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Does It? Really? “WHO Admits: There Is No Evidence for Recommending a 10-15% Caesarean Limit”

October 30th, 2009 by avatar

This is the title of a Medical News Today piece, actually a re-posting of a press release from a coalition of websites that promote elective cesarean surgery. The press release claims that the 2009 edition of the WHO’s “Monitoring Emergency Obstetric Care: A Handbook”  has rescinded its 1985 recommendation that cesarean rates not exceed 10-15%. Can this be true? Not so much.

In fact, not at all.

The handbook still reads, as it always has:

WHO chart

The press release goes on to state that the WHO “updated” its (actually unchanged) recommendation, “admitting” that, quote, “no empirical evidence for an optimum percentage” exists, an “optimum rate is unknown,” and world regions may now “set their own standards.” The material from the WHO handbook is accurately quoted so far as it goes, but it doesn’t go very far. The handbook goes on to say: “A growing body of research shows . . . a negative effect of high rates,” cites studies in support of this (see below), and continues, “It should be noted that the proposed upper limit of 15% is not a target to be achieved, but rather a threshold not to be exceeded. Nevertheless, the rates in most developed countries and in many urban areas of lesser-developed countries are above that threshold” [emphasis mine]. In other words, countries with rates under 15% should not be striving to increase their rates, and countries “setting their own standards” means determining optimal rates, which may vary, within the WHO range.

This brings us to the second flat out untruth: The press release states that rates above the 10-15% range recommended by the WHO “have not led to a concomitant rise in maternal mortality or foetal, perinatal and neonatal mortality.” The WHO supports the 15% upper limit precisely because cesarean rates above the 15% ceiling result in higher maternal and perinatal death and morbidity rates. Here are the studies they cite:

Deneux-Tharaux (2006)
This French study determined maternal deaths directly attributable to cesarean surgery by excluding women with risk factors that could lead to the need for cesarean surgery and reviewing the confidential reports generated after each maternal death. “After adjustment for potential confounders, the risk of postpartum death was 3.6 times higher after cesarean than after vaginal delivery. . . . Knowledge of the causes of death associated with this excess risk informs contemporary discussion about cesarean delivery on request.” The analysis, moreover, undercounts cesarean-related deaths because investigators excluded deaths that might have arisen from complications that occur more often in women with prior cesarean surgery, including ectopic pregnancy and deaths from hemorrhage due to placenta previa, placental abruption, and placenta accreta.

MacDorman (2006)
Investigators in a U.S. study found that after isolating an ultra-low-risk population with no indication for cesarean, babies born after cesarean surgery were 1.8 times more likely to die than babies born after vaginal birth. This amounted to an excess of about 1 per 1000. They conclude: “Understanding the causes of these differentials is important, given the rapid growth in the number of primary cesareans without a reported medical indication.”

Villar (2006)
A report on Latin America derived from a WHO 2005 survey of maternal and perinatal health, it found that “Rate of caesarean delivery was positively associated with . . . severe maternal morbidity and mortality, even after adjustment for risk factors. Increase in the rate of cesarean delivery was associated with an increase in fetal mortality rates and higher numbers of babies admitted to intensive care for 7 days or longer even after adjustment for preterm delivery. Rates of preterm delivery and neonatal mortality both rose at rates of caesarean delivery of between 10% and 20%.” In other words, 15% is a liberal and probably overly generous maximum.

Shame on whoever is behind these websites for circulating such dangerous misinformation—but even more shame on Medical News Today for passing it on without spending two minutes to fact check its accuracy.

In this video from the Lamaze Video Library, Eugene Declercq, PhD, fact checks claims about the rates of perinatal mortality, maternal mortality, and cesarean surgery in the United States. Special thanks to Orgasmic Birth for sharing this DVD Extra with Lamaze International.

[flashvideo file=http://www.lamaze.org/portals/0/video/Birth_by_the_Numbers512k.flv /]

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Basic Tracking Skills: How to find what you’re hunting for

October 16th, 2009 by avatar

This is the third article in our Understanding Research series.

So you are at your index of choice. What now? You will need to use key words to search. The best way to learn to use key words effectively is to do a lot of practice searching. Some tips to help you get the most out of your practice:

1. Make sure you spell the words correctly. Seems almost silly that I would have to say it, but it is one of the most common mistakes.

2. Use quotation marks around phrases you want to search together. This can be a two-edged sword, though, as a search for “active management of labor” might miss a study that uses the phrasing “an active approach to labor management.”

3. Make use of the terms “and” “or” and “not”. If you wanted studies on smoking in pregnancy, you’d search for smoking AND pregnancy. The “or” command would be useful if you have similar terms you want to search at once, like hypertension OR high blood pressure. The “not” command can be used to eliminate unrelated results. For example labor NOT workforce. In some databases, you may need to capitalize these operators.

4. Don’t be too broad. If you’re looking for something on the risks of induction before 40 weeks, don’t just search “induction” because you’ll get a lot of results – and some won’t even have to do with labor! If you do find you get too many results, look for an option to refine your search to narrow the results to a manageable number. Often you’ll see a set of checkboxes where you can limit the results to a certain date range, only those with full text, or other criteria. Here is an example of the results limiting box found within EBSCO.

LimitResults

I’ve used the slider to show that I only want results published since the year 2000. When I click “update results” I’ll have refined my search so I have fewer results to look through.

5. Don’t be too specific. A search for induction risks labor 40 weeks gestation might eliminate a study titled “Timing of Elective Labor Induction at Term”.

6. If your first term doesn’t yield good results, try a different word that means the same thing. If birth location isn’t getting results, try place of birth. Or just start off using both terms with the “or” in between.

“birth location” OR “place of birth”

Also consider alternate spellings, like labor/labour or breastfeeding/breast feeding to see what comes up under each of those.

7. Finding little on Cytotec? Try searching “misoprostol” the generic name for the drug. Most published research will use the generic names for drugs since brand names can vary from country to country.

8. Use the medical lingo. I once got a call from a student who was frustrated beyond measure that she couldn’t find a single study to support her client in refusing a c-section for a baby that was estimated to weigh 9 pounds. “There’s GOT to be something!” Come to find out, she was searching for “big babies” and “c-section”. A search for macrosomia risks did turn up some helpful results.

9. Some (but not all) indexes will allow you to use the asterisk * symbol to truncate (or shorten) your search term. So if you want to do a search for something on episiotomy, you can search for “episiotom*” and the index will pull up anything with episiotomy, episiotomies, episiotomological, or any other word that starts with “episiotom-”. (OK, I admit, I made up the word “episiotomological”!) Be careful you don’t go too vague on this. A search for “epi*” will pull up episiotomy, epidural, epigastric, epistemology, epi-everything!

The best way to learn how to search is to practice, practice, practice. I find that it helps me to keep a running log of the terms I have tried to avoid repeating searches and to see things I may have missed. If you’re not finding what you want after several tries in one index, try another. If you are in a library building while you search, find a librarian and ask for help. Librarians can be great sources for the tips and tricks of searching!

Next week: Advanced Tracking Tools: MeSH Keywords

Research for Advocacy ,

Understanding Research: Introducing Andrea Lythgoe

September 14th, 2009 by avatar

[Editor’s Note: I’m absolutely thrilled to announce our newest regular contributor, Andrea Lythgoe. Andrea is a DONA-certified doula, hospital-based Lamaze childbirth educator, and instructor at the Midwives College of Utah. She is the author of the website UnderstandingResearch.com where she aims to help those just beginning to read research to understand the language of research. Look for the first article in her series tomorrow!- AMR]

“Are you sure that’s right? On the news last night, they said a study just proved that ……..”

“My doctor said that since there are no randomized controlled trials, it’s not safe.”

“Is it REALLY true that sex starts labor? Because last night on the news they said it did not, but last month on the news they said it did!”

Andrea Lythgoe, CD(DONA), LCCE

Andrea Lythgoe, CD(DONA), LCCE

As a childbirth educator and doula, I have run across these kinds of situations many times. It’s hard for expectant parents to understand what “the research says” when the headlines are their only source of information. In order to best help the families we serve, we should be as up to date as we can on current research. There are lots of excellent ways out there for birth professionals to stay caught up on the current research, but often it can be overwhelming to those just starting out.

I’ll be writing a series of articles here designed to help you learn the basics:

  • How (and why) to find the actual research study when you hear about a study on the news, or from a student.
  • Basic questions to consider when reviewing a study
  • The various types of studies you may come across and which types might be most appropriate for research in pregnancy, birth and parenting.
  • Classroom techniques for the educator to use when a birth-related study makes a big media splash.
  • Simple statistics you should know. I promise there will be no math!

As the series progresses, please feel free to ask questions, suggest topics for future articles, and share your tips as well. I’m looking forward to this project!

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Home Birth: The rest of the story

September 11th, 2009 by avatar

As most readers of this blog are probably already aware, The Today Show ran an inflammatory piece about home birth this morning that parroted ACOG’s long-standing scare tactics and anti-midwife rhetoric.

