Conflicting studies

Ok, so long story short, I happened across these two articles from the UK, both from the same woman, Medical Editor Rebecca Smith, which had conflicting results. The first report, written almost exactly a year ago, was titled, “Death Risk Higher for Women ‘Too Posh to Push’“; and the second report, written this past April, was titled, “Women Choosing Cesarean Have Low Death Rate.” I’ll see if I can find something like the actual study, and not just go by what the author said about the study, but just had to say this while it was fresh on my mind.

The first report was published in the BMJ (which if I remember correctly has all of its articles available free online, so it should be easy to find), and Ms. Smith reported that the study found that

the risk of maternal death was three to five times higher compared with natural deliveries. The risk of requiring a hysterectomy after a caesarean section was four times higher than for a natural birth and twice as high for being admitted to intensive care and needing a hospital stay of more than seven days.

For babies in a breech position, a caesarean section was safer but for those in a normal head-first position the risk of the baby dying or suffering serious problems was raised by one and a half times. Experts said the study was a “reality check” that caesarean sections carry risks and are not ‘just another delivery option’.

The second report was attributed to “The Birth Trauma Association”, an organization in the UK, and I’m not sure if the report was actually published anywhere, but I’ll try to find it.

The Birth Trauma Association found that of the 2,113,831 women who delivered a baby after 24 weeks gestation between 2003 and 2005, one in 10 had a caesarean before labour had begun.

Seven women died, giving a mortality rate of 0.31 per 10,000.

This compared to 74 deaths amongst the remaining women who had a natural birth or an emergency caesarean section, giving a mortality rate of 0.39 per 10,000.

Since reports published in well-respected peer-reviewed medical journals such as the BMJ typically analyze the results to see if they are statistically valid, I will assume that the data reported in the BMJ article is statistically significant; I’m not sure about the other — we’ll have to see.

The question that weighs most heavily on my mind is, what is the maternal mortality rate among women who had a vaginal birth? And the morbidity rate of the infants?

Most studies that are undertaken to look at mortality and morbidity in birth will typically restrict participants to be only those in the term period (unless they are looking specifically at pre-term births). There is no definition of “emergency” C-section given, so I am going to assume that it just means any unplanned C-section. I will accept that surgeries performed under stressful situations (such as an absent fetal heart-rate, in which the baby will need to be cut out immediately) may predispose the mother to extra risks due to the probability that the doctor is cutting faster and not taking as much time as in a scheduled C-section. So, what things can be done to reduce the rate of fetal distress? I’m unsure if other factors play into this — such as if having a pre-term C-section may cause more problems than having a term C-section; or a failed induction for non-medical reason ending in an “emergency” C-section. Also, I’m curious if only 10% of women had planned C-sections. It seems probable to me that there would be many women who planned a C-section but actually went into labor before the date of the scheduled surgery, so were automatically included in the 2nd group, which combined women who gave birth vaginally with those who had a C-section after labor began.

There may have been many women who had pre-term labor and had their babies by C-section because their babies were so small that they may have been traumatized by such an early vaginal birth. I seem to remember reading somewhere that in very early pre-term births, C-section is the preferred birth mode because of the delicate condition of the baby, specifically the head trauma he may endure being so fragile, going through the birth canal; plus the fact that many babies are still in the breech position in early pregnancy, and would be put at severe risk if allowed to be born vaginally — their heads are much more out of proportion to their bodies that term babies (this means that there may be more complications like head entrapment in a partially dilated cervix). If women at 24-30 weeks present to the hospital in pre-term labor that the hospital can’t stop, it is likely in their babies’ best interests to be born by C-section. Since the women were in labor before the C-section began, they would not be included in the first group, yet it isn’t exactly fair to include them in the planned vaginal birth group since they didn’t even make it to term, and most C-sections done prior to the beginning of labor would take place during the term period. It makes a difference for the babies; it might make a difference in the mothers. There are some preterm C-sections that do take place prior to labor beginning, such as some for twins or other multiples, or those in which the baby seems to be not developing well in utero, or he stops moving or something.

