New National Recommendations for Safe Reduction of Primary Cesarean Births

In recent years, several national partners including ACOG, AWHONN, SMFM, CDC, HRSA and others came together as the National Partnership for Maternal Safety and have worked with the Council on Patient Safety in Women’s Health to create several “bundles” of recommendations to improve the outcomes and safety of pregnant women.

A bundle is a checklist of specific changes that, if followed, will lead to improvement.

Bundles are a collection of succinct evidence-based components that when implemented together should have a positive impact on outcomes and safety for pregnant women. The bundles have four domains, Readiness, Recognition and Prevention, Response, and Reporting/Systems Learning. The bundles provide the core elements that every hospital can implement for every woman, every time. Birth facilities are encouraged to expand on the core component by developing policies, protocols and standardized practices that best meet local needs and are evidence based.

The first bundle that was released by this partnership focused on obstetric hemorrhage, one of the leading causes of maternal mortality. It has since been followed by other bundles focusing on high impact, high volume health and safety issues such as hypertension in pregnancy and safe reduction of primary cesarean births.

Below, I share with you the new national patient safety bundle recommendations for supporting intended vaginal births. You may click the image to enlarge. Lowering the primary cesarean section will increase maternal safety by decreasing morbidity from unnecessary surgeries and the consequences of prior cesarean delivery in future pregnancies.

 

Safe Reduction of Primary Cesarean Births: Supporting Intended Vaginal Births

READINESS:
Every patient, provider, and facility

• Build a provider and maternity unit culture that values, promotes, and support spontaneous onset and progress of labor and vaginal birth and understands the risks for current and future pregnancies of cesarean birth without medical indication.
• Optimize patient and family engagement in education, informed consent, and shared decision making about normal healthy labor and birth throughout the maternity care cycle.
• Adopt provider education and training techniques that develop knowledge and skills on approaches which maximize the likelihood of vaginal birth, including assessment of labor, methods to promote labor progress, labor support, pain management (both pharmacologic and non-pharmacologic), and shared decision making.

RECOGNITION AND PREVENTION
Every patient

• Implement standardized admission criteria, triage management, education, and support for women presenting in spontaneous labor.
• Offer standardized techniques of pain management and comfort measures that promote labor progress and prevent dysfunctional labor.
• Use standardized methods in the assessment of the fetal heart rate status, including interpretation, documentation using NICHD terminology, and encourage methods that promote freedom of movement.
• Adopt protocols for timely identification of specific problems, such as herpes and breech presentation, for patients who can benefit from proactive intervention before labor to reduce the risk for cesarean birth.

RESPONSE

to every labor challenge

• Have available an in-house maternity care provider or alternative coverage which guarantees timely and effective responses to labor problems.
• Uphold standardized induction scheduling to ensure proper selection and preparation of women undergoing induction.
• Utilize standardized evidence-based labor algorithms, policies, and techniques, which allow for prompt recognition and treatment of dystocia.
• Adopt policies that outline standard responses to abnormal fetal heart rate patterns and uterine activity.
• Make available special expertise and techniques to lessen the need for abdominal delivery, such as breech version, instrumented delivery, and twin delivery protocols.

REPORTING/SYSTEMS LEARNING

Every birth facility

• Track and report labor and cesarean measures in sufficient detail to: 1) compare to similar institutions, 2) conduct case review and system analysis to drive care improvement, and 3) assess individual provider performance.
• Track appropriate metrics and balancing measures, which assess maternal and newborn outcomes resulting from changes in labor management strategies to ensure safety.

I listened to the organization's conference call presentation on this new bundle. Chair of the workgroup. David Lagrew, noted:
- that 53% of disparity in cesarean section rates is related to labor induction and early admission.
- rates vary from provider to provider, so individual provider data tracking is helpful to make change
- He also emphasized creating a Culture of Supporting Intended Vaginal Delivery:

To be successful, one must achieve development of a culture in which the clinical providers, administrative support and public: 1) appreciate the true value of achieving a vaginal delivery; 2) respectfully acknowledges the desires of the patient and 3) maintains educational processes, facilities, equipment and staff expertise which can maximize the chance of successfully obtaining vaginal delivery which is safe for mother and infant(s).

Co-presenter Lisa Kane Low noted these recommendations:
- don't admit women prior to 6 cm (especially first time moms) for active labor
-in-house persons, e.g. laborists, available without other demands, are associated with an increase in spontaneous vaginal deliveries
- make doulas part of the team
- look at Bishop score to schedule inductions and reduce inductions prior to 41 weeks.
- have specialized providers available for breech version, instrumental delivery, and twin delivery

Keep an eye out on the Safety Actions Series website if you'd like the slides and recording from this call. Listen especially to the Q&A and discussion at the end!

The California Maternal Quality Care Collaborative will be coming out with a toolkit for this topic, as they have in the past for previous topics, so I will be excitedly waiting for that!



Additionally, here is the list of resources that the Council includes as part of this safety bundle:

New Ricki Lake & Abby Epstein Documentary on Birth Control

Ricki Lake and Abby Epstein, the duo who brought us the ever popular Business of Being Born, are back together. They are planning a new documentary called Sweetening the Pill (based on a book of the same name) which aims to open our eyes the way that BoBB did, but this time, about birth control.

BoBB questioned the "one size fits all" and over-medicalized approach to childbirth, showing women that there are more options out there for birth. Sweetening the Pill hopes to do exactly the same thing, questioning the ubiquity of hormonal contraceptives (including the pill and hormonal IUDs, rings, implants).

