24h-payday

Archive

Archive for the ‘Medical Interventions’ Category

“Pathway to a Healthy Birth” – Using Consumer Materials from Hormonal Physiology of Childbearing Report in Your Classes.

January 22nd, 2015 by avatar

Screen Shot 2015-01-21 at 6.01.46 PMLast week, Dr. Sarah Buckley in coordination with Childbirth Connection released a new research report, “Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies and Maternity Care.”  This massive tome gathers in one place, all the current information available on the role of various hormones on pregnancy, labor, birth, breastfeeding and postpartum and provides information on what happens to the processes when interventions are introduced.  Well known childbirth educator Penny Simkin reviewed the report on Science & Sensibility on January 13th and then Michele Ondeck followed up with an exclusive Science & Sensibility interview with Sarah Buckley later in the week.

I think that everyone will acknowledge that this report is a remarkable and valuable piece of work, but at over 400 pages if you take into account all accompanying documents and with a bibliography consisting of over 1100 sources, the typical pregnant woman is hardly going to be keeping a copy on their bedside table for some light reading before drifting off to sleep.  Today on Science & Sensibility, I would like to highlight the resources and tools that Childbirth Connection has thoughtfully provided that are geared specifically for the consumer.  Childbirth educators, doulas and health care providers can access and share these materials with their students, clients and patients.

Pathway to a Healthy Birth – How to Help Your Hormones to Do Their Wonderful Work – consumer booklet

This 17 page colorful consumer booklet is written in easy to comprehend language and illustrated with attractive photographs that show a diverse collection of families.  Families are introduced to the hormones of birth and postpartum; oxytocin, beta-endorphins, catecholamines and endorphins.  Each hormone has a brief description and a short explanation about the role it plays in childbearing.

Families are told that events can interfere with the intended actions of the childbearing hormones.  Birthing women are encourage to think about how activities around them during their labor and birth may interfere with hormones and prevent the hormones from working effectively.

Women learn that hormones prepare her body for an efficient labor and birth.  The booklet addresses how women’s bodies are prepared by some hormones to handle the pain and stress that may accompany labor. They also find out that the hormones help prepare their babies for the newborn transition.  Infant attachment and maternal behaviors are also supported by the role of the hormones.

Follow Angela’s Birth Story

Families are introduced to “Angela” and read about her labor and birth story.  The story shows how the hormones allow the labor and birth to unfold in support of the normal processes and how small things can have a big impact and disrupt the process.  For example, The transition from home to hospital reduces the intensity and frequency of Angela’s contractions as a result of interference with the normal hormonal process.  The story is filled with lots of strategies to encourage and allow the hormonal effects as they are intended to occur.

It is easy to see from Angela’s story, that while labor and birth are hard and do involve pain, with the right support and environment, along with best practices that endorse physiological birth, Angela is able let her body do the work it is designed to do, and have a birth that is very satisfying to her.

“What’s Happening”

Accompanying the story is an easy to read guide that demonstrates exactly what the hormones of childbearing are doing at each particular point in Angela’s story.  Explanations of the role of each hormone as things unfold help families to understand how what happens in their own birth can affect their own birth story and outcome.

What Can You Do

The next portion of the brochure offers steps that families can take to help them identify providers and facilities that support physiologic birth.  Lists of questions to ask, tips for making a hospital room comfortable and private, interview questions for their doctor or midwife, how to pick a childbirth class, find a doula, how to determine if medical procedures are necessary and explore less interventive alternatives and more are all there in an easy to digest format. Included are valuable links in the final section that makes the booklet resource rich.  There are many web links to get more information about all the topics covered above.  This makes the booklet an ideal handout for a childbirth class, doula consultation or meet and greet with potential health care providers.

Infographic

Screen Shot 2015-01-21 at 6.03.49 PMThere is a consumer infographic that can be printed in a size suitable for hanging in a classroom or office, or provided in a smaller format that makes a great accompaniment to the above booklet.  The infographic identifies things that can keep a woman on the “pathway” to a physiological birth and what can steer her away from the pathway.  There is a lot of similarity between the points made in this infographic and the Lamaze Six Healthy Birth Practices.

One teaching idea

After discussing the role of hormones in labor and sharing the infographic as a visual aid, I can easily see how an educator can play a game with her class – making and distributing cards to class members with scenarios on them, and asking families to share if those scenarios and activities are making it easier for the mother to stay on the physiological pathway or what steers her further away and having the students identify which hormones are affected.

We have a responsibility as childbirth educators to share the important role the hormones of childbearing play in supporting healthy mothers, healthy births and healthy babies.  Using the Pathway to a Healthy Birth consumer booklet and accompanying infographic as part of your teaching materials provides a simple to understand but effective tool for conveying this information to the families you interact with.

How do you see yourself using these consumer products in your childbirth classes?  With your doula clients?  Please share your ideas for teaching, discussing and using this material and covering these topics with the families you work with.  I would love to hear your thoughts.

