OBJECTIVES: The effect of body mass index (BMI) was assessed on unplanned cesarean section (CS) rate and its indications among healthy, nulliparous women without other risk factors for CS. METHOD: A cross sectional study was performed on 1649 healthy, nulliparous women at term who were admitted in spontaneous labor and delivered at Boston Medical Center between Jan 1st 2008 and Dec 31st 2012. The demographics and outcomes were compared by using a logistic regression analyses. RESULT: There were no statistically significant differences in unplanned CS rates between the three BMI groups (19% in normal weight, 24% in overweight, and 21% in obese women, p=0.1). Compared with normal weight women the crude odds ratio for overweight women was 1.34 (95%CI 1.03-1.76) and for obese women 1.04 (95%CI 0.84-1.54). A multivariate logistic regression analysis was used to adjust for maternal age, birth weight, race and augmentation of labor. The adjusted ORs were 1.073 (95%CI 0.781-1.473) for obese and 1.291 (95%CI 0.978-1.705) for overweight women. Obese women had a higher rate of CS for non-reassuring fetal status (56%, p= 0.01) compared to overweight (46.5%) and normal weight women (37%). CONCLUSION: high maternal BMI per se does not appear to be an independent risk factor for unplanned CS in healthy nulliparous women presenting at term with a singleton pregnancy in spontaneous labor.

<p>Until 1976, women in Alabama could choose to make use of a midwife when they gave birth. In that year, the Alabama state legislature outlawed the practice. This dissertation explores the consequences of that decision as well as the efforts of contemporary non-nurse midwives, also known as Certified Professional Midwives (CPM’s), to re-establish the practice as an option available to birthing women in the state.</p><p> In order to address the consequences of outlawing non-nurse midwives in the state of Alabama a mixed methodology approach is applied. Two years of ethnographic data collection approached with a feminist and cultural anthropology lens, reveal that the lack of medical infrastructure within the state of Alabama prohibits the ability for CPM’s to practice safely. This is owed to historically grounded stigma in racism and classism. As a result, the current CPM community within the state of Alabama, along with their clientele, is predominantly white. This is reflected in the case studies within the dissertation as all the families and care providers, regardless of clinical expertise, are all white. An examination of cesarean rates via quantitative analysis supports the historical and ethnographic findings. Cesarean rates are highest within counties that have a low median household income, and a population that is predominately African American.</p><p> The dissertation features five case studies of women who gave birth attended by a CPM. By relating the experiences of the birthing mothers, a CPM, and certified medical professionals, the dissertation offers evidence of the kind of supplemental medical care and knowledge that can be offered by practitioners of midwifery. At the same time, while contemporary midwives such as the one featured here offer important medical service to their clients, they are not equipped to or knowledgeable about political work necessary to push for the re-legalization of midwifery. This dissertation thus sheds light on the challenges facing midwives who would prefer to work openly and legally in the state.</p><p> Ultimately what is revealed is the value of supplementary healthcare networks within the state. While care and birth services provided by CPM’s is not readily accessible to all, those giving birth in Alabama can find support within the current system through supplementary healthcare networks. These networks include doulas, lactation support groups, babywearing groups, etc. It is a piecemeal system to be sure, but it is a piecemeal system that is working diligently to unlearn biases, and support women and birthing families. However, it is important to understand that the supplemental networks cannot fully address the larger structural crisis that is a lack of infrastructure within the state’s medical system. Ideally, a system that utilizes Obstetricians, Nurse Midwives, and Non-nurse Midwives, all with mutual respect for their own expertise, would exist to provide quality care to women throughout the state.</p>