39 weeks isn't that long

How many times have you heard (or said yourself) "I am so ready for this baby to just get here already"? Many women are told by their care provider that 37 weeks is long enough for the baby to develop. But this simpy is not true, nor is it based upon current research. Much has been brought to light about inducing and cesarean birth before 39 weeks. How as much as a day or two can mean the difference.

In this article in the Wall Street Journal, the problems with early and especially convenience deliveries are outlined well. Respiratory and neurological problems in the immediate and long term are common. Insurance companies are taking note as well and partnering with such groups as March of Dimes to ensure that women are encouraged to gestate for as long as possible.

Upcoming Teleseminar on Birth from Karen Brody

November 19, 2010
1:00pm-2:00pm

This tele-seminar will discuss preparing for your pregnancy and birth. It looks like an excellent resource for mothers-to-be and a good way get useful information in a world of misinformation.

To learn more about the tele-seminar or to register go to:

http://birthsecrets.eventbrite.com/

Support H.R.5807: The REAL MOMS Bill

Recently the Maximizing Optimal Maternity Services for the 21st Century bill was introduced in Congress. It needs our support and the support of our legislative bodies to become a reality. In this bill there would be more educational funding for more midwives (CNM and CPM) and family practice doctors to enter the workforce. These care providers offer lower-cost, less intervention heavy care for pregnant women. This adds up to less cesareans and better care for women in general. It also helps to increase the awareness of the public regarding racial disparities and evidence-based medicine. This can help close the gaps in maternity care.

True to form the American Congress of Obstetricians and Gynecologists have introduced their own "MOMS" bill. They have taken some of the key points of the MOMS Bill introduced in July and turned them around to suit OB/GYNs. Is this a surprise that a lobbying organization to protect the interests of OB/GYNs should do this? No, but it is underhanded to name their bill an approximation. And it takes the collaborative aspect out of the equation and reinforces the paternalistic nature of the current medical maternity model.

So please support the MOMS bill introduce by Congresswoman Lucille Roybal-Allard. Let ACOG know you cannot be swayed by clever relabeling and faulty research. Let your Congressperson know you stand for evidence-based, low-cost and effective maternity care from an array of providers.

Rethinking "Too Posh to Push"

A recent study in the United Kingdom has come out that takes a closer look at the "Too Posh to Push" phenomena. For many the idea of a truly elective (no medical indication, just preference) seems like a good way to make the rising cesarean rates appear like they are consumer driven. But it seems like that is not the case. While there do exist truly elective cesareans and repeat elective cesareans, they were not found in the study to be a majority or even a strong contender for majority within the causes for cesareans studied. Many of the cesareans in the study were the result of a medically indicated factor like breech or a repeat cesarean.

While this still does not excuse the rapidly increasing cesarean rates, it does take some of the blame off women. Because in many cases the mothers may have chosen an elective cesarean without medical indication due to lack of informed consent or fear of trauma. It seems unfair to label these women "too posh to push" if they are consenting to a cesarean based on faulty knowledge of recovery and risk to subsequent pregnancies.

And for the women who feel they are truly educated before they consent to an elective cesarean, we can only hope them a safe surgery and speedy recovery. It would be sour grapes to hope for them to have an adverse outcome simply because of birth choice.

Doulas and Cesarean Section

I recently found this in response to a query about finding doulas on a local expectant mother listserv:

Word to the wise...when choosing a doula, make sure that the contract you sign does not state that they can keep your money (or half of it) if you end up going into pre-term labor or have a c-section.

Not taking anything away from the mother who went through this, but is a doula really irrelevant within the confines of a cesarean section? While I understand that many hospitals have in place protocols that allow for only one support person in the operating room, can a doula enhance your experience when you have a cesarean birth?

According to this checklist on Pregnancy Today, a doula can help in many ways though the process of cesarean; be it scheduled or emergency. If the doula is comfortable with the process and knowledgeable, she can in fact enhance the process. For many families they are so wholey unprepared so it can be a blessing to have an objective support person there who is not part of the medical team to help guide you and your partner through the process. Here is one mother's story about how her doula facilitated her cesarean birth. She was thankful for her doula.

So perhaps instead of amending the contract to state that the doula will not get paid in the case of the cesarean birth, you should have an open and honest conversation with the doula you are interviewing about her services if you end up with a cesarean. Many mature and responsible doulas are able to work with clients appropriately and interface with the hospital staff to make the process a little less scary and clinical.

