Cytotec Adverse Event Site

Zorah Oden, mother of Tatia Oden French, has launched a new website for Cytotec awareness, with an email address for anyone to send stories of adverse events from the use of this drug. Tatia and her baby lost their lives when she was induced with Cytotec (without being told anything about the drug), and she suffered an amniotic fluid embolism. Cytotec (miso, misoprostol) is not FDA-approved for this use — nor indeed for any use in pregnancy or inducing labor. Among warnings on the package insert is that it may cause uterine rupture, the need for a hysterectomy, or even the death of the mother or baby.

While some people look favorably upon Cytotec for inductions, I am not one of them — it doesn’t seem to have been tested enough, despite what its supporters say. The risks seem just too great. But to each her own — as long as the woman has been given full information, and been made to understand the risks of this drug, as well as any possible options – if she chooses to take it then, that’s one thing; but many women are not told anything about the drug, including known adverse events.

There are some possible obstetric-related uses for this drug which definitely hold more benefit than risk. Once the baby has been born, the risk of uterine rupture or danger to the baby is nonexistent, so even if it doesn’t work well (and it doesn’t always work — few medications work every time, and I’ve heard numerous stories of miso having little or no effect on, say, postpartum hemorrhage), the risks are minimal. When used for evacuation of the uterus in the case of a miscarriage (i.e., in early pregnancy), the risk of uterine rupture is much lower than in later pregnancy, the baby has already died so there is no risk to him or her, and the risks of alternate options may be worse than the risk of uterine rupture (for instance, the increased risk of infection with retained products of conception, or the risk of infertility from a D&C).

Cytotec is one of those odd drugs which can cause or relieve the same problem. For instance, it may cause retained placenta when given to induce labor; but when given after the baby has been born, may induce the birth of the placenta, instead of having to resort to harsher measures. When given prior to birth, it may lead to postpartum hemorrhage; but it can also cure PPH if given after the birth of the baby. To be perfectly honest, the fact that it can do this bothers me quite a bit — I wonder if the pharmacists, doctors, and other people involved in this medication even understand how it works, and how it can have this “split personality” as it were. There are several other drugs used in gynecology that do this, so it may just be an oddity of the female body and female hormones… but I still don’t like it.

You can click on the tag “cytotec” over in the right-hand side bar to see other posts that talk about this drug. And if you know of an adverse event due to Cytotec (miso, misoprostol), please email it to Zorah French at the email address provided on the website.

One woman suffered a uterine rupture, although she had absolutely no risk factors for it — hadn’t had a uterine surgery, not even any fibroids. When she investigated, on her own, what could have made her uterus rupture without any warning or risk, she came across something that finally mentioned that Cytotec had that possible risk.

Amniotic fluid embolism can happen without drugs; but it is a known risk of Cytotec. It is typically deadly to both mother and baby, although some have survived it.

Uterine hyperstimulation can cause a uterine rupture, which can kill the baby and many times necessitates a hysterectomy to save the life of the mother. This can happen even with an unscarred uterus, but is more common in women who have had uterine surgeries, including C-sections.

Doctors are not required to report adverse events, so the rate and number of “official” adverse events is woefully inadequate (not just this pill, but for other medications as well, including vaccines). It is up to us to report them to each other and to educate each other. They may not be official — just “anecdotal” — but that doesn’t mean they didn’t happen. A common refrain of the stories currently on the Cytotec Adverse Event Site is that of women thinking that what happened to them or their babies was “just one of those things”. It wasn’t for weeks or months afterwards, when they got to the point in their grief and recovery that they had a need to know the details surrounding the loss of baby, uterus, or both, that they investigated and found that they had been given Cytotec. Or, perhaps they knew they had been given it, but didn’t know the adverse events, until they themselves became a statistic.

R – E – S – P – E – C – T

It’s more than the name to a catchy tune. In real life, it matters quite a bit. Unfortunately, so many people just don’t get it. That’s not an intentional pun, although it could be a play on words: many people don’t understand that despite their education and training and knowledge, they still need to treat others with respect; and many people do not get the respect they deserve.

Let me give you an example.

