A Midwife's Perspective on Money

I have read this blog for quite some time now and just came across this new post today. She has put into words what most midwives deal with on a regular basis. I appreciate her frankness and honesty.

Reducing Infant Mortality

This is an awesome video on reducing infant mortality here in the states. Take the time and watch it - it is under 17 minutes long.

Reducing Infant Mortality from Debby Takikawa on Vimeo.

The Real Risk of C-Section - Medscape Interview

Editor's Note:

Cesarean section (c-section) is the most commonly performed surgery in the United States. The frequency of surgical birth has increased from 4% in 1965 to about 33% today, despite World Health Organization (WHO) recommendations that a 5% to 10% rate is optimal and that a rate greater than 15% does more harm than good.^[1-3]

Reasons for this increase have been discussed profusely:

• The surgical focus of obstetrics and the need to train residents;
• The low priority and few practical skills for supporting women's abilities to labor and give birth naturally;
• A rigid view of the duration of normal labor; and
• A low threshold of definition for 'labor dystocia' (the justification for up to 60% of cesarean births^[4]).

Surgical birth is also a 'side effect' of interventions associated with actively managed labor: induction, artificial rupture of membranes, labor medications, and fetal monitoring.^[5,6] Policies against vaginal birth after cesarean (VBAC) and, increasingly, unsupported 'supply-side' justifications such as "baby seems large," also drive the trend toward cesareans. A recent report by the Lamaze Institute associates surgical birth with obstetricians' personalities -- specifically their anxiety levels.^[7-9]

The risks for birth by surgery have also come under discussion. Maternal risks include a higher overall death rate, rehospitalization for wound complications and infection, placenta accreta and percreta (both with 7% mortality rate), placenta previa, uterine rupture with subsequent pregnancy, and preterm birth, with its own set of risks and complications for the newborn.^[10-15]

Pamela K. Spry, BSN, MS, CNM, PhD, the President of Lamaze International, a leading childbirth-advocacy group, spoke with us about the risks for birth by scalpel.

Medscape: Childbirth methods are often trend-driven. In the 1960s and 1970s, there was a big push for natural childbirth. What has driven women away from that method since then?

Dr. Spry: In the 1960s, women were rebelling against twilight sleep -- childbirth under heavy narcotics that required being strapped down to the delivery table. There was also the push for fathers to be in the delivery room, which wasn't allowed, and certainly not during heavily sedated birth. Now we have a widespread availability of local and regional methods of pain relief that let women be awake and aware, share the birth with their families, and basically rely on technology to assist them at birth. I think this drive has been somewhat alleviated, but there is still a push for natural childbirth. This is the reason women are still seeking classes, making birth plans, and choosing home birth and birthing centers.

"Natural childbirth" can mean different things to different people. For Lamaze, it means a birth that's allowed to happen on its own without the use of unnecessary medical interventions, to provide women the safest and healthiest birth possible.

Medscape: Are rates of surgical delivery being driven up by women or clinicians? Is this the age of Blackberry birth -- scheduling everything ahead of time?^[16]

Dr. Spry: Actually, there are 2 parts to this question. One is, what has driven up the rate of repeat cesareans, and that answer is easy: there has been a big decrease in the availability of choosing to labor and deliver vaginally (VBAC) after having 1 or 2 previous cesarean births, causing a huge increase in the rate of surgical delivery [for repeat cesareans]. Compared with the early 1990s when VBACs were encouraged and acceptable, many hospitals, insurance companies, and clinicians now refuse to allow women to try laboring after a previous c-section because of perceived medical and legal risks.

The second part of the question is whether women or clinicians are responsible for the increase in the primary c-section rate, and I think that's more difficult to answer. In a study of more than 1500 women, we tried to determine just that. The research results indicated that only 1 woman in the study actually reported that she requested a cesarean, which leaves the decision for the vast majority of cesarean deliveries up to clinicians. So understanding when cesareans are medically necessary, as well as the risks involved, is important in achieving a safe and healthy birth.

Although it might be convenient, babies who are born before they are ready are at increased risk for major medical problems.

Medscape: Could fear be the reason for women agreeing to surgical birth? Are women enduring pain differently than in previous decades? Is the surgical scenario easier to contemplate than the unknowns of a natural labor and delivery?

Dr. Spry: Exactly. I think all of that has to do with the fact that our culture actually breeds fear around childbirth. We've got TV shows, popular culture, and horror stories from friends and families; women are taught to expect a negative experience and incredible pain. Lamaze is focused on trying to help women get the facts, know what to expect, and help take the fear out of the process. But the unknown parts, such as labor, its duration, birth, and even the unknown of when labor will start, makes it more appealing for some women to schedule a cesarean.

Medscape: The culture of hospital obstetrics seems designed for interventions, with cesarean procedures bringing in more money than natural delivery. Do you think hospital financial incentives are a reason for the rise in cesareans? Or would the costs for longer hospital stays with cesarean procedures balance out the revenues from them?^[17]

Dr. Spry: I think that sometimes financial concerns, convenience, or concerns over lawsuits do rule medical decision-making around childbirth. When women have a good understanding of what constitutes quality care, they are in a better position to ask for it from their care providers. Interestingly enough, I just returned from our nurse-midwifery convention in Seattle, and I heard a speaker address this very thing: reducing the cesarean rate. Among his suggestions was the provocative notion that providers should be reimbursed the highest rate for labor and vaginal birth after cesarean, followed by labor and vaginal birth, and the lowest reimbursement for scheduled, elective cesarean delivery. That way, providers would be compensated for their actual time involved in the process, and scheduled c-sections would have the lowest reimbursement. He thought that would make a difference.

