The Trial of Labor

I was irritated to discover that Time magazine published an article entitled “Choosy Mothers Choose Cesareans” in their special Environmental Issue. Since cesarean surgery is an over-used procedure[1], it is quite inappropriate for this type of article to appear along-side articles dealing with the Presidential candidates’ climate change positions and how the US can be more green.  Needlessly consuming medical services is anything but green, and Time magazine should take responsibility for its poor choice in content.

According to the article, more women are choosing cesareans, a trend doctors expect will continue.  I do not know nor have heard of anyone actually choosing a cesarean, save the stories I read or hear about through the media.  I believe that the media is creating this belief that women choose cesareans, and that this is a trend we should expect to see continue.  But perhaps it is true that women are choosing major surgery for reasons cited, such as (1) fear of ripping/tearing the perineum, (2) fear of incontinence, (3) fear of pain, (4) fear of birth, (5) or fear of having a stretched-out vagina.  Time’s article feeds into the misperceptions of birth generated by Hollywood blogs and reality shows like A Baby Story.

Fear of ripping/tearing:  from what I have learned over the years, women rarely rip or tear during childbirth if they push following their body’s signs, are given appropriate time to labor and birth their babies, and/or have the perineum massaged or supported during pushing.  Episiotomies can cause more damage to the perineum, vagina, and anus than a natural tear anyway.  I wonder if this fear stems from botched episiotomies?

Fear of incontinence: cesarean delivery does not prevent incontinence.  Sorry!

Fear of pain: I wonder why so many women are taught to fear the pain of childbirth.  Granted labor was one of the most challenging things I have ever done, but I think my exercise habits and outdoor enthusiasm (road biking, hiking, backpacking, running) had prepared me for childbirth.  I don’t look back on my labor and regret the pain - I regret the fact that a cesarean became necessary.  Anyone who has done a little bit of study on the purpose of pain in childbirth can tell you that it is actually beneficial - it can indicate problems that need attention as well as provide important feedback to the mother and her careproviders regarding her progress.

Fear of birth: there actually is a term for women who have a fear (phobia) of childbirth - lockiophobia.  If a woman is not phobic, then she should work with a psychologist or psychotherapist to determine the root causes of her fear and overcome those.  Pregnancy can bring up psychological pains of the past, but they are not avoided through cesarean surgery.

Fear of a stretched-out vagina: do I really need to address this?

The title of my post suggests that cesareans will limit future choices.  This is true - women who have had a cesarean are at risk of being pressured into repeating surgery for future births, have a slightly more elevated risk of uterine rupture and other poor birth outcomes, are unable to have normal birth at most birth centers [2], may not be able to have a normal birth at their local hospitals [3], will be pressured to comply with hospital protocols that may lead to interventive birth outcomes for future births, may have difficulty finding providers who will support their choices in future births to name a few limitations.

Other things you may not know about cesarean aftermath [4]

1. Risk of post-partum depression and post-traumatic stress disorder
2. Negative impact on breastfeeding, bonding, and other key mammalian birth-related processes
3. Stillbirth, miscarriage, infertility
4. Pain, adhesions, slow recover, unsightly scaring
5. Negative impact on relationships with other family members, particularly partners/spouses
6. Rejection of birth - some women choose to never have another baby because they don’t want to go through surgery again; some women don’t feel like they gave birth; some women equate cesarean birth with “birth rape“

Thankfully I have come to learn about the viability and appropriateness of vaginal birth after cesarean.  I was encouraged to subscribe to the ICAN Yahoo list where I learned much of what I know now about birth that I didn’t know before my daughter was born.  I know the dangers of choosing cesarean for the first, second, or fifth time.  I have experienced stress, depression, and other tangible and intangible outcomes related to cesarean surgery.  I worry that my current trouble with recurrent pregnancy loss is related to the cesarean.  I resent that I have to consume more medical services to rule out uterine defects caused by the cesarean.  Tomorrow I will have a hysterosalpinogram performed.

