HOW WOMEN DELIVER: NEW GUIDELINES
TRANSFORMING STANDARDS TO SAFELY PREVENT THE
FIRST CESAREAN DELIVERY
INTRODUCTION
New maternity care guidelines issued by The American College of Obstetricians and Gynecologists
(ACOG) and the Society for Maternal-Fetal Medicine (SMFM) in February of 2014 have the potential to
dramatically improve the quality and experience of maternity care.1 The joint consensus statement on
the “Safe Prevention of the Primary Cesarean,” takes a significant step towards reducing unnecessary
cesarean surgeries by supporting maternity care practices that better reflect the most up-to-date
medical evidence.
Choices in Childbirth (CiC) is a non-profit consumer advocacy group focused on promoting safe, healthy,
respectful, and deeply satisfying maternity care in New York City. Over the past ten years, our policy and
advocacy work has been directed towards advancing the implementation of childbirth care practices
that will improve health outcomes and the experience of care for women and their babies. These new
evidence-based guidelines will support doctors and midwives in offering the highest quality maternity
care. Over the long term, these new guidelines can contribute to efforts to reduce the high rates of
severe complications and maternal deaths in New York City. CiC endorses the recommendations set
forth by ACOG and SMFM to standardize and put into practice the evidence-based care measures that
can safely prevent a woman’s first cesarean.
This policy brief will provide an overview of these landmark recommendations, address their potential
impact in New York City, and make policy recommendations to ensure that the promise of the
consensus statement is transformed into a reality for the women of this city.
BACKGROUND
Cesareans can be life-saving when needed, but like all major surgery, they carry serious risks. When
cesareans are used in situations where they have not been found to offer health benefits, women are
needlessly exposed to potential harm. Overuse of cesarean delivery is associated with increased risks of
serious, even life-threatening short- and long-term complications. The risks for women include cardiac
arrest, hysterectomy, hemorrhage, blood clots, major infection, longer hospital stays, hospital
readmission and death.2 Babies face an increased chance of respiratory distress syndrome, death, and
long-term chronic problems including asthma, diabetes, allergies, and obesity.3 Risks are magnified in
subsequent pregnancies, with each repeat cesarean increasing potentially life-threatening maternal
complications such as abnormalities of the placenta, hysterectomy, infertility and uterine rupture.4
One in three babies is now born surgically, and cesareans rank as the most common operating room
procedure in the United States.5 Over the last two decades, the rate of cesarean births in the United
States has skyrocketed by approximately 60% from 20.7% in 1996 to a record high of 32.9% in 2009.
Beyond 2009, the cesarean rate decreased slightly to 32.8% and has remained stable from 2010 through
2012.6 While Choices in Childbirth is encouraged by the interruption of this steep upward trend, the
current rate is still well beyond the World Health Organization recommended rate of between 5 and 15
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percent. In fact, research suggests that when rates exceed 15 percent, the harms of unnecessary
cesareans may outweigh the benefits, resulting in needless complications and deaths.7
New York State’s cesarean rate of 34.3% hovers even higher than the national average,8 while New York
City’s rate is slightly lower at 32.7%.9 A comparison between states with cesarean rates above the
national average and those with rates below the national average shows a 21% greater risk of maternal
mortality among the high cesarean rate states.10 Of New York City women who died of pregnancyrelated causes, nearly 8 in 10 gave birth by cesarean.11 While this number is not risk-adjusted to reflect
whether these women had additional complicating factors, the magnitude of the discrepancy is cause
for concern and requires further investigation.
Approximately 60% of all cesareans are primary (or first) cesareans.12 New York City and New York State
both have relatively high primary cesarean rates, exceeding those of two thirds of the 37 other states
reporting this data.13 Both New York State and New York City have reported reductions in their primary
cesarean rate, but more work needs to be done to further lower these numbers.