Medscape: What are the main risks these days with c-sections? Are these risks underplayed by obstetricians, and, if so, why?

Dr. Spry: Many of them were covered in the introduction. Any time we schedule a surgery or an induction, we are assuming that we know the baby's due date. Anything that's scheduled before a woman's estimated due date could result in a baby being born before it's ready. [And iatrogenic prematurity is a reality with any scheduled birth -- that is, due dates may have been calculated wrong and inadvertently, babies are born before they are actually term.] We're getting more research looking at the near-term preemie. We find that they have breathing and developmental problems and that the risk for death is increased. Certainly, cesarean delivery increases the risk for the baby being injured from the incision. Surgery also carries risks for women, such as blood loss, clotting, infections, severe pain, and adverse anesthesia-related events. This is something that we haven't focused on, and I'm not certain that informed consent includes this information -- that there are complications during future pregnancies and that it does risk future children. There is an increased risk for stillbirth with a second or third c-section, as well as placental problems like percreta and accreta (abnormal growth and attachment of the placenta into the uterus), increasing the risk for hemorrhage. Women may experience dire complications as a result -- bladder injury, hysterectomy, and maternal death. I don't know that I would describe these risks as "underplayed" by obstetricians, but rather that women are not prepared to ask the right questions that lead to informed decision-making.

It would be interesting to read the informed-consent documents for cesarean deliveries, and see what risks are included.

Medscape: A story in The New York Times recently reported that women who have c-sections seem to have fewer children. That story provoked over 200 comments, from women who have had all of their children by planned cesarean to women who had had births at home. A strong fear-driven contingent regarded childbirth as fraught with pain and danger, and that anyone who risked giving birth outside of a hospital was committing child abuse. Can you discuss any evidence comparing the risks to mothers and children between in-hospital and at-home births?^[18]

Dr. Spry: A number of studies have looked at this. Some of the criticism of these studies has been that hospitals end up with higher-risk women, so it's an unfair comparison. But there are studies of low-risk women who had a planned home birth with a qualified birth attendant, compared with low-risk women who chose hospital births; the outcomes for home birth were better or as good as outcomes for women who birthed in hospitals.

Each study limits what kind of comparisons are made, but certainly women with previous surgical uterine scars, medical complications, or breech babies are all considered high-risk.

Medscape: The recovery period after any birth, from time immemorial known as the "lying-in" period, used to last several weeks after a birth. Now, even after surgical birth, women are up and around within a few days. Postpartum depression is another health consideration that has been much in the news lately. Do you think we have lost something with this shortened period of rest and recovery?^[19]

Dr. Spry: I do. Studies have shown that it's better for mothers and babies to stay together after birth. Experts agree that unless a medical reason exists, healthy mothers and babies should not be separated following birth. Interrupting, delaying, or limiting the time that a mother and her baby spend together may have a harmful effect on their relationship and on breast-feeding. Babies stay warm, cry less, and have a better start on breast-feeding if moms and babies are together.

[As for the question about depression], women with postpartum depression do experience difficulty bonding with their babies. But this could be a result of depression rather than the cause, so it's really hard to answer [whether a shortened period of recovery is related to causing postpartum depression]. Most people get 6 weeks off of work, but even in those 6 weeks, women are still running around [trying to take care of other children, do chores, and manage the household]. I don't know whether we, as a culture, discourage mothers and babies to be together in the postpartum period by no longer posting signs on the doors that say "Don't knock, baby sleeping!" I'm just not aware of any comparative studies on how different postpartum protocols correlate with postpartum depression.

Medscape: There's a marked trend toward inducing delivery -- vaginally or surgically -- before 40 weeks, with mounting evidence that this is risky business. Where is this coming from?^[20,21]

Dr. Spry: This increased induction rate has occurred for several reasons: the desire on the part of the women or the providers to arrange a convenient time for delivery. Again, it's a scheduling issue. Concerns about postmaturity, or a post-dates baby, with a fear of adverse outcome and litigation may have contributed to this. But despite the large number of women experiencing induction, one-half of the women who responded to the "Listening to Mothers" study said that they felt that labor should not be interfered with unless it's medically necessary. Eleven percent of the mothers also said that they had experienced some pressure from their care providers to have an induction. Lamaze gives this information to women to help them select their place of birth and communicate with their healthcare provider. These tools can assist women in having a safe and healthy birth.

Medscape: Even truly full-term infants born by cesarean end up in intensive care more frequently than their vaginally born peers. Is this because such infants born by cesarean are high-risk to begin with, or is the procedure itself responsible for this?

Dr. Spry: I think that it's both. I definitely think that some medically indicated surgical deliveries do end up with babies that were higher-risk to begin with. But if you compare low-risk babies that are born by cesarean with vaginal-birth babies, vaginal-birth babies do better. There is an increased likelihood of babies born surgically having problems with fluid in the lungs and less ability to clear it. So actually going through the birth canal seems to be better for the baby.

Medscape: In 2005, surgical birth was the most common Medicaid-billed procedure, performed on women who are most likely at risk for the poorest aftercare, complications, and support. Why is this population at highest risk for c-section?^[21]

Dr. Spry: I don't think this statistic indicates that the Medicaid population is at highest risk if they were compared to the insured population. I think that a large part of the Medicaid population consists of pregnant women, because this is a time when they can get coverage. So Medicaid often ends at the 6-week postpartum exam. A childbearing woman would be more likely to be covered under Medicaid than a woman in her forties who needed gallbladder surgery.

