This video begs to differ.
From the Safe Motherhood website:
The Safe Motherhood Quilt Project is a national effort developed to draw public attention to the current maternal death rates, as well as to the gross underreporting of maternal deaths in the United States, and to honor those women who have died of pregnancy-related causes since 1982.
This is a wonderful visual adjunct to my previous post on maternal mortality, with additional statistics. This project is the vision of Ina May Gaskin, who nearly single-handedly brought back midwifery, home birth, and normal birth in the 70s. She also wrote an article about this, “Masking Maternal Mortality,” in the current issue of Mothering magazine. I think it is an important reminder of how much further we have to go. Please visit this site, and if you know of someone who died of pregnancy-related causes within 1 year of the end of her pregnancy (whether miscarriage, abortion, or birth), you may there find out how to add a quilt block in her memory.
First the facts: WHO/UNICEF/UNFPA Estimates of maternal mortality for 2005 lists the U.S. maternal mortality rate as being 11/100,000; but more recent figures show it to be 13/100,000. On the opening page of the National Center for Health Statistics “Maternal Mortality and Related Concepts” Feb. 2007 report (p. 6 of the pdf), it says that “35 percent more maternal deaths are identified through surveillance efforts than solely by the death certificate.” This discrepancy is caused by numerous factors, including different ways of assessing and coding death. If this is correct, then the current U.S. maternal mortality rate should be more like 17-18/100,000. Here are a few countries’ maternal mortality rates (but the information for all countries is there on that link; most of the countries’ numbers are estimates, due to poor or absent record-keeping in these places): Australia is 4; Belgium is 8; Brazil is 110; Burundi is 1100; Ethiopia is 720; Japan is 6; North Korea is 370, and South Korea is 14. Sierra Leone is the worst, with 2100/100,000. At the bottom of the page, it groups countries by level of development, and shows the average maternal mortality rate:
8/100,000 for industrialized countries
450/100,000 for developing countries
870/100,000 for least developed countries
So, the United States is worse than average for industrialized countries. I’m not going to engage in post-hoc arguments, but just point out some facts–the U.S. has the highest rate of obstetrician-attended birth in the world, and among the highest rates of hospital birth and C-section (if not the highest). We are the richest country in the world by just about anyone’s estimation, yet our maternal mortality rate is worse than Australia, Austria, Belgium, Bosnia, Canada, Croatia, Czech Republic, Denmark, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Japan, Kuwait, Latvia, Malta, Netherlands, New Zealand, Norway, Poland, Slovakia, Slovenia, Spain, Sweden, Switzerland, and the former Yugoslav Republic of Macedonia. We are tied with Bulgaria, Lithuania and Portugal, and just barely edge out Luxembourg and Qatar. Why?
One factor that I have heard blamed for the U.S.’s poor standing compared to the world is the much-higher rate of maternal mortality for black women. The NCHS document I referenced above shows that in 2003 (the latest figures in the document), white maternal mortality was 8.7 while black maternal mortality was 30.5. But looking at only white births (and of course, European nations are going to be almost entirely white), the U.S. MMR is still only “average”–and we’re the richest country in the world! We have everything high-tech available, and the Emergency Medical Transport and Labor Act requires that hospitals give care to women who present to them in active labor, regardless of whether the woman can afford her care or not.
