International Women’s Day: Investing in Women and Girls

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

Contrast these homebirth news stories!

I have followed homebirth legislation news in Utah and South Dakota with interest and concern.  I don’t want Montana getting any stupid ideas. 

UtahI blogged about their nonsense recently.  Yesterday, the Utah Senate voted to restrict homebirth practices.  The bill was supposed to have been a compromise, but what resulted was something restrictive and punitive.  Women will be forced to attempt VBACs in hospitals or on their own.  Were this the case in my state, I would have an overwhelminly large chance at “failure” since my hospital’s VBAC rate is a pitiful <1%.  They only had 16 successful VBACs at the hospital in 2006.  Utah legislators have chosen a path that makes homebirth less safe.  To search for Senate Bill 93, click here.

South DakotaI also blogged about their homebirth “situation,” and it appears that both the SD House and Senate have approved a homebirth bill. 

The bill would require midwives to become registered nurses, get master’s degrees in nursing, and pass additional tests. Certified nurse midwives wanting to attend home births would need approval of both the Nursing board and the Board of Medical Examiners.

Allowing certified nurse midwives to attend home births in South Dakota would be allowed on a trial basis until 2013.  (click here for source article)

My concern is that CNMs were previously required to have OB back-up, and evidently no OBs were agreeing to provide back-up services.  What will be different?  And I’m not sure that having a Masters Degree makes anyone particularly qualified to attend labor.  Shouldn’t these homebirth midwives have assisted on “x” number of births before they become licensed?  Why is it always about the piece of paper??

Also, the bill states that CNMs will be able to attend homebirths “under certain circumstances” but doesn’t clarify what those circumstances may be.  I suppose we must find the Board guidelines to find more clear language.  To read the bill, click here.

Thought Provoking

By now most people involved in childbirth advocacy are aware that ACOG released a statement reaffirming its opposition to homebirth.  I was directed – via Bellies and Babies and Enjoy Birth- to House of Harris’s response and dissection of the statement. 

People who read my weblog know that I’m certainly all for a woman’s choice of childbirth venue.  I’d like to think that birth can be empowering regarless of venue, but the most likely location for empowering, rewarding, and safe birth is home, assuming that you feel safe in your home.  I am not suggesting that homebirth is necessarily safer than hospital birth.  But I cannot show any evidence that hospital birth is necessarily safer than homebirth for low-risk women and babies.  Even though I bear a cesarean scar, I am not “high risk”.

One thing that concerns me as I consider and plan for a homebirth in the Fall is what might happen to me and the baby should we need to transfer.  I’ve asked the midwives I interviewed about their experiences with transfers.  Most of them say that it really depends on which OB is on call.  Great.

Team Harris addresses this in the comments section of the above post:

I’ve heard the argument that it’s inconvenient for hospitals to have to rally around and scramble when a homebirth mother takes that risk and it fails. While I see what these people are saying, I must also point out that we also rally around for every other emergency in life. We don’t judge the drug addicts who come in overdosed – we treat them. We don’t judge the obese who come in with MI’s. – we treat them. We don’t judge the diabetic who refuses to take his meds yet wants medical help when he has a diabetic crisis – we treat him. We don’t judge the elderly for forgetting their CHF meds and overloading – we treat them. We don’t judge many other behaviors which really ARE obviously poor choices – because they are just that – choices. Mothers deserve the same treatment.

What an excellent point!  Why is it that homebirth transfers are treated as “trainwrecks” and sometimes subjected to chastisement, intimidation, and contempt at a particularly vulnerable time?  I wish OBs who have no appreciation for and understanding of homebirth would take the above comment to heart.

I know in our area, the midwives are very good about calling ahead to apprise of situations so that we CAN have all hands on deck when they arrive. In fact, we did a section recently for a homebirth transfer (a very needed section) and the timing was perfect. Midwife called ahead to warn us. We called the team, and everyone arrived at the same time. Will it always work out that easily? Sadly, no. But that is life. I’ve had to really learn to come to grips with what life is all about. Sometimes bad things happen. And while it’s tragic and horrific, we can’t save the world.

Again, I read last night in Marsden Wagner’s Birth Plan book that the decision to incision time is about 30 minutes, even if a woman has been laboring in a hospital.  Because homebirth midwives are in direct and regular contact with normal/natural birth, they are better able to recognize emergent problems that can only be rectified at the hospital.  In most cases there should be enough time to transfer and receive an emergent cesarean should it be necessary.  I live 10 minutes away from our hospital, so I feel comfortable with the choice to birth at home.

