August 13, 2007
Inducing labor for convenience gets a second look
New studies show the practice has a role in rising costs and the risk of complications.
By Shari Roan
Los Angeles Times Staff Writer
August 13, 2007
HER first baby wasn’t due for four days, but Misa Hayashi was advised by her obstetrician during a routine exam to check into the hospital that day.
“The doctor said the baby was too big for me to push out and we should go ahead and induce labor,” says the Alhambra woman, 24. “I didn’t really question it. Induction sounds so common. We went home and packed a bag and checked in at the hospital.”
Once there, however, Hayashi’s plans for an uncomplicated birth faltered. After receiving the drug Pitocin to trigger contractions, she labored for 20 hours. The pain was so intense she needed medication to ease it — something she had hoped to avoid — and eventually the baby became distressed, requiring constant monitoring of his heart rate.
Finally, almost a day after Hayashi entered the hospital, her son was born. Although he was healthy at 7 pounds, 10 ounces, Hayashi was left questioning the wisdom of labor induction.
Some hospitals and healthcare organizations across the nation share her concerns. Several have barred elective labor induction under certain circumstances, such as before 39 weeks of gestation (one week before the due date) or when there isn’t clear evidence that the mother’s cervix is primed for childbirth.
“There is renewed interest in these seemingly benign medical interventions,” says Dr. William Grobman, an assistant professor of maternal-fetal medicine at Northwestern University. “But the topic is somewhat hazy. We don’t have all the information we’d like to have about risks and benefits.”
The move appears to be a push back against the trend in recent decades to medically manage childbirth. Fewer than 10% of women underwent induction in 1990, but more than 21% did so in 2004, according to federal government statistics. No one knows how many of those inductions were prompted by legitimate medical concerns. But various studies have put the number of inductions for convenience at 15% to 55% of the total number.
At the same time, rates of caesarean sections increased to more than 29% in 2004, up from 23% in 1990, with many women requesting elective C-sections — surgical births without any medical justification. That trend too has generated debate about whether patients are undertaking unnecessary risks.
Labor induction is frequently, and legitimately, recommended when health problems complicate a pregnancy or when pregnancies are more than two weeks past the due date, obstetricians and gynecologists say. But sometimes the procedure is done solely for convenience. In a busy society, doctors and patients have grown increasingly comfortable with this practice.
“People want to schedule their birth like they schedule their nail appointments,” says Janie Wilson, director of nursing operations for women and newborns at Intermountain Healthcare, a Salt Lake City-based chain of hospitals that has tried to reduce the rate of labor inductions.
Until recently, few have questioned whether elective labor induction is appropriate. “There is not a unique description of elective labor induction that every single provider can agree on,” Grobman says. Indeed, the practice appears to vary widely among patients, doctors and hospitals. According to the national figures, for example, labor induction for both medical and nonmedical reasons occurs in 25% of white women but in only 18% of black women and 14% of Hispanic women. And a study published in 2003 in the journal Birth found that the percentage of inductions that were elective varied from 12% to 55% among hospitals and from 3% to 76% among individual doctors.
But some experts say the practice creates unnecessary risks and costs. It can lead to more interventions, such as caesarean sections, and increased use of forceps and vacuum devices to assist in delivery, research has shown. A 2005 study in the journal Obstetrics & Gynecology found that C-sections occurred 12% of the time among women having spontaneous labor compared with 23.4% for women having medically necessary labor induction and 23.8% for women having elective labor induction.
Other studies have found that, compared with spontaneous labor, elective induction leads to longer hospital stays and higher costs. Induced labor also may be more painful because some of the drugs administered to trigger labor can cause more intense contractions.
The risks of C-section or other complications appear highest when induction is performed before 39 weeks and in women who have not had a previous vaginal birth.
Charting a new course
NOW, some hospital administrators are saying, “Enough.” Intermountain Healthcare, which operates 21 hospitals in Utah and Idaho, implemented strict guidelines on elective labor induction eight years ago. Today, the company’s results are held up as a model for reining in birth practices that cannot be medically or financially justified.
The chain, which delivers 53% of all babies in Utah, told its doctors they must seek permission from a supervisor before inducing labor prior to 39 weeks. Doctors must also make sure the cervix is favorable for delivery.
When the cervix is optimal (it must be opened and thinned out enough to allow the baby’s head to pass through the vagina), labor averages about nine hours in a first-time pregnancy, according to Intermountain. If the cervix is not ready, however, an average labor is about 22 hours. The guidelines have reduced rates of elective labor inductions performed before 39 weeks gestation from 28% in 1999 to 3.4% in 2006. The percentage of first-time moms with an elective induction has fallen from 15% in 2003 to 4.7%.
