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New Research: Majority of Preeclampsia-Related Maternal Deaths Deemed Preventable

May 12th, 2015 by avatar

By Eleni Z. Tsigas

Preeclampsia Awareness Month 2015May is Preeclampsia Awareness Month and the journal Obstetrics and Gynecology highlighted some new research published by doctors and researchers at the California Maternal Quality Care Collaborative that demonstrated that the majority of preeclampsia-related deaths could have been prevented.  This is significant because preeclampsia is one of the top perinatal causes of death. Today on Science & Sensibility, Preeclampsia Foundation Executive Director Eleni Z. Tsigas provides an update on this new research and important facts that birth professionals should know.  As childbirth educators, along with teaching families about normal labor and birth, we have an obligation to share information about warning signs and potential complications.  While not as much “fun” as teaching how to cope with a contraction, it is equally important.  Have you checked out the information available at the Preeclampsia Foundation‘s website?  There is a great short video, class tear sheets and even information en español.  How do you teach about preeclampsia to the families that you work with?  Let us know in the comments section. – Sharon Muza, Science & Sensibility Community Manager

Research published in the April 2015 issue of Obstetrics & Gynecology shows that 60 percent of preeclampsia-related maternal deaths were deemed preventable. This large study – Pregnancy-Related Mortality in California: Causes, Characteristics, and Improvement Opportunities – analyzed U.S. pregnancy-related mortality administrative reports and medical records for each maternal death to identify the causes and contributing factors, and improve public health and clinical practices.

Over the last 20 years, a previous decline in maternal deaths has reversed and is cause for concern. The 2009 U.S. pregnancy-related mortality rate was 17.8 deaths per 100,000 live births, up from 7.7 per 100,000 in 1997 and above that of other high-resource countries.

One of every eight U.S. births occurs in California, resulting in more than 500,000 annual deliveries with extensive racial and ethnic diversity. With California’s large population-based sample, this study provides a unique opportunity to compare major causes of pregnancy-related mortality and identify improvement opportunities.

Preeclampsia-related maternal death deemed most preventable

Among the 207 pregnancy-related deaths from 2002 to 2005 studied in California, preeclampsia or eclampsia were identified as one of the five leading causes. The others were cardiovascular disease, hemorrhage, venous thromboembolism, and amniotic fluid embolism.

Of the five leading causes of death, preeclampsia was deemed one of the most preventable – preeclampsia-related deaths had a good-to-strong chance of preventability, estimated at 60%.

Healthcare provider factors were the most common type of contributor, especially delayed response to clinical warning signs followed by ineffective care.

Patients play important role in preventing preeclampsia-related deaths 

The leading patient factors among preeclampsia deaths were delays in seeking care (42%), presumed lack of knowledge regarding the severity of a symptom or condition (39%), and underlying medical condition (39%).

Preeclampsia deaths were most common among foreign-born Hispanic and African American women and associated with early gestational age, consistent with studies demonstrating the increased severity of early-onset preeclampsia.

These findings illustrate the need for public health interventions aimed at helping all women understand and recognize their risks and attain optimal pre-pregnancy health and weight.

It’s worth noting that since the study period, patient awareness has improved, led by several Preeclampsia Foundation education initiatives – currently preeclampsia awareness among pregnant women is 83%, according to a survey conducted last year by BabyCenter®.

The findings also underscore the need for focused approaches to improve care such as hospital-based safety bundles as well as comprehensive programs for patient education, communication, and teamwork development. Read the full report here.

Maternal health improvement initiatives underway 

As these Pregnancy-Related Mortality research findings are announced, several states have already moved forward with maternal health improvement initiatives. Recently the California Maternal Quality Care Collaborative (CMQCC), Hospital Corporation of America, and the American College of Obstetricians and Gynecologists released guidelines and quality improvement toolkits with standardized approaches to recognize and treat severe hypertension, and to increase awareness of atypical clinical presentations and patient education.

CMQCC’s Preeclampsia Toolkit incorporated the Preeclampsia Foundation’s Illustrated Symptoms Tear Pad that effectively informs women who are pregnant or recently gave birth about preeclampsia, which can strike up to six weeks after delivery. Developed by the Preeclampsia Foundation and researchers at Northwestern University Feinberg School of Medicine, the tear pad uses illustrations to describe the symptoms of preeclampsia so they are easily understandable, especially for those with poor health literacy. This toolkit is freely available online and has been downloaded by over 5,100 persons in the United States and more than 60 other countries. It is also being implemented in more than 150 California hospitals as part of the California Partnership for Maternal Safety.

