UnBreaking Birth

I recently watched this video "UnBreaking Birth" - a lecture by Ryan McAllister. It is basically a version of the lecture I have given a couple of times as a guest lecturer undergraduate women's/sexual health classes.

"How you're born affects the rest of your life, and can affect the rest of your mother's life, too"

"There are a host of values at play beyond safety"

He says our birth care system is broken for at least 4 reasons:

1. There isn't a sufficient amount of space and time to build an adequate relationship between the mother and the caregivers
2. Our interventions have become routine, instead of based on the mom and baby's best interests
3. Those interventions are often opinion-based
4. There are conflicts of obligation within the hospital that systematically cause behavior that is out of alignment with the mom and baby's best needs

"Even when they know that practicing a different way would be better for their clients, they have some reason to practice differently. That means that there are conflicts of obligation in the hospital. At times, when the hospital's best interest is over here, and the patient's best interest would mean you behave this way, the hospital's best interest wins."

"Obstetrics has been organized around handling high-risk, emergency surgical births. and they may do this well. But treating all births this way actually derails well-birth, which is the vast majority of births. So I think we need to keep the good of this system and pair it with another approach that doesn't break well-birth."

"How could we possibly find or create highly trained experienced professionals who have evidence based practices, who work within a strong relationship wit h the mother, compassion for newborns, and don't experience conflicts of obligation with a large institution?... Those practitioners already exist. They are independent midwives."

The video does not have ALL of the information on the topic, but is a nice overview for consumers. It covers:

• Why birth is broken (evidence that we spend more on maternity care in the U.S. but have worse outcomes; evidence that c-sections are too high and it is not caused by women being in worse health)
• The 4 reasons he believes our maternity care system is broken 
• A system that would work better for well-birth (certified professional midwives, birth centers)
• What YOU can do to help improve the system

This would be a great video to share in a class, because it is only 32 minutes long.

"Being aware of and making available these other options, especially independent midwives, but also including other birth assistants such as doulas, is key to unbreaking birth in the U.S."

I like the way the UnBreaking Birth says about the indicators that we have a serious problem. It is basically a run-down of why I do what I do as a public health professional and a doula/childbirth educator:

there are terrible health disparities by race and socioeconomic status

infant and maternal mortality rates are higher than in 45 other nations

the maternal mortality rate has risen every year since 1995 while in most other countries it has decreased

only 25% of obstetric practice guidelines are based on good scientific evidence, many are overtly contra-indicated

common hospital policies are not in the best interest of moms and babies

and we spend more than any other nation on healthcare

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

Rally to Improve Birth

Join the National Rally for Change! A full scale birth revolution on Labor Day

Support evidence-based maternity care! 

The National Rally for Change is to encourage and insist that all maternal healthcare providers practice evidence-based care. On average it takes 20 years for proven research to become practice. For the sake of mothers and babies everywhere, we can’t wait 20 years. The long-term effects of unnecessary inductions and cesareans are just starting to be realized. This matters for all people. Despite the dire situation, this is not a protest, but a public outreach event located where the vast majority of the population gives birth.

The Improving Birth rallies are taking place in more than 100 cities across the United States on Monday September 3rd from 10:00 am - 12:00 pm.

Why Rally to Improve Birth?

The results of Childbirth Connection's national "Listening to Mothers" survey show that high c-section rates don't come from maternal request, and that although most women want to make the ultimate decisions in their own care, they don't always have this option.  (If you'd like to read a summary of the findings of these surveys, I wrote one up a while back here.)

Improving Birth was founded with the vision of encouraging hospital administrators to review their birth-specific policies and procedures. We ask that they implement incentive programs for doctors and nurses to get up-to-date information and education about the most current care practices. The U.S. outspends every country in the world for maternity care, and yet we rank #49 for maternal mortality rates.

The U.S. has trailed behind most of the developed or industrialized world for many years and our maternal and infant mortality rates have gotten worse in the last few years. It's more dangerous to give birth in the United States than in 49 other countries. From Amnesty International:

Maternal deaths are only the tip of the iceberg. During 2004 and 2005, more than 68,000 women nearly died in childbirth in the USA. Each year, 1.7 million women suffer a complication that has an adverse effect on their health.

