I have been informed the blog network I was loosely part of is folding. I appreciate the administrator’s work, but it was already an awkward situation with the ads for McCain and Pregnancy Crisis Clinics and anti-homebirth sites that would pop up incessantly. It’ll be nice to be on my own again.

Sheesh, I hope I don’t lose my 2 1/2 readers.

Posted by MomTFH | Mom's Tinfoil Hat | WebbleYou Blog Network | © 2008 | Permalink | Comments

Maternal morbidity and mortality, especially that of women of color and/or low socioeconomic status, is a problem in the United States. Despite skyrocketing rates of medical interventions in labor and delivery, including the majority of labors being artificially induced or augmented1, infant mortality in the United States is ranked 25th among industrialized nations. The maternal mortality rate in the United States has not fallen since 1982, nor have disparities of maternal mortality between African American mothers and white mothers. The national maternal mortality rate for African American mothers is three to four times the rate of white mothers2, and this discrepancy is reflected in the maternal mortality rates in Miami-Dade county. In fact, in some recent years, the maternal mortality rate for non whites in Miami-Dade county has been more than ten times that of whites, reaching about 50 per 100,000 twice in the past decade.3
Other indicators of maternal and infant health have been outlined by the Healthy People 2010 as maternal and infant child health objectives, spearheaded by the U.S. Department of Health and Human Services. Along with maternal and infant mortality rates, the report recommends reductions in cesarean section rates, which have topped 30% nationally. 4 This increase has occurred without a corresponding decrease in Neonatal Intensive Care Unit (NICU) admissions.5 without reductions in low birth weight and preterm deliveries, and increases in early prenatal care and initiation and continuation of breastfeeding. All of the maternal and infant health outcomes under surveillance in the report are stratified according to race, and all show similar disparities between African Americans and whites.6 These disparities are all either identical or magnified in Miami-Dade County.7
Forty two years ago, Scottish epidemiologist Archie Cochrane awarded a “wooden spoon” to obstetrics in his book Effectiveness and Efficiency: Random Reflections on Health Services, a dubious honor awarded by use of treatments without scientific justification. His criticism inspired the development of the Cochrane Pregnancy and Childbirth Database, an online database evaluating evidence-based medical practice. Unfortunately, even with this source of data for justifying interventions, it seems that many standard practices prevalent in typical hospital care are not indicated for nor supportive of a healthy, normal birth. Jennifer Block laments in her 2007 book, Pushed: The Painful Truth About Childbirth and Modern Maternity Care:

A common theme emerges in the history of obstetric care: procedures and devices developed for the treatment of abnormality rather quickly become routine practice in the name of prevention, and then simply in the name of speeding up and ordering an unpredictable, at times tedious, process. 8

If our goal is to improve maternal and child outcomes, using evidence based care is our best chance at results. Although the Cochrane database is a valuable tool for evaluating randomized studies of single treatments, birth does not occur in a vacuum. If actual institutions are achieving better outcomes, there are lessons to be learned from retrospective studies of successful protocols and practices. This is especially true of patient sample groups with disadvantaged and ethically diverse patients.9
The model of midwifery care has been examined as an alternative to the prevalent paradigm of labor and birth in hospitals. Midwives are twice as likely to care for minority clients.10 Several studies have indicated that births attended my midwives have improved outcomes for low risk patients, even disadvanted patients.11 In fact, not only was midwifery attended births and maternal outcomes among the medically underserved researched in Miami-Dade county, but specific practices, distinct from typical hosptial practices in the United States, were described in the study protocol Study subjects were match controlled to patients at a typical tertiary care center at an adjoining hospital. Patients delivering at the birth center did not have access to regional or general anesthesia, so they were not administered epidurals. No induction or augmentation of labor were performed. Women were encouraged to drink and eat lightly, and were encouraged to move around and change positions during labor. This was made easier by the practice of intermittent auscultation. In the tertiary hospital, as it is in virtually every hospital in the United States, control matched mothers were tethered to a constant external fetal monitor.12 Despite significantly fewer interventions, outcomes were the same between the two groups of low risk, predominantly African American women.
Analysis of protocols and practices in successful institutions can help lead reform in birthing practices, and can avoid the expense and possible negative outcomes of unecessary interventions. Use of metanalysis of controlled studies of individual practices can be field tested in actual real world settings. For example, the Cochrane database review of continuous external fetal monitoring (EFM), more specifically called Continuous cardiotocography (CTG), concludes:

