Thursday, December 08, 2011
A birthday thanks
Today is Harrison's birthday. Four years ago, he was born in a pool of water (chronicled here) in his bedroom at our home in Boston, a VBAC attended by an amazing midwife, Deborah. As I do every year on this day, I say thank you to her for guiding me through one of the most amazing experiences of my life. This is a poem I wrote about her.
Wednesday, October 26, 2011
More Business of Being Born
I wanted to pass along the brand new trailer for More Business of Being Born from Executive Producer Ricki Lake and Filmmaker Abby Epstein. This release follows their landmark documentary, The Business of Being Born, with a four part DVD series that continues their provocative and entertaining exploration of the modern maternity care system. More Business of Being Born, available November 8th, offers a practical look at birthing options as well as poignant celebrity birth stories from stars including Alanis Morissette, Gisele Bundchen, Christy Turlington-Burns, Cindy Crawford, Molly Ringwald, Laila Ali, Kimberly Williams-Paisley and Melissa Joan Hart. Part 4: The VBAC Dilemma is currently available for rental on demand. You can watch a trailer here.
As part of the cast of the first film, I was excited to go to its debut at the Tribeca Film Festival, unexpectedly pregnant. The film confirmed my decision -- and my husband's decision -- to have a home birth. Here's what I wrote about some of the reviews of the original film.
As part of the cast of the first film, I was excited to go to its debut at the Tribeca Film Festival, unexpectedly pregnant. The film confirmed my decision -- and my husband's decision -- to have a home birth. Here's what I wrote about some of the reviews of the original film.
Monday, October 24, 2011
An amazing birth-artifact
This is an amazing image for two reasons: First, it was found by a man who is legally blind. Second, it shows a common position women gave birth -- standing up, supported by ropes or vines -- before doctors determined it was more convenient for women do to deliver on their backs. Which, it turns out, is the worst possible position because it is more difficult for both baby and mother. Thanks to Carey Goldberg at the CommonHealth Blog for pointing it out to me.
Friday, October 21, 2011
Carla Bruni-Sarkozy gives birth -- without the president there
Carla Bruni-Sarkozy gave birth this week to a girl, but her husband wasn't there -- he was busy jetting off to Germany to meet Angela Merkel on important business. Fair enough. Or is it? I quickly received a couple calls from journalists asking what I thought.
Throughout all of human history in almost every culture, until the last 30-50 years, men never witnessed the births of their babies. They didn't want to see it and the mothers didn't see the upside of having them there. Before birth moved from the home to the hospital in the early 20th Century, moms typically had a gaggle of other women and a midwife to support her through labor. Men were considered useless and it was not their place. This changed when birth moved to the hospital because suddenly women were often left to labor alone -- with the obstetrician stepping into the room at the last minute. This trend made women crave support -- and fathers, being family, were the only ones hospitals would allow, even if it took lawsuits to open the gates. (P.S. If the mother and father weren't married, hospitals initially refused to allow him to witness the birth. Lawsuits changed this practice, too.)
Despite that history, men are now expected to attend the births of their babies. Which is great, if they want to be there and the mother wants them to be.
But there are many dads who are squeamish, fight with staff, or freak out the mother. If the mother has other support -- and she always should -- and if she doesn't mind him not being there, fine. It may be best for everyone.
As for Sarkozy, he's left with a public perception problem. Is Angele Merkel more important than your wife? Did this birth seem less important than those with your previous wives? At the very least, when he did show up at the clinic, he should have brought flowers.
Throughout all of human history in almost every culture, until the last 30-50 years, men never witnessed the births of their babies. They didn't want to see it and the mothers didn't see the upside of having them there. Before birth moved from the home to the hospital in the early 20th Century, moms typically had a gaggle of other women and a midwife to support her through labor. Men were considered useless and it was not their place. This changed when birth moved to the hospital because suddenly women were often left to labor alone -- with the obstetrician stepping into the room at the last minute. This trend made women crave support -- and fathers, being family, were the only ones hospitals would allow, even if it took lawsuits to open the gates. (P.S. If the mother and father weren't married, hospitals initially refused to allow him to witness the birth. Lawsuits changed this practice, too.)
Despite that history, men are now expected to attend the births of their babies. Which is great, if they want to be there and the mother wants them to be.
But there are many dads who are squeamish, fight with staff, or freak out the mother. If the mother has other support -- and she always should -- and if she doesn't mind him not being there, fine. It may be best for everyone.
As for Sarkozy, he's left with a public perception problem. Is Angele Merkel more important than your wife? Did this birth seem less important than those with your previous wives? At the very least, when he did show up at the clinic, he should have brought flowers.
Tuesday, July 19, 2011
Regulating midwives
Below is the written testimony I provided today during a hearing for a bill that would essentially sanction home birth midwives in Massachusetts -- some home birth midwives.
Good morning. My name is Tina Cassidy. Some of you may recall that I spent many years here in this building as a member of the Boston Globe’s State House Bureau, covering many of these sorts of hearings. If I learned anything from that experience relevant to the task before me today – it’s do your research, keep it brief, and make your case clearly. So stop me if I fail on any of those points.
First, I wholeheartedly support the concept of what you are trying to achieve with House Bill 2368. Anything that promotes midwifery care – especially out of hospital midwifery care -- is good for women’s health, and the health care system, because better care can be provided for much less. Numerous rigorous studies prove this to be true.
I also support this bill’s mandate that out-of-hospital births be covered by insurance for the reasons stated above. In the UK, the government is actually encouraging more women to give birth at home as part of the National Health System because they, too, understand the benefits of home birth, not just for women but for all of society – and the public coffers.
However, I am dismayed that in an attempt to “allow” homebirths, this bill prevents women from choosing a lay midwife, a person who could have more experience and more knowledge than those who are regulated. That is something I viscerally oppose.
At a minimum, this bill prevents many worthy and wise women from practicing an ancient tradition – a deeply respectable and important tradition as old as human history – a tradition that stopped about 100 years ago when medical colleges in the US began churning out “educated” doctors ready to deliver babies without having ever seen an actual birth. But those male doctors were regulated. The midwives, with millennia of hands-on practice, were not, and they were forced to the brink of extinction, with mothers paying the consequences when that continuum of knowledge passed on from generation to generation was all but lost. Want to know how to naturally deliver a breech baby? Ask a midwife.
I urge you today, please don’t have this bill be referendum on one lawsuit, or one midwife, or one story about a birth that went awry. Sadly, bad outcomes happen with even the best doctors with years of practice and all the technology money can buy. There are fantastic doctors in this room who have said, it’s not whether, it’s when.
