In traditional obstetric medicine, every woman is treated as an “impending disaster,” Kozhimannil said. That’s great if you have a dangerous medical condition—and some pregnancies can involve potentially life-threatening complications which make them dangerous medical conditions. But for normal pregnancies, most women don’t need abdominal surgery, and unnecessary abdominal surgery can be more dangerous than a natural birth.

The World Health Organization suggests that only 5% to 10% of women need Cesareans. Once Cesarean rates rise over 15%, outcomes for mothers and children start to get worse rather than better. Yet in the United States, Cesarean rates nationally hover around 33% according to the CDC, which means that 1 in 3 pregnancies ends in surgery. And that’s the average; Louisiana’s C-section rate, the worst in the nation, is almost 40%. Regionally, the rates vary dramatically: While some hospitals have rates as low as 5%, others may be as high as 57%, according to a national survey by Consumer Reports.

That level of variation hints at the medical community’s inconsistent and subjective attitude toward Cesareans. After all, why would mothers at one hospital need Cesareans ten or eleven times more often than those at another location?

In many cases hospital policy is to blame. One major problem, Kozhimannil said, is that hospitals and professional organizations in the US often refuse VBACs, or vaginal births after Cesareans, except in cases where emergency medical personnel and anesthesiologist are immediately available. In part because of such restrictions, 90% of births involving women who had previously undergone Cesareans ended with another Cesarean, according to a 2009 study published in Obstetrics & Gynecology. (There are of course other reasons for C-sections, including mother preference, although such requests account for less than 10% of all surgeries, according to the study.) This despite the fact that the American Congress of Obstetricians and Gynecologists issued guidelines in 2010 acknowledging that VBAC is a safe and often preferable option for women. More, the federal Healthy People 2020 guidelines put forward by the US Department of Health and Human Services call for an increase in VBAC rates.

The director of Mama Sherpas, Brigid Maher, had her own VBAC delivery aided by GW’s midwifery practice—an experience which inspired the film. George Washington University Hospital’s VBAC success rate is 93%—basically reversing the situation in the rest of the country. That’s a stunning difference, and one which suggests that midwives can change the hospital birth experience drastically, if they’re given the chance.

In one incident in documentary, for example, a midwife tells a woman that the contractions she’s experiencing may be false labor. Unable to sleep and in terrible pain, the mother-to-be starts to cry at the thought that she may to have to continue her extremely uncomfortable pregnancy for a while longer. Many OBGYN’s might just induce labor at that point, but the midwife reassures her patient, reminding her that allowing the baby come naturally is the safest course, absent complications. Midwives emphasize the importance of patience, Kozhimannil explained, in a way that doctors, and OBGYNs, often do not.

Still, midwives won’t on their own reduce Cesarean rates in the US—in part because midwives have already been so thoroughly disempowered by a healthcare system that is much not interested in their help. As one of the midwives in Mama Sherpas acknowledges, there are many instances in which midwives in hospitals aren’t able to have much effect because doctors retain control of the birth process. Kozhimannil said that in many cases, even doctors can’t control the process. If the hospital says doctors must perform C-sections after four hours of contractions, the decision may be out of their hands.

One midwife in the film declares proudly that her job isn’t just to deliver babies; she’s also, “in the business of training doctors.” This is good news because doctors are the ones who have pull with medical establishments and institutions. Those institutions aren’t going to change, and Cesarean rates aren’t going to come down, until doctors begin to see pregnancy as a natural event rather than a surgical emergency.

Ideally, if enough doctors receive that training, we can finally start reducing Cesarean rates. Midwives, Mama Sherpas suggests, can help create a birth experience based in support rather than panic. “I needed someone who was with me,” Maher says in the film of her birth experience. “Having [the midwife] with me enabled and empowered me to have [my daughter] Josephine.” Midwives can help make the birth experience empowering—or, at the very least, can help reduce the chances that mothers will have to risk unnecessary abdominal surgery if they choose to have their child in a hospital.

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