“While specific abnormalities of the fetal heart rate pattern on CTG are proposed as being associated with an increased risk of cerebral palsy (Nelson 1996), the specificity of CTG for prediction of cerebral palsy is low with a reported false positive rate as high as 99.8%, even in the presence of multiple late decelerations or decreased variability (Nelson 1996).

Concerns have been raised about the efficacy and safety of routine use of continuous CTG in labour (Thacker 1995). The apparent contradiction between the widespread use of continuous CTG and recommendations to limit its routine use (RCOG 2001a), indicates that a reassessment of this practice is warranted.”13

Comparisons of continuous monitoring and intermittent auscultation, which involves regular monitoring of fetal heart tones with a handheld Doppler device, have mixed results. The Cochrane review reports a higher risk of neonatal seizure with intermittent auscultation, but no increased risk of NICU admission, cerebral palsy, low Apgar score (a rating of neonatal well being), or perinatal death. EFM was linked to higher risk of cesarean section and operative vaginal delivery, especially in low risk women.The comparison review concludes:

There is a reasonable consensus of opinion that continuous electronic fetal monitoring
should be reserved for women whose fetuses are at high or increased risk of cerebral palsy, neonatal encephalopathy or perinatal death.

The article continues to say that for every neonatal seizure attributable to intermittant monitoring, doctors would be performing eleven cesarean sections.14 Yet, EFM continues to be required in the vast majority of hospital births. It is less common in freestanding birth centers.
Similar conclusions are drawn about the type of birth procedures found in the majority of hospitals in general, termed “active management”. Active management includes induction and augmentation of labor, EFM, and early amniotomy (breaking of the amniotic sac to increase contractions). The Cochrane report on active management warns that a low threashold for early intervention is “not without its risks”, and suggests the frequency of these complications should be better quantified.15 These interventions are specifically outlawed in freestanding birth centers in Florida.16
Other common interventions with dubious efficacy in Cochrane reviews are significantly less common in birth centers than in hospitals. Epidural anesthesia has been linked to longer labor, use of oxytocin, malposition of the fetal head, increased risk of fetal distress, cesarean section, instrumental vaginal delivery, need for neonatal resucitation, maternal hypotension and maternal and neonatal fever.17 Having mothers spend the majority of the first stage of labor in a supine position, practically mandated by the use of EFM and epidurals, has also been linked to potential adverseevents. Lying on her back can compromise maternal blood flow, cardiac function, and the blood supply to the uterus. Studies showed that contractions slowed and weakened when the woman is lying down, and resulted in negative fetal acid-base outcomes.18 Freedom of movement and alternative delivery positions have been shown to decrease episiotomy (an operative incision in the vaginal linked to severe tears), perineal tears, and operative vaginal birth, but increases maternal blood loss.19 Induction of labor is warned to increase maternal and fetal distress, increased cesarean section, and may lead to uterine rupture.20 Restriction of food and fluids, which are replaced with intravenous (IV) therapy for the entirety of labor and birth in almost all hosptial births is more than just restrictive and inconvenient for women. The Cochrane review of this practice questions any medical justification for its widepread application. IV therapy is associated with hypoglycemia in the newborn, immobilization of the mother, fluid overload, maternal stress, and does not provide required nutrients for labor and delivery.21
Some practices that are frequently found in midwifery based care, but not in typical hosptial care, are also reviewed in the Cochrane database. Continuous support of a woman in labor, usually provided by a trained birth attendant called a doula, has been shown to have numerous benefits, including women who were more satisfied with their birth experience, reduced cesarean section rate, increased spontaneous vaginal birth, slightly shorter duration of labor, less use of analgesia or anesthesia, and reduced maternal fear and stress, without any plausible risks. The report concludes that continuous labor support “should be the norm, rather than the exception.” Costs of private doula services maybe a barrier to access for lower income women. Some hospitals have started to fund doula services.22
Although the reviews in the Cochrane database emphasize the need for randomized controlled trials of single interventions, pregnancy, labor and birth continue in real communites without randomization. Successful care with improved maternal outcomes and reduced intervention can be a guide for effective care for similar populations, or a guide for protocols for intervention studies in nearby hospitals. It is not one intervention, but the general atmosphere of drastically over treating labor and birth that seems to be the problem. As one review warns, “any effect on caesarean section rates from a policy of active management is as a result of the combination of interventions rather than the individual interventions.” Midwives and freestanding birth centers do not have an exclusive claim on expectant management of labor and birth. Even with use of continuous support during labor, the reviewers recommendations indicate that:

