarean rate has increased dramatically from the 1970s into the 21st century. Dystocia, abnormal labor due to problems with the fetal position or size, is diagnosed more with advanced technology and is often controlled with cesarean delivery. While the primary cesarean rate rose, so too did resultant cesareans because of the established tenet asserting “once a cesarean, always a cesarean.” Fetal distress is tracked during labor by electronic fetal monitoring and is more commonly managed with cesarean delivery. Breech positioning is correlated with a rise in both morbidity and mortality; therefore, many obstetricians perform cesarean delivery when they observe breech presentation.

These four medical presentations motivate cesarean delivery for seemingly appropriate reasons. However, they also seem inextricably tied to technology. With more capability of diagnosing dystocia, fetal distress, and breech, more cases are resolved with a cesarean. But the infant and maternal mortality rates remain constant, suggesting that these advanced technologies and resultant cesareans are not saving lives. Then why are obstetricians still performing cesarean sections? How does NARH manage these conditions during pregnancy, and is the immediate solution a cesarean? With increased use of electronic fetal monitoring in medicalized hospitals, more fetal distress cases are diagnosed, leading to more cesareans. With NARH’s lower cesarean rate and trained nurse-midwives, is electronic fetal monitoring used less frequently or do fewer fetal distress diagnoses proceed to cesarean? The statistics reveal that fetal monitoring is used in the majority of cases (94 %) at NARH. This data would seem to suggest that NARH has adopted a dependence on technology during childbirth. Then how does NARH maintain such a comparatively low primary cesarean rate (10.8 %) and comparatively high vaginal delivery rate (76.9 %) when technology seems to be one of the key driving forces behind the steep incline in cesareans?

In 1989, The cesarean myth was published, shedding light on what the authors claim are the myths of childbirth—that cesareans are just as safe as vaginal births with just as favorable outcomes (Rosen & Thomas, 1989: xi). In fact, a cesarean is a major surgical procedure that is more dangerous for the mother and for the baby, inducing more short and long-term complications, such as respiratory distress syndrome and prematurity for the baby and infection and future reproductive problems for the mother, among many others (Wagner, 2000: 7). Still, health officials, like the ACOG president Benson Harer in 2001, bolster the “cesarean myth” and perpetuate the cycle with their authority (Goer, 2002: 5-6). Unfortunately, women are easily convinced by their doctors to elect a cesarean, ignorantly believing that the obstetrician is looking out for their health instead of choosing the fast, convenient solution for birth.

Along with the medically justified reasons discussed above, cesareans are performed for nonmedical motivations as well. Even if the primary cesarean is medically validated, the first is the beginning of a slippery slope; therefore, we must pay close attention to the reasons behind the primary cesarean. Using such medical intervention allows obstetricians to maintain a busy schedule, to avoid litigation, to protect their business of labor and delivery through establishing dependency on their service, and to place a “blind faith in technology and the mantra technology = progress = modern” (Wagner, 2006: 40). According to Marsden Wagner (2006: 58), a physician, a scientist, and former Director of Women’s and Children’s Health at the World Health Organization, obstetrics has deviated from evidence-based practice where a procedure or medical intervention is considered unsafe until proven safe. Instead, obstetric interventions are pioneered, adopted, and instituted almost simultaneously, widening the gap between science and practice and championing antiprecautionary methodology. Odent (2004: 18) explains that the high rates of cesareans are rooted in, simply, a lack of knowledge of birth physiology that creates cascades of electronic fetal monitoring, absence of midwives, excessive rates of labor induction, high incidence of epidural blocks as pain relief, and the modification in the role of midwives. Sadly, these shifts are all divergences from what is best for the woman and her baby, but we have allowed this trend to continue.

The International Federation of Gynecology and Obstetrics (FIGO) claims,

At present, because hard evidence of net benefit does not exist, performing cesarean delivery for nonmedical reasons in not ethically justified. (Menacker et al., his emphasis, 2006: 240) 

Interestingly, a U.S.-based policy-maker, the American College of Obstetricians and Gynecologists (ACOG), asserts differently,

In the absence of significant data on the risks and benefits of cesarean delivery…if the physician believes that cesarean delivery promotes the overall health and welfare of the woman and her fetus more than vaginal birth, he or she is ethically justified in performing a cesarean delivery. (Menacker et al., his emphasis, 2006: 240) 