Maternity care providers, hospitals, and birth centers can use the “Safe Prevention of the Primary
Cesarean” guidelines as a tool to ensure that all women have access to high quality care. Creating an
evidence-based standard of care can help reduce the striking variation in cesarean rates across states,
facilities and even individual providers. For instance, of the two hospitals serving similar client
populations in Staten Island, one hospital has a cesarean rate of 40.5% and the other 23.1%, among the
highest and lowest in the city respectively.14 Research suggests that the dramatic variation in rates
among otherwise comparable facilities is driven by factors other than medical necessity or health risk
factors, such as hospital practices and the provider’s preferred practice style and beliefs.15 These new
recommendations for best practices can help reduce this unwarranted variation.
IMPROVING THE VALUE OF CHILDBIRTH CARE
Reducing primary cesarean rates can improve the value of maternity care by simultaneously improving
health outcomes and reducing health care expenditures. The total cost of a cesarean compared with a
vaginal birth is, on average, 50 percent higher for both commercial insurance and Medicaid. Medicaid
costs for cesarean delivery in New York State are nearly $6300 greater than for vaginal births.16 Because
Medicaid covers nearly half of all births in New York State, and nearly 6 in 10 births in New York City,17
even a modest reduction in the number of cesarean births can result in significant health care cost
savings, while reducing unnecessary complications and deaths.
NEW GUIDELINES FOR THE PREVENTION OF PRIMARY CESAREAN DELIVERY
The ACOG/SMFM guidelines on “Safe Prevention of the Primary Cesarean Delivery” recommends steps
that maternity care providers and facilities can take to safely avoid unnecessary cesareans. The
recommendations include allowing women to labor longer before considering a cesarean, ensuring that
obstetric providers are trained in alternative delivery techniques, and standardizing interpretations of
common indicators for cesarean to ensure a uniform, evidence-based approach to care.
The new ACOG guidelines advise that in many circumstances, the current rationales behind
recommending cesareans are not supported by the most up-to-date medical evidence. The most
common reasons for the rising numbers of first cesareans include arrest of labor, fetal heart rate
patterns that may indicate distress, a breech position of the baby, twins and a suspected large baby, and
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each of these areas are addressed by the consensus statement.18 For instance, the guidelines support
increasing the amount of time allowed for early and active labor before suggesting a cesarean, and
limiting cesareans for “large” babies to cases where the baby is suspected to be over 11 lbs. ACOG
additionally recommends consistent training in alternative approaches that can avoid cesareans such as
the use of forceps or vacuum assistance during delivery, training in version (turning the baby) for breech
presentation and training to deliver twins vaginally. The report also highlights the benefits of continuous
labor and delivery support (doula support) as an evidence-based intervention to reduce first cesarean
rates. A brief synopsis of the new recommendations can be found below.
LONGER LABORS
As a consumer advocacy organization, Choices in Childbirth has heard repeatedly from parents,
providers, childbirth educators, and doulas that some women feel pressure from their provider or other
hospital staff to agree to a cesarean section, solely because their labor has gone on for “too long.” The
new guidelines explain why women should be given more time for their labor to progress, before a
cesarean is recommended.
Early, or “first stage,” labor that is slow but progressing is not an indication for cesarean.
 New data show that early or “first stage” labor progresses more slowly than previously
believed.19 Based on new data finding that longer labors can still be considered “normal” and
safe, first stage labor that is slow but showing signs of progress should not be considered an
indication for cesarean delivery.

Active labor should be considered to begin when a woman’s cervix has dilated to 6 cm, rather
than 4 cm, the benchmark that was previously used. During “active” labor (when the cervix
begins to dilate more rapidly), a cesarean is only indicated when women are at or beyond 6 cm
dilation with ruptured membranes and have not progressed after four hours of contractions or
six hours of oxytocin administration.
Allow for longer second stage labors
 There is no time limit for the pushing phase of labor. If mother and baby are doing well, at least
3 hours of pushing during first births, and 2 hours during second or subsequent births, should be
considered normal. The use of an epidural adds an hour to the suggested timeframes.
