Sunday, November 25, 2012

Everything You Never Wanted To Know About Birth In America- But Probably Should

"A good obstetrician needs two things: a big, round bottom and the sense to know when to sit on it."
- Husband Coached Childbirth by Dr. Bradley
    • In the United States, roughly 1% of all births are planned home births, birth centers are slightly more common, but the overwhelming majority of births for both low-risk and high risk women take place in hospitals.
    • The Cesarean section rate in the United States is over 30% with elective c-sections being only a very small percentage of all c-sections. A 5-10% c-section rate is considered optimal.
    • The United States has one of the worst rates of neonatal mortality in the developed world at 6 deaths per 1,000 births. (On par with Croatia, Bosnia and Herzegovina, and Lithuania.)
    • There has been much debate about whether the Netherlands is, in fact, a good case study for the safety of home birth. What is true is that planned home births attended by a doctor or midwife are very common in the Netherlands (most sources place it at roughly 1/3) and that the Netherlands rate of neonatal deaths is 3.73 deaths per 1,000 births. They are by no means in the "top ten" of low infant mortality (those spots belong to Monaco, Japan, Bermuda, Singapore, Sweden, Hong Kong, Macau, Iceland, Italy, and Spain, in that order with rates ranging from 1.8/1,000 to 3.37/1,000), but their infant mortality rate is still almost half of what America's is right now.
    • The United States has the worst maternal death rate of any developed country. In 2007, the maternal death rate was 12.7/1,000 in the United States. In 2009, it jumped to 16.1/1,000.
    • Approximately 19% (roughly 1 in 5) low-risk mothers end up with a c-section in U.S. hospitals.
    • A 1998 report from the CDC found that maternal deaths from obstetrical causes are widely underreported, estimating that they are missing about 2/3 of maternal deaths from the currently reported rates of maternal death. A 2005 Massachusetts study estimated a 93% underreporting in maternal deaths for that state.
    • For all American women the maternal death rate is 5 times what it should be and for black women, it is 10 times what it should be.
    • The United States spends more on hospitalization and health care than any other country in the world.
Wow. Not the rosy picture we're used to hearing. What can be done to fix the abysmal state of maternity care in America? The general consensus seems to be that we need more and new laws, more contraception availability (is it just me or does that seem to be the answer we get for all women's health issues?), and of course more money from the government. I really don't think that any of those will actually solve the problem. Here are my thoughts on what the medical profession can do to save the lives of more mothers and babies:
  • Focus more of doctors' education on natural birth and low-intervention techniques...  Medical organizations point with pride to the fact that doctors may attend as many as 20 births a week. But most, if not all, of those are births with medications, other interventions or c-sections. Since that is how most women in America give birth right now, that is what the average intern or resident thinks birth is. Medical schools don't train doctors on how to deal with natural birth, they train them how to use medications, forceps, vacuum extraction, and c-sections to get births accomplished in the time limits the hospital mandates for second-stage labor. The reality is that most OB-GYN's have no idea what a physiologically normal birth looks like or what to do during one. By educating OB-GYN's about what normal birth is like, they will be able to give better care to low-risk women.
  • ...while educating them to better spot and handle true emergencies. One of the things I often hear people say is that the vast majority of problems with American obstetrical care concern poor and minority women. Maybe this is comforting if you are white and live in a middle or upper class neighborhood, but it isn't actually true. (See the above statistic about how all women in the U.S. are at a 5 fold risk for death.) Pre-eclampsia, for example, can and does kill thousands of babies and mothers  every year, and one of the biggest reasons why is that doctors and nurses often fail to notice the symptoms or excuse them as hypochondria or even healthy signs of pregnancy. I really recommend that you read Jamie Grumet's experience with HELLP syndrome at her blog I Am Not the Babysitter. Jamie is a white woman living in Beverly Hills, California with great access to health care. She was seeing both a midwife and an OB, plus a slew of doctors and nurses at the ER and by the time she was finally able to get a life-saving c-section, it was almost too late. In fact, the nurses accused her of being hypochondriac and told her that her sudden weight gain was healthy because skinny women need to gain more weight during pregnancy. This is just one example of how lives could be saved by better educating doctors and nurses recognize and effectively intervene in genuine emergencies.
  • Reserve c-sections, medications, forceps and vacuum extraction for emergencies. I know this is really tough for us women to hear because in America we are so used to being told that we can't get through labor without an epidural or that we need to be induced or that a c-section is the safest way to get the baby here, but in countries like Japan that have really low rates of maternal and infant deaths, medications, surgery and mechanical extraction are reserved for emergencies and women are encouraged to deliver naturally. (I think I understand where you're all coming from, up until a few years ago, I thought women who gave birth naturally were pretty much nuts. Why put yourself through unnecessary pain?) All these interventions have their place. My mother-in-law, and by that token my husband, are here today because she was able to have an emergency c-section for placenta previa with her first baby. I think we as Americans tend to look at technology as being a solution, and if a little is good in certain situations, then a lot in all situations is better. But the more interventions you start adding, the more chances you have for something to go wrong. In a life or death situation, the risks are worth taking, but these are rare and most problems in labor can be solved through simpler, less invasive means. There are women who have died when a bag of another medicine was accidentally injected into them instead of an epidural or an epidural was improperly administered. C-sections increase the risk of hemorrhage after the birth and deadly blood clots- and the risk goes up with subsequent c-sections. C-sections also increase the risk of hysterectomy, uterine infection, and placenta previa. So, I know that many of you have had c-sections, I don't think you're bad mothers, I don't think any less of you, all I'm trying to do is call attention to an issue that is affecting the lives of mothers and babies across the country.