“Policy makers and hospital administrators in high income countries who wish to effect clinically important reductions in inappropriately high caesarean rates should be cautioned that continuous support by nurses or midwives may not achieve this goal, in the absence of other changes to policies and routines.”

Using a combination of evidence based reivews, retrospective analysis of successful programs already serving the target population, and selective ethical randomized trials, maternity care and outcomes can improve, even in demographically high risk populations.

References

1. Declercq ER et al. Listening to Mothers II: Report of the Second National U.S. Survey of Women’s Childbirthing Experiences. New York: Childbirth Connection; 2006.
2. U.S.Department of Health and Human Services. Maternal, Infant and Child Health. Healthy People 2010; With Understanding and Improving Health and Objectives for Improving Health. 2 ed. Washington, D.C.: U.S. Government Printing Office; 2008.
3. Rivera L, Leguen F. Vital and Morbidity Statistics 2003. Miami-Dade County Health Department; 2008.
4. U.S.Department of Health and Human Services. Maternal, Infant and Child Health. Healthy People 2010; With Understanding and Improving Health and Objectives for Improving Health. 2 ed. Washington, D.C.: U.S. Government Printing Office; 2008.
5. Resnik R. Can a 29% cesarean delivery rate possibly be justified? Obstet Gynecol 2006 April;107(4):752-4.
6. U.S.Department of Health and Human Services. Maternal, Infant and Child Health. Healthy People 2010; With Understanding and Improving Health and Objectives for Improving Health.
7. Riviera et al, Vital and Morbidity Statistics 2003.
8. Block J. Pushed: The Painful Truth About Childbirth and Modern Maternity Care. Cambridge: De Capo Press; 2007.
9. Raisler J, Kennedy H. Midwifery care of poor and vulnerable women, 1925-2003. J Midwifery Womens Health 2005 March;50(2):113-21.
10. Declercq ER et al. Listening to Mothers II: Report of the Second National U.S. Survey of Women’s Childbirthing Experiences.
11. Raisler and Kennedy, Midwifery care of poor and vulnerable women.
12. Scupholme A, McLeod AG, Robertson EG. A birth center affiliated with the tertiary care center: comparison of outcome. Obstet Gynecol 1986 April;67(4):598-603.
13. Alfirevic Z. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews 2006 April 24;(2).
14. Devane D. Cardiotocography versus intermittent auscultation of fetal heart on admission to labour ward for assessment of fetal wellbeing. Cochrane Database of Systematic Reviews 2004 September 16;(2).
15. Wei SQ. Early amniotomy and early oxytocin for delay in first stage spontaneous labor compared with routine care. Cochrane Database of Systematic Reviews 2007 June 21;(2).
16. Birth Center Licensure Act, XXIX, Florida Legislature, (2007).
17. Anim-Somuah M. Epidural versus non-epidural or no analgesia in labour. Cochrane Database of Systematic Reviews 2005 August 16;(2).
18. Lewis L. Maternal positions and mobility during first stage labour. Cochrane Database of Systematic Reviews 2002 August 26;(2).
19. Gupta JK. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database of Systematic Reviews 2003 April 25;(2).
20. Singata M. Restricting oral fluid and food intake during labour. Cochrane Database of Systematic Reviews 2002 August 2;(2).
21. Hofmeyr GJ. Methods for cervical ripening and labour induction in late pregnancy: generic protocol. Cochrane Database of Systematic Reviews 2000 February 15;(2).
22. Hodnett ED. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2007 April 18;(2).
23. Brown H. Package of care for active management in labour for reducing caesarean section rates in low-risk women. Cochrane Database of Systematic Reviews 2004 April 27;(2).
24. Hodnett, Continuous support for women during childbirth.

Posted by MomTFH | Mom's Tinfoil Hat | WebbleYou Blog Network | © 2008 | Permalink | One comment

As a future Ob/gyn, I see no conflict at all in going from one clinic room with a infertile woman to the next room with a woman who wants an abortion. I have always had a real problem with people who somehow think one woman’s fertility is worth more than another’s. Fertility is incredibly random and totally fucking unfair, and I am not going to heap guilt or blame on a woman with an unwanted pregnancy because another woman can’t conceive. They both have one thing in common: reproductive choice and a menu of shitty options. I will be serving both of their needs and desires, supporting both of them 100%, emotionally and professionally.

Of course I do not believe doctors should be forced to perform abortions, just as the author of this blog claims she does not support extremist anti-choicers.You know, the ones that kill health care workers, bomb clinics, terrorize doctors, have their children wave signs with gruesome photos on them, try to restrict birth control access, try incessantly to make the procedure, which is the most common surgery in the United States, illegal and unsafe, and succeed in forcing the discussion of abortion underground.

No, XX, the majority of the country is NOT anti choice, as any survey will tell you. Yes, the procedure is not pretty and causes uncomfortable feelings, but so does the birth process. Want to talk about fourth degree tears through the rectum from pushing right now? How about many of numerous gruesome and/or ethically challenging medical procedures that DON’T involve a woman’s sexuality? Are you blogging about force feeding terminally ill cancer patients? Aren’t they patients, too? Where is the outrage?

A child can be a patient. A blastosphere or embryo is a future child, not a patient as you claim. In the vast majority of cases, more than 80%, it is a small amount of tissue. If abortion was killing a child, almost 40% of women of childbearing age would not be getting the procedure. Killing a child is a horrid, gruesome thing, and I am offended you would accuse so many women in this country of doing such a thing or accuse the majority of the country of supporting it. Please stop using inflammatory language. You are kicking women when they are down. If you think it is wrong, don’t get one, and don’t become an abortion provider. It’s simple.

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I have already started having nightmares.

I am doing research for a grant writing class (my MPH classes started earlier this summer). I found out that the author of many studies on midwifery care and maternal inequalities is affiliated with the University of Miami Jackson Medical Center, which is where I want to do my residency. I am excited about trying to find her. I am hoping she can come and give a talk about doing research in women’s health.

I am also thrilled to see this kind of a paragraph in an article about women’s health, especially obstetrics. I love seeing examples that feminist does NOT equal anti motherhood:

“From a feminist perspective, research on childbirth and women’s
health is a means to social change, conducted in partnership
with women and for their benefit.51 Feminists try to make
the research process cooperative and transparent by including
women’s and community groups on research advisory boards
to help formulate research questions, design studies, and
interpret their results. Sometimes women are asked directly
what they want and need from health care, and interventions
are designed on the basis of their responses, rather than on
researchers’ preconceived objectives. A feminist perspective
could add an important new dimension to research on midwifery
care of the poor by involving women as partners as
well as subjects.”

from Midwifery Care of Poor and Vulnerable Women, 1925-2003, by Raisler and Kenndey, J Midwifery Womens Health 2005;50:113–121

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It should be no surprise to people who know me that I would love a class based on a message board. Well, here is my latest post, in response to the teacher discussing whether or not our culture promotes abortion. She told a personal story about growing up in Cuba, and how she thought abortion was promoted there by public policy.

Here is my post:

I totally agree, first of all, that government attitudes and health
policies do affect women’s choices. In Cuba, overt religion was not part
of the political picture, and neither was contraceptive access. Since
abortion was free and accessible, it was the predominant method of
controlling pregnancy and birth for women outside of herbal remedies.