My sister had an abnormal Pap. A nurse at her gynecologist’s office said she had to have a certain procedure — no ifs, ands, or buts — no other options. My sister fired her gynecologist — the doctor who had attended the births of her last two children — because of this basic lack of respect. She went to her family doctor (who had had training in obstetrics and gynecology, but practices family medicine because it is less hazardous to his malpractice insurance costs), and while he came to the same conclusion, he did it in a different, more respectful way. Had the gynecologist’s office practiced this way, she would have remained with him. The family doctor explained the reasons why she had to have this procedure — what it did, why there really was no other procedure for an alternative, etc., etc. Since she felt she had full information, she had no problem with submitting to this necessary procedure. She accepted it from a doctor who was respectful of her, but refused it from someone who just expected her to be a good little girl and follow orders without question.

Inductees in basic training learn how to follow orders without question. They learn how to be subordinate; to do as told. They are dressed uniformly, as a part of the “breaking down” process in order to act uniformly. While these actions and this behavior are perfectly suited for the military (their lives, and the lives of their comrades may be lost by hesitating at a command given by a superior), is that what birthing women are supposed to act like? Allowing the doctors and nurses to think for them? Never to question the opinion of the medical establishment?

I was made to think along these lines, not simply because of my sister’s experience, but because of a recent commenter’s story. She had had a miscarriage, and the doctor told her she had retained products of conception, and the only choice she had was for an emergency D&C. She ended up with Asherman’s Syndrome, and impaired fertility. She asked about alternatives (including medications) and was told her only choice was a D&C. She tried to get a second opinion, but no gynecologists would make time for her, saying the earliest appointment was some months future. Although she didn’t want to have the surgery in which the walls of her uterus would be scraped with a knife — wanted to miscarry naturally or take a pill to complete the miscarriage — she was given no alternative, so submitted to the D&C, which took away her ability to have a child. She was not told of that possibility at the time of the operation.

Why did the doctor treat her like that? Although I haven’t read a whole lot about miscarriages, use of medications (such as misoprostol or mifepristone) to complete a miscarriage, D&Cs, etc., I read up on the subject while discussing it with this woman. Apparently, misoprostol is most effective (with the least side effects) in the first two months of pregnancy; and the further along in pregnancy a woman is, the less effective it is. It’s possible that her doctor took it upon himself to decide that in her case, the medication would not work, and she would end up needing a D&C anyway, so issued an edict that she just have it. But that wasn’t his call to make — it was hers! It was her uterus, which ended up being scarred! It was her body, not his, which cannot now bear children (unless surgery to remove the adhesions is successful in her case).

Although I may have some of the particulars wrong — I’m not a gynecologist, and as I said, only have passing knowledge in this area — this is what I envision could have happened, had her doctor been respectful: “Mrs. Smith, I regret to tell you that your baby has died. From the ultrasound, it looks as if the baby stopped growing a few weeks ago. We can wait, to see if you will miscarry naturally, but the risk of infection goes up the longer it takes for the pregnancy to pass. You can take these pills, which may induce a miscarriage, but at your stage of pregnancy, there is a slight risk of uterine rupture, and the pills may not work. I’m recommending a D&C — a procedure in which we artificially dilate the cervix and scrape the walls of the uterus with a curved knife, to remove all of the products of conception. The risks of this procedure include [fill in the blank, including telling her about Asherman’s syndrome, and the risk of infertility]. The longer the time from fetal demise until we do the D&C, the more likely you are to get Asherman’s syndrome. Since the pills may not work, and you may not miscarry naturally, I’d like to do a D&C, so that we can reduce both the risks of infection and of having to do the D&C at a later date.”

I’m not suggesting that D&C is the way to go, by any means! In fact, I rather suspect that D&Cs are much overused, just like C-sections, episiotomies, and hysterectomies. These are old, well-established procedures, and many doctors are trained to use them as the first resort, or as a sort of cure-all. Any female problem can be solved by removing the uterus, right?, so why not just take it out at the first sign of trouble? Except that a hysterectomy is not easy on a woman — the surgery takes weeks of recovery, and the sudden removal of the female organs plunges a woman overnight into full-blown menopause. (The term “hysterical” is derived from “hysterectomy”, to describe women who had undergone that procedure and had periods of apparent uncontrollable emotions.) Nor does a hysterectomy solve all female problems: by removing the uterus the source of one problem may end, only to have the lack thereof lead to other problems. There is disagreement and ignorance about the full roles that female hormones play — every year it seems that some new study is released with a flourish proving the benefits of hormone replacement therapy, only to be contradicted the next year by a study showing that HRT leads to this or that risk — the risk of one cancer may be reduced, only to have the risk of another cancer increased, for instance; or the risk of some already rare cancer is reduced but the risk of osteoporosis is greatly increased.

