Archive for May, 2009

Do Breathing Exercises Work? Why Today’s Lamaze Is Not Your Ma’s Lamaze

May 27th, 2009 by avatar

The BBC is reporting on a new study about the effects of childbirth education classes that emphasize breathing and relaxation techniques. The headline, “Natural birth classes questioned” stands to fuel an already troubling trend that has more women skipping childbirth classes altogether.

Before we get swayed by headlines, let’s take a look at the study itself. This randomized controlled trial was conducted in Sweden with roughly 1,000 couples who attended four 2-hour sessions of childbirth education classes in the third trimester of pregnancy. It compared two different types of classes. The “standard” class gave equal time to childbirth topics as well as early parenthood and newborn care skills. The “natural birth” class did not cover early parenthood or newborn care, spending that time on relaxation breathing exercises instead. Seventy percent of the women actually used the breathing exercises in labor. The women who took the natural birth class were just as likely to have an epidural (52% in both groups) or give birth by cesarean surgery (20% versus 21%) compared with the women who took the standard classes. Likewise, there were no differences in the memory of labor pain at three months, whether the women reported positive birth experiences, and whether the women or men rated their parenthood experience positively.

There is plenty that this study does not tell us:

  • The study tells us nothing about the value or effectiveness of childbirth classes themselves. The study did not include a group that had no childbirth education.
  • The study tells us nothing about the use of other interventions, such as induction of labor, continuous electronic fetal monitoring, pitocin augmentation, or episiotomy. It is not surprising that the study does not report on these outcomes, because information about the indications for and side effects of interventions were not included in either type of childbirth class.
  • The study does not tell us at what point in labor women got epidurals. Some adverse effects of epidurals, including fevers (which can lead to antibiotic use and separation of the mother and baby after birth) and possibly cesarean surgery, are more likely when epidurals are given early in labor. If breathing and relaxation exercises enable a woman to delay getting an epidural, they might offer some health benefit after all. 
  • The study does not tell us what other pain relief methods were available to laboring women. It is possible that breathing exercises are more effective when used in combination with other methods, such as immersion in water, continuous doula support, or position changes.

Despite these limitations, the study provides important evidence that breathing techniques alone may not be enough to change women’s experience of childbirth, or their exposure to potentially harmful interventions. This trial, which is “all about the breathing,” reminds us that childbirth education shouldn’t be. Lamaze has known this for years, moving away from teaching a particular method or technique and toward educating women about how to achieve safe and healthy birth outcomes. The Six Lamaze Healthy Birth Practices form the foundation for optimal safety and wellbeing. If women are deprived of these basic elements of care – or don’t know about them – the labor experience becomes unnecessarily complex, not to mention more painful. Today’s Lamaze can simplify the process by teaching women how their bodies work, how to achieve greater comfort and control, and how to keep the process as safe and healthy as possible.

Citation: Bergstrom, M., Kieler, H., & Waldenstrom, U. (2009). Effects of natural childbirth preparation versus standard antenatal education on epidural rates, experience of childbirth and parental stress in mothers and fathers: a randomised controlled multicentre trial. BJOG An International Journal of Obstetrics and Gynaecology, doi 10.1111/j.1471-0528.2009.02144.x.

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Birth Bloggers: Enter to Win the Lamaze Media Award!

May 26th, 2009 by avatar

Each year, Lamaze International presents awards to the best and brightest in childbirth education and advocacy at its annual conference. We are thrilled to announce that for the first time, bloggers will be considered for the annual Lamaze Media Award. Increasingly, bloggers are shaping the conversation about birth, highlighting the need for maternity care reform, and reaching childbearing women with critical messages about safe and healthy birth practices. Be recognized for your unique voice and important impact in childbirth education and advocacy.

The winner will receive:

  • Publicity in communications to Lamaze members, the public, and the media
  • One free registration to the 2009 Annual Conference in Walt Disney World, FL, where the award will be presented
  • Up to $500 reimbursement for travel to the 2009 annual conference

Nominations are due by June 15 and should be sent to amyromano@lamaze.org. You may nominate yourself or another blogger.

