Continuing Education Resources for Birth Professionals

I love how the internet brings such a wide variety of wonderful educational resources right to our fingertips! Earlier this week I posted a link on the CfM Facebook page to some great presentation downloads from the 2010 CIMS Forum. Then, check out all these free podcasts from MIDIRS (Midwives Information Resource Services). Site registration is required to listen to the podcasts.

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Molly
CfM Blogger

Cesarean Article

Cesarean section linked to increased risk for maternal death, serious complications

By Ingrid Grasmo

25 January 2010

Lancet 2010; Advance online publication

MedWire News: The risk for maternal death and serious complications is high for women undergoing cesarean section and should therefore be done only when medically indicated, show findings from the third phase of World Health Organization (WHO) global survey on maternal and perinatal health.

For the survey, Metin Gulmezoglu (WHO, Switzerland) and co-authors analyzed 107,950 deliveries reported in 122 facilities from nine Asian countries.

The overall rate of cesarean section was 27.3 percent, while that of operative vaginal delivery was 3.2 percent. Facilities in China, Sri Lanka, Vietnam, and Thailand had higher rates of cesarean section than did those in Cambodia, India, Japan, Nepal, and the Philippines.

Women undergoing operative vaginal delivery had a 2.1-fold increased risk for maternal mortality and morbidity index (at least one of: maternal mortality, admission to intensive care unit [ICU], blood transfusion, hysterectomy, or internal iliac artery ligation) compared with women delivering spontaneously.

An increased risk was also seen for all types of cesarean section, with respective odds ratios (ORs) of 2.7, 10.6, 14.2, and 14.5 for antepartum delivery without indication, antepartum delivery with indication, intrapartum without indication, and intrapartum with indication, respectively.

However, cesarean section was associated with improved perinatal outcomes for breech presentation (OR = 0.2 antepartum and 0.3 intrapartum), but also with an increased risk for stay in neonatal ICU (2.0, and 2.1, respectively).

The researchers conclude: “Cesarean section should be done only when there is a medical indication to improve the outcome for the mother or the baby.”

MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010

Journal abstract

Grassroots Network: Australian home birth study

Dear Friends,

A new home birth study based on data from South Australia has just been published. Of course, an editorial on the topic in the same issue of the journal, penned by the President of the Australian Medical Association ("which is opposed to home birth in Australia") helped to "spin" the findings to show that home birth is much more dangerous than hospital birth, even though the actual data show no such thing.

You can read the whole article here: "Planned home and hospital births in South Australia, 1991-2006: differences in outcomes" (Robyn Kennare, Marc Keirse, Graeme Tucker and Annabelle Chan, MJA 192(2), 18 January 2009).

You can also find some great analysis of what the study actually tells us. If you are interested in reading research critically and understanding how data and results can be twisted (on purpose or by not thinking about what they mean), these analyses are worth your time:

"That Homebirth Study in South Australia"
by Lauredhel on January 16, 2010

“More critique of the homebirth study and its reporting by the media"
January 20, 2010 – 7:58 pm, by Croakey

You can be sure that US medical organizations, especially ACOG, are well aware of this study, and the chances are we’ll see and hear references to it in the weeks and months ahead; we can be prepared!

Sincerely,
Susan Hodges, “gatekeeper”

Cochrane Review about Eating During Labor

Most you are probably already aware of the recent Cochrane review about eating during labor--concluding that there is no justification to support fasting during labor. Of course, midwives have known this for a long time...

As the background statement notes, restricting fluids and foods during labor is common practice in many hospitals with some women only being allowed sips of water or ice chips. This restriction is unpleasant for lots of women and may have a variety of negative impacts on their births. I don't know if people in different geographic areas are starting to see changes in their local hospitals' fasting-during-labor guidelines, but I have yet to notice any loosening of restrictions in my own community.

The conclusion of the review is as follows:

"Since the evidence shows no benefits or harms, there is no justification for the restriction of fluids and food in labour for women at low risk of complications. No studies looked specifically at women at increased risk of complications, hence there is no evidence to support restrictions in this group of women. Conflicting evidence on carbohydrate solutions means further studies are needed and it is critical in any future studies to assess women's views.

The full Cochrane review is here. And there is a podcast available about it here.

There is a Reuters Health article about it here.

I noticed that less well-circulated amongst the birth community is the Cochrane review that was released the same day about Doppler use during high-risk pregnancies reducing risk in high-risk groups. I'd like to be mindful of the tendency to NOT share information that perhaps does not support our own views--isn't this what the medical community frequently does with evidence about the healthy birth practices we support so strongly?