When women choose a lay midwife, they often do it with far more research than a woman choosing an obstetrician. I say this from experience – as someone who was a first-time pregnant busy journalist who blindly chose the first OB with an opening for an appointment – and ended up a statistic in America’s unabiding cesarean epidemic, attended by a doctor whose definition of “normal birth” becomes more constricted every year, due to increasingly onerous guidelines and rising malpractice premiums.
For my second birth, I would have been blessed to have any of the certified professional midwives in this room attend the home birth. But the midwife I choose was a lay practitioner, someone I deeply trusted and connected with. She supported me emotionally and physically during an amazing and gentle experience, as well as in the weeks postpartum. It was blue chip care that I was willing to pay for out of my own not very deep pockets.
As she supported me, I am here to support her and others like her. In an effort to allow greater access to midwifery care, please don’t limit it.
Doing such will only drive underground those practitioners who are not CPMs and lead to the persecution of women who choose them.
Finally, please accept this additional written testimony – a chapter on the history of midwifery – from my book, Birth: The Surprising History of How We Are Born. It tells the story of the role that Massachusetts played in the near-final crusade against midwives. I believe if we don’t understand history we are doomed to repeat it.
Thank you so much for your hard work on this important issue.
Tina Cassidy
Good morning. My name is Tina Cassidy. Some of you may recall that I spent many years here in this building as a member of the Boston Globe’s State House Bureau, covering many of these sorts of hearings. If I learned anything from that experience relevant to the task before me today – it’s do your research, keep it brief, and make your case clearly. So stop me if I fail on any of those points.
First, I wholeheartedly support the concept of what you are trying to achieve with House Bill 2368. Anything that promotes midwifery care – especially out of hospital midwifery care -- is good for women’s health, and the health care system, because better care can be provided for much less. Numerous rigorous studies prove this to be true.
I also support this bill’s mandate that out-of-hospital births be covered by insurance for the reasons stated above. In the UK, the government is actually encouraging more women to give birth at home as part of the National Health System because they, too, understand the benefits of home birth, not just for women but for all of society – and the public coffers.
However, I am dismayed that in an attempt to “allow” homebirths, this bill prevents women from choosing a lay midwife, a person who could have more experience and more knowledge than those who are regulated. That is something I viscerally oppose.
At a minimum, this bill prevents many worthy and wise women from practicing an ancient tradition – a deeply respectable and important tradition as old as human history – a tradition that stopped about 100 years ago when medical colleges in the US began churning out “educated” doctors ready to deliver babies without having ever seen an actual birth. But those male doctors were regulated. The midwives, with millennia of hands-on practice, were not, and they were forced to the brink of extinction, with mothers paying the consequences when that continuum of knowledge passed on from generation to generation was all but lost. Want to know how to naturally deliver a breech baby? Ask a midwife.
I urge you today, please don’t have this bill be referendum on one lawsuit, or one midwife, or one story about a birth that went awry. Sadly, bad outcomes happen with even the best doctors with years of practice and all the technology money can buy. There are fantastic doctors in this room who have said, it’s not whether, it’s when.
When women choose a lay midwife, they often do it with far more research than a woman choosing an obstetrician. I say this from experience – as someone who was a first-time pregnant busy journalist who blindly chose the first OB with an opening for an appointment – and ended up a statistic in America’s unabiding cesarean epidemic, attended by a doctor whose definition of “normal birth” becomes more constricted every year, due to increasingly onerous guidelines and rising malpractice premiums.
For my second birth, I would have been blessed to have any of the certified professional midwives in this room attend the home birth. But the midwife I choose was a lay practitioner, someone I deeply trusted and connected with. She supported me emotionally and physically during an amazing and gentle experience, as well as in the weeks postpartum. It was blue chip care that I was willing to pay for out of my own not very deep pockets.
As she supported me, I am here to support her and others like her. In an effort to allow greater access to midwifery care, please don’t limit it.
Doing such will only drive underground those practitioners who are not CPMs and lead to the persecution of women who choose them.
Finally, please accept this additional written testimony – a chapter on the history of midwifery – from my book, Birth: The Surprising History of How We Are Born. It tells the story of the role that Massachusetts played in the near-final crusade against midwives. I believe if we don’t understand history we are doomed to repeat it.
Thank you so much for your hard work on this important issue.
Tina Cassidy
Wednesday, February 16, 2011
Benefits of Continuous Support in Labor
Press release RE:continuous labor support leads to lower c-section rates and better outcomes for moms and babes. http://tinyurl.com/4c5pojv
FOR IMMEDIATE RELEASE - 11 am ET, February 16, 2011
Continuous Labor Support Reduces Risk of Cesarean Section and Other Adverse Outcomes in Women and Newborns
Type of Caregiver Can Make a Big Difference in Labor Experience
New York NY — Women who labor with a dedicated support companion are less likely than women without such support to experience a series of risky birth procedures, according to a review published in the current issue of The Cochrane Library. The comprehensive study of experiences of 15,061 women who participated in 21 randomized controlled trials confirms previously known benefits for maternal health, identifies an additional benefit for newborns, and finds no downsides. The study was carried out through the prestigious Cochrane Collaboration, an independent international organization that prepares and keeps up to date rigorous systematic reviews of evidence from the best available studies.
Overall, women who received supportive care from a companion throughout labor were less likely than women without such support to have a cesarean section, to use narcotics or any other pain medication, to use regional pain medication such as epidural analgesia, to give birth with vacuum extraction or forceps, and to rate their childbirth experience poorly. Having continuous support shortened labor and increased the likelihood of having a “spontaneous” birth with neither cesarean nor vacuum extraction nor forceps. These results confirm previous research. With the inclusion of six new randomized controlled trials, the present systematic review, identified another benefit of continuous labor support: reduced likelihood of a baby with a poor “Apgar score” rating of well being five minutes after birth. The authors conclude that all women should have continuous support while giving birth.
Ellen D. Hodnett, RN, PhD, Professor and Heather M. Reisman Chair of Perinatal Nursing Research, University of Toronto, and co-authors of “Continuous Support for Women During Childbirth” limited the study to randomized controlled trials. This type of research helps ensure that study groups are similar and that results are a true reflection of the effects of the care being studied — here, continuous labor support.
“Cesarean section, vacuum extraction and forceps, and pain medications are interventions that increase the likelihood of adverse short- and longer-term effects in women and babies. Continuous labor support is an important way for women to avoid overuse and harms of these practices, and to have a positive experience at this special time,” said Carol Sakala, PhD, MSPH, Director of Programs at Childbirth Connection. Dr. Sakala is a co-author of the report.
Supportive care during labor and birth does not involve clinical care, and may include:
• helping women with physical comfort
• providing emotional support
• offering information
• helping women communicate their wishes to caregivers
• engaging women’s husbands or partners, as desired by the couple.
