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The Healthy Birth: Dyad or Triad? Exploring Birth and the Microbiome

April 28th, 2015 by avatar

By Anne Estes, PhD, Illustrated by Cara Gibson, PhD

There has been much discussion and burgeoning research on how the mode of birth affects the microbiome of the infant (and later on the adult).  It is becoming clear that how babies are born impacts the type of bacteria that take up residence in and on our bodies. Today, I would like to welcome researcher and writer Anne Estes, PhD, and researcher and illustrator Cara Gibson, PhD to Science & Sensibility.  Anne shares information on the research into a newborn’s (and later on the adult) microbiome and how it can be affected by the location of birth, the type of birth and the interventions that occur during birth.  Learn more about what this new field of research is telling us about the importance of the microbiome. Stay tuned for a future interview by Anne, with some of the research scientists attempting to supplement the microbiome of infants delivered by planned Cesareans. – Sharon Muza, Science & Sensibility Community Manager

Birth plans often change. Neither my husband nor I anticipated the series of interventions with my first daughter’s birth. In the end, though we had the most important outcome – a healthy mom and baby dyad. How did these interventions influence the health of the third, silent, and invisible member of my daughter’s birth that I hadn’t included in her birth plan – her microbiome?

The helpful and harmful bacteria, viruses, and fungi that live in and on every environment, both living and nonliving, are the microbiome of that environment. The bacterial component of the microbiome is best understood to date and will be this post’s focus. An organism’s microbiome influences the development and health of those animals and plants, whereas the microbiome of soil and buildings influence organisms that reside in those non-living environments. Our helpful microbes provide services that range from vitamin synthesis and food degradation to preventing attacks by pathogens. However, in the last few centuries of human-microbe interactions, changes in our birth and medical practices and living conditions may have altered the acquisition of our microbial communities. Our altered microbiomes, especially in the industrialized world, may help explain the increase in allergies, asthma, diabetes, gastrointestinal diseases, and mental disorders, such as depression, anxiety, and autism.

Humans as ecosystems for microbes

To a bacterium, you are a planet made up of several different ecosystems. From the dry, UV-intense “deserts” of your skin to the warm, wet, nutrient-rich “lakes” of your mouth, specific bacteria live in different regions on a person, just as specific vertebrate animals live in different ecosystems on the Earth. As ecosystems of the human environment change during development, pregnancy, or with changing diets, which bacterial species remain or how these microbial species function may shift is slowly becoming understood. How do we first acquire these microbes? Previous posts here and other blogs have done excellent reviews of the human microbiome and birth, so my post will serve to provide updates and pose new questions for consideration.

Fig1_MapLadies6

 

The source of the infant microbiome

The infant microbiome is acquired during birth [1, 2], from first foods [3-5], and the environment [6], and may also be partially colonized in utero [7]. The Fig2_MicrobirthVagvC5microbiome of infants born vaginally most closely represents the microbiome of the mother’s vagina and feces [1], and is rich in beneficial bacteria such as Bifidobacterium longum subsp. infantis and Bacteroidetes [8, 9]. In contrast, the microbiome of infants born via planned Cesarean is more similar to that of the mother’s skin and hospital environment [1]. The microbiomes of planned Cesarean-born infants are more likely to have hospital-acquired pathogens such as Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA), and pathogenic Es. coli [1] and lack beneficial Bacteroidetes and Bi. longum subsp. infantis [10]. However, when beneficial Bifidobacterium were occasionally present in Cesarean-born infants, pathogenic Es. coli and C. difficile were not found [11] suggesting that one benefit of Bifidobacterium, especially Bi. longum subsp. infantis, may be outcompeting these potential pathogens.

Influence of birth mode on microbiome transmission

Repeatedly, studies in different countries, ethnic groups, ages, and health status have suggested that planned Cesarean-born infants are more likely to have more health issues and a different microbiome, as compared to vaginally born infants [2, 10, 12-14]. These differences in community composition can even be seen in adulthood [15]. A new Canadian study finds that the microbiome of infants born via unplanned Cesarean had increased bacterial richness and diversity, more similar to that of vaginally born infants than planned Cesarean [10]. Unfortunately, this was only a small study where fewer than ten mother-infant pairs were examined. Several variables such as length of time in labor or how far labor progressed, antibiotic use, natural vs. artificial rupture of membranes, and/or other interventions that may influence the microbiome were also not examined [10]. However, it does suggest that the process of labor, perhaps the hormonal or other physiological changes, may influence the microbiome. Additionally, some maternal bacteria may be transmitted when membranes rupture during labor [10]. Are bacteria “eavesdropping” on the chemical changes in the human to prepare themselves for transmission to the baby? Do these maternal hormone changes lead to increased vaginal or gut epithelial sloughing to transmit more or specific bacteria? Certainly, studies with larger sample sizes that can help control for these variables along with experimental studies on model animals are warranted.

Influence of birth place on microbiome transmission

Infants also acquire a proportion of their microbiome from their physical, inanimate surroundings. What proportion of the microbiome and which bacteria are acquired most likely depends on how many and what kinds of bacteria are acquired in utero, through birth method, and first foods. Since Cesarean delivered infants seem to be exposed to a lower density of maternal bacteria than vaginally delivered babies, the former may be more likely to acquire bacteria from their environment. However, this hypothesis has not been examined.

Fig3_Locations4

Just as living organisms are a microbial environment, so are non-living structures such as buildings. Scientists at several universities working together on The Microbiology of the Built Environment Project funded by the Sloan Foundation are comparing the microbes of homes and hospitals. They have found that buildings are quickly colonized by the microbes of the people living in them [16]. Such rapid colonization specific to the individual being housed is even seen in infants in the neonatal intensive care unit (NICU) [17, 18] . One group is surveying the microbiome of a hospital over time, as it is being built and then occupied. Hospital-acquired infections are an increasing concern for all patients, especially newborns. Infants born by Cesarean have an increased rate of MRSA, C. difficile, and other opportunistic pathogens [1]. However, different hospitals and even wards within a hospital might be expected to have disparate levels of pathogens depending on how prevalent the disease is within the hospital patients and staff. Whether freestanding birth centers, operating rooms dedicated to labor-and-delivery only, and mixed-use operating rooms have dissimilar microbiomes has yet to be investigated. Infants born in private homes would be exposed to the same microbiomes of members of the household.

Influence of first foods on microbiome transmission

First foods are a third source of the infant microbiome. Breastfed infants have two “moms:” their human mother and their Milk-Oriented Microbiota (MOM). The MOM are a diverse group of about 200 species of beneficial bacteria transmitted via breast milk and fed by the breast milk sugars. Fig4_MicrobirthBreastvBottle5The average breastfed baby receives between 1 and 10 million bacteria daily from their mother’s milk – quite the bacterial soup [5]! The bacterial diversity and concentrations of specific bacteria change dramatically between colostrum and mature milk with colostrum having over 1,000 different bacterial types [4]. The milk microbiome is a unique assemblage of bacteria, different from human skin, gut, oral, vaginal, and other specific site microbiomes [4]. Although only ten women were followed, it is intriguing that the milk microbiome of women delivering via planned Cesarean at birth, one month, and six months post-birth, was more similar to their gut microbiome than the breast milk of mothers who delivered vaginally [4]. Milk of mothers undergoing unplanned Cesarean and vaginally delivering mothers were most similar [4]. Breast milk also includes the food, or prebiotics, for the developing infant microbiome. Sugars found in breast milk, the human milk oligosaccharides (HMOs), differ in sugar types and concentrations between pre-term and full term birth, vaginally delivering and planned Cesarean births (reviewed in [19]), and even between mothers with different types of “secretor” genes [20]. These HMOs are digested by the microbes, not the infant. Additionally, the changes in sugar types and concentrations seem to influence bacterial diversity, keeping strains of Bifidobacterium longum subsp infantis in highest abundance in the first few months of life [19]. How the presence of different microbes influences the developing infant immune system has yet to be determined.

Formula-fed babies have a more diverse and rich microbiome than breast-fed babies, with lower numbers of Bifidobacterium and higher abundances of Peptostreptococcaceae, which includes C. difficile [10, 21]. Gut bacterial diversity is essential in increasing the ability of adults to digest a wide variety of foods. However, bacterial diversity may be detrimental in the infant stage when the immune system is developing and learning to distinguish between microbes that are friends and those that are foes. Breast milk sugars may mediate the relative abundances of different bacterial species [22]. Through studies like the Milk Bioactives Program at University of California at Davis, more is learned about the interaction between breast milk sugars and specific bacteria that can lead to better probiotic and prebiotic formulas and improve infant health.

