It seems so intuitively right. You’re facing the risk of delivering your baby early and the doctor prescribes bed rest. What could be more cozy and safe? Why wouldn’t you endure a little extra annoyance (you’re pregnant, after all) if it would help keep your tiny, oh-so-vulnerable fetus floating inside the fortress of your womb as long as possible? Even the words “bed” and “rest” feel so inherently soothing and therapeutic.

Think again.

Bed rest, a growing body of research suggests, may be bad for you.  And for physicians to blithely prescribe it is, in a word, “unethical,” argue a trio of doctors from the University of North Carolina School of Medicine.

In a paper called “‘Therapeutic’ Bed Rest in Pregnancy: Unethical and Unsupported by Data” recently published in the journal Obstetrics and Gynecology, Dr. Christina A. McCall and her colleagues make a powerful case against the practice many perceive as cuddly and innocuous.

They cite the medical paradox in which bed rest remains widely used despite no evidence of benefits and, on the contrary, “known harms.” They further suggest that in its current form, strict bed rest should either be discontinued or else viewed as a “risky and unproven intervention” requiring rigorous testing through formal clinical trials.

In an email exchange, Dr. McCall clarifies that she is talking about strict bed rest here and adds:

“If a woman feels that increasing her daily rest lessens anxiety or improves symptoms (whatever they may be), then we are not suggesting this should be discontinued. We are merely suggesting that every woman receive INFORMED CONSENT regarding the literature on bed rest and the autonomy to make her own decision.”

Research suggests that the potential harms for women on bed rest (a broad term that can include everything from total inactivity to limits on strenuous endeavors like household chores, exercise and sex) can be significant. They range from potentially dangerous blood clots and bone demineralization to muscle and weight loss, financial harship due to restrictions on working and a range of psychological suffering, notably depression. A report earlier this month, for instance, found high rates of depression and anxiety among hospitalized pregnant women on bed rest and suggested that all women facing this type of confinement undergo mental health screening.

No Benefits

Dr. McCall’s conclusions are based on a broad review of the medical literature that found bed rest offers no benefit for the most common conditions it’s prescribed for: threatened abortion, hypertension, preeclampsia, pre-term birth, multiple gestations or impaired fetal growth.  (Another study published in the same issue of Obstetrics & Gynecology found that activity restriction did not reduce the rate of pre-term birth in women with a short cervix.)

Even beyond these physiological considerations, Dr. McCall asserts that prescribing bed rest is morally questionable and “inconsistent with the ethical principles of autonomy, beneficence, and justice.”

Still, the practice remains deeply ingrained. Here are the numbers, according to an accompanying editorial:

As many as 95% of obstetricians report recommending activity restriction or bed rest, in some form, in their practices. Nearly 20% of gravid women in the United States — approximately 800,000 per year — will be placed on bed rest between 20 weeks of gestation and delivery.

Questioning the wisdom of bed rest — which has been used for centuries and viewed mostly as an inconvenient, potentially beneficial and essentially harmless cost of pregnancy — isn’t new. For years, data has been mounting on the negative effects of prolonged activity restriction in other medical arenas. Last year the influential American College Of Obstetricians and Gynecologists issued a practice bulletin challenging — but not fully condemning — the practice:

Although bed rest and hydration have been recommended to women with symptoms of preterm labor to prevent preterm delivery, these measures have not been shown to be effective for the prevention of preterm birth and should not be routinely recommended. Furthermore, the potential harm, including venous thromboembolism, bone demineralization, and deconditioning, and the negative effects, such as loss of employment, should not be underestimated.”

What About Maternal Harm?

But Dr. McCall and her colleagues go further, suggesting that bed rest should be limited to formal clinical trials, with written protocols, approval from an institutional review boards and informed consent. As it’s currently used, she writes, the practice undermines the spirit of the physician’s premier commandment — “do no harm” — in several ways:

“…bed rest conflicts with the ethical principle of justice. Justice requires that clinicians treat individuals fairly and that the provision of care not be discriminatory. Numerous Cochrane reviews regarding pregnancy and childbirth are available, yet the evidence frequently is ignored or interpreted selectively in a way that disregards maternal interests. For example, findings of fetal harm often lead to immediate prohibitions (such as caffeine or various medications), whereas findings of maternal harm or relative fetal safety are overlooked or slowly integrated into practice.”

Online Shopping, No Husband

For Kristen Rathjen, pregnant with twins and currently hospitalized and on bed rest at Beth Israel Deaconess Medical Center in Boston, the reasons for staying put are simple: she’s already about 2.5 centimeters dilated at 30 weeks pregnant, and she doesn’t want to give birth to a premature infant in an ambulance rushing from Mashpee, on Cape Cod, where she lives, into the city.

“I’m just doing what’s in the best interest of my child,” says Rathjen, a 32-year-old marine biologist. “Sure there’s stress, I’m not at home, I don’t have my husband or my pets and I’ve definitely gotten weaker. But the big stress of ‘How am I going to get here?’ is off my shoulders.”