Babies, Breastfeeding, Childbirth Education, Healthy Birth Practices, Infant Attachment, Medical Interventions, Newborns, Research, Transforming Maternity Care , , , , , ,

An Interview with Sarah Buckley: Discussing Her New Report – “Hormonal Physiology of Childbearing”

January 15th, 2015 by avatar

By Michele Ondeck,RN, MEd, IBCLC, LCCE

© Sarah Buckley

© Sarah Buckley

Sarah Buckley is a family doctor, mother of four, and author of the bestselling book Gentle Birth, Gentle Mothering. She has been writing and lecturing about the hormones of birth, among other topics, since 2001. Mothering Magazine published her article “Ecstatic Birth, Nature’s Hormonal Blueprint of Labor” in 2002.  She lives with her family near Brisbane, Australia.  On Tuesday, January 13th, 2015, Dr, Buckley released a comprehensive report entitled “Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care” in cooperation with Childbirth Connection.  Two days ago, Penny Simkin reviewed the report and shared valuable information on how birth professionals will be able to use this report in their classes or practices.  Today, Lamaze International Past President, Michele Ondeck, shares her recent interview with Dr. Buckley.  In this interview, they discuss Sarah’s thoughts on what this report means for both families and professionals. Sarah speaks to how it we are just beginning to recognize the downstream effects of disturbing the normal hormonal process that occurs during labor, birth and postpartum and what this disturbance might mean for future generations. – Sharon Muza, Community Manager, Science & Sensibility.

Michele Ondeck: Sarah, thank you for the in-depth review of the hormones of labor in the Hormonal Physiology of Childbearing (HPOC) report. I am thankful for the support you received for this project from the Childbirth Connection programs with the National Partnership for Women & Families. As a board member of Lamaze International, I am proud that we were able to also provide some support to make this report possible. How are you celebrating the report’s release?

Sarah Buckley: Finishing the report has been a big milestone, not just for me but also for my family who have been very involved and supportive. We’ll be celebrating with champagne and, as its summer down here, with an Aussie barbeque.

MO: Sarah, I have been sharing orchestration of the hormones of birth: oxytocin, beta endorphins, epinephrine and nor-epinephrine and prolactin from Ecstatic Birth with parents and professionals since its publication. You have expanded, clarified, and synthesized that basic information in your report. I know that you have been working on this report since 2011. What was your inspiration to keep at it? How did you find time to review more than 1,100 publications?

SB: Yes, it’s been a long gestation! What has kept me engaged is the practical relevance of the material for mothers, babies, fathers, and families, and my own lived experiences. For me, its much more than an academic body of knowledge, it’s a paradigm that recognizes the superb design of our female bodies, and describes the smoothest, safest, easiest, and most pleasurable path to parenting. I am also lucky to receive much support and positive feedback about this material, both from maternity care providers, who gain a scientific understanding of what they are seeing every day in the birth room, and from women themselves, who realize that there are positive ways to support their hormones and increase safety, ease, and pleasure for themselves and their babies.

Screen Shot 2015-01-13 at 6.38.16 PMMO: Now with the publication of the Hormonal Physiology of Childbearing, there is the potential to educate so many more professionals in the maternity and newborn care community. How does the timing of the report fit with the changes that you see happening today that can influence professionals?

SB: I have been writing and lecturing about the hormonal physiology for more than 10 years and I have seen a significant shift in receptiveness to this perspective, especially in the last 2 to 3 years. I think we are maturing as birth professionals and beginning to think more widely about the perinatal period. The microbiome paradigm, for example, which looks at the effects of birth on the transfer of healthy bacteria from mother to newborn, is giving us solid evidence that what happens at birth can have long-term consequences.

It is also a very exciting time to launch the report because this material is very much aligned with other initiatives, including ACNM’s Physiologic Birth Initiative and the ACOG/SMFM Safe Prevention of the Primary Cesarean Delivery statement. It’s also a pleasure to me that the Hormonal Physiology of Childbearing supports and extends other current models including the Lamaze Healthy Birth Practices.

MO: You refer to the growing recognition of the significance of the Developmental Origins of Health and Disease (DOHaD) in the report. Midwives, childbirth educators and doulas among others have long discussed the unintended consequences of interventions in childbirth. Now with more recognition of the importance of the perinatal period as a sensitive period that potentially affects long term health, how do you simply explain this fascinating concept and others like epigenetic programming for childbearing families?

SB: The perspective of Hormonal Physiology is very much aligned with these big-picture models including DOHaD, epigenetics, and Lifecourse Health Development, which is a multi-system model looking at the potential for early events to change the trajectory of long-term health and development.

Epigenetics refers to the biochemical processes that switch genes on or off, which helps organisms to adapt to their environment and circumstances. We know that epigenetic changes give critical adaptations (“programming”) in early life that increase the chance of survival in the environment they have come into.

In relation to DOHaD, it is now scientifically established, and widely accepted — e.g., you read this research in the media and online — that the baby’s exposures in the womb can have long-term health effects. We also know from animal studies (with a growing interest in human research also) that early life events can have long-term programming effects, and we have even identified the associated epigenetic changes in some animal studies.

What the HPOC perspective adds to these models is the possibility that these long-term programming effects may occur not only before and after birth but also during birth, and it provides possible mechanisms for such effects. In other words, changing the hormonal experiences around the time of birth could have far-reaching effects.

In fact, we would expect very significant epigenetic effects at this time, as part of the enormous shifts involved with adapting to life outside the womb and, for the mother, optimally adapting her to the essential tasks of nurturing and nourishing her young. We have substantial animal research showing long-term effects from perinatal hormone exposures, including exposure to high doses of synthetic oxytocin.

MO: When you were doing this in-depth research on the hormones of labor. What finding(s) were most meaningful to you as a mother?

SB: As we describe in the report, this is a “consistent and coherent mosaic coming into view,” so we don’t have all the gaps filled in. However, what strikes me as a mother, and in relation to my own experiences of birth and mothering, is evidence that the hormonal processes of labor and birth, including mother-newborn contact in the first hour after birth, might switch on maternal reward systems in the brain at this powerful time, so that the new mother finds her offspring rewarding into the future. This is a critical mechanism for species survival, and ensures that mammalian mothers give the dedicated care that their newborns need- without going to a prenatal class! And after birth, these systems are reinforced for the mother by rewarding hormones including oxytocin and beta-endorphins released with breastfeeding and also with close infant contact.

