Science & Sensibility

[Editor's Note: This marks the beginning of our coverage of the 5th International Normal Labour & Birth Research Conference, taking place July 20-23 in Vancouver. Sharon Dalrymple, staff development nurse, prenatal educator, doula, and Lamaze's first Canadian president, will present a session she developed with maternity care quality expert and Lamaze's president-elect, Debra Bingham. They were both part of a research team that investigated how women perceive terms like "normal birth" and "natural birth" and what that means for helping them understand evidence-based information to make health and healthcare choices. There are many reasons that women's perceptions and priorities matter in birth. One is that meaningful improvements in maternity care quality and safety are impossible without a strong consumer movement. Dalrymple's and Bingham's findings have major significance for "normal birth," however we each define it.

Remember, there's an Open Thread for conference attendees and enthusiasts to post messages. You can follow all of the updates from the conference on Twitter by following the #birthconf hashtag and find more analysis here on the blog - AMR]

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For the past 50 years Lamaze International has been promoting normal birth practices in North America and more recently worldwide. Despite these educational efforts women are being over-treated more now than they have been in over 30 years. For example, 31% of women in the United States give birth by cesarean surgery. The overuse of interventions with harmful side effects when there is little or no expected benefit for mother or baby has led to worsening maternity care outcomes in the United States and many other countries. In addition, women do not get adequate information so they are aware of the excess, unnecessary risks they and their infants are being exposed to.

One of the reasons these educational efforts may not have been as effective as desired is that our conversations may not be persuasive enough or clear enough. For example, it is not universally understood or agreed upon how to define a normal birth, the differences between normal and natural birth, and which behaviors constitute a normal birth. Conversations and language affect how persuaded others are to make changes. In fact, 50 years of diffusion of innovation research tell us that for women to demand safe, high quality maternity care, we must engage in clear conversations that outline specific desirable behavior changes and show that women and babies can expect better health outcomes if these changes are made.

Lamaze International hired a public relations market research firm to conduct research and identify which messages are the most effective for persuading women to adopt normal birth practices. Online surveys were conducted among 811 women aged 16-44  and 408 Lamaze Certified Childbirth Educators.

Indeed, the research showed that the meaning of the words “normal” and “natural” was not interpreted by the women and educators the same way. For example, 36% of women felt that ALL vaginal births are “normal birth”, while 63% of Lamaze Certified Childbirth Educators defined “normal birth” to be a birth without medical intervention. Women and Lamaze childbirth educators are likewise divided when deciding if the terms “natural birth” and “normal birth” are generally similar or generally different in meaning.

Lamaze International found that the words safe and healthy are the most effective words for communicating and promoting the birth practices Lamaze has endorsed for years. Everyone wants a safe and healthy birth. Mothers are particularly motivated to keep their baby and themselves safe and healthy. Most importantly, the practices are safe and healthy.

As a result of these and other findings, Lamaze International updated our six evidence-based key practice papers in Fall 2009 to ensure women realize that these practices simplify the birth process with a natural approach that helps alleviate fears and manage pain, with the ultimate goal of keeping labor and birth as safe and healthy as possible for each individual woman. Every woman needs clinicians who promote, support, and protect these six practices:

1. Let labor begin on its own

2. Walk, move around and change positions throughout labor

3. Bring a loved one, friend or doula for continuous support

4. Avoid interventions that are not medically necessary

5. Avoid giving birth on your back and follow your body’s urges to push

6. Keep mother and baby together – It’s best for mother, baby and breastfeeding

Conflict of Interest Disclosure: The research was funded by Lamaze International.

Sharon Dalrymple Uncategorized childbirth education, lamaze, Normal Labour & Birth Conference

According to a recent article in the Boston Globe, hospital noise has become problematic and researchers, along with some hospital administrators, are starting to listen.

From The Boston Globe article:

In 2005, a team of researchers at Johns Hopkins University led by the engineers Ilene Busch-Vishniac (now the provost at McMaster University) and James West looked at the best available historical data and found that, since 1960, the average daytime noise level in hospitals had doubled. At night, it was four times louder.

So what’s the buzz all about? The numerous studies cited in this article repeatedly point to concerns and, in many cases, concrete evidence that hospitalized patients tend to fare much worse as decibel levels rise. Vitals signs (blood pressure, heart and breathing rates and body temperatures) are less stable. Perceived pain and therefore request for pain medication is higher. Newborns in intensive care nurseries stay longer and can potentially suffer hearing damage. Surgical patients take longer to heal.

