childbirth

RECENT POSTS

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:

OB Talks About Home Birth, Midwives And Re-Engineering U.S. Maternity Care

Dr. Neel Shah (Courtesy)

Dr. Neel Shah (Courtesy)

Just mention the phrase “home birth,” and controversy will surely follow.

One example: a recent opinion piece in the New England Journal of Medicine by Dr. Neel Shah, an obstetrician at Beth Israel Deaconess Medical Center in Boston. In the piece, Shah suggests that for many pregnant women, giving birth in the U.K. — with its streamlined system of midwives and greater acceptance of births in the home — may be better than the high-intervention childbirth system that dominate U.S. labor wards.

Shah wrote the piece in response to the release of new guidelines from the U.K.’s National Institute for Health and Care Excellence (NICE), recommending healthy women with low-risk pregnancies opt for home or midwife-led births. Shah’s conclusion? “The majority of women with straightforward pregnancies may truly be better off in the United Kingdom.” In other words, the intense treatment U.S. obstetricians are trained to provide is unnecessary in many cases.

Dr. Shah continued the conversation on Radio Boston earlier this week. Highlights from the segment include his analysis of why the U.S. and U.K. have such different approaches to childbirth and discussion of the possible movement towards a model more like the U.K. Listen to the segment or read an excerpt below:

Host Meghna Chakrabarti: You also point out in your piece — and we spoke with people in preparing for this conversation — that these are relatively new recommendations, and the vast majority of women in the U.K. as of today still have their babies in hospitals there.

Dr. Neel Shah: They do. So about 90 percent of babies in the UK are born in hospitals, although I’ll say that the model even for babies born in hospitals is that midwives provide the first level of care and the obstetricians are there for complexity, even if you’re in the hospital. But here it’s more like 99 out of 100, so there’s still a big difference.

MC: But how do we change that, though? If in the U.K., from what you’re describing, it seems that obstetricians are viewed upon as highly trained specialists who should be called on in the event of specialty care when it’s needed, and midwives provide more of the primary care. It feels like we don’t have that framework here in the United States. When a woman gets pregnant, her first thought is “I need to go see an obstetrician to provide what’s essentially primary care during a pregnancy.”

NS: That’s exactly right. I think there’s a few different things that we could do to move forward. There are a lot of strategies and, like I said in the piece, I think there are lessons in the U.K., but I think our model will obviously need to look different from the U.K. One of the things I think we should start to think about is health care systems in 2015 in the United States are starting to take responsibility for populations and trying to think about not just the surgery but your health care overall. And 25 percent of all hospitalizations are childbirth related; it’s the number one reason to come into the hospital. So it seems like this should be a big piece of the pie, and I think as big health systems start to take ownership over the health of people that they serve there’s an opportunity to reinvent and re-engineer the way we approach it.

MC: Let’s take a couple more calls. Emily is calling from Westford; you’re on the air, Emily.

Emily: Hi. Thank you for taking my call, and I’m thrilled that Dr. Shah is young and freshly out of medical school and doing what he’s doing. My experience was very different. I was 30 and 34 when I had my two children, and I worked with midwives both times in the Boston area. The first was Beth Israel’s Ambulatory Care Unit, and the two midwives there were ex-nuns, and they were both at the birth, and the obstetrician actually took pictures; he had nothing to do with the birth, which was great. And then the next one, four years later, was in Beverly, at the North Shore Birth Center, which was a house setting across the driveway from the hospital. So both of them were under the umbrellas of the hospital. Now I have to say this was in 1979 and 1983, but I was starting at an OB/GYN practice, and a friend of mine said, “You know, the OBs look for the abnormal. When you go to a midwife, they’re looking for the normal.” And I felt that was so true because all my appointments with my husband with me were an hour and a half at the midwife. Continue reading

Why A U.S. Obstetrician Says Some Women May Be Better Off Having Baby In U.K.

Despite the fact that we all go through it, birth remains a fraught topic. Everyone, it seems, has an opinion on the ideal place, position and method of childbirth, and those views can be unshakable.

Into this prickly arena steps Dr. Neel Shah, an obstetrician at Beth Israel Deaconess Medical Center in Boston and assistant professor at Harvard Medical School. In a smart, nuanced and provocative opinion piece in the current New England Journal of Medicine on the cultural and systemic differences between giving birth in the United Kingdom compared to the United States, Shah suggests what might seem like heresy to some in his field: “The majority of women with straightforward pregnancies,” he writes, “may be better off in the United Kingdom.”

Dr. Neel Shah (Courtesy)

Dr. Neel Shah (Courtesy)

Why write about this now? The U.K.’s National Institute for Health and Care Excellence (NICE) recently issued new guidelines saying that healthy women with uncomplicated, low-risk pregnancies are “safer giving birth at home or in a midwife-led unit than in a hospital under the supervision of an obstetrician.” When the recommendations came out, Shah notes, “eyebrows went up. The New York Times editorial board (and others) wondered ‘Are midwives safer than doctors.’ How can hospitals be safer than homes?”

Before you, too, reject Shah’s conclusion out of hand, consider the careful thinking behind it and the larger context, which is that one in three births are now carried out by cesarean section — major abdominal surgery — and that C-sections are the most commonly performed surgery on the planet. But Shah’s argument focuses more on the vastly different medical cultures involved: “At its core,” he writes, “this debate is not about the superiority of midwives over doctors or hospitals over homes. It is about treatment intensity and when enough is enough. Nearly all Americans are currently born in settings that are essentially intensive care units: labor floors have multi-paneled telemetry monitors, medications that require minute-by-minute titration, and some of the highest staffing ratios in the hospital. Most labor floors are more intensive than other ICUs in that they contain their own operating rooms. Surely, every birth does not require an ICU.”

I asked Shah to lay out the key points of his piece. Here they are, edited:

RZ: Why do you conclude that it may be safer for women to give birth in the U.K. rather than the U.S.?

NS: I think the biggest takeaway from this piece is that there are harms from doing too much just like there are harms from doing not enough and that’s a big paradigm shift in U.S. health care. Childbirth is one of the biggest illustrations of that: We err on the side of overdoing it and for the healthy majority, we end up causing a lot of harm from overdoing it in the interest of making it safe for the high-risk minority.

People think that C-sections are like a rip cord — they are if you are truly at risk. But if you are low-risk, C-sections have a lot of bad consequences. Major complications such as hemorrhage, severe infection and organ injury are three times as likely to occur with cesarean deliveries as they are with vaginal deliveries. But even more fundamentally: you could go home with a 12-centimeter incision with a newborn or you could go home without a 12-centimeter incision and a newborn….moms are resilient so they just deal with it but that has a major impact. Continue reading

Opinion: Why Gut A Program That Truly Helps New Mothers?

pumicehead/flickr

pumicehead/flickr

By Claudia M. Gold, M.D.
Guest Contributor

As any parent knows, caring for an infant is a 24/7 job. Contrary to the idealized “myth of motherhood” — which usually involves a quick, seamless return to pre-pregnancy weight, emotions and all-around functionality — there is no “schedule” to be had. Life has officially turned upside down.

All kinds of research suggest that new moms need help.

But in our culture today, where extended family may be far away, where spouses often return to full-time work almost immediately after the birth, mothers may be very much alone in the task of caring for a new baby. Mother-baby groups have a critical role to play in filling that void.

I have seen these groups in action working as a consultant to the William James College Freedman Center. When mothers feel supported and listened to, extraordinary thing happen: they share experiences not only about the lack of sleep and ability to take a shower, but also fears, anxieties, self-doubt, sadness and even depression. By the end of these groups, many mothers developed powerful, sustaining bonds with each other and interact with their babies with new confidence and joy.

A particularly innovative Massachusetts-based program for mothers is now at risk.