They are probably assuming that the same audience who cheered at their questioning of the assumption that hospital birth or cesareans are right for everyone would also cheer at their questioning of the assumption that hormonal birth control is right for everyone.

I find the concept of this film fascinating from a medical anthropology perspective. Reproductive anthropologists examine phenomena like menstruation, menopause, and birth control from a cross-cultural and biological perspective, often finding that ideas we hold true are not always universal.

If you look at a the history of medicine, you find that men's bodies were considered the ideal, while women's bodies were thought to be defective machines. Men's bodies were the basis for a normal, healthy functioning body, without the confusing aspects of menstruation, pregnancy, and menopause. Female bodies were seen as problems that needed to be solved.

Controlling our bodies' menstrual cycles allows the female body to be more like a man's, as we can control our "out-of-whack" hormones, keep from getting pregnant at any unknown time, and even cease bleeding. It created a freedom for women who were somewhat enslaved by their bodies making decisions for them, consequences that kept some from living a life they wanted or working outside of the home.

These days, the white Western body is seen as the norm, while women of color or women from other nations are to us what women used to be to men. Hormonal birth control was developed based on what would be appropriate for the European/American body, not for the Asian, African, or Latina body. Standard hormone dosages, or any hormones at all, may not be right in all bodies, similar to how not everyone's body can process lactose.

Many women find they have side effects from taking The Pill that they do not like, like feeling sick or uncomfortable, and often stop taking the pill. There has been some research on biological side effects, and we know that the pill does increase your risk of blood clots. Unfortunately, so does being pregnant! Other serious issues are rare, and it is up to women to make the right choice for themselves. Many think that choosing when to be pregnant (or never being pregnant) is the right choice for them, so taking the pill is worth the small medical risks.

There is research that has found that hormonal birth control can affect sexual desire. We know that it affects hormones, and studies have found that it might affect who we find attractive. Women might wonder "Would I be different if I wasn't on this birth control?" It is a valid question to ask.

Sweetening the Pill doesn't say that hormonal birth control isn't great, they just wonder why its the only one that is usually recommended to women when they talk to their doctors about birth control. Are there other options? What's right for me? Maybe a lot of women don't even know there are non-hormonal birth control options, other than condoms. Maybe their doctors don't even tell them the side effects.

I think that this is a valid perspective. I think that women deserve to know that there are non-hormonal options, such as the diaphragm and a non-hormonal copper IUD (Paragard).  Other examples include cervical caps, spermicide and sponges, the pull-out method (withdrawal), and natural family planning (also called fertility awareness).

The main method that the film seems to focus in on is Fertility Awareness (Natural Family Planning). They argue that though we felt empowered by The Pill, being aware of your own body's processes is even more empowering. You don't need a medication or "unnatural" hormones messing up your own natural processes, you just need to get in tune with your body.

Fertility Awareness Method: a mathematical calculation of a woman’s cycle in order to determine periods of fertility and is only effective if a woman has regular 28-day periods. Fertility Awareness requires that the woman daily monitor cervical fluid, temperature and other factors to determine fertile days. In either case, either abstinence or use of a barrier method during fertile times is required in order to prevent pregnancy. 

Fertility Awareness is a great thing to learn to do, especially if you're trying to get pregnant, but it is not a highly reliable form of birth control if you are really super trying NOT to get pregnant. If people used it perfectly, it would be as effective as people perfectly using the pill or the patch, but people don't use these things perfectly. In typical use, you take the pill at different times each day, and you might mess up or forget your tracking.

Typical use of Fertility Awareness methods (including cervical mucus methods, body temperature, methods and periodic abstinence) has a 24% "failure rate," which means it is about 76% effective. That is quite close to the effectiveness of Withdrawal (pulling out), which people often refer to as a ridiculous method to use to prevent pregnancy. The success rate for withdrawal is 78% (surprisingly effective, all things considered)! I've seen other website cite Fertility Awareness as 80% effective and pulling out as 73% effective, but I trust the data from the Guttmacher Institute, a highly respected reproductive health research organization:

So, the public health side of me thinks that it is not wise for Sweetening the Pill to get too many people moving away from their hormonal birth control, which has quite a few benefits for women, especially low income women and marginalized women and women of color. Birth control that is highly effective, like the pill (91% effective with typical use) and the hormonal IUD (99% effective), is not something we should step away from lightly. It allows women control over their lives, it helps women who truly shouldn't (medical reasons, youth, or otherwise) get pregnant, and it avoids abortions. The Natural Family Planning method really doesn't have the efficacy that these methods do.

I'm not vehemently against starting the conversation that this documentary is starting, the way some articles on the internet have been -- see the infamous Amy Tuteur's post on Time.com and Slate.com's articles to hear some outrageously unbalanced reviews. I think that this is a valuable conversation to have. I recognize that I am of a class privileged enough to be able to afford all types of birth control and have the time to track fertility, if we want to. Not everyone actually has the financial and temporal freedom to actually choose what is right for them, so we need true open and honest information on all of the options.

You can find more information on the film Sweetening the Pill at the Kickstarter site (which has been fully backed).




I think a great part of this conversation, from an academic viewpoint, is whether the Pill or Natural Family Planning is more empowering, more feminist. The film's preview implies that though the Pill was the ultimate female empowerment 55 years ago, being one with your body's processes and not relying on pharmaceuticals is more empowering. Others might think that by rejecting the pill, we are undoing the work that was done to become less enslaved by our biology.

