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

April 15th, 2015 by avatar

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

RD: I would recommend asking these questions:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References

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

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

 

 

 

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

Ebola, Fearbola, and the Childbirth Educator

November 6th, 2014 by avatar

By Rebecca Dekker, PhD, RN, APRN

ebola infographic cc cdcMany news outlets and social media venues have been disseminating information on the Ebola virus and the impact on populations both in West Africa as well as the potential impact on developed nations, including the USA.  The expectant families that you work with may have shared concerns for themselves, their children and their unborn baby with you?  How have you responded?  Did you feel like you had the information that you needed to provide them with facts to calm their concerns?  Occaisonal contributor Rebecca Dekker of EvidenceBasedBirth.com takes a look at the facts about the Ebola virus and shares resources and information applicable to pregnant and breastfeeding families that you can share. – Sharon Muza, Community Manager, Science & Sensibility

What’s the childbirth educator got to fear about Ebola? How do you address your students and clients’ fears?

Well, if you live in the U.S. or in any other country other than Africa—right now, there’s really not much to actually fear. That is, if you’re only worried about yourself and your own community.

The truth is, here in the U.S., there are so many more things that are more likely to kill you than Ebola—other infectious diseases such as influenza, motor vehicle accidents, smoking, secondhand smoke exposure, cardiovascular disease, cancer, even radon—an odorless, colorless gas that exists in many of our homes in the Southeast and can cause lung cancer—you name it, and it’s probably more likely to harm you than Ebola.

So why all the fear here in the U.S.? 

Ebola is a rare but deadly disease, and it has been ravaging West Africa. In developed countries, we feel fear because cases of the disease have finally reached our own shores, when in fact we should have paid attention much sooner to what is happening to our brothers and sisters in Liberia, Guinea, and Sierra Leone.

Does all this fear of Ebola do any good?

Personally, I believe that the fact that so much attention has been drawn to Ebola in developed countries may be a good thing. Fear here means that our governments have finally begun to put energy and resources into stopping the epidemic in Africa– not necessarily for humanitarian reasons– but to prevent the spread of this disease to us.

The Ebola epidemic that has affected parts of West Africa has been a fast-moving event that is only just now showing signs of slowing down. Researchers have conclusive evidence that this is the largest, most severe and most complex Ebola epidemic that we have witnessed since Ebola was first discovered nearly 40 years ago. The number of cases and deaths in this epidemic is many times larger than all past Ebola outbreaks combined.

Before the current epidemic, the Ebola virus had mostly been contained to small outbreaks in rural communities. This time, all of the capital cities in in Liberia, Guinea, and Sierra Leone have experienced large outbreaks.

For the first time, Ebola has entered communities like West Point, in Monrovia, Liberia. According to the World Health Organization, “West Point is West Africa’s largest and most notorious slum: more than 70,000 people crowded together on a peninsula, with no running water, sanitation or garbage collection. The number of Ebola deaths in that slum will likely never be known, as bodies have simply been thrown into the two nearby rivers.”

Ebola has been especially hard-hitting on health care workers. Health workers on the front lines are often exposed to very infectious bodily fluids—blood, vomit, and diarrhea. The fact that health care workers can be at high risk for catching and dying from Ebola was first discovered during the very first Ebola outbreaks that took place in Zaire and Sudan in 1978. Fortunately, researchers have found that proper use and training with personal protective equipment can drastically lower health care workers’ chances of catching the virus. It’s probable that the cases we saw in the U.S. among nurses were due to improper training, inadequate protection equipment, or both.

Interestingly, Ebola actually isn’t as contagious as many other infectious diseases. Measles is an airborne disease, and it is highly contagious. Someone with measles can walk through a room, and another person can walk through that same room two hours later and catch the same measles infection. For every one person who has measles and lives among an unvaccinated population, they will—on average—infect 18 more people.

© CDC

© CDC

In contrast, one person with Ebola infects two other people on average, usually people who have had close, prolonged contact with that person. And the research we have on humans so far shows that Ebola is not airborne—although there have been a few primate studies that suggested otherwise (but some researchers think that maybe the monkeys were spitting on each other!)

One reason Ebola has spread so widely in West Africa – in spite of the fact that this virus is relatively hard to catch compared to other infectious diseases—is that the countries affected are extremely poor. Many people lack running water and soap in their homes.

This means that in West Africa, if one family member comes down with Ebola, there’s a good chance that others in the home will become infected, especially if patients bleed and vomit profusely. Families without modern toilets and washing machines have trouble cleaning up after patients who lose control of their bowels and produce huge amounts of diarrhea. Even burying the dead can spread Ebola in these countries, because common burial rites involve washing the dead and preparing the bodies. However, news organizations are reporting that communities have begun adhering to recommendations to refrain from traditional burial practices that expose more people to the disease.

So, it makes sense that we would fear for our fellow humans in West Africa. They are experiencing what can only be described as a humanitarian crisis. What’s even more concerning is that the virus has—at least for now—crippled an already weak health care infrastructure. This has created what the World Health Organization calls, “an emergency within an emergency.” A great example of this is that pregnant women and infants cannot receive emergency care while resources are drained by the Ebola virus epidemic.

So why are some people panicking about Ebola in the U.S., where the chances of an infection are completely remote? How do we make sense of this?

Well, when it comes to understanding how people perceive risk, and why some people are panicking about Ebola in the U.S., it may be helpful to understand some basic scientific principles behind how people perceive risk.

First of all, risk is subjective. And emotions and our mood change how we interpret risk. So facts matter less when emotions take over.

Also, many people also have an inherent lack of trust in scientists and the government– both here in the U.S. and in West Africa. People often believe their own senses and own experiences more than what scientists say. Many people don’t really understand the scientific process, and have doubts about what they hear. They confuse the research evidence on Ebola with the legal system, and they think there is lots of room for reasonable doubt about whether or not Ebola is airborne, for example.

Also, it’s really important to understand that people perceive a higher risk from rare events with really severe outcomes than they do for common outcomes with less severe or delayed outcomes.

[Does this sound familiar? Just take that sentence above and think about the concept of VBAC and repeat Cesarean. Obstetricians perceive a higher risk from rare events with really severe outcomes—such as uterine rupture—than they do for common outcomes with less severe or delayed outcomes—such as serious maternal infections after a planned repeat Cesarean, or placental abnormalities in future pregnancies].

People also tend to worry more over things that we can’t control. We can control our driving, and getting a flu vaccine, and our diet, and cigarette smoking. But we can’t control Ebola, so that scares us more.

So when we bring fear and emotion into the mix, people’s risk perceptions can end up looking like they do for some people in the U.S. right now– paranoia about Ebola.

It is unfortunate that we have overblown fears of contracting Ebola in the U.S., but if we could redirect our thoughts and channel our efforts into containing the outbreak in West Africa, this is where we will make the biggest difference.

So, in summary:

  • Ebola is a rare but deadly viral infection
  • We are currently witnessing the largest Ebola outbreak in history.
  • The chances of any one of us contracting the virus in the U.S. are extremely remote
  • Fear of Ebola will hopefully trigger people in developed countries to reach out to our fellow humans in West Africa and help them fight the virus

Items of interest related to childbirth and breastfeeding

How can we help?

If you’re worried about Ebola, don’t panic but do put your concern into action. Many health and relief organizations in West Africa are in need of resources, and you can help. This blog article has a comprehensive list of charities working in West Africa right now.

Have your clients and students asked you about Ebola?  Have they expressed concern for themselves or their baby?  Have families discussed the fear of entering the hospital to birth, due to their perceived risk of the hospital as being a potential source of exposure to the Ebola virus?  Hopefully after reading this blog post by Rebecca, you can help provide the facts.  You can also direct them to the Evidence Based Birth online class “Ebola, Fearbola: Separating Facts from Paranoia” and the About.com article “Five Things Pregnant Women Need to Know about Ebola” written by Robin E. Weiss. The Centers for Disease Control and Prevention also provides a wealth of information that you can access and share with the families you work with. – SM

About Rebecca Dekker

Rebecca Dekker

Rebecca Dekker

Rebecca Dekker, PhD, RN, APRN, is the founder of Evidence Based Birth and teaches pathophysiology at a research university. She has taught continuing education classes on HIV and recently developed an in-depth class on the pathophysiology and epidemiology of Ebola (2 nursing contact hours). To learn about how Ebola is transmitted, prevented, diagnosed, and treated, check out Rebecca’s class on “Ebola or Fearbola? Separating Facts from Paranoia,” here.

Childbirth Education, Continuing Education, Evidence Based Medicine, Guest Posts, Maternal Mortality, Maternity Care, Newborns, Research , , , ,

Evidence on Water Birth Safety – Exclusive Q&A with Rebecca Dekker on her New Research

July 10th, 2014 by avatar

 

Evidence Based Birth , a popular blog written by occasional Science & Sensibility contributor Rebecca Dekker, PhD, RN, APRN, has just today published a new article, “Evidence on Water Birth Safety” that looks at the current research on the safety of water birth for mothers and newborns.  Rebecca researched and wrote that article in response to the joint Opinion Statement “Immersion in Water During Labor and Delivery” released in March, 2014 by the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics.  I had the opportunity to ask Rebecca some questions about her research into the evidence available on water birth, her thoughts on the Opinion Statement and her conclusions after writing her review. – Sharon Muza, Science & Sensibility Community Manager.

Sharon Muza: First off, is it waterbirth or water birth?

Rebecca Dekker: That’s actually good question! Research experts tend to use the term “waterbirth.” Google prefers “water birth.” So I used both terms in my article to satisfy everyone!

SM: Have you heard or been told of stories of existing water birth programs shutting down or being modified as a result of the recent AAP/ACOG opinion?

RD: Yes, definitely. There was a mother in my state who contacted me this spring because she was 34 weeks pregnant and her hospital decided not to offer waterbirth anymore. She had given birth to her daughter in a waterbirth at the same hospital two years earlier. With her current pregnancy, she had been planning another hospital waterbirth. She had the support of her nurse midwife, the hospital obstetricians, and hospital policy. However, immediately after the release of the ACOG/AAP opinion, the hospital CEO put an immediate stop to waterbirth. This particular mother ended up switching providers at 36 weeks to a home birth midwife. A few weeks ago, she gave birth to her second baby, at home in the water. This mother told me how disheartening it was that an administrator in an office had decided limit her birth options, even though physicians and midwives at the same hospital were supportive of her informed decision to have a waterbirth.

In another hospital in my hometown, they were gearing up to start a waterbirth program this year—it was going to be the first hospital where waterbirth would be available in our city—and it was put on hold because of the ACOG/AAP Opinion.

Then of course, there were a lot of media reports about various hospital systems that suspended their waterbirth programs. One hospital system in particular, in Minnesota, got a lot of media coverage.

SM: Did you attempt to contact ACOG/AAP with questions and if so, did they respond?

RD: Yes. As soon as I realized that the ACOG/AAP Opinion Statement had so many major scientific errors, I contacted ImprovingBirth.org and together we wrote two letters. I wrote a letter regarding the scientific problems with the Opinion Statement, and ImprovingBirth.org wrote a letter asking ACOG/AAP to suspend the statement until further review. The letters were received by the President and President-Elect of ACOG, and they were forwarded to the Practice Committee. We were told that the Practice Committee would review the contents of our letters at their meeting in mid-June, and that was the last update that we have received.

SM: What is the difference between an “Opinion Statement” and other types of policy recommendations or guidelines that these organizations release? Does it carry as much weight as practice bulletins?

RD: That’s an interesting question. At the very top of the Opinion Statement, there are two sentences that read: “This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.” But, as you will see, some hospitals do see this statement as dictating an exclusive course of treatment, and others don’t.

I have heard that “opinions” do not carry as much weight as “practice bulletins,” but it really depends on who the audience is and who is listening. In other words, some hospitals may take the Opinion Statement word-for-word and feel that they must follow it to the letter, and other hospitals may ignore it. A lot of it probably depends on the advice of their risk management lawyers.

For example, a nurse midwife at a hospital in Illinois sent me a letter that their risk-management attorneys had put together to advise them on this issue. (She had the attorney’s permission to share the letter with me). These lawyers basically said that when a committee of two highly-respected organizations says that the practice of waterbirth should be considered an experimental procedure, both health care providers and hospitals are “charged with a duty to heed that statement,” unless they find research evidence that waterbirth has benefits for the mother or fetus, and that the evidence can override the Committee’s conclusions.

On the other hand, another risk management lawyer for a large hospital system told me that of course hospitals are not under any obligation to follow an ACOG/AAP Opinion Statement. It’s simply just that—an opinion.

So as to how much weight the Opinion Statement carries—I guess it is really dependent on who is reading it!

SM: How would you suggest a well-designed research study be conducted to examine the efficacy and safety of waterbirth? Or would you say that satisfactory research already exists.

RD: First of all, I want to say that I’m really looking forward to the publication of the American Association of Birth Centers (AABC) data on nearly 4,000 waterbirths that occurred in birth centers in the U.S., to see what kind of methods they used. From what I hear, they had really fantastic outcomes.

And it’s also really exciting that anyone can join the AABC research registry, whether you practice in a hospital, birth center, or at home. The more people who join the registry, the bigger the data set will be for future research and analysis. Visit the AABC PDR website to find out more.

I think it’s pretty clear that a randomized trial would be difficult to do, because we would need at least 2,000 women in the overall sample in order to tell differences in rare outcomes. So instead we need well-designed observational studies.

