This week, Time magazine published an article on genital cosmetic surgery,
“Plastic Surgery Below the Belt,” focused on women getting procedures such as labiaplasty, vaginoplasty, and “G-spot enhancement.” It notes that the American College of Obstetricians and Gynecologists issued a statement that these procedures may lead to “scarring, chronic pain, obstetric risks or reduced sexual pleasure,” and that many are calling for more research on the procedures. In fact, ACOG noted this very problem in their statement, explaining that “No adequate studies have been published assessing the long-term satisfaction, safety, and complication rates for these procedures.”

Featured in the article are protests from the New View Campaign, which has at its goal to “to expose biased research and promotional methods that serve corporate profit rather than people’s pleasure and satisfaction. The Campaign challenges all views that reduce sexual experience to genital biology and thereby ignore the many dimensions of real life” and in general to “limit the medicalization of sexuality.” The group protested New York City’s Manhattan Center for Vaginal Surgery on Monday. Time reports that some attendees held signs referencing the normal variation in female anatomy that read “No two alike;” a visit to the group’s website reveals other messages as well, such as “stop marketing discontent.”

The piece also covers the (mis)conception that cosmetic surgery is an adequate solution to relationship or self-esteem problems. LeLaina Romero of the New View Campaign noted that, “Promoting a very narrow definition of what women’s genitals ought to look like — even for those women who don’t want surgery, it harms them.” Similarly, last year’s statement from ACOG suggested “a frank discussion of the wide range of normal genitalia” and “exploration of nonsurgical interventions, including counseling.”

Along these same lines, I just recently learned via a post at Mom’s Tinfoil Hat about the “MENding Monologues,” an all-male performance inspired by the Vagina Monologues conceived as “a love letter to women, a healing for men, and a call to end violence in all its forms.” One of the monologues is a somewhat humorous character, “Dr. Vaginsky,” who challenges the idea that women aren’t fine just the way they are.

For related OBOS content, see Female Sexual Dysfunction: A Feminist View as well as our previous blog posts, Marketing Female Sexual Dysfunction: The Search for the Pink Viagra and Selling Women Unsupported Health Messages and Insecurity about Their Vaginas.

North Shore Birth Center in Beverly, MA has been in the news recently, as its parent company, Northeast Health System, had planned to close the center and transfer all births to the Beverly Hospital. The center is staffed by nurse-midwives and is intended to offer a more “home-like” and less interventionist approach to birth - it is described in the Boston Globe as “one of only two hospital-affiliated centers statewide that offer natural birth options.”

In their initial statement on the issue, hospital officials explained that, “As with other birth centers around the nation, North Shore Birth Center is experiencing a significant rise in the cost of malpractice insurance premiums.” News of the expected closure sparked pickets, fliers and letters of protest, as well as a Facebook group and blog.

OBOS Executive Director Judy Norsigian issued a letter to the trustees along with Cindy Pearson of the National Women’s Health Network, Ann Sweeney of Massachusetts Friends of Midwives, and Eugene Declercq, Professor of Maternal and Child Health at the Boston University School of Public Health supporting the continued operation of the center. The letter urged the trustees to postpone any decision to close the center in favor of “open[ing] a dialog with community members and women’s health advocates who are deeply concerned about the critical importance of this reproductive choice.”

Yesterday, according to the Boston Globe, supporters of the center rallied outside Beverly Hospital during the anticipated meeting of the Board of Trustees, which responded with a statement indicating that the objections to closure had been noticed and that the Board “is diligently weighing the impact that the closure of the Birth Center would have on the community. The board intends to leave the Birth Center services unchanged while it continues to examine and discuss this important issue.”

Although this may eventually represent a victory for choices in maternal care and birth in one part of Massachusetts, the situation at North Shore reflects an overall climate of reducing choices for women nationwide. As the Globe notes, “The controversy comes amid a larger debate in the medical and legal communities about maternity care and high medical malpractice insurance premiums paid by hospitals and doctors. Concern about malpractice lawsuits has prompted physicians nationwide to become hyper-cautious, and that has driven up the numbers nationwide of more controlled, caesarean section births.”

Please see the Choices in Childbirth statement for discussion of related issues, and this companion content on choosing your health care provider and birth setting.

The Cochrane Collaboration recently released a publication on midwifery-led care for childbirth compared with “other” or “shared care” models. The authors defined midwifery-led care as follows: “the midwife is the woman’s lead professional, but one or more consultations with medical staff are often part of routine practice.”

Other models generally means an ob/gyn as the lead professional (although nurses and midwives may be part of the support team), and shared care might have a varying lead professional depending on where the woman is and whether she is pregnant, in labor, or has already given birth. In other words, the review looks at maternal and neonatal outcomes not by strictly midwife vs. physician, but by who was primarily in charge of the woman’s care over the course of her pregnancy, including labor and the postpartum period.

The authors also note that the included studies were conducted in the public health systems of Australia, Canada, New Zealand and the United Kingdom, so it might be useful to look at the individual studies themselves to assess whether they would be applicable to the U.S. situation and population.

The authors also explain that they selected studies in which women were randomly allocated to midwifery-led vs. other models of care, and that consisted of low- or mixed-risk women. They selected 11 studies, and examined a number of outcomes such as hemorrhage, use of analgesia, induction of labor, c-section, episiotomy, maternal or neonatal death, breastfeeding initiation, and postpartum depression.

The authors concluded that women randomised to midwife-led models of care were less likely to have regional anesthesia/analgesia, instrumental birth, or episiotomy, and were more likely to have spontaneous vaginal birth, to initiate breastfeeding, and to report high perceptions of control during labor. There were no significant differences on a number of other outcomes, such as hemorrhage, neonatal death, labor augmentation or induction, c-section, or duration of hospital stay.

I do have questions about some of the outcomes and limitations of the paper which may require more in-depth analysis of the methods and the original studies. For example, the authors list as a finding that those in midwife-led teams were less likely to experience fetal loss or neonatal death less than 24 weeks; however, they note elsewhere that they included miscarriage and termination of pregnancy in the neonatal outcomes, and it’s not immediately apparent if this might have affected that finding. Readers also might have expected, for example, a lower c-section rate with the midwife-led teams, but it’s not entirely clear how the protocols in place during each individual study affected this decision-making.

Although it is not likely to be a defining paper on midwifery care and choice of birth providers, this Cochrane piece does suggest an interesting consideration - that maternity care often happens via teams of providers working together, and women may want to be better informed about who is primarily in charge of those teams and how that control is negotiated in practice.

Our Bodies Ourselves has just posted “Choices in Childbirth: A Statement by Physicians, Midwives and Women’s Health Advocates who Support Safe Choices in Childbirth,” which articulates concerns about preserving safe choices in childbirth and respect for the diversity of women’s needs. Currently signed by more than 35 midwives, physicians, educators, and other women’s health advocates, the statement urges the following actions:

1. That communities preserve the option of vaginal births after cesarean (so-called “VBACs”).

2. That options for hospital-based midwifery care (utilizing Certified Nurse Midwives and Certified Midwives) be made available in all communities across the country.

3. That Certified Professional Midwives (CPMs) be licensