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Does It? Really? “WHO Admits: There Is No Evidence for Recommending a 10-15% Caesarean Limit”

October 30th, 2009 by avatar

This is the title of a Medical News Today piece, actually a re-posting of a press release from a coalition of websites that promote elective cesarean surgery. The press release claims that the 2009 edition of the WHO’s “Monitoring Emergency Obstetric Care: A Handbook”  has rescinded its 1985 recommendation that cesarean rates not exceed 10-15%. Can this be true? Not so much.

In fact, not at all.

The handbook still reads, as it always has:

WHO chart

The press release goes on to state that the WHO “updated” its (actually unchanged) recommendation, “admitting” that, quote, “no empirical evidence for an optimum percentage” exists, an “optimum rate is unknown,” and world regions may now “set their own standards.” The material from the WHO handbook is accurately quoted so far as it goes, but it doesn’t go very far. The handbook goes on to say: “A growing body of research shows . . . a negative effect of high rates,” cites studies in support of this (see below), and continues, “It should be noted that the proposed upper limit of 15% is not a target to be achieved, but rather a threshold not to be exceeded. Nevertheless, the rates in most developed countries and in many urban areas of lesser-developed countries are above that threshold” [emphasis mine]. In other words, countries with rates under 15% should not be striving to increase their rates, and countries “setting their own standards” means determining optimal rates, which may vary, within the WHO range.

This brings us to the second flat out untruth: The press release states that rates above the 10-15% range recommended by the WHO “have not led to a concomitant rise in maternal mortality or foetal, perinatal and neonatal mortality.” The WHO supports the 15% upper limit precisely because cesarean rates above the 15% ceiling result in higher maternal and perinatal death and morbidity rates. Here are the studies they cite:

Deneux-Tharaux (2006)
This French study determined maternal deaths directly attributable to cesarean surgery by excluding women with risk factors that could lead to the need for cesarean surgery and reviewing the confidential reports generated after each maternal death. “After adjustment for potential confounders, the risk of postpartum death was 3.6 times higher after cesarean than after vaginal delivery. . . . Knowledge of the causes of death associated with this excess risk informs contemporary discussion about cesarean delivery on request.” The analysis, moreover, undercounts cesarean-related deaths because investigators excluded deaths that might have arisen from complications that occur more often in women with prior cesarean surgery, including ectopic pregnancy and deaths from hemorrhage due to placenta previa, placental abruption, and placenta accreta.

MacDorman (2006)
Investigators in a U.S. study found that after isolating an ultra-low-risk population with no indication for cesarean, babies born after cesarean surgery were 1.8 times more likely to die than babies born after vaginal birth. This amounted to an excess of about 1 per 1000. They conclude: “Understanding the causes of these differentials is important, given the rapid growth in the number of primary cesareans without a reported medical indication.”

Villar (2006)
A report on Latin America derived from a WHO 2005 survey of maternal and perinatal health, it found that “Rate of caesarean delivery was positively associated with . . . severe maternal morbidity and mortality, even after adjustment for risk factors. Increase in the rate of cesarean delivery was associated with an increase in fetal mortality rates and higher numbers of babies admitted to intensive care for 7 days or longer even after adjustment for preterm delivery. Rates of preterm delivery and neonatal mortality both rose at rates of caesarean delivery of between 10% and 20%.” In other words, 15% is a liberal and probably overly generous maximum.

Shame on whoever is behind these websites for circulating such dangerous misinformation—but even more shame on Medical News Today for passing it on without spending two minutes to fact check its accuracy.

In this video from the Lamaze Video Library, Eugene Declercq, PhD, fact checks claims about the rates of perinatal mortality, maternal mortality, and cesarean surgery in the United States. Special thanks to Orgasmic Birth for sharing this DVD Extra with Lamaze International.

[flashvideo file=http://www.lamaze.org/portals/0/video/Birth_by_the_Numbers512k.flv /]

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Healthy Birth Blog Carnival: Walk, move around, and change positions throughout labor

October 28th, 2009 by avatar

On the heels of our successful “Let Labor Begin On Its Own” Carnival, here is our second Healthy Birth Carnival! This time the theme is Lamaze’s second Healthy Birth Practice: Walk, move around, and change positions throughout labor.

Every single one of these posts is great, and on top of some really thoughtful writing, I’m also excited about the amazing photos, illustrations, and videos our contributors used to show laboring women using various positions and movements. It’s so nice to see active birth rather than the conventional images of women passively laboring in bed connected to a bevy of tubes and wires.

Let’s get moving!

