Maternal Mortality in the USA

As I'm sure everyone has heard the heartbreaking news about our AZ Treasurer who lost his wife and newborn son due to complications during her delivery. My heart goes out to him and his family. While Kerry Martin's complications were very rare, I feel that this has definitely drawn attention to the subject of maternal mortality. I found a link to the following information from the most recent post at NursingBirth. This fact sheet originally came from The Safe Motherhood Quilt Project which aims at bringing awareness to the high maternal mortality rate in the US, as well as remembering those mothers who have died due to pregnancy related causes. I found this information to be very eye opening.

Maternal Mortality in the USA
A Fact Sheet

• The World Health Organization reported in 2007 that 40 other countries
have lower maternal death rates than the United States.

• The Centers for Disease Control (CDC) report that there has been no
improvement in the maternal death rate in the United States since 1982.

• The CDC estimated in 1998 that the US maternal death rate is actually 1.3
to three times that reported in vital statistics records because of
underreporting of such deaths. (1)

• The CDC reported in 1995 that the “magnitude of the pregnancy-related
mortality problem is grossly understated.” (2)

• The rate of maternal death directly related to pregnancy or birth appears
to be rising in the United States. In 1982, the rate was approximately 7.5
deaths per 100,000 live births. By 2004, that rate had risen to 13.1 deaths
per 100,000 births. By 2005, the rate was 15.1 deaths.

• The CDC estimates that more than half of the reported maternal deaths
in the United States could have been prevented by early diagnosis and
treatment. (1)

• Autopsies should be performed on all women of childbearing age who die
if there is to be complete ascertainment of maternal deaths.

• Numerous studies have found that in 25 to 40 percent of cases in which an
autopsy is done, it reveals an undiagnosed cause of death.

• In the 1960s, autopsies were performed on almost half of deaths.

.• The United States now does autopsies on fewer than 5 percent of hospital
deaths.

• Reporting of maternal deaths in the United States is done via an honor
system. There are no statutes providing for penalties for misreporting or
failing to report maternal deaths.

• In the United States, the risk of maternal death among black women is
about 4 times higher than among white women. For 2005, the rate was 36.5
deaths per 100,000 live births.

• Most countries with lower maternal death rates than the United States use
a different definition of “maternal death”, which, unlike the United States’
definition, includes those deaths directly related to pregnancy or birth
which take place during the period between six weeks postpartum and
one year after the end of pregnancy.

• Complete and correct ascertainment of all maternal deaths is key to
preventing maternal deaths.

• The Confidential Enquiry into Maternal Deaths in the United Kingdom
(England, Scotland, Wales, Northern Ireland), which has functioned since
1952, is the system believed to have achieved the most complete
ascertainment of maternal deaths while guaranteeing utmost
confidentiality. See http://www.cemach.org.uk/

• The maternal mortality rate for cesarean section is four times higher than
for vaginal birth and is still twice as high when it is a routine repeat
cesarean section without any emergency. (3,4)

• There is currently no federal legislation mandating maternal mortality
review at a state level.

• Fewer than half of the states conduct state-wide maternal mortality
review.

• Hospitals do not release reports of maternal deaths to the public; hospital
employees are required to keep such information to themselves.

• The Healthy People 2010 Goal is no more than 3.3 maternal deaths per
100,000 births. This is a goal that other nations have achieved.

Notes
1. Morbidity and Mortality Weekly Report, September 4, 1998, Vol. 47, No. 34.
2. Atrash HK, Alexander S, Berg CJ. Maternal mortality in developed
countries: Not just a concern of the past. Obstet Gynecol 1995;86:700-5.
3. Petitti D et al. In hospital maternal mortality in the United States. Obstet
Gynecol, Vol 59, pp. 6-11, 1982.
4. Petitti D. Maternal mortality and morbidity in cesarean section. Clin Obstet
Gynecol, Vol. 28, pp. 763-768, 1985.
5. The Confidential Enquiry into Maternal Deaths in the United Kingdom
www.cemach.org.uk
Prepared by Ina May Gaskin, MA, CPM
Coordinator for the Safe Motherhood Quilt Project
149 Apple Orchard Lane
Summertown, TN 38483
www.rememberthemothers.net
http://www.inamay.com/

For a great list of 10 ways to reduce your risk for complications in pregnancy and childbirth check out this post at NursingBirth.

Article from Time Magazine

Here is an article that was featured in Time Magazine back in February. I ran across it again today and wanted to share. I think it does a good job of shedding light on some of the challenges women are faced with when wanting a vbac in America, along with some of the reasons why there is so much resistance from doctors and hospitals.

