Breastfeeding Facts for Fathers

75 percent of women breastfeed if their partners support it. Check out "Breastfeeding Facts for Fathers,” a short booklet highlighting the crucial role men have in encouraging their partners to breastfeed.

Why do OBs like induction so much?

Thanks to a CIMS report for spotting the latest American College of Obstetricians and Gynecologists practice bulletin on induction, in which ACOG approves of inducing labor for "psychosocial" (non-medical) reasons and cervical ripening with the synthetic prostaglandin misoprostol (trade name Cytotec). By contrast, Canada and the UK do not approve of these risky methods.

Compared to women who go into labor on their own, women who have an elective induction are at increased risk for intrapartum fever, instrumental birth, cesarean section, and are more likely to use analgesia including epidurals. Babies are at risk for irregular heart rate patterns, shoulder dystocia, neonatal phototherapy to treat jaundice, neonatal resuscitation and admission to a neonatal intensive care unit. According to the white paper "Idealized Design of Perinatal Care" published by the Institute for Healthcare Improvement, "Based on a review of U.S. medical malpractice claims, [the labor-inducing drug] oxytocin is involved in more than 50 percent of the situations leading to birth trauma."

These complications of labor also impact mother-infant attachment and the initiation and continuation of breastfeeding.

ACOG approves of inducing labor at 39 weeks while a similar professional group in Canada states gestational age should be at least 41 completed weeks; UK guidelines state induction for non-medical reason can be considered at or after 40 weeks.

Misoprostol, an inexpensive synthetic prostaglandin, was developed and is marketed to prevent and treat gastric and duodenal ulcers. The use of misoprostol for cervical ripening and induction of labor (off-label use) is approved by ACOG, but not recommended by either Canada or the UK. Misoprostol is not approved by the manufacturer for use in pregnancy. Misoprostol is associated with excessive uterine contractions, fetal heart abnormality, hemorrhage, hysterectomy, and sometimes fetal death. Both Canada and the UK recommend its use be restricted to clinical trials.

Nearly one in four births in the U.S. is induced (many more receive oxytocin to speed things up) and according to the Agency for Healthcare Research and Quality (AHRQ), although it is not entirely clear what proportion of these inductions are elective (i.e. without a medical indication), the overall rate of induction of labor is rising faster than the rate of pregnancy complications that would lead to a medically-indicated induction. According to Childbirth Connection's report, "Evidence-Based Care: What it Is and What It Can Achieve," the most common gestational age at birth among single babies in the U.S. is now 39 weeks rather than 40 weeks.

A Walk to Beautiful

I watched a very powerful film the other night called "A Walk to Beautiful." The documentary, released in 2008, just came out on DVD. It's the heartbreaking story of the silent epidemic of obstetric fistula in Ethiopia. This film, besides telling the first-person stories of the five women it follows from their villages to the capital for treatment, also reveals a larger narrative about maternal mortality, reproductive rights, child marriage, malnourishment, and birthing practices in a third world country.

The film has traveled the festival circuit and met continual praise from critics, for good reason.

A fistula usually develops when a prolonged labor presses the unborn child so tightly in the birth canal that blood flow is cut off to the surrounding tissues, which then rot away. The result is a hole between either the rectum and vagina or between the bladder and vagina, which means the mother leaks feces or urine uncontrollably, leaving her a social pariah, typically abandoned by her husband or family.

The most common reason for fistulas shown in this film is the practice of girls being married off too young and becoming pregnant well before their bodies can fit a baby through the birth canal. Of course, lack of proper nutrition throughout their lives can also lead to them being smaller than they should be for a safe birth.

My sister-in-law in Tampa drew my attention to this front page story in the St. Pete Times; the piece about women seeking to have a VBAC came a month after another story explaining that c-sections in Florida were so common, mothers expected them. It's nice to see balanced reporting on the topic. Thanks for sending, Melissa (who managed to have two natural births in Florida somehow!).

The trouble with NICUs

I have been chewing this one over for more than a month because the idea is so distasteful. But alas, I feel compelled to write about it because a friend's baby, born a little bit early but weighing more than 5 pounds, was in the NICU for no great reason and she had to go home without him.

So here it is: At a recent maternity care conference, a couple people had the courage to speak out regarding the "elephant in the room," ie. neonatal intensive care units as the new cash cows for hospitals. These specialized units are popping up even well outside the realm of the urban teaching hospital. And more babies are being sent there. If more babies need NICUs than ever before, that is alarming and we need to ask ourselves why (too many c-sections, perhaps?. If more babies don't need them but the hospitals do, that is horrible, and probably unethical.

For skeptics who may ask, "What is the harm in providing extra services for borderline cases," such as my friend's baby?

Atul Gawande's piece in a recent New Yorker explains it far better than I could.

Last year in Miami-Dade County more women had cesareans than vaginal births.

This is tragic and outrageous from a medical ethics perspective. One reason for the high section rate? Virtually no docs in that part of the world carry malpractice insurance because it is too costly, so they fly bare and use cesareans as a shield if the tiniest issue crops up during labor. The rest of us pay the price of soaring medical expenses.

I also think there is something culturally different there. During my book tour, I spoke in just about every major city in this country but there was only one place -- Miami -- where a woman stood up after my talk to say that she would rather have a c-section "just because" than deal with the pain and inconvenience of a vaginal birth. It's a culture of Botox and face lifts and filling in swamp lands to build fake castles. Why do we try so hard to cheat nature?

Support midwifery, save a life

Since May 5th is International Midwives Day, I wanted to do two things. First, say thank you to the two midwives who attended my second son's birth, at home.

And second, spread the word about Americans For UNFPA, the United Nations Population Fund, which provides women’s health care and promotes the rights of women around the world. AMERICANS FOR UNFPA is dedicated to building moral, political and financial support within the United States for the work of UNFPA.

