Thursday, September 30, 2010

Link Round-Up

Wow, I can't believe I used to post every single day and now I'm eking out maybe two per week! Having to keep up with graduate school assignments barely gives me enough time to read all the birth blogs I love to follow, let alone blog about them. So here is a round-up of awesome posts to go check out:


  • Molly from First the Egg reviews the book The Modern Period: Menstruation in Twentieth Century America which discusses the modern trend to manage menstruation and how an "individuals’ experiences of menstruation are shaped by the knowledge, technologies, and value systems that surround us." 



  • Robotic Vagina Gives Birth:
    • This is a video of a robotic vagina giving used to instruct labor and delivery staff. This video is quite unlike the others I posted in the past in that this robot is really only the buttocks/vagina/upper thigh region... Oh and also because it makes EXTREMELY DISTURBING SOUNDS.

Wednesday, September 29, 2010

¿sabía que las "Prácticas de Atención y Cuidados que Promueven el Parto Natural" son en español?

Did you know that the Lamaze Health Birth Practices are available online in English, Spanish, Russian, Mandarin, Portuguese, Czech and Romanian?


Prácticas de Atención y Cuidados que Promueven el Parto Natural

#1: El Trabajo de Parto Inicia por Si Solo
#2: Libertad de Movimiento a lo Largo del Trabajo de Parto
#3 Apoyo Continuo Durante el Trabajo de Parto
#4 : No Realizar Intervenciones de Rutina
#5: No Dar a luz en Posiciones Supinas, Elegir Posiciones Verticales o Recostada de Lado
#6 No separar a la madre y al bebé después del nacimiento

Ver los videos (en ingles)

Monday, September 27, 2010

Fetal Origins

Imagine how excited I was when I opened my mailbox and saw this as the front cover of Time Magazine this week! We've actually been talking a lot about this very subject - how fetal origins can shape your health - in our Biocultural Medical Anthropology course. 

Here is an excerpt of the article, the full version of which isn't online:

How the First Nine Months Shape the Rest of Your Life



What makes us the way we are? Why are some people predisposed to be anxious, overweight or asthmatic? How is it that some of us are prone to heart attacks, diabetes or high blood pressure?

There's a list of conventional answers to these questions. We are the way we are because it's in our genes. We turn out the way we do because of our childhood experiences. Or our health and well-being stem from the lifestyle choices we make as adults.

But there's another powerful source of influence you may not have considered: your life as a fetus. The nutrition you received in the womb; the pollutants, drugs and infections you were exposed to during gestation; your mother's health and state of mind while she was pregnant with you — all these factors shaped you as a baby and continue to affect you to this day.


This is the provocative contention of a field known as fetal origins, whose pioneers assert that the nine months of gestation constitute the most consequential period of our lives, permanently influencing the wiring of the brain and the functioning of organs such as the heart, liver and pancreas. In the literature on the subject, which has exploded over the past 10 years, you can find references to the fetal origins of cancer, cardiovascular disease, allergies, asthma, hypertension, diabetes, obesity, mental illness. At the farthest edge of fetal-origins research, scientists are exploring the possibility that intrauterine conditions influence not only our physical health but also our intelligence, temperament, even our sanity.

As a journalist who covers science, I was intrigued when I first heard about fetal origins. But two years ago, when I began to delve more deeply into the field, I had a more personal motivation: I was newly pregnant. If it was true that my actions over the next nine months would affect my offspring for the rest of his life, I needed to know more.


Of course, no woman who is pregnant today can escape hearing the message that what she does affects her fetus. She hears it at doctor's appointments, sees it in the pregnancy guidebooks: Do eat this, don't drink that, be vigilant but never stressed. Expectant mothers could be forgiven for feeling that pregnancy is just a nine-month slog, full of guilt and devoid of pleasure, and this research threatened to add to the burden.


But the scientists I met weren't full of dire warnings but of the excitement of discovery — and the hope that their discoveries would make a positive difference. Research on fetal origins is prompting a revolutionary shift in thinking about where human qualities come from and when they begin to develop. It's turning pregnancy into a scientific frontier: the National Institutes of Health embarked last year on a multidecade study that will examine its subjects before they're born. And it makes the womb a promising target for prevention, raising hopes of conquering public-health scourges like obesity and heart disease through interventions before birth.


Adapted fromOrigins: How the Nine Months Before Birth Shape the Rest of Our Lives, by Annie Murphy Paul, published in September by Free Press.

Friday, September 24, 2010

VBAC and the Law

Women who desire a Vaginal Birth After Cesarean (VBAC) run into a lot of opposition, and with the climbing cesarean rate in the U.S. (now at 32%), VBAC has become a very hot topic.

There is a great deal of controversy surrounding VBACs, and many hospitals do not give women who have had a previous c-section an option of a VBAC - they say its cesareans only, forever.  More than 9 out of 10 births following a C-section are now surgical deliveries.

There have been some recent developments on this topic, including ACOG issuing less restrictive VBAC Guidelines, and the creation of A Woman’s Guide to VBAC: Navigating the NIH Consensus Recommendations.


Many women worry that even though they want to try for a VBAC, they will be told that they legally have to have a repeat cesarean section. Just so everyone knows...

THERE IS NO LAW ANYWHERE AGAINST VBAC. 

If your OB tells you there is, DUMP 'EM!