© Sarah Buckley

© Sarah Buckley

I wonder if some of the problems we have with parenting in our culture, that it seems like hard work, that we can find caring for our young children boring, are because we can miss all of these sources of rewarding hormones.

MO: The forward to the report was written by leaders in medicine, midwifery, nursing, obstetrics, and pediatrics urging maternity care to support physiologic birth in order to uphold the Precautionary Principle of “do no harm.” What do you want to say to us on where to start in changing the current environment?

SB: I think one of the most powerful things we can do is to share the information in this report, including the knowledge gaps, with professionals and with expectant parents, so that we can shift our cultural understanding towards appreciating how superbly designed women’s bodies are for childbearing, how these hormonal systems can be disrupted, and that we actually don’t know the long-term effects for our children, so we should be applying precaution.

I especially want to reach high-technology settings, so that we can begin to recognize the gap between physiology and current practice and work to bridge it. In situations where interventions are genuinely needed, I want care providers to be asking “How can we safely add more hormonal physiology?” and take actions. This could be as simple as supporting skin-to-skin after cesarean, or promoting doula care for women with pregnancy complications.

I also want this report to get the attention of policy makers and funders. Physiologic childbearing is a low-technology approach that is generally inexpensive compared to our current high-technology models of care. The hormonal physiology perspective also suggests significant longer-term and public health benefits, for example through support for breastfeeding. This could give even greater benefits and cost-effectiveness in the longer-term, making it an excellent investment of health-care funds

About Michele Ondeck

michele ondeck head shot 2015Michele Ondeck,RN, MEd, IBCLC, LCCE serves the Lamaze International Board of Directors as its immediate past president. She was employed by Magee-Womens Hospital of University of Pittsburgh Medical Center for more than thirty years in a number of positions including education and research in the pursuit of improving women’s health and maternity care. She is the mother and grandmother of four. Currently, she is a director of a Lamaze International Accredited Childbirth Educator Program and self-employed as a perinatal education consultant.

 

 

 

 

 

 

 

Babies, Childbirth Education, Guest Posts, Healthy Birth Practices, Infant Attachment, Medical Interventions, Newborns , , , , , ,

Sarah Buckley’s “Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care” – A Review for Birth Educators and Doulas

January 13th, 2015 by avatar

by Penny Simkin, PT, CD(DONA)

Today, a long awaited report written by Dr. Sarah Buckley, “Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care” is being released by Childbirth Connection. In this valuable report, Dr. Buckley gathers the most current research and provides the definitive guide for the role of hormones in normal, natural birth.  Esteemed childbirth educator, doula and author/filmmaker Penny Simkin has reviewed Dr. Buckley’s latest offering and shares today on Science & Sensibility how childbirth educators, doulas and other birth professionals can use this information to inform parents on how best to support the physiological process of childbirth.  In coordination with this research report, Dr. Buckley and Childbirth Connection are releasing a consumer booklet geared for families and consumers as well as other material, including infographics in support of this report.  On Thursday, Lamaze International Past President Michele Ondeck will share her interview with Dr. Buckley. In that interview,  S&S readers can get the full story directly from Dr. Buckley, on just what it took to create this remarkable tome. – Sharon Muza, Community Manager, Science & Sensibility.

© Childbirth Connection

© Childbirth Connection

Introduction

For many of us who work in the maternity field, Sarah Buckley’s fine work is well-known. Her book, “Gentle Birth, Gentle Mothering” (Buckley, 2009) has provided scholarly and enlightening guidance on natural childbirth and early parenting for many years. Her 16 page paper, “Ecstatic Birth,” (Buckley, 2010) guides educators and doula trainers, who rely heavily on her explanations of hormonal physiology in childbearing, for teaching about labor physiology and psychology and the impact of care practices.

Her newest publication, “Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care,” (Buckley, 2015) is a gift to us all. It represents a massive scholarly effort, a review of all the related scientific literature on the topic. With 1141 references, most of which were published in recent years, Dr. Buckley’s overview provides the transparency to allow readers to trace her statements to the evidence on which they are based. She exercises caution in drawing concrete conclusions when the evidence is insufficient; she presents such information as theory (rather than fact), and points out when more research is necessary for concrete conclusions. The “theory” that undisturbed birth is safest and healthiest for most mothers and babies most of the time is impressively supported by her exhaustive review, as stated in the conclusion (Buckley, 2015):

“According to the evidence summarized in this report, the innate hormonal physiology of mothers and babies – when promoted, supported, and protected – has significant benefits for both during the critical transitions of labor, birth, and the early postpartum and newborn periods, likely extending into the future by optimizing breastfeeding and attachment. While beneficial in selected circumstances, maternity care interventions may disrupt these beneficial processes. Because of the possibility of enduring effects, including via epigenetics, the Precautionary Principle suggests caution in deviating from these healthy physiologic processes in childbearing.”

The Precautionary Principle, to which she refers, has been stated as follows:

“When an activity raises threats of harm to human health or the environment, precautionary measures should be taken even if some cause and effect relationships are not fully established scientifically. In this context the proponent of an activity, rather than the public, should bear the burden of proof. . . . It (the activity) must also involve an examination of the full range of alternatives, including no action.” (Science and Environmental Health Network, 1998).

In other words, when applied to maternity care, The Precautionary Principle states that when a practice, action, or policy may raise threats of harm to mother, baby, or family, the burden of proof that it will result in more good than harm falls on those who wish to adopt it – the policy maker, caregiver, or administrator, not on the pregnant person.

© Sarah Buckley

© Sarah Buckley

What’s new in this document and how might you use it and apply it in your classroom or practice?

This document represents the “State of the Science” regarding hormonal physiology of childbirth (HPOC). It should be the starting point for consideration of proposed changes in maternity care management and education. The question, “How might this policy, practice, or new information impact the HPOC and subsequent outcomes for mother and/or baby?” should be asked and answered about both existing and proposed interventions.

Sarah Buckley has asked and answered this question, and reveals the unintended consequences of numerous widespread practices, including scheduled birth – induced labor or planned cesarean; disturbance and excessive stress during labor; synthetic oxytocin (Pitocin); opioids and epidural analgesia for labor pain; early separation of mother from infant or wrapping the infant in a blanket to be held (i.e., no skin-to-skin contact); breastmilk substitutes, and many more. All of these practices cause more harm than good, except in unusual or abnormal circumstances.

One of the greatest contributions of this book is showing that hormonal physiology is affected by virtually every intervention –major and minor — and understanding this is the key to appropriate maternity care. The topic is complex and not nearly fully understood, but Sarah Buckley has pulled together just about everything that is now known on this topic. If you’re a maternity care practitioner or student, who wants to approach the care you give from a physiological perspective, or want information on the impact of common interventions on the physiological process, it’s all here. If you’re a researcher interested in studying some aspect of HPOC, your literature search has already been done for you and you can discover the many areas that have been insufficiently studied and plan where to go from there.

If you’re a childbirth educator seeking to give accurate information to expectant parents about how normal childbirth unfolds and how it can be altered (for better or worse) with common procedures and medications, you can learn it here. If you’re a doula who wants to understand how your presence and actions may contribute to normalcy, you can learn it here. If you’re an expectant parent who wants to make choices that maintain or improve the pregnant person and infant’s well-being, you can learn it here or access the consumer guide.

Organization of the Chapters

This book, with its numerous references, sheer number of pages, level of detail and broad scope, may seem daunting at first. However, if you take some time to familiarize yourself with the layout of the book before plunging in, you will find that the material in each chapter is arranged so that readers can explore each topic at varying levels of detail.

The book begins with a very helpful 10 page executive summary of the contents. There are then two chapters introducing concepts relevant to HPOC, and on the physiologic vs. scheduled onset of birth (induction and planned cesarean birth). The 7 chapters are organized with topics and subtopics. The first paragraph beneath the headings for each topic or sub-topic briefly and clearly summarizes the information in that section in italics, so that you can skim each topic by reading only the italicized summary. If you wish to investigate some subtopics more deeply, you can read everything included on those topics. Each chapter also ends with a summary of the entire chapter. Chapters 3, 4, 5, and 6 (Chapter 3 — “Oxytocin;” 4 —“Beta-Endorphins;” 5 —“Epinephrine-Norepinephrine and Related Stress Hormones;” ; and 6 —“Prolactin”) follow the same outline of topics and subtopics.

Using Chapter 6 (“Prolactin”) as an example, here is the outline:

  • 6.1 Normal physiology of prolactin
    • 6.1.1 Introduction: Prolactin
    • 6.1.2 Prolactin in pregnancy
    • 6.1.3 Prolactin in labor and birth
    • 6.1.4 Prolactin after birth
  • 6.2 Maternity care practices that may impact the physiology of prolactin
    • 6.2.1 Possible impacts of maternity care provider and birth environment on prolactin
    • 6.2.2 Prostaglandins for cervical ripening and labor induction: possible impacts on prolactin
    • 6.2.3 Synthetic Oxytocin in labor for induction, augmentation, and postpartum care: possible impacts on prolactin
    • 6.2.4 Opioid analgesic drugs: possible impacts on physiology of prolactin
    • 6.2.5 Epidural analgesia: possible impacts on physiology of prolactin
    • 6.2.6 Cesarean section: possible impacts on physiology of prolactin
    • 6.2.7 Early separation of healthy mothers and newborns: possible impact on physiology of prolactin
  • 6.3 Summary of all findings on prolactin

For childbirth educators: how might we use this information to benefit our students?

I especially appreciate that Dr. Buckley begins every section with a description of the relevant physiology. In order to be truly effective, we educators should do the same in our classes, to ensure that our students understand how and when their care is consistent with physiological childbearing and when (and why) it is not. “’Physiological childbearing’ refers to childbearing conforming to healthy biological processes,” (Buckley, 2015, page 11) as opposed to what many might refer to as “medicalized childbearing,” in which the physiologic process is altered or replaced with interventions and medications.

© Childbirth Connection

© Childbirth Connection

Childbirth education should be designed to allay the pregnant person’s anxiety, not by avoiding mention of potentially troubling labor situations, or minimizing concerns mentioned by the students, but rather by giving realistic portrayals of birth, encouraging expression of feelings, and dealing with them by informing, reframing, desensitizing, and strategizing ways to handle troubling situations. Following is an example of how an educator might include hormonal physiology of childbearing to teach about one critical topic – Physiologic Onset of Labor, which is Lamaze International’s First Healthy Birth Practice.

Let labor begin on its own: How to teach from the standpoint of HPOC

Chapter 2 in HPOC , “Physiologic Onset of Labor and Scheduled Birth,” details the ‘highly complex orchestrated events that lead to full readiness for labor, birth and the critical postpartum transitions of mother and baby.” (Buckley, 2015). As educators, we should try to convey this information, in simplified form, to help our students appreciate the beauty and connectedness of the whole mother-baby dyad. They need to understand the consequences of interrupting the chain of events that usually result in optimal timing of birth. Most parents (and many caregivers as well) have no idea that the fetus determines the onset of labor. Nor do they know that fetal readiness for labor (including protection against hypoxia and readiness for newborn transitions after birth) is coordinated with preparation of the mother’s body for labor, breastfeeding and mother-infant attachment. Once students have some grasp of these processes, they appreciate and want to protect them from interruption or replacement by medical means. As we know, most inductions and many planned cesareans are done without medical reason (ACOG, 2014). Out of ignorance and/or misinformation from their caregivers, parents often agree or even ask for these procedures.

While many educators know and teach about the risks and benefits of induction and planned cesarean, they often don’t convey the physiology on which the benefits and risks are based. It’s all here in HPOC, and this information may inspire parents to question, seek alternatives or decline these procedures.

Over the years, I have wrestled with the challenge of conveying this information fairly simply and concisely, and now, with the help of Katie Rohs, developed a new animated PowerPoint slide, “The Events of Late Pregnancy” (Simkin, 2013) that I use in class. You may access this animated slide and accompanying discussion points/teacher guide here.© Penny Simkin

© Penny Simkin

This is just one example of how we may shift our focus as teachers to incorporate basic hormonal physiology as a starting point. Dr. Buckley gives us a solid understanding of what is known about the key role the endocrine system plays in orchestrating the whole childbearing process, and why we shouldn’t disrupt this elegant process without clear medical reasons. If we teachers and other birth workers incorporate this information in our practices and in our teaching, outcomes will improve.

“Hormonal Physiology of Childbearing” is surely the most extensive search ever done on this topic, and is a solid guide to learning this crucial information. Encyclopedic in its scope, and multi-layered in its depth, this book will be most useful as a reference text, rather than a book to read straight through. It is pretty dense reading, but when you have a question relating to reproductive physiology or the effects of interventions, you can search for well-explained answers. The evidence-based conclusions that Sarah Buckley has synthesized from an abundance of research (1141 references!) are authoritative and must be made accessible. This is truly “State of the Science” on Hormonal Physiology of Childbearing.

Conclusion

Typical maternity care today has departed so far from physiology that in many cases it causes more harm than good, as borne out by Dr. Buckley’s discussions throughout the book of the impact (i.e., unintended consequences) of common maternity care practices on hormonal physiology and mother-baby outcomes. Our job is to inform expectant parents of these things and help them translate information into preparedness and confident participation in their care. If we do our job well, our students will want to support, protect, and participate in the physiological process, which has yet to be improved upon. Parents and their babies will benefit! Our thanks should go out to Sarah Buckley and to Childbirth Connection for bringing this gift to us.

In conclusion, Sarah Buckley’s “Hormonal Physiology of Childbearing” is an impressive exploration of the major hormonal influences underlying all aspects of the labor and birth process. As we understand and incorporate the knowledge included in the book, the birth process will become safer, with effects lasting over the life span.

References 

American College of Obstetricians and Gynecologists and Society of Maternal-Fetal Medicine, 2014. Safe Prevention of the Primary Cesarean Delivery. Obstetric Care Consensus Number 1. Obstet Gynecol ;123:693–711.

Buckley S. Ecstatic Birth. Nature’s Hormonal Blueprint for Labor. 2010. www.sarahbuckley.com

Buckley S. 2009, Gentle Birth, Gentle Mothering: A Doctor’s Guide to Natural Childbirth and Gentle Early Parenting Choices. Celestial Arts, Berkeley

Buckley S. 2015. Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies and Maternity Care. Childbirth Connection, New York

Science & Environmental Health Network. 1998. Wingspread Conference on the Precautionary Principle. Accessed Jan. 8, 2015, https://www.google.com/search?q=The+Precautionary+Principle&ie=utf-8&oe=utf-8.

Simkin P. 2013, Events of Late Pregnancy. Childbirth Education Handout and Slide Penny Simkin, Inc. Seattle. https://www.pennysimkin.com/events-powerpoint

About Penny Simkin

penny_simkinPenny Simkin is a physical therapist who has specialized in childbirth education and labor support since 1968. She estimates she has prepared over 13,000 women, couples and siblings for childbirth, and has assisted hundreds of women or couples through childbirth as a doula. She has produced several birth-related films and is the author of many books and articles on birth for both parents and professionals. Her books include The Labor Progress Handbook (2011), with Ruth Ancheta, The Birth Partner (2013), and When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse of Childbearing Women (2004), with Phyllis Klaus. Penny and her husband have four adult children and eight grandchildren. Penny can be reached through her website.

 

Babies, Breastfeeding, Cesarean Birth, Childbirth Education, Guest Posts, Healthy Birth Practices, Infant Attachment, Maternity Care, Medical Interventions, New Research, Newborns, Uncategorized , , , , ,

A Tale of Two Births – Comparing Hospitals to Hospitals

December 9th, 2014 by avatar

By Christine H. Morton, PhD

Today, Christine H. Morton, PhD, takes a moment to highlight a just released infographic and report by the California Healthcare Foundation that clearly shows the significance of birthing in a hospital that is “low performing.”  This is a great follow up post to “Practice Variation in Cesarean Rates: Not Due to Maternal Complications” that Pam Vireday wrote about last month. Where women choose to birth really matters and their choice has the potential to have profound impact on their birth outcomes.   – Sharon Muza, Science & Sensibility Community Manager.

