New VBAC recommendations from ACOG

In July 2004 the American College of Obstetricians and Gynecologists issued practice bulletin #54 - which changed the status quo for treatment of women with a history of prior cesarean.  The big change was that ACOG recommended that women attempting a vaginal birth after cesarean (VBAC) should labor with a "physician immediately available throughout active labor capable of monitoring labor and performing an emergency cesarean delivery."

The big word there was "immediately".  It appears exactly once in the practice bulletin but it is an important word.  It caused a string of practice changes for obstetricians, policy changes for hospitals and health outcome changes for pregnant women.  In short, the VBAC rate plummeted and hospitals demanded that women submit to surgery.

Yesterday, ACOG issued a new practice bulletin, #115, that they intend to replace the infamous bulletin #54.  This bulletin doesn't seem to remove the damning word (though I just read the press release, it costs $ to order the active bulletins).

This time the press release opens with, "Attempting a vaginal birth after cesarean (VBAC) is a safe and appropriate choice for most women who have had a prior cesarean delivery, including for some women who have had two previous cesareans"


But it also uses the word "immediately" three times.  And while ACOG acknowledges that women should not be forced to submit to surgery in hospitals that do not have "immediately available" staff, they are rather vague about what an acceptable plan for these facilities would be for women undergoing a trial of labor after cesarean.  


I appreciate the more nuanced understanding that ACOG has demonstrated with this new practice bulletin.  Maybe they are beginning to recognize the serious impact these statements have on the care women receive across our country.  I certainly hope so.


However, this is not a situation in which the organization can simply say "Our bad" and undo all the damage that has been done by bulletin #54.  It would be nice if we could just "withdraw from circulation" (see here) the fear and ingrained policies and the lack of access that #54 has visited upon American women.  


We know that women who have given birth by cesarean are less likely to choose or achieve another pregnancy and that their subsequent pregnancies are subject to greater risks.  We know that the more cesareans a woman has, the more dangerous it is.  We know that #54 increased the number of cesareans that were performed on women.  We know that #54 was a mistake, and now ACOG has admitted it.


But admitting a mistake and even rectifying that mistake with a nuanced and understanding new practice bulletin doesn't undo the damage of that mistake.  #115 isn't going to be able to undo all the havoc #54 has wrecked upon American maternity care.


 We need a comprehensive approach to cesarean reduction, we need consumer education, targeted interventions for women with prior cesarean, policy reviews at hospitals, practice standards for physicians (set by the physicians themselves, I'm not trying to tell anyone how to practice medicine) and we need public access to cesarean data so that consumers can make truly informed decisions.  


#115 is a nice start, but it doesn't have the chops to undo what #54 has brought down upon us.  So thanks, ACOG, for a great start.  What else have you got for us?

Extreme morning sickness

This article came across my screen this evening as I'm re-adjusting to life at home.  It tells the story of a woman who had such severe morning sickness during her pregnancies that she decided to terminate her second pregnancy because of the health and personal problems it was creating.

What she had was not your usual morning sickness.  Hyperemesis Gravidarum is a condition that is more than inconvenient or uncomfortable.  It is a serious disruption to a woman's health and life.

In my experience with clients diagnosed with HG, the nausea can be debilitating and have a serious impact on a woman's health and life.  Women who experience HG in one pregnancy often have the condition again in subsequent pregnancies and sometimes it gets worse with each pregnancy.

One of the key factors in successful treatment of HG is early, agressive intervention.  Treatment with acceptable anti-nausea drugs, maintaining hydration and vitamin/electrolyte balances through IV if necessary and bedrest and hospitalization at the earliest appropriate time can keep HG from becoming so debilitating that a woman's health is at risk.

Whether or not these measures were available to Mrs. Harrison is unclear in this brief article.  For a public health doula, the article is a poignant story about one woman's suffering that leaves many questions unasked about how terminating her pregnancy became the necessary step.  What does the public health care system in the UK do to screen early pregnancies?  What knowledge of treatments did the doctors have?  Was Mrs. Harrison advised of the importance of early intervention with her subsequent pregnancy?  Were she and her husband and daughter supported at all with family leave and child care options while she dealt with a debilitating medical condition during pregnancy?

Anti-nausea medications are expensive, maybe they weren't covered by her health care.  I know that has been an issue for my clients in the past.  I have absolutely no doubts about Mr. and Mrs. Harrison's ability to decide for themselves to terminate the second pregnancy.  I just think it would be a shame if something could have been done for her health before it became so compromised that the best solution was to terminate the pregnancy.  And I applaud Mrs. Harrison for speaking up and sharing her experience.  The more women give voice to their experiences with pregnancy and abortion, the less shame and shadow we have surrounding these parts of our lives.  She's right when she suspects that other women have terminated for the same reason but have kept silent because of the taboo.

I've only just returned from a 9 day vacation with my family.  The experience was fantastic, and has left me re-energized and ready to hop back into my work life.  It won't be another 3 months before I post again, I promise!

Re-certified

I just finished my recertification paperwork for my Lamaze Childbirth Educator and DONA International Birth Doula certifications.  This is the 3rd time I've recertified as a DONA doula and my first official re-cert with Lamaze.  I was pleased with how easy it was to do online continuing educaiton through the Lamaze member center.  I took two ethics courses worth one CEU hour each and they actually took me less than an hour to complete while being interesting, educating and thought provoking.

Here's to another 3 years as a birth junkie.

Internal Consistency

Today I was had a wide-ranging and interesting conversation with a woman who runs a local emerging non-profit organization.  Though the conversation was organizational development-this and capacity building-that, I realized that my explanations of how I could help the board grow the organization sounded a lot like my conversations with expectant couples and how I can help them be strong advocates and educated consumers of health care.

Internal consistency, in statistics and research tools, is the ability of a tool to measure or demonstrate a value consistently throughout.  It means that if someone answers a question one way in one question, they will answer a later question in a way that supports their previous position.  

I don't advocate for people, I teach them to and support them in advocating for themselves.  I can't take the burden of labor away from a woman but I can support her in finding her own strength to labor as she will.  Similarly, when working with an emerging organization, I don't tell them how to grow and develop their missions and programs, I help them articulate their collective passion and vision.

I realized today, happily, that though my work as a doula, public health professional, and even as a temporarily home-schooling parent, looks fragmented and random, it is actually very internally consistent with who I am, what I enjoy and what I'm good at doing.

What a lovely way to start a day.

Retired military leaders and public health officials have something in common.

News today from Mission: Readiness, 75% of American youth are too out of shape [read: obese] to serve in the military.

From their press release:

"Declaring that escalating rates of child obesity pose a serious threat to national security, retired military leaders joined Sen. Richard Lugar (R-IN) and U.S. Secretary of Agriculture Tom Vilsack today in support of new child nutrition legislation to help reduce the obesity epidemic and expand the pool of healthy young adults available for military service."

I agree.  Our nation needs soldiers fit to defend our borders and our interests.  We also need a healthy enough population that we will be able to compete in the global marketplace, create art, serve on juries, and raise families.

If what speaks to policy makers and the average American is that we need better food policy in order to get better soldiers, then I am all over it.  Because they aren't wrong and the policies and cultural changes necessary to create healthier 17-24 year olds will also create healthier <17 and >24 year olds too.

Prepared foods need to be healthier, we need to be able to eat fast and convenient food without getting 300% the RDI of sodium.  Poor communities need access to fresh food.  School lunches need to be healthier.  Fast food joints should put calorie counts up with the prices.  We need physical education in schools and bike paths in cities.

These things will make more American's fit to serve in our armed forces (shout out to my little brother the vet!).  And if we are fit enough to serve in the military, then we'll be fit enough to stand up for ourselves in democracy as well.

Wow, has it really been almost a month since I posted last?  Spring breaks were tough on my professional productivity and things are just starting to creep back into controlled chaos.  Plus, I need to stop thinking that I need to write novels and term papers for my blog.  I'm a blogger who doesn't know how to whip out a post, which makes me either a lousy blogger or a very green one.  Time will tell...

Pseudo-live Blogging - Maternal morbidity elevator speech

What is the one thing I'd say to a woman on an elevator about her risks from cesarean delivery?

"Try really hard not to have a cesarean.  It can be very dangerous to your health."

A longer version - I'm really impressed with the data that are available about the risks of adverse outcomes for women after their first cesarean.  It is also shocking how much strong evidence there is about how dangerous the 2nd and 3rd and upward cesareans are.

Given what we know from these data, it seems clear that the lack of VBAC availability is not driven by concern for women's health outcomes.

A lot of the reasearch for this conference was compiled by OHSU's evidence-based practice center.  Go Oregon!

On with the webcast...

Pseudo-live Blogging - Cringe

I remember at the last NIH conference how hard it was for me to listen to my non-scientific birthing community colleagues rail at the deaf (or at least hard of hearing) ears of the researchers who had planned and were running the conference.  I'm cringing again while I watch the first participant comment opportunity.

It isn't that the researchers are bad guys (there that is again) it is just that they are dealing with the issues of VBAC in such a different way from the birthing community that they barely speak the same language, are barely talking about the same subject.

I wish there were more public health doulas & folks like my friend Judith (she was on the VBAC conference planning committee) who could advocate for women's rights in ways the researchers and scientists can understand.

Maybe after my kids go to college, I'll take that one on too.

Pseudo-live Blogging - VBAC conference

I've decided that during my kids' spring break I'm trying to watch the entire NIH Consensus Development Conference on VBACthat happened in Bethesda, MD March 8-10.  This conference is one of those important policy influencing events in which doctors, midwives, epidemiologists, lay birth professionals and consumers get togther and lay out personal experience, scientific research and policy decisions that influence important health outcomes.  Several years ago, while still living in Maryland I had the chance to attend a "State of the Science" conference put on by the same office.

What came after the conference, as came after this one, was a draft position statement that sounded rather benign and exploratory but was in fact quite controversial.  If I hadn't been in the room with the people directing the conference, it would have been hard for me to understand just how rigged the whole game had been.  So, I decided that even though I can read the draft statement for the VBAC conference quite easily, I would be missing something crucial not to watch as much of the actual event as possible.  Fortunately the whole thing is webcast and archived at the link above so if you were so inspired, you could watch too.

I am also finding the whole thing a thrilling challenge to my public health professional's brain - I am surprised at how much I am enjoying the talk about developing models to predict individual women's odds of VBAC success.  The whole thing is biostats and taking population-based knowns and translating them into something that will impact individually-based unknowns.

I have heard that there are many tear-jerking stories from women and providers about VBACs denied and I imagine it will evoke some of my own professional memory.  I have seen women bullied into primary cesareans, tricked out of VBACs and mis-managed all the way to the OR.  I don't have a good-guys V bad guys mentality, and I do honestly think that the nurses and doctors who's views on birth are so divergent from my own still have their patient's best interests at heart.  But I have seen flawed people act badly toward innocent women and even though I acknowledge that that doesn't make them bad guys, it is still hurtful to remember.

Transitions

Spring is my favorite season.  The year unfolds before us in the Spring, trees slowly bud, flower and then leaf.  The dreary landscape livens with a vague green fuzz on branches until suddenly the city is even greener than it was before.  I enjoy watching these changes regularly throughout our busy days and weeks.

One of the tings I especially love about Spring is the longer days.  I’m not a morning person by nature so getting up in the dark is sometimes(strikethrough) always a painful process for me (I’m so thankful for my little little blue light  that helps me wake my brain up before noon!).  As the world is waking from the Winter, I enjoy waking a bit more every morning.

Until the second Sunday of March, when my naturally unfolding awakening is jarred by the reality of Daylight Saving Time.  The “springing forward” of time is arbitrary and annoying and it undoes my body’s trust in the lengthening day.  It usually takes me at least a week to recover from the shock and never again does my mind feel as in tune with the lengthening days and the earlier sunshine. 

This shock to my system reminds me a lot of the way women’s bodies react to disruption during labor.  They may be able to see a change coming, they may adapt to the change eventually, but the shock to her system is real, the impact on her psyche, her body and her labor is real.

Successful transitions are meant to be smooth and gentle.  We don’t wake up one morning and find our bodies hugely pregnant, they grow, slowly over time.  Most women don’t go straight to hard, fast labor, but ease into it slowly, with contractions building in duration, intensity and frequency.  Our bodies give us the gradual pace so that we can wrap our minds around what is happening. So that we can successfully cope.

Most women’s labor will be interrupted from this natural unfolding by a myriad of transitions.  Whether it is something as simple as driving to the hospital or something as important as the administration of epidural anesthesia, the jarring change in environment or physiology causes changes in labor.

As a doula, I’ve seen women navigate these transitions – building up a labor that has slowed down from the car ride and transition to the hospital, agreeing to pitocin to stimulate contractions that dwindled after receiving an epidural, changing coping strategies as labor naturally unfolds from early to active to transition to pushing – and I’m regularly impressed with the grace and willingness they have to do what is necessary for themselves and their babies during labor. 

There are those who would uphold the extreme position to abandon all distraction that most women in labor in industrial nations experience.  I agree that one of the most impressive and wonderful things to witness in labor is a woman’s instinctive and natural coping.  And I think we all, hospitals, doctors, nurses, midwives and even doulas and partners, are inclined to do things that take away from a woman’s instincts.  I’ve found over the years that instead of pulling tricks out of my labor bag, I watch and hold space and worry less about what I should be doing. Instead I watch women to plug into their natural instincts and then follow their lead.

But most women are not going to give birth in a secluded room in their homes.  Most women give birth in hospitals and as such, are subjected to many interruptions to the natural flow of their labor.  Does that mean they can’t have instinctive, low-intervention birth experiences?  Absolutely not.  What it means is that they need a little extra help staying connected to their instincts, their natural ability to cope and their vision for how they want to be in labor.

Just like Daylight Saving Time interrupts our observation of Spring, interruptions in labor are inevitable (except in Arizona? Okay, probably not a perfect analogy).  But with trust, planning, coping and a little blue light, women can make it through. 

Maternal death and public health

A news story came out yesterday that inspired me to vary from my original plan of introductory blog posts.  It is just too important and interesting to pass up.  Plus, as a new blog, I want to give you a picture of what kind of posts you are going to see here.  I’m not so interested in celebrity pregnancies, though I am pleased when they say positive things about birth.  I am very interested in public health. I’m interested in the trends and patterns of health outcomes and how that information can help both individual women and broader communities.

Yesterday the San Francisco Chronicle published an article about the increasing maternal death rate for California women.  The story is not a shock to most birth professionals, as people who have been paying attention have been watching the creep of the statistics for years.  Ina May Gaskin, professional midwife extraordinaire, has been talking about maternal death for over a decade.  California is doing a better job of counting all the complicated ways that maternal death can be calculated and with over a half million babies born in California each year, many in public health look at the trends in the California population as a harbinger of national changes. 

But while it may not be a shock, the numbers are sobering.  The Maternal Mortality Rate (MMR) in California has climbed from 7.7 per 100,000 births in 1999 to 16.9 in 2006 (it takes a long time to process public health data, so that is the last year they have calculated).  The national numbers are also disturbing if less extreme – 9.9 per 100,000 in 1999 to 13.3 in 2006.   Risks for non-Hispanic Black women are four times greater than other population groups, with California numbers of 28.7 per 100,000 for 1999 and 54.9 for 2006.  (Health disparities like this one are a huge issue that I’ll address in another post, it deserves its own discussion)

Since I don’t want this to be a fear-mongering blog let me just clarify the MMR for you a bit.  While any deaths are tragic and the goal of reducing maternal deaths is an important one, remember that  the rate of 16.9 is spread over 100,000 live births.  That means the percentage of women dying is 0.0169%. Very, very small.