It is regrettable that women such as Ms. Chung are led to believe and accept that cesarean birth is risk free, complication free, and consequence free.  It is simply not the case, and it does not take more than 30 seconds with an internet search engine to learn that much care should be taken when deciding if cesarean surgery is right for a woman and her baby.  The March of Dimes states that cesarean surgery should only be performed when the mother’s life or baby’s life is at risk.  Cesarean surgery is a blessing when used appropriately, but its safety is not justification for indiscriminate use.

[I sent a slightly abridged version of this post to Time magazine's Editor.]

[1] The World Health Organization maintains that an acceptable rate of birth via cesarean surgery is 10-15%.  When the cesarean rate exceeds this range, the risks outweigh the benefits.
[2] To read the AABC’s recent statement on VBACs at birth centers, click here.
[3] Go to http://www.ican-online.org to see if your hospital allows VBACs.
[4] See also http://www.childbirthconnection.org/article.asp?ck=10166; read ICAN’s book, Cesarean Voices to learn how cesareans have impacted real women and real babies.

In about an hour I will be interviewed for a local news station regarding Montana’s cesarean rate.  I don’t know much more than that.  The reporter has a young child.  The reporter is supposed to be meeting with a local hospital official.  Other than that, who knows what her focus will be.  In anticipation of this interview, I decided to review some things that I have read and wrote regarding cesarean rates.

With regard to rates, it is important to consider that the US cesarean rate (2006, preliminary) is 31.1%.  The rate has increased by 50% since 1996.  The rate recommended by the World Health Organization is 10-15%.  Once the cesarean rate exceeds 15%, the risks (statistically speaking) outweigh the benefits.  The Montana cesarean rate (2006, preliminary) is 28%, nearly a 3% increase from the year prior.  According to a source at the local hospital, our local rate is around 31%.  I was told that only 16 VBACs took place in 2006 at my hospital.  (A local CNM questioned the accuracy of the VBAC figure, suggesting that VBACs were under-reported.)

I can list many contributing factors to the continued increase in the cesarean rate:

• Medico-legal concerns on the part of doctors, hospitals, and insurance providers (it’s HUGE, actually)
• “So and so had a cesarean . . .”
• Hollywood stars having elective cesareans
• Young and underpriviledged mothers are more at risk for cesarean surgery
• An unchecked trust in care providers - most women do not seek second opinions when it comes to maternity services
• Sensationalization of birth - Baby Story and OR Live come to mind
• Society - our view of birth has changed; the culture of fear has spread to childbirth
• Cesareans ARE more safe now than they ever have been

Of course I’ll direct the reporter to resources such as:

• ICAN
• The Mother-Friendly Childbirth Initiative
• Childbirth Connection
• Conscious Woman

Last Friday one of my students presented me with a potted mini rose bush.  I assumed it was a gesture related to my recent miscarriage, but actually it was a gift in celebration of International Women’s Day (3/8/08).  International Women’s Day?  I had never heard of such a thing, but in my student’s home country, it is customary to present women with flowers on IWD.  I was glad she chose a potted flower!

My last post listed the top 10 countries for being a woman according to the UN Development Programme.  The US (12) did not make the list, but neither did the UK (16), Mexico (52), my student’s Ukraine (76), or Germany (22). [1]  In the course of looking up the data I found Kemal Dervis’s statement for International Women’s Day.  The theme is “Investing in Women and Girls.”  Dervis states that this theme “is about changing the systems and attitudes that discriminate against women and prevent them from fully participating in and benefiting from the economies and societies in which they live.”  How do we plan to honor this goal in the US?  How can we tackle important women’s issues in our communities?  How will we positively influence local, statewide, and national political trends to discuss and improve the lives of women and girls in the US?

Are you “unseen” in your community or recognize women at risk in your community?  Do something proactive!  Whether it’s starting a support group, mentoring teen moms, taking a meal to a family or friend in need, picketing City Hall, raising legislative awareness, or even simply smiling at a woman or girl who looks like she needs it, you can make a difference. 

[1] UN Development Programme, Human Development Report 2007/2008, GDI Rank

BEST COUNTRIES TO BE A WOMAN

Measures of well-being include life expectancy, education, purchasing power and standard of living. Not surprisingly, the top 10 countries are among the world’s wealthiest.

1. Iceland
2. Norway
3. Australia
4. Canada
5. Ireland
6. Sweden
7. Switzerland
8. Japan
9. Netherlands
10. France

SOURCE: UNDP Gender-related development index

Hmm . . . it seems like there’s a country missing off of that list.  Wait . . . oh yeah, it’s the good old U.S. of A.  Ask your congressional leaders what they are doing to improve well-being for women in the US.

Here is something that ICAN’s Advocacy Director is asking the membership to accomplish - find out the status of VBAC in hospitals across the country.

Gretchen of “Birth Matters” writes:

The VBAC ban project is finally up and running! What is this you ask? Well, simply put, we are going to call every hospital in the U.S. and find out what their policy is on VBAC. The International Cesarean Awareness Network did this a few years back and found out that over 300 hospitals officially “ban” VBAC (even though this is patently illegal). Needless to say, we are sure the situation is much worse now. But, the cool thing is that ICAN is about to launch a fantastic new website and included on that website is a map of the U.S. upon which every one of the hospitals we call will appear….with information about that hospital and its policies on VBAC. AND, there will be a way for anyone to leave feedback about that hospital, so you can see what other women experienced there. But, in order for this to happen, we need people to call! So if you are interested in helping out, please email me at advocacy@ican-online.org and I’ll get you set up and going.

Help ICAN shine the light into the oppression that so many hospitals are inflicting on women.

For those of us in Montana, it looks like the MHA website can be of assistance, especially their map and their contact list. 

In September I posted twice about local birth statistics.  You can read them here and here.  Since the CDC released a preliminary report for 2006, I thought I should review some interesting data from 2004 and 2005 (source).

Montana (state-wide) cesarean rates:
2004 - 25.3%
2005 - 25.7%
2006 - 28% (preliminary estimate)
I find it interesting that 85% of Montana cesareans in 2004 and 86% of cesareans in 2005 took place in counties with 100,000 or more residents.  Granted, high-risk pregnancies would transfer to larger hospitals and might be more susceptible to cesarean delivery.

Montana (state-wide) VBAC rates:
2004 - 1.4%
2005 - n/a
2006 - n/a (yet?)
I’m not sure why the CDC didn’t provide the 2005 VBAC figures.  Could it be that VBAC is so rare that it was statistically insignificant to report?

Only 16 VBACs took place at Missoula’s Community Hospital in 2006.  That was about 1% of their live birth population.  Yikes!  Double yikes when you consider that Community is one of a small handful of hospitals across the state that still allow VBACs.

Place of delivery (2005):*
57 of 1850 births in Missoula County took place outside of a hospital.  And I’m not sure that the Birth Center was even up and running at that time.  This accounts for 3.1% of the live birth population.  This slim percentage is at least twice the national average, from what I’ve heard.
44 of 240 births (18.3%) in nearby Ravalli County took place outside of a hospital.  Now I call that statistically significant!
The state out of hospital rate was 2.5%.

Although Montana’s cesarean rate is a few percentage points below the national average (estimated at 31.1% in 2006), it still greatly exceeds the recommended level of 10-15% established by the World Health Organization.  Cesarean rates above 15% reflect an abuse of the life-saving medical procedure.  Cesarean surgery is a major abdominal surgery with its own tangible list of risks.

* Data obtained from Montana’s Department of Health and Human Services

Today I was informed that the CDC released preliminary vital statistics for 2006 which includes state-by-state cesarean birth information.  Here in Montana the 2006 cesarean rate was 28%, earning us a rank of number 37 (of 51).  The national cesarean rate was 31.1%, an all-time high.  Although Montana was 3 percentage points below the national average, the rate still exceeded World Health Organization (WHO) recommendations by 13-18%!  The WHO determined that when cesarean rates exceed 10-15%, the risks of the surgery outweigh the benefits.  It is my understanding from a recent discussion with a hospital administrator that Community Hospital’s (Missoula) cesarean rate exceeded 30% in 2006.  Missoula’s cesarean rate is headed in the wrong direction. 