Hospital administrators no longer see sudden spikes in deliveries before major holidays, three-day weekends and Jazz basketball playoff games.
The program has resulted in plunging C-section rates, fewer newborns in intensive care and fewer medical interventions in delivery. Length of labor has decreased by an average of two hours per patient. That’s important, Wilson says, because length of labor is linked to a higher risk of dehydration and infection.
“We feel pretty confident that it does make a difference,” she says.
There is little scientific evidence that labor induction causes any long-lasting harm to mother or baby. But even short-term medical problems are significant given the nation’s healthcare economics crisis, Wilson says. According to Intermountain’s data, healthy deliveries in the 39th week (and women whose cervixes were fully prepared) incur the lowest costs.
“It could be contributing to the double-digit premium increases you pay each year,” she says of elective labor induction’s effect on insurance rates. “Cost is the icing on the cake. But it’s not the main reason we should be doing this. We should do it because it’s safer.”
Trend starts to take hold
OTHER hospitals and provider organizations are also curbing elective labor induction.
Ascension Health Inc., the largest nonprofit healthcare system in the country with facilities in 20 states, last year requested its doctors follow criteria before proceeding with an elective labor induction. The criteria specified that the fetus must be at least 39 weeks in gestational age, in a specific size range and have established lung maturity, and that the mother isn’t already having contractions.
“We don’t discourage elective induction, but there have to be a number of things in place,” says Dr. Robert Welch, chairman and program director of obstetrics and gynecology at Providence Hospital in Southfield, Mich. The goal is not only to reduce C-sections, he says, but to “have zero preventable birth trauma.”
“Some doctors do many elective labor inductions at 38 weeks. But if you do them long enough, eventually you’re going to have a baby with respiratory distress and complications. And that can be very serious.”
Other healthcare organizations and hospitals have applauded the actions taken by Intermountain and Ascension. The Institute for Healthcare Improvement, a nonprofit group based in Cambridge, Mass., that advocates for improved quality in healthcare, and Premier Inc., in Charlotte, N.C., an alliance aimed at improving quality in 1,700 nonprofit hospitals, have also called for lower rates of elective labor induction as a way to reduce harm to infants during childbirth.
Not everyone thinks elective labor induction is harmful. A study published July 31 in the Annals of Family Medicine suggested that “preventive labor induction” may produce the best safety outcomes, including lower C-section rates.
Doctors practicing in a rural Connecticut hospital found that the approach, which includes the use of a mild-acting prostaglandin gel to ripen the cervix before inducing labor, significantly lowered C-section rates compared with women receiving traditional care. Specific criteria were used to determine the “optimal time” for the patient to undergo the preventive induction.
The idea is to perform an induction before the baby gets too big and the placenta can no longer fully support a healthy pregnancy.
If women are carefully selected — based on an accurate due date, fetal maturity and other risk factors — induction may produce the best results, says the study’s author, Dr. James M. Nicholson, assistant professor at the University of Pennsylvania Department of Family Medicine and Community Health.
“Over the last two or three years, there is evidence that if you induce when the cervix is favorable, then induction doesn’t cause adverse outcomes like C-sections,” he says.
The method needs more proof, Nicholson says. He is conducting a randomized, controlled trial at the University of Pennsylvania.
“If this is true, it really could change thoughts on how to manage labor in a big way,” he says. “It would lead to all sorts of different research questions: How to induce, when to induce, is race a factor? The questions are numerous.”
Calls for more study
MANY researchers believe elective labor induction — like elective C-sections — should be submitted to more rigorous research on safety outcomes.
Until then, however, interventions that are performed without an obvious medical need should be viewed skeptically, says Dr. Michael C. Klein, emeritus professor of family practice and pediatrics at the University of British Columbia, who wrote an editorial in the same journal calling the study’s conclusions into question.
“Childbirth is complex,” says Klein, who has studied birth outcomes. “What they are doing is complex, but they are not acknowledging it.”
Klein says the lower C-section rates may be due to the especially attentive and intense care the laboring women in the study received — not because they were induced at an optimal time.
“This is another study saying to women, ‘You can’t survive without us making things better; nature is completely off-track,’ ” says Klein. “And there is a huge reservoir of practitioners out there who want to hear this message.”
Women of childbearing age today also seem to be receptive to the message that a medically managed birth is the best route, says Intermountain’s Wilson.
“We’ve been hammering on this guideline for a long time. It’s hard to get doctors to buy into it,” she says. “Their patients are really putting a lot of pressure on them.”
Despite the lack of research and sometimes conflicting data, women undergoing elective induction should discuss the potential risks and benefits with their doctors, says Wilson.
