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A VBAC is Safer on an Indian Reservation than in a Major US Hospital
March 10th, 2010NIH Consensus Development Conference on Vaginal Birth After Cesarean Section
For the past 2 days, the National Institutes of Health has hosted a conference to develop a consensus statement on Vaginal Birth after Cesarean Section (VBAC). In the United States, nearly one in every three births is via cesarean section, a number that is more than double the 15% cesarean section rate recommended by the World Health Organization. The high number of cesarean sections in the United States comes in large part from repeat cesareans. The current NIH discussion is to determine whether or not a woman who has had a prior cesarean section should automatically have cesarean sections with subsequent pregnancies, whether or not VBAC’s are safe and in what situations should they be performed.
Proponents of VBAC argue that VBAC’s are safe in women who are at relatively low risk and when the procedure is performed by competent labor attendants (midwives) in a mother friendly environment. (For more on mother friendly childbirth, see MFCI.) Opponents say that VBAC’s pose unacceptable risks to both the mother and baby due to the risk of uterine rupture, hemorrhage, and potential death of both mother and baby. So who is right? Ironically, both sides because the success of VBAC rests in large part with where it is done and who attends that birth.
One with nature-The Indian Health Service
The March 6, 2010 New York Times published an article by columnist Denise Grady reporting on the successful birth rates at the Tuba City Regional Healthcare System in Tuba City, Arizona. This hospital is part of the Indian Health Service, A federally funded healthcare program that serves Native American Indians and Alaska Natives, and is run by the Navajo Nation. This small hospital which delivers about 500 infants annually has a 32% VBAC rate and an overall cesarean section rate of 13.5%, despite the fact that many Native American women develop gestational diabetes and hypertension during pregnancy which, if they were being cared for by the conventional US health care system, would make them more likely to have cesarean section deliveries. How is such success possible?
Parameters that contribute to a low cesarean section rate overall and to high VBAC rates
To Fully understand the success of Tuba City and other hospitals like it, one must look at how the the overall system is structured. There are 5 specific things that Tuba City has in place that allows for their success.
1. Midwives attend most of the vaginal deliveries.
Midwives are more likely to “wait it out” if a woman is having a long labor and the baby isn’t in distress than to recommend a cesarean section. Midwives never induce labor, a process known to increase the likelihood of a cesarean section becoming necessary. Midwives are trained to assist women during childbirth process rather than to try to control it.
There is additional incentive amongst Native Americans to avoid cesarean sections. Many Native American couples wish to have more than 2 children and are educated about the dangers of repeat cesarean sections. Additionally, Native Americans believe that incisions are a threat to the spirit of the person being cut, so surgery is something to be avoided as much as possible.
2. Any and all family members are present and welcome.
In Tuba City as well as within any Navajo community, a laboring woman is never left alone. Not only will her partner be present, most likely her mother, grandmother, aunts, cousins and any other female relatives or family members. The laboring mother is constantly massaged and offered sips of water and small bits of food. With all of this support and her own prior exposure to labor and childbirth, the laboring mother has no fear whatsoever of her own labor and delivery.
3. Easier Adherence to ACOG VBAC Guidelines
The American College of Obstetricians and Gynecologists hs issued guidelines for VBAC’s. An obstetrician and anesthesiologist should be present or very quickly accessible while a woman who has had a previous cesarean section is laboring in the event that she requires and emergent cesarean section.
While many community hospitals have been unable to meet this criteria citing cost prohibition of maintaining professional staff on call at all times, hospitals on Indian reservations have had no such problem. The Tuba City Hospital is located within the property of the Navajo Indian reservation. Many of the physicians who work at the hospital either live on the reservation or within minutes of the hospital. Many doctors who are on call may actually go home while a midwife attends a birth because if they are needed, they can be at the bedside within minutes.
4. No Threat of Malpractice litigation
The Tuba City Hospital and its doctors are federally insured against malpractice because it is a federally funded facility. Hence the obstetricians are not as concerned about being sued if complications arise or about increases to or complete cancellation of their malpractice premiums.
5. No threat of wealth
The professionals that staff the hospitals in the Indian Health Services are paid flat salaries; $190,000 to $285,000 annually for the physicians and $80,000 to $120,000 for midwives. Since the staff is not paid per procedure, there is no incentive to do more and potentially unnecessary procedures.
“Conventional” Wisdom
In conventional western medicine, childbirth is a procedure to be managed and controlled. In most US hospitals, laboring women are not allowed to move freely because they are hooked up to fetal monitors. They labor in bed and primarily on their backs-the least comfortable position in which to labor.
A woman is not allowed to have anyone she pleases at her side and many times is alone during her labor process when the doctor or nurse needs to “check her progress.”While many women hire doulas, many US hospitals still try to and successfully block their presence in the labor and delivery rooms.