In the year since implementing a Severe Maternal Morbidity Pre- and Post-Toolkit, CMQCC has noted a 34% reduction in maternal adverse outcomes. After implementing Pre- and Post-Hypertension Bundles, the rate of eclampsia has decreased by 31%.

New York joins California in distributing the tear pad throughout the state – as part of a statewide Maternal Preeclampsia Initiative, the New York State Perinatal Quality Collaborative, an initiative of the New York State Department of Health and the New York State Partnership for Patients – has adopted this patient education tool, making it available to all New York birthing facilities.

The Preeclampsia Foundation is proud to play a role in reversing the rate of maternal mortality and severe morbidity; it’s a team effort that requires the combined efforts of public health, clinical and hospital leaders and their institutions, and professional and consumer organizations.

References

Main, E. K., McCain, C. L., Morton, C. H., Holtby, S., & Lawton, E. S. (2015). Pregnancy-related mortality in California: causes, characteristics, and improvement opportunities. Obstetrics & Gynecology, 125(4), 938-947.

About Eleni Z. Tsigas

G8FK7644Eleni Z. Tsigas is the Executive Director of the Preeclampsia Foundation. Prior to this position, she served in a variety of volunteer capacities for the organization, including six years on the Board of Directors, two as its chairman. Working with dedicated volunteers, board members and professional staff, Eleni has helped lead the Foundation to its current position as a sustainable, mission-driven, results-oriented organization.

As a preeclampsia survivor herself, Eleni is a relentless champion for the improvement of patient and provider education and practices, for the catalytic role that patients can have to advance the science and status of maternal-infant health, and for the progress that can be realized by building global partnerships to improve patient outcomes.

She has served as a technical advisor to the World Health Organization (WHO) and participated in the Hypertension in Pregnancy Task Force created by the American College of Obstetricians and Gynecologists to develop the national guidelines introduced in 2013, as well as a similar task force for the California Maternal Quality Care Collaborative (CMQCC). Eleni also serves on the National Partnership for Maternal Safety initiative, the Patient Advisory Board of IMPROvED (IMproved PRegnancy Outcomes via Early Detection), Ireland, and the Technical Advisory Group and Knowledge Translation Committee for PRE-EMPT (funded by the Bill & Melinda Gates Foundation). Eleni is frequently engaged as an expert representing the consumer perspective on preeclampsia at national and international meetings, and has been honored to deliver keynote addresses for several professional healthcare providers’ societies.

Eleni has collaborated in numerous research studies, has authored invited chapters and papers in peer-reviewed journals, and is the Principal Investigator for The Preeclampsia Registry.

A veteran of public relations, she has secured media coverage about preeclampsia in national consumer magazines, as well as newspapers, radio and online. Eleni previously spent 8 years executing and managing strategic communications and public relations for technology and biotech companies with Waggener Edstrom Worldwide and for 6 years prior in the television industry.

She is married, and has had two of her three pregnancies seriously impacted by preeclampsia. 

 

Childbirth Education, Guest Posts, Maternal Quality Improvement, Maternity Care, Pre-eclampsia, Research , , , ,

World Health Organization: Provide Cesareans for Women in Need, Don’t Focus on Specific Rate

April 21st, 2015 by avatar
© Patti Ramos Photography

© Patti Ramos Photography

As we have mentioned earlier this month, when Jen Kamel discussed placenta accreta as a downstream risk factor of the increasing cesarean rate, April is Cesarean Awareness Month and the World Health Organization (WHO) has come out with a new statement (WHO Statement on Caesarean Section Rates) that discourages identifying a “cesarean target rate” but rather encourages the use of cesarean surgery worldwide only when appropriate to protect the health of mother and baby. The goal should be that every cesarean performed is done out of true medical necessity and the decision to do so should be based on individual circumstances evaluated at the time for each mother/baby dyad.

Since 1985,  it has been stated that a safe and appropriate cesarean target rate was between 10-15%.  It was believed that if the cesarean rate exceeded that target rate, the mortality and morbidity for both mothers and babies would rise as a result of potentially unnecessary surgeries being performed.  Everyone recognizes that a cesarean birth can save the life of a mother and/or a baby.  But it needs to be acknowledged that there are no benefits to mothers and babies when a cesarean is done when it is not required.  WHO has decided to revisit the decades old suggested target rate as the number of cesarean surgeries being performed are increasing all around the world.  In the USA, in 2013, 1,284,339 cesarean surgeries were performed.  32.7% of all babies born in the USA that year were delivered by surgery.