This is not just a public health emergency - it is a human rights crisis. Women in the USA face a range of obstacles in obtaining the services they need. The health care system suffers from multiple failures: discrimination; financial, bureaucratic and language barriers to care; lack of information about maternal care and family planning options; lack of active participation in care decisions; inadequate staffing and quality protocols; and a lack of accountability and oversight.

The facts speak for themselves.  The World Health Organization recommends cesarean rates should be no higher than 10-15% and that anything higher does more harm than good for moms and babies.  Despite this warning, 1 in 3 American women are giving birth surgically.  That equates to a high number of medically unnecessary surgeries.  Additionally, the recommended rate of induction is 10% or less but in an analysis of 19 hospitals across the country, it was found that 44% of women planning a vaginal birth were medically induced.

http://www.improvingbirth.org/the-evidence-shows/

An eye-opening study published in the journal Obstetrics and Gynecology examined the “quality of evidence that underlies the recommendations made by the American College of Obstetricians and Gynecologists.”  It was discovered that only 30% of these guidelines were based on “good and consistent scientific evidence” and that 32% were based simply on “consensus and opinion.”  When obstetric guidelines were looked at individually, a mere 25% was found to be based on quality science and nearly 35% based on opinion.

 Reducing medically unnecessary interventions will not only save lives, but also a huge sum of money.  Childbirth Connection and WHO report that the US could save an estimated $3.4 Billion dollars each year by reducing the cesarean rate to 15%, the rate recommended by WHO.  The Amnesty International report states “an estimated $1 Billion could be saved annually—mostly by reducing neonatal intensive care unit admissions—if early elective deliveries were reduced.”

RALLY TO IMPROVE BIRTH!

Where's the Evidence-Based Medicine?

Birth Advocates are always saying that obstetricians shouldn't be doing such-and-such routine procedure anymore, because it is not the best for mother and baby. Doulas always talk with their clients (and anyone who will listen) about how unnecessary and unhelpful episiotomies, continuous electronic fetal monitoring and pushing on your back, just to name a few examples. But we are frustrated time and again by obstetricians (and sometimes midwives) who do them anyway! And we ask, "Why don''t they follow evidence-based medicine?!"

So have you ever wondered what exactly IS the evidence?Well, thanks to the Midwife Next Door, I didn't have to go find all the studies myself!

Complete with references, here are 10 Common Obstetric Procedures Not Supported By Science  (Please note:  many of these procedures are beneficial in specific situations.  It is their routine use without medical indication that is being addressed here) 

 

1.  Inductions/elective c-sections for suspected macrosomia (big baby): The Cochrane Database reports “no evidence of improved outcomes following induction of labour for non-diabetic women who are thought to be carrying large babies. Babies who are very large (macrosomic – over 4500 g) can sometimes have difficult and, occasionally, traumatic births. One suggestion to try to reduce this trauma and to reduce operative births has been to induce labour before the baby grows too big. However, the estimation of the baby’s weight in utero is difficult and not very accurate. Clinical estimations are based on feeling the uterus and measuring the height of the fundus of the uterus, and both are subject to considerable variation. Ultrasound scanning is also not accurate.”

• Cochrane Database of Systematic Reviews.  Induction of labor for suspected fetal macrosomia.  http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD000938/pdf_fs.html
• Gherman RB, Chauhan S, Ouzounian JG, Lerner H, Gonik B, Goodwin TM.  Shoulder dystocia: the unpreventable obstetric emergency with empiric management guidelines.  Am J Obstet Gynecol.2006 Sep;195(3):657-72. Epub 2006 Apr 21.

2.  Pitocin to speed labor: I am referring here to the routine use of pitocin to speed up a normal labor.  Unfortunately, this happens more frequently than one might think.  Doctors and midwives have lives outside the hospital, and the temptation to speed labor in order to get home sooner is difficult to resist when you’re tired and anxious to get home.  Evidence shows:  “Early amniotomy and high doses of oxytocin may both increase the risk of fetal heart rate anomalies, but are both useful for avoiding prolonged labour.” 