This apparent inconsistency in obstetric recommendation further substantiates the lack of coordination between the international and national obstetric communities. FIGO makes declarations for all women in the world, whereas ACOG has a specific agenda to protect American obstetricians. Hence, FIGO believes that a cesarean is not ethically justified if performed for nonmedical reasons. In contrast, ACOG grants the physician the ultimate authority to determine if a cesarean will uphold the overall health of the woman and her baby more than a vaginal delivery. In addition, ACOG grounds its statement in the claim that there is not enough significant research on the risks and benefits of a cesarean, therefore warranting a cesarean if the obstetrician sees fit. Obstetricians seem to operate under the flawed notion that technology is science and thus medicine. However, when is performing surgery because there is not enough data an ethically justified reason? Are obstetric nurses and doctors at NARH operating with awareness of FIGO and ACOG? Does the geographic isolation of NARH contribute to an ability to act more independently by having a lower cesarean rate than national recommendations? What are the major reasons for the nearly 10 % difference in primary cesarean rates between NARH and the state of Massachusetts?

In the 1990s, there was a brief yet sudden decline in the national cesarean rate as the rate of vaginal birth after cesarean (VBAC) rose, countering the “cesarean myth.” However, when ACOG revised its policy on VBAC, claiming VBAC was too contentious to support, the cesarean rate continued on its upward climb once again (Block, 2007: 112-113). As soon as we reached the year 2000, although there was research tied to poor outcomes and higher maternal mortality rates with cesarean delivery, obstetricians resumed practicing defensive medicine—preventing possible future complications with surgery now (Minkoff and Schwarz, 1980: 143). In previous generations when a cesarean would have been contested because the mother felt cheated of the natural birth experience, now more women are actually requesting the surgery, which further perpetuates its rise (Cassidy, 2006: 130). As Mortimer Rosen, a prominent obstetrician in New York City and expert on perinatal care, and Lillian Thomas (1989: xi), a professional writer, remind us, many people are uninformed about the risks of cesarean delivery and blindly support such a procedure because of the belief that when a medical intervention is available, science and technology are always safer than a more natural route.

In 2004, 29.1 % of all U.S. births were cesarean deliveries (Menacker et al., 2006: 236). At NARH in 2008, the combined primary plus secondary cesarean rate was 18 % compared with the Massachusetts state average of 34 %. While some people support governmental regulations, peer-reviewed journals, and physician-managed labor and delivery as temporary fixes to counteract the rising cesarean rate, others call for more radical changes to the health care system in the form of checks and balances. These solutions include an increase in midwifery within hospitals and required second opinions for surgery (Sachs et al., 1999: 55). Although these programs are difficult to implement nationwide, they address the root of the problem and use a top-down approach towards improvement. Has NARH adopted any of these programs to combat the rising national cesarean rate?

The very nature of the relationship between doctor and patient is changing. While doctors rely on instruments not only to assist but also to supplant medical judgment, patients are treated like consumers of medical service from suppliers where their demands affect supply (Anderson, 2004: 697). When considering childbirth, demands are typically uninformed conclusions shaped by society and physician recommendations. Therefore, the rise in cesarean delivery is a self- perpetuating vicious cycle that needs to be remedied. Through studying NARH, I hope to learn from its model in order to form more complete solutions to the national epidemic of the rising cesarean rate.

3. Outcomes

After reviewing the Hospital Feedback Report 2008 published by the Massachusetts Department of Health, many statistics dramatically differed between NARH and the Massachusetts state averages. I have chosen to enumerate the following statistics that are either 5-15 % greater or lower than the Massachusetts state average:

I. Risk Factors for this Pregnancy

a. Anemia

b. Diabetes

c. Genital Herpes

d. Hypertension

e. Previous infant 4000+ g

f. Previous preterm or SGA

g. STD

h. Other (Breech, single vs. multiple, mother 35+ years)

II. Complications of Labor and Delivery

a. Breech/malpresentation

b. Cephalopelvis disproportion

c. Dysfunctional labor

d. Febrile

e. Fetal distress

f. Precipitous labor

g. Other

h. No complications

III. Labor and Delivery Procedures

a. Electronic Fetal Monitor-ext/int

b. Induction of labor

c. Steroid for neonatal pulmonary

d. Stimulation/augmentation

e. Other

f. No Procedures

IV. Methods of Delivery

a. Vaginal


c. Primary c-section

d. Repeat c-section

V. Abnormal Conditions of the Newborn

a. Other birth trauma

b. Jaundice (bili>10)

c. Tachypnea

d. Other

VI. Delivery Payment, Pediatric Provider, Certifier and Transfer Data

a. Medicaid/MassHealth

b. Maternal Transfer

c. Infant Transfer

4. Future plans

During the summer 2009, I plan to investigate this quantitative data through interviews of doctors and nurses who work in the Labor and Delivery ward at NARH and through comparisons with data from previous years. With this newly obtained qualitative data, I hope to discern the very issues I address in this proposal in the context of a rural hospital. This project will continue into the 2009-2010 academic year as a senior thesis.