Here are the facts on VBAC and the Law:

Legal Rights and Protections for VBAC

By Rebecca Spence and Farah Diaz-Tello
This article is part of A Woman’s Guide to VBAC: Navigating the NIH Consensus Recommendations, a collection of resources that address the most common and pressing questions women may have about their birth choices.


What Is this Body of Ethics and Law, and What Does it Mean for a Woman Making Decisions About Birth after Cesarean?

Ethics
The American Congress of Obstetricians and Gynecologists (ACOG) consistently confirms a pregnant patient’s right to refuse medical intervention as a part of her basic right to privacy and bodily integrity. ACOG’s Committee on Ethics’ Opinions respect the pregnant patient as the person in the best position to make decisions about herself and her baby.[3] The American Medical Association (AMA) also recognizes that performing medical procedures against the pregnant woman’s will violates her right to informed consent and her constitutional right to bodily integrity.[4] Yet, some providers may subscribe to the view, described by the NIH panelist, that separates a woman from the fetus she carries. This view may lead them to try to override the woman’s decision-making authority based on the idea that the doctor, rather than the woman, is best situated to make decisions for the separate “fetal patient” where there is any amount of perceived risk to the fetus. Nevertheless, this idea is not supported by ACOG or AMA guidelines.

Law
There is no law anywhere against VBAC. While there is no guaranteed right to healthcare under U.S. law, federal law prohibits a hospital from refusing to accept a woman in active labor as a patient, and there is no law permitting facilities to deny treatment to women with uterine scars. Any person, pregnant or not, has the right to refuse medical treatment—even in an emergency. The Constitution and court decisions recognize a person’s right to informed consent and bodily integrity. Patients also have the right to change their minds about treatment and can revoke consent at any time. While the law does contemplate circumstances where these rights are not absolute, there is no legal basis for suggesting that women have fewer rights than other people upon becoming pregnant.

You may find these and other rights outlined in a “Patient’s Bill of Rights” or similar document from the hospital.  You may also write your wishes for a VBAC in a birth plan that you review with your provider. However, it is important to remember that birth plans and patient’s bills of rights are not legally binding documents, even if they are in your chart or your doctor signs them.




And let me just repeat this, so you can really have this idea put into your mind:

There is no legal basis for suggesting that women have fewer rights than other people upon becoming pregnant! 

Is this really a concern? Yes. Pregnant women are often treated like second-class citizens, and are court-ordered to comply with cesarean sections (among other things) against their will because they may be hurting the fetus. 
Do we really want to make a pregnant woman’s behavior and choices, any health condition she suffers, or even that she lacks health insurance, a crime because it could hurt the fetus? If we do, then virtually everything a pregnant woman does or does not do could land her in jail, because virtually everything a pregnant woman does or does not do — from what she eats, where she works, and what condition her health was in before she became pregnant — is going to have an affect on her fetus. Allowing the government to exercise such unlimited control over women's bodies, and every aspect of their lives, would essentially reduce pregnant women to second-class citizens, denying them the basic constitutional rights enjoyed by the rest of us.  (from Blog of Rights)

What About Cases of Court-ordered Medical Interventions?
There have been a few rare cases of court-ordered cesarean surgery reported. These cases are outliers and do not represent the law in the area. The only state appellate courts to have ruled on this issue on a non-emergency basis with all the evidence before them all conclude that pregnant women have the same right to informed refusal as any other adult. The few cases in which surgery was ordered were decided on an emergency basis, and the judge did not have the benefit of a full presentation of evidence or participation by experts that would have brought attention to the woman’s rights.  Often, the woman did not even have a lawyer, and was in labor during a quick “hearing” over the telephone. Most of these cases are not binding precedent, for various reasons. The only places where a court might be required to follow the rulings are in the jurisdictions where the cases were decided (a legal concept called “mandatory authority”). In other jurisdictions, they do not have to be followed, but they can be cited to try to persuade a court (“persuasive authority”). The fact that a few women were deprived of their rights is a terrible thing, but it does not mean that these cases are now the law.

Tuesday, September 21, 2010

Re-Blog: Why African Babies Don't Cry

Below is a re-blog of a post written by Elita at Blacktating that I found fascinating!
_________________________

Why African Babies Don't Cry

I recently read Gabrielle Palmer's book The Politics of Breastfeeding: When Breasts are Bad for Business and reviewed it on the blog. One of the many passages that struck me was when Palmer was discussing the breastfeeding culture in Africa. She said that in the United States and other developed nations, we tell moms to feed "on cue," which should be about 8 to 12 times a day. But that to ask a mother in Africa how many times a day she breastfeeds is like asking a person covered in mosquito bites how many times a day they scratch. It's not quantifiable because it's done with such frequency. Most mothers carry their babies in a sling, with access to the breast 24/7. When the baby stirs, he is quickly latched on and mom goes about her business. None of this silliness about spoiling a baby or overfeeding. Just a baby's needs being met by his mother, as it should be.




So when Maya from Musings of a Marfan Mom sent me the link to a guest post entitled Why African Babies Don't Cry, I had a feeling I knew the reason. The author, Dr. Claire Niala, says:

In the UK it was understood that babies cry - in Kenya it was quite the opposite. The understanding is that babies don't cry. If they do - something is horribly wrong and must be done to rectify it immediately. My English sister-in-law summarized it well. "People here," she said, "really don't like babies crying, do they?"