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Molly
CfM Blogger
P.S. I saw lots of general news articles about this doppler review and received an update directly from the Cochrane Library explaining it, but then did not find the actual review on the Cochrane site...Here is a link to an article from Science Daily about it.

Nils Bergman Kangaroo Care Presentation

Via the lovely ladies at Independent Childbirth, I came across this slideshow presentation about skin-to-skin contact, breastfeeding, and perinatal neuroscience by Dr. Nils Bergman. Lots and lots of amazing and useful information!

Super short summary of the 243 slides: babies NEED to be with their mothers following birth in order to develop proper neural connections and ensure healthy brain development and proper brain "organization." Mother's chest is baby's natural post-birth "habitat" and is of vital developmental and survival significance. Breastfeeding = Brain wiring.

It would be nice to see every NICU and hospital have an in-service about this.

I was lucky enough to hear Dr. Bergman present on this subject in person at the La Leche League International conference in 2007. (Indeed, I actually ended up "performing" on stage with him in a mimed play put on immediately prior to his presentation!) He is a dynamic and engaging speaker (with a great accent!) and has so much of value to share. I will never forget hearing his duet with an LLL Leader of the song "Anything Tech Can Do, Mum Can Do Better."

Yes she can, yes she can, yes she CAAAANNNNNN!!

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Molly
CfM Blogger

Grassroots Network: NEW Canadian Study shows safety of home birth!

Dear Friends,

Yet another large study, just published in the Canadian Medical Association Journal, demonstrates the safety of planned, midwife-attended home birth!

In the abstract, the authors conclude:

“Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician.”

The new Canadian study compares outcomes for planned midwife-attended home births, planned midwife-attended hospital births (with the same cohort of midwives), and planned physician-attended hospital births. The women in all three groups all met the requirements to be eligible for a home birth, so the study groups are as comparable as possible.

The study used data from one health region in British Columbia. Canadian midwives practice in both home and hospital settings, which allowed a comparison of midwife-attended home and midwife attended hospital birth where ONLY the setting was different.

There are many interesting facts, data and observations in this study which is well worth reading!

You can read the abstract and the complete article (the early-release version) at:
http://www.cmaj.ca/cgi/rapidpdf/cmaj.081869. I have pasted the abstract below.

Sincerely,
Susan Hodges, “gatekeeper”

Note from Molly: The ever-informative and intelligent Science and Sensibility blog took an in-depth look at this study in this post. A particularly good point that Amy made about the new study was "3. The researchers isolated the effect of the birth setting itself by comparing midwife-attended home birth with midwife-attended hospital birth. In fact, the same group of midwives cared for women in both settings, so differences are likely to be related to the setting and its protocols and technological accoutrements (or lack thereof) rather than differences in the providers who actually provide the care."

==============================================================

Early release, published at www.cmaj.ca on August 31, 2009. Subject to revision.

Outcomes of planned home birth with registered midwife
versus planned hospital birth with midwife or physician
Patricia A. Janssen PhD, Lee Saxell MA, Lesley A. Page PhD, Michael C. Klein MD,
Robert M. Liston MD, Shoo K. Lee MBBS PhD