Impact Depends on Type of Caregiver
The study provides new knowledge about effects of continuous labor support under different conditions. A major finding is that the impact of this care appears to differ, according to the type of person providing the care. Effects were strongest when the caregiver was neither a member of the hospital staff nor a person in the woman’s social network, and was present solely to provide one-to-one supportive care, such as a doula. Compared with women who had no continuous support, women with companions who were neither on the hospital staff nor in the woman’s social network were:
• 28% less likely to have a cesarean section
• 31% less likely to use synthetic oxytocin to speed labor
• 9% less likely to use any pain medication
• 34% less like to rate their childbirth experience negatively.
When compared with no continuous support, continuous support by members of the hospital staff did not appear to reduce the likelihood of having a cesarean section or improve ratings of the childbirth experience and may have increased the likelihood of using synthetic oxytocin. These results may reflect the fact that hospital staff can experience divided loyalties, additional duties, and constraints of institutional policies when providing continuous support. Continuous support from a person in the mother’s social network (for example, her partner, husband, other relative, or friend) appeared to increase the mother’s satisfaction with her childbirth experience, but did not seem to impact her likelihood of undergoing a series of labor and birth interventions.
Background
Historically, laboring women routinely received support from female companions. However, more recently in hospitals worldwide, continuous labor support has become the exception rather than the norm. “There is concern about widespread dehumanization of women’s birth experiences,” said Dr. Hodnett. “Concern about institutional routines, high rates of intervention in healthy women and newborns, limits on women’s autonomy and control, unfamiliar personnel, and lack of privacy is leading to calls for making continuous labor support widely available to childbearing women.”
Leading options for continuous labor support in the United States include trained labor support companions known as doulas and — for satisfaction with the childbirth experience — the help of a friend or family member who is invited to be present when a woman gives birth. Childbirth Connection’s second national Listening to Mothers survey found that just 3% of women who gave birth in U.S. hospitals in 2005 experienced the most beneficial type of labor support, in the form of doula care. Although insurance coverage of doula services is limited, trained doulas are available in many communities throughout the United States. Typically, a woman (and her partner, if she has one) selects a doula during pregnancy, and they discuss the woman’s goals, preferences, and concerns. Some hospitals sponsor doula programs to increase access to continuous labor support. In addition to continuous presence during labor, birth doulas may provide some support in the days after birth.
“Hiring a doula was one of the best decisions my husband and I made during pregnancy,” said new mom Jenny McElroy. “Though we prepared by reading books, taking childbirth classes, and practicing comfort techniques, we were inexperienced with childbirth. Our doula knew exactly how to help my husband support me, help me cope with the pain, and help us stay calm and have the birth experience we wanted.”
Effective Strategy for Improving Maternity Care Quality and Value
Medicaid programs and taxpayers cover about 42% of the nation’s births, and private insurers and employers cover about half. The review authors encourage policy makers to provide coverage and hospitals to provide programs for continuous labor support. “The benefits of continuous labor support for mothers and babies are numerous, well established, and compelling, and warrant economic analyses of the relative costs and benefits,” said Maureen Corry, MPH, Executive Director of Childbirth Connection. “Medicaid programs and others seeking ways to improve maternity care quality and value and women’s experiences of care should consider continuous labor support as a key component of a high-quality, high-value maternity care system.”
Resources for Childbearing Women, Health Professionals and Policy Makers
Childbirth Connection’s website includes an in-depth evidence-based section to help childbearing women understand the benefits of continuous labor support, decide whether to have a continuous labor support companion, and arrange for such care (see www.childbirthconnection.org/laborsupport/). The professional area of the website includes a summary of results of the updated review and provides access to the full review, at www.childbirthconnection.org/laborsupportreview/.
# # #
FOR IMMEDIATE RELEASE - 11 am ET, February 16, 2011
Continuous Labor Support Reduces Risk of Cesarean Section and Other Adverse Outcomes in Women and Newborns
Type of Caregiver Can Make a Big Difference in Labor Experience
New York NY — Women who labor with a dedicated support companion are less likely than women without such support to experience a series of risky birth procedures, according to a review published in the current issue of The Cochrane Library. The comprehensive study of experiences of 15,061 women who participated in 21 randomized controlled trials confirms previously known benefits for maternal health, identifies an additional benefit for newborns, and finds no downsides. The study was carried out through the prestigious Cochrane Collaboration, an independent international organization that prepares and keeps up to date rigorous systematic reviews of evidence from the best available studies.
Overall, women who received supportive care from a companion throughout labor were less likely than women without such support to have a cesarean section, to use narcotics or any other pain medication, to use regional pain medication such as epidural analgesia, to give birth with vacuum extraction or forceps, and to rate their childbirth experience poorly. Having continuous support shortened labor and increased the likelihood of having a “spontaneous” birth with neither cesarean nor vacuum extraction nor forceps. These results confirm previous research. With the inclusion of six new randomized controlled trials, the present systematic review, identified another benefit of continuous labor support: reduced likelihood of a baby with a poor “Apgar score” rating of well being five minutes after birth. The authors conclude that all women should have continuous support while giving birth.
Ellen D. Hodnett, RN, PhD, Professor and Heather M. Reisman Chair of Perinatal Nursing Research, University of Toronto, and co-authors of “Continuous Support for Women During Childbirth” limited the study to randomized controlled trials. This type of research helps ensure that study groups are similar and that results are a true reflection of the effects of the care being studied — here, continuous labor support.
“Cesarean section, vacuum extraction and forceps, and pain medications are interventions that increase the likelihood of adverse short- and longer-term effects in women and babies. Continuous labor support is an important way for women to avoid overuse and harms of these practices, and to have a positive experience at this special time,” said Carol Sakala, PhD, MSPH, Director of Programs at Childbirth Connection. Dr. Sakala is a co-author of the report.
Supportive care during labor and birth does not involve clinical care, and may include:
• helping women with physical comfort
• providing emotional support
• offering information
• helping women communicate their wishes to caregivers
• engaging women’s husbands or partners, as desired by the couple.
Impact Depends on Type of Caregiver
The study provides new knowledge about effects of continuous labor support under different conditions. A major finding is that the impact of this care appears to differ, according to the type of person providing the care. Effects were strongest when the caregiver was neither a member of the hospital staff nor a person in the woman’s social network, and was present solely to provide one-to-one supportive care, such as a doula. Compared with women who had no continuous support, women with companions who were neither on the hospital staff nor in the woman’s social network were:
• 28% less likely to have a cesarean section
• 31% less likely to use synthetic oxytocin to speed labor
• 9% less likely to use any pain medication
• 34% less like to rate their childbirth experience negatively.
