Archive for March, 2011

Babies and No Woman, No Cry: Stories, Culture and Birth

March 31st, 2011 by avatar

The mother’s womb is replaced by the womb of culture, which, comfortably or uncomfortably, cradles us all (Robbie Davis-Floyd 1992: 149).


Pregnancy, birth, breastfeeding –these practices are simultaneously natural and universal,  connecting women across the world and over history. They are profoundly local and culturally shaped, with the potential to divide women from men, but also from other women in different circumstances.

In the past couple of weeks, I’ve had the pleasure of viewing two documentary films that examine reproductive experiences across culture, and stimulate a reconsideration of culture and birth.  The first, Babies, is a French

Photo credit: http://focusfeatures.com/babies

documentary released in 2010 which centers on four babies from birth to their first birthday: Mari in Tokyo, Japan; Hattie in San Francisco, CA, US; Opuwo in Namibia, and Bayar in Baynchandmani, Mongolia.   Babies is a delight to watch, and interestingly, it features no dialogue, no subtitles and no narration.  The babies really are the center of the film—we see the world as they encounter it, whether a pet cat swishing by on the hard wood floors or a goat checking out the bath water through the window of a yurt.  Each baby’s lifeworld is vividly and intimately shared.   The film’s balanced portrayal of each culture means that we see the US as only one of many places a baby can be born and grow up.  Even things we think are universal and timeless, such as birth and breastfeeding, are profoundly shaped by the cultural context in which they occur. Robbie Davis-Floyd’s quote is apt here:  culture can be a comfortable cradle, as it is for these individual babies, who are loved, healthy and safe.

However, without a cultural context, we have no way of knowing how their mothers’ journey through pregnancy and birth affected their outcomes and life chances.   Not all babies and mothers have an equal chance at a healthy pregnancy, birth and first year of life.   A new documentary film on maternal health, No Woman, No Cry, introduces us to at-risk pregnant women in four parts of the world: a remote Maasai tribe in Tanzania, a slum of Bangladesh, a post-abortion care ward in Guatemala, and a prenatal clinic in the United States. Directed by Christy Turlington Burns, former fashion model, now mother of two, a public health master’s student at Columbia University, NYC and an ambassador for CARE – the film is a courageous and inspiring look at the reality of women’s lives when pregnancy occurs in the context of ill health, lack of access to timely and quality care, so that birth is a precarious, life-threatening event.

No Woman No Cry had its world premiere at the Tribeca Film Festival in NY last year, and is on a select west coast tour during which I saw it in the company of many public health students and professionals at the University of California, San Francisco campus in Mission Bay, SF.  Speaking on the panel after the film were Suellen Miller, PhD, CNM, Associate Professor at UCSF [Director, Safe Motherhood Programs, Dept. Obstetrics, Gynecology & Reproductive Sciences, Bixby Center for Global Reproductive Health and Policy,  Center of Expertise, Women’s Health and Empowerment, Global Health Institute]; Nan Strauss, a researcher at Amnesty International USA and the co-author of 2010 report on US maternal mortality, “Deadly Delivery: The Maternal Health Care Crisis in the US” and Christy Turlington Burns herself.

No Woman, No Cry is a beautifully photographed film, with haunting images.  The music is a perfect accompaniment, never obtrusive.   I admire Ms. Burns’ vision for this film:  to tell a story “giving viewers an informative and powerful look at this compelling global issue without having to leave their ZIP code.”  One such story is that of Janet from Tanzania, whose labor in her third pregnancy was long and protracted, and for whom the $30 bus fare to the hospital was a nearly insurmountable obstacle.  Another story portrays the immense cost of anti-abortion policies on women’s health with a focus on a Guatemalan physician, Dr. Linda Valencia, whose mission is to educate women about contraception and

Country Estimated MMR* Lifetime Risk of Maternal Death:  1 in __
Bangladesh 340 110
Guatemala 110 210
United Republic of Tanzania 790 23
United States 24 210

provide nonjudgmental medical care to them following self-induced abortions.   In Dhaka, Bangladesh, the focus is on Monica, a young mother living in the slums whose labor requires a visit to the hospital, where she is helped , but experiences as very traumatic due to her poverty and how she is treated.  Finally, the US context, while not in the same scale as the other countries, is an important part of this story, showing that developed countries cannot be complacent. The US has fallen in world ranking to 50th, with maternal mortality ratios (24) higher than almost all European countries, as well as several countries in Asia and the Middle East  according to statistics released in September 2010 by the United Nations.*   The burden of worsening maternal health outcomes is felt most strongly by African American women, who face a three-four fold higher risk of death than women of other race/ethnicities, the largest and most long lasting disparity in public health.  But as the film points out, some maternal causes of death do not distinguish by race or class – as the example of the woman who died from an amniotic fluid embolism, a common yet less preventable cause of death than more prevalent issues such as cardiovascular disease, hypertensive disorders and hemorrhage.

