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The PregSense Monitor: A useful new tool or fear-based marketing

August 18th, 2015 by avatar

By Deena Blumenfeld, ERYT, RPYT, LCCE 

pregsensePart of a parent’s job description is to worry about their children. In doing so, parents can help the child maintain their physical health and their emotional wellbeing. However, when the line is crossed into fear based parenting; they may become overprotective to the point of stifling a child’s natural curiosity and the need to learn by making mistakes. They are then at risk of becoming “helicopter parents”.

This is an issue of control. When parents take full control, of their child’s overall well being, they feel that they are protecting them from all the negative aspects of the world. This is a fallacy.

Advertisers and marketers play into this fear and the need for control, that feeds into the parents’ feelings of limited or lack of control. Companies create and market products that provide the impression of safety and security. These products provide a false sense of control for parents, which furthers the illusion that they are doing something “good” or “right” as they “protect” their baby.

Making the rounds of Facebook, and other social media feeds, was this nifty little video about an at-home, wearable baby monitor. It’s called the PregSense Monitor by Nuvo Group. The general consensus from the online community, both mothers and professionals alike, was “Wow! This is amazing! We’ll save so many babies this way!”

My own reaction was a bit different. I’m a skeptic at heart and like all Lamaze educators; I’m a big fan of evidence based products, treatments, procedures and medications. So, I knew I needed to learn more about the PregSense monitor. What’s the evidence behind it? Would it really meet expectations, and save babies and reduce moms’ anxiety?

I attempted to contact Nuvo Group for an interview, but I have not received a response from them at the time of this writing.

Nuvo Group claims

The Israeli tech firm hopes the device will reassure anxious mothers like Michal, in week 32 of her pregnancy, who require monitoring without having to see her doctor.

Claim:  “(The monitor will) allay mothers’ fears by transmitting data about the health of the mother and fetus.”

  • It appears to monitor all of the mother’s vital signs, not unlike a Fitbit or other activity tracker. But how does having the knowledge about your own vital signs and getting additional information about baby’s activities reduce fear?
  • What if the monitor malfunctions? What does that do to a mother’s level of fear?
    • Can one make the assumption that if the monitor isn’t picking up the baby, the mother will become more worried, rather than less. This might lead to increased health care provider visits and further unnecessary medical testing.
  • Could wearing this monitor increase anxiety and potentially cause mothers to be so focused on the monitor it becomes a bit of an obsession?
    • Mothers may become hypervigilant and reliant on the constant stream of “data” available to be reviewed.
  • How would a mother feel if she was unable to wear the monitor one day? Would that increase her fears, even if those fears were unfounded?
    • Removing access, even for a short time could increase worry and interefere with a mother’s ability to continue her daily activities.
  • When there is a constant stream of data it becomes easy to tune out the information. Wouldn’t that defeat the purpose of this device?
    • The information may become white noise and fade into the background, because it’s a nonstop stream.

Claim: Mothers can connect, see and hear the fetus whenever they want, without needing to consult a doctor.

  • Do mothers need a device to help them connect with their babies?
    • This product is trying to create a consumer need that does not exist.
    • Mothers connect with their babies all the time by feeling their movements; talking to them; touching their growing bellies, etc. Would the device reduce this natural mother/fetus interaction? Would a mother be more likely to turn to her smartphone for results from the monitor instead of paying attention to what her baby is actually doing throughout the rhythm of the day.?
  • Using this device would require a health care provider to be monitoring all of these women, all the time. This doesn’t take into account staffing levels or time to complete the task. 24/7 monitoring would be a massive time commitment and responsibility.
  • What about additional liability for the health care provider for not monitoring a woman properly or correctly identifying a problem?
    • We live in a very litigious society. A care provider might be facing a lawsuit if the data from the monitor is not evaluated regularly and an anomaly was missed.
  • Since there are two monitor types – the clinical monitor and the consumer monitor, this raises additional questions. What if the mother is low-risk and healthy, but chooses to wear the consumer model, without a prescription to “reassure” herself that all is well?
    • Would the physician then be required to monitor this mother, if there is no medical need and was not advised by the physician?
    • What is the physician’s liability in this case?