Anyway, I’m looking forward to trying to find this report, and seeing if it answers some of the questions, or if they give a statistical analysis to back up their claim of a lower maternal mortality for planned C-sections. Comparing it to the BMJ (which is almost certainly statistically significant), it surprises me that such a large difference noted by the BMJ article is contradicted but with only a slight difference by this other report. It may mean nothing more than that C-section after failed induction is a hidden risk factor for higher maternal mortality; or that an emergency C-section done because the baby’s heartrate plummeted after the mother’s blood pressure took a nose-dive after she got an epidural helped to increase the MMR. The BMJ reported that maternal death was 3-5x higher for C-sections (but the article I read did not say whether that looked at planned vs. unplanned C-sections), whereas the higher rate of maternal death for vaginal births and C-sections which took place after labor began was only 8 per million higher (3.1/100,000 vs. 3.9/100,000) — very slight. Considering all of the other risks of C-section (especially repeat C-section, with the higher rate of complications including placental problems with future pregnancies and hysterectomies, not to mention things like maternal hemorrhage and blood transfusions and risk of infection and pain), I think that women need to look at the full picture of both what vaginal and surgical birth have to offer and what the risks and benefits of each are.

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I’m flabbergasted!

A doctor who was recruited from Germany to fill a position in Australia that was underserved has been declined permanent residency because his son has Down’s Syndrome! The reasoning stated is that the government is concerned that the boy may have expensive medical needs which the Australian socialized medicine system (i.e., the taxpayer) will have to pay for. What next? Forced abortions on women who discover that their babies have Down Syndrome or some other problem to save money?

Support Birth and Breastfeeding at IdeaBlob

Here’s the information, passed on to me from Enjoy Birth — vote and pass it on!

In Sept I asked you to vote – well we made the OCTOBER FINALS!!!

Here’s the update – I need you to vote again please!!! And blog about
it too!

A while ago, I entered my business, 9 Months & Beyond at Ideablob.com.
Well, I finally got enough overall votes to make it into the finals
for October. That means I have to get the MOST votes between now and
Oct 31st to win $10,000 for my business. The money is given by
Advanta, a credit card company, but it is truly a check for 10,000
that I can use to grow my business however I see fit.

If I win, it will change my life. I will be able to get a site of our
own and expand the programming and hours/availability for classes.
There is NOTHING like this in Nashville (where I live) and little like
it in the Southeast. As you know, this is also the part of the country
with the most abysmal breastfeeding rates. I want to change the world.
I have big dreams and a big vision. I can SEE it on the horizon.

Will you please help me make this dream a reality? It will take just a
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can even launch one of your own. I don’t think a birth related
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Lastly, please pass this on too. If you blog, twitter, or just email –
tell EVERYONE who has computer access to vote for 9 Months & Beyond,
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Micky Jones

Micky Jones, BS, CLE, CLD, CHBE, HCHI
9 Months & Beyond, LLC
Hypnobabies classes, Breastfeeding consultation and Medela pump
rentals, Birth Doula services and more
www.ninemonthsandbeyond.com
1-877-365-(MAMA) 6262
…helping you enjoy the most precious years of life
Vote for us on Idea Blob.com
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Inaccurate Diagnosis — what to do?

Several months ago, a friend of mine went to the doctor, and he happened to be wearing shorts, and the doctor noticed a spot on his leg which he thought looked suspicious. He took a biopsy, sent it off to the lab, and it was diagnosed as being a very rare form of cancer. They quickly removed a chunk from his leg, hoping they had gotten the entire spot that may have been cancerous, so they didn’t have to do anything more drastic (like amputatation or chemotherapy). Further tests revealed my friend was cancer-free. Excellent, right?

Problem is, the original diagnosis was wrong — the spot was not cancerous. The lab screwed up. My friend now has $15,000 in medical bills that he can’t pay because of the lab screw-up. The lab that screwed up has actually sent it to collections already — even though their screw-up was the cause of them not having the money to pay for everything that happened– in addition to sending them through several weeks of fear (because of their screw-up), and the discomfort of the (minor) operation (because of their screw-up), and life-long scarring of this young man’s leg (because of their screw-up). The man’s wife recently lost both her mother and one of her uncles to cancer, so when she heard that her thirty-something husband was diagnosed with cancer (did I mention the lab screwed up?), she immediately went into worst-case scenario mode and thought she’d likely be a widow at 35.

They’ve contacted a lawyer, and there’s not enough money in it for the lawyer to even take the case, so what can they do? If his life had been materially altered (he’d had his leg amputated, or the surgery took out so much of his leg that it made him hobble, or he ended up dead somehow), then a greedy lawyer would take it for a nice percentage of a million-dollar lawsuit. Fifteen grand don’t cut it, though, apparently.

It was an innocent human error — the lab didn’t misdiagnose maliciously. The doctor’s recommendations based on what he thought was accurate was a legitimate course of action, so they’re not mad at him. They’re not mad at anybody, but they just don’t think they ought to have to pay so much money when the lab (that is now trying to collect several thousand dollars) screwed up.