Research Plan:

Through establishing a foundation in obstetric literature, ACOG principles and guidelines, and birth advocates’ recommendations, I hope to determine where NARH and its practitioners fit within this spectrum. Does the isolated setting affect the hospital’s approach to obstetrics and medical interventions? Do the nurse-midwives on the hospital staff directly correlate to a comparatively low cesarean section rate and low labor and delivery complications? Do the patient demographics contribute in any way to the delivery choices and outcomes? With its impressively low primary cesarean section rate yet difficult patient population, NARH is trying to provide a service to its citizens at the same time as it tries to fight against the medicalization of childbirth. As Odent (2004: 24) claims, childbirth should be mammalized and de-humanized. In other words, childbirth should return to its roots as a unifying experience for all female mammals and as a rite of passage filled with privacy and security for all women. When our society can abandon the cultural milieu and lack of understanding of birth physiology that has medicalized birth and industrialized obstetrics, we will be able to reclaim childbirth as the natural, momentous journey it should be for all women.

Proposal Bibliography:

“Cesarean Childbirth.” Consensus Development Conference Summaries / National Institutes of Health 3, (1980): 39-53

Anderson, G. M. “Making Sense of Rising Caesarean Section Rates.” BMJ (Clinical Research Ed.) 329, no. 7468 (Sep 25, 2004): 696-697

Block, Jennifer. Pushed : The Painful Truth about Childbirth and Modern Maternity Care. 1 DaCapo Press ed. Cambridge, MA: Da Capo Lifelong, 2007

Cassidy, Tina. Birth : The Surprising History of how we are Born. 1st ed. New York: Atlantic Monthly Press : Distributed by Publishers Group West, 2006

Davis-Floyd, R. E. “The Role of Obstetrical Rituals in the Resolution of Cultural Anomaly.” Social Science & Medicine (1982) 31, no. 2 (1990): 175-189

Davis-Floyd, Robbie. Birth as an American Rite of Passage. Comparative Studies of Health Systems and Medical Care. Vol. 35. Berkeley: University of California Press, 1992

Goer, H. “The Assault on Normal Birth: The OB Disinformation Campaign.” Midwifery Today with International Midwife (63), no. 63 (Fall, 2002): 10-14.

Khan, K. S., D. Wojdyla, L. Say, A. M. Gulmezoglu, and P. F. Van Look. “WHO Analysis of Causes of Maternal Death: A Systematic Review.” Lancet 367, no. 9516 (Apr 1, 2006): 1066-1074

Menacker, F., E. Declercq, and M. F. Macdorman. “Cesarean Delivery: Background, Trends, and Epidemiology.” Seminars in Perinatology 30, no. 5 (Oct, 2006): 235-241

Minkoff, H. L. and R. H. Schwarz. “The Rising Cesarean Section Rate: Can it Safely be Reversed?” Obstetrics and Gynecology 56, no. 2 (Aug, 1980): 135-143

Odent, Michel. The Caesarean. London: Free Association Books, 2004

Rosen, Mortimer and Lillian Thomas. The Cesarean Myth. New York, New York: Penguin Group, 1989

Sachs, B. P., C. Kobelin, M. A. Castro, and F. Frigoletto. “The Risks of Lowering the Cesarean-Delivery Rate.” The New England Journal of Medicine 340, no. 1 (Jan 7, 1999): 54-57

Song, S., Downie, A., Gibson, H., Kloberdanz, K., & McDowell, J. Too posh to push? Time, April 19, 2004 from,9171,993857,00.html

Vadnais, M. and B. Sachs. “Maternal Mortality with Cesarean Delivery: A Literature Review.” Seminars in Perinatology 30, no. 5 (Oct, 2006): 242-246

Wagner, Marsden. Born in the USA : How a Broken Maternity System must be Fixed to Put Mothers and Infants First. Berkeley: University of California Press, 2006

Wagner, Marsden. “Technology in Birth: First Do No Harm.” Midwifery Today (2000) from

Preliminary Bibliography:

“ACOG Practice Bulletin. Vaginal Birth After Previous Cesarean Delivery. Number 2, October 1998. Clinical Management Guidelines for Obstetrician-Gynecologists. American College of Obstetricians and Gynecologists.” International Journal of Gynaecology and Obstetrics: The Official Organ of the International Federation of Gynaecology and Obstetrics 64, no. 2 (Feb, 1999): 201-208.

