Consumer Reports On Maternity Care

March 3, 2009

Back to basics for safer childbirth
Too many doctors and hospitals are overusing high-tech procedures

Noninvasive measures can mean better outcomes for baby and Mom.When it’s time to bring a new baby into the world, there’s a lot to be said for letting nature take the lead. The normal, hormone-driven changes in the body that naturally occur during delivery can optimize infant health and encourage the easy establishment and continuation of breastfeeding and mother-baby attachment. Childbirth without technical intervention can succeed in leading to a good outcome for mother and child, according to a new report. (Take our maternity-care quiz to test your knowledge.)
“Evidence-Based Maternity Care: What It Is and What It Can Achieve,” co-authored by Carol Sakala and Maureen P. Corry of the nonprofit Childbirth Connection analyzed hundreds of the most recent studies and systematic reviews of maternity care. The 70-page report was issued collaboratively by Childbirth Connection, the Reforming States Group (a voluntary association of state-level health policymakers), and Milbank Memorial Fund, and released on Oct. 8, 2008.

Overuse of high-tech measures

The report found that, in the U.S., too many healthy women with low-risk pregnancies are being routinely subjected to high-tech or invasive interventions that should be reserved for higher-risk pregnancies. Such measures include:

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
In fact, the current style of maternity care is so procedure-intensive that 6 of the 15 most common hospital procedures used in the entire U.S. are related to childbirth. Although most childbearing women in this country are healthy and at low risk for childbirth complications, national surveys reveal that essentially all women who give birth in U.S. hospitals have high rates of use of complex interventions, with risks of adverse effects.

The reasons for this overuse might have more to do with profit and liability issues than with optimal care, the report points out. Hospitals and care providers can increase their insurance reimbursements by administering costly high-tech interventions rather than just watching, waiting, and shepherding the natural process of childbirth.

Convenience for health care workers and patients might be another factor. Naturally occurring labor is not limited to typical working hours. Evidence also shows that a disproportionate amount of tech-driven interventions like Caesarean sections occur during weekday “business hours,” rather than at night, on weekends, or on holidays.

Underuse of high-touch, noninvasive measures

Many practices that have been proven effective and do little to no harm are underused in today’s maternity care for healthy low-risk women. They include:

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
The study suggests that those and other low-cost, beneficial practices are not routinely practiced for several reasons, including limited scope for economic gain, lack of national standards to measure providers’ performance, and a medical tradition that doesn’t prioritize the measurement of adverse effects, or take them into account.


Doulas on the Edge

February 7, 2009

Doula work is rewarding.

Doula work can be difficult.

But doula work is non-clinical and non-invasive.

When I became a doula for military wives in the early 1980’s, the word doula was just a Greek word for the most favored woman in the ancient Greek household. It had not yet been linked to a trained (and often certified) woman who gives informational, educational and physical support to laboring women and their families. Today, after 24 years of practicing as a doula and seven years as a doula trainer for DONA, it disturbs me to hear stories of how my fellow colleagues have stretched…and in some cases stepped outside of the scope of practice of being a doula.

By mutual definition of “doula” of the major organizations now training and certifying doulas (such as ICEA and DONA), doulas perform no clinical tasks such as altering IV drips, rearranging electronic fetal monitors, or performing vaginal exams. Yet doulas in many communities contact us expressing fears of “doulas on the edge” performing such tasks in their communities. What are the implications of these actions and are there any safety nets for either the clients or medical professionals who experience the actions of such “doulas on the edge?”

The implications of such actions is that even though one doula in a community chooses to step outside the bounds of accepted practice, all doulas in that community will feel the repercussions for a long time…months, years. And this ripple affect is difficult to stop!

Women enter the doula profession for many reasons: they have a passion for birth; they have had wonderful birth experiences and would like to “give back” to others so that they may have equally as wonderful experiences; they desire to enter the nursing or midwifery field in the future but choose doula work now as a stepping stone; OR they have a conscious (or unconscious) agenda of saving women from the medical community.

