Inside the Hospital with Canada’s Highest C-section rate

courtesy Walrus

“‘We don’t want to over-medicalize childbirth,’ Dr. Alison Michel tells me in the pastel maternity ward of the Victoria General Hospital. The forty-year-old family physician is a member of Quintessence, an all-female maternity care group known across BC’s capital as the most ‘woman centred,’ next to midwives. ‘We assume childbirth is a normal, natural, healthy thing that a woman’s body does,’ she explains, ‘so we do a lot of hands-on work with moms when they’re in active labour; things like massage and sometimes even acupressure.’ That’s the explicit goal, anyway. When I called to confirm the tour first thing in the morning, Michel had been up all night assisting with three deliveries, all via Caesarean section. In fact, she admitted the staff was a little nervous about a visit by a journalist. By the time I arrived, the local paper had broken some dispiriting news: ‘South Island Reports Highest C-section Rate.’ Just over one-third of the hospital’s births — more than at any other Canadian hospital — take place in the surgery.” Read more at The Walrus magazine.

Mothers Skip Banks and Share Milk Directly via Facebook

Courtesy Time.com“In one of the photos that keeps getting Emma Kwasnica’s Facebook account suspended, the Montreal-based mother and breast-feeding activist is tandem nursing, with a newborn at one breast and a two-year-old at the other. Classical art and public health be damned, Facebook has censored countless breast-feeding photos for violating the company’s terms of use, a policy that has inspired more than 250,000 people to join a Facebook group called ‘Hey Facebook, Breastfeeding Is Not Obscene!’ Kwasnica has protested her four account suspensions by e-mailing administrators and keeps doggedly reposting photographs and organizing virtual ‘nurse-ins’ via her Facebook group, Informed Choice: Birth and Beyond. But last month it occurred to her that the global breast-feeding community could use social media to organize real-world, offline “lactivism,” in the form of milk sharing.” Read more at Time.com.

Jezebel jumps into “Birth Rape” debate

courtesy JezebelThe bloggers at Jezebel have picked up on the somewhat controversial term “birthrape” used by some women who have been traumatized during childbirth — rough exams, waters broken without consent, episiotomies cut against a woman’s will, forced cesarean sections — and question whether it’s a fair use of the word. “Whether or not you find it appropriate, the insistence on the use of the word ‘rape’ — and not simply ‘birth trauma’ — is interesting because both childbearing and sexual assault are points in which, despite all modern progress, women’s bodily functions and reproductive organs could seem to define them or take them back to a primal vulnerability,” writes Irin Carmon. “It points to how broadly disempowered so many women feel within the medical system.” The post is tagged “pushed” and a lively debate follows in the comments.

ACOG Scraps “Restrictive” Guidelines on Vaginal Birth After Cesarean

Quoting from the press release issued today by the American College of Obstetricians and Gynecologists:

“…restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will if, for example, a woman in labor presents for care and declines a repeat cesarean delivery at a center that does not support TOLAC ["trial of labor after cesarean"]. On the other hand, if, during prenatal care, a physician is uncomfortable with a patient’s desire to undergo VBAC, it is appropriate to refer her to another physician or center.”

“‘…interpretation of The College’s earlier guidelines led many hospitals to refuse allowing VBACs altogether,’ said Dr. Richard Waldman, president. ‘Our primary goal is to promote the safest environment for labor and delivery, not to restrict women’s access to VBAC.’”

But the New York Times suggests the trend will be difficult to reverse: “Women’s health advocates praised the new guidelines because they expand the pool of women considered eligible for vaginal births, but they expressed doubts about whether the recommendations go far enough to change a decade of entrenched behavior by doctors, hospitals and insurers…Maureen Corry, executive director of Childbirth Connection, an advocacy group, said, ‘Overall, it’s dubious that these guidelines will in fact open up access for women.’” The Times goes on to name several hospitals that currently ban VBAC and have no intention of changing the policy.

New AJOG Home Birth Study Political?

Home birth is hotly controversial, so you can bet that when any study about it is released it gets thoroughly dissected (or torn to pieces) by the side bound to clash with its conclusions. That’s exactly what’s happening to the new study being fast-tracked by the American Journal of Obstetrics and Gynecology.

The meta-analysis, led by Joseph Wax, MD, of Maine Medical Center, pools data from several studies and is making headlines that home birth triples the risk of infant death. It is also being widely criticized as “deeply flawed.” “We are puzzled by the authors’ inclusion of older studies and studies that have been discredited because they did not sufficiently distinguish between planned and unplanned home births — a critical factor in predicting outcomes,” says a press release by the American College of Nurse Midwives. “A meta-anlysis is only as good as the articles you put into it,” explains Michael Klein, MD, a professor and researcher based at the University of British Columbia. If you put “garbage in,” he says, you get “garbage out.”

