Cesarean Section

Mamas on Bedrest: US Maternity Care-Living in a Glass House Throwing Stones

August 15th, 2012

I am increasingly dismayed by the fact that the US seems to think it has no maternal or infant morbidity and mortality issues. The sad truth is that the United States, in many situations surrounding maternity and childbearing, has statistics that rival many developing nations and in some cases are actually worse.

When I read various articles and news briefs, many US researchers with big money grants are reporting data from developing nations and the implications seem to be that we must reduce maternal and infant morbidity and mortality globally-i.e. “in these developing nations” to lower the global statistics. I want to go on the record asking, “How can we even begin to critique issues of maternal and infant morbidity and mortality worldwide when the US has some of the worst maternal and infant morbidity and mortality rates in the world?” In the recent blog post “Minority Mamas are More Likely to Die in Childbirth” I cited data published about maternal mortality in the United States and the disparity between women of color (primarily black women) and white women. It is one of few pieces that has actually noted and questioned high maternal mortality in black women in the United States. While it did not offer much in the way of theories as to why the rates are so unbalanced, the obvious initial steps would be to look at disparities in health care delivery in areas with a high black population and in lower socioeconomic areas.

Hold on, some of you may be saying. The US has exceptional health care, some of the best in the world. This is quite true. But not everyone in the United States has access to the exceptional health care that exists in this country. As evidenced by the heated health care reform debates, millions of Americans are without health insurance and despite the passage of the Affordable Care Act and its many provisions for women’s health care, there will still be a substantial number of people, many of them women and children, for whom our “exceptional health care” is woefully out of reach. Some will argue that saving some is better than saving none at all. Personally speaking, until everyone in this country has access to high quality health care, we as a nation have no business studying and critiquing health care practices in other countries.

In its groundbreaking work Deadly Delivery, Amnesty International shines a glaring light on the maternal morbidity and mortality issues in the United States and raises the questions are race and poverty to blame? Few if any other research groups have deigned to make the connection. But with the numbers such as they are, we are going to have to tread that road.

The United States is one of only 4 nations globally that offers no paid maternity. Out of some 178 nations, The United States, Papua New Guinea, Swaziland, and Lesotho are the only nations that offer no paid maternity leave. Of those nations, the United States is the only industrialized nation, and one of the richest nations in the world. But with all of our riches, the gap between “those who have” and “those who have not” is becoming a gaping chasm with no end to the widening in sight.

The Cesarean Section rate in the United States approximately 32% meaning that almost 1 of every 3 babies born in this country is delivered via cesarean section. This far exceeds the rate proposed by the World Health Organization (WHO) yet, we are far from finding a solution to this problem. Several maternity advocacy groups (Childbirth Connection,International Cesarean Awareness Network (ICAN) and others) are challenging the US health care system, the American Congress of Obstetricians and Gynecologists (ACOG) in particular, to take steps to turn the tide on this quelling cesarean section rate. We’re all waiting to see changes in birth policies and subsequent reduction in the national Cesarean section rates.

And then there is bed rest. How could I possibly not address one of the more controversial treatment practices in all of medicine? To date there is not solid evidence that bed rest in any way prevents preterm labor and premature delivery. We don’t have solid evidence that it in any way improves or strengthens an incompetent cervix, helps lower blood pressure or prevents any of the complications of pre-eclampsia. There is some evidence that bed rest is harmful to pregnant women and may do more harm than good. Yet annually, nearly a 3/4 of a million pregnant women are prescribed bed rest for complications of pregnancy.

I want the US to stop casting stones towards other countries for their maternity practices and to focus instead on how to lower maternal morbidity and mortality rates here at home. Until we have impeccable maternity rates and until all mamas have access to high quality health care we must focus our attention on ourselves and stop pointing fingers of criticism elsewhere.

Mamas on Bedrest: It’s okay to have a C-section

August 10th, 2012

Whaaaaat?????

Yes, you are reading correctly, I am saying that it’s okay to have a c-section.

I realize that much of my platform here is about normal birth and allowing mamas (and babies) to come into and move into this world naturally.

Yet, I have had 2 C-sections.