Influence of in utero environment on microbiome transmission

Many other factors surrounding birth may influence the infant microbiome. High levels of reported maternal stress and high cortisol concentrations during pregnancy, correlated with lower relative abundances of beneficial Lactobacillus and Bifidobacterium sp. and higher abundances of Proteobacteria, such as Enterobacter and Escherichia. Infants of these highly stressed mothers had increased reports of gastrointestinal symptoms and allergic reactions, though these issues were reported by caregivers, not physicians, which may confound the findings [23]. A separate study found infants whose gestation lengths were less than 38 weeks had microbiome communities that were low in Bifidobacterium and took three to six months to reach a normal Bifidiobacterium-rich community as compared to infants born at 40 or more weeks [9]. Finally, the use of antibiotics during pregnancy [12] may also lead to infant health issues.

Do birth interventions change the microbiome?

The potential “eavesdropping” of bacteria on human hormones during pregnancy and labor lead me to wonder how the use of synthetic hormones such as Pitocin, especially during stalled labor, might influence the microbiome and overall infant health. There are so many variables to the birth process that many of these questions could only be answered with extremely detailed data of tens of thousands of mother-infant-microbiome triads over time. The influence of interventions such as epidurals, frequency of cervical checks, vaginal preparation with betadine, enemas, and other procedures used during labor and delivery also have not been extensively examined. In general, any procedure that “sterilizes” or cleans the vaginal and rectal area would most likely decrease the transmission of the mother’s microbial community. Whether cervical checks introduce skin or environmental microbes to the infant should also be considered. Finally, what effect does postponing baby’s first bath until 24 or 48 hours after birth have on microbial colonization? What role does the vernix have in facilitating the colonization of the infant’s microbiome?

From lab bench to birth room

Antibiotics, Cesarean delivery, and other interventions are valuable and life-saving for many women and infants; however, as they have become more commonly used we have seen an increase in many long-term diseases and disorders. Recent microbiome research suggests that we should consider birth as delivering and nurturing a healthy triad – mom, infant, and microbiome. Currently, studies are being conducted to swab Cesarean delivered infants with vaginal secretions immediately after birth. Should fecal microbiome members also be considered? If hormone surges are important for the microbiome transmission during labor and in breast milk, as the unplanned Cesarean data suggest, how could the natural hormone surges of labor be mimicked for planned Cesarean? When antibiotics are needed for mother or infant, how best can we quickly repopulate the disturbance to the native microbiome?

Humans, and all organisms, are planets with diverse ecosystems. In sequencing of the human genome, we learned that diseases rarely correlated to specific human genes. Most likely instead of focusing on only the human or only the microbes, we should be examining the intersection between human genomics and microbiome structure and function to best understand health and disease of human-microbe ecosystems. Both human genomics and microbiome work are in their infancy (pun intended). Researchers examine correlations to develop testable hypotheses that can be examined in non-human animal models. Yet many of the microbes of interest are currently unable to be cultivated for direct testing or probiotic use. At this time, directly translating research findings to the delivery room is difficult, but I hope that this post will stimulate thought and conversations about the silent, invisible, yet important third member of human birth and life.

References

  1. Dominguez-Bello, M. G., E. K. Costello, M. Contreras, M. Magris, G. Hidalgo, N. Fierer, and R. Knight. 2010. Delivery mode shapes the acquisition and structure of the initial microbiota across multiple body habitats in newborns. Proceedings of the National Academy of Sciences 107:11971-11975.
  2. Mueller, N. T., E. Bakacs, J. Combellick, Z. Grigoryan, and M. G. Dominguez-Bello. 2015. The infant microbiome development: mom matters. Trends in Molecular Medicine 21:109-117.
  3. Zivkovic, A. M., J. B. German, C. B. Lebrilla, and D. A. Mills. 2011. Human milk glycobiome and its impact on the infant gastrointestinal microbiota. Proceedings of the National Academy of Sciences 108:4653-4658.
  4. Cabrera-Rubio, R., M. C. Collado, K. Laitinen, S. Salminen, E. Isolauri, and A. Mira. 2012. The human milk microbiome changes over lactation and is shaped by maternal weight and mode of delivery. The American Journal of Clinical Nutrition 96:544-551.
  5. Fernández, L., S. Langa, V. Martín, A. Maldonado, E. Jiménez, R. Martín, and J. M. Rodríguez. 2013. The human milk microbiota: Origin and potential roles in health and disease. Pharmacological Research 69:1-10.
  6. Thompson, A. L., A. Monteagudo-Mera, M. B. Cadenas, M. L. Lampl, and M. A. Azcarate-Peril. 2015. Milk- and solid-feeding practices and daycare attendance are associated with differences in bacterial diversity, predominant communities, and metabolic and immune function of the infant gut microbiome. Frontiers in Cellular and Infection Microbiology 5.
  7. Prince, A. L., D. M. Chu, M. D. Seferovic, K. M. Antony, J. Ma, and K. M. Aagaard. 2015. The Perinatal Microbiome and Pregnancy: Moving Beyond the Vaginal Microbiome. Cold Spring Harbor Perspectives in Medicine.
  8. Jost, T., C. Lacroix, C. P. Braegger, and C. Chassard. 2012. New Insights in Gut Microbiota Establishment in Healthy Breast Fed Neonates. PLoS ONE 7:e44595.
  9. Dogra, S., O. Sakwinska, S.-E. Soh, C. Ngom-Bru, W. M. Brück, B. Berger, H. Brüssow, Y. S. Lee, F. Yap, Y.-S. Chong, et al. 2015. Dynamics of Infant Gut Microbiota Are Influenced by Delivery Mode and Gestational Duration and Are Associated with Subsequent Adiposity. mBio 6.
  10. Azad, M. B., T. Konya, H. Maughan, D. S. Guttman, C. J. Field, R. S. Chari, M. R. Sears, A. B. Becker, J. A. Scott, and A. L. Kozyrskyj. 2013. Gut microbiota of healthy Canadian infants: profiles by mode of delivery and infant diet at 4 months. Canadian Medical Association Journal 185:385-394.
  11. Musilova, S., V. Rada, E. Vlkova, V. Bunesova, and J. Nevoral. 2015. Colonisation of the gut by bifidobacteria is much more common in vaginal deliveries than Caesarean sections. Acta Paediatrica 104:e184-e186.
  12. Mueller, N. T., R. Whyatt, L. Hoepner, S. Oberfield, M. G. Dominguez-Bello, E. M. Widen, A. Hassoun, F. Perera, and A. Rundle. 2014. Prenatal exposure to antibiotics, cesarean section and risk of childhood obesity. Int J Obes.
  13. Neu, J., and J. Rushing. 2011. Cesarean versus Vaginal Delivery: Long term infant outcomes and the Hygiene Hypothesis. Clinics in perinatology 38:321-331.
  14. van Nimwegen, F. A., J. Penders, E. E. Stobberingh, D. S. Postma, G. H. Koppelman, M. Kerkhof, N. E. Reijmerink, E. Dompeling, P. A. van den Brandt, I. Ferreira, et al. 2011. Mode and place of delivery, gastrointestinal microbiota, and their influence on asthma and atopy. J Allergy Clin Immunol 128:948-55 e1-3.
  15. Goedert, J. J., X. Hua, G. Yu, and J. Shi. 2014. Diversity and Composition of the Adult Fecal Microbiome Associated with History of Cesarean Birth or Appendectomy: Analysis of the American Gut Project. EBioMedicine 1:167-172.
  16. Lax, S., D. P. Smith, J. Hampton-Marcell, S. M. Owens, K. M. Handley, N. M. Scott, S. M. Gibbons, P. Larsen, B. D. Shogan, S. Weiss, et al. 2014. Longitudinal analysis of microbial interaction between humans and the indoor environment. Science 345:1048-1052.
  17. Brooks, B., B. Firek, C. Miller, I. Sharon, B. Thomas, R. Baker, M. Morowitz, and J. Banfield. 2014. Microbes in the neonatal intensive care unit resemble those found in the gut of premature infants. Microbiome 2:1.
  18. Raveh-Sadka, T., B. C. Thomas, A. Singh, B. Firek, B. Brooks, C. J. Castelle, I. Sharon, R. Baker, M. Good, M. J. Morowitz, et al. 2015. Gut bacteria are rarely shared by co-hospitalized premature infants, regardless of necrotizing enterocolitis development, vol. 4.
  19. Smilowitz, J. T., C. B. Lebrilla, D. A. Mills, J. B. German, and S. L. Freeman. 2014. Breast Milk Oligosaccharides: Structure-Function Relationships in the Neonate. Annual Review of Nutrition 34:143-169.
  20. Lewis, Z., S. Totten, J. Smilowitz, M. Popovic, E. Parker, D. Lemay, M. Van Tassell, M. Miller, Y.-S. Jin, J. German, et al. 2015. Maternal fucosyltransferase 2 status affects the gut bifidobacterial communities of breastfed infants. Microbiome 3:13.
  21. Bezirtzoglou, E., A. Tsiotsias, and G. W. Welling. 2011. Microbiota profile in feces of breast- and formula-fed newborns by using fluorescence in situ hybridization (FISH). Anaerobe 17:478-482.
  22. Guaraldi, F., and G. Salvatori. 2012. Effect of Breast and Formula Feeding on Gut Microbiota Shaping in Newborns. Frontiers in Cellular and Infection Microbiology 2:94.
  23. Zijlmans, M. A. C., K. Korpela, J. M. Riksen-Walraven, W. M. de Vos, and C. de Weerth. 2015. Maternal prenatal stress is associated with the infant intestinal microbiota. Psychoneuroendocrinology 53:233-245.

