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Upcoming Webinar! Transparency in Maternity Care: Bringing birth out of the dark to improve quality

August 24th, 2009 by avatar

On September 15 I will give my webinar, Transparency in Maternity Care: Bringing Birth Out of the Dark to Improve Quality. I’ve presented this talk many times before and the feedback is always great. The webinar will give you the evidence to build the case for transparency in maternity care. We will review a body of evidence that shows:

  • Intervention rates and outcomes vary widely across providers and facilities
  • Most of this variation has to do with factors unrelated to the woman’s health status
  • Excess use of interventions leads to excess injury and cost
  • Intervention rates can be lowered without compromising safety
  • Public awareness of quality indicators results in improved quality
  • Mother-friendliness is a measure of quality

Participants will also learn about a grassroots effort to improve transparency in maternity care: The Birth Survey, supported in part by Lamaze International.

Lamaze has approved one contact hour for participants. You can find out more about the webinar and register online.

The Birth Survey

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ACOG’s 2009 Induction Guidelines: Spin Doctoring Misoprostol (Cytotec)

August 17th, 2009 by avatar

Cytotec (Misoprostol)

Ahh, the new ACOG induction guidelines, so much to dislike, so little time. Still, others are also commenting, so I will focus on debunking ACOG’s portrayal of misoprostol.

ACOG STATEMENT: “There is . . . a large body of published reports supporting (misoprostol’s) safety and efficacy when used appropriately” (p. 387).

FACT: None of the studies have been big enough either alone or in the aggregate to detect differences in rare, catastrophic events, a point acknowledged by a Cochrane systematic review, and it is those rare, catastrophic events that are the issue with “miso.” And while more disasters will occur with higher doses and in women with prior cesareans, there is no “appropriate” use of misoprostol in terms of safety.

ACOG STATEMENT: “No studies indicate that intrapartum exposure . . . has any long-term adverse health consequences to the fetus in the absence of fetal distress [emphasis mine]. . . .” (p. 387).

FACT: Well, that’s the catch, isn’t it? The long-term adverse health consequences to the fetus occur in the presence of fetal distress subsequent to uterine rupture—including in unscarred uteruses and with moderate doses of misoprostol—and amniotic fluid embolism. In some cases, of course, the fetus doesn’t survive to experience long-term consequences.

ACOG STATEMENT: “Although misoprostol currently is approved by the U.S. Food and Drug Administration (FDA) for the prevention of peptic ulcers, the FDA in 2002 approved a new label on the use of misoprostol during pregnancy for cervical ripening and for the induction of labor. This labeling does not contain claims regarding the efficacy or safety of misoprostol” (p. 387).

FACT: A reader can be forgiven for assuming from this convoluted phrasing that the FDA now approves of using misoprostol to induce labor. The reader would be wrong. The FDA removed the “black box” designation prohibiting use in pregnant women, but it takes a much dimmer view of “miso” than merely not claiming it is safe. Here is an excerpt from the FDA’s 2002 statement (PDF):

A major adverse effect of the obstetrical use of Cytotec is hyperstimulation of the uterus which may progress to uterine tetany [uterus contracts and doesn't let go] with marked impairment of uteroplacental blood flow, uterine rupture (requiring surgical repair, hysterectomy, and/or salpingo-oophorectomy [removal of the ovaries and Fallopian tubes]), or amniotic fluid embolism [maternal and infant mortality is very high from this]. Pelvic pain, retained placenta, severe genital bleeding, shock, fetal bradycardia [profound slowing of the fetal heart], and fetal and maternal death have been reported.

There may be an increased risk of uterine tachysystole [contractions coming too fast], uterine rupture, meconium passage, meconium staining of amniotic fluid, and Cesarean delivery due to uterine hyperstimulation with the use of higher doses of Cytotec; including the manufactured 100 mcg tablet. The risk of uterine rupture increases with advancing gestational ages and with prior uterine surgery, including Cesarean delivery. Grand multiparity [usually defined as more than four births] also appears to be a risk factor for uterine rupture.

