childbirth

RECENT POSTS

Investigating High C-Section Rates, Researchers To Examine Floor Plans

A woman’s chance of having a C-section can be almost three times higher from one hospital to the next in Massachusetts. But why? No one has the definitive answer. Researchers have looked at the ratio of doctors to nurses or midwives, at payment rates, at medical malpractice policies, at on-call schedules — and still the question lingers.

Could it be the layout of the labor and delivery unit?

Dr. Neel Shah, an associate faculty member at Ariadne Labs, began asking himself this question a little more than a year ago during a tour of hospitals. He watched nurses run down long hallways, from patient to patient. He noticed walls that divided patients, but also decision makers who might benefit from collaboration. And, he was struck by all the ways a labor and delivery floor mirrored an intensive care unit: one nurse per patient for women in active labor, machines that track vital signs in real time and medicines that are titrated minute to minute.

“The only difference between an ICU and a labor floor is that on the labor floor the ORs are attached,” Shah said. “So you’ve got the most intense treatment area in the entire hospital for the healthiest patients. It doesn’t take a rocket scientist to figure out why we overdo it.”

Lighting, furniture placement and waiting areas are not typically the focus of health care quality improvement projects, but maybe they should be.

Shah, working with architects at Mass Design Group, has a one-year grant from the Robert Wood Johnson Foundation to study how the design of a maternity ward affects C-section rates at 12 hospitals around the country. Continue reading

Related:

Panel Recommends Depression Screening For Women During And After Pregnancy

(Chris Martino/Flickr)

(Chris Martino/Flickr)

On Tuesday the U.S. Preventive Services Task Force released new recommendations on screening for depression in adults, notably calling for depression screening in women both during and after pregnancy.

The recommendations, published in the Journal of the American Medical Association, suggest: “All adults older than 18 years should be routinely screened for depression. This includes pregnant women and new mothers as well as elderly adults.”

Why?

“Depression is among the leading causes of disability in persons 15 years and older,” the task force statement said. “It affects individuals, families, businesses, and society and is common in patients seeking care in the primary care setting. Depression is also common in postpartum and pregnant women and affects not only the woman but her child as well. …The [task force] found convincing evidence that screening improves the accurate identification of adult patients with depression in primary care settings, including pregnant and postpartum women.”

The government-appointed panel found that the harms from such screening are “small to none,” though it did cite potential harm related to drugs frequently prescribed for depression:

The USPSTF found that second-generation antidepressants (mostly selective serotonin reuptake inhibitors [SSRIs]) are associated with some harms, such as an increase in suicidal behaviors in adults aged 18 to 29 years and an increased risk of upper gastrointestinal bleeding in adults older than 70 years, with risk increasing with age; however, the magnitude of these risks is, on average, small. The USPSTF found evidence of potential serious fetal harms from pharmacologic treatment of depression in pregnant women, but the likelihood of these serious harms is low. Therefore, the USPSTF concludes that the overall magnitude of harms is small to moderate.

Nancy Byatt, medical director at the Massachusetts Child Psychiatry Access Project for Moms (MCPAP for Moms) and an assistant professor of psychiatry and obstetrics and gynecology at UMass Medical School, said the new recommendations “are an incredibly important step to have depression care become a routine part of obstetrical care.”

She added: “Depression in pregnancy is twice as common as diabetes in pregnancy and obstetric providers always screen for diabetes and they have a clear treatment plan. The goal [here] is that women are screened for depression [during pregnancy and postpartum] and they are assessed and treated and this becomes a routine part of care just like diabetes.”

Dr. Ruta Nonacs, who’s in the psychiatry department at Massachusetts General Hospital and editor-in-chief at the MGH Center for Women’s Mental Health, sent her thoughts via email:

In that the USPSTF recommendation recognizes pregnant and postpartum women as a group at high risk for depression, this represents a step in the right direction in terms of ensuring that psychiatric illness in this vulnerable population is identified and appropriately treated. However, there remain significant obstacles to overcome. Research and clinical experience indicate that while pregnant and postpartum women with mood and anxiety disorders can be identified through screening, many women identified in this manner do not seek or are not able to find treatment.

While screening is important, we must also make sure we tend to the construction of a system that provides appropriate follow-up and treatment. Because stigma continues to be significant with regard to mental health issues in mothers and mothers-to-be and because there are concerns regarding the use of medication in pregnant and nursing women, we must make sure that after screening, we help women to access appropriate resources and treaters who have expertise in the treatment of women during pregnancy and the postpartum period.