About Anne Estes

AnneMEstes_headshot 2015Anne M. Estes, PhD is a postdoctoral fellow at the Institute for Genome Sciences in Baltimore, MD. She is interested in how microbes and their host organisms work together throughout host development. Anne blogs about the importance of microbes, especially during pregnancy, birth, first foods, and early childhood at Mostly Microbes.

 

 

About Cara Gibson

cara gibson head shot 2015Cara Gibson, BSc (Hon), MS, PhD was trained as an entomologist (insect scientist) and her interests include ecology, biodiversity, and interactions with microbial symbionts. She has worked as a field ecologist, research scientist, educator, outreach coordinator, and scientific illustrator. Dr. Gibson would like to help bridge the gap between current practices and new research to improve women’s health and birth outcomes. Contact Cara at caramgibson at gmail dot com for illustration inquiries / permissions.

 

 

 

 

Babies, Breastfeeding, Cesarean Birth, Childbirth Education, Evidence Based Medicine, Guest Posts, New Research, Newborns , , , , , ,

Exclusive Q&A with Rebecca Dekker – What Does the Evidence Say about Induction for Going Past your Due Date?

April 15th, 2015 by avatar

What does the evidence say about dueToday on Evidence Based Birth, occasional contributor Rebecca Dekker, Phd, RN, APRN, provides a comprehensive research review –  Induction for Going Past your Due Date: What does the Evidence Say?  I had an opportunity to preview the article and ask Rebecca some questions about her most recent project on due dates. I would like to share our conversation here on Science & Sensibility with all of you. Rebecca’s website has become a very useful tool for both professionals and consumers to read about current best practice.Consumers can gather information on the common issues that they maybe dealing with during their pregnancies. Professionals can find resources and information to share with students and clients.  How do you cover the topic of inductions at term for due date?  After reading today’s S&S post and Rebecca’s research post, do you think you might share additional information or change what you discuss?  Let us know in the comments section.- Sharon Muza, Community Manager, Science & Sensibility.

Note: if the Evidence Based Birth post is not up yet, try again in a bit, it should be momentarily.

Sharon Muza: Why did you decide to tackle the topic of due dates as your next research project and blog post?

Rebecca Dekker: Last year, I polled my audience as to what they would like me to write about next. They overwhelmingly said that they wanted an Evidence Based Birth article about Advanced Maternal Age (AMA), or pregnancy over the age of 35. As I started reviewing the research on AMA, it became abundantly clear to me that I had to first publish an article all about the evidence on due dates. This article on induction for due dates creates a solid foundation on which my readers can learn about induction versus waiting for spontaneous labor in pregnant women who are over the age of 35.

SM: When you started to dig into the research, were there any findings that surprised you, or that you didn’t expect?

RD: There were two topics that I really had to dig into in order to thoroughly understand.

The first is the topic on stillbirth rates. I began to understand that it’s really important to know which mathematical formula researchers used to calculate stillbirth rates by gestational age. It was interesting to read through the old research studies and letters to the editors where researchers argued about which math formulas were best. In the end, I had to draw up diagrams of the different formulas (you can see those diagrams in the article) for the formulas to make sense in my head, and once I did, the issue made perfect sense!

Before 1987 (and even after 1987, in some cases) researchers really DID use the wrong formulas, and it’s kind of funny to think that for so many years, they used the wrong math! In general, I thought the research studies on stillbirth rates by gestational age were really interesting…it raised questions for me that I couldn’t answer, like why are the stillbirth rates so different at different times and in different countries? Also, it was really clear from the research that stillbirth rates are drastically different depending on whether you are looking at samples that include or don’t include babies who are growth-restricted.

The other big breakthrough or “ah ha” moment I had was when I finally realized the true meaning of the Hannah (1992) Post-Term study. There was such a huge paradox in their findings… why did they find that the expectant management group had HIGHER Cesarean rates, when clinicians instinctively know that inductions have higher Cesarean rates compared to spontaneous labor? Since all of the meta-analyses rely heavily on the Hannah study, I knew I needed to figure this problem out.

There are a couple different theories in the literature as to why there were higher C-section rates in the expectant management group in Hannah’s study. One theory is that the induction group had Prostaglandins to ripen the cervix, while the expectant management group did not. However, in a secondary data analysis published by Hannah et al. in 1996, they found that this probably played just a minor role.

Another theory is that as women go further along in their pregnancy, physicians get more nervous about the risk of stillbirth, and so they may be quicker to recommend a Cesarean in a woman who is past 42 or 43 weeks, compared to one who is just at 41 weeks. This theory has been proposed by several different researchers in the literature, and there is probably some merit to it.

But in the end, I found out exactly why the C-section rates are higher in the expectant management group in the Hannah Post Term study (and thus in every meta-analysis that has ever been done on this topic). Don’t you want to know why? I finally found the evidence in Hannah’s 1996 article called “Putting the merits of a policy of induction of labor into perspective.” The data that I was looking for were not in the original Hannah study… they were in this commentary that was published several years later.

dekker headshotThe reason that Cesarean rates were higher in the expectant management group in the Hannah study is because the women who were randomly assigned to wait for spontaneous labor, but actually ended up with inductions, had Cesarean rates that were nearly double of those among women who had spontaneous labor. Some of these inductions were medically indicated, and some of them were requested by the mother. In any case, this explains the paradox. It’s not spontaneous labor that leads to higher Cesarean rates with expectant management… the higher Cesarean rates come from women who wait for spontaneous labor but end up having inductions instead. 

So the good news is that if you choose “expectant management” at 41-42 weeks (which is a term that I really dislike, because it implies that you’re “managing” women, but I digress), your chances of a Cesarean are pretty low if you go into spontaneous labor. But if you end up being one of the women who waits and then later on chooses to have an induction, or ends up with a medically indicated induction, then your chances of a Cesarean are much higher than if you had just had an elective induction at 41 weeks.

SM: What information do you recommend that childbirth educators share to help families make informed decisions about inductions and actions to take as a due date comes and then even goes, and they are still pregnant.

RD: First of all, I think it’s important for all of us to dispel the myth of the 40 week due date. There really is no such thing as a due date. There is a range of time in which most women will go into labor on their own. About half of women will go into labor by 40 weeks and 5 days if you’re a first-time mom (or 40 weeks and 3 days if you’ve given birth before), and the other half will go into labor after that.

The other thing that it is important for childbirth educators to do is to encourage families—early in pregnancy—to talk with their health care provider about when they recommend induction, and why.

There are some health care providers who believe strongly that induction at 39, 40, 41, or 42 weeks reduces the risk of stillbirth and other poor outcomes. There are parents who have the same preference. Then there are other health care providers who believe strongly that induction for going past your due date is a bad thing, and shouldn’t be attempted unless there are clear medical reasons for the induction. And there are parents who will tend to share that same preference. Either way, parents need accurate information about the benefits and risks of waiting versus elective induction at 41-42 weeks—because both are valid options.

But it’s probably best to avoid a mismatch between parents and providers. If parents believes strongly that they want to wait for spontaneous labor, and they understand the risks, but they have a care provider who believes strongly in elective induction at 41 weeks, then they will run into problems when they reach 41 or 42 weeks and their care provider disagrees with their decision.

