pregnancy

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Culture Clash: U.K. Embraces Homebirth As Best For Some Women

Sarah Parente shortly after the homebirth of her daughter Fiona (Courtesy of Leilani Rogers)

Sarah Parente shortly after the homebirth of her daughter Fiona (Courtesy of Leilani Rogers)

By Jessica Alpert

Sarah Parente, an Austin, Texas-based doula and mother of four, gave birth to her first child in the hospital with no complications. But then she decided to make a shift: Parente delivered her next three babies at home. “For women with low-risk pregnancies, home birth can be a great choice,” she says. “You have less stress because you are in your own home surrounded by a birth team of your choosing.”

Though home birth has recently gained cache in the U.S. — with some celebrities trumpeting the benefits of having their babies at home  — the practice remains uncommon and the majority of pregnant women give birth in a hospital setting. Still, Parente may be getting a little more company, albeit slowly. Data released by the Centers for Disease Control (CDC) earlier this year shows the rate of homebirths in the U.S. has increased to 0.92 percent in 2013 and the rate of out-of-hospital births (including home) has increased 55 percent since 2004.

Experts in the United Kingdom are saying that’s a good thing.

The London-based National Institute for Health and Care Excellence (Nice) recently released recommendations that homebirths and midwife-led centers are better for mothers and often just as safe for babies as hospital settings, the BBC reports. Of the 700,000 babies born in England and Wales each year, nine out of 10 are born in obstetric-led units in hospitals. Continue reading

Opinion: New Pregnancy Drug Guidelines A Mixed Bag For Consumers

pumicehead/flickr

pumicehead/flickr

By Dr. Adam Urato
Guest Contributor

Last week the Food and Drug Administration published a final rule that will change how drug companies present information on the risks of medications during pregnancy. This is considered a very important step as there are approximately 6 million pregnancies in the U.S. every year and the average pregnant woman takes between three and five prescription drugs during the course of a pregnancy.

For decades, the public has relied on the FDA’s Letter Category system in which a Category A drug was considered safe, Category D unsafe, with B and C falling in between, and Category X meaning contraindicated in pregnancy.

This past week the FDA announced that it is scrapping that letter system and replacing it with a new system that will offer descriptions about the effects of the drug during pregnancy and lactation. A third section (the “Females and Males of Reproductive Potential” subsection) will include information about pregnancy testing, contraception and about infertility as it relates to the drug.

So what exactly does all this mean for consumers?

As a Maternal-Fetal Medicine specialist, here’s my read on the changes:

What this means is that men and women are going to have to actually go to the drug information label and read it. No longer will a pregnant woman simply be able to look up a drug and find out that it’s a Category D in pregnancy, for instance, and then avoid it.

And this is a major problem that I see with the new system: many patients and physicians do not take the time to read through the label prior to using a medication. A description-based system risks losing the benefit of warning that the current Letter System provides when the drug is simply listed as Category D or X.

Also, it seems that the drug companies themselves are going to be asked to write these pregnancy sections on the label. This strikes me as absurd. Continue reading

Study: Pregnant Women Hungry For Better Info Earlier On

Pregnancy test (Wikimedia Commons)

Pregnancy test (Wikimedia Commons)

The “+” sign pops up on your pregnancy test. You call the office of the obstetrician you’ve chosen for just this eventuality, and the receptionist congratulates you and sets you an appointment four or six or eight weeks away.  “But,” you think, “I have so many questions now!” The books aren’t enough. So you turn, of course, to Google, and navigate the thickets of information alone.

If this was your pregnancy experience and it struck you as odd or off or wrong, you’re not alone, according to a recent small study that likely reflects a far broader opinion. Writes one pregnant friend: “My docs are wonderful and insanely knowledgeable, and I call them for the big stuff. However, there’s so much little stuff when you’re pregnant, especially for the first time. It’s constant googling, is this normal? Everything from symptoms, food, exercise routines, massages, whether to dye your hair – it’s endless.”

And some things you need to know early, she notes. “I did have the books – I found the Mayo Clinic guide to a healthy pregnancy to be quite good. But, not so easily searchable, especially when you’re at dinner and you’re like, ‘Can I eat xyz?’ My husband downloaded a few apps right away that allow you to search what you can eat, what to avoid. Some are obvious: alcohol, sushi, some way less so – um, lunch meat?”

From the study’s press release:

Pregnant women are using the Internet to seek answers to their medical questions more often than they would like, say Penn State researchers.