So the reason this is an important topic is not because “Oh no, be afraid, you could DIE if you have a baby, pregnancy is SO dangerous!!!” Please no. This is an important topic not because of the risk to one woman as an individual but rather the growing risk to women as a population.  When a negative outcome is trending up, it means that something is changing to make pregnancy and birth more risky.

What is it that is making birth more risky to women?  The official answer at this point is “We don’t know.”  Certainly we know the causes of death but what is the cause of the cause and why they are increasing, that part is still unknown.

We do know that the demographic of women having babies has changed over the last 20 years or so.  Childbearing women are, in general, older and more likely to have overweight.  But we also know that while these changes indicate an increased risk, they cannot account for all the change in the MMR.  According to the Chronicle, “Changes in the population - obese mothers, older mothers and fertility treatments - cannot completely account for the rise in deaths in California, said Dr. Elliott Main, the principal investigator for the task force.”  So this isn’t one that is going to be blamed on the women.  Whew!

The data in the article was compiled by the California Maternal Quality Care Collaborative and released in a newsletter-type publication by an accrediting body for hospitals.  Last week the Joint Commission published a Sentinel Event Alert that highlighted the report on MMR increases by the CMQCC.  The Joint Commission reported data from several sources including theCDC and the Hospital Corporation of America.

Additionally, the Sentinel Event Alert stated recent studies had found that 28-50% of maternal deaths were preventable.  HCA found that “better individual care” is a key to preventing those preventable deaths.  The most common preventable errors that were identified in the HCA study were:

1.  Failure to adequately control blood pressure in hypertensive women

2.  Failure to adequately diagnose and treat pulmonary edema in women with pre-eclampsia

3.  Failure to pay attention to vial signs after a Cesarean section.

4.  Hemorrhage after a Cesarean section.

And this is not just about preventing death.  In the Joint Commission alert Dr. Callaghan from the Centers for Disease Control and Prevention reminded us that it isn’t just about the 0.0169% risk, “For every woman who dies, there are 50 who are very ill, suffering significant complications of pregnancy labor and delivery.” For most women, this isn’t about life or death, but it is about improving your quality of life and reducing your risk of getting a dangerous infection or hemorrhaging and needing a blood transfusion.

HCA also found that “The data showed the individual causes of death to be very heterogeneous [with only one cause] amendable to nationwide systematic prevention efforts.”  That means that the circumstances of each woman’s case were unique, that there isn’t a specific change that can be implemented to prevent all their deaths. 

So what can be done? Well, if there isn’t one systematic prevention effort to make a difference, then it will have to be many small prevention efforts that keep women from becoming very ill and dying as a result of the care they receive (or don’t receive) during labor and birth. 

Remember that you are a part of your care, that being treated as an individual, not as a statistic can have a significant impact on the way your labor & birth unfold.

What I am talking about here is reducing medical errors. The good news is that this is something that women can do something about.  Something that patients are encouraged to be a part of.  According to the Agency for Healthcare Research and Quality, the number one thing that you can do to prevent medical errors is “Be Involved in Your Health Care”.  Ask questions, insist on answers, when you have concerns, don’t let yourself be dismissed.  

There is a lot you can do before you go into labor as well.  Hire a midwife or doctor you trust – someone you can ask hard questions  of and get satisfying answers.  Know what to expect – learn about hospital procedures and standards of care from your midwife or doctor.  Take an independent childbirth education class so that you can triangulate your information and learn what is necessary for good care and what is just hospital procedure.  Hire a doula who can help you have the best communication possible with your hospital care team.  Get educated, make a plan and get support.

Remember that you are not a statistic so there is no reason that you should be accept being treated like one.  