When compared with no continuous support, continuous support by members of the hospital staff did not appear to reduce the likelihood of having a cesarean section or improve ratings of the childbirth experience and may have increased the likelihood of using synthetic oxytocin. These results may reflect the fact that hospital staff can experience divided loyalties, additional duties, and constraints of institutional policies when providing continuous support. Continuous support from a person in the mother’s social network (for example, her partner, husband, other relative, or friend) appeared to increase the mother’s satisfaction with her childbirth experience, but did not seem to impact her likelihood of undergoing a series of labor and birth interventions.
Background
Historically, laboring women routinely received support from female companions. However, more recently in hospitals worldwide, continuous labor support has become the exception rather than the norm. “There is concern about widespread dehumanization of women’s birth experiences,” said Dr. Hodnett. “Concern about institutional routines, high rates of intervention in healthy women and newborns, limits on women’s autonomy and control, unfamiliar personnel, and lack of privacy is leading to calls for making continuous labor support widely available to childbearing women.”
Leading options for continuous labor support in the United States include trained labor support companions known as doulas and — for satisfaction with the childbirth experience — the help of a friend or family member who is invited to be present when a woman gives birth. Childbirth Connection’s second national Listening to Mothers survey found that just 3% of women who gave birth in U.S. hospitals in 2005 experienced the most beneficial type of labor support, in the form of doula care. Although insurance coverage of doula services is limited, trained doulas are available in many communities throughout the United States. Typically, a woman (and her partner, if she has one) selects a doula during pregnancy, and they discuss the woman’s goals, preferences, and concerns. Some hospitals sponsor doula programs to increase access to continuous labor support. In addition to continuous presence during labor, birth doulas may provide some support in the days after birth.
“Hiring a doula was one of the best decisions my husband and I made during pregnancy,” said new mom Jenny McElroy. “Though we prepared by reading books, taking childbirth classes, and practicing comfort techniques, we were inexperienced with childbirth. Our doula knew exactly how to help my husband support me, help me cope with the pain, and help us stay calm and have the birth experience we wanted.”
Effective Strategy for Improving Maternity Care Quality and Value
Medicaid programs and taxpayers cover about 42% of the nation’s births, and private insurers and employers cover about half. The review authors encourage policy makers to provide coverage and hospitals to provide programs for continuous labor support. “The benefits of continuous labor support for mothers and babies are numerous, well established, and compelling, and warrant economic analyses of the relative costs and benefits,” said Maureen Corry, MPH, Executive Director of Childbirth Connection. “Medicaid programs and others seeking ways to improve maternity care quality and value and women’s experiences of care should consider continuous labor support as a key component of a high-quality, high-value maternity care system.”
Resources for Childbearing Women, Health Professionals and Policy Makers
Childbirth Connection’s website includes an in-depth evidence-based section to help childbearing women understand the benefits of continuous labor support, decide whether to have a continuous labor support companion, and arrange for such care (see www.childbirthconnection.org/laborsupport/). The professional area of the website includes a summary of results of the updated review and provides access to the full review, at www.childbirthconnection.org/laborsupportreview/.
# # #
Sunday, June 20, 2010
Random thoughts on Father's Day
Dictionary.com's word of the day today was couvade, and quoted a sentence from my book to describe what it means. A fitting word for Father's Day.
I also heard from my friend Jeanette, who said she was watching the film "Being Dad," a good flick for fathers-to-be. I recommend it.
I also heard from my friend Jeanette, who said she was watching the film "Being Dad," a good flick for fathers-to-be. I recommend it.
Thursday, February 04, 2010
Gisele and home birth
I can finally say that Gisele and I used the same home birth midwife, a wonderful woman who believes in what she does, believes in women "owning" their birth and the empowerment it can provide.
Choosing the same midwife is not all Gisele and I have in common. Our sons were born on the same date, Dec. 8 (two years apart), and... well, we both have handsome husbands.
But seriously, I am so eager to see what effect, if any, a Brazilian supermodel's choice to give birth at home can have on women's perceptions about it and whether the publicity can help reduce the soaring c-section rate in the US and Brazil (where it is close to 90 percent in some places).
One can hope.
Choosing the same midwife is not all Gisele and I have in common. Our sons were born on the same date, Dec. 8 (two years apart), and... well, we both have handsome husbands.
But seriously, I am so eager to see what effect, if any, a Brazilian supermodel's choice to give birth at home can have on women's perceptions about it and whether the publicity can help reduce the soaring c-section rate in the US and Brazil (where it is close to 90 percent in some places).
One can hope.
Monday, December 21, 2009
More on mammograms at 40
Having recently turned 40, my CNM suggested a mammogram was in order, just in time for the national debate over whether and when to have one. For those like me, here's some historical context to help with the decision. I found the author's historical context very helpful in understanding the modern dialogue...But hey, that's why I love history. (I added the bolding for emphasis.)
November 20, 2009
Op-Ed Contributor
Addicted to Mammograms
By ROBERT ARONOWITZ
Philadelphia
THE United States Preventive Services Task Force’s recommendation this week that women begin regular breast cancer screening at age 50 rather than 40 is really nothing new. It’s almost identical to the position the group held in the 1990s.
Nor is the controversy that has flared since the announcement something new. It’s the same debate that’s gone on in medicine since 1971, when the very first large-scale, randomized trial of screening mammography found that it saved the lives only of women aged 50 or older. Despite the evidence, doctors continued to screen women in their 40s.
Again in 1977, after an official of the National Cancer Institute voiced concern that women in their 40s were getting too much radiation from unnecessary screening, the National Institutes of Health held a consensus conference on mammography, which concluded that most women should wait until they’re 50 to have regular screenings.
Why do we keep coming around to the same advice — but never comfortably follow it? The answer is far older than mammography itself. It dates to the late 19th century, when society was becoming increasingly disappointed, pessimistic and fearful over the lack of medical progress against cancer. Doctors had come to understand the germ theory of infectious disease and had witnessed the decline of epidemic illnesses like cholera. But their efforts against cancer had gone nowhere.
In the 1870s, a new view of the disease came to be developed. Cancer had been thought of as a constitutional disorder, present throughout the body. But some doctors now posited that it begins as a local growth and remains so for some time before spreading via the blood and lymph systems (what came to be understood as metastasis).
Even though this new consensus was more asserted than definitively proved by experimental evidence or clinical observation, it soon became dogma, and helped change the way doctors treated cancer. Until this time, cancer surgery had been performed only rarely and reluctantly. After all, why remove a tumor, in a painful and dangerous operation, when the entire body is diseased?
The new model gave doctors reason to take advantage of newly developing general anesthesia and antiseptic techniques to do more, and more extensive, cancer surgery. At the turn of the 20th century, William Halsted, a surgeon at Johns Hopkins, promoted a new approach against breast cancer: a technically complicated removal of the affected breast, the lymph nodes in the armpit and the muscles attached to the breast and chest wall.