It all made much more sense when I finally delivered and my grandmother came from the village to visit. As it happened - my baby did cry a fair amount, and exasperated and tired, I forgot everything I had ever read and sometimes joined in the crying too. Yet for my grandmother it was simple - nyonyo (breastfeed her!). It was her answer to every single peep.

I loved this post not only for the glimpse at what breastfeeding is like in Africa, but also because breastfeeding was a life changing experience for Dr. Niala, the same way it was for me. While her friends' babies were eating rice cereal and sleeping through the night, Niala was waking every two hours to nurse a baby who had never tasted anything but breast milk. Breastfeeding begins to permeate her entire life, including the way she counsels her patients.

I loved the gentle wisdom she received from her grandmother. At a time when so many of us are advised to become hardened, to ignore our instincts and our babies cries, Niala's grandmother tells her to follow her baby's cues and to breastfeed, breastfeed, breastfeed.

No wonder babies in Africa don't cry.

_______________
Subscribe to Elita's wonderful Blacktating Blog here or follow her on Twitter @Blacktating

To read more about Why African Babies Don't Cry, click!

Saturday, September 18, 2010

A Doula Story

Nicole at Bellies and Babies posted this slightly older video recently and said it was worth a view... and she was right!

The ~60 min video follows an amazing woman named Loretha who does an incredible job working with teen mothers in Chicago as a prenatal educator, labor coach and postpartum parenting aid, and much more! I really enjoyed it a lot.

              video platform   video management   video solutions   video player


A Doula Story documents one woman’s fierce commitment to empower pregnant teenagers with the skills and knowledge they need to become confident nurturing mothers. A woman of remarkable magnetism and complexity, Loretha Weisinger returns to the same disadvantaged neighborhood, where she once struggled as a teen mom. She uses compassion and humor to teach the young mothers-to-be about everything from the importance of breast-feeding and reading to their babies to the practical details of communicating effectively with health care professionals.

Teenage pregnancy is a fact of American life. Nearly 10 percent of births in this country are to teens, many of them poor, uneducated and alone. A community doula (from the Greek word for birth attendant) for more than 10 years, Loretha knows that pregnant teens need guidance and education, not judgment or pity. In the face of overwhelming challenges—from absentee fathers and drug addiction to the disparagement of society—doulas are making a difference in the futures of young mothers and their babies.

Thursday, September 16, 2010

The Nestle Boycott

In the 1970's the media revealed to the world shocking photos of dying babies in developing countries. Everyone found out that the marketing of baby formula to women in developing countries who could not afford to pay for it, didn't have access to clean water or who didn't understand that using formula would interfere with going back to breastfeeding. Babies were fed diluted formula or formula mixed with bad water and were missing out on immune protection from breastfeeding and therefore developed infections and illness.


In response, in 1981 NGO's, UNICEF, the World Health Organization, formula companies, and scientists got together and created a code of ethics on marketing infant formula and bottles. The basic gist of the agreement was: 


1. Marketing couldn't directly or indirectly target the consumer (no free samples given to pregnant women or parents at all), but advertising about formula can be given to providers (doctors and nurses); 

2. Literature on infant feeding must be provided by the government, not formula companies and all donations of money or equipment by formula companies to health care providers must be done openly and without special benefits.  

To view the entire WHO International Code of Marketing of Breast-milk Substitutes, click here (pdf).

This code, however, is not law, and the formula companies disregard it. Nestle, who owns Carnation, especially, disregards these rules in countries all over the world, and this is a big reason for the Nestle product ban. They, along with many other companies, advertise heavily to doctors and hospitals, giving money, equipment and free products. They also directly advertise to consumers through the mail and provide discharge packs for new moms leaving the hospital full of formula samples and brochures on how "formula is just as good as breast milk."


Overview of Nestlé’s Unethical Business Practices

via phdinparentin's excellent post on this topic
Nestlé is accused by experts of unethical business practices such as:
Nestlé defends its unethical business practices and uses doublespeak, denials and deception in an attempt to cover up or justify those practices. When laws don’t exist or fail to hold Nestlé to account, it takes public action to force Nestlé to change. Public action can take on many forms, including boycotting Nestlé brands, helping to spread the word about Nestlé’s unethical business practices, and putting pressure on the government to pass legislation that would prevent Nestlé from doing things that put people, animals and the environment at risk.


The Nestlé boycott has been going on for more than 30 years and Nestlé is still one of the three most boycotted companies in Britain. Although Nestlé officials would like to claim that the boycott has ended, it is still very much alive. But it needs to get bigger in order to have a greater impact.

Nestlé owns a lot of brands and is the biggest food company in the world, so people wishing to boycott their brands need to do a bit of homework first to familiarize themselves with the brand names to avoid in the stores.

SPREAD THE MESSAGE  #noNESTLE

Wednesday, September 15, 2010

Nighttime Breastfeeding and Pospartum Depression

Nighttime Breastfeeding and Maternal Mental Health
from Science and Sensibility, by Kathleen Kendall-Tackett, Ph.D., IBCLC. 

