Last week, I attended the Normal Labour & Birth International Research Conference in Vancouver, British Columbia. With over 250 attendees from 23 countries, the conference set out to disseminate research about the nature of and optimal care for physiologic labor and birth, and to garner multidisciplinary perspectives on the implications for clinical practice, perinatal outcomes, education, management, collaboration, and policy.
I went as an agent of data dissemination. My job: to use social media (blogs, Twitter) to help make sure the conference proceedings didn’t just rattle around the four walls of the conference hotel, but got out to those in the field working to improve maternity care wherever we each are.
And I have some research I want to write about – really interesting, important research from every discipline you could imagine. But I left the three-day meeting thinking more about the (broken) link between evidence and practice than about any of the new, emerging evidence. I’ll get to the new research over the coming weeks, but first, a look at two stories that dominated the conference.
#1: Home birth on the defensive?
The plenary session by Dutch physician and epidemiologist, Simone Buitendijk, might have highlighted the unique model of midwife-led primary care geared toward planned home birth for low-risk women – a model that many birth advocates and researchers look to as a beacon of hope and reason. Buitendijk herself was co-author of the definitive study of planned home birth safety, a population-based study of over half a million births that found planned midwife-attended home birth as safe as planned midwife-attended hospital birth. And a Cochrane systematic review that came out around the same time as the Dutch home birth study provided definitive evidence that midwife-led care is superior to physician-led or shared models of care. So the Dutch have gotten it right, right? Time to celebrate and emulate? No, instead of a plenary about Dutch primary maternity care as a model to emulate, Buitendijk’s talk was a sobering call to action.
According to Buitendijk, in spite of this evidence (or perhaps in direct response to this evidence?) a well-coordinated media campaign in the Netherlands over the past year has emphasized the dangers of home birth, pointing to an entirely different body of evidence: comparative data showing that Dutch perinatal mortality rates are higher than those in other European countries. Although only about 30 of the 1700 Dutch perinatal deaths occurred at home, and perinatal mortality at the population level is affected far more by incidence and management of preterm birth and congenital anomalies than by the labor and birth care of low-risk women with term pregnancies, the Dutch mass media have made this a story about midwifery care and home birth. The result: the rate of home birth has dipped below 25% for the first time in Dutch history.
#2 VBAC is Back?
Eugene Declercq, who gives – hands down – the world’s most engaging and fun lectures about perinatal statistics, had the pleasure of making an 11th hour revision to his plenary talk on vaginal birth after cesarean (VBAC) thanks to ACOG, who released their new VBAC practice guidelines at 5pm the day prior. (Hat tip to yours truly for tipping him off about the new guidelines. I even got written into his plenary remarks, as the young woman with whom he had a “stimulating conversation” that led him to “stay up all night.” Har har, Gene!)
Anyway, we see in Declercq’s talk the familiar story of how VBAC rates increased briefly then plummeted in the early 2000’s as a result of new research on uterine rupture and, more precisely, an editorial by the ob-gyn editor for the New England Journal of Medicine saying that planned repeat cesarean is “unequivocally” safer than planned VBAC.
Research driving practice! That is, if the research (or overzealous interpretations of it) supports restricting practice.
Where’s the up-tick in VBAC rates when the Cochrane systematic review was published in 2004 concluding that “Planned elective repeat caesarean section and planned vaginal birth after caesarean section for women with a prior caesarean birth are both associated with benefits and harms?” The up-tick isn’t there because by then research wasn’t driving practice – ACOG guidelines calling for “immediately available” emergency obstetric care in VBAC labors were driving practice. And it wasn’t the NIH Consensus Development Conference on VBAC or the massive AHRQ systematic review underpinning the conference (i.e., evidence) that have been heralded as the beginning of the end of hospital “VBAC bans,” it’s ACOG’s (somewhat noncommittal) move away from the “immediately available” standard.
Evidence is not driving practice. Between evidence and practice there lives some kind of cocktail of power, money, activism, media, influence and serendipity (and preservatives). The relative strength of the ingredients dictates how practices evolve. Keeping with the cocktail metaphor, the VBAC plenary ended with an invitation to consumers and our advocates to shake things up – activism being the best hope for ACOG’s new guidelines to be used to drive meaningful change for the many, many childbearing women in the United States with scarred uteruses.
This all reminds me of a third plenary talk at the Normal Birth Conference – Patti Janssen’s lecture, Transforming Research into Policy: Ingredients of Influence, in which she quotes social scientist, Martin Rein.
It also reminds me of Kay Dickerson of the Cochrane Collaboration who said, “We are only to get evidence-based healthcare in this country through consumer activism.”
More on Janssen’s plenary, and updates on the research, coming soon.
This Latin phrase is familiar to every medical student, taught in all medical schools as a fundamental axiom of patient care (for you fellow Trekkies, akin to the prime directive of non-interference). The general idea is that, when weighing the risks and benefits of a medical intervention for a given condition, the physician must first consider the intervention’s potential for harm in deciding if it should be done at all. In other words, sometimes the cure can be worse than the disease.
Dr. Williams
The principle of primum non nocere came into widespread use at the turn of the twentieth century, in large part due to Dr. J. Whitridge Williams, a prominent obstetrician at Johns Hopkins and original author of that Bible of the field, Williams Obstetrics. In 1911, Dr. Williams was invited to speak before the Committee on Midwifery:
The generally accepted motto for the guidance of the physician is ‘primum non nocere’ and yet… incompetent doctors kill more women each year by improperly performed operations than the ignorant midwife does by neglect of aseptic precautions.
His pejorative attack on midwives aside (and Dr. Williams was thought to be more magnanimous towards midwives than most obstetricians in his day!), it’s clear from his statement that this maxim of nonmalfeasance had become standard medical approach. If Dr. Williams were alive today, what do you think he might say of our practice of elective inductions and the high rate of Cesarean sections. Primum non nocere underlies many of the guidelines physicians use today for medical decision making—it’s why powerful antibiotics are not routinely prescribed for viral infections, why operative ear tube placement is not a first-line treatment for ear infections, and why EMS responders first stabilize the head and neck of a car accident victim even before beginning CPR. Although there are limitations to its applicability resulting in endless debates within medical ethics circles, primum non nocere has nevertheless undoubtedly saved many lives and averted unnecessary suffering.