Massachusetts Child Psychiatry Access Project for Moms is a collaboration between the Massachusetts Psychiatry Access Project and MotherWoman, an organization that offers a network of groups as well as training for group leaders and seeks to make these groups available to mothers all across the state.

The program has its roots in a special legislative committee chaired by Representative Ellen Story. While at first the focus of the commission was to implement statewide screening for postpartum depression, it quickly became clear that such a step was meaningless without first having resources in place to help mothers identified by the screening.

That is where MCPAP for Moms comes in to play. In collaboration with William James INTERFACE referral service, when a mother is struggling, she can find support that is available close to home and right away. When a new mother feels alone, scared and overwhelmed, a three-month- or even a three-week-wait is unacceptable. She needs help today.

MCPAP for Moms offers a unique constellation of services: it offers toolkits and training for primary care clinicians — obstetricians, pediatricians and family practitioners, many of whom now do not know where to turn when they see a mom struggling with postpartum depression and/or anxiety. Second, it helps mothers connect with help — individual clinicians experienced in treating perinatal emotional complications as well as groups — right away. And last, MotherWoman has a growing network of support groups and trainings for group leaders so that the service can extend throughout the state. So, it’s a whole safety net that involves many things.

“I was so overwhelmed and stressed as a new mom that I didn’t know what to do and felt like a failure. Without MCPAP for Moms I don’t know where I would be today,” said one postpartum mom, Amanda Martin. “I am so grateful for them helping me get the help I needed to feel better for me and for my family.” Continue reading

Wide Hips? Take Heart: Study Finds You Can Run Just As Efficiently

As a woman who describes herself — matter-of-factly, not self-hatingly — as shaped like a cello, I’m deeply pleased by this fascinating marathon-season report from our friends over at Boston University’s Research Website, headlined “In Defense of Wide Hips.” Re-posted with their permission:

Biological anthropologist and evolutionary anatomist Kristi Lewton of BU School of Medicine. (Jackie Ricciardi for BU)

Biological anthropologist and evolutionary anatomist Kristi Lewton of BU School of Medicine. (Jackie Ricciardi for BU)

By Kate Becker

What can you learn from a pelvis? Among the qualities that make humans unique are two physical features: our way of walking and running upright on two legs, and our newborn babies’ very large heads. Those two traits of humanity meet at the pelvis, a set of bones that includes the ilium, ischium, pubis, and sacrum.

For more than 50 years, anthropologists thought that the human pelvis was shaped by an evolutionary tug-of-war between the competing demands of bipedalism and childbirth. Now, a team of scientists that includes Kristi Lewton, an assistant professor in the department of anatomy and neurobiology at Boston University School of Medicine, and colleagues at Harvard University and Hunter College has shown that this so-called “obstetric dilemma” might not be a dilemma at all.

They found no connection at all between hip width and efficiency: wide-hipped runners moved just as well as their narrow-hipped peers.

Humans give birth to very large (“ginormous!”) newborns, says Lewton. While chimps and other nonhuman primate babies emerge from the birth canal with room to spare, human infants must perform a complicated series of rotations to make their way into the world, and the pelvic opening is just barely big enough. If something goes wrong, the lives of both mother and baby are at risk. So, why hasn’t the human body evolved a wider pelvis? Anthropologists have long believed that an evolutionary trade-off was at work; they assumed that a wide pelvis was “bad for bipedalism,” says Lewton. Yet, until now, no one had rigorously tested this assumption.

Lewton and her colleagues set out to discover whether wide hips really do make running and walking less efficient. They recruited 38 undergraduates, including both men and women, and had them walk and run on a treadmill while gauging how hard they were working by measuring their oxygen consumption. While the participants exercised, their motion was tracked by eight cameras trained on infrared markers attached to the participants’ hips, knees, ankles, thighs, and shanks. Lewton and her colleagues estimated the subjects’ hip width using the results from the infrared trackers, and later combined their data with results from a Washington University in St. Louis research team that used MRI to get a direct measure of hip width. (True hip width is defined as the distance between the hip joints, points out Lewton, and is different from what you would measure with a tailor’s tape.)