There is a movement afoot in childbirth education and perinatal health urging mothers to avoid nighttime breastfeeding to decrease their risk for postpartum depression. We know that if mothers follow this advice, it will have a negative impact on breastfeeding. But let’s put that issue aside for the moment and consider whether avoiding nighttime breastfeeding will preserve women’s mental health by allowing them to get more sleep. In short, is this good advice?

At first glance, it may seem to be. Since breast milk is lower in fat and protein than formula, we might assume that breastfeeding mothers sleep less than their formula-feeding counterparts. And when a mother’s mental health is at stake, avoiding nighttime breastfeeding might be worth the risk. However, recent research has revealed the opposite: that breastfeeding mothers actually get more sleep—particularly when the baby was in proximity to the mother. And that has major implications for their mental health. So if you want one more good reason for mothers to exclusively breastfeed their babies, here it is.

Breastfeeding Mothers Get More Sleep
In a study of 33 mothers at 4 weeks postpartum, Quillin and Glenn (2004) found that mothers who were breastfeeding slept more than mothers who were bottle-feeding. Data were collected via questionnaire that recorded 5 days of mother and newborn sleep. When comparing whether bedsharing made a difference in total sleep, they found that bedsharing, breastfeeding mothers got the most sleep and breastfeeding mothers who were not bedsharing got the least amount of sleep. Mothers who were bottle-feeding got the same amount of sleep whether their babies were with them or in another room.

Sleep patterns of 72 couples were compared from pregnancy to the first month postpartum via sleep diaries and wrist actigraphy (Gay et al., 2004). Most of the mothers were at least partially breastfeeding (94%) and 80% were exclusively breastfeeding. Most of the babies slept in their parents’ room and 51% regularly slept in their parents’ beds. Sleep and fatigue outcomes were not associated with type of birth, parent-infant bedsharing, or baby’s age. Mothers who were exclusively breastfeeding had a greater number of nighttime wakings (30 vs. 24) compared with mothers who are not breastfeeding exclusively. The exclusively breastfeeding mothers slept approximately 20 minutes longer than mothers not exclusively breastfeeding.

In a study of mothers and fathers at three months postpartum, data were collected via wrist actigraphy and using sleep diaries (Doan et al., 2007). The study compared sleep of exclusively breastfed infants vs. those supplemented with formula. In this sample, 67% were fed exclusively with breast milk, 23% were fed a combination of breast milk and formula, and 10% were exclusively formula fed. Mothers who exclusively breastfed slept an average of 40 minutes longer than mothers who supplemented. Parents of infants who were breastfed during the night slept an average of 40 to 45 minutes more than parents of infants given formula. Parents of formula-fed infants had more sleep disturbances. They concluded that parents who are supplementing with formula under the assumption that they are going to get more sleep should be encouraged to breastfeed so they will get an extra 30-45 minutes of sleep per night.

Not only do breastfeeding mothers get more sleep, but the sleep they get is of better quality. This study compared 12 exclusively breastfeeding women, 12 age-matched control women, and 7 women who were exclusively bottlefeeding (Blyton et al., 2002). They found that total sleep time and REM sleep time were similar in the three groups of women. The marked difference between the groups was in the amount of slow-wave sleep (SWS). The breastfeeding mothers got an average of 182 minutes of SWS. Women in the control group had an average of 86 minutes. And the exclusively bottle-feeding women had an average of 63 minutes. Among the breastfeeding women, there was a compensatory reduction in light, non-REM sleep. Slow-wave sleep is an important marker of sleep quality, and those with a lower percentage of slow-wave sleep report more daytime fatigue.

The most recent study was published in the journal Sleep, a major sleep-medicine journal not necessarily known for their support of breastfeeding. This was a study of 2,830 women at 7 weeks postpartum (Dorheim et al., 2009). They found that disrupted sleep was a major risk factor for postpartum depression. But here is where it really gets interesting. When considering what disrupted sleep, they found that the following factors were related to disturbed sleep: depression, previous sleep problems, being a first-time mother, a younger or male infant, and not exclusively breastfeeding. In other words, mothers who were not exclusively breastfeeding had more disrupted sleep and a higher risk of depression.

Conclusions
The results of these previous studies are remarkably consistent. Breastfeeding mothers are less tired and get more sleep than their formula- or mixed-feeding counterparts. And this lowers their risk for depression. Doan and colleagues noted the following.
Using supplementation as a coping strategy for minimizing sleep loss can actually be detrimental because of its impact on prolactin hormone production and secretion. Maintenance of breastfeeding as well as deep restorative sleep stages may be greatly compromised for new mothers who cope with infant feedings by supplementing in an effort to get more sleep time. (p. 201)
In sum, advising women to avoid nighttime breastfeeding to lessen their risk of depression is not medically sound. In fact, if women follow this advice, it may actually increase their risk of depression.

(For References, click over to original post)

Sunday, September 12, 2010

Did You Know? Doula Services are Covered By Insurance



Would you love to hire a Doula but you honestly can't afford one? Fear not! Your Health Insurance may cover it!


There is a great post on BirthSource.com about Third Party Reimbursement for Doulas aka Insurance pays the Doula's Fees.

Over twenty insurance companies have begun paying for doula services and, now that there is a CPT code covering doula services, this is more of a possibility than ever before. (CPT stands for Current Procedural Terminology, and is a copyright of the American Medical Association.) The CPT code commonly used to claim doula services is 99499 for Evaluation and Management Services/Labor Support.