ABSTRACT
Background: Studies of planned home births attended by
registered midwives have been limited by incomplete
data, nonrepresentative sampling, inadequate statistical
power and the inability to exclude unplanned home
births. We compared the outcomes of planned home
births attended by midwives with those of planned hospital
births attended by midwives or physicians.
Methods: We included all planned home births attended
by registered midwives from Jan. 1, 2000, to Dec. 31, 2004,
in British Columbia, Canada (n = 2889), and all planned
hospital births meeting the eligibility requirements for
home birth that were attended by the same cohort of midwives
(n = 4752). We also included a matched sample of
physician-attended planned hospital births (n = 5331). The
primary outcome measure was perinatal mortality; secondary
outcomes were obstetric interventions and adverse
maternal and neonatal outcomes.
Results: The rate of perinatal death per 1000 births was
0.35 (95% confidence interval [CI] 0.00–1.03) in the group
of planned home births; the rate in the group of planned
hospital births was 0.57 (95% CI 0.00–1.43) among women
attended by a midwife and 0.64 (95% CI 0.00–1.56) among
those attended by a physician. Wo men in the planned
home-birth group were significantly less likely than those
who planned a midwife-attended hospital birth to have
obstetric interventions (e.g., electronic fetal monitoring,
relative risk [RR] 0.32, 95% CI 0.29–0.36; assisted vaginal
delivery, RR 0.41, 95% 0.33–0.52) or adverse maternal outcomes
(e.g., third- or fourth-degree perineal tear, RR 0.41,
95% CI 0.28–0.59; postpartum hemorrhage, RR 0.62, 95%
CI 0.49–0.77). The findings were similar in the comparison
with physician-assisted hospital births. Newborns in the
home-birth group were less likely than those in the midwife-
attended hospital-birth group to require resuscitation
at birth (RR 0.23, 95% CI 0.14–0.37) or oxygen therapy
beyond 24 hours (RR 0.37, 95% CI 0.24–0.59). The findings
were similar in the comparison with newborns in the
physician-assisted hospital births; in addition, newborns in
the home-birth group were less likely to have meconium
aspiration (RR 0.45, 95% CI 0.21–0.93) and more likely to
Abstract be admitted to hospital or readmitted if born in hospital
(RR 1.39, 95% CI 1.09–1.85).
Interpretation: Planned home birth attended by a registered
midwife was associated with very low and comparable
rates of perinatal death and reduced rates of obstetric
interventions and other adverse perinatal outcomes compared
with planned hospital birth attended by a midwife
or physician.

Health Care or Medical Care?

For quite some time, breastfeeding advocates have been working to change the language of infant feeding to reflect that breastfeeding is the biological norm (and formula feeding is the replacement/substitute). This includes sharing about the "risks of formula feeding" rather than the "benefits of breastfeeding" as well as encouraging research that no longer uses formula-fed babies as the control group or considers formula to be a benign variable (i.e. the babies in the breastfed group of many research projects also received some formula, but since our culture views formula as the "norm," this was not seen as a conflict). I love Diane Wiessinger's example--would we ever see a research project titled "Clear air and the incidence of lung cancer." No! Problem behavior is linked to problem outcomes in other areas of research, so it would be "Smoking and the incidence of lung cancer." However, we routinely see research titles like "Breastfeeding and the rate of diabetes" rather than linking problem to outcome--"Infant formula and the rate of diabetes."

Similarly, "intactivists" (people who oppose circumcision) have pointed out that there should be no need to refer to some boys as "uncircumcised"--being uncircumcised is the biological norm, it is "circumcised" boys that should received the special word/label. (On a related side note, I have written about "pleonasms"--words that contain unnecessary repetition--and birth and breastfeeding on another blog before.)

So, this brings me to another need for a change in the common language--correctly identifying whether we are really talking about "Health Care" or "Medical Care." This was brought to my attention recently by Jody McLaughlin the publisher of Compleat Mother magazine. We have a tendency to refer to "health care" and to "health care reform" and "health insurance" and and "health care providers" and "health care centers," when it reality what we are truly referring to is "medical care"--medical care reform, medical insurance, medical care providers, and medical care centers. As she says (paraphrasing), "we do not have a HEALTH care system in this country, we have a MEDICAL care system." She also makes an interesting point about a trend to re-name medical care systems with names that use the word "health" instead:

This is what I have observed: Our local facility was called Trinity HOSPITAL, later re-named Trinity MEDICAL CENTER, and now it is Trinity HEALTH.

In the late 70’s and early 80’s the discussions centered around the MEDICAL crisis, MEDICAL reform, MEDICAL insurance and MEDICAL care cost containment.

MEDICAL insurance morphed into HEALTH CARE insurance. MEDICAL reform morphed into HEALTHCARE reform.

This is a difference with a distinction.

Health care includes clean air and safe water, enough good food to eat, exercise, rest, shelter and a safe environment as well as healing arts and the availability of and appropriate utilization of medical care services.

Medical care is surgery, pharmaceuticals, invasive tests and procedures. Malpractice tort reform is on the agenda too but no one is talking about reducing the incidence of malpractice, or alleviating the malpractice crisis by improving outcomes.

Why does this discussion belong on a midwifery blog? First, I wanted to address it because we have sent out several Grassroots Network messages regarding "health care reform" (and including access to CPMs in this legislation). Secondly, because I think it is clear that midwifery care can truly be described as health care, whereas standard maternity care in the U.S. can much more aptly be described as medical care.