For me, this suggests the obvious question about mothers who are supposedly resting up from childbirth—particularly the ~30% of US women who are recovering from cesarean section deliveries—and what type of true “recovery” they are garnering during their 48 – 72 hour stays.

Some cultures around the world take the postpartum recovery of a woman so seriously, they expect mom to do nothing but remain at home, sleeping, eating and nursing her baby for upwards of forty days. In the United States, our hustle and bustle, noise-filled culture accompanies a woman’s postpartum experience.

Typical doctor’s orders on a maternity ward dictate a woman’s nurse(s) to visit her room no less than once every four hours to perform basic nursing duties—and assuming baby is rooming in with mom, there is often times a completely separate schedule of nursing visits for the newborn. But, following each of my three hospital birth experiences, I seem to recall the door to my room swinging open and shut many more than six times in a twenty-four hour period. Between doctors performing medical rounds, someone from the nutrition department collecting food orders, lactation specialists making their daily visits, hospital photographers stopping in for a quick snapshot of each bundle of joy and occasional hospital volunteer drop-ins, there’s actually very little time for a woman to rest following the birth of her baby.

Sleep studies tell us that when a person’s sleep is frequently interrupted, they are less likely to slip into non-REM sleep—the mode of rest during which growth and healing is most likely to occur. With overhead pages echoing down the halls, sitcom canned laughter from the neighbors’ too-loud television, and, let’s face it, the sound of multiple babies crying in poorly insulated quarters, it’s no wonder most women leave the hospital more rather than less tired when they entered. (And, if you’ve recently been pregnant, you’ll likely recall how tired you felt by the end of your third trimester.)

But it’s not just the postpartum wing where noise is a problem. The L&D room can be a rather cacophonic place as well. With fetal monitors tapping out the baby’s twice-per-second heart rhythm, constantly spewing out reams of paper, and bing-bonging an alert every time the baby’s heart rate falls outside certain parameters…with patient controlled analgesia pumps pumping and beeping away…with alarms sounding every time an IV line gets kinked or the bag empties…with a infant warming table blaring when it reaches its preset temperature…with labor and delivery nurses, aides, technicians, nursery nurses, midwives, doctors, PAs and possibly residents and interns floating in and out, a hospital birth room can become as busy as the intensive care department.

We know from observing animals that from an instinctual basis, it’s pretty darned hard for childbirth to take place amidst noise and lack of privacy. And, surprise, surprise: human beings are no different. Could the ever-increasing rates of labor augmentations, epidural usage, suction-assisted deliveries, and cesareans for “failure to progress” be explained, in part, by hospital setting noise? Is it possible that with every “unnatural” sound we hear, our bodies shut down just a little more—whether during the process of birth, or during the healing, resting, and mother-baby bonding period that is supposed to occur afterward?

Recently, a dear friend of mine delivered her second baby. Having shared a room with another woman in the postpartum wing, my friend initially spoke favorably of her experience being so close to another puerperal woman. “That’s when I realized how much I needed to be with other women following my birth experience,” she confessed.

But our conversation quickly turned to the idea of a postpartum floor lounge—a place specifically designed for mothers and babies…a spa reception-like setting where women could sit in comfortable rocking chairs and heavenly couches, nurse their babies, share stories, exchange words of advice and encouragement amidst quiet music (or no music at all) and dim lighting, drink from the endless supply of healthy teas, water and juices, and languish in an uninterrupted setting for as long as they desired.

“It wasn’t exactly ideal sharing a [hospital] room with someone else,” she later told me of her two-day postpartum roommate. “I could hear all their conversations and she constantly had the TV on. But still, I learned a lot about myself and my needs following my second baby’s birth.”

In the United States and many, if not most other developed nations, women do not look forward to a 40-day lying in period following childbirth. So, that cultural practice being what it is, perhaps hospitals that are currently looking at their facility-wide noise levels and amelioration plans should also contemplate the overall setting of the labor, delivery and postpartum wing.

This is a guest post by Kimmelin Hull, PA, LCCE. Kimmelin is a Lamaze Certified Childbirth Educator, mother of three, and author of A Dozen Invisible Pieces and Other Confessions of Motherhood. You can visit Kimmelin at her blog site: http://kimmelin.wordpress.com.

Photo by debsilver, used under a Creative Commons license.