Some people blame the lack of socialized medicine, and I’m sure that lack of prenatal care does adversely affect some women; yet women who are in the lower socioeconomic brackets can get government assistance while pregnant (I worked at a pharmacy for over 5 years, and saw numerous women who did not need to be on Medicaid receiving these benefits just because they could). Some undoubtedly fall through the cracks; but there are also undoubtedly many women who simply don’t care enough about themselves or their babies to take measures–through better nutrition, getting off of drugs, etc. The higher black MMR has been blamed by some on their being more likely to be in lower socioeconomic brackets. While I do not disagree with the fact that poor people tend to be in worse health than those who are better off, I think this highlights the bias that exists against women who are poorer or who are on government assistance. It is sad that health-care providers can ignore signs and symptoms of problems in minorities or poor women that they will pick up on in white and/or well-off women. And those in the obstetric community who would say, “We can’t have the low MMR that European countries have, because we have a higher percentage of black women, and they have almost 4 times the death rate of white women.” That is simply “blaming the victim”! It is also fatalism, because this attitude suggests that this rate cannot be changed. But if this be the case, then that starts sounding like black women must somehow be genetically weaker or inferior to white women. [As an aside, I would like to know if there have been any studies of infant or maternal mortality that have had women of the same socioeconomic class, and divided by race. Are the statistics that much worse for wealthy black women, versus wealthy white women; or middle class, or lower class? Is the disparity more due to racism or "classism" by care providers against the poor or minorities, or is it simply a health or genetic thing? If it's racism, then shame on those who perpetrate it! If it's the poor health of these women, then care providers should first educate their clients on the importance of nutrition, and try to raise their clients' health in that way. I don't believe it's genetics.]
Others blame obstetric interventions that are overused, used too frequently, or used without a specific need or benefit. Routine use introduces risks without the corresponding benefit; when used specifically, interventions have a higher presumed benefit than known risk. [You can check out my posts entitled "safe motherhood" for more information on this topic.]
Even accepting the racial disparity as an unalterable fact for the moment, looking just at the white MMR, the U.S. 2003 death rate was 8.7, which puts it equal to or worse than all but about 3 of the countries mentioned above. This is unacceptable for the richest and best nation in the world!
Update — at this blog is a world map showing different maternal mortality rankings by different colors.
I save a lot of stories and websites on my computer bookmarks or “favorites,” and just the other day, I came across this link to an article in a British newspaper entitled, “Cramp blamed for Caesarean boom.” It says that doctors have found higher-than-normal levels of lactic acid in the wombs of women who have had a C-section. Interesting. In doing some more research on lactic acid, I’ve discovered that there are conflicting theories. The old idea (which this newspaper and/or doctor hold to) is that lactic acid is a waste by-product of muscles working too hard with not enough oxygen–this stemming from experiments a scientist did about a century ago and just handed down as unassailable truth. Newer theories and newer research does not back up the idea that lactic acid causes muscle cramps, although it is noted that high levels of lactic acid are indicative of muscle cramps and fatigue. But whether it’s a “cause and effect” question, or that excess lactic acid is simply a marker of muscle fatigue is unknown. More research is needed, but what is known is that intense activity causes lactic acid to accumulate.
In the article, it mentioned that lactic acid build-up is well-known among athletes, so I dug further and found this article on Muscle Cramps/Spasms: Nutritional Causes, Prevention, and Therapies. Again, very interesting. Although it deals primarily with athletes, and training for things like long-distance running and biking, as well as weight-lifting, it made me wonder if some of the things could apply to labor. Since labor typically takes many hours, perhaps even more than 24 hours in some cases (I’ve even heard of labors taking several days), it would definitely qualify as an athletic event. This article makes me wonder how much of the pain of labor, and the length of labor, and labor dysfunction and dystocia, can actually be traced to nutritional deficiency (since it implicates low calcium or vitamin E intake in some causes of cramps and lactic acid build-up).
This article was also interesting in that it says that lactic acid is made by breaking down glucose, and is used as fuel by the muscles; and when athletes train in brief intense spurts before their competitions, they increase their ability to burn lactic acid as fuel. Braxton Hicks contractions, anyone?