 Best Daily's post quotes Ricki Lake/Abby Epstein:

"The progression of mainstream feminism is founded in part on women overcoming and controlling their biology", they explained. "This is because for a long time women's biology or difference has been used against us as justification for our mistreatment and oppression. Women have come to feel that they must overcome their biology in order to have equality and freedom."

To enjoy the same privileges as men, do we feel we must we be more like them, not just in our attitudes, but in our biology? Lake and Epstein think so: "The male body is held up as the "ideal" in the medical industry and the female body is seen as inherently faulty and problematic. Women have had to make sacrifices to be allowed to work alongside men in a patriarchal society. The fear is that if we stop making those sacrifices we will lose that ground."

I don't think Ricki Lake and Abby Epstein are "anti-choice" or "anti-feminist" as the Time and Slate articles call them, but I do hope that they present their information in a balanced way. I do hope they talk about the pros of hormonal birth control for so many women, and the potential cons of fertility awareness methods. I hope they talk about other methods that aren't usually talked about in the mainstream.

We will have to wait for its release to find out!

Birth by the Numbers Update

Eugene Declerq and the team at Birth by the Numbers have very recently updated their statistics and their video!

Two years ago I posted the video Birth by the Numbers, a fantastic resource for mothers, public health professionals, students, and teachers. If you haven't seen it yet, I highly recommend you check it out.

This brand new updated Birth by the Numbers covers several maternal and infant health indicators, including maternal mortality and neonatal mortality, compared to other countries. This may sound dry, but he makes some jokes to start you off.

Dr. Declerq then covers Cesarean sections, with a great overview of trends in primary cesarean section rates. He even discusses cost savings of reducing these rates.

Are we doing better? Worse? Tune in to find out this answer and more!





I really like this slide:

I also recently saw a graph elsewhere showing the c-section rate rise with the introduction and push of the electronic fetal monitor. And of course, the decrease in the rate during the period in the 90's when Trial of Labor after Cesarean was promoted.


For further information, I highly recommend the Birth by the Numbers website, or any of the sites he references at the end of the video.

Also, if you're into the research on c-sections, here is an article on the variation in cesarean section rates across the country and in each hospital, and some analysis of why:

Cesarean Delivery Rates Vary 10-Fold Among US Hospitals; Reducing Variation May Address Quality, Cost Issues
"We found that cesarean rates varied tenfold across hospitals, from 7.1 percent to 69.9 percent. Even for women with lower-risk pregnancies, in which more limited variation might be expected, cesarean rates varied fifteen-fold, from 2.4 percent to 36.5 percent. Thus, vast differences in practice patterns are likely to be driving the costly overuse of cesarean delivery in many US hospitals."

Public Health Ryan Gosling

...I just can't help myself. I am cracking up at these!

Do you know about the Ryan Gosling meme? (If not, read all about it at Know Your Meme)

Have you all seen Home Birth Ryan Gosling?  

Or what about Feminist Ryan Gosling? 

Well now there is Public Health Ryan Gosling!   

Here are a few of my favorites:

Get it? Hehe. Do you have a favorite Ryan Gosling meme?

Link Round Up to Hold You Over

You would think with graduation behind me I'd have a lot more free time to blog, but the opposite has been true!

I've got 3 part time jobs plus doula work while I apply for full-time jobs. I'm actually quite happy with this situation, as it keeps me on my toes and I can do some of it from home! And it is all related to my future career, so I still feel on-track. Furthermore, I've agreed to some other things, lately, that have been using up my free time - mainly spending time with my fiance, as I promised him I'd use all my free no-homework evenings with him (and wedding planning)! But don't worry, I've got several blog post ideas started in draft form that I plan to get to, eventually.

I missed posting anything for Mother's Day because I was with my mama, but HAPPY MOTHER'S DAY EVERYONE! Also, this past week was National Women's Health Week, and the month of May is International Doula Month.

I've been trying to still keep up with reading, tweeting, and posting on Facebook  though! So if you haven't been able to follow along over there, I'd thought I'd provide you with a link round-up to satisfy your love for all things birthy during my hiatus:

• The big news recently is the Listening to Mothers III survey results! The previous survey reports have been my go-to for so much information on maternity care in the U.S. over the past couple of years, and I am so nerdily excited for these new reports. I sat in on a live teleconference/webcast with Maureen Corry (Childbirth Connections), Eugene Declerq (Epidemiologist), several others who were involved with the survey, and a lot of other maternity care junkies like me :) Childbirth Connection has made the results really accessible - you don't have to read the whole report if you don't want to, they have several briefs and major survey findings documents. I tweeted a lot of the findings during the webcast, so you're welcome to go back to my #LTM3 tweets and skim through those! 
• What does this survey cover, you ask? Things like: maternal satisfaction with care; # who used doulas, midwives, OBs, other providers; # who did childbirth education; breastfeeding care received; disparities by ethnicity or health insurance; what interventions women received; treatment received and attitudes; and more! 

• A recent study in Pediatrics reported that early limited formula supplementation increased exclusive breastfeeding at 3 months. I've spoken about this study with an IBCLC who is a friend of mine and read through a lot of the analyses. This study is a great reminder to always be a critical reader! There are some flaws to this study, and the post from Best for Babes goes through almost all of them, and this post from Breastfeeding Medicine adds some more great points. Mainly, there could have been some errors and bias in the study that need to be understood before everyone jumps to the extreme that many of the news outlets have: How Formula Could Increase Breastfeeding Rates (TIME)

• This story is still going around - Disney made Merida from Brave "sexier" so that she could join the Disney Princess line of merchandise, and everyone flipped out. Several thousands signed a petition that included this great quote: "The redesign of Merida in advance of her official induction to the Disney Princess collection does a tremendous disservice to the millions of children for whom Merida is an empowering role model who speaks to girls' capacity to be change agents in the world rather than just trophies to be admired. Moreover, by making her skinnier, sexier and more mature in appearance, you are sending a message to girls that the original, realistic, teenage-appearing version of Merida is inferior; that for girls and women to have value — to be recognized as true princesses — they must conform to a narrow definition of beauty." 
• Disney said they are pulling back, and everyone rejoiced, and then they indicated that they were still going to sell the merchandise that they already made with sexy Merida on it. Most recent update is here.

• Another big story that went around was an ACOG Study on the adverse effects of Pitocin augmentation on full-term newborns. They found that Pitocin was an independent risk factor for NICU admission and low APGAR scores. 
• (Also, I found out that ACOG has a pretty good source for women's health news - "Today's Headlines)

• If you're into Science and want more Pregnancy and Childbirth news outlets, I read Science Daily's posts on those topics. If you're into social and political updates on Health issues in the U.S., check out Think Progress' health feed. 

• Currently Reading: The Business of Baby: What Doctors Don't Tell You, What Corporations Try to Sell You, and How to Put Your Pregnancy, Childbirth, and Baby Before Their Bottom Line. Stay tuned for a review!

Universal Rights of Childbearing Women

Women's memories of their childbearing experiences stay with them for a lifetime

Too often, pregnant women seeking maternity care receive ill treatment that ranges from relatively subtle disrespect of their autonomy and dignity to outright abuse: physical assault, verbal insults, discrimination, abandonment, or detention in facilities for failure to pay.

The White Ribbon Alliance is working to break the silence surrounding ill treatment of women during pregnancy, childbirth, and postpartum:

The White Ribbon Alliance envisions a world in which a woman’s right to Respectful Maternity Care is embedded at all levels of all maternal health systems around the globe and that these rights are reflected in a sense of entitlement among women.

Interpersonal care that is disrespectful and abusive in nature to women before, during, and after birth is appalling because of the high value societies attach to motherhood and because we know the intense vulnerability of women during this time. All childbearing women need and deserve respectful care and protection of their autonomy and right to self‐determination; this includes special care to protect the mother‐baby pair as well as marginalized or highly vulnerable women (e.g., adolescents, ethnic minorities, and women living with physical or mental disabilities or HIV). Furthermore, disrespect and abuse during maternity care are a violation of women’s basic human rights.

WATCH THIS VIDEO! It gave me chills. 

MotherBaby Rights

• You and your baby have the right to be treated with respect and dignity. 
• You have the right to be involved in and fully informed about care for yourself and your baby. 
• You have the right to be communicated with in a language and in terminology that you understand.
• You have the right to informed consent and to informed refusal for any treatment, procedure or other aspect of care for yourself and your baby. 
• You and your baby have the right to receive care that enhances and optimizes the normal processes of pregnancy, birth and postpartum under a model known as the midwifery (or motherbaby) model of care. 
• You and your baby have the right to receive continuous support during labor and birth from those you choose. 
• You have the right to be offered drug-free comfort and pain-relief measures during labor and to have the benefits of these measures and the means of their use explained to you and to your companions. 
• You and your baby have the right to receive care consisting of evidence-based practices proven to be beneficial in supporting the normal physiology of labor, birth and postpartum. 
• You and your baby have the right to receive care that seeks to avoid potentially harmful procedures and practices.   
• You have the right to receive education concerning a healthy environment and disease prevention.  
• You have the right to receive education regarding responsible sexuality, family planning and women’s reproductive rights, as well as access to family planning options.
• You have the right to receive supportive prenatal, intrapartum, postpartum and newborn care that addresses your physical and emotional health within the context of family relationships and your community environment.
• You and your baby have the right to evidenced-based emergency treatment for life-threatening complications. 
• You and your baby have the right to be cared for by a small number of caregivers who collaborate across disciplinary, cultural and institutional boundaries and who provide consultations and facilitate transfers of care when necessary to appropriate institutions and specialists. 
• You have the right to be made aware of and to be shown how to access available community services for yourself and your baby.  
• You and your baby have the right to be cared for by practitioners with knowledge of and the skills to support breastfeeding. 
• You have the right to be educated concerning the benefits and the management of breastfeeding and to be shown how to breastfeed and how to maintain lactation, even if you and your baby must be separated for medical reasons. 
• You and your baby have the right to initiate breastfeeding within the first 30 minutes after birth, to remain together skin-to-skin for at least the first hour, to stay together 24 hours a day and to breastfeed on demand.  
• Your baby has the right to be given no artificial teats or pacifiers and to receive no food or drink other then breast milk, unless medically indicated.  
• You have the right to be referred to a breastfeeding support group, if available, upon discharge from the birthing facility.

National Public Health Week

Happy National Public Health Week 2013!

A lot of people don't realize that public health is all around them. Public health is one of those things that is not noticed when it is working well, but generally when something goes wrong (a disease outbreak, an emergency, and so forth).

