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.

High-Tech vs. High-Touch — Consumer Reports on Childbirth

In an article titled “Back to basics for safer childbirth,” and subtitled “Too many doctors and hospitals are overusing high-tech procedures,” Consumer Reports finds the same problems with modern birth practices for low-risk women that natural-birth advocates have been reporting for years: overuse of high-tech, often invasive measures, and underuse of high-touch, usually non-invasive measures.

Overuse of high-tech measures

  • Inducing labor. The percentage of women whose labor was induced more than doubled between 1990 and 2005
  • Use of epidural painkillers, which might cause adverse effects, including rapid fetal heart rate and poor performance on newborn assessment tests
  • Delivery by Caesarean section, which is estimated to account for one-third of all U.S births in 2008, will far exceed the World Health Organization’s recommended national rate of 5 to 10 percent
  • Electronic fetal monitoring, unnecessarily adding to delivery costs
  • Rupturing membranes (“breaking the waters”), intending to hasten onset of labor
  • Episiotomy, which is often unnecessary

Underuse of high-touch, noninvasive measures

  • Prenatal vitamins
  • Use of midwife or family physician
  • Continuous presence of a companion for the mother during labor
  • Upright and side-lying positions during labor and delivery, which are associated with less severe pain than lying down on one’s back
  • Vaginal birth (VBAC) for most women who have had a previous Caesarean section
  • Early mother-baby skin-to-skin contact

They also have a link to a true-false quiz on maternity care (I scored 100%).

Now that Consumer Reports has jumped on the natural-birth bandwagon, maybe, just maybe, all those people who denigrate natural birth advocates will shut up. Hey, I can dream, can’t I? 🙂

My thanks to Empowering Birth for the link to the article!

Update on “Natural” Inductions

I had previously mentioned a friend from church who chose to have a “natural” induction instead of letting labor take its course. I’ve gotten some more information about the birth, as well as an update on the baby.

The baby was in the hospital for about ten days — part of that time on a respirator, then gradually weaned. She was so young that they had to give antibiotics through an IV, which is why they kept her for so long — although it was touch and go for several days, right at first. She is home now, although she will be pretty much kept in seclusion for the rest of the winter (cold and flu season), to minimize the chance of her catching anything contagious and giving her delicate lungs a setback. As far as I know, they don’t anticipate any long-lasting consequences from her brush with death.

I’ve heard almost nothing about the birth story beyond what I had said before, except…

  • she had her membranes stripped to kick-start labor, and
  • her labor was 32 hours long

She was expecting a short labor, and even fearing a precipitous labor, because her mom had had very short labors with all of her children — the longest was about 4 hours from start to finish. Another of her friends, due about the same time, also had her membranes stripped (four times) in an effort to “naturally” start labor. Her labor was 26 hours.

[Stripping or “sweeping” the membranes is a procedure in which the midwife or doctor during a vaginal exam loosens the amniotic sac (the membranes) from the cervix, which supposedly stimulates labor by the irritation, or hastens the onset of labor “naturally” by jump-starting the production of prostaglandins that occurs in late pregnancy. It may work, and it may not. It may accidentally break the bag of waters (the amniotic sac), which means you will likely then be required to give birth by a set time, or carted off for a C-section, rather than risk a uterine infection. It may introduce an infection, although this is rare. It may also be done without your knowledge or consent at a standard vaginal exam in those last every-week visits.]

Who’s to say how long these labors would have been had they started completely spontaneously, with no intervention or interference (including castor oil, herbs, and stripping of membranes)? It may have been just the same. But I wonder if in her haste to start labor and meet her baby, she ended up making it take longer, and being more difficult than it had to be.

Let me restate here that there was no medical reason for either of these inductions. If there was a medical reason, then the risk introduced by these interventions (even if it was very slight) would have been worth it; but without a reason, introducing any risk is making a situation riskier than it has to be.

I know what it is to be “great with child.” I remember all too well the desire to have the baby out of my body and into my arms. I’ve never gone even to my due date, much less past it, so I can only imagine what that must be like — to watch your due date come and go with no baby. But neither of these young women were really “overdue” — they were both probably at 40 weeks and a few days when they gave birth. My friend from church knew (because I had told her, if she didn’t know this already), that most white first-time moms naturally go into labor at 41 weeks, 1 day. She chose to hurry it up, when she was at her due date, and presumably used more stringent methods as the hours and (two) days went by.

It greatly reminds me of the article I linked to in my original “natural inductions” post, which I will quote to end this post:

On the subject of all the women in a hurry to get their babies born: I was 3 weeks ‘overdue’ with my oldest daughter. What really helped me was that I had lunch with a friend at about 8 months pregnancy. Her son had been born 6 months before. When she saw me walk in the restaurant all hugely pregnant she said ‘Oh, Gloria, when I see you I miss my pregnancy so much’. I knew that one day I’d be saying that, too, so I made up my mind to enjoy it as long as possible and I’m so glad I did. Six months from now you’ll be wondering what the rush was.

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.

Coercive Medicine

Wow. What an astounding article (and not necessarily in a good way).

Brief synopsis — pregnant women court-ordered to undergo C-sections many of which were not necessary (several women mentioned all left the hospital and gave birth vaginally, without either themselves or their babies dying).

It also mentioned a woman who was court-ordered to undergo a C-section. The woman had cancer, and was 25 weeks along. There aren’t really any details about it, but some questions that popped into my mind were the following: 1) why did they want her to have a C-section — was she at death’s door, and they thought the baby would die if she died? If so, 2) why didn’t they have a court order to keep her in the hospital (where she likely would be anyway, if she were dying of cancer), and if it became apparent that her life was fading, do a C-section then before the baby died along with the mother. 3) Could they not have waited to do the surgery until the baby was a bit bigger, so would have more of a chance at life with fewer disabilities? As it was, both she and the baby died. The C-section was listed as a contributing factor in her death; and the baby died within two hours, so prematurity was obviously a factor.

Honestly, I’m in the middle here. I know that C-sections are too common, and many times unnecessary. I know that doctors use scare tactics to get women to submit to C-sections. Women have the right to informed consent and refusal, and it sounds as if these women were of sound mind and were therefore within their rights to refuse the procedure. However, I also believe that fetuses have a right to live, and if it is patently clear that the baby will die without medical intervention, then medical intervention is warranted. Few mothers, however, will refuse medical intervention when they believe the life of their baby is at risk.

The article (written in 2004) opened with the story of a woman arrested for murder, because she refused a C-section and one of her twins died in utero. Her case is discussed in ACOG’s Green Journal, and you can also search for the story, which is quite interesting (there are too many links with too many opinions to do them justice, so I’m not going to link to all of them here). Obviously, some people come down more on the “rights of the baby” side, while others come down more on the “rights of the mother” side. (I will point out that this woman is not exactly a “Mother of the Year” — the surviving twin had cocaine in her system; and also there was possibly some degree of mental illness, which may have played into the decision.) The murder charges were eventually dropped, and she pled guilty to child endangerment, for using drugs while pregnant.

Some of the “he said – she said” part of the story, is that she said she wasn’t told that the babies were in serious danger when she refused the C-section; the doctors assert that they told her in no uncertain terms the babies were in danger. The babies were born by C-section after she refused the C-section, which was performed because the baby boy had already died and the baby girl seemed to be in distress. Many of the news reports said that she refused a C-section because of vanity — the scar; while others are quick to point out that weighing some 300+ pounds rather overshadows the scar; and at least one story I read said that she had previously given birth by C-section, so therefore already had a scar.

Was she afraid of the surgery? (Perhaps justifiably so, if she had a horrible surgery and/or recovery after a previous C-section.) Was she just selfish? Did she not truly understand the lives of her babies were at risk? Did her doctors try to talk to her as if she were a reasonable person, or did they get in her face and brow-beat her, so that she felt justified in walking out and refusing to hear them? Were there other options — other things that could have been done to stabilize the babies in utero? What if she had had both babies, but one or both died because they were too premature? So many questions; so few answers.

But I can’t quite come down on the side of “murder,” in this case. I might think that if I knew the reason given by the doctors for C-section, and the accuracy of the diagnosis in general. (I’ve read about too many “unnecessarians” in which women were told that their babies would die without the surgery, only to find out later that it was not the case.) The “M.D.” after the doctor’s name does not stand for “Minor Deity” — he cannot predict the future with 100% reliability. Stillbirths happen for a variety of reasons — and many stillbirths are for entirely unknown reasons. I don’t really know what to do about women who take illicit drugs while pregnant. Yes, it’s child endangerment, but is prison the best or only answer for that? It may be punishment, and it may even be just, but does it help the situation? If doctors know or suspect that a pregnant woman is using drugs, is there some way to reach the women and help them (and their babies) apart from the criminal system? Smoking and drinking while pregnant also raise the risk of stillbirth and a host of other fetal and neonatal problems. But no one is suggesting that mothers of babies who are stillborn or born with nicotine in their systems should be charged with murder.

