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April is Cesarean Awareness Month – Resources and a Test Your Knowledge Quiz

April 10th, 2014 by avatar

fb profile cam 2014April is Cesarean Awareness Month, an event meant to direct the American public’s attention to the United States’ high cesarean rate. 32.8% of all birthing women gave birth by cesarean in 2012. A cesarean delivery can be a life-saving procedure when used appropriately, but it takes one’s breath away when you consider that one third of all women birthing underwent major abdominal surgery in order to birth their babies.

Professionals that work with women during the childbearing year can be a great resource for women, pointing them to evidence based information, support groups and organizations that offer non-biased information to help women lower their risk of cesarean surgery, receive support after a cesarean and work towards a trial of labor after a cesarean (TOLAC) and achieve a vaginal birth after a cesarean (VBAC) for subsequent births if appropriate.

Here are my top suggestions for websites and resources every birth professional should have on their short list to share with students and clients when it comes to cesarean awareness.

1. International Cesarean Awareness Network – an international organization with almost 200 volunteer led chapters, (most in the USA) offering peer to peer support for cesarean recovery and VBAC information by way of a website, e-newsletters, webinars, online forums, Facebook groups and monthly meetings in the community.

2. VBACFacts.com – Led by birth advocate Jen Kamel, this website is big on research and helps consumers and professionals alike understand the evidence and risks and benefits of both repeat cesareans and vaginal birth after cesarean, including vaginal birth after multiple cesareans.

3. Lamaze International’s “Push for Your Baby” – is a great resource for families to learn about the Six Healthy Care Practices, what evidence based care looks like and how to work with your health care provider to advocate for a safe and healthy birth. Also Lamaze has an wonderful infographic that can be shared online or printed.

4. Spinning Babies – Midwife Gail Tully really knows her stuff when it comes to helping babies navigate the pelvis during labor and birth. Many cesareans are conducted for “failure to progress” or “cephalopelvic disproportion” when really it is a case of a malpositioned baby who needed to be in a different position. This website is a wealth of information on what women can do to help their babies into the ideal position to be born, prenatally and during labor. It includes valuable information about helping a breech baby turn vertex. This is important, because finding a health care provider who will support vaginal breech birth is like finding a needle in a haystack.

© Patti Ramos Photography

© Patti Ramos Photography

5. Childbirth Connection – This website is a virtual goldmine of evidence based information about cesareans and VBACs including a valuable guide “What Every Pregnant Woman Needs to Know about Cesareans.” There are questions to ask a care provider and includes information on informed consent and informed refusal.

6. Cesareanrates.com is a great website run by Jill Arnold for those who love the numbers. Find out the cesarean rates of hospitals in your area. All the states are represented and families can use the information when searching out a provider and choosing a facility. Jill’s resource page on this site is full of useful information as well.

7. Safe Prevention of the Primary Cesarean –  The American Congress of Obstetricians and Gynecologists along with the Society for Maternal Fetal Medicine recently published a groundbreaking document aimed at reducing the first cesarean. While fairly heavy reading, there is so much good information in this committee opinion that I believe every birth professional should at least take a peek. You may be pleasantly surprised.

Test your knowledge of the facts around cesareans and VBACs with this informative quiz:

As a birth professional, you can be a great resource for all your clients, helping them to prevent their first cesarean, providing support if they do birth by cesarean and assisting them on the journey to VBAC by pointing them to these valuable resources. You can make every day “Cesarean Awareness Day” for the families you work with, doing your part to help the pendulum to swing in the other direction, resulting in a reduction in our national cesarean rates and improving outcomes for mothers and babies. What are your favorite resources on the topic of cesareans and VBACs? Share with us in the comments section.
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Book Review: Cut It Out: The C-Section Epidemic in America

November 7th, 2013 by avatar

By Christine Morton, PhD

What accounts for the dramatic rise in cesarean delivery in the United States over the past two decades? In her new book, Cut it Out: The C-Section Epidemic in America, sociologist Theresa Morris addresses this question by going to the source: she interviewed maternity clinicians (obstetricians, midwives and labor and delivery nurses) as well as women who had recently given birth. She examines guidelines from the major professional group of obstetricians and gynecologists. Morris goes beyond simply documenting the rise in C-sections, the health risks they pose to women and their babies, although she does that very well. To explain how we got to an epidemic of c-sections in the U.S, she applies an organizational lens, making it clear how “organizational changes constrain the decisions and behaviors of maternity providers and women.”

