Friday, April 23, 2010

How Every Mother Can Improve the U.S. Maternal Mortality Rate

Christine Sheets-Nutile

In January of this year, the Joint Commission issued an alert1 to U.S. hospitals which stated, “trends and evidence suggest that maternal mortality rates may be increasing in the U.S.” The national rate is currently three to five times GREATER than that of European countries.2 Unbelievably, a woman giving birth in the U.S. today has a greater risk of dying than a woman birthing in 40 other countries.2

The Commission (which is the leading health care accreditation and standards group in the United States) went on to state that between 28-50% of maternal deaths were PREVENTABLE. In fact, half of the most common errors were related to post-operative care following caesarean sections.1

Recent reports also show that, in the U.S.,3 rates of both labor induction and c-section are TWICE the World Health Organization’s recommendations.2 As we are seeing, these medical interventions (while common) are not without risk.

Labor induction typically involves the use of synthetic oxytocin. This artificial substitute interferes with a woman’s own oxytocin receptors and can lead to postpartum hemorrhaging, delayed or inhibited bonding with her newborn and difficulty establishing breastfeeding.4 A medically induced labor also significantly increases a woman's chances of having an unplanned c-section.5

The risk of a mother’s death after a c-section is more than three times greater than a mother who gave birth vaginally.6 Over a 10 year period, California had a 50% increase in c-sections AND a 50% increase in maternal mortality.7


A Climate of Coercion

The current mainstream birth culture in the U.S. is simply appalling. Pregnancy and birth are treated as a disease and acute trauma-waiting-to-happen. Many women are not given complete information about the birth process. More and more cases are being reported of maternity patients being coerced into submission; their basic human rights are ignored or even revoked through the courts.

Serious medical interventions are presented as a matter of course and focus exclusively on the expected benefits. Risks and adverse effects are usually not even acknowledged! The provider states whatever he or she believes will result in the mother's compliance with the provider’s desired course of action.8

According to “Evidence-Based Maternity Care” (Sakala and Corry), a truly informed choice “requires access to a range of options, good understanding of best evidence about benefits and harms of offered care and of alternatives and solid support for the choices women make.” This rarely occurs among U.S. maternity patients. 4

In a 2009 interview, Dr. Debra Bingham, Executive Director for the California Maternal Quality Care Collaborative and a member of a Maternal Mortality Review Committee, told Amnesty International that the process of gaining an obstetric patient’s consent is highly variable and can depend on who provides information, what information is shared, and how that information is presented to a pregnant woman. “For example, someone who will benefit financially from the woman’s decision may provide information differently than someone who is not financially affected by her decision. Currently, there is limited documentation on what information is shared, how and by whom.”9

Astonishingly, this behavior is not limited to maternal care providers for disadvantaged, low-income or uneducated women. Time and time again, I’ve seen high-powered, confident, educated women become completely submissive. They forgo asking questions and just trust their doctors to make decisions for them, and then accept whatever course of treatment may result.


The Alternative Birth Movement (or What’s “Normal” for the Rest of the World)

83% of women in the U.S. have low-risk pregnancies.10 In most countries, these low-risk women would receive their maternal care from midwives or family practice physicians and often give birth at home. Outside of the U.S., the goal is to minimize risks and maximize good outcomes for mothers and babies, rather than maximize income for a provider and facility. So most obstetricians limit their practice to treating women with high-risk pregnancies and those who develop unexpected complications.11 Ironically, many OB’s in the U.S. no longer have the aptitude or knowledge possessed by their predecessors for such uncommon procedures as: external version to manually turn a baby, vaginal breech birth or vaginal birth of twins.4

It’s interesting to note that groups of maternal care providers identify their roles very differently. OB’s feel it is their responsibility to actively manage childbirth. Midwives and other physicians perceive their function to be facilitators in the birthing process.12 This fundamental distinction is evidenced in the care and treatment of their patients: 4 Midwives possess more hands-on skills and are better able to support a woman in labor and assist her during birth than OB’s; midwives use medical intervention more judiciously than OB’s; and midwives understand that a woman’s individual mind-set, desires and personal history play an important part in her birth, while OB’s deny these influences. 12

In low risk situations, intervention can, in fact, actually impede the birthing process and create those life or death situations that doctors claim to be trying to avoid. Despite their lengthy and expensive educations, far too many U.S. care providers have little or NO experience in observing a normal, natural birth. Therefore, they have no idea what a normal birth looks like, much less what a woman in that situation may need.