So, for the next few weeks, Rathjen is resigned to forgoing work, accepting boredom and generally following her doctor’s advice. “I’ve got books, my laptop, crafts and really bad TV,” she said. “Plus, it’s given me time to research baby products and do some online shopping.”

Dr. Adam Wolfberg, a maternal-fetal specialist with Boston Maternal-Fetal Medicine, says despite the lack of evidence to support bed rest, there is something real, almost a kind of placebo effect, to women feeling like they are doing something to protect their babies, as opposed to doing nothing.

“Obstetrics is a field in which we have a very limited number of tricks up our sleeve when it comes to preventing preterm delivery,” he said. “So to say, ‘I’m sorry ma’am, there is nothing we can do,’ is harder then saying, ‘Well, there’s no evidence bed rest helps, but it is something we can try…The idea that there’s something they can do that’s proactive — that can be meaningful.”

In a recent post called “The Truth About Bed Rest” on the Isis blog Parenting Starts Here, Dr. Wolfberg lays out some other reasons why doctors — himself included — continue this “nutty” practice:

Why is it that most obstetricians I know still recommend bed rest, when peer-reviewed literature and the American College of Obstetricians and Gynecologists suggest the practice doesn’t work and might even be dangerous? Here are some possible explanations:

•Bed rest seems logical: the reclining posture theoretically reduces the force of gravity on the cervix – another theory entirely lacking evidence.
•It feels better to prescribe bed rest than to tell a patient, “we really don’t have anything to offer you to reduce the chance that you will deliver early.”
•Women on bed rest are doing something, which feels a whole lot better than doing nothing.
•If bed rest isn’t recommended, and the patient delivers prematurely, they and their doctor will always wonder whether bed rest would have changed the outcome.

Dr. Wolfberg says despite his skepticism, he would not go so far as to brand bed rest as ethically unsound. “There are so many things in medicine we do without evidence, I really don’t think bed rest is unethical. In many ways, medicine isn’t just about evidence, it’s evidence plus — it’s experience and skill and intuition — not to say those are replacements for evidence. But evidence isn’t all there is.”

This may sound good, says ob/gyn Dr. David. A Grimes, co-author on the bed rest article, but doctors should be wary of relying too heavily on instinct alone. “If we have anything to learn from the history of medicine,” Dr. Grimes says via email. “It is that instincts and good intentions are a highly fallible compass without the check of scientific controls.”

And course, every woman is different and the complications of pregnancy vary, notes Angela Davids, who moderates an online forum, keepemcookin.com for women who have been prescribed bed rest. She tells me in an email that 76 percent of her forum participants deliver at 36 weeks or later:

Any one of them will tell you that bed rest helped to prolong their pregnancies, and I think that is what researchers need to look at. Instead of looking at 37 weeks of gestation as a measure of success, look at how many days of gestation there were following the diagnosis of a specific complication. Every additional day in the womb counts toward the health of a baby…

So, what’s an expectant mom to do?

Dr. Wolfberg offers this advice:

•Patients who are worried about pre-term labor, short cervix, or vaginal bleeding should consult their midwife or physician.

•In his own practice, Wolfberg says he works hard to identify patients who would benefit from progesterone and get them on that medication when appropriate.

•He says it is reasonable for women at high risk for pre-term delivery to limit strenuous activities or exercises.

•He says he’s never had a patient suffer long term consequences of bed rest, and notes that since he’s never met a mother who delivered prematurely who didn’t – irrationally – blame herself, he prescribes activity reduction because it’s something patients can do.

•If bed rest is going to interfere with a patient’s need to earn a living, hold down a job, or take care of her family, he says he support her decision to remain active (and cites the evidence that bed rest doesn’t help).

Beyond that, Dr. Wolfberg said, “if they do bed rest and fail, at least they feel like they did everything they could…we all need a little bit of magical thinking to get through the day.”

Oftentimes, what helps or hurts a pregnancy is in the eye of the beholder. A friend offers this memory of her six weeks on bed rest:

I started bleeding and the baby seemed like it was low, plus I’d had two prior miscarriages, so the doctor prescribed “modified bed rest,” meaning I could get up to eat, go to the bathroom, or recline on the sofa. It wasn’t fun — I spent alot of time reading and looking at the clouds…One day I wandered downstairs to rest on the sofa, and saw the 9/11 airplanes hit the twin towers. I think it was the stress that brought on the delivery — a late miscarriage at 19 weeks — and that was that.

So, just in time, here’s a new report that does just that. “Listening to Mothers III,” produced by the nonprofit Childbirth Connection, is an in-depth look at women’s pregnancy and birth experiences that covers a huge range of topics, from pregnancy weight gain, breast-feeding and postpartum depression to use of pain medication during birth and paying for maternity care.

The report, the third of its kind, is based on online surveys of 2,400 women who gave birth to a single baby from July of 2011 through June of 2012 in a U.S. hospital. There’s a lot to digest here, but for anyone interested in birth, it’s worth spending time wading through the material.

Here, as highlighted by authors of the report, are some of the more salient findings:

–A quarter of women surveyed experienced three or more of five major medical procedures such as labor induction, drugs to speed labor, and cesarean section, while only one in eight women had none of these interventions.