There have been a couple of studies that looked at the cesarean delivery rate of women with private insurance delivering in private hospitals, and found that privately insured women had a higher surgical risk than the Medicaid population. The rate in New York was 30% for private vs 21% for Medicaid, if the Medicaid women delivered in a public hospital (a teaching hospital). So what has happened is that we've had somewhat of a shift of Medicaid patients moving into the private sector; they've shifted their deliveries from teaching hospitals to private institutions, and this has increased their probability for cesareans.

A study from Kaiser in California showed that this increased risk persists even after adjusting for patient demographics and clinical factors. The risk was associated not so much with Medicaid, but with delivering in a private institution. Teaching hospitals tend to follow evidence-based practice, and encourage women to deliver vaginally.

Medscape: What's your perspective on recent reports about the rate of repeat cesareans jumping from 65% to 90% between 1997 and 2006?^[22]

Dr. Spry: Again, I think it's litigation fear. There have been more and more restrictions placed on women who want to have VBACs. Some insurance companies won't cover clinicians or hospitals [if they provide a trial of labor after cesarean; and] there are certainly clinicians who won't do VBACs. Women are finding it more and more difficult to seek and have a vaginal birth after a prior cesarean.

I just went to a conference where I talked to a number of women whose previous experience was with c-section, but who wanted a vaginal birth. Some of them chose home birth for their next pregnancies because it was their only option.

Medscape: As the concept of birth transitions from a physical, sexual, and societal passage to a billable surgical procedure, placing women in a more passive role, how is the overall well-being of women affected?

Dr. Spry: Within the maternity system, there's a distinct drive toward convenience: predictable process of labor and birth, maximized reimbursement, and limited liability. All of these factors can lead any care provider to make decisions that aren't necessarily based on the mother's and baby's needs. Women's decisions are affected as well, because without maximum reimbursement, they can't select a place of birth that they can't afford. I think it's critical for every birthing woman to recognize the realities of the environment and be prepared to advocate for herself, taking a more active role in her birth. This is something that Lamaze focuses on.

Studies have been done where a woman has experienced a kind of birth that she didn't want, and she felt that she had no control over it. Penny Simkin just gave an excellent talk on the risk of posttraumatic stress syndrome resulting from a birth in which a woman felt not in control, who felt decisions were made for her and were imposed on her. I think that sense of control is really important to the mental health and to the feeling of being competent and OK after birth.

Medscape: Obstetrics is a surgical specialty. So far, the significant numbers of women now practicing in the field have done little to change the surgical view of birthing women. Do you think there will be a tipping point away from the surgical approach to birth among obstetricians?

Dr. Spry: Sometimes it takes us years to figure out what we've been doing wrong; this is an alarming aspect of surgery, and few women are aware of the poor state of maternity care that we have in the United States. Many women assume that because they're birthing in the United States, they're getting quality care. Research and outcome studies suggest that this isn't necessarily the case, but I don't think our population knows that yet. We're seeing an increased number of maternal deaths. We haven't seen an increase in maternal deaths in this country for a long time. [An example of a delay in recognizing risk of accepted treatment is, that] in the 1950s, 1960s, and 1970s, we gave diethylstilbestrol to women to prevent miscarriage. It wasn't until the next generation, and even after the next generation -- 30 years -- that we got rid of that practice. So I think change will come. And I think that we need to continue to perform research, monitor maternal morbidity, and look at these statistics, and then we'll see a shift.

The other issue is that really adverse, terrible events are rare; maternal deaths are rare, even though they are increasing. So an obstetrician having a personal experience of a maternal death is infrequent.

Essential skills are being lost in obstetrics -- for example, breech deliveries or twins. However, they are preserved in the world of midwifery.

I hope that we get the message across that women want and need a positive birthing experience, and that they will choose a birth team that will support that goal. We would like for everybody to have a safe and healthy birth.

Cesarean vs, VBAC - a dramatic difference

This is such a touching video and eye opening video. Most people do not realize the force needed to get a baby out during a cesarean section - in the second birth, a vacuum is used as well as manual force. It is 16 minutes long, but worth the time.

Cesarean vs. VBAC: A Dramatic Difference from Alexandra Orchard on Vimeo.

For some, life begins at home

Emma Downs
The Journal Gazette

Kat Hickey was nine months pregnant – although anyone who has gone through a pregnancy knows that nine months feels a lot like 19 somehow – and ready … really ready … to deliver.

Sitting in a bathtub inside her Fort Wayne home, Hickey diligently breathed through a series of contractions and waited patiently for her certified nurse midwife to arrive.

OK. Maybe not that patiently.

“My husband asked me if I could hang on just a little longer,” Hickey says. “The midwife was just 10 minutes away.”

And then Hickey felt the crown of her soon-to-be-born daughter’s head touching her hand. So that answered that question.

Ummm … no. Huh-uh. There would be no hanging on for a little longer.

“Knowing it would just take one good push and I would have her in my arms,” Hickey says. “That was the motivation.”

So she pushed. And, with the help of her husband, a few minutes later a beautiful, healthy baby girl was staring at them with that “Whoa. What just happened?” newborn expression.

“It was beautiful. We had the baby the same way we made it,” Hickey says. “Just two idiots, in our own house.”

And as dramatic as this story sounds, this is exactly what Hickey and her husband had planned from the beginning: a home birth involving the whole family.

As with many women who choose to deliver at home, Hickey wanted to avoid what she considered to be the unnecessary medical interventions she’d encountered while delivering her first child at a hospital. For her, this had included Pitocin to speed up or regulate labor, an epidural and narcotics, an IV, a catheter, a constant fetal monitor and, eventually, forceps used to extract the baby from the birth canal.

“When it came to pushing, I could’ve been blowing my nose for all I knew,” she says. “It was a bazaar situation. It seemed like the baby had been ejected from my body. And that left me thinking, ‘Did I do that? Or did they?’ I knew that couldn’t be the best way to do it.”

