Births by the day of the week

On page 53 of the 2006 National Vital Statistics Report (released Jan. 7, 2009), there was an interesting little chart: number of births by the day of the week. Not surprisingly, there were the fewest births over the weekend. Monday through Friday there were about 12,000-13,000 births per day; but on Saturday and Sunday there were only 7,000-8,000.

Of course, it shouldn’t be that way — there should be an even distribution. But there’s not. Reason being, that doctors are trying to practice “daylight obstetrics”, so they will induce or section a woman who doesn’t go into labor or give birth on their time table. I’ve read somewhere (but don’t have a link) that the birth rates right before holidays, especially long holiday weekends, is much higher than normal — doctors want to have the time off, so will make sure all the women they think might go into labor while they’re playing golf, or relaxing around the pool, or spending time with family, have already given birth before they leave.

Women should only be given C-sections when there is a medical reason. Women should only be induced when there is a medical reason. Women should only have their labors augmented when there is a medical reason. Any of these interventions done for non-medical reasons introduces medical risks to mother or baby for no good reason.

Is there any medical reason for inductions to be started on Monday through Friday and not on Saturday or Sunday? I remember reading someone’s birth story, and she said that she “had to be induced” for some medical problem, so went in on Friday. She wasn’t ready for labor, so nothing happened. So she was instructed to go home and come back on Monday or Tuesday to try for a second induction. Hmmm. How “medical” was that problem? I’d really be curious to know. It was “so medical” that she “had to be induced” one day… but then apparently not medical enough for it to be a problem over the weekend. Seems to me that if it was a problem on Friday, it would be a greater problem on Saturday and Sunday. But that’s just me. What do I know? I’m sure every obstetrician in America knows that medical problems only present half as much over the weekend (yes, I’m being sarcastic).

I’ve read too many stories of women who have found out after the intervention that the intervention that they were scared or coerced into agreeing to was actually not medically necessary — it was just done for obstetrician convenience. Stories of women who were told their babies were in dire need of a C-section… only to find out that it was really their doctor in dire need of getting home to dinner — that sort of thing.

One factor in the Monday to Friday induction/C-section rates is that hospitals are better staffed during daylight hours on the week. But why should that be? Of course, everyone wants off on the weekend and at night. That’s understandable. But birth shouldn’t be made to fit within those confines. It is understandable that elective pre-labor C-sections would be done M-F during office hours. But everything else…? Shouldn’t hospitals arrange staff so that they have more even distribution at all hours? It seems to me a vicious cycle — doctors section or induce during daylight hours because they have the most staff on hand during those times; and then because there are so many women being induced or sectioned plus those who go into labor naturally, that hospitals have more staff on hand during the day; then since there is more staff on hand during the day… You get the picture.

What if hospitals had the same number of nurses on hand at all times, 24/7? or nearly the same number? Would it change the picture of obstetrics? There is a type of obstetrician called a “laborist” — s/he’s an obstetrician who works a set schedule at a hospital, ensuring that there is an obstetrician in the hospital at all times. At the end of the shift, the person goes home, and another person comes on shift. If a woman hasn’t given birth, I would assume that it would be no big deal — the incoming laborist would be briefed about her situation, and take over labor-watching. That’s the way it is now with nurses — at the end of a shift, the nurse’s duties are over (although paperwork may not be!), and she can hand off the woman to the next shift. The way it is now, doctors are inclined to “hurry things up” so that they can be sure of when the woman will give birth, to make sure that they aren’t interrupted in the middle of the night to come and catch a baby, to be able to plan, go out to dinner, go to a movie, etc. If a woman goes into labor in the middle of the night, and is progressing normally but slowly, do you think the doctor will allow her to go 24 hours before giving birth? or do you think he’ll be at least a little bit tempted to have nurses augment her contractions so that she gives birth well before dinnertime, so he can go home and have a relaxing evening at home? I’m guessing the latter.

I blogged about a month ago about an L&D nurse’s blog post in which she mentioned having a woman have a completely natural labor (i.e., no induction or augmentation). This woman had gone into labor over the Christmas or New Year’s holiday, and the doctor was in no hurry to speed up her labor, because the doctor didn’t want to come in early and attend the birth. He was more than willing to let labor take however long it was going to take. He didn’t care about clock-watching… because he was home and wanted to stay there. But if he was at the hospital and wanting to get home, I daresay the situation would be quite the reverse.