(I highlighted some parts that really stood out to me)

The Trouble With Repeat Cesareans
By Pamela Paul Thursday, Feb. 19, 2009

To avoid another C-section, Barton has to drive 100 miles to deliver in Los Angeles.

For many pregnant women in America, it is easier today to walk into a hospital and request major abdominal surgery than it is to give birth as nature intended. Jessica Barton knows this all too well. At 33, the curriculum developer in Santa Barbara, Calif., is expecting her second child in June. But since her first child ended up being delivered by cesarean section, she can't find an obstetrician in her county who will let her even try to push this go-round. And she could locate only one doctor in nearby Ventura County who allows the option of vaginal birth after cesarean (VBAC). But what if he's not on call the day she goes into labor? That's why, in order to give birth the old-fashioned way, Barton is planning to go to UCLA Medical Center in Los Angeles. "One of my biggest worries is the 100-mile drive to the hospital," she says. "It can take from 2 to 3 1/2 hours. I know it will be uncomfortable, and I worry about waiting too long and giving birth in the car."

Much ado has been made recently of women who choose to have cesareans, but little attention has been paid to the vast number of moms who are forced to have them. More than 9 out of 10 births following a C-section are now surgical deliveries, proving that "once a cesarean, always a cesarean"--an axiom thought to be outmoded in the 1990s--is alive and kicking. Indeed, the International Cesarean Awareness Network (ICAN), a grass-roots group, recently called 2,850 hospitals that have labor and delivery wards and found that 28% of them don't allow VBACs, up from 10% in its previous survey, in 2004. ICAN's latest findings note that another 21% of hospitals have what it calls "de facto bans," i.e., the hospitals have no official policies against VBAC, but no obstetricians will perform them. (Read "The Year in Medicine 2008: From A to Z.")

Why the VBAC-lash? Not so long ago, doctors were actually encouraging women to have VBACs, which cost less than cesareans and allow mothers to heal more quickly. The risk of uterine rupture during VBAC is real--and can be fatal to both mom and baby--but rupture occurs in just 0.7% of cases. That's not an insignificant statistic, but the number of catastrophic cases is low; only 1 in 2,000 babies die or suffer brain damage as a result of oxygen deprivation.
After 1980, when the National Institutes of Health (NIH) held a conference on skyrocketing cesarean rates, more women began having VBACs. By 1996, they accounted for 28% of births among C-section veterans, and in 2000, the Federal Government issued its Healthy People 2010 report proposing a target VBAC rate of 37%. Yet as of 2006, only about 8% of births were VBACs, and the numbers continue to fall--even though 73% of women who go this route successfully deliver without needing an emergency cesarean.

So what happened? In 1999, after several high-profile cases in which women undergoing VBAC ruptured their uterus, the American College of Obstetricians and Gynecologists (ACOG) changed its guidelines from stipulating that surgeons and anesthesiologists should be "readily available" during a VBAC to "immediately available." "Our goal wasn't to narrow the scope of patients who would be eligible, but to make it safe," says Dr. Carolyn Zelop, co-author of ACOG's most recent VBAC guidelines.But many interpreted the revision to mean that surgical staff must be present the entire time a VBAC patient is in labor. While major medical centers and hospitals with residents are staffed to provide this level of round-the-clock care, smaller hospitals typically rely on anesthesiologists on call. Among obstetricians, many solo practitioners are unable to stay for what could end up being a 24-hour delivery; others calculate the loss of unseen patients during that time and instead opt to do hour-long cesareans, which are now the most commonly performed surgeries on women in the U.S.

Some doctors, however, argue that any facility ill equipped for VBACs shouldn't do labor and delivery at all. "How can a hospital say it can handle an emergency C-section due to fetal distress yet not be able to do a VBAC?" asks Dr. Mark Landon, a maternal-fetal-medicine specialist at the Ohio State University Medical Center and lead investigator of the NIH's largest prospective VBAC study. (See 9 kid foods to avoid.)

Part of the answer has to do with malpractice insurance. Following a few major lawsuits stemming from VBAC cases, many insurers started jacking up the price of malpractice coverage for ob-gyns who perform such births. In a 2006 ACOG survey of 10,659 ob-gyns nationwide, 26% said they had given up on VBACs because insurance was unaffordable or unavailable; 33% said they had dropped VBACs out of fear of litigation. "It's a numbers thing," says Dr. Shelley Binkley, an ob-gyn in private practice in Colorado Springs who stopped offering VBACs in 2003. "You don't get sued for doing a C-section. You get sued for not doing a C-section."