This way of looking at c-sections will be useful for childbirth educators, doulas and childbearing women because it goes one step farther than most research on c-sections, which demonstrate trends and possible associations between clinical causal factors, or characteristics of women. It is also different from advocacy around c-sections that largely frames the issue as one of individual agency or rights (“women must advocate and prepare for vaginal birth,” or “women have right to informed choice”). And although we have some research on how organizational structure impacts c-section rates, such as teaching hospitals and health maintenance organizations (HMOS), absent from these studies are explanations as to why this is so. Morris argues that the research on c-section epidemic is missing an “understanding that is rooted in the experience of maternity care providers and pregnant women” (p. 21).

While most childbirth educators and doulas have a good understanding of pregnant women’s experience, Morris takes the reader into the perspectives of a range of maternity clinicians, arguing that organizational policies and procedures constrain their actions. We can’t blame individual clinicians for the high c-section rate, she argues, nor can we hold them responsible for reducing it. Social constraints on individual behavior are very powerful and need to be understood if they are to be changed. As many sociologists have observed, deviance from social norms has real consequences for individuals. Imagine yourself riding in an elevator filled with people you don’t know, with your back to the doors. It’s not easy to do. Morris notes, “Maternity providers may face professional consequences for deviance—for example, being informally scolded by colleagues, formally reprimanded by a supervisor, or having a malpractice insurer deny coverage in a case of a bad outcome” (p. 22). By talking to maternity clinicians about how they see the problems, and what they do about them, Morris is able to show how obstetricians are also caught in systems not of their own making.

“Hospitals are organizations with fixed rules to guide individual behavior” (p. 22) and this applies to all individuals within organizations. Morris has provided a nuanced and rich picture of what she calls the “organizational paradox, in which the increasing rates of c-section do not protect the health of women or babies or make birth safer or good outcomes more likely,” and argues that if we look at the c-section rate as the result of how health care organizations respond to their legal, political and economic environments, we can understand, and hopefully change, the system.

I found one of the most compelling sections of her argument in her discussion of the patient safety movement and its emphasis on standardized protocols, language and peer review. Until very recently, c-section rates were not considered part of the patient safety movement in obstetrics. Morris shows that when a hospital embarks on patient safety initiatives, with the goal of malpractice claims due to a bad baby outcome, these initiatives often result in an increase, or at best, no change in c-section rates.

Morris also reviews how doctors frame risks of VBAC vs. repeat c-section in ways that foreground the statistically rare risk of uterine rupture (indeed, the more dangerous rupture vs. the more common, but still rare, occurrence of uterine dehiscence). The more common risk to women of repeat c-section is often not included. Here we see how possible risks for the baby (and to the physician in the event of a bad outcome) are prioritized over risks to women’s health. Organization pressures influence how these risks are defined and described to women, says Morris.

“Any effort to resolve the c-section epidemic requires organizational solutions” (p. 153).

