Thursday, December 18, 2014

The Primary Cesarean Reduction Movement

There is good news to report: Health Care Professionals are paying attention!

When we work on our grass roots advocacy we think that our issues are so important, and everyone we talk to cares, that we must be making change. Sometimes, however, we come to the sad realization that people are not paying attention. But we plug along and keep on hoping that because our issue is important, eventually society and culture will catch up and begin listening to what we have to say.

Well, this is starting to happen. Birth advocates who have been fighting for years to get hospitals, obstetricians, departments of health, the federal government, ANYONE to pay attention to the increasingly harmful Cesarean epidemic are finally making a difference.

How do I know?

I work for an organization that works to improve the quality of health care for mothers and babies in the state. We work in collaboration with ACOG, ACNM, AWHONN, March of Dimes, the hospital association, private and public health insurance agencies, hospitals networks, and individuals willing to be part of maternal and neonatal quality improvement. We network with State Perinatal Quality Collaboratives and members of the Council on Patient Safety in Women's Health. We hear what is developing nationally and discuss issues with organization representatives in our state. We hear directly from nurses, midwives, and physicians about what the environment is like in their hospitals. And I can tell you, people are talking about this issue!

Furthermore, the Society for Maternal and Fetal Medicine (SMFM) and the American Congress of Obstetricians and Gynecologists (ACOG) recently released their Consensus Statement Safe Prevention of the Primary Cesarean Delivery.

The movement to reduce unnecessary Cesarean sections is picking up speed.

Cost-Savings

One reason folks are starting to pay attention is the cost. Insurance companies generally pay quite a bit for a cesarean delivery, which is more costly than a vaginal delivery. In 2013, on average, the total cost for maternal and newborn care associated with a cesarean was $51,125, compared to $32,093 for a vaginal birth.

Additionally, because cesareans are associated with increased risk of blood clots, bleeding, infection, complications in future pregnancies, hysterectomies, and even death, it would save the health care system a great deal of money to reduce these primary cesarean deliveries. 

Researchers from the California Maternal Quality Care Collaborative make the suggestion that financial incentives be put into place, for example, reforming payment for cesarean deliveries: 
Payment reform could create the proverbial “burning platform” that spurs change more quickly than other strategies. The first step is to remove the perverse financial incentives that currently help drive the rising rate.
This move would have to be made by payers (insurance companies) and/or policymakers. Movements like this are slow to occur, but are one direction that we can move toward.

NTSV Cesareans

The emphasis is on reducing Cesareans among low-risk first-time mothers. The rationale for this is that repeat Cesareans would be reduced if we reduced primary C-sections (makes sense, since VBAC rates are so low), and of course comparing a low risk group makes for an easy comparison group and leaves less room for argument for "medical indication." Nationally, the data and the proposed initiatives focus on nulliparous, term, singleton, vertex Cesareans (NTSV). An NTSV is a pregnant woman who has never had a baby before, delivers at term, there is only one baby (no multiples), and the baby is head-down.

Though this removes some indications for a Cesarean, others could still exist: preeclampsia, fetal distress, failure to progress, cord prolapse, elective delivery, and so on.

Epidemiological data analysis has found extremely wide variation in primary cesarean rates in different parts of the country and across hospitals. What this means is that hospital primary cesarean rates range from 2% to 36%. That means that where you give birth determines whether or not you have a cesarean, not necessarily your personal or medical situation. Wide variation in hospital NTSV cesarean rates suggests that clinical practice patterns and patient preferences are affecting these rates.

National research has shown that it is not individual factors (e.g. mother's age, race/ethnicity) nor pre-existing medical conditions (e.g. gestational diabetes) that account for this variation. We know that maternal request for cesareans, while highly visible among celebrities or in Brazil, is actually quite low in the U.S. What this leaves is physician practice patterns.

