Thursday, April 30, 2009

April is Cesarean Awareness Month

I'm slow on this one, but while it's still April, I want to acknowledge Cesarean Awareness Month. You can read anywhere that the cesarean birth rate in the United States is climbing each year - both because the rate of primary cesarean births is rising, and because the rate of VBACs (vaginal birth after cesarean) is falling. As of 2007, an average of one out of three babies are born surgically. The Centers for Disease Control (CDC) reports that in 2007, 31.8% of women birthed by cesarean in the United States.

There is support for women who are recovering from a cesarean birth, including ICAN chapters in many states. If you live in Maine where there is currently no chapter listed, you can still request support. There are also online communities that support women recovering from traumatic birth (cesarean or vaginal), like Solace for Mothers.

In my opinion, one of the most troubling effects of cesarean birth is that it can severely limit women's options for future births. In Maine, there are only a handful of hospitals that "permit" VBACs. In central Maine, the only hospitals I know that do VBACs are CMMC in Lewiston and Maine General in Waterville. Nationally, VBACs are only permitted in about half of hospitals, and frequently only under certain specific conditions or with select care providers who are willing to attend them. Is this information that is offered to women as part of informed consent, especially in the many non-emergent situations like "failure to progress" or "you have a big baby"?

You can read about the lack of choice in Time Magazine, "The Trouble with Repeat Cesareans" and Pamela Paul's follow-up article in the Huffington Post, "Childbirth Without Choice".

You can read about why the rate of VBAC is so low at The Well-Rounded Mama.

Also, you can click on the Cesarean label below this post to read more blog entries on Cesarean birth.

Christina @ Birthing Your Baby
Independent Childbirth Classes for Central Maine
New Mothers Support Circle

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Thursday, January 15, 2009

More on Vitamins: Vitamin D & DHA in Formula

In my last post on vitamins, I included the hugely informative link to Navelgazing Midwife's post on Vitamin D & It's Role in Women and Children.

I want to add a link to a New York Times article I read that summarizes a study done at Boston University that concluded that Vitamin D deficiency may increase the risk of an emergency cesarean.
"The researchers studied 253 births at a Boston hospital from 2005 to 2007. After controlling for other variables, the scientists found that women with low blood levels of vitamin D were almost four times as likely to have an emergency C-section as those with normal levels. Vitamin D deficiency has been associated with muscle weakness and high blood pressure, which might help explain the finding."
I would be interested to know if these cesareans were truly emergency, and even more importantly, what specific, medical reason for the cesarean birth was given.

I also wanted to offer this link to the Motherwear blog post on Vitamin D. There is great information on breastmilk and Vitamin D in the two links provided in this post. And, there is interesting discussion in the comments.

Finally, when I wrote the post on Omega-3's during pregnancy, I wasn't thinking about formula, and the attempts on the part of formula-makers to manipulate mothers into buying DHA-"enhanced" formula.

I believe that adding DHA/ARA is a marketing ploy made to manipulate mothers into buying a more expensive product that contains additives of questionable value. As someone who believes in the inherent superiority of breastmilk for infants, I also would hate to think that any mother ever gives up on nursing thinking that DHA/ARA formula is "close enough" to human milk - that the DHA/ARA confers some magic benefits. I am not anti-formula - there are times when it is necessary; however, I am firmly against the manipulative scare tactics employed by many companies marketing to mothers.

According to an article in Mothering's May/June 2008 magazine, "test results have shown the additives have negligible positive effects on infant development. The FDA's initial analysis of the additives reached no determination of their safety, while noting that some studies reported unexpected deaths among infants who have been fed DHA/ARA formula" and that there have been an array of symptoms (vomiting and diarrhea) reported by parents and doctors that "disappeared when the infants were switched to a non DHA/ARA formula".

To read more about DHA/ARA in formula, read the .pdf "Replacing Mother: Imitating Breastmilk in the Laboratory".

Christina @ Birthing Your Baby
Independent Childbirth Classes for Central Maine

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Sunday, January 11, 2009

Cesarean Births: Too Early?

A USA Today article, "Elective C-sections performed too early 36% of the time", reporting on a recent study published in the New England Journal of Medicine, begins with this startling information:
"More than a third of elective C-sections are performed too early, increasing newborns' risk of respiratory distress and other problems, researchers report today."
Full-term is now defined as 37-41 weeks (used to be full-term was considered 38-42 weeks), and although the American College of Obstetricians and Gynecologists (ACOG) recommend that elective cesareans are performed no earlier than 39 weeks gestation, the study results found that 36% of the time, ceseareans are performed before 39 weeks.