As a woman with one cesarean scar, these statistics are frightening.  Is cesarean birth becoming “normal” birth?  If one out of three babies is born through major abdominal surgery, then yes, I’d say the norm is swinging that direction.  You need to know that the percentage of birth by cesarean has risen 50% in the past decade.  This is straight from the horse’s mouth!  You also need to know that Montana’s VBAC (vaginal birth after cesarean) rate in 2005 was only 1%. 

For the second year in a row, ICAN has compiled a list of research from the past year that shows cesarean surgery should be used more judiciously and that VBACs should be routine/normal.  Currently, more than 300 hospitals across the U.S. ban women from having a VBAC, essentially coercing them into unnecessary surgery and feeding the growing rate of cesarean.  Very few Montana women have access to vaginal births after cesarean sections.  Only a handful of hospitals across the state allow VBACs – one of those hospitals is Community Hospital in Missoula

In August, the Centers for Disease Control released a report showing that, for the first time in decades, the number of women dying in childbirth has increased.  Experts note that the increase may be due to better reporting of deaths but that it coincides with dramatically increased use of cesarean.  The latest national data on infant mortality rates in the United States also show an increase in 2005 and no improvement since 2000.  ”At a time when maternal and infant mortality rates are decreasing throughout the industrialized world, the United States is in the unique position of having both a rapidly increasing cesarean rate and no improvement in these basic measures of maternal and infant health.” says Eugene Declercq, Ph.D., Professor of Maternal and Child Health at Boston University School of Public Health.

Another report released in October by the World Health Organization, the United Nations Population Fund, the U.N. Children’s Fund, the U.N. Population Division and The World Bank, and published in the Lancet shows that the U.S. has a higher maternal death rate than 40 other countries.  “Women in the U.S. think they’re getting top notch care, but our death rate for mothers shows otherwise,” says ICAN’s President, Pamela Udy.  The U.S.’s maternal death rate tied with that of Belarus, and narrowly beat out Bosnia and Herzogovena.

Research from 2007 also shows that VBAC continues to be a reasonably safe birthing choice for mothers. “The research continues to reinforce that cesareans should only be used when there is a true threat to the mother or baby,” said Udy. “Casual use of surgery on otherwise healthy women and babies can mean short-term and long-term problems.” For women who encounter VBAC bans, ICAN has developed a guide to help them understand their rights as patients. The resource discusses the principles of informed consent and the right of every patient to refuse an unwanted medical procedure. Click here for a pdf copy of this important resource.

Women who are seeking information about how to avoid a cesarean, have a VBAC, or are recovering from a cesarean can visit www.ican-online.org for more information, to find a local chapter, and to receive support.

About Cesareans: ICAN recognizes that when a cesarean is medically necessary, it can be a lifesaving technique for both mother and baby, and worth the risks involved. Potential risks to babies include: low birth weight, prematurity, respiratory problems, and lacerations. Potential risks to women include: hemorrhage, infection, hysterectomy, surgical mistakes, re-hospitalization, dangerous placental abnormalities in future pregnancies, unexplained stillbirth in future pregnancies and increased percentage of maternal death. http://www.ican-online.org/resources/white_papers/index.html Mission statement: ICAN is a nonprofit organization whose mission is to improve maternal-child health by preventing unnecessary cesareans through education, providing support for cesarean recovery and promoting vaginal birth after cesarean. There are 94 ICAN Chapters across North America, which hold educational and support meetings for people interested in cesarean prevention and recovery. 

My Google Alerts keep me more current on traditional news and weblog posts regarding childbirth, VBACs, and cesareans.  Two alerts from the same source, The Daily Mail (UK), piqued my interest today.