Public health is...

in the water you drink
in the seat belts and car seats that keep us safe in our cars
in your child's early education
in your workplace safety
in your neighborhood playgrounds and sidewalks
in your cafeterias
in your doctors' offices and pharmacies
in the clean air you breathe

... and more!

Public Health's mission is to help every individual to attain a complete state of physical, mental, and social well-being. Health is not merely the absence of disease or infirmity. We work at the population level, to improve the well-being of communities as a whole, not just one individual at a time.

This year's NPHW's theme is ROI - Return on Investment

The U.S. spends far more on health care than any other country, with such costs rising ten-fold from 1980 to 2010.

Did you know that only 2% of our U.S. healthcare dollars are spent on public health?

But we get BIG returns. Public health initiatives save millions of dollars and millions of lives! The more we focus on PREVENTION, the bigger the health impact.

• Routine childhood immunizations save $9.9 million in direct health care costs, save 33,000 lives and prevent 14 million cases of disease.
• A $52 investment in a child safety seat prevents $2,200 in medical costs, resulting in a return of $42 for every $1 invested. Similarly, a $12 investment in a child’s bicycle helmet can prevent $580 in medical costs, resulting in a return of $48 for every $1 invested.
• The cost of providing dental care for children enrolled in Medicaid and living in communities without fluoridation is twice as high as for children who receive the oral health benefits of drinking water fluoridation.
• Each 10 percent increase in local public health spending contributes to a 6.9 percent decrease in infant deaths, a 3.2 percent decrease in cardiovascular deaths, a 1.4 percent decrease in deaths due to diabetes, and a 1.1 percent decrease in cancer deaths.
• Every year, newborn screening efforts test nearly every baby born in the U.S. for health conditions that — if detected early enough — can be treated in time to prevent developmental problems, disability and death. For example, testing the 4 million infants born every year for congenital hypothyroidism costs $5 per newborn and prevents 160 cases of intellectual disability.
• By 2020, the direct benefits of the federal Clean Air Act will have reached almost $2 trillion, much more than the $65 billion it will have cost to implement the law. About 85 percent of the $2 trillion is attributable to decreases in premature death and illness related to air pollution.
• Citing the protective health benefits of breastfeeding, research finds that a minimum of $3.6 billion could be saved if more women began and continued to breastfeed their newborns through 6 months of age.

Whether it’s through research, data collection, health education, policy change or direct services, public health lays the foundations and creates the conditions that put the healthy choice well within reach.

Click here for more information on National Public Health Week

Would you like a little more information on how public health works? Here are some great visuals:

These are all the groups that public health works through - the government, universities, the media, business, community organizations, and health care

This shows how public health works from one end of things - protection, promotion, prevention, preparedness for safer healthier people - and overlaps somewhat with the healthcare delivery system - disease care for affected persons. 

Your health is affected by your health behaviors, the clinical care you receive, the physical environment in which you live, and social and economic factors. Social and economic factors have the largest impact (40%), and physical environment has the least (10%), but they all play a role in your health outcomes. 

Lobbying with the March of Dimes

This past week a group of students, a professor, and I went to our state capital to lobby on the March of Dimes Advocacy Day.

I think the March of Dimes is a great public health organization. The MoD has been the leading non-profit organization for infant health in the U.S. since 1938 when founded by President Franklin D. Roosevelt to find a cure for polio. Today the MoD works for healthier, stronger babies. The mission is to improve the health of babies by preventing birth defects, premature births, and infant mortality. The organization funds research to understand problems and find solutions, helping moms have full-term babies and healthy pregnancies. The MoD also provides support to families of preterm infants.

I had never been lobbying before and I wanted to see how it was done. I think lobbying is a great way to try to let your representatives know what issues are important to you, so they keep them on their mind when they are voting! Also, it provides them with information.

This year's MoD Advocacy Day focused on two issues: Critical Congenital Heart Disease (CCHD) screening and a Clean Air Act.

Critical Congenital Heart Disease causes structural damage to the heart and is present at birth. This heart defect causes severe, life-threatening symptoms and requires medical intervention (such as surgery) within the first few days, and some cases hours, of life. It can be detected and treated before there is a problem. It can be identified using a non-invasive and painless method called pulse oximetry (A monitor is placed on the end of your finger or toe to measure the percent oxygen saturation of hemoglobin in the arterial blood). Most hospitals already have this device, and actually already screen infants for this before discharge. However, not every birth facility does so, especially in rural areas. As there are so many other newborn screenings to prevent infant morbidity or mortality in place, this would add a very quick and simple one that would only cost about $5-$8 per infant.

The second issue is related to the harm of secondhand smoke on pregnant women and babies. Smoke exposure during pregnancy can cause babies to be born premature or at low birthweight. Also, babies exposed to smoke are more likely to die from SIDS, are at greater risk for respiratory issues such as asthma, pneumonia, eat infections, etc, and may experience slow lung growth.

Another issue that I was able to bring up was Booster Seat legislation that has been in the works in my state for years. This isn't a March of Dimes project, but one that I am working on for a class advocacy project. Apparently, my state is one of only two in the nation that has no legislation in place requiring booster seat use for children ages 4 - 8 who are under 4 ' 9 ". These children are too large for car seats but not appropriately restrained in an adult seat belt. When these children are in a car crash with only a seat belt designed for an adult body, they are 59% more likely to be injured. Booster seats raise a child up so the belt fits over their hip bones so that they do not experience what is called "seatbelt syndrome" - injuries to the spinal cord, torn liver, spleen or bowel, and internal bleeding.