What actually happened was this: ACOG held that “misoprostol is one of the most important medications in obstetrical practice. . . . The real victims in this scenario [i.e., prohibition in pregnancy] are pregnant women who receive treatment in hospitals that will not allow the use of misoprostol” (Hale 2001, p. 59). Lobbied by ACOG, the FDA rescinded the black box designation on the grounds that obstetricians were using it to induce labor, a rationale that amounts to “but all the kids are doing it.”

ACOG STATEMENT: “The majority of adverse maternal and fetal outcomes associated with misoprostol therapy resulted from the use of doses greater than 25 mcg” (p. 387).

FACT: The “majority” of adverse outcomes is hardly reassuring. What about the minority? Not to mention that obstetricians may ignore recommended dosages, and even the guidelines say “Misoprostol in higher doses (50 mcg every 6 hours) may be appropriate in some situations” (p. 390). In any case, misoprostol is formulated in 100 mcg tablets for use as an oral ulcer medication. Getting a 25 mcg dose means cutting an unscored tablet in quarters. It’s anybody’s guess what dosage is really delivered.

The real kicker is that according to the Cochrane systematic review, misoprostol is no more effective than the FDA approved medication, PGE2 (a.k.a dinoprostone, trade names Cervidil and Prepidil). More vaginal deliveries happened within 24 hours after administration, but cesarean rates overall did not differ between groups. Cesarean rates in trials comparing misoprostol with with intravenous oxytocin (trade names Pitocin or “Pit” and “Syntocinon”) were more variable, but not all of them found reductions in cesarean rates with misoprostol. Meanwhile, misoprostol results in higher rates of uterine hyperstimulation and uterine hyperstimulation with adverse changes in the fetal heart rate than other agents. And misoprostol has yet another major disadvantage: Oxytocin has a short half-life. If contractions get too strong or too close together, turn the I.V. drip down or off, and within a little while, contractions fade. If misoprostol hyperstimulates the uterus, you are stuck. Moreover, lurking in the “miso works faster” benefit is a problem not captured in the trials because they only measure major morbidity: some women are thrown into violent labors. These labors should have given researchers pause, though, if for no other reason than they are the precursor, the shark fin in the water, of misoprostol’s potential for severe fetal distress, massive hemorrhage, uterine rupture, and amniotic fluid embolism.

Why, then, are obstetricians so enamored of misoprostol? The answer is summed up by this obstetrician enthusiast:

The best part about it is that you can block-schedule your nurses so that you have enough on hand. . . [I]f we start our inductions at 7 a.m., we know that we’re going to have X number of patients in labor being admitted by 4 p.m. That’s helped our hospital tremendously, . . . [Cytotec is] a great agent. It works very, very efficiently. . . . And it’s ungodly inexpensive: 27 cents per tablet.

In other words, Cytotec’s real benefits are convenience for obstetricians and helping the hospital’s bottom line. For women and babies, though, it’s a roll of the dice. Most times things go fine, but sometimes the dice come up snake eyes.

Reference:

Hale, R. W., & Zinberg, S. (2001). Use of misoprostol in pregnancy. N Engl J Med, 344(1), 59-60.

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An Interview with Stand and Deliver’s Rixa Freeze, Winner of Lamaze International’s 2009 Media Award

August 13th, 2009 by avatar

Earlier this year, I announced on this blog that, for the first time, bloggers would be eligible for Lamaze International’s Annual Media Award. The Media Award is intended for individuals or organizations shaping the public discourse about natural, safe and healthy choices for childbirth. With blogs and other social media now firmly on the scene, it was clear that restricting our award to “traditional media” would have been looking too narrowly.

Stand and DeliverThe response was tremendous, and we faced a difficult task of choosing from among many wonderful and informative blogs written by mothers, fathers, nurses, childbirth educators, doulas, midwives, and consumer advocates. But one blogger rose to the top. Rixa Freeze, MA, PhD, blogs at Stand and Deliver, and reaches over 30,000 readers a month. Known for her warm, thoughtful tone and expert critical analysis of all things birth- and mothering-related, Rixa has built a strong community of engaged readers who comment often, challenge Rixa and one another, and shape and shift a conversation about birth that very often trickles onto other blogs and online forums and, occasionally, even the mass media. Rixa will receive her award, along with the recipients of Lamaze International’s other prestigious awards (to be announced this Fall), on October 3 at the 2009 Lamaze International Annual Conference in Orlando.