There are both short term and long term risks to mothers, babies and future pregnancies every time a cesarean is performed.  These risks are even more elevated in areas where women have limited access to appropriate obstetrical care.

The WHO strived to identify an ideal cesarean rate for each country or population as well as a worldwide country level analysis.  The cesarean rate at the population level is determined by two items – 1) the level of access to cesareans and 2) the use of the intervention, both appropriate and inappropriately. Governments and agencies can use this information to allocate funding and resources.  Cesareans are costly to perform and doing more than necessary puts undue financial hardship on resources that may already be stretched too thin in many places around the world.

After conducting a systematic review – the team tasked with determining the population based cesarean rate determined that indeed, when cesareans are performed up to a rate of approximately 10-15%, maternal, neonatal and infant mortality and morbidity is reduced.  When the cesarean rate starts to increase above this level, mortality rates are not improved. When socioeconomic factors were included in the analysis, the relationship between lower mortality rates and an increasing cesarean rate disappeared.  In locations where cesarean rates were below 10%, as the rate increased, there was a decrease in mortality in both mothers and babies.  When the rate was between 10-30%, they did not see a continued decrease in mother or newborn mortality rates. The team also acknowledged that once the cesarean rate increased to 30% or above, the link between newborn and maternal mortality becomes difficult to assess.

In countries that struggle with resources, staffing and access to care, the common complications of surgery, such as infection, make cesarean surgery even more complicated and even dangerous for those women who give birth this way.

The team also struggled with analyzing the morbidity rate due to the lack of available data.  They did acknowledge that while the social and psychological impact of cesarean sections were not analyzed, potential impacts could be found in the maternal–infant relationship, women’s psychological health, women’s ability to successfully initiate breastfeeding and pediatric outcomes.  More research is needed.

WHO Cesarean Rate Conclusions

© WHO

 

The WHO team also felt it is important to establish, recognize and apply a universal classification system for cesareans that can be applied at the hospital level and allow comparisons to take place between different facilities and the unique populations that they serve. Once established, rates and systems could be compared between geographic regions, countries, different facilities and on a global level and the data analyzed effectively to help identify where change can be effective at reducing poor outcomes.

robson high res 2

© WHO – click image for full size version

After reviewing the different classification systems currently available, they determined that universal use of the Robson classification would best meet the needs of both international and local analysis.  The Robson classification system is named after Dr. Michael Robson, who in 2001 developed this system to classify women based on their obstetric characteristics for the purpose of research analysis.  This allows for comparisons to be made regarding cesarean section rates with few confounding factors.  Every woman will be clearly classified into one of the ten known groups when admitted for delivery. The WHO team states that the Robson classification system “is simple, robust, reproducible, clinically relevant, and prospective.”

The WHO team believes that using the Robson classification will aid in data analysis on many levels and the information obtained from these analyses be public information.  This information can be used to help facilities to optimize the use of cesarean section in the specific groups that will benefit from intervention.  It will also help determine the effectiveness of different strategies that are currently being used to reduce this intervention when not necessary.

Cesarean sections can be a life-saving tool under certain circumstances.  When cesareans are performed when not medically necessary, there are both long term and short term risks to both mothers and babies, including increased mortality and morbidity and risks to future pregnancies.  This becomes especially significant in areas of low resources and scare obstetric care.  Better data is needed to help reduce the cesarean rate in locations where it is unnecessarily high and to be able to direct resources where they are needed and can improve outcomes.  The World Health Organization hopes that this data becomes available so that more accurate research can be conducted and the reduction in mortality and morbidity for mothers and babies can be reduced.

Are you sharing with your classes, clients and families the importance of having a cesarean only when medically necessary?  While April may be Cesarean Awareness Month, we need to be diligent all year long to prevent cesareans that are not needed.

Lamaze International has created and made available three infographics that can help families learn more about cesareans and VBACs.

Screenshot 2015-04-20 19.52.53

What’s the Deal with Cesareans?

Avoiding the First Cesarean

VBAC, Yes, It’s an Option! (NEW!)

You can download and print these and other Lamaze International infographics from this page here.

Share what you are doing to honor Cesarean Awareness Month in your professional practice in our comments section below.