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Illinois CPM Legislation!

Forwarded from an email list I’m on — please email, forward, blog, etc. — however you can get the word out…

Greetings home birth supporters.

We have an extremely urgent message. PLEASE DROP ALL YOUR PLANS AND HEAD TO
THE STATE CAPITOL NEXT TUESDAY, MARCH 3, 2009!

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@ We cannot overstate how important this is.  @
@@@@@@@@@@@@@@@@@@@@@@@

The Home Birth Safety Act (HB 226), which will license Certified
Professional Midwives (CPMs) for home birth, is going to be heard in the
Health Care Availability Access Committee next Tuesday, March, 3, 2009, at
4pm. This will either be the beginning of a great era or the final chapter
in our decades long efforts to pass a CPM licensure law. The next time after
this year to introduce a viable bill will be years from now, so we must make
our best efforts now.

We have gone down every possible avenue over the past few years, to get as
much support as possible, and even reached agreement with our state’s
nursing groups. We have built a strong coalition with many state groups
including Illinois Public Health Association, Illinois Maternal Child Health
Coalition, Health and Medicine Policy Research Group, and Health and
Disability Advocates, among others. We’ve even managed to get our bill
placed in a better committee. So it all comes down to this: will we make it
out the House Health Care Availability Access Committee, or will our bill
die?

We have just received word from our people on the ground in Springfield that
individual doctors have been traveling to Springfield to lobby against our
bill. A lot of them. And they are making an impression. This is
unprecedented in Illinois and even across the whole country that large
numbers of individual doctors are actually going to the state capitol to
lobby against a CPM licensure bill. So please PLEASE if you value home birth
and want the option available for your future pregnancies or for your
daughters in the years to come, then make it your number one priority to
come to Springfield, Illinois next Tuesday, March 3, 2009!

We need EVERYONE to take a vacation day or call in sick, pull your kids out
of school, and bring your sister, your best friend and your mother to
Springfield that day to pack the hallways and the hearing room! We have to
show Illinois legislators that the people of Illinois need access to
licensed midwives!

Please forward this message to everyone you know and ask them to do the
same!

See you there!
Colette

B’s Birth Story

My middle sister has three children; this is the story of the birth of the middle one.

Her first birth was two years before, in a hospital with a CNM (she ended up with pitocin, but no epidural — just some injected narc like morphine or something). For some reason, that option was not available when B was born [either that CNM had moved, or the hospital had changed policies so she wasn’t allowed to practice, or something], so she opted for a home birth with a midwife. Our state does not require regulation for midwives, so I don’t know what this woman’s credentials or training were, although she had attended numerous women in our area who had chosen home birth (and eventually moved out of state, so not a possibility for me now).

My sister said that her “ideal” would be to have a midwife in the hospital — the midwife for the low-tech high-touch “natural” aspects that she wants, with the “safety net” of being the hospital should the need arise for quick action. That not being available, she opted to go with the midwife at home instead of an OB at the hospital.

My sister and her family had been living in their house for about two years at that point, and had not yet been able to afford to replace the carpet. The lady they bought the house from was elderly, senile, and let’s just say needed to wear diapers. While they had gotten the carpet thoroughly cleaned, it was the same carpet that was in the house when the previous owner was…using it. While this may seem like a completely off-the-wall paragraph for a birth story, it’s not; because my sister said that she had a real mental hangup about this carpet while she was in labor. Whenever the midwife knelt on the floor to check my sister, or anything else, my sister could only think about the fact that the midwife was probably kneeling where the senile old lady had peed. And she just felt like it was too dirty to give birth there.

Other “mental hangups” included that she was distracted by the messy closet. She told me afterwards that she kept staring at the closet door, hoping that somebody would take the hint to close it, but she never could quite get the words from her brain to her tongue, to actually tell someone to close the door. And finally, the previously mentioned feeling that the hospital was really safer, and she didn’t feel totally comfortable giving birth at home.