The fact that their insurance company might reimburse at least some portion of the fee for your services might make you attractive to a group of potential clients who might not have been interested before. Getting reimbursement for doula services requires patience and persistence, but it can be done. If you are going to offer this as a possibility for your clients, you will also need to be willing to offer some guidance and, most likely, a fair amount of support, as they attempt to get reimbursed.

The following is a partial list of insurance companies have reimbursed in whole or in part for doula services:

Aetna Healthcare
AltPro
Baylor Health Care System/WEB TPA
Blue Cross/Blue Shield
Blue Cross/ Blue Shield PPO
Cigna
Degussa, a German Chemical Company
Elmcare, LLC, C/O North American Medical Management
Foundation for Medical Care
Fortis Insurance
Glencare Managed Health Inc.
Great-West Life & Annuity Ins. Co.
HNTB (Peoria, IL)
Houston New England Financial, Employee Benefits (Fort Scott, KS)
Humana Employers Health
Lutheran General Physician's Organization
Maritime Life
Medical Mutual
Oschner HMO, Louisiana
Professional Benefits Administrators
Prudential Healthcare
Qualchoice
Summit Management Services, Inc
Travelers
United HealthCare of Georgia (San Antonio, TX)
United Health POS
Wausau Benefits, Inc
Thanks so much for April Kline for putting the list together. 

How to Request Insurance Reimbursement for Doula Services
___     Pay your doula in full.
___     Get an invoice from her which includes the following information:
a. The doula's name and address
b. Her social security number/taxpayer ID number or NPI number
c. The date and location services were provided
d. The CPT code for the services provided
e. A diagnosis code
f. The doula's signature
___     Submit the invoice with a claim form to your insurance company.
___     Within four weeks, expect a letter telling you either that
a. They need more information before they can process your claim.
b. This is not a covered expense.
___     Ask your Doula to send you the following:
a. A copy of her certification (if she is certified)
b. Other credentials or relevant training
c. A letter detailing her training and experience and what she did for you
___     If possible, ask your obstetrician or midwife for a letter explaining why a doula helped you, was necessary, or saved the insurance company money. (Did you have a high-risk pregnancy? Did the doula's suggestions appear to prevent complications or help your labor to progress more quickly? Did the doula's presence decrease your need for expensive pain medications?)
___     Write a letter explaining why you felt the need for a doula and how you believe the doula was beneficial to your health.
___     Submit to your insurance company: the doula's letter and credentials the letter from the doctor your cover letter
___     If they refuse it, write a letter to Health Services requesting that they review the claim, as you feel it was a cost-cutting measure and they should cover the cost.
___     Follow up by telephone if necessary.
___      If they refuse, write a letter to the CEO explaining why you feel that doula care should be a covered expense. They may not pay your claim, but they will consider it for the future. (Kelli Way, ICCE, CD(DONA) 1998. 



If you are a doula, I suggest you click over and read the guide to getting a National Provider Number and helping your clients get reimbursed. 
Also, here is a pdf from DONA with several FAQ's on insurance reimbursement.  

Doulas - Do you have a Provider Number? Have you had your services covered by insurance? Please share your experience! 

 

Saturday, September 11, 2010

A Medical Anthropologist Discusses Home Birth

This is a fantastic article that touches on the medicalization of childbirth, an important issue in medical anthropology, as well as the safety of home birth, the high rates of high maternal and perinatal death in the US, public health, the dominance of biomedicine, how midwives and doctors should be working together, etc etc!

I wish I had seen this before I presented on biomedicine and medicalization of childbirth in my biocultural medical anthropology class this week, I totally would have loved to use it!



Why Home Births Are Worth Considering

by Melissa Cheyney

Posted: September 9, 2010 07:00 AM


A new analysis by Dr. Joseph Wax comparing home births and hospital births, which was published in the recent issue of the American Journal of Obstetrics and Gynecology, not only presents misleading conclusions, it drives a wedge between two groups that cannot afford a greater divide: medical doctors and midwives.

The study documents similar perinatal (or the period immediately surrounding birth) mortality rates for home and hospital births, but claims a three-fold increase in neonatal (measured up to 28 days after delivery) mortality for home deliveries. Yet this analysis contains serious limitations and concerns those of us who practice midwifery in an out-of-hospital setting.

Beyond the issue of the flawed methodology, which has been addressed by several national organizations, including the Coalition for Improving Maternity Services and the Midwives Alliance of North America, there are serious cultural implications to this study.

As a medical anthropologist, I am concerned with the chasm with doctors and the medical establishment on one side, and midwives and the home birth movement on the other. In Oregon, where we have both licensed and unlicensed midwives working in home and in birth center settings, research has shown deep mistrust between doctors and some midwives. Many doctors have expressed the belief that only hospital births are safe, while midwives say they often feel marginalized and disrespected.

Such studies only deepen this mistrust and have the potential to increase hostility during encounters when midwives and their clients have to seek hospital care for complications. The end result is a system that can be detrimental to women and their babies because of the impaired ability to communicate across a cultural divide. Instead of a maternity system based on fear and misinformation, we need a system based on collaboration and mutual respect.