Highlights from the article include this statement about the difference between baby-initiated labor and induced labor/cesarean birth:
"At 37 weeks, babies are considered fullterm, but there's a difference between those delivered vaginally and by elective C-section, says coauthor John Thorp, professor of obstetrics and gynecology at the University of North Carolina, Chapel Hill. "We would not worry about a 37 1/2-week baby born vaginally with the onset of labor," Thorp says. In that case, 'there is some signal from a baby to his mother that says, "I'm ready …"'".
People mature - physically and emotionally - at very different rates. Think of the range for puberty... some girls start menstruating at age nine, and others at fourteen. Both situations are within the normal range, and indicate that particular body's readiness for puberty. I was one of the fourteen year olds; my body was no where near puberty or womanhood at age nine. Of course, we can't induce menstruation on young girls - who would want to?

But ask a woman when she's nine months pregnant if, uninformed of any risks, she might want to birth her baby a few weeks early. She just might be inclined to jump at the chance to meet her baby and end the last, frequently uncomfortable, stage of pregnancy.

What are the risks? Well, the USA Today article explains that
"Overall, about 10% of the babies at birth had at least one of these problems: respiratory distress, low blood sugar, infection or need for a respirator or intensive care. Those born at 37 weeks were twice as likely and those born at 38 weeks 50% more likely to have a problem than those at 39."
Are most women informed about these risks when their cesarean birth is scheduled? I doubt it.

Also, note that this article discusses "elective" cesarean births. Just to clarify, so this post does not add to the myth that many women are choosing elective cesarean births, the vast, vast majority of "elective" cesarean births are not a mother's first choice. In the Listening to Mothers II study, only one mother in 1500 indicated that a cesarean was her personal birth choice while many others (25%) indicated that they felt pressure from their care providers to "choose" a cesarean. Read Childbirth Connections interesting article, "Why the National U.S. C-Section Rate is Rising" for more information.

What's the best way to minimize the risk of performing a cesarean birth too early? If possible, don't schedule it! Wait until labor begins, and then go to the hospital for the cesarean birth. In many "elective" cesarean births, this method should be without additional risks: for a twin birth, or a breech birth, or birth after a previous cesarean (though for all of these situations, a trained care provider can frequently have just as safe or safer outcomes with a vaginal birth). There are, of course, other situations when this "contractions before cesarean" method would not be safe, for example, if the placenta covers part or all of the cervix (placenta previa).

Does waiting until labor sound inconveniant? There could certainly be inconveniances with this strategy, of waiting for labor to begin and then going in for surgery: the inconveniance of waiting; the inconveniance of not knowing when labor will start; the possible discomfort/inconveniance of going into labor; inconveniance for the doctor's schedule. But balance those inconveniances with the increased risk of a NICU stay... short- or long-term medical problems... the emotional roller coaster... the larger possibility of immediate and prolonged separation.

Add future safety to the list too: ICAN reports that women who went into labor on their own before a Cesarean birth were less likely have a uterine rupture during a subsequent VBAC. The study, published in Obstetrics and Gynecology found that
"Women with a history of either spontaneous labor or vaginal birth had one rupture for every 460 deliveries, compared with one rupture in 95 among women without this history who also required induction for their trial of labor."
For more information about the risks of Cesarean births versus the risks of vaginal births, as well as several links on this topic, visit one of my earlier posts: "In the News: Where is Birth Going & Who is Taking it There?" Additional, very complete and scholarly information is available on ICAN's webpage "Fighting the VBAC-Lash: Critiquing Current Research".

Christina @ Birthing Your Baby
Independent Childbirth Classes for Central Maine

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Wednesday, January 7, 2009

Cesarean Births: Preventable?

I'm home, and everyone's healthy: a state of affairs that hasn't happened much over the past two months! I am caught up on email and reading blogs and online newsletters (whew!). It was a lot of interesting reading, which, over the next week or so, I'll be providing links to so you can read too if you've missed it, say, because someone's been sick or you've been traveling!

I have read a lot about cesarean birth in the past several weeks. Many readers have probably heard stories about emergency cesareans - when something happened with mother or baby which made a very fast procedure necessary. I'm thinking about cord prolapse (when the baby's umbilical cord slips past the baby's head is being compressed during contractions) or placental abruption (when the placenta detaches prematurely), for example. In an emergency situation, the time from indication to decision to incision and birth is very quick - a matter of ten or fifteen minutes.

These emergency situations represent a very small number of the cesarean births. Much more commonly, cesarean births are urgent or they are the end result of a series of mother or careprovider choices, many of which are not openly acknowledged by care providers as increasing the risk of cesareans. Check out this very useful discussion defining types of cesarean births - moving beyond "unplanned = emergency vs planned = non-emergency" at Enjoy Birth.

In fact, there is wide belief that many of the cesarean births happening in the United States right now are actually preventable. The World Health Oranization recommends a cesarean birth rate of 5-10%; at rates higher than 15%, the harm to mothers' and babies' health statistically outweighs perceived health benefits for the group as a whole. The United States is well past the "harm outweighing the benefits" range, with most hospitals performing a (very unusual) low of 15% cesarean birth to the average ~30% and some doing Cesareans for 50% of women's births.