Clearly, there are benefits to experiencing spontaneous labor and avoiding unnecessary interventions. But at the same time there is a rise in the relative risk of stillbirth starting at about 39 weeks, depending on which study you are looking at. However, the overall risk is still low up until 42 weeks. At 42 weeks, the risk of stillbirth rises to about 1 in 1,000 in babies who are not growth-restricted. The risk may be higher in some women who have additional risk factors for stillbirth. Women who experience post-term pregnancy (past 42 weeks) are more likely to experience infections and Cesareans, and their infants are more likely to experience meconium aspiration syndrome, NICU admissions, and low Apgar scores.

SM: Would you recommend that families have conversations about how their due date is being calculated, at the first prenatal with their health care providers. What should that conversation include?

RD: I would recommend asking these questions:

  • What is the estimated date range that I might expect to give birth—not based on Naegele’s rule, but based on more current research about the average length of a pregnancy?
  • Did you use my Last Menstrual Period or an early ultrasound to determine my baby’s gestational age?
  • Has my due date been changed in my chart at any point in my pregnancy? If so, why?

SM: The concept of being “overdue” if still pregnant at the due date is firmly ingrained in our culture. What do you think needs to happen both socially and practically to change the way we think about the “due date?”

RD: We need to start telling everyone, “There is no such thing as a due date.” To help women deal with the social pressure they may experience at the end of pregnancy, I’ve created several Facebook profile photos that they can use as their Facebook profile when they get close to their traditional “due date.” To download those photos, visit www.evidendebasedbirth.com/duedates

SM: How available and widely used are first trimester ultrasounds? If first trimester ultrasounds were done as the standard of care in all pregnancies, would it result in more accurate due dates and better outcomes? Do you think there should be a shift to that method of EDD estimation?

RD: I think the option of having a first trimester ultrasound definitely needs to be part of the conversation between a woman and her care provider, especially because it has implications for the number of women who will be induced for “post-term.” I could not find any data on the percentage of women who have an ultrasound before 20 weeks, but in my geographic area it seems to be nearly 100%, anecdotally.

If your estimated due date is based on your LMP, you have a 10% chance of reaching the post-term period, but if it’s based on an early ultrasound, you only have a 3% chance of reaching 42 weeks.

One strange thing that I noted is that ACOG still prefers the LMP date over an early ultrasound date. They have specific guidelines in their practice bulletin about when you need to switch from the LMP date to an ultrasound date, but the default date is still the LMP. I found that rather odd, since research is very clear that ultrasound data is more accurate than the LMP, for a host of reasons!

Before I published the due dates article, I reached out to Tara Elrod, a Certified Direct Entry Midwife in Alaska, to get her expert feedback as a home birth midwife. She raised an excellent point:

“It is of significant interest to me as a licensed midwife practicing solely in the Out-of-Hospital setting that ultrasounds done in early pregnancy are more accurate than using LMP. If early ultrasound dating was achieved, it’s thought that this would ultimately equate to less women being induced for post-term pregnancy. This is significant to midwives such as myself due to the scope-of-care regulation of not providing care beyond 42 weeks. While an initial- and perhaps arguably by some ‘elective’ ultrasound-  may not be a popular choice in the midwife clientele population, a thoughtful risk versus benefit consideration should occur, as to assess the circumstance of “risking out” of care for suspected post-dates. [In my licensing state, my scope of care is limited to 37+0 weeks to 42+0 weeks, with the occasional patient reaching 42 weeks and therefore subsequently “risking out,” necessitating a transfer of care.]” ~Tara Elrod, CDM

SM: What do you think the economic cost of inductions for due dates is? The social costs? What benefits might we see if we relied on a better system for determining due dates and when to take action based on being postdates?

RD: There are economic costs to both elective inductions and waiting for labor to start on its own. The Hannah Post-Term trial investigators actually published a paper that looked at the cost effectiveness of their intervention, and they found that induction was cheaper than expectant management. This was primarily because with expectant management, there were extra costs related to fetal monitoring (non stress tests, amniotic fluid measurements, etc.) and the increased number of Cesareans in the expectant management group.

But there are many unanswered questions about the cost-effectiveness of elective induction of labor versus waiting for labor to begin (with fetal monitoring), so I’m afraid I can’t make any definitive statements or projections about the economic and social costs of elective inductions. Here is a study that may be of interest to some with further information on this topic.

I do know that in a healthy, low-risk population, birth centers in the National Birth Center Study II provided excellent care at a very low cost with women who had spontaneous births all the way up to 42 weeks. I would love to see researchers analyze maternal and neonatal outcomes in women stratified by gestational age in the Perinatal Data Registry with the American Association of Birth Centers.

 SM: I very much look forward to all your research posts and appreciate the work  and effort you put into doing them. What is on your radar for your next piece?

RD: The next piece will be Advanced Maternal Age!! After that, I will probably be polling my audience to see what they want, but I’m interested in tackling some topics related to pain control (epidurals and nitrous oxide) or maybe episiotomies.

SM: Is there anything else that you want to share about this post or other topics?

RD: No, I would just like to give a big thank you to everyone who helped in some way or another on this article!! There was a great interdisciplinary team who helped ensure that the due dates article passed scrutiny—we had an obstetrician, family physician, nurse midwife, several PhD-prepared researchers, and a certified direct entry midwife all provide expert review before the article was published. I am so thankful to all of them.

References

Hannah, M. E., C. Huh, et al. (1996). “Postterm pregnancy: putting the merits of a policy of induction of labor into perspective.” Birth 23(1): 13-19.

Hannah, M. E., W. J. Hannah, et al. (1992). “Induction of labor as compared with serial antenatal monitoring in post-term pregnancy. A randomized controlled trial. The Canadian Multicenter Post-term Pregnancy Trial Group.” N Engl J Med 326(24): 1587-1592.

 

 

 

Cesarean Birth, Childbirth Education, Evidence Based Medicine, informed Consent, Maternal Quality Improvement, Maternity Care, New Research, Research , , , , ,

Advocacy: Lamaze International Leaders on Capitol Hill

April 7th, 2015 by avatar

By John Richardson, Director, Government Relations, Lamaze International

I am proud of being both a member of Lamaze International and a Lamaze Certified Childbirth Educator for many reasons.  Today’s post by John Richardson, Lamaze International’s Director of Government Relations is just one reason why I am happy to pay my membership dues and be a part of the Lamaze organization.  Lamaze is actively working in both the private sector and with public/governmental leaders to help every family to have access to the resources to have a safe and healthy birth.  Today on the blog, we share about how our Board of Directors met with Congressmen and Congresswomen to share the importance of an evidence based childbirth education class being available to all families.  My certifying organization works hard for me and the families I teach every day.  – Sharon Muza, Science & Sensibility Community Manager.

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Lamaze BoD on Capitol Hill, 2015

Advocacy is a foundational element of the Lamaze International mission to advance safe and healthy pregnancy, birth and early parenting through evidence-based education and advocacy. Assisting women and their families to make informed decisions for childbearing and acting as an advocate to promote, support, and protect safe and healthy birth are two core competencies of a Lamaze Certified Childbirth Educator.

Advocacy comes in many different forms. The new Lamaze Strategic Framework specifically calls for taking advocacy efforts to the next level, focusing on government and legislative advocacy — leveraging strategic partnerships to advocate for perinatal/childbirth education coverage under the Affordable Care Act (ACA) and partnering with insurance companies, including the Centers for Medicaid and Medicare Services (CMS), to become part of the “bundled care” system. (Bundled care payment programs refer to the concept of grouping together the multiple services associated with a certain health “episode” versus the current fee for service system where each service associated with a condition is charged separately, and is one of the ACA’s many attempts to incentivize health care providers to be more cost efficient.)

BoD President Robin Elise Weiss and BOD Christine Morton

BoD President Robin Elise Weiss and BOD Christine Morton

Over the years, Lamaze has been involved in a variety of coalition and advocacy efforts related to improving access to high-quality maternity care that includes evidence based childbirth education by qualified educators and the promotion of breastfeeding within the health care industry. These efforts will continue with Lamaze taking its message directly to Capitol Hill to have a stronger voice with federal policymakers on behalf of the organization, its members, and the women and families that Lamaze serves. We want to let Congress know that Lamaze International provides gold standard childbirth education which can play an important role in promoting healthier outcomes for mother and baby and reducing healthcare costs and burdens on the healthcare system.

What does advocacy look like?

Advocacy campaigns at the federal level in the United States are typically a set of actions targeted to create support for a specific policy or proposal. The goals of an advocacy campaign may include drafting and passing a new law, drafting and passing amendments to existing laws, commenting on regulation, or influencing public perception and awareness of a particular issue.

Why is advocacy important for Lamaze?