The United States is already the butt of jokes in the international public health community. We spend more on health care than any other high-income nation, while simultaneously serving the lowest percentage of pregnant women, as several of our key health indicators continue to decline each year. According to Eugene Declercq of the Boston University School of Public Health, the U.S. now has the highest number of maternal deaths relative to all other high-income nations, and we also rank second worst for perinatal deaths.

The U.S. has not reported a significant decrease in maternal mortality rates since 1982, and the Center for Health Statistics indicates that the rate of cesarean section in this country is now at a whopping 32 percent, marking the 11th consecutive year of increase. As the incidence of cesarean section rates rise, so do medical complications for mothers and babies, along with associated health care costs. The World Health Organization recommends a cesarean rate of no more than 10 to 15 percent, so our rate is two to three times higher than it should be.

The answer among the U.S. medical establishment has been to throw more expensive technology at the problem rather than retracing our steps to see where we went wrong. Instead of admitting that something is fundamentally broken with the system, organizations like the American College of Obstetrics and Gynecology continue to endorse the idea that medicalized hospital births are the only safe route for women.

We know that 99 percent of women in the U.S. are giving birth in hospitals, yet the United States has one of the highest infant mortality rates of any developed country, with 6.3 deaths per 1,000 babies born. Meanwhile, the Netherlands, where one-third of deliveries occur in the home with the assistance of midwives, has a lower rate of 4.73 deaths per 1,000.

While maternal mortality rates decreased among our peer nations between 2000 and 2005, they increased by more than 54 percent in the United States during the same time period. The two major differences between the U.S. and other nations, which have superior maternal and infant health outcomes, are that the latter offer universal health care and rely more extensively on cost-effective midwives as a public health strategy.

Consider the economics of the situation. The cost of a cesarean in the United States is about $15,000 and an uncomplicated vaginal birth averages $8,000 (without prenatal or postpartum care), while homebirth midwives charge $2,000 to $4,000 -- a fee that includes care from conception through the postpartum period. Exploring the option of home and birth center birth with midwives for low-risk women should be at the core of national health care reform and research. Instead, several generations of high-tech, low-touch birth and a pervasive cultural belief that birth is imminently dangerous -- even in healthy, low-risk women -- has led to powerful cultural blinders that limit options for women.

In anthropology, we say that "normal is simply what you are used to." The power of socialization and the dominance of biomedicine have kept us from systematically examining a variety of birthing environments and providers as viable alternatives to the expensive and interventive hospital delivery that has become the norm in the U.S.

Finally, I must briefly address the study by Dr. Wax and his associates. Let me first say that their study found no difference between home births and hospital births when measuring perinatal death, which is the primary indicator for evaluating the safety of a mode of delivery. Yet, the study chose instead to focus on neonatal death, generally accepted as death within the first 28 days of birth and to emphasize this part of their research. A complex mix of psychosocial and clinical factors, including congenital anomalies, Sudden Infant Death Syndrome, unsafe home environments, and poverty, can all contribute to death in the first month of life. As Dr. Michael Klein of the Child and Family Research Institute in Vancouver, B.C. points out, after removing low-quality studies and out-of-date statistics, the Wax study actually demonstrates no difference in outcomes between home and hospital-based delivery, even for neonatal mortality.

Yet the authors included faulty data in their total analysis, comparing apples to oranges by mixing different types of data sets, such as grouping low-risk with high-risk mothers, and including babies born unintentionally at home.

As an anthropologist, I see a study like this as harmful to women and as having a much larger social impact than the authors possibly intended. For instance, there are many women in rural areas and women who are uninsured, or under-insured, whose only option is to give birth under the care of a midwife. How does this study affect these women? A study like this only exacerbates and undermines often already negative and tension-fraught relationships, making it more difficult for out-of-hospital midwives and physicians to work together when needed.

There is something to be learned from the centuries-old traditions of midwifery, and I believe that if doctors and midwives, including those who work in the home setting, could be willing to learn from and respect one another, women and babies in our country would benefit. After all, we are all working for the same end result: a happy and healthy mother and baby. Our differing visions of how to get there will require an attitude of cultural humility and a willingness to listen. Studies like the Wax study take us in the wrong direction.

Friday, September 10, 2010

7 Reasons You Can't Have an Epidural

Planning on having epidural anesthesia?  Just because you want one doesn't mean you'll get it! 
Here are seven reasons why you may not be able to have one...