Two phenomenal posts show how important movement is in VBAC labors. Kristin at Birthing Beautiful Ideas writes about how she “moved and grooved” to a healthy VBAC, and the labor and birth nurse at NursingBirth offers another powerful story of how movement and great labor support helped a mother achieve a healthy and triumphant VBAC in the hospital.

Jill at The Unnecesarean points out that, “For first time mothers who have had no exposure to a birth, the time between, ‘I felt a contraction!’ and ‘I have to push!’ is often a total mystery.” She demystifies the in-between time with a plethora of selections from women’s birth stories that illustrate how movement helps.

Wendy at Aruban Breastfeeding Mamas offers “Birthing Positions 101” to an island where women are too often restricted to the lithotomy position to birth, discussing the potential benefits and disadvantages of each position.

The Well-Rounded Mama brings us another incredibly thoughtful and thorough post, this time about the importance of movement in labor and how mobility restriction – and its harms – affect women of size disproportionately.

Do we need to show harms of restricting mobility in order to advocate for freedom of movement? I discuss how a “medical model” approach to research can actually be an impediment to change in my post, “Do we need a Cochrane Review to tell us that women should move in labor?

Carol Van Der Woude shares a story of how 1970’s technology inadvertently helped a woman birth vaginally after progress had slowed. In the course of getting out of bed and going to another part of the hospital to get an x-ray of her pelvis (yes, this was common practice 30 years ago!) the baby finally found the right fit through the woman’s pelvis and was born soon after. Carol’s post also offers a story of how plenty of patience and freedom of movement kept a home birth safely at home.

Jen at Pursuing Harmony shares another simple story of birth at home, in which she followed her instincts to find the right positions and movements to help labor progress smoothly. Lauren Wayne at HoboMama shares a personal story of using movement to give birth to a nearly 12 pound baby vaginally with no drugs. Her story illustrates both how home birth offers optimal freedom of movement and how mobility can be maintained even when a planned home birth results in a transfer to the hospital. Sheridan at Enjoy Birth shares another personal experience, and also answers a common question, “can I still move around if I am using hypnosis in labor?

The hospital bed can be a potent symbol to a laboring woman that she has no choice but to get into it. This summer, Henci Goer wrote a post here at Science & Sensibility about a pilot study showing that removing the labor bed from the hospital room entirely resulted in less use of oxytocin augmentation. But most women birth in environments with hospital beds, and some women need to stay in or near the bed for medical reasons, so Molly Remer brings us a fantastic handout,”How to Use a Hospital Bed Without Lying Down“. The Lamaze-Certified Childbirth Educator and student nurse-midwife at Hands for Catching points out, however, that the bed is not the only element of the conventional birth environment that keeps women from moving while Moms Tinfoil Hat shares a personal story that demonstrates that mobility is an all-too-common casualty of the cascade of interventions. All of these posts reinforce the relevance of Birth Territory, a new theory for labor care that emphasizes the role of the physical environment and individuals’ use of power in promoting optimal labor outcomes. Rixa Freeze introduced this theory in a recent post at Stand & Deliver. (Stay tuned, we’ll soon be featuring an interview with the researchers who developed the theory and a review of their book here on Science & Sensibility!)

And last but not least, the News Moms Need blog reminds us that moving our bodies offers health benefits in pregnancy and after giving birth, not just in labor. The blog also offers tips and guidelines for exercising safely while pregnant. Our bodies were made to move!

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Do We Need a Cochrane Review to Tell Us That Women Should Move in Labor?

October 25th, 2009 by avatar

I am reposting this post from the archives in anticipation of this week’s Healthy Birth Blog Carnival about movement in labor. It was one of the first posts I ever wrote, back before anyone was reading this blog. It’s also one of my personal favorites.

Earlier this year, media outlets shared the news of a new Cochrane review that concludes upright positions are beneficial because they shorten labor by about one hour. The birth blogs were buzzing about this, and the consensus is that we should feel delighted and vindicated to have the scientific evidence to prove what women and midwives have always known.

ResearchBlogging.orgCochrane reviews synthesize all of the research on a particular topic, and because the reviewers bring together and analyze all of the data from many studies, the study population gets very big. Big populations yield greater statistical power and often (but not always) more reliable findings.

Prior to this Cochrane review there was a large body of literature on movement in labor, including a good sized U.S. randomized controlled trial. There was even another systematic review! But this body of research never consistently supported the hypothesis that movement improved labor and birth outcomes. Now we have a Cochrane review, which is the gold standard for evidence-based practice.  So we can put the evidence-based “stamp of approval” on freedom of movement.