First, an article about pelvic floor surgery entitled “The pelvic prolapse operation that gives women their lives back after childbirth.”  I am sure that living with pelvic prolapse is quite challenging, and it seems as though this particular woman featured in the article dealt with pelvic floor dysfunction from an early age, so the title of this article is misleading.    The patient claimed that she sometimes wet herself as a child when sneezing, coughing, or laughing.  Clearly, in this case the woman suffered a degenerative problem that began in childhood and became more pronounced during the childbearing years.  Childbirth did not cause her incontinence.  She was “disappointed” that the physician’s first recommendation was to do pelvic strengthening exercises instead of offering surgery.  I just don’t understand why people are so quick to want surgery.  She now has pig parts sewed to her innards . . . (shudder)  I did post a comment on the article and hope that it will be published.

Another article brought my attention to a new study just published in the American Journal of Epidemiology: “Association of Fewer Hours of Sleep at 6 Months Postpartum with Substantial Weight Retention at 1 Year Postpartum” by Erica Gunderson et al.

Here is the study abstract:

Shorter sleep duration is linked to obesity, coronary artery disease, and diabetes. Whether sleep deprivation during the postpartum period affects maternal postpartum weight retention remains unknown. This study examined the association of sleep at 6 months postpartum with substantial postpartum weight retention (SPPWR), defined as 5 kg or more above pregravid weight at 1 year postpartum. The authors selected 940 participants in Project Viva who enrolled during early pregnancy from 1999 to 2002. Logistic regression models estimated odds ratios of SPPWR for sleep categories, controlling for sociodemographic, prenatal, and behavioral attributes. Of the 940 women, 124 (13%) developed SPPWR. Sleep distributions were as follows: 114 (12%) women slept 5 hours/day, 280 (30%) slept 6 hours/day, 321 (34%) slept 7 hours/day, and 225 (24%) slept 8 hours/day. Adjusted odds ratios of SPPWR were 3.13 (95% confidence interval (CI): 1.42, 6.94) for 5 hours/day, 0.99 (95% CI: 0.50, 1.97) for 6 hours/day, and 0.94 (95% CI: 0.50, 1.7 for 8 hours/day versus 7 hours/day (p=0.012). The adjusted oddsratio for SPPWR of 2.05 (95% CI: 1.11, 3.7 was twofold greater f(p=0.02) for a decrease in versus no change in sleep at 1 year postpartum. Sleeping 5 hours/day at 6 months postpartum was strongly associated with retaining 5 kg at 1 year postpartum. Interventions to prevent postpartum obesity should consider strategies to attain optimal maternal sleep duration.

The only way I found more sleep was to cosleep.  My daughter did not sleep for long periods of time by herself.  We weren’t initially comfortable with the idea and fell into it out of necessity.  I am thankful that my daughter is now happily in her own bed, but I miss sleeping with her.  I am so glad that we had that special time together because it all goes by so fast.  I will say that I lost my pregnancy weight fairly quickly, so perhaps there is a relationship between sleep and weight retention/loss.  “Strategies to attain optimal maternal sleep duration”?!  Ha!!

I am glad to see more attention being given to the problem of artificial rupture of membranes (AROM), also known as amniotomy.  I am encouraged to see this because I believe AROM is what lead to my unnecesarean.

Authors’ conclusions (Cochrane Review, July 13, 2007)

On the basis of the findings of this review, we cannot recommend that amniotomy should be introduced routinely as part of standard labour management and care. We do recommend that the evidence presented in this review should be made available to women offered an amniotomy and may be useful as a foundation for discussion and any resulting decisions made between women and their caregivers.

[Click here to read the review abstract.]

A few articles in the press that piqued my interest:

Childbirth: purposely breaking water does not speed delivery - New York Times
“We advise women whose labors are progressing normally to request their waters be left intact,” said the lead author, Dr. Rebecca Smyth, a research associate at the University of Liverpool. “There is no evidence that leaving the waters intact causes any problems, and there is not sufficient evidence to suggest any benefit to either themselves or their baby.”