7 Reasons You Can't Have an Epidural

by Robin Elise Weiss

Epidural anesthesia is the most popular form of medicinal pain medication for labor and birth. Many women decide on using an epidural prior to labor and don't even look at other forms of pain relief for labor and birth. This is not necessarily a wise choice for labor and birth because there are many reasons why an epidural may not be in your future. Here are a few of the reasons you might not be able to have an epidural:
  1. You are taking certain medications.
    Medications that you take can effect how likely you are to be able to get an epidural. The biggest culprit are blood thinners.
  2. Your blood work isn't just right.
    If you have a low platelet count or sometimes other problems with your blood work may make the placement of an epidural more risky.
  3. The doctor can't find the right space.
    Sometimes due to the normal growth of your back, your weight or back problems, including scoliosis, it may be impossible for the anesthesiologist to find the epidural space. Therefore you can't have the epidural placed in labor.
  4. You are bleeding heavily.
    If you are bleeding heavily or are suffering from shock, you will not be given an epidural for safety reasons. Since many women tend to have lower blood pressure with an epidural, this may be made even more dangerous with the lowered blood pressure of some of these problems.
  5. You have an infection of the back.
    It is not in your best interest to have your anesthesiologist place an epidural through an area that is infected. This can cause the infection to spread to the spine and other areas of your body and can potentially cause a great deal of damage.
  6. No anesthesiologist is available.
    Your hospital may only have an anesthetist available during certain hours of the day or days of the week. You may also have an anesthesia department that covers an entire hospital and not just the labor and delivery unit.
  7. Labor restrictions.
    Some hospitals will place restrictions on when you can have an epidural. It may be that you must be at a certain point in labor, like four (4) centimeters before an epidural can be given. Other hospitals may decide that epidural should not be given after a certain point of labor, for example when you've reached full dilation (10 centimeters).
What to Do if the Doctor Says No
You might be able to find out beforehand that an epidural is not in your laboring future. If this happens you are able to prepare by looking at other methods of pain relief for labor. A good childbirth class that focuses on many different types of pain relief from medications to natural forms of relief of pain may be the best option for filling your birth bag with many tools to cope with labor, particularly for the surprise revelation that you can't have an epidural.

Enlist support for getting through labor. Labor is hard work, with or without pain medications. Consider hiring a doula, even if you prefer an epidural. A professional labor assistant can help you and your partner through different pain relief options including natural pain relief like relaxation, positioning, massage, etc. She will also be trained in letting you know what your other options are for pain relief like Transcutaneous Electrical Nerve Stimulation (TENS), IV medications, etc.

If you are concerned about these issues be sure to talk to your doctor or midwife about your fears. It's also possible and highly recommended in some cases to actually visit the hospital and have a consultation with the anesthesiology department. They may do a physical exam of your spine, take a medical history, etc. This can help answer questions you may have about epidurals and labor. Being informed ahead of time is your best solution.


Moral of the story... GET A DOULA! :) 


Tuesday, September 7, 2010

Doulas: Strangest Places and Times

Sometimes doulas get called to labors at strange times or attend some unconventional births!

I haven't yet been called at any strange times or in any strange places. I always wonder if I'll be called in the middle of a movie, or if I'll end up catching a baby in the car on the way to the hospital, etc. I've been trying to find out if any doulas have had any strange experiences to share. Below are a few I know of:

If you're a doula, 
1. Where is the most unique time and place you have ever gotten a labor call? Or maybe the most inconvenient?
2. Has a mom ever chosen to labor, or accidentally ended up laboring, in an a-typical location?
3. Have you ever witnessed/caught a baby being born in a strange location or at an odd time? 



Here are some unexpected situations that have happened to real doulas:

Calls:
-Thanksgiving dinner

Labors:
- Mom walking up hospital stairs so fast during contractions that doula couldn't keep up!
- Moms singing through contractions
- Moms who drive themselves to the hospital in transition

Births:
- By a creek in the moonlight
- On the front lawn

Sunday, September 5, 2010

Racism and Birth Weight

Over the past two decades in the United States there have been concerted efforts to reduce the number of preterm deliveries and low birth weight babies. Such births are the second leading cause of infant mortality across the population at large, and among African Americans the first cause. Furthermore, African American women are two to  three times more likely than white women to deliver preterm. Although the overall number of preterm births has been reduced in the US the gap appears to have widened because preterm births have declined faster among white than African American women. A large number of epidemiological studies have attempted to account for this disparity in terms of maternal age, education, lifestyle, and or socio-economical position. However, the results make it clear that these variables account for only a small proportion of the difference. Moreover, college-educated black mothers are more likely to deliver very low birth weight infants than are college-educated white mothers. And, further, it has been shown that women recently immigrated to the US bear infants of higher birth weight than do women of the same race/ethnic category (as defined by the US census) born and raised in the United States, despite the frequency of lower socioeconomic status among the immigrants. Researchers involved with these studies argue that their findings "suggest that growing up as a woman of color in the US is somehow toxic to pregnancy, and imply a social etiology for racial/ethnic disparities in prematurity that is not solely explained by economics or education.

Regardless of their socioeconomic level, African Americans who reported the experience of racial discrimination in three or more situations proved to be at more than three times the risk for preterm delivery as compared to women who reported no experience of racism. Further, recent studies have supported this conceptual model. [Epidemiologist Nancy] Krieger's conclusion is that "biological expressions of race relations" appear to be at work in accounting for the findings about low birth weight and she goes on to caution that human biology should never be studied in the abstract. this example makes strikingly clear how individual women should not be held fully accountable for the outcomes of pregnancies. in the united states, and elsewhere too, no doubt, persistent experiences of racism in every day life continue to take their toll, despite dramatic political reforms throughout the latter part of the 20th century.

from Local Biologies and Human Differences By Margaret Lock, Nguyen Vinh-Kim

Thursday, September 2, 2010

Cultural Relativism

One of my courses this semester is a Biocultural Medical Anthropology course (and my professor actually has a blog all about this topic, if you're interested).

The course consists of Anthropology graduate students and non-Anthropology graduate students. For instance, there are some nursing students who are taking the course to fulfill a requirement, probably something like "health and cultural competency."
 