Doctors widely embraced Halsted’s strategy. But they seem to have paid little attention to his clinical observations, which indicated that while the operation prevented local recurrence of breast tumors, it did not save lives. As Halsted himself became aware, breast cancer patients die of metastatic, not local, disease.
By 1913, the surgeons and gynecologists who started the American Society for the Control of Cancer (later the American Cancer Society) had begun an anti-cancer campaign that, among other things, advised women to see their doctors “without delay” if they had a breast lump. Their message promoted the idea that if cancer was detected early enough, surgery could cure it.
This claim, like the cancer theory it was built on, was based on intuition and wishful thinking and the desire to do something for patients, not on detailed evidence that patients were more likely to survive if their cancer was caught early and cut out. But it did create a culture of fear around breast cancer, and led the public to believe that tumors needed to be discovered at the earliest possible moment.
The “do not delay” campaign reached its heyday in the 1940s, when through lectures, newspaper articles, posters and public health films, doctors exhorted people to survey their bodies for cancer warning signs like breast lumps, irregular bleeding and persistent hoarseness. This campaign generated greater fear, which led to more demand for some means to gain a sense of control over cancer — typically satisfied by more surveillance and treatment.
During the 1930s and ’40s, more and more cancer was being diagnosed. The rising numbers led to even greater pressure to define early stages of cancer and find more cases as early as possible. Meanwhile, the apparent improved cancer survival rates — a result of more people receiving diagnoses, many for cancers that were not lethal — seemed to prove the effectiveness of the “do not delay” campaign, as well as radical cancer surgery.
By the 1950s, some skeptics were pointing out that despite all the apparent progress, mortality rates for breast cancer had hardly budged. And they continued not to budge; from 1950 to 1990, there were about 28 breast cancer deaths per 100,000 people. But calls for earlier diagnosis only increased, especially after screening mammography was introduced in the 1960s.
When the 1971 evidence came along that mammograms were of very limited benefit to women under 50, it ran up against the logic of the early-detection model and the entrenched cycles of fear and control. Detecting cancer in women under 50 should work, according to the model; indeed, younger women are the ones most likely to have the localized cancers that have “not yet” metastasized. And many doctors and women understandably objected, as they do today, to giving up the one means they had to exercise some control over cancer.
Critics of this week’s recommendations have poked holes in the Preventive Services Task Force’s data analysis, have warned against basing present practice guidelines on the older imaging technology used in the studies, and have called for still more studies to be done. They generally sidestep the question of whether the very small numbers of lives potentially saved by screening younger women outweigh the health, psychological and financial costs of overdiagnosis.
You need to screen 1,900 women in their 40s for 10 years in order to prevent one death from breast cancer, and in the process you will have generated more than 1,000 false-positive screens and all the overtreatment they entail. This doesn’t make sense. We could do more research and hold more consensus conferences. I suspect it would confirm the data we already have. But history suggests it would never be enough to convince many people that we are screening too much.
Robert Aronowitz, an internist and a professor of the history and sociology of science at the University of Pennsylvania, is the author of “Unnatural History: Breast Cancer and American Society.”
November 20, 2009
Op-Ed Contributor
Addicted to Mammograms
By ROBERT ARONOWITZ
Philadelphia
THE United States Preventive Services Task Force’s recommendation this week that women begin regular breast cancer screening at age 50 rather than 40 is really nothing new. It’s almost identical to the position the group held in the 1990s.
Nor is the controversy that has flared since the announcement something new. It’s the same debate that’s gone on in medicine since 1971, when the very first large-scale, randomized trial of screening mammography found that it saved the lives only of women aged 50 or older. Despite the evidence, doctors continued to screen women in their 40s.
Again in 1977, after an official of the National Cancer Institute voiced concern that women in their 40s were getting too much radiation from unnecessary screening, the National Institutes of Health held a consensus conference on mammography, which concluded that most women should wait until they’re 50 to have regular screenings.
Why do we keep coming around to the same advice — but never comfortably follow it? The answer is far older than mammography itself. It dates to the late 19th century, when society was becoming increasingly disappointed, pessimistic and fearful over the lack of medical progress against cancer. Doctors had come to understand the germ theory of infectious disease and had witnessed the decline of epidemic illnesses like cholera. But their efforts against cancer had gone nowhere.
In the 1870s, a new view of the disease came to be developed. Cancer had been thought of as a constitutional disorder, present throughout the body. But some doctors now posited that it begins as a local growth and remains so for some time before spreading via the blood and lymph systems (what came to be understood as metastasis).
Even though this new consensus was more asserted than definitively proved by experimental evidence or clinical observation, it soon became dogma, and helped change the way doctors treated cancer. Until this time, cancer surgery had been performed only rarely and reluctantly. After all, why remove a tumor, in a painful and dangerous operation, when the entire body is diseased?
The new model gave doctors reason to take advantage of newly developing general anesthesia and antiseptic techniques to do more, and more extensive, cancer surgery. At the turn of the 20th century, William Halsted, a surgeon at Johns Hopkins, promoted a new approach against breast cancer: a technically complicated removal of the affected breast, the lymph nodes in the armpit and the muscles attached to the breast and chest wall.
Doctors widely embraced Halsted’s strategy. But they seem to have paid little attention to his clinical observations, which indicated that while the operation prevented local recurrence of breast tumors, it did not save lives. As Halsted himself became aware, breast cancer patients die of metastatic, not local, disease.
By 1913, the surgeons and gynecologists who started the American Society for the Control of Cancer (later the American Cancer Society) had begun an anti-cancer campaign that, among other things, advised women to see their doctors “without delay” if they had a breast lump. Their message promoted the idea that if cancer was detected early enough, surgery could cure it.
This claim, like the cancer theory it was built on, was based on intuition and wishful thinking and the desire to do something for patients, not on detailed evidence that patients were more likely to survive if their cancer was caught early and cut out. But it did create a culture of fear around breast cancer, and led the public to believe that tumors needed to be discovered at the earliest possible moment.
The “do not delay” campaign reached its heyday in the 1940s, when through lectures, newspaper articles, posters and public health films, doctors exhorted people to survey their bodies for cancer warning signs like breast lumps, irregular bleeding and persistent hoarseness. This campaign generated greater fear, which led to more demand for some means to gain a sense of control over cancer — typically satisfied by more surveillance and treatment.
During the 1930s and ’40s, more and more cancer was being diagnosed. The rising numbers led to even greater pressure to define early stages of cancer and find more cases as early as possible. Meanwhile, the apparent improved cancer survival rates — a result of more people receiving diagnoses, many for cancers that were not lethal — seemed to prove the effectiveness of the “do not delay” campaign, as well as radical cancer surgery.