–Unnecessary interventions — such as inducing labor for convenience or routine repeat cesareans — exposed women and their babies to avoidable risk.

–Most of the women could not correctly identify risks of labor induction or cesarean section, revealing problems with prenatal education.

–One in four who had these procedures reported experiencing pressure from a care provider to do so.

–Mothers expressed a high degree of trust in maternity care providers, with nearly half rating them as “completely trustworthy.”

Maureen Corry, Executive Director of New York-based Childbirth Connection, said in an interview that a perfect storm of forces — including pressure on women and complete trust in their provider — could lead to unwanted outcomes.

“The pressure to have an induction or c-section, a lack of awareness about the risks of those interventions and an unqualified trust in their health care providers is a potent combination that could result in women and their babies being exposed to unnecessary risk and receiving care that isn’t based upon the evidence,” Corry said. “You can imagine if providers put a little bit of pressure on and the women don’t have all the facts, they might make decisions that aren’t good for them.”

In the survey, mothers were asked if they felt pressure from a health profesional to have one of three interventions and, according to the report, “notable proportions indicated that they had experienced such pressure. The proportions reporting pressure varied very slightly by intervention: labor induction (15%), epidural analgesia (15%), or cesarean section (13%).”

Here’s more detail from the survey:

We looked at these finding by whether or not mothers had the specific intervention, and there was significant difference in each case. In terms of induction, 25% of mothers who experienced an induction cited pressure compared to 8% who did not have an induction. Most notably, there was a difference in the case of cesarean sections. Of those mothers with a vaginal (not VBAC) birth, 7% indicated they felt pressure while among those who had a primary cesarean 28% said they felt pressure. For those with a prior cesarean, 28% of the mothers with a VBAC and 22% of those with a repeat cesarean indicated they felt pressure. Overall, 8% of mothers who did not have a cesarean experienced pressure for surgery versus 25% of mothers who had a cesarean.

The report also found that many effective pregnancy and birth-related practices that help women weren’t routinely used. From the news release:

In pregnancy, for example, these included help with smoking cessation. Around the time of birth, just a fraction received continuous labor support from a doula, though many would have liked to have had doula care. Half of the women were not exclusively breastfeeding a week after the birth, and many had not received help from a provider for notable symptoms of depression. Many women who would have liked the option of vaginal birth after a cesarean (VBAC) reported that their maternity care provider and/or hospital was unwilling to provide this option, and faced another cesarean and the range of risks associated with repeated surgeries.

“Underused maternity practices tend to be non-invasive, pose few if any risks, and use relatively few resources,” said Dr. Eugene Declercq, the survey’s lead investigator, and a professor of community-health sciences at the Boston University School of Public Health. “They offer many opportunities to improve the quality, outcomes and cost of maternity care, with benefits for mothers and babies, and those who pay for their care,” he said.

Readers, were you pressured by providers to have one or another intervention during childbirth? Or were there things you wished you could have had (like a doula or breastfeeding support) that were not available to you? Please comment and let us know.

Ananda explains that a new “natural cesarean technique” is being developed here in Boston at Brigham and Women’s Hospital:

While talking with my friend Dr. William Camann, director of obstetric anesthesiology at Brigham and Women’s hospital in Boston, I was surprised and excited to learn that he recently helped the hospital adopt components of what is being called “the natural cesarean” technique. Bill is co-author of the book “Easy Labor: Every Woman’s Guide to Choosing Less Pain and More Joy During Childbirth,” and the Brigham is Boston’s largest maternity hospital, so its adoption of these methods is good news. In the past, some mothers reported feeling “a disconnection from their cesarean baby because they did not actually see or feel the baby born,” according to the International Cesarean Awareness Network (ICAN). The natural cesarean technique offers parents the option of viewing the emergence of the baby if they wish. (For years, ICAN has been a pioneer in proposing guidelines for family-centered cesareans, as well as advocating for other reforms related to the use of cesarean sections—I encourage everyone to support their work!)

I spoke with Camann today and he said the preferred term for the new technique is “family-centered Cesarean,” or “gentle Cesarean.” The concept has been evolving for several years, he said, with some elements of it — like early skin-to-skin contact between mom and baby in the operating room — becoming more standard. The newest element — a clear surgical drape that allows the mom to actually see the birth — just started a few months ago. “To my knowledge, the Brigham is the only hospital doing that,” Camann says. “It was my idea; the patients love it.”

But a bird’s eye view of a surgical birth isn’t for everyone, he added, and some new moms don’t want to see anything. “You pick up cues from the patients and other providers,” Camann says. “It’s very much a judgement call.”

Here, Camann offers more details on the technique:

A growing movement is attempting to make the cesarean delivery a more natural, or family-centered, event.

Modifications of the standard technique include:
· Early skin-to-skin contact in the operating room (with either mom or dad)
· A slow delivery (with intent to mimic the “vaginal squeeze”)
· Placement of IV catheter, oximeter, and blood pressure cuff all on the
same and non-dominant arm to allow a completely free arm for maternal contact with baby
· Placement of ECG leads on the back, to allow a free chest for early maternal skin-to-skin contact
· Intraoperative breastfeeding
· Clear surgical drapes to allow better view of the delivery

Benefits of this approach include a more family-centered experience for the mother and partner, improved thermoregulation of the neonate, better bonding, early feeding, and overall greater satisfaction with the procedure.