“We found that first-time moms were upset that their first prenatal visit did not occur until eight weeks into pregnancy,” said Jennifer L. Kraschnewski, assistant professor of medicine and public health sciences, Penn State College of Medicine. “These women reported using Google and other search engines because they had a lot of questions at the beginning of pregnancy, before their first doctor’s appointment.” Continue reading

Pregnancy Woes: Why Did The Price Of My Progesterone Skyrocket?

(Photo: Rekha Murthy)

(Photo: Rekha Murthy)

By Rekha Murthy
Guest Contributor

Update: KV Pharmaceutical changed its name to Lumara Health, two days after this post was published.

I’m 34 weeks pregnant and working hard to keep this baby inside me for as long as possible. As with my last pregnancy, there’s a real risk that the baby could come too early. But we’re both holding on so far, thanks to a combination of luck, modified bed rest and medical science.

The science is my biggest concern right now. I will spare you much of it because, man or woman, you will instinctively cringe and close your legs. However, one critical medical intervention that has been proven to work for countless women and babies is again under threat, and I must speak up.

Every week, my husband injects me with 250 mg (1 ml) of 17 alpha-hydroxyprogesterone caproate (“progesterone” for short). Leaving aside what this does to an otherwise tender and loving marriage, these injections have been found to significantly lower the risk of preterm birth.

Two weeks ago, my insurance co-pay for progesterone went from $5.50 per dose to $70 per dose. Just like that. For those without insurance (or with a deductible), the medication went from $32.50 per dose, according to my local compounding pharmacy, to…wait for it…$833 per dose, according to the new pharmacy my insurer is now requiring me to use.

$833. Per. Dose.

Pricing varies somewhat across pharmacies and insurers, but not enough to make this price change any less breathtaking. In fact, the drug’s list price is $690 per dose.

The 12-fold leap in my co-pay sent an epic shock through my (natural and synthetic) hormone-laden system. I immediately called both pharmacies, my insurer, and my doctor, and started digging around online. I soon learned that the price increase came from a new requirement to buy expensive brand-name progesterone, instead of the affordable compounded version I had been getting. A disturbing picture came into focus. Continue reading

Mass. Senate Approves Anti-Shackling Bill

State House News Service reports:

The Senate approved legislation Thursday aimed at preventing the shackling of pregnant inmates in Massachusetts correctional facilities. Sen. Karen Spilka said the bill (S 2063) would also make sure that women in prison, who she said often have high-risk pregnancies, receive medical screenings and assessments and nutrition and post-partum counseling.

The passage comes a month after Gov. Deval Patrick issued emergency regulations banning restraints on pregnant inmates in labor. He also urged the Legislature to send him pending legislation that would make his ban the law.

Campaign To Reduce Early Births Pays Off — Mass. Now Leads Nation

Most obstetricians agree that babies should not be delivered early, before 39 weeks, unless the health of the mother or her child is at risk. Research shows important brain, lung and vital organ development occurs late in pregnancy. So hospitals across Massachusetts have been working to reduce so-called “early elective deliveries.”

(popularpatty/flickr)

(popularpatty/flickr)

Over the last three years, most hospitals have either stopped scheduling early deliveries, or set a goal of less than 5 percent. Last year, the state’s rate dropped, on average, to 1 percent, the lowest in the country. There is still variation from one hospital to the next. But the numbers, compiled by Leapfrog, a business group that advocates for improved hospital quality and safety, show the significant progress hospitals made in just one year.

The state’s low rate “should decrease some of the complications that newborns may experience from being born electively,” including, “admissions to the intensive care unit and long-term complications,” said Dr. Glenn Markenson, an obstetrician at Bay State Medical Center. Continue reading

Ban On Handcuffing Pregnant Inmates In Labor Clears Hurdle In Mass. Legislature

A proposal to prohibit the scary practice of handcuffing pregnant inmates during labor has cleared its first hurdle through the Massachusetts Legislature. If passed, the so-called “anti-shackling bill” would “create uniform laws in county jails and the state prison system banning the shackling of pregnant women during childbirth and post-delivery recuperation — unless they present a specific safety or flight risk,” according to an earlier WBUR report.

(MOZ278/flickr)

(MOZ278/flickr)

“This bill has been on file for over a decade — the language has changed a bit — but it’s never seen the light of day,” says Megan Amundson, executive director of NARAL Pro-Choice Massachusetts. The bill was reported out of committee on Friday, and now it will be given a new number and then most likely go to the House Ways and Means Committee, Amundson says.