And then there is this article, which has the following quote:
Lactic acid does not cause that dreaded burning sensation during intense exercise. Lactic acid is formed from the breakdown of glucose, our body’s main source of carbohydrate. When made, it’s split into a lactate ion (lactate) and a hydrogen ion. The hydrogen ion is the bad guy–the acid in lactic acid that interferes with electrical signals in nerve and muscle tissue. When the rate of lactic acid entry into the blood exceeds our ability to control it effectively, then those pesky hydrogen ions begin to lower the pH of muscle. This invariably interferes with how the muscles contract and thus our ability to perform. [emphasis added]
So this makes me think that glucose is burned as the first muscle fuel, and lactic acid is secondary. The more efficient your muscles are at burning lactic acid the better, because if too much lactic acid builds up then it lowers the pH of muscle, and causes problems with contractions. Or perhaps this hypothesis is wrong, and that high levels of lactic acid simply indicate that your muscles can’t use it quickly enough, so it’s running out of fuel. Your uterus is a muscle, and it needs to be able to efficiently contract in order for your cervix to dilate, and then to push your baby out.
This leads me to an article in the current Runner’s World magazine (March 2008), about world-record holder Paula Radcliffe. This article talks about her pregnancy, baby and birth as part of a larger discussion of the British runner’s life and running career. As a birth junkie, the birth part is what I’m most interested in. She was induced because she was more than a week overdue–no reason other than she went past a magic date on a calendar. Although she ended up having a vaginal birth, inductions are much more likely to fail (and then necessitate a C-section) in first-time moms. She did, however, have an extremely long and painful labor, which is also pretty typical of inducing a first-time mom–in her case, 24 hours of Pitocin-induced contractions, which most women will say is harder than normal labor. Here is a quote from the magazine article:
There were the 14 hours sitting immobile and cross-legged, under orders not to get up; there was the raging thirst she wasn’t permitted to quench because they told her she might eventually need a cesarean and therefore could have nil by mouth, as doctors say. (‘They said, “Imagine that this is a marathon and so you can’t have anything to drink!” I said, “Actually, in a marathon you can start drinking at five kilometers.” They said, “You can wet a flannel, and we’ll squeeze it into your mouth.”‘)
[As an aside, just from the scanty information provided in this article, the following things in Ms. Radcliffe’s labor went against the World Health Organization’s “Safe Motherhood” guidelines: Of “Practices which are Demonstrably Useful and Should be Encouraged,” she did not have #4. Offering oral fluids during labour and delivery, or #15. Freedom in position and movement throughout labour; of “Practices for which Insufficient Evidence Exists to Support a Clear Recommendation and which Should be Used with Caution while Further Research Clarifies the Issue,” she had #3. Fundal pressure during labour; of “Practices which are Frequently Used Inappropriately,” she had #1.Restriction of food and fluids during labour, #3. Pain control by epidural analgesia, #7. Oxytocin augmentation, and #12. Operative delivery (vacuum assistance). While I do not blame her for getting an epidural (after many, many long hours of Pitocin-induced contractions, without being able to move from the bed), that probably made vacuum assistance necessary. “[T]hings culminated in a wild finale with two nurses pushing on her belly and a suction device on Isla’s head and the doctor bracing one foot against the delivery table in order to yank full strength.”]
In Henci Goer’s book, The Thinking Woman’s Guide to a Better Birth, she discusses IVs in labor (usually a glucose solution) being used instead of the woman being allowed to eat and drink as she wishes. On page 77 she says, “IVs are problematic by nature. Hunger and thirst and our natural responses to them invoke complex balances in both mother and unborn child. These balances are disrupted when they are bypassed by dumping huge amounts of fluids, often over a short period of time, directly into the bloodstream.” Then on page 79 is this, “Dehydration and starvation are associated with longer labors, increased use of oxytocin (trade name: Pitocin or “Pit”) to stimulate stronger contractions, and instrumental delivery. In addition, during pregnancy, starvation causes a faster, sharper drop-off in blood sugar levels and an earlier switch to metabolizing body fat. Vigorous exercise–in this case, labor–accelerates this process.” Then on page 80 is the following, “Glucose-containing IV fluids, also called ‘dextrose’ IVs, can raise maternal and fetal blood glucose levels to diabetic levels (hyperglycemia). Hyperglycemia in the baby increases the production of lactic acid, a metabolic by-product when there is insufficient oxygen.”