Stand and Deliver, like many pregnancy and parenting blogs, started as a family affair. Rixa launched the blog as a way to explain to her family and friends why she was making certain pregnancy and birth choices, without the emotion involved in sharing these choices with unsupportive loved ones face-to-face. Over time, her blog has evolved to include a wider range of posts: research updates and analysis, guest posts, meditations on birth and mothering, academic essays, critiques of North American obstetric practices, links to blogs and news articles, birth stories, and book reviews. And, of course, updates and pictures of her beautiful family!

Rixa may be best known for her choice to have a planned, unassisted home birth, and later, to complete her doctoral dissertation (PDF) on the modern unassisted childbirth movement, the first analysis of its kind. Let’s be clear – Lamaze International does not endorse unassisted childbirth, and granting the Lamaze Media Award to Rixa should not be considered an endorsement of unassisted childbirth. But we feel that Rixa’s personal and academic journeys to explore the entire range of childbirth choices can help us better understand the practices that facilitate normal physiologic childbirth, and how to humanize childbirth in all settings.

Rixa agreed to answer some interview questions about her blog, her philosophy, and what she would like to see change in our maternity care system. We hope Science & Sensibility readers enjoy hearing from this powerful voice in the birth blogosphere.

Lamaze: Did you have an “a ha” moment about natural birth? How did you come to your beliefs about birth and our maternity care system?

Rixa: During my first year as a PhD student at the University of Iowa, a fellow graduate student had a baby. I had a few conversations with her about her pregnancy and birth. She initially wanted a home birth but was unable to find a midwife. (Direct-entry midwifery is currently illegal in Iowa, and there are very few nurse-midwives who attend home births. I knew next to nothing about midwifery, let alone that direct-entry midwifery was illegal in my state.) So she went with the CNM practice at the university hospital and was very disappointed with her experience there. She asked me if I had ever considered home birth, and I said something to the extent of: “Well, nurse-midwives in a hospital seem like a good idea, but I would NEVER give birth at home!”

Ha.

As it happened, I was also looking for a paper topic for a feminist research seminar I was taking. I decided that writing about home birth midwifery in Iowa would be really interesting, so I started reading. I checked out stacks of books. The first one I read was Peggy Vincent’s memoir Baby Catcher. I still remember the hallway and chair in the library where I read that book. It turned my worldview upside down and inside out. When I started reading, I imagined that when I had a baby I’d go to a hospital, have a nurse-midwife because they spend more time with you and are more personal than physicians, probably have an epidural, and that would be the end of my story. By time I finished the book, I was transformed. I knew deep in my soul that I would birth my babies at home.

Discovering the world of midwifery and home birth changed the way I think about birth. I used to see childbirth as disempowering and degrading. I resented that we as women had to go through such a horrible experience. And I felt that men definitely lucked out. Some of these attitudes came from a passive absorption of cultural images and beliefs about birth. In film, for example, giving birth is always horribly painful–the woman is screaming and sweating and out of control, swearing at her husband, and lying on her back with her legs spread open, exposed to the world. In addition, hearing stories of my own experience of being born certainly had an effect on me. My mom gave birth to me upside-down, strung up from the ceiling by her ankles, only her shoulder blades making contact with the bed. This was not her choice. Her physician believed that giving birth upside down would prevent hemorrhoids. My mother screamed to be let down, to no avail. (And she never had hemorrhoids, either, not with my older sister or any of my other siblings who were born more conventionally.) That was all I knew about birth until my graduate student years.

In a way, naming my blog “Stand and Deliver” brings the story of my own birth full circle. My mother was lain (upside) down and delivered of a baby. When I was in labor, I stood up and delivered both of my babies myself, with full autonomy over my body and my labor.

Lamaze: You have written extensively about both midwife-assisted and unassisted home birth, had an unassisted birth of your own followed by a midwife-assisted home birth for your second child, and for your doctoral dissertation examined the modern unassisted birth movement (PDF). Can you briefly discuss what you think the existence and apparent growth of the unassisted birth movement means for the broader maternity care reform movement?