Claim: “We will be able to analyze this data to predict about events of pregnancy, like preterm labor, like preeclampsia and more and we will be able to intervene in the right time…”

  • Preterm labor may be able to be detected with continuous monitoring. However, the monitor is only identifying contractions. It’s not looking at vaginal discharge, cervical change, flu-like symptoms or downward pressure from the baby.
  • Would the monitor be able to tell the difference between Braxton-Hicks contractions and early labor?
    • The limited information on Nuvo Group’s website and in their press release does not provide enough information to say for sure.
  • What about those women who experience Braxton-Hicks regularly throughout pregnancy but are not in labor? Would the monitor be helpful or harmful for them in identifying mothers in preterm labor? Would they be in and out of their care provider’s offices more frequently, causing disruption to their daily lives?
  • Preeclampsia cannot be prevented at this time. So, at best, the monitor would let the mother and her care provider know that her blood pressure is high. It would not test for protein in her urine, swelling in her face, headaches, vision changes or any of the other symptoms of preeclampsia, so it’s an incomplete test. Would preeclampsia be missed because mother’s blood pressure is borderline and no other tests were administered.

Claim: Regarding monitoring high risk mothers with continuous monitoring in hospital; the monitor will benefit the health care provider by replacing a bulky machine with one that is lightweight and not connected to the wall.

  • We already have telemetry units for Electronic Fetal Monitoring (EFM), in many hospitals. This device is now redundant and may not integrate with the current software used to monitor the EFM units.
  • How much will this cost a hospital to replace all of their current EFM units by purchasing these PregSense clinical monitors? Is the financial outlay for a new convenience worth the expense?
  • Does the new monitor increase safety for mother and baby in comparison to traditional EFM. Is this alternative truly better for mothers and for doctors in an in-patient setting? Where are the studies that compare the two options? Is the data we get any better? Or are we still subject to human interpretation of the data in identifying the appropriate course of action?

Claim: The PregSense monitor is safer than ultrasounds that can cause tissue damage

nuvo-ritmo-beats-pregsenseAt this point in time there is no evidence and no research, to support monitoring mothers at home during pregnancy. All of the literature refers to full time electronic fetal monitoring (EFM) during labor. Therefore my assumptions are based off of that literature.

Consensus among professional and governmental groups is that, based on the evidence, intermittent auscultation is safer to use in healthy women with uncomplicated pregnancies than electronic fetal monitoring (EFM).  (Heelan 2013) These professional groups include ACOG and AWHONN.

The issue with the beneficial claims made by Nuvo Group is they are in opposition to what the research finds for routine continuous EFM. Continuous EFM in low risk mothers provides no benefit for babies and increases the risk of cesarean for mothers. Therefore the whole concept of the PregSense Monitor is based on an erroneous assumption. It is not possible to prevent a problem by monitoring the baby. A problem can only be detected as it is occurring. So, even if a problem is observed while doing at home monitoring, by the time the mother makes it to the hospital it is may be too late to intervene effectively.

There is also the risk of false positive results. The monitor may detect an anomaly that then increases the mother’s fear about her baby’s well being only to be examined to find out that her baby is doing just fine, causing undue stress and panic.

The claims of the manufacturer of this product don’t hold up under current EFM guidelines and are not FDA approved.

Simplifying fetal monitoring for the care provider may not actually be the case when we look at 24/7 monitoring which still needs to be interpreted by a human being and a potentially large financial investment for a hospital that already has an EFM system that is adequate.

The claim that this product is safer than what currently exists with today’s EFM technology and ultrasonography is unsubstantiated. Without proper research, we do not know if it is safer, more harmful or neutral in relation to EFM and ultrasound as they are done today.