With all the confusion and uncertainty, it is all the more important for women to be given full knowledge of all the known risks and benefits of all courses of treatment, and not just the doctor’s favorite treatment, or what is most commonly done. What might be right for one woman may not be right for another. It’s your body; know your options; demand respect.

Off-label uses of medication

Here is a recent article from the AP entitled “FDA faulted over unapproved uses of medications.” The upshot of the article is that drug companies are only allowed to market their drugs to doctors for the express purpose of the medication. When pharmaceutical companies get a new drug, they send it through trials to make sure it’s better than nothing (a placebo) and/or as good as or better than another drug, without causing excess problems. You may not know this, but the medication in Viagra was intended for use as a blood pressure medication. Many of the human test subjects discovered that when they took sildenafil citrate, that they were able to have sex, although they had been impotent. The manufacturers quickly realized that it would be much more profitable to have the drug be used for that purpose than for reducing blood pressure, so they sent it through trials for the approved usage of treating erectile dysfunction. More frequently, though, it is after a drug is put on the market, that somebody will discover additional uses for it.

As the AP article put it,

“Although widely accepted, off-label prescribing can amount to an uncontrolled experiment. While some patients benefit, others get drugs that do not do them much good and end up wasting their money. Some people have been harmed by unexpected side effects.”

I am not against all off-label uses of drugs; but I do think that patients need to be told that the doctor is prescribing and/or using this medication in a way that is not FDA-approved; or perhaps it could be phrased that the drug “hasn’t gone through trials for this indication, although a lot of people have gotten benefit from it, and I think you might too.” The problem arises when a person takes such a medication off-label, and is harmed instead of helped. As long as the person has been given full information and allowed to make the choice himself, then that is one thing; but when the person has essentially just been told, “Do as you’re told,” or even lied to about the benefit of the drug (because the drug rep may exaggerate the claims of the drug, or minimize the known risks), then that is another, because it is the patient who runs all the risks should the medication not work or indeed if it should harm him.

I remember when Vioxx and all the other cox-2 inhibitors came out — everybody and his brother was on them for arthritis or any other kind of pain. Doctors were eager to prescribe them to anyone with arthritis pain (even if ibuprofen or other NSAIDs worked just fine. Some people said the new drugs were better; most said they were about the same; other said they were worse. The new drugs were a lot more expensive than the generics, that’s for sure! And they simply didn’t have the safety record of drugs like ibuprofen that has been around for so many years. Consequently, the “rare but serious side effects” simply could not be known, until people started having problems.

Sometimes pregnant women need medications. I would suggest having a long talk with your doctor and pharmacist about how long the drug has been on the market, and what alternatives may exist, and the safety data for pregnant women and their babies for this and other drugs. There are drugs that have been around for decades — long enough for any major deleterious effects to be known in the fetal population. They may not be “safe” as in “never causing any problems whatsoever”; but their safety data is well-established. Newer drugs simply cannot have that. They may not be any worse than long-established drugs, and may in fact be safer; but for myself, if I had to have a drug, I’d go with the older drugs and the lowest dosages I could.

Finally, here is a link which talks about pharmaceutical drugs in labor and birth. Many drugs used in labor and birth are used off-label. Some drugs, such as Pitocin (oxytocin), are labeled only for medically-indicated inductions, but not for elective inductions; yet they are used for elective inductions every day. Drugs have risks and side effects. When there is a medical reason for the baby to be born (whether to benefit the mother or child or both), then the risks of continuing the pregnancy outweigh the risks of the drugs. But when there is no such medical reason, then there is only risk.

Home birth stats

This is just a “still thinking about my last post on neonatal mortality, and wanted to write some more” post.