An Internet search of “A Tale of Two Births” brings up several blog posts about disparities in experience and outcomes between one person’s hospital and subsequent birth center or home births. Sometimes the disparity is explained away by the fact that for many women, their second labor and birth is shorter and easier than their first. Or debate rages about the statistics on home birth or certified professional midwifery. Now we have a NEW Tale of Two Births to add to the mix. However, this one compares the experiences of two women, who are alike in every respect but one – the hospital where they give birth.

Screen Shot 2014-12-08 at 5.15.04 PM

 

The California HealthCare Foundation has created an infographic drawn from data reported on California’s healthcare public reporting website, CalQualityCare.org. In this infographic, we meet two women, Sara, and Maya who are identical in every respect – both are the same age, race, and having their first baby, which is head down, at term. However, Sara plans to have her baby at a “high-performing” hospital while Maya will give birth at a “low-performing” hospital. “High performing” is defined as three or more Superior or Above Average scores and no Average, Below Average, or Poor scores on the four maternity measures. “Low performing” is defined as three or more Below Average or Poor scores on the four maternity measures.

Based on the data from those hospitals, the infographic compares the likelihood of each woman experiencing four events: low-risk C-section, episiotomy, exclusive breastmilk before discharge, and VBAC (vaginal birth after C-section) rates (the latter one of course requires us to imagine that Sara and Maya had a prior C-section).

First-time mom Sara has a 19% chance of a C-section at her high-performing hospital, while Maya faces a 56% chance of having a C-section at her low-performing hospital. These percentages reflect the weighted average of all high- and low- performing hospitals.

Screen Shot 2014-12-08 at 5.15.22 PM

 

The readers of this blog will no doubt be familiar with these quality metrics and their trends over time. Two of these metrics (low risk C-section and exclusive breastmilk on discharge) are part of the Joint Commission’s Perinatal Care Measure Set. The other two – episiotomy and VBAC are important outcomes of interest to maternity care advocates and, of course, expectant mothers.

Hospitals with >1100 births annually have been required to report the five measures in the Joint Commission’s Perinatal Care Measure Set since January 2014, and these metrics will be publicly reported as of January 2015.

Childbirth educators can help expectant parents find their state’s quality measures and use this information in selecting a hospital for birth. In the event that changing providers or hospitals is not a viable option, childbirth educators can teach pregnant women what they can do to increase their chances of optimal birth outcomes by sharing the Six Healthy Practices with all students, but especially those giving birth in hospitals that are “low-performing.”

You can download the infographic in English and en Español tambien!

About Christine H. Morton

christine morton headshotChristine H. Morton, PhD, is a medical sociologist. Her research and publications focus on women’s reproductive experiences, maternity care advocacy and maternal quality improvement. She is the founder of an online listserv for social scientists studying reproduction, ReproNetwork.org.  Since 2008, she has been at California Maternal Quality Care Collaborative at Stanford University, an organization working to improve maternal quality care and eliminate preventable maternal death and injury and associated racial disparities. She is the author, with Elayne Clift, of Birth Ambassadors: Doulas and the Re-emergence of Woman Supported Childbirth in the United States.  In October 2013, she was elected to the Lamaze International Board of Directors.  She lives in the San Francisco Bay Area with her husband, their two school age children and their two dogs.  She can be reached via her website.

Babies, Cesarean Birth, Childbirth Education, Do No Harm, Evidence Based Medicine, Guest Posts, Healthy Birth Practices, Maternal Quality Improvement, Maternity Care, Medical Interventions, New Research, Newborns, Push for Your Baby , , , , , ,

Practice Variation in Cesarean Rates: Not Due to Maternal Complications

November 13th, 2014 by avatar

By Pam Vireday

Pam Vireday, an occasional contributor to Science & Sensibility reviews the recent study by Katy Kozhimannil, PhD and colleagues that examined the differences in cesarean rates between over a thousand hospitals in the USA.  Consumers of maternity care quite possibly do not realize what a significant impact their choice of facility (and provider) may have on their birth outcome.  Can you think of hospitals in your own community serving similar populations of pregnant families that have drastically different cesarean rates.  Have you considered why that might be?  Do you think that the families you work with have explored this too?  Do they even have access to this information?  Read Pam’s discussion of this recent study below.  – Sharon Muza, Community Manager, Science & Sensibility.

© Patti Ramos Photography

© Patti Ramos Photography

There’s a new study out that discusses the variation in cesarean rates between hospitals in the United States. “Maternal clinical diagnoses and hospital variation in the risk of cesarean delivery: Analyses of a national US hospital discharge database” was released late last month and has received a lot of press and discussion ever since.

Practice variation is a serious problem in obstetrics (Arcia 2013). Women are often far more at risk for a cesarean in certain hospitals than in others, even when the hospitals serve the same geographical area and population (Arnold, January 2013 and August 2012).

Of course, care providers protest that some hospitals have higher cesarean rates because they serve higher-risk patients. This is a valid point, but it still doesn’t explain the wide variation in rates between many hospitals (Clark 2007).

For example, in a press release about the new study, the mother’s risk status and diagnoses did not explain the variation in cesarean rates between hospitals:

“We found that the variability in hospital cesarean rates was not driven by differences in maternal diagnoses or pregnancy complexity,” said [lead study author] Kozhimannil. “This means there was significantly higher variation in hospital rates than would be expected based on women’s health conditions. On average, the likelihood of cesarean delivery for an individual woman varied between 19 and 48 percent across hospitals.”