Interesting to note was that all our discussions had to include these points:
1. How does this save money - I feel like this is a "what's in it for me?" type of argument. But the argument in all of these cases was, of course, it would save massive health care costs if all of these issues were prevented.
2. Ideology. We ran into issues where the legislators don't like "mandates" - particularly the conservative ones.
3. Who is leading the bill. Apparently this is important, though I haven't yet figured out why. So they can decide based on if they like or hate that person?


I highly recommend attending an advocacy day in your state if you ever hear about one. They trained us on our talking points, split us into groups for who would see which people, and gave us food and things to hand out to the representatives and their aids. Seeing the busy in-session house of representatives and senate was lots of fun - basically they just leave their doors open all the time so anyone can come try to catch them and talk to them. There are people walking around all over the place! And, we got to go inside and walk around on the House floor. Great fun!


The March of Dimes - March for Babies is coming up! If you haven't already, I highly recommend that you either sign up to walk or find someone who is walking and donate to them. This will be my third year participating!

Moving Videos

I've seen a few powerful, moving videos in the past week that I'd like to share far and wide. So, for your Weekend Movie viewing pleasure...

This is My Body
or, as Upworthy called it, "These Women Are About to Tell You Some Things That Are Absolutely None of Your Business"


I wish I were as eloquent. Some of these monologues are so amazing!


Same Love


Pay attention to the lyrics, they're really good.


One Billion Rising


One Billion Rising is a worldwide movement to stop violence against women and girls, because 1 in 3 women on the planet will be raped or beaten in her lifetime. It is a celebration of the 15th anniversary of V-Day.

Enjoy!
And let me know what you think!

Short Link Roundup

A News story illustrates how Patriarchy works in Subtle ways
Florida Man Accused of Fraud After Adopting His Wife's Last Name 
"The man says he followed the same process that a woman would follow to change her last name after she got married, but was later told that that process is "only for women" and that he has to go through a much more time-consuming and expensive process if he wants to legally change his name."
The blogger says only nine states have gender-neutral marriage name change laws.


How "Personhood" Strips Mothers of their Fundamental Rights
I really liked this series on Spirt of Ilithyia blog about how "personhood" (the idea that the fetus holds equal or sometimes greater rights than the woman carrying it) issues affect birthing women's rights (not just women who want abortions).
"Stories ranged from forced c-sections to prosecution for homicide for actions a pregnant woman took during her pregnancy to murder charges for miscarriage."


There is a new study out with data on Birth Center births!
Because I'm in public health, I'm really into the data, and what it means for maternity care. 

94% of these women ended up with vaginal births (this c-section rate of 6% compares favorably to the national rate of 27% for low-risk women), and 84% of the total sample gave birth at the birth center. Of the 16% that did not, some were referred to the hospital prior to labor, some during, and some after birth. 

Less than one percent of the study sample transferred to the hospital during labor for emergency reasons. There were no maternal deaths. Rates for infants (0.047% stillbirth and 0.04% death within the first 28 days of birth) are consistent with the results of several previous studies of low-risk women that included births at hospitals, birth centers, and home. 

The “bottom line” is that birth centers offer “high-quality, family-centered care with a Cesarean rate of approximately 6%” and a lower than 2% urgent transfer rate (for either mother or baby).

Rebecca Dekker wrote an 8-pg analysis of the study, and here is some additional information I find interesting: 

• About 75% of the women were white 
• Women were cared for by certified nurse-midwives (80%), certified professional midwives and licensed midwives (14%), or teams made up of all three types of midwives (6%)
• 85% were between 18 and 34 years of age
• The researchers estimated that, in this study, more than $30 million was saved because of the 15,574 women who chose to give birth in birth centers.

What this means is that birth centers provide low-risk pregnant women with safe care at a fraction of the  cost of the hospital, with a C-section rate that is 4 times lower in the same population. 


Shakira had a baby!
I admit, I love Shakira. Various news stories have said that she had a C-section and she is breastfeeding.


In personal news, I turned in my first draft of my thesis, I graduate in 3 months, I'm interviewing with some doula clients and I'm looking for jobs!

Your Zip Code Determines Your Health

"Your zip code shouldn't determine how long you live, but it does."

There are "vast differences in life expectancy that can exist from one zip code to the next."

"If you're lucky enough to move to a neighborhood with a grocery store, safe parks and good schools, your health will improve."

Inequities in health must be assessed and addressed on a local level, whether by region, city, neighborhood or even block-by-block.

WHO Code, No Nestle, Conflict of Interest

Recently, news broke that the World Health Organization accepted money from corporate sponsors such as fast giants, such as Nestle, to fund its obesity-fighting campaigns. Oh, the irony.

A Reuters investigation found that WHO's regional office has turned to the very companies whose sugary drinks and salty foods are linked to many of the maladies it's trying to prevent.
The office, the Pan American Health Organization, not only is relying on the food and beverage industry for advice on how to fight obesity. For the first time in its 110-year history, it has taken hundreds of thousands of dollars in money from the industry.
Accepting industry funding goes against WHO's worldwide policies. Its Geneva headquarters and five other regional offices have been prohibited from accepting money from the food and soda industries, among others. 

This is a conflict of interest - Food and beverage companies donating money to nonprofit groups that are fighting the very diseases that their products have helped to create. The WHO is unwilling to accept money from tobacco agencies, why should this situation be different? 