“ACOG Practice Bulletin. Vaginal Birth After Previous Cesarean Delivery. Number 5, July 1999 (Replaces Practice Bulletin Number 2, October 1998). Clinical Management Guidelines for Obstetrician-Gynecologists. American College of Obstetricians and Gynecologists.”

International Journal of Gynaecology and Obstetrics: The Official Organ of the International Federation of Gynaecology and Obstetrics 66, no. 2 (Aug, 1999): 197-204.

Alexander, J. M., K. J. Leveno, J. Hauth, M. B. Landon, E. Thom, C. Y. Spong, M. W. Varner, et al. “Fetal Injury Associated with Cesarean Delivery.” Obstetrics and Gynecology 108, no. 4 (Oct, 2006): 885-890.

Allen, V. M., C. M. O’Connell, R. M. Liston, and T. F. Baskett. “Maternal Morbidity Associated with Cesarean Delivery without Labor Compared with Spontaneous Onset of Labor at Term.” Obstetrics and Gynecology 102, no. 3 (Sep, 2003): 477-482.

Anderson, G. M. and J. Lomas. “Explaining Variations in Cesarean Section Rates: Patients, Facilities Or Policies?” Canadian Medical Association Journal 132, no. 3 (Feb 1, 1985): 253-6, 259.

———. “Determinants of the Increasing Cesarean Birth Rate. Ontario Data 1979 to 1982.” The New England Journal of Medicine 311, no. 14 (Oct 4, 1984): 887-892.

Bailit, J. L. and T. E. Love. “The Role of Race in Cesarean Delivery Rate Case Mix Adjustment.” American Journal of Obstetrics and Gynecology 198, no. 1 (Jan, 2008): 69.e1-69.e5.

Bailit, J. L., T. E. Love, and N. V. Dawson. “Quality of Obstetric Care and Risk-Adjusted Primary Cesarean Delivery Rates.” American Journal of Obstetrics and Gynecology 194, no. 2 (Feb, 2006): 402-407.

Bailit, J. L., T. E. Love, and B. Mercer. “Rising Cesarean Rates: Are Patients Sicker?” American Journal of Obstetrics and Gynecology 191, no. 3 (Sep, 2004): 800-803.

Bakoula, C. and N. Matsaniotis. “Why Choose Caesarean Section?” Lancet 357, no. 9256 (Feb 24, 2001): 636.

Belizan, J. M., M. L. Cafferata, F. Althabe, and P. Buekens. “Risks of Patient Choice Cesarean.” Birth (Berkeley, Calif.) 33, no. 2 (Jun, 2006): 167-169.

Bergeron, V. “The Ethics of Cesarean Section on Maternal Request: A Feminist Critique of the American College of Obstetricians and Gynecologists’ Position on Patient-Choice Surgery.” Bioethics 21, no. 9 (Nov, 2007): 478-487.

Betran, A. P., M. Merialdi, J. A. Lauer, W. Bing-Shun, J. Thomas, P. Van Look, and M. Wagner. “Rates of Caesarean Section: Analysis of Global, Regional and National Estimates.” Paediatric and Perinatal Epidemiology 21, no. 2 (Mar, 2007): 98-113.

Bettes, B. A., V. H. Coleman, S. Zinberg, C. Y. Spong, B. Portnoy, E. DeVoto, and J. Schulkin. “Cesarean Delivery on Maternal Request: Obstetrician-Gynecologists’ Knowledge, Perception, and Practice Patterns.” Obstetrics and Gynecology 109, no. 1 (Jan, 2007): 57-66.

Bickell, N. A., M. S. Zdeb, M. S. Applegate, P. J. Roohan, and A. L. Sui. “Effect of External Peer Review on Cesarean Delivery Rates: A Statewide Program.” Obstetrics and Gynecology 87, no. 5 Pt 1 (May, 1996): 664-667.

Bloom, S. L., K. J. Leveno, C. Y. Spong, S. Gilbert, J. C. Hauth, M. B. Landon, M. W. Varner, et al. “Decision-to-Incision Times and Maternal and Infant Outcomes.” Obstetrics and Gynecology 108, no. 1 (Jul, 2006): 6-11.

Bofill, J. A., O. A. Rust, M. Devidas, W. E. Roberts, J. C. Morrison, and J. N. Martin Jr. “Shoulder Dystocia and Operative Vaginal Delivery.” The Journal of Maternal-Fetal Medicine 6, no. 4 (Jul-Aug, 1997): 220-224.