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Board member Alice Turner

The delivery of health care is one of the most regulated industries in the United States. State and federal regulations often define whether services are covered by insurance, which practitioners are allowed to deliver services, the manner in which services are delivered, and how much individual practitioners and health care organizations are reimbursed. Naturally, there are a lot of people and organizations invested in steering and influencing these policies. There are literally thousands of issues and groups vying for policymakers’ attention. For Lamaze, it is critical to engage directly in advocacy activities so that policymakers become aware of the issues that are important to our organization and make them priorities.

There have been several recent successful advocacy initiatives to improve care for pregnant and postpartum women. For example, Lamaze has worked in collaboration with other organizations and lawmakers to improve breastfeeding services under the Affordable Care Act. As a result, there are several benefits now available to women who receive coverage through the Health Insurance Marketplaces (exchanges) and private non-grandfathered plans. Benefits such as lactation support and counseling by trained professionals are now covered without co-pay or co-insurance. Breast pumps are also covered at no charge and most employers must provide access to clean and private locations to pump for women who are hourly employees.

These victories are impressive and it is important to note that they did not occur in a vacuum. Advocates flooded the halls of Congress for years to ensure that policymakers appreciated the importance of breastfeeding. A key component of the success of these advocacy efforts was that they were based on research, focused on higher quality health outcomes, and provided fiscal benefits to the health care system and the federal government.

The Lamaze Board of Directors’ “Hill Day”

cbe graphicBearing all this in mind and in conjunction with their in-person meeting in Washington, DC, members of the Lamaze Board of Directors took to Capitol Hill on March 19, 2015 to meet with their Representatives and Senators about the excellent childbirth education that Lamaze provides and its potential to reduce costs and improve outcomes. The members of the Board met with a total of 23 Congressional offices, the majority of whom sit on committees with jurisdiction over health policy.

Our advocacy efforts on Capitol Hill centered on the following core messages:

  1. Promoting greater utilization of evidence-based childbirth education is a critical element in closing quality outcomes gaps and reducing unnecessary costs. In the face of high rates of cesarean sections, early inductions, and maternal/infant mortality, there is an increasing imperative for women to be informed and in charge of their maternity care to improve birth outcomes.

Maternal or neonatal hospital stays make up the greatest proportion of hospitalizations among infants, younger adults and patients covered by private insurance and Medicaid, which is why improvements in care are a major opportunity to reduce overall healthcare spending. Increasing quality outcomes by reducing the rates of unnecessary interventions, such as early induction of labor and cesarean section, are critical to reduce healthcare spending, particularly with Medicaid.

  1. The ACA has provided an opportunity for millions of uninsured Americans to access health care coverage through the creation of the exchanges. For those that do not enroll in a plan during the “open” enrollment period, there are qualifying “life events” that trigger special enrollment periods. One of those life events is when a woman gives birth. After the birth, the mother can sign herself and her infant up for coverage.

Lamaze believes, along with many others, that pregnancy, rather than birth, should be the life event that triggers the special enrollment period. Recently, 37 Senators and 55 Representatives sent a letter to U.S. Health & Human Services Secretary Sylvia Mathews Burwell  requesting this change. It appears Secretary Burwell can make this change administratively, as it does not require an act of Congress. Lamaze will join a chorus of other organizations that are making this request directly to the Secretary. Lamaze will also emphasize the importance of ensuring that ACA and state Medicaid plans include childbirth education as a covered service under maternity care benefits.

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Hill Day meetings

While meeting and communicating with legislators and staff on Capitol Hill may seem intimidating, it is actually very easy. Legislators are elected (and re-elected) by their constituents (you) so they have an obligation to listen to their constituents (you). That is a very important dynamic to remember. They are naturally inclined to help address the issues raised by their constituents.

However, advocates should always be well-prepared, a task that proved to be almost second nature for the Lamaze Board members as they met with Congressional offices. As experts in the field and natural educators, Lamaze leadership did a fantastic job representing the views of childbirth educators and establishing a rapport with the officials and staffers they met – the most important accomplishment of any first meeting on Capitol Hill.

Check out all the pictures of our Board of Directors on the “Hill” last month here.

Getting Involved

If you want to get involved and contact or meet with Congressional offices in your state, the most important action is to convey who you are, what you do, how you do it, and why it is important. Then, continue a dialogue of how specific policies might be improved for safer, higher quality, lower cost birth outcomes. In preparation for the first Lamaze “Hill Day,” several key documents were developed, including a policy paper and supporting documents to convey Lamaze’s core message in meetings with Congressional offices. By following this link, you can access and use these documents for advocacy efforts with your state’s representatives and in your local communities with insurers, health care providers, and hospitals.

Providing Lamaze’s unique perspective on the state and national level is extremely important and we can only be successful with the help of our members and supporters. In the coming months, we will provide a webinar on how to become an effective advocate and what Lamaze is doing to have an impact on access to high-quality childbirth education. Stay tuned!  If you are already an advocate in your community, on the county or state level or even nationally, share what you are doing to help families receive good care and improve outcomes in our comments section.

About John Richardson

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© John Richardson

John Richardson joined SmithBucklin, Lamaze International’s management company, in 2001 as Director of Government Relations, Healthcare Practice Group. He guides the policy efforts of healthcare organizations whose members include healthcare administrators; allied health professionals; physicians and hospitals. His experience provides his clients with a deep understanding of policy and politics and their effects on the healthcare system.

John lobbies Congress and government agencies at the federal level and also develops strategy for state lobbying efforts. He also has experience pursuing client objectives such as the development of practice guidelines, CPT codes, evidence based research, and technologies that promote efficiencies within healthcare administration.

Prior to joining SmithBucklin, John served as an Associate to the House Committee on Appropriations for a former member of the committee. Preceding his work of 5 years on the Hill, John acquired extensive political and grassroots experience working as a campaign aide to congressional and presidential campaigns.

A New Hampshire native, he graduated with a B.A. in Political Science from Roger Williams University in Bristol, R.I, and currently resides in Bowie, MD with his wife Kristin and sons Garrett and Holden.

 

Childbirth Education, Evidence Based Medicine, Guest Posts, Healthcare Reform, Healthy Birth Practices, Lamaze International, Lamaze News, Maternal Quality Improvement, Push for Your Baby, Research for Advocacy , , , , , ,

Too Bad We Can’t Just “Ban” Accreta – The Downstream Consequences of VBAC Bans

April 2nd, 2015 by avatar

April is Cesarean Awareness Month (CAM), and throughout the month, Science & Sensibility will be covering issues that are directly related to the number of cesareans (1,284,339 in 2013) performed every year in the United States.  To start our CAM series off, Jen Kamel, founder of VBACFacts.com, shares important information about placenta accreta.  Tomorrow, April 3rd, is the Hope for Accreta Awareness National Blood Drive, as part of the 30 Day Hope for Accreta Challenge sponsored by the Hope for Accreta nonprofit that provides consumer information and offers support to families affected by placenta accreta. – Sharon Muza, Community Manager, Science & Sensibility

cam lamaze 2015Even though the American College of Obstetricians and Gynecologists (ACOG) and the National Institutes of Health (NIH) have described vaginal birth after cesarean (VBAC) as a safe, reasonable, and appropriate option for most women, VBAC bans (hospital or practice wide mandates that requires repeat cesareans for all women with a prior cesarean) remain in force in almost half of American hospitals. It’s true that scheduled repeat cesareans almost always successfully circumvent the most publicized risk of VBAC (uterine rupture) by virtually eliminating its incidence and for this reason, many people celebrate and credit the repeat cesarean section for resulting in a good outcome for mother and baby. But what most people do not consider is that VBAC bans translate into mandatory repeat cesareans, and those surgeries expose women and babies to a condition far more life-threatening and difficult to treat than uterine rupture: placenta accreta.

Photo Credit: http://fetalsono.com/teachfiles/PlacAcc.lasso

Photo Credit: http://fetalsono.com/teachfiles/PlacAcc.lasso

Placenta accreta occurs when a placenta abnormally attaches to (accreta), in (increta), or through (percreta) the uterine wall. No one knows exactly why some women develop accreta other than there is some abnormality in the area where the fertilized egg implants (Heller, 2013). Anyone who has had a prior surgery on her uterus is at a substantially increased risk of accreta and, as it happens, cesarean section is the most common surgery in the United States (Guise, 2010). In fact, the rate of accreta has grown along with the rate of cesarean surgery: from 1 in 4,027 pregnancies in the 1970s, to 1 in 2,510 pregnancies in the 1980s, to 1 in 533 from 1982-2002 (American College of Obstetricians and Gynecologists [ACOG], 2012). That rate escalates to 1 in 323 among women with a prior uterine surgery and the risk rises at a statistically significant rate with each additional cesarean section (Silver, Landon, Rouse, & Leveno, 2006).