A couple days ago our class got on a tangent discussion, and we started talking about Cultural Relativism. Cultural Relativism is the idea that a person needs to be viewed in terms of their own culture. You may think something you learn about another culture is weird, or wrong, but you have to realize that culture is all relative, and your ideas or practices may seem just as weird or wrong to someone in an outside culture. It is about accepting cultural traditions, practices, beliefs, and so on as being different but not necessarily wrong, and removing your ethnocentricity.

Unfortunately, this creates many moral problems when you get into an issue that is borderline a human rights issue, for instance the burning of wives on their dead husband's funeral pyre, stoning to death for adultery, or circumcision.

One of the nursing students brought up the issue of female genital mutilation, aka female circumcision.  She asked how one could argue for cultural relativism, in saying that it is OK for a physician in the United States to perform this procedure.

I believe she was referring to a statement issued by the American Academy of Pediatrics in April that many bloggers reacted strongly to. Here are some excerpts from a NYTimes article to give you some background information on the subject:

In a controversial change to a longstanding policy concerning the practice of female circumcision in some African and Asian cultures, the American Academy of Pediatrics is suggesting that American doctors be given permission to perform a ceremonial pinprick or “nick” on girls from these cultures if it would keep their families from sending them overseas for the full circumcision.
“It might be more effective if federal and state laws enabled pediatricians to reach out to families by offering a ritual nick as a possible compromise to avoid greater harm,” the group said.
“If we just told parents, ‘No, this is wrong,’ our concern is they may take their daughters back to their home countries, where the procedure may be more extensive cutting and may even be done without anesthesia, with unsterilized knives or even glass,” she said. “A just-say-no policy may end up alienating these families, who are going to then find an alternative that will do more harm than good.” 
Another classmate, an Anthropologist, said that it is a woman's right to go to a physician and asked him/her to perform female circumcision, if that is an aspect of her culture she desires. If she does not get it done in the doctor's office, she may go home and have it done in an un-sterile environment with a razor blade. That may be a requirement of her culture... If she is not circumcised, even a little bit, she may not be able to find a husband, be accepted into the circles of adult women, etc. She would get it done no matter what, and it is preferable that it be a tiny cut by a skilled physician than a huge slice by an unskilled hand.

The nursing student could NOT understand this. She got really mad and started saying "how could a medical doctor in this country allow himself to believe it was OK to mutilate a woman in a way that may cause her to be unable to birth a baby without complications? We read all about how women with female genital mutilation develop fistulas during labor and it's just awful. What would you do if you were the physician, and you knew doing this could cause her to be unable to have a baby later?"
(to read about obstetric fistula, click)

The anthropology student tried to explain what I outlined above, about viewing it from the woman's cultural perspective, how it would be better for the physician to do it for her and have her "sign a form" saying he is not liable for future complications, she asked for it, etc.

Now this whole conversation reminded me of similar issue that you could argue similarly, that no one is shocked enough by (as we are by FGM aka female circumcision).

What about when a pregnant women goes to a doctor and says, "I want you to cut through the tissue and muscle of my abdomen and cut my baby out of me" even if there are ZERO health reasons to do so, and no matter what personal preferential reason the woman gives, and even if cutting through this woman's gut and uterus could cause uterine rupture with her subsequent pregnancies with the risk of hysterectomy (removal of the uterus entirely). Plus a host of other issues, including blood clots, infection, growth of adhesion tissue, bowel obstruction, ongoing pelvic pain, and so on.

Should that physician feel OK about cutting into that woman's gut just because she asked for it? Even though he is causing her a host of health issues and possibly making her unable to have a baby later?

DOCTORS DO THIS EVERY DAY.


And I am sure that there are many people, in cultures other than my own, who would find it morally repugnant to have physicians perform such a procedure, and yet it is done. It is called an elective cesarean section.
Why aren't there MORE outraged people?!


I feel like I have to note that just as I find it awful to perform an elective cesarean section for no health-related reason at all, I also find it awful to perform female circumcision. And I understand the reasons why many in this country and others find male circumcision equally immoral. Just because I understand cultural relativism, doesn't mean I necessarily condone the American Academy of Pediatrics' statement.

Here is a quote from the above-quoted NYTimes article,
“There are countries in the world that allow wife beating, slavery and child abuse, but we don’t allow people to practice those customs in this country. We don’t let people have slavery a little bit because they’re going to do it anyway, or beat their wives a little bit because they’re going to do it anyway.”
The academy’s statement acknowledged that opponents of the procedure, “including women from African countries, strongly oppose any compromise that would legitimize even the most minimal procedure.” 
Though the nursing student wasn't taking into account that the physician's would only be performing a tiny nick on the clitoris, not even near the vagina (where childbirth issues, such as fistula, would be caused), I do not think it is right to condone even a minimal procedure if we are to attempt to rid the world of all forms of female genital cutting.


By the way, here is the result of the backlash:
(from CNN)

The American Academy of Pediatrics has rescinded a controversial policy statement raising the idea that doctors in some communities should be able to substitute demands for female genital cutting with a harmless clitoral "pricking" procedure.
"We retracted the policy because it is important that the world health community understands the AAP is totally opposed to all forms of female genital cutting, both here in the U.S. and anywhere else in the world," said AAP President Judith S. Palfrey.
The contentious policy statement, issued in April, had condemned the practice of female genital cutting overall. But a small portion of statement suggesting the pricking procedure riled U.S. advocacy groups and survivors of female genital cutting.
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