Kimmelin Hull Uncategorized newborns, no separation, postpartum, sleep

I kicked off this blog carnival with a post titled, “Six Reasons I *Heart* Qualitative Research.”  I had been wanting to write a post about qualitative research for a while, and the topic of the second stage of labor was the perfect opportunity, since there’s so much great qualitative research on second stage.

After collecting the posts for this carnival, I have discovered why. Women want to tell their stories about pushing their babies out. With only a couple exceptions, everyone who contributed to this blog carnival wrote about their own personal experiences.

Just like good qualitative research, the stories show what spontaneous, upright pushing looks, feels, and sounds like.

• Kristin at Birthing Beautiful Ideas posted three remarkable videos that show how a pushing urge develops, grows into strong bearing down efforts, and culminates in the baby’s birth.
• Sheridan at the Enjoy Birth Blog prepared educational videos showing several women instinctively birthing at home and others using mother-directed pushing in the hospital.
• Well-rounded Mama, who blogs about the maternity care needs and experiences of women of size, shares photos of women of all sizes pushing in upright positions.
• The nurse blogging at At Your Cervix posted her thoughts on upright positions and shares a diagram of images of nearly every position imaginable.
• Macondo Mama describes in detail how her care providers supported her in second stage (proving that care during a spontaneous birth need not mean the care provider or labor companions sit there doing nothing.) They helped her work with her voice, breath, and movements to birth her baby, provided feedback about the baby’s descent, and gave support to her partner.
• Tiffany at Birth In Joy shares some of the encouraging words from her labor support team: “Way to go, you’re moving the baby down!” “I’m not in a hurry, rest if you want.” and so many other phrases of support and caring.
• boheime at Living Peacefully with Children shares the words she herself said while birthing her baby. When her water broke just as she transitioned to second stage, she coped with the intensity by talking tenderly to her baby “Okay baby, let’s go slow. We will do a little bit and then take a little break. Mommy needs to take a break, and then we will go a little more. It won’t be long and then I can hold you. Just a little bit and then Mommy needs a break.”
• The midwife blogger at Birth Sense recalls attending a birth of a mother who wanted a more calm and unrushed experience the second time around. “The room was quiet, except for the soothing music she had chosen, and the soft sound of her breaths. Carolina was bearing down gently with her contractions for several minutes, then made eye contact with me and said, ‘The baby’s coming.’ I couldn’t see anything, as she had her hand covering her perineum, but moments later, the baby’s head was out. One more push, and the rest of the baby was born into Carolina’s waiting hands. She smiled at me, ‘That was so much better than being yelled at to push!’”
• Desirre at Preparing for Birth collected the comments of two dozen women sharing what it felt like to push and give birth.
• Three bloggers offered analogies. Lori at Choices in Childbirth compares the shifting and wiggling that gets a baby born with the best way to get a stuck wedding ring off. “I’ll grab hold of my wedding band and pull forcefully toward the tip of my finger,” she writes. “Invariably, it moves a fraction and then gets stuck. The flesh between the band and my knuckle gets all bunched up, my finger starts to turn frighteningly red, and I begin to wonder if the ring will ever come off. On my second try, I tug on the ring while gently jiggling it back and forth. This time it moves right along without any trauma to my finger at all.” Doula, Annie Reeder suggests that the winning combination of upright posture and relaxed pelvic floor that helps get the baby out is something some women may already be familiar with – that is, if they have ever hovered over a public restroom toilet while urinating. The aspiring Lamaze educator at the Birthing Goddess Blog presents a common sense analogy many of us are already familiar with: “Who would ever think of having a bowel movement while lying down? No one, right? Same goes with a baby being born.”

Contrast these with the stories that document the opposite: our cultural norm of rushed and managed birth, and the emotional and physical toll this approach can take.