  • Do away with continuous electronic fetal monitoring for most mothers. EFM gives a false sense of security to doctors and parents. "We can monitor the baby's heart with every contraction and never miss anything!" The problem is that EFM requires that mom lie on her back throughout labor which puts the baby in danger. Remember how you're not supposed to lie on your back after 12 weeks because it will cut off the blood flow and oxygen supply to the baby? Well the same thing goes when you're in labor, which may be why EFM has been found to lead to higher emergency c-section rates. But how, ask OB-GYN's, will you detect fetal bradychardia (drop in baby's heart rate)? Well, I will now share with you my ultra-dramatic fetal bradychardia story. Malamute and I had been at the birthing suite for about two hours and I had been lying on my side laboring and doing a little pushing for about a half hour-ish. The midwives were using a handheld doppler to monitor Duckling's heart rate about every other contraction. And then it happened. Duckling's heart rate dropped. Did the midwives start freaking out? Did they start rushing me to the hospital for c-section? Nope. They had me switch to an upright position. That was it. I know, loads of excitement. Duckling's heart rate went right back up and holy cow, my labor really accelerated! Within about 15 minutes or so of moving upright, I had a baby in my arms! Unfortunately, when you're hooked up to a machine, that really isn't an option. The other problem with EFM is that it puts mom and baby in an unnatural and far more difficult position for labor. Medical professionals love the lying down position because it makes it easier to give medications,  utilize EFM, and perform forceps or breech extractions, but unfortunately women are not physiologically designed to give birth lying down. (Have you ever been told to "push like you're having a bowel movement?" during birth? Have you tried to poop lying down? Not so easy...) And lying down in a hospital bed compresses your tailbone and narrows your pelvis so that you're baby is now having to fight gravity to get out of the birth canal. So, imagine you're on a hike to the top of a mountain. There's a beautiful vista up at the top, but it's definitely some work getting up there. Now imagine that someone has just added several large stones into your pack in addition to the water and snacks you've brought. That hike just got a lot harder. That's what happens when you labor on your back! This is why so many babies "get stuck" in the birth canal. EFM has not been found to improve the outcome of the birth or the health of the baby.  The biggest reasons that doctors are still using EFM is that they don't know how to monitor intermittently and they're afraid of being sued for malpractice if they don't use EFM.
  • Rethink working hours for doctors and nurses. This may come as a surprise to the medical community (who are very well-versed in anatomy, biochemistry, and physiology), but the human body has not evolved to perform well without regular, restful sleep. There is something appealing about the idea of the doctor who sacrifices everything- including sleep- to care for her patients. Television dramas glorify it, and within the community the ability to go for long hours without sleep and keep working seems to be a point of pride. But as attractive as this archetype is, it has no grounding in research as a safe or effective way to care for patients. In fact, the idea of working extremely long shifts is nothing more than a tradition dating back to the 1890's. It was originated by William Halstead, the first chief of surgery at Johns Hopkins, who required that his residents be on-call 362 days a year. (History has revealed that Halstead was able to put up such a manic schedule because he was using cocaine. Studies show that as many as 1 in 10 medical professionals- including anesthesiologists and neurosurgeons- are following in Halstead's  footsteps by abusing drugs to get through their day.) Sleep research shows that missing one night of sleep causes as much impairment as a legally intoxicating blood-alcohol level. So, chances are that by the time you get to the hospital in labor, at least some of the nurses and the newer doctors are already operating with the capabilities of a drunk driver- and that's if they're clean. Even the decrease in residents' hours from 30 hour shifts to 16 hours hasn't been shown to be enough to prevent sleep deprivation slip-ups- some of them very serious. In the case of sixteen year old Jasmine Gant, the nurse who administered the lethal bag of penicillin instead of an epidural was very experienced but had been working two consecutive eight hour shifts. I really think that health care professionals (both doctors and nurses) need to be limited to one eight hour shift per day. If that means extending out the actual number of months that it takes to complete a medical residency, I think it's worth it to protect the safety of patients and the health of doctors. Just like other businesses that need to be open 24/7, the eight hour shifts can be any time of the day or night, preferably on a regular schedule for each individual, but only one eight hour shift in a 24 hour period.
  • No more time limits on second stage labor. No, it's not a good thing to have a long second stage of labor, but imposing an artificial time limit really doesn't help the problem- especially since a lot of couples rush off to the hospital way too soon, sometimes even in first stage labor. Research indicates that time limits on second stage labor don't actually improve outcomes, and that using a more woman-centered approach actually is more beneficial

1 comment:

  1. I agree with your post, I think a lot of drugs and interventions are overused. I do have to add though I think women need to become more educated too.