Changing Practice Patterns

If you've watched Eugene Declerq's Birth by the Numbers videos, you have heard him examine the rising cesarean rates. He shows us that rates and patterns of diagnoses/cesareans for maternal complications such as placenta abruptio, cord prolapse, fetal distress, dysfunctional labor, and so on all decreased until 1996, and then all have increased since then. His data shows that it is not mothers changing, it is a change in medical practice. He notes an article that came out decades ago called "The rise in the cesarean rate: same indications but a lower threshold."

Even the ACOG/SMFM Statement notes
Variation in the rates of nulliparous, term, singleton, vertex cesarean births also indicates that clinical practice patterns affect the number of cesarean births performed.

Quality Improvement Initiative

I envision the creation of a quality improvement (QI) initiative for hospitals to work to reduce primary cesarean sections through a focus on. A few fantastic places to start are the recommendations that ACOG and SMFM came up with themselves. I will also go beyond their recommendations to offer some of my own.

Here are some changes that need to be made:
  1. Labor Curve. Physicians need to alter the "definition of labor dystocia because recent data show that contemporary labor progresses at a rate substantially slower than what was historically taught." This also goes for the pushing phase (second stage).
    • "A prolonged latent phase (eg, greater than 20 hours in nulliparous women and greater than 14 hours in multiparous women) should not be an indication for cesarean delivery.
    • Slow but progressive labor in the first stage of labor should not be an indication for cesarean delivery.
    • Cervical dilation of 6 cm should be considered the threshold for the active phase of most women in labor. Thus, before 6 cm of dilation is achieved, standards of active phase progress should not be applied.
    • Cesarean delivery for active phase arrest in the first stage of labor should be reserved for women at or beyond 6 cm of dilation with ruptured membranes who fail to progress despite 4 hours of adequate uterine activity, or at least 6 hours of oxytocin administration with inadequate uterine activity and no cervical change.
    • A specific absolute maximum length of time spent in the second stage of labor beyond which all women should undergo operative delivery has not been identified.
    • Before diagnosing arrest of labor in the second stage, if the maternal and fetal conditions permit, allow for the following: At least 2 hours of pushing in multiparous women, and At least 3 hours of pushing in nulliparous women (1B) Longer durations may be appropriate on an individualized basis (eg, with the use of epidural analgesia or with fetal malposition) as long as progress is being documented."
  2. Fetal Monitoring. "Improved and standardized fetal heart rate interpretation and management" are certainly needed. Because providers differ so greatly on how they read the electronic fetal monitoring output, there needs to be some increased training on this. More importantly, however, I would suggest following the evidence, which concludes that the continuous EFM is completely worthless at reducing infant morbidity and mortality. I don't think low risk women should be on it at all. However, I don't think that in our highly litigious society it will ever go away. 
    • "Intermittent monitoring has been shown by the research to be just as good at identifying possible fetal distress as continuous EFM. It has a quite a few benefits, too: Does not increase cesarean deliveries like continuous EFM does, and does not limit women's movement in labor."
  3. Doulas. "Increasing women’s access to nonmedical interventions during labor, such as continuous labor and delivery support, also has been shown to reduce cesarean birth rates". It should be no surprise to anyone reading this blog that the evidence supports the use of doulas to reduce cesareans.
    • "Given that there are no associated measurable harms, this resource is probably underutilized."
  4. Deliveries for Medical Reasons. Stop inducing for non-medical reasons, at any gestation, but particularly before 41 weeks. Stop inducing with a non-favorable cervix. Stop scheduling cesareans for non-medically indicated reasons, particularly suspected macrosomia (big baby).
    • "Cesarean delivery to avoid potential birth trauma should be limited to estimated fetal weights of at least 5,000 g in women without diabetes and at least 4,500 g in women with diabetes. The prevalence of birth weight of 5,000 g or more is rare, and patients should be counseled that estimates of fetal weight, particularly late in gestation, are imprecise."
  5. Operative Vaginal Delivery. Many obstetricians are quick to jump to a cesarean section rather than deliver with forceps or a vacuum. This is most likely because they are not well-trained to use these methods, while they get plenty of experience doing cesarean sections. While these procedures have pros and cons, cesareans certainly do as well, and comparably, these have much fewer associated injuries and morbidities. 
    • "Operative vaginal delivery in the second stage of labor by experienced and well trained physicians should be considered a safe, acceptable alternative to cesarean delivery. Training in, and ongoing maintenance of, practical skills related to operative vaginal delivery should be encouraged."
    • Manual rotation of the fetal occiput in the setting of fetal malposition in the second stage of labor is a reasonable intervention to consider before moving to operative vaginal delivery or cesarean delivery. In order to safely prevent cesarean deliveries in the setting of malposition, it is important to assess the fetal position in the second stage of labor, particularly in the setting of abnormal fetal descent."
  6. Variations. Many obstetricians are not taught how to attend a vaginal breech birth or a twin birth, and go straight to delivering by surgery. Increasing the availability of care providers trained in safely delivering these variations vaginally would greatly reduce the primary cesarean rate. "External cephalic version for breech presentation and a trial of labor for women with twin gestations when the first twin is in cephalic presentation are other of several examples of interventions that can contribute to the safe lowering of the primary cesarean delivery rate."
    • "Fetal presentation should be assessed and documented beginning at 36 0/7 weeks of gestation to allow for external cephalic version to be offered."