Some mothers and their partners wish to view as much of the actual delivery as possible. Lowering of the surgical drapes at the time of delivery may allow this to some extent but issues related to possible contamination of the sterile field, or blood and other fluid spillage, might preclude a complete view by this method. The use of a clear, see-through surgical drape will allow a full view of the delivery while still maintaining full sterile and other precautions.

He adds that there is no evidence that this family-friendly approach has any impact on lowering the national C-section rate, which is nearing 35%. Indeed, he says, it could have the opposite effect:

Some may argue that making the cesarean delivery experience friendlier would be counterproductive to any attempts to decrease the overall cesarean rate. In contrast, an attempt to make any childbirth experience, whether vaginal or cesarean, more pleasant for patients and partners should be considered as part of the services we can offer.

At long last (according to some folks), a darker side of Dr. Amy has been unveiled in an excellent piece by Jennifer Block in Slate called “How To Scare Women: Did a Daily Beast story on the dangers of home birth rely too heavily on the views of one activist?”

That activist is, of course, Tuteur, who is extensively quoted in Michelle Goldberg’s Daily Beast story about scary homebirths.

Block writes:

For many parents, home birth is a transcendent experience. … Yet as the number of such births grows, so does the number of tragedies—and those stories tend to be left out of soft-focus lifestyle features. Now a small but growing number of people whose home deliveries have gone horribly awry have started speaking out, some of them on a blog, Hurt by Homebirth, set up by former Harvard Medical School instructor Amy Tuteur. “These people are beating themselves up over this,” says Tuteur, perhaps the country’s fiercest critic of the home-birth subculture. “They did it because they thought it was safe, and it wasn’t safe.”

Goldberg’s reliance on Tuteur is an interesting choice. Also known as “Dr. Amy,” Tuteur let her medical license lapse in 2003 and created the blog Home Birth Debate in 2006, which she used to advocate for her position, which is basically: Home birth kills babies. “Even the studies that claim to show that home birth is as safe as hospital birth actually show the opposite,” she’d frequently post in response to a challenge, smearing the researchers of those studies in dedicated blog posts and igniting flame wars in the comments section. On other sites, including Nature and RH Reality Check, her comments have been flagged and removed for being defamatory or basically spam.

In 2009 Tuteur moved over to her new blog, The Skeptical OB, the name of which is, on the one hand, misleading because she hasn’t been in practice for more than a decade, but is ultimately more appropriate because her old site was never really about debate. She wrote briefly for Open Salon, where she took issue with Amnesty International’s research on maternal mortality, and had a mutual parting with the blog Science Based Medicine (“mutual efforts between the editors and Dr. Tuteur to resolve our differences came to an impasse,” managing editor David Gorski wrote in the announcement). Her prose tends to be inflammatory. “It’s hard to beat homebirth midwives when it comes to stupidity,” she recently blogged on her own site.

In January 2011, Tuteur added a new domain to her brand, Hurt by Home birth, in which she invites guest posts—“and please include pictures if you can”—from tragedy-stricken mothers.

Surely it’s no crime for Tuteur to have her point of view and blog about it. As I mentioned, she is one of the most prolific blog-post-commenters out there. The problem, Block writes, is “when a dogged journalist like Goldberg elevates Tuteur to expert. Tuteur is not a researcher, she’s not currently affiliated with any medical institution, and more importantly, she’s never published any of her kitchen-table calculations on the risks of home birth in any peer-reviewed journal. Yet she presents herself with the authority of a CDC epidemiologist when she writes, “Homebirth increases the risk of neonatal death. All the existing scientific evidence says so.”’

Block quotes Boston University epidemiologist and professor of public health Eugene Declercq, who says it’s challenging to precisely quantify the absolute risk of homebirth. He says: “the outcomes tend to be pretty good…So when Tuteur says no study anywhere has found this, it’s a crock. There are studies that have found good results.” But to really nail it down here in the U.S., he says, we’d need to study tens of thousands of home births, “to be able to find a difference in those rare outcomes.” With a mere 30,000 planned home births happening each year nationwide, “We don’t have enough cases.”

But in a ruling last week, the state’s Supreme Judicial Court effectively said that the actions of women who refuse medical treatment during childbirth shouldn’t be criminalized. And that unanimous decision, some say, put Pugh at the center of a battle over whether mothers should be allowed to make their own decisions about how to progress through pregnancy and give birth.

Here’s Pugh’s story:

In the fall of 2006, Pugh was 28 and working at an animal hospital when she discovered she was pregnant, according to court records. She told no one. In January, after feeling abdominal pain, she left work, went home and sat on the toilet, thinking she might be having a miscarriage. When her water broke, Pugh realized she was in labor, the court records say. At that point, she reached inside herself, felt a foot, pushed approximately 10 times and then “pulled on the baby’s feet, legs, and body to hasten the delivery.”