But Klein is not only calling the Wax study garbage, he says the garbage stinks. Klein told CBC News that it is “a politically motivated study.” Klein’s colleague Patricia Janssen, who led a study out of British Columbia that was included in Wax’s paper, called it “sensationalist.” The grassroots Big Push for Midwives campaign charges: “Their ultimate goal is obviously to defeat legislation that would both increase access to out-of-hospital maternity care for women and their families and increase competition for obstetricians,” says Susan Jenkins, legal counsel for the campaign. (Bills are currently on the governor’s desk in New York and in the Massachusetts’ senate.)

There is of course no way to know for sure if politics is influencing science, but the Journal’s own July 1 press release announcing the article (named an “Editor’s Choice” two months before its pub date) quotes the journal’s editors stating, “This topic deserves more attention from public health officials at state and national levels.” At the very least, we can say that the editors believe the study has political implications.

Here’s what’s particularly curious: Wax and coauthors acknowledge that some of the included studies were not powered to report mortality rates, and when they analyzed the data for mortality and excluded those studies, they found “no significant differences between planned home and planned hospital births,” to quote the study verbatim. But this is not the study’s banner finding. Instead, the authors include the very studies they had excluded and report as their conclusion that “less medical intervention during planned home birth is associated with a tripling of the neonatal mortality rate.”

The ACNM calls this conjecture. “This conclusion cannot be drawn from the data presented in this meta-analysis. In fact, a number of credible studies have shown that the increased use of technology and interventions in childbirth for low risk women…do not improve birth outcomes.” The National Association of Certified Professional Midwives accuses, “the authors of this study are obscuring important information about the safety of home birth and neonatal outcomes.” The daggers are coming from all directions, including Canada and the UK, where 4 in 10 women are now offered the option of home birth.

If politics are at play here, what’s most troubling is that they are deaf to patients’ rights. The reality is that some women choose home birth, and several large, well-designed cohort studies (of actual women planning home births) have found comparable safety and significant benefits over hospital birth. Those studies (out of Canada, the Netherlands, and the U.S.) suggest that part of what makes home birth safe is the presence of an attendant trained to handle emergencies who has the ability to transfer to obstetric care if needed. Why does the (newly renamed) American Congress of OB/GYNs continue to oppose legislation that licenses and regulates home birth midwives as it prohibits its members from collaborating with them?

*UPDATE 7/10 — For a great break down of the science, look to Amy Romano’s Science & Sensibility. She asks why the authors did not graphically display their results using the customary “forest plot,” which usually accompanies meta-analyses (perhaps because it would have shown “a confidence interval you could drive a truck through”?). But she also questions whether meta-analysis is even appropriate for studying the safety of home birth. “We need to continue to study home birth using all of the tools in the research toolbox, qualitative and quantitative, to determine under what circumstances home birth is safe and how to optimize care and outcomes in all birth settings. And we need to stop pushing home birth underground in the United States where it remains a fringe alternative, poorly integrated with the maternity care system,” she writes. “Shame on the American Journal of Obstetrics and Gynecologists for making this task even more difficult than it already was, by publishing and publicizing a junk meta-analysis.”

C-secs Not Due to Obesity or “High Risk” or Demand

At six hospitals in Massachusetts, forty percent of first-time mothers give birth by cesarean, according to this editorial in the Boston Globe, by Judy Norsigian (Our Bodies, Ourselves) and Timothy Johnson, MD (U Michigan). “Yet none of these hospitals is designated as a high-risk center. So much for the argument that high-risk pregnancies are the reason for these rates.” They also slash through other myths, like that more mothers are too old, too fat, or too posh to push. The C-section rate for women on Medicaid is rising faster than for women with private insurance, they report (which costs taxpayers more). “Considerable media attention has focused on how extreme obesity can raise the risk of having a caesarean, but more emphasis is needed on these system-based approaches,” they write, and go on to recommend that hospitals support vaginal birth after cesarean, restrict labor induction, and offer more nurse-midwifery.

They point out that in Boston, the two hospitals with no midwives had cesarean rates of 37% and 42%, while those with midwives had rates between 27%-35% (though they don’t say what rates the midwives alone achieved). “Enhancing access to midwifery care might well be the most effective approach to safely reducing the overall caesarean rate,” they write. “We must finally make midwives more central in maternity care — as do all other countries whose birth outcomes are superior to ours.” A true and brave statement from an obstetrician, but those numbers suggest that nurse-midwives can only do so much to mitigate a hospital culture that tends toward interventions and surgery. When midwives attend births autonomously outside the hospital setting, cesarean rates are closer to 5%.

 

Can ACOG Block Midwife Competition in NY?

courtesy WolfeHere’s how precarious women’s birthing rights are, even in New York City: when Bellevue hospital shut down its midwife-run birth center, women — particularly women with low incomes — lost one of the most supportive places in the city to give birth: the C-section rate there was less than 4%.

Then, in April, when St. Vincent’s hospital closed entirely, nearly all of the home birth midwives lost their legal right to practice. That’s because the state requires that every midwife have a written “practice agreement” with a physician or hospital, and St. Vincent’s was practically the only one willing to sign.

