Deadly Delivery

Someone recommended that I read the Deadly Delivery report on maternal mortality by Amnesty International. It really was eye opening. Their key recommendations include:

• Health care providers should ensure that sufficient, accessible information is available to all women so that they can make informed decisions about their health care.
  

• The US Congress should direct and fund the Department of Health and Human Services to establish an Office of Maternal Health with a mandate to improve maternal health care and outcomes, and eliminate disparities.

• State and federal authorities should devise and implement programs to improve data collection and analysis in order to better identify and develop responses to issues contributing to maternal deaths and complications. This may include requiring all states to report maternal deaths and morbidity to federal agencies, including the CDC, on an annual basis and standardizing data collection tools.

The stories are so touching and the “care” so appalling.

Don’t forget the blog carnival!

With all this talk of VBAC and NIH, I didn’t want you to forget about the Women’s History blog carnival. Perhaps you found someone to write about who has inspired you, maybe even someone you met at NIH? Your childbirth class? Your birth? Submissions are due by 3/20.

VBAC from a Care Provider’s Perspective

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What is it really like to be a hospital care provider attending VBACs? Janelle from Birth Sense describes it in this post submitted to the ICAN VBAC Blog Carnival.

The whole post provides a very rational, no nonsense description of the actual problems that care providers face without an emotional “WE’RE ALL GOING TO BE SUED AND EVERYONE IS GOING TO DIE AND YOU JUST DON’T UNDERSTAND RISK!” She calls upon providers of modern obstetrics to “speak up on behalf of women who want VBAC and insist that realistic, evidence-based guidelines are instituted.”

Furthermore, Janelle points out something that would probably shock the public about hospitals. The “special” mandate that an OB remain in the hospital during the entire VBAC labor with an operating team standing by is hypocritical. If hospitals are so serious about having a team ready to handle VBAC-related emergencies, why would they not want to have the same safety net available to deal with comparable emergency scenarios in “low-risk” women? When I gave birth in a hospital for the first time, I mistakenly assumed that there was an OB and an operating team on hand for those rare emergencies. Why else would I have been in a hospital?

What is most perplexing to me is the mandate that the provider remain in the hospital during a VBAC labor “just in case”, yet other serious causes of perinatal morbidity and mortality are not considered adequate reason to have a surgeon and operating team standing by.  Some examples are:

1. Cord prolapse, with an incidence of 0.14-0.62 percent.  This can cause permanent fetal injury or death.¹
2. Placental abruption, with an incidence of 0.6 percent.  Again, this complication of labor can cause permanent fetal injury or death, as well as potentially life-threatening blood loss for the mother.²
3. Placenta accreta, and its variations (placenta increta and placenta percreta).  With a reported incidence of as many as 1 in 533 births, this is a serious maternal complication which can cause death.³

If we are serious about being able to take immediate action in the event of uterine rupture (approximately 0.5% incidence in low-risk labors VBAC labors), we should be equally serious about being prepared to immediately manage other perinatal emergencies.   The truth is, VBAC is not much riskier than a normal first birth, provided a few criteria are met:

• One low transverse uterine scar
• Normal onset of labor, no cervical ripening or induction
• No use of pitocin augmentation during labor
• Prior vaginal delivery increases chances of successful VBAC
• At least 18 months since cesarean birth

The risk associated with VBAC that concerns hospitals, insurance companies and care providers isn’t just the potential risk to women and babies. They are naturally concerned about the risk to their financial bottom line associated with a potentially predictable obstetric emergency.

The next time you hear anyone try to tell you that patients or laypeople just don’t understand risk, the question should be “The risk to whom?” I would argue that, given accurate information and percentages, most patients understand risk just fine. When you read between the lines, it’s clear that patients are expected to believe that the risk that lies behind scare tactics and lies about necessity of many cesareans and inductions is based on a certain risk to them or their baby. Unfortunately, it often has little or nothing to do with risk to the patient and everything risk to the care provider or institution.

And that’s the risk that most patients do not understand about how decisions are made about their bodies until it’s too late.

Famous Women - Blog Carnival

It’s Women’s History Month and I  know that there are several women who I enjoy learning about because of how they changed the world for me.  My early days were consumed with the fascination of Elizabeth Blackwell, MD, reportedly the first women doctor.  From there I branched out to so many amazing women…  Though I know I’ve just scratched the surface of the really neat women who have changed my life without every knowing me or even being alive during my lifetime.

When we look at how pregnancy and childbirth have changed through the years, there is a long line up of women who have advocated and outright fought to help women.  I’d like to announce that Birth Activist is hosting a blog carnival about women in history who have changed pregnancy and birth.  Who is your heroine?  Who amazes you?