Every minute a woman dies in childbirth somewhere in the world — 536,000 deaths per year — and almost all of them are preventable. Every year, the world loses $15 billion in productivity because of maternal death. It would only cost $6 billion to provide the health services to save women's lives. The Obama administration has restored funding of UNFPA, which had been suspended since 2002. And in March, Congress allocated $50 million to UNFPA and its life saving programs in 150 countries around the world. With this financial contribution the U.S. stands in solidarity with the world’s women and the 180 governments that support UNFPA’s efforts each year. This contribution will help support, among other UNFPA initiatives, training midwives to make birth safer.
Click here to help end maternal death, and declare yourself an American for UNFPA.

Inductions at record levels

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


STUDY: MANY LABOR INDUCTIONS ARE UNNECESSARY
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.

Best-feeding

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.

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.

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.

Sigh.

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.

Breastfeeding vs. The BlackBerry

Check out "The Case Against Breastfeeding," by Hanna Rosin, in this month's Atlantic.

http://www.theatlantic.com/doc/200904/case-against-breastfeeding

I read the article as I was breastfeeding my 15-month-old, trying to put him to bed at night. It was the first moment, after a full day at work, that I could relax, yet I was getting worked up. Rosin may be right about the slim evidence about breast feeding's benefits. But having studied the social and scientific approaches to childbirth around the world over the last million or so years, I know that evidence doesn't matter much. The real driver behind the decisions women make regarding pregnancy, birth and the postpartum period have more to do with fashion and zeitgeist. Right now, our culture says breast is best. Just ask Angelina Jolie. However, Rosin's point about breast feeding being a tool to keep women down in the way that Hoover vacuums did in the 1950s? Absurd. My BlackBerry is a far worse offender. It is a cynical and exhausted woman who thinks of breastfeeding as another thing on her to-do list. Yet we've all been there. Especially those of us with more than one child. But the real issue is not breastfeeding; it's everything else: The laundry, grocery shopping, mortgage, preschool tuition, and clients who don't care how many times a baby woke you up the night before. Instead of backbiting at the playground mommy circle over who is formula feeding, wouldn't it be more productive to fight the system over the fact that women are paid less than men for the same work? Or directing that energy toward fighting for paid maternity leave -- or even an unpaid leave of any substantial amount of time -- for all women of America?

Herbal expertise

Someone asked me for reading suggestions on midwifery herbs...

I haven't cracked a book on the subject in a while, but my mind went to two tomes: The Byrthe of Mankynde, the first known midwifery text written in the English language in the 16th century. Of course, the book is written in Olde English so it is a bit hard to parse its concoctions...I read an original copy at the Harvard Medical School's rare books department (you can't actually take the book out of the room, and it was while ago, so my memory may not be right) but I found a repro version exists on Amazon in the UK. Too geeky to ask for my birthday?

Another cult classic (circa 1979) is by Jeanine Parvati, called Hygieia: A Woman's Herbal.

Anyone have other ideas?

Got orgasm?

My friend Viv, a journalist in the UK, was asking me recently about the film "Orgasmic Birth." She, like any good reporter, was skeptical.

"The more I read on this subject the more I just refuse to believe in the existence of the birth orgasm... They are confusing one sensation with another, I feel," she said.

Ah, Viv.

I told her that while I do believe it is minutely possible (like a plane crash) for a woman to have an orgasm while giving birth, I feel like viewers are taking the title too literally. In general, the concept of orgasmic birth should be more about enjoying the experience. I think there are many ways a woman can increase her chances of enjoying birth, especially -- and not despite -- going without pain medication.

I like to think of childbirth like running a marathon or climbing a mountain. Those who do either clearly can suffer exhaustion and pain, but there is an amazing high they feel upon successful completion from going through something so intense and those feelings would be diminished if any part of the journey were numbed...

Video contest

I am trying to spread the word about an interesting film project...

Birth Matters Virginia is inviting mothers, fathers, filmmakers, film students, birth advocates, and others to create a 4-7 minute documentary video about birth. The subject can be anything related to mother-friendly maternity and delivery care, and the goal is to educate women about their options and choices. The first-place winner will receive a cash prize of $1000. Second place $500 and an honorable mention prize of $100 will also be awarded. The deadline for entering the contest is Mother's Day, May 10, 2009. The organization is based in Virginia, but entries from around the world are welcome and all are eligible for prizes, both amateur and professional.

Guest judges of the video contest are Sarah Buckley, Ricki Lake, and Abby Epstein (the former is an MD, homebirth mother of four and author of "Gentle Birth, Gentle Mothering: A Doctor's Guide to Natural Childbirth and Gentle Early Parenting Choices," and the latter two known for "The Business of Being Born," which you must see if you haven't).

For rules and to see how to enter, please visit http://www.birthmattersva.org/videocontest.html You can also join their Facebook group to get updates about the contest and exchange ideas with other participants at http://www.facebook.com/groups/edit.php?gid=73753459808#/group.php?gid=737534598\\08.

Home birth photos

I just wanted to pass along the profile of a fellow former journalist who is now taking home birth photos in the Boston area. Her name is Cydney Scott and this is what she says:

I recently had the honor of photographing two home births in the greater Boston area. I am a professional photographer with over ten years experience in journalism and I have never enjoyed photographing something as much as the big event of a child's arrival!

After having to take a buy-out from my newspaper a few months ago, I have been dealing with the challenge of continuing to do what I love - document life. I would welcome the opportunity to make my services known to other parents who might want their birthing day documented.

The birth photos can be seen on my site, cydneyscott.com, listed under "Birth" under the "portfolios" dropdown menu.