Of course, the alternative to a VBAC isn't risk-free either. With each repeat cesarean, a mother's risk of heavy bleeding, infection and infertility, among other complications, goes up. Perhaps most alarming, repeat C-sections increase a woman's chances of developing life-threatening placental abnormalities that can cause hemorrhaging during childbirth. The rate of placenta accreta--in which the placenta attaches abnormally to the uterine wall--has increased thirtyfold in the past 30 years. "The problem is only beginning to mushroom," says ACOG's Zelop.

"The decline in VBACs is driven both by patient preference and by provider preference," says Dr. Hyagriv Simhan, medical director of the maternal-fetal-medicine department of Magee-Womens Hospital of the University of Pittsburgh Medical Center. But while many obstetricians say fewer patients are requesting VBACs, others counter that the medical profession has been too discouraging of them. Dr. Stuart Fischbein, an ob-gyn whose Camarillo, Calif., hospital won't allow the procedure, is concerned that women are getting "skewed" information about the risks of a VBAC "that leads them down the path that the doctor or hospital wants them to follow, as opposed to medical information that helps them make the best decision." According to a nationwide survey by Childbirth Connection, a 91-year-old maternal-care advocacy group based in New York City, 57% of C-section veterans who gave birth in 2005 were interested in a VBAC but were denied the option of having one.

Zelop is among those who worry that "the pendulum has swung too far the other way," but, she says, "I don't know whether we can get back to a higher number of VBACs, because doctors are afraid and hospitals are afraid." So how to reverse the trend? For one thing, patients and doctors need to be as aware of the risks of multiple cesareans as they are of those of VBACs. That is certain to be on the agenda when the NIH holds its first conference on VBACs next year. But Zelop fears that the obstetrical C-change may come too late: "When the problems with multiple C-sections start to mount, we're going to look back and say, 'Oh, does anyone still know how to do VBAC?'"

On Being Prepared

A few weeks ago I began questioning myself as to why I was preparing so much ahead of time for my vbac and taking the time to blog about it. I'm not pregnant, and I'm not 100% sure when I will be pregnant again. Why do all this without a due date in sight? After breaking down and talking to my husband about it, I was able to reconfirm my true intentions.

1st- When I do see those two pink lines confirming that I am pregnant, I don't want to immediately feel dread thinking that I am going to relive my last birth experience. I don't want there to be any feelings of negativity or fear in sight. I want to feel happy, happy to be pregnant and happy because I know this time will be better no matter what. Even if I end up truly needing a cesarean section it will be better. Even if I have to be in the hospital again it will be better. It will be better because I took the time to prepare myself. This doesn't mean that my need to prepare will end once I am pregnant.
2nd- I want to get the word out on the high statistics of cesarean sections in the US, along with resources and support for those wishing to VBAC. I've been through one cesarean section and honestly I would love to help prevent an unnecessary one from happening to any woman out there. I know so many who have had unnecessary cesarean sections and I can't help but want to warn others of this is a major issue. I have also found that a lot of pregnant women out there were a lot like me and didn't know all their birthing options and rights. I didn't know anything about the effects of certain medical interventions and unfortunately these tend to lead to cesarean sections. Knowlegde=power and can ultimately lead to a better birth experience.

3rd- Preparing yourself for a birth experience takes a good amount of time. Just as finding a new home, purchasing a car or any other big life change, there is a lot of planning involved. The birth of your child can be the most life changing event, thus it should require even more careful thought and research. This includes researching ones birth options, interviewing care providers and deciding on ultimately where one wants to birth. Eating well and exercising to promote good health should be practiced before becoming pregnant so your body is more physically prepared. Another essential part is working past the previous experiences and conquering those fears that could inhibit a woman from being successful in her future birth. Some might be able to do all this in 9 months time and that is wonderful. I'm the type that likes to have things planned out far in advance because it gives me more peace of mind.

For those of you who are pregnant or not yet pregnant and wanting a VBAC here is a great resource from VBAC Facts that can help you on your way.

Top 8 Ways To Have An Unnecessary Cesarean Section

I loved this post from Nursing Birth, and I wanted to share it because one of my (and hopefully every woman's) main goals is to avoid an unnecessary c-section in the future. It originally started with 7 ways, but she added an 8th at the end. Most of the research that she cites in this post came from the book "The Thinking Woman's Guide to a Better Birth" by Henci Goer.