Growing demand

The process of delivering at home – even in the bathtub – was transformative, Hickey says. And it convinced her to become a doula, a trained labor coach. She began assisting with home births in 2000, shortly after her daughter was born.

“One of the biggest misconceptions is that giving birth at home is not an informed choice,” Hickey says. “A lot of people who do research on birth and the risks of giving birth come to the conclusion that the risks of the medical interventions are higher than the risks of delivering naturally at home.

“And the number of women who encounter an unexpected complication – when no problems existed prenatally – is incredibly small. My husband, for instance, was mostly just worried about our carpet. I knew we could work around that.”

Hickey frequently assists in births with Laura Gilbert, a certified nurse midwife with Homebirth & Women’s Health in Goshen. Gilbert, who assists with births in Fort Wayne, has recently started to turn clients away. The demand for home births is growing for a number of reasons, she says.

“There really is a desire to avoid unnecessary medical interventions,” Gilbert says. “But there is also a drive to have the birth be a family-centered event instead of a medical-centered event.”

Gilbert performs about six deliveries a month and insists that all of her clients be single, low-risk pregnancies. Although the majority of her clients are Old Order Amish, the next largest group are conservative Christians looking to save money, she says.

“The cost is probably less than half of a natural birth in the hospital,” Gilbert says. “But despite the cost, I always tell people who are thinking about home birth to have the baby in the place where they feel most comfortable.

“For me and my clients, that’s at home. For some people, that’s the hospital. There is no right or wrong.”

‘Informed choice’

For local mom Kristin Rahn, the most comfortable place to have her most recent child was standing up next to the living room couch. Gravity, it turns out, helps more than you’d think.

“That’s the big advantage to having a baby at home,” Rahn says. “You’re on your own turf, so your fight-or-flight instinct is less likely to kick in and inhibit your labor.

“And you’re more comfortable listening to your own body. You decide whether to eat or drink, whether to stand up, squat, take a bath, take a shower. You’re not flat on your back, hooked up to an IV and a catheter.”

Rahn and her husband have four children; two born in the hospital, two born at home. And when the couple first made the decision to deliver at home, they didn’t tell all of their relatives.

The midwifery model of care treats birth as a normal occurrence, relying on the idea that biologically a woman is designed to give birth. It was easy for Rahn to trust that her body and the process of giving birth naturally would work.

But not everyone felt the same. Some people she encountered felt a home birth was innately risky, she says.

“There were people who were worried,” she says. “People who frowned and said, ‘We’ll be praying for you.’ And people who thought my decision was based on bravado and not research. And that is a misconception.

“It’s totally evidence based. It’s definitely an informed choice, not second-rate or a last choice. It’s always something consciously chosen.”

Gilbert combats the misconception that home birth is dangerous with a rundown of what’s inside the travel bag she carries with her to every home birth – a dopler to check the fetal heartbeat, injectable Pitocin, oxygen and an IV for any needed antibiotics.

Fewer than 10 percent of Gilbert’s patients end up in the hospital – most of them due to long drawn-out labors when pain relief is needed.

“It’s important for the mother and baby to be low risk,” Gilbert says. “Prenatally, we check for anything out of the norm. And thank goodness hospitals are there. It’s the best of both worlds, really. You can have a home birth, but the hospital is nearby, too.

“If you were living 600 years ago, you wouldn’t have had that choice.”

For Hickey, the birth of her daughter – at home, in the bathtub – is a story worth retelling. Every year on her birthday, Hickey and her husband tell their daughter about the day she was born.

“My husband has this visceral memory of seeing our daughter’s little face, fitting perfectly in the palm of his hand,” she says. “And it’s that – those memories. That’s the beautiful thing about home birth.”

Canadian docs to stop automatic C-sections for breech babies

Unfortunately here in St. George, there are no providers at the hospital that will do a planned vaginal breech birth. Hopefully, the US will take notice of Canada's new stance on breech birth and follow.
Vaginal breech birth is possible and surgical birth should not be the only choice. Your best chance for a vaginal breech birth, if you find yourself in that position, is a homebirth midwife. Do your research.
___________________________________________________________________

By Sharon Kirkey, Canwest News Service

In a major shift in medical practice and another assault on Canada's rising cesarean section rate, Canada's delivery doctors are being told to stop automatically scheduling C-sections for breech babies and attempt a normal delivery instead — something significant numbers of obstetricians aren't trained to do.

New guidelines issued Wednesday by the Society of Obstetricians and Gynaecologists of Canada say women carrying babies in the breech, or bottom-first, position should be given the right to choose to attempt a traditional delivery when possible.

The society says that women in Canada want the choice, and that some women with breech babies are delivering at home "because they knew if they went to hospital A, B or C it would not be offered," says Dr. Andre Lalonde, executive vice-president of the obstetricians' group and an adjunct professor of obstetrics and gynecology at McGill University and the University of Ottawa.

Lalonde says the group is working aggressively to ensure future specialists are trained in breech vaginal deliveries and is organizing courses across Canada for practising doctors to refresh their training.

"Paramount is the safe birth of the child," he said.

Most babies are positioned in the head-down position when labour starts. With breech babies, the feet or buttocks come out first during birth.

Breech babies account for about three to four per cent of all pregnancies in Canada, or about 11,000 to 14,500 pregnancies each year.

"Breech pregnancies are almost always delivered using a cesarean section, to the point where the practice has become somewhat automatic," Dr. Robert Gagnon, a principal author of the new guidelines and chair of The Society of Obstetricians and Gynaecologists of Canada's maternal fetal medicine committee, said.