Induction of labor
 Before 41 weeks, labor induction is not recommended without a medical reason.
 Before inducing labor, if a woman’s cervix is not softening and becoming ready to open,
medication or devices for cervical ripening should be used to help prepare it for labor.
 Cesareans for failed inductions can be avoided by allowing for longer labors (allowing up to 24
hours to reach 6 cm dilation), and administering oxytocin for a longer period of time (12-18
hours) with ruptured membranes, before determining that a cesarean is needed.
RECOGNIZING AND MANAGING COMMON INDICATORS FOR CESAREAN
A cesarean can improve outcomes for women and babies when targeted to address a specific condition
or set of circumstances. Health care providers and facilities offer the best care when they have clear
guidelines to help them determine which situations call for medical intervention, and when intervention
is expected to increase the risks without offering any benefit.
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Variations in heart rate are not always dangerous
 Abnormal or indeterminate heart rate patterns are the second most common indication for first
cesareans. It is important that providers take measures to eliminate or resolve elements of
concern before recommending cesarean delivery. For example, the baby’s heart rate may
improve if the mother changes position or if the provider stimulates the baby’s scalp.
A suspected large baby is rarely an indication for cesarean
 Cesarean is frequently recommended to avoid potential birth trauma to a baby suspected to be
of greater than average weight. The guidelines report that first cesareans to avoid birth trauma
are only indicated when the baby weighs at least 5,000 grams (11.0 pounds) or 4,500 grams (9.9
pounds) for women with diabetes.20 Only one-tenth of one percent of babies weigh more than
5,000 grams at birth, suggesting that only very rarely should a cesarean be performed because
the baby is too large.21
Excessive weight gain during pregnancy can increase the risk of first cesarean
 ACOG recommends consistent discussion about healthy weight gain during pregnancy as a way
to reduce primary cesarean risk.22
TRAINING IN SKILLS THAT WILL REDUCE THE USE OF CESAREANS
Currently, many women and families find that certain options to avoid cesareans are not widely
available in New York City. Some women have indicated to CiC that they have had difficulty finding a
provider willing to attempt to turn a breech baby, to deliver twins vaginally, or to attempt a vaginal birth
after cesarean (VBAC). Training in these and other skills, and hospital policies that support these
alternatives to cesarean, can help to reduce cesareans when they are not medically indicated.
Instrument assisted birth can be a safe alternative to cesarean
 Use of forceps or vacuum assistance to facilitate vaginal birth is recommended as a safe
alternative to cesarean. In contrast to the steadily increasing national cesarean rate, instrument
assisted delivery rates continue to decline each year.23 ACOG recommends expanding training in
instrument deliveries to decrease the number of cesareans performed.
Risk of cesarean for breech presentation may be reduced by turning the baby
 Cesarean is often recommended to reduce the risk of harm to the baby when it is in breech
position. The new guidelines recommend attempting to turn the baby before labor begins to
increase the likelihood of a vaginal birth.24
Twin delivery requires training
 Three quarters of all twin deliveries occur via cesarean,25 but when the first twin is head-down,
cesareans do not improve health outcomes. Before advising a cesarean, ACOG recommends that
practitioners counsel women carrying twins to first attempt vaginal delivery when at least one
twin is in a head-down position.
THE WAY FORWARD
DISSEMINATION, PROTOCOL DEVELOPMENT AND EVALUATION
These guidelines create an opportunity for hospitals to review current practices, compare current
practices with recommended best practices, and develop strategies to align practices with the evidence-
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based care presented by the guidelines. Hospitals can engage existing task forces or committees
charged with ensuring quality of care or they may wish to take advantage of this opportunity to
establish such a task force or committee. Leadership from within maternity care facilities can review
hospital communication and decision-making processes to ensure that effective systems are in place.