Rixa: Although some women choose unassisted childbirth (UC) solely out of a desire to have an autonomous, undisturbed birth, many come to it from some sort of previous trauma, fear, or disappointment. Today’s obstetric climate pushes many women into considering alternatives, from birth centers to midwife-attended home birth to unassisted birth. Other women have had disappointing experiences with their home birth midwives–some traumatic, others highly disturbed and controlled–and they conclude that the only way to have a safe and satisfying birth is to have no one there to boss them around. Some women choose UC because all of their local hospitals have banned VBAC and they refuse to have an unnecessary repeat surgery. Whatever one’s perspective on unassisted birth, there is no question that the existence and growth of unassisted birth is, in large part, a vote of no-confidence in our maternity care system. Some women would still have a UC regardless of how many other options were available, but others would hire a midwife or perhaps even have a hospital birth if they felt that they would have control over what happened to them in labor. I was probably in the minority, because I choose an unassisted birth for my first baby. I had never had a traumatic birth experience that left me leery of all birth attendants. I wasn’t fighting for the right to have a VBAC. I choose UC freely, because I felt an intense need for privacy during this pregnancy and birth. I also came to UC from a deep background in midwifery. I had apprenticed with a home birth midwife for a year. I had read hundreds of books about birth. I had attended births in both home and hospital as a doula. I was certified in neonatal resuscitation.

The existence of UC has been used as a political tool to garner support for legalizing home birth midwifery. Advocates of home birth midwives argue that women will continue to choose home birth, and if midwives are not legal, they will choose “riskier” unassisted births rather than going to a hospital. While I’m not enthusiastic about this approach, it does seem to work.

I have mixed feelings about the increasing popularity and visibility of unassisted birth, because it is a choice that should never be made lightly. During the time that I have been following UC communities on internet discussion boards and forums, I have witnessed a trend devaluing education and preparation, dismissing midwives and physicians too quickly, and valuing intuition and the need to “trust birth” over everything else. Unlike other birth choices, unassisted birth carries a lot more responsibility on the parents’ end, as there is no one else there with birth skills or knowledge. I would almost prefer that UC remain invisible and “unpopular,” rather than the somewhat trendy thing it has become on the internet, to be sure that no one makes that choice for the wrong reasons.

Lamaze: You have written a lot about hospitals, and blogged about your experience touring local hospitals while pregnant with your son. What would you like to see change in hospitals? Do you think those changes are likely to happen?

Rixa: At a bare minimum, all hospitals should implement Baby-Friendly and Mother-Friendly protocols. US hospitals have shown remarkably slow progress in adopting the Baby-Friendly Hospital Initiative. It began in 1991 and was introduced in the US in 1997, yet as of July 2009, only 83 hospitals and birth centers have Baby-Friendly status. Contrast this to the 19,000+ facilities around the world that have become Baby-Friendly. Implementation of Mother-Friendly protocols, which share many of the same conclusions as the Six Lamaze Healthy Birth Practices, has been even more sluggish. Surely we can do better!

There is a great deal of resistance to changing institutional protocols, even when those changes would benefit both mother and child. I like to call it institutional inertia. It’s discouraging to see how long it takes for evidence to translate into practice. We’ve known for several decades that the supposed benefits of episiotomies are nonexistent and that they are more harmful than helpful. Still, somewhere around 25% of women still receive them, and almost three-quarters of those women were not asked for their consent before the cut. For example, the first birth I attended as a doula was with an OB who had an 80% episiotomy rate for first-time moms, and a 50% rate for multips. And he saw that as a good thing. At this birth, the mom pushed the baby out too quickly for him to cut an episiotomy–a fortunate thing, given she was a first-time mom and had a heavy epidural–and he told her afterwards in a regretful tone that he didn’t have time to do one. And another thing: this mom was adamant that she did NOT want an episiotomy. Did her OB know that? I don’t know, but I doubt it. Did she know about his episiotomy rate? Nope. Was the OB aware of the vast research showing that episiotomies cause more harm than good? Either he wasn’t aware of the research at all, or he knew about the research and chose to ignore it. I don’t know which of those two scenarios is more disturbing.

Another pressing issue is the widespread ban on VBACs. ICAN recently surveyed all maternity hospitals in the US and found that 49% banned VBAC, either through formal written policies or by a defacto ban (no doctors would do VBACs at that hospital, even though they were not officially banned). With the national cesarean rate at 31.8% and rising, VBAC bans affect a vast number of birthing women. It is unethical for the ACOG to support women’s right to choose elective cesarean section while maintaining policies that are directly responsible for the VBAC ban and the subsequent rise in the national cesarean rate. Cesarean sections are not without a host of risks, and each successive surgery becomes more and more dangerous.

I know this would be nearly impossible to implement in a country where only 2% of women give birth out-of-hospital, but I would love for every hospital-based provider (nurses, midwives, and physicians) to have experience witnessing out-of-hospital births. I think a lot of hospital-based providers would do things differently if they had sufficient exposure to women laboring without all the gadgets and protocols. If you’ve never seen a woman kneeling or squatting or standing up to give birth, you’ll probably stick to what’s comfortable and familiar: the woman lying down with her legs pulled back, her perineum in full view.

I would also love to see hospitals and care providers “giving” (as much as I hate that word, since it’s not really theirs to give in the first place) women more autonomy in their pregnancy and birth care. I personally know women whose OBs have dropped them from care for refusing certain prenatal tests or procedures (such as amniocentesis or prenatal Rhogam) or for making their home birth plans known. I’d guess that many women do not even know they can refuse hospital protocols–they are told they “have” to have IV access, they “cannot” eat or drink during labor, they “have” to have continuous monitoring. If women do not even know they can say no, we have taken away their ability to make crucial decisions about their care, their bodies, and their babies–decisions that may affect them for a lifetime.

Lamaze: Do you think blogs and bloggers have a role influencing the quality and safety of maternity care? If so, how?

Rixa Freeze, MA, PhD

Rixa Freeze, MA, PhD

Rixa: This is a question best answered by my readers! I would hope that I and other birth bloggers have made a difference. I imagine that blogging has helped individual women think more critically about their maternity care and their birth options. I am a little less optimistic that blogging has, or will be able to, dramatically affect maternity care on a systemic level. But who knows? Perhaps our message needs to reach a critical mass and then–wishful thinking here–changes will start occurring rapidly. Think of the impact that Dooce, the mother of all mommy bloggers, will have on birth after she wrote about her empowering natural birth (in three parts: Part 1, Part 2, and Part 3) and enthusiastically endorsed Ricki Lake’s and Abby Epstein’s documentary The Business of Being Born and book Your Best Birth.

Lamaze: Your blog strikes a remarkable balance among personal testimonial, comprehensive and nuanced analysis, sociopolitical commentary, and more light-hearted fare. It’s a balance that I think really resonates with your readers and sets your blog apart from many others. How do you determine this balance? And how do you decide when the personal is personal and when the personal is political (or “blogworthy”)?

Rixa: There’s no formula or pattern I try to follow; it’s how I avoid blogging boredom. I sometimes worry that my personal posts–you know, the everyday stuff like “we went the park and Dio spit up on me 5 times and Zari said something really funny”–are too mundane. But if I didn’t have those things about my everyday life, my blog would become too one-sided, too heavy-handed. What I post also depends on how much computer time I have. Reporting news or sharing interesting links is much faster than writing original essays or critiques. Since the birth of my second child, I’ve had much less free time to blog. I often need to put the computer down and spend more time with my family, especially my husband. My computer time is usually in the evenings once the kids are sleeping, but that’s also the only time my husband and I have to share with just the two of us.

Lamaze: What are some of your favorite posts?

Rixa: In rough chronological order:

Better is not good enough

My hospital rant

I am selfish

Cesarean sections and SUVs

Pregnant women are second-class citizens

Formative words

Is fat a moral failure?

Vision of Unity

10 Responses to ACOG’s statement on home birth

Let’s talk about pain (with links to earlier posts about pain)

On your back, please

More! Better! BirthTrack (TM)!

Mother who have lost children to death

Have patient’s rights undermined obstetrics?

Is brown the new green?

Biodynamism–Body and Soil

Conversation with the ultrasound tech

Working through some conflicted feelings and The root of my worries and midwife’s role at my birth: about hiring a midwife for my second pregnancy after having an unassisted birth

Not staying true to my word…whatever that means

Belly photos

What does giving birth feel like?

Litigation and the obstetric mindset

Burn the male midwife!