While they’re thrilled that he’s not dying of cancer, and never even had cancer to begin with, the reality is that they’ve got all these medical bills (due to the rarity of the falsely diagnosed cancer, multiple tests were required, including the State Lab, so they owe several different people money). Any suggestions? My first thought is to tell them to take their bills and shove ’em where the sun don’t shine, and forward all the other medical bills to them too. But I don’t think that would actually help. I’m hoping at least one of my readers has a suggestion that can help my friends.

Poll question on birth prep

Over at our childbirth educators group blog, there’s a good, thought-provoking poll question on how we prepare ourselves for birth. Of course, the traditional way has always been talking to our mothers, aunts, older sisters, or others who may have given birth before us, but with so many of us in the West having moms who were knocked out for birth or were given drugs to forget labor, we’ve lost that vital connection. I can’t talk to my mom about birth, because all she knows is that contractions hurt, and when she woke up, she had a baby, a pubic shave, and a big episiotomy. Against her will, I might add. She was not given a choice in being knocked out, and she even begged them not to knock her out with me, her last baby (she was planning on getting her tubes tied), but they refused. Lovely. After giving birth four times, she still says, with regret in her voice, I have no idea what birth is like.

Anyway, go over to to the blog post and let us know what were your main sources in preparing for your birth!

Legal help for VBAC bans

One of the most pernicious problems with a primary (first-time) C-section, is that so many women nowadays are being denied the right to have a subsequent vaginal birth, and are required to have an “elective” repeat C-section. Some doctors refuse to attend them; some hospitals have it as policy that VBACs are not allowed. A large part of this problem is the malpractice insurance provider for either doctor or hospital that has it as part of their policy that they will not cover doctors or hospitals who participate in VBACs. The reason is the possibility of uterine rupture, which though rare is a known risk factor in an attempted VBAC (Overall — 7/1000 in that study — and this probably includes both catastrophic uterine rupture as well as the more benign uterine dehiscence; the breakdown goes as follows: Spontaneous TOL: 7/1544 or 4.5/1000; Prostaglandin E2 gel: 5/172 or 29/1000; Foley catheter: 1/129 or 7.75/1000; induction w/o cerv. ripening: 2/274 or 7.3/1000). The fact that other potential problems that can affect all women and their babies (such as a cord prolapse [2.34/1000, 4/1000, & 1.7/1000 were all figures given in published research; and this study said that obstetrical interventions contribute to 47% of cord prolapses], or placental abruption [9.9/1000, 6.5/1000]) together take place more than the known uterine rupture risk in an attempted VBAC (provided drugs like Pitocin, Cytotec and Cervidil or Prepidil are not used), does not alter the equation at all. It seems to me that the risks to the doctor ought to be the same, but since a previous C-section is a known risk factor for uterine rupture, and because ACOG has made it their guidelines that surgery be “immediately available” to a woman who attempts a VBAC, many hospitals are interpreting this as saying that a full surgical team must be in-hospital the entire time a VBACer is there in labor. Many hospitals, especially small rural ones, do not have this, so many women are being denied their legal rights by having an unwanted surgery forced on them, by an administrative decision made by a body of obstetricians, which is not legally binding. However, if a VBAC goes bad, and the woman decides to sue, you can bet your bottom dollar that the woman’s lawyer will bring up the ACOG guideline as if it were The Eleventh Commandment.

As I wrote in an email to an ICAN group,

So if they don’t induce or augment TOLACs, the rate (which may include dehiscence which is generally not associated with negative perinatal outcomes) is 4.5/1000, which is less than the rate of placental abruption — although women are not required to be at the hospital from 20 weeks onward, just in case their placentas suddenly decide to separate, and PA is definitely associated with higher perinatal morbidity and mortality (partly but not completely due to premature births) than is UR in labor, especially with dehiscence. Obstetric interventions contribute to almost half of all cord prolapses, which may be as high as 4/1000 (almost the rate of UR in TOLACs) but I bet docs aren’t required to be at the hospital before the L&D nurse is allowed to break any woman’s amniotic sac, or otherwise intervene. This study said that these interventions were not associated with higher perinatal morbidity and mortality, presumably because the woman was already at the hospital and quick action was taken. If this can happen for these women, why not VBACers?
 
This also doesn’t begin to touch the future problems women may encounter during pregnancy and birth should they have multiple C-sections, which they will be required to do, if they can’t have VBACs and want more than 2 kids. I guess I should look up rates of placenta accreta/percreta/previa in uteri that are unscarred vs. 1 C-section, 2 C-sections, etc. These not only pose potential hazards for that baby but for the mom as well — and C-sections are more strongly associated with AFE than with vaginal births, too, which has a high maternal and perinatal mortality and morbidity.
Click here to see what the free legal help offered in overturning VBAC bans is — even if you’re not personally involved — even if you, like me, have never had a C-section so VBAC is not even in your considerations. You should keep this information in mind — bookmark it, even, so you can find it easily in case you in the future are pregnant after having had a C-section, or you have a friend who is. Considering that 1/3 of American women each year have a C-section, the odds that you’ll know somebody who may need this information is pretty high.