The film invites questions and dialogue.  For those not familiar with pregnancy and associated risks, the stark presentation of women whose lives are at risk due to their cultural and individual circumstances may overshadow the reality that for many women, pregnancy is a low risk event.  Even in Dhaka, where the lifetime risk of maternal death is 1 in 110, many women have babies without incident.   The comparative risks are less elaborated, as is a discussion of the dual problems in maternity care – under utilization of medical care for some women and over utilization of medical interventions, including cesareans for others.  Evidence of our greater misunderstanding of the gravity of this problem, the audience gasped when panel member Nan Strauss informed them that the US cesarean rate is now 33%.

Pregnancy and childbirth can be a joyous, rather than feared and dangerous time, but this requires a global reprioritization of women’s reproductive health care.   This can be done, with enough political, and moral, will.  The obvious cost of a maternal death is seen in the eyes and heard in the voice of the US widower, who is clearly bereft after the death of his wife.  Yet the  hidden costs of maternal death are found in the torn social fabric remaining when a woman dies needlessly in childbirth — as a worker and major contributor to the household income and food sources, and as a mother, sister, friend.

There are more stories to tell than this film had the time or space to do.  These include stories of poor women in the US, the voices of politicians who vote for increases in certain types of spending over that of maternal health – and of course, the voices of women in the US and the world, speaking out for the mothers who die.

Posted by:  Christine Morton, PhD, CD



Disclaimer: Christine Morton provided consultation to the film’s producers, and has retweeted and been retweeted by Christy – we follow each other on Twitter.


[For both documentaries, much more information, background and context, is provided on the websites and here].

*WHO. Trends in maternal mortality: 1990 to 2008 estimates developed by WHO, UNICEF, UNFPA and The World Bank, World Health Organization 2010, Annex 1. 2010. http://whqlibdoc.who.int/publications/2010/9789241500265_eng.pdf.

Films about Childbirth, Maternal Mortality, Maternal Mortality Rate, Uncategorized

Outrageous Price Charged for 17 alpha-hydroxyprogesterone caproate (17OHP): A Blessing in Disguise?

March 30th, 2011 by avatar

A recent New England Journal of Medicine commentator was shocked, shocked, to find that a drug company was price gouging. Joking aside, this is a particularly egregious example of Big Pharma behaving badly. After locking in the right to manufacture 17OHP, K-V Pharmaceutical Company raised the price of treating one pregnant woman at risk for preterm birth by virtue of a prior preterm birth from $300 to more than $29,000, limiting access, according to the commentary, to “the drug’s demonstrated clinical efficiency against a complication for which there are few effective preventive options.”

Why might this be a blessing in disguise? Earlier, I did a blog post, “Does Progesterone Treatment Prevent Preterm Birth? A Case of ‘Skim Milk Masquerades as Cream’”, questioning the effectiveness of progesterone in women with prior preterm birth, including a critique of the trial the commentary cites as demonstrating the effectiveness of intramuscular injections of 17OHP. In that trial, progesterone did not reduce the rate of preterm birth. The rate remained what it had been in similar women before the trial began. Instead, the rate in the control group was much higher than before, and that’s what created the difference between groups. Moreover, the rationale for progesterone is quieting the uterus, but it didn’t do that either. Just as many women in the progesterone group as the placebo group needed treatment for bouts of preterm contractions. Furthermore, another, bigger trial reported no difference in preterm birth rates. So much for “effective.” As I also pointed out in the earlier post, we have no data on the long-term effect of exposing fetuses to weeks of excessive levels of a sex hormone. True, exposure starts after sex organs have developed, but there is more to differentiating boys from girls than looking different, and it is mediated by an ongoing interplay of hormones. The new price barrier could, therefore, protect women and their babies from a treatment that probably doesn’t do them any good and might do their babies harm.