“I’m not sure consumers think about the risks. They think, ‘Gosh, I want elective induction at 38 weeks because I’m tired of being pregnant,’ ” she says. “Hopefully, educating them up front and setting expectations will make it easier.”
Doctors who want the convenience to schedule daytime deliveries may be the biggest force for elective labor induction, says Lisa Sherwood, a certified nurse midwife and women’s healthcare nurse-practitioner based in San Clemente. Women who “haven’t slept well in weeks, have swollen ankles and sore backs” are vulnerable to the suggestion of elective induction. “People look at the doctor as the expert and will do whatever he or she suggests.”
But, she says, “once you do an intervention, it begets more interventions, and many women feel they are led down a road they didn’t understand. Women tell me, ‘I didn’t know it was going to end up like this.’ Women need to be given all the information on what they are signing up for, not just told, ‘You’re going to have your baby today.’ ”
Hayashi turned to Sherwood this year to deliver her second baby after she was informed — in the first trimester — that she would be induced again.
“I think these doctors kind of play bully. They give you the better of two horrible options and say your body can’t do it.”
Her second son was born two weeks after her due date following a spontaneous, four-hour labor.
May 31, 2007
60-Year-Old Woman Delivers Twin Boys
December 22, 2006
Birth as easy as 1-2-3: one woman, two wombs, three babies
Thu Dec 21, 8:03 AM ET
LONDON (AFP) – A British mother could get into the record books after she gave birth to twins and a single baby at the same time — from two wombs — in what is believed to be a world first.
Hannah Kersey, 23, gave birth to the rare triplets — identical twins Ruby and Tilly, and singleton Gracie — by Caesarean section seven weeks prematurely in September.
She was born with a condition called uterus didelphys, which means she developed two wombs, but doctors had warned her that she was unlikely to become pregnant in both.
After their early birth the triplets had to stay in hospital for nine weeks, but are now doing fine at home with Hanna and her partner Mick Faulkner, 23, in Devon in southwest England.
“We are just over the moon at how healthy and happy the girls are,” she said. “They are three lovely and incredible children, all with very different personalities.
“Gracie seems to be the ringleader — maybe because she grew up in her own womb. She is very determined and independent, always wanting her food before the others and to do things first,” she said.
Doctors say there are only 70 women in the world known to have become pregnant in two wombs, and this is the first reported case of triplets.
“This is so rare you cannot put odds on it,” said Ellis Downes, consultant obstetrician at Chase Farm Hospital in London. “I have never heard of this happening anywhere ever before – it is quite amazing.
“Women with two wombs have conceived a baby in each womb before but never twins in one and a singleton in the other. It is extremely unusual.”
December 5, 2006
New moms and newborns need privacy, study shows
By Rita Rubin, USA TODAY
Flowers are always nice, but perhaps the best gift you can give a brand-new mom is some quiet time alone with her baby.
Now that hospital visiting hours — not to mention staffing — are 24/7, maternity units are taking steps to minimize interruptions and lower the volume. They recognize that lack of privacy can get breast-feeding off to a rocky start, while lack of sleep might play a role in postpartum depression.
A study in the latest Journal of Obstetric, Gynecologic, and Neonatal Nursing found that women typically experienced dozens of interruptions during their first day after delivering a baby.
Researchers recorded the number and duration of visits and phone calls from 8 a.m. until 8 p.m. for 29 brand-new moms who intended to breast-feed. During that period, the mothers on average experienced 54 visits or phone calls, averaging 17 minutes in length. On the other hand, they were alone with their baby (or their baby and the baby’s father) only 24 times on average, and half of those episodes were nine minutes or less.
“I can remember when I first got into obstetrics, back in the late ’70s, early ’80s, fathers could stay on the floor all the time, and grandparents and siblings were the only ones who could come to visit,” says lead author Barbara Morrison, an assistant professor of nursing at the Case Western Reserve University Frances Payne Bolton School of Nursing. “I think we’ve kind of gone overboard in the other direction.”
Concern about how the hospital environment affects breast-feeding spurred her to do the study, Morrison says. “They need to breast-feed immediately after delivery and then very, very frequently in the first three or four days. They can’t do that if they don’t have private time.”
Mommy ‘nap time’
New moms often feel uncomfortable turning away visitors or hospital personnel so they can focus on breast-feeding, Morrison says.
At Covenant health care, a Saginaw, Mich., hospital that delivers about 3,500 babies a year, nurses are “the bad guys” when it comes to keeping the peace in the maternity unit, says Susan Garpiel, a perinatal and pediatric clinical nurse specialist.
A few years ago, the unit instituted a daily “nap time” from 2 to 4 p.m. For those two hours, the unit dims the lights and discourages — but doesn’t ban — visits by friends, family and staff.