My dream study on waterbirth would be this: A large, prospective, multi-center registry that follows women who are interested in waterbirth and compares three groups: 1) women who have a waterbirth, 2) women who want a waterbirth and are eligible for a waterbirth but the tub is not available—so they had a conventional land birth, 3) women who labored in water but got out of the tub for the birth. The researchers would measure an extensive list of both maternal and fetal outcomes.

It would also be interesting to do an additional analysis to compare women from group 2 who had an epidural with women from group 1 who had a waterbirth. To my knowledge, only one study has specifically compared women who had waterbirths with women who had epidurals. Since these are two very different forms of pain relief, it would be nice to have a side-by-side comparison to help inform mothers’ decision making.

SM: What was the most surprising finding to you in researching your article on the evidence on water birth safety?

RD: I guess I was most surprised by how poorly the ACOG/AAP literature review was done in their Opinion Statement. During my initial read of it, I instantly recognized multiple scientific problems.

A glance at the references they cited was so surprising to me—when discussing the fetal risks of waterbirth, they referenced a laboratory study of pregnant rats that were randomized to exercise swimming in cold or warm water! There weren’t even any rat waterbirths! It was both hilarious and sad, at the same time! And it’s not like you have to read the entire rat article to figure out that they were talking about pregnant rats—it was right there in their list of references, in the title of the article, “Effect of water temperature on exercise-induced maternal hyperthermia on fetal development in rats.”

These kind of mistakes were very surprising, and incredibly disappointing. I expect a lot higher standards from such important professional organizations. These organizations have a huge influence on the care of women in the U.S., and even around the world, as other countries look to their recommendations for guidance. The fact that they were making a sweeping statement about the availability of a pain relief option during labor, based on an ill-researched and substandard literature review—was very surprising indeed.

SM: What was the most interesting fact you discovered during your research?

RD: With all this talk from ACOG and the AAP about how there are “no maternal benefits,” I was fascinated as I dug into the research to almost immediately find that waterbirth has a strong negative effect on the use of episiotomy during childbirth.

Every single study on this topic has shown that waterbirth drastically reduces and in some cases completely eliminates the use of episiotomy. Many women are eager to avoid episiotomies, and to have intact perineums, and waterbirth is associated with both lower episiotomy rates and higher intact perineum rates. That is a substantial maternal benefit. It’s kind of sad to see leading professional organizations not even give the slightest nod to waterbirth’s ability to keep women’s perineums intact.

In fact, I’m puzzled as to why keeping women’s perineums intact and uncut is not perceived as a benefit by anyone other than the women themselves. And here is the heart of declaring waterbirth as “not having enough benefits” to justify its use: Who decides the benefits? Who decides what a benefit is, if not the person benefitting? Who should be weighing the potential harms and the potential benefits of waterbirth, and making an informed decision about their options? Should it be the mother? Or should it be the obstetrician?

SM: What can families do if they want waterbirth to be an option in their local hospital or birth center and it has been taken away or not even ever been offered before?

RD: That’s a hard question. It’s a big problem.

Basically what it boils down to is this—there are a lot of restraining forces that keep waterbirth from being a pain relief option for many women. But there are also some positive driving forces. According to change theory, if you want to see a behavior change at the healthcare organization level, it is a matter of decreasing the restraining forces, while increasing the driving forces. Debunking the ACOG/AAP Opinion Statement is an important piece of decreasing restraining forces. On the other side, increasing consumer pressure can help drive positive change.

SM: Do you think that consumers will be responding with their health dollars in changing providers and facilities in order to have a waterbirth?

RD: I think that if a hospital offered waterbirth as an option to low-risk women, that this could be a huge marketing tool and would put that hospital at an advantage in their community, especially if the other hospitals did not offer waterbirth.

SM: The ACOG/AAP opinion sounded very reactionary, but to what I am not sure. What do you think are the biggest concerns these organizations have and why was this topic even addressed? Weren’t things sailing along smoothly in the many facilities already offering a water birth option?

RD: I don’t know if you saw the interview with Medscape, but one of the authors of the Opinion Statement suggested that they were partially motivated to come out with this statement because of the increase in home birth, and they perceive that women are having a lot of waterbirths at home.

I also wonder if they are hoping to leverage their influence as the FDA considers regulation of birthing pools. You may remember that in 2012, the FDA temporarily prohibited birthing pools from coming into the U.S. Then the FDA held a big meeting with the different midwifery and physician organizations. At that meeting, AAP and ACOG had a united front against waterbirth. So I guess it’s no surprise for them to come out with a joint opinion statement shortly afterwards.