As for lack of preventive options, a social intervention holds great promise. A randomized controlled trial of group prenatal care by midwives (A.K.A. “Centering Pregnancy” ) was published in 2007 in Obstetrics and Gynecology—in other words, hardly buried in an obscure journal. Participants were 1000 women, most of whom were low-income black women, a group at high socioeconomic risk for preterm birth, who were assigned to either group prenatal care or standard care. The preterm birth rate was 14% in the standard care group versus 10% in the group prenatal care group, a one-third risk reduction after controlling for factors that increase risk of adverse perinatal outcomes. In African-American women, the reduction was even more striking: 16% versus 10%. Nothing, nothing anyone ever has tried has reduced preterm birth by a third in a general population.

Why would group prenatal care work? Because preterm delivery is strongly associated with chronic maternal stress. Group prenatal care builds community and helps women feel more competent and confident, as shown by the trial’s other positive outcomes: women in group sessions were less likely to have suboptimal prenatal care, knew more about pregnancy, felt better prepared for labor, were more likely to initiate breastfeeding, and were more satisfied with their prenatal care. With social interventions, everyone wins, not just women spared a preterm birth. Best of all, there is NO downside to group prenatal care, no worries about adverse effects of treatment short- or long-term. As has been said about doula care, another social intervention—which, BTW, is thought to work the same way to reduce cesareans by reducing fear and stress in labor—if group prenatal care were a drug, clinicians would have rushed to obtain it for every hospital pharmacy in the country. And you can bet that providing group prenatal care would cost a lot less than $30,000 per person and probably not even as much as $300, the cost of the cheap version of 17OHP.

Of course it is disappointing that 17OHP isn’t what it’s being cracked up to be. But social interventions have yet to be tried, and at the very least, as the 18th century French surveyor Cassini de Thury said,


“It is better to have absolutely no idea where one is than to believe confidently that one is where one is not.”


Posted by: Henci Goer

Doula Care, Evidence Based Medicine, Pre-term Birth, Science & Sensibility , , , , , , , , ,

Birth Matters: The Latest Book from Midwife Ina May Gaskin

March 29th, 2011 by avatar

In my recent response to the editor about an article published in Clinician Review (which, by the way, still remains unanswered), I discussed my beliefs on why more than just pregnant women, and the birth workers with whom they interact, ought to care about pregnancy and birth.  Last week, during a long drive home beside the barely-thawing Yellowstone River, I discussed this same issue with a dear doula friend of mine:  birth has got to matter to more than just those of us working in this field, and the women we tend to.

And so, hackles still raised, I am particularly refreshed to see Ina May Gaskin has released yet another book, entitled Birth Matters, which apparently discusses just this issue:  why does and should childbirth matter to the whole of our human species…not just an isolated segment of us?

To read a lovely interview with Gaskin about her new book, check out what Babble posted recently.

To you, the reader:
*Why does the issue of childbirth matter to you?  *Who else do you think needs to be apart of this ongoing dialog?
**I challenge each and every reader of this post to forward it onto one person who might not otherwise be drawn to frequently thinking and talking about birth.

Birth matters to all of us–whether we think so or not, whether our work lives bring us adjacent to childbirth or not–because it affects all of us in one way or another.

Posted by:  Kimmelin Hull, PA, LCCE

Uncategorized , , , ,

Breastfeeding: The First Few Weeks of Life

March 27th, 2011 by avatar

Colostrum We know that a mother produces colostrum in pregnancy and continues to do so for up to 10 days or so after her baby is born.  We know that newborn babies require nothing other than colostrum and that though it is not there in plentiful amounts it is adequate for baby’s growth and health[1].  Yet, how often do we hear that a mother must begin expressing her milk because she probably won’t have enough?  We know that a baby who is well latched with an asymmetric latch will get the colostrum that is there, and a poorly latched baby won’t[2], and yet we see thousands of mothers in our clinic who have been taught to latch baby symmetrically.  Instead of adjusting the latch for better milk

Image Source

transfer mothers are being told to pump.  And incidentally, colostrum does not respond well to a pump, it responds better to hand expression.  And so when mothers can pump nothing,  they are told they have no milk.  Best to adjust the latch and use breast compressions[3] and watch for baby’s drinking (don’t listen, you are unlikely to hear a baby drinking at that age)[4].