Barriers

No one is quite sure how to remove fears of malpractice litigation, which "leads many physicians to have a lower tolerance for any perceived labor abnormality."

Another issue is time efficiency. Greater patience is needed on the part of the care providers. One possible solution to this might be increasing the use of midwives to handle low-risk labors and births in hospitals. This has yet to be supported by research.

Out-of-hospital births should also be promoted for women with low-risk pregnancies, as cesarean rates are much lower for planned home and birth center births. More states need to legally recognize and license out-of-hospital midwives.



As Main et al of the California paper write,
The most promising mix includes clinical quality improvement strategies with careful examination of labor management practices to reduce those that lead to the development of indications for cesarean deliveries; payment reform to eliminate negative or perverse incentives; health care provider and consumer education to recognize the value of normal vaginal birth; and full transparency through public reporting and continued public engagement.
I agree with the authors of the California paper that we can't focus on just the clinical aspect of this issue (as outline in my QI Initiative recommendations, above), but it is an excellent place to start.


What do you think? Do you have additional ideas?



Thursday, November 20, 2014

Breastfeeding Problems Linked to Mom's Post-Birth Meds?

"Evidence-based care acknowledges that, sometimes, having no intervention is safest, and, sometimes, having interventions is safest.... Advocating for evidence-based practices and interventions is not an ideology that interventions are bad. It's taking an objective look at scientific research and actually applying it to individuals, rather than basing care on outdated traditions, fear, and the ridiculous idea that women shouldn't be involved in their own health care." - ImprovingBirth.Org

A new study is out that takes a look at the effect of intramuscular injections mothers receive immediately after birth and their effect on breastfeeding. These are injections that occur during the third stage of labor (before or after delivery of the placenta) that are intended to help the uterus begin to contract down to normal size. This helps prevent postpartum hemorrhage.

The International Breastfeeding Journal notes:
Existing RCTs found no links between uterotonics administered in third stage of labour and breastfeeding. These trials were published ten and twenty years ago, and, to our knowledge, more recent trials have not examined the impact of uterotonics on breastfeeding. In the absence of trial data, observation studies and biological mechanisms assume greater importance.
This Brown and Jordan article notes the background information on the literature:
Analysis of a large birth cohort (n=48,366) indicated that intramuscular injection of oxytocin, with or without ergometrine, in the third stage of labor reduced breastfeeding rates at 48 hours by 6-8% (adjusted odds ratio [OR]= 0.75, 95% confidence interval [CI] = 0.61-0.9 1; adjusted OR=0.77, 95% CI=0.65- 0.9 1), consistent with other observational studies. A randomized controlled trial (n = 132) of active management of the third stage with intravenous ergometrine indicated an increase in supplementation and cessation of breastfeeding by 1 and 4 weeks postpartum, mainly because lactation was inadequate for the infants' needs.
The medications this 2014 Brown and Jordan study looked at included oxytocin and ergometrine. The study gave mothers who had a vaginal birth within the past 6 months a questionnaire that asked about whether they received uterotonic injections, breastfeeding at birth, breastfeeding duration, and, where applicable, reasons for breastfeeding cessation, whether physical, social, or psychological. 82% of the mothers had received active management of the third stage, and 17% received physiological management.