Bofill, J. A., O. A. Rust, K. G. Perry Jr, W. E. Roberts, R. W. Martin, and J. C. Morrison. “Forceps and Vacuum Delivery: A Survey of North American Residency Programs.” Obstetrics and Gynecology 88, no. 4 Pt 1 (Oct, 1996): 622-625.

Bofill, J. A., O. A. Rust, K. G. Perry, W. E. Roberts, R. W. Martin, and J. C. Morrison. “Operative Vaginal Delivery: A Survey of Fellows of ACOG.” Obstetrics and Gynecology 88, no. 6 (Dec, 1996): 1007-1010.

Bofill, J. A., O. A. Rust, S. J. Schorr, R. C. Brown, R. W. Martin, J. N. Martin Jr, and J. C. Morrison. “A Randomized Prospective Trial of the Obstetric Forceps Versus the M-Cup Vacuum Extractor.” American Journal of Obstetrics and Gynecology 175, no. 5 (Nov, 1996): 1325-1330.

Caire, J. B. “Are Current Rates of Cesarean Justified?” Southern Medical Journal 71, no. 5 (May, 1978): 571-573.

Caton, D., M. P. Corry, F. D. Frigoletto, D. P. Hopkins, E. Lieberman, L. Mayberry, J. P. Rooks, et al. “The Nature and Management of Labor Pain: Executive Summary.” American Journal of Obstetrics and Gynecology 186, no. 5 Suppl Nature (May, 2002): S1-15.

Clark, S. L., G. S. Eglinton, M. Beall, and J. P. Phelan. “Effect of Indication for Previous Cesarean Section on Subsequent Delivery Outcome in Patients Undergoing a Trial of Labor.” The Journal of Reproductive Medicine 29, no. 1 (Jan, 1984): 22-25.

Coleman, V. H., K. Erickson, J. Schulkin, S. Zinberg, and B. P. Sachs. “Vaginal Birth After Cesarean Delivery: Practice Patterns of Obstetrician-Gynecologists.” The Journal of Reproductive Medicine 50, no. 4 (Apr, 2005): 261-266.

Cowan, R. K., R. A. Kinch, B. Ellis, and R. Anderson. “Trial of Labor Following Cesarean Delivery.” Obstetrics and Gynecology 83, no. 6 (Jun, 1994): 933-936.

de Regt, R. H., H. L. Minkoff, J. Feldman, and R. H. Schwarz. “Relation of Private Or Clinic Care to the Cesarean Birth Rate.” The New England Journal of Medicine 315, no. 10 (Sep 4, 1986): 619-624.

Declercq, E., M. Barger, H. J. Cabral, S. R. Evans, M. Kotelchuck, C. Simon, J. Weiss, and L. J. Heffner. “Maternal Outcomes Associated with Planned Primary Cesarean Births Compared with Planned Vaginal Births.” Obstetrics and Gynecology 109, no. 3 (Mar, 2007): 669-677.

Declercq, E., M. Barger, and J. P. O’Grady. “Uterine Rupture among Women with a Prior Cesarean Delivery.” The New England Journal of Medicine 346, no. 2 (Jan 10, 2002): 134-137.

Declercq, E., D. K. Cunningham, C. Johnson, and C. Sakala. “Mothers’ Reports of Postpartum Pain Associated with Vaginal and Cesarean Deliveries: Results of a National Survey.” Birth (Berkeley, Calif.) 35, no. 1 (Mar, 2008): 16-24.

Declercq, E., F. Menacker, and M. Macdorman. “Maternal Risk Profiles and the Primary Cesarean Rate in the United States, 1991-2002.” American Journal of Public Health 96, no. 5 (May, 2006): 867-872.

Declercq, E., F. Menacker, and M. MacDorman. “Rise in “no Indicated Risk” Primary Caesareans in the United States, 1991-2001: Cross Sectional Analysis.” BMJ (Clinical Research Ed.) 330, no. 7482 (Jan 8, 2005): 71-72.

DeMott, R. K. and H. F. Sandmire. “The Risks of Lowering the Cesarean-Delivery Rate.” The New England Journal of Medicine 341, no. 1 (Jul 1, 1999): 53; author reply 54-5.

Edris, F. E., P. von Dadelszen, L. M. Ainsworth, and R. M. Liston. “Predictors of Cesarean Section Following Elective Post-Dates Induction of Labor in Nullipara with Uncomplicated Singleton Vertex Pregnancies.” Saudi Medical Journal 27, no. 8 (Aug, 2006): 1167-1172.