I’ve tried to remember, and I can think of 23 home births among women I know personally, excluding myself (this doesn’t include those I know by email, but just those I’ve actually been in the same room with). I could be mistaken, because I’m not 100% certain that all of the births took place at home, and there may be some I’m forgetting, but it’s approximately right. All of these births were without incident. Two women had all five of their children at home; several women had their 5th and 6th children at home; one woman had her 11th and 12th children at home; and a few other women had children of various birth orders. Of these 23 births, there were 2 neonatal deaths. Of all the other women in my acquaintance (which would include dozens of women and probably hundreds of births), I know of only one other neonatal death, and it was a hospital birth. So does home birth have a 2/23 death rate while hospital birth has 1/200+? Not exactly.

The one hospital-born neonatal death was to a woman I struck up an acquaintance with years ago, and only knew of her pregnancy and subsequent loss, and could not ask for particulars. I don’t know if there was any inkling leading up to the baby’s birth that something may have been wrong, but just an hour or two after her birth, she was observed having seizures, and was diagnosed as having had a stroke. There was nothing they could do, and she died within a day or two of her birth. Did birth practices have anything to do with that? Possibly — perhaps the mother was given some medication that caused a problem with the fetal brain. For instance, if she was given something to induce or augment her labor that caused the uterus to become hyperstimulated, producing overly long or overly strong contractions, it could interfere with the placental blood supply and fetal oxygen, and perhaps lead to a stroke. Perhaps a vacuum was used to get the baby out and traumatized the brain. I don’t know the particulars of the birth, so it’s possible she had a completely intervention-free birth, and the stroke was completely unrelated to the birth, but “just one of those things” that happened even prior to the onset of labor.

The first neonatal death in the home-birth group was the 11th-born child I mentioned earlier. She had multiple congenital anomalies, and died within a few days. Her oldest sister was a CNM and attended her birth as well as the birth of the couple’s 12th and final child. This death statistically goes against home-birth and goes against CNM-attended home birth, although if you know the particulars, you can see that place of birth had nothing to do with anything. Her parents sought care, of course, with the hospital, but there was just too much wrong with baby Mary.

The second neonatal death was one of the 5th-born children. I am particularly acquainted with this case because I was friends with the baby’s oldest sister, was there within a few days of his birth, and thought something just didn’t seem right. I was in my teens, and had been taking care of another baby for several months, from the time he was two weeks old, and I remember thinking that something was wrong. At first, I passed it off to the baby’s odd color — he had jaundice; but I remember thinking his breathing seemed not right — that it was labored, almost, and shallow. I remember his nostrils flaring out, but thought maybe it was just his nose shape. A week later, after I had already gone home, his parents knew something wasn’t right and took him to the doctor. He discovered a heart problem, and they went to a pediatric cardiologist for more detailed tests. The baby’s heart hadn’t developed correctly — I forget the exact problem, but the doctor said that without an operation, the baby would definitely die within 6-8 weeks, that an operation might help him to live, but he had only a 50/50 chance of surviving the surgery. They had to drive several hours to go to LeBonheur, which is the pediatric hospital in Memphis, where my heart surgeries took place, in order to have the surgery. He didn’t survive it. He was three weeks old.

So, it’s important to know the particulars of cases before making judgments. It might appear from bare data that these two home-born babies might have survived had they been born in the hospital — that perhaps if they had had immediate care — been rushed from the womb to the NICU or OR — they might have survived. But that is simply not the case. In fact, had the second baby been operated on immediately, he probably would have died immediately.

As an aside, his parents were vacillating about whether they should circumcise him. It was the man’s first son, although the woman had a son from a previous marriage who had been circumcised. Finally, they decided to circumcise him, but to wait until the baby’s 8th day, just like in the Old Testament (the father was a preacher, and said that there must be some reason for God to have said that, so if they were going to circumcise, it would be on the day God said to circumcise). The baby was diagnosed before his 8th day, so was not circumcised. The heart doctor said that it was a good thing he hadn’t been circumcised, because the shock might have killed him.

A closer look…

Previously, I had written this post about the CDC statistics for neonatal and infant mortality for the years 2003-2004. It included a link to the online searchable query, so you can do the computations and searches yourself.