It seems that the good Dr. Williams was on to a curious paradox regarding healing and harm, however, and was perhaps an unwitting early patient safety pioneer. Nearly 100 years after his speech above, the Institute of Medicine released a landmark report titled To Err is Human. In this year 2000 report, the authors estimated that anywhere from 44,000-98,000 people die each year in hospitals due to medical error. This report also confirmed a finding published nearly ten years earlier by the Harvard Medical Practice Study in the New England Journal of Medicine: More than two-thirds of medical errors are preventable, and a 28 percent are due to negligence of a health care professional.
What do these numbers mean? It means that, every day and a half, a fully loaded Boeing 747 would have to drop out of the sky before passenger loss of life surpassed patient loss of life. It means that at least three fatal plane crashes every week would be the result of problems like faulty instruments, poor aircraft design and construction, control tower miscommunications, and pilot fatigue. Would we tolerate such odds each time we board a plane? Why then do we tolerate them each time we enter a hospital?
Coming soon: A closer look at causes of medical errors
Our Consider the Source series offers an inside look at research from the researchers themselves. In this installment, my guest is a prominent midwife-researcher who was the lead investigator on The National Birth Center Study published in the New England Journal of Medicine, researched and wrote the landmark book, Midwifery and Childbirth in America, and sits on the Editorial Board of the international journal of evidence-based maternity care, Birth, among many other distinctions. But she has not actually conducted any of the clinical trials on the topic at hand – nitrous oxide (also known as “gas and air”) for pain relief in labor.
Instead it was her experience overseeing arguably the most important systematic investigation of labor pain and its management that led Judith Rooks to begin advocating for greater access to nitrous oxide for laboring women. In this interview, Rooks discusses how she became so passionate about nitrous oxide, the American College of Nurse-Midwives’ new position statement on the topic, and why advocates for safe and healthy birth practices should join the movement to improve access to this important option for childbearing women.
Since many of my readers will be unfamiliar with nitrous oxide in labor, I offer this YouTube video of a woman using gas and air in the second stage of labor. If I could have edited out the editorializing by the TV producer, I would have! So please ignore her and have a look at the birth of baby Willow.
Science & Sensibility: You have been a very vocal advocate for increased access to nitrous oxide for laboring women. How did you get interested in nitrous oxide?
Judith Rooks: In 2001 the Maternity Center Association (MCA, since segued into Childbirth Connection) and the New York Academy of Medicine convened an invitational evidence-based symposium on the Nature and Management of Labor Pain. I directed this project on behalf of MCA and began by forming a multidisciplinary steering committee of experts. Penny Simkin was one of the first people I asked to serve on that committee. When she agreed, I asked her to help me develop an agenda for the seminar, and thus the topics to be addressed. Penny suggested that nitrous oxide (N2O) should be included, even though it was so little used and known in the US. She told me that it is widely used in many other countries and has advantages that are needed in this country. I had known almost nothing about it, but educated myself as best I could, after which I agreed with Penny.
At that time, as now, the University of California at San Francisco (UC/SF) and the University of Washington (UW) Hospital in Seattle were the only hospitals in the United States that were still offering N2O analgesia to women during labor. Dr. Mark Rosen, who had 30 years experience offering N2O analgesia to women during labor at UC/SF’s Moffitt Hospital in San Francisco, agreed to conduct a systematic review of the risks and benefits of N2O analgesia for labor and presented his findings during the symposium. Systematic reviews of all other labor analgesics used in the US were also conducted and presented at the symposium—one presentation each for parenteral administration of opioids, paracervical blocks, and nonpharmacologic methods, and three presentations on epidurals, two to deal with the extraordinary lack of consensus regarding the unintended effects of epidural analgesia on labor and its outcomes, and a third paper to describe side effects, necessary co-interventions, and the care required by women who labor with an epidural. Other systematic reviews were presented on the nature of labor pain, pain and women’s satisfaction with the experience of childbirth, and the degree to which American women have access to a choice of methods to relieve and/or help them cope with labor pain. Manuscripts of the systematic reviews were published in a special issue of the American Journal of Obstetrics and Gynecology.
I began to think more deeply about labor pain as a result of planning and directing this symposium, and I learned a lot from the experience: Epidurals can virtually eliminate labor pain but have strong negative effects on the normal physiology of labor, thereby causing a myriad of complications and other negative effects, including an increase in operative deliveries (forceps, vacuum extraction, or cesarean deliveries) and fewer spontaneous vaginal births. Opioids are not very effective at reducing pain and have negative effects on newborns. Paracervical blocks provide effective pain relief but are associated with adverse fetal and neonatal effects. Nitrous oxide is not a potent analgesia but is safe and seems to help most women who use it during labor. Nonpharmacologic measures help to relieve labor pain and have minimal or no side effects; but even women who want an entirely drug-free birth often need something more at some point during labor. Use of epidurals was increasing every year, as was the cesarean section rate and the even higher rate of total operative deliveries. I was and am still on the Editorial Board of Birth, a highly respected multidisciplinary international professional journal that focuses on pregnancy and birth. Reading and reviewing papers about childbirth in other countries made me increasingly aware that women in most English-speaking (or Scandinavian) countries have more options for pain relief during labor, whereas most women the US were increasingly being offered an epidural or nothing. I decided to try to “bend the curve” by expanding access to nitrous oxide.
Science & Sensibility: What do you see as the major benefits of nitrous oxide? Are there risks women should be aware of?
Judith Rooks: The major benefits are mainly lack of disadvantages associated with relying on epidurals, opioids and nonpharmacologic methods to relieve and help women cope with pain during labor:
After almost a century of use by many millions of women in countries with high standards of medical care and research, no studies or published observations have identified any negative effects of maternal use of nitrous oxide analgesia on the alertness and responsiveness of the newborn during the important early period of maternal-infant bonding or on early effective breastfeeding. The newborn of a woman who used nitrous oxide analgesia during labor is not at increased risk of respiratory depression. A pediatrician armed with a drug to counter the effects of opioids does not need to be present at the birth. Her newborn will not be admitted to a neonatal intensive care unit (NICU) for observation on the basis of risks associated with her method of labor analgesia.