Does this sound harsh or blunt? Probably so. However this last reason for choosing doula work is a stepping stone for becoming a doula on the edge. Armed with a little information/knowledge and a whole lot of attitude, these doulas on the edge chip away at the acceptance that others have worked so hard to attain. They strain relationships between physicians and doulas, nurses and doulas, the public and doulas and each other.

Doula organizations have a Scope of Practice and Code of Ethics that their certified members are expected to follow. It is vital that doulas be held accountable when they step outside of the Scope and Code. If a non-conflictive conversation with the “doula on the edge” does not produce positive responses, contacting that doula’s certifying organization is the next step. Many of the organizations have grievance committees that are activated when a situation arises. Having the committee examine the situation and make recommendations/sanctions to the doula relieves the local doula community of this potentially explosive responsibility and hopefully helps the doula in question to get back on the right track.

Dealing with people that are negative or passive are some of the most challenging relationships. It is not always possible to correctly identify the reason(s) for someone’s poor behavior and so speculation can often lead to additional conflict. In your doula community, try to develop potential solutions for resolving a problem BEFORE it happens. Try to maintain a positive attitude about the person or the situation and this will help you to manage conflict with confidence…resulting in a positive outcome for all!

Link betweeen Maternity Leave, C-sections and Breastfeeding.

January 11, 2009

Two new studies led by researchers at the University of California, Berkeley, suggest that taking maternity leave before and after the birth of a baby is a good investment in terms of health benefits for both mothers and newborns.

One study found that women who started their leave in the last month of pregnancy were less likely to have cesarean deliveries, while another found that new mothers were more likely to establish breastfeeding the longer they delayed their return to work.

Both papers were part of the Juggling Work and Life During Pregnancy study, funded by the Maternal and Child Health Bureau of the U.S. Health Resources and Services Administration and led by Sylvia Guendelman, professor of maternal and child health at UC Berkeley’s School of Public Health. The research takes a rare look into whether taking maternity leave can affect health outcomes in the United States.

“In the public health field, we’d like to decrease the rate of C-sections (cesarean deliveries) and increase the rate of breastfeeding,” said Guendelman. “C-sections are really a costly procedure, leading to extended hospital stays and increased risks of complications from surgery, as well as longer recovery times for the mother. For babies, it is known that breastfeeding protects them from infection and may decrease the risk of SIDS (Sudden Infant Death Syndrome), allergies and obesity. What we’re trying to say here is that taking maternity leave may make good health sense, as well as good economic sense.”

The study on the use of antenatal leave – time off before delivery with the expectation of returning to the employer after giving birth – and the rate of C-sections is the first examination of birth outcomes in U.S. working women, the researchers said. It will appear in the January/February print edition of the journal Women’s Health Issues.

The researchers analyzed data from 447 women who worked full-time in the Southern California counties of Imperial, Orange and San Diego, comparing those who took leave after the 35th week of pregnancy with those who worked throughout the pregnancy to delivery. Only women who gave birth to single babies with no congenital abnormalities were included in the analysis. They adjusted for sociodemographic factors such as income, age and type of occupation, as well as for various health measures such as high blood pressure, body mass index, amount of self-reported stress and average number of hours of sleep at night.

Using a combination of post-delivery telephone interviews and prenatal and birth records, the researchers found that women who took leave before they gave birth were almost four times less likely to have a primary C-section as women who worked through to delivery.

The study authors pointed out that the United States falls behind most industrialized countries in its support for job-protected paid maternity leave. The federal Family and Medical Leave Act provides for only unpaid leave of up to 12 weeks surrounding the birth or adoption of a child.

