In case you’ve wondered where I have wandered off to recently, let me cordially invite you to Lamaze International’s Science & Sensibility research blog site–which I am now managing. I am thrilled, humbled and excited to be steering my writing and childbirth education work toward an actively (and internationally) accessed social media site where I gain the honored opportunity to interact with brilliant writers, researchers, maternity care clinicians and professionals and normal birth advocates. Please drop on by, sign up for an RSS feed from Science & Sensibility and, most importantly, join the conversation! (And invite your friends and colleagues to do the same!)
Category Archives: Childbirth Issues
It’s always wonderful to come across stories like this, that highlight successes in the pursuit of improved maternal and infant outcomes revolving around pregnancy, birth and the postpartum period. Congratulations to Rwanda for making drastic changes and improvements, with the plan to meet the Millennium Development Goals of 2015 in regards to maternal and infant mortality. For a highlight on improvements made toward maternal and fetal/infant/child health throughout many African countries, read this July 2010 article.
We moved back home to Montana two months ago. It has been an amazing home-coming after what now feels like an extended vacation in the SF Bay area. Our kids are settled into school. Boxes are unpacked. Life feels normal again.
But for me, a huge part of life in Bozeman involved my role as a childbirth educator, and Director of my childbirth education program, Pregnancy to Parenthood, LLC. Since returning home, I’ve had tons of folks ask me if I’m going to start teaching again.
Last night, I had the chance to get back in the saddle again.
My neighbor owns a chic couture baby supply store in town and she’s working on developing a program of bringing various baby-pregnancy-postpartum classes into her store in a kind of a meet & greet fashion. Last night’s class was to be on breastfeeding basics and guess who got to run the class?
Boy, do I miss teaching.
With well over twenty interested, motivated, expectant or new moms in the audience, we had a great two-hour class during which we covered everything from how does a new mom continue to nurture her body after baby’s birth and during the breastfeeding time period, to the physiology of breast milk production and let down, to latch-on pitfalls and proper methods…breastfeeding baby positions…products a nursing mom does and doesn’t likely need…warning signs of problems to watch out for and, yes, the legal rights of breastfeeding moms.
Community health education at its’ best, this was a free class delivered to people who had a vested interest in the topic during and after which they could mingle, ask extra questions, and share their thoughts/feelings about this important time in their lives. I was happy to be apart of a fun evening, and so glad to be putting my teaching skills to use again!
Check out this interesting debate, spear-headed by Henci Goer on Lamaze International’s blog, Science & Sensibility, over what constitutes “normal” in terms of labor length. Gone are the days when every first time mom ought to be held to the expectation that her baby should be delivered in 12-14 hours following the onset of labor. But still, plenty of folks are holding women to that standard. Read up on the debate (and my response) here.
Last week, in response to a blog post I wrote entitled In the News: Stores About Childbirth, I received some heated comments from one of my frequent readers. The sentiments in her comments are highlighted here:
“This article from the UK just today…
“Home births are three times riskier for babies than those which take place at hospital, new research suggested yesterday.
Doctors warn that women could be putting their unborn children at risk by not given birth on traditional maternity wards with specialist care and equipment on hand.”
Also this for consideration of all sides to the debate..
“A newborn baby died from an infection just days after two midwives told the mother not to bother giving him antibiotics.”
(She added a third comment, pointing to the same article above, as if it was evidence of another study.)
So, here’s my response:
Yes, of course, you can always find a study to support your point of view. Just like this article, from the very same newspaper “Shelly” referred to, about a newborn who died of hemorrhage and heart failure do to a lethal overdose of hospital-administered glucose.
And what about and this study, published in the same medical journal as the study referred to in Shelly’s second point, which concludes, “Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States.”?
And how about this article (again, same newspaper as referred to above) about a new mom who died hours after giving birth to her son, following a legal narcotic overdose administered by hospital staff?
Shall I go on?
How about this article on CNN.com about how the US has the second worst newborn mortality rate in the developed world (incidentally, maternal mortality rate here is 15.1/100,000–worse than several northern European countries, Australia and Japan–many of those communities in which midwife-attended births are more common than here).
Have you ever heard about the Safe Motherhood Quilt Project by esteemed midwife Ina May Gaskin? Go here to see actual quilt squares that represent hundreds of women who have died surrounding their baby’s births–a vast majority of them having delivered in hospital.
An article on Our Bodies Ourselves reviewed a couple recent studies (one being the study from BMJ–referred to above) including a study published in the Canadian Medical Association Journal (follow link above to OBO website, then click on link to CMAJ article–mid way through the post) about a retrospective study of almost thirteen thousand women who gave birth at home with a midwife, in hospital with a midwife and in hospital with a physician in attendance. Although outcomes were similar, the neonatal mortality rates (death of the infants) were best among the home birth cohort, second best among those who delivered in hospital with a midwife and third best when attended by a physician. (The leap of an implication is, of course, that the physicians handled the more complicated cases and, therefore, realized higher rates of neonatal mortality.)
And yes, there are also other articles and studies out there that will further defame the practice of midwifery (heck, The American College of Gynecologists has an official statement on their website denouncing the practice of delivering babies in a home environment. In some cases, I totally and completely agree with this: when a pregnant woman is deemed high risk–due to cardiac or other significant health conditions, gestational diabetes requiring insulin, moderate to severe high blood pressure to name a few–she absolutely should have her baby’s birth attended to in a hospital and most likely by an OB. (other definitions of high risk are well outlined in the OBO article, linked to above) But for low-risk women with no foreseeable complications, birth should not be attended to as if it is a medical disease state from which she needs saving.
Delivering a baby in a hospital includes having quick access to medical intervention. In the small percentage of cases when in-depth intervention becomes life saving, there is, in my opinion, no legitimate argument against this (that’s why the best of the best midwives out there always have some transfers each year to the hospital from a home birthing environment.) But the truth about medical interventions (aka-hospital births) is that much of the high-tech/high intervention practices (labor induction/augmentation, breaking the bag of waters, constant fetal heart beat monitoring, episiotomies, c-sections) are employed unnecessarily…carrying with them well documented risks.
Take labor induction with the use of Cytotec, for example. While prohibited in some hospitals due to its risk of uterine rupture, uterine over stimulation and fetal stress, Cytotec is widely used in other hospitals as a labor induction medication. From nursingcenter.com, regarding labor induction medications including Cytotec:
“Cytotec, a brand of misoprostol, is FDA approved for prevention of nonsteroidal anti-inflammatory drug-related gastric ulcers. It is listed as Category X (not to be used) in pregnancy. Physicians in the United States, however, may use FDA-approved drugs for “off label” indications. Hofmeyer and Gulmezoglu (2003) recommended further research to establish the ideal route of administration, dosage, and safety for this drug and stated that information on informed consent for misoprostol use and women’s views of the drug are “conspicuously lacking” (Hofmeyer & Gulmezoglu, 2003).
The risk of maternal or fetal death among Cervidil, Prepidil, and misoprostol is comparable. In 25 trials that involved 3,651 subjects, however, misoprostol was shown to be more effective and had more rapid onset of action. There was an increased rate of uterine hyperstimulation with FHR changes and meconium-stained amnionic fluid. Clinicians were advised in this study to be concerned about this apparent increase in uterine hyperstimulation, because it might increase the risk of uterine rupture (Hofmeyer & Gulmezoglu, 2003). These same authors found that the cesarean birth rate for failed induction after misoprostol was not significantly reduced compared to the other prostaglandins or oxytocin. Evidence for its use, aside from cost savings and rapidity of action, is no stronger than for other prostaglandin preparations.”
Translation? US doctors are granted the privilege, by the FDA, to use approved medications for non-FDA researched purposes. (In some cases, this IS a good thing–but that is the topic for another post.) While Cytotec forces a woman into labor quite efficiently, it puts both mom and baby at risk because of how hard and fast the uterus begins to contract. Cytotec is a Category X medication for pregnancy–meaning there is no way, no how a pregnant woman should be consuming this medication. And yet, despite all facts above, it is still widely used intervaginally to synthetically begin a woman’s labor for her.
My point here? Allopathic medicine is not infallible, either. Nobody is. That’s a part of being human and having the power of choice.
Are there midwives out there employing less than best-practices maternity care? Sure. I had a sixteen-year-old young lady attend my Lamaze class series a couple years ago, as a part of a distance learning midwifery program. If she graduated from said program “on-time” she’d be practicing home birth midwifery by the time she was nineteen. She may have been extremely smart, applied, motivated and well instructed in one form or another, but she was sixteen.
The potential of this scared the heck out of me. Because, really, how many teenagers in present-day USA do you know who have the maturity to safely and logically handle the (rare) birth-related true emergency–like a retained placental postpartum hemorrhage, a severe shoulder distocia, or a newborn in respiratory distress?
My very long-winded point here is this: it’s easy to quickly cite one or two articles or studies and use those to make a big, sweeping statement that supports your opinion. But before doing so, I would encourage anyone to look closely at the data:
1. Is the study/article truly unbiased?
2. Does the study compare apples to apples? (similar patient populations in each cohort)
3. Are the numbers and percentages represented statistically significant?
4. Are individual articles cited worthy of applying to a whole system or group of people, or are they just that–individual stories about isolated events?
5. Do larger bodies of work support conclusions made by smaller studies? Is the result of a study reproducible? What do studies conducted by organizations like the World Health Organization, National Institutes of Health and Cochran Database say?
I have always been leery about sweeping generalizations and I would encourage you, dear reader, to follow suit.
I also encourage and invite feedback on my thoughts contained herein. What are other folks out there reading/teaching/learning?
The world finally gets it (OK, some parts of the world). Childbirth does not have to be as dangerous as it is for many women and fetuses in developing countries. For that matter, it does not have to be dangerous for the vast majority of women in developed countries, either, but that is a whole other ball of wax (in short, think: high rates of medical intervention in low-risk women have the propensity to create more problems that require fixing, than they necessarily do solve or prevent potential problems).
Here is yet another example of a relatively simple technology with a focus on reducing perinatal maternal mortality, as presented at the American College of Nurse Midwives‘ annual convention. The device? A strap-on belly with uterus, baby and blood contained within. The goal? To get as many birth attendants around the world–especially in areas like Afghanistan, the Central African Republic and rural India– trained with basic life-saving knowledge of how to catch a baby (or help to deliver a malpositioned fetus) and intervene when postpartum hemorrhage is occurring. Truthfully, most of the life-threatening scenarios surrounding childbirth can be handled successfully, as long as the knowledge of how to handle those scenarios is there, and well practiced.
As described in this article, “Using both hands, the teacher wearing the device can move the baby through the birth canal, which is formed from a flexible plastic frame. Simulated blood flows out of the vagina, controlled by a thumb-operated roller valve. To simulate the contraction of the uterus after delivery, the teacher squeezes air from a large bladder into a smaller one while pulling the latter lower in the pelvis. She can tap on a piece of hard plastic inside the mannequin to create a heartbeat, varying the rate and loudness to simulate fetal distress. In all cases, the sense of reality is heightened because the equipment is connected to and manipulated by a human being.”
The “Mama Natalie” simulator can even replicate a retained placenta fragment–the primary cause of third stage and postpartum hemorrhage. When would-be birth attendants know how to recognize this condition, they can also learn how to remedy it (by manually removing the left-over piece of placenta that is stuck to the internal uterine wall, thus allowing continued bleeding). In extremely rural areas or home birth scenarios where high-tech intervention is miles away, the performance of this relatively simple procedure, and appropriate follow-up techniques and care, can be a matter of life and death.
Kudos to Laerdal Medical for creating this device, making it available to poor countries at cost ($100/each), and adding to the overall trudge toward the Millennium Development Goal 5 which “seeks to cut the 1990 maternal mortality ratio of 320 deaths per 100,000 births by 75 percent.”