Resolving mother’s fears and helping her connect with the baby are at best an assumption regarding the “softer side” of the product’s results. It may be that some women do have greater piece of mind and feel a greater connection with their baby when using the device. Selling a feeling does not provide medical benefit to mother or baby. It is, however, good marketing.

The takeaway for your students is to have them look at all products with a discerning eye. Fear based marketing is insidious and plays to their emotions. They need to be making informed decisions based on accurate and evidence based information, rather than an emotional response to something that hits them in the heart.

References:

 Nuvo Group’s website

Reuters, “Wearable device provides continuous fetal monitoring”

Dekker, Rebecca, Evidence Based Fetal Monitoring, 2012

Dekker, Rebecca, What is the Evidence for Fetal Monitoring on Admission, 2012

FDA, Avoid Fetal “Keepsake” Images, Heartbeat Monitors, 2014

FDA, Ultrasound Imaging

ACOG Practice Bulletin #106, “Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Principles,”, July 2009

ACOG press release, ACOG Refines Fetal Heart Rate Monitoring Guidelines, 2009

Lisa Heelan, MSN, FNP-BC, Fetal Monitoring: Creating a Culture of Safety With Informed Choice, J Perinat Educ. 2013 Summer; 22(3): 156–165.

 

 

 

ACOG, Babies, Fetal Monitoring, Guest Posts, Medical Interventions, News about Pregnancy , , , ,

Elective Induction at 40 Weeks? “Decision-Based Evidence Making” Strikes Again

July 14th, 2015 by avatar

Today on Science & Sensibility, contributor Henci Goer takes a look at a systematic review released in spring that examined the impact of elective inductions on the cesarean rate.  Sound analysis or a house of cards?  Looking closer at the studies reviewed provides insight into how the conclusions reached by the investigators might need to be examined more closely.  Henci does that in this review.  Have you read this new systematic review?  Did you come to the same conclusions?  I invite you to share your thoughts in our comments section below. – Sharon Muza, Community Manager, Science & Sensibility.

flickr photo by catharticflux http://flickr.com/photos/catharticflux/2710057340  CC licensed.

flickr photo by catharticflux http://flickr.com/photos/catharticflux/2710057340 CC licensed.

Yet another systematic review has surfaced “Induction of labor at full term in uncomplicated singleton gestations: a systematic review and metaanalysis of randomized controlled trials”  in which reviewers claim that electively inducing healthy women, this time at 40, not 41 weeks, offers benefits and doesn’t increase the cesarean surgery rate (Saccone 2015).

Let’s take a closer look.

Reviewers included five trials: three of them conducted in the 1970s (Cole 1975; Martin 1978; Tylleskar 1979), the fourth published in 2005 (Nielsen 2005), and the fifth in 2014 (Miller 2014). Already we have a problem. Induction management in the 1970s is sufficiently different from management today that results are unlikely to apply to contemporary care, but let’s get down to specifics. Two of the 1970s trials were deemed inadequate for inclusion in the Cochrane review of elective induction (Gulmezoglu 2012), and Miller 2014 is published only as an abstract. Quality systematic reviews exclude abstracts because they don’t provide enough information to evaluate the study. For these reasons, these three trials should be taken off the table..

That leaves us with the other two. Nielsen 2005 states in the title “Comparison of elective induction of labor with favorable Bishop scores versus expectant management: a randomized clinical trial” that it is confined to women with favorable Bishop scores. Anyone familiar with elective induction research should know that inducing when the cervix is ready to go won’t increase the cesarean rate compared with spontaneous onset, but inducing with an unripe cervix is a different story even when using cervical ripening agents (Dunne 2009; Jonsson 2013; Le Ray 2007; Macer 1992; Prysak 1998; Thorsell 2011; Vahratian 2005). As you move the induction date earlier and earlier, more and more women will have an unfavorable cervix, so including a trial limited to women with a ripe one will tilt the playing field in favor of induction. Furthermore, half the participants were multiparous women (113/226). Women with prior vaginal births will go on having vaginal births pretty much no matter what you do to them, which raises another point: inducing earlier means a higher percentage of the inductees will be first-time mothers because first time mothers tend to run longer pregnancies (Mittendorf 1990). Nulliparous women are much more vulnerable to anything that pushes them in the direction of a cesarean. That’s not all: The authors tell us that their hospital has a 7% cesarean rate for dystocia in women at term. If a hospital has a cesarean rate much higher than that—and many do—then results can’t be generalized to it, although, frankly, if the doctors are performing cesareans left and right, induction or spontaneous onset may not make much difference. In short, Nielsen (2005) doesn’t make a compelling argument for 40-week elective induction.