The stakes are high, and unless there is concerted and coordinated effort to reduce the c-section rate through organizational and policy change, we are unlikely to see a downward trend. Morris concludes, however, by listing what individual women and maternity clinicians can do to help solve the c-section epidemic. For women, this includes learning about and advocating for evidence-based care, with the assistance of independent childbirth educators and birth doulas, and finding maternity physicians and hospitals with low rates of c-section. Maternity providers, she notes, may find it helpful to be up front with women about the risks of childbirth, and that even with best of care, sometimes things go wrong. The policy and social changes Morris recommends are quite sweeping and it’s not clear where political will for these will come, but happily, there are some efforts being made on the organizational solutions she proposes. In particular reporting of c-sections as a quality measure will be required by The Joint Commission as of January 2014 for hospitals with more than 1100 births/year. A recent publication on Preventing the first cesarean delivery summarized the evidence from a joint workshop held by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists.

In this YouTube video, author Theresa Morris shares why she wrote Cut It Out: The C-Section Epidemic in America. 

Here are several more videos in the video series, where Theresa talks about the cesarean epidemic

This book is highly recommended for all childbirth educators, doulas and other maternity care professionals who wish to help pregnant women understand how the organization in which they are giving birth will likely shape both they, and their maternity clinicians’ actions. Yet, it also holds out the promise of hopeful change, especially when it is clear that many of these efforts are underway. With states seeking ways to drive down costs and with support from national government action focusing on maternal health, more pressure from payers, women and maternity care advocates, we can look forward to reducing c-sections and turning the tide of this epidemic. Let’s discuss what we can do to bring down the c-section rate.

About Christine Morton

Christine Morton

Christine Morton

Regular contributor Christine H. Morton, PhD, is a sociologist whose research on doulas is the topic of her forthcoming book, with Elayne Clift, Birth Ambassadors: Doulas and the Re-emergence of Woman-Supported Birth, which will be published by Praeclarus Press in Fall 2013. Christine is also a new member of Lamaze International’s Board of Directors. For more on Christine, please see Science & Sensibility’s Contributor page.

Babies, Book Reviews, Cesarean Birth, Childbirth Education, Evidence Based Medicine, Guest Posts, Maternal Quality Improvement, Maternity Care , , , , , , ,

Maternity Care On the National Agenda – New Opportunities for Educators and Advocates

January 17th, 2013 by avatar

Today, Amy Romano, CNM, MSN, Associate Director of Programs for Childbirth Connection (and former Community Manager for this blog) follows up last Thursday’s post, Have You Made the Connection with Childbirth Connection? Three Reports You Don’t Want to Miss with her professional suggestions for educators and advocates to consider using the data and information contained in these reports and offering your students, clients and patients the consumer materials that accompany them.- Sharon Muza, Community Manager.

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As we begin 2013, it is clear from my vantage point at the Transforming Maternity Care Partnership that the transformation is underway. In Childbirth Connection’s nearly century-long history, we’ve never seen so much political will from leaders, so much passion from grassroots advocates, and so much collaboration among clinicians and other stakeholders. This new landscape presents many new opportunities for educators and advocates.

One area of maternity care that has garnered increasing attention is the overuse of cesarean section, especially in low-risk women. Last year, the multi-stakeholder Maternity Action Team at the National Priorities Partnership set goals for the U.S. health care system and identified promising strategies to reach these goals. One of the goals was to reduce the cesarean section rate in low-risk women to 15% or less. This work served as the impetus for Childbirth Connection to revisit and update our Cesarean Alert Initiative. We undertook a best evidence review to compare outcomes of cesarean delivery with those of vaginal birth. Based on the results, we also updated and redesigned our consumer booklet, What Every Pregnant Woman Needs to Know About Cesarean Section. These are powerful new tools to help educators and advocates push for safer care, support shared decision making, and inform and empower women.

Two of the biggest obstacles to change have been persistent liability concerns and the current payment system that rewards care that is fragmented and procedure-intensive. Efforts to make maternity care more evidence-based or woman-centered often run up against policies and attitudes rooted in fear of lawsuits or increasing malpractice premiums, or against the reality that clinicians can not get easily reimbursed for doing the right thing. But these barriers are shifting, 

Recently the literature has provided example after example of programs that reduced harm and saw rapid and dramatic drops in liability costs as a result. That’s right – one of the best ways to decrease liability costs is to provide safer care. Rigorous quality and safety programs are the most effective prevention strategy among the ten substantive solutions identified in Childbirth Connections new report, Maternity Care and Liability. The report pulls together the best available evidence and holds potential liability solutions up to a framework that addresses the diverse aims of a high-functioning liability system that serves childbearing women and newborns, maternity care clinicians, and payers.  