Every analgesic and anesthetic drug that enters a woman’s body during labor passes through the placenta, enters the blood of her fetus, and remains active until it is detoxified or eliminated. Opioids (narcotics derived from opium and synthetic drugs that have the same effects) and the anesthetics used in epidurals are detoxified relatively slowly by the liver. Any opioids and anesthetics that are in the baby’s blood at birth have to be detoxified by the baby’s liver, which is immature and not very efficient. It can take several days for a newborn’s liver to eliminate them completely. Opioids depress respiratory function. Babies born with opioids in their blood may need to be resuscitated immediately after birth and tend to be sleepy and unable to nurse effectively. Anesthetics used in epidurals enter the mother’s blood in low amounts, but can still have effects on the newborn. N2O also passes through the placenta and enters the baby’s blood but is rapidly eliminated from the mother’s body (and thus the body of her fetus) through her lungs. Any nitrous oxide that is in the baby’s blood at birth is eliminated as the newborn takes its first few breaths of air. Opioids should not be used close to the time when the baby is expected to be born, yet many women need analgesia during a rapid delivery. Since nitrous oxide does not make the baby less responsive or depress respirations, it can be used up to and during the actual birth without increasing the risk of an unresponsive baby that needs to be resuscitated; it is never too close to the delivery for a woman to continue using nitrous oxide.
Nitrous oxide does not have any negative effects on the normal physiology of labor—the pulsatile release of endogenous oxytocin from the mother’s pituitary gland, maintenance of uterine muscle tone, the force and effectiveness of uterine contractions, blood flow to the uterus, the ability of the fetal head to rotate from a posterior position to an optimal position during second stage, and the mother’s ability to sense when and how to push most effectively, maintain upright positions, and change her posture as needed. There is no need to administer synthetic oxytocin (Pitocin) to make up for the lost effectiveness of endogenous oxytocin and no increased need to use forceps or force applied to the baby’s head by suction (vacuum) to rotate its head from a posterior position in order to deliver the baby vaginally. Because there are no negative effects on the normal physiology of labor, there is no reason to delay starting nitrous oxide during early labor out of concern that it will slow down or stop the woman’s labor before it can get a good start, and there is no reduction in the rate of spontaneous vaginal births.
In contrast, epidurals diminish the pulsatile release of endogenous oxytocin from the woman’s pituitary gland, which is in her brain. Pulses of natural oxytocin produced in the mother’s brain stimulate labor contractions. Reduction in the mother’s own supply of oxytocin causes labor to slow and become less effective. Most women who have epidurals are given an intravenous drip of synthetic Pitocin to make up for this loss. But a steady IV drip of synthetic Pitocin is very different from the synchronized release of natural (“endogenous”) oxytocin produced in and released from the mother’s brain. During normal labor there is a feedback loop between the release of oxytocin by the woman’s pituitary gland and the frequency and intensity of her contractions. Unfortunately, there is no way for an IV Pit drip to know how frequent, long or intense the mother’s contractions are. Without the feedback loop, it is easy to give a mother too much Pitocin, which can cause contractions that are too frequent, too long, and too intense. The arteries that bring blood to the baby through the placenta pass through the uterine muscle. When the contractions are too frequent, too long and too intense, the blood supply to the fetus can be severely compromised because the uterine muscle squeezes the arteries, not allowing enough blood to get through. Pitocin is the drug most commonly associated with preventable adverse effects of labor on babies. In 2007 Pitocin was added to the Institute for Safe Medication Practices short list of medications “bearing a heightened risk of harm,” which may “require special safeguards to reduce the risk of error.” Approximately half of all successful malpractice suits against obstetricians are related to misuse of Pitocin.
Nitrous oxide is not associated with any of the other known adverse effects of epidurals. These include :
a sudden drop in the mother’s blood pressure, in some cases leading to an emergency cesarean section
persistent fetal occiput posterior position in labor, highly associated with cesarean section for slow labor progress
need for bladder catheterization, which increases the risk of urinary tract infections
maternal fever in labor, which, despite not being infectious in origin, will often lead to neonatal sepsis work-ups and separation of mothers and babies after birth
Finally, a woman who is having an epidural requires continuous electronic fetal monitoring and an intravenous infusion as precautions against such complications. As a result, a woman who is having an epidural is tied to her bed by tubes and wires that connect her to the equipment that is providing the epidural, the intravenous infusion, and the equipment for continuous electronic fetal monitoring. None of these things are necessary for a woman who is using nitrous oxide, although her mobility is constrained by the need to access the source of the Nitronox (a blend of 50% nitrous oxide and 50% oxygen). But many women who use nitrous oxide don’t use it during their entire labor. Some women set it aside once their cervix has opened fully and they feel the urge to push. If the equipment for use of nitrous oxide is portable, a woman can continue to use it while walking, going to the bathroom, or relaxing in a tub of warm water. And it is not necessary for her to be attached to other equipment.
Although there are several relatively effective nonpharmacologic ways to help women cope with labor pain, most of them are not provided in most American hospitals. Some women who enter labor wanting to avoid an epidural come to a point, especially during their first birth, at which they feel that they cannot take the pain any longer and must have some kind of pharmacologic help. Although a pain crisis can occur at various points during labor, it is not unusual for a women to become exhausted and ask for an epidural during the period shortly before her cervix becomes completely dilated, when she would begin to feel the urge to push. Some women get a second wind once they move into the second stage of labor, but if she gets an epidural at that point, she will have it on board for the remainder of her birth. Although a woman who wanted to avoid an epidural should be able to change her mind and have one, she should also have access to a method of pain relief that is simple and fast to start, takes the edge off her pain and helps her cope, but can be put away—or continued, at her choice—once the crisis has passed, if she wants to re-engage and push with full sensation while giving birth.
Every woman and labor is unique. There is no single best method of labor analgesia. Every method has advantages and disadvantages, and different women value different things. Women should have choices, and some will do better and be more satisfied if they can use a variety of methods at different stages of their experience of giving birth.
Nitrous oxide can be started simply, quickly, easily and safely and begins to take effect almost immediately. There is no need to wait until an anesthesiologist or nurse-anesthetist is available to insert a catheter into the epidural space surrounding the woman’s spinal cord—a delicate procedure that requires sterile conditions. And, because nitrous oxide does not interfere with the normal forces of labor, it is not necessary to wait until labor is well established before the woman can begin to use it. Women who want to have an epidural can use nitrous oxide while they wait to be able to have an epidural.
After a brief period of explanation and supervision, nitrous oxide is self-administered through a mask that the woman holds to her own face. Self-administration allows the woman to determine when and how much nitrous oxide she uses. She can pick the mask up and use it as much or as little as she wants. She can also control the amount of nitrous oxide she takes in by adjusting the speed and depth of her inhalations. Being able to control her use of analgesia gives many women a reassuring sense of self-control.