Things got worse from there, the records show:

After approximately five minutes of this combined effort, the baby fully emerged from the defendant’s body.
The baby was blue. The defendant stated that she tried scooping out the baby’s mouth and made repeated attempts at rescue breaths, but the baby’s color never changed and the baby never appeared to cry or move. Despite her efforts, the defendant could not resuscitate the baby. She disposed of the baby’s body in the trash. During the delivery and immediately thereafter, she did not call for help or seek emergency medical assistance. On discovery of the mangled body several days later, a police investigation led officers to the defendant.

In 2009, a Superior Court judge found Pugh guilty of involuntary manslaughter for “inflicting fatal injuries on a viable and near full term fetus during the birthing process” in violation of her “legal duty … to refrain from wanton or reckless acts committed against her own viable fetus,” according to court records:

Specifically, the judge concluded that the defendant committed [these acts] by using “a significant amount of force” to bring about the delivery, and by failing to summon medical help on realizing she was giving birth in the “breech” position…thereby disregarding a substantial likelihood of harm…

Pugh appealed. On Friday, the SJC threw out her involuntary manslaughter conviction, reversing the lower court’s decision.

The SJC ruling, written by Justice Barbara Lenk, was, in some ways, fairly narrow: it said prosecutors failed to prove the baby was born alive or that Pugh’s failure to summon medical assistance was the cause of his death. Lenk also noted that Pugh’s was not a case of “intentional homicide.”

But the ruling also highlighted the case’s broader significance: That a woman does not have a duty to seek medical intervention when she gives birth:

…because the matter is of significant public importance…we consider the question of duty and decline to recognize a duty of a woman, in these circumstances, to summon medical assistance, breach of which may give rise to criminal liability for involuntary manslaughter..existing criminal laws proscribing murder, most late-term abortions, and the neglect and abuse of children appropriately protect the State’s interests in safeguarding viable fetuses and living children without the need to subject all women undergoing unassisted childbirth to possible criminal liability.

Imposing a broad and ill-defined duty on all women to summon medical intervention during childbirth would trench on their “protected liberty interest in refusing unwanted medical treatment….Moreover, such a duty is inchoate and would be highly susceptible to selective enforcement.

But what about the baby, wondered Worcester District Attorney Joseph Early Jr. who was quoted in The Globe rehashing the grisly details of the case: “The baby’s abdominal cavity was filled with blood. She then threw the baby’s body in a trash can, and it was only discovered when it was crushed in a trash truck. I am proud to have stood up for this child, when no one else cared what happened to him. I will continue to fight for victims…”

Pugh’s case attracted attention from a range of interest groups, including the ACLU, the Massachusetts Association of Criminal Defense Lawyers, the Women’s Bar Association of Massachusetts and others. You can read their amicus briefs here.

Andrea Kramer, an attorney at Hirsch Roberts Weinstein in Boston, wrote the brief for the women’s bar association. She said the ruling was not only a victory for women’s reproductive freedom in general, but also for women who choose unassisted births (sometimes called freebirths) and midwife-assisted home-births, the vast majority of which are thoughtfully and rationally planned.

In her brief, Kramer (who planned to birth her own children at home, but ultimately delivered in a hospital) characterized the facts of Pugh’s case as “gruesome and sad.” But those distressing facts, she wrote, shouldn’t “encroach on other areas of pregnant women’s autonomy and decision-making activity, such as where to give birth, who attends the birth, whether to obtain prenatal care, whether to follow medical advice and whether to engage in legal activities during pregnancy that might adversely affect the fetus.”

In an interview, Kramer pointed out that over many years, doctors have instituted practices and techniques that don’t always improve pregnancy outcomes or serve women well, such as having them give birth flat on their backs, shaving their pubic area or using forceps for delivery. She said, “the point is that women — not their doctors, not the legislature or prosecutors — should make the decision regarding what is best for themselves and their fetuses.” Implicit in the SJC decision, she said, is that “if you have to defer to someone, you defer to the woman because she is in the best position to make the decision and also has both hers and her fetus’s interests in mind.”

Others, who agreed with the SJC ruling, said that the Pugh case differed so dramatically from typical home-births, it should be viewed in an altogether unique context.

Eugene Declercq, a professor at Boston University School of Public Health who conducts research on childbirth trends, said via email:

I would distinguish this case from what we usually consider planned (either assisted or unassisted) home births. This seems closer to the cases of babies abandoned to shelters or emergency rooms by distraught mothers.

There has been some attention given to unassisted home births (or freebirthing as some term it) and there have been YouTube postings by some of those mothers involved, which is about as far away as one can get from the tragic case of Ms. Pugh who was trying to hide her pregnancy.

I haven’t seen any evidence that freebirthing is anything other than a very, very rare phenomenon, though there’s no hard data to prove that. The closest we can get to it with the data we have is to look at 2009 (most recent year available) U.S. data. There were a reported 9,522 home births (1/5th of 1%) attended by “other” (as opposed to doctors or midwives who are typically listed as the birth attendant) which is how an unassisted home birth would presumably be recorded. However, most of these “other attendant” births probably involve midwives…who are not licensed to do home births in a given state or accidental home births (i.e. precipitous labors).