"What we've found is that, in some cases, vaginal breech birth is a safe option and obstetricians should be able to offer women the choice to attempt a traditional delivery."

An international, Canadian-led study reported in 2000 that the safest way for breech babies to enter the world was via C-section. The study of more than 2,000 women found babies of mothers in the cesarean group were three to four times less likely to die, or have serious problems in the first six weeks of life, compared to those in the vaginal birth group (1.6 per cent versus 5.0 per cent).

The study had widespread influence worldwide. Many doctors stopped doing vaginal deliveries for breech babies, and many medical schools stopped training doctors in how to do them.

But the doctor who led the study said the risks, while different, were never huge. "The risks were still quite low," says Dr. Mary Hannah, a professor in the department of obstetrics and gynecology at the University of Toronto and Sunnybrook Health Sciences Centre.

More recent studies, including a study of more than 8,000 French and Belgian women carrying breech babies, found no significant differences in risks to babies whether they were born vaginally or via C-section.

Hannah says that a planned vaginal delivery of breech babies can be a safe and reasonable option. But, she said, most women she knows "will still want the option that is possibly safer, and that will be a planned cesarean section."

The main concern has always been delivery of the head — that the body will deliver, but that the baby's head will get caught.

"You can push the baby all the way back up into the uterus and do a cesarean section. But that's very traumatic," Hannah says. "And by the time that you are able to do that the baby may have suffered severe hypoxia," or lack of oxygen.

The new guidelines say that many breech deliveries will still require a C-section, and that a vaginal birth is not recommended for a "footling" breech, where the baby is positioned feet-first, with one or both feet pointing directly down toward the birthing canal.

Vaginal breech births also aren't recommended if the woman's pelvis is narrow or small, if the umbilical cord is likely to become entangled or compressed during delivery, or for babies that are too big (weighing more than 4,000 grams, or 8.8 pounds) or too small (less than 2,500 grams, or 5.5 pounds).

Breech deliveries are one of the main reason for C-sections, "and, if you do one (C-section), you increase the risk for another" in future pregnancies, Lalonde says. Repeat C-sections account for 30 to 40 per cent of all cesareans.

Beautiful HBA2C Video

Check out this beautiful HBA2C (homebirth after 2 cesarean) video.

Home births 'as safe as hospital'

The largest study yet on the safety of home births suggests that, in most cases, the risk to babies is no higher than if they are born in a hospital.

Research from the Netherlands - which has a high rate of home births - found no difference in death rates of either mothers or babies in 530,000 births.

However, only women who were deemed to be at low risk of complications were included in the Dutch study.

UK obstetricians welcomed the study but said it may not apply universally.

Home births have long been debated amid concerns about their safety.

But the number of mothers giving birth at home has been rising since it dipped to a low in 1988. Of all births in England and Wales in 2006, 2.7% took place at home, the most recent figures from the Office for National Statistics showed.

The research - published in the BJOG - was carried out in the Netherlands after figures showed the country had one of the highest rates in Europe of babies dying during or just after birth.

It was suggested that home births could be a factor, as Dutch women are able and encouraged to choose this option.

But a comparison of "low-risk" women who planned to give birth at home with those who planned to give birth in hospital with a midwife found no difference in death or serious illness among either baby or mother.

"We found that for low-risk mothers at the start of their labour it is just as safe to deliver at home with a midwife as it is in hospital with a midwife," said Professor Simone Buitendijk of the TNO Institute for Applied Scientific Research.

"These results should strengthen policies that encourage low-risk women at the onset of labour to choose their own place of birth."

Hospital transfer

Low-risk women in the study were those who had no known complications - such as a baby in breech or one with a congenital abnormality, or a previous caesarean section.

Nearly a third of women who planned and started their labours at home ended up being transferred as complications arose - including for instance an abnormal fetal heart rate, or if the mother required more effective pain relief in the form of an epidural.

But even when she needed to be transferred to the care of a doctor in a hospital, the risk to her or her baby was no higher than if she had started out her labour under the care of a midwife in hospital.

The researchers noted the importance of both highly-trained midwives who knew when to refer a home birth to hospital as well as rapid transportation.

While stressing the study was the most comprehensive yet into the safety of home births, they also acknowledged some caveats.

The group who chose to give birth in hospital rather than at home were more likely to be first-time mothers or of an ethnic minority background - the risk of complications is higher in both these groups.

The study did not compare the relative safety of home births against low-risk women who opted for doctor rather than midwife-led care. This is to be the subject of a future investigation.

Home option

But Professor Buitendijk said the study did have relevance for other countries like the UK with a highly developed health infrastructure and well-trained midwives.

In the UK, the government has pledged to give all women the option of a home birth by the end of this year. At present just 2.7% of births in England and Wales take place at home, but there are considerable regional variations.

Louise Silverton, deputy general secretary of the Royal College of Midwives, said, the study was "a major step forward in showing that home is as safe as hospital, for low risk women giving birth when support services are in place.

"However, to begin providing more home births there has to be a seismic shift in the way maternity services are organised. The NHS is simply not set up to meet the potential demand for home births, because we are still in a culture where the vast majority of births are in hospital.

"There also has to be a major increase in the number of midwives because they are the people who will be in the homes delivering the babies."

The Royal College of Obstetricians and Gynaecologists (RCOG) said it supported home births "in cases of low-risk pregnancies provided the appropriate infrastructures and resources are present to support such a system.

But it added: "Women need to be counselled on the unexpected emergencies - such as cord prolapse, fetal heart rate abnormalities, undiagnosed breech, prolonged labour and postpartum haemorrhage - which can arise during labour and can only be managed in a maternity hospital.