My sincere hope is that the FDA is able to recognize the seriously flawed methods of the literature review in this Opinion Statement, before they come out with any new regulations.

SM: How should childbirth educators be addressing the topic of waterbirth and waterbirth options in our classes in light of the recent ACOG/AAP Opinion Statement and what you have written about in your research review on the Evidence on Water Birth Safety?

RD: It’s not an easy subject. There are both pros and cons to waterbirth, and it’s important for women to discuss waterbirth with their providers so that they can make an informed decision. At the same time, there are a lot of obstetricians who cannot or will not support waterbirth because of ACOG’s position. So if a woman is really interested in waterbirth, she will need to a) find a supportive care provider, b) find a birth setting that encourages and supports waterbirth.

You can’t really have a waterbirth with an unwilling provider or unwilling facility. Well, let me take that back… you can have an “accidental” waterbirth… but unplanned waterbirths have not been included in the research studies on waterbirth, so the evidence on the safety of waterbirth does not generalize to unplanned waterbirths. Also, you have to ask yourself, is your care provider knowledgeable and capable of facilitating a waterbirth? It might not be safe to try to have an “accidental” waterbirth if your care provider and setting have no idea how to handle one. Do they follow infection control policies? Do they know how to handle a shoulder dystocia in the water?

SM: What kind of response do you think there will be from medical organizations and facilities as well as consumers about your research findings?

RD: I hope that it is positive! I would love to see some media coverage of this issue. I hope that the Evidence Based Birth® article inspires discussion among care providers and women, and among colleagues at medical organizations, about the quality of evidence in guidelines, and their role in providing quality information to help guide informed decision-making.

SM: Based on your research, you conclude that the evidence does not support universal bans on waterbirth. Is there anything you would suggest be done or changed to improve waterbirth outcomes for mothers or babies?

RD: The conclusion that I came to in my article—that waterbirth should not be “banned,” is basically what several other respected organization have already said. The American College of Nurse Midwives, the American Association of Birth Centers, the Royal College of Obstetricians and Gynaecologists, and the Royal College of Midwives have all said basically the same thing.

How can we improve waterbirth outcomes? I think continuing to be involved in clinical research studies (such as the AABC registry) is an important way to advance the science and provide evidence on which we can base practice and make more informed decisions with. Also, conducting clinical audits (tracking outcomes) in facilities that provide waterbirth would be important for quality control.

SM: Let’s look into the future. What is next on your plate to write about?

RD: I recently had a writing retreat with several amazing clinicians and researchers who flew from across the country to conduct literature reviews with me. We made an awesome team!! The topics that we have started looking at are: induction for post-dates, induction for ruptured membranes, and evidence-based care for women of advanced maternal age. I can’t decide which one we will publish first! The Evidence Based Birth readers have requested AMA next, but the induction for ruptured membranes article is probably further along than that one. We shall see!!

SM: Is there anything else you would like to share with Science & Sensibility readers on this topic?

RD: Thanks for being so patient with me! I know a lot of people were eagerly awaiting this article, and I wish it could have come out sooner, but these kinds of reviews take a lot of time. Time is my most precious commodity right now!

Has the recent Opinion Statement released by ACOG/AAP impacted birth options in your communities?  Do you discuss this with your clients, students and patients?  What has been the reaction of the families you work with? Let us know below in the comments section! – SM.

ACOG, American Academy of Pediatrics, Babies, Childbirth Education, Evidence Based Medicine, Home Birth, informed Consent, Maternity Care, New Research, Newborns, Research , , , , , , , ,

Can Moxibustion Help Turn Breech Babies?

November 5th, 2013 by avatar

By Rebecca Dekker, PhD, RN, APRN

Occasional Science & Sensibility contributor Rebecca Dekker of www.EvidenceBasedBirth.com examines the practice of Moxibustion to help turn breech babies head down.  Rebecca looks at what the current research shows on this ancient treatment for turning babies and shares the results with Science & Sensibility readers in an article that can be easily shared with students, clients and patients. – Sharon Muza, Science & Sensibility Community Manager.

A mother tries moxibustion to turn her breech baby. © EvidenceBased Birth.com

About 3-4% of pregnant women end up with a baby who is in breech (bottom first) position at term. The vast majority of these babies (90%) are born by planned cesarean section. In order to avoid a cesarean section, many women try various ways to turn their babies into a head-down position. I have written in the past about using external cephalic version (ECV), also called the hands-to-belly procedure, for turning breech babies. However, although ECV is safe and frequently effective, it can be uncomfortable and women may want to try different options for turning a breech baby. One potential option is moxibustion.