In Massachusetts, the numbers are even more minute. In 2009, there were only 323 home births in the state and of these 20 were attended by “other.” That’s 1/30th of 1% of Massachusetts births. Given the uncertain status of Certified Professional Midwives in Massachusetts, many of the 20 actually have been midwife-attended births. Hence freebirthing, while attention-getting, doesn’t really account for many births here in Massachusetts or in the US.

Declercq added: “As a public health advocate, I’d like to see systems in place that help women like Ms. Pugh avoid such a terrible outcome.”

(For more of a visual grasp of “freebirthing,” watch this fairly graphic video with the understanding that you’ve been warned.)

Before Ricki Lake gave birth in her bathtub and before “Orgasmic Birth” was a top movie pic among the doula set, there was Ina May Gaskin, the earth-mother-high-priestess-venerated-goddess of natural childbirth.

This weekend, The New York Times discovers what proponents of home birth have known for decades: Ms. Gaskin, a self-taught midwife who launched her communal birthing center, The Farm in Summertown, Tennessee, with her husband Stephen in the 1970s, has helped deliver thousands of healthy babies without any medical help.

Gaskin’s statistics are eye-popping: out of approximately 3,000 total births, The Farm’s C-section rate is about 2 percent, The Times reports (compared to a more than 30% rate in the U.S.) and epidural anesthesia has been used only once. “Failure to progress,” a frequent diagnosis for long-laboring moms in American hospitals (and often the trigger for a cascade of medical interventions, including C-sections) are virtually non-existent at The Farm. This less-medicalized approach is, once again, gaining momentum and Gaskin’s ideals are increasingly going mainstream.

Samantha Shapiro writes:

Unmedicated home birth is being chosen by a growing minority of women. Between 2004 and 2009, giving birth at home increased 29 percent. Most of this rise is among white women. Recent pregnancy documentaries like “Pregnant in America,” “Orgasmic Birth” and “The Business of Being Born” — all of which feature Gaskin — present hospital birth as profoundly disempowering to women.

Shapiro weaves her own birth story into her profile of Gaskin. She wants a natural childbirth but in the end, with a failure to progress diagnosis, she ends up with a C-section. Her story concludes on a bittersweet note:

“…it is unfortunate that the choices and the rhetoric around birth — like many of the choices and rhetoric around motherhood in general — are so polarized. It should be possible both to have a baby in a place that doesn’t have financial and legal incentives to medicalize a low-risk pregnancy and to still have immediate access to top-level care if it’s needed. It shouldn’t be necessary to leave the medical establishment entirely to give birth vaginally to a breech baby or after a previous Caesarean. It should be possible both to acknowledge that something real was lost in the way my baby was born and to know that this loss is finite; there is not one pure route to authentic motherhood. Eight months with my son have offered ample evidence that there is not only one opportunity for joy.

Lately, though, he’s been thinking about a particularly low-tech, centuries-old device that is getting new attention as a method to prevent premature delivery: the pessary, described by researchers as “a tiny inverted cereal bowl with a hole cut in the center” more typically used hold up sagging pelvic organs. Writing in the Huffington Post, Wolfberg details the latest, promising research:

In this excellent study, published in the prestigious British journal The Lancet, obstetricians at five Spanish hospitals randomized 385 women with a short cervix to use of pessary or nothing. Pessaries are centuries-old devices that women place in their vagina to support their uterus and pelvic organs and prevent symptoms of pressure when these organs “fall” (prolapse) typically later in life. A handful of small studies using pessaries to prevent preterm delivery (the idea is that the pessary supports the cervix or lower uterus) have been published over the past 50 years, but none has had the size or scientific rigor to convince the obstetric community.

In their study, the Spanish group used the Dr. Arabin pessary, named after the German scientist who developed it… The Dr. Arabin pessary is approved for sale in Europe but not in the U.S…”

Wolfberg offers these recommendations:

No one is going to make a lot of money selling pessaries, so this is going to take some kind of partnership between a medical device company with very patient shareholders and an entrepreneurial philanthropy. That may work out well, because the Dr. Arabin pessary is produced in small quantities by its namesake’s idealistic daughter, Dr. Birgit Arabin, who told me, “I am happy with the idea that I can help a lot of people.”

Then it’s going to require a large American clinical trial, because physicians the world over (and the all-important Food and Drug Administration) are notoriously snobby when it comes to medical devices and tend to insist on proof from a population of Americans.

But it’s worth it, because the consequences of preterm birth are an enormous burden of lifelong disability the world over, and we need another tool in our kit besides progesterone.

Wolfberg, who starts a new job at Boston Maternal Fetal Medicine as a staff physician next month, has yet to encounter a single patient who has used the pessary to halt a pre-term birth. He emailed that “most clinicians had really abandoned the idea that a pessary could prevent preterm delivery years ago, after some of the preliminary papers were disappointing (many, many years ago), and I don’t know of anyone who has ever used a pessary for that indication…That’s why I find this Lancet article so exciting.”