The first step childbirth facilities can take towards implementing the new ACOG/SMFM guidelines is to
familiarize providers with their recommendations. Facilities can develop or adapt existing toolkits,
materials, and training programs to engage providers and help them adapt the guidelines to the context
of their practice. Facilities should prioritize the development of standardized protocols and policies
related to cesarean delivery to support physicians and midwives in offering care grounded in the best
medical evidence. Data should be collected to determine the most common factors motivating or
leading to preventable first cesareans in a particular setting. This will allow each facility to develop
effective strategies, targeting the most relevant factors. Developing plans to implement these
recommendations will ensure more consistent care, by giving providers the tools they need to make
care practices more effective.
Following training in evidence-based practices, facilities should develop plans for evaluation to ensure
that positive changes become established as the standard of care. Identifying clear benchmarks for
success and collecting data around changes in practice will highlight areas that demonstrate
improvement or need additional attention.
The abundance of teaching hospitals in New York City makes this a critical environment for educating
new and future physicians, midwives, and nurses about best-practice care, including the practices
addressed in these recommendations. Educational institutions have a unique opportunity – and a
special responsibility – to train the next generation of providers in the most up-to-date, evidence-based
care, setting the standard that new clinicians will carry with them into practices across the country.
PROVIDING SPECIALIZED TRAINING OPPORTUNITIES
Childbirth facilities should facilitate and incentivize ongoing training and skills maintenance drills that
will improve the quality of obstetric care and decrease the rate of primary cesareans. For instance,
forceps and vacuum delivery can be a safe and less invasive alternative to cesarean, but some providers
have reported not feeling technically competent to perform these types of deliveries.26 Likewise, twins
are increasingly delivered by cesarean, even in circumstances where evidence suggests that a vaginal
birth is a safe option (where one or both twins are head down).27 Expanded training in how to
successfully turn a breech baby (external cephalic version) can also contribute to greater success rates.
Training and updating of skills in instrument assisted delivery, version, and vaginal delivery of twins can
take place at medical school and in residency, as well as in continuing education for practicing health
care clinicians. Grand rounds can serve as a useful platform to engage practitioners in ongoing education
to enhance their skills. Outside experts – such as physicians with experience in particular skills or quality
improvement efforts, or midwives with clinical experience achieving low cesarean rates – can be invited
in to offer practical training based on their experience and insight.
PATIENT EDUCATION AND ADVOCACY
In order to ensure that patients can make informed and educated decisions about their care, it is
important for providers to discuss common indicators for cesareans as well as their risks and benefits,
before labor begins. Birth plans outline the mother’s preferences for how she would like her labor and
birth to proceed, and are an excellent tool to encourage discussion between women and their maternity
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care providers. Preventative measures that may decrease the likelihood of a cesarean can be included in
birth plans. When multiple providers are involved in the labor and delivery process, a birth plan can
become even more important in communicating the woman’s wishes regarding procedures that may
not be necessary unless complications develop.
CiC has developed a consumer resource on preventing the first cesarean, which it will disseminate citywide. This tool will help educate expectant parents about recommended best practices, and women
and families can use this tool to generate and guide discussion with their maternity care providers.
Efforts to improve the quality of care, patient satisfaction measures, and the experience of care will be
most effective when informed and guided by feedback from women who have given birth at the specific
facility. Childbirth facilities should seek input from the women and families they serve by creating
patient feedback mechanisms and by establishing patient advisory committees to ensure that their
feedback is actually incorporated to inform policies and practices. Feedback from women who have
given birth can help inform strategies to safely reduce cesareans and ensure that they are successful in
addressing the concerns of the facility’s population.
CONTINUOUS LABOR SUPPORT TO DECREASE CESAREAN RATES
The ACOG/SMFM statement recommends doula support as an essential strategy to reduce cesareans.