If the basic assumptions of the obstetric dilemma are right, says Lewton, participants with wider hips should run and walk less efficiently than those with narrow ones. But that wasn’t what Lewton and her team found. Continue reading

Viewpoint: Doctors Respond To Home Births That End Up In Hospital

By Shirie Leng, M.D. and Cindy Ku, M.D.

As physicians we are concerned about a recent post on CommonHealth — “What to Expect When You’re Birthing At Home: A Hospital C-Section (Possibly)” — that focuses on planned home births that end up in the hospital.

While we respect the right of women to labor and deliver in the environment of their choosing, requiring medical intervention in childbirth is neither shameful nor a moral failing. Life-threatening complications which, 100 years ago, would have meant a death sentence for mothers and babies, are now treatable and even preventable in the modern hospital maternity ward. Suggesting that women are unduly traumatized by transfer to and treatment in a medical facility does a disservice to the obstetricians, nurses, anesthesiologists, and neonatologists who work so hard to save these lives.

Here’s an example of the kind of case that could possibly result from a home birth that goes awry. While on a routine morning on the obstetrics unit, the usual routine was interrupted by a phone call from the emergency room. A laboring mother was in distress and needed an emergency caesarean, and she was about to arrive into the trauma OR. Since caesareans are not normally performed in the emergency room trauma room, everyone dropped their plans and hurriedly prepared the trauma OR. One minute later a petite young woman on a stretcher crashed through the door along with the obstetrician. “Get the baby out of me!” she screamed, writhing and crying in agony as the team transferred her to the operating table. Between her moans and her desperate outbursts, she could barely understand the questions as the anesthesiologist tried to ascertain three things: did she have heart or lung problems, did she have allergies, and did she have any potential problems with her airway?

 (meme_mutation/flickr)

(meme_mutation/flickr)

We had no other information to go by – no laboratory data, no history, not even her name. All we knew was the baby was in breech position (legs down, not head down) and was in distress. We had five seconds to decide how we would help to save the two lives in front of us. We told her as gently as we could (though it likely didn’t register with her at all) that she needed to breathe in oxygen for herself and her unborn child, that she would be unconscious for about an hour, and we would see her and her baby in the recovery room. Vaginal delivery is not the standard of care for breech presentations because of the significantly elevated risk of shoulder entrapment in the birth canal and stillbirth. Months after this case we all still wonder how we could have done better and what would’ve happened if she hadn’t arrived in time.

Thankfully, our team — the obstetricians, anesthesiologists, nurses and neonatologists — worked together successfully and both mother and child did well. We don’t know for sure if this case began as a home birth, but it does represent the sorts of difficulties that we medical staffs wrestle with when a home birth becomes complicated and ends up at the hospital.

Childbirth always brings with it an element of danger. While everything usually goes right, when it goes wrong it usually does so quickly and seriously. To expect the idealized experience in every case is to deny reality. In 1900, when women were having the arguably blissful natural birth experience home birthers seek, the maternal mortality rate was more than 800 deaths per 100,000 births. According to the CDC, in 1997 that number was 7 per 100,000. This statistic, an upwards of 99 percent decrease in mortality rate, was not achieved by midwives and doulas with the latest technology in birthing balls and labor tubs. It was achieved through advances in science and medicine. Continue reading

What To Expect When You’re Birthing At Home: A Hospital C-Section (Possibly)

Screen shot 2015-03-20 at 9.07.11 AM

By Ananda Lowe
Guest Contributor

The term “homebirth cesarean” didn’t exist before 2011, when Oregon mother and student midwife Courtney Jarecki coined it. But now, a Google search returns almost 2,000 entries on the topic.