Yup, 2 C-sections!

So how come I am such a proponent of “normal birth?”

I’ve often berated myself for not “trying harder” to deliver vaginally. I should have at least tried, shouldn’t I? These feelings welled up once again as I was about to pen another post about the virtues of normal, vaginal birth, this time about how normal birth is now associated with important positive brain proteins in babies. Then just when I was about to get started, I looked over at my 2 sleeping children (I’m writing this in a hotel on my way back to Austin from Summer vacation) when I had to stop myself and ask, “Are my children somehow brain deprived because they were delivered via c-section? Are they in anyway developmentally impaired or otherwise “less than” because they were c-section deliveries?” My children are beautiful and as healthy and cunning as they come!  

I also know that without c-sections, neither of my children (or myself for that matter) may be here. My daughter’s birth, my first c-section delivery was emergent, traumatic and both of us are lucky to be alive! I don’t remember all the details of her “coming out” but according to my husband, she was in distress, blue and the neonatologists worked on her for a bit before she cried. I was vomiting profusely from the pregnancy (I had all day sickness all 9 months!) and the anesthesia only made things worse. Added to that, my uterus was lacking in tone, so once my daughter was born, it didn’t contract but was kind of like a stretched out balloon. And I bled. I’m not talking a little sputter, I’m talking this side of hemorrhage! Everything started to move more quickly, there was a lot of clatter as more instruments were opened and soon I was given something in my IV to “calm me down” (translation-make me out of it so that I’d stop trying to see what was going on and getting more agitated in the process.) I watched my OB’s eyes over her mask; they were set, focused and soon you could hear a pin drop in that OR suite. I knew that things were not good.

But I lived to tell about it and I am thankful that I and my almost 10 year old sassy girl are just fine. And I can tell you, there is no brain deficit in this one! In fact, that smart mouth is about to drive me crazy!

Same with my son. My darling boy was born at 39 weeks via c-section. While his birth was much calmer, my uterus was again an overused balloon, lacking in tone and contractility. This time, my baby was put to my breast and with a bit of pitocin, I was stitched up, good as new (sort of!).

I know that I may not be here to write this blog or to critique and share the various articles that I read had I not had 2 c-sections. I would not have the 2 children that I adore beyond words without my 2 c-sections.

 “So how are my words affecting mamas who may have had a C-section or are about to have, a truly medically necessary, a C-section?”

I hope that my words will give you some solace. Sometimes you have to do what is right for you, and if a C-section is what is needed for you to have a healthy baby-and to survive yourself, then by all means, go for it! Yes, C-section rates in the United States have reached unacceptable rate. They are also often performed for “unnecessary” reasons. And there is no denying that c-sections carry with them risk. So if you can avoid having one, I prayerfully ask that you do. There really are benefits to having a normal vaginal birth for both mamas and babies. I look at it this way: If this is the way in which Mother Nature designed us to have our young, it must be good because she’s not been wrong so far!

But I am also very thankful for medical science and technology for evolving and developing such that I was able to have my children and live to tell about it! Without seeming mellow dramatic, I am quite convinced that I would be dead otherwise.

We do need to curtail the number of c-sections performed in the United States. I do believe that health care providers need to meticulously scrutinize each situation to evaluate if a proposed c-section is truly necessary. But if a health care provider, after careful analysis of the situation deems it in you and your baby’s best health interest to have a c-section, it (you) will be okay!

When is it better to induce Mamas on Bedrest?

June 13th, 2012

Labor induction is always controversial. There are times when induction of labor is completely appropriate; when mamas are in crisis with pre-eclampsia or other obstetrical complications, when the baby is struggling or when progression of the pregnancy will put the life of the mother and/or baby at risk. But many mamas are induced for what seems like “convenience”; Mamas are tired, their OB’s want to schedule the delivery so that mama is not delivered by a partner, etc… While many obstetricians advocate for induction as a way to “prevent” adverse outcomes, we can’t ignore the fact that labor induction carries with it an increased risk of intervention in the birth process and adverse outcomes for mama and baby.