When I was conducting my interviews I learned that the midwives are required to call the hospital and let them know that a woman is in labor at home.  The midwives are not sure what the hospital does with this information.  I wonder that myself and should probably investigate . . .

Caring for Women Who Suffer Birth Loss

I posted the information below elsewhere on the internet in response to a request for advice regarding care protocol for women who experience miscarriage or stillbirth.  I am amazed at how upset I got just writing these seven points.  Women who miscarry or otherwise lose their babies are treated so strangely.  I’ve been reading a terrific book called Motherhood Lost which looks at birth loss from a feminist perspective.  It really speaks to me, so click on the link and check it out.

For what it’s worth, here was my personal advice regarding birth loss “care” – something we don’t always experience when we’re being “treated”:

1. Take women having active bleeding IMMEDIATELY to a room. Don’t make them sit bawling their eyes out around other pregnant women or in a horrible ER waiting room.2. Don’t subject them to unnecessary protocols when they make a request – I was “forced” to accept a heplock, and not only was it completely unnecessary, but the nurse sucked at getting it into place.

3. Don’t tell a woman (especially when you’re not her provider) that she put the pregnancies too close together and that she pushes herself too much. We already blame ourselves enough.

4. Don’t misread ultrasounds. Misread ultrasound leads to misdiagnosis which further complicates care and treatment. Because of this misdiagnosis, I was treated like a woman who wasn’t miscarrying “correctly” instead of a woman experiencing “threatened miscarriage” due to a subchorionic hematoma.  5w4d may be too early to see a fetal pole, and the presence of a yolk sac implies the existence of a fetal pole.  I did NOT have a blighted ovum.

5. If your patient miscarries over the weekend . . . follow-up with her. It’s the least you could do.6. Make the billing process more clear and more simple to digest. I don’t know where all of my bills come from and why I continue to have to pay so much out of pocket. I thought I had insurance???

7. Make sure you have RESOURCES to share with your patients/clients in the form of personal support, support groups/networks, reading materials, etc.

Yeah . . . all of this (and more, I’m sure) I experienced with my 10/07 miscarriage. That was my one and only experience with our local hospital. I won’t be going back there unless I’m seriously dying.

I have to give a shout out to Bellies and Babies for her most recent post, some of which is excerpted below.  I encourage you to go read the entire post.  My commentary continues below the excerpt. 

16 Recommendations from the World Health Organization

These 16 recommendations are based on the principle that each woman has a fundamental right to receive proper prenatal care: that the woman has a central role in all aspects of this care, including participation in the planning, carrying out and evaluation of the care: and that social, emotional and psychological factors are decisive [emphasis mine] in the understanding and implementation of proper prenatal care.

1. The whole community should be informed about the various procedures in birth care, to enable each woman to choose the type of birth care she prefers.

2. The training of professional midwives or birth attendants should be promoted. Care during normal pregnancy and birth and following birth should be the duty of this profession.

15. Obstetric care services that have critical attitudes towards technology and that have adopted an attitude of respect for the emotional, psychological and social aspects of birth should be identified. Such services should be encouraged and the processes that have led them to their position must be studied so that they can be used as models to foster similar attitudes in other centers and to influence obstetrical views nationwide.

The WHO report, Care in Normal Birth, she draws from is dated 1997.  However, this does not negate the principles outlined in the post.  Perhaps the normal birth advocacy groups should appeal to the WHO to update this report, since some people might be inclined to discredit the information due to the time stamp.  Again, I stand by the information in the report that I have read thus far and that has been collated by Bellies and Babies.  Kudos to you, my friend!

I would like to draw special attention to point 15 regarding critical attitudes within the maternal care system.  I agree that it is imperative to identify care providers in our local communities who are critical of the over-use of technology, medication, and other interventions in normal (natural) birth.  Birth advocates must join with these individuals and work together to decrease the unnecessary complication of normal (natural) birth.  

There is a time to “fight” the system, but there is also a time to “join together”.  It doesn’t matter that I desire to have a homebirth in the future if 9 other women I know still prefer to go to the hospital.  It doesn’t matter that my neighbor might have a baby at the birth center even though I have been “risked” out of that possibility.  We need to work for mutual understanding and respect for all birth options and guide women and their careproviders to make evidence-based, ethical, and empowering decisions.

Montana birth stats revisited

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

2006 Cesarean Statistics Released – it ain’t good

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.