By the 1950s, some skeptics were pointing out that despite all the apparent progress, mortality rates for breast cancer had hardly budged. And they continued not to budge; from 1950 to 1990, there were about 28 breast cancer deaths per 100,000 people. But calls for earlier diagnosis only increased, especially after screening mammography was introduced in the 1960s.
When the 1971 evidence came along that mammograms were of very limited benefit to women under 50, it ran up against the logic of the early-detection model and the entrenched cycles of fear and control. Detecting cancer in women under 50 should work, according to the model; indeed, younger women are the ones most likely to have the localized cancers that have “not yet” metastasized. And many doctors and women understandably objected, as they do today, to giving up the one means they had to exercise some control over cancer.
Critics of this week’s recommendations have poked holes in the Preventive Services Task Force’s data analysis, have warned against basing present practice guidelines on the older imaging technology used in the studies, and have called for still more studies to be done. They generally sidestep the question of whether the very small numbers of lives potentially saved by screening younger women outweigh the health, psychological and financial costs of overdiagnosis.
You need to screen 1,900 women in their 40s for 10 years in order to prevent one death from breast cancer, and in the process you will have generated more than 1,000 false-positive screens and all the overtreatment they entail. This doesn’t make sense. We could do more research and hold more consensus conferences. I suspect it would confirm the data we already have. But history suggests it would never be enough to convince many people that we are screening too much.
Robert Aronowitz, an internist and a professor of the history and sociology of science at the University of Pennsylvania, is the author of “Unnatural History: Breast Cancer and American Society.”
It's all Greek to me
What is the proper plural form of doula? Doules or doulas? A reader of this story in the Telegraph UK suggests that it should be doules. Regardless, US doules may be shocked to see that UK doules earn alot more per birth. (OK, the spelling felt awkward.)
Saturday, November 14, 2009
A note from a nurse
I received an email from a maternity nurse in Maine and I thought I'd share it anonymously because she has valid points about the issues her profession faces. My responses are in bold after her comments.
"I became a nurse out of an interest in women’s health and feminism. Initially I thought I would work for a Planned Parenthood type of organization, helping to provide safe, confidential STI testing, pregnancy prophylaxis or abortion care. I wasn’t too interested in labor until I witnessed my first delivery. It was in a tiny rural Maine hospital. The woman came in and delivered precipitously, laboring on the toilet and in hands and knees position sideways on the bed. I was in awe of her beauty and her likeness to a wild animal in those moments before and during birth. I knew then and there that I had found what I was meant to do. It is my job not only to administer medications and follow physician and midwife orders, but to tune into and meet a laboring woman’s needs as well as her and baby‘s needs in the postpartum period.
I found that the discussion of registered nurses in your book did not do the profession justice or give it depth. When nurses are mentioned outside the realm of becoming nurse-midwives, the remarks are cursory or indicative of laziness. On page 232 you account a nurse-midwife’s disdain for the Leboyer baths. Though you do go on to say that later studies showed no evidence-based benefits from the practice, I am not sure whether you intended this quote to demonstrated how difficult something like the bath is to prepare and administer properly or if you wanted nurses to seem stubborn, lazy, and unwilling to adapt as the text implies." In terms of a nurse's disdain for Leboyer baths, I actually understand their annoyance. It was a ridiculous practice of yet another fad. Such fads must weigh heavily on the staffs, and have implications for childbirth in general.
"On page 102 you describe nurses undermining a woman’s wishes for natural labor by asking her “’Do you want your epidural now?’” in the hopes of having an easier-to-manage, more stationary patient. While I do not doubt that this happens, I can tell you that I try my best to respect a woman’s wishes for pain management in labor. If she comes in stating she wants a drug-free labor, I make sure she knows that resources are available if she changes her mind and that it is up to her to bring up the subject of pain medications if she wants them. Things become complicated when an obstetrician or a partner say to a woman repeatedly “You can have an epidural if you want.” It is also tricky when a woman who is initially adamantly against labor anesthesia begins to ask for these medications when she hits active labor. What is a nurse to do? Should I try and hold her off until delivery, after which she may or may not thank me and her partner for not letting her get the drugs she was requesting? Or should I immediately contact the obstetrician or midwife with her requests and give her what she says she wants now. Either way I face a conflict in respecting patient rights and autonomy, not just for mother but for baby. If she is asking for IV medication and delivery occurs within four hours, the baby may be drowsy and have a difficult time breathing because the narcotic medications typically given pass through the placenta and decrease both mother and baby‘s respiratory rates." This is, perhaps, the most salient issue of modern childbirth. The only right answer is having uninterrupted supportive care and to have the woman be comfortable in her surroundings and with people she knows are there for her. For typical hospital births, unless a woman hires a doula, or has a mother or friend there who really understands the stages of labor, she will typically be alone for long stretches with a partner who is equally anxious, and perhaps feeding her own anxiety. Of course women ask for pain relief in these circumstances, often changing their own minds. But I think what they are really asking for is someone to hold their hand or truly be there with them to encourage progress. In large urban maternity units, constant handholding is a staffing impossibility. The epidural is not. So I feel your dilemma. It is not nurses who are the problem. They are just dealing WITH the problem, just as mothers are. The system is the issue and we should all find ways as a nation to spend more money on supportive care and less on narcotics because, as you know, it will be cheaper in the long run with better outcomes and happier mothers and babies.
"Due to your extensive research and your own childbearing experience, I am sure none of the following information is news to you. However, I urge you to read the next paragraphs from a nursing perspective, imagining the responsibilities that registered nurses carry throughout the labor, delivery, recovery and postpartum period. The fact of the matter remains that emergencies do happen. Women with low-risk pregnancies can and sometimes do seize in labor or the postpartum period, a potentially fatal condition for both mother and baby. Postpartum hemorrhages after routine, low-intervention deliveries sometimes bring women to near-death experiences." I had one c-section and I witnessed several others during the course of research for my book.
"In addition to these and other emergencies, routine care duties are continuously increasing. During labor, external fetal monitoring and a highly-litigious society require that nurses document progress every 15 minutes during continuous monitoring (per protocols when a patient has an epidural, or a high-risk medication infusing such as pitocin or magnesium sulfate). Women with a positive GBS status generally have physician orders for antibiotics to be infused every 4 hours during labor. The bladder is drained every 3-4 hours by catheter if a woman has an epidural. If a fetus has a prolonged deceleration in its heart rate, it is the nurse’s job to turn her (usually many times), place an oxygen mask on her face, give her IV fluids if she has venous access, stop a pitocin infusion, call the midwife or physician to the bedside, administer terbulatine by physician order to relax the uterus, perhaps transfer her to the operating room for an emergency cesarean and, not least of all, explain everything that is happening to the patient and her family. It is not uncommon for a laboring woman to have almost all of these things simultaneously: epidural, pitocin, magnesium, GBS, and/or signs of chorioamnionitis (a condition that, if delivery is not immediately imminent, will buy a laboring woman a ticket to the OR). Having worked in a high-risk, high-interventional labor and delivery setting, I pride myself on patient interaction, understanding that labor can go in several different directions, many of which even the most educated family would not be able to imagine for themselves." As you so clearly state, much of this is done first and foremost to protect the hospital and the doctors and alot of these interventions can actually create more dangerous situations for mothers and babies. I understand postpartum hemorrhage is dangerous, but being forced to lay in bed during labor so you can be "monitored" is not a healthy way to enable labor to progress. So again, I believe the system is messed up, and if nurses didn't have so many machines to pay attention to, there would be no need for so many machines.