Recently in the British Medical Journal, researchers looked at elective inductions to see if they had any benefit on birth outcomes when compared to allowing labor to progress naturally. Sarah J. Stock, PhD, from the MRC Centre for Reproductive Health, University of Edinburgh in the United Kingdom was the lead researcher for the study.

Using Scottish birth and death records, they analyzed data for more than 1.2 million women with single pregnancies who gave birth after 37 weeks’ gestation between 1981 and 2007.

What Stock and her colleagues found is that

There was no significant difference in spontaneous vertex (normal head down) delivery rates between elective induction of labor and the expectant management groups (normal labor progression) for weeks 37, 38, and 39. However, a primary analysis showed an association of elective induction of labor with a reduction in spontaneous vertex delivery rates compared with the expectant management group at weeks 40 and 41. This difference was maintained for week 41, but not week 40, during secondary analysis. (so did more induced mamas have c-sections?? This is what previous data have stated.)

The authors estimate that for every 1040 women having elective induction of labor at 40 weeks, 1 newborn death may be prevented. This would result, however, in 7 more admissions to a special care baby unit (NICU).

The authors conclude that although residual confounding may remain, our findings indicate that elective induction of labour at term gestation can reduce perinatal mortality in developed countries without increasing the risk of operative delivery.

There are a couple of issues that I have with this study. First, while the sample size is definitely adequate, there was no way to control for confounding variables such as maternal size, number of pregnancies, pregnancy complications (i.e bed rest), prenatal state, etc… Additionally, the data has been run through a couple of multivariate analyses which controlled for possible confounding variables. I always wonder, if those “confounders” are incorporated into the data, how do they change the results and conclusions?

The authors conclude that elective induction of labour at term gestation can reduce perinatal mortality in developed countries. Is this reduction in mamas, babies or both? This was not clear to me.

The authors also state that they did not see any increase in operative deliveries.This is very interesting in that the United States has some of the highest c-section rates worldwide and the probability of having a c-section goes up with labor induction. Were these some of the variables removed a confounders?

Finally, the authors estimate that for every 1040 babies born, 1 would be saved from death while 7 would end up in the NICU. Now these aren’t huge numbers, but if you are the mama with the one baby who died, this number is significant. Likewise, it’s not good if your baby ends up in the NICU.

While the authors state that the intention of induction is to reduce perinatal morbidity and mortality in developing countries (and the United States certainly has some of the worst statistics for maternal and infant morbidity and mortality, i.e. maternal and infant complications and deaths, in the developed world) I don’t agree that induction is the way around these potential problems.

Induction of labor initiates a cascade of events that more times than not are not ready to begin. There is a delicate, yet complex interaction between the baby and mama that goes on as the baby begins to enter this world. Both mama and baby’s bodies have to transition from interdependence to independence and for the baby especially, there are several physiological mechanisms that must occur to prepare the fetus (inside baby) to become a neonate (outside baby). Induction speeds up these transitions and in some cases, certain transitions don’t occur (hence the NICU admissions for babies). While some may argue that babies may spend “just a few days” in the NICU, these babies have experienced a traumatic birth, their bodies have not had time to adjust to life on the outside and everyone involved (mama, dad and baby) are all traumatized. Is it really worth it? Further, we can only “guesstimate” gestational age. We really don’t know when the sperm fertilized the egg nor when the embryo embedded in the uterine wall. So a woman we may think is 40 weeks may really be 39  or even 38 weeks. Hence the induction is more of an intrusion. What if she is in fact 42 weeks?

I don’t know what the authors intend to do or recommend with this data, but I hope that they don’t use this data as a way to recommend elective induction as standard of care-especially in low risk uncomplicated pregnancies. I believe that human gestation is intended to be 40 weeks for a reason and that as much as possible, human babies should be allowed to gestate for those 40 weeks. If a baby comes at 38 or 39 weeks, so be it. But if the baby stays in until 40 weeks, are we to assume that there is something wrong or that something will go wrong and intervene?  I believe that babies should be left alone to gestate for a long as they need, and only in the situation of maternal/baby distress or markedly being post dates (say 42 weeks or more) should induction even be an option.