#7 Go the hospital in the early phases of labor.
Crawford is just plain right-on with this one! Too many obstetricians are quick to label a mom as having “dysfunctional labor” if she does not progress at least one centimeter an hour (for first time moms) or two centimeters and hour (for multiparous moms) immediately upon arriving to the hospital. I have even had some doctors I work with take a call from a mom at home that “sounds like she is in labor” and turn around and tell the residents to “start her on pit as soon as she gets here.” WHAT??!! Pam England, CNM, MA writes in her book Birthing From Within, “One advantage to laboring in the privacy of your home, with one-on-one midwifery support, is that should a problem arise that requires medical support at the hospital, you will not wonder whether your labor problems were caused by routine, unnecessary, or ill-timed hospital interventions.”

#6 Don’t eat or drink during a long labor.
Goer writes that dehydration and starvation caused by restricting food/drink intake during labor causes a woman not only considerable discomfort but can also lead to fever, prolonged labor, increased use of oxytocin (aka pitocin), instrumental delivery, and a non-reassuring fetal heart rate pattern/fetal distress. And what can all of these lead to…that’s right…a cesarean section! (Goer, 79-83)

#5 Get an amniotomy too soon.
Amniotomy (or artificially “breaking the bag of waters”) too soon can lead to umbilical cord compression/fetal distress, abnormal fetal heart rate patterns, cord prolapse (a surgical emergency where the umbilical cord slips out into the birth canal before the baby’s head), increased likelihood of maternal infection and hence a “race against the clock” to get a woman “delivered” before 24 hours is up, and lastly, a greater chance that the baby get “stuck” in a posterior (back of head toward your back) or acynclitic (head tilted off to one side) position which can stall labor and make pushing at best, difficult and at worse, unsuccessful. Bottom line, if it ain’t broke, leave it alone! Not obeying that rule could lead you to an unnecessary cesarean! (Goer, 99-104)

#4 Accept pitocin to induce or stimulate contractions.
The use of oxytocin (pitocin) for labor augmentation (aka “revving up a slow labor”) or induction (aka artificially starting a labor that hasn’t started on its own) has its own risks. Although oxytocin is quite effective at stimulating contractions, it often makes contractions stronger and longer than natural contractions, can cause too many contractions too close together (aka uterine tachysystole or hyperstimulation) which can lead to fetal distress, can double the chances of a baby being born in poor condition, and eventually can lead you to the operating room! (Goer, 65)

#3 Request an epidural.
Research has shown that epidurals 1) interfere with a mother’s natural release of labor hormones which can in turn (among other things) slow or stop her progress of labor, 2) increase her chances of needing pitocin augmentation for said slowed labor, 3) numb her pelvic floor muscles, which are important in guiding her baby’s head into a good position for birth , 4) can cause maternal fever than can be mistaken as a sign of infection, 5) can cause a significant drop in her blood pressure which can interfere with how much blood supply is getting to the baby and can lead to profoundly negative effects on the baby’s heart rate, 6) significantly impair in her ability to push her baby out effectively. All of these side effects/risks, as research has shown can, and often does, lead to a cesarean section. (See “Epidurals: risks and concerns for mother and baby” by Dr Sarah J. Buckley)

#2 Accept hospital staff’s comments on lack of progress without challenge.
In my opinion, nothing is more detrimental to a woman’s labor progress and ultimately her birth experience than negativity in the labor room from labor & birth attendants, especially the people who are the “professionals” like obstetricians, midwives, and nurses. As Marsden Wagner, MD, MS writes in his book Born in the USA, fear and anxiety stop labor. And giving a woman the impression that she is “failing” can lead to a helpless and hopeless attitude and eventually a cascade of interventions that might very well lead to a cesarean section.

#1 Just ask!
Believe it or not, there are some OBGYNs out there that will agree to perform a cesarean section on a first time mom without medical indication. Goer writes, “Popping up lately in the medical literature are arguments that women should be able to have first cesareans for the asking as well. Again, this is presented as a freedom of choice issue. But how much real freedom do women have in a culture that portrays labor as torture and C-sections as a ‘no muss, no fuss’ option?” Goer states that the obstetric belief that choosing between a cesarean and vaginal birth is like choosing “between chocolate and vanilla” is really about six things: money, impatience, convenience, peer pressure, hospital culture, and defensive medicine. What I find even more disturbing than this, however, is that women who do desire to avoid a cesarean and plan for a vaginal birth after a cesarean (VBAC) are finding themselves with less choice and opportunity to do so in more and more communities around this country as more and more obstetricians are refusing to attend VBACs and hospitals are either banning or placing de facto bans on VBACs.

And lastly here is my own addition…number 8!