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Molly
CfM Blogger

New Research Blog

I am really excited about a new blog called Science and Sensibility hosted by Lamaze and written by Amy Romano. It is "a research blog about healthy pregnancy, birth and beyond."

I've previously mentioned two great posts by Amy:

Rotating Theories of the Increasing C-section Rate: Vitamin D Edition

Why the largest study of planned home births won’t sway ACOG

Two more good ones:

Do We Need a Cochrane Review to Tell Us that Women Should Move in Labor?

NICUs: If We Build It, They Will Come?

I love her style and look forward to following this new blog!

--
Molly
CfM Blogger

Grassroots Network: New home birth study from the Netherlands

Dear Friends,

As many of you may have heard, a very large study of home birth in the Netherlands was just published last week. The abstract is below, as well as the link to the abstract on the website of BJOG (an International Journal of Obstetrics & Gynecology). The study concludes that giving birth at home is as safe as hospital (if the birth is planned, with a well-trained midwife, and there is adequate transportation to and communication with medical services). It anticipates a similar study out of the UK that will be forthcoming. Mary Newburn, head of research and information at the National Childbirth Trust, commented that the study "makes a significant contribution to the growing body of reassuring evidence that suggests offering women a choice of place of birth is entirely appropriate."

Molly previously posted some additional links regarding this study. A comment to Rixa's blog included a link to a letter to the editor of the British Medical Journal from Madeleine Akrich, PhD and Bernard Bel, PhD, Collectif interassociatif autour de la naissance), that included these comments:

"We do share Visser & Steegers' concern about high transfer rates in low-risk births. As suggested in their paper, bad rates point at the detrimental effect of discontinuity of care, rather than at unforeseen serious complications. In their words, "healthy pregnant women need care, not cure."

"Besides, the transfer rates of home births seem to be rising in the Netherlands. They were 40% and 9% for nulliparae and multiparae respectively in 2002. It is also significant that these rates were even higher from polyclinics to hospital: 43% and 19% respectively, as deducted from the enclosed graphs. (The leftmost bars indicate home and polyclinic births and the central ones indicate transfers from home and from polyclinics.)

"Midwives comment that they feel more under pressure to accelerate labour when working closer to "the machines". This observation remains consistent with the conclusions of Wiegers and colleagues comparing midwifery practice at home and in hospitals: Outcome of planned home and planned hospital births in low risk pregnancies: prospective study in midwifery practices in the Netherlands (TA. Wiegers, MJNC. Keirse, J. van der Zee, GAH. Berghs). BMJ 1996;313:1309-1313"

The bottom line is that the vast majority of women, especially for first births, benefit from continuous support during labor, not more medical attention.

In addition, you may also find it useful to read CfM's article about ACOG and the AMA here and a discussion of "safety" here.


Sincerely,
Arielle Greenberg Bywater and Susan Hodges


Article Citation:
de Jonge A, van der Goes B, Ravelli A, Amelink-Verburg M, Mol B, Nijhuis J, Bennebroek Gravenhorst J, Buitendijk S. Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births. BJOG 2009. Accepted 26 February 2009. Published Online 15 April 2009.

ABSTRACT

Objective: To compare perinatal mortality and severe perinatal morbidity between planned home and planned hospital births, among low-risk women who started their labour in primary care.

Design: A nationwide cohort study.

Setting: The entire Netherlands.

Population: A total of 529 688 low-risk women who were in primary midwife-led care at the onset of labour. Of these, 321 307 (60.7%) intended to give birth at home, 163 261 (30.8%) planned to give birth in hospital and for 45 120 (8.5%), the intended place of birth was unknown.

Methods: Analysis of national perinatal and neonatal registration data, over a period of 7 years. Logistic regression analysis was used to control for differences in baseline characteristics. Main outcome measures Intrapartum death, intrapartum and neonatal death within 24 hours after birth, intrapartum and neonatal death within 7 days and neonatal admission to an intensive care unit.

Results: No significant differences were found between planned home and planned hospital birth (adjusted relative risks and 95% confidence intervals: intrapartum death 0.97 (0.69 to 1.37), intrapartum death and neonatal death during the first 24 hours 1.02 (0.77 to 1.36), intrapartum death and neonatal death up to 7 days 1.00 (0.78 to 1.27), admission to neonatal intensive care unit 1.00 (0.86 to 1.16).

Conclusions: This study shows that planning a home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low-risk women, provided the maternity care system facilitates this choice through the availability of well-trained midwives and through a good transportation and referral system.