Efekhar, K. and P. Steer. “Caesarean Section Controversy. Women Choose Caesarean Section.” BMJ (Clinical Research Ed.) 320, no. 7241 (Apr 15, 2000): 1073; author reply 1074.

Enkin, M., M. J. Keirse, J. Neilson, C. Crowther, L. Duley, E. Hodnett, and G. J. Hofmeyr. “Effective Care in Pregnancy and Childbirth: A Synopsis.” Birth (Berkeley, Calif.) 28, no. 1 (Mar, 2001): 41-51.

Feinmann, J. “How to Limit Caesareans on Demand–Too NICE to Push?” Lancet 359, no. 9308 (Mar 2, 2002): 774.

Flamm, B. L. “Cesarean Section: A Worldwide Epidemic?” Birth (Berkeley, Calif.) 27, no. 2 (Jun, 2000): 139-140.

———. “Once a Cesarean, always a Controversy.” Obstetrics and Gynecology 90, no. 2 (Aug, 1997): 312-315.

———. “Vaginal Birth After Cesarean Section: An Appraisal of the Reappraisal.” American Journal of Obstetrics and Gynecology 163, no. 2 (Aug, 1990): 691-692.

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———. “Vaginal Birth After Cesarean Section: Controversies Old and New.” Clinical Obstetrics and Gynecology 28, no. 4 (Dec, 1985): 735-744.

Flamm, B. L., D. M. Berwick, and A. Kabcenell. “Reducing Cesarean Section Rates Safely: Lessons from a “Breakthrough Series” Collaborative.” Birth (Berkeley, Calif.) 25, no. 2 (Jun, 1998): 117-124.

Flamm, B. L., J. R. Goings, Y. Liu, and G. Wolde-Tsadik. “Elective Repeat Cesarean Delivery Versus Trial of Labor: A Prospective Multicenter Study.” Obstetrics and Gynecology 83, no. 6 (Jun, 1994): 927-932.

Flamm, B. L., O. W. Lim, C. Jones, D. Fallon, L. A. Newman, and J. K. Mantis. “Vaginal Birth After Cesarean Section: Results of a Multicenter Study.” American Journal of Obstetrics and Gynecology 158, no. 5 (May, 1988): 1079-1084.

Flamm, B. L., L. A. Newman, S. J. Thomas, D. Fallon, and M. M. Yoshida. “Vaginal Birth After Cesarean Delivery: Results of a 5-Year Multicenter Collaborative Study.” Obstetrics and Gynecology 76, no. 5 Pt 1 (Nov, 1990): 750-754.

Frigoletto, F. D.,Jr, E. Lieberman, J. M. Lang, A. Cohen, V. Barss, S. Ringer, and S. Datta. “A Clinical Trial of Active Management of Labor.” The New England Journal of Medicine 333, no. 12 (Sep 21, 1995): 745-750.

Gamble, J. A. and D. K. Creedy. “Women’s Request for a Cesarean Section: A Critique of the Literature.” Birth (Berkeley, Calif.) 27, no. 4 (Dec, 2000): 256-263.

Goer, H. “Patient Choice Cesarean and Informed Consent.” Birth (Berkeley, Calif.) 33, no. 1 (Mar, 2006): 87-8; author reply 88.

———. “The Assault on Normal Birth: The OB Disinformation Campaign.” Midwifery Today with International Midwife (63), no. 63 (Fall, 2002): 10-14.

———. “The Case Against Elective Cesarean Section.” The Journal of Perinatal & Neonatal Nursing 15, no. 3 (Dec, 2001): 23-38; quiz 89.

Gonen, R., A. Tamir, and S. Degani. “Obstetricians’ Opinions regarding Patient Choice in Cesarean Delivery.” Obstetrics and Gynecology 99, no. 4 (Apr, 2002): 577-580.

Greene, M. F. “Making Small Risks Even Smaller.” The New England Journal of Medicine 360, no. 2 (Jan 8, 2009): 183-184.

———. “Obstetricians Still Await a Deus Ex Machina.” The New England Journal of Medicine 355, no. 21 (Nov 23, 2006): 2247-2248.

———. “Vaginal Birth After Cesarean Revisited.” The New England Journal of Medicine 351, no. 25 (Dec 16, 2004): 2647-2649.

———. “Vaginal Breech Delivery is no Longer Justified.” Obstetrics and Gynecology 99, no. 6 (Jun, 2002): 1113-1115.