Not surprisingly, across the nation, low-risk women and their babies have better outcomes when attended by a midwife, rather than an OB.4, 8


Loss of Faith, Rise of Fear

In contrast to the rest of the world, almost all pregnant women in the U.S. choose to receive their care from an OB and give birth in a hospital. When it's truly needed, medical intervention can, of course, mean the difference between life and death.

But women’s bodies are designed to give birth -- without any interference! It’s only been in the past 100 years13, that birth was appropriated from women and transformed into a paternalistic, medical, mechanized event.14 As such, women lost the knowledge that comes from witnessing and assisting their mothers and sisters give birth. And women lost faith in their bodies’ innate abilities.

Today’s mother-to-be has probably heard more birth-related horror stories than she can count. From the time she was a young girl, she may have heard her mother, her aunts, and even her friends discuss childbirth as a painful, frightening injury. Unfortunately, these misconceptions are perpetuated and reinforced through popular culture of television and movies. In reality, a normal birth wouldn’t bring in big ratings or box-office dollars.


Follow the Money

The U.S. spends more on health care than any other country.15 And more money is spent on maternal health than ANY other form of hospital care.8 Unfortunately, the majority of OB policies, routine procedures and official recommendations are woefully out of date in regards to evidence-based care.4

Outside of the U.S., hospitals typically have a variety of low-tech equipment to aid a woman giving birth – tubs, birthing balls, robes, birthing stools, squatting bars, etc. Any of these can help make birth safer and more comfortable. Unfortunately, very few U.S. hospitals can offer anything besides pharmaceuticals. For the hospital administrator, a birth free of medical interventions is a lost billing opportunity.11

The vast majority of births do NOT require any intervention; but 50-80% of births in U.S. hospitals have AT LEAST one. In reality, any one of these procedures is truly medically necessary in fewer than 20% of all births.8 Ergo between 30-60% of women giving birth in U.S. hospitals are having unnecessary medical procedures performed upon them! But, necessary or not, all of these medical procedures and interventions allow physicians to maximize their billing opportunities.11

In some parts of the country, it’s extremely difficult to find a provider willing to intervene ONLY when truly medically necessary -- especially if the woman has had a previous c-section. Fewer and fewer facilities are willing to accept VBAC (Vaginal Birth After Cesarean) patients.

After years of increased c-sections, most hospitals have reconfigured their maternity units to accommodate more surgical deliveries: more services scheduled during weekday hours, and more post partum beds – needed for the longer stays required after c-sections. These changes required costly capital investments. Now administrators need to see a return on those investments. So it’s not surprising that hospital policies reflect the facility’s increased dependence on the revenue generated by c-sections. After all, a c-section brings in TWICE the revenue of a vaginal birth.4 A surgical birth is also easier on the doctor. It takes less time and is much more predictable than a normal labor and delivery.

For years, the medical establishment has been working to limit birthing options. They've fought against birthing centers, homebirth, midwives, even against their own accountability.

Many believe that they’re more interested in protecting their revenues than improving outcomes for our mothers and babies.11

Rather than abolishing choices, vilifying alternatives and criminalizing their competition, I'd prefer to see them working for other, more worthy goals – such as educating their patients, encouraging normal/natural births and working with facilities to update protocols to reflect evidence-based medicine, all of which will ultimately reduce maternal mortality.

Until then, it’s up to us to change the birth culture!


Improve Your Own Chances of Survival

If you are pregnant or planning to become pregnant:

* Examine your pre-conceived ideas on birth. How were these formed? From stories of women of previous generations? From fictional or sensationalized movies and tv shows? YouTube is awash with amazing, joyous videos of women experiencing normal, natural births. Use these to visualize the kind of birth YOU want.



* Take responsibility for your own education on birth! While pregnant, you have months to prepare and can seek out accurate, complete information. Labor is a time of extreme, internal focus. It would be difficult to absorb and comprehend a significant amount of new information. So preparation is key, in case you need to make decisions quickly. Research common interventions such as: ultrasounds, fetal monitoring, induction of labor, epidurals, extractions and c-sections. Learn the risks and what factors determine when each may truly become necessary. Insist that your provider obtain informed consent for each procedure.