Rapid elimination of N2O through the lungs means that if a woman decides after starting to use nitrous oxide that she doesn’t like it or no longer needs it, she can set the mask down and stop inhaling the gas. Her body will be completely free of nitrous oxide in less than 5 minutes. In contrast, it may take many hours for a woman’s body to be completely free of the effects of an opioid or epidural.
Science & Sensibility: How many hospitals or birth centers are using nitrous oxide in the United States?
Judith Rooks: To my knowledge only two hospitals in the United States are using as of early April 2010—the University of Washington (UW) Hospital in Seattle and the University of California at San Francisco’s Moffitt Hospital in San Francisco. The company that was manufacturing the equipment for self-administration of Nitronox (the 50%/50% blend of nitrous oxide and oxygen that’s used during labor) lost its subcontractor almost two years ago, resulting in a total lack of new equipment. As a result, hospitals and birth centers that wanted to start using it have not been able to move forward. Now another company is preparing to begin making new equipment. At least two hospitals and one birth centers are in line to buy the equipment and begin to use it as soon as it becomes available. Some other hospitals are considering it. I believe that there will be considerable early demand from smaller hospitals that cannot provide access to epidurals at night and during weekends.
Science & Sensibility: The ACNM Position Statement discusses two concerns with the use of nitrous oxide in labor: reproductive health risks for health care personnel who have repeated exposures to nitrous oxide in the workplace and a theoretical risk of injury to neurons in the newborn’s brain. These are cited as barriers to increased availability of nitrous oxide in the U.S. How have other countries addressed these concerns?
One long-standing concern relates to possible reproductive risk (more months to conceive, possibly due to early spontaneous abortions) among female health workers, including midwives and nurses who work closely with women using nitrous oxide analgesia during labor. This was a problem during an earlier time, especially in the United Kingdom (UK), where many hospitals were not well ventilated and people weren’t aware of the need to prevent the breath exhaled by women using nitrous oxide analgesia from entering the ambient air. Nitrous Oxide inhaled by a woman during labor stays in her body for only a short period of time before it is eliminated by her lungs. It is important for her exhaled breaths to be captured and pulled out of the room. Now that this is understood, a “scavenging” capacity has become an integral part of the equipment for using N2O. The woman breathes N2O and oxygen from a mask and exhales carbon dioxide and N2O back into the mask, which suctions it away. Eventually it is released into the outside air at a time and in a place and manner that are safe. Although nitrous oxide is a “greenhouse gas”, the amount used for medical and dental purposes is minor compared to other sources of nitrous oxide in the earth’s atmosphere, and it is not a poisonous gas that people should be afraid of in low concentrations. Nitrous oxide is produced when organic materials that contain nitrogen are burned or broken down in other ways. The leaves of deciduous trees contain a nitrogen that is turned into N2O by bacteria in the soil under a tree. Humans have always been exposed to low concentrations of naturally occurring nitrous oxide and have evolved an effective way to deal with having it enter their bodies.
The National Institute of Occupational Safety and Health (NIOSH) and the Occupational Safety and Health Administration (OSHA) are responsible for safe use of all anesthetic and analgesic gases in the United States. Their recommendations for maximum occupational exposure to N2O are more stringent than the rules that govern use of N2O in many other countries. Current OSHA recommendations call for limiting occupational exposure to N2O to not more than an 8-hour time-weighted average concentration of 25 parts per million (ppm). Although the Netherlands adheres to the same standard, the UK, Italy, Sweden, Norway and Denmark set 100 ppm as their upper limit. NIOSH’s recommendation to limit occupational exposure to nitrous oxide to 25 ppm was established during the 1970s, without benefit of actual data. Nevertheless, the American Society of Anesthesiologists (ASA), NIOSH and OSHA all agree that this standard has been effective in protecting American health workers.
The concern about a theoretical risk of injury to neurons in the brain of a human fetus while its mother uses N2O analgesia during labor resulted from research that found seemingly severe but reversible nerve cell damage in the brains of baby rodents, mainly rats, exposed to very high concentrations of N2O, as well as alcohol and many other neuro-active drugs, including all general anesthetics. The period of susceptibility in rodents coincides with the time during which the immature brain is growing and developing at a rapid rate—the first week of life for a baby rodent. The comparable period for humans is from the 6th month of gestation until about three years of age. The research leading to this concern began with research on the pathology that underlies fetal alcohol syndrome and expanded to looking at whether other drugs might causes similar damage to the brains of baby rats. A large body of laboratory research was done and published in the 1990s but did not gain widespread attention until about 2007, which also happened to be the time when midwives and others were becoming concerned about the lack of access to labor analgesia choices for women in the US, resulted in growing interest in nitrous oxide. By 2008 two US hospitals were considering beginning to offer nitrous oxide analgesia to women during labor—a major academic medical center in the southeast and a Kaiser Permanente hospital in California. Both hospitals were leaning towards going forward with N2O obstetric analgesia when leaders of their anesthesiology departments attended a national professional meeting during which this body of research was summarized and discussed. Shortly thereafter the anesthesiology departments of both hospitals decided against any expanded use of nitrous oxide, decisions that were probably minor from their perspective. The much bigger concerns among the anesthesiologists who learned about the damage to rat brains from exposure to nitrous oxide related to the important role of N2O as a component of anesthesia for long but essential surgeries on infants and toddlers.
Nitrous oxide has long been a staple of anesthesia for surgery, not as a single agent but as part of a mixture of anesthetic gases. The addition of nitrous oxide makes it easier to both induce and bring a patient out of anesthesia with less stress, including preventing unpleasant and sometimes very frightening memories. Those benefits are considered so important for children that concerns about risks associated with exposing children to nitrous oxide created a crisis for anesthesiologists and pediatricians, who continued to use nitrous oxide during pediatric surgeries until more information on the clinical significance of the baby-rat studies for humans could be assessed. This all occurred in the context of a wider challenge to continued used of nitrous oxide in anesthesia practice in the US. Development of new anesthetics that can be administered intravenously has made it possible to give adult patients pure oxygen to breathe during surgery. Several studies have shown that patients who breathe 100% oxygen during surgery have fewer infections and better wound healing, apparently due to higher levels of oxygen in their body tissues. A randomized trial that proved this was published in Anesthesiology (the journal of the American Society of Anesthesiologists) in 2007 under the title “Avoidance of Nitrous Oxide for Patients Undergoing Major Surgery.” The study was conducted as part of the Evaluation of Nitrous oxide In a Gas Mixture for Anaesthesia (ENIGMA). An editorial published in the same issue of Anesthesiology pointed out that the important finding of the study was the benefit of high inspired oxygen rather than avoidance of nitrous oxide, which, she pointed out, “is certainly useful for inhalation inductions in children, as well as for analgesia in laboring parturients [women giving birth] or in patients having dental procedures.”