 

 

 

Babies, Cesarean Birth, Childbirth Education, Maternal Mortality, Maternal Mortality Rate, Maternal Quality Improvement, Maternity Care, Medical Interventions, Newborns, Research, Systematic Review , , , , , ,

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 , , , , ,

Remembering Sheila Kitzinger – An Amazing Advocate for Women, Babies and Families

April 13th, 2015 by avatar

“Sheila Kitzinger is a giant upon whose shoulders we will stand on as we continue our important work for women and their babies. She will be sorely missed.” – Judith Lothian

SheilaKitzinger85Birthday_lSheila Kitzinger passed away on April 12th at her home in Oxfordshire, England after a short illness  Ms. Kitzinger was 86 years old. My eldest son, the father of four, forwarded me the BBC announcement. It shouldn’t have been a shock because I had heard she was very ill. But it is. We have lost a birth advocate who “rocked the boat” and taught the rest of us how to do it.

Kitzinger was an anthropologist and childbirth educator. As a childbirth educator, she pushed educators to go beyond just sharing knowledge, beyond just educating women about birth. She believed that we needed to confront the system in which birth takes place, to advocate in powerful ways so that women could give birth without being traumatized physically or emotionally. She wrote more than 25 books, an endless number of articles in scholarly journals, including her wonderful “Letter from Europe” column in Birth, and a steady stream of newspaper and magazine articles and letters to the editors. Her latest book, A Passion for Birth: My Life; Anthropology, Family, and Feminismher memoirs, will be published in the UK in June.

Sheila came to New York City in the 1970s several times. I was a young mother and new childbirth educator who knew nothing about Kitzinger before I heard her speak. Her passion, her knowledge, and her genuine interest in everyone she met inspired and motivated me, really all of us, to meet the challenges (and they were substantial) that we faced back then. I have spent the last 40 years reading literally everything Sheila Kitzinger has written. Many of those books and articles I have read over and over again, always learning something new. I consider Sheila Kitzinger one of my most important mentors, although we only spoke at length on four occasions in all those years.rediscovering birth kitzinger

With a handful of others, Kitzinger turned the world of birth upside down. Although we still have a long way to go, Sheila Kitzinger’s work has made contributions that simply cannot be measured. Kitzinger’s work going back to the 1970s on episiotomy and the value and importance of home birth were the start of what would become prolific contributions. Her books for women on pregnancy and childbirth, breastfeeding, sex and pregnancy, and the sexuality of birth and breastfeeding can’t be beat. Her work on post traumatic birth in the Uk was groundbreaking. Her books on the politics of birth, the culture of birth, becoming a mother, and becoming a grandmother are major contributions to the literature. Rediscovering Birth is a personal favorite. If that book doesn’t inspire women to think differently about birth, I don’t know what can!

sheila kitzinger 2The article that made the biggest difference in my life was “Should Childbirth Educators Rock the Boat?” published in Birth in 1993. At the time I was new to the Board of Directors of Lamaze International (then ASPO Lamaze) and was soon to become President of the organization. Kitzinger wrote powerfully of the need for childbirth educators to not just teach women about birth but to advocate within the system for change, to take strong stands in support of normal physiologic birth, home birth, and humane, empowering childbirth. Her call to action drove my own work within Lamaze. The result was a philosophy of birth that was courageous and groundbreaking and has driven the work of the organization since then. Advocacy is a competency of a Lamaze Certified Childbirth Educator and the mission of the organization clearly identifies the role of advocacy. Lamaze International’s six evidence based Healthy Birth Practices “rock the boat” of the standardized childbirth education class that creates good patients and hospitals that claim to provide safe care to women and babies. When The Official Lamaze Guide: Giving Birth with Confidence was first published in 2005, Sheila reviewed the book. In her review she wrote, “…It’s humane, funny, tender, down-to-earth and joyful. Essential reading for all pregnant women who seek autonomy in childbirth.” I wanted to tell her – “Without your passion and inspiration that book might not have been written.”

There are a number of other bits of wisdom from Kitzinger that I often quote. They have made a difference to me and, I suspect, to everyone who knows Sheila’s work.

  • What breastfeeding mothers need most is a healthy dose of confidence
  • Home birth should be a safe, accessible option for women
  • Touch in childbirth has changed from warm, human touch to the disconnected touch of intravenous, fetal monitors, blood pressure cuffs
  • Women know how to give birth
  • The clock is perhaps the most destructive piece of modern technology

Kitzinger gave me a healthy dose of confidence in myself and in the importance of what we do in small and big ways as we go about the work of changing the world of birth. She convinced me that talking about birth and writing about birth, even if only to the choir, makes a difference. We know we’re not alone and we become more passionate and more committed. We develop the courage to “rock the boat”.

Sheila Kitzinger is a giant upon whose shoulders we will stand on as we continue our important work for women and their babies. She will be sorely missed. May she rest in peace. Our deepest sympathies go out to her family and friends.