“We wanted to be advocates on behalf of our mothers and babies,” Garpiel says. “Women who are having their first babies don’t realize how much their sleep is impacted with a new baby.”
Covenant patient Pamela Williams, who delivered Maegan, her first child, at 3:19 a.m. last Monday, says visitors began arriving around 8:30 a.m. Williams, 36, an elementary-school principal from Saginaw Township, says she welcomed the chance to nap undisturbed that afternoon. “I needed that time just to relax and refresh. They put a sign on the door: ‘Mom and baby resting,’ which I love. It takes some of the pressure off you.”
Since the establishment of a formal nap time, Garpiel says, “we saw a huge turnaround in terms of breast-feeding problems and moms who were melting down at night.”
By napping with their babies in the afternoon, she says, moms are more likely to keep the newborns with them at night — facilitating frequent breast-feeding — instead of shipping them off to the nursery so they can get some sleep.
New use for the Yacker Tracker
Covenant is one of 46 institutions working with the Institute for health care Improvement, a non-profit organization based in Cambridge, Mass., to improve the care of mothers and newborns during the perinatal period, or around the time of birth. The institute is encouraging all members of its perinatal network to institute “peace and quiet time,” says nurse Sue Gullo, who directs the program.
Gullo came to the institute from Elliot Hospital in Manchester, N.H., where 1:30-2:30 p.m. is nap time in the maternity unit. “You wouldn’t believe what it took to implement it,” she says. “Notifying every department in the hospital that they can’t do their work as usual for one hour just throws people over the edge.” But, says Gullo, “when people understood the reason for doing it, they were totally open to the idea.”
Oklahoma City’s Mercy Health Center, which delivers 3,000 babies a year, has taken a novel approach to keep noise to a minimum in its maternity unit: the Yacker Tracker. The portable device, developed by a teacher to reduce classroom noise levels, looks like a stoplight. Users can set their preferred decibel limits.
“Green means it’s quiet, yellow means you’re starting to get noisy,” explains Cindy Jennings, nurse manager of the Mercy BirthPlace, which also has “privacy please” lights above each patient door.
Some doctors saw red when the Yacker Tracker was first mounted near the BirthPlace nurses’ station earlier this year, Jennings says. But it has worked. Nurses duck behind closed doors if they need to talk. Doctors and visitors have lowered their voices.
“Now we notice it’s a lot quieter than it used to be.”
October 22, 2006
Drug-Induced Labor Carries Risk of Rare But Dangerous Complication
10.20.06 , 12:00 AM ET
FRIDAY, Oct. 20 (HealthDay News) — Drug-induced labor nearly doubles the risk for a serious delivery complication that can cost the mother her life, a new study finds. In light of the increased risk for this problem, called amniotic-fluid embolism, women and physicians should think twice about elective induction, though not necessarily about medically indicated induction, says the study in the Oct. 21 issue of The Lancet.
“There’s very good evidence that a week or two after the due date, routine induction reduces the risk of stillbirth, so I would not say that that should change,” said Dr. Michael Kramer, lead author of the study and scientific director of the Institute of Human Development and Child and Youth Health at the Canadian Institutes of Health in Ottawa, Ontario. The real question is those inductions that occur as a matter of convenience, say, for example, the mother’s obstetrician is going away or the in-laws are in town.
“This should at least be known by the women and the doctors who are making the decision,” Kramer said. Other experts, however, felt that the study findings were unlikely to change current practice.
“It’s a rare, rare occurrence, and I don’t think this is going to affect how people manage things at this point,” said Dr. Abe Shahim, an obstetrician/gynecologist and attending physician at Lenox Hill Hospital in New York City.
And, the study authors themselves said that even though the number of women having induced labor has risen, there has been no commensurate rise in the rate of amniotic-fluid embolism. “That’s my point,” Shahim said. “It’s so rare, it has no significant bearing on day-to-day practice.”
An amniotic-fluid embolism is thought to arise when a simultaneous tear occurs in the fetal sac and in the vessels surrounding the uterus, allowing amniotic fluid to seep into the mother’s circulatory system. Despite its rarity, the complication is one of the leading causes of maternal death in developed countries.
The new study marks the first time that anything has been identified as a risk factor for the condition. “The suspicion that induction of labor might be involved has been there for a couple of decades, but it has been unsubstantiated,” Kramer said.
Because the complication is so rare, the investigators needed to study a very large population of women. Such a dataset was available in Canada , which keeps records of all hospital discharges in most provinces. Records include clinical diagnoses of conditions and of procedures like Caesarean sections and inductions that wouldn’t be found on birth certificates.
In all, the database included information on more than 3 million hospital births in Canada from 1991 through 2002.