Continue reading

Related:

Commentary: When Sexual Violence Survivors Give Birth, Here’s What You Should Know

By Sarah Beaulieu
Guest Contributor

Sarah Beaulieu (Courtesy of the author)

Sarah Beaulieu (Courtesy of the author)

It shouldn’t have been a surprise that childbirth would leave me traumatized.

In retrospect, it seems obvious that when a survivor of sexual violence feels pain in her vagina caused by a strange being inside of her, the experience might trigger memories of an earlier trauma. But what wasn’t so obvious were the many ways that the childbirth and medical professionals didn’t prepare me for these unexpected and painful emotions related to giving birth.

With 20 years of therapy under my belt, I consider myself to be a fairly confident survivor with many tools in my resilience box. None of these tools prepared me for what happened during the birth of my son. After 12 hours of relatively peaceful labor in the hands of midwives, I dozed off, preparing for a long night. I woke up with at least two sets of hands inside of me, alarms ringing and a sense of panic in the room. My son’s heart rate had dropped dangerously low, and I needed an immediate C-section.

This experience — traumatic for even the healthiest woman — wrecked me, surfacing old post-traumatic stress disorder symptoms and pulling me into depression and anxiety. With the help of a hospital social worker, I emerged from my emotional dark place a few months later, and immersed myself in learning more about birthing as a sexual assault survivor. My experience was scary, but it couldn’t be that uncommon, I thought. After all, 1 out of 4 women share a sexual abuse history like mine, and U.S. women gave birth to nearly 4 million babies last year.

My research led me to Penny Simkin and Phyllis Klaus, two legendary birth educators who compiled much of the existing research into a single manual, “When Survivors Give Birth.”

I learned that, in fact, there were approaches to childbirth that were especially helpful to survivors of sexual violence. Not only that, but it was fairly common for pregnancy and birth to re-trigger memories and emotions related to past sexual violence. Yet despite this, the topic of sexual violence wasn’t typically covered by my midwifery practice, recommended childbirth literature or my natural childbirth class.

First and foremost, health care providers can adopt a trauma-informed approach to care for laboring mothers. Knowing that 25 percent of patients in labor and delivery will have a history of sexual violence, there is a benefit for all staff to be educated about sexual violence and its impact on birth. There are medical reasons too: Childhood trauma, including child sexual abuse, is a documented risk factor of postpartum depression and anxiety, which impacts 10 to 15 percent of new mothers — and their babies and families — each year.

Knowledge starts with screening for a history of sexual violence on standard intake forms and first visits. It also means creating a health care environment where survivors feel comfortable disclosing such histories. In my midwife’s office, there were pamphlets for every possible pregnancy complication, from gestational diabetes to heartburn to exercise during pregnancy. So, why not a pamphlet on giving birth as an abuse survivor?

Cat Fribley, an Iowa-based sexual assault advocate and doula whose practice focuses specifically on sexual violence survivors, describes trauma-informed care as “supporting the whole person with collaboration, choice and control, cultural relevance, empowerment and safety — both physical and emotional. This requires making certain adjustments to the way they work with survivors, acknowledging both the challenges that arise from sexual trauma, as well as unique coping skills — such as dissociation — that may help the survivor through the process of childbirth.”

Here’s an example: At one birth Fribley attended, “the birthing mother became visibly upset when new and unknown staff would enter the room while she was laboring. A simple sign on the door asking people to knock and announce themselves before entering helped make the birthing mom feel more in control of her environment — and the exposure of her body.” Continue reading

Childbirth As An Extreme Sport — And Why Its Injuries Can Take So Long To Heal

A study finds some childbirth-related injuries are surprisingly like sports injuries. (popularpatty/Flickr)

A study finds some childbirth-related injuries are surprisingly like sports injuries. (popularpatty/Flickr)

Childbirth, as anyone who’s been through it knows, can feel very much like an extreme sport. And, it turns out, some childbirth-related injuries are surprisingly like sports injuries, including the very long time they need to heal.

That’s the conclusion of a recent study that tracked 68 pregnant women at risk for pelvic injuries and followed up using diagnostic imaging techniques more typically used in sports medicine.