flickr photo by Selbe <3 http://flickr.com/photos/stacylynn/11944718954 shared under a Creative Commons (BY-NC-ND) license

flickr photo by Selbe < http://flickr.com/photos/stacylynn/11944718954 shared under a Creative Commons (BY-NC-ND) license

This brings us to the last trial, Cole (1975). Investigators allocated healthy women either to induction at 40 weeks (111 women) or 41 weeks (117 women). As with Nielsen, half the women had prior vaginal births. Despite being healthy, 22 women were induced for “obstetric complications” (undefined) in the 41-week induction group before reaching 41 weeks. If their doctors induced labor because they had concerns, then this would likely put the women at heightened risk for cesarean. Another 32 women were induced for exceeding 41 weeks. This means that overall, nearly half (46%) of the comparison group didn’t begin labor spontaneously, which would mask any association between induction and cesarean. Leaving the induction vs. spontaneous onset issue aside, the U.S. cesarean rate in the early 1970s was around 5%, which means it was a rare woman who would have one regardless of circumstances. Again, not exactly a strong case for inducing at 40 weeks.

What about the benefits? The best reviewers can come up with are a clinically meaningless reduction in mean blood loss (-58 ml); a lower rate of meconium-stained amniotic fluid (4% vs. 14%), not, mind you, a reduction in meconium aspiration, and therefore clinically meaningless as well; and an equally meaningless reduction in mean birth weight of -136 g (5 oz). If they had found something more impressive, surely they would have reported it.

Really? This merited a pre-publication media blast? Because it amounts to a textbook example of “garbage in, garbage out.” I can see only three possibilities to explain it: either 1) the authors and peer reviewers at the American Journal of Obstetrics and Gynecology (AJOG) don’t know as much as they should about what constitutes a quality systematic review, 2) they are so steeped in medical model thinking—“How early can we get the baby out of that treacherous maternal environment?”—that their judgment is compromised, or 3) we have a “pay no attention to what’s behind the curtain” effort to promote elective induction. I don’t know which is the more troubling, but if it’s the last one, the sad thing is that because it’s got the magic words “systematic review,” “meta-analysis,” and “randomized controlled trials” in the title, it’s likely to succeed.

References

Cole, R. A., Howie, P. W., & Macnaughton, M. C. (1975). Elective induction of labour. A randomised prospective trial. Lancet, 1(7910), 767-770.

Dunne, C., Da Silva, O., Schmidt, G., & Natale, R. (2009). Outcomes of elective labour induction and elective caesarean section in low-risk pregnancies between 37 and 41 weeks’ gestation. J Obstet Gynaecol Can, 31(12), 1124-1130.

Gulmezoglu, A. M., Crowther, C. A., Middleton, P., & Heatley, E. (2012). Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database Syst Rev, 6, CD004945.

Jonsson, M., Cnattingius, S., & Wikstrom, A. K. (2013). Elective induction of labor and the risk of cesarean section in low-risk parous women: a cohort study. Acta Obstet Gynecol Scand, 92(2), 198-203. doi: 10.1111/aogs.12043

Le Ray, C., Carayol, M., Breart, G., & Goffinet, F. (2007). Elective induction of labor: failure to follow guidelines and risk of cesarean delivery. Acta Obstet Gynecol Scand, 86(6), 657-665.