Since I just wrote a post on the safety of home birth, I thought that rather than repeating the same old story that home birth is safe for healthy women with qualified attendants and access to referral, I would share with readers some other thoughts, culled from this blog, the rest of Lamaze.org, and other trustworthy resources.

One of the first posts I wrote for Science & Sensibility (actually written as a guest post at the Giving Birth with Confidence Blog while this site was getting up and running) was titled, “Why the Largest Study of Planned Home Births Won’t Sway ACOG.” ACOG prefers to hold home birth to a standard of evidence to which hospital birth was never held.  Even while actively compiling the lowest form of evidence on the supposed “perils” of home birth in a membership survey, ACOG repeatedly calls for a randomized controlled trial comparing perinatal death rates in the two settings, fully aware that such a trial is literally guaranteed never to happen. I discuss some of the reasons why in my post, concluding that we face much more urgent research priorities for the study of planned home birth than a full-scale clinical trial.

We need more and better research on home birth. We can use data from the Netherlands to determine the safety of home birth in systems that support and integrate home birth midwifery. After all, it is the only place left with a maternity care system that lends itself to home birth safety research, and national registers to conduct that research soundly. In the U.S., we must study how we can reform our maternity care system to provide access to midwife-led care in all settings, and best practices for caring for the women who rightly and inevitably will continue to desire birth at home.

Why exactly do women desire to birth at home? It’s is not because they are hedonistic or selfish, as ACOG likes to suggest. Judith Lothian, PhD, RN, LCCE, wrote recently about the qualitative research she will present at next month’s Lamaze Conference. (Rixa Freeze, PhD, Lamaze International’s 2009 Media Award recipient, has conducted similar research.) Judith asked women themselves why they planned to give birth at home, and then observed them doing so. Their responses describe motivations far from reckless desire and hedonism. She writes:

I was surprised that all of the women described themselves as “mainstream”. They all wanted a natural birth. All the women came to believe that “intervention intensive” maternity care increased risk for them and their babies. They valued the personal relationship with their midwife and believed that this relationship increased safety. They believed they could manage the work of labor more easily and more safely in their own homes. They all expressed confidence that a hospital and skilled physician care were available if needed. ‘Being Safe’ emerged as the theme that captured the essence of women’s decision to plan a home birth. In stark contrast to the current thinking, that birth is safer in hospitals under the care of an obstetrician, these women believe that giving birth at home is safer for them and their babies.

It seems likely that women believe that home birth is safer than hospital birth because word is getting out that hospitals routinely deprive women of the style of care that is proven to produce the safest, healthiest outcomes. Just last week, Lamaze released the third revision of the Healthy Birth Practice Papers, a collection of evidence-based articles about the care practices that ease and facilitate labor, prevent complications, and protect breastfeeding and early mother-infant attachment:

1. Let labor begin on its own

2. Walk, move around, and change positions throughout labor

3. Bring a loved one, friend, or doula for continuous support

4. Avoid interventions that are not medically necessary

5. Avoid giving birth on the back and follow the body’s urges to push

6. Keep mother and baby together – it’s best for mother, baby, and breastfeeding

The 2006 U.S. Listening to Mothers II Survey revealed what anyone who advocates for home birth could tell you even without the data: almost no one who births in a hospital actually experiences these care practices. The survey found that fewer than 2% of women had all 5 of the care practices that the survey measured. (The practice they were unable to measure was “no routine interventions”. Since interventions are routine and rampant in hospitals, this likely means that the proportion of hospital birthing women who experienced all six care practices was effectively zero.)  Instead, the authors of the survey tell us what is happening in current, hospital-based maternity care:

The data show many mothers and babies experienced inappropriate care that does not reflect the best evidence, as well as other undesirable circumstances and adverse outcomes. This sounds alarm bells…Few healthy, low-risk mothers require technology-intensive care when given good support for physiologic labor. Yet, the survey shows that the typical childbirth experience has been transformed into a morass of wires, tubes, machines and medications that leave healthy women immobilized, vulnerable to high levels of surgery and burdened with physical and emotional health concerns while caring for their newborns.
– Maureen Corry, Executive Director of Childbirth Connection.

In fact, ACOG themselves acknowledged in a press release today that the current style of obstetric practice (high-tech defensive medicine) “ultimately hurts patients“.

I continue to believe that if hospitals provided the Six Healthy Birth Practices as the standard of care and offered evidence-based treatments for women and babies experiencing complications, hospital birth would be safer and so would home birth. That’s because midwives would initiate transfers with more confidence that it would improve the outcome, women would transfer more willingly, and care at the receiving facility would be safe and effective. What’s not to like about that plan, ACOG? Now, let’s make it happen!