Of almost 3 million single births, there were 180 cases of amniotic-fluid embolism, 24 of them (13 percent) fatal. This translated into a total rate of six amniotic-fluid embolisms per 100,000 single-birth deliveries and a mortality rate of 0.8 per 100,000 deliveries.
The problem arose twice as often in women who had drug-induced labor versus those who did not. Other risk factors included maternal age of 35 or older, multiple pregnancy, Caesarean or vaginal forceps delivery, cervical laceration or uterine rupture, eclampsia and fetal distress.
The absolute risk remained small — only four or five cases and one or two fatal cases per 100,000 women induced.
But with 4 million births each year in the United States, and induction rates approaching 20 percent, that could mean 30 to 40 cases each year in the U.S. alone, 10 to 15 of those fatal, the researchers said.
The relationship between induced labor and amniotic-fluid embolism is, so far, just an association, not one of cause-and-effect. But it’s unlikely anything more concrete will turn up, according to the researchers.
“If there’s something about the nature of that association that’s not causal, that’s going to be almost impossible to find out because the only way to know that for sure is a randomized trial which is almost impossible,” Kramer said. “We would have to have hundreds of thousands if not millions of deliveries.”
More information
The American Pregnancy Association has more on inducing labor.
October 16, 2006
The Score: How Childbirth Went Industrial
September 22, 2006
For Low-risk Women, Risk Of Death May Be Higher For Babies Delivered By Cesarean
http://www.sciencedaily.com/releases/2006/08/060830075513.htm
For mothers at low risk, infant and neonatal mortality rates are higher among infants delivered by cesarean section than for those delivered vaginally in the United States, according to recent research published in the latest issue of Birth: Issues in Perinatal Care.
Researchers at the Centers for Disease Control and Prevention analyzed over 5.7 million live births and nearly 12,000 infant deaths over a four-year period. In general, neonatal (<28 days of age) deaths were rare for infants of low-risk women (about 1 death per 1,000 live births). However, neonatal mortality rates among infants delivered by cesarean section were more than twice those for vaginal deliveries, even after adjustment for socio-demographic and medical risk factors.
The overall rate of babies delivered by cesarean increased by 41% between 1996 and 2004, while the rate among women with no indicated risk for cesarean delivery (term births with no indicated medical risk factors or complications of labor and delivery) nearly doubled.
“These findings should be of concern for clinicians and policy makers who are observing the rapid growth in the number of primary cesareans to mothers without a medical indication,” says lead researcher Marian MacDorman. While timely cesareans in response to medical conditions have proven to be life-saving interventions for countless mothers and babies, we are currently witnessing a different phenomenon- a growing number of primary cesareans without a reported medical indication. Although the neonatal mortality rate for this group of low-risk women remains low regardless of the method of delivery, the resulting increase in the cesarean rate may inadvertently be putting a larger population of babies at risk for neonatal mortality.
In the past it was assumed that babies were delivered by cesarean because of a medical risk, thereby explaining the higher infant and neonatal mortality rates typically associated with cesarean births. In this study, only women with no identified medical risk or labor and delivery complication were included in the analysis and a substantial neonatal mortality rate differential was still found, according to MacDorman’s research.
This paper is published in the journal Birth: Issues in Perinatal Care.
Marian F. MacDorman, Ph.D., has been a Statistician and Senior Social Scientist in the Division of Vital Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention, for the past 18 years. She received her Ph.D. in Demography from the Australian National University in 1987, and an M.A. in Population Geography from the University of Hawaii, Manoa, in 1981. She is currently co-chair of the SIDS and Infant Mortality Committee for the American Public Health Association (MCH section).
Birth: Issues in Perinatal Care, edited by Diony Young, is a multidisciplinary, refereed journal devoted to issues and practices in the care of childbearing women, infants, and families. It is written by and for professionals in maternal and neonatal health, nurses, midwives, physicians, public health workers, doulas, psychologists, social scientists, childbirth educators, lactation counselors, epidemiologists, and other health caregivers and policymakers in perinatal care.
September 19, 2006
Support helps parents through labor
By AMY FUHRMAN
afuhrman@navigatethelake.com
The contractions were coming every five minutes. It had been more than 22 hours since Melanie Rockefeller had started feeling them, and a few hours since she and husband Scott had checked into the hospital. Relying on a malfunctioning monitor, her doctor didn’t think that the first-time mom was really in labor, even though her body was sending a very different message. In the midst of those mixed signals, the LKN couple was able to turn to a comforting presence in the room — their doula, Lara Miller.
“I was looking at her with desperate eyes,” Melanie said. “I remember her saying, ‘Melaine, is your body changing? Are you feeling these contractions? You are in labor.’
“She was walking me through what (my body) already knew but the doctor wasn’t saying.”