Macer, J. A., Macer, C. L., & Chan, L. S. (1992). Elective induction versus spontaneous labor: a retrospective study of complications and outcome. Am J Obstet Gynecol, 166(6 Pt 1), 1690-1696; discussion 1696-1697.

Martin, D. H., Thompson, W., Pinkerton, J. H., & Watson, J. D. (1978). A randomized controlled trial of selective planned delivery. Br J Obstet Gynaecol, 85(2), 109-113.

Miller, N., Cypher, R., Pates, J., & Nielsen, P. E. (2014). Elective induction of nulliparous labor at 39 weeks of gestation: a randomized clinical trial. Obstet Gynecol,132(Suppl 1):72S.

Mittendorf, R., Williams, M. A., Berkey, C. S., & Cotter, P. F. (1990). The length of uncomplicated human gestation. Obstet Gynecol, 75(6), 929-932.

Nielsen, P. E., Howard, B. C., Hill, C. C., Larson, P. L., Holland, R. H., & Smith, P. N. (2005). Comparison of elective induction of labor with favorable Bishop scores versus expectant management: a randomized clinical trial. J Matern Fetal Neontal Med, 18:59-64.

Prysak, M., & Castronova, F. C. (1998). Elective induction versus spontaneous labor: a case-control analysis of safety and efficacy. Obstet Gynecol, 92(1), 47-52.

Saccone, G., & Berghella, V. (2015). Induction of labor at full term in uncomplicated singleton gestations: a systematic review and metaanalysis of randomized controlled trials. American journal of obstetrics and gynecology.

Thorsell, M., Lyrenas, S., Andolf, E., & Kaijser, M. (2011). Induction of labor and the risk for emergency cesarean section in nulliparous and multiparous women. Acta Obstet Gynecol Scand, 90(10), 1094-1099. doi: 10.1111/j.1600-0412.2011.01213.x

Tylleskar, J., Finnstrom, O., Leijon, I, et al. (1979). Spontaneous labor and elective induction – a prospective randomized study. Effects on mother and fetus. Acta Obstet Gynaecol Scand, 58:513-518.

Vahratian, A., Zhang, J., Troendle, J. F., Sciscione, A. C., & Hoffman, M. K. (2005). Labor progression and risk of cesarean delivery in electively induced nulliparas. Obstet Gynecol, 105(4), 698-704.out

About Henci Goer

Henci Goer

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

 

ACOG, Cesarean Birth, Childbirth Education, Do No Harm, Evidence Based Medicine, Guest Posts, Medical Interventions, New Research, Research , , , , , ,

Webinar – “Childbirth Class for Students Who Want An Epidural” – Today! Register Now.

June 25th, 2015 by avatar
Photo by Patti Ramos Photography

Photo by Patti Ramos Photography

Robin Weiss, PhD, MPH, CPH, ICCE-CPE, ICPFE, CLC, CD(DONA), BDT(DONA), LCCE, FACCE, President of Lamaze International, has an absolutely great webinar scheduled for later today that you definitely don’t want to miss. This 60 minute live webinar, titled “Childbirth Class for Students Who Want an Epidural” will be valuable for both new educators and experienced educators alike at 1 PM EST.

When families enroll in Lamaze classes, some people may be planning to birth without pain medications while others may already have made a different decision and are intending to get an epidural.  Then of course, there are those people who prefer to “see how it goes” and make a decision at during labor.

As a childbirth educator, we won’t necessarily know who falls into which category, and honestly, it simply doesn’t matter.  Our role is to present information that is unbiased, based on evidence and best practice and helps families to make the best decision for themselves. Everyone who takes a childbirth class needs to receive quality information and deserves to have the facts presented in a nonjudgmental manner.