Now, I’d like to take a closer look at them. This is partly because of the ensuing comment-debate on “Who’s Catching Your Baby?” at the RHRealityCheck blog. It is quite an interesting discussion, which was, of course, started by the ubiquitous Dr. Amy Tuteur (does that woman never sleep?? It seems like whenever there’s a homebirth discussion anywhere, she’s one of the first commenters; in addition to quickly responding to or deleting comments I’ve posted on her blog as late as midnight or as early as 6 a.m. Maybe she’s a clone…) Anyway, now that the CDC stats are able to be queried online, she’s been able to go from beating the dead horse of the Johnson & Daviss 2000 CPM study to riding the 2003-2004 stats to death. In a comment on July 21, she says that the CDC data, “shows that homebirth with a DEM is the most dangerous form of planned birth in the US!” She follows it up with a triumphant table with the following death-rates per 1,000 live births: CNM — 0.37, MD — 0.61, “other midwife”– 1.15.

And she says there’s nothing to “interpret” but there is. (I encourage you to read several of the rebuttal comments, and preferably all of them, because there is some extremely important information given in them.) Let’s take a closer look at these numbers which ostensibly show that homebirth with a DEM has a threefold death-rate over women in a similar risk category (hospital birth with a CNM).

First, I want to point out that there may be some “bad apples” in every profession, including obstetrics and midwifery. The laws on midwifery vary from state to state. About half of the states have legalized non-nurse midwives, some states have them declared illegal, and other states don’t have laws one way or the other. Mississippi is one such state. I could be wrong, but I believe that it would not be illegal for me in my state to start calling myself a midwife and start attending births. My qualifications? None. I’ve given birth twice in my home and I’ve read a lot of books and other information. While most of the time nothing would go wrong, if it ever did, I would be completely unequipped to handle anything. Yet in compiling statistics, my incompetence would be grouped in together with competent non-nurse midwives, skewing the statistics and giving the whole profession a black eye.

A brief aside — midwives can be grouped into two broad groups: certified nurse midwives (CNMs) and non-nurse midwives, also known as direct-entry midwives, since they bypass nursing school and enter midwifery directly. Of these non-nurse midwives, some are certified and some are not. Not being certified does not necessarily mean that one is not qualified or competent; but certification does show that one has passed a certain rigorous education. Some states have much stricter regulations than others on who midwives can have as clients — women with certain previous or current obstetrical histories “risk out” and must seek care from an obstetrician. While some of these restrictions are debatable, many are just plain common sense, and even in unregulated states, many midwives will not take such clients — for their own good and for the sake of their babies. But some might. So there may be some high-risk births in the “other midwife” set as compared to the CNM set. Dr. Amy would like to pretend that the home-birth group is homogeneous and uniform, but it may not be — I’ve heard enough anecdotal accounts of riskier women giving birth at home to verify it. I’ve also heard several accounts of midwives who resisted a transfer when she should have transferred; and others when the midwife strongly urged the woman to transfer and she refused to go to the hospital — sometimes with deadly results. Whether this changes the statistics or not, or whether it is “significant” or not, is for someone else to determine.

Now onto the numbers.

In the above “Oh, my goodness, homebirth kills three times as many babies as CNM-attended hospital birth!!” scare, Dr. Amy has made a few correct restrictions of data.

The first was maternal age, which is restricted to the low-risk 20-44 year old sets. Also, for some reason, the majority of women who give birth at home are white. (I just ran a query for all births attended by “other midwife” — regardless of cause of death, length of gestation, age of mother, etc. — it was as broad as I could make it — and found that 93% of women who gave birth with “other midwife” as the birth attendant were white, while CNMs and MDs had 79%. Since there is a recognized difference in birth outcome based on race — although we may question and debate the reasons — it is correct to look at just white births, to more closely approximate the groups.