"Such emergencies would always require the transfer of women by ambulance to the hospital as extra medical support is only present in hospital settings and would not be available to them when they deliver at home."

The Department of Health said that giving more mothers-to-be the opportunity to choose to give birth at home was one of its priority targets for 2009/10.

A spokesman said: "All Strategic Health Authorities (SHAs) have set out plans for implementing Maternity Matters to provide high-quality, safe maternity care for women and their babies."

http://news.bbc.co.uk/2/hi/health/7998417.stm

Breech Vaginal Birth is NOT an Emergency

This blog was written by a blogger friend. It was so good, I asked if she would mind me posting it here. Thanks Emily (http://jeremyscorner-grifter.blogspot.com) for letting me share this with my readers!

In my continuing crusade to shoot down OB myths, this week I am tackling breech vaginal birth. This post has taken a lot longer to write than I thought it would. At first I thought I was having trouble with the amount of information available about it, but that isn't the problem. The problem is that I can't really understand why breech vaginal birth is considered an emergency in the first place. Sure, I know that there are risks associated with breech vaginal birth, but I just can't shake the idea that babies are born breech all over the world with little fanfare or issue. Nevertheless, obstetricians continue to look for more and more excuses to avoid the topic entirely by just cutting the babies out. So, in the interest of being thorough, here is some food for thought.

According to this article, "Vaginal breech deliveries were previously the norm until 1959 when it was proposed that all breech presentations should be delivered abdominally to reduce perinatal morbidity and mortality." Typical of obstetric mentality, instead of looking at the cause of morbidity and mortality in the first place, they chose to focus on the correlative factor instead - that many babies who presented breech had a high rate of injury or death. But as far as I know, no one thought to ask if medications, managed, or instrumental delivery could have contributed to those injuries or deaths.

Fast forward to today, and more than 90% of all breech births in the U.S. are delivered by c-section. This has happened largely because of a study that was done in 2000 by Hannah, et al, that shows a higher rate of perinatal morbidity and mortality associated with breech vaginal birth, as compared to planned c-section. Consequently, the American College of Obstetrics and Gynecology (ACOG) has systematically condemned breech vaginal birth, and it is no longer offered as a choice to women today. Henci Goer does a good job here of explaining why the conclusions of that 2000 study are not valid.

However, the ACOG has a history of picking and choosing those studies that support its own position. They also prefer to ignore any studies not done in the United States, as those studies are often contrary to American obstetric practics. For example:

A study out of Sweden in 2003 in the European Journal of Obstetrics & Gynecology and Reproductive Biology showed no difference between elective cesarean vs. planned vaginal birth for term breech deliveries.

Another study actually published with the American Journal of Obstetrics and Gynecology in 2006 examined planned breech delivery in France and Belgium, and found no discernable difference in outcome with more than 8,000 breech patients studied.

A different study from France in 2002 and published in European Journal of Obstetrics & Gynecology and Reproductive Biology looked at more than 500 patients and found no difference in outcome.

The International Journal of Gynecology & Obstetrics published a study in 2004 from the United Emirates which found no clear difference in breech vaginal vs. cesarean, but did find more maternal morbidity associated with cesarean section.

The Malaysian Journal of Medical Sciences, published a study in 2007, which concluded, "Most of the perinatal mortality was due to IUD, congenital abnormality and prematurity and there
were no perinatal death related to mode of delivery or due to birth trauma."

and there have been other studies to support these findings.

Danell Swim writes in her article, A Breech of Trust,

So I ask you, what are the United States hospitals doing wrong for their vaginal breech deliveries?

It is NOT that cesarean section is safer for breech deliveries in this nation, it is that vaginal breech is more dangerous in this country. US hospital policy and procedure are killing more breech babies than their European counterparts.

And to remedy the situation, it’s been recommended that nearly all babies in a breech presentation be delivered via cesarean section. This is despite the study published with the American Journal of Obstetrics and Gynecology that discovered that France and Belgium are able to safely deliver them vaginally, and safely.

So rather than teach our doctors how to safely deliver a breech baby, the ACOG's answer to the breech problem is to simply take them by c-section at term.

This article describes how best to safely deliver a breech baby. Included in the highlighted points are:

• Spontaneous onset anytime after about the 37th week.
• No augmentation if labour is slow or there is poor progress - caesarean section.
• Mother encouraged to assume positions of choice during the first stage.
• Fetal heart listened to frequently with a Pinard stethoscope or a hand held Doppler Sonic aid using ultrasound.
• Food and drink encouraged, but remembering that women in strong progressing labour rarely want to eat.
• Membranes not ruptured artificially.
• Vaginal examinations restricted to avoid accidental rupturing of the membranes.
• If, and when spontaneous rupture occurs conduct a vaginal examination as soon as possible.
• Second stage by maternal propulsion and spontaneous expulsive efforts guided by the attendant if judged appropriate.
• Mother encouraged to be in an all-fours position.
• No routine episiotomy.
• Third stage without chemical or mechanical assistance, usually managed according to woman's wishes.

Of that list, tell me how many of those are likely to occur in a medically managed birth in a US hospital today?

The most dangerous aspect of this trend is that American health care providers are losing, or have completely lost, the art of safely delivering breech babies. While some doctors may envision a 100% c-section rate for breech births, that will never be possible. The World Health Organization (WHO), in this publication about planned c-section for breech says,

It will be impossible to deliver all term breech pregnancies by caesarean section. The systematic review showed that 9% of women with breech presentation still have a vaginal breech delivery because the mother may insist on vaginal delivery, breech labour may be precipitate, or special situations such as the second fetus in twins. It is therefore imperative to continue providing expertise in vaginal breech delivery to all the intrapartum care providers.