Teaching about epidurals in a Lamaze class allows families to gain knowledge in a safe and welcoming environment.  Whether this topic is covered extensively during your regular classes (which it should be) or you decide to offer a module for those who are positive they want medication, families should have the opportunity to learn what they need to know.

Robin Weiss is the perfect facilitator to lead us through this potentially tricky topic. She has been a childbirth educator, author and trainer of Lamaze educators for many years. She recently completed her Ph.D in Maternal Infant Health at the University of Louisville in KY.

This will be a great check-in to help you evaluate how you are presenting this topic to your students, give you some new ideas and perspective for approaching the subject and possibly even provide the impetus to offer a specialized class.

© Robin Elise Weiss

© Robin Elise Weiss

If you participate in this webinar, you have the option of receiving contact hours for a small additional fee upon completion of a post-webinar evaluation.

Won’t you consider registering now for this webinar that happens today, at 1 PM EST.  After you participate in the webinar, I invite you to come back and share your thoughts, ideas and any learning moments that you have taken away on this topic.

 

Childbirth Education, Epidural Analgesia, Medical Interventions, Webinars , , , , ,

Looking Back in Time: What Women’s Bodies are Telling Us about Modern Maternity Care

June 18th, 2015 by avatar

By Christina Gebel, MPH, LCCE, Birth Doula

Christina Gebel, MPH, LCCE, Doula writes a reflective post examining current birthing conditions to see how today’s practices might be interfering with the the normal hormonal physiology and consequently impacting women’s ability to give birth.  Times have certainly changed and birth has moved from the home to the hospital.  A slow but steady increase in out of hospital births is examined and Christina asks us to consider why women are increasingly choosing to birth outside the hospital – and what do hormones have to do with it? – Sharon Muza, Science & Sensibility Community Manager

“Pregnancy is not a disease, but a beautiful office of nature.” These are the words of Victoria Woodhull, the first female candidate for President of the United States in 1872.

Lajja_gauri ancient birth art

© “Lajja gauri

The world in which pregnant women find themselves today looks a lot different than the time of Woodhull’s campaign run. For instance, hospitals didn’t become the mainstream setting for labor and delivery until the 1930s and 40s. While modern medicine has undoubtedly helped millions of women who may have otherwise died in childbirth, mothers and birth advocates across the nation are beginning to ask if we are paying a price for today’s standard maternity care. With increasing protocols and interventions, pregnancy is viewed less like the office of nature Woodhull spoke of and more like a pathological condition.

The Hormonal Physiology of Childbearing, a recent report by Sarah Buckley, systematically reviews existing research about the impact that common maternity practices may have on innate hormonal physiology in women and fetuses/newborns. The report finds strong evidence to suggest that our maternity care interventions may disturb these processes, reduce their benefits, or even create new challenges. To find out more, read an interview that Science & Sensibility did with Dr. Buckley when her groundbreaking report was released.

Let’s examine something as simple as the environment that a woman gives birth in. In prehistoric times, laboring women faced immediate threats and dangers. They possessed the typical mammalian “fight-or-flight” reaction to these stressors. The hormones epinephrine and norepinephrine caused blood to be diverted away from the baby and uterus to the heart, lungs, and muscles of the mother so that she could flee. This elevation in stress hormones also stalled labor, to give the mother more time to escape. Essentially, she told her body ‘this place is not safe,’ and her body responded appropriately by stopping the labor to protect the mother and her child during a very vulnerable time.

Today, mothers are not fleeing wild animals but rather giving birth in hospitals, the setting for nearly 99% of today’s births, where this innate response may cause their labor to stall. The sometimes frenetic environment or numerous brief encounters with unfamiliar faces may trigger a sense of unease and, consequently, the fight-or-flight response, stalling the mother’s labor. Prolonged labor in a hospital invariably leads to concern and a need to intervene, often by the administration of Pitocin, synthetic oxytocin, to facilitate regular contractions. Arrested labor could lead to further interventions up to and including a cesarean section. The fight-or-flight response may be further reinforced by these interventions, as they potentially come one after the other, in what is often referred to as the “cascade of interventions.”