In the United States, contraception is not readily available for
different reasons. Religion and cultural social conservatism are playing
a role in this, to a certain extent. There was already a great
discussion about this on Stephanie’s post about contraception use in the
Netherlands.

Recent legislation has slashed contraceptive funding and contraceptive
prices have skyrocketed, especially on college campuses. The doctor
appointed to oversee Title X funding for reproductive health and birth
control (Dr Susan Orr, the Assistant Deputy Secretary for Population
Affairs, who just stepped down after 3 years) has a public stance
against birth control, and used to work for the Family Research Council,
an organization lobbying to ban Title X funding. The largest “pro-life”
group, the American Life league, recently organized a national protest
day against the birth control pill, with the slogan “The Pill Kills”.
Even though 98% of women use contraception at some point in their lives,
our culture sends a very mixed message to women.

Recent changes in public health programs in the United States have had a
definite effect on teen birth rates, contraception use, and abortion.
Access to abortion in rural areas, which has plummeted due to political
resistance, and funding for abortions has dropped, and so has the
abortion rate, slightly, but to what end? More unplanned pregnancies
being carried to term by women who would terminate if they had the
funding and access to care?

I do not agree that the culture in the United States necessarily
encourages abortion. In the oxymoronic ideal we are given as women,
abortion is definitely not supported or encouraged. Yes, a certain level
of sexual appearance and behavior is expected of women, but once it gets
to the sexual level, we are supposed to say no, and not even think about
birth control, premarital sex, sex for recreation, women’s pleasure or
sexual appetite, or abortion. It is the virgin/whore dichotomy that is
the ideal. In a way, abortion is expected since contraception is not
promoted and our public health policy results in more unplanned
pregnancies. But, abortion is heavily stigmatized as a way to deal with
unplanned pregnancy.

The way that the public dialog has been framed when it comes to abortion
is in the extremes. No one talks about the reality that it is the most
common surgical procedure in the United States. I doubt many of us know
the 30-40% of women around us who have had them. It is not like the
public attitude towards plastic surgery, which is overwhelmingly
positive. The dialog either focuses on the 5% of abortions that are in
the second trimester, or tries to ignore the discussion all together.

The recent blockbuster movies about birth and reproduction are perfect
examples of this. In the movie “Knocked Up”, the characters can’t even
use the real word abortion when discussing it as an option in an
unplanned pregnancy. The supporting character says “shmamortion” or
something to that effect, since it is the procedure which cannot be
named, like the villain Voldemort in Harry Potter.

In “Juno”, the abortion clinic is staged as a place for purple haired,
insensitive freaks, and the teenage character is glorified for deciding
to become a “baby Santa” to an infertile couple. Incorrect medical
information about embryos having fingernails was given as a reason for
avoiding abortion. Without any counseling or remorse, she gives the baby
up for a closed adoption in which she cannot make contact, and skips
back to the father of her child who wouldn’t even admit paternity due to
the shame.

I have already talked about the complicated topic of adoption, which is
another huge issue. Statistics show that almost no women give up their
children for adoption in the UK, and it is thought to be due to the fact
that they have good social support for single mothers and universal
health care. What would Juno do if she had that waiting for her? Or,
would she have even gotten pregnant if she lived in the Netherlands?

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This week’s topic is reproduction in different cultures. *Double squeal!!!*

Here is a copy of my post on the class board about homebirth in the US, UK, and the Netherlands:

There is a hubbub brewing right now, since the American Medical
Association (AMA) just passed a resolution encouraging state legislation
regulating childbirth, specifically to regulate that childbirth only
takes place in a hospital or a licensed freestanding birth center.

link

The American College of Obstetrics and Gynecologists (ACOG) adopted a
similar resolution, originally also discouraging birth in freestanding
birth centers.An outpouring of negative reaction, with evidence, led
them to revise their position to admit that free standing birth centers
have a strong safety record. However, the ACOG resolution was just a
position statement. This AMA resolution recommends drawing up model
legislation to enforce the position.

