Grassroots News: $40 Million Going Towards Early Inductive Election, Prematurity

Hello Friends,

The US Department of Health and Human Services (HHS) has launched a campaign called the “Strong Start Initiative,” which is designed to decrease the number of preterm births occurring every year. Babies born prematurely are more likely than babies born at full term to experience a vast array of medical complications both in infancy and across the lifespan. In order to reverse a 20 year trend of increasing rates of prematurity, the HHS has announced the availability of $40 million in grant money for programs that are exploring ways to reduce prematurity through improved prenatal care.

The “Strong Start Initiative” will focus on reducing early elective inductions, which are labors that are induced prior to 39 weeks and without any medical indication. The rate of early elective inductions has increased dramatically over the past decade and is associated with poorer outcomes for babies and increased obstetrical interventions, including cesarean section. Reversing this trend can improve the health of babies and reduce unnecessary medical intervention in birth.

In addition to creating conditions for healthier births and babies, the Strong Start Initiative has the potential to save considerable health care costs that are typically associated with preterm births. The HHS will partner with the March of Dimes, the American Congress of Obstetricians and Gynecologists, and other organizations to implement this campaign.

To learn more about current research on early elective inductions, see the recent Citizens for Midwifery article.
To learn more about the “Strong Start Initiative,” read the full press release.

Warmly,

Lauren Korfine & The CfM Team

Keepsake Ultrasound Ban

The governor of Connecticut recently signed a ban on "keepsake ultrasounds" (the kind that are performed "for fun" at a store in the mall, for example). The bill "bars anyone from performing ultrasounds on pregnant women unless a doctor orders them for medical or diagnostic purposes."

See: Conn. governor signs keepsake ultrasound ban

I have very mixed feelings about this ban. While I agree that unnecessary ultrasounds should not be performed, legal "bans" make me uneasy--for example, what if a governor decides "banning homebirth" is a good idea or "banning midwifery." When things like this happen, I start to worry about a slippery slope of governmental interference with parental health care decision-making.

--
Molly
CfM Blogger

Media Coverage of Birth Issues

A lot of good stuff came my way this week. In the Poughkeepsie Journal on March 29: Modern medicine increasingly intervenes in the birth process. The article opens with this: "In the decade through 2002, something momentous happened to babies in the wombs of American women, especially white women. The average time fetuses spent there decreased from 40 weeks to 39. The decline, reported in a 2006 study in the medical journal Seminars in Perinatology, appears to have little to do with nature."

"Instead, earlier births may be the outcome of 'increased use of induction (of labor) and other obstetric interventions such as cesarean delivery,' said a January report by the U.S. Centers for Disease Control. Prematurity rose 20 percent since 1990, the report said, and the rate of low birth-weight babies hit a 40-year high."

"'We are shortening the gestational age,' said Dr. Carol Sakala, program director for the research and advocacy group Childbirth Connection. 'That is a big interference with mammalian evolution, human evolution.'"

The article then sidelines into a discussion of elective cesareans and concludes with a short paragraph subheaded, enjoyably, "Advantage of Midwives."

In the Livingston Daily was a short article titled Midwife mom discovers best of both worlds.

I also found out that midwifery was covered on a radio program called Health and Health Care Forum: Midwifery.

Then from The Journal of Perinatal & Neonatal Nursing there was this article about second stage: Best Practices in Perinatal Nursing: Implementing Safe and Effective Practices for Second-Stage Labor (recommending against "purple pushing" [closed glottis/ forced/directed]!)

Jennifer Block was on the scene in a timely manner yet again with her newest piece in The Huffington Post. Titled Extreme Birth, Indeed, this article is a reaction to the "Extreme Birth" article that was recently in New York magazine. A good quote from Block's article: "The truth is, standard maternity care is not evidence-based care (see this recent report.) And this is why more women are interested in giving birth at home. Not just so they can have candles and music and a better 'experience,' but because they know that checking into a hospital means exposure to preventable risks."

Speaking of some of the evidence for people with questions about the methodology and findings of the well-known BMJ homebirth study, you can get answers: BMJ Homebirth Study: Questions and Answers

And finally, I enjoyed reading this blog post: My Thoughts on the Midwifery Model of Care

--
Molly
CfM Blogger

New Midwifery Fact Sheet from CfM!

Citizens for Midwifery has prepared another summary fact sheet based on the Evidence Basis for the 10 Steps of Mother-Friendly Care (an extensive analysis that was published by Lamaze last year). This new fact sheet highlights the evidence regarding access to midwifery care and out-of-hospital birth.

Earlier this year, CfM and BirthNetwork National partnered to prepare a two page fact sheet summarizing the highlights from entire Evidence Basis document.

All of these documents are great resources and the fact sheets make good conference table handouts!

What Would an Evidence Based Statement from ACOG Say?

I just got the summer issue of Midwifery Today. In it was an article by Judy Slome Cohain in response to the ACOG homebirth statement issued in February. Given all of the recent uproar over the AMA's resolution, I thought her piece was very timely. It is called "What Would an Evidence-based Statement on Homebirth from ACOG Say?" and it opens like this:

"This is the statement ACOG would file if facts interested them: We at ACOG recognize that, according to our most recent poll, none of our members have homebirth practices and, therefore, making a homebirth statement is unnecessary since this subject is outside the expertise of ACOG members. For the purpose of making an informed choice, consumers should not look to ACOG for a statement on this subject."

:-D

Induced Labor

A recent article has been making the rounds through various blogs and newsletter and I wanted to call your attention to it as well--Avoiding Induced Labor is More Beneficial to Moms and Babies, an article posted to Medical News Today and sent as a press release from Lamaze International.

Also in regard to induced labors we received a call to action from the Tatia Oden French Foundation regarding the continued off label use of Cytotec (Misoprostol) to induce labor despite documented deaths related to its use as a method of induction.

From the call to action:

"In Sept of 2007, through the Freedom of Information Act, the Tatia Oden French Memorial Foundation requested the FDA to supply the Medwatch Forms they received for the time period Jan. 2001 through Sept. 2007, dealing with the adverse events occurring from the use of Cytotec. We received a file containing 1746 records of adverse events. Three hundred and fifty (350), 20% of these adverse events were the result of cytotec being used to induce labor."

A letter from Searle (the manufacturer of Cytotec), was sent to over 200,000 physicians in August of 2000, but as the Medwatch forms show, off label use has persisted.

More About Pushed (& more about evidence based care)

In October, I was delighted to finally read Pushed by Jennifer Block. I wanted to add my thoughts and comments to those shared earlier by Susan Hodges. This book is seriously GOOD! Wow! Lots of weighty, meaty information, scathing critiques, astute observations, and clever commentary. She has plenty of scientific backup for her claims and the book is written in an engaging, fast paced style that skillfully weaves facts into descriptive commentary and personal, illuminating interviews. I checked this book out of the library, but after seeing all of the data contained within--she's pulled together vast quantities of data about effectiveness of "routine" practices, etc. and made it accessible to the average reader--I knew I had to put it at the top of my Amazon wish list.

Pushed is a thorough critique of obstetrics as an industry and how women and babies are being HURT by the systems ostensibly in place to "protect" them. Especially thought provoking is her descriptive exploration of the cesarean epidemic. She points out on one occasion when discussing uterine rupture as the common reason used to deny women VBACs, that a cesarean is a "controlled uterine rupture." Later, in a separate section regarding blood loss during birth, she mentions that average loss is 300-500 mil and over 500 is considered a hemorrhage. She then notes that during a cesarean the average loss is 1000 mil. Reading that, I was struck with the realization that essentially with a cesarean you have a 100% chance of a uterine rupture AND a 100% chance of a hemorrhage. Wow!

During the conclusion of the book after a discussion about the NAPW and whether childbirth is a reproductive right or not:

"To her [a doctor who thinks it is not], it is a medical issue, one that may need reform, but one that belongs under the purview of physicians. 'To my mind, I'm all for people having a pleasant and safe birth experience,' she says. 'But my highest priority would be for them to have a safe birth experience.' But what's considered safe is political. What's safe changes. Thirty years ago obstetricians said VBAC was dangerous. Then they said it was safe. Now they've gone back to saying it's dangerous. ACOG says out-of-hospital birth isn't safe, but the research has consistently suggested that for women with normal, uncomplicated pregnancies it is not just safe, but safer, because those women are far more likely to have a normal, spontaneous vaginal birth and far less likely to experience harmful, unnecessary interventions...."

"...The goal is to have a healthy baby. 'This phrase is used over and over and over to shut down women's requests,' she [Erica Lyon] says. 'The context needs to be that the goal is a healthy mom. Because mothers never make decisions without thinking about that healthy baby. And to suggest otherwise is insulting and degrading and disrespectful'...What's best for women is best for babies. and what's best for women and babies is minimally invasive births that are physically, emotionally, and socially supported. This is not the kind of experience that most women have. In the age of evidence based medicine, women need to know that standard American maternity care is not primarily driven by their health and well-being or by the health and well-being of their babies. Care is constrained and determined by liability and financial considerations, by a provider's licensing regulations and malpractice insurer. The evidence often has nothing to do with it." (emphasis mine)

The only critique I have of this book is one I echo from several other reviews. The book fires you up and has a lot of passion and energy, but provides no outlet or ideas for where to channel that energy. There is no "resources" section, no suggestion to join Citizens for Midwifery or your state midwifery advocates, no list of birth-positive organizations who are working diligently for birth change in our culture, etc.

Evidence Based Care

Simply put, evidence based care is care that is based on the best available evidence (research, studies, accurate, up-to-date published materials) and upon the individual woman’s unique situation. Any interventions are applied judiciously and with consideration of true medical indication and also the needs of the woman. Evidence based care is different than “routines” or “policies” which may or may not have a basis in evidence.

Childbirth Connection defines evidence based care as: "using the best research about the effects of specific procedures, drugs, tests, and treatments, to help guide decision-making."

The excellent exhaustive research summary and review A Guide to Effective Care in Pregnancy & Childbirth (also available for free download from Childbirth Connection) includes a helpful series of six tables classifying hundreds of maternity practices according to effectiveness and safety. The tables range from: "Beneficial forms of care" to “Forms of care likely to be ineffective or harmful.” Pregnant women and their support people may wish to refer to these tables in order to be informed consumers of the care they are being offered. They may also wish to refer to the tables and to the rest of the book if they are concerned about a test or procedure recommended by their caregiver or if they would like to suggest a practice that differs from that offered "routinely" at the location where they are choosing to birth or if they would like to double check the consistency of their local policies, procedures, and routines with the scientific research.

Lamaze's Six Care Practices, referenced earlier in this blog, are evidence-based practices that promote, support and protect normal birth.

Finally, Citizens for Midwifery has an excellent fact sheet summarizing the evidence behind the Mother Friendly Childbirth Initiative’s 10 Steps.