Contrary to popular belief engorgement is not a sign mother has a lot of milk.  Engorgement is a sign things have gone wrong.  And worse off, if the engorgement is severe enough it can cause depletion in mother’s milk significantly on that breast, perhaps even for the breastfeeding experience of that baby.  To avoid this, latch asymmetrically and deeply.  Ensure baby drinks well, use breast compressions (see the video clip and info sheet at www.nbci.ca for the “how to”) to ensure the milk continues to flow.  Keep baby skin to skin so mother will be able to read baby’s early cues and thus the necessary frequency of feeding that needs to happen (no timing how long per side or how long in between feeding, no counting sucks or drinking, no schedules[5]—just following baby’s early cues and keeping baby drinking) and that will suffice.  If mother does become engorged then using RPS [6],[7](Reverse Pressure Softening), developed by Jean Cotterman, will allow the baby to latch on immediately and drain the breast, see www.nbci.ca for the info sheet on engorgement.  It is very important not to pump engorged breasts, nor to massage downward toward the nipple.  Once baby is on, use breast compressions (which are always stationary) to keep baby drinking.


Sore Nipples We also know that a well-latched baby should not cause mother pain[8] and yet women are told around the world to put up with the pain, or grin and bear it because it is supposed to hurt.  A troubling practice is one where the mother is told to unlatch baby and re-latch over and over until she gets it right—this repeated activity can cause damage to the nipple and is not only painful, mothers become so dejected by doing it.  Instead, it’s best to adjust the latch mother has already by ensuring the nose stays far away from the breast and keep baby drinking.  Of course, if mother felt that the latch was absolutely unbearable and she could get a better one if she tried again, by all means.   Mothers are also told to prepare their nipples (a completely non-evidenced informed practice!!) and to apply various creams and ointments on their nipples: petroleum jelly, lanolin-based creams, nipple balms—none has been supported by research.  Some make matters worse.  Again, simly by adjusting the latch the pain is dealt with—if not, there is something else going on.

[Lastly, if the above measures have failed to reduce soreness,] check for tongue tie [9],[10],[11].

[1] GamePlan for Protecting and Supporting Breastfeeding in the First 24 hours of Life and Beyond. Kernerman, E. 2010

[2] L-eat Latch and Transfer Tool, Kernerman, E. Park, E, Newman, J, Kouba, J. 2010

[3] Breast compressions info sheet, www.nbci.ca

[4] L-eat Latch and Transfer Tool, Kernerman, E. Park, E, Newman, J, Kouba, J. 2010

[5] Kent JC, Mitoulas LR, Cregan MD, et al. Volume and frequency of breastfeedings and fat content of breastmilk throughout the day. Pediatrics. 2006;117(3):e387-95

[6] Engorgement info sheet, www.nbci.ca

[7] Cotterman KJ. Reverse Pressure Softening: A Simple Tool to Prepare Areola for Easier Latching During Engorgement. J Hum Lact 2004 20: 227-237.

[8] Righard L Alade MO. Effect of delivery room routines on success of first breast-feed. The Lancet 1990; 336:1105-07

[10] Dollberg S, Botzer E, Grunis E, Mimouni FB. Immediate nipple pain relief after frenotomy in breast-fed infants with ankyloglossia: a randomized, prospective study. J Pediatr Surg. 2006; 41(9):1598-600.

[11] Geddes DT, Langton DB, Gollow I, et al. Frenulotomy for breastfeeding infants with ankyloglossia: effect on milk removal and sucking mechanism as imaged by ultrasound. Pediatrics. 2008; 122(1):e188-94


Breastfeeding, Uncategorized , , , , , , , ,

Positioning During Second Stage of Labor: Dorsal Lithotomy vs. Lateral Lying

March 24th, 2011 by avatar

The final post in this blog series will examine the pros and cons of assuming a lateral lying position during the second stage of labor as compared to dorsal lithotomy position. Anatomical implications, perineal outcomes, and orthopedic concerns will all be addressed.

Anatomical implications
As discussed in earlier posts, dorsal lithotomy puts the birth canal in an “uphill” orientation. Conversely, the lateral lying position places the birth canal in a gravity-eliminated orientation, allowing the laboring mother to have a mechanical advantage during the pushing stage.  Also, when in side lying on the left side, there is optimal blood flow as compression of the inferior vena cava by the uterus is avoided.

