Monday, April 27, 2009

Inductions at record levels

A report released today from thh Childbirth Connection shows a shocking induction rate in the US of 40 percent!

Widespread Use of Induction Potentially Harmful to Woman and Baby

NEW YORK, NY – Induction of labor is on the rise in the U.S., standing at 41% according to a large national survey of women who gave birth in 2005. But, a new study published in the April issue of BJOG, the peer-reviewed journal of the Royal College of Obstetricians and Gynaecologists, finds that the best available evidence does not support many reasons medical providers give for using drugs or other measures to cause labor to begin.

The investigators found support only for inducing labor at or beyond 41 completed weeks of gestation and under some conditions when a woman's membranes break before labor. However, there is not good evidence for inducing labor in many other situations, including when the fetus is believed to be large or to have restricted growth, or when a woman is pregnant with twins, has insulin-dependent diabetes, or has low levels of amniotic fluid.

The study’s lead author, Dr. Ellen Mozurkewich, a maternal-fetal medicine specialist at the University of Michigan, said, “The best available evidence does not support routine inductions in many situations for which induction is currently being recommended to patients. More research is necessary to clarify the risks and benefits of induction in these situations."

Many pregnant women may be receiving inappropriate care. For example, 17% of women who participated in Childbirth Connection's national Listening to Mothers II survey in 2005 said they had been induced because their caregiver was concerned that their baby was too big. However, best evidence suggests that labor induction is not beneficial in this case.

“We now know that every week of gestation counts in terms of brain and lung development. When there is no good reason to end pregnancy, mothers and babies benefit from waiting for labor to begin on its own,” said Carol Sakala, Director of Programs, Childbirth Connection. “Starting labor early can lead to negative outcomes for the woman and/or baby."

To foster high quality maternity care, Childbirth Connection, a research and advocacy organization, commissioned this study through a grant from the Transforming Birth Fund of the New Hampshire Charitable Foundation.

Concerns about inducing labor without an established medical rationale include increased risk of cesarean section for some mothers (e.g., first-time mothers and women with a cervix that is firm and closed), and babies who are born before full lung and brain maturation. Estimates of how long a fetus has been developing can be off by up to two weeks, and labor induction can unwittingly end with a preterm birth.

Thursday, April 23, 2009


Thanks to Jennifer Block for setting the record straight on breast-is-best evidence. It was also good to come across a story in the NY Times a couple days ago that emphasises that not only is breastfeeding good for babies, it is good for moms. Both of these pieces come on the heels of the controversial piece that Hanna Rosin wrote for Atlantic Monthly, essentially equating the duties of breastfeeding with shackles.

Wednesday, April 15, 2009

Dutch treat

A new study out of the Netherlands shows what we already knew: That home birth for low-risk women is as safe as hospital birth. They studied more than 500,000 births to prove it. While it may be difficult for some to understand how on earth this could be, look at the concept backwards: Hospitals can be more dangerous than your home.

Dim the lights, cut, action

This is an fascinating concept: "The Natural Cesarean."

Given that c-sections are the most common surgery performed in this country, this a great step forward to humanize the experience and improve the immediate health of the newborn.... But still, nothing "natural" about it.

Saturday, April 04, 2009

Transforming Maternity Care Part IV

Two last things that were interesting at the maternity care summit organized by the Childbirth Connection.

1. Several people pushed to have nitrous oxide -- a.k.a "laughing gas" in the US or "gas and air" in the UK -- be a serious contender with the epidural. Why? It's easy; a woman can practically administer it to herself. That is great when you consider that 18 percent of women giving birth in this country live in rural areas, where the closest hospital does not have an anesthesiologist 24/7, a fact that usually pushes women to drive farther during labor to a hospital where they CAN get an epidural.

2. someone mentioned that infant mortality in Pittsburgh is 12.9 percent. Could that possibly be true?

Transforming Maternity Care Part III

There has been much to write about related to last week's birth professional summit called Transforming Maternity Care , whose goal is to make evidence-based care the standard in America, the land where obstetrical practices -- even bad ones -- die hard in the hospital.

But one midwife stood to say that while the hours of discussion were riveting, the average mother-to-be does not even know there is a problem with maternity care.