Many more interventions are involved; from intravenous fluid administration, to epidural anesthesia, to labor induction with oxytocin, an episiotomy (a surgical incison in the perineum to allow passage of the baby without tearing. Not usually needed but frequently done “just in case.”), to forceps and/or vacuum extraction of the baby to cesarean section. The natural process of labor and delivery is now seldom allowed to “play itself out.”
Why is there such a disparity between the two methods?
In this era of Health care reform and in the midst of this contentious debate, the Navajo nation is a blatant example of less being more. The United States spends more money than most industrialized nations for health care and yet we have some of the sickest, most obese citizens in the world. We also have some of the highest maternal and infant mortality rates in the industrialized world. We are in no way, shape or form getting what we are paying for.
If the United States truly wants to lower cesarean section rates to be more in line with WHO recommendations, if it wants to improve VBAC rates and if the US truly wants to improve maternal, fetal and infant mortality, we have to change how we do things.
- Births should be attended to by the most qualified attendants-midwives.
- In uncomplicated situations, labor and delivery should be allowed to progress naturally at their own times.
- Women should be allowed to move freely during labor and to have anyone they need present. Cultural and religious traditions should be respected.
- Treatments and interventions should be administered on a case by case basis and not as standards of care. Interventions should be kept to a minimum and not be performed as a defense against litigation.
- Monetary incentive should not be given to providers for more interventions, yet providers should be assured of adequate compensation for their skills.
Most physicians in our current health care system would balk at these recommendations because these would represent sweeping changes in the way they are trained, how they practice medicine and most especially in the way that they are paid. However we Americans, especially we women, have to ask ourselves how much longer are we going to put up with and pay into a system that clearly does not have our best health at its core?
It will be interesting to see what the NIH consensus comes up with. Quite frankly I am not all that encouraged that much is going to change, but the fact that there was even the discussion means that we are moving, ever so slowly, in a more positive direction.
When Love Hurts: Domestic Abuse in Pregnancy
February 23rd, 2010Pregnancy is a time when a couple should be savoring their time together while eagerly anticipating the arrival of their new little one. Sadly for some couples, pregnancy becomes a time of increased stress and ends in abuse-both physical and emotional.
Reasons for Domestic Abuse During Pregnancy
The most common reason for abuse during pregnancy is that it is a continuation of pre-pregnancy abuse. Women who are abused prior to pregnancy are at increased risk of being abused during the pregnancy. Domestic abuse during pregnancy is also the result of:
- Stress related to the pregnancy-especially if the pregnancy was unintended.
- Financial concerns regarding the pregnancy, delivery and subsequent addition to the family
- Change in the partner’s relationship, especially insecurity and/or jealousy of the father regarding mother’s divided time and increased attention to the baby.
How Common is Domestic Abuse in Pregnancy?
The March of Dimes and other resources state rates of domestic abuse during pregnancy reach as high as 25% of all pregnancies. Abuse of pregnant women occurs in all ages, races and ethnic groups and in all socioeconomic levels.
What is Considered Abuse?
The abuse can range from name calling, verbal insults and controlling/isolating behavior to pushing, hitting, punching, kicking or choking. While emotional abuse is extremely stressful, physical abuse can be extremely harmful-even deadly to mother and baby. If you are unsure if you are in an abusive relationship, ask yourself the following questions:
- Does my partner always put me down and make me feel bad about myself?
- Has my partner caused harm or pain to my body?
- Does my partner threaten me, the baby, my other children or himself?
- Does my partner blame me for his actions? Does he tell me it’s my own fault he hit me?
- Is my partner becoming more violent as time goes on?
- Has my partner promised never to hurt me again, but still does?
If you answered “yes” to any of these questions, you are in an abusive relationship and need to get help-if not for yourself, then do it for your baby.
Effects on Mother and Baby
Abuse certainly has detrimental effects to both mother and baby. For mother, the increased and persistent stress can cause her to withdraw. She may begin missing prenatal appointments and thus not getting much needed care for herself and her baby. She may not eat well or sleep well and is at increased risk of depression. If the abuser is controlling, she may have lost contact with family, friends and loved ones. Isolation is an integral part of abuse as it keeps women from seeking and obtaining help. It also helps hide the physical signs of abuse-if there are any.
If mother has any sort of chronic disease, these will likely get worse and can cause complications for both mom and baby. Mother may not be taking necessary medications or getting necessary treatments so her overall physical health is compromised. Hence the energy and nutrients she has to give to her baby are also compromised.
The added stress is no better. When mom is stressed, so is baby. Additional stress has been linked to preterm labor, miscarriage and even still birth.
Physical abuse is quite possibly the most dangerous form of abuse. In addition to the overall physical injuries a pregnant woman may sustain, physical blows to a pregnant woman’s belly can result in placental damage or abruption, vaginal bleeding, injury to the fetus, preterm labor or even miscarriage.
What To Do
First and foremost, if a pregnant woman (or any woman) is at risk for domestic abuse, she needs to get help.
Start by speaking with your obstetrician or midwife (if you can speak with them alone). Health care providers often have access to resources or people on their staff can help you get help.