The rules are simple:

• Write a post featuring your heroine from pregnancy and childbirth history. (Your amazing woman does not have to be deceased to be included!)
• Send us a link to your post at birthactivist@gmail.com by March 20
• The blog carnival will run on March 25, 2010

Need some inspiration?  Leave a comment and we’ll share with you some women who will knock your socks off!

Join the National Institutes of Health’s Consensus Development Conference on Vaginal Birth After Cesarean Delivery: New Insights

March 8–10, 2010

Natcher Conference Center | NIH Campus| Bethesda, Maryland

For most of the 20th century, clinicians believed that once a woman had undergone a cesarean, all of her future pregnancies required delivery by that procedure as well. In the 1980s, vaginal birth after cesarean (VBAC) also began to be considered a viable option for these women. Since 1996, however, VBAC rates in the United States have consistently declined, while cesarean delivery rates have been steadily rising.

What accounts for these changing practice patterns? Frequently cited concerns about VBAC include the possibility of uterine rupture during labor, infection, and other complications. However, repeat cesarean delivery carries risks for both mother and baby, and may impact future pregnancies.

An improved understanding of the clinical risks and benefits of both procedures, and how these risks interact with legal, ethical, and economic forces to shape provider and patient choices about VBAC, may have important implications for health services planning.

Be part of a pivotal discussion that will explore these issues. On March 8–10, 2010, in Bethesda, Maryland, the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Office of Medical Applications of Research of the National Institutes of Health will convene a Consensus Development Conference on Vaginal Birth After Cesarean.

After weighing the scientific evidence from a systematic literature review, expert presentations, and audience input, an unbiased, independent panel will prepare and present a consensus statement of its collective assessment addressing six key conference questions.

The conference is free and open to the public. Your input is valuable. Please join us!

Information and Registration

consensus.nih.gov | 1-888-644-2667 | consensus@mail.nih.gov

Can’t attend?

Webcast registration consensus.nih.gov/vbacvideocast.htm

Pre-order statement consensus.nih.gov/vbacstmt.htm

Continuing Education for this activity is pending. Please see the final announcement for details.

Take Responsibility

Liberal news magazine The Nation ran an article on “Ten Things You Can Do to Improve Your Healthcare” by Donna Brook, poet and associate editor of Hanging Loose Press.  Her “ten items focus on prevention, the key to saving money and minimizing suffering.”  I give Brooks kudos for encouraging all to take measures to improve our individual health — not the least of which includes our maternity care, not opting for elective c-sections or choosing a provider known to have a high c-section rate.  Number 5 on the list:

“If you are pregnant or looking for an obstetrician, keep in mind that the US rate of C-sections is more than double what the World Health Organization considers acceptable. You should not have this major surgery–with all its risks–simply for the sake of convenience. Read more at thebirthsurvey.com.”

As universal as maternity care is, more people need to know and hear about responsibly choosing a care provider and seeking transparency.  What are you doing to help spread the word?

Angie’s List Induction-Turned-Cesarean Commercial

Screen cap of laboring woman being rushed to surgery

Transcript of an actual Angie’s List review:

At my 41 week appointment, my OB decided to induce me, but I guess I took longer than he expected because just as I went into hard labor, he told me he was leaving for an important meeting. On his way out, he said goodbye, dressed in his tennis clothes. One hour later, I was getting a c-section… while he was out practicing his serve.

Congenital Heart Defect Awareness Week

Starting on February 7th, and going through till February 14th, we will be celebrating Congenital Heart Defect Awareness week. I was first touched by this subject on Twitter when I met a mother who had lost her daughter, Cora, to an undetected congenital heart defect shortly after she was born. Since that time, Kristine Brite, the mother of baby Cora has become an internet advocacy all star making strides to help others know about the issue and prevent other mothers from going through what she had to endure.

According to Congenitalheartdefectfact.com an estimated 10,830 babies are born a day, and 411 of them are born with a congenital heart defect, making it the most common birth defect according to the March of Dimes.

“In the US alone, over 25,000 babies are born each year with a congenital heart defect. That translates to 1 out of every 115 to 150 births. (To put those numbers into perspective, only 1 in every 800 to 1,000 babies is born with Downs Syndrome.)”

Knowing this information, and learning about Cora’s Story has made me realize that in the United States this is an issue we need to work on tackling, and work on testing, and mandatory pulse oximetry testing in newborns, which Kristine Brite is currently working towards, even only two short months after the loss of her baby girl.

On Sunday February 7th, 2010, at 3:00pm EST, to help kick off Congenital Heart Defect Awareness Week, Kristine Brite will be joining myself for the Momotics Radio show to help kick off CHD awareness week with Cora’s Story.

Please join us and help spread the word on Cora’s Story.