Which is why we need a more effective communications campaign to reach them.

On my way back from the conference in DC to Boston, I shared a cab (and hours of delay at the airport) with Gene Declercq of BU's School of Public Health. I asked him, given the success of the breastfeeding campaign in recent decades, is there hope that similar tactics could be applied to a campaign to improve maternity care, so that women know what practices are truly good for them based on the evidence?

He was dubious, saying that with breastfeeding, the only stakeholders to truly oppose nursing were the formula companies and they needed to be subtle in their marketing.

With childbirth, a whole medical system -- one that is paid for performing procedures, many unnecesary and some even harmful -- is set up to keep the status quo.


He may be right, but as one speaker made clear, childbirth is still a sexy issue that gets people's attention. And with more than 4 million births a year in this country, there is a built in audience. Let's try to reach them.

Transforming Maternity Care Part II

At last week's landmark gathering of childbirth, legal and insurance experts from around the country for "Transforming Maternity Care: A High Value Proposition," there were great ideas on how to make care more evidence-based. (Also interesting people spotting. There was Marshall Klaus, the doctor who did groundbreaking research on bonding, standing next to supermodel Christi Turlington, who is working on a documentary on maternal mortality...) But I digress.

In the blog post below I talk about insurance payments being used as a carrot and stick to influence methods of care -- to make them the right ones at the right time.

Today, let's talk about how the threat of malpractice influences care and how to change that.

Many panelists suggested setting up a financial system for disastrous outcomes that are no one’s fault (Sweden and New Zealand are models for this). The system should also incentivize having obstetric teams practice emergency situations to earn a reduction in malpractice insurance premiums, something already being done in Boston’s Harvard system. Another idea: Establish “apology” laws so providers can express remorse without admitting malpractice.

Aside from tackling malpractice issues, we also need to find legislative options to fix the disjointed system of health information technology, or HIT. Only 17 percent of American hospitals have such systems, but the number is expected to grow. HIT won’t work if we just digitize patient information; we need to embed performance measurements and code information better to enable data collection. One panelist noted that in the UK, women carry their own medical records for maternity care – “no they don’t lose it,” she said, explaining how the practice is a symbolic shift of authority that seems antithetical to the US system.

Other suggestions that came out of the conference:
--Develop national measures for birth outcomes, something necessary to accomplish the above.
--Look at what other countries are doing right (for less cost and better care).
--Within health plans, foster transparency and access to caregiver choice (ie. midwife, doula, doctor, etc.)
--Increase cultural competency as we rapidly become a nation of minority majority.

Transforming Maternity Care

Yesterday I was in Washington D.C., where the scent of health care reform is as pleasant as the cherry blossoms, for a meeting of the minds on the subject of a particular brand of care: That for pregnancy and childbirth.

Childbirth is the number one reason why someone is admitted to the hospital (more than 4 million babies are born in the US every year) and the biggest contributor to the cost of health care, comprising 17 percent of the country’s GDP. About 47 million people are uninsured in this country and many more are underinsured.

So the topic is huge, no pun intended.

About 150 thought leaders from around the country attended "Transforming Maternity Care: A High Value Proposition," a confab to make evidence-based care a national conversation.

Long overdue, in my book, given that the national c-section rate is at an all-time high of nearly 33 percent, and other procedures and interventions endure despite research showing they should be a last resort, not the first. But evidence-based care isn’t always enough to change the behavior of consumers, doctors or public policy makers. There needs to be a carrot and a stick.

There were many great recommendations from the conference which have broader applications throughout the health care universe. I am going to dole it out one post at a time over the next week or so.

Starting with:

In the absence of a consumer groundswell, we need to change the system, specifically, we need a new payment system. Right now we pay for procedures. An overhauled system would reward good evidence-based practices (and discourage those that are not). For example, steer payments toward things such as providing a safe environment for VBACs, offering smoking cessation programs and diabetes control; don’t reward the overuse of technology, don’t reimburse elective inductions at 39 weeks. What if insurers paid more for first-trimester visits than third-trimester visits? Paid more for vaginal births than c-sections? Paid more for midwives than physicians?

I think we all know birth would be different in America.