Having a doula at their birth helped both mom and dad feel more emotionally supported, Scott said.
“At the end of the day, she was an extension of my family,” the proud father of now-3-month-old Emmy said.
Miller, who has been at more than 40 births, says offering that support is one of the main roles of a doula.
“It’s nice to have somebody say, ‘It’s OK. I know you’re scared and this is normal,’ ” she said.
What is a doula?
Many people have never heard of a doula, and those who have often “imagine hippies in long skirts,” jokes Miller.In reality, doulas are trained and experienced birth assistants who work with doctors, nurses and midwives, staying focused on the needs of the mother and father. Some doulas also provide lactation advice and post-partum help at home for families.
“Doulas are really hands-on,” says Davidson doula Julie Harris, who has been involved in eight births.
“Our roles are different” from doctors and nurses, Harris said. “Our contact is different.”
A doula stays by the laboring mother’s side for her entire labor, no matter how long it lasts.
For Melanie and Scott, that was more than 34 hours.
“(Our) doula was there for me every step of the way,” Melanie said. “She was much more connected to me” than the medical staff.
Miller joined Melanie and Scott at their home soon after contractions began, and helped them with the early parts of labor. The three even went to Birkdale Village and had lunch, strolling around as Melanie labored.
Doulas will often suggest different labor positions and ways to get a mother moving to help labor progress and will do what they can to make sure a mother is comfortable, Harris said.
Doulas also provide emotional and physical support for the couple, Harris said, and help them respond to choices — like whether to have an epidural — that come up during a birth.
“Doulas will support a woman no matter what her decisions are,” Miller said.
‘A safety net’ for dads
The traditional picture of a birth has a woman laboring, her husband by her side, coaching her through every breath. While some husbands might worry a doula would replace them in that role, both Harris and Miller stress that the father plays a vital part in the birth.“The whole thing is for them both to have a good birth,” Harris said.
Having a doula “takes the pressure off dad,” Miller said. “He knows someone else is there as a safety net. He can 100 percent be there emotionally for his wife.”
And the dads themselves often wind up needing some support.
“I’ve rubbed a good share of dad’s backs before,” Miller laughs.
Scott, who readily admits that at moments he probably looked “like a deer in headlights” during Emmy’s birth, says Miller helped him more fully participate in the experience.
“I can see where I could have taken a back seat and just let the doctors do their thing,” he said. “She helped me stay on track and be attentive to Melanie.”
In short supply
Melanie and Scott say they clicked right away with Miller, and knew she was the doula for them. For other couples, though, it might take a little more research.Most important, both Miller and Harris say, is spending time talking with the doula, making sure personalities and philosphies are a match.
“That’s more important than a doula’s training or level of experience,” Miller said.
Though rates vary, doulas in the LKN area usually charge between $450 and $650 for their services.
Also good to ask, Harris said, is why a doula chose the profession, their views on a medicated or natural birth and how many births they’ve assisted.
Miller has one last piece of advice for anyone interested in finding a doula: “Look early,” she said. “We have an undersupply of doulas” in the Lake Norman area.
‘An age-old profession’
Years ago, women lived in communities, helping each other through birth and with family responsibilities after the baby was born. These days, however, families are increasingly isolated, and doulas are helping to fill those traditional roles.“I love the fact that I have an age-old profession — what our mothers, sisters and neigbors did for each other 200 years ago,” Miller said.
For Harris, the idea of being part of something bigger than herself serves as an inspiration.
“When you leave a birth you, you feel grounded again,” she said. “It’s such an awesome thing to go through with a couple.”
Even after witnessing dozens of births, Miller says she’s still overwhelmed by the experience.
“Everytime I see a baby born, I go, ‘Oh my God, it worked again.’ It’s totally amazing to me — every time,” she said.
Want to learn more?
There are several organizations that certify doulas and list those in the area. Good places to start looking are www.dona.org; www.charlottedoulas.org and www.cappa.net
September 18, 2006
Elective Cesarean: Babies On Demand
C-Sections are on the rise and moms are getting blamed, but is it really the woman’s fault?
One look at People Magazine or Entertainment Tonight, and you might think the old-fashioned labor and delivery way to birth a baby has gone the route of the horse and buggy.
In its place: The mother-requested cesarean, or C-section, delivery — the fast, high-tech, hip celebrity way to have a child.
Or so, a popular theory goes.
“There’s no doubt in my mind that the current interest in elective cesarean births has been ignited by the fact that in our in pop culture many celebrity deliveries have been elected cesareans,” says Manuel Porto, MD, chairman of the department of obstetrics and gynecology at the University of California, Irvine.