Here’s more from the NARAL Pro-Choice Massachusetts news release:

In a step toward joining the 18 states that have passed legislation banning the shackling of pregnant incarcerated women, the Massachusetts Joint Committee on Public Safety has released the Anti-Shackling Bill, a bill the prohibits the practice of shackling pregnant women in our jails and prisons, sponsored by Senator Karen Spilka. The bill has now passed the first hurdle to passage.

“As hard as this is to believe, it is not unusual for pregnant women in Massachusetts jails to be handcuffed to the hospital bed even while in labor,” said Megan Amundson, Continue reading

Opinion: License Professional Midwives For More Childbirth (And Home Birth) Options

Home birth announcement (Courtesy Sarah Whedon)

Home birth announcement (Courtesy Sarah Whedon)

By Sarah Whedon
Guest Contributor

When I was expecting my first baby in 2009, I planned a home birth with a wonderful midwife. My pregnancy was healthy and normal, my prenatal care with my midwife was both empowering and attentive to my health needs and my labor began spontaneously at full term.

Everything was going according to plan, until about 20 hours into active labor at home when my midwife alerted me that my baby’s heart rate indicated a serious problem and we needed urgent medical attention.

In the amount of time it took the ambulance to arrive at my Somerville home, my midwife cut an episiotomy (a skill in which home-birth midwives are trained but don’t practice as a matter of routine) and performed an emergency delivery. My baby had aspirated meconium (the sticky tar-like substance in a newborn’s bowels that is occasionally expelled during birth) and was having trouble breathing even with the aid of the oxygen my midwife carried with her. She needed a transfer to the level III NICU at Children’s Hospital, where she made a complete recovery.

I had a home birth because I wanted the kind of low intervention pregnancy and birth that Certified Professional Midwives (CPMs) offer. But I tell my birth story publicly because it demonstrates something important that people don’t often realize about CPMs: they are skilled professionals who are prepared to handle emergencies, including facilitating transfer to medical care when needed.

CPMs are midwives who are specially trained in out-of-hospital care. They differ from Certified Nurse Midwives (CNMs) who are trained as nurses and typically practice in hospital settings. Currently, Massachusetts licenses CNMs but has no licensing system for CPMs, who provide care for approximately 500 women across the state each year.

So when I recently learned of a petition asking me to support licensing of CPMs in Massachusetts, I immediately wanted to get more involved. I found other moms who want this bill to pass and I’ve had the pleasure of lending my support to this work being carried out by a coalition of advocates from the Massachusetts Midwives Alliance, Massachusetts Friends of Midwives and others. More than 500 Massachusetts residents have now signed the petition.

The bills (HB 2008 and SB 1081) would require all midwives practicing out of hospital to become CPMs, create state licensing requirements for CPMs and establish a Committee on Midwifery under the Board of Registration in Medicine. The nine-member committee will include five CPMs, one obstetrician, one CNM and one consumer of midwifery services.

Supporters of the measures that would license and regulate home birth midwives were energized by an amazing turnout at a Committee on Public Health hearing last month, testifying to the professional skill of these midwives and the valuable ways they serve Massachusetts families. Several moms even brought their charming home birth babies along for the day at the State House.

I have heard from some midwifery supporters who oppose licensing, worrying that new regulations will hamper midwives’ ability to truly practice the midwifery model of care. But midwives themselves will be involved in determining details of regulation. Overall, licensing of our midwives would mean more moms will feel able to choose home birth, because they’d have the security of knowing that in order to hang out her shingle, a midwife must meet state licensing standards.

The Massachusetts Medical Society has also opposed the bills, expressing disapproval of any health care that is delivered outside the team context with immediate M.D. supervision. Continue reading

Tragically Wrong: When Good Early Pregnancies Are Misdiagnosed As Bad

An ultrasound of a pregnancy at six-and-a-half weeks (meaning that it was done two-and-a-half weeks after the woman's missed period.) The pregnancy sac  is outlined by four short arrows within the uterus and the embryo is within the pregnancy sac. (Courtesy P. Doubillet)

An ultrasound scan of a normal pregnancy at six-and-a-half weeks (meaning that it was done two-and-a-half weeks after the woman’s missed period.) The pregnancy sac is outlined by the four arrows and the embryo is within the pregnancy sac. (Courtesy P. Doubilet)

A beautiful, supremely talented young friend of our family recently fell victim to a terrible medical mistake. Newly married, she was having some pelvic pain and bleeding, and the doctor who saw her diagnosed a probable ectopic pregnancy — an embryo that develops outside the womb. Concerned that such pregnancies can turn life-threatening, the doctor prescribed the standard treatment: methotrexate, a drug used for chemotherapy and to help induce abortions.