• Verspyck E, Sentilhes L.  Abnormal fetal heart rate patterns associated with different labour managements and intrauterine resuscitation techniques.  J Gynecol Obstet Biol Reprod (Paris).2008 Feb;37 Suppl 1:S56-64. Epub 2008 Jan 9.
• Enkin M, Keirse M, Neilson J, Crowther C, Duley L, Hodnett E. A guide to effective care in pregnancy and childbirth. 2000et al. New York: Oxford University Press.
• Fraser W, Turcot L, Krauss I, Brisson-Carrol G. Amniotomy for shortening spontaneous labour. The Cochrane Database of Systematic Reviews. 1999;4:CD000015.F.
• Clark SL, Simpson KR, Knox GE, Garite TJ. Oxytocin: new perspectives on an old drug. Am J Obstet Gynecol. 2009; 200(1):35.e1–6.

3.  Amniotomy to speed labor: The Cochrane Library reports:  “Evidence does not support the routine breaking the waters for women in spontaneous labour.  The aim of breaking the waters (also known as artificial rupture of the membranes, ARM, or amniotomy), is to speed up and strengthen contractions, and thus shorten the length of labour. The membranes are punctured with a crochet-like long-handled hook during a vaginal examination, and the amniotic fluid floods out. Rupturing the membranes is thought to release chemicals and hormones that stimulate contractions. Amniotomy has been standard practice in recent years in many countries around the world. In some centres it is advocated and performed routinely in all women, and in many centres it is used for women whose labours have become prolonged. However, there is little evidence that a shorter labour has benefits for the mother or the baby. There are a number of potential important but rare risks associated with amniotomy, including problems with the umbilical cord or the baby’s heart rate.  The review of studies assessed the use of amniotomy routinely in all labours that started spontaneously. It also assessed the use of amniotomy in labours that started spontaneously but had become prolonged. There were 14 studies identified, involving 4893 women, none of which assessed whether amniotomy increased women’s pain in labour. The evidence showed no shortening of the length of first stage of labour and a possible increase in caesarean section. Routine amniotomy is not recommended for normally progressing labours or in labours which have become prolonged.”

• The Cochrane Library.  Amniotomy for shortening spontaneous labor.  http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD006167/frame.html

4.  Continuous electronic fetal monitoring:  The American Congress of Obstetricians and Gynecologists (2005) recommends that healthy women with no complications may be monitored with intermittent auscultation or with EFM. Intermittent auscultation instead of EFM may safely reduce the cesarean rate.

• American College of Obstetricians and Gynecologists [ACOG]. (2005). ACOG practice bulletin #70: Intrapartum fetal heart rate monitoring. Obstetrics and Gynecology, 106(6), 1453–1460.
• Gourounti, K., & Sandall, J. (2007). Admission cardiotocographyversus intermittent auscultation of  fetal heart rate: Effects on neonatal Apgar score, on the rate of caesarean sections and on the rate of instrumentaldelivery—A systematic review. InternationalJournal of Nursing Studies, 44(6), 1029–1035.

5.  Requirement of “immediate” emergency services for women attempting a VBAC.  The recent NICHD consensus statement speaks:  “Given the low level of evidence for the requirement for “immediately available” surgical and anesthesia personnel in current guidelines, we recommend that the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists reassess this requirement with specific reference to other obstetric complications of comparable risk, risk stratification, and in light of limited physician and nursing resources.”

• Consensus Development Conference Panel Final Statement on VBAC.  http://consensus.nih.gov/2010/vbacstatement.htm

6.  Routine Episiotomy:  None of the following studies found a benefit to routine episiotomy.  Current recommendations are to use episiotomy when there are  indications of fetal distress and birth does not appear to be imminent.