She also limited it to 37+ weeks of gestation and 2500+ grams of birthweight. Since it is known that babies born pre-term or low-birthweight fare worse, this is a logical step to take. I would like, however, to see a study which takes women of equal risk at the beginning of pregnancy, and see how they fare when comparing midwives to doctors — in other words, do midwives do a better job at keeping women pregnant until term, and having normal-weight babies? This is only a tangential discussion of neonatal mortality; but babies do better when they’re born at term and at a healthy weight. If midwives do a better job at keeping babies healthily on the inside until they’re ready to be born, then that is significant. There was a recent article I blogged about, which talked about “the worrisome rise in underweight babies,” and included the fact that many doctors are contributing to this by inducing or giving women C-sections before they reach term. If doctors are contributing to the neonatal death toll by inducing or sectioning women before they reach 37 weeks, or if these babies are born weighing less than 2500 grams, then that simply won’t show up when doing a CDC query of babies born at 37+ weeks and 2500+ grams. Now, obviously, there are many reasons why some babies should be born preterm, so I’m not advocating for refusing to do inductions or C-sections when it’s obvious that babies would do better on the outside, but I’m talking about when they are done for non-medical or quasi-medical reasons. I’m also talking about the possibility that fewer women end up with these medical concerns if they choose midwifery care. But of course, to look at this, would require a study which looks at women at the start of a pregnancy, matching women in as many characteristics as possible, to ensure a “matched cohort” for doctors and midwives. It would be interesting to find, for instance, that the rate of preeclampsia was 1% in the midwife group while 5% in the doctor group, even though the women had identical risk characteristics at the beginning of the pregnancy.

I do have a word more about the “37+ weeks of gestation.” You will find when you go to the CDC query that the gestational ages are broken down into several groups, including “37-39,” “40,” “41,” and “42 weeks and above.” Term is generally considered to be 37-42 weeks, and most women will naturally give birth at some point in that time. Obviously, there will be preterm births, but generally if a woman makes it to term, she will give birth before the end of 42 weeks. Only about 10% of women, will naturally go longer; in 95% of these cases, without a problem. However, placentas will not last forever, and in some cases, their function decreases so that babies are put at risk, due to the lack of blood flow — primarily oxygen, but possibly also nutrition. Some have suggested that part of the reason for going into labor is some mother-baby signal that the baby has outgrown the placental supply and needs to be born. Brief labor lesson — when the uterus contracts to dilate the cervix, no blood exchanges between the mother and fetus — the baby lives off of the oxygen currently in the placenta. If the oxygen level is already low or failing, then the baby could suffer. Consequently, many midwives will automatically transfer care (either from their own protocols or because of legislation) to doctors, because the woman is no longer considered “low-risk.” Since all births from 42 weeks onward (and I’m unsure if that’s the start or the completion of 42 weeks of pregnancy) are categorized together, it’s possible that some of these births happened even at 44 or 46 weeks of pregnancy. But I would point out that there are 9 cases of babies dying from “extreme prematurity” in the 42+ weeks of pregnancy group, 2 of which supposedly weighed 500-749 gm! I think somebody made a clerical error, although it’s also possible for some babies to have been induced or sectioned due to being over-due when in fact they were premature (the remaining 7 babies’ births were all attended by MDs).

It’s a little difficult looking at mere birth and death certificate data to get a concrete understanding of what happened in these cases. In some cases, the cause of death may not be due to the place of birth at all, but rather due to outside causes (such as car wrecks), or would have happened regardless. Genetic defects and congenital abnormalities such as anencephaly and thanatorphic short stature have a near-100% neonatal death rate, regardless of care. Other defects and abnormalities may have a high survival rate, but it is still possible to be lethal — some terms comprehend a wide range of abnormalities, from mild to severe. Take Down Syndrome, for instance. Most of the time it is non-lethal, but sometimes the heart is so badly affected that the baby cannot survive. It is also possible that some women who choose to give birth at home will also refuse to go to the doctor for any reason, including religion, fear, or sheer willfulness. It is indeed possible for a midwife to attend such a woman, and urge her to take her baby to the doctor because something is wrong, but the mother will refuse. Such a death would go against the midwife in these statistics, even though she did everything right. Also, if a baby is kept alive by a hospital until the 28th day (just past the neonatal period), it will not count as neonatal mortality… but the baby will still be dead.