When our friend returned to be checked a few days later, the imaging revealed that in fact, the pregnancy had not been ectopic; it was in place, in her uterus. But because she had taken the methotrexate, a known cause of birth defects, her pregnancy was doomed.  She soon miscarried. What may have been a perfectly healthy pregnancy had been ended by well-meant medical treatment.

I assumed her horrifying case was an exceedingly rare medical fluke — until now. A paper just out in the prestigious New England Journal of Medicine shows that such misdiagnosed pregnancies are part of a pattern — a pattern that needs to be changed. “Considerable evidence suggests that mistakes such as these are far from rare,” it says.

When I told our friend’s story to the paper’s lead author, Dr. Peter Doubilet, he responded that he knows of “dozens and dozens and dozens of similar cases that have come to lawsuits, and that’s probably the tip of the iceberg.” There is even a Facebook group, Misdiagnosed Ectopic, Given Methotrexate, run by a mother given methotrexate whose daughter was born with major birth defects.

The New England Journal of Medicine paper stems from a panel of international experts who resolved to change medical practice to stop such misdiagnoses. I spoke with Dr. Doubilet, who is senior vice chair of radiology at Brigham and Women’s Hospital and a professor of radiology at Harvard Medical School. Our conversation, lightly edited:

Before we get into the nuts and bolts of the problem, what’s the upshot for women of child-bearing age? What’s your message to them?

When a woman gets pregnant, a number of serious complications can occur early in pregnancy, including miscarriage or ectopic pregnancy. When a doctor diagnoses these problems within the first two to three weeks after her missed period, it’s very traumatic to the patient and it’s critically important that the woman and the doctor are confident that the diagnosis is correct, because the steps that will be taken would harm a normal pregnancy if one is present.

Dr. Peter Doubilet (Courtesy)

Dr. Peter Doubilet (Courtesy)

It’s become apparent over the past two to three years that errors in diagnosis of miscarriage and ectopic pregnancy occur more frequently than they should, and that’s why we put together a multi-specialty panel of expert doctors from radiology, obstetrics-gynecology and emergency medicine to come up with new, more stringent guidelines for diagnosing these complications, taking into account the most recent research on the subject.

And just to simplify, when a woman in very early pregnancy has been told that it appears that she has an ectopic pregnancy or a failed pregnancy, it would very rarely be overly risky — and often be wise — to wait a couple of days and be sure of the diagnosis before acting?

Yes. That’s a very important message. In 2010,  I, together with Dr. Carol Benson, wrote an editorial in The Journal of Ultrasound in Medicine entitled “First, do no harm to early pregnancies,” and that was the key message: Unless the doctor is sure that the woman has a miscarriage or an ectopic pregnancy, the doctor should err on the side of waiting, as long as the woman is stable and shows no signs of serious internal bleeding.

If the patient meets definite criteria for a miscarriage or ectopic pregnancy, there’s no reason to wait, but if there’s any degree of uncertainty, the prudent thing is to wait. Continue reading

Birth Control: Talking ‘Bout The Pullout Generation

When a recent study concluded that nearly 1 in 3 straight, sexually active young women used the withdrawal method for contraception, the media breathlessly coined a neat phrase to characterize these 15- to 24-year-olds: “The Pullout Generation.”

Elite Daily asked: “Gen-Y Or Gen-Pullout? Coitus Interruptus Is The New Form Of Birth Control” and New York Magazine breezily headlined its coverage, “No Pill? No Prob. Meet The Pullout Generation.” The Huffington Post held a forum, asking “Is this an appropriate method of birth control in this day and age?”

youngloveThe truth is, “pulling out” is old news. Indeed, it’s perhaps the oldest form of contraception (besides abstinence) and has been practiced for millennia. Though clearly not the most effective method of birth control, and offering no protection against STIs, withdrawal is free and when done with skill it can be somewhat effective.

According to Planned Parenthood:

–Of every 100 women whose partners use withdrawal, 4 will become pregnant each year if they always do it correctly.
–Of every 100 women whose partners use withdrawal, 27 will become pregnant each year if they don’t always do it correctly.
–Couples who have great self-control, experience, and trust may use the pull out method more effectively. Men who use the pull out method must be able to know when they are reaching the point in sexual excitement when ejaculation can no longer be stopped or postponed. If you cannot predict this moment accurately, withdrawal will not be as effective.

To find out more, I crowd-sourced the issue on SurveyMonkey and asked why my 20-something peers — savvy, educated — relied on such a frowned-upon form of contraception. I got over 30 responses that fell into five overarching categories: Continue reading