Other key points highlighted included:

  • Among lower risk women, likelihood of cesarean delivery varied between 8 and 32 percent across hospitals.
  • Among higher risk women, likelihood of cesarean delivery varied between 56 and 92 percent across hospitals.
  • Hospital variability did not decrease after adjusting for patient diagnoses, socio-demographics, and hospital characteristics.

This shows that practice variation in cesarean rates is real, substantive, and not just a reflection of the mother’s risk level. 

Perhaps now we can stop playing the mother blame-game when we talk about cesarean rates? (Declerq 2006, Oganowski 2011)

This study is not the first to show that the culture of a hospital, its policies, and its routine practices all help determine how likely a woman is to “need” a cesarean in that hospital.

For example, Cáceres 2013 found that even after adjusting for socio-demographic and clinical factors and including only NTSV (Nulliparous, Term, Singleton, Vertex) pregnancies, the cesarean rate varied significantly between Massachusetts hospitals, “suggesting the importance of hospital practices and culture in determining a hospital’s cesarean rate.”

In addition, a 2014 consensus statement from the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine notes, “Variation in the rates of nulliparous, term, singleton, vertex cesarean births also indicates that clinical practice patterns affect the number of cesarean births performed.”

Preventing cesareans when possible is important because while cesareans can be life-saving at times, they present more risk for maternal infection, bleeding and blood clots, and more neonatal breathing problems (Liu 2007, Visser 2014).

Notably, a large case-control study in U.K. maternity units found that delivery by cesarean was a strong risk factor for severe sepsis (Acosta 2014). Other research has found a high rate of maternal complications (Pallasmaa 2010) and poorer neonatal outcomes (Kolås 2006) associated with cesareans.

In addition, a cesarean’s potential negative effect on future pregnancies is important (Silver 2012). One American study found that the rate of an abnormal placental attachment increased in conjunction with the rise in cesarean delivery rate (Wu 2005), while a Canadian study found that a prior cesarean was associated with an increased risk for adverse neonatal outcomes in subsequent pregnancies (Abenhaim and Benjamin 2011).

Bottom line, it matters where and with whom a woman gives birth in order to lessen the risk for complications, both now and in the future.

But many women naively choose their care provider for pregnancy based mostly on convenience and location, not realizing that their chances of surgical birth may vary greatly depending on which hospital and caregiver they use (Arnold 2014, Arnold January 9 2013).

Childbirth Connection, a leading consumer education site, points out:

Research suggests that the same woman might have a c-section at one hospital but a vaginal birth if she gave birth at another, just because of the different policies and practices of those hospitals. One of the most effective ways to lower your chance of having a c-section is to have your baby in a setting with a low c-section rate.

Yet it is not always easy to find out the cesarean rates of local hospitals in some areas. For example, the health departments of Missouri, South Carolina, and Washington D.C. do not make hospital-level cesarean rates available to consumers.

Hospitals remain largely unaccountable for high cesarean rates, although we are beginning to see marginal progress in some places towards more accountability (Gentry 2014 and Dekker 2014). In the meantime, however, thousands of women are undergoing cesareans, many of which might be preventable with changes in clinical practices (Boyle 2013).

And even when a cesarean is truly necessary, there can be large discrepancies in complications afterwards between hospitals (Alonso-Zaldivar 2014). It’s not just about how many cesareans are done, but also about which hospitals have the best outcomes when a cesarean is done. Without more information, how is a woman to know which hospital to choose?

Bottom line, more transparency and accountability are needed. As the lead author of the study states:

Women deserve evidence-based, consistent, high-quality maternity care, regardless of the hospital where they give birth…and these results indicate that we have a long way to go toward reaching this goal in the U.S.

*To search for hospital-level cesarean rates in your area, see www.cesareanrates.com or the 2014 Consumer Reports article (subscription required) rating hospitals in 22 states.

Do you ever encourage your students and clients to look at the cesarean rates (and rates of other interventions which may lead to cesareans) of the hospitals they are considering birthing in.  Please share your experience in our comments section. – SM

References

Abenhaim, H. A., & Benjamin, A. (2011). Effect of prior cesarean delivery on neonatal outcomes. Journal of perinatal medicine39(3), 241-244. PMID: 21426242

Acosta, C. D., Kurinczuk, J. J., Lucas, D. N., Tuffnell, D. J., Sellers, S., & Knight, M. (2014). Severe Maternal Sepsis in the UK, 2011–2012: A National Case-Control Study. PLoS medicine11(7), e1001672. PMID: 25003759

Alonso-Zaldivar, R (2014, August 27). Study: Wide hospital quality gap on maternity care. Retrieved from http://www.fosters.com/apps/pbcs.dll/article?AID=/20140827/GJLIFESTYLES/140809539/0/SEARCH.

Arcia, A (2013, February 3). What is practice variation in obstetrics and why should I care? Retrieved from http://www.cesareanrates.com/blog/2013/2/3/what-is-practice-variation-in-obstetrics-and-why-should-i-ca.html.

Arnold, J (2012, August 22). Practice variation in New Jersey: 27 miles and 28 percentage points. Retrieved from http://www.cesareanrates.com/blog/2012/8/22/practice-variation-in-new-jersey-27-miles-and-28-percentage.html.

Arnold, J (2013, January 9). Practice variation in East Los Angeles cesarean rates. Retrieved from http://www.cesareanrates.com/blog/2013/1/9/practice-variation-in-east-los-angeles-cesarean-rates.html.