•  Dannecker, C., Hillemanns, P., Strauss, A., Hasbargen, U., Hepp, H., & Anthuber, C. (2004). Episiotomy and perineal tears presumed to be imminent: Randomized controlled trial.Acta Obstetricia et Gynecologica Scandinavica, 83(4), 364–368.
• Hartmann, K., Viswanathan, M., Palmieri, R., Gartlehner, G., Thorp, J., & Lohr, K. N. (2005). Outcomes of routine episiotomy: A systematic review. Journal of the American Medical Association, 293(17), 2141–2148.
• Klein, M., Gauthier, R., Robbins, J., Kaczorowski, J., Jorgensen, S., Franco, E., et al. (1994). Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation. American Journal of Obstetrics and Gynecology, 171(3), 591–598.

7.  Routine ultrasound to estimate fetal size:“Fetal weight estimation is inaccurate, with poor sensitivity for prediction of fetal compromise.”  (Dudley 2005).  “Prediction of fetal macrosomia remains an inaccurate task even with modern ultrasound equipment” (Henrickson2oo8). ”Considerable error in fetal weight estimations. . .may limit the accuracy and clinical utility of these measurements” (Landon 2000).

• Dudley NJ.  A systematic review of the ultrasound estimation of fetal weight.  Ultrasound Obstet Gynecol. 2005 Jan;25(1):80-9.
• Henrickson T.  The macrosomic fetus: a challenge in current obstetrics.  Acta Obstet Gynecol Scand. 2008;87(2):134-45.
• Landon MB.  Prenatal diagnosis of macrosomia in pregnancy complicated by diabetes mellitus.  J Matern Fetal Med. 2000 Jan-Feb;9(1):52-4.

8.  Immediate cord clamping:  “Delaying clamping of the umbilical cord in full-term neonates for a minimum of 2 minutes following birth is beneficial to the newborn, extending into infancy” (Hutton & Hassan 2007).

• Hutton, E. K., & Hassan, E. S. (2007). Late vs early clamping of the umbilical cord in full-term neonates: Systematic review and meta-analysis of controlled trials. JAMA, 297(11), 1241-1252.

9. Directed (purple) pushing:  The following studies concluded that allowing the mother to push spontaneously (when, how long, and how hard to push are left up to the mother rather than directing her how to push), is superior to directed pushing.  Directed pushing is not recommended as there is greater risk of perineal trauma, fetal distress, and it does not significantly shorten the pushing phase of labor.

• A randomized trial of coached versus uncoached maternal pushing during the second stage of labor. American Journal of Obstetrics and Gynecology, 194(1), 10–13
• Mayberry, L. J., Wood, S. H., Strange, L. B., Lee, L., Heisler, D. R., & Nielsen-Smith, K. (2000). Second-stage management: Promotion of evidence-based practice and a collaborative approach to patient care. Washington, DC: Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN).
• Roberts, J., & Hanson, L. (2007). Best practices in second stage labor care: Maternal bearing down and positioning. Journal of Midwifery & Women’s Health, 53(3), 238–245.
• Schaffer, J., Bloom, S., Casey, B., McIntire, D., Nihira, M., & Leveno, K. (2006). A randomized trial of the effects of coached vs. uncoached maternal pushing during the second stage of labor on postpartum pelvic floor structure and function. American Journal of Obstetrics and Gynecology, 192(5), 1692–1696.

10. Supine Pushing:  This, along with routine amniotomy and continuous fetal monitoring, is used in the vast majority of hospital births.  The following studies concluded that supine pushing is not beneficial and can even be harmful to the mother, by working against gravity, decreasing blood pressure which can lead to fetal intolerance of labor, increased episiotomy, increased use of vacuum/forceps, and increased pain for the mother.

• Gupta, J. K., Hofmeyr, G. J., & Smyth, R. (2004). Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD002006.
• Johnson, N., Johnson, V., & Gupta, J. (1991). Maternal positions during labor. Obstetrical and Gynecological Survey, 46(7), 428–434.
• Roberts, J., & Hanson, L. (2007). Best practices in second stage labor care: Maternal bearing down and positioning. Journal of Midwifery & Women’s Health, 53(3), 238–245.