Now he’s trying to drum up interest in exploring the pessary for wider use in the U.S. “I would love to see a group of U.S. obstetricians join together to conduct a well-designed clinical trial of the pessary, as the European data are never going to be sufficient to convince U.S. obstetricians that the pessary really prevents preterm delivery.”

Wolfberg also knows about the danger and emotional tumult of pre-term birth on a more personal level.

His book, Fragile Beginnings, Discoveries and Triumphs in the Newborn ICU, published in February, recounts his own daughter Larissa’s premature birth at twenty-six weeks. After a traumatic emergency C-section, Larissa weighed in under two pounds and had suffered a brain hemorrhage. At the time, Wolfberg was an ob-gyn resident at the Brigham and Women’s Hospital in Boston with just enough knowledge to get just how bad things were. And if he wasn’t completely sure, the neurologists at Children’s Hospital Boston offered this stark prognosis while Larissa struggled in the NICU a few days after her birth:

Chance of movement impairment on the right side is 100% — degree of impairment is difficult to predict.
Chance of normal cognitive function (IQ greater than 70): 50%

The book is a page-turner that goes beyond Wolfberg and his wife Kelly Lowery’s family saga. It explores neuroplasticity, the history and evolution of the NICU, abortion and medical ethics. More than anything, though, its takeaway is that much of parenting is about ridiculously hard work, good luck and trusting your instincts.

Larissa is now 10, a fourth-grader at a mainstream private school in Cambridge (full disclosure: my kids go to the same school), a happy child with a sharp sense of humor and no cognitive impairments. She has mild cerebral palsy, so is somewhat limitated when using her right hand and arm (friends sometimes help open her yogurt container at lunch, Wolfberg says) and has a bit of trouble with her gait. Certain activities, like riding a bike, were harder for her to learn.

Though Larissa’s birth was far more fraught and perilous than is typical, Wolfberg ends his book with a sentiment familiar to many parents: a little bit of sorrow over the obstacles of childhood combined with deep thanks that things are actually pretty good.

“First, there is gratitude that our child is riding a bike; at one point neither of us knew if she’d even walk,” he writes. “Next, there is sadness that so many times every day Larissa is reminded of the activities — trivial and significant — that are harder for her than they are for her friends. Last, we share awe at the spirit and determination that have helped Larissa more than all the miracles of therapy and neuroplasticity combined.”

No matter, here she is, reports Politico, not so subtly suggesting that the Obama administration’s birth control coverage policy for women might lead inexorably to a government-mandated childbirth policy. Wow.

The Minnesota congresswoman said the Obama administration’s contraception coverage mandate could be a slippery slope to a point where a “health dictator” decrees that women could only have one or two children.

Bachmann, in an appearance on Glenn Beck’s online television venture GBTV that was picked up by media watchdogs and liberal websites, said “it isn’t beyond the pale” to move from the birth control policy to a government-mandated childbirth policy.
“Going with that logic, according to our own Health and Human Services secretary, it isn’t far-fetched to think that the president of the United States could say, we need to save health care expenses — the federal government will only pay for one baby to be born in the hospital per family, or two babies to be born per family. That could happen. We think it couldn’t?”
Asked if she was suggesting that Obama was going to follow a China-style one-child rule, she said, “I’m not saying that he is going to do it, I’m saying that he has the power and the authority to do it.”

Readers responded passionately to a story we posted earlier this week about the rate of cesarean deliveries in the U.S. creeping up to 50 percent. The comments section included some intense back-and-forth on how to fix things.

So here are 11 suggestions for lowering the c-section rate. The first six come from John Queenan, an emeritus professor at Georgetown University’s department of obstetrics and gynecology and author of a recent editorial on the topic in the medical journal Obstetrics and Gynecology. The last batch are from readers.

1. Get a commitment from hospital obstetric departments to work on lowering the C-section rate and also cut down on the number of drug-based labor inductions. (See this related post on pregnant women inducing their own labor.)

2. Alert patients about the true risks of major abdominal (C-section) surgery, compared to normal vaginal deliveries.

3. Initiate tort reform to protect doctors from performing defensive c-sections. (This is controversial– most docs support it, but will it really change practices?)

4. Use more nurse midwives, the ones that mostly work in hospitals (see also #11, about certified professional midwives).

5. Provide equal compensation for vaginal and C-section births; compensate Vaginal Births After Cesareans (VBACs) at a higher rate than normal delivery. (This is Queenan’s idea but one reader, Denise, noted: “I do not agree that someone who is birthing in a Normal Biological State should be paying the same or more than the high rate of a major surgery.”)

6. Re-establish teaching and training for breech deliveries. One reader also said medical students should have more exposure to normal deliveries and recounted this story:

My cousin did her med school OB rotation while I was pregnant with my daughter. She asked me at a holiday gathering if i had any questions for her. I had one – did you see any completely intervention-free births? Answer – nope.

7. The number one suggestion by readers for reducing the C-section rate is increasing the use of doulas, who provide continuous labor support, for women and their families. Multiple studies have found that having a doula present at birth can cut your chances in half for having major interventions, such as epidurals and C-sections. (Full disclosure, I have a dog in this race: I co-wrote a book on birth, with a doula, back in 2008.)