Indeed, from media reports on the pregnancies of rock stars like Madonna, Victoria Beckham, and Britney Spears, to actresses like Gwyneth Paltrow, Kate Hudson, Patricia Heaton, and Elizabeth Hurley — not to mention a gaggle of super models in between — the C-section appears to be the “it” activity of the decade.
Despite health risks for both baby and mom — including a life-threatening uterine rupture for women and a greater risk of stillbirth for baby — C-section deliveries are rising. According to the National Institutes of Health, the current rate is 29.1% — up some 40% between 1996 and 2004.
But who is really responsible for the rise? Not everyone is ready to blame the lady on the table.
Some suspect the guy wielding the scalpel. After all, the word “elective” simply means there is no medical justification — it doesn’t specify who made the request.
True, in celebrity-conscious New York City, some doctors say women are at least partly to blame.
“I have definitely seen an increase in C-section requests, even when there is no real medical justification behind it,” says Ashley Roman, MD, a maternal fetal medicine specialist at NYU Medical Center in New York.
Her patients don’t necessarily want to mimic celebrity life. They frequently cite other reasons — particularly a reduced risk of incontinence and an easier, less painful birth, though she says medical literature is scant in support of either.
But organizations like Childbirth Connection argue this doesn’t reflect the attitudes of women nationwide. Their surveys show less than 0.08% of pregnant women request a C-section.
“From our research we can say for sure that it is not mothers who are causing the elective C-section rate to rise,” says Maureen Corry, executive director of ChildbirthConnection.org.
What Mothers Say
Indeed, when you look beyond the glitter of the Hollywood delivery and into the nurseries of working class America, a very different picture emerges.
“Some of the increase in elective cesareans is due to mother request, but I personally believe that group is a very small, very affluent subset of women and does not represent the desires or needs of most mothers,” says Peter Bernstein, MD, MPH, a maternal-fetal medicine specialist at Montefiore Medical Center in the Bronx.
In fact, in two surveys aptly titled, “Listening to Mothers,” Childbirth Connection says they found that the numbers prove this is so.
Referring to the group’s latest survey, released in March 2006, Corry says, “Despite some professional and mass media discourse about ‘maternal request’ or ‘patient demand’ cesarean … just one woman (0.08%) among 1,315 survey participants who might have initiated a planned primary cesarean … did so.”
According to the report, of 252 survey participants who had a primary, or first birth, cesarean, only one woman (0.4%) initiated it.
Applying these numbers to the most recent figure for annual births, Corry estimates a scant 2,600 out of 4.1 million pregnant women actually requested a C-section.
Moreover, while in March 2006, the National Institutes of Health held a state-of-the-science conference entitled “Cesarean Delivery on Maternal Request” to address the issue of rising C-section births, officials were not able to pin the rise on moms, according to Corry.
“They failed to report a single study citing the extent to which American women are initiating C-sections and revealed only ‘limited evidence’ suggesting that mother-requested cesarean deliveries are what are spiking the rise,” says Corry.
She says many women are curious enough about a C-section to question their doctors, but, she adds, “being curious and requesting a C-section are two very different things.”
So if mothers aren’t responsible for the burgeoning C-section trend, who is?
An alternative answer, Bernstein says, can be found in the medical-legal climate pervading every labor and delivery floor.
The Labor Room: Who’s Really Pushing?
In the not so distant past, the drive to reduce cesarean deliveries caused hospitals in many states to require the signature of two obstetricians before this surgery could be performed.
“There was this notion out there for awhile that doctors were doing C-sections for their own convenience … for financial reasons, for social reasons … and so the push was on to lower the rates,” says Porto.
Even though the general birthing rule had long been “once a cesarean, always a cesarean”, by the 1980s the drive to push rates down was so great that doctors developed the VBAC — vaginal birth after cesarean. It soon became the default procedure for the next birth after every cesarean delivery.
Unfortunately, studies began to show that women undergoing VBACs had the highest rate of complications, including uterine rupture, hemorrhaging, and sometimes the need for a total hysterectomy. Moreover, babies didn’t do so well either, frequently landing in neonatal intensive care immediately after birth.
It wasn’t long before hospitals and insurance companies began refusing to back a doctor doing a VBAC. The end result: The idea of performing a cesarean delivery went from a medical decision to a legal one — and the VBAC died.
“The medical-legal climate on labor floors became such that many doctors no longer went out of their way to convince a woman to have a vaginal delivery, particularly if she had a C-section in the past,” says Bernstein.
The “Listening to Mothers” survey seems to second this opinion, finding that “9% of mothers reported experiencing pressure to have a cesarean — far outweighing the number of mothers who voluntarily chose this procedure.”
Perhaps even more telling are the observances of the mothers themselves. The survey found some 42% believe the current system leads maternity care providers to perform a C-section simply to avoid being sued.
