Friday, August 31, 2007

Midwife with a Knife: Forceps Are Your Friends

Forceps, as we know them in the west, were invented by men, specifically the Chamberlen family in England in the 16th century. For hundreds of years, only members of the all-male barber-surgeon trade could use the the tools, so midwives would have to call a barber to a birth gone awry. This post below, by a female OB -- and most OBs under 35 today in America are women -- caught my attention because its sentiment is so unexpected.

Midwife with a Knife: Forceps Are Your Friends

Tuesday, August 28, 2007

Maternal mortality

I know many people find America's maternal mortality statistics shocking -- particularly the fact that nearly two dozen countries have lower death rates attributable to pregnancy and birth than the US does -- but this report ratchets up the alarm.

Experts: U.S. Childbirth Deaths on Rise

The Associated Press
Friday, August 24, 2007; 4:43 PM

ATLANTA -- U.S. women are dying from childbirth at the highest rate in decades, new government figures show. Though the risk of death is very small, experts believe increasing maternal obesity and a jump in Caesarean sections are partly to blame.

Some numbers crunchers note that a change in how such deaths are reported also may be a factor.

"Those of us who look at this a lot say it's probably a little bit of both," said Dr. Jeffrey King, an obstetrician who led a recent New York state review of maternal deaths.

The U.S. maternal mortality rate rose to 13 deaths per 100,000 live births in 2004, according to statistics released this week by the National Center for Health Statistics.

The rate was 12 per 100,000 live births in 2003 _ the first time the maternal death rate rose above 10 since 1977.
National Center for Health Statistics 2004 deaths report:

To read the full AP story go to:

To read the government report, see page 12 at:

Saturday, August 18, 2007

Summer reading

I have just finished reading two books. First was the thoroughly researched and thoroughly readable Pushed: The Painful Truth about Childbirth and Modern Maternity Care, by Jennifer Block, a former editor at Ms. Magazine and Our Bodies, Ourselves. The second was Animal, Vegetable, Miracle: A Year of Food Life, by Barbara Kingsolver, about her radical 12-month undertaking of eating only that which she grew herself or that grew nearby. What struck me about both of these books -- besides how well each was done -- is how much these seemingly disparate topics, how babies are born and how food gets to our table, overlap in modern life. In Pushed, Block writes how "there was a direct tie between the rise of the assembly line -- of mass production -- and the rise of standardized, mechanize birth." Pitocin, the labor inducing and augmenting drug that half of all American women receive in the hospital today during labor and delivery, "owed its commercial availability to the centralization of the meatpacking industry. One pound of dried extract became the profitable by-product of pituitary glands from twelve thousand young cattle."

Kingsolver, for her part, talks about how agribusiness has brought us the unlikely phenomenon of cheap bananas all year round in places where they don't grow, and farm subsidues that actually help companies like Monsanto put small-town farmers out of business. In the end, we are left with grocery stores full of foods that are less healthful and more damaging to the environment, given the fertilizers and pesticides involved, as well as the fuels used to transport the food.

The bottom line in Pushed is that the natural way of giving birth should be the default, not the exception today. And that we still don't fully understand how we are messing with our complex biological systems when we override them with drugs and tools and schedules in a room full of strangers.

Likewise, Kingsolver argues that we all need to be reeducated about the local seasonality of food, why it is important not just to eat organic but to buy local. She writes: "The drift away from our agricultural roots is a natural consequence of migration from the land to the factory...But we got ourselves uprooted entirely by a drastic reconfiguration of US farming, beginning just after World War II. Our munitions plants, challenged to beat their swords into plowshares, retooled to make amonium nitrate surpluses into chemical fertilizers instead of explosives. The next explosions were yields on midwestern corn and soybean fields." Which is why we are glugging down products sweetened with corn syrup and getting fat in the process. To say nothing of our 30-plus percent cesarean rate.

Monday, August 13, 2007

Simpson's house

I am here in Edinburgh, a gorgeous cobbled, hilly city with a castle, plucky people and an overwhelming amount of artist events to see at one of its various festivals (The Fringe, The International Festival, and The Edinburgh International Book Festival, for which I am here). But the most interesting sight for me to see this morning was the home of James Young Simpson, the first person to use chloroform to alleviate the pain of childbirth. In 1847, Simpson, two medical assistants, and some other guests passed around a tumbler (preserved in the red wall-papered dining room) that was filled with the "curious liquid." After inhaling the chloroform, they all flopped to the floor, with the exception of Simpson's woozy niece who looked down on them as she cried out "I'm an angel! Oh I'm an angel." With that, Simpson knew he had found a cure for pain and administered the drug to his first obstetric patient shortly thereafter. The woman gave her baby girl the middle name "Anaesthesia." One other interesting note: Simpson's house, the place where a drug was invented, is now used as a drug treatment center.

Said in Scotland

I gave a talk today at the Edinburgh International Book Festival about my book, published in the UK as Birth: A History. In the front row of the event sat Gillian Smith, head of Scotland's Royal College of Midwives. At one point, the audience and I were lamenting the lack of one-on-care women often receive during labor in the hospital, and how this was feeding the trend, in western countries, of women hiring doulas. Ms. Smith, however, quickly pointed out that in Scotland -- unlike England where there is a severe midwifery shortage -- women DO receive continuous care from a midwife during labor and birth. "How?" I asked. "Is it a function of the modest size of Scotland's population or the government's understanding of the value of such care and its support of having enough midwives to service the population. (Don't forget, they have nationalized medicine here.) She credited the government's evidence-based view that continuous care leads to better labors and easier births.
Bonnie good!

Wednesday, August 08, 2007

It was only a matter of time...