================================================

Vitamin D and Cesareans

Several people have sent me a link to news articles about a recent study linking Vitamin D Deficiency to Increased C-Section Rate.

Amy Romano, blogging as a guest on the Giving Birth with Confidence blog, has a really fabulous analysis of the study: Rotating Theories of the Increasing C-section Rate: Vitamin D Edition

Her conclusion is particularly astute:

"Another red flag for bias? One of the study’s four authors is a paid consultant to none other than Quest Diagnostics, the company that made me listen to an ad for vitamin D blood testing while I was on hold.

Debunking this study doesn’t mean that vitamin D deficiency is harmless or that there aren’t other potential public health benefits to preventing and treating vitamin D deficiency in pregnant women. But we need a lot more information before we start blaming the increasing cesarean rate on vitamin D. It’s tempting in the face of a cesarean epidemic to assume that women’s bodies are deficient in something or another, or to just assume that women are asking for it. These theories direct attention away from the systemic problems that keep the cesarean rate marching higher and higher."

Speaking of the Giving Birth with Confidence blog, Amy also has an in-depth post there looking at the new homebirth study from the Netherlands that concluded giving birth at home is at least as safe as giving birth in the hospital. Rixa at Stand and Deliver also has a good post about this homebirth study, including lots of links to the difference media coverage of it. Make sure to check these out!

--
Molly
CfM Blogger

Media Assortment

+ A Spanish Bed Commercial that features a homebirth has been airing all over Spain: “La cama no es un lugar solo para dormir; en ella también vivimos algunas de las experiencias más importantes de nuestra vida, incluso el comienzo de la misma--The bed isn't just a place to sleep..it is also where we live some of the experiences most important of our lives...including the beginning of said life!

+ A recent Cochrane evidence review came out on Maternal positions and mobility during first stage of labor:

So why would staying out of bed shorten labor and reduce pain?

"Women who are upright and mobile are able to change their positions more easily," said Annemarie Lawrence, lead review author and a research midwife at the Institute of Women's and Children's Health at Townsville Hospital in Queensland, Australia.

"The ability to change positions, to utilize a wider variety of positions, and try other options, such as hot showers, birthing balls and beanbag supports, may help reduce overall pain and give women a greater sense of control over the progress of their labor," she said.

+ I was interested to read the article Abu Dhabi doula about a multicultural doula training conducted by Debra Pascali-Bonaro.

+The Sierra Vista Herald published an article about a midwife: Bisbee midwife has assisted at hundreds of births

+ And, the Chicago Tribune weighed in on the Atlantic breastfeeding article I've posted about previously:

Breast-feeding's debate not related to infants' health:
But the guilt and the angst over whether to breast-feed is her problem, as is her perception that she'll be less than an uber-mom if she gives her baby a bottle. Who told her she had to be an uber-mom, anyway? The reality is, moms make trade-offs over what they do for their babies all the time in light of their time, energy, abilities and financial and emotional resources.

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Molly
CfM Blogger

BBC Articles

I wanted to share links to two articles that I accessed on the BBC News website today. The first, Home births 'as safe as hospital', shares that "The largest study of its kind has found that for low-risk women, giving birth at home is as safe as doing so in hospital with a midwife. Research from the Netherlands - which has a high rate of home births - found no difference in death rates of either mothers or babies in 530,000 births."

The second was originally published last month: Women 'unprepared for childbirth'. From the article's opener: "Many women are going into labour vastly underestimating how painful it can be and overly optimistic that they will be able to manage without drugs, a study suggests. How has this happened?"

As a childbirth educator, I definitely have lots of thoughts about this. In fact, there is a very telling segment later in the article: "Much evidence suggests, however, that women who are well supported by midwives and partners throughout their labour and made to feel at ease are the ones who manage their pain the most effectively and require the fewest drugs."

My short take on the question "How has this happened?" is that many hospitals simply do not support the six care practices that support normal birth (care practices that greatly add to women's ability to cope with labor) and that women's access to the Midwives Model of Care is very limited!