But, were we any less justified in endorsing freedom of movement before the Cochrane? Although studies have given us inconsistent results as to whether movement shortens labor or decreases the need for c-section, a few conclusions have been loud and clear from the literature since researchers began looking at maternal position and movement:

  1. Women prefer to move around, primarily because they experience less pain when they can move.
  2. Women who stay in bed usually do so because they are connected to machines or IV lines, and/or because a health care provider tells them to.
  3. Movement and walking are not harmful to the woman or the baby.

Freedom of movement is the thing that would happen if women did not have any interaction with a health care system or provider in labor. In other words, it’s the default state of affairs. Anything that we do in the name of “health care” to improve upon this normal unfolding of things is referred to as an “intervention”. In scientific research, researchers compare a control group, which should represent the default/normal, with an experimental group, which represents the intervention. The burden of proof should be on the intervention.

Somehow, things have gotten turned around, and the normal condition is now the “experiment” and the intervention is the “control”. In addition to being irrational, this is a set-up to perpetuate conventional obstetric care, which imposes unhealthy and unfounded restrictions on women in labor. This is because in “intervention versus control” research, you have to show that the intervention performs significantly better, otherwise the control condition remains standard practice. While many of us believe that encouraging a laboring woman to move when and how she wants to is healthier and safer than making her stay in bed, waiting for evidence that it produces better health outcomes is putting a burden of proof on normal birth that has never been applied to routine intervention. Besides, lack of evidence of harm, less pain, and maternal satisfaction are valid and important outcomes in and of themselves, and provide the justification we need to reject routine policies and practices that restrict maternal movement.

Lawrence A, Lewis L, Hofmeyr GJ, Dowswell T, & Styles C (2009). Maternal positions and mobility during first stage labour. Cochrane database of systematic reviews (Online) (2) PMID: 19370591

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Can we improve research by crowd sourcing peer review?

October 21st, 2009 by avatar

Since we launched six months ago, Science & Sensibility has become a multidisciplinary hub for analysis of research in maternity care. I’m proud that we have a childbirth educator, a consumer advocate, and two clinicians among our regular contributors. We also regularly have consumers, childbirth educators, doulas, nurses, midwives, doctors, and researchers leave comments. Together, we shape our understanding of research, discover new ways to look at questions, and find out which research pertains to us and which doesn’t. And we do it in ways that none of us could do alone.

In most cases, our work begins when a study is published in a peer-reviewed journal. The journal issue is published, the press releases go out, and then the rest of us get to weigh in. With much at stake in how the evidence will be used (the findings may impact our bodies and our babies, or change the conditions in which we practice, after all), we set to work. Too often, this process reveals flaws, detects biases, or raises other red flags. But the study is peer-reviewed, so it gets to shape policies and practices – especially if the findings align with the dominant obstetric management model – while we get to air our frustrations in blogs and letters to the editor. If you need more proof of the power of a deeply flawed but nevertheless published trial, consider the rise and fall of the Term Breech Trial, and the multi-stakeholder movement for evidence-based breech birth finally taking hold nearly a decade later. (Several bloggers have covered the recent Breech Birth Conference, including Rixa Freeze, PhD, at Stand & Deliver.)

Also consider these thoughts from the editors of two of the most prominent peer reviewed journals:

It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of The New England Journal of Medicine. – Marcia Angell, MD,  in Drug Companies & Doctors: A Story of Corruption

If editors were to examine [the] body of literature [on the peer review process], they would discover that evidence on the upside of peer review is sparse, while evidence on the downside is abundant. We struggle to find convincing evidence of its benefit, but we know that it is slow, expensive, largely a lottery, poor at detecting error, ineffective at diagnosing fraud, biased, and prone to abuse.  Sadly we also know — from hundreds of systematic reviews of different subjects and from studies of the methodological and statistical standards of published papers — that most of what appears in peer reviewed journals is scientifically weak. – Richard Smith, MD, former editor of BMJ in In Search of an Optimal Peer Review System

jopmToday marks the launch of a new journal, The Journal of Participatory Medicine. Participatory Medicine itself is based on the fact that all stakeholders, especially engaged, empowered consumers, are valuable assets for improving the quality and efficiency of healthcare. The Journal mirrors this philosophy. They will break most of the rules of ivory tower academic journals by inviting contributions from patients, providing free open access to anyone, asking for comments and feedback, and, perhaps most importantly, allowing anyone (yes, even you) to volunteer to be a peer reviewer.

As I have said before, maternity care advocates have much to contribute to and gain from the Participatory Medicine movement. I encourage my readers to check out the new journal. No, none of it has to do with maternity care specifically (yet), but here are a few gems that may make you realize that, when it comes to the power of being engaged and empowered and the harms of being a passive patient, it doesn’t matter if the context of care is sickness or health. [Note, free registration required to access journal articles.]