Where Do We Go From Here
Doctors say that while advances in C-section delivery have increased its safety profile considerably, risks still remain higher than for a vaginal delivery, and rise still higher with every C-section a woman has.
“By the time a woman gets to her third cesarean, she’s at serious risk for life-changing and even life-threatening complications,” says Bernstein.
In the September 2006 issue of Obstetrics and Gynecology, a group of French researchers found that the rate of maternal death from C-section was three times that of vaginal delivery, due mostly to increased risk of blood clots, infections, and complications from anesthesia.
Moreover, the first study to examine risks to babies born via elective cesarean, published in this month’s edition of Birth, reported that in 6 million births, the risk of death to newborns delivered vaginally was 0.62 per thousand live births versus 1.77 for those delivered by elective C-section.
Recent news statements by Stanley Zinberg, MD, deputy executive vice president of the American College of Obstetricians and Gynecologists, show that while ACOG continues to review maternal-request cesarean, “At this time, our position is that cesareans should be performed for medical reasons.”
Still, all the experts interviewed by WebMD said individual patient need — and choice — should remain the prime considerations when deciding how to give birth.
For example, Bernstein says that for a woman who is 40 and having her one and only child, a C-section isn’t a bad choice, while for a young fertile woman having her first child it could be a mistake.
Explains Bernstein: “Essentially the first delivery lays down the risks for all subsequent deliveries — so if you can have your first and hopefully your second baby delivered vaginally, it’s better for you, and better for your baby.”
Hollywood … are you listening? Stay tuned.
September 6, 2006
Voluntary C-Sections Result in More Baby Deaths
A recent study of nearly six million births has found that the risk of death to newborns delivered by voluntary Caesarean section is much higher than previously believed.
Researchers have found that the neonatal mortality rate for Caesarean delivery among low-risk women is 1.77 deaths per 1,000 live births, while the rate for vaginal delivery is 0.62 deaths per 1,000. Their findings were published in this month’s issue of Birth: Issues in Perinatal Care.
The percentage of Caesarean births in the United States increased to 29.1 percent in 2004 from 20.7 percent in 1996, according to background information in the report.
Mortality in Caesarean deliveries has consistently been about 1½ times that of vaginal delivery, but it had been assumed that the difference was due to the higher risk profile of mothers who undergo the operation.
This study, according to the authors, is the first to examine the risk of Caesarean delivery among low-risk mothers who have no known medical reason for the operation.
Congenital malformations were the leading cause of neonatal death regardless of the type of delivery. But the risk in first Caesarean deliveries persisted even when deaths from congenital malformation were excluded from the calculation.
Intrauterine hypoxia — lack of oxygen — can be both a reason for performing a Caesarean section and a cause of death, but even eliminating those deaths left a neonatal mortality rate for Caesarean deliveries in the cases studied at more than twice that for vaginal births.
“Neonatal deaths are rare for low-risk women — on the order of about one death per 1,000 live births — but even after we adjusted for socioeconomic and medical risk factors, the difference persisted,” said Marian F. MacDorman, a statistician with the Centers for Disease Control and Prevention and the lead author of the study.
“This is nothing to get people really alarmed, but it is of concern given that we’re seeing a rapid increase in Caesarean births to women with no risks,” Dr. MacDorman said.
Part of the reason for the increased mortality may be that labor, unpleasant as it sometimes is for the mother, is beneficial to the baby in releasinghormones that promote healthy lung function. The physical compression of the baby during labor is also useful in removing fluid from the lungs and helping the baby prepare to breathe air.
The researchers suggest that other risks of Caesarean delivery, like possible cuts to the baby during the operation or delayed establishment of breast-feeding, may also contribute to the increased death rate.
The study included 5,762,037 live births and 11,897 infant deaths in the United States from 1998 through 2001, a sample large enough to draw statistically significant conclusions even though neonatal death is a rare event.
There were 311,927 Caesarean deliveries among low-risk women in the analysis.
The authors acknowledge that the study has certain limitations, including concerns about the accuracy of medical information reported on birth certificates.
That data is highly reliable for information like method of delivery and birth weight, but may underreport individual medical risk factors.
It is possible, though unlikely, that the Caesarean birth group was inherently at higher risk, the authors said.
Dr. Michael H. Malloy, a co-author of the article and a professor of pediatrics at the University of Texas Medical Branch at Galveston, said that doctors might want to consider these findings in advising their patients.
“Despite attempts to control for a number of factors that might have accounted for a greater risk in mortality associated with C-sections, we continued to observe enough risk to prompt concern,” he said.
“When obstetricians review this information, perhaps it will promote greater discussion within the obstetrical community about the pros and cons of offering C-sections for convenience and promote more research into understanding why this increased risk persists.”