In reading more of these articles and comments (I was trying to find out how far along this woman was, when she refused the C-section initially), I found that this woman went to a few different hospitals over the course of a few weeks, before finally having the babies by C-section. My question is, if they can charge her with murder for refusing a C-section (even if the charge was ultimately dropped), what could they have done to prevent it? If there was enough evidence of problems with the babies, why didn’t they try to get a court order for a C-section? Did any of the doctors or medical staff find out about her life and her history — you know, talk to her like a real person? Did they suspect drug abuse? Why didn’t they alert the authorities before the baby died, instead of after? If there isn’t a law to prevent the woman from doing what she did, how could she be breaking the law for doing what she did?

And the final question: could she have charged the doctors with murder, had her babies died after being born premature?

Worrisome rise in underweight babies

Here is the full article, but I’ll pull some quotes (all emphases mine).

A recent study released by UNICEF ranked the U.S. … 29th in regard to the percentage of babies with low birth weights.

According to Kids Count, the latest available federal data, from 2005, showed that 8.2 percent of U.S. babies were born at low birth weight, a level not seen since 1968.

And this is with fully-entrenched welfare and other government benefits and programs designed to prevent this! Something is failing here. Incidentally, that was the year my husband and his twin brother were born, weighing in at 5 something and 6 something pounds. Their two younger brothers each weighed in the 9 pound range!

Beavers said part of the overall increase in low-birthweight babies was due to a rise in multiple births as more older women use fertility treatments to conceive. But she said the birth-weight problem also has been worsening for single-baby deliveries.

It would be good to know how much of the increase is due to multiple births, and how much is due to single births! Let’s compare apples and apples, here. After all, if a woman gets pregnant with quadruplets due to fertility treatment, and these babies are born at 25 weeks weighing less than 1 pound apiece, that is quite a bit different from a baby at 36 weeks weighing 4 pounds. As I stated above, my mother-in-law was obviously able to produce normal-weight babies, but having the twins some 6 weeks early complicates matters!

The rate of low-weight births is sharply higher for blacks (13.6 percent) than for whites (7.3 percent) or Hispanics (6.9 percent). One important factor, Beavers said, is the mother’s overall health at the time of pregnancy and her access to good prenatal care.

Did you know that most doctors, including obstetricians, only get one class in nutrition during med school? Dr. Amy seemed quite proud of that, and said that she learned all she needed to know about nutrition during that one course, because nutrition has only a small effect on health. Um, yeah.

There is another opinion — Dr. Tom Brewer’s opinion, who formulated The Brewer Diet. (On the original “Blue Ribbon Baby” website, [Updated to add: since taken down — I don’t know why — here’s an alternative website], much of the information is in regards to preeclampsia and its various related conditions. I have read many stories of women who followed the diet to a ‘T’ and still ended up with symptoms of preeclampsia, so I don’t consider it to be 100% effective. However, I’ve read many more stories of women who had symptoms of preeclampsia, which went away when they started the Brewer Diet, or simply increased the amount of protein in their diets. I have read a study which suggested that adding too much protein in your diet is linked to babies that were small for their age, so there can be “too much of a good thing.” While I can’t find a link to the study that mentioned it [and I think only the abstract was free], if my memory serves me right, the amount of protein in the study was either 125 or 150 gm per day, while the Brewer Diet is about 100 gm of protein per day.) In general, though, proponents of the Brewer Diet tend to brag about the excellent birthweights of their babies. Here is one such mother. She had a planned home VBAC of twins…. which ended up being triplets! Not only did she not give birth at the average gestational age for triplets (about 32 weeks +/- 1 week, depending on who you ask), nor for twins (about 36-37 weeks). but she actually gave birth a few days after her due date! The triplets ranged in birthweights from 6 lb. 7 oz. to 7 lb. even. Wow. The mom and midwife attributed it to her excellent diet, which was the Brewer Diet.

Dr. Alan Fleischman, medical director of the March of Dimes, said the increase in underweight newborns is closely linked to a rise in premature births.

He agreed with Beavers that better socio-economic conditions for pregnant mothers would help. But Fleischman also said the U.S. medical profession should be more rigorous in encouraging women to continue their pregnancies as close to term as feasible, and reduce the number of early, induced deliveries, often caesarian, that frequently produce underweight infants.

No comment!