* Read books on natural birthing options. Consider alternatives to the standard OB-attended hospital birth. Choosing a high-tech OB at a high-tech hospital doesn’t guarantee you a safe birth. But it WILL increase your risk for high-tech interventions which may or may not be medically necessary.16 Certified Nurse Midwives (CNM’s) are licensed in all 50 states and can attend births in hospitals, birth centers or even your home. Don’t be afraid to make an unusual choice when it comes to what’s best for you and your baby!



* Don’t choose your provider or facility simply based on location or insurance coverage. Seek out like-minded mothers and local doulas and get their recommendations.



* Schedule a consultation with potential providers before committing to one. Get their rates of various interventions – fetal monitoring, inductions, episiotomies, forcep delivery, vacuum extraction and c-sections. Ask how much freedom you’ll have during labor – particularly on movement, eating/drinking and positioning for birth. Are there limitations on who is allowed to attend your birth? If they’re anything less than forthcoming with these answers, find another provider. Tour the facility. Ask questions there as well, specifically regarding their procedures for newborn care, policies on rooming-in and breastfeeding support.



* Listen to your instincts. More women are educating themselves and seeking providers based on their shared philosophies of birth. Unfortunately, medical professionals can also offer the all too familiar “bait-and-switch.” The provider will agree with everything the mother-to-be wants for her birth throughout her pregnancy, but has NO intention of letting the birth happen on those terms. Shockingly, some will even go out of their way to make SURE it doesn’t, regardless of what’s in the best interest of the mother and her baby. So if you have any reservations about your provider or facility, especially if you feel they are patronizing you, don’t be afraid to make a change – no matter how far along you are.



* Surround yourself with others who have had intervention-free births. Listen to their stories. Ignore those who tell you that you won’t be able to handle it.



* Take a childbirth class, preferably one OUTSIDE of a hospital setting. (Too often, classes hosted by the hospital are more about “How to Be a Good Patient.”) Bradley and Hypnobirthing are excellent choices.



* Choose your labor support team wisely. While your partner, family members and friends may want to be present at the birth, consider hiring a doula. She can provide physical and emotional support throughout your pregnancy, birth and post-partum period. She is knowledgeable about the process of birth, familiar with area providers and facilities and can facilitate communication with staff to help you make informed decisions. A woman in labor is vulnerable – both physically and emotionally. A doula can help protect your space and your choices.




Empower yourself to have the birth YOU desire! Birth is a business. As more mothers demand normal, natural births, providers and facilities will be forced to adapt to attract consumers. Reducing unnecessary interventions will lead to healthier mothers and babies!


Christine Sheets Nutile is a mother of three. She was supported by a doula and used Hypnobirthing for each of her midwife-attended hospital births. She is the co-founder of an Attachment Parenting group in the south suburbs of Chicago. She is also an advocate for natural childbirth, breastfeeding, babywearing and home education.



REFERENCES

1 The Joint Commission, Sentinel Event Alert, Issue 44 from January 26, 2010, “Preventing Maternal Death”; available at http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_44.htm

2 WHO, UNICEF and Wellstart International, “Baby-friendly Hospital Initiative: Revised, Updated and Expanded for Integrated Care”, 2009; available at http://www.who.int/nutrition/publications/infantfeeding/9789241594967_s1/en/index.html

3 J. A. Martin et al, Centers for Disease Control, Births: “Final Data for 2006”;

National Vital Statistics Reports, Volume 57, Number 7, from January 7, 2009; available at http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_07.pdf

4 C. Sakala and M. P. Corry, “Evidence-Based Maternity Care: What It Is and What It Can Achieve,” Childbirth Connection and the Reforming States Group, 2008, pages 37, 47, 62-67; available at http://www.childbirthconnection.org/pdfs/evidence-based-maternity-care.pdf