Defining "Unnecessary"

Many women feel that their cesarean section was "unnecessary". They felt that, given a different set of criteria and birth setting, they should have been allowed to have a vaginal birth. Recently a obstetrician wrote this piece titled "The Myth of the Unnecessary Cesarean". In this article he explains how he finds the term tiring and incorrect. But for many women, his arguments fall flat.

He argues that one could not conclusively say the cesarean was necessary or unnecessary since you cannot guarantee birth outcome either way. Sure, "hindsight is 20/20" plays a big role in the term "unnecessary", but that does not mean it cannot be a legitimate term. If the cesarean, that was medically indicated at the time of incision, was precipitated by a series of interventions that were NOT indicated, would this not be deemed unnecessary? No one is saying that definitively the woman would have gone onto a vaginal birth. They are just saying given the terms of their OWN birth, they felt it was not necessary to have been coerced/rushed into the cesarean.

And as to elective cesareans, it could be said that many of them are "unnecessary" as well. It could be possible that a woman who is having an "elective" cesarean was not given true informed consent (realities of risk for this pregnancy, future pregnancies and a realistic expectation of recovery) or was expected/forced to have a repeat procedure due to lack of support for VBAC (vaginal birth after cesarean).

Birthing Beautiful Ideas also has an eloquent post devoted to this topic. I think this blogger also understands the sentiment of women who have had cesarean birth and the emotional/physiological/psychological impact of an "unnecessary" one.

Multiple Cesareans Present Increased Risk to Placenta

This video from NBC 4 in NYC is making the round on the blogs. It tells the story of a NJ woman who discovered she had placenta percreta (placenta growing through the uterine wall) and placenta previa (placenta covers the opening of the cervix) during her pregnancy. She had 3 prior cesarean births and did not realize that they presented an increased risk for placental abnormality.

She luckily found out about the complication before birth as it would have presented an issue for increased risk of hemorrhage and/or hysterectomy. The comments from both the mother and the physician interviewed are important.

The mother comments, "if you haven't given yourself the chance at labor, you should". This is a woman with 3 previous cesareans. While we do know her circumstances exactly, we can guess that her 2nd and 3rd cesareans were scheduled. If she were given the chance to have a trial of labor and successful VBAC, her odds of developing placental abnormalities would not be as high.

And the doctor comments, "if we don't do anything about decreasing cesarean section rates in this country we are going to have a lot of mothers who are going to lose their lives". NJ had a cesarean section rate of 40% in 2009.

Update:

According to Rixa's Stand and Deliver blog, the journalist quoted the 40 deaths wrong. There were 42 maternal deaths total, with 12 of those being attributed to "preventable loss" such as placenta acreta. This is still a disturbing number of deaths.

Test to Predict Necessity of Cesarean?

According to this BBC article, there are now European companies using a test to determine if a prolonged labor will result in cesarean section. They base the outcome on the presence of lactic acid in the body. The higher the acid, the more likely it is that the uterus will become fatigued and not be able to birth.

Could this test be a good thing that would allow mothers to go one with longer labors if their acid levels remain low or another tool to further burden women with more unnecessary cesarean sections? Looking at the article it seems like it would swing more towards the latter. The doctors interviewed did not seem to grasp what could be the cause behind the increases in prolonged labors: artificial inductions, no positional change, lack of motility, etc. Perhaps they should look into fixing the standard hospital birth experience before coming up with more technology to interfere with a natural life process.

My Body Rocks Cesarean and VBAC Workshop

Karen Brody, playwright and activist who created "Birth", is holding a workshop in the DC Metro area for women who would like to tell their cesarean and/or VBAC story. This workshop combines storytelling, movement therapy and yoga nidra.

For more information please visit her website. She also offers a pregnancy circle. I had an opportunity to talk to Karen recently about this workshop and it sounds like a wonderful opportunity for all mothers who had cesarean births and VBACs.

http://www.mybodyrocksproject.com/index.html

VBAC Success Predictor Tool: Helpful or Junk

There is a tool on this website for the purpose of prediciting your potential percentage of success for VBAC. While many would consider such a tool suspect, it can be useful as just another reminder that VBAC is possible a lot more than the standard 4%-10% that we find in most areas.

But with such factors as "BMI" and race as the only determining factors, one can wonder if perhaps they are missing the point. For many women who prepare for VBAC there are several things (emotional and mental support, supportive practitioner and increased healthy lifestyle to name a few) that help them acheive success. And for others still the same set of criteria do not ensure success.

It is hard to imagine that you could plug in a set of numbers and yes/no answers and come up with a set way to determine who will be successful. But it is just another tool, even if it isn't the most useful.

ACOG Articles Highlighting a Potential Change in Perspective

In this recent post on Our Bodies Our Blog, two recent articles regarding the American Congress of Obstetricians and Gynecologists and their take on the recent forums and studies on VBAC and the rising cesarean rate.

The first is an article from Obstetrics and Gynecology. It highlights the fact that the current VBAC policy of ACOG limits, if not outright denies, the option of vaginal birth after cesarean for most women. It also touches on the subject of informed consent.

The second article is a synopsis from an address given to the ACOG annual meeting. The physician giving the commentary discusses the need to tone down and reassess the current use of induction and cesarean surgery. His tone is encouraging to those who hope to see current trends in maternal care reversed and women given the opportunity to have a say in their own care.

Women Deliver Conference 2010

Often as we work towards lowering the cesarean rate and improving maternal care in DC, we forget that there is another side to the coin. There are places in the world with poor outcomes where a higher cesarean rate would be a blessing. To shed some light on the plight of women and girls throughout the world Women Deliver is holding a conference in the DC area in June 2010.

From their website:

Women Deliver 2010, a global conference, will be held in Washington DC on June 7-9, 2010. The theme of the conference is: "Delivering solutions for girls and women," and we plan to focus on political, economic, social/cultural, and technological solutions. This global meeting will expand on Women Deliver's hallmark of inclusivity, reaching out to new partners and new communities. With all these partners in one room, we will further prove that maternal and reproductive health is a global priority. Women Deliver 2010 will move the dialogue to the global arena with two strong messages:

•The MDGs will not be achieved without investing in women.
•There is just enough time, if the world commits funding now, to achieve MDG5 — additional US$10 billion annually by 2010 and US$20 billion by 2015.

For more information or to register to attend the conference, please visit their website.

VBAC Petition: Please sign!

VBAC Access Petition

Please sign this petition to the American Congress of Obstetricians and Gynecologists (ACOG). The authors of the petition and those who sign it are asking that ACOG look at the recent position statement from the National Institute of Health on vaginal birth after cesarean (VBAC). ACOG has stated a rather strict (and some say hardly feasible) set of guidelines for choosing a candidate for trial of labor (TOL). According to the NIH statement, they should rethink their position on VBAC access and include the mothers themselves in the decision making process.

ICAN of DC is Looking for Birth Pictures/Stories

In April, we would like to hold a multimedia presentation called "Positive Birth: Images to Inspire". But for this even to be a success, we need your birth pictures and stories. We are looking for your pictures and the accompanying stories of your empowering home/birth center/hospital birth, we would really appreciate it. Please know that this will be part of a presentation that will be shown to the public. Thank you for your support of ICAN of DC.


(If you would like to donate please email me.)

Upcoming Midwifery Booth at NBC Health Fair

There will be a health fair at the Washington DC Convention Center sponsored by NBC 4next weekend (January 16-17, 2010). At this health fair will be a booth sponsored by the Citizens for Midwifery. They are looking for women willing to speak to others about their positive experiences with midwifery care and/or homebirth. If you are interested in volunteering an hour, please contact:

Cynthia Warren watershedrangers@gmail.com

This is an excellent opportunity to reach an audience that may not normally have much exposure to the midwifery model of care and/or homebirth.

Recent Washington Post Article on Breech

Today in the Washington Post there was an article about the safety and prevalence of vaginal breech births. Breech is a common reason for primary cesarean sections; something that some mothers and obstetricians are beginning to question. In the article it talks about a flawed study in 2000 that resulted in the thought that across the board cesarean section was indicated for all breech presentations. However since then this article has been questioned as many of the providers who performed the breech extractions/births were not skilled enough in breech birth to attend the women. This provided the authors of the study with inadequate data regarding the true safety of breech.

Recently in Canada the breech protocols were changed and doctors were encouraged to support vaginal breech deliveries under a limited set of criteria. This is promising as vaginal delivery of a breech baby would limit the need for many primary and secondary cesareans. Of course, fear of litigation is a driving factor as not all breech births (or births in general) have a necessarily desired outcome. But that should not limit the ability of other mothers to try. True, individualized care is what is appropriate for women, not fear-based protocols.

And also accepting that not every breech presentation is appropriate for vaginal delivery is another important factor to changing the mindset. It is almost universally accepted that footling breech and transverse presentations are not a good candidate for vaginal birth. That is not to say women have not successfully delivered this way, it is just not optimum for success. For more information about breech and breech vaginal deliveries please click here for the ICAN article on breech.

Upcoming NIH Conference on VBAC

In March the National Institute of Health (NIH) will be hosting a conference on vaginal birth after cesarean (VBAC) nearby in Bethesda, MD. This conference will be free and open to the public. If you cannot attend the conference, it will be broadcast live via webcam.

This will be an interesting event. Many of the speakers lined up and the topics seem to point to a resistance towards positive outcomes for women looking for vaginal birth after cesarean. I think it is important to have some represenation of mothers who have had successful and empowering VBACs to attend, especially for the Public Discussion on the 10th. It will be interesting to see what the outcome of this conference is. Hopefully not more of the same with a smattering of lip service played to women who are looking for true choice for their maternity care and birth options.

ICAN Presents New Date

This event was rescheduled because of the unexpected snowstorm. We hope that all who had previously gotten tickets will be able to attend. There are still a few tickets left. Thank you for supporting ICAN of DC.

ICAN of DC is pleased to present a free showing of the film, "It's My Body, My Baby, My Birth" on Sunday January 10, 2009 at 3:00pm at the Marting Luther King Jr Library (901 G St NW Washington DC) in room A-9. This excellent film tells the story of 7 mothers and their journey to natural childbirth.

Limited amount of tickets left. Hopefully the weather will cooperate this time.


The schedule will be as follows:

3:00pm: Welcome
3:15pm-3:45pm: Film
4:00pm-4:30pm: Dicussion: Birth Choices in DC


To get a ticket to this free event please visit:

http://icanofdcpresents.eventbrite.com

Space is limited, so please make sure you get a ticket.

The District of Columbia chapter of the International Cesarean Awareness Network provides an online forum for women seeking information about cesarean prevention, recovery and support for healthy and non-surgical birth after cesarean surgery(VBAC)

For more information about our monthly meetings or to join please visit our Yahoo! Group page:

http://health.groups.yahoo.com/group/icanofdc/

Maternity Care and the Military

In the Washington DC Metro area it is a pretty good chance you or someone you know works for one of the branches of the military. So that means many of the active duty members and their spouses are covered by TRICARE. In looking at TRICARE's page regarding maternity care, it does not look like it gives a lot of options. Maternity care is expected to be carried out at an MTF or military treatment facility. However there is a catch if the local MTF does not provide obstetrical services:

If the local MTF does not provide obstetric services, the service member's primary care physician can refer her to a civilian provider.

So does this mean that in theory the primary care physician would refer to a midwife or a family physician? Would they consider out of hospital births? According to a local nurse-midwife, there are versions of the TRICARE plan (Standard and Prime) that allow for homebirth and out of hospital birth, but it takes some doing.

Why is this important? Well, because if a woman covered by TRICARE is limited to her MTF for care and her MTF has a high rate of cesarean or does not allow VBAC, that is not much of a choice is it. Many women with non-military insurance face these limitations as well, but they are not promised insurance for risking their lives or having their spouses risk their lives.

That being said, a study designed to find ways to reduce primary and repeat cesarean found that military hospitals represented lower rates for both compared to civilian plans. This was found to be the result of cost saving measures by a managed care plan rather than any special consideration towards physiological birth.

A Happy End to a VBAC Ban Story

Many people read about Joy Szabo's journey from pregnant mom looking for a repeat VBAC to fight with local hospital complete with threatening court-ordered cesarean if she arrived in labor to her eventual move to Phoenix to be able to have a trial of labor. Well as CNN reports, Ms Szabo had a successful and wonderful VBAC. It is a real happy ending to a journey that no woman should have been forced to take.

Pregnancy is a time of anticipation and excitement. It is also exhausting and sometimes a little scary. It represents the great unknown. Sure birth is wonderful and trusting it is the right of every woman, but what is going to happen with your body and your birth. And unfortunately many women do not get the support necessary or the informed consent/education required to make decisions that are truly in their best interests. They get instead anecdotal advice and scare tactics. And that is not to say it does not come from both sides.

What women really deserve is clear-cut information that allows them to make their own "best decision". And doctors and hospitals should be able to listen and work with women in a fair and equal partnership without the fear of unnecessary litigation or protocol that benefits the overhead of the hospital.