I don’t know when she went into labor, nor how long it was; the only thing I really remember that she said, was that she stayed at 6 cm dilation for 9 hours. As a second-time mother, that was quite a plateau! Her husband was a less than perfect labor partner, too. Let’s just say, he’s nearly the poster child for “men should go hunting while their wives give birth.” Rather than supporting and encouraging her through the difficult and painful contractions, he got irritated and tired of her “screaming” and was relieved when she finally went to the hospital so she could have an epidural. He’s a nice man and a good husband in many ways, but labor support is not one of them.

After having been stuck at 6 cm for so long (and being distracted by thoughts of urine-soaked carpet padding, a messy closet, and being not quite comfortable with the idea of giving birth at home), she finally went to the hospital. The midwife had thought about breaking her water in order to apply the head directly to the cervix, but the baby was still pretty high up, and not engaged, so she was worried that breaking the amniotic sac might precipitate a cord prolapse, so she was unwilling to take that step at home. [Note — a CNM friend said that she will “leak” the bag of waters, letting it out slowly, as an alternative to transferring to the hospital.]

So, off to the hospital they went. Perhaps it was the sitting in the car on the way to the hospital; perhaps it was that my sister was able to relax since she was away from the distractions at home; perhaps it was just a coincidence, but when they arrived at the hospital 20 minutes later, she was already dilated to 8 cm. They started her on pitocin and an epidural, and the baby was born soon after.

Lesson to learn: even when someone ought to be able to give birth at home, as far as level of risk and quality of care-provider, it doesn’t always mean that she will actually be able to. Distractions can interfere with labor in even the best of circumstances. I remember another story I read on an email list, in which a woman was just completely distracted by a drop of blood on her foot. She kept staring at it, waiting for somebody to wipe it off (I guess never thinking to do it herself, and certainly never speaking about it). La-la-labor land!

Breastfeeding an Adopted Baby

I’ve heard about that — I think Dr. Sears has it in his The Baby Book — but as far as I know, none of the adoptive parents I know have breastfed their children (although many of them adopted older children). Anyway, it was discussed a few weeks ago on the Permission to Mother blog, and out of curiosity I asked what the protocol was to induce milk production in a woman who had not been pregnant — perhaps ever — so that she could nurse the baby. Here is the link that was provided. It has a lot of information and insights into it, so I thought I’d pass it along in case anyone else was curious or needed the information for themselves or someone they know.

Oral Hygiene, Preeclampsia, Preterm Birth

I’d previously read that gingivitis is associated with higher rates of preeclampsia, but that it was not known if it was a “cause and effect” or just an association. If gingivitis causes preeclampsia, then better oral hygiene might prevent some cases of preeclampsia; but if it’s just an association — that women who are predisposed to either gingivitis or preeclampsia, or just are in poorer health or have an underlying health condition — then combatting gingivitis would do nothing.

In that vein, I was intrigued when I read this article, which said that bacteria has been found in the amniotic fluid of women who have given birth prematurely. One possible pathway given was that a kind of bacteria normally found in the mouth (and harmless there) may make its way into the bloodstream, and from there through the placenta into the baby’s amniotic fluid. This might weaken the amniotic sac, or perhaps cause some sort of uterine infection or fetal infection, or something that would account for the preterm birth. This is a new discovery, because this bacteria does not respond to traditional culturing, but instead requires examining DNA.

I wonder if preeclampsia might also be a manifestation of some sort of infection, perhaps transmitted through the weakened areas of the mouth when gingivitis occurs — the puffy and bleeding gums just seem like wide-open places for bacteria to cross into the blood-stream.

As an aside, I had two heart surgeries as a young child, and am supposed to take antibiotics for life whenever I have dental work done. It’s to prevent this sort of thing from happening — nasty oral bacteria (that may do nothing worse than cause bad breath, plaque or cavities when kept in the mouth) upon entering the bloodstream move to the weakest point, which for heart patients would typically be the heart. Southern humorist Lewis Grizzard eventually lost his life because of this — after four heart surgeries. In a pregnant woman, the baby may be “the weakest point” which is attacked, or at least may be the area with the least defenses. Antibiotics are given with the hope and assumption that if the dental patient’s mouth is pricked or otherwise open and/or bleeding, and oral bacteria enter the bloodstream, that the prescription antibiotics will prevent these bacteria from setting up a heart infection.