What is moxibustion?

Moxibustion is a type of Chinese medicine where you burn an herb (Artemesia vulgaria) close to the skin of the fifth toes of both feet. The fifth toe is a traditional acupuncture point called Bladder 67.

How do you use moxibustion?

There is no one recommended way to use moxibustion, but many women burn the moxa sticks close to their toes for about 15-20 minutes, from anywhere to 1-10 times per day, for up to two weeks. This treatment is usually started between 28 and 37 weeks of pregnancy.

How could moxibustion work?

The burning of the moxa stick stimulates heat receptors on the skin of the toe. It is thought that the heat encourages the release of two pregnancy hormones—placental estrogen and prostaglandins—which lead to uterine contractions. These contractions can then stimulate the baby to move (Cardini & Weixin, 1998).

So, does moxibustion work?

In 2012, researchers combined results from eight studies where 1,346 women with breech babies were randomly assigned to moxibustion, no treatment, or an alternative treatment (like acupuncture). The women in these studies lived in Italy, China, and Switzerland (Coyle et al., 2012).

For the women who were assigned to receive moxibustion, some used moxibustion alone, some had moxibustion plus acupuncture, and some used moxibustion plus posture techniques.

When moxibustion alone was compared to no treatment (3 studies, 594 women) there was:

• No difference in the percentage of babies who were breech at birth

• No difference in the need for external cephalic version

• No difference in cesarean section rates

• No difference in the risk of water breaking before labor began

• No difference in Apgar scores at birth

• A 72% decrease in the risk of using oxytocin for women in the moxibustion group who ended up with a vaginal birth

Side effects of the moxibustion included smelling an unpleasant odor, nausea, and abdominal pain from contractions.

When moxibustion alone was compared to acupuncture alone, fewer women in the moxibustion group had breech babies at birth compared to the acupuncture group. However, there were only 25 women in the single study that compared moxibustion alone to acupuncture alone, so this doesn’t really tell us that much.

When moxibustion plus acupuncture was compared to no treatment (1 study, 226 women), women who had moxibustion plus acupuncture had a:

• 27% decrease in the risk of having a breech baby at birth

• 21% decrease in the risk of having a cesarean section

When moxibustion plus acupuncture was compared to acupuncture alone, one study with only 24 women found no difference in the number of women who had breech babies at birth. Because this study was so small, it doesn’t really give us much meaningful information.

When moxibustion plus postural techniques was compared to postural techniques alone (3 studies, 470 women), women in the moxibustion plus postural group had:

• a 74% decrease in the risk of having a breech baby at birth

Are there any limitations to this evidence?

A homemade moxa stick holder helps a mother administer a moxibustion treatment. © EvidenceBasedBirth.com

Overall, the studies that were used in this review were good quality. However, some of the studies were very small, and sometimes researchers did not measure things that we would be interested in—for example, when moxibustion plus postural techniques was compared to postural techniques alone, we have no idea if it made a difference in cesarean section rates or any other health results. Also, all of the researchers used different methods of moxibustion. Some women may have had more frequent or longer sessions, and some women may have been more compliant with the therapy than others.

Is there any other good evidence on moxibustion?

After the review above was published, evidence from a new randomized controlled trial that took place in Spain came out in 2013. In this new study, 406 low-risk pregnant women who had a baby in breech position at 33-35 weeks were randomly assigned to true moxibustion, “fake” moxibustion, or regular care.

What kind of treatments did the women receive?

In the true moxibustion group, the women laid face up, and the hot moxa stick was held near the outside of the little toenail 20 minutes per day for two weeks, changing from one foot to the other when the heat became uncomfortable. The women did the moxibustion at home with the help of a family member. In the fake moxibustion group, the same treatment was carried out, except that the moxa stick was applied to the big toe, which is not a true acupuncture point. Women in all of the groups were educated on how to use a knee-chest posture to try and turn the baby.

Did the moxibustion work?

Women who did moxibustion plus postural techniques were 1.3 times more likely to have a baby in head-down position at birth when compared to both the fake moxibustion and the usual care groups. If you look at the exact numbers, 58% of the women who used moxibustion had a baby who was head-down at birth, compared to 43% of the fake moxibustion group and 45% of the usual care group. The number of women who would need to use moxibustion in order to successfully turn one baby is, on average, eight women.

There was no statistical difference in cesarean section rates among the three groups, but it looked like the numbers were trending in favor of true moxibustion: 51% of the women in the true moxibustion group had cesarean sections, compared to 62% of the fake moxibustion group and 59% of the usual care group.