The evidence and analysis show that some of the most widely advocated reforms do not stand up to the framework, while quality improvement programs, shared decision making, and medication safety programs, among other interventions, all have potential to be win-win-win solutions for women and newborns, clinicians, and payers. If we are to find our way out of the intractable situation where liability concerns block progress, we must learn to effectively advocate for such win-win-win solutions.  Advocates and educators can better understand these solutions by accessing the 10 fact sheets and other related resources on our Maternity Care and Liability page.

Evidence also shows that improving the quality of care reduces costs to payers. As payment reforms roll out, there will be many more opportunities to realize these cost savings. To predict potential cost savings, however, it is necessary to know how much payers are currently paying for maternity care. Surprising, this information has been largely unavailable, and as a result we have had to settle for using facility charges as a proxy. This is a poor proxy because payers negotiate large discounts, and because charges data do not capture professional fees, lab and ultrasound costs, and other services. Childbirth Connection, along with our partners at Catalyst for Payment Reform and the Center for Healthcare Quality and Payment Reform, recently commissioned the most comprehensive available analysis of maternity care costs. The report, The Cost of Having a Baby in the United States shows wide variation across states, high costs for cesarean deliveries, and rapid growth in costs in the last decade. It also shows the sky-high costs uninsured women must pay – costs that can easily bankrupt a growing family. Even insured women face significant out-of-pocket costs that have increased nearly four-fold over six years. Fortunately, health care reform legislation has made out-of-pocket costs for maternity care more transparent by requiring a simple cost sample to each person choosing an individual or employer-sponsored health plan.

Educators and advocates have to be able to help women be savvy consumers of health care. That means being informed about their options and also being able to identify and work around barriers to high quality, safe, affordable care. Childbirth Connection produced this trio of reports to provide a well of data and analysis to help all stakeholders work toward a high-quality, high-value maternity care system.

How Childbirth Educators and Consumer Advocates Can Help

 What is the first thing that you are going to do to join this maternity care transformation? Can you share your ideas for using this information in your classroom or with clients or patients.  Can you bring others on board to help with this much needed transformation?- SM

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Attitudes Drive Everything: With providers and women fearful of birth and operating in an evidence vacuum, the results are not wonderful

June 22nd, 2011 by avatar

Research by our UBC affiliated Child and Family Research Institute has revealed that the increase in Caesarean section rates across Canada may be largely due to the attitudes and beliefs of the obstetricians and other providers towards birth technology and Caesarean sections. 81 per cent of obstetricians 40 years or younger were women versus 40 per cent over 40 years of age. The attitudes and beliefs vary by age of practitioner. In contrast to their older counterparts, younger obstetricians were significantly more likely to favour a hospital based medically managed birth and the routine use of epidural analgesia in normal births. They were less likely to support vaginal birth after Caesarean section or to appreciate the importance of mothers’ role in their own birth. They also appeared to be more “fearful” of the consequences of vaginal birth, particularly in relation to urinary incontinence and sexual problems and more likely to select Caesarean section for their own births. Older obstetricians, the majority of which are male, were more supportive of a woman-centered model of care, more positive about birth plans, and were more likely to see vaginal birth as more empowering to the mother than Caesarean section. (1) The finding that younger obstetricians, who are mostly women, appeared to have less appreciation of the role of a woman in her own birth than older usually male obstetricians is counterintuitive and requires further study. These attitudes appear related to experiences in training rather than to gender, as younger male obstetricians have attitudes similar to their female counterparts. Without addressing the educational system, attitudes will be difficult to change.