Seemingly endless repetition with no apparent progress

What comes to your mind when you see this phrase which is the title of the post? Ponder it for a second before going on. What are you thinking of?

 

There’s a lot of situations in life that this could refer to.

I was made to see a parallel between motherhood and giving birth recently as I thought about my job as a stay-at-home mom. I’m sure many of my readers — even those who are not SAHMs — can identify with this, the never-ending tasks of keeping a home in running order (laundry, cleaning, cooking — and notice that I did not say “in perfect running order” — I make no claims of perfection!); and also the work of teaching children everything they need to know as 2- and 4-year-olds, from how to use the potty (we’re almost done!!) to what buttermilk is (that was this morning’s question… I turned on a YouTube video [please refer back to previous statement of no claims of perfection 🙂 ]).

When my son asks the same question over and over, I recognize on some levels that he is learning something each time I answer, but the process is agonizingly slow. When I played Candyland with my kids, there was many a time when I had to correctly identify each color, but now they know their colors with rarely a mix-up. Looking back, I can see it was worth it, but having to say three times a minute, “No, this is purple,” or “this isn’t orange, it’s red,” made the process seem slow and endless. Now I’m potty-training, and I’m still having to clean up the floor way too much (at least partly my fault for not taking my son to the potty often enough, and somehow expecting him to just “get it” — although he does frequently take himself), and it seems to be taking way too long. (I couldn’t wait, because he was pulling off his diapers and going in the floor anyway.) I’m already at least half-way to the point of not needing diapers any more, so looking at it that way makes it seem worth-while, and looking into the future of diaper-less reality definitely makes it worthwhile. But while I’m here, “in the trenches” as it were, it’s almost mind-numbling boring and even sometimes exhausting.

Oh, and how many times can a person read “The Cat in the Hat” in one day? I can’t even recall the number of books I’ve got memorized from reading them over and over and over and over and over….

Isn’t that somewhat like labor? Hours of contractions with no apparent progress (especially if you don’t have vaginal exams, then you don’t even have some number of dilation to attach to the contractions). In my first labor, I know I had an exam when the midwife first came to the house and again right before I started officially pushing (possibly once more in between); in my second labor, I didn’t call the midwife in time, so I didn’t have any exams at all. I remember thinking while in labor the second time (contractions ranging from 7-15 minutes for 24 hours), that I wasn’t “really” in labor until my contractions settled into a pattern, so since they weren’t regular, I wasn’t “really” in labor, therefore I was having all these contractions (without “really” being in labor), so since it wasn’t “really” labor, they were pointless although exceedingly painful (back labor). I was wrong, of course — that was the labor hormones talking, not really me — it was “real” labor after all, and the contractions were doing something, even if I didn’t have anything apparent to show for it.

And, just like so many other seemingly pointless and endless repetitions with no apparent progress, all of a sudden, I pushed my baby out in three or four contractions. Then it became apparent that all of the contractions had done something — my cervix had slowly but surely dilated while I kept waiting for “real labor” to begin. One day “all of a sudden” my children will begin to read — but their ability to read will be built on the countless number of times I read dozens or even hundreds of books to them, as well as the many times I recited the alphabet, etc.

This is one thing many people “don’t get” about labor. I’ve heard both men and women (more commonly men) say that there is no point to labor, or ask rhetorically, “Why not just get a C-section?” or wonder why some women choose natural childbirth or are hesitant to have interventions. I’ve heard new fathers whose babies arrived by C-section after labor make comments like, “We should have just had a C-section to start with — all that labor for nothing!” First, that assumes that there is no difference between vaginal birth and C-section. Secondly, it assumes that there is nothing to be gained by having a vaginal and/or natural birth. I’ve heard women who have had labor ending in a C-section say that if they had to do it all over again, they would choose to labor even knowing that they’d have a C-section at the end. To them, there were enough benefits in the labor that they would choose it again, even when they knew it would be “pointless” by so many people’s standards. Right now, many people think that my staying at home with my children is similarly “pointless” — after all, somebody else could watch my kids and make sure that they don’t get hurt; they could read them stories, change diapers, feed them, answer their endless questions, etc. While the process of being a mom and raising my children is usually not glorious, and is frequently difficult, tedious, and definitely time-consuming, I find enough benefits in it to make the trade-offs worth it.