———. “Vaginal Delivery After Cesarean Section–is the Risk Acceptable?” The New England Journal of Medicine 345, no. 1 (Jul 5, 2001): 54-55.

Grobman, W. A., Y. Lai, M. B. Landon, C. Y. Spong, K. J. Leveno, D. J. Rouse, M. W. Varner, et al. “Can a Prediction Model for Vaginal Birth After Cesarean also Predict the Probability of Morbidity Related to a Trial of Labor?” American Journal of Obstetrics and Gynecology 200, no. 1 (Jan, 2009): 56.e1-56.e6.

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Guise, J. M., M. Berlin, M. McDonagh, P. Osterweil, B. Chan, and M. Helfand. “Safety of Vaginal Birth After Cesarean: A Systematic Review.” Obstetrics and Gynecology 103, no. 3 (Mar, 2004): 420-429.

Guise, J. M., M. S. McDonagh, J. Hashima, D. F. Kraemer, K. B. Eden, M. Berlin, P. Nygren, P. Osterweil, K. P. Krages, and M. Helfand. “Vaginal Birth After Cesarean (VBAC).” Evidence report/technology Assessment (Summary) (71), no. 71 (Mar, 2003): 1-8.

Guise, J. M., M. S. McDonagh, P. Osterweil, P. Nygren, B. K. Chan, and M. Helfand. “Systematic Review of the Incidence and Consequences of Uterine Rupture in Women with Previous Caesarean Section.” BMJ (Clinical Research Ed.) 329, no. 7456 (Jul 3, 2004): 19-25.

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———. “Quo Vadis Cesarean Delivery?” Obstetrical & Gynecological Survey 57, no. 2 (Feb, 2002): 61-64.

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Landon, M. B., C. Y. Spong, E. Thom, J. C. Hauth, S. L. Bloom, M. W. Varner, A. H. Moawad, et al. “Risk of Uterine Rupture with a Trial of Labor in Women with Multiple and Single Prior Cesarean Delivery.” Obstetrics and Gynecology 108, no. 1 (Jul, 2006): 12-20.

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Liston, R. M. “Birth can be a Hazardous Journey: Electronic Fetal Monitoring does Not Help.” Journal of Obstetrics and Gynaecology Canada : JOGC = Journal d’Obstetrique Et Gynecologie Du Canada : JOGC 26, no. 1 (Jan, 2004): 17.

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Lomas, J., M. Enkin, G. M. Anderson, W. J. Hannah, E. Vayda, and J. Singer. “Opinion Leaders Vs Audit and Feedback to Implement Practice Guidelines. Delivery After Previous Cesarean Section.” JAMA : The Journal of the American Medical Association 265, no. 17 (May 1, 1991): 2202-2207.

MacDorman, M. F., E. Declercq, F. Menacker, and M. H. Malloy. “Neonatal Mortality for Primary Cesarean and Vaginal Births to Low-Risk Women: Application of an “Intention-to-Treat” Model.” Birth (Berkeley, Calif.) 35, no. 1 (Mar, 2008): 3-8.

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MacDorman, M. F., E. Declercq, F. Menacker, and M. H. Malloy. “Infant and Neonatal Mortality for Primary Cesarean and Vaginal Births to Women with “no Indicated Risk,” United States, 1998-2001 Birth Cohorts.” Birth (Berkeley, Calif.) 33, no. 3 (Sep, 2006): 175-182.

MacDorman, M. F., F. Menacker, and E. Declercq. “Cesarean Birth in the United States: Epidemiology, Trends, and Outcomes.” Clinics in Perinatology 35, no. 2 (Jun, 2008): 293-307, v.

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McNiven, P. S., J. I. Williams, E. Hodnett, K. Kaufman, and M. E. Hannah. “An Early Labor Assessment Program: A Randomized, Controlled Trial.” Birth (Berkeley, Calif.) 25, no. 1 (Mar, 1998): 5-10.

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Menacker, F. and S. C. Curtin. “Trends in Cesarean Birth and Vaginal Birth After Previous Cesarean, 1991-99.” National Vital Statistics Reports : From the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System 49, no. 13 (Dec 27, 2001): 1-16.

Minkoff, H. and F. A. Chervenak. “Elective Primary Cesarean Delivery.” The New England Journal of Medicine 348, no. 10 (Mar 6, 2003): 946-950.

Minkoff, H. and S. McCalla. “Uterine Rupture among Women with a Prior Cesarean Delivery.” The New England Journal of Medicine 346, no. 2 (Jan 10, 2002): 134-137.