Looking at the “other midwife” statistics then for 2003-2004 — for white women age 20-44, at 37+ weeks of gestation, with birthweights of 2500 grams or more, there were 29 deaths out of 29,493 births, or 0.98/1000. (I’m not sure where Dr. Amy got 1.15 — if you can figure it out, let me know the exact criteria.) Taking a closer look at the 29 deaths, we see that 19 of them (those with a cause of death code starting with “Q”) were due to congenital malformations and genetic defects. Back when I was still commenting on her blog, I pointed that out in a discussion on the Johnson & Daviss homebirth study, and she said that you can’t take out these deaths because most such babies survive in the hospital. That may be true — it may be that babies with such defects (heart problems, for instance) may survive with immediate high-tech care or perhaps surgery. But what is definitely reality, is that many home-birthing women (such as myself) decline all prenatal testing including ultrasounds and amniocentesis, which help to identify many affected babies. This has a two-fold effect — first, if immediate care will help affected babies, then that might affect the death rate of babies with severe problems; and second, and more important, women who refuse all such testing will not have abortions, which means that more of these babies will be born. It is a fact that women who find out they have a baby with a genetic or congenital defect are counseled to abort. Some of them will have an abortion– even among those who are nominally pro-life. Women who do not know they are carrying an affected baby will not have a reason to consider an abortion; therefore, more home-birthing women will give birth to an affected baby — without regard to their stance on abortion. Also, some women who know they are carrying an affected baby may be more likely to have an abortion if the prenatal diagnosis is that the defects are severe, as opposed to mild. Women who do not know that their babies are affected — perhaps severely — will not seek an abortion, as opposed to a certain rate of women who do know; therefore home-birthing women will be more likely not only to have a baby with a genetic or congenital defect, but also to have a more severe case, one more likely to end in neonatal death.

Taking out those deaths, we are left with 10/29,493. Looking at these deaths, we see that 4 occur in the 42+ weeks (which I’m near-100% certain is a higher-risk group, for reasons stated above). Three were due to “birth asphyxia” while one was due to an unspecified “complication of labour and delivery.” Taking out these higher-risk births, there are 6 deaths out of 26,496 births, or 0.23/1000, which is identical to the CNM rate (taking out deaths due by accident or homicide).

It is tempting to restrict deaths to those due to infection; pregnancy, childbirth and the puerperium; “certain conditions originating in the perinatal period”; and symptoms, signs & abnormal lab & clinical findings. For instance, one of the babies died of “diaphragmatic hernia without obstruction” — was this due to his or her being born at home? Somehow I doubt it. But if a baby dies of lung problems which may have been exacerbated by having been born by C-section, then that ought to be counted. Yet, to be fair, we will look at just the above causes of death. After all, hospitals are where sick people go; it’s where MRSA resides. People get hospital-caused infections all the time, and sometimes babies die of them in the neonatal period. While that doesn’t necessarily mean that it was due to their births being attended by doctors or CNMs, they would not have been exposed to those infections at home. This takes out 2 deaths from the midwife-attended group (because it takes out the above hernia, as well as a case of pneumonia), lowering the death rate to 0.15/1000. The CNM rate becomes 0.21 and the doctor rate becomes 0.25/1000.

Anyway, this is just playing with the numbers — I’ve provided the links so you can satisfy your curiosity, if you are curious. If you would like to take the time to look at the causes of death for hundreds and thousands of babies, you can look at the specifics of CNM- and doctor-attended births. I’m not saying that most or even all of these deaths were preventable — some things just happen. Some babies have lethal defects. If you want to look at anything, you are free to do so. If you think I’ve fiddled with the numbers too much, you can change it to just what you want.

Having another child

This is more of a musing “talking to myself” post, just because I’ve been thinking on this subject lately. No, I’ve not really gotten the “baby bug” yet, although on occasion, rarely, and briefly, I get a slight urge that way. My mother-in-law spent a few weeks with us over the summer and said that my husband “needs a girl.” I said, “Talk to somebody else about it!”

My two kids are 19 months apart, and that is plenty close for me (although I know several women who have children spaced much closer together, and more children than I have). A friend of a friend has children nine months apart. Wow. My younger son recently turned two, so if I were to get pregnant now, they’d be about 3 years apart, which would be doable. Except I don’t want to do it. 🙂

One thing that turned my mind towards having another child, is that yesterday I had a pain in my lower right abdomen, and (since I was on my period) my first thought was appendicitis. After looking up the symptoms of said problem, it didn’t really sound like that, so I opened my mind a bit more and realized it felt almost like mittelschmerz. I’ve heard of women getting pregnant while on their period, so I know it is possible that I was ovulating, even if it is unlikely. Since we use “natural family planning” instead of birth control or other forms of contraception to avoid pregnancy, I’m pretending right now that I’m in my fertile time.