And, of course, the birth stories of my daughter (a planned unassisted birth) and my son (a midwife-attended home birth)

As I browsed through my blog to choose these posts, I was struck by the evolution in my writing and thinking. I’m still mostly the same person I was three years ago, but I see a definite maturation in my posts: more nuance, less emotion (although my passion for all things birth & breastfeeding still occasionally escapes), less dogmatism. I’m glad to see these changes; it means I am continuing to evolve as a blogger and as a mother.

Lamaze: What are some of your favorite blogs (birth-related or not)?

Rixa:

Taurus Rising: An Aussie who writes about food, sustainable living, gardening, and occasionally birth stuff

Balance: Chou writes all about food, food, and more food (and is a good friend of mine). She’s currently doing a PhD in food studies. Lots of great recipes and ideas.

Casaubon’s Book: food, peak oil, sustainability, gardening, farming

The Unnecesarean: sharp, sometimes biting, often funny blog about cesareans and VBAC.

Baby Makin(g) Machine: a future mama thinking hard about how she wants to mother

House Fairy: a fierce, honest mama of five

Keyboard Revolutionary: mama of 2, first born by c-section and second a HBAC, I love her birth posts

Feminist Childbirth Studies and The Feminist Breeder always give me things to think about

Nursing Birth and Reality Rounds are both fantastic L&D nurse blogs

The Happy Sad Mama: mother of three children; the first, Charlotte, was stillborn at term

Mom’s Tinfoil Hat: ob-gyn student who trained with midwives in a freestanding birth center before medical school

I am stopping here, otherwise the list will become too long! I have links on my sidebar to the many other fantastic blogs I visit regularly. (I’m still working on updating my breastfeeding links, so keep an eye out for them in the future.)

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Independent Childbirth Education: Sharing Lamaze’s Message

August 12th, 2009 by avatar

[Editor’s Note: This is our second installment of guest posts from Lamaze International’s 2009 Annual Conference speakers. You can read all of our conference previews by clicking on the Lamaze 2009 Annual Conference tag. We hope to see you October 1-4 in Orlando at the Lamaze International 2009 Annual Conference. – AMR]

In a decade of being a childbirth educator, I have had the opportunity to teach hundreds of expectant families in various settings: a community health center, hospitals, maternity retail/class centers affiliated with hospitals, a spa, living rooms, and the occasional kitchen. I love teaching Lamaze, and for the last 5 years have only taught independent classes.

There are two things I’ve learned over the years:

  1. The research supports The Six Lamaze Healthy Birth Practices
  2. Most women are not experiencing these practices.

I know that the challenge is not that we don’t have evidence to support what we teach. The challenge is that for some reason, evidence-based maternity care is too often not the standard of care.

Ami Burns, LCCE, CD(DONA)

Ami Burns, LCCE, CD(DONA)

Women who do experience all of the Healthy Birth Practices almost always have achieved this by carefully and fully informing themselves about their options, and childbirth classes remain one of the most important sources of trustworthy information. As an independent educator, I’m able to present evidence-based information without any restraint. When I taught for hospitals, I never had anyone tell me not to teach certain subjects, but know other LCCEs who are in the challenging position of wanting to teach according to the evidence but being unable to because evidence-based maternity care is not being practiced by the institution responsible for signing their paychecks.

Independent educators focus not only on the Healthy Birth Practices and Lamaze philosophy, but also on communication skills. This may sound obvious, but I’m still surprised by the number of people who have no idea they have choices or don’t need permission to say “yes” or “no” to an intervention. I don’t make decisions for my students, but give them the evidence-based information needed so they (hopefully) gain the confidence to make them and feel informed and positive about them. We can’t control mothers’ choices or outcomes for their babies. But what we can do is teach according to the evidence and make sure they are learning what they need to know for a safe, healthy and satisfying birth.

Here is one example of a benefit of independent Lamaze education: I recently taught a class to a couple expecting their first baby. The mother expressed her wish to have an epidural but use natural comfort measures and coping techniques for as long as possible before getting it administered. She told me her doctor said she’d probably break her water and start pitocin when she’s admitted to labor and delivery. This contradicts what the mother had read, what she wanted, and we all know contradicts the evidence that states it’s best for labor to progress on it’s own unless there is a medical reason to induce or augment. I had the time to address these issues and give her some tips for how to communicate her wishes with her doctor and also hospital staff once she’s in labor. The mother shared her birth story with me, and while she felt at times that her “doctor wasn’t too happy” with her, she labored and birthed her way. This is just one example of how Lamaze is “not just about the breathing! Teaching based on the research gives mothers the tools to make informed decisions and build confidence in their ability to birth their babies on their terms.