Reader KMB offered this quote from the venerable, pro-doula doctor and researcher John Kennell MD, who said: “If a doula were a drug, it would be unethical not to use [one].”

8. Provide more training and support for women giving birth to twins to do so vaginally.

9. Mobilize an effort to evaluate the effectiveness and need for labor induction, continuous fetal monitoring and epidurals because all of these procedures can lead to more C-sections.

10. Focus on the mothers. One reader noted that a mother’s behavior truly impacts the way she gives birth:

…increasing numbers of pregnant women are overweight or obese, and are giving birth at an advanced maternal age. Blaming obstetricians, blaming inductions, blaming litigation, blaming hospital finances, blaming lack of training etc. will only get you so far. We also need to be honest with women about their individual risks, and their likelihood of achieving positive outcomes with different birth plans, by telling them how these can be affected by their personal circumstances too.

11. One popular suggestion — removing barriers so that more low-risk mothers can give birth at home, including more widespread use of  certified professional midwives (the ones most likely to attend a home birth) — triggered the most controversy. In particular, Amy Tuteur, MD, came out swinging, writing:

As H.L. Mencken said: “For every complex problem there is an answer that is clear, simple, and wrong.”

The rising C-section rate is a complex problem and the idea that it can be addressed by increasing CPMs and doulas is clear, simple and spectacularly wrong. CPMs are a second, inferior class of midwife that can’t hold a candle to CNMs (certified nurse midwives). CPMs are grossly undereducated, grossly undertrained and don’t meet the requirements for licensing of midwives in ANY first world country.

CPMs, and to a lesser extent doulas, privilege process over outcome. It is far more important to them how a baby is born than whether it is born healthy. Anybody can lower the C-section rate at the price of increasing the perinatal death rate. That’s hardly a desirable solution.

The rising C-section rate is a result of a variety of factors, including societal expectations. Modern obstetrics has lowered the neonatal mortality rate 90% and the maternal mortality rate 99% in the past 100 years. As a result, Americans expect that every baby will be born perfect and want to punish someone if anything is less than perfect…

Which triggered this response from Ananda Lowe (my co-author on the birthing book):

Dr. Amy, I am not sure why you have made it your career to slander home birth practitioners. What do you get out of it? How many home births have you ever attended, and why do you claim to be an expert on home birth if you are not experienced with it? Parents who deliver with home birth practitioners generally express very high satisfaction with their care, and take on a high amount of personal responsibility for their decision to birth at home. The top reason parents give for making this choice is the increased safety and decreased risk of unnecessary intervention they will encounter at home. No one is insisting that all mothers birth at home, and no one is insisting that women birth at home without becoming educated about, and taking responsibility for, their care. The only mothers I know personally whose babies have died are those who birthed in hospitals, due to fetal distress after the use of epidurals or induction drugs. The field of obstetrics decreased maternal mortality in the past 100 years by finally admitting that lack of handwashing was killing mothers and babies, and by the development of antibiotics, when the cesarean rate was still BELOW 5 percent, not by increasing the rate of surgical births to unheard of proportions. As for whether the use of CPMs and doulas reduces the rate of cesareans, the scientific evidence is clear. There is no other intervention that has such a dramatic impact on the cesarean rate.

In a recent editorial in the medical journal Obstetrics and Gynecology, Deputy Editor Dr. John Queenan suggests that we have yet to reach the peak. “The rate is likely to exceed 50% very soon in the U.S.,” he writes. “How can we curtail this runaway increase in cesarean deliveries?”

What’s really troubling, says Queenan, Professor and Chair emeritus at Georgetown University’s Department of Obstetrics and Gynecology, is that almost one-third of C-sections are for women who are having their first child, and that sets up a vicious cycle of future surgeries since vaginal births after cesareans (VBACs) are decreasing — some hospitals won’t even do them.

It didn’t used to be this way. In the past, C-sections required a prior consultation and full department review. Now, scheduled c-sections are often done at the patient’s request and vaginal delivery of breech babies “is no longer taught in many training programs,” he writes.

Of course, C-sections are safer now, but they are also more profitable for hospitals than normal, vaginal deliveries, and for doctors, they can be more efficient from a time-management perspective.

Nevertheless, if the numbers continue upward, Queenan says, “our profession will lose both credibility and the opportunity to determine our direction as third-party payers and the government will become involved.”

He offers a few suggestions to fix the problem:

1. A commitment from hospital obstetric departments to lower the c-section rate (this might also involve fewer labor inductions, which can also lead, inexorably, to surgical birth).

2. Better patient education so they are more fully aware of the risks and benefits of their choices.

3. Tort reform, so that ob/gyns don’t resort to C-sections as frequently “if any element of risk arises.”

4. Use more nurse midwives, whose “motivation to achieve vaginal delivery would be stronger.”

5. Provide equal compensation for vaginal and C-section births; compensate VBAC’s at a higher rate than normal delivery

6. Re-establish teaching and training for breech deliveries

Readers, childbirth experts, moms, do you have any other suggestions for this list?