The news went viral, and social media users began to tweet their outrage:

From the article on Breastfeeding Science Outrage sparks Twitter battle between UN health watchdogs WHO, PAHO:

After fighting industry for years to uphold an international code to protect moms and babies from predatory marketing, there was outrage when it was learned PAHO accepted $150,000 from Nestlé. This is a direct violation of what is known as the WHO Code and moms and breastfeeding support workers are furious.

No Nestle
Nestle violates the WHO/UNICEF International Code of Marketing Breast-milk Substitutes, which it agreed to abide by in 1984. Nestle unethically markets infant formula to poor mothers in developing countries, where babies are more likely to suffer and die from gastrointestinal issues caused my feeding their babies formula (often with un-clean water) than breast milk (which protects the baby from illness). They promote infant formula unethically, providing gifts to health providers to promote their product, and they distribute free formula in hospitals (disrupting lactation) which poor families must then continue to pay for after there are no more freebies. (Click for more on the Nestle boycott)

Using Social Media for Powerful Change
The Lactation Matters blog, in the post  World Wide Impact in 10 Minutes or Less: Using Social Media for Powerful Change, wrote that the WHO began to respond to tweets:

Breastfeeding Science posted a tweet where PAHO responded to the WHO, but interestingly, it has been deleted from their Twitter page. PAHO does have different standards than the WHO regarding business partners, and they have been cash-strapped on programs dealing with obesity due to budget cuts.

Clearly, social media can have an impact. As Anthropologist Margaret Mead is famously quoted “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.” 

Join the conversation!
1. By joining the Facebook group Friends of the WHO Code and 
2. Tweeting about it! This is one example of how Twitter can be really useful. If you have a twitter account, just copy and paste:


#WHOCode protects women&babies from predatory marketing. Shame @Nestle for trying to buy seat at the @PAHOWHO table #nonestle #breastfeeding

Tell @PAHOWHO to give back @Nestle $150K #nonestle #WHOCode #breastfeeding #conflictofinterest http://t.co/nnWJCIfX @WHO

We will not be bought! @PAHOWHO please return the money to @nestle Stand up for mothers and babies. #WHOCode #breastfeeding #nonestle

Regulation
It is important to note that the WHO has no regulatory authority, and many nations lack legislative reinforcement. So while this is a conflict of interest, pressure on PAHO and especially Nestle may be the biggest ways to have an impact. Don't let this move undermine the Code. 

World Prematurity Day

Did you know that no one knows why some babies are born premature? The exact cause remains unknown. 

Some things are associated with the risk of preterm labor and birth, but correlation does not equal causation. These include infection, placental abruption and bleeding, multiples, a short cervix, and too much amniotic fluid. Young or old mothers are at increased risk, as are women who have had a previous preterm birth. It has also been associated with women who are unmarried, low-income, and African American.

EDIT: I just found a recent study published in the Lancet that found that the following five interventions can reduce the preterm birth rate from about 9.6% of live births to 9.1% and save $3 billion in the process:

1.Discouraging elective C-sections and labor inductions unless there’s a compelling medical reason
2. Reducing the number of embryos transferred during fertility treatment
3. Helping pregnant women give up smoking
4. Providing women with high-risk pregnancies with progesterone supplementation
5. Performing cervical cerclage, a minor surgical procedure, on pregnant women with short cervixes

Many people don’t realize the statistics of preterm birth: 15 million babies are born preterm around the world every year—that’s 1 in 10. More than 1 million babies die due to complications of preterm birth and many of those who survive face a lifetime of disability.

The U.S. map is looking a bit different than it was last year. This year there is more than 1 state that has an "A"! But, the same four states still have an "F"

March of Dimes 2012 U.S. Premature Birth Report Card

Learn about Premature birth all over the World:




The World Prematurity Day facebook page has some pretty photos posted from other countries for World Prematurity Month:

N Ireland

Brazil

Macedonia

Slovakia

Once Upon a Birth

Have you heard about Merck's Campaign to improve maternal health and save women from dying for giving life - Merck for Mothers?

Their new effort, "Once Upon a Birth," is a campaign to raise awareness about maternal health and help prevent the deaths of some 800 women around the world who die during pregnancy and childbirth every day. Melissa Joan Hart is the spokeswoman for this campaign, and shared her birth story on the Merck for Mother's Facebook page.

For every person who shares their birth story, a monetary donation will be made to Join My Village, which is a charitable initiative that helps women and girls through education, and supports safe pregnancies and deliveries. These deaths are preventable - family planning, access to health care that can recognize preeclampsia, or timely treatment for postpartum hemorrhage!

All you have to do is share your birth story! Or, if you don't want to go through Merck, there are ways to help Join My Village directly. 



This video is our way of highlighting the urgent issue of maternal mortality and demonstrating how we hope to improve the health of women during pregnancy and childbirth.

I think this is a great video, but I disagree with one aspect... I don't think research into more technologies is what is needed to save the lives of these mothers. I think it's access to quality care, reduction in structural violence, improvement in the lives of the poor and the marginalized. Gender equality, improved transportation, food, etc. Health policies that improve the social and ecological factors that keep people in poor health.

Birth by the Numbers

I just realized that I've never posted this fabulous video on my blog before! It's not a new one, but it is classic. I refer to this all the time, and it was also shown in one of my MCH courses.

Epidemiologist Eugene Declerq examines Birth by the Numbers. First he discusses the neonatal, perinatal, and maternal mortality rates and how the United States continually ranks low compared to other countries. Then he moves onto Cesarean section rates compared to other nations and in what situations it is life-saving, and what situations it is actually harmful. 