Here are the study results:
No significant association was found between infant feeding mode at birth (breast/formula) and injection of uterotonics. However, mothers who had received uterotonics were significantly less likely to be breastfeeding at all at 2 and 6 weeks. Among mothers who had stopped breastfeeding, those who had received parenteral prophylactic uterotonics were significantly more likely to report stopping breastfeeding for physical reasons such as pain or difficulty.
What this means is that their study might imply that uterotonic injections during the third stage of labor do not affect breastfeeding initiation, but may affect breastfeeding duration.

As with all research, we can say that this study showed an association between the injections and the cessation of breastfeeding due to physical reasons, but we cannot necessarily say it is causation. It is an important point to keep in mind when reading about research.

There is a great deal of evidence for the benefits of uterotonics for prevention of postpartum hemorrhage. Randomized control trials and metasyntheses of research by organizations such as the World Health Organization and the Cochrane Library have found that administration of oxytocin or other uterotonic are highly effective at reducing postpartum bleeding and prolonged third stage, with no apparent side effects for the baby. Ergometrine is associated with nausea for the mother.

The data for this study was collected by self-report on a questionnaire filled out by the mothers. Of course there are data collection errors, like selection bias and recall bias, involved in this type of study. It is not secondary data analysis (e.g. they did not look at medical charts to determine if an injection was received and then link it to data for the mother showing whether she stopped breastfeeding at a certain point in time). It is not a prospective randomized control trial (the gold standard of research, though not always possible).

Interestingly, they removed mothers who had intravenous oxytocin from their statistical analyses, as they were likely to have been receiving it during labor for induction, and also more likely to have an epidural. However, when they did analyze this small sample, they found that the finding was still significant: women who had the intramuscular injection compared to those receiving it intravenously were less likely to be breastfeeding at 2 and 6 weeks. So what is it about the injection, then?



Also, their psychological questions on reasons for stopping found that mothers who had an active third stage were significantly more likely to say they stopped breastfeeding for reasons of pain and/or embarrassment. Why would receiving uterotonics after labor contribute to difficulty latching or embarrassment? Perhaps they are correlated but not causational.  Or perhaps the medication affects the baby's ability to latch. The authors suppose the two are related: mothers who have trouble latching will be more embarrassed to nurse in front of others. This is all conjecture.

Brown and Jordan note in their discussion section that active management may not reduce postpartum hemorrhage for women at low risk of hemorrhage. This is a good argument for more risk assessment antenatally and upon birth admission. Many obstetric hemorrhage initiatives in the U.S. include this as a recommendation for hospitals. There is always the argument, however, that even low risk women sometimes hemorrhage after birth (there are instances of low risk home birth mothers transferring due to excessive bleeding). In rural or resource-poor settings, it may be beneficial to standardize receipt of prophylactic uterotonics when transfer could be life-threatening.

Furthermore, when care is not standardized, more health care mistakes are made. This is what the field of quality improvement in healthcare has found, and the reason standards of care are emphasized. It also means that everyone is doing the same thing, which reduces the receipt of poor care one place and better care at another. Standardization of care has been shown to reduce life-threatening errors in healthcare. There are times when we have to weigh the pros and cons (e.g. prophylatic uterotonics can reduce morbidity and mortality associated with hemorrhage, but may decrease breastfeeding success and duration). I work with a lot of doctors and nurses in my job in healthcare quality improvement, and I've learned a lot about the capabilities of the providers in our healthcare system. I've seen how changes are made in a system.

As a doula and a social researcher, I am also a strong proponent of patient-centered care. I think that care should also focus on what is right for each individual. Sometimes that means asking the patient what they want, though they may defer to the care provider to make the decision. The care provider may then decide that the pros outweigh the cons.