Arnold, J (2013, January 7). Practice variation in West Virginia: 60 miles and 54 percentage points. Retireved from http://www.cesareanrates.com/blog/2013/1/7/practice-variation-in-west-virginia-60-miles-and-54-percenta.html.

Arnold, J (2014, March 13). Three miles/Cinco Kilometros. Retrieved from http://www.cesareanrates.com/blog/2014/3/13/three-miles-cinco-kilometros.html.

Boyle, A., Reddy, U. M., Landy, H. J., Huang, C. C., Driggers, R. W., & Laughon, S. K. (2013). Primary cesarean delivery in the United States. Obstetrics & Gynecology122(1), 33-40. PMID: 23743454

Cáceres IA, Arcaya M, Declercq E, Belanoff CM, Janakiraman V, Dohen B, Ecker J, Smith LA, Subramanian SV (2013). Hospital differences in cesarean deliveries in Massachusetts (US) 2004-2006: the case against case-mix artifact. PLOS One, 8(3):e57817. doi: 10.1371/journal.pone.0057817. PMID:23526952

Clark SL, Belfort MA, Hankins GD, Meyers JA, Houser FM (2007). Variation in the rates of operative delivery in the United States. American journal of obstetrics and gynecology, 196(6):526.e1-526.e5.  PMID: 17547880

Caughey, A. B., Cahill, A. G., Guise, J. M., & Rouse, D. J. (2014). Safe prevention of the primary cesarean delivery. American journal of obstetrics and gynecology,210(3), 179-193. doi: 10.1016/j.ajog.2014.01.026. PMID:24565430

Declercq, E., Menacker, F., & MacDorman, M. (2006). Maternal risk profiles and the primary cesarean rate in the United States, 1991–2002. American journal of public health, 96(5), 867. PMID: 16571712

Dekker, R (2014, October 29). U.S. hospitals held accountable for C-section rates. Retrieved from http://www.birthbythenumbers.org/?p=1731

DePoint, M (2014, October 22). Maternal diagnoses doesn’t explain variation in cesarean rates across US hospitals. University of Minnesota, School of Public Health. Retrieved from http://sph.umn.edu/maternal-diagnoses-doesnt-explain-variation-cesarean-rates-across-us-hospitals/.

Gentry, C (2014, May 14). FL still C-section hotspot. Retrieved from http://health.wusf.usf.edu/post/fl-still-c-section-hotspot.

Kolås, T., Saugstad, O. D., Daltveit, A. K., Nilsen, S. T., & Øian, P. (2006). Planned cesarean versus planned vaginal delivery at term: comparison of newborn infant outcomes. American journal of obstetrics and gynecology,195(6), 1538-1543. PMID: 16846577

Kozhimannil KB, Arcaya MC, Subramanian SV (2014). Maternal clinical diagnoses and hospital variation in the risk of cesarean delivery: Analyses of a national US hospital discharge database.  PLoS medicine, 11(10):e1001745. doi: 10.1371/journal.pmed.1001745. PMID: 25333943

Liu, S., Liston, R. M., Joseph, K. S., Heaman, M., Sauve, R., & Kramer, M. S. (2007). Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. Canadian medical association journal176(4), 455-460. PMID: 17296957

Oganowski, K (2010, January 13). The C-section blame game: I’ve reached my boiling point. Retrieved from http://birthingbeautifulideas.com/?p=1245.

Pallasmaa, N., Ekblad, U., AITOKALLIO‐TALLBERG, A. N. S. A., Uotila, J., Raudaskoski, T., ULANDER, V., & Hurme, S. (2010). Cesarean delivery in Finland: maternal complications and obstetric risk factors. Acta obstetricia et gynecologica Scandinavica89(7), 896-902. PMID: 20583935

Phend, C (2013, March 5). C-Section rates vary widely between hospitals, study finds. MedPage Today. Retrieved from http://abcnews.go.com/Health/section-rates-vary-widely-hospitals-study-finds/story?id=18656847.

Silver, R. M. (2012, October). Implications of the first cesarean: perinatal and future reproductive health and subsequent cesareans, placentation issues, uterine rupture risk, morbidity, and mortality. In Seminars in perinatology (Vol. 36, No. 5, pp. 315-323). WB Saunders. PMID: 23009962

Visser GH (2014). Women are designed to deliver vaginally and not by Cesarean section: An obstetrician’s view. Neonatology, 107(1):8-13. PMID: 25301178

What every pregnant woman needs to know about Cesarean section (2012). Childbirth Connection. Retrieved from http://www.childbirthconnection.org/pdfs/cesareanbooklet.pdf.

What hospitals don’t want you to know about C-sections (2014, May). Consumer Reports. Retrieved from http://consumerreports.org/cro/2014/05/what-hospitals-do-not-want-you-to-know-about-c-sections/index.htm.

Wu, S., Kocherginsky, M., & Hibbard, J. U. (2005). Abnormal placentation: twenty-year analysis. American journal of obstetrics and gynecology192(5), 1458-1461. PMID: 15902137

A version of this post originally appeared on www.wellroundedmama.blogspot.com

About Pam Vireday

Painting by Mary Cassatt, 1844-1926. (public domain) Image from Wikimedia Commons.

Pam Vireday is a childbirth educator, writer, woman of size, and mother to four children. She has been collecting the stories of women of size and writing about childbirth research for 17 years. She writes at www.wellroundedmama.blogspot.com and www.plus-size-pregnancy.org.

 

Cesarean Birth, Childbirth Education, Evidence Based Medicine, Guest Posts, Medical Interventions, New Research, Research , , , , ,