We’re not Catholic, by the way, so we don’t have a moral problem with condoms or spermicide — this is just what we’ve chosen. Our older son was conceived despite spermicide, and I’ve heard of numerous other “failures” that resulted in such blessings. (I and my next older sister are also here because of failure of spermicide. My mom had her tubes tied after she gave birth to me.) I’ve also previously written about birth control, but would add this one thing: I’ve read since writing that post that it’s possible that birth control does not cause abortions. The author is extremely pro-life, and said that the studies that indicated that birth control pills might cause a fertilized egg not to implant were flawed, because they looked at hormone levels of women who did not ovulate (because of the Pill) and said that these levels were not sufficient to sustain a pregnancy; however, if a woman has breakthrough ovulation, the follicle and ovary itself will produce hormones that can maintain a pregnancy, regardless of the Pill. I say, “Perhaps.” The old birth control pills had very high levels of hormones, which did prevent almost all ovulation; but Pills from 10-20 years ago had much lower levels of these hormones, which had more breakthrough ovulation, but not necessarily a higher failure rate. Modern “mini-pills” have an even lower level of hormones, and I’ve read that the breakthrough ovulation for them is fairly high… yet they still have a low failure rate. It’s possible that even when ovulation occurs, that the sperm can’t reach the egg because of the thickened cervical mucus due to the Pill, but I’m still not personally comfortable morally with taking birth control pills.

Morality aside, when I was first pregnant, I gave the midwife my medical history, and when I told her that I had never been on the pill, she immediately said, “Good!!” Medications can do weird things, and I’m simply not comfortable taking them if a suitable alternative exists. Some women wouldn’t find NFP to be a suitable alternative, and that’s fine. To each her own. Now, back to the subject at hand.

Our second baby was a planned pregnancy, although there have been many times I wished there were more space between my children. I’ve also counseled other women who were considering having children that close together, and suggested they wait. It’s just hard. There are some good things about it — don’t get me wrong — but it’s just hard, because the older baby is still a baby in so many ways, and the younger baby is truly a baby and very needy. Both of my boys are “mama’s boys”, so when they need comfort, they come to me — only mommy will do. And there were countless times when they both needed me to be cuddling just one, but had to try to hold both at the same time. (And this doesn’t even take into account meal-times, laundry, chores, and everything else a mom has to do.) The good side about having them this close together is that now they play together better, since they’re interested in the same things (but then, they also have more fights, too, because of the same reason).

One thing I read before getting pregnant the second time was a mother saying that your older child (or children) doesn’t become a big brother (or sister) at the birth of the younger baby, but rather, s/he becomes that when your second (or third, etc.) child is conceived. At the time I discounted that; but now believe it to be accurate. I don’t think I “baby” my younger child; however, he does seem more babyish than my older son was at the same ages. And I think it was because when he was 10 months old, I was pregnant, and moving him into “older brother” status already, and preparing him for that. I haven’t done that with my younger son. I’ve let him be a baby longer, and I recognize that now. Part of me thinks that I wouldn’t do much different if I were pregnant now, but most of me thinks I would be pushing him to do things differently — to be more mature — to prepare him for taking on the role of big brother.

At this point, I’m not planning on having another baby. I wouldn’t cry or freak out if I found out I were pregnant, and I think I might even be able to quickly be happy, after getting over the shock of an unplanned pregnancy. If it were just the pregnancy part, or giving birth, I wouldn’t have a problem — but seeing a newborn infant, and the extreme neediness of the baby, and thinking about all the work involved in raising a child from birth to age 2 (in other words, repeating the last 2 years of my life), I just don’t want to go through all that again. I like being able to sleep all night, instead of waking up every two hours to nurse. I like being able to have my kids help dress themselves, instead of being all floppy. I don’t want to go through teething again. And so many reasons more.

But I’m a positive thinker, so if I found out I was pregnant, I’d start thinking about all the positives — another baby to love and hold and raise. Another pregnancy to try to do things better, and another chance to give birth (hopefully without all the negatives of Seth’s birth). Now, I’d better stop, or else I’m going to think so positively about everything that I’ll forget about everything I’ve just spent this whole post talking about, and start trying to talk my husband into having another baby!