Please include:

  • The name and URL of the blog
  • The direct link to a post that best exemplifies blog content that supports the Lamaze mission
  • The credentials of the main blogger(s)
  • A summary of the traffic and influence of the blog (e.g., monthly site traffic; links from other influential blogs or the mass media)

Lamaze News

The Soaring Cesarean Rate: It’s the Economics, Stupid

May 22nd, 2009 by avatar

I was reading a Los Angeles Times article on the overuse of cesarean surgery when one quote leapt off the page at me. Said Dr. Elliot Main, chief of obstetrics of a California hospital chain, “Cesarean birth ends up being a profit center in hospitals, so there’s not a lot of incentive to reduce them.” This was not news to me. Some years ago, Susan Hodges of Citizens for Midwifery and I gave a joint talk on “Economic Disincentives for Mother-Friendly Childbirth,” a talk Susan later expanded into an article, but I never thought I’d see the day when a system insider acknowledged this.

The L.A. Times article didn’t elaborate on Dr. Main’s statement, but let’s take a cold blooded look at the business side of cesarean surgery: From the hospital’s point of view, cesareans – especially scheduled cesareans – make staffing needs predictable and maximize patient throughput, essential elements of reducing costs. They also increase billing opportunities and lengthen postpartum stay, which enhance revenues. On the obstetrician’s side, she or he may be paid more, although this isn’t always the case, but the real savings is in time management—and time is money. Minimizing time spent in the hospital allows obstetricians to increase patient load and, what’s more, deliver those patients at times that don’t conflict with office hours or disrupt nights or weekends. And both hospital administrators and obstetricians believe that cesareans prevent malpractice suits. In short, cesareans are good for everybody, except, of course, mothers and babies.

When a system makes it financially disadvantageous to change obstetric practice, it is human nature to find reasons to maintain the status quo, which explains why we see so many obstetricians, prominent and otherwise, downplay or deny cesarean’s harms, tout benefits that are minimal or nonexistent and generally frame cesarean surgery versus vaginal birth as “chocolate versus vanilla.” According to the American College of Obstetricians and Gynecologists, all an ob/gyn has to do is “believe” a cesarean is a good idea—never mind the reality—to make it ethical to perform one on a healthy woman. Small wonder that one in three U.S. women now has her baby via major abdominal surgery, a rate approaching three times what it should be, with no end in sight, and no one trying to do anything about it.

Well, that’s not quite true. The L.A. Times article cites the Institute for Healthcare Improvement’s Strategic Partners program. Despite the impressive title, it is merely a garden hose solution for putting out a forest fire. The best its program director could come up with from its clinical guidelines were recommendations to use oxytocin more carefully and hold off on elective deliveries until 39 weeks. The program director called the latter a “tipping point” and “culture change.” This would be funny if it weren’t so pathetic. Even this feeble reform attempt hasn’t generated much enthusiasm. In four years, only 60 hospitals have signed on, and the article didn’t say whether the program has yielded any meaningful improvements.

It isn’t as if we don’t know what to do. We have Lamaze’s Healthy Birth Practices, the Coalition for Improving Maternity Service’s Ten Steps to Mother-Friendly Childbirth (PDF), and now, Childbirth Connection’s Eight Steps to Reform Maternity Care. But as the maternity care system is currently organized and with the current reimbursement structure, a hospital would find it difficult to implement them and still keep its maternity unit open. If we hope to do anything meaningful about the cesarean rate, we need real culture change, and the tipping point will come when we somehow make vaginal birth an economically viable option. Change starts with understanding the barriers. In this case, it starts with not confusing cost-effective for the greater society with cost-effective for hospitals and doctors, much less with revenue generating.

For an excellent analysis of economic and other system barriers to maternity care reform, and recommendations for how to overcome them, download the report: Sakala, C., & Corry, M. P. (2008). Evidence-based maternity care: What it is and what it can achieve. New York: Milbank Memorial Fund.