"Infant abductions cause scandal and add security interventions that must be completed almost immediately after birth along with standard neonatal resuscitation for the normal newborn (tactile stimulation and bulb suction), assignment of Apgar scores with the required assessment, and administration of erythromycin and vitamin K per the parents‘ request. A healthy mother and baby pair are generally allowed two hours of one-to-one nursing care before staffing regulations allow that pair to be transferred to a postpartum unit or, in the case of an LDRP set-up, that nurse is assigned other new families to care for. The nurse-patient ratio on a unit may be as high as five or six couplets, meaning a nurse is really caring for 10 to 12 patients at a time. All this inhibits a nurse’s ability to provide timely, individualized care to a family in the 2 or 3 precious days before they go home." If an infant was never separated from its mother, there would be no avenue for abductions, unless someone actually ripped the babe from arms, which seems preposterous and likely that the mother would tackle the intruder. As for postpartum care, I agree. It's a shame for all concerned, including the harried staff. Postpartum care should last longer than two days in a hospital. I believe having a checkup even two weeks out at home could prevent or help diagnose postpartum depression and breastfeeding issues, which have greater costs for society.
"I have seen how women who end up with emergency c-sections and their families can be traumatized by the experience and I want to be clear that I work very hard to help my patients process what is happening to them. I am making no statement here about whether the interventions themselves are right or wrong - I have often struggled with those questions - but let me be clear that as a nurse I do everything I can to help support my patient and her family emotionally throughout the birth process and afterwards." That is wonderful to hear. I bet nurses themselves can be traumatized by what they see tough. You have a very hard job. I couldn't do it. I remember clearly what a postpartum nurse said to me about 6 hours after my c-section, when she asked why I was crying. "I wouldn't want that to happen to me either," she said. Needless to say, it did not make me feel better.
"Maternity nurses are not merely overworked minions of obstetricians and pediatricians, we are patient care advocates who take an interest in our patients’ wellbeing and childbirth experiences. I don’t know a single nurse working in labor and delivery, mother/baby care or lactation who does it just for the paycheck. The nurses I know are passionate about patient care, are constantly asked to adapt to changing practices and are strained by ethical dilemmas. Obstetrical nurses work in a complex ethically, legally and politically driven environment, having to balance all of these factors as providers and patient advocates. I hope that I have impressed upon you the multiple stressors nurses face when providing patient care, along with this nurse’s desire to meet every need of her patient: mother, baby, partner, family." Excellent points.
"I became a nurse out of an interest in women’s health and feminism. Initially I thought I would work for a Planned Parenthood type of organization, helping to provide safe, confidential STI testing, pregnancy prophylaxis or abortion care. I wasn’t too interested in labor until I witnessed my first delivery. It was in a tiny rural Maine hospital. The woman came in and delivered precipitously, laboring on the toilet and in hands and knees position sideways on the bed. I was in awe of her beauty and her likeness to a wild animal in those moments before and during birth. I knew then and there that I had found what I was meant to do. It is my job not only to administer medications and follow physician and midwife orders, but to tune into and meet a laboring woman’s needs as well as her and baby‘s needs in the postpartum period.
I found that the discussion of registered nurses in your book did not do the profession justice or give it depth. When nurses are mentioned outside the realm of becoming nurse-midwives, the remarks are cursory or indicative of laziness. On page 232 you account a nurse-midwife’s disdain for the Leboyer baths. Though you do go on to say that later studies showed no evidence-based benefits from the practice, I am not sure whether you intended this quote to demonstrated how difficult something like the bath is to prepare and administer properly or if you wanted nurses to seem stubborn, lazy, and unwilling to adapt as the text implies." In terms of a nurse's disdain for Leboyer baths, I actually understand their annoyance. It was a ridiculous practice of yet another fad. Such fads must weigh heavily on the staffs, and have implications for childbirth in general.
"On page 102 you describe nurses undermining a woman’s wishes for natural labor by asking her “’Do you want your epidural now?’” in the hopes of having an easier-to-manage, more stationary patient. While I do not doubt that this happens, I can tell you that I try my best to respect a woman’s wishes for pain management in labor. If she comes in stating she wants a drug-free labor, I make sure she knows that resources are available if she changes her mind and that it is up to her to bring up the subject of pain medications if she wants them. Things become complicated when an obstetrician or a partner say to a woman repeatedly “You can have an epidural if you want.” It is also tricky when a woman who is initially adamantly against labor anesthesia begins to ask for these medications when she hits active labor. What is a nurse to do? Should I try and hold her off until delivery, after which she may or may not thank me and her partner for not letting her get the drugs she was requesting? Or should I immediately contact the obstetrician or midwife with her requests and give her what she says she wants now. Either way I face a conflict in respecting patient rights and autonomy, not just for mother but for baby. If she is asking for IV medication and delivery occurs within four hours, the baby may be drowsy and have a difficult time breathing because the narcotic medications typically given pass through the placenta and decrease both mother and baby‘s respiratory rates." This is, perhaps, the most salient issue of modern childbirth. The only right answer is having uninterrupted supportive care and to have the woman be comfortable in her surroundings and with people she knows are there for her. For typical hospital births, unless a woman hires a doula, or has a mother or friend there who really understands the stages of labor, she will typically be alone for long stretches with a partner who is equally anxious, and perhaps feeding her own anxiety. Of course women ask for pain relief in these circumstances, often changing their own minds. But I think what they are really asking for is someone to hold their hand or truly be there with them to encourage progress. In large urban maternity units, constant handholding is a staffing impossibility. The epidural is not. So I feel your dilemma. It is not nurses who are the problem. They are just dealing WITH the problem, just as mothers are. The system is the issue and we should all find ways as a nation to spend more money on supportive care and less on narcotics because, as you know, it will be cheaper in the long run with better outcomes and happier mothers and babies.