--
Molly
CfM Blogger

Homebirth & Safety

A topic that often closely follows a mention of homebirth is that of safety. Women often say that they would like to have a homebirth, but decided on the hospital for "safety reasons." As we are well aware, ACOG also feels that all women should birth in the hospital for safety. And, as I've posted about several times previously, there is the insidious claim that to birth at home is to place the experience of giving birth over having a healthy baby. So, I was very interested to read a recent study about the reasons why women stay home to birth. Co-authored by a blogger that many people are familiar with, Rixa Freeze, the article was published in the Journal of Midwifery & Women's Health this month. One of the most common reasons given to birth at home was "safety" (the three other most common reasons were "intervention free," "negative previous hospital experience," and "control"). While obviously the study did not address physical outcomes, it backs up what I have always believed which is that women who choose homebirth are NOT choosing to do so because they value a "birth experience" over a "healthy baby."

Speaking of healthy mother, healthy baby, I shared a quote in another blog recently that I'd like to also share here. From the Winter 2008 issue of Midwifery Today:

"Although the popularly desired outcome is 'Healthy mother, healthy baby,' I think there is room in that equation for 'Happy, non-traumatized, empowered and elated mother and baby.'"

This is the equation that midwives and mothers who birth at home have figured out!

--
Molly
CfM Blogger

Cesarean Research

Last week I read a recent article connecting cesareans to a risk for strokes.

From the American Journal of Obstetrics & Gynecology 2008; 198: 391.e1-391.e7 (29 April 2008) via MedWire News Cesarean section (CS) delivery is an independent risk factor for stroke, a study of almost a million births has revealed. The researchers found that women who had cesareans had significantly higher stroke rates at 3 months postpartum, 6 months postpartum, and 12 months postpartum.

"Shiyng-Yu Lin and co-workers suggest CS delivery could alter hemodynamic and coagulation status, thereby predisposing to stroke.

'Based on the results of this study, a reduction in the CS delivery rate should prove to be beneficial for stroke prevention,' they conclude."

This week, another study reported that unexplained stillbirth is not linked to prior cesarean section. Source: BJOG: International Journal of Obstetrics and Gynecology 2008; 115: 726-31
(MedWire Posted: 6 May 2008).

Recent VBAC Research

From Susan Hodges:

VBAC should be widely available and is low risk for many VBAC hopefuls.

A just-published large study found that a woman with a prior cesarean but who has since given birth vaginally is at low risk for complications for herself and the baby, and with increasing number of prior VBACs has a greater likelihood of successful VBAC as well as lower risks for complications such as uterine rupture and perinatal complications for the baby. (Brian M. Mercer, et al. Labor Outcomes With Increasing Number of Prior Vaginal Births After Cesarean Delivery. Obstet Gynecol 2008;111:28591).

Another recently published study concluded that: A history of multiple cesarean deliveries is not associated with an increased rate of uterine rupture in women attempting vaginal birth compared with those with a single prior operation. Maternal morbidity is increased with trial of labor after multiple cesarean deliveries, compared with elective repeat cesarean delivery, but the absolute risk for complications is small. [emphasis added] Vaginal birth after multiple cesarean deliveries should remain an option for eligible women. (Mark B. Landon,et al., Risk of Uterine Rupture With a Trial of Labor in Women With Multiple and Single Prior Cesarean Delivery Obstet Gynecol 2006;108:1220).

With each successive cesarean section, the risk of increasingly serious complications in the future rises. (Robert M. Silver, et al. Maternal Morbidity Associated With Multiple Repeat Cesarean Deliveries Obstet Gynecol 2006;107:122632). For women who were traumatized by their initial cesarean section experience or felt betrayed by their doctor or hospital staff, the hospital may be the least conducive setting for a successful VBAC, especially if the doctor or staff are unsupportive or unskilled in providing appropriate emotional support and encouragement. Furthermore, in many hospitals it is routine to induce or stimulate labor with drugs, even for VBACs, which significantly increases the risks of uterine rupture and other complications. (Brian M. Mercer, et al. Labor Outcomes With Increasing Number of Prior Vaginal Births After Cesarean Delivery. Obstet Gynecol 2008;111:28591).

Childbirth Connection Evidence Columns

We've previously mentioned some of the many great resources offered by Childbirth Connection and we'd like you to call attention to another one of them--Evidence Columns. This e-news summary is issued once every two months and is an excellent way to keep up with the latest research about maternity care and childbirth.

In the January/February 2008 issue there is an interesting graph visually contrasting the rising cesarean rate with the dropping VBAC rate and another interesting chart about costs of birth by setting (unfortunately it does not include home births). Birth activists can easily access both of the charts to print out as free pdf handouts after registering and logging in.

To sign up to receive the newsletter you may register (free) by signing up on the Childbirth Connection registration page. Registration is required to download pdfs.