This is just one example of how a woman’s body’s natural physiology can go from purposeful to working against the labor, the mother and the baby. Epinephrine and norepinephrine are both necessary in labor and delivery. In fact, at appropriate levels, these hormones support vital processes protecting the infant from hypoxia and facilitating neonatal transitions such as optimal breathing, temperature, and glucose regulation, all markers for a healthy infant at birth.

Recent data show that mothers themselves may already think what the Hormonal Physiology of Childbearing report suggests. The series of Listening to Mothers (LtM) studies, a nationally-representative survey of childbearing women, shows a shift in mothers’ attitudes towards normal physiologic birth: In 2012, 58% of mothers agreed somewhat or strongly that giving birth is a process that should not be interfered with unless medically necessary, up from 45% in 2000. According to 2013 national birth data, out-of-hospital (home and birth center) births have increased 55% since 2004, but the overall percentage is still only 1.35% of all births nationwide. While low, this shows that a small core of mothers are voting with their feet and choosing to give birth out of the hospital. Though their choice may seem extreme, they’re not alone. In the LtM data, which only surveys women who have given birth in a US hospital, 29% of mothers said they would definitely want or would consider giving birth at home for a future birth, and 64% said the same of a birth center. All this raises the question: What’s happening in a hospital that is leading mothers to consider other settings for their next birth?

One answer to upholding women’s preferences, autonomy, and the value of normal physiologic birth is a mother’s involvement in shared decision making with her provider, along with increasing access to models of care that support innate physiologic childbearing, like midwives in birth centers. Increasing access to these options may present a challenge, as demand seems to outweigh availability.

Leslie Ludka (MSN, CNM) has been the Director of the Cambridge Health Alliance Birth Center (Cambridge, Mass.) as well as the Director of Midwifery since 2008. Like other birth centers, the center has seen a steady increase in demand each year, with patients coming from all over New England. Ludka sees many barriers to having more birth centers available including finances (the reimbursement for birth not being comparable to an in-hospital birth), “vacuums in institutional comprehension” of the advantages of the birth center model for low-risk women, and the rigorous process to be nationally certified by the Commission for the Accreditation of Birth Centers (CABC), requiring “a great commitment and a lot of support by all involved.” In order to overcome these barriers, Ludka suggests marketing the safety of birth centers to the general public, sharing outcome statistics for women and infants cared for in birth centers, and educating insurers and providers about the overall benefits and financial savings of midwifery and the birth center model. With supportive policy and better understanding on the part of insurers, the public, and healthcare institutions, models like the birth center could become more plentiful, more easily meeting the demand.

Women’s bodies are sending subtle messages that our current healthcare system is, at times, not serving their needs. It’s time to respond to these messages, beginning by viewing childbirth foundationally as a life event and not first as pathology, and adapting our models of care to speak to this viewpoint. If we fail to do so, we run the risk of creating excess risk for women and newborns.

It’s been 143 years since Woodhull ran for president. We’ve made progress in getting much closer to seeing our first woman president, but with childbirth, perhaps our progress now starts with looking back in time.

About Christina Gebel

© Christina Gebel

© Christina Gebel

Christina Gebel holds a Master of Public Health in Maternal and Child Health from the Boston University School of Public Health. She is a birth doula and Certified Lamaze Childbirth Educator as well as a freelance writer, editor, and photographer. She currently resides in Boston working in public health research. You can follow her on Twitter: @ChristinaGebel and contact her through her website duallovedoula.com

Childbirth Education, Guest Posts, Home Birth, Maternity Care, Medical Interventions, Midwifery , , , ,