This atmosphere of fear and foreboding surrounding breech births is leading women to choose dangerous options to avoid having a breech baby at all costs. The current recommendation is to attempt an external cephalic version (ECV), in which the care provider attempts to turn the baby from the outside into a head-down position. But ECV is not without risks. According to this publication:

The largest review which included 44 studies and 7377 patients found the most common complication of ECV to be transient fetal heart rate abnormalities (5.7%). The risk of placental abruption, emergency cesarean section, vaginal bleeding, and perinatal mortality were less than 1 percent combined. Because of the risk of alloimmunization, Rhogam is recommended for non-sensitised Rh negative women following ECV. There currently is not enough evidence from randomized controlled trials to assess complications of ECV.

In addition, in order to perform an ECV, tocolytics such as terbutaline, and epidural anesthesia are sometimes used. The risks of epidural anesthesia are well-documented. Risks of terbutaline to the baby include fetal tachycardia, hyperinsulinemia, hyperglycemia, myocardial and septal hypertrophy, myocardial ischemia. Terbutaline not only does not have FDA approval but the FDA disapproves of its use as a tocolytic.

ECV is only successful 50-60% of the time (various sources). When ECV is unsuccessful, the only other option is to schedule a planned c-section for some arbitrary date. The problem with this is that breech babies can and do turn, up to, and even during labor. So planning a c-section may be taking a baby even before it is ready to be born, and without giving it a chance to get itself into a favorable position.

It is clear to me that breech birth, while carrying some risk, is not unreasonably dangerous in itself. The danger lies in breech birth in a highly managed hospital setting. For this reason, I would suggest that if a woman plans to birth in the hospital in the U.S, and her baby is breech, she should plan to have c-section. In fact, if a woman is planning a hospital birth and her baby is breech, she probably won't have a choice about it. If she does not want to have a c-section, she should stay home. But she should know a c-section for breech is not necessary! In fact, I don't even believe any undue concern should be attributed to breech presentation, especially if one has a midwife who is experienced and skilled in delivering breech babies.

If you find yourself pregnant, approaching term, and your baby is breech, please try these suggestions for gently encouraging your baby to turn. If you want to avoid unnecessary surgery, start now looking for a midwife who is experienced in breech delivery. Don't schedule a c-section - allow baby all the time it needs to turn itself. You can visit spinningbabies.com to learn how to tell whether your baby is head-down.

Labor of Love

This trailer is for the new book Labor of Love, written by Cara Muhlhahn. Cara is a homebirth midwife in NYC. You may remember her from documentary, The Business of Being Born.
I just love this clip! I relate so much to her feelings of what it is to be a midwife and why I do it.

More Moms Choose To Give Birth At Home

More moms choose to give birth at home
Too pricey » Many cite economic factors when deciding not to deliver in a hospital.

By Heather May
The Salt Lake Tribune
By Heather May
The Salt Lake Tribune

If Samara Hines had health insurance, she'd deliver her baby in a hospital, away from the demands of her five other children and with help from nurses for the new little one.
But Hines' husband is self-employed and the family can't afford insurance or the estimated $6,000 hospital fees, plus the cost of a nurse-midwife and prenatal care. So in August, the Provo woman will deliver her baby at home, where it will cost $1,900 for everything.
Spending thousands of dollars is "excessive, considering birth is a natural thing," said her husband, Dane. With no history of pregnancy complications and no insurance, home birth is "the most reasonable way to go," he said.
Midwives say the same economic forces that have led consumers to stay home instead of shopping is hitting the birthing business, albeit on a small scale. Licensed home-based midwives say they are seeing a slight increase in interest in their practice, in part because of cost.
A hospital-based birth can run about $8,300. That includes the $6,000 average hospital charge in 2006, calculated by the state health department. Women who want a certified nurse-midwife to care for them and the baby add an average fee of about $2,350.
"The fact people are having a lot of financial troubles is causing people to look for alternatives," said Suzanne Smith, Hines' midwife, who is taking more calls from people who are uninsured or have high deductibles. "Once they look at it they say, 'This is actually a pretty good option and it costs me a lot less.'?"
Smith placed an advertisement in the magazine Healthy Utah , noting the cost of pregnancy and delivery could be as low as $1,000 with supervised midwife students, though the average home birth is a little less than $2,000. Smith also runs a one-room birthing suite -- with a fridge stocked with snacks, a jetted tub and queen-sized bed -- in Orem, called BellaNatal. A birth there costs $2,800, including the midwife's fee.
She said eight women a week are making initial consulting appointments, when the norm in December is three.
It costs $4,350 to deliver at the Birth and Family Place, a birth center in Holladay, including the provider fee. The percentage of women touring the center who say they are attracted by its price has spiked to about a third, according to medical director Rebecca McInnis. "I don't think it's been that high before," she said.
Ann Stuart, who's due in March, would give birth at home, even if she had insurance. The Springville mother has delivered three times in the hospital and once already at home.
"It was so nice just to be in my own surroundings, not have to worry about packing a hospital bag, just be where I could go get food when I wanted it," she said, noting this birth will cost $1,400 because a supervised student will be her attendant. "If I feel more comfortable going one way and it's cheaper, I'd much prefer spending less."
Delivering at home or in a birthing center only makes sense for certain women, midwives say, noting that cost is rarely the only factor. The women must be willing to forgo an epidural or Caesarean section and must able to cope with pain using alternative methods. They must be healthy and have low-risk pregnancies. And they have to weigh the risks and benefits to delivering outside of a hospital.
"You really should be where you feel safe, where you feel good," Smith said. "Nobody's going to go to the cheapest place when it comes to the life of their baby."
That's why even though Shara Sumnall wanted to deliver her son, Jackson, in Smith's less-expensive birthing suite, she ended up in the hospital on Dec. 19 when her labor wouldn't progress.
Sumnall, whose husband works on commission in the sputtering auto industry, has insurance but could have saved money paying out of pocket to deliver at BellaNatal. After 12 or 13 hours of labor, she was admitted to a hospital and tried an epidural and pitocin to move things along. When that didn't work, she had a Caesarean section.
Sumnall hasn't received the bill and is "trying not to stress about it right now. I'm just enjoying my baby. There's a certain level of hope things will pick up with the economy."
Besides the cost, midwives tout the amount of control women can have at home, including the ability to deliver in water or in various positions instead of prone in a bed.
Cost and control were important to Paula Williams, of Provo. She wanted a home birth with her second child after a natural birth in the hospital with her first. Like many women who choose home birth, the massage therapist was dissatisfied with her hospital birth, particularly the rushed delivery of the placenta. She said she was so tired she didn't want to hold her baby.
The price tipped the scale in favor of birthing at home, because Williams doesn't have insurance. In late November, she delivered her son in a tub in her parents' house in Highland. She showered soon after the delivery and was in bed with her husband that night.
"It was a lot better experience. I got to do it my way," she said. "I will be doing it again, not just because of the money."