Minkoff, H., K. R. Powderly, F. Chervenak, and L. B. McCullough. “Ethical Dimensions of Elective Primary Cesarean Delivery.” Obstetrics and Gynecology 103, no. 2 (Feb, 2004): 387-392.

Minkoff, H. L. and R. Berkowitz. “The Myth of the Precious Baby.” Obstetrics and Gynecology 106, no. 3 (Sep, 2005): 607-609.

Muhuri, P. K., M. F. Macdorman, and F. Menacker. “Method of Delivery and Neonatal Mortality among very Low Birth Weight Infants in the United States.” Maternal and Child Health Journal 10, no. 1 (Jan, 2006): 47-53.

Myers, S. A. and N. Gleicher. “The Mount Sinai Cesarean Section Reduction Program: An Update After 6 Years.” Social Science & Medicine (1982) 37, no. 10 (Nov, 1993): 1219-1222.

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———. “Breech Delivery: Why the Dilemma?” American Journal of Obstetrics and Gynecology 156, no. 1 (Jan, 1987): 6-10.

Norman, P., S. Kostovcik, and A. Lanning. “Elective Repeat Cesarean Sections: How Many could be Vaginal Births?” CMAJ : Canadian Medical Association Journal = Journal De l’Association Medicale Canadienne 149, no. 4 (Aug 15, 1993): 431-435.

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  1. Oral consent presented to all interview subjects.

Tape record all interviews. I am Mia DeSimone, a student at Williams College conducting research to write a senior thesis studying childbirth at North Adams Regional Hospital. During this study, you will be asked to answer some questions. Your participation in this interview is voluntary and if, for any reason, at any time, you wish to stop the interview, you may do so without having to give an explanation. All identifying information will be kept confidential. If you have any questions about this research, please ask me now. If you have any questions at a later time, you can feel free to contact me (I will provide my business card). Thank you for your time.

  1. Potential interview questions for obstetricians and nurses


Tell me about your experience working at NARH.

How long have you worked here?

Tell me about the Labor and Delivery ward.

Do doctors and nurses operate with an awareness of FIGO and ACOG?

How does the location of NARH contribute to its functioning in the medical community?

Do you have any concerns about the current state of childbirth in the United States?

Do you have any concerns about the current state of childbirth at NARH?

Do you have any questions about my research?

Do you have any additional information that you think would be useful to my study of childbirth in North Adams?

Medicalized birth

How is childbirth viewed at the hospital?

What are the rates of surgical interventions here?

How often do obstetricians perform episiotomies?

How often do obstetricians use forceps or vacuum extraction?

Are all obstetricians present during the labor and delivery of their patients?

Do midwives attend births?

How are midwives viewed and treated in the hospital?

What types of technology are used for monitoring before, during, and after delivery?

What services does the hospital provide to pregnant women?

Can a woman invite anyone she wants to be present at the birth?

Can a woman come with a written birth plan for her birthing process?

How many hours does a typical birth last?

What is the typical birthing position?

How do you assist a woman in making an informed decision about her method of delivery?

Are ultrasounds routine early in a woman’s pregnancy?

Is such a scan safe?

What is the chance the scan will make things worse?

What is the chance the scan will make things better?

What is the chance a defect will be correctly identified and what is the chance a defect will be incorrectly identified?

Is there a better chance a woman’s baby will survive the pregnancy and birth if an ultrasound scan is done, and what are the data?

How often are epidural blocks used as pain relief?

Are there risks for the baby?

How often is labor induced?

What drugs are used—Cytotec? Pitocin?

How often are you faced with litigation?

Can a birth be filmed?

Describe the prenatal, perinatal, and postnatal care.

Cesarean section

How often do obstetricians perform cesarean sections—Scheduled cesareans? Emergency cesareans? Primary cesareans? Repeat cesareans? Multiples? Maternal request versus physician recommended?

How does NARH maintain a comparatively low cesarean rate and high vaginal delivery rate?

How are complications like dystocia, repeat cesarean, fetal distress, and breech managed?

What is the hospital’s policy on secondary cesarean deliveries and vaginal birth after cesarean?

How safe is a cesarean section?

What are the major reasons for the nearly 10 % difference in primary cesarean rates between NARH and the state of Massachusetts?

Has NARH adopted any programs to combat the national rise in the cesarean rate—increase in midwifery within hospitals, second opinions for surgery, physician-managed labor and delivery?


Discuss the anomalies in the Hospital Feedback Report 2008 (statistics of note enumerated within body of proposal).

What happens to the baby after birth?

Are mothers ever transferred from the hospital? Where to?

Are infants ever transferred from the hospital? Where to?