The report by a team of researchers at the University of Michigan found that some women sustain long-lasting pelvic injuries after childbirth — and these aren’t the kinds of injuries that Kegel exercises alone can fix. (For the uninitiated, Kegels are pelvic floor strengthening exercises that involve squeezing and releasing certain muscles.) The research team also found that some childbirth-related injuries may take longer to heal, but ultimately do.

Janis Miller, an associate professor at Michigan’s School of Nursing, and the study’s lead author, says just like elite athletes, new mothers should acknowledge what their bodies have been through.

“If you’ve just run a marathon, it may take longer to heal than if you’ve just run a mile,” Miller said in an interview. “Some women’s birthing experiences are more strenuous than others, so one of the main points is to let women know their bodies will recover…but it can take a long time.”

And while many doctors give new moms the green light to resume normal activities — from sex to exercise — after the standard six-week postpartum exam, the reality is that it can take far longer to feel “normal” again. (I remember dragging my still-sore, depleted body in to that six week follow-up exam, and feeling I was decidedly not good to go.)

Indeed Miller calls the six-week marker for postpartum recovery “arbitrary.” “There is no rationale for that six-week time frame in terms of the body’s responses and healing,” she said.

The study, published earlier this year in the American Journal of Obstetrics and Gynecology, concludes that a clinical examination alone may not be able to detect the range of pelvic injuries from childbirth; and in certain women, specialized MRI scans may be warranted if there is “unexplained or prolonged pain after delivery,” or other complications, Miller says.

One surprising new finding was related to the types of injuries sustained by the women, who were all at higher risk for pelvic muscle tears because they had a long pushing phase during delivery or they were older women.

Miller said that the conventional wisdom at the start of the study was that postpartum pelvic injuries were primarily nerve-to-muscle or muscle-stretch related, but the researchers discovered that in this higher risk group of women, “one-quarter of them showed fluid in the pubic bone marrow or sustained fractures similar to a sports-related stress fracture, and two-thirds showed excess fluid in the muscle, which indicates injury similar to a severe muscle strain. Forty-one percent sustained pelvic muscle tears, with the muscle detaching partially or fully from the pubic bone.” Continue reading

Study Suggests 19 Percent Could Be Benchmark C-Section Rate

Ask 10 different obstetricians what the optimal cesarean delivery rate is and you’ll likely get 10 different answers. But there is widespread agreement that 32.2 percent, the U.S. average in 2014, is too high. Way too high in light of research out Tuesday that finds no benefit in preventing death for the mother or infant when C-section rates rise above approximately 19 percent.

The findings, published in the Journal of the American Medical Association, are based on 2012 mortality rates from the 194 World Health Organization (WHO) member countries. There’s a dramatic range, from South Sudan where just 0.6 percent of deliveries were by C-section, to Brazil where the rate was 55.6 percent.

Study authors say they are not presenting 19 percent as an ideal rate, but rather as a benchmark above which doctors need to consider: “We’re unlikely to be improving maternal mortality or neonatal mortality, are there other benefits or harms to doing cesarean sections?” says Dr. Alex Haynes, a lead author on the study who works in the safe surgery program at Boston-based Ariadne Labs. The research was done in collaboration with Stanford University Medical School.

In the U.S., and in Massachusetts where the C-section rate is 31.6 percent, doctors say having a number, like 19 percent, will make a difference in doctor’s offices and in hospitals.

This graph that compares maternal mortality and C-section deliveries per 100 live births shows that C-section rates above 19.1 percent do not increase a mother’s chance of surviving childbirth. (Source: JAMA)

This graph that compares maternal mortality and C-section deliveries per 100 live births shows that C-section rates above 19.1 percent do not increase a mother’s chance of surviving childbirth. (Source: JAMA)

“This will push all of us to say, what general practices contribute to inappropriate cesarean deliveries and how, with individual patients, can we make decisions about when it’s necessary?” said Dr. Jeffrey Ecker, a high-risk obstetrician at Massachusetts General Hospital and chair of the committee on obstetric practice for the American College of OBGYNs, which does not have a target number for cesarean delivery.

Nineteen percent is higher than a 10 to 15 percent C-section range recommended by the WHO for roughly three decades. The WHO revised its recommendation in April, and no longer suggests an optimal or ideal rate, Dr. Ana Pilar Betrán, with the WHO’s Department of Reproductive Health and Research, said in an email.

“The important message,” Betrán said, “was that rather than striving to achieve a specific rate, every effort should be made to provide cesarean sections to women in need.”