American Obstetrician Takes Rational Position on Home Birth

June 16th, 2015 by avatar

Neel Shah, Harvard Medical School assistant professor and practicing obstetrician, commenting in the New England Journal of Medicine Perspectives section –  “A NICE Delivery – The Cross-Atlantic Divide over Treatment Intensity in Childbirth“, agrees with new United Kingdom National Institute for Health and Care Excellence (NICE) guidelines concluding that healthy, low-risk women are better off at home or in a midwife-led unit than in a hospital under the supervision of an obstetrician. Citing a table comparing outcomes in low-risk multiparous women from the Birthplace in England data, Shah writes:

The safety argument against physician-led hospital birth is simple and compelling: obstetricians, who are trained to use scalpels and are surrounded by operating rooms, are much more likely than midwives to pick up those scalpels and use them. For women giving birth, the many interventions that have become commonplace during childbirth are unpleasant and may lead to complications . . . .

He quite reasonably adds the caveat that the guidelines apply to low-risk women only and that even these women may develop labor complications without warning, but then, responsible home birth advocates acknowledge those same two points. That being said, I can’t resist adding a couple of caveats of my own.

© Families Upon ThamesFirst, one reason why women with risk factors plan home birth, women with prior cesareans being a common example, is that doctors and hospitals deny them the possibility of vaginal birth (Declercq 2013). With their only hospital alternative being unwanted and unneeded cesarean surgery, planned home birth becomes their least, worst option. This dilemma puts their choice squarely in the lap of the medical system. Another reason is that some women have been so emotionally traumatized by their treatment during a previous birth that they reject planned hospital birth and refuse intrapartum transfer even when this may be the safer option (Boucher 2009; Symon 2010). Again, the failure and its remedy lie with the system, not the woman.

Second, if the hospital lacks 24/7 obstetric, anesthesia, and pediatric coverage and at least a Level 2 nursery, which many do, then a woman is probably no better off in the hospital in an emergency than she would be at home or at a freestanding birth center. Furthermore, most urgent situations—a baby who doesn’t breathe, excessive bleeding, even umbilical cord prolapse—can be managed or stabilized by a properly trained and equipped home birth attendant. In fact, what would be done in the hospital is no different from what would be done at home: neonatal resuscitation, oxygen, medications to stop bleeding, maternal knee-chest position and manually holding the fetal head off the cord until cesarean.

Finally, with admirable frankness, Shah notes that unlike the U.K., and to the detriment of safety, “[A]ccess to obstetric care that is coordinated among homes, birthing centers, and hospitals is both unreliable and uncommon.” And while he doesn’t cast any blame, once more, the fault lies with the system. (Just as an FYI, a model guideline for transfer of care developed by a workgroup that included all stakeholders is publically available.)

Shah concludes: “The majority of women with straightforward pregnancies may truly be better off in the United Kingdom.” True that, but it doesn’t have to be that way. Dialing back the overuse of medical intervention and cesarean surgery; respecting the woman’s right to give informed consent and refusal; implementing a culture of care that is kind, compassionate, and respects a woman’s dignity; and ensuring that out-of-hospital birth attendants can consult, collaborate, and transfer care appropriately would have two benefits: it would reduce the number of women refusing hospital birth while minimizing the chance of adverse outcomes in those who continue to prefer to birth at home or in a freestanding birth center. Nonetheless, despite the generally positive responses accompanying Shah’s commentary, rather than inspiring a wave of reform, I would lay odds that the more common reaction to Shah’s piece within the medical community will be to shoot the messenger.

References

Boucher, D., Bennett, C., McFarlin, B., & Freeze, R. (2009). Staying home to give birth: why women in the United States choose home birth. J Midwifery Womens Health, 54(2), 119-126.

Declercq, E., Sakala, C., Corry, M. P., Applebaum, S., & Herrlich, Ariel. (2013). Listening to Mothers III. Pregnancy and Birth. New York: Childbirth Connection.

Symon, A., Winter, C., Donnan, P. T., & Kirkham, M. (2010). Examining autonomy’s boundaries: a follow-up review of perinatal mortality cases in UK independent midwifery. Birth, 37(4), 280-287.

About Henci Goer

© Henci Goer

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

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

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