Were there any safety concerns?

Overall, evidence showed that moxibustion treatment was safe. About 1 out of 3 women reported having contractions during the treatment, but there was no increase in the risk of preterm birth. Some women (14%) said they felt heart palpitations. One woman experienced a burn from the moxibustion. Other complaints from women in all three groups included heartburn, nausea and vomiting (2%), dizziness (1.7%), mild high blood pressure problems (1.7%), stomach pain (1.5%), and baby hiccups (1.2%). However, there were no differences among the three groups in the number of women who had these complaints. There were also no differences in newborn health issues or labor problems among the three groups. All of the babies had good Apgar scores five minutes after birth.

So what’s the bottom line?

• Evidence suggests that moxibustion—when combined with either acupuncture or postural techniques—is safe and increases your chances of turning a breech baby

• We still don’t know for sure which kind of moxibustion method (timing during pregnancy, number of sessions, length of sessions, etc.) works best for turning breech babies. However it appears that using moxibustion twice per day for two weeks (during 33-35 weeks of pregnancy) will work for 1 out of every 8 women.

• If women are interested in using Chinese medicine (moxibustion and acupuncture) to help turn a breech baby, they may want to consult a licensed acupuncturist who specializes in treatment of pregnant women.

Here is a video where an acupuncture physician shows how to use moxibustion to turn a breech baby:

Thank you to Kiné Fischler L.Ac. of Willow Tree Wellness Clinic, who provided feedback on this article.

As a childbirth educator or other birth professional, do you share information on moxibustion as a method that mothers might use to turn a breech baby?  How do you present this information?  How do the families you work with feel after learning about this option? If you did not cover this before, do you feel like you might start to include this information in your classes after reading Rebecca’s information here and on her blog? Are you aware of physicians who also encourage patients to try this treatment?  Please share your experiences in our comments section. I welcome your discussions. – SM

References

Cardini F. & Weixin H. (1998). Moxibustion for correction of breech presentation: A randomized controlled trial. JAMA 280(18), 1580-1584. Free full text: http://jama.jamanetwork.com/article.aspx?articleid=188144

Coyle ME, Smith CA, & Peat B. 2012. Cephalic version by moxibustion for breech presentation. Cochrane Database of Systematic Reviews 2012, Issue 5. Art. No: CD003928. http://www.ncbi.nlm.nih.gov/pubmed/22592693

Vas J, Aranda-Regules JM, Modesto M, et al. (2013). Acupuncture Medicine 31: 31-38. http://www.ncbi.nlm.nih.gov/pubmed/23249535

About Rebecca Dekker

Rebecca Dekker, PhD, RN, APRN, is an Assistant Professor of Nursing at a research-intensive university and the founder and author of EvidenceBasedBirth.com.  Rebecca’s vision is to promote evidence-based birth practices among consumers and clinicians worldwide. She publishes summaries of birth evidence using a Question and Answer style. The mission of Evidence Based Birth is to get birth evidence out of medical journals and into the hands of the public. You can follow Rebecca on Facebook, Twitter or follow the Evidence Based Birth newsletter to get free printable handouts and other news.

 

 

Babies, Cesarean Birth, Childbirth Education, Do No Harm, Guest Posts, New Research, Research , , , , , , , , , ,

Six Birth Blogs Every Childbirth Educator Should Be Reading

September 17th, 2013 by avatar

Today on Science & Sensibility, I wanted to share with readers some of my favorite birth related blogs, after Science & Sensibility of course! I subscribe to over 400 blogs, on a variety of topics, not just birth. I hope that someone has a larger blog list then I do, otherwise I will start to worry about how this might be an obsession.

I really enjoy reading what experts in the field of maternal and infant health have to say on their blogs and frequently find myself sharing information in my classes and with the families that I work with as well as with other professionals. I appreciate the effort, the research, the time and the energy that goes into making my favorite blogs so rich and useful for me, and so relevant to the work I do as an LCCE. 

Here are six of my favorite blogs, in no particular order:

1. Spinning Babies Blog

Midwife Gail Tully has long been well known for her website, Spinning Babies and her blog is an added bonus!  Gail frequently answers questions from readers, describes some new research she came across or shares a new technique to help babies move easier through the pelvis.  Here you can frequently find a video snippet you can use in your childbirth class, a book review or an inspiring birth story usually related to babies who chose to do things their way, as they work to be born.  