1st of 3 - Support

By way of an introduction I want to elaborate on my tag line -  "Support, Education, Advocacy".  Having a marketing professional for a spouse, I appreciate the importance of a concise, memorable tag line and I think there is a lot you can learn about me and the work that I do from those 3 words.  Today, we’ll tackle the first word – Support.

On the surface, support is probably the most straightforward of the three to understand.  I promote the interests and causes of my clients.  I validate and reassure.  When serving a woman as her birth doula, support is woven throughout our relationship; as an educator and a public health professional the support is a wider net, cast over the interests and needs of groups as well as individuals.

Because it is so easy to understand and appreciate the value of support, I wonder if people think this is the easiest part of my job.  People like being supported and most of us understand what it means to be supportive of others. It sounds simple, passive, doesn’t it – being supportive? And maybe now, after over a decade of practice, it is an instinctive and natural role that I play.  But being supportive is not passive at all, it requires a lot of awareness and work.

People are self-centered by nature.  This is not a design flaw, just a design characteristic.  We see the world relative to our own selves and experiences.  When we hear about the lives of others, we imagine how it would feel if their lives were ours.  This imagination is what makes us capable of empathy.  And remembering that they are not us is the root of compassion. Compassion and empathy are necessary in order for me to be a supportive doula, educator and public health worker.

Compassion and empathy allow me to accept the diversity of what is possible in the world without judging some parts as right and others as wrong, some choices as good and others as bad.  Releasing judgment through compassion and empathy requires me to release my own ego.  To let go of the illusion that any of part someone else’s experience has anything to do with me. 

As a birth doula, when I’m with a couple in labor, supporting their experience, I am challenged to function in two worlds at the same time. Key parts of my job require me to be aware of the laboring woman’s experience.  I have to keep an eye on her needs and desires, an ear to her words and her thoughts as labor unfolds, to take care of creature comforts for her and her partner - making sure that she and her partner are eating, hydrating, staying warm and are as comfortable as possible.  I have to be in touch with them both emotionally and physically. 

But in order to be the best doula I can, I have to keep track of my own experience as well – I have to eat, hydrate, stay warm, and get enough sleep.  I have to build relationships with the hospital staff and midwife/doctor so that I can continue to be welcomed into labor & deliver units as an ally.

As an educator, I have to remember that I am there so that my students can learn, not so that I can teach.  Plowing quickly through material just so that I can say that we covered it does not serve my classes.  Using teaching techniques that are easy for me is pointless if my students need other methods in order to master the content. 

As a creator of public health programs, supporting the needs of a community is crucial to success.  The desire to improve the health outcomes of childbearing women must be accompanied with the humility to recognize that what I think the community needs in order to be healthier doesn’t matter as much as what the members of the community themselves think they need in order to be healthier.

As a doula, educator and program developer, I have all kinds of strategies and tricks to help women and their partners, students and communities cope with all kinds of situations.  But all those neat tricks don’t mean a thing if I have my ego wrapped up in my client’s labor or a community’s needs.  Supporting, whether it is of a woman in labor, a couple in a childbirth education class or a community trying to improve its health status, requires constant release of my own expectations and experiences. 

In order to support well, I remind myself that I don’t know what is going on in someone else’s life; I don’t have her relationships, her memories, her expectations, her challenges or her resources. I also don’t have her blood pressure, her nervous system or her hormones. I have no idea what she is experiencing, except for what she tells me. 

In order to support well, you have to be truly listening to and respecting the place others are coming from. Anyone who tells you that this is an easy thing to do is probably lying to themselves (or maybe just to you!). But you can build your compassion and empathy skills.  You can remind yourself that everyone has different experiences and needs.  You can learn more about groups and individuals who hold positions and make choices you don’t initially understand.  You can do this until it becomes very easy, most of the time.

Except when it is not.  As the blog unfolds, I’ll share more lessons I’ve learned about support.

Thanks for reading!

Welcome to my blog!

Thanks for visiting!  I look forward to sharing something interesting here eventually.