According to the guidelines, data indicate that continuous labor support is “one of the most effective
tools to improve labor and delivery outcomes,” but find that it is underutilized.28 The presence of a
dedicated support person, such as a doula, who is trained to provide continuous physical, emotional and
informational support can maximize the likelihood of a healthy and satisfying birth. Doula support has
been found to reduce cesarean rates by an average of 28%, as well as leading to shorter labors,
decreased need for epidural and improved patient satisfaction.29 Doula care can be particularly
beneficial for women from low-income and medically underserved communities and can help reduce
health disparities by ensuring that women who face the greatest risks have the added support they need
to improve their health outcomes.
Hospitals can facilitate access to doula support by developing their own hospital-based doula programs,
by establishing volunteer doula programs, or by partnering with existing doula groups. Hospital-based
programs have the advantage of making doula care available to women who are already in labor, and
decide at that time that they would benefit from the additional support that a doula would offer.
Childbirth facilities are well-situated to facilitate education about doula services and the benefits of
doula care for both expectant parents and their own staff. Hospitals and birth centers can host
continuing education programs where nurses and physicians can discuss the evidence-based benefits of
doula care and learn strategies for collaborating effectively with doulas to enhance women’s health
outcomes and experience of care. Some facilities host “Meet the Doula” events where prospective
parents can learn about what doulas do and the benefits of doula services, and can ask questions about
birth doula services.
Hospital policies that limit the number of people able to be present in the room should not count doulas
toward the limit, to ensure that women do not need to choose between having a doula or a family
member with them during their birth. Hospitals can also take steps to improve the effectiveness of
doula care by ensuring that during labor women have the option of getting out of bed, walking, and
changing positions as they wish, and by providing simple and inexpensive tools such as birth balls that
can assist doulas in providing comfort techniques.
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INTEGRATION OF THE MIDWIFERY MODEL OF CARE
While the ACOG/SMFM recommendations do not address the subject of midwifery care, expanding
access to the midwifery model of care in hospitals and birth centers is another key strategy to reduce
first cesareans. Research has demonstrated that women cared for by midwives have significantly lower
cesarean rates than women cared for by physicians.30 A midwifery model focuses on pregnancy and
childbirth as a normal and healthy event, and prioritizes protecting, supporting, and enhancing the
normal physiologic processes of labor and childbirth. Many of the recommendations made by ACOG and
SMFM include practices commonly employed or recommended as part of the midwifery model of care,
including supporting longer labors, version for breech presentation, and continuous support during
labor and birth.
Midwifery emphasizes an evidence-based model of care and aims to limit medical interventions to
situations where the medical evidence suggests they are likely to be beneficial. This model has been
associated with significantly lower cesarean rates, as well as decreased rates of other medical
interventions such as the use of continuous fetal heart rate monitoring, the use of medication to initiate
or speed labor, and the use of epidural anesthesia.31 Women who give birth with midwives also report a
high degree of satisfaction with the childbirth experience.32
In order to increase the availability of midwifery care, hospitals should actively take steps to increase the
number of midwives with admitting privileges and existing hospital-based midwifery practices should be
strengthened. Midwives working in birth centers have also demonstrated good health outcomes, while
keeping cesarean rates at an average of 6% - a fraction of the national rate of 27% for comparably low
risk women.33 Establishing and expanding free-standing and in-hospital birth centers has the potential to
significantly reduce cesarean rates.
Facilitating collaboration between an interdisciplinary maternity care team of midwives, physicians,
nurses, and doulas would further integrate woman-centered, comprehensive models of care, and would
result in improved maternal and neonatal health outcomes.
CONCLUSION
The “Safe Prevention of the Primary Cesarean” guidelines create a rare opportunity for all those
involved in maternity care and policy to step back and review the status quo. Evidence demonstrates
that it is possible to safely reduce the number of cesarean deliveries and enhance maternal health in
New York City. Based on a shared interest in improving health outcomes and the experience of care for
women and babies, Choices in Childbirth is joining together with health care providers, hospitals,
consumers, community-based organizations, and policy-makers to ensure that these recommendations
are put into practice. While the guidelines and recommendations suggest a path forward, change will
not come easily. In order to make good on the promise of this statement, policy-makers, health care
professionals, and members of the public will need to ensure that practices actually change, so that all
women in New York City can experience a safe, healthy and respectful birth.