Betrán did not comment on the paper’s findings or the value of using 19 percent as a C-section benchmark. And it makes some leaders in the U.S. movement to measure health care quality nervous.

Continue reading

Related:

App-Assisted Labor: Smartphones During Childbirth Are All The Rage, But Do They Help?

When Juli Simon Thomas gave birth to her son last year, she wanted a generally low-tech environment: a midwife instead of an ob-gyn, a quiet room and no drugs. “I was bound and determined to avoid an epidural,” she said, even despite 25 hours of labor.

But Thomas had one important, technical requirement: an app on her smartphone that allowed her to precisely track her contractions.

“I use my phone for everything, and this was really helpful,” said Thomas, 35, a post-doctorate fellow in population research. “The process of labor is so variable, and what you end up hearing is how you have to ‘go with the flow,’ ‘see how it turns out,’ ‘just relax and wait’ — I can’t do that. This gave me something more concrete to focus on … Just standing around in various levels of pain while breathing wasn’t a good choice for me.”

We already date, order takeout and document supremely intimate moments on our phones. So it’s no surprise that smartphones have also permeated the realm of childbirth.

contraction timerPeople in the birthing world say labor apps have become ubiquitous — part of the landscape and akin to written birth plans, which were all the rage a decade or more ago.

Rise Of The Labor App

According to the iPhone App Store, there are at least 80 “labor apps” alone that help women time their contractions to assess how close they are to giving birth. Some are free, some aren’t. Some have advertisements for infant formula, some don’t.

Moms who’ve used them say they all operate in similar ways, usually with start-and-stop icons you press at the beginning and end of each contraction in order to record duration and frequency until you get to the magic number 5-1-1. (That means contractions are 5 minutes apart, lasting 1 minute each, for 1 hour.)

At that point, doctors and midwives pretty universally want you to call to determine if it’s time to get to the hospital, or for a home birth, get a practitioner to you.

Of course, there are also apps for pretty much every aspect of pregnancy, birth and postpartum as well: from tracking the baby’s kicks and mom’s breast milk production to documenting hours of sleep (or lack thereof) and diaper use. In 2013, ABC News reported that nearly 50 percent of total mobile subscribers using one or more health apps are using a pregnancy-related app.

Elizabeth Henry, 36, of Cambridge, Massachusetts, stood by as her husband worked out her contractions on a Microsoft Excel spread sheet when she gave birth four years ago. When she gave birth in July, she used the Full Term contraction app on her own while her husband watched their toddler. “I’m a data person, and this app kept me honest. I was trying to do last-minute things in the house and stay home as long as possible, and I didn’t think the contractions were coming so fast. But then when I looked at the screen, I saw it really was time to go to the hospital.”

Not Everyone So App-Happy

Labor doesn’t always unfold in a predictable pattern. Continue reading

Related:

Where Does Life Begin, And Other Tough Abortion Questions For Doctors In Training

Our recent post on how residents training to be OB-GYNs think about providing abortions (or not providing them) went viral earlier this month and triggered a broader conversation among readers. The topic was also featured on Radio Boston and WBUR’s All Things Considered.

I asked Janet Singer, a nurse midwife on the faculty of Brown University’s obstetrics-gynecology residency program, and the person who organized the initial discussion among the residents, to follow up. She, in turn, ​asked Jennifer Villavicencio, a third-year resident​, to lead a discussion digging even more deeply into the topic.

Two of the residents ​in the discussion ​perform abortions, two have chosen not to do so. ​But they are colleagues and friends who have found a way to talk about this divisive issue in a respectful and productive way. ​Here, edited, is ​a transcript of ​their discussion, which gets to the heart of a particularly fraught question: When does life truly begin? ​Three of the residents have asked that their names not be included, for fear of hostility or violence aimed at abortion providers.

Jennifer Villavicencio (Resident 3): Let’s talk about a woman who comes in, has broken her water and is about 20 to 21 weeks pregnant and after counseling from both her obstetricians and the neonatologist [a special pediatrician who takes care of very sick newborns] has opted for an abortion. Let’s talk about how we each approach these patients.

Resident 2: As a non-abortion provider I will start just by saying that a patient of this nature in some ways is on one extreme of the spectrum. As an obstetrician, I view the loss of her pregnancy as an inevitability. I think we would all agree with that. So, taking part in the termination [another word for abortion] of her pregnancy is different to me than doing that for someone whose pregnancy, but for my involvement, would continue in a healthy and normal fashion.

