…is up! Go check it out at Giving Birth with Confidence. What a PHENOMENAL collection of contributions about the moments, hours, and days after birth. Each of our Blog Carnivals has vastly surpassed my own expectations. I hope you’ll agree.
I have felt a little bit like a slacker blogger lately, but it’s not for lack of thinking and writing about birth. I just wrapped up an article called Social Media, Power, and the Future of VBAC with Hilary Gerber from Mom’s Tinfoil Hat and Desirre Andrews from Preparing for Birth which we submitted to the 50th anniversary “Looking Back – Looking Forward” special issue of Lamaze’s Journal of Perinatal Education. I’ve also been working with Kristen Oganowski from Birthing Beautiful Ideas to coordinate the development of an NIH VBAC Statement Primer for consumers. We have a bunch of brilliant contributors on board and will be launching the primer later this month at Lamaze’s new (very cool!) social networking site for women, Giving Birth with Confidence.
Now the big looming work comes in the form of conference season. And I want you (yes YOU) to help me. I have a love-hate relationship with conferences. Mostly love. I love how much sharing, connecting, and learning happens. I love finding out what old friends and colleagues are up to and meeting the people doing the most interesting, innovative, and important work in the field. But attending (and especially speaking at) a conference is a lot of work, and often disrupts progress in my other (equally if not more important) work. Also, I hate that conferences take me away from my family.
So…I want to make the most of the opportunities these conferences offer. I want to maximize the amount of sharing, connecting, and learning we – collectively – do. And I want to leave these conferences not with tons of new projects and commitments for myself, but with tons of new opportunities for the broader maternity care community (that means YOU) to drive meaningful improvements for women, infants, and families.
Here’s some more about the conferences I’m attending, and how YOU can be part of them.
On June 7 I’ll be at Health 2.0 Goes to Washington.
Um, have I mentioned lately that I think social media is going to transform maternity care? Well I developed this delirious optimism by hanging around (online) with the Participatory Medicine crowd. I get to actually meet most of them next week!
I first caught on to the Participatory Medicine train when I read a Grand Rounds blog carnival on the theme of “Meaningful Use” almost exactly a year ago. “Meaningful Use” is government speak for the goal of implementing electronic health records (with piles and piles of stimulus money) in a manner that actually improves care. The Participatory Medicine folks are front and center in the conversation, pushing for patient-access to be the defining characteristic of meaningful. It’s all about liberating the mounds of data that will exist in electronic health records and letting innovators, policy-makers, scientists, and – most importantly – patients themselves use that data to improve health.
I have 10 minutes to speak but a whole day to connect and learn. Here are my questions for you to help me make the most of this opportunity:
The following week (June 12-16), I’ll be at the American College of Nurse-Midwives Annual Meeting.
I’m only attending ACNM for one day, but traveling with my family for my kids’ first-ever trip to the nation’s capitol. I’m giving two educational sessions that couldn’t be more different from one another. First, I’m presenting a talk called, “How Not to Get Duped by Obstetric Research” about the importance of thinking critically about evidence, and how honing critical analysis skills can can help midwives practice and advocate for safe and effective care. The other talk is a panel discussion with Amie Newman from RH Reality Check and Mary Murry, CNM, from The Mayo Clinic “Pregnancy Week by Week Blog,” moderated by Melissa Garvey from ACNM’s own Midwife Connection Blog. We’ll be talking about why more midwives should be blogging and how they can get started. We recorded a really lively discussion about these issues on The Feminist Breeder & Friends Radio Show on International Day of the Midwife – a preview of our ACNM panel – which you can listen to here:
My questions for YOU:
Lastly but Oh-So-Not-Leastly, I’ll be attending the Normal Labour and Birth 5th International Research Conference in July.
I’m not speaking at this conference. I’m going for the sole purpose of blogging it! I wrote a proposal to the conference organizers suggesting that they let me attend and help disseminate the proceedings. They agreed! I think this is a huge opportunity to learn from the people doing the research about how to optimize the health and safety of healthy women and their babies around the time of birth. We’ll also hear from leaders who are creating and maintaining integrated, midwife-led primary maternity care systems, the gold standard for achieving “woman-centered, safe, effective, timely, efficient, and equitable” care.
What happened when bloggers and other connected consumers attended the NIH Consensus Development Conference on VBAC was astounding and continues to deliver. Since that experience, I’m addicted to putting scientific findings in the hands of engaged, connected consumers, because, as Kay Dickerson from the Cochrane Collaboration says, “We’ll only get evidence-based healthcare in this country through consumer activism.” Today activists have more access than ever before to information and are getting increasingly social media savvy. There’s no telling what we can do if we put our innovative, passionate minds to it and work collaboratively.
So here’s what I want to know from YOU:
Finally, any readers who are planning to attend any of these conferences – I invite you to submit a guest post. I’d love to share multiple perspectives (not to mention the tremendous work of blogging all of these meetings!) Just email me at amyromano [at] Lamaze [dot] org.
The Institute for Healthcare Improvement (IHI), the leading nonprofit organization working to accelerate change in healthcare, has been in the news this month because its CEO, Donald Berwick, was recently nominated to head up the Centers for Medicare and Medicaid Services. (For those not familiar with Berwick, read his phenomenal article, “What ‘Patient-Centered’ Should Mean: Confessions of an Extremist“). Berwick himself and IHI’s Managing Director, Sue Gullo, RN, were key players in the recent Transforming Maternity Care Project coordinated by Childbirth Connection. Now, the IHI is rolling out programs to help hospitals and health care systems implement some of the work put forth in the project’s Blueprint for Action. These initiatives also coincide with the new Joint Commission perinatal core measures which hospitals may implement as of this month. Here’s what is on offer so far:
To keep up with other IHI offerings, you can follow them on Facebook or Twitter
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.
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.