1
Safe prevention of the primary cesarean delivery. Obstetric Care Consensus No. 1. American College of Obstetricians and Gynecologists.
Obstet Gynecol 2014;123:693–711. Available at
http://www.acog.org/Resources_And_Publications/Obstetric_Care_Consensus_Series/Safe_Prevention_of_the_Primary_Cesarean_Delivery
2 Sakala C, Corry M. Evidence-based maternity care: What it is and what it can achieve. (2008). Vaginal or Cesarean Birth: What is at Stake for
Women and Babies? A Best Evidence Review. (2012). Liu S, Liston RM, et al. Maternal mortality and severe morbidity associated with low-risk
planned cesarean delivery versus planned vaginal delivery at term. Canadian Medical Association Journal. 2007; 176.4: 455-460.
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3
Sakala C, Corry M. Evidence-based maternity care: What it is and what it can achieve. (2008).
Silver RM, Landon MB, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstetrics & Gynecology. 2006; 107.6:
1226-1232. Sakala C, Corry M. Evidence-based maternity care: What it is and what it can achieve. (2008). Getahun D, Oyelese HM, et al.
Previous cesarean delivery and risks of placenta previa and placental abruption. Obstetrics & Gynecology. 2006; 107.4: 771-778.
5
Osterman MJK, Martin JA. Primary cesarean delivery rates, by state: Results from the revised birth certificate, 2006-2012. Available at:
http://www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_01.pdf. Pfuntner A, Wier LM, Stocks C. Most Frequent Procedures Performed in U.S.
Hospitals, 2011. HCUP Statistical Brief #165. October 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcupus.ahrq.gov/reports/statbriefs/sb165.pdf.
6
Osterman MJK, Martin JA. Primary cesarean delivery rates, by state.
7 World Health Organization. Appropriate technology for birth. Lancet 1985; 2: 436-7; Gibbons L, Belizan J, et al. The global numbers and costs
of additionally needed and unnecessary caesarean sections performed per year: overuse as a barrier to universal coverage. World Health
Report (2010): 3-8.
8 Martin JA, Hamilton BE, et al. Births: Final data for 2012. National vital statistics reports; vol 62 no 9. Hyattsville, MD: National Center for
Health Statistics. 2013, Supplemental Table, I-7.
9 Zimmerman R, Li W, et al. Summary of Vital Statistics, 2012: Pregnancy Outcomes. New York, NY: New York City Department of Health and
Mental Hygiene, Office of Vital Statistics, 2013.
10 Singh GK. ,Maternal mortality in the United States, 1935–2007: substantial racial/ethnic, socioeconomic, and geographic disparities persist. A
75th anniversary publication, 2010, Health Resources and Services Administration, Maternal and Child Health Bureau, U.S. Department of
Health and Human Services: Rockville, MD. Available at www.hrsa.gov/ourstories/mchb75th/mchb75maternalmortality.pdf.
11 NYC Maternal Mortality Review Project Team. Pregnancy-Associated Mortality: NYC, 2001-2005. Table C-5.
12
Osterman MJK, Martin JA. Primary cesarean delivery rates, by state.
13 Primary cesarean rates are available for 38 states and New York City, based on data from states using the 2003 revision of the U.S. Standard
Certificate of Live Birth. Osterman MJK, Martin JA. Primary cesarean delivery rates, by state: Results from the revised birth certificate, 20062012. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_01.pdf
14
New York State Department of Health. New York State Hospital Profile: Richmond University Medical Center. Maternity Information, 2011.