Opponents and supporters of an abortion bill hold signs outside the Texas Capitol on July 9 in Austin. (Eric Gay/AP)

Opponents and supporters of an abortion bill hold signs outside the Texas Capitol on July 9 in Austin. (Eric Gay/AP)

JV: Would your opinion change if she were 22 or 23 weeks and theoretically could make it to viability [the concept that a fetus could survive outside of the mother. Currently, in the U.S., the generally accepted definition of viability is 24 weeks gestation or approximately six months pregnant]?

Resident 2: Personally, it wouldn’t, because I feel there is a very slim chance of an intact survival [refers to an infant not having significant mental or disabilities] of an infant. If she were 22 or 23 weeks gestation and could potentially make it to the point of a survivable child, that likelihood is so rare. But for my involvement, she will still lose this pregnancy. My point is, if I help terminate this pregnancy, I am not playing an integral role in the loss of this pregnancy. I feel that supporting her in proceeding in the safest possible way, protecting her while accepting the loss of her pregnancy, is my job.

Future Health Of The Child

JV: Does the future health of the child really play a role in it for you?

Continue reading

CDC: Certain Antidepressants, But Not All, Taken During Pregnancy May Raise Birth Defect Risk

The debate over whether or not it’s safe to take antidepressants during pregnancy is heated, with extreme emotions — and conflicting research studies — on both sides.

But a broad new analysis led by researchers at the U.S. Centers for Disease Control and Prevention came to a fairly measured conclusion when comparing pregnant women who took SSRIs — a class of antidepressants — to women who did not take those medications during pregnancy.

The analysis suggests that certain serious birth defects occur 2 to 3.5 times more frequently among babies born to mothers taking the antidepressants Prozac or Paxil early in pregnancy. But the researchers also conclude that for pregnant women taking other SSRIs, such as Zoloft, the data “provide some reassuring evidence” that earlier studies linking the drug with specific birth defects could not be replicated.

The analysis of 17,952 mothers of infants with birth defects and 9,857 mothers of infants without birth defects was published in The BMJ.

“What our paper really adds, is that we can now offer women more options,” said Jennita Reefhuis, an epidemiologist with the CDC’s National Center on Birth Defects and Developmental Disabilities and the study’s lead author. Reefhuis said that since Zoloft (sertraline) was the most common SSRI taken among the women, “it was reassuring that we could not replicate the five earlier links with birth defects.”

In an interview, Reefhuis said: “The main message is that depression and other mental health conditions can be very serious and many women need to take medication to manage their symptoms. So women who are pregnant, or thinking of becoming pregnant, shouldn’t stop or start any antidepressants without speaking to a health care provider.”

The issue, she added, isn’t clear cut, but highly dependent on each individual woman and a very personal calculation of risks versus benefits. “We are trying to find the nuance here,” Reefhuis said. “It is really important that women get treated during pregnancy. Their illness doesn’t stop the moment they get pregnant. Women need options.”

It’s also important to retain perspective when evaluating risk, Reefhuis said, noting that in every pregnancy there is already a 3 percent risk of a birth defect. Continue reading

Having A Baby? Big Differences In Hospital Quality Across Massachusetts

If you’re one of the roughly 70,000 women who will give birth in Massachusetts this year, you may be planning to deliver at a hospital close to home or where your OB practices. But what you might not realize is that when it comes to childbirth, there are big differences in hospital quality across the state.

For example:

  • Your chance of having a Cesarean section is almost three times higher at some hospitals
  • While some hospitals allow you to schedule an early delivery even when it’s not medically necessary, other hospitals have stopped this practice because a baby’s brain, lungs and liver need the full 39 weeks to develop
  • Your chance of having an episiotomy — a surgical cut to enlarge the vaginal opening — ranges from 0 to 31 percent
  • Trying for a natural delivery after having had a C-section is encouraged at some hospitals but not offered at others
  • Three times as many women breastfeed their babies at some hospitals as compared to others

“The door you walk in will have a big impact” on what happens during and after childbirth, says Carol Sakala, director of programs at the nonprofit maternity quality group Childbirth Connection.

The hospital where women choose to deliver “absolutely matters,” says Dr. Neel Shah, an assistant professor of obstetrics at Harvard Medical School. Take C-section rates, Shah says. “In many ways, which hospital you go to is a bigger predictor of whether or not you’re going to get a C-section than your own risk or your own preferences.”

Continue reading

Related: