Birth in Georgia
If you created a list of factors that have a heavy influence on how a birth unfolds, what might you include? Childbirth education, prenatal nutrition and exercise, having a doula? All of these can (and I believe do) play a role. However, the fact remains that you can have all the knowledge about birth and have done all the right things to prepare, but if you do not have a supportive provider and birth place, labor and birth can still be an uphill battle.
Access to evidence based care can be tough to get depending on where you live and what your options are. On average, there is about a 15-20 year gap between what the evidence says and it being implemented in practice. This means that many of the routine policies and practices in birth are not supported by evidence. So what is a pregnant person to do?
Education and awareness about your local birthing culture is a great place to start. For my fellow Georgians, how are we stacking up?
Georgia Birth Statistics
For the following statistics, lower rates are generally considered better.
NTSV Cesarean Rate
NTSV stands for a nulliparous (first time mother), who carried a singleton baby to term in the vertex position (head down). What is the significance of this number? Up until about the 1970’s, the Cesarean rate in the U.S. was stable at about 5% for decades. By the end of the decade, the Cesarean rate was 17%., and by 1988, it was up to 25%. After 1988, it fell back to about 15%, partially due to an increase in vaginal deliveries after Cesareans (VBACs). In the 2000’s, it has steadily climbed to hover around 33%. The belief that “once a Cesarean, always a Cesarean” has contributed to the overall rate, and it can still be challenging today to find providers who are truly supportive of VBACs. 
How does Georgia’s NTSV Cesarean rate compare to the rest of the country? Georgia is 40th on the list and is one of the 29 states that has not meet The Healthy People 2020 target of 23.9% Cesarean rates. Furthermore, the World Health Organization (WHO) recommendation for ideal rates is between 10-15%. 
Vaginal birth after Cesarean (VBAC) rates remained low as the Cesarean rates began to climb in the 1970’s in the U.S. “Once a Cesarean, always a Cesarean” held sway with most providers, and is still a common belief. In the 1990’s, there was a peak for VBACs with a rate of 28%, but in 1996, the supposed risks of VBACs and fears of litigation brought back a decrease in the VBAC rates. 
What about VBACs today? In 2010, the American College of Obstetrics and Gynecologist (ACOG) issued a statement that “attempting a VBAC is a safe and appropriate choice for most women who have had a prior cesarean delivery, including for some women who have had two previous cesareans.”  The International Cesarean Awareness Network (ICAN) states that “when discussing a VBAC, the primary concern of any individual is that of uterine rupture. Uterine rupture occurs when a separation of the uterine wall occurs at the scar of the previous cesarean. Uterine rupture can be life-threatening and serious, however, the risk of uterine rupture occurring is very rare, affecting less than 1% of women who attempt a VBAC. After a woman has had a VBAC, her risk of uterine rupture decreases more with each vaginal delivery.”  Lastly, the American Pregnancy Association shares that, “In most published studies, 60-80% –roughly 3 to 4 out of 5– women who have previously undergone cesarean birth can successfully give birth vaginally.”  Despite ACOG’s stance on VBACs, the fact that most VBACs are successful, and the fact that risks increase with each Cesarean, it can still be challenging to find providers who are truly supportive of VBACs and, in fact, some hospitals have a VBAC ban in place.
So where does Georgia stand? Georgia is listed fourth among the top ten states for the lowest VBAC rates in the country, with the national average of 12.8%. 
Whether or not to get an epidural is a personal decision; however, it is important to understand that epidurals are not without risks. In the U.S. today, more than 60% of people giving birth have either an epidural or a spinal block during labor.  For more information about the risks and benefits of epidurals, check out Evidence Based Birth®’s articles on Epidural during Labor for Pain Management, Effects of Epidural on Second Stage Labor, and Effect of Epidurals on Breastfeeding. An important consideration is that the epidural is not an intervention that can be chosen in isolation. When a birthing person consents to or requests an epidural, there are a handful of interventions that coincide with the epidural. These are likely to include continuous blood pressure monitoring, oxygen monitoring with a probe on your finger, a cuff on your arm to measure your blood pressure, a probe on your finger to measure your oxygen level, IV fluids, a catheter in your bladder, and the use of continuous fetal monitoring.  Additionally, the use of an Epidural restricts movement, and often leads to the birthing person birthing on their back.
Additionally, in the ACOG Committee Opinion on Approaches to Limit Intervention During Labor and Birth, it is recommended that “labor management may be individualized (depending on maternal and fetal condition and risks) to include techniques such as intermittent auscultation and nonpharmacologic methods of pain relief.”  So it is important for the birthing person to evaluate the goals for the birth and determine how medicalized an experience they are wanting (or wanting to avoid).