• Dionna at Code Name: Mama recently helped her sister have a natural birth and describes her as calm and coping well until the hospital staff forced her into bed to give birth. She writes, “She was uncomfortable on the bed, and when the nurses forced her to lie down, she began to cry from the pain and pressure – not from the fact that the baby’s head was crowning – but because she had felt more comfortable and in control in the position she chose for herself previously.”
• Mamapoekie at Authentic Parenting had an urge to push that stopped her in her tracks as she walked across her room. “When the contraction subsided,” she writes “they led me to the birthing bed, positioned me on my back and had my legs in the stirrups before I knew what happened.Everything was kind of a blur, but I remember wondering where everybody came from, because all of a sudden, there were three midwifes, two OB’s and my husband miraculously reappeared. I had not the strength to fight the position I was in and my husband was shaking like a leaf in a thunderstorm.”
• Rebecca at Public Health Doula laments the many great labors she has attended that take a turn for the paternalistic, medicalized worse once the woman is 10 centimeters dilated. She writes, “The second a woman is judged to be ‘complete’, everyone in the room suddenly gets license to, quite frankly, be a total jerk to her. Before she has pushed even once, there is the presumption that she is going to push ‘wrong.’ She is never even given a chance to try pushing in different positions or for a few contractions to get the hang of it. Instead, the nurse spells out the position she should assume (chin to chest, pulling back on her thighs, on her back? but of course!), support people are given her legs to hold, and she gets the 3-pushes-per-contraction speech. Then from the first push she is loudly coached, counted off, and urged on MORE MORE MORE KEEP GOING PUSH HARDER HARDER HARDER and that’s about when I start grinding my teeth.”

Women who prepared carefully for birth were not necessarily immune to repression and coercion in second stage.

• Simone Snyder, blogging at ICEA.org, had prepared a birth plan that clearly laid out her wishes for a spontaneous, upright second stage. Instead, she got “doctor’s high pitched, screeching voice-’Push Push Push’-the nurse counting in my face-the confusion and fear as I lay there on my back in the hospital bed”. In her post, she writes, “There is a point [in my birth video] where you can hear me say ‘I don’t understand what to do-do I push-what do I do?’ All the direction, all the shouting and commotion-I was not encouraged to listen to my own body and therefore I was lost.”
• Karen Angstadt at Intentional Birth went on the hospital tour, heard all the right answers and even saw the squatting bar she hoped to use, only to find out when it was time to push that none of the doctors would agree to use one. In her birth story she recalls that with persistence she was “allowed” to try a few squats, “before being told, ‘This isn’t working’, and put on my back for the remainder of the birth.”
• Hilary at Moms Tinfoil Hat had been careful to do her homework, and thought hiring a nurse-midwife would ensure that she could have a natural birth. “I ended up flat on my back…pushing against a cervical lip for three hours, while being barked at and blamed by my CNM,” she writes. “I remember begging her to stop, and feeling defeated while I was forced to push, and push, and push, as my mother, husband, and even the labor nurse looked on with dread. I was unprepared for pushing the first time around, and terrified of it the second.”
• Melodie at Breastfeeding Moms Unite planned a home birth and wrote a birth plan and still got told what to do. In her birth story, she recalls, “I remember when transition was finally over. A sudden peace washed over me. A calm in the storm. I was 10 cms. They told me I was ready to push. Except I wasn’t. My body wasn’t. I didn’t feel the urge. My midwife decided that this would then be the perfect time to instruct me ‘how’ to push.”

On the other hand, several bloggers’ stories show that it is possible, healthy, and feels amazing to push a baby out with one’s own immense power in all sorts of unexpected circumstances.

• even with an epidural. Paige at The Baby Dust Diaries had complications that necessitated an epidural and confinement to bed. When the nurse began counting and coaching, she simply told her to stop. In her post, Paige shares the breathing technique she used to birth her baby gently.
• even lying flat. Kiki at The Birth Junkie shows that it is the freedom to experiment with positions in second stage – not a certain position per se – that makes the difference. In her first birth, she knew instinctively to stay off her back, a knowledge that was confirmed when she tried it briefly. In her second birth, something deep down told her to try pushing on her back again, and this time it was just the thing to get her baby to come under the pubic bone . He was born with the next contraction.
• even in the midst of grief. Molly Remer at Talk Birth, recalling her own three births, shares the story of birthing her third son too early for him to survive. (She was experiencing a second trimester miscarriage.) She writes, “I found myself kneeling on the floor in child’s pose. This position felt safe and protective to me, but I finally coached myself into awareness that the baby wasn’t going to come out with me crouched on the floor in that manner. I told myself that just like with any other birth, gravity would help. So, I pushed myself up into a kneeling position and my water broke right away.” Her baby was born moments later.
• even when birthing twins. With the deck stacked against her (twins, one baby breech, an epidural, and stuck on her back) the mother of four blogging at Cream of Mommy Soup gave into the urge. She writes: “For a million reasons, I was impressed with my body. But pushing was the most surprising part of the whole adventure. I could not believe that my body had done that for me — had given birth to two children, in fairly rapid succession — without any assistance from my brain. It was awesomely primal, that experience.”
• even when the baby is 11+ pounds.  Three (count’em – THREE) of our bloggers shared stories of pushing out 11+ lb. babies. In “How My Wife Had an 11+ lb. Baby At Home and Didn’t Die,” the nurse blogging at Man Nurse Diaries invites a guest post from said superhero wife, who uses gravity to birth her baby quickly when the umbilical cord begins to get squeezed during pushing. Born not breathing, their daughter resuscitates herself via an intact umbilical cord after birth, never needing the oxygen the midwives had handy. Things were a little less dramatic for our other two 11 pounders. Lauren at Hobo Mama reports having a really good time pushing out her baby, despite it being the culmination of a 42 hour home birth turned hospital transfer. As she pushed, Lauren overheard her midwife and nurse praising her pushing efforts. She writes, “Even in the distraction of pushing out an 11-pound, 13-ounce, baby, that exchange brought a smile to my face!” Finally, Jill at The Unnecesarean tried a bunch of positions until she found the sweet spot. In a post that started the “Captain Morgan maneuver” meme, Jill writes, “I put one leg on the edge of the tub and felt the baby spin out. It was freaking glorious feeling. I wouldn’t trade those twenty or thirty ridonkulous transition contractions for anything in the world if it meant that I would have had been unable to feel that.”

But we know that these stories are not the norm, at least in U.S. hospitals, where more than half of women with vaginal births give birth on their backs and 4 out of 5 are told how and when to push, according to the 2006 Listening to Mothers II Survey. Not surprisingly, many of the stories women shared were of births that took place at home, where women can more easily follow their own instincts to birth their babies, and are usually attended by midwives and labor companions who encourage and support those instincts.

• Amy at 263-and-dna felt the urge to push before her midwife even arrived, then settled into the urge once she got there. She writes, “I started to push almost immediately – b/c we were READY. I didn’t need coaching or encouragment. I knew what to do and when to do it.”
• Carol at Aliisa’s Letter has attended many births at home, learning something new from each one. She writes, “I saw the benefits of a variety of pushing positions: sitting (curled around the uterus), kneeling, hands/knees, squatting and side-lying. Each labor pattern and birth was unique and unfolded with its own revelation.”

The stories bloggers shared for this carnival are phenomenal and important. They call into question our cultural norms of what is safe, healthy, and appropriate care. Just as Robin at The Birth Activist learned in her childbirth class to reject the dominant cultural image of  laboring woman as stranded beetle and Michelle at The Parent Vortex likewise began to question cultural ideals of men telling women how to give birth after reading Janet Balaskas’ book, Active Birth, perhaps the posts in this carnival will be the spark the next woman needs to question unhealthy, unsafe obstetric routines.

To me, the posts in this collection suggest that what happens during the second stage of labor and how well the women is cared for may be the most important factor in how she sees herself and interprets her experience after giving birth. Not surprisingly, the care and support that helped women feel triumphant and strong are also supported by evidence of optimal safety. But reading through these posts, I’m also struck at how difficult it is to foresee the roadblocks to safe and healthy second stage care, and give women the tools to navigate around them. Having made her choice to have a hospital birth with a group of doctors she likes, pregnant blogger Jenn from Baby Makin’ Machine is sick of people telling her how to have her baby. Jenn has discovered what almost every mom has discovered before her: everyone wants to tell you what to do and how to do it, whether or not you ask for their advice, and it doesn’t stop once the baby is born. The best way to find a path through it all and parent with confidence? Follow your instincts, be patient with yourself, be assertive when something seems unsafe or uncomfortable (even if everyone else seems to be going along with it), and fall back on common sense. It’s good advice for second stage and for parenting.

Amy Romano Uncategorized Healthy Birth Blog Carnivals, Healthy Birth Practices, second stage

We’ve been featuring each of the Six Lamaze Healthy Birth Practices in our series of blog carnivals, and this time we’re talking about interventions. Interventions in labor and birth can be helpful – even life-saving. But there’s no denying the fact that too often they are used when a safer, more supportive approach would have worked just as well or better.