So how does this all work together? Here is my summary: Lactic acid is indicative of muscle fatigue (even if it’s not a cause or effect). To analogize, glucose is cash in your pocket that your muscles “spend” in order to work; lactic acid is “money in the bank.” Your body automatically converts glucose to lactic acid, so dumping too much glucose in your system at once (such as with an IV) can be counter-productive because the glucose is too-quickly converted into lactic acid (the “cash” is automatically deposited into your “savings account”); while the body’s normal digestive system allows you to take in a large amount of food and slowly converts it into “cash.” If you run out of glucose (easily expendable cash), then you must do the harder work of getting energy from lactic acid (taking a trip to the bank, waiting in line….). If you run out of cash at the grocery store, it doesn’t matter if you have a million bucks in a money market account–you still can’t buy your groceries because you have no cash in your pocket. Your body can increase the efficiency at which it burns lactic acid, but this takes time and training, neither of which is available in labor. (It’s possible that Braxton Hicks contractions leading up to labor are making the muscle of the uterus become more efficient at burning lactic acid–but this is just my hypothesis.) If your body is not very efficient at “spending” lactic acid, then the overload of lactic acid may make your uterus contract less efficiently–either due to the overload itself, or the fact that your muscles can’t efficiently “spend” the lactic acid, so you’re standing in line at the bank too long, trying to “liquidate your assets,” as it were. Marathon runners (or any athletes, for that matter) speak of hitting “the wall” when they simply can’t go any further. One of the articles I read says that the body has only so much possible reserves of calories to spend, and loading up on carbs before the event can help you overcome “the wall”; but food and drink during competition are necessary, too. As the world-record holder Paula Radcliffe said, “You get to drink at the 5-K mark!” Expert runners can complete a marathon in a few hours, average runners take several hours to complete. Volunteers line the race path with food and drink for the runners to have if they need it. This “quick energy” is enough to keep them going. When women are forbidden to eat or drink during labor, it seems like there is a time when the uterus hits “the wall” and simply can’t keep working under such adverse conditions. (Could you walk, run, or bike for hours without anything to eat or drink? Would that even be considered healthy? Is fasting a good thing for your baby?) Glucose IVs can help, but they can be “too much of a good thing” in a lot of ways, including the too-quick conversion of glucose (which your body is best at burning) into lactic acid (which your uterus is not as used to using). Artificial stimulation of the uterus through Pitocin can force it to contract and may prevent a C-section from being necessary, but this is not always the case.
A better way to avoid uterus fatigue is what midwives have always known and what women have always done (prior to about a century ago, when they started going into hospitals)–eat if you’re hungry, and drink if you’re thirsty.
Filed under: birth choices, C-section, eating and drinking in labor, induction | Tagged: braxton hicks, childbirth, contractions, health, home birth, hospital birth, IV, labor, labor and birth, lactic acid, marathon, muscle, muscle fatigue, paula radcliffe, pregnancy, runner's world | 3 Comments »
It’s interesting to see what the search terms people use to find your website or blog. The latest was, “does blood come out when you give birth?” Short answer: yes.
As always, this is not medical advice; and any bleeding should be discussed with a healthcare professional.
Leading up to labor, many women have a tinge of pink discharge occasionally. This is usually from the dilation or possibly effacement of the cervix. Occasionally it may be from other causes–a friend had this due to a yeast infection that irritated a spot on her cervix. She was of course concerned that she was spotting, but it ended up being not a concern. Any bright-red bleeding is a cause for concern.
When the baby is born, there will likely be some blood on the baby. If the woman has an episiotomy (a cut at the vaginal opening), then she will definitely bleed. Most women do not need an episiotomy, although some will tear. Most tears will be smaller and less damaging than an episiotomy, and most tears extending into the rectum are caused by an episiotomy. How much blood is on the baby depends on how much the woman bleeds when she gives birth.
My first birth was in the water, so the baby had his first bath at his birth, and he didn’t have any blood on him, although I did tear. My second birth was “on land” and there was minimal blood on the baby. The tears were minor “skid marks” not requiring any stitches at all.