Labor induction is when artificial means, such as artificial hormones like oxytocin, are used to start labor rather than waiting for the onset of spontaneous labor. How long is a normal pregnancy and what are some common reasons for induction? In Evidence Based Birth®’s article on the Evidence on: Due Dates, “According to the 2013 Listening to Mothers III survey, more than four out of ten mothers (41%) in the U.S. said that their care provider tried to induce labor (Declercq et al. 2014).… Out of everyone who was induced, 44% said that they were induced because their baby was full term and it was close to the due date. Another 18% said that they were induced because the health care provider was concerned that the mother was overdue.”  Currently, full term is considered to be between 39 weeks 0 days to 40 weeks and 6 days. Most providers today use something called Naegele’s rule to determine an estimated due date, which dates back to the 1800’s. In order to predict a pregnant person’s due date, the provider will add 7 days onto the first day of the last cycle and then count forward 9 months. However, current evidence does not support this rule and it is questionable if this is what Naegele intended. 
So if 40 weeks is not supported by current evidence, then how long is a normal pregnancy? The answer is that there is a variation of normal. “About half of all pregnant people will go into labor on their own by 40 weeks and 5 days (for first-time mothers) or 40 weeks and 3 days (for mothers who have given birth before). The other half will not.”  Whether or not to induce for fear of being overdue is a personal decision in which the risks and benefits should be discussed with a trusted care provider.
Lastly, some moms prefer to know their Bishop Score when weighing the option of an induction. A Bishop Score rates the readiness of the cervix for labor.  It is important to note that it is possible for the induction to not work, and that there are various methods of induction as well. Depending on the birthing person’s preferences, the risks and benefits of these options should be discussed and weighed with a trusted provider.
For the following statistic on breastfeeding, higher rates are generally considered better.
Breastfeeding at a year
Breastfeeding not only provides optimal nutrition for baby, but it provides immunological benefits and meets baby’s emotional needs as well. Health benefits with breastfeeding extend to babies, children and mothers, and can make an impact on improving public health.  The World Health Organization (WHO) recommends exclusive breastfeeding for the first six months followed by continued breastfeeding with complementary foods up to two years of age or beyond.  To get breastfeeding off to an ideal start, it is also recommended to begin breastfeeding during the first hour after birth, also known as the golden hour.
Many hospitals have International Board Certified Lactation Consultants (IBCLCs) to help get breastfeeding off to a good start after birth, and often they are available for support even following discharge from the hospital. La Leche League (LLL) provides mother to mother support, and meetings are facilitated by accredited leaders who also offer support, education, encouragement and information between LLL meetings. You can find our local LLL chapter here.
There is also The Baby Friendly Hospital Initiative (BFHI) that aims to promote and increase breastfeeding rates around the world. BFHI was first implemented in 1991, and is an effort by UNICEF and WHO to ensure that maternity care centers, whether free standing or in a hospital, offer breastfeeding support. “A maternity facility can be designated 'baby-friendly' when it does not accept free or low-cost breastmilk substitutes, feeding bottles or teats, and has implemented 10 specific steps to support successful breastfeeding.” 
How is Georgia doing regarding WHO’s breastfeeding recommendations? According to the CDC’s most recent Breastfeeding Report Card, 84% of babies in Georgia were ever breastfed, compared to a national average of 83.2% of babies ever breastfed. 55% of babies are still breastfed at 6 months, and 34.9% are still breastfed at 12. months. 43.8% are exclusively breastfed through three months and 22.1% are exclusively breastfed through 6 months. 
Unfortunately, despite most mothers wanting to breastfeed (demonstrated by high breastfeeding initiation rates), lack of support and education about breastfeeding can cause breastfeeding relationships to end prematurely. Lack of support may come from family who does not have much experience with breastfeeding, from the work place with limited (or no) maternity leave and/or resistance to provide adequate time and space to pump upon returning to work, and an overall cultural view that is not highly supportive of breastfeeding.
Thankfully, steps are being taken towards normalizing breastfeeding. All 50 states and the District of Columbia now have laws in place that protect the rights of those who breastfeed in public, and 29 states (including Georgia) have laws in place regarding breastfeeding in the workplace.  Lactation rooms and breastfeeding pods are popping up in more locations as well for those who may need to pump or may be uncomfortable nursing in public. The Atlanta airport features six breastfeeding pods.  Lastly, the World Alliance for Breastfeeding Action (WABA) coordinates and organizes World Breastfeeding Week every year since 2016 between August 1-7 to promote and educate about breastfeeding worldwide. 