The most recent study on home births in the United States shows them to
not only to be safe, but to have better outcomes than comparable low
risk deliveries in US hospitals:

link

Currently, 30% of babies are delivered at home in the Netherlands, and
they enjoy a much lower maternal mortality rate and infant mortality
rate than the US.

link

The Royal College of Obstetricians and Gynaecologists (RCOG) issued a
joint statement with The Royal College of Midwives (RCM) (they work
together in the UK! and in the Netherlands! Imagine…integrated care!)
supporting and even encouraging home birth. They also enjoy a much lower
rate of maternal and infant perinatal morbidity and mortality than the US.

link

I broke the format rules. Consider that all one paragraph! As for my
opinion, I think it is clear that I support home birth in the full
spectrum of reproductive choice and informed consent. I am afraid that
obstetrics, the field I love and plan to practice, is in a very confused
state in the United States. Interventionist practices are not based on
evidence of improved outcomes. I just spoke to an attending at the
closest Ob/Gyn residency who was appalled by the practices she saw when
she started at that well renowned research and teaching hospital. What
was the most appalling to her, and to me, is not simply that these are
medical interventions. We are all in support of life saving technology.
But, when these interventions have been shown in easily accessible peer
reviewed research to lead to negative perinatal outcomes, why have they
become standard of care in normal pregnancy instead of in the rare cases
that they are indicated?

Announcement of bias/conflict of interest: I trained as a midwife for
two years, and had both of my children with a midwife. One in a
hospital, on in a freestanding birth center. I have attended births in
hospitals, including cesareans, in birth centers and at homes. I am
training to be an Ob/Gyn, however, so you can take anything I say with
whatever flavor grain of salt you like

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I can’t see why midwives and doctors can’t work more cooperatively here. There is successful cooperation between physicians and midwives in other medically advanced nations, like the Netherlands and England. With a shortage of ob gyns wanting to deliver, and skyrocketing malpractice rates, I can’t see why more doctors don’t leave the uncomplicated births to midwives, at home, in a birth center, or in a hospital.

The best births I ever attended were home births. Even the complicated one that reminded me of my own complicated birth, which was attended by a midwife, but took place in a hospital. The worst births, the ones that made me the most scared, were almost all at a hospital.

I went to the hospital with a fellow midwife student who was fully dilated at 28 weeks. We waited for the doctor on call at the hospital. We called before we even showed up and made it very clear how urgent the situation was. We waited. And waited. I was there with a midwife from our center, and the labor nurse happened to be a nurse midwife that we knew because she had graduated with one of our midwives. She was working at the hospital as a labor nurse, however, and was not there to deliver babies, just assist.

We waited almost 45 minutes. It only took us five minutes to drive there. Most home births happen within 20 minutes of a hospital. We waited for the doctor, and the NICU team waited patiently for the very vulnerable baby to come out. We called the head midwife at the birth center, and she said “That baby has to come out. Tell her to push.” The labor nurse / midwife nodded her head, and told her to push. The baby was born and whisked away by the NICU unit. The doctor showed up another 45 minutes after that.

I could tell you more stories about bad hospital births, but I am not just knocking hospitals. The issue I have with most of these stories is that the doctor is not there. The patient may be in the hospital, this magic building with the magic rooms and the machines that go ping, but the doctors are spread so thin that they are not there to help these women, and these are the HIGH risk women who can’t have a home birth. Seems like there is enough to go around.

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Click on the picture to see it. It is a uterus and fallopian tubes, surrounded by tiny rhinestones! Bedazzling!!

Posted by MomTFH | Mom's Tinfoil Hat | WebbleYou Blog Network | © 2008 | Permalink | One comment

Posted by MomTFH | Mom's Tinfoil Hat | WebbleYou Blog Network | © 2008 | Permalink | 3 comments

It is going to say “Be the doctor your mother wanted you to marry” and have this graphic on it. The suitor will be mirror imaged on the other side, so there will be two suitors.

You like?

Posted by MomTFH | Mom's Tinfoil Hat | WebbleYou Blog Network | © 2008 | Permalink | 2 comments