Another study by our group (2) found that clients of midwives, were more supportive of women’s roles in their own deliveries and less likely to support the use of technology, compared to physicians’ patients. It should be noted that regardless of the type of care provider, many women reported inadequate knowledge of common procedures. Women’s lack of knowledge about procedures such as epidural analgesia, Caesarean section and episiotomy, raise concerns about prenatal education and prenatal care. Attendance at prenatal education classes is decreasing in all regions of Canada and most pregnant women indicated they use health care providers, books and the internet as their main sources of prenatal information. (2) When combined with evidence on the nature of obstetrical power and control, and research showing that many providers are not evidence-based in their views, (3) this suggests that even a woman with strong values and beliefs could find it challenging to assert her choices in the professionally controlled process of birth. Women, especially first time mothers, who do not have evidence-based knowledge, are likely to be particularly sensitive to negative attitudes toward birth procedures and processes, from providers and other sources.

A third study from our group found that family doctors who do not provide intrapartum care have more negative attitudes toward birth and are less evidence-based about what is going on in the delivery suite. (4) Since this group provides more than 50% of the antenatal care in Canada, efforts to keep them up to date need to be implemented, lest they transmit their negative attitudes to women before transfer for birth care to other providers.

Finally as Caesarean section rates are steeply rising, with BC having the highest rates in Canada, and for the first time, maternal mortality and morbidity rates are increasing in the US and Canada due to overuse of Caesarean sections, (2)it is time for the public to realize that Caesarean section, while life-saving when needed, is not as safe a vaginal birth (5-7), and it is not just another way to have a baby.

And lest you think that this is a Canadian problem, the educational and training systems for medical students and obstetrical and family practice residents is the same both sides of the border. Educational, rather than health care models, trumps evidence. We are teaching directly and indirectly that childbirth is just an opportunity for things to go wrong. Medical students, obstetrical and family practice residents rarely see normal birth, and they are not exposed to midwives in hospital or at home births. It is going to take a revolution driven by women to change this, as practitioners are not going to change very soon. To the barricades!

Posted by:  Michael Klein, MD

[Editor's note:  As an example of the debate Dr. Klein introduces here, proposing that Caesarean birth is "not just another way to have a baby," check out this article in today's edition of The Sun, questioning whether or not Caesarean birth is "normal."]

 

References

 

1.         Klein M, Liston R, Fraser W, Baradaran N, Hearps S, Tomkinson J, et al. The attitudes of the new generation of Canadian obstetricians: how do they differ from their predecessors. Birth. 2011.

2.         Klein M, Kaczorowsk J, Hearps S, Tomkinson J, Baradaran N, Hall W, et al. Birth technology and maternal roles in birth: knowledge and attitudes of Canadian women approaching childbirth for the first time. JOGC. 2011(June):598-608.

3.         Klein M, Kaczorowski J, Hall W, Fraser W, Liston R, Eftekhary S, et al. The Attitudes of Canadian Maternity Care Practitioners Towards Labour and Birth: Many Differences But Important Similarities. Journal of Obstetrics & Gynaecology Canada: JOGC. 2009;31(9 ):827-40.

4.         Klein M, Kaczorowski J, Tomkinson J, Hearps S, Baradaran N, Brant R. Family physicians who provide intrapartum care and those that do not: very different ways of viewing childbirth. Can Fam Phys. 2011 57(4):e139-e47.

5.         SOGC. Joint Policy Statement on Normal Childbirth. JOGC. 2008;221(December):1163-5.

6.         SOGC. C-sections on demand—: SOGC’s position. [Press Release].  Society of Obstetricians and GynecologistsMar 10, 2004.

7.         Liu S, Liston RM, Joseph KS, Heaman M, Sauve R, Kramer MS, et al. Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. Cmaj. 2007 February 13, 2007;176(4):455-60.

 

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