Midwives Deliver

Midwives deliver
America needs better birth care, and midwives can deliver it.
By Jennifer Block December 24, 2008

Some healthcare trivia:
In the United States, what is the No. 1 reason people are admitted to the hospital? Not diabetes, not heart attack, not stroke. The answer is something that isn't even a disease: childbirth.Not only is childbirth the most common reason for a hospital stay -- more than 4 million American women give birth each year -- it costs the country far more than any other health condition. Six of the 15 most frequent hospital procedures billed to private insurers and Medicaid are maternity-related. The nation's maternity bill totaled $86 billion in 2006, nearly half of which was picked up by taxpayers.

But cost hasn't translated into quality. We spend more than double per capita on childbirth than other industrialized countries, yet our rates of pre-term birth, newborn death and maternal death rank us dismally in comparison. Last month, the March of Dimes gave the country a "D" on its prematurity report card; California got a "C," but 18 other states and the District of Columbia, where 15.9% of babies are born too early, failed entirely.The U.S. ranks 41st among industrialized nations in maternal mortality. And there are unconscionable racial disparities: African American mothers are three times more likely to die in childbirth than white mothers.In short, we are overspending and under-serving women and families. If the United States is serious about health reform, we need to begin, well, at the beginning.

The problem is not access to care; it is the care itself. As a new joint report by the Milbank Memorial Fund, the Reforming States Group and Childbirth Connection makes clear, American maternity wards are not following evidence-based best practices. They are inducing and speeding up far too many labors and reaching too quickly for the scalpel: Nearly one-third of births are now by caesarean section, more than twice what the World Health Organization has documented is a safe rate. In fact, the report found that the most common billable maternity procedures -- continuous electronic fetal monitoring, for instance -- have no clear benefit when used routinely.The most cost-effective, health-promoting maternity care for normal, healthy women is midwife led and out of hospital. Hospitals charge from $7,000 to $16,000, depending on the type and complexity of the birth. The average birth-center fee is only $1,600 because high-tech medical intervention is rarely applied and stays are shorter. This model of care is not just cheaper; decades of medical research show that it's better. Mother and baby are more likely to have a normal, vaginal birth; less likely to experience trauma, such as a bad vaginal tear or a surgical delivery; and more likely to breast feed. In other words, less is actually more.

The Obama administration could save the country billions by overhauling the American way of birth.

Consider Washington, where a state review of licensed midwives (just 100 in practice) found that they saved the state an estimated $2.7 million over two years. One reason for the savings is that midwives prevent costly caesarean surgeries: 11.9% of midwifery patients in Washington ended up with C-sections, compared with 24% of low-risk women in traditional obstetric care.

Currently, just 1% of women nationwide get midwife-led care outside a hospital setting. Imagine the savings if that number jumped to 10% or even 30%. Imagine if hospitals started promoting best practices: giving women one-on-one, continuous support, promoting movement and water immersion for pain relief, and reducing the use of labor stimulants and labor induction. The C-section rate would plummet, as would related infections, hemorrhages, neonatal intensive care admissions and deaths. And the country could save some serious cash. The joint Milbank report conservatively estimates savings of $2.5 billion a year if the caesarean rate were brought down to 15%.

To be frank, the U.S. maternity care system needs to be turned upside down. Midwives should be caring for the majority of pregnant women, and physicians should continue to handle high-risk cases, complications and emergencies. This is the division of labor, so to speak, that you find in the countries that spend less but get more.In those countries, a persistent public health concern is a midwife shortage. In the U.S., we don't have similar regard for midwives or their model of care. Hospitals frequently shut down nurse-midwifery practices because they don't bring in enough revenue. And although certified nurse midwives are eligible providers under federal Medicaid law and mandated for reimbursement, certified professional midwives -- who are trained in out-of-hospital birth care -- are not. In several state legislatures, they are fighting simply to be licensed, legal healthcare providers. (Californians are lucky -- certified professional midwives are licensed, and Medi-Cal covers out-of-hospital birth.)

Barack Obama could be, among so many other firsts, the first birth-friendly president. How about a Midwife Corps to recruit and train the thousands of new midwives we'll need? How about federal funding to create hundreds of new birth centers? How about an ad campaign to educate women about optimal birth?

America needs better birth care, and midwives can deliver it.

Jennifer Block is the author of "Pushed: The Painful Truth About Childbirth and Modern Maternity Care."