After the baby is born, the placenta sheers away from the wall of the uterus, and the blood vessels that supplied the placenta begin to bleed (my second midwife called “the placental gush”). The uterus begins to contract, clamping down on the site where the placenta attached, minimizing the blood flow. If the uterus doesn’t contract enough, the woman may bleed too much and hemorrhage. While postpartum hemorrhage is a major cause of maternal death in the developing world, this is rarely a problem in the U.S.
Anything over 200-250 ml of blood loss (about 2 cups) is considered a maternal hemorrhage for a vaginal birth; the average blood loss for a C-section is about 500 ml. When women are pregnant, their blood volume increases by half, so a large amount of blood loss is not as traumatic as might otherwise be. Most midwives carry Pitocin to home-births, which when administered after the baby is born can stop a hemorrhage. Occasionally, a woman must transfer to the hospital for help, including potential transfusions (extremely rare). It is standard procedures in many hospitals to give a shot of Pitocin to the mom as soon as the baby’s shoulders are born, but according to the WHO guidelines for Safe Motherhood, this can increase the possibility of retained placenta, and have other adverse maternal reactions, so they do not recommend it as a matter of course.
With my first birth, I had postpartum hemorrhage, and my midwife gave me a shot of Pitocin in the thigh. I was quite weak afterwards (a few days later, I couldn’t walk more than a few blocks at a time). I’ve had problems with anemia, and try to remember to take iron fairly regularly. When I have tried to give blood, I was denied one time for low iron, and another time just barely made the cut. This latter time, I couldn’t do anything after giving blood because I was so tired. When I was pregnant with my second baby, I was more diligent to keep my iron intake up, as well as eating foods high in vitamin K (a natural blood-clotting substance). Anecdotally, I will say that these things helped me avoid excess blood loss in my second birth.
After the birth, the uterus begins shedding its very rich lining that sustained the pregnancy (this occurs regardless of whether you had a vaginal birth or a C-section). While the amount of time varies, it usually takes a couple of weeks to lose the lochia (as it is called). At first, it is red and heavy, like the blood of a period, and gradually lightens up until it is gone. Any recurrence of heavier bleeding or redder color indicate that you have probably done too much, and need to rest more.
I haven’t posted on my blog about this topic (ACOG’s support of elective C-section, but opposition to home-birth), although I did post something to the Independent Childbirth Educators’ blog. But I came across this short article written by Amy Haas which expresses so well and succinctly the problem, that I asked her permission to post it on my blog. In addition to the well-written post, she provides a plethora of studies so that others can look up and verify what she says. I have noticed a trend among doctors (especially obstetricians) to have an attitude of “trust me, I know what’s best.” This is what I like about being a childbirth educator–finding out the facts for sure, and not just relying on anyone’s opinion. I’ve found that sometimes there is a great difference between what people say and what the research actually shows. Enjoy!
From Amy V. Haas, BCCE:
Trendy Birth: An Odd Dichotomy
Recently the American College of Obstetricians and Gynecologists (ACOG) released a statement against homebirth, calling it, among other things, a dangerous popular trend in modern times. Oddly enough the latest trend in birth truly isn’t homebirth (an occurrence that has existed since the beginning of time) but elective cesareans, or Too Posh to Push, as the media has dubbed it. A few years ago ACOG released a statement about elective cesareans, acknowledging the serious risks to choosing major abdominal surgery for birth, but stated that it was a choice that should be left up to the doctor and his patient.
When I started looking into existing research on both issues I was quite fascinated to note that, contrary to ACOG’s opinion, there was quite a bit of good research showing the safety of homebirth. In fact the one study used as the reason to restrict homebirth was actually flawed to the point of uselessness, due to, among other things, poor controls. Other than that one flawed study, used as the basis for ACOG’s opinion, I could find no other studies that showed homebirth to be riskier than hospital birth for low risk women. In addition to the latest large study on homebirth published in the British Medical Journal in 2005, I also found over ten years worth pervious studies that showed the safety of homebirth for low risk women attended by Midwives.
Conversely one of the sad benefits of the latest trend toward elective cesareans is that we now have enough of a population to determine the pros and cons of an extreme choice like elective cesarean. The results show some very extreme negative risks that are punctuated by increases in maternal and infant mortality.
So why, if there is this laundry list of serious risks to elective cesarean, but no real studies showing serious risks for low risk moms having homebirth, is ACOG coming out full force against homebirth, but not against elective cesarean? Very strange, and very scary.
(References available upon request)
American College of Obstetricians and Gynecologists, News Release, February 6, 2008, ACOG statement on homebirths; Office of communications, firstname.lastname@example.org 201-484-3321.
American College of Obstetricians and Gynecologists (ACOG). (2000). Planning your pregnancy and birth. Washington , DC : ACOG.
Bernstein, P. S.; “Elective Cesarean Section: An Acceptable Alternative to Vaginal Delivery?” Field Notes in Obstetrics and Maternal-Fetal Medicine
Medscape Ob/Gyn & Women’s Health 7(2), 2002
Citizens for Midwifery; “Out-Of- Hospital Midwifery care: Much Lower Rates of Cesarean sections for Low Risk Women”.; www.cfmidwifery.org/pdf/cesarean2.pdf
Johnson, KC; Daviss, BA; “Outcomes of planned homebirths with certified professional midwives: large prospective study in North America ”; British Medical Journal,; 330:1416; 2005.
Johanson R, et al; “Has the medicalization of childbirth gone too far?” British Medical Journal 324:892-895 (April 2002)
Kolas, T. , et. al, , “Neonatal Outcomes Worse With Planned Cesarean Than Planned Vaginal Deliveries” Innlandet Hospital Trust, Lillehammer , Norway, Am J Obstet Gynecol 2006;195:1538-1543
MacDorman MF, et al; “Infant and neonatal mortality for primary cesarean and vaginal births to women with “no indicated risk,” United States, 1998-2001 birth cohorts, Division of Vital Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland 20782, USA. PMID: 16948717
Martin J., et al ; , “Births: Final Data for 2004”; National Vital Statistics Report; Center for Disease Control Volume 55 # 1, September 29th, 2006, http://www.cdc.gov/nchs/data/nvs…5/ nvsr55_01.pdf
Pang, JWY, et al; “Outcomes of Planned Home Births in Washington State ” Obstetrics and Gynecology Volume100:#2;253-259 (August 2002)
Schlenska, P F; “Safety of Alternative Approaches To Childbirth” Doctoral Dissertation; Stanford University , California , www.vbfree.org/docs/meadsum.html.
Weaver, J. J., Statham, H., & Richards, M. (2007). ” Are there “unnecessary” cesarean sections? Perceptions of women and obstetricians about cesarean sections for nonclinical indications.” Birth, 34(1), 32-41.
Weigers, TA, et al; “Outcome of planned home and planned hospital births in low risk pregnancies: prospective study in midwifery practices in Netherlands ” British Medical Journal 313: 1309-1313 ( November 1996)
“For Low-Risk Women, Risk of Death May Be Higher for Babies Delivered by Cesarean”, Birth: Issues in Perinatal Care. Black Well Publishing, August 29, 2006; email@example.com.
Amy V. Haas©2008
“I agree completely with the excellent article by Amy Haas on the ACOG position on home birth and on elective C section. The simple explanation for both these ACOG positions is the same—MONEY. ACOG is against home birth because it takes clients away from them and they are in favor of elective C section because they get more money with C section than with a vaginal birth “ Marsden Wagner , MD (Former head of the committee on maternal child health for the World Health Organization) 2/14/08
Filed under: birth choices, C-section, labor and birth | Tagged: baby, C-section, cesarean, childbirth education, elective C-section, health, home birth, hospital birth, labor, pregnancy | 1 Comment »