Certified Nurse Midwife (CNM): 13.3%
Other Midwife: 0.5%
In 2016, almost 90% of births in the U.S. listed a doctor as the attendant and 98.4% of births occurred in a hospital. Alternatively, only 8.8% of births were attended by a Certified Nurse Midwife (CNM) and less than one percent of births listed another type of midwife.  Why does this matter? Typically, the midwifery model of care views birth as a normal physiological process, and minimizes interventions. Midwives also tend to spend more time during prenatal visits, fostering a relationship and providing education and emotional support in addition to the prenantal care. On the other hand, the medical model of care usually views birth as pathological and may intervene preventively. This isn’t to say there isn’t cross over on either side, or that it isn’t possible to have a medical doctor who is attentive and implements evidence based care; however, it is important to be aware that there are typically differences between the two models of care,
Unfortunately, in Georgia, birth choices are more limited than in some other states because “the practice of midwifery by direct-entry midwives is effectively unlawful, because certification by the Department of Human Resources, required by law, is unavailable. “  Who you have attending your birth and where you choose to birth are two of the biggest factors impacting how the birth unfolds.
Though Georgia’s state statistics could be better, there are things that birthing people can do to help them better navigate maternity care. Some options include a comprehensive childbirth class, hiring a doula, interviewing providers to find the right fit, researching birthing places in their area, and becoming educated about their rights as a birthing person. One of the reasons I am excited to be an Evidence Based Birth® Instructor is because of the workshops and seminars that Evidence Based Birth® provides for parents and birth workers alike to work towards making evidence based care the norm in maternity care. If you are a parent and feeling overwhelmed, join us for the Savvy Birth Parent Workshop on August 22 from 6-9 PM at Quest Church where we will talk about the “tickets” out of the typical assembly-line care for a more positive and empowering birth experience. Get your tickets here starting Monday, June 24. Early bird pricing available until July 8th. Space is limited, so don’t miss out! Subscribe to our mailing list below to stay up to date on services offered.
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Header Image Credit: Maiden Musgrove Photography
 Romano, Amy. “Optimal Care in Childbirth: the Case for a Physiologic Approach.” Optimal Care in Childbirth: the Case for a Physiologic Approach, by Henci Goer, Classic Day Publishing , 2016, pp. 27–29.
 “Cesarean Rates.” Cesarean Rates, 2019, www.cesareanrates.org/.
 “New VBAC Guidelines .” ACOG Today, Aug. 2010, www.acog.org/-/media/ACOG-Today/acogToday0810.pdf?dmc=1&ts=20190615T0157472353.
 “FAQs about VBAC.” International Cesarean Awareness Network, 10 Oct. 2016, www.ican-online.org/faqs-about-vbac/.
 “VBAC: Vaginal Birth after Cesarean.” American Pregnancy Association, Aug. 2015, americanpregnancy.org/labor-and-birth/vbac/.
 Dekker, Rebecca. “Epidural during Labor for Pain Management.” Evidence Based Birth®, 31 Jan. 2018, evidencebasedbirth.com/epidural-during-labor-pain-management/.
 “Approaches to Limit Intervention During Labor and Birth.” ACOG, Feb. 2017, m.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Approaches-to-Limit-Intervention-During-Labor-and-Birth.
 Dekker , Rebecca. “The Evidence on: Due Dates.” Evidence Based Birth®, 15 Apr. 2015, evidencebasedbirth.com/evidence-on-inducing-labor-for-going-past-your-due-date/.
 “Labor Induction .” ACOG, Sept. 2017, m.acog.org/Patients/FAQs/Labor-Induction.
 “Breastfeeding Report Card.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 2018, www.cdc.gov/breastfeeding/data/reportcard.htm.
 “Breastfeeding.” World Health Organization, World Health Organization, 6 Aug. 2018, www.who.int/topics/breastfeeding/en/.
 “The Baby-Friendly Hospital Initiative.” UNICEF, 12 Jan. 2005, www.unicef.org/nutrition/index_24806.html.
 “Breastfeeding State Laws.” Breastfeeding State Laws, 30 Apr. 2019, www.ncsl.org/research/health/breastfeeding-state-laws.aspx.
 Yamanouchi, Kelly. “More Lactation Pods Added at Hartsfield-Jackson.” Ajc, Ajc.com, 20 Feb. 2018, www.ajc.com/blog/airport/more-lactation-pods-added-hartsfield-jackson/Kfal0LCgmsFo1ZUwPRTf7L/.
 “WABA WORLD BREASTFEEDING WEEK.” World Breastfeeding Week 2019, worldbreastfeedingweek.org/.
 “Georgia.” Status of Midwives and Midwifery, cfmidwifery.org/states/states.aspx?ST=GA.