Contact your local police department if you feel you are in immediate danger.
Find a safe place to stay where you can get help. This may be with a good friend, neighbor or family member. You may be able to get help from your church or other civic organizations. If woman’s shelters are available in your area, contact them to see if they can assist you.
Gather some of your things, especially important documents such as bank account numbers, credit card information, prescriptions, etc…Have a bag ready and easily accessible in the event you have to leave abruptly. You may even want to have them somewhere outside your home (at a friend’s home for example) in the event that you have to flee unexpectedly.
Domestic abuse during pregnancy is more common than many of us realize. However, it is not normal and need not be tolerated. Help is available from the resources below.
National Council of Child Abuse and Family Violence
http://www.nccafv.org
Alliance for Children and Families
http://www.alliance1.org
Stop Abuse for Everyone
http://www.safe4all.org/resource-list/
National Domestic Violence Hotline (800) 799-SAFE (7233)
http://www.ndvh.org
This post was compiled using data from The March of Dimes, Cyberparent.com and Women’s Healthcare topics.com
9 Ways a Mama on Bed Rest can Say “I Love You!” this V-Day
February 11th, 2010Let’s face it, bed rest is a killer to your love life. All month I have been offering ways for you and your partner to “Keep the Love Alive”. Now here we are, just a few days from Valentine’s Day, and you may be thinking, “Shoot, I’m stuck here on bed rest. How can I make this day special?”
Well, I’m glad that you asked. Sitting over breakfast I too was thinking of how to make this a special day for my own “hunny bunny”. As per usual, I am running late for the train, so I was thinking of things that I could order for quick delivery. So here are 9 ideas that I came up with over my breakfast taco and chai tea. If you use one for your “hunny” send a comment and let me know how it turned out!!
9 Valentine Ideas for Mamas on Bedrest to share with their partners
- Send flowers. Yeah, kinda screams “I forgot” but at least you remembered in time to order something.
- Edible Arrangement. The company that bears the name will deliver a beautiful arrangement composed of fruit. If you choose certain arrangements, you can have chocolate dipped fruit (strawberries, bananas, etc…) or hunks of chocolate on skewers added to the arrangements. www.ediblearrangements.com
- Luv’s Brownies. I add this one because it belongs to a friend out in my beloved San Jose, CA. Aundrea Lacey is the owner and founder of Luv’s brownies (www.luvsbrownies.com) and has taken brownies to another level. You can order brownie cakes, brownies in coffee mugs, she’s written a book…If it’s brownies your love likes, they will love Luv’s Brownies.
- Candy. Believe it or not, candy (namely chocolate) is still an all time favorite for Valentine’s Day. No longer is it just Lammes or Russell Stover’s. If you go to Candygram.com, you can order a wide range of candy items and have them shipped directly to your honey. Won’t that be a nice little “pick me up” to their day at the office??
- Massage. Okay, this is if you want to spend a little change. Now if you’re feeling the love, you’ll arrange to have a local massage therapist come out to your home and give your honey a relaxing massage. But if you’re like me, no one is allowed to be massaged in my home without me! Solution, order a couple’s massage. It’s really great. 2 massage therapists arrive at your home, will bring their tables and you and your honey can be massaged at the same time. If that’s too pricey, you can still have the massage therapist do you both in tandem. In any event, it’s sure to please!!
- Pajamagram. My husband ordered me one of these a couple of years ago, I think for my birthday and I got a real kick out of it. Pajamagram.com has a whole catalogue of pajamas that you can order and they will ship them in the cutest boxes, sometimes with cute little accessories and all. Wouldn’t your honey look cute in a pair of boxers??? You may not be able to “touch” but hey, a little eye candy never hurt anyone!
- Personal Chef Services. There’s nothing like a really good home cooked meal. Now that you are on bed rest, you can’t give your honey that special “luvin’ from the oven!” But a personal chef can do that and more. After a consultation (and this can be done over the phone!) the chef will go grocery shopping, arrive at your home with their own cutlery and cookware, cook a sumptuous dinner and prepare it for service. Many personal chefs will also bring table cloths, china, flatware, candles….Check in the catering sections of your local listing to see if there are personal chefs in your area and see what types of services they offer. Bon Appetit!
- Portrait Photography. If this is your first baby, this will be the last time you and your partner will be a “duo” for many years to come. Why not capture the moment? There are many photographers that specialize in pregnancy photography, of if you prefer, you can do something a bit more formal of you and your partner. If your children are anything like mine, they’ll enjoy looking at such photos of themselves in “mama’s tummy.”
- Write love letters to one another. With all of the hoopla surrounding your pregnancy and ensuing bed rest, it’s easy to forget that it was love that brought you to this very moment in time. Take a moment to remember those things that made you fall in love with your partner; a smile, a laugh, special times spent together. Write them all down in a keepsake letter. Choose beautiful paper and perhaps a spritz of your favorite perfume or oil. It’s guaranteed to be something they’ll cherish.
Image courtesy of PublicDomainPictures.net