The term refers to a small but emerging community of mothers who have experienced the extremes of birth: They’d planned to have their babies at home, but ended up in a hospital, most often in the operating room having a cesarean section, major abdominal surgery. Needless to say, the effect of such a dramatic course change takes a toll, and can often be overwhelming.

(“Homebirth cesarean” can also refer to births that were planned to occur at a freestanding birth center outside of a hospital, but eventually were transferred to the hospital for a cesarean.)

How often does this happen?

Home births, though a small fraction of the approximately 3.9 million births a year in the U.S., are on the rise. Based on the most recent birth data from the National Center for Health Statistics, “the 36,080 home births in 2013 accounted for 0.92% of all U.S. births that year, an increase of 55% from the 2004 total.”

Eugene Declercq, a professor of community health sciences at Boston University School of Public Health, studies national birth trends. He said in an email that while there are no nationwide numbers on homebirth transfers to the hospital, “the studies that have been done usually report about a 12% intrapartum transfer rate.”

But beyond the numbers, what happens emotionally when your warm and fuzzy image of natural childbirth in the comfort of home suddenly morphs into the hard reality of a surgical birth under fluorescent lights?

A woman who'd planned a homebirth but ended up having a cesarean in the hospital. (Photo courtesy: Courtney Jarecki)

A woman who’d planned a homebirth but ended up having a cesarean in the hospital. (Photo courtesy: Courtney Jarecki)

Jarecki founded the homebirth cesarean movement to figure that out. She connected women who, like herself, shared the experience of giving birth through full surgical intervention, despite their original plans of having their babies at home or outside of the established medical system.

In Jarecki’s case, she labored at home for 50 hours until her midwives detected a rare complication known as a constriction ring, or a thickened band of tissue in her uterus that was impeding progress. Shortly after this, meconium appeared, and Jarecki knew it was time to go to the hospital. Her emotional response to the intensity of the situation, however irrational, was one of anger, shame and failure at her ability to give birth normally. A cesarean followed.

Over the next several years, Jarecki began helping other homebirth cesarean mothers emerge from the silence and shame they felt confronting their unexpected surgeries. Some of these women also report that their postpartum recovery was tougher because their unique needs were not adequately addressed by their home birth midwives or their hospitals.

Jarecki started by launching a (now busy) Facebook page as a support group for these mothers and their health care providers.

Childbirth Expectations vs. Reality

Rule number one in childbirth is that it rarely unfolds as you expect. Continue reading

Falling Into The Postpartum Mood Disorder Abyss: A Personal Story

By Deb Wachenheim
Guest Contributor

Over the past two days, The New York Times published a series of articles about postpartum depression and other related mood disorders. The first article looked at the science and policy on this topic and highlights a few women’s stories.

Today’s article is about my sister, Cindy Wachenheim, who took her own life in March of 2013 after struggling for six months with postpartum mood disorders. I say mood disorders because it was not just depression (and the fact that there are other postpartum mood disorders in addition to postpartum depression was something about which I was previously completely unaware). She had extreme anxiety about, and obsession with, her baby’s health and she was depressed because she believed she caused him to have serious health problems. Also, according to what I have been told by experts, she may have been psychotic: she was so convinced that something was seriously wrong with her baby — despite doctors telling her otherwise — that she strapped him to her chest when she jumped out of her apartment window, believing, I can only assume, that this was what was best for him. Thank goodness, he survived and is thriving.

Beyond what is written in the article, I think it is important to give more detail and information on some resources and policy activities in Massachusetts, in the hope that this could possibly help others who are facing similar struggles. As is mentioned in the article, I reached out to Cindy’s son’s pediatrician after Cindy had gone to see her multiple times about her concerns.

Pediatricians are key to screening for postpartum mood disorders and making referrals for needed treatment. Most women see their OB a few weeks after giving birth and if everything seems okay at that point then they are sent on their way until the following year’s annual exam.

However, woman bring their infants to see the pediatrician many times over that first year. It is pediatricians who could notice if something seems to not be right with the mother. Continue reading