In October 2008 Anesthesiology published a comprehensive review of the biologic effects of nitrous oxide authored by an international team of leading anesthesiologists from the UK and Germany. They noted that, although N2O causes morphologic neurotoxicity in the immature brains of baby rats, this “occurs at doses in excess of those normally administered in clinical practice (i.e., in hyperbaric conditions) and resolves within 3 hours.” They further found no evidence of neuropathology in neonatal rat brains from exposure to N2O concentrations less than 75%. The abstract summarized the situation:
Nitrous oxide is the longest serving member of the anesthesiologist’s pharmacologic armamentarium but remains a source of controversy because of fears over its adverse effects. Recently, the (ENIGMA) trial reported that that nitrous oxide use increases postoperative complications; further preclinical reports have suggested that nitrous oxide may contribute to neurocognitive dysfunction in the young and elderly. Therefore, nitrous oxide’s longevity in anesthetic practice is under threat. In this article, the authors discuss the evidence for the putative toxicity of nitrous oxide, from either patient or occupational exposure, within the context of the mechanism of nitrous oxide’s action. Although it would seem prudent to avoid nitrous oxide in certain vulnerable populations, current evidence in support of a more widespread prescription from clinical practice is unconvincing.
Blood levels of nitrous oxide in women during labor never go very high. Self-administration protects the mother and fetus from getting too much N2O. If the mother becomes drowsy, her hand will fall away from her face, the supply of nitrous oxide will turn off, and she will begin to breathe room air. Nitrous oxide as used during labor is not a very potent analgesia—enough to take the edge off the pain but not a concentration that is even close to what was being given to the poor baby lab rats used in the studies that caused so much concern.
Science & Sensibility: Do you think there are other barriers to increasing access to nitrous oxide: perhaps economic, logistical, or cultural?
Judith Rooks: Lack of equipment has been a big problem during the past two years because the demand for nitrous oxide analgesia was not great enough for the company that had produced the equipment for many years to find a new subcontractor to make the equipment when the one that had been doing so stopped. It turned out to be the problem of all “orphan drugs”, for which there is not enough demand for large companies to invest in producing a supply to meet a limited demand. Now a new company is preparing to begin making new equipment, but it has been a big problem.
Epidurals are big money makers for hospitals and, of course, for anesthesiologists, whereas nitrous oxide is an old, off-patent, cheap drug that can’t compete as a money maker (but may at some point compete as a money saver, as the US moves towards placing value on cost-effective health care). Profit is a powerful force in American health care. If no one is making a profit, no one is pushing for a product to have a place on the shelf, whereas those who are making big profits are always trying to push the product that is not profitable off the shelf.
Once anesthesiologists decided to introduce epidurals for labor analgesia it became important to get rid of anything that might compete. If a hospital or physician wants to be able to tell pregnant women that they can have an epidural during labor, the hospital has to make a commitment to providing access to an epidural 24 hours a day every day of the year. It requires more than 5 full-time people to provide any service 24/7, and it costs a lot to pay full-time salaries for 5.2 anesthesiologists and/or nurse anesthetists. In order to make it practical for a hospital to providing labor epidurals on a 24/7 basis, it is necessary for a large proportion of women who give birth at that hospital to have epidurals. Nitrous oxide was maligned as old fashioned, dangerous to the health of nurses and midwives, making women vomit and thereby posing a threat to their lives because they might inhale some of their vomit, etc. Bad-mouthing nitrous oxide is still going on very actively, whether by ignorance of changed facts (e.g., much lower doses than were used decades ago, scavenging to prevent contamination of the air), repetition of unfounded rumors, financial considerations, or a desire to avoid the need to provide the time-intensive care needed by women who are experiencing some degree of pain.
Most obstetricians were delighted to hand responsibility for dealing with labor pain to anesthesiologists. Some time ago I had protracted communication with a fine obstetrician who banned continued use of nitrous oxide analgesia in an major university hospital when he went there to head the department of obstetrics and gynecology during the 1990s. After he offered several unconvincing rationales for having banned it, he said that he is just uncomfortable seeing women in pain. An epidural is the only method that can totally obliterate labor pain for an individual woman and result in a completely quiet labor unit, with no woman making any sound associated with discomfort. Many obstetricians may resist any change that would put them in the position of having to deal with more women who are experiencing some level of pain.
Most young nurses (all but a few OB nurses at this point) have had little if any experience with women who are laboring without an epidural and have never been taught or had role models to help them learn how to comfort and support a woman who does not have an epidural. Continuing education for labor-unit nurses tends to focus on the technical aspects of care, such as electronic fetal monitoring. Little value is assigned to being able to work effectively with a woman who is trying to go through labor and give birth without an epidural. The few nurses who are interested and able to do it may be criticized by their peers for “spoiling” the patients. Doulas would be a good solution but are not widely accepted in obstetrics. In addition, doulas are most effective as agents of the pregnant woman, but most women can’t afford to hire on and it is not clear that doulas employed by a hospital would be as effective.
Epidurals are clearly the most effective way to eliminate pain during labor. That makes them “the Gold Standard”, even though complete obliteration of pain is not the real goal for many women during labor. Superficially it may seem silly, stupid or sadistic to advocate for introduction of a “less effective” method of analgesia for women during labor. And women are most likely to want to use the method that is “best”.
Few women have full information about the pros and cons of various approaches to reducing and helping women cope with labor pain. The benefits and harms are complicated, time during prenatal visits is limited, and childbirth education is now being provided mainly by hospitals which slant it to encourage women accept and want the kind of care that the hospital can provide most expeditiously.
American health care is remarkably isolated from what is happening in other countries. Although the recent focus on the need for “health care reform” has informed many Americans that health status of Americans is poorer overall than that of the citizenry of many wealthy countries, most Americans think that the only thing wrong with American health care is that some people can’t afford it. There is little understanding that overuse of invasive procedures can actually result in harm, and that more, more expensive, and more “sophisticated” care is not always better. In addition, it is hard for Americans to learn anything about health care from another country. Many American physicians don’t read other English-language medical journals and discount research conducted in other countries as not being as good, important or valid as studies done in the US. As a result, we rarely benefit from progress that is being made in other countries. Most of the use of nitrous oxide analgesia occurs in other countries, so most of the research on it comes from other countries too. Most American physicians don’t have any idea that two of our best academic medical centers, UC/SF and the University of Washington, provide nitrous oxide anaglesia to women during labor.
Nitrous oxide analgesia is most compatible with the midwifery model of intrapartum care, and the supply of midwives is very limited in the United States.
The Joint Commission on Accreditation of Hospitals (JCHA) mandates regular pain assessments of all hospitalized patients, mainly by asking patients to rate the degree of pain they are experiencing using a standard 0 to 10 Numeric Rating Scale. Asking women who are trying to cope with labor pain to rate the degree of pain they are experiencing at regular intervals is counterproductive, since women who don’t want or can’t have an epidural are focusing on something else; it isn’t helpful to interrupt their focus by asking them to think about pain. Some tools that replace use of the Pain Assessment Rating Scale with a way for nurses and midwives to assess how the woman is coping with labor have been developed. I believe that Penny Simkin has developed such a tool, and one was described in a recent issue of the Journal of Midwifery & Women’s Health. This approach is acceptable to the JCHA but is not widely known or used.
Science & Sensibility: If consumers or health care providers are interested in reintroducing nitrous oxide in their communities, what steps should they take?
Judith Rooks: Pregnant or hope-to-become-pregnant women should talk to others, especially maternity care providers in their areas, about the need for nitrous oxide as an option for women who will give birth in local hospitals. Talk about it. Ask about it. Request it. Find out who is responsible for the hospital at which you will or would use for a birth- some kind of board of directors is responsible. Get their names and addresses, and send them letters asking for this. Do the same for the leaders of the departments of obstetrics and anesthesiology. Invite someone who can speak about this to give a talk somewhere in your city or town and get other women (and their partners) involved. Ignorance is the enemy, and in this case it is not just ignorance. Many professionals who think they are well informed about options for analgesia during labor are ignorant about options to epidurals but don’t know—and would be insulted by any inference—that they are ignorant. Don’t antagonize people and make enemies, but provide opportunities for them to learn more. Go on talk radio programs. Local public affiliates of National Public Radio (NPR) are usually open to discussions of topics of interest. Inform yourself thoroughly first. Reading and having a copy of the ACNM Position Statement on Nitrous Oxide for Labor Analgesia is a good place to start. This blog post is also full of authoritative information.
To arm yourself fully with the most current information, you should consider joining the nitrousoxideduringlabor listserv. Go to (http://health.groups.yahoo.com/group/N2Oduringlabor/) and follow directions to join. After you join, return to the listserv home page and click on “Files” in the light blue sidebar on the left side of the page to go the Files section, which contains copies of important published papers and other documents relevant to use of N2O analgesia during labor. As a member of the listserv you have access to all of those documents, as well as most of the messages that have been sent to members of the listserv. The files are listed alphabetically based on the name the given to the gave to the file when it was posted on the website. For example, an important paper by Sanders et al. is listed alphabetically after a very important systematic review of the best available evidence about the safety, risks and use of nitrous oxide for labor analgesia authored by Dr. Mark Rosen, Chief of Obstetric Anesthesia at the University of California at San Francisco and published in the American Journal of Obstetrics and Gynecology in 2002. Both are key documents. Mickey Gillmor, who is on the faculty of the largest midwifery education program in the US (the Frontier School of Midwifery and Family Nursing) helps me run the N2Oduringlabor website.If you have any trouble making this work for you, please let Mickey or me know. My email address is jprooks1@comcast.net. Mickey’s email address is mickey.gillmor@gmail.com.
This advice basically applies to health care workers too.
I think that N2O analgesia is going to become increasingly in demand as the growing imbalance between the supply of anesthesiologists and nurse-anesthetists to provide 24/7 access to OB epidurals and the need for some kind of relatively effective analgesia for women during labor. I believe that women are currently being urged to accept being induced (which leads to more cesareans) or have an elective preemptive cesarean in order to avoid the possibility of going into labor over the weekend or at night with no choice but a hospital that does not have weekend or night coverage for epidurals. I assume that is part, maybe even a significant part of the reason for the great and growing disparity in the average number of births that occur on specific days of the week in the US. As this problem becomes more apparent—amid increasing evidence of increased harms to both mothers and babies of unnecessary inductions and cesareans—the animosity among many anesthesiologists and some obstetricians towards any method of labor analgesia other than the “gold standard” epidural will have to wane.
Information about nitrous oxide is slowing seeping out to women, not all of whom want an epidural; that is why I am doing this interview—as long and tedious as it may seem. Our Bodies Ourselves, Childbirth Connection, and a growing number of books, movies, journals and blogs are bringing more and more women better, fuller and more evidence-based information about their choices and chances to have a non-surgical physiologic birth.
First the good news: based on the presenters, it looks like the NIH VBAC conference will be a great improvement over the elective cesarean surgery travesty of four years ago. The conference seems likely to provide solid, evidence-based information on for whom and under what circumstances VBAC is safest and most likely to end in vaginal birth. Objective, unbiased information on these points is sorely needed, as illustrated by this 2008 response by ACOG vice president Dr. Ralph Hale, who one would expect to know better, to a plea to make VBAC more available:
VBAC is potentially an extremely dangerous procedure for both mother and infant. Although 98% of women can potentially have a successful VBAC, in two percent of cases the result can be a rupture of the old scar. If this happens, then death of the baby is almost certain and death of the mother is probable. Even if the mother does not die, virtually 100% will lose their child bearing ability. To prevent these disasters, the ability to perform immediate surgery is critical.
In point of fact, with appropriate care the scar rupture rate can be 0.5% or less (6,13,15), not 2%, and the chance of the baby dying as a result of scar rupture is 5% (9), not “almost certain.” As for the mother, women rarely die or have hysterectomies, but both are more common with elective repeat cesarean than planned VBAC (3,17,18,19).
Before we break out the champagne, though, consider this: nowhere in the program is any acknowledgement of a patient’s fundamental right to refuse surgery. Quite the opposite. The background statement is rife with the language of doctors giving (or withholding) permission:
For most of the 20th century, once a woman had undergone a cesarean . . ., many clinicians believed that all of her future pregnancies required delivery by cesarean as well. However, in 1980 a National Institutes of Health Consensus Development Conference panel questioned the necessity of routine repeat cesarean deliveries and outlined situations in which VBAC could be considered.
Even more telling, VBAC is positioned as a patient and provider “preference.” The background section uses this term as does the title of the session on obstetric decision making, and Anne Lyerly, the obstetrician speaker on VBAC ethics, is co-author of the commentary “Mode of delivery: toward responsible inclusion of patient preferences.”
The problem with patient preference is that it is readily trumped by provider preference. If VBAC is no more than a menu option, the danger in determining who makes a good candidate and what constitutes optimal circumstances for VBAC is that it legitimizes its opposite: doctors and institutions denying VBAC to women they don’t think make the cut or where they don’t think safety for VBAC is adequate. (The latter, BTW, is spurious. Emergencies occur in non VBAC labors. If a hospital isn’t safe for a VBAC labor, then it isn’t safe for any woman to labor there. Not to mention that ACOG guidelines for labor induction and American Society of Anesthesiologist guidelines for epidurals require the ability to perform an urgent cesarean because of the potential for just such emergencies, but no one is setting strictures on these procedures [1,2].)
A secondary danger of the “preference” perspective is that conference presenters may treat non-clinical factors such as “medico-legal concerns” and “economic considerations” as valid reasons for VBAC refusal instead of obstacles that must be overcome. This would leave us where we are now with obstetricians and hospitals free to do as they choose, and what they choose is no VBACs. A 2005 survey found that more than half the women wanting a VBAC were denied that option, a 2009 survey of 2850 hospitals revealed that half of them had a ban or de facto ban against VBAC, and Lord knows we do not need any more stories like Joy Szabo’s.
To give the conference planners and presenters their due, normally, it makes perfect sense to limit procedures to those with the skill to perform them and require their performance in environments with adequate resources. It makes sense as well as to allow providers and institutions to decline performing them. But VBAC is the exception because it is not a procedure. Labor is what inevitably happens at the end of pregnancy. Refusing VBAC means forcing women to agree to major surgery they neither want nor need in order to obtain medical care.
Depriving a woman of choice on grounds of the baby’s safety, the primary clinical rationale for VBAC denial, values the child over the mother. This is not hyperbole. According to studies of a large U.S. population, the maternal risk of death (3 per 10,000) with elective repeat cesarean is in the same ballpark with the risk of the baby dying subsequent to scar rupture during a VBAC labor (1 per 10,000) (13,19). Moreover, as the conference will discuss, a woman undergoing repeat cesarean not only runs the risks of that surgery, but an increasing risk of placental attachment abnormalities in any future pregnancies as she accumulates surgeries, abnormalities that threaten both her life and that of the fetus. By contrast, once a woman has a VBAC, she will almost always continue to have uneventful VBACs in future pregnancies. VBAC denial is the sole instance where doctors feel justified in compelling one person to undergo a medical procedure to benefit another party, but no ethical principle or law allows this, including when the beneficiary will otherwise surely die, which is far from the case with VBAC.
Failure to recognize that VBAC is a right has another consequence as well. If you start from this premise, it follows that a key question will be how best to promote safe vaginal birth in women desiring VBAC, but this is missing from the agenda. My researches for the VBAC chapter of the new edition of Obstetric Myths turned up much food for thought on this issue. For example, a study on the large U.S. population mentioned above reported scar rupture rates of 9 per 1000 with labor augmentation and 10 per 1000 with induction but only 4 per 1000 in women laboring spontaneously (13). If every woman had labored without stimulation, 63 women would have had scar ruptures instead of 124. On the other hand, a study reported equally low scar rupture rates in induced labors (3 per 1000) as in labors with spontaneous onset (16), which suggests that while spontaneous labor is optimal, women who truly require induction can be induced without excess risk provided clinicians pay proper attention to patient selection and induction protocol. Research also shows that physiologic care substantially increases VBAC rate and reduces scar rupture rate (15). The birth center VBAC study reported a VBAC rate of 81% in women with no prior vaginal birth, 9 to 20 more women per 100 than among similar women in nine studies (4,5,7,8,10-12,14,20) who had conventional obstetric management. The scar rupture rate overall was a mere 2 per 1000.
We rightly should applaud any effort that helps women and clinicians decide between planned VBAC or repeat cesarean but lament any attempt to curtail a woman’s right to refuse surgery, be it on clinical or nonclinical grounds. VBAC is a right, not a preference, a right, let me add, not abrogated by the clinician’s opinion of its wisdom. It does not matter if you, me, and everyone on the planet were to line up and say to a woman VBAC is a bad idea in your case, she still has the right to say “no” to surgery. Clinicians and institutions must be brought to accept their ethical and professional obligation to provide best practice care to every woman wanting planned VBAC. If the conference fails in this task, then whatever it accomplishes, it will fall short of its duty to childbearing women with previous cesareans.
1. ACOG. Induction of labor. ACOG Practice Bulletin No 107 2009.
2. ASA. Guidelines for regional anesthesia in obstetrics. 2007. (Accessed 2/12/2010, at http://www.asahq.org/publicationsAndServices/standards/45.pdf.)
3. Blanchette H, Blanchette M, McCabe J, et al. Is vaginal birth after cesarean safe? Experience at a community hospital. Am J Obstet Gynecol 2001;184(7):1478-84; discussion 84-7.
4. Cahill AG, Stamilio DM, Odibo AO, et al. Is vaginal birth after cesarean (VBAC) or elective repeat cesarean safer in women with a prior vaginal delivery? Am J Obstet Gynecol 2006;195(4):1143-7.
5. Caughey AB, Shipp TD, Repke JT, et al. Trial of labor after cesarean delivery: the effect of previous vaginal delivery. Am J Obstet Gynecol 1998;179(4):938-41.
6. Chauhan SP, Martin JN, Jr., Henrichs CE, et al. Maternal and perinatal complications with uterine rupture in 142,075 patients who attempted vaginal birth after cesarean delivery: A review of the literature. Am J Obstet Gynecol 2003;189(2):408-17.
7. Gonen R, Barak S, Nissenblat V, et al. The outcome and cumulative morbidity associated with the second and third postcesarean delivery. Am J Perinatol 2007;24(8):483-6.
8. Goodall PT, Ahn JT, Chapa JB, et al. Obesity as a risk factor for failed trial of labor in patients with previous cesarean delivery. Am J Obstet Gynecol 2005;192(5):1423-6.