Do you have a memory or story to share about Sheila Kitzinger?  How has she or her work impacted you personally or professionally?  Share your stories in our comments section. – SM

About Judith Lothian

@ Judith Lothian

@ Judith Lothian

Judith Lothian, PhD, RN, LCCE, FACCE is a nurse and childbirth educator. She is an Associate Professor at the College of Nursing, Seton Hall University and the current Chairperson of the Lamaze Certification Council Governing Body. Judith is also the Associate Editor of the Journal of Perinatal Education and writes a regular column for the journal. Judith is the co-author of The Official Lamaze Guide: Giving Birth with Confidence. Her research focus is planned home birth and her most recent publication is Being Safe: Making the Decision to Have a Planned Home Birth in the US published in the Journal of Clinical Ethics (Fall 2013).

Babies, Breastfeeding, Childbirth Education, Guest Posts, Healthy Birth Practices, Home Birth, Infant Attachment, Lamaze International, Maternity Care, Midwifery, Newborns , , , ,

Birth By The Numbers Releases New Video – Myth and Reality Concerning US Cesareans

March 19th, 2015 by avatar

birth by numbers header

I have been a huge fan of Dr. Eugene Declercq and his team over at Birth by the Numbers ever since I watched the original Birth by the Numbers bonus segment that was found on the Orgasmic Birth DVD I purchased back in 2008.  I was on the board of REACHE when we brought Dr. Declercq to Seattle to speak at our regional childbirth conference in 2010 and since then have heard him present at various conferences around the country, including most recently at the 2014 Lamaze International/DONA International Confluence, where Dr. Declercq was a keynote speaker.  I enjoy listening to him just as much now as I did back in 2008.  You  may also be familiar with Dr. Declercq’s work as part of the Listening to Mothers research team that has brought us three very valuable studies.

Birth by the Numbers has grown into a valuable and up to date website for the birth professional and the consumer, filled to the brim with useful information, videos, slide presentations and blog posts.  This past Tuesday, the newest video was released on the website: Birth By The Numbers: Part II – Myth and Reality Concerning US Cesareans and is embedded here for you to watch.  We shared Part I in a blog post last fall.


Also available for public use is a slide presentation located in the the “Teaching Tools” section of the Birth by the Numbers website designed to provide additional information, maps, data and resources for this new Myths and Reality Concerning Cesareans video. Included in this slideshow are notes and updates to help you understand the slides and share with others.  This material is freely given for your use.

© Birth by the Numbers

© Birth by the Numbers

This video explores how cesareans impact maternity care systems in the USA.  After watching the video and reviewing the slides, here are some of my top takeaways.

1.  The common reasons given for the nearly 33% cesarean rate in the USA (bigger babies, older mothers, more mothers with obesity, diabetes and hypertension, more multiples and maternal request) just don’t hold water when examined closer.

2. Many women feel pressure from their healthcare provider to have a cesarean, either prenatally or in labor.

3. The leading indicators for cesareans are labor arrest (34%) and nonreassuring fetal heart tracings (23%).

4. The rise in cesareans is not a result of a different indications.  Dr. Declercq quotes a 20 year old article’s title that could still grace the front pages today. “The Rise in Cesarean Section Rate: the same indications – but a lower threshold.”

5. When examining the distribution of cesarean births by states over time, it is clear that those states with the highest cesarean birth rate decades ago, still remain in those spots today.

6. “We are talking about cultural phenomena when we are talking about cesareans, not just medical phenomena.”

7. First time, low risk mothers who birthed at term and experienced labor had a 5% cesarean rate if they went into spontaneous labor and did not receive an epidural.  If they were induced and received an epidural, the cesarean rate was 31%.

8. The United States has the lowest VBAC rate of any industrialized country in the world.

© Birth by the Numbers

© Birth by the Numbers

While the video is rich (and heavy) in data laden charts and diagrams, the message, though not new, is clear.  The US maternity care system is in crisis.  We have to right the ship, and get back on course for healthier and safer births for pregnant people and babies. Take a look at this new video, and think about what messages you can share with the families you work with and in the classes you teach, to help consumers make informed choices about the care they receive during the childbearing year.

Please watch the video, visit the website to view the slides and let me know here in the comments section what you are going to use from this information to improve birth.

Babies, Cesarean Birth, Childbirth Education, informed Consent, Maternal Obesity, Maternal Quality Improvement, Maternity Care, Medical Interventions, New Research , , , ,