5 K. E. Kaufman, “Elective Induction: An Analysis of Economic and Health Consequences”.

6 C. Deneux-Tharaux et al, “Postpartum Maternal Mortality and Cesarean Delivery”, Obstetrics & Gynecology, Volume 108, Number 3, Part 1, September 2006; available at

http://www.acog.org/from_home/publications/green_journal/2006/v108n3p541.pdf and

J. Villar et al, “Maternal and Neonatal Individual Risks and Benefits Associated with Caesarean Delivery: Multicentre Prospective Study”, BMJ, 2007; 335; 1025; page 5; available at

http://www.bmj.com/cgi/reprint/335/7628/1025?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=Caesarean+delivery+rates&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT

7 California Maternal Quality Care Collaborative, www.cmqcc.org/maternal_mortality and www.cmqcc.org/maternal_disparities

8 R.M. Andrews, “The National Hospital Bill: The Most Expensive Conditions by

Payer, 2006”, Healthcare Cost and Utilization Project, Statistical Brief 59, 2008, page 7;

available at http://www.hcup-us.ahrq.gov/reports/statbriefs/sb59.pdf
9 Amnesty International Publications, “Deadly Delivery: The Maternal Health Care Crisis in the USA”, 2010, page 1 and 79, available at http://www.amnestyusa.org/dignity/pdf/DeadlyDelivery.pdf


10 National Center for Health Statistics. 2006. 2003 Natality Data Set. SETS 2.0, Rev. 805. Vital and Health Statistics. CD-ROM Series 21, Number 17, May.

11 S. Goodman, “Piercing the Veil: The Marginalization of Midwives in the United

States”, Social Science & Medicine, 65, 2007, pp. 610–21; available at

http://www.collegeofmidwives.org/Citations%20or%20text%2002/Marginalizing_NurseMfry_May07.pdf

12 B Reime et al, “Do Maternity Care Provider Groups Have Different Attitudes Towards Birth?” BJOG: An International Journal of Obstetrics & Gynaecology, Volume 111, Issue 12, Pages 1388-1393; available at http://www3.interscience.wiley.com/cgi-bin/fulltext/118813477/HTMLSTART

13 Y. Lapp Cryns, “Homebirth: As Safe as Birth Gets” The Compleat Mother Magazine 1995; available at http://www.compleatmother.com/homebirth/hb_safety.htm
14 J.J. Mathews and K. Zadak, “The Alternative Birth Movement in the United States: History and Current Status”, Women Health, 1991, Volume 17, Number 1, Page 39; available at http://www.ncbi.nlm.nih.gov/pubmed/2048321


15 Organisation for Economic Co-operation and Development, OECD Health Data 2009–

Frequently Requested Data; available at http://www.oecd.org/document/16/0,3343,en_2649_33929_2085200_1_1_1_1,00.html

16 M. Wagner, “Technology in Birth: First Do No Harm”, Midwifery Today, 2000;

available at http://www.midwiferytoday.com/articles/technologyinbirth.asp#sources

7 comments:

  1. this was fantastic. I do have a question though--I was under the impression that midwives were not licensed to attend a home birth--that only nurses and doctors were--and that they don't do it. I had such an awful hospital experience with my first (successful Bradley birth with no interventions)that I am considering a home birth. thanks for any info you can offer

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  2. Certified Nurse Midwives (CNM’s) are licensed in all 50 states. They can attend births anywhere -- hospitals, birth centers, hotels, homes, etc.

    That said, I live just outside one of the largest cities in America. And there are only a few CNM's who would attend a homebirth for me. Either they've chosed to practice in hospitals or they don't cover my neighborhood.

    Licensing of other types of midwives (Certified Professional, Licensed, Certified, Lay, Direct-Entry) varies state to state.

    Hope that helps! Christine Sheets Nutile

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  3. This comment has been removed by the author.

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  4. Another consideration is often a low episiotomy rate = a high c-section rate. I know this as a labor & delivery nurse. Moms often choose this or that provider because of a 'low epis' rate, but don't consider what exactly that may mean.

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  5. This article is absolutely awesome. I lay down reading it as I am breathing through my contractions. I have all the women in my family thinking I must be crazy for choosing a home birth. I have wanted to have a home birth since forever and this article solidifies all that I already believe. Thanks much!!

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  6. One thing no one ever thinks about is planning for the unexpected. I had a fabulous intervention-free birth planned. Unfortunatley for me, I was given the green light to travel far away while actually in very pre-term labor. Our story has a happy ending but I could have used more information about how to recognize a situation turning bad fast.

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