Ya Say You Want an Intervention? Well, You Know…

Women need the information about what interventions might take place in labor, when they are beneficial, what the risks are, and how to minimize those risks. Rachel Leavitt at The Beginnings of Motherhood offers a very balanced discussion of the pros and cons of two very common interventions: epidurals and pitocin. Desirre Andrews at Preparing for Birth shares a list of “hidden in plain sight” interventions that may affect a woman’s emotional state, slow her labor progress, or even cause physical harm. Lauren Wayne at HoboMama writes about her experience with an intervention that can sometimes seem invisible - vaginal exams. Well Rounded Mama discusses the disproportionate use of various interventions in women of size and argues for a supportive, proactive approach to preventing labor dystocia.

Interventions carry risks of other interventions, which introduce risks of their own. Carol van der Woude cared for a woman whose labor turned complicated and high tech when the simple act of breaking a woman’s water set into motion a cascade of intervention. It’s an all-too-common story she she tells in her post, One Thing Leads to Another. Code Name Mama also describes a typical cascade-of-interventions birth story, contrasts that story with her real birth story (made safely possible by the supportive care of a midwife and a few interventions used judiciously), and provides a treasure trove of information about all of the interventions she could have ended up with but didn’t. Kiki at The Birth Junkie describes her birth planning process as “a domino effect in reverse” – in learning how to avoid a much-unwanted episiotomy she was forced to explore alternatives to lying flat on her back and discover that many routine labor interventions restricted mobility. Learning long before labor begins about interventions and knowing which you’re okay with and under which circumstances is essential for informed decision making, she argues.

Having Interventions: An Experience in the Eye of the Beholder

When we talk about interventions that are “medically necessary” it implies that sometimes the use of interventions (and their downstream effects) are unnecessary. In reality, there are few if any interventions in labor for which you can draw a perfect line between “necessary use” and “unnecessary use”, and different women are willing to accept different risks and value different benefits, so an objective assessment of necessity may in fact be meaningless. Rixa Freeze of Stand and Deliver explores this issue in her post, Necessary/Unnecessary, a round-up of four birth stories, and suggests an alternative view:

The prominent theme in these four sets of birth stories is that the women who felt the interventions were necessary and welcome … rather than unnecessary and traumatizing…, freely chose the interventions on their own–on their own request, on their own timetable, and on their own initiative. They knew it was time for assistance. They were the primary actors in their births, rather than recipients of others’ agendas. They held the locus of control, even when that meant asking others to do things for or to them at some point (IV, epidural, Pitocin, or c-section).

One of the birth stories Rixa reflected upon was that of my sister, Katherine. Katherine, who shared her story at her midwife’s blog, Women in Charge, planned a home birth and ended up with a c-section after over three days of labor. Her birth story offers an important example of midwife-led physiologic care with timely access to needed interventions, given in a humane, and respectful manner.  Over the phone just a half a day after her cesarean, Katherine told me her birth was “fun” and audibly beamed with pride and amazement, which was about the most inspiring thing I’ve experienced in a very long time.

At the other end of the spectrum are the women whose “care” in labor is emotionally or even physically traumatic and who experience lack or loss of autonomy. Jenne Alderks at Descent Into Motherhood advocates for women who experience their births as trauma (as many as 9% of women, according to the Listening to Mothers II Survey) and coordinates a support group at Solace for Mothers. Jenne writes about these issues in the context of  her own traumatic birth story in which her efforts to exercise her right to informed refusal led her midwife to kick her out of the hospital.

Changing the Culture of Birth

Women can protect themselves from unnecessary interventions by choosing a care provider and birth setting with low intervention rates. Unfortunately, most women currently lack access to the information they need to assess intervention rates in their communities. I spoke about this issue last month with Danielle from Momotics in her radio show on the importance of Transparency in Maternity Care.

We don’t have adequate transparency now, and until we do, women will have to find out about routine practices at community hospitals by asking hospital staff or local birth advocates. Sheridan Ripley at the Enjoy Birth Blog brings us through a four part story of a woman who learned about routine hospital practices during a tour of the labor and birth unit and made a courageous choice to change hospitals and care providers just days before her estimated due date. The result was worth it!

Greater transparency is only one aspect of a larger political and cultural shift needed to reduce unnecessary interventions. Maureen Finneran Hetrick writes about some of the health care reform efforts currently underway, including payment reform and midwifery legislation, that might help rein in intervention rates in her guest post at the ICAN blog, Can healthcare reform decrease unnecessary interventions? Mom’s Tinfoil Hat gives readers an update on her fellowship research examining obstetrical culture by assessing obstetricians’ knowledge of the evidence basis for various common interventions and their attitudes toward routine use.