In labor, breaking a woman’s water may be futile - Los Angeles Times
“The hormones in the amniotic fluid have been thought to stimulate contractions, but not only does an amniotomy fail to speed up and strengthen labor, it also fails to improve a woman’s satisfaction with the birth experience, an analysis by the Cochrane Review found. Nor does it result in the baby being in better condition after birth.”

Don’t ‘Break the Waters’ During Labor Without Good Clinical Reason, Concludes Cochrane Review - Science Daily
“This Cochrane Systematic Review found that breaking the waters may be associated with a slightly (non-significantly) higher rate of Caesarean section. Breaking the waters may cause changes in the baby’s heart rate.”

Breaking waters not needed in routine births - Globe & Mail
“Yet many medical centres perform amniotomy for routine deliveries. One Toronto hospital does it for 80 per cent of the births under its roof.”
[The "annoying cough" begins a new brief and is not related to this discussion.]

Review Finds That “Breaking the Water” Does Not Speed or Help With Labor - Health Behavior News Service
“However, several American doctors said the findings are unlikely to change the way obstetricians help women give birth in the United States. “Most of us believe it works, so there will be a lot skepticism about this,” said Mark Nichols, M.D., professor of obstetrics and gynecology at Oregon Health & Sciences University.”

The Cochrane Group is an international independent non-profit organization whose goal is to help people like you and me make better-informed decisions about healthcare and interventions.  Archie Cochrane was a British epidemiologist and is the organization’s namesake.  The Cochrane Collaboration was founded in 1993.

In Born in the USA, Marsden Wagner hails the Cochrane Library as “a frequently updated, highly respected electronic library of reviews of the scientific evidence on different obstetric practices”.  Know that doctors (such as Mark Nichols, the man quoted in the Health Behavior News Service bulletin) don’t always practice evidence-based care.  They often “follow the crowd” (ACOG) or repeat unnecessary procedures just because “they work”.  My response to that style of practice is that it is unethical, unfounded, reckless, irresponsible, subversive, and the list of negative modifiers could go on and on for hours.  We all know that cesareans “work”, for instance, but that does not mean that even a significant minority (30% of all live births for example) should be undergoing this procedure.  “It works” is not acceptable.

Something else you should know about the Cochrane group is that several members produced a textbook called A Guide to Effective Care in Pregnancy and Childbirth.  You can download this book  for free from Childbirth Connection.  This is an amazing resource!

These sorts of stories are so common and so infuriating . . .

A fellow ICAN lister posted a recent conversation with a midwife regarding VBA2C (VBAC after 2 cesareans).  The midwife didn’t really even know VBAC rates and quoted this woman a rupture rate of “um, I think like 6-8%” for VBA2C.  Where did she get that statistic?  I’m thinking it came from her . . . “um”.

The midwife called her back shortly thereafter to give her the ACOG act:  Rupture rate for VBAC after one cesarean is 1-3% and after two cesareans the risk is (supposedly) 5 times greater, somewhere in the amorphous neighborhood of 5-17%.  Was this woman given any references?  Well, no of course not.  You have to ask them, and then watch them squirm, and then of course they don’t have that information readily available.  Give us a primary author for chrissake!  Can’t you at least remember an author?  Or is your “author” ACOG?  ACOG the trade union.  ACOG is NOT a research-based college.  The fact that “college” is in their name makes me sick.

Luckily for women across the country and all over the world, there exist numerous evidence-based transparent resources for women who would otherwise get cut.  I talk about them here like a broken record, but it’s necessary.  Again, here’s where I recommend you start:

• International Cesarean Awareness Network
• Childbirth Connections
• Coalition for Improving Maternity Services
• Planning a VBAC (one woman’s collation)
• Plus Sized Pregnancy’s (for ALL women not just plus size) VBAC/Cesarean information

If your care providers aren’t aware of these organizations (ICAN, CIMS, Childbirth Connections), please refer them to these sites.  And here is one recent study that they should have read already:

Landon, MB et al.  “Risk of uterine rupture with a trial of labor in women with multiple and single prior cesarean delivery.”  Obstetrics and Gynecology.  July 2006;108(1):12-20.