2. Evidence Based Birth

This blog burst onto the scene in mid-2012, and has been a fantastic resource ever since.  Rebecca Dekker, PhD, RN, APRN is an assistant professor of nursing at a research university in the U.S. She teaches pathophysiology and pharmacology, but has a strong personal interest in birth, and hence the blog was created.  The mission of Evidence Based Birth is to “promote evidence-based practice during childbirth by providing research evidence directly to women and families.”  Rebecca takes a look at the big issues (failure to progress, big babies, low AFI, for example) that face women during their pregnancy and birth, and does a thorough job of evaluating all the research and explaining it in a logical, easy to understand post.  Rebecca sums up her posts with recommendations based on the evidence and gives readers the bottom line and take-away.  Additionally, there are “printables” that are concise versions of some of her blog posts that families can print out and take to appointments with their healthcare providers in order to help facilitate discussions about best practice.

3.  VBAC Facts

Jennifer Kamel has created a plethora of useful information on vaginal birth after cesarean (VBAC) facts and statistics.  She founded her blog after doing a huge amount of research on the benefits and risks of VBAC, after her first birth ended in a Cesarean and she prepared for her second.   The amount of information, statistics, research summaries and discussion found on her blog is amazing.  Jen is a “numbers gal” and does a great job of explaining risks and numbers in an easy to understand presentation.  I frequently find myself going to her blog when I want to know the risk of placental complications after a cesarean or to better understand some of the new research and policy statements from ACOG and other professional organizations.  When 1 in 3 women in the US will give birth by Cesarean, it is good to have a resource such as VBACFacts.com to go to that can help me understand and explain options to families birthing after a cesarean.

4. The Well-Rounded Mama

Pamela Vireday has written “The Well-Rounded Mama” blog since 2008 and it has been a valuable resource for women of all sizes, when they are looking for answers and facts about options for birth.  The mission of the blog is “to provide general information about pregnancy, birth, and breastfeeding, to discuss how to improve care for women of size, to raise awareness about the impact of weight stigma and discrimination on people of size, and to promote health by focusing on positive habits instead of numbers on a scale.” Pamela does an awesome job of gathering, explaining and summarizing research, particularly related to women of size, but in all honestly, extremely relevant to all birthing women.  I appreciate her plus size photo galleries of pregnant and breastfeeding women of size. If you might be a  woman who is larger than many of the models in today’s pregnancy magazines, seeing the gallery of women who look beautiful pregnant and breastfeeding, with a wide range of body shapes, can be comforting.  In addition to providing evidence based information,  Pamela answers some of the questions that plus sized mothers might have, but are hesitant to ask their healthcare provider, such as concerns about about whether fetal movement will be noticeable if they are larger sized.  A great blog, with relevant articles for all women!

5. Midwife Thinking

This blog is written by Rachel Reed, an Australian PhD midwife, who enjoys taking a look at the research and sharing her thoughts on how well the research is applied to application.  I enjoy reading her blog for that reason, and often find myself amazed that she chooses to write about the very topics that I wonder about and want to learn more on.  Rachel’s aim is to “stimulate thinking and share knowledge, evidence and views on birth and midwifery. ”  I also appreciate her “Down Under” perspective and celebrating the commonalities of birth across the many miles.  Rachel is not afraid to agree when the science backs up the “less popular” treatment and care amongst childbirth advocates, allowing the evidence to speak for itself and carefully explaining why.   Rachel does a great job of normalizing many of the topics that bog women down during labor and birth, such as the “anterior cervical lip” or “early labor and mixed messages.”  I like to share Rachel’s posts with families who are experiencing the very situation she is writing about.

6. ACOG President’s Blog

Every week, the current president of the American Congress of Obstetricians and Gynecologists (ACOG) writes a blog post on a matter of importance to women.  Not all the posts are on birth related topics, but I find it very interesting to see what Dr. Jeanne A. Conry, M.D. PhD shares with readers.  While some of her blogs are directed at her fellow physicians, many of the posts highlight information and resources directly related to women’s health, especially during the reproductive years.  I enjoy learning more about what Dr. Conry feels is important, and especially what messages and information she is directing to her colleagues. I appreciate her middle of the road approach and look forward to a new post every week.

I hope that you might consider following some of the blogs I mentioned here, if you are not already doing so.  I would also love if you shared your favorite blogs with myself and our Science & Sensibility readers.  I always have room for more good birth related blogs in my blog reader!  What blogs do you read?

ACOG, Authoritative Knowledge, Breastfeeding, Cesarean Birth, Childbirth Education, Continuing Education, Evidence Based Medicine, Maternity Care, Midwifery, Research, Science & Sensibility , , , , , , , , , , , , , ,

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