Research for Advocacy , ,

First, Do No Harm: Another Reason to Ditch Routine IVs in Labor

May 21st, 2009 by avatar

In the latest Listening to Mothers Survey 83% of women reported having intravenous (IV) lines in labor or birth. This number is probably not surprising to many of us – IV’s are part of the routine package of care in most settings, even for low-risk women. Their ubiquitous place in modern obstetrics renders them practically invisible. And although the American Society of Anesthesiologists revised its guidelines in 2007 to encourage clear fluids in labor – which would presumably eliminate the need for IVs in most cases – the practice of routine IVs appears to be continuing unabated. Why? Because the medical model presumption is that it’s nice to have that IV access just in case an urgent complication is lurking around the corner. And besides – IVs are relatively harmless, right?

Wrong. In 2007, I was part of a team that conducted a systematic review (PDF, see p. 34S – 36S) of the research on IV fluids in labor. We found that IVs can cause anemia and that they reduce colloid osmotic pressure – which can lead to swelling in the tissues or lungs (pulmonary edema) of both the laboring woman and her infant. In addition, not all IV fluids are created equal: IV fluids with glucose in them were associated with low blood sugar in newborns, and salt-free fluids increased the likelihood of potentially serious electrolyte imbalances. The body of research also confirmed common sense – that women find IVs uncomfortable and that IVs limit mobility. Finally, we failed to find a single study that supported the notion that IV access improves outcomes when urgent problems arise. Despite this nearly universal belief, no one has in fact studied the question.

This week I happened to see two different bits of news blip onto my radar that raise other troubling concerns about the rampant use of IVs on maternity wards. Both pieces looked at possible harmful effects of the chemicals that may leach out of the plastic IV bags and tubing. A recent NPR story reported on an ongoing study looking at sexual maturity in teenagers who were exposed to high levels of phthalates as infants in neonatal intensive care units. The phthalates came from intravenous lines, including those used for extracorporeal membrane oxygenation (ECMO). The Wall Street Journal posted a short blurb about an animal study showing that another chemical found in IV bags and tubing, cyclohexanone, can trigger health problems in the hearts and neurological systems of the rats that were exposed. We can not – and should not – extrapolate the findings of these studies to possible effects on laboring women and their newborns. But they add new fuel to an already compelling case to do away with IVs whenever safely possible. With no evidence that their routine use is beneficial, a small but consistent body of evidence that they can cause harm, and important questions unanswered, a change in practice is long overdue.

For more information about potentially harmful chemicals used in health care settings and ways to reduce the environmental impact of our health care system, visit Health Care Without Harm. Along with other great resources, HCWH published a booklet with the American College of Nurse-Midwives called Green Birthdays (PDF) in 2001.

Citation: Goer, H., Leslie, M. S., & Romano, A. (2007). The Coalition for Improving Maternity Services: Evidence basis for the ten steps of mother-friendly care: Step 6: Does not routinely employ practices, procedures unsupported by scientific evidence. Journal of Perinatal Education (16)1, 32S-64S.

Do No Harm, New Research, Research for Advocacy , ,

Seat Belt Use is Associated with Less Injury to the Fetus in Accidents Involving Pregnant Women

May 18th, 2009 by avatar

With Memorial Day around the corner and the unofficial beginning of the summer road trip season upon us, here’s an important bit of news from the annual meeting of the Society for Academic Emergency Medicine. Emergency medicine researchers from Wake Forest University analyzed a national database of over 2 million people injured in car accidents and identified over 2400 cases involving pregnant women. They found that women who were wearing a seat belt or driving in a car with an airbag were less likely to experience fetal complications than women with neither a seat belt or airbag. Women with both a seat belt and an airbag had the best outcomes. This research confirms findings from several smaller studies.

The March of Dimes provides a nice summary of car safety guidelines for pregnant women.

New Research ,

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