9. Guise JM, McDonagh M, Hashima JN, et al. Vaginal birth after cesarean (VBAC) Report/Technology Assessment No. 71. Rockville, MD: Agency for Healthcare Research and Quality; 2003 March 2003. Report No.: AHRQ Publication No. 03-E018.
10. Gyamfi C, Juhasz G, Gyamfi P, et al. Increased success of trial of labor after previous vaginal birth after cesarean. Obstet Gynecol 2004;104(4):715-9.
11. Hendler I, Bujold E. Effect of prior vaginal delivery or prior vaginal birth after cesarean delivery on obstetric outcomes in women undergoing trial of labor. Obstet Gynecol 2004;104(2):273-7.
12. Kwee A, Bots ML, Visser GH, et al. Obstetric management and outcome of pregnancy in women with a history of caesarean section in the Netherlands. Eur J Obstet Gynecol Reprod Biol 2007;132(2):171-6.
13. Landon MB, Hauth JC, Leveno KJ, et al. Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. N Engl J Med 2004;351(25):2581-9.
14. Landon MB, Leindecker S, Spong CY, et al. The MFMU Cesarean Registry: factors affecting the success of trial of labor after previous cesarean delivery. Am J Obstet Gynecol 2005;193(3 Pt 2):1016-23.
15. Lieberman E, Ernst EK, Rooks JP, et al. Results of the national study of vaginal birth after cesarean in birth centers. Obstet Gynecol 2004;104(5 Pt 1):933-42.
16. Locatelli A, Regalia AL, Ghidini A, et al. Risks of induction of labour in women with a uterine scar from previous low transverse caesarean section. BJOG 2004;111(12):1394-9.
17. Loebel G, Zelop CM, Egan JF, et al. Maternal and neonatal morbidity after elective repeat Cesarean delivery versus a trial of labor after previous Cesarean delivery in a community teaching hospital. J Matern Fetal Neonatal Med 2004;15(4):243-6.
18. McMahon MJ, Luther ER, Bowes WA, Jr., et al. Comparison of a trial of labor with an elective second cesarean section. N Engl J Med 1996;335(10):689-95.
19. Spong CY, Landon MB, Gilbert S, et al. Risk of uterine rupture and adverse perinatal outcome at term after cesarean delivery. Obstet Gynecol 2007;110(4):801-7.
20. Turner MJ, Agnew G, Langan H. Uterine rupture and labour after a previous low transverse caesarean section. BJOG 2006;113(6):729-32.
When I heard that the cesarean had taken place at Beth Isreal Deaconess Medical Center in Boston, I had an “a-ha” moment: That’s the place where Paul Levy is President and CEO. And he has a blog. And his blog has been a sounding board for ideas about health care reform in general and transparency and practice variation in particular. I decided to leave a comment.
Here’s what I wrote about what I really think about the Red Sox the responsibility of hospital leadership to address problems in maternity care including the excess use of cesarean surgery.
I’m sure that the Today Show piece was just a convenient PR opportunity, but when I heard the birth occurred at BIDMC I came here to see what, if any, analysis you offered. Given your recent coverage of practice variation in endoscopies and hypertension treatment, it would seem this is a good opportunity to address practice variation in the use of cesarean surgery. Especially since just last week, a multi-stakeholder group released major recommendations for maternity care reform, which included many recommendations for reining in unwarranted practice variation.
Your hospital currently has the fourth highest cesarean rate in the state of Massachusetts (42%), 12 percentage points higher than the “normal range” (”25-30%”) reported by one of your OR staff during the Today Show piece, and nearly three times the rate recommended by the World Health Organization. True, your hospital cares for many women with high risk pregnancies, but studies that have looked at risk adjustments in cesarean rates have found that these adjustments make little to no difference in the rank order of hospital cesarean rates, and in fact many academic tertiary hospitals are able to safely maintain rates lower than those of community hospitals. The National Quality Foundation, Healthy People 2010, and, beginning in April when new perinatal measures are rolled out, the Joint Commission, all consider the rate of cesarean surgery in nulliparous women with singleton, head down babies (NTSV cesarean rate) to be a measure of hospital quality. You may have “Red Sox Nation plus 1″ but you now also have “NTSV cesarean rate plus one” – the woman who gave birth on the Today Show did not have an indication for cesarean delivery that is accepted by ACOG or any other standard-setting bodies. (Her indication was “big baby”.)
I urge you to use this opportunity to ask yourself and your staff what you could be doing better to safely lower your cesarean rate.
(BTW, Paul Batalden’s [whom Levy mentioned in a recent blog post about practice variation] daughter is a nurse-midwife (and a great one at that) so he might have some insights to share with you.)
After another commenter suggested that perhaps the circumstances of the cesarean were a private matter, I had more to say:
I agree that this isn’t an appropriate venue to share commentary about whether or not the televised c-section was appropriate. But as someone who cares deeply about maternity care safety and effectiveness, I often feel that people doing the heavy thinking about health care reform are completely oblivious to maternity care as a major area for improvement. So infrequently in health care debates do we hear about childbearing women or newborns, despite that 4.5 million women give birth each year, outcomes are poor, and hospital charges for maternity care far exceed those of other specialties. I have seen some coverage of maternity care issues on this blog, but the coverage seems to be out of proportion with how much “business” the maternity unit accounts for. That the current post about a televised birth was a lighthearted plug for the Red Sox, I have to admit, was extremely disappointing from my perspective. If we’re going to have a major surgery on live television with zillions of people watching, it seems a fine time to start talking about the procedure, under what circumstances it is safe, evidence-based indications for its use, and how to make sure every hospital is performing it to the highest standard of safety.
Just in the past week, there’s been a Joint Commission Sentinel Event Alert on maternal mortality, the major national reform recommendations I mentioned earlier, and today a front page article at the San Francisco Chronicle on the contribution of cesareans to California’s maternal mortality rate. Seems like there’s plenty of “blog fodder” other than the Red Sox angle.
Levy’s commitment to openness and transparency is unique in the hospital administration world and I support it wholeheartedly. I have to admit it felt like quite a thrill to leave a cogent comment on a blog of a hospital CEO. Even when I’ve worked for hospitals I never had that kind of access. Of course listening doesn’t necessarily translate into doing. I hope that Levy recognizes that his hospital could be doing much better in their provision of maternity care to the community, begins documenting quality improvement efforts on his blog, and welcomes the input he receives from those of us who have thought quite a bit about what high-quality, high-value maternity care looks like and how to get there.