Loves Letters

It’s February and our minds turn to love. Everything seems to be hearts and flowers no matter where you go. So I’m going to take a minute here to spend some time sharing the love, naming thank you notes.

I actually do call these loves letters when I talk about them in my childbirth classes or to my doula clients. You write love letters to people who went out of their way to help you during your birth. (There is a flip side to this and while those letters are equally important, we’re going to save that for another day.)

Thank you notes should be personal. Share how their actions helped you specifically, but quickly, no need to be wordy. If you can do it hand written, that is always a nice thing to do. But sometimes, that’s hard or you don’t feel like your handwriting is legible. Consider enclosing a photo of you together with this person if applicable. (More tips on writing thank you notes.)

If you gave birth in a hospital and you are writing to someone from that institution be sure to consider the following:

• Include as much identifying information as you can about the recipient. It may have been difficult to get a last name during labor or you’ve forgotten it. But addressing it to Eve, BSN on 3-11 p.m. 12/8/09 will get to the right person.
• Copy that person’s supervisor. This can mean a difference come raise time or even promotion wise.

Some families want to do gifts. While this can be appropriate consider your recipient. Many nurses say that while they love the trays of cookies or flowers, the thank you note would help them more with their bosses.

Midwives, doulas, childbirth educators and lactation consultants may have varied needs for recognition with a boss. That will depend on a variety of factors. But if you want to do a gift in addition to your letter, consider donations to favorite charities, a scholarship fund for their profession, or a local fund set up to help cover childbirth class or doula fees, breast pump rentals and the like.

Show us your examples of loves letters you’re written or received as it pertains to birth in the comments!

Restriction of Food and Drink in Labor from a Medical Anthropologist’s Perspective

The recent Cochrane review, Restricting oral fluid and food intake during labour, analyzed five studies and concluded that women should be free to eat and drink in labor at will.

Since the evidence shows no benefits or harms, there is no justification for the restriction of fluids and food in labour for women at low risk of complications. No studies looked specifically at women at increased risk of complications, hence there is no evidence to support restrictions in this group of women.

The rationale behind denying laboring women food is that the danger of aspiration and the potentially lethal complication known as Mendelsohn’s syndrome while under general anesthesia is greatly reduced.

Medical anthropologist Robbie Davis-Floyd wrote extensively about the cultural myths about non per os and childbirth in the 1992 book, Birth as an American Rite of Passage. Mendelsohn’s original 1946 article reported several cases of aspiration and subsequent pneumonia, but no deaths. Davis-Floyd cites Baggish’s 1974 study which showed that at most 2 percent of maternal deaths were caused by aspiration under general anesthesia and Scott’s 1978 work that placed the risk of death at 1 in 200,000 women.

So what purpose would denying food and drink to all laboring women serve more than six decades after Mendelsohn’s work and with the great improvements made to regional anesthesia? Davis-Floyd wrote:

According to Feeley-Harnik, “persons undergoing rites of passage are usually prohibited from eating those highly valued foods that would identify them as full members of society” (1981:4). In rites of pregnancy and birth across cultures, food tabus serve the purpose of marking and intensifying the liminal status of the pregnant woman. The pseudo-foods (ice chips and lollipops have no nutritional value) allowed in the hospital are often fed to the laboring woman by her partner as if she herself were the baby, a symbolic process that can heighten her own sense of weakness and dependence.

In a recent article in Birth, Broach and Newton (1988) address the question of why laboring women are still prohibited from eating and drinking in labor in spite of mounting evidence that such prohibitions are medically contraindicated. Pointing out that this custom started in the 1940’s when general anesthesia was widely used for childbirth and the danger from aspiration was therefore higher, they posit that its continuance is the result of “culture lag”—that is, of “culturally patterned behavior that continues to be practiced long after the reasons for doing so have disappeared” (1988:84).

Davis-Floyd views denying food in labor as indicative of the confirmation of a woman’s initiate status as a dependent of the institution.

On the contrary, I would suggest that this custom forms an integral part of the technocratic tapestry of birth in the United States, continuing as routine procedure not because of culture lag but because it serves so well to legitimate and further necessitate the technocratic interventions we investigate here as transformative rituals. To deny a laboring woman access to her own choice of food and drink in the hospital is to confirm her initiatory status and consequent loss of autonomy, to increase the chances that she will require interventions, and to tell her that only the institution can provide the nourishment she needs—a message that is most forcefully conveyed through the “IV.”

Restriction of food and liquids in labor was the subject of many discussions last year following the American Congress of Obstetricians and Gynecologists’ press release that women should be allowed “modest amounts” of water and clear liquids in labor, with physicians defending IV use and telling women to calm down their rhetoric and fight for things that matter.