Amy Romano Uncategorized Healthy Birth Blog Carnivals, Healthy Birth Practices, home birth, hospitals, interventions, midwives

The Joint Commission Sentinel Alert #44: “Preventing Maternal Deaths” is an important document and public recognition that many of the maternal deaths in the United States are preventable. However, the alert is missing important and useful information for women and childbirth educators since the recommendations in the alert are downstream approaches or recommendations for how to save a woman from dying who may have been thrown in the river. It fails to alert our healthcare system about the need to keep women out of the river in the first place.

Let me give you some examples:

One Joint Commission recommendation is to consistently use techniques that have proven effective in the prevention of thromboembolism (blood clots) in women having surgical births. Clearly it is critical that we reduce the risks of surgery and this recommendation needs to be heeded. We need to make surgical births as safe as possible. However, if we eliminated the overuse of cesarean sections we would eliminate even more deaths and injuries. Based on publicly released data, the increase of cesarean surgical intervention is related to where a woman gives birth.

Debra Bingham, DrPH, RN, LCCE

Indeed there is often as much as a three-fold variation in the number of surgical births performed at different hospitals even after adjusting for the woman’s age and risk factors. Reining in practice variation has been a focus of efforts to improve care in other healthcare specialties, yet wide and unwarranted practice variation remains a serious problem in maternity care.

So why are there so many more surgical births and such wide variation in rates of cesarean sections? Well one clear factor at work is variation in how women are treated in labor. For example, some hospitals keep women who present in early labor while other hospitals are more likely to offer supportive care to these women and encourage that they remain at home until active labor. Why is being in a hospital in early labor a problem? When a woman is in a hospital in early labor she is put in a bed, her movements are restricted, and she is tethered to a fetal monitor. None of these interventions has been shown by research to improve maternal or infant outcomes, and in fact they all have documented harms. In addition, it is normal and expected for early labor to start and stop for several days. However, if a woman is admitted to a hospital in early labor and her labor stops then she is likely to have an unnecessary induction of labor. Overuse of inductions lead to more cesarean sections. This becomes the beginning of a cascade of events that all too often leads to a surgical intervention.

Let’s move to the hemorrhage recommendations as another example. Hemorrhage remains a leading cause of death and severe morbidity despite more efforts over recent years to control blood loss at birth. Why haven’t these efforts succeeded? One reason is that as the cesarean rate rises, more pregnant women have uterine scars. The uterine scar increases a woman’s risk for abnormal placenta implantation when they get pregnant again. These abnormal placenta implantations are called percretas, accretas and previas. When a woman has placenta accreta or percreta this can lead to internal organ damage and permanent damage to her uterus because the placenta literally grows into the uterine muscle or even into her bowel and bladder and cannot detach from these organs after the baby is born. This abnormal implantation leads to hemorrhage and also often necessitates the removal of her uterus to save her life. Abnormal placenta implantations used to be very rare emergencies; they are becoming common now due to the overuse of cesarean sections. This is a trend that is frightening to me because based on the current rates of cesarean sections the number of women affected will only increase. Things are going to get much worse.

Lamaze International has issued our own “Sentinel Alert” on how to prevent maternal deaths. Lamaze’s recommendations are called the Six Healthy Birth Practices. Following these key practices will prevent women from being thrown in the river and needing to be rescued.

The critical behaviors that Lamaze recommends to improve health and safety are to let labor start on it’s own, encourage freedom of movement, offer labor support rather than labor management, avoid all routine interventions not supported by evidence, avoid interfering with a woman’s freedom to push in an upright position or any position of her choice, and keep the baby with the mother after birth.

Hospitals can help achieve the Joint Commission goal of reducing preventable maternal deaths while also making progress toward Joint Commission core measures by training staff in these practices. Lamaze International offers an Evidence-Based Nursing Care Workshop to do just that. Registration is currently open for our March workshop in Hollywood, Florida.

Debra Bingham, DrPH, RH, LCCE is President-Elect for Lamaze International, Executive Director of the California Maternal Quality Care Collaborative (CMQCC), a member of the California Pregnancy-Associated Maternal Mortality Review Committee and a lead researcher for determining how to prevent maternal deaths.

Debra Bingham Uncategorized cesarean, complications, hospitals, induction, interventions, Joint Commission, practice variation, safety