Up to seven percent of women with accreta will die from it (ACOG, 2012). After the baby is born, the placenta does not detach normally, causing bleeding, which can’t be stopped before the doctors are able to either surgically remove the placenta or perform an emergency cesarean hysterectomy. Babies die from accreta due to the very high rate of preterm delivery associated with accreta. In fact, 43% of accreta babies weigh less than 5.5 lbs (2,500 gm.) upon delivery (Eshkoli, Weintraub, Sergienko, & Sheiner, 2013). Accreta is not a routine complication. Accreta is serious.

As Silver (2006) points out, the risk of accreta after two cesareans (0.57%) is greater than the risk of uterine rupture after one prior low transverse cesarean during a non-induced/augmented planned VBAC (0.4%) (Landon, Hauth, & Leveno, 2004). In other words, women are literally exchanging the risk of uterine rupture in a current pregnancy for the more serious risk of accreta in future pregnancies. This poses a striking public health issue when you combine what the CDC (2012) has reported for numbers of unintended pregnancies–49%–and the lack of access to vaginal birth after cesarean: over half a million repeat cesareans every year, resulting in higher rates of accreta.

Yet due to the nonmedical factors that inhibit access to VBAC and influence how the risks and benefits of post-cesarean birth options are communicated to the public, women are rarely informed of these risks in a transparent and straightforward way. Additionally, it can be very difficult for the woman to obtain social support when confusion and fear about giving birth after cesarean remains the norm.

Given all this, providers are ethically obligated to inform patients of the future implications of their current mode of delivery. However, it can be especially difficult for providers working within the political climate of a hospital where VBAC is banned to frankly inform their patients of this reality. How can providers clearly explain to women the risks and benefits of their options, with VBAC as a viable option, when they do not offer that option at the facility? Such a situation could even result in professional ramifications for the provider, like revocation of hospital privileges. Additionally, some providers do not offer VBAC, “not because of an explicit hospital policy against it, but because [they] were unwilling to stay in the hospital with a woman attempting [a planned VBAC]” (Barger, Dunn, Bearman, DeLain, & Gates, 2013).

It is for this reason that some argue that VBAC bans create a conflict of interest among providers (ACOG, 2011; Charles, 2012). On one hand, they are bound by ethical obligations to the patient’s well-being, respect for patient autonomy, and support of an informed decision-making process. But these obligations are threatened by financial and professional ties to the hospital.

ACOG stresses throughout their guidelines and committee opinions that informed consent and patient autonomy are paramount (ACOG, 2011). They share how obstetrics should be moving from a paternalistic system to a more collaborative model (ACOG, 2013). They acknowledge that women should be allowed to accept increased levels of risk (ACOG, 2010). They assert how there is no “right” or “wrong” answer, only what is right or wrong for a specific woman (ACOG, 2010). And they are clear that restrictive VBAC policies cannot be used to force women to have a repeat cesarean or to deny a woman care during active labor (ACOG, 2010).

Yet, with 48% of women interested in the option of VBAC, 46% of them cannot find a provider or facility to attend their VBAC (Declercq, Sakala, Corry, Applebaum, & Herrlick, 2013). Only 10% of U.S. women have a vaginal birth after cesarean, as opposed to another cesarean (National Center for Health Statistics, 2013). Barriers to VBAC remain firm.

Those barriers often include one-sided counseling to women of the risk of uterine rupture in a VBAC. Rarely are they told of the complication rates of accreta, which are higher across several measures. This is true when we look at maternal mortality (7% vs. 0%) (ACOG, 2012; Guise, et al., 2010), blood transfusion (54% vs. 12%) (Eshkoli, Weintraub, Sergienko, & Sheiner, 2013; Barger, et al., 2012), cesarean hysterectomy (20-70% vs. 6%) (Eshkoli, Weintraub, Sergienko, & Sheiner, 2013; Barger, et al., 2012), and maternal ventilation (14% vs. 3%) (Eshkoli, Weintraub, Sergienko, & Sheiner, 2013; Barger, et al., 2012). Further, 5.8% of accreta babies will die within the first week of life (Eshkoli, Weintraub, Sergienko, & Sheiner, 2013) in comparison to 2.8 – 6.2% of uterine rupture babies (Guise, et al., 2010).

Accreta results in higher rates of mortality and morbidity because it requires a complex response which most hospitals are not equipped to provide. A 2012 study advises, “Treatment of placenta accreta is best accomplished in centers that have the expertise to handle the management, which involves multiple disciplines, including blood bank, interventional radiology, anesthesia, and surgical expertise, gynecologic oncology, urology, or obstetric subspecialty expertise” (Heller, 2013).

It ís worth noting that uterine rupture does not require this level of response in order to generate a good outcome. As Aaron Caughey, OB-GYN and Chairman of the Department of Obstetrics and Gynecology at Oregon Health & Science University in Portland explains, “From an obstetrician standpoint, there are no particular special skills to managing a VBAC. Even in an emergency situation, we all have the surgical skills to deal with it” (Reddy, 2014).

Because some hospitals are not equipped to manage an accreta, some women who are diagnosed prenatally find themselves traveling hundreds of miles away from their family in order to deliver with accreta specialists.

At 19 weeks pregnant, Dawn was diagnosed with percreta, the most severe form of accreta where the placenta goes through the uterine wall and attaches to other structures in the abdominal cavity. She had nine prior pregnancies. Dawn was among the 93% of women who were never informed of the risks of accreta when she was pregnant after her first, second, or third cesarean (Kamel, 2014). All she heard were the dangers of VBAC. Thus, she had three cesareans.

Mother after cesarean hysterectomy in ICU. © Dawn Johnson-Baranski

When she got pregnant again, she heard the word accreta for the first time upon her diagnosis as is the case in 59% of women diagnosed with accreta (Kamel, 2014). Dawn ultimately traveled from her home in rural Virginia to Houston, Texas, at 27 weeks pregnant, to the Fox-Texas Children’s Pavilion for Women, an accreta specialty center. Due to complications related to her precreta, her son was delivered by cesarean hysterectomy at 33 weeks. Her son spent 19 days in the NICU before they could return back home to Virginia (personal communication, March 30, 2014).

It’s because accreta is so dangerous, complex to treat, and unknown to the general public, that professionals and researchers are sounding the alarm about the risk exchange that happens when repeat cesarean is chosen (or forced) over VBAC. As Dr. Elliot Main, Medical Director of the California Maternal Quality Care Collaborative, cautions, “In California, we are seeing a lot of hysterectomies, accretas, and significant blood loss due to multiple prior cesareans. Probably the biggest risk of the first cesarean is the repeat cesarean” (Main, 2013). (The state of California has a 9% VBAC rate, just a point below the national rate) (State of California Office of Statewide Health Planning and Development, 2013). A 2009 study from the Netherlands advises, “Ultimately, the best prevention [of uterine rupture] is primary prevention, i.e. reducing the primary caesarean delivery rate. The obstetrician who decides to perform a caesarean has a joint responsibility for the late consequences of that decision, including uterine rupture” (Zwart, et al., 2009). And a 2012 study warns, “Because cesarean delivery now accounts for about one-third of all deliveries in the United States, rates of abnormal placentation and subsequent hysterectomy will likely continue to rise” (Bateman, Mhyre, Callaghan, & Kuklina, 2012). By reducing the primary cesarean rate and increasing access to VBAC, we could also reduce the incidence of accreta, cesarean hysterectomy, and hemorrhage.

Following multiple uterine rupture lawsuits in the 1990s, some hospitals crafted their restrictive VBAC policies around litigation fears. However, the concern over lawsuits resulting from “VBAC gone wrong” may soon be overshadowed by the worry of being sued when women or babies die from accreta, after failing to adequately respond to this dangerous condition and/or denying access to VBAC (Associated Press, 2013; Children to sue hospital over death of mother, n.d.). This will certainly become the case as the public becomes more aware of the connection between VBAC bans, cesareans, and accreta.

It could also become a public relations nightmare as Americans begin to realize that litigation fears–not patient safety, drive hospital policy. This becomes more likely as more women are diagnosed with accreta.

As mothers are the ones who carry the risk of either uterine rupture or accreta, shouldn’t they be the ones deciding which set of risks are tolerable to them? As ACOG (2010) says, “the ultimate decision to undergo [planned VBAC] or a repeat cesarean delivery should be made by the patient in consultation with her health care provider” –  not by hospital administrators, malpractice insurance companies, or providers who simply don’t want to deal with VBAC.

As Dr. Howard Minkoff (2010) shared at the 2010 NIH VBAC Conference, “We should be starting with a sense of what’s the best interest of the mother. Unfortunately, the decision here is not always who are better equipped, it’s more like who are willing. There are a lot of hospitals that are quite capable of providing VBACs but exercise an option not to do it particularly if there’s someone nearby that will take that on for them.”

Hospitals around the country, and particularly those that are located in areas where VBAC bans mean that all women have repeat cesareans, are seeing and will continue to see increasing numbers of accreta. They have no choice but to manage it – which can be especially problematic for smaller facilities in rural areas that don’t offer the sophisticated response accreta requires.

But motivation remains the driving factor in hospital VBAC policy even in rural hospitals. Take the five small community hospitals in New Mexico that serve the Navajo Nation. As Dr. Jean Howe (2010), their Chief Clinical Consultant for Obstetrics, shared at the 2010 NIH Conference, these rural facilities collectively deliver 3,000 babies each year and maintain a 15% cesarean rate and a 38% VBAC rate. Numbers like that just don’t happen. They are the result of motivated administrators, providers, and patients who want VBAC to be an option at their facility.

The bottom line is, VBAC bans simply delay risk. The sooner hospital administrators and the American public realize this, the sooner we can mobilize–reducing future risks of accreta by making VBAC a viable option in more hospitals. It is one thing for a woman to knowingly plan a repeat cesarean understanding this risk. That is her choice as both VBAC and repeat cesarean come with risk. However, it is unconscionable when a woman is not presented with her options and she develops accreta in a subsequent pregnancy.

As the American public becomes more aware of the serious risks associated with repeat cesarean, will more providers and facilities be sued as a result of accreta-related complications and death? Will it have to come to fear of litigation, again, in order for hospitals to throw aside their current VBAC bans, listen to what the NIH, ACOG, and the medical research has to say; to create an environment that is supportive of VBAC, respect a mother’s right to make her own medical decisions, and prepare accreta-response protocols?

Women are entitled to understand what that first cesarean means in terms of their future birth options and their long term health. Consumers and providers should work with hospital administration to reverse VBAC bans, review current VBAC policies to insure they are aligned with national guidelines and evidence, and improve response times for obstetrical emergencies through team training and drills (Cornthwaite, Edwards, & Siassakos, 2013). Providers should have frank conversations with patients about the immediate and long-term risks and benefits of their options within the context of intended family size, acknowledging that sometimes the stork delivers when you’re not expecting it. This is about administrators, providers, professionals, and consumers working together for better processes and healthier outcomes. Let’s get to work.

References

American College of Obstetricians and Gynecologists. (2010, August). Practice Bulletin No. 115: Vaginal Birth After Previous Cesarean Delivery. Obstetrics & Gynecology, 116(2), 450-463. Retrieved from http://dhmh.maryland.gov/midwives/Documents/ACOG%20VBAC.pdf

American College of Obstetricians and Gynecologists. (2011). Code of Professional Ethics. Retrieved May 16, 2013, from ACOG: http://www.acog.org/About_ACOG/~/media/Departments/National%20Officer%20Nominations%20Process/ACOGcode.pdf

American College of Obstetricians and Gynecologists. (2012, July). ACOG Committee Opinion No. 529: Placenta accreta. Obstetrics & Gynecology, 201-11. Retrieved from http://www.acog.org/Resources%20And%20Publications/Committee%20Opinions/Committee%20on%20Obstetric%20Practice/Placenta%20Accreta.aspx

American College of Obstetricians and Gynecologists. (2013). Elective surgery and patient choice. Committee Opinion No. 578. Obstetrics & Gynecology, 122, 1134-8. Retrieved from http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Ethics/Elective_Surgery_and_Patient_Choice

Associated Press. (2013, Nov 25). $15 million awarded in Illinois childbirth death lawsuit. Retrieved from Insurance Journal: http://www.insurancejournal.com/news/midwest/2013/11/25/312169.htm

Barger, M. K., Dunn, T. J., Bearman, S., DeLain, M., & Gates, E. (2013). A survey of access to trial of labor in California hospitals in 2012. BMC Pregnancy and Childbirth. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3636061/pdf/1471-2393-13-83.pdf

Barger, M. K., Nannini, A., Weiss, J., Declercq, E. R., Stubblefield, P., Werler, M., & Ringer, S. (2012, November). Severe maternal and perinatal outcomes from uterine rupture among women at term with a trial of labor. Journal of Perinatology, 32, 837-843. Retrieved from http://www.nature.com/jp/journal/v32/n11/full/jp20122a.html

Bateman, M. T., Mhyre, J. M., Callaghan, W. M., & Kuklina, E. V. (2012). Peripartum hysterectomy in the United States: nationwide 14 year experience. American Journal of Obstetrics & Gynecology, 206(63), e1-8. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21982025

Charles, S. (2012, Jul-Aug). The Ethics of Vaginal Birth After Cesarean. The Hastings Center Report, 42(4), 24-27. Retrieved from Medscape: http://onlinelibrary.wiley.com/doi/10.1002/hast.52/abstract

Cornthwaite, K., Edwards, S., & Siassakos, D. (2013). Reducing risk in maternity by optimising teamwork and leadership: an evidence-based approach to save mothers and babies. Best Practice & Research Clinical Obstetrics and Gynaecology, 27, 571-581. Retrieved from http://www.bestpracticeobgyn.com/article/S1521-6934(13)00051-5/abstract

Declercq, E. R., Sakala, C., Corry, M. P., Applebaum, S., & Herrlick, A. (2013). Listening to Mothers III: Pregnancy and Birth. New York: Childbirth Connection. Retrieved from http://www.childbirthconnection.org/article.asp?ck=10450

Eshkoli, T., Weintraub, A., Sergienko, R., & Sheiner, E. (2013). Placenta accreta: risk factors, perinatal outcomes, and consequences for subsequent births. American Journal of Obstetrics & Gynecology, 208, 219.e1-7. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/23313722

Guise, J.-M., Eden, K., Emeis, C., Denman, M., Marshall, N., Fu, R., . . . McDonagh, M. (2010). Vaginal Birth After Cesarean: New Insights. Rockville (MD): Agency for Healthcare Research and Quality (US). Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK44571/

Hale, B. (n.d.). Children to sue hospital over death of mother. Retrieved from Daily Mail: http://www.dailymail.co.uk/health/article-129801/Children-sue-hospital-death-mother.html

Heller, D. S. (2013). Placenta accreta and percreta. Surgical Pathology, 6, 181-197. Retrieved from http://www.surgpath.theclinics.com/article/S1875-9181(12)00183-3/abstract

Howe, J. (2010). National Institutes of Health VBAC Conference, Day 2, #04: Public Comments. 14:45-17:08. Retrieved from Vimeo: http://vimeo.com/10898005

Kamel, J. (2014, Dec 14). Online poll of 227 women with prior cesareans.

Landon, M. B., Hauth, J. C., & Leveno, K. J. (2004). Maternal and Perinatal Outcomes Associated with a Trial of Labor after Prior Cesarean Delivery. The New England Journal of Medicine, 351, 2581-2589. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMoa040405

Main, E. (2013). HQI Regional Quality Leader Network December Meeting. San Diego.

Minkoff, H. (2010). National Institutes of Health VBAC Conference, Day 2, #04: Public Comments. 11:16. Retrieved from Vimeo: http://vimeo.com/10898005

National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health. (2012, Apr 4). Unintended Pregnancy Prevention. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/index.htm

National Center for Health Statistics. (2013). User Guide to the 2012 Natality Public Use File. Hyattsville, Maryland: National Center for Health Statistics. Retrieved from ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2012.pdf

Reddy, S. (2014, Dec 8). A type of childbirth some women will fight for. Retrieved from Wall Street Journal: http://www.wsj.com/articles/a-type-of-childbirth-some-women-will-fight-for-1418081344

Silver, R. M., Landon, M. B., Rouse, D. J., & Leveno, K. J. (2006). Maternal Morbidity Associated With Multiple Repeat Cesarean Deliveries. Obstetrics & Gynecology, 107(6), pp. 1226-1232. Retrieved from http://journals.lww.com/greenjournal/fulltext/2006/06000/maternal_morbidity_associated_with_multiple_repeat.4.aspx

State of California Office of Statewide Health Planning and Development. (2013, December 17). Utilization Rates for Selected Medical Procedures in California Hospitals, 2012. Retrieved from http://www.oshpd.ca.gov/HID/Products/PatDischargeData/ResearchReports/Hospipqualind/vol-util_indicatorsrpt/

Zwart, J. J., Richters, J. M., Ory, F., de Vries, J., Bloemenkamp, K., & van Roosmalen, J. (2009, July). Uterine rupture in the Netherlands: a nationwide population-based cohort study. BJOG: An International Journal of Obstetrics and Gynaecology, 116(8), pp. 1069-1080. Retrieved January 15, 2012, from http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2009.02136.x/full

About Jen Kamel

Jen kamel head shot 2015Jen Kamel is a consumer advocate and a leading national speaker on the medical facts and political, historical climate surrounding vaginal birth after cesarean.  She is the founder of VBACFacts.com and has brought her workshop “The Truth about VBAC: Politics, History and Stats” to over 900 people around the country, giving accurate, current information about post-cesarean birth options directly to families, practitioners, and professionals.