Then he focuses on the U.S.'s c-section rate. I love this video because he addresses the falsity that the rising cesarean rate is attributable to upper-middle class white mothers choosing elective cesarean sections. These exist, but it's a very small percentage, and is not driving the increase in c-sections. 

It's also not the case that U.S. mothers are more high risk than other mothers. 

The video is about 22 minutes long, but it's worth a viewing. 

So what is the reason for the increasing cesarean rates? Provider practice changes.

Truth be told, mothers are feeling pressured to have a cesarean by their care provider. They're scheduling more women for inductions, which increase risk for surgery. Providers are lowering their threshold for "medically indicated" c-sections. They fear the tiny percent possibility of something going wrong, and the possibility of a lawsuit. C-sections are more convenient for doctors who want to make it home in time for dinner. 

Don't believe me? Listen to the data, and watch the video above!

 

 

Breastfeeding and the Working Mom

I recently attended an occupational health presentation entitled "Breastfeeding and the Working Mom: The Impact of Perceived Breastfeeding Support at Work on the Well-Being and Job Attitudes of Women"

This was a presentation on a study from an occupational health and psychology perspective. The presenter, Dr. Bruk-Lee, explained that much of the research on women pumping at work focuses on evaluating lactation programs and their effectiveness, and the work-family conflict interventions/policies. The purpose of her particular study was to investigate the impact of perceived breastfeeding support at work on the job attitudes and psychological well-being of women who express milk at work.

Psychological 'well-being' encompassed burnout, postnatal depression, work family conflict, and job satisfaction. 'Job attitudes' related to performance, turnover, commitment, counterproductive behaviors, and organizational citizenship. Breastfeeding support came either from the organization (policies, physical accommodations, etc), or from supervisors and co-workers.

Interestingly, 82% felt they could often or always express all of the milk the baby required during the workday. 62% reported no company designated place for women to breastfeed or pump (and these were women in a variety of professions and settings). Reasons they stopped expressing breast milk (on average when babies were 33 weeks old): 54% personal choice; 26% employer; 14% supervisor; 6% health care provider.

Organizational policies affect more than breastfeeding duration, i.e. psychosocial work environment and performance. What the study concluded overall was that co-workers/supervisor support was more important for levels of well-being and good job attitude than the organizational support (like physical spaces to pump). Breastfeeding support offered by supervisors and coworkers was a stronger predictor of outcomes than other forms of support.

Much of the focus on improving breastfeeding support for working moms is targeted at adding reasonable break time for moms to express milk and the provision of a private non-bathroom space in which to do so. This is important, but this study shows that this organizational support is not as effective at improving mom's psychosocial well-being, work performance, turnover rates, etc as coworkers and supervisor social support.

So what can be done? What should we be doing to improve this aspect of work support? Giving workshops on lactation? That might never happen in most work environments.
The presenter had no solutions. The answer is basically that it will take cultural change, which takes time. But we clearly can't remain focused solely on the physical space. Perhaps, though, having a space, and breaks times, etc, will make it more the norm, which will contribute to changing attitudes about expressing milk at work.

What are your thoughts?

Does Choice Matter?

For more than 55 years, Pathfinder International has worked to expand access to quality sexual and reproductive health care to enable and empower individuals to make choices about their body and their future. 

At Pathfinder, they believe choice is everything. When people take charge of their life choices such as if or when and how often to have children, they gain confidence and strength. They can better pursue their education, contribute to the local economy, and engage in their communities. 

Pathfinder International has a new video to share:



No Joke. Choice Matters. Everywhere. 

The video is funny, but the circumstances are not. More than 220 million women still lack access to contraceptives.
 

Can you imagine walking 18 miles to get contraceptives? Or being told your clinic is out of stock? It seems absurd right? But in many countries, this happens every day. Doctors are overworked, under supported, and stressed out. Women struggle to care for their large families and access the services they need, sometimes waiting hours, even overnight to visit a clinic.

We try to make it funny in this video but the reality is no joke. Choice matters about if, when, and how often to have children; choice matters about getting tested for and STI or HIV; choice about sexual and reproductive health matters for all women, everywhere.
 

Even here in the United States, we see barriers to reproductive choice. However, oftentimes those barriers are even more challenging in developing countries. Shannon Wu, one of our donors said, “Most women in America have access to knowledge and health care when it comes to their sexual and reproductive life. But in other parts of the world, women’s health is almost always the last thing to be discussed or taken care of, if at all.”

Right now more than 220 million women want, but lack access to contraceptives. One woman dies every 90 seconds during pregnancy or childbirth because she lacks access to maternal care. And HIV is the number one cause of death for women of reproductive age in the developing world.

If you want to change these numbers, and improve the lives of women, take a simple action now: share the video. Help start an important conversation with your friends, family, girlfriends, boyfriends, husbands, wives, colleagues that reproductive health care is no joke. 

Choice matters. 

Want to help Pathfinder International spread the word? 

Sample Tweets or Posts:

• Do you know anyone who has waited an entire day in for #reprohealth appt? It happens in many countries WATCH: http://pathfinder.org/notfunny
• Do u agree ALL women deserve access to #contraception?  Watch video to see barriers many women face. http://pathfinder.org/notfunny #ChoiceMatters
• Around the world women face barriers to basic #familyplanning VIDEO http://pathfinder.org/notfunny Let’s remove barriers! #ChoiceMatters