When I was pregnant the first time, I didn’t know about the gingivitis-preeclampsia risk, much less this newly released bacteria-preterm birth link. But I did know about the possibility that always exists (no matter how small) for oral bacteria to enter the bloodstream through an open sore in the mouth. I assume the risk is much greater when, say, the pick that cleans your teeth and may have untold numbers of bacteria on it jabs into the gum and more or less “injects” the bacteria below the surface. However, when my gums bled during pregnancy — which is not uncommon — I was concerned and wondered what to do about it. Sometime in the past, I had read that gingivitis might be caused by a lack of vitamin C, or at least, that taking vitamin C would stop it. You’re not supposed to take large amounts of vitamin C while pregnant because the baby might develop scurvy (although I think this is mostly talking about large doses around the time of birth, causing the baby to develop scurvy after birth when he’s withdrawn from the maternal vitamin C; and I’ve read one doctor who prescribes large doses of vitamin C, and his protocol for dealing with this is to give the baby vitamin C as well, and then gradually wean him off of it), so do your own research before doing anything! So I took a couple of grams of vitamin C for a few days, in addition to whatever was in my prenatal vitamin, whenever my gums started bleeding, and usually within a day it would stop. I only had to do this a few times during pregnancy.

One Little Word

Well-Rounded Mama has an excellent and thoughtful post on the importance of one little word — that word being the change in ACOG’s guidelines in 1999 concerning VBACs, which changed from suggesting that doctors be “readily available” to being “immediately available.” Go read the article, pass it along to your friends, blog about it, etc. Even if you have not had a C-section yet (hey, neither have I!), read this article, because you never know when you will be faced with the knife, and then be forced into subsequent C-sections from then on, for no evidence-based reason! Besides, even if it doesn’t affect you personally, it probably affects several of your friends; and the climate that allows a VBAC ban is not a beneficial attitude for any birth-related practices.

Define “Safe”

In chapter 5 of Dr. Rixa‘s Born Free dissertation, she discusses risk and safety in birth.

How do you define “safe”?

Is “safe” defined solely as a birth in which both mother and baby survive? In that case, birth is universally defined as safe, since most mothers and babies survive birth even in Sierra Leone, which has the highest maternal and infant mortality in the world. And even among the unassisted births that most obstetricians and even many midwives warn against are safe.

Is safety defined as only births that happen in a high-tech hospital with the high-risk obstetrician in the room and the neonatal doctor just down the hall?

Rixa goes even further — does the woman feel safe?

I daresay that in many births, the mothers do not feel safe — they feel on edge, fearful that something will go wrong because all the technology is in use which must mean that all the technology is necessary to keep them and their babies safe. Some women choose unnecessary C-sections because they do not feel safe in attempting a vaginal birth — afraid that either they or their babies will be damaged or killed. Or maybe their doctors have told them that they must have this intervention or that intervention, so they think that either they or their babies are or will be at risk if they decline. They may be physically safe — that is, these women may not be in danger of their lives or a serious injury, but do they feel safe?

A lot of women do feel safest and best in the hospital, so for them, a home birth would make them feel unsafe (regardless of how safe it actually is or would be). But I remember a doula on an email list I’m on saying several months ago that she couldn’t remember the last hospital birth she’d attended in which the staff (nurses and doctor) were relaxed during labor. Instead, she said that the labors were always very tense, as if the nurses and doctor were on edge, just waiting for something to go wrong, and only seeming surprised when it didn’t.

If “safe” is defined as only those births that take place within the hospital, then any birth outside those parameters that ultimately ends in the safe birth of the child and without serious maternal injury or death is viewed as “lucky.” Hospital-birth advocates may even try to say that every safe out-of-hospital birth is anomalous, or an exception — or even if it is admitted that they are the rule and not the exception, it will still be intoned that such births are risky.

But it depends on how you define “safe.” And until everyone involved in birth can agree on a definition of “safety in birth,” there will never be agreement on which births are safe and which are risky.