The Lamaze newsletter "Building Confidence" for Week 30 mothers has an excellent assessment of preventable cesareans,
"Talk with almost any woman who has had a cesarean and she’ll say her surgery was necessary. Indeed, by the time many cesareans take place, the surgery has become necessary—either because the baby is signaling distress or labor is not progressing. But if you take a closer look, you’ll see that these problems often occurred as side effects of the way labor was managed. Some cesareans can be prevented with care that supports—rather than interferes with—the normal processes of labor and birth. By talking about “preventable cesareans,” instead of “unnecessary cesareans,” we can point to specific choices and care practices that might change the course of labor."
Lamaze offers excellent information about The Six Care Practices that Support Normal Birth.

Choosing a care provider and birth place can be a process, approached in a similar way to other big decisions, like buying a car. A person might go through a process like this to buy a car: deciding what qualities in a car are important - size, fuel efficiency, price, longevity, style; finding out which cars match their priorities; trying to find a reputable place that sells this kind of car; getting the car checked out and then buying it. This process, in my opinion, is much more likely to result in a car that matches a person's needs compared with a process which simply involves driving to the closest car dealership and asking the first salesperson to show you a car and buying it after a brief look-see.

Reading and asking questions about birth, discussing options and the typical routine care offered by a care provider/birth place is of critical importance, in my opinion.

If you're looking to minimize the likelihood of a Cesarean for your first birth experience, think about how to minimize the likelihood of having one of those preventable Cesarean.

Read about the six care practices in the link above. Read independent blogs and books and magazines.

Choose your care and birth place carefully. Understand that not all the care provided by hospitals and doctors/midwives is equal in preventing preventable Cesareans. For example, many hospitals automatically hook women up to electronic fetal monitoring (EFM) devices for all, or the majority, of their labor and birth experience. But in that same Week 30 newsletter, Lamaze excerpts this study,
"Continuous electronic fetal monitoring is used in more than 90 percent of labors in the United States. However, decades of research show that this ubiquitous machine does not live up to its promise of safeguarding babies in labor. In fact, researchers who evaluated all of the published studies comparing continuous fetal monitoring with intermittent auscultation (a method where a provider listens to the baby’s heartbeat regularly throughout labor) found that, when the mothers are healthy and labor is uncomplicated, there were no differences in important outcomes for babies regardless of the method used. However, their research confirmed that intermittent auscultation has a major advantage—it results in far fewer cesarean surgeries.

Source: Alfirevic, Z., Devane, D., & Gyte, G. M. (2006). Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews, 3, CD006066."
Take independent birth classes instead of the ones offered by the local hospital! Independent Childbirth offers insightful commentary on the cesarean epidemic in the United States, and the role of independent birth classes. If you're in Central Maine, consider calling me at 512-2627 to find out about the independent classes I teach. If you're in Southern Maine, consider calling Birth Roots at 772-4784. If you're outside of Maine, visit the Independent Childbirth Educators directory, or google search independent educators near you. You may not hear about us from the local hospital or doctor's office, but ask a midwife (especially a homebirth midwife); ask at your local health food store; ask at a La Leche League meeting: we're out there!

** Edited to add a link to this great birth story that serves as a real life "illustration" of the topics in this entry: Floppy's Birth.

Christina @ Birthing Your Baby
Independent Childbirth Classes for Central Maine

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Tuesday, December 9, 2008

What If?

In an email on a list I read, the fabulously wise childbirth educator and doula, Joni Nichols, recommends that pregnant women "Choose a care provider who is congruent with the kind of birth you want. Everyone talks about the 'work' of labor. The real 'work' is the election of the caregiver".

And I read a terrific blog entry by Monica Dux this week, "Homework is the Mother of Prevention". Here is an excerpt:
"There seems to be a widespread culture of passivity when it comes to labour. Many expecting mothers do dedicate an enormous amount of time and effort to preparation, yet, in my experience, there are just as many who refuse to do adequate homework, preferring to sit back and see how things develop. It's not that these women are unsure about what sort of labour they'd like to have (almost always an uncomplicated vaginal delivery). They've simply decided that "waiting and seeing" is the only realistic approach. Why bother committing to a detailed birth plan when it will probably go wrong anyway? Perhaps other wait-and-seers are simply in denial, preferring not to think about an experience that is understandably terrifying. The end result is that they approach the business of labour with less preparation than they would bring to buying a new car."
It's a great post, and I highly suggest clicking the link to read it!