Medicine in the US has become extremely proficient at many technically advanced diagnostic and therapeutic methods. However, they are often applied — very competently — to patients who don’t need them at all. Can participatory medicine improve this situation? One way perhaps, is by facilitating actual informed consents (not merely legal rote signings) for therapeutic and diagnostic procedures, including screening tests and procedures. – George Lundberg, MD, in Why Healthcare Professionals Should Practice Participatory Medicine: Perspective of a Long-Time Medical Editor

As our bodies healed from the assaults of cancer treatment, we began to respond to the needs of others, discovering that we had something to offer, a knowledge that was hard won and deeply felt, and that somehow in that sharing we could both help and be helped. We joined groups and formed groups and sometimes organizations, moving beyond isolation to community. – Musa Mayer in A Seat at the Table: A Research Advocate’s Journey

Purchasers, in other words, understand that participatory medicine is not just about helping an individual patient better understand how to manage their own health and make important health care decisions. Participatory medicine is also about creating a broad awareness that a health system that only rewards services, that is not based on evidence, that sanctions an unaccountable professional and managerial elite to dispense and withhold services — is not just, effective, or affordable. – David Lansky, PhD, in Why Purchasers Should Care About Participatory Medicine

Participation means that we as patients, we as providers and we as health care system managers must be willing to acknowledge our interdependence and meet on a level if changing environment. To do otherwise is dangerous and will lead to poor outcomes. We have no choice. – Kate Lorig in What it Will Take to Embrace Participatory Medicine: One Patient’s View

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Basic Tracking Skills: How to find what you’re hunting for

October 16th, 2009 by avatar

This is the third article in our Understanding Research series.

So you are at your index of choice. What now? You will need to use key words to search. The best way to learn to use key words effectively is to do a lot of practice searching. Some tips to help you get the most out of your practice:

1. Make sure you spell the words correctly. Seems almost silly that I would have to say it, but it is one of the most common mistakes.

2. Use quotation marks around phrases you want to search together. This can be a two-edged sword, though, as a search for “active management of labor” might miss a study that uses the phrasing “an active approach to labor management.”

3. Make use of the terms “and” “or” and “not”. If you wanted studies on smoking in pregnancy, you’d search for smoking AND pregnancy. The “or” command would be useful if you have similar terms you want to search at once, like hypertension OR high blood pressure. The “not” command can be used to eliminate unrelated results. For example labor NOT workforce. In some databases, you may need to capitalize these operators.

4. Don’t be too broad. If you’re looking for something on the risks of induction before 40 weeks, don’t just search “induction” because you’ll get a lot of results – and some won’t even have to do with labor! If you do find you get too many results, look for an option to refine your search to narrow the results to a manageable number. Often you’ll see a set of checkboxes where you can limit the results to a certain date range, only those with full text, or other criteria. Here is an example of the results limiting box found within EBSCO.

LimitResults

I’ve used the slider to show that I only want results published since the year 2000. When I click “update results” I’ll have refined my search so I have fewer results to look through.

5. Don’t be too specific. A search for induction risks labor 40 weeks gestation might eliminate a study titled “Timing of Elective Labor Induction at Term”.

6. If your first term doesn’t yield good results, try a different word that means the same thing. If birth location isn’t getting results, try place of birth. Or just start off using both terms with the “or” in between.

“birth location” OR “place of birth”

Also consider alternate spellings, like labor/labour or breastfeeding/breast feeding to see what comes up under each of those.

7. Finding little on Cytotec? Try searching “misoprostol” the generic name for the drug. Most published research will use the generic names for drugs since brand names can vary from country to country.

8. Use the medical lingo. I once got a call from a student who was frustrated beyond measure that she couldn’t find a single study to support her client in refusing a c-section for a baby that was estimated to weigh 9 pounds. “There’s GOT to be something!” Come to find out, she was searching for “big babies” and “c-section”. A search for macrosomia risks did turn up some helpful results.

9. Some (but not all) indexes will allow you to use the asterisk * symbol to truncate (or shorten) your search term. So if you want to do a search for something on episiotomy, you can search for “episiotom*” and the index will pull up anything with episiotomy, episiotomies, episiotomological, or any other word that starts with “episiotom-”. (OK, I admit, I made up the word “episiotomological”!) Be careful you don’t go too vague on this. A search for “epi*” will pull up episiotomy, epidural, epigastric, epistemology, epi-everything!

The best way to learn how to search is to practice, practice, practice. I find that it helps me to keep a running log of the terms I have tried to avoid repeating searches and to see things I may have missed. If you’re not finding what you want after several tries in one index, try another. If you are in a library building while you search, find a librarian and ask for help. Librarians can be great sources for the tips and tricks of searching!

Next week: Advanced Tracking Tools: MeSH Keywords

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