Cesarean Birth, Childbirth Education, Evidence Based Medicine, Guest Posts, Maternal Mortality, Maternal Quality Improvement, Pregnancy Complications, Vaginal Birth After Cesarean (VBAC) , , , , , , ,

Henci Goer – Fact Checking the New York Times Home Birth Debate

February 26th, 2015 by avatar
home birth

© HoboMama

An article in The New York Times Opinion Pages – Room for Debate was released on February 24th, 2015.  As customary in this style of article, the NYT asks a variety of experts to provide essays on the topic at hand, in this case, the safety of home birth. Henci Goer, author and international speaker on maternity care, and an occasional contributor to our blog, takes a look at the facts on home birth and evaluates how they line up with some of the essay statements. Read Henci’s analysis below.  – Sharon Muza, Science & Sensibility Community Manager

As one would predict, three of the four obstetricians participating in the NY Times debate “Is Home Birth Ever a Safe Choice?“assert that home birth is unacceptably risky. Equally predictably, the evidentiary support for their position is less than compelling.

John Jennings, MD president of the American Congress of Obstetricians & Gynecologists, in his response- “Emergency Care Can Be Too Urgently Needed,” cites a 2010 meta-analysis by Wax and colleagues that has been thoroughly debunked. Here is but one of the many commentaries, Meta-Analysis: The Wrong Tool Wielded Improperly, pointing out its weaknesses. In a nutshell, the meta-analysis includes studies in its newborn mortality calculation that were not confined to low-risk women having planned home births with a qualified home birth attendant while omitting a well-conducted Dutch home birth study that dwarfed the others in size and reported equivalent newborn death rates in low-risk women beginning labor at home and similar women laboring in the hospital (de Jonge 2009).

The other naysayers, Grunebaum and Chervenak, in their response – “Home Birth Is Not Safe“, source their support to an earlier NY Times blog post that, in turn, cites a study conducted by the two commentators (and others) (Grunebaum 2014). Their study uses U.S. birth certificate data from 2006 to 2009 to compare newborn mortality (day 1 to day 28) rates at home births attended by a midwife, regardless of qualifications, with births attended by a hospital-based midwife, who almost certainly would be a certified nurse midwife (CNM) in babies free of congenital anomalies, weighing 2500 g or more, and who had reached 37 weeks gestation. The newborn mortality rate with home birth midwives was 126 per 10,000 versus 32 per 10,000 among the hospital midwives, nearly a 4-fold difference. However, as an American College of Nurse-Midwives commentary on the abstract for the Society for Maternal-Fetal Medicine presentation that preceded the study’s publication observed, vital statistics data aren’t reliably accurate, don’t permit confident determination of intended place of birth, and don’t follow transfers of care during labor.

As it happens, we have a study that is accurate and allows us to do both those things. The Midwives Alliance of North America study reports on almost 17,000 planned home births taking place between 2004 and 2009 (Cheyney 2014b), and therefore overlapping Grunebaum and Chervenak’s analysis, in which all but 1000 births (6%) were attended by certified or licensed home birth midwives. According to the MANA stats, the newborn death rate in women who had never had a cesarean and who were carrying one, head-down baby, free of lethal congenital anomalies was 53 per 10,000, NOT 126 per 10,000. This is less than half the rate in the Grunebaum and Chervenak analysis. (As a side note, let me forestall a critique of the MANA study, which is that midwives simply don’t submit births with bad outcomes to the MANA database. In point of fact, midwives register women in the database in pregnancy [Cheyney 2014a], before, obviously, labor outcome could be known. Once enrolled, data are logged throughout pregnancy, labor and birth, and the postpartum, so once in the system, women can’t fall off the radar screen.)

We’re not done. Grunebaum and Chervenak’s analysis suffers from another glaring flaw as well. Using hospital based midwives as the comparison group would seem to make sense at first glance, but unlike the MANA stats, which recorded outcomes regardless of where women ultimately gave birth or who attended them, hospital-based midwives would transfer care to an obstetrician when complications arose. This would remove labors at higher risk of newborn death from their statistics because the obstetrician would be listed on the birth certificate as the attendant, not the midwife. For this reason, the hospital midwife rate of 32 per 10,000 is almost certainly artificially low. So Grunebaum and Chervenak’s difference of 94 per 10,000 has become 21 per 10,000 at most and probably much less than that, a difference that I’d be willing to bet isn’t statistically significant, meaning unlikely to be due to chance. On the other hand, studies consistently find that, even attended by midwives, several more low-risk women per 100 will end up with cesarean surgery—more if they’re first-time mothers—then compared with women planning home births (Romano, 2012).

Hopefully, I’ve helped to provide a defense for those who may find themselves under attack as a result of the NY Times article. I’m not sanguine, though. As can be seen by Jennings, Grunebaum, and Chervenak, people against home birth often fall into the category of “My mind is made up; don’t confuse me with the facts.”

photo source: creative commons licensed (BY-NC-SA) flickr photo by HoboMama: http://flickr.com/photos/44068064@N04/8586579077

References

Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D., & Vedam, S. (2014). Development and validation of a national data registry for midwife-led births: the Midwives Alliance of North America Statistics Project 2.0 dataset. J Midwifery Womens Health, 59(1), 8-16. doi: 10.1111/jmwh.12165 http://www.ncbi.nlm.nih.gov/pubmed/24479670

Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D., & Vedam, S. (2014b). Outcomes of care for 16,924 planned home births in the United States: the midwives alliance of north america statistics project, 2004 to 2009. J Midwifery Womens Health, 59(1), 17-27. doi: 10.1111/jmwh.12172 http://www.ncbi.nlm.nih.gov/pubmed/24479690

de Jonge, A., van der Goes, B. Y., Ravelli, A. C., Amelink-Verburg, M. P., Mol, B. W., Nijhuis, J. G., . . . Buitendijk, S. E. (2009). Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births. BJOG 116(9), 1177-1184. http://www.ncbi.nlm.nih.gov/pubmed?term=1177%5Bpage%5D+AND+2009%5Bpdat%5D+AND+de+jonge%5Bauthor%5D&cmd=detailssearch

Grunebaum, A., McCullough, L. B., Sapra, K. J., Brent, R. L., Levene, M. I., Arabin, B., & Chervenak, F. A. (2014). Early and total neonatal mortality in relation to birth setting in the United States, 2006-2009. Am J Obstet Gynecol, 211(4), 390 e391-397. doi: 10.1016/j.ajog.2014.03.047 http://www.ajog.org/article/S0002-9378(14)00275-0/abstract

Romano, A. (2012). The place of birth: home births. In Goer H. & Romano A. (Eds.), Optimal Care in Childbirth: The Case for a Physiologic Approach. Seattle, WA: Classic Day Publishing.

Wax, J. R., Lucas, F. L., Lamont, M., Pinette, M. G., Cartin, A., & Blackstone, J. (2010). Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis. Am J Obstet Gynecol, 203(3), 243.e241-e248. http://www.ajog.org/article/S0002-9378%2810%2900671-X/abstract

About Henci Goer

Henci Goer

Henci Goer

Henci Goer, award-winning medical writer and internationally known speaker, is the author of The Thinking Woman’s Guide to a Better Birth and Optimal Care in Childbirth: The Case for a Physiologic Approach She is the winner of the American College of Nurse-Midwives “Best Book of the Year” award. An independent scholar, she is an acknowledged expert on evidence-based maternity care.  

 

 

Babies, Evidence Based Medicine, Guest Posts, Home Birth, Maternal Quality Improvement, Maternity Care, Midwifery , , , , ,