The bulk of studies on leave-taking and health outcomes from other countries suggest that taking leave prior to birth can be beneficial. The authors point to a macroanalysis of 17 countries in Europe that linked failure to take such leave with low birthweight and infant mortality. Rates of pre-term delivery were lower among female factory workers in France if the women took antenatal leave, and a study conducted in several industrialized countries found that paid leave, but not unpaid leave, significantly decreased low birthweight rates.

According to the U.S. Census, among working women who had their first birth between 2001 and 2003, only 28 percent took leave from their jobs before giving birth while an additional 22 percent quit their jobs. Twenty-six percent of women took no leave before birth.

“We don’t have a culture in the United States of taking rest before the birth of a child because there is an assumption that the real work comes after the baby is born,” said Guendelman. “People forget that mothers need restoration before delivery. In other cultures, including Latino and Asian societies, women are really expected to rest in preparation for this major life event.”

The authors added that financial need may also deter women from taking leave in the last month of pregnancy. Only five states – California, Hawaii, New Jersey, New York, Rhode Island – and the territory of Puerto Rico offer some form of paid pregnancy leave, and none offer full replacement of the woman’s salary.

The study on maternity leave and breastfeeding is in the January issue of the journal Pediatrics. Using data from 770 full-time working mothers in Southern California, researchers assessed whether maternity leave predicted breastfeeding establishment, defined in this study as breastfeeding for at least 30 days after delivery. Phone interviews were conducted 4.5 months, on average, after delivery.

In this study, women who had returned to work by the time of the interview took on average 10.3 weeks of maternity leave. Overall, 82 percent of mothers established breastfeeding within the first month after their babies were born. Among women who established breastfeeding, 65 percent were still breastfeeding at the time of the interview.

Researchers found that women who took less than six weeks of maternity leave had a four-fold greater risk of failure to establish breastfeeding compared with women who were still on maternity leave at the time of the interview. Women who took six to 12 weeks of maternity leave had a two-fold greater risk of failing to establish breastfeeding.

Having a managerial position or a job with autonomy and a flexible work schedule was linked with longer breastfeeding duration in the study. After 30 days, managers had a 40 percent lower chance of stopping breastfeeding, while those with an inflexible work schedule had a 50 percent higher chance of stopping.

Overall, the study found that returning to work within 12 weeks of delivery had a greater impact on breastfeeding establishment for women in non-managerial positions, with inflexible jobs or who reported high psychosocial distress, including serious arguments with a spouse or partner and unusual money problems.

“The findings suggest that if a woman postpones her return to work, she’ll increase her chances of breastfeeding success, especially if she’s got a job where she’s on the clock and has less discretion with her time,” said Guendelman. “Also, women who are in jobs where they have more authority may feel more empowered with how they use their time.”

The American Academy of Pediatrics (AAP) recommends that babies be breastfed for at least the first year of life, and exclusively so for the first four to six months.

According to the AAP, increased breastfeeding has the potential for decreasing annual health costs in the U.S. by $3.6 billion and decreasing parental employee absenteeism, the environmental burden for disposal of formula cans and bottles, and energy demands for production and transport of formula.

The study authors noted that just having maternity leave benefits offered by an employer was not helpful in breastfeeding establishment unless the leave was actually used, indicating the importance of encouraging the use of maternity leave and making it economically feasible to take it.

“These new studies suggest that making it feasible for more working mothers to take maternity leave both before and after birth is a smart investment,” said Guendelman.

Article adapted by Medical News Today from original press release.

Other co-authors of the paper in Women’s Health Issues are Michelle Pearl and Steve Graham, senior research scientists at the Sequoia Foundation, a California-based non-profit organization focused on public health research; Alan Hubbard, UC Berkeley assistant professor of biostatistics; Dr. Nap Hosang, lecturer at UC Berkeley’s Maternal and Child Health program and a practicing obstetrician; and Martin Kharrazi, research scientist supervisor in the California Department of Public Health Genetic Disease Screening Program.