"Due to your extensive research and your own childbearing experience, I am sure none of the following information is news to you. However, I urge you to read the next paragraphs from a nursing perspective, imagining the responsibilities that registered nurses carry throughout the labor, delivery, recovery and postpartum period. The fact of the matter remains that emergencies do happen. Women with low-risk pregnancies can and sometimes do seize in labor or the postpartum period, a potentially fatal condition for both mother and baby. Postpartum hemorrhages after routine, low-intervention deliveries sometimes bring women to near-death experiences." I had one c-section and I witnessed several others during the course of research for my book.
"In addition to these and other emergencies, routine care duties are continuously increasing. During labor, external fetal monitoring and a highly-litigious society require that nurses document progress every 15 minutes during continuous monitoring (per protocols when a patient has an epidural, or a high-risk medication infusing such as pitocin or magnesium sulfate). Women with a positive GBS status generally have physician orders for antibiotics to be infused every 4 hours during labor. The bladder is drained every 3-4 hours by catheter if a woman has an epidural. If a fetus has a prolonged deceleration in its heart rate, it is the nurse’s job to turn her (usually many times), place an oxygen mask on her face, give her IV fluids if she has venous access, stop a pitocin infusion, call the midwife or physician to the bedside, administer terbulatine by physician order to relax the uterus, perhaps transfer her to the operating room for an emergency cesarean and, not least of all, explain everything that is happening to the patient and her family. It is not uncommon for a laboring woman to have almost all of these things simultaneously: epidural, pitocin, magnesium, GBS, and/or signs of chorioamnionitis (a condition that, if delivery is not immediately imminent, will buy a laboring woman a ticket to the OR). Having worked in a high-risk, high-interventional labor and delivery setting, I pride myself on patient interaction, understanding that labor can go in several different directions, many of which even the most educated family would not be able to imagine for themselves." As you so clearly state, much of this is done first and foremost to protect the hospital and the doctors and alot of these interventions can actually create more dangerous situations for mothers and babies. I understand postpartum hemorrhage is dangerous, but being forced to lay in bed during labor so you can be "monitored" is not a healthy way to enable labor to progress. So again, I believe the system is messed up, and if nurses didn't have so many machines to pay attention to, there would be no need for so many machines.
"Infant abductions cause scandal and add security interventions that must be completed almost immediately after birth along with standard neonatal resuscitation for the normal newborn (tactile stimulation and bulb suction), assignment of Apgar scores with the required assessment, and administration of erythromycin and vitamin K per the parents‘ request. A healthy mother and baby pair are generally allowed two hours of one-to-one nursing care before staffing regulations allow that pair to be transferred to a postpartum unit or, in the case of an LDRP set-up, that nurse is assigned other new families to care for. The nurse-patient ratio on a unit may be as high as five or six couplets, meaning a nurse is really caring for 10 to 12 patients at a time. All this inhibits a nurse’s ability to provide timely, individualized care to a family in the 2 or 3 precious days before they go home." If an infant was never separated from its mother, there would be no avenue for abductions, unless someone actually ripped the babe from arms, which seems preposterous and likely that the mother would tackle the intruder. As for postpartum care, I agree. It's a shame for all concerned, including the harried staff. Postpartum care should last longer than two days in a hospital. I believe having a checkup even two weeks out at home could prevent or help diagnose postpartum depression and breastfeeding issues, which have greater costs for society.
"I have seen how women who end up with emergency c-sections and their families can be traumatized by the experience and I want to be clear that I work very hard to help my patients process what is happening to them. I am making no statement here about whether the interventions themselves are right or wrong - I have often struggled with those questions - but let me be clear that as a nurse I do everything I can to help support my patient and her family emotionally throughout the birth process and afterwards." That is wonderful to hear. I bet nurses themselves can be traumatized by what they see tough. You have a very hard job. I couldn't do it. I remember clearly what a postpartum nurse said to me about 6 hours after my c-section, when she asked why I was crying. "I wouldn't want that to happen to me either," she said. Needless to say, it did not make me feel better.
"Maternity nurses are not merely overworked minions of obstetricians and pediatricians, we are patient care advocates who take an interest in our patients’ wellbeing and childbirth experiences. I don’t know a single nurse working in labor and delivery, mother/baby care or lactation who does it just for the paycheck. The nurses I know are passionate about patient care, are constantly asked to adapt to changing practices and are strained by ethical dilemmas. Obstetrical nurses work in a complex ethically, legally and politically driven environment, having to balance all of these factors as providers and patient advocates. I hope that I have impressed upon you the multiple stressors nurses face when providing patient care, along with this nurse’s desire to meet every need of her patient: mother, baby, partner, family." Excellent points.
Tuesday, November 03, 2009
And she lived to tell the tale
There is a great post on Unnecessarean that aggregates lots of stories about Ines Ramírez Pérez of Rio de Talea, Mexico, who became the first woman known to have survived a self-inflicted cesarean section. I wrote about her case in my book, but you can read a bunch of fascinating news accounts about it here.
Wednesday, October 21, 2009
I got a nice email today from a woman in Missoula, Montana, who had read my book. She said there is a big controversy in her town between the only hospital that has an OB ward and a longtime certified nurse midwife who opened a tiny independent birth center... and lo and behold, the same week that she opened her birth center for business, she was personally banned from the property of the hospital.
I think more attention (and appropriate outcry) might force the hospital to really reevaluate the issue or at least make some concessions.
Go forth and tell the hospital why they are wrong and why it is women who lose, not their bottom line. Read her story.
The midwife, Jeanne Hebl, has a website.
I think more attention (and appropriate outcry) might force the hospital to really reevaluate the issue or at least make some concessions.
Go forth and tell the hospital why they are wrong and why it is women who lose, not their bottom line. Read her story.
The midwife, Jeanne Hebl, has a website.
Tuesday, September 01, 2009
Evolution and birth
Interesting connection between fat and newborns. I am on vacation catching up on my significant stack of unread New Yorkers and in the July 20th issue Elizabeth Kolbert has an interesting piece on the many books out there postulating on why we as a society are fat. In it, she discusses "The Evolution of Obesity" (Johns Hopkins), written by researchers at the American College of Obstetricians and Gynecologists. The authors argue that a person with a genetic knack for storing fat would have a competitive advantage in life because fat is energy rich and lightweight (surprisingly) and it helps our big brains run. "Human infants," Kolbert writes, "are unusually portly; among mammals, only hooded seals have a higher percentage of body fat at birth....Tellingly, humans, unlike most other animals, have no set season of fertility. Instead, ovulation is tied to a woman's fat stores: Those who are very thin simply fail to menstruate."
Tuesday, August 25, 2009
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.
Sunday, August 23, 2009
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.
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.
Thursday, July 23, 2009
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.
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.
Wednesday, July 15, 2009
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!).
Wednesday, June 17, 2009
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.
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.
Thursday, May 14, 2009
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?
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?
Subscribe to:
Posts (Atom)