I had wonderful experiences when I taught for hospitals. But I know not every hospital-based educator can say the same. I recall a few articles and letters in The Journal of Perinatal Education that have addressed this all-too-common challenge LCCEs face. Some hospital-based educators have advocated effectively using evidence to obtain greater autonomy in teaching. Hospital-based educators can also collaborate with independent childbirth educators, offering courses that compliment, rather than compete with, one another. Many of my students attend their hospital’s one-day childbirth class then attend my classes to focus more on natural birth.

On October 3rd, I’ll be presenting Inspiration for Independent Educators at Lamaze International’s Annual Conference in Orlando. I encourage LCCEs and educators-in-training to attend. You don’t even have to be an independent educator! Hospital-based LCCEs are more than welcome, and I know we can learn a lot from each other. I believe there are “pros” and “cons” to both types of education, and will talk more about this during my presentation.

Whether we teach in or out of hospitals, our mission should be the same: support normal birth and provide evidence-based information to help women gain confidence and make informed decisions about their care.

Ami Burns is the founder of Birth Talk (www.birthtalk.com). She is a Lamaze Certified Chidlbirth Educator, DONA International Certified Doula, and will be inducted as a Fellow in the American College of Childbirth Educators at the Lamaze International Annual Conference in October. Ami’s formal degree is a B.S. in Mass Communication from Emerson College, and she combines her background in media with her passion for birth as a freelance writer and award-winning birth video producer.

Lamaze International Annual Conference

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No Difference? The case of cesarean surgery and postpartum infection

August 7th, 2009 by avatar

When a study compares one practice with another and reports “no difference” in outcomes, is that the end of the story? Not necessarily. “No significant difference” can mean any of these:

  • there really is no difference
  • the study was too small to find the difference that really is there (it lacked “statistical power”)
  • the outcome was measured or reported in a way that obscured a difference that really is there
  • the statistical test yielded a “false negative result,” failing to find a difference that really is there (this type of error occurs in up to 1 out of 20 statistical results)

So in 3 out of our 4 possibilities, the difference really is there, we just can’t see it. How do we know when “no difference” means “no difference” and when “no difference” means “keep looking”?

To understand this problem, and how to best get around it, let’s have a look at postpartum maternal morbidity after cesarean surgery versus vaginal birth.

Perhaps you’ve heard that there’s “no difference” in health outcomes between cesarean surgery and vaginal birth. This is what women have been told ever since a so-called “State-of-the-Science Conference” report was issued by the National Institutes of Health in 2006.  After evaluating the body of literature comparing planned vaginal birth and planned cesarean section in healthy women, the NIH reported, among other findings, that the evidence that infection is more likely with planned cesarean is “weak”. The report said that, although observational studies find a link between cesarean and infection, the only randomized controlled trial (RCT) of planned cesarean versus planned vaginal birth showed “no significant difference” in infection rates.

It's basically 50/50, right?

It's basically 50/50, right?

In contrast, a new population-based study from Denmark involving over 32,000 women giving birth between 2001 and 2005 reported that women who gave birth by cesarean were nearly 5-times more likely than women who gave birth vaginally to experience a wound infection, urinary tract infection, or blood stream infection. Most of the difference was attributed to wound infection, which occurred in 5.6% of women having unscheduled cesareans in labor, 3.9% of women having scheduled cesareans, and only 0.08%  of women giving birth vaginally. In the United States, where up to 500,000 cesareans may be safely preventable each year,  these data suggest that more than 20,000 postpartum wound infections could be avoided annually along with the excess cesareans.

So what is the disconnect between the “state of the science,” which tells us evidence is “weak” and this new study, which paints a very different picture?

First, the NIH conference, and the AHRQ-sponsored systematic review underpinning the conference, compared planned routes of delivery while the Danish study compared actual routes of delivery. The reviewers acknowledge that studies comparing planned vaginal birth and planned elective cesarean delivery in women with no pregnancy complications are scarce and randomized controlled trials are absent. Rather than conduct a systematic review without any randomized controlled trials, the reviewers included the Term Breech Trial (which I have previously posted about), even though the results of the review would affect recommendations made to women carrying head-down babies.  But the Term Breech Trial’s results  are not applicable to women carrying head-down babies, especially when infection is the outcome of interest. Why? Because 57% of women randomized to give birth vaginally actually had cesareans, and most of these presumably underwent the cesareans in labor, which increases infection risk (along with risks of hemorrhage and other complications). What’s more, breech vaginal births are much more likely than vertex vaginal births to involve episiotomies, instrumental delivery, or both, which increase the likelihood of infection. So in the Term Breech Trial, the vaginal birth group included far more women with cesareans, episiotomies, and instrumental deliveries than we would expect to see in a similar group of women planning vaginal birth of head-down babies. Despite these limitations that make the trial useless for evaluating the true risks of infection associated with each birth route, the AHRQ reviewers rated the Term Breech Trial as the highest quality evidence comparing planned vaginal with planned cesarean birth, trumping observational studies. In the process, the message to women – and clinicians for that matter – transformed from “Planning a cesarean is risky because you expose yourself to excess infection risk” to something more like, “there could be an excess risk of infection with cesarean, but it’s probably small and, hey, for all we know there may be no real difference after all.”

Another reason behind the disconnect is that the Term Breech Trial (again, the “highest quality” evidence in the AHRQ review underpinning the NIH conference) only measured infections occurring prior to hospital discharge, a very common cut-off in both RCTs and observational studies. The new Danish study provides striking evidence that this way of measuring infection is grossly inadequate – more than three-quarters (77%) of infections occurred after hospital discharge. In other words, they would have been missed if the researchers had stopped counting the number of infections as soon as the woman left the hospital. The researchers were able to capture these infections because Denmark has a national database of all births, which was linked to a national database of all clinical laboratory results of infectious diseases, a national database of all antibiotics prescribed, and a national database of all hospital readmissions. (The United States, by the way, has none of these, rendering this type of study literally impossible to conduct here.) In randomized controlled trials, following participants beyond the initial hospital stay is logistically difficult and very costly. Even when follow-up is intended, substantial numbers of new mothers may not respond to surveys or return (to the same provider/facility or at all) for postpartum care. As a result, properly constructed national databases provide an important source – sometimes the only source – of evidence on long-term outcomes.

So which “evidence” do we tell women? The “state of the science” or our less rigid but almost certainly more reliable assessment of the observational studies and our common sense? Of course cesarean can lead to infection – it’s surgery after all. And yes, even with optimal care, some women who plan vaginal births will need to have cesareans and some of those women will get infections. If we’re serious about helping women avoid serious complications like infections, we must:

Women experience many physical and mental health problems in the postpartum period, some of which may be safely prevented with a different approach to care given in pregnancy, labor, and birth or better education provided prenatally. We do not know the factors contributing to postpartum health problems because they are shamefully understudied. But one treasure trove of postpartum data in the United States provides a powerful foundation for addressing and researching postpartum health outcomes. Childbirth Connection’s 2008 report, New Mothers Speak Out, compiles the postpartum data and new mother testimonials from both the 2006 Listening to Mothers II Survey and a follow-up survey conducted with participants six months later.  All women’s health professionals and advocates should spend time with this report so we can begin to give postpartum concerns their due attention.

Citations:
Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, & Willan AR (2000). Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet, 356 (9239), 1375-83 PMID: 11052579

Leth RA, Møller JK, Thomsen RW, Uldbjerg N, & Nørgaard M (2009). Risk of selected postpartum infections after cesarean section compared with vaginal birth: A five-year cohort study of 32,468 women. Acta obstetricia et gynecologica Scandinavica, 1-8 PMID: 19642043

Visco AG, Viswanathan M, Lohr KN, Wechter ME, Gartlehner G, Wu JM, Palmieri R, Funk MJ, Lux L, Swinson T, & Hartmann K (2006). Cesarean delivery on maternal request: maternal and neonatal outcomes. Obstetrics and gynecology, 108 (6), 1517-29 PMID: 17138788

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