The agreement is a piece of paper that midwives and advocates argue doesn’t mean very much — their professional standards already require that they have “back up” in place to transfer clients who need advanced medical care. But without this piece of paper, the midwives are now effectively illegal. Advocates are trying to change the law, and the New York Times reports that “a week ago, a bill that would repeal that requirement breezed through Assembly and Senate committees, and its champions expected it to pass the full Legislature within days. Then it hit heavy opposition from the American Congress [formerly "College"] of Obstetricians and Gynecologists.” The professional group’s reasoning? It would allow the midwives to “expand their turf and directly compete with doctors.”

And that’s not all: “This legislation…has the ability to pave the way for midwives to open their own independent birthing centers,” said ACOG.

Where will it end?? If more midwives were able to practice, more women would have access to out-of-hospital birth, and there would be fewer cesareans, fewer related complications, and less cost to taxpayers. There should really be a law…

Amnesty Calls U.S. Maternal Health Care a “Crisis”

Ina May Gaskin's Safe Motherhood QuiltAmnesty International minces no words in its new report on U.S. maternity care. Deadly Delivery: The Maternal Health Care Crisis in the U.S.A., reports that more than 2 women die per day in the United States from pregnancy- or childbirth-related complications, a rate that’s worse than in 40 other industrialized countries. “Preventable maternal mortality
is not just a public health issue, it is a human rights issue,” states Amnesty.

“Women in the USA face a range of obstacles in obtaining the services they need. The health care system suffers from multiple failures: discrimination; financial, bureaucratic and language barriers to care; lack of information about maternal care and family planning options; lack of active participation in care decisions; inadequate staffing and quality protocols; and a lack of accountability and oversight.”

The report profiles several women who died or nearly died because of inadequate, inappropriate, or discriminatory care: one woman dies of a blood clot following a cesarean section, which could have been prevented with simple circulation stockings (a standard prophylactic for other major surgeries); another woman bleeds to death following a C-section, even after she and her husband plead with medical staff to address her troubling symptoms; a high-risk woman experiencing complications late in pregnancy is turned away from a prenatal clinic because she can't afford a $100 deposit; both she and her baby die after care is delayed.

Each death represents dozens of “near misses” that often leave women in worse health; of the 4 million American women who give birth each year, 1.7 million women experience complications that lead to adverse effects. "The US health care system is failing women," says Amnesty. Read the full report here.

 

NYT: Res Midwives a Model for U.S. Health Debate

courtesy NYT

In today’s New York Times, Section A, a story about a tiny, impoverished Navajo hospital in Tuba City, AZ, doing birth better than anyone: “this small hospital in a dusty desert town on an Indian reservation, showing its age and struggling to make ends meet, somehow manages to outperform richer, more prestigious institutions when it comes to keeping Caesarean rates down, which saves money and is better for many mothers and infants.”

How do they do it? Midwives attend the majority of births; obstetricians are available if needed. All the providers are on salary, so the profit motive is gone. And the hospital is federally insured, so it hasn’t been bullied into banning VBAC like so many others around the country. Even though the patient population has risk factors like hypertension and diabetes, the cesarean rate is a mere 13.5%.

“Tuba City…could probably teach the rest of the country a few things about obstetrical care,” writes the Times. “But matching its success would require sweeping, fundamental changes in medical practice, like allowing midwives to handle more deliveries and removing the profit motive for performing surgery.”

Maternal Deaths Rising in CA, State Sitting on Report

Investigative journalism lives at California Watch, which published this article about maternal mortality. An independent task force investigating the problem found “the most significant spike in pregnancy-related deaths since the 1930s…it’s more dangerous to give birth in California than it is in Kuwait or Bosnia.” But the state has yet to release a report.

This investigation is not the first to reveal higher than officially reported numbers of deaths, but it appears to have gone deeper than previous reviews in Virginia, New York, and Florida. “The group’s initial findings provide the first strong evidence that there is a true increase in deaths — not just the number of reported deaths.” And unlike previous reviews, it sought to determine causes, which are usually attributed to women: obesity, older mothers, and fertility treatments. The data, however, suggest otherwise, according to Elliot Main, MD, the task force’s lead investigator: “What I call the usual suspects are certainly there,” he told California Watch. “However, when we looked at those factors and the data analyzed so far, those only account for a modest amount of the increase.” What then is to blame for the increase?

Main said scientists have started to ask what doctors are doing differently. And, he added, it’s hard to ignore the fact that C-sections have increased 50 percent in the same decade that maternal mortality increased. The task force has found that changing clinical practice could prevent a significant number of these deaths.

While the findings appear to be languishing with the state department of public health, the Joint Commission, which certifies and accredits hospitals, is taking action. On January 26 it issued an alert, stating: “Unfortunately, current trends and evidence suggest that maternal mortality rates may be increasing in the U.S.”  After receiving the CA task force’s report, the Commission “issued incentives for hospitals to reduce inductions and fight what it called ‘the cesarean section epidemic.’”

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