In addition to Guendelman, Pearl, Graham and Kharrazi, the Pediatrics paper was co-authored by Jessica Lang Kosa, research associate, and Julia Goodman, former graduate student, both at UC Berkeley’s School of Public Health.

The study published in Women’s Health Issues received additional funding from the Center for Health Research at UC Berkeley. The paper in Pediatrics also received support from the UC Labor and Employment Research Fund and the UC Berkeley Institute for Research on Labor and Employment.

Source: Sarah Yang
University of California – Berkeley

Article URL:

Homebirth Classes Beginning in the Springs!

January 11, 2009

**HOMEBIRTH SERIES begins Saturdays 1/24/09**

I created this home birth series specifically to meet the needs of home birthing couples.

When planning a home birth, the run-of-the-mill childbirth course won’t cut it!

This series is focused on heath and preventative care, practical, non-medical alternatives to pain relief, practice of relaxation techniques (for labor and life with babies), moving through labor, and presenting information in a non threatening way so you can make your own informed choices for every aspect of pregnancy, labor and caring for your newborn. Classes are taught in small groups of home birthing couples, by a homebirth couple in a relaxed home environment.

We meet SATURDAYS, 7:30pm at my centrally located home.
Series is $150/6 weeks, but you are welcome to pick and choose which classes to attend for a flat $25/per class fee.
see website or call for specific question or to check out my class outline

Carrie Anderson, CCE, LD
Birthing Naturally Childbirth Education

December 7, 2008

preventable Cesarean costs in the US and Colorado

November 29, 2008

The Unkindest Cut

     Cesarean is the most common surgery performed on women in the United States.  A cesarean (si-‘zar-E-an) section is major abdominal surgery used for the delivery of an infant through an incision in the mother’s abdomen and uterus. According to the Centers for Disease Control, the cesarean rate in 2007 hit an all time record high of 31.1% of all births.  This is a 50% rise over the past decade, and almost a six-fold increase since 1970, when 5.5% of women gave birth via cesarean section. To combat this alarming trend, professionally trained Doulas should be offered to all laboring women because the support they offer has been shown to significantly reduce the cesarean rate.
     Obstetricians often offer the excuse of defensive medicine for rising U.S. cesarean rate. This means that they are choosing to perform unnecessary surgery in the belief that it will help avoids lawsuits. I think it’s unconscionable to put a woman’s a life, quality of life, relationship with her husband and family, relationship with her child, and future childbearing at risk; not to mention costing the healthcare industry billions each year; simply in the hope of avoiding a lawsuit. Their logic is understandable, but faulty.
According to a study published in the Lancet, “decision to take legal action was determined not only by the original injury, but also by insensitive handling and poor communication after the original incident” (Why do people sue Doctors? Lancet 1994, p343). A doula’s role in a hospital setting is often one of interpreter; being trained both in hospital protocols and communicating with women under the influence of labor hormones and stress, she is in a unique position to prevent misunderstandings which lead to litigation.  We also know that a doula’s support during labor increases a woman’s satisfaction with her experience. In a recent study, of 422 couples who had the support of a doula during their birth, 100% rated their experience with the doula positively (Birth Journal June 2008 pg 2).
 The risk to mothers and babies, as well as the financial costs the of all of these unnecessary operations births, has prompted leading medical agencies such as the World Health Organization, the Centers for Disease Control and Prevention, and the National Institutes of Health to call upon the medical community to reduce the cesarean rate to 15% or less. Last year over 4 million babies were born in United States which translates to 1.8 million unnecessary surgeries.   
    A cesarean poses serious risk the mother and her child, and those risks can only be accepted when the reason for the cesarean has higher risks then the operation.  Some of the risks to the mother include infection, blood loss, hemorrhage, hysterectomy, transfusions, bladder and bowel injury, endometriosis of the site of the incision, heart and lung complications, blood clots in the legs, anesthesia complications, and re-hospitalization. Fully one-half of all women who have undergone a cesarean section suffer complications, and the death rate for mothers is two to four times higher then with vaginal birth. Approximately 200 women die yearly in the United States from complications of elective repeat (cesareans, done at women’s request for no medical need) cesarean. Each successive cesarean greatly increases the risk of developing placenta problems in future pregnancies (such as placental previa,  accreta  and abruption).These complications pose life-threatening risks to both mother and baby. Cesareans also increase the odds of secondary infertility, miscarriage and ectopic pregnancy in subsequent pregnancies.
A cesarean also poses documented medical risks to the baby’s health as well. These risks include respiratory distress syndrome, iatrogenic prematurity (this is when surgery is performed because of error in determining the due date), persistent pulmonary hypertension (PPH), and surgery-related fetal injuries such as lacerations.
Having a trained non-medical support person, or doula, present during labor reduces the need for medical intervention, and raises parents’ satisfaction after childbirth. A tremendous amount of research has been done surrounding the importance and benefit of having a labor doula assist as a part of the birth team. Research shows that having a labor doula “reduces the overall cesarean rate by 50%, the length of labor by25%, Oxytocin use by 40%, pain medication by 30%, the need for forceps by 40%, and requests for epidurals by 60%”.  Mothers who were attended by labor doulas also felt their birth experiences were more positive, their self-image was improved; they felt their babies were healthier, and they felt their relationship with their husband or partner was improved. (Mothering the Mother by Klaus, Kennell, and Klaus ).  Furthermore, in 1999, the Cochrane Library reported on 14 clinical studies involving more than 5000 women. They found that with the continuous presence of a trained support person, the likelihood of episiotomy, cesarean delivery, operative vaginal delivery, medication for pain relief, and a 5-minute apgar score for the baby was reduced.
     Unnecessary cesarean surgery costs the US government billions in health care costs each year.  Last year alone, over four million babies were born; 1.2 million of them by this largely preventable operation.  While vaginal delivery typically requires two days of hospitalization and a one-week recovery, C-section requires four days of hospitalization and a two-week recovery. According to the Agency for Healthcare Research and Quality in Rockville, Md., the average cost of a vaginal delivery is $5,574, while the average cost of C-section is $11,361. If we were able, by the benefit of doulas supporting women in hospitals, to reduce the national rate of cesareans from 31- 15% we could save insurance companies, taxpayers, business owners and private citizens roughly $1,704,150,000 annually. These numbers do not even include the cost of anesthesia, prescription pain relief often used in the days and weeks following a cesarean, prolonged hospital stay or the use of neonatal intensive care for infant.
     The Colorado statewide cesarean rate is below the national average at only 25.9%; however that is still 10% higher then it should be. If we were able to lower just our state of Colorado’s cesarean rate to about 15%, which is what the World Health organization, the Centers for Disease Control and Prevention, and the National Institutes of Health have all called “the highest rate that is acceptable”, the cost savings would have been approximately $5,264,778,905.  In 2007, there were 4,315,000 babies born in Colorado hospitals.  25.9% of those babies were born by cesarean section surgery at a cost to area hospitals of $6,008,639,905.  A hospital based doula program would allow more mothers to have their babies without costly, painful and dangerous risks of a preventable cesarean surgery.

copyright Carrie Anderson 2008, refrences available upon request

Childbirth Refresher Course

November 29, 2008

I’m cutting the price of my Labor Skills Workshop, due to the Holidays (and celebrating my Shingles recovery and ability to work around pregnant woman and infants again)!

One Night Childbirth Refresher $30
7-9pm Sat. December 13th, 2008
by Carrie Anderson, CCE, LD

This two hour  fast-paced workshop was created for women and their partners. You will learn the how, what, where, when and why of providing comfort during labor. Get  hands on practice, practical knowledge, reference guide to positions and LOTS of useful BTDT advice. Holiday price includes workbook and refreshments.