Many pregnant women, and their partners, spend a certain amount of time "preparing" for their new baby's arrival - especially if it is their first baby. There are the clothes to buy; the car seat and the stroller and the crib to pick out and set up and figure out; the fun yet overwhelming task of registering at various stores and websites. The room needs to be painted... decorated... organized. Feeding and diapering and bathing supplies. Toys.

What if most women put a fraction of the energy that they dedicate to amassing and arranging baby stuff into choosing a care provider and place to give birth, and discussing their options with that care provider? What if women talked - offered each other important, real information - about care providers and birth places - like we give each other useful information about our favorite baby toy or supply? Why don't more women stay away from A Baby Story and other birth dramas that are unrealistic and emergency-filled?

I think there would be big changes in birth if women insisted on accurate information about care providers and birth in general, especially if they shared what they learned with each other.

If women had access to information about doctors Cesarean birth rates AND information about the risks of Cesarean births, I think we would see changes. If women knew the benefits of laboring (and/or birthing) in water AND which birth places had labor and birth tubs, I think we would see changes. If women had accurate information about CPM midwives and homebirth, I think we would see changes.

Unfortunately, at this point, what I see are lots of inaccuracies - about the safety of homebirth, for example, or about the risks of Cesarean births. There are lots of barriers to making informed choices about doctors and hospitals: inaccurate information; vague answers; insurance issues. I think that for many women, it's just psychologically easier to do what "everyone" else does - to use the same care provider, at the same hospital, to read What to Expect When You're Expecting and watch A Baby Story on television.

Preparing to bring baby home is very exciting - thinking about dressing her or getting his room ready can be a lot of fun. This type of preparation, and the daydreams of snuggling that sweet little baby, are obviously important and wonderful.

But just as important is the responsibility to learn about care provider and birth place options... and then using what we learn to interview doctors and midwives and visit hospitals and birth centers. This work may not be as appealing. It may sometimes be challenging or uncomfortable. But in the long run, the time spent choosing a care provider is going to be a lot more influential in our lives as new parents than choosing a nursery theme or picking out a going-home outfit.

What do you think could change the balance of how women prepare for birth? I'm hoping The Birth Survey will help: results of the surveys are due out nationwide in Spring 2009. I can't wait to read about women's experiences in Central Maine and to be able to offer this resource to clients.

Christina @ Birthing Your Baby
Independent Childbirth Classes for Central Maine

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Monday, December 1, 2008

In a recent New York Times article, "Scorpios Get More Asthma," the author suggests reasons why babies born in the fall are prone to asthma: the New England Journal of Respiratory and Critical Care Medicine has reported that babies born in the fall have a 30% increased risk of developing asthma. The author goes on to write that:
"As for how a baby is born, Swiss researchers are reporting in the journal Thorax this month that a Caesarean delivery is linked to a much higher risk for asthma compared with babies born vaginally.

In a study of nearly 3,000 children, the researchers found that 12 percent had been given a diagnosis of asthma by age 8. In that group, those born by C-section were nearly 80 percent more likely than the others to develop asthma. The explanation may be that a vaginal birth “primes” a baby’s immune system by exposing it to bacteria as it moves through the birth canal."
Interesting, isn't it? Espcially since,
"Asthma has emerged as a major public health problem in the United States over the past 20 years. Currently, nearly 15 million Americans have asthma, including almost 5 million children. The number of asthma cases has more than doubled since 1980. Approximately 5,500 persons die from asthma each year, and rates have increased over the past 20 years. Rates of death, hospitalization, and emergency department visits are 2-3 times higher among African Americans than among white Americans. The costs of asthma have also increased to 12.7 billion dollars in 1998."


Christina @ Birthing Your Baby
Independent Childbirth Classes for Central Maine

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Friday, October 10, 2008

USA Today Article on High-tech Interventions

High-tech Interventions Deliver Huge Childbirth Bill

I am so pleased to see this article in a mainstream newspaper! I do wonder about the title though... I would love to have seen something about how the costs don't produce healthier mothers and babies - that piece, to me, is the real story.

Here are two excerpts:
"Childbirth is the leading reason for hospitalization in the USA and one of the top reasons for outpatient visits, yet much maternity care consists of high-tech procedures that lack scientific evidence of benefit for most women, a report says today.

U.S. hospital charges for maternal and newborn care jumped from $79 billion in 2005 to $86 billion in 2006, the authors write. More than $2.5 billion a year is spent on unnecessary C-sections, which now represent nearly a third of all deliveries.
[The language in this sentence is unclear to me: it makes it sound like ALL of the Cesareans are unnecessary; clearly there are times when a Cesarean birth is appropriate use of technology. Maybe the "which now represent" refers to C-sections in general, not unnecessary ones in particular? Anyway...]

Reducing expensive techniques such as C-sections and increasing low-cost approaches such as childbirth assistants called doulas would improve mothers' and babies' health while cutting costs, the authors say.

. . .

"The University of Wisconsin's Douglas Laube, a former president of the American College of Obstetricians and Gynecologists, blames "very significant external forces" for the overuse of expensive technologies in maternity care.

"I don't like to admit it, but there are economic incentives" for doctors and hospitals to use the procedures, says Laube, who reviewed the new report before its release.

For example, some doctors might get bonuses for performing more labor inductions, which adds costs and increases the risk of C-sections, which, in turn, increase hospital profits because they require longer stays.

In addition, some doctors order unnecessary tests and procedures to protect against malpractice suits, Laube says."
It's important to remember that these higher prices DO NOT equal better care. The United States is not the standard-bearer for safety for mothers and babies. Using 2008 statistics, the United States (6.3/1000) currently ranks BEHIND the following countries for infant mortality rates: South Korea (5.94/1000), Cuba, Isle of Man, Italy, Taiwan, San Marino, Greece, Monaco, Ireland, Canada, Jersey, New Zealand, United Kingdom, Gibraltar, Portugal, Netherlands, Luxembourg, Guernsey, Liechtenstein, Australia, Belgium, Austria, Denmark, Slovenia, Macau, Isreal, Spain, Switzerland, Andorra, Germany, Czech Republic, Malta, Norway, Anguilla, Finland, France, Iceland, Hong Kong, Japan, Sweden, and Singapore (2.3/1000).

If you are interested in reading the report, it is available in pdf format, and a print copy can be obtained for free by emailing your contact information.

Milbank Report: Evidence-based Maternity Care
"What are top implications for policy makers, childbearing women and maternity professionals?"

Policymakers can play an important role in improving quality, health outcomes and resource use by addressing barriers to evidence-based maternity care. Recommendations for addressing barriers in the new report (PDF) fall in four areas: measuring performance and leveraging results, fixing perverse financial incentives, educating the key groups, and filling priority research gaps.

Childbearing women need to understand that maternity care that is routinely available often is not in the best interest of themselves and their babies. Pregnant women have the right and responsibility to become informed and make wise choices — for example, their choice of caregiver, birth setting and specific procedures, drugs and tests. Becoming informed and taking responsibility can be a big task — and can have very big pay-offs.

Health professionals need to recognize that usual ways of practicing frequently do not reflect the best evidence about safe, effective maternity care. The field of pregnancy and childbirth care ushered in the era of evidence-based practice: many hundreds of currently underutilized systematic reviews point the way to improved maternity practice and outcomes. The Evidence-Based Maternity Care report (PDF) identifies dozens of reviews that are relevant to care of a large segment of the maternal-newborn population. Engaging with the unparalleled move for health care quality and patient safety can improve professional performance and satisfaction and reduce risk of liability.

I am so excited to read this report and be able to include this information in my classes!

Christina @ Birthing Your Baby
Independent Childbirth Classes for Central Maine

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Great Blog Posts

I've been reading some great blogs lately, and wanted to list the posts I've enjoyed/learned from the most. In no particular order:

The Profit of Pain Relief and All About Due Dates: Do Due Dates Mean Your Baby is Due? on Bellies and Babies

We Birth the Way We Live on Birth Change

Conscious Cesarean Birth on Making Birth Safe in the U.S.

This blog post includes a link to the full text of an amazing article, "The Natural Cesarean: A Woman-Centred Technique"
Abstract: Although much effort has gone into promoting early skin-to-skin contact and parental involvement at vaginal birth, caesarean birth remains entrenched in surgical and resuscitative rituals, which delay parental contact, impair maternal satisfaction and reduce breastfeeding. We describe a 'natural' approach that mimics the situation at vaginal birth by allowing (i) the parents to watch the birth of their child as active participants (ii) slow delivery with physiological autoresuscitation and (iii) the baby to be transferred directly onto the mother's chest for early skin-to-skin. Studies are required into methods of reforming caesarean section, the most common operation worldwide.

An FYI post on Breastfeeding and Codeine on the Motherwear blog

Where Have All the Flowers Gone on Real Women, Real Options, Real Birth discusses this article - "Doctor Won’t Make The Cut: Feeling Pressure from Hospital for More C-sections, She Leaves".

And from the same blog, Behind the Numbers: Surgical Birth in the USA.

Christina @ Birthing Your Baby
Independent Childbirth Classes for Central Maine

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Saturday, September 13, 2008

Bonding after Cesarean Birth in the News

I read Tara Parker-Pope's most recent blog entry in the Health section of the New York Times, "Delivery Method Affects Brain Response to Baby's Cry" last week and I've been thinking about it ever since.

Pope opens with some personal experience, explaining that her feelings of "being numb" and "uninvolved" with her daughter's Cesarean birth surprised her, and that "When I finally heard a baby cry, it took a minute for me to realize that the sound belonged to my own baby."

She goes on to summarize the study:
"That’s why I was particularly interested to read of new research showing that the method of delivery seems to influence how a mother’s brain responds to the cries of her own baby. The brains of women who have natural childbirth appear to be more responsive to the cries of their own babies, compared to the brains of women who have C-section births . . . The study, published in The Journal of Child Psychology and Psychiatry, found that the cry of a woman’s own baby triggered significant responses in several parts of the brain related to sensory processing, empathy, arousal, motivation, reward and habit-regulation"
(I'm going to interrupt myself here to say that I hate it when people euphemize "vaginal birth" with "natural birth" - is the word vagina that threatening? because to me, and to lots of other people, natural birth is not the same as, or interchangeable with, vaginal birth. A vaginal birth could have been induced with cytotec (to soften the cervix) and pitocin (to stimulate contractions); the amniotic membranes could have been artificially ruptured; the mother could have been hooked up to an IV (with the Pitocin drip) and an epidural and a catheter; baby could be removed with a vacuum extractor. Does all this result in a vaginal birth? Yes, certainly! But is that a "natural" birth?? I'm not sure how all those medications and procedures equal "natural", even in the loosest sense of the word. And when doctors and/or scientists, and those who report their findings, start choosing not to distinguish between the two, that's when we're in real trouble - see VBAC link below...).

Anyway! Here are two links to a summary of the study: "Maternal brain response to own baby-cry is affected by cesarean section delivery". I like this summary because it reports that this study was done on a sample size of (only!!) TWELVE women - six who "delivered vaginally" and six who elected for a Cesarean birth; and "Natural childbirth makes mothers more responsive to own baby-cry", which I think summarizes the study in easier to understand language, though they do make that pesky trick of making "vaginal" into "natural" in their title (!!).

Another blogger, who writes about oxytocin (the "hormone of luuuuuvv" is what I call it in class), has this blog entry about the study.

Reading that study made me think back to something that I read (or heard?) about monkeys who reject their babies born by Cesarean. After a little searching, I found out that the reknowned French obstetrician has a very interesting website called WombEcology. In one terrific article, "In-labor Physiolocial Reference", he reminds us that humans are mammals, and that we give birth as mammals. He describes the handicaps that are special to human mothers giving birth, and how we can help minimize them. It's really a terrific article - much better than the title makes it sound - go read it!

One thing he highlights in the article is that:
"Physiologists constantly refer to what they learn from non-human mammals. This leads to keep in mind the main differences between human beings and other species. One of the main differences is that the effects of a disturbed birth process on maternal behaviour are much more evident at an individual level among non-human mammals . . .

Today caesareans are common in veterinary medicine, particularly among dogs. This is possible as long as human beings compensate for a frequently inadequate maternal behaviour, assist the process of nursing and provide, if necessary, commercial canine milk replacers. The effects of a caesarean on the maternal behaviour of primates are well documented, because several species of monkeys are used as laboratory animals. This is the case of the ‘crab-eating macaques’ and the rhesus monkeys.(3) In these species the mothers do not take care of their baby after a caesarean; laboratory personnel must spread vaginal secretions on the baby’s body in order to try to induce the mother’s interest for her newborn.

We don’t need to multiply the examples of animal experiments and observations by veterinarians and primate-using scientists to convince anyone that a caesarean – or just the anaesthesia that is necessary for the operation – can dramatically alter the maternal behaviour of mammals in general. In this regard humans are special. Millions of women all over the world have taken care of their baby after a caesarean birth or simply an epidural birth or a ‘twilight sleep birth’.

We know why the behaviour of humans is more complex and more difficult to interpret than the behaviour of other mammals, including primates.(4) Human beings have developed sophisticated ways to communicate. They speak. They create cultures. Their behaviour is less directly influenced by their hormonal balance and more directly by the cultural milieu. When a woman knows that she is expecting a baby, she can anticipate displaying some maternal behaviour. This does not mean that we cannot learn from non-human mammals. The spectacular and immediate behavioural responses of animals indicate the questions we should raise about ourselves."
The reason I include this excerpt is because I think that for some women, feelings of distance, or not feeling immediately "bonded" to her baby, become one more thing that she feels guilt or shame about. I think it's critical to realize that bonding happens over time, and that we as humans can overcome a less-than-optimal beginning. I think the truth - that feelings of distance can be a part of some women's postpartum experience - gets covered up, which can make women feel alone and also make it very hard to find resources for help.

If we realized, accepted, and publicized as part of informed consent that epidural anesthesia and/or Cesarean birth can have a physiological impact on bonding and post-partum blues/depression, women could make more informed decisions about their care and could prepare in one of the many ways (extra support, more skin-to-skin contact with baby, and massage come immediately to mind) that are shown to promote bonding and lessen post-partum blues.

If any of this gets you wondering about choices for VBAC (vaginal birth after cesarean), or the safety of VBAC, I came across a great article on the Midwifery Today website, Homebirth after Cesarean: The Myth and the Reality (see also if you're interested in how equating vaginal birth with natural birth as affected hospital policies on VBACs).

You can also visit the Online Resources section of my site for links to VBAC.com and ICAN (International Cesarean Awareness Network), as well as lots of links to postpartum depression and support sites.

Christina @ Birthing Your Baby
Independent Childbirth Classes for Central Maine

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Wednesday, June 4, 2008

In the News: Where is Birth Going & Who is Taking it There??!

Wow, has there ever been a bunch of coverage about birth in the news this week!

I came across the link to a NY Times article, "After Caesareans, Some See Higher Insurance Cost" on Navelgazing Midwife's blog earlier this week.

Basically, the article describes an emerging trend in insurance: that women who have had a Cesarean birth can either be refused coverage, or expected to pay a higher premium, unless the Cesarean included sterilization or they are otherwise less-likely to get pregnant (over forty years old, for example). This trend primarily applies to women who have individual insurance (not group insurance purchased through an employer), because insurers have more control over individual insurance prices.

I wonder how many women who are considering a Cesarean birth know that it may affect how much they pay for insurance, and/or how many choices they have for insurers later on down the road?

From the article: "'Obstetricians are rendering large numbers of women uninsurable by overusing this surgery,' said Pamela Udy, president of the International Caesarean Awareness Network, a group whose mission is to prevent unnecessary Caesareans.

Although many women who have had a Caesarean can safely have a normal birth later, something that Ms. Udy’s group advocates, in recent years many doctors and hospitals have refused to allow such births, because they carry a small risk of a potentially fatal complication, uterine rupture. Now, Ms. Udy says, insurers are adding insult to injury. Not only are women feeling pressure to have Caesareans that they do not want and may not need, but they may also be denied coverage for the surgery.

'You have women just caught in the middle of this huge triangle of hospitals, insurance companies and doctors pointing the finger at each other,' Ms. Udy said."

To me, this seems like a feminist issue: with some doctors who don't adequately explain the risks/benefits of both Cesarean births and vaginal births and their potential long-term ramifications* and insurers who can choose to hike up their policies for an operation which a woman may have absolutely needed or have been pressured into (which would be worse? I don't even know!)... women are right in the middle, between the ACOG recommendations and money-hungry insruance companies.

For example, if a woman is having a breech baby, no matter how much she might research and decide that having an attended vaginal birth would be preferable to her than a Cesarean, if no providers in her area attend vaginal breech births - what does she do? She has a Cesarean or an unattended breech birth!

And where does this leave women who have already had a Cesarean and are giving birth again - what if there are no hospitals in their local area who do VBACs?? Here in central Maine, I'm only aware of a handful of hospitals who do VBACs: CMMC in Lewiston and MaineGen in Waterville. St. Mary's in Lewiston doesn't; Inland Hospital in Waterville doesn't; neither do MidCoast Hospital or Parkview in Brunswick. You can go all the way to Bangor or down to Maine Med in Portland, but otherwise, in the relatively sizeable area of central Maine, you only have two choices. So, the problem only gets sticker once a woman has a prior Cesarean, with choices getting narrower & narrower.

As Navelgazing Midwife mentions in her blog entry, I'm wondering where this trend - if/when enough women become aware of it - might take this country's ridiculously high rate of Ceasarean-births (about 1/3 of all births are Cesearean births), and whether it will have an impact on hospital's VBAC policies.

Further from the article: "Dr. Mary D’Alton, chief of obstetrics and gynecology at Columbia University Medical Center . . . said she was amazed to hear that insurers would charge higher premiums or deny coverage because of a past Caesarean. 'I would think if it’s happening, the medical profession has to take a stand,' Dr. D’Alton said."

What would "a stand" made by the ACOG on higher premiums for Cesarean births look like, I wonder? How could we encourage obstetricans to take such a stand?

To learn more about Cesarean births, visit Childbirth Connections Cesarean birth page.

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Speaking of obstetricians, this article, "Giving Patients the VIP Treatment" from Time, reports on another interesting trend: family doctors and OBs who offer women "boutique" individualized prenatal/birth care, including longer appointments, 24/7 access to the doctor via phone or email, private childbirth classes, and a guarantee of attending the birth. AND... a bigger price tag: all of these add-ons also add on an additional $15,000 or so, in addition to the regular insurance co-pays.

Wait a minute, some women might say... the packaging of one-on-one, individualized, personalized care that includes wonderful "extras" like education, massage, house visits etc... that sounds awfully familiar... hold on, it's coming to me: homebirth midwives! Isn't that what they do?? Yes. Yes, it is. Except without the extra $15,000 pricetag!!!!

But what about safety? Well: many, many studies have shown that for low-risk pregnancies (which are the majority), attended homebirth is just as safe as a hospital birth (ask some people, and they'll tell you it's safer!). Check out this Citizens for Midwifery fact sheet on planned homebirth safety or this Index on Homebirth Resources or this Mothering Magazine Article: No Place Like Home.

What I find discouraging is that the Time article makes no mention of midwifery care and how similar it is to "boutique" care, without the hefty pricetag. Why not?

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And now for the good news! For women who have a choice regarding which hospital they go to for their child's birth, there may soon be an easy way for her to compare her options: what is the hospital's episiotomy rate? the first-time Cesarean birth rate? breastfeeding rates at discharge? and more. To find out about this set of perinatal performance measures currently being put together by NQF (National Quality Forum), go here for the short version, or here for the long version.

Another group is working on a way to compare hospitals (and possibly caregivers, at some point): check out The Birth Survey project, which is online now for NYC as a pilot project and is working toward a national database this summer.

If you're wondering "why can't I just ask a hospital what their rates are on x or y, or what a caregiver's rates are?": I'll assume you've never tried. Sometimes it's possible, but it's rarely easy, especially if you're trying to get that kind of information at the beginning of your pregnancy in order to "comparison shop". Compiling this information in an accessible way would truly be revolutionary because it would enable women to "vote with their feet" by going to the hospital/caregiver whose care (not what they say they do, but what they actually do) best matches what that particular woman wants.

Have you heard or read anything interesting in the news re: pregnancy and birth lately?



*Wondering how a vaginal birth compares with a cesarean birth?? This is the kind of information which, in my opinion, would constitute informed consent:

VAGINAL BIRTH…

Typically includes:

Stretching and stinging of the perineum while pushing.

If unmedicated, high levels of endorphins (natural morphine) for pain relief that lasts two weeks after the birth for mom.

Opportunity for immediate bonding and/or breastfeeding.

More choices: who is in the room with you during the birth, who cuts the cord, positions for birth, freedom after the birth.

Healthier start for baby.

Quicker physical recovery for mom.


Some possible risks:

More likely to experience pain in the vaginal area in the weeks and months after birth.

Though few women experience troubling symptoms beyond the postpartum period, there is a greater risk of urinary or bowel incontinence (more because of episiotomies and purple pushing).



CESAREAN BIRTH…

Typically includes:

About twice as much blood loss as a vaginal birth.

Longer hospitalization.

Longer-lasting and more severe pain.

Less early contact with baby.

The risks of epidural, spinal or general anesthetic to mother and baby.

A four to six inch long permanent scar.

12 hours (or more) of IV, catheter and no eating after the baby is born.

Gas pain and bloating.

Cutting of seven layers of tissue and muscle.

Post-operative recovery room for 2-4 hours.


Some possible risks:

Higher risk of hemorrhage (severe bleeding).

Scarring and adhesions increase risk for ongoing pelvic pain and twisted bowel.

Limits choices for future births.

Higher risk for infection.

Mother is more likely to rate her birth experience poorly.

Increased challenges to start breastfeeding.

Baby at risk of being cut.

Baby (at 39 weeks or earlier) at higher risk of mild to serious lung and breathing problems.

Baby at greater risk for asthma later in life.

Puts woman at risk for developing complications during further pregnancies:
**ectopic pregnancy: pregnancies that develop outside her uterus or within the scar

**reduced fertility

**placenta previa: the placenta attaches near or over the opening to her cervix

**placenta accreta: the placenta grows through the lining of the uterus and into or through the muscle of the uterus

**placental abruption: the placenta detaches from the uterus before the baby is born

**rupture of the uterus: the uterine scar gives way during pregnancy or labor.


Puts babies from future pregnancies at risk:
**of being born too early (preterm)

**of low birthweight

**of dying before or shortly after the birth.


Most of this information was compiled from Best Evidence: C-Section, on Childbirth Connection - they include even more risks on their list, with more details. There's also C-Section Myth vs. Reality, which is interesting too.

This statement will probably be obvious, but I'll include it just in case: even with all the additional risks Cesarean births are an important tool that can save the lives of women and babies. It's just that study after study and statistic after statistic suggest that our country's national rate of Cesarean (31-ish%) increases the mortality and morbidity of women and babies instead of protecting them. While Ceseareans are critical to the safe birth of a few babies and their mothers, I believe they are only necessary a fraction of the time they are currently performed in this country. For example, The Healthy People 2010 report included achieving an overall national rate of cesarean birth of 15% (good luck with that!). Ina May Gaskin's community reports a cesarean birth rate of less than 2%, while maintaining excellent mother/baby outcomes.

Christina @ Birthing Your Baby
Independent Childbirth Classes in Central Maine

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