When people talk about technology creeping into the delivery room, this is not usually what they have in mind. Check out this link to a piece on

Monday, August 06, 2007

An excellent op-ed

From today's Boston Globe:

The folly of 1 percent policy
By Eugene Declercq and Judy Norsigian | August 6, 2007

THE PHRASE that comes to mind when you hear Dick Cheney is probably not "reshaping American childbirth." Yet Vice President Cheney's "One Percent Doctrine" -- the title of Ron Suskind's 2006 book on post9/11 national security policy -- perfectly captures an approach to decision-making in American medicine that misallocates resources and undermines primary care. By focusing maximum resources on preventing an extremely rare but potentially disastrous outcome over necessary preventive care, this model has shaped healthcare decision-making in areas ranging from hysterectomies to coronary bypasses. One shift -- the rapidly rising caesarean rate -- exemplifies this problem.

Suskind reports that in debates over national security policy following 9/11, Cheney repeatedly invoked the principle that if there's even a 1 percent chance of a terrorist attack, we must prepare as if it were a certainty. This extreme position invariably gave Cheney the moral high ground in debates, where he could appear more willing to protect American interests than others with a broader focus. Of course, in winning the immediate argument, Cheney also ignored myriad longer-term complications involving problems not solved while the "emergency" is addressed.

In healthcare, caesarean sections represent the most recent example of this doctrine, as births are increasingly treated as potential emergencies requiring expensive, high-tech interventions. The caesarean rate in the United States has increased from 20 percent in 1996 to a record high of more than 30 percent in 2005, trailing only Italy (37 percent) and South Korea (35 percent) among industrialized countries. Obstetricians are more skilled at performing caesareans than ever before and caesareans are safer than ever. But they are not without negative consequences. When they are performed as elective surgery on mothers with little or no medical risk, these harms outweigh the benefits.

Yet caesareans are advocated as necessary to avert potential disasters that might occur. At a 2006 meeting sponsored by the National Institutes of Health, one doctor captured the 1 percent (or in this case 1/30th of 1 percent) doctrine when he described rare conditions and noted the benefits of a 100 percent caesarean rate (you read that right) in avoiding these outcomes in 3 in 10,000 cases.

Likewise, a 2006 position statement from the American College of Obstetricians and Gynecologists states that "Labor and delivery is a physiologic process that most women experience without complications," but then goes on to emphasize the 1 percent doctrine: ". . . serious intrapartum complications may arise with little or no warning, even in low risk pregnancies." The statement and the doctor's claim are true, of course -- anything can occur -- but does that mean that society benefits when every birth is handled as a disaster (or worse yet a lawsuit) waiting to happen?

No one wishes a health problem on any mother or child, but the "1 percent" advocates of higher caesarean section rates assert they care more about infant outcomes than those who oppose them. However, the consequences of universal caesarean sections on a largely healthy population are profound in both the short run (longer recovery, greater postpartum pain, higher maternal rehospitalization rates for surgical complications, higher costs) and long run (higher rates of subsequent stillbirths, greater risk of future uterine rupture, longer stays requiring more hospital space). The 1 percent doctrine cares little about such consequences since its focus is on winning the current argument.

Creating a crisis atmosphere is essential to the 1 percent doctrine and its ability to override all obstacles -- be they constitutional restrictions on national security measures or concerns about the United States ranking last among industrialized countries on infant mortality. Such an atmosphere encourages more centralized decision-making and stifles debate. The fact that most of these crises never occur and that countless resources are expended to prevent something that was unlikely to happen anyway is lost in the relief of the immediate positive outcome (a healthy baby or no terrorist attack). In the long run, however, we've wasted time and money, created new problems, and ignored systematically documented, if less emotional, evidence.

A version of the 1 percent doctrine has been invoked for decades in steering the US healthcare system away from an emphasis on preventive care for the whole population to an obsession with treating rare events. As a debating strategy, the 1 percent doctrine is extremely persuasive. As a policy guideline, it makes no sense in either politics or healthcare.

Eugene Declercq is a professor of maternal and child health at the Boston University School of Public Health. Judy Norsigian is executive director of Our Bodies Ourselves.

Wednesday, August 01, 2007

Food for thought

Hospital told to return placenta to mom
The Associated Press
News Fuze
Article Launched:07/19/2007 09:33:19 AM PDT

LAS VEGAS—A woman has won a court fight to keep the placenta after her daughter's birth. She had planned to grind it up and ingest it as a way to fight postpartum depression, but now plans to bury it.
Clark County District Court Judge Susan Johnson granted a preliminary injunction Tuesday, ordering Sunrise Hospital and Medical Center in southern Nevada to return the placenta to Anne Swanson. Hospital officials said they will comply.

The hospital had refused to give the uterine lining to Swanson following the April 12 Caesarean birth of her daughter, with officials calling it contaminated biohazardous waste. The judge ordered the hospital not to destroy the placenta, which was frozen, and ordered that it be turned over to Swanson within two weeks.

Swanson, who was 30 when she gave birth, originally wanted to give her placenta to a friend to be dried, ground into a powder and packed into capsules. She said she now plans to dry, store and eventually bury the organ instead of eating it.

"I hope this brings about a better awareness about the benefits of placenta," she said, citing a theory that placental hormones can help control postpartum blues.

Amy Stevens, system vice president for Sunrise Health, which operates Sunrise Hospital, described the ruling as specific to Swanson. She said the hospital must comply with strict regulations in handling human biohazardous waste.

There is no Nevada law prohibiting hospitals from returning placentas to mothers. But several Las Vegas area hospitals told the Las Vegas Review-Journal the organ is usually destroyed unless a physician designates it for medical tests or a patient seeks it for specific religious or cultural reasons.