#8 Agree to a labor induction without medical indication.
Induction of labor comes with risks and the BIGGEST risk is the risk of cesarean section. When induction of labor is done for a medical reason, either related to mom or baby, and the risks of continuing the pregnancy are greater than the risks of induction, then this is the only time when labor induction is appropriate and warranted. But when a woman agrees to a labor induction without any medical reason, then she is putting herself at risk for an unnecessary cesarean section, plain and simple.
Many obstetricians I work with claim that all the “elective” labor inductions (that is, inductions without medical indication) are because the woman “demands” it. And don’t get me wrong, there are some women out there who are a bit mislead. But all to often a woman shows up for a labor induction and it is overwhelmingly obvious that she: 1) wasn’t fully explained both the benefits AND risks of labor induction, 2) wasn’t told that labor induction can take up to three days to complete, 3) wasn’t told that comfort measures like using a jacuzzi tub or shower, walking, using the birthing ball, eating, drinking, and general freedom of movement are MAJORLY restricted during labor induction either because of hospital policy, obstetrician’s philosophy, or the requirement of continuous external fetal monitoring, 4) didn’t realize she had the option to say NO.

So there you have it, the Top 8 ways to have an unnecessary cesarean section. I wish it wasn’t true but unfortunately it IS!

In closing I would like to leave you with one of my favorite quotes:

“We have a secret in our culture, and it’s not that birth is painful; it’s that women are strong.” ~ Laura Stavoe Harm

One Labor & Delivery Nurse's View From the Inside

I just heard about a blog called Nursing Birth through another birthing blog that I frequent (thanks Diana!). It's been less than 24 hours and I have read every single thing she has posted, and I can't wait to read more! The author is a labor & delivery nurse in the U.S. that shares her experiences as she assists parents in their hospital births. I loved reading her "Don't let this happen to you" stories as they shed light on a lot of issues that birthing mothers should be aware of. After reading a few of her stories you can tell that she truly has her patients best interest at heart even when their doctor does not. She is one of those angel nurses that you hope to have when giving birth at the hospital. If only all L&D nurses could be like her! She also posts about recent news articles as well as studies regarding birth,breastfeeding etc. Oh, and her name is Melissa so you know she's gotta be smart:)

Here is a quote where she describes the purpose of her blog:

"NursingBirth is a blog in support of change for the current state of maternity care in the United States. My goal in starting this blog is to get the word out there that if things stay the way they are, the safety and welfare of our mothers and baby continues to be at risk. I also want the birth advocacy community to know that there are nurses out there that are on your side! The time is NOW! I hope my blog will include ramblings of my day to day life as a labor and delivery nurse, resources for birth advocacy and tips for becoming involved in the cause, book reviews, commentary on current events, new perspectives on past experiences, and thoughts towards change!"

I LOVE this blog!

Check out NursingBirth here.

From Behind the Blue Curtain

One of the things on my to-do list was to get a copy of my operative report from my c-section. I had never thought of doing this until a midwife at an ICAN meeting mentioned it. So today I took my girls and went down to the doctor's office and got a copy. It was quick and painless and didn't cost a thing. Once it was in my hands, I was suddenly so anxious to read it. I knew it had a lot of medical details that I probably wasn't aware of; mysteries from behind the blue curtain.

For some women who are still unsure of the medical events around their cesarean section, this might provide some help. While it doesn't give all the information, it should state the reason for the c-section, a detailed description of the placenta, delivery of the child, and how the incision was closed.

Believe it or not, I enjoyed reading about my placentas. That might seem weird, but I didn't have the chance to see what my girls were living off of for all those months. I also learned my girls APGAR scores for the first time, as I was never told in the hospital (or maybe I was told and was really drugged at the time). I read the specifics on the events that occurred right after their births, when they were cleaned, weighed and taken to the nursery. These were all things that my eyes never saw that day. The report also confirmed the type of incision I had along with the details of how my incision was closed. I was glad to read that my doctor used two layers of sutures to close my uterus instead of just one.

The other benefit of getting a copy for yourself, is that when you go to your health care provider for a future pregnancy, you know just as much as they know about your c-section (medically speaking).

Now I can also see how this might be hard for some who are still recovering from a traumatic experience with their c-section. Sometimes knowing all the details at the moment isn't beneficial when the emotional pain is still very raw. It's definitely a personal decision but something to think about for the future.

Happy Friday!

I've found a lot of confidence in watching successful vbac and hbac videos. Here is one that was inspiring to me. Enjoy watching and happy Friday:)

p.s. I always get chills watching these, is it just me?