Another point is that women are more and more high risk for OB hemorrhage in industrialized countries. With the increase in medical conditions, inductions, cesarean sections, pitocin augmentation, use of pain medication and analgesia, advanced maternal age, etc., more women are going to be high risk and therefore more will receive active management of the third stage. So a great intervention would be to recognize that more women need assistance with breastfeeding in the first 2 - 6 weeks so that they can overcome latch issues, embarrassment, perceived low milk supply, and so on.

Moreover, how do we know that the women who have physiologic third stages are somehow different than the women who do not? Since active management is, at the moment, is the norm, and is in the population in this study, the women who "choose" to have no uterotonic injections may already be better informed on breastfeeding, better linked-into breastfeeding help networks, etc.

I did find their explanation of the interaction and possible mechanism behind uterotonics and breastfeeding. The authors speculate:
It is possible that disruption of neuroendocrine/paracrine pathways may lead to suboptimal latching, nipple trauma, pain, and feeding difficulty.
They explain a bit more in the discussion how ergometrine and oxytocin may disrupt hormone balance.

More research is needed on active management of the third stage and its effect on breastfeeding!

I definitely think this article contributes to what a lot of lactation professionals have been noticing, however: Interventions during labor have an effect on breastfeeding success, and we know that epidurals and pitocin augmentation during labor are associated with breastfeeding issues. But does the post-delivery dose have a large enough effect to change practice?

I don't think this particular research article should lead to full-scale changes in recommendations or standards of care at this time. I was inspired to write this article for just that reason - those who may think this is definitive evidence that we should stop promoting prophylactic uterotonics. We do a lot of things prophylactically in our lives. A prophylactic is something that is designed to prevent something from occurring. I think that a lot of birth and breastfeeding advocates are quick to judge all medical interventions as bad, and also to believe research that reinforces their beliefs, and not believe research that does not (well, most people do that). I have taught to be critical of research and to examine it from all sides.

I also think its unfair to blanket statement that all physicians and hospital medical professionals are the only ones to use interventions that may be harmful. Sometimes medical professionals close their eyes to the evidence of harm from routine interventions, but sometimes natural birth advocates (doulas, midwives) do to. 

"Midwives are often quick to criticize medical birth attendants for unwise interventions that disrupt normal birth and may cause harm. But how many of us are guilty of the same thing?" - Gail Hart

Even home birth midwives sometimes use supplements, herbs, etc that have not been tested or approved for effectiveness and safety. Doulas, too, make suggestions for some interventions for pregnant women and babies that we don't know are entirely safe or efficacious. We all have to pay close attention to good, solid evidence, and keep in mind that sometimes things are true even if they contradict what we believe. 

If you're interested in learning more on how to be a critical reviewer of research, I suggest you peruse Science and Sensibility's series of posts on "Understanding Research."


Brown, Amy and Sue Jordan (2014) Breastfeeding Medicine. Vol 9, No 10. DOl: 10.1 089/bfm.2014.0048


Friday, October 24, 2014

Halloween, Pregnancy and Birth Style

I LOVE Halloween! It is my very favorite holiday. I love all of the creativity that goes into becoming someone else, and that we all love to see and be seen. I love that people decorate and go all out to create haunted houses. I am not even all that into the candy, but I think a holiday that is big about giving out free stuff is pretty cool.  And there are so many fantastic birth-related halloween fun things to do and make when you're pregnant!

Do you have your costume yet? There are a wide variety of costume possibilities that work best when you are pregnant.

I'm a big fan of the creepy ones...







But you can just go funny, especially with couples costumes. Here are just a few:








Or just super cute on the days leading up to Halloween!





I really hope that I have a baby bump during Halloween sometime in the future!


I also love carving pumpkins this time of year, and working on my creativity. Here are some beautiful pregnancy ones:





Here are a few (of many) birth-related pumpkins that have brought many a happy tear to my eye:



home birth


 


water birth




HAPPY HALLOWEEN!


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