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Independent Childbirth Education: Sharing Lamaze’s Message

August 12th, 2009 by avatar

[Editor’s Note: This is our second installment of guest posts from Lamaze International’s 2009 Annual Conference speakers. You can read all of our conference previews by clicking on the Lamaze 2009 Annual Conference tag. We hope to see you October 1-4 in Orlando at the Lamaze International 2009 Annual Conference. – AMR]

In a decade of being a childbirth educator, I have had the opportunity to teach hundreds of expectant families in various settings: a community health center, hospitals, maternity retail/class centers affiliated with hospitals, a spa, living rooms, and the occasional kitchen. I love teaching Lamaze, and for the last 5 years have only taught independent classes.

There are two things I’ve learned over the years:

  1. The research supports The Six Lamaze Healthy Birth Practices
  2. Most women are not experiencing these practices.

I know that the challenge is not that we don’t have evidence to support what we teach. The challenge is that for some reason, evidence-based maternity care is too often not the standard of care.

Ami Burns, LCCE, CD(DONA)

Ami Burns, LCCE, CD(DONA)

Women who do experience all of the Healthy Birth Practices almost always have achieved this by carefully and fully informing themselves about their options, and childbirth classes remain one of the most important sources of trustworthy information. As an independent educator, I’m able to present evidence-based information without any restraint. When I taught for hospitals, I never had anyone tell me not to teach certain subjects, but know other LCCEs who are in the challenging position of wanting to teach according to the evidence but being unable to because evidence-based maternity care is not being practiced by the institution responsible for signing their paychecks.

Independent educators focus not only on the Healthy Birth Practices and Lamaze philosophy, but also on communication skills. This may sound obvious, but I’m still surprised by the number of people who have no idea they have choices or don’t need permission to say “yes” or “no” to an intervention. I don’t make decisions for my students, but give them the evidence-based information needed so they (hopefully) gain the confidence to make them and feel informed and positive about them. We can’t control mothers’ choices or outcomes for their babies. But what we can do is teach according to the evidence and make sure they are learning what they need to know for a safe, healthy and satisfying birth.

Here is one example of a benefit of independent Lamaze education: I recently taught a class to a couple expecting their first baby. The mother expressed her wish to have an epidural but use natural comfort measures and coping techniques for as long as possible before getting it administered. She told me her doctor said she’d probably break her water and start pitocin when she’s admitted to labor and delivery. This contradicts what the mother had read, what she wanted, and we all know contradicts the evidence that states it’s best for labor to progress on it’s own unless there is a medical reason to induce or augment. I had the time to address these issues and give her some tips for how to communicate her wishes with her doctor and also hospital staff once she’s in labor. The mother shared her birth story with me, and while she felt at times that her “doctor wasn’t too happy” with her, she labored and birthed her way. This is just one example of how Lamaze is “not just about the breathing! Teaching based on the research gives mothers the tools to make informed decisions and build confidence in their ability to birth their babies on their terms.

I had wonderful experiences when I taught for hospitals. But I know not every hospital-based educator can say the same. I recall a few articles and letters in The Journal of Perinatal Education that have addressed this all-too-common challenge LCCEs face. Some hospital-based educators have advocated effectively using evidence to obtain greater autonomy in teaching. Hospital-based educators can also collaborate with independent childbirth educators, offering courses that compliment, rather than compete with, one another. Many of my students attend their hospital’s one-day childbirth class then attend my classes to focus more on natural birth.

On October 3rd, I’ll be presenting Inspiration for Independent Educators at Lamaze International’s Annual Conference in Orlando. I encourage LCCEs and educators-in-training to attend. You don’t even have to be an independent educator! Hospital-based LCCEs are more than welcome, and I know we can learn a lot from each other. I believe there are “pros” and “cons” to both types of education, and will talk more about this during my presentation.

Whether we teach in or out of hospitals, our mission should be the same: support normal birth and provide evidence-based information to help women gain confidence and make informed decisions about their care.

Ami Burns is the founder of Birth Talk (www.birthtalk.com). She is a Lamaze Certified Chidlbirth Educator, DONA International Certified Doula, and will be inducted as a Fellow in the American College of Childbirth Educators at the Lamaze International Annual Conference in October. Ami’s formal degree is a B.S. in Mass Communication from Emerson College, and she combines her background in media with her passion for birth as a freelance writer and award-winning birth video producer.

Lamaze International Annual Conference

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