Perineal outcomes

Shorten (2002) compared birth positions, Accoucher, and perineal outcomes in almost 2900 births.  It was found that the lateral lying position produced quite favorable results with regards to the health of the perineum.  Below average rates of episiotomy were observed and intact perineums were seen in 66.6% of the women who delivered while lying on their side.  The lateral lying position was, by far, the best choice for decreasing the risk for tears and the need for sutures in their research.

In a study by Soong (2005), the need for perineal sutures was decreased when a lateral lying position was assumed during delivery with epidural anesthesia.  The semi-recumbent position was associated with an increased need for suturing.  If a woman does choose to receive an epidural during her labor, it is important to realize that there are a fewer number of possible positions that she can assume because of the effects of the anesthesia.  However, given the aforementioned study by Soong, a woman should be able to make an informed decision about what position may be the best choice to improve perineal outcomes.


Orthopedic concerns
Although the lateral lying position does not have as many advantages as, for example, squatting or quadruped during a “normal” birth, it does have many indications when looking at births that involve a mother with orthopedic issues present.  One example is when a woman is suffering from coccygeal (tailbone)pain. Lateral lying may be the best choice for her to be in as this position does not place any force on this area and also allows the coccyx to move freely and out of the way as the baby descends.  Furthermore, it may be helpful to the woman who has pubic symphysis dysfunction, if careful attention is given to not overly abduct the lower extremities, placing undue stretch to the already separated joint.

In consideration of the spine, the side lying position is beneficial to keep the lumbar spine in a flexed position when spondylolisthesis or spinal stenosis are present.  The amount of flexion may be easily adjusted to maintain or improve maternal comfort during second stage and may improve her ability to recruit the proper musculature to push, if pain due to spine impairments is decreased.

Lastly, the lateral lying position may be optimal if hip joint dysfunction, knee joint dysfunction or superficial/deep vein thrombosis (while lying on unaffected side) is present (Hobel 2004).  Once again, attention must be paid to avoid end ranges of motion to decrease strain on the hip and knee joints and decrease risk for further injury. (See previous posts in this series for further discussion on the above-mentioned orthopedic conditions)


I have covered many advantages and disadvantages over the last three posts when considering second stage labor positions.  It is important to note that further research is needed in this area so we may better understand the implications of each position.  Likewise, additional information will further support  our education of women on optimal second stage positioning.  There are many different individual concerns of every woman, in every circumstance, in every birth.  It is my hope that women everywhere will be empowered to make an informed decision according to what birth outcome is important and specific to them based on the evidence presented in these posts.

picture source: http://www.flickr.com/photos/joygant/1447261129/


Gardosi, J., Sylvester, S. and B-Lynch, C. (1989), Alternative positions in the second stage of labour: a randomized controlled trial. BJOG: An International Journal of Obstetrics & Gynaecology, 96: 1290–1296.

Hobel CJ, Chang AB.  “Normal Labor, Delivery, and Postpartum Care:

Anatomic Considerations, Obstetric Analgesia and Anesthesia, and Resuscitation of the Newborn” in Essentials of Obstetrics and Gynecology, 4th Edition, Editors Hacker, Moore, Gambone.  Elsevier Saunders:

Philadelphia.  2004.

Liddell, H. S. and Fisher, P. R. (1985), The Birthing Chair in the Second Stage of Labour. Australian and New Zealand Journal of Obstetrics and Gynaecology, 25: 65–68

Oxorn, Harry MD Human Labor and Birth (University of Ottawa, Ontario, Canada,McGraw-Hill Professional Publishing)1986

Sax TW, Rosenbaum RB.  Neuromuscular disorders in pregnancy.  Muscle Nerve.  2006 Nov; 34(5):559-71

Shorten, A., Donsante, J. and Shorten, B. (2002), Birth Position, Accoucheur, and Perineal Outcomes: Informing Women About Choices for Vaginal Birth. Birth, 29: 18–27.

Snow, R., Neubert, A. Peripartum Pubic Symphysis Separation:  A Case Series and Review of the Literature.  Obstetrical & Gynecological Survey: July 1997 – Volume 52 – Issue 7 – pp 438-443

Soong B, Barnes M.  Maternal position at midwife-attended birth and perineal trauma: is there an association?  Birth.  2002;32(3):164-169.

Posted By:  Amanda Blaz, DPT

Practice Guidelines, Research, Research for Advocacy, Science & Sensibility, Second Stage, Uncategorized , , , , , , , ,

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