Available at: http://hospitals.nyhealth.gov/browse_view.php?id=232&p=svc&subpage=maternity. New York State Department of Health. New
York State Hospital Profile: Staten Island University Hospital North. Maternity Information, 2011. Available at:
http://hospitals.nyhealth.gov/browse_view.php?id=233&p=svc&subpage=maternity
15 Kozhimannil KB, Law MR, Virnig BA. Cesarean delivery rates vary tenfold among US hospitals; reducing variation may address quality and cost
issues." Health Affairs 32.3 (2013): 527-535. Cáceres IA, Arcaya M, Declercq E, et al. (2013) Hospital Differences in Cesarean Deliveries; Baicker
K., Buckles KS, et al. Geographic variation in the appropriate use of cesarean delivery. Health Affairs (Project Hope), 2006: 25(5): w355-67.
16
Data Source: U.S. Agency for Healthcare Research and Quality, HCUPnet, Healthcare Cost and Utilization Project. Rockville, MD: AHRQ.
Available at: http://hcupnet.ahrq.gov/
17
Bureau of Vital Statistics data compiled by Bureau of Maternal, Infant, and Reproductive Health, New York City Department of Health and
Mental Hygiene, August 2011, available at: http://www.nyc.gov/html/doh/downloads/pdf/ms/bimt-medicaid-coverage.pdf
18 Barber EL, Lundsberg LS, et al. Indications contributing to the increasing cesarean delivery rate. Obstetrics & Gynecology. 2011; 118.1: 29-38.
19
Zhang J, Landy HJ, et al. Contemporary patterns of spontaneous labor with normal neonatal outcomes. Obstetrics & Gynecology. 2010; 116.6:
1281.
20 American College of Obstetrics & Gynecologists. Fetal Macrosomia. ACOG Practice Bulletin 22. Washington, DC: ACOG; 2000.
21 Martin JA, Hamilton BE, et al. Births: Final data for 2012.
22
Weight gain during pregnancy. Committee Opinion No. 548. American College of Obstetricians and Gynecologists. Obstetrics & Gynecology
2013; 121:210-2.
23 Werner EF, Janovic TM, et al. Mode of delivery in nulliparous women and neonatal intracranial injury. Obstetrics & Gynecology. 2011; 118.6:
1239.
24 Clock C, Kurtzman J, et al. Cesarean risk after successful external cephalic version: a matched, retrospective analysis. Journal of Perinatology.
2009; 29.2: 96-100.
25 Lee HC, Gould JB, et al. Trends in Cesarean Delivery for Twin Births in the United States: 1995 to 2008. Obstetrics & Gynecology. 2011; 118.5:
1095.
26 Powell, J, Gilo n, et al. Vacuum and forceps training in residency: experience and self-reported competency. Journal of perinatology . 2007;
27.6: 343-346.
27 Lee HC, Gould JB, et al. Trends in Cesarean Delivery for Twin Births in the United States: 1995 to 2008.
28 Safe prevention of the primary cesarean delivery. Obstetric Care Consensus No. 1. American College of Obstetricians and Gynecologists.
29 Hodnett ED, Gates S, et al. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews. 2013; Issue 7: Art.
No.: CD003766.
30
Newhouse RP, Stanik-Hutt J, et al. Advanced practice nursing outcomes 1990- 2008: a systematic review. Nurs Econ. 2011;29(5):1-22.
31 Janssen PA, Saxell L, et al. Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician.
Canadian Medical Association Journal. 2009; 181.6-7: 377-383. Hatem M, Sandall J, et al. Midwife-led versus other models of care for
childbearing women (Review). Database of Systematic Reviews 4 (2008).
32 Johnson KC, Daviss BA. Outcomes of planned home births with certified professional midwives: large prospective study in North America.
Bmj. 2005; 330.7505: 1416. Powell-Kennedy HP. A model of exemplary midwifery practice: A Delphi study. J Midwifery Womens Health. 2000;
45(1):4-19.
33 Stapleton SR, Osborne C, et al. Outcomes of care in birth centers: Demonstration of a durable model. Journal of Midwifery and Women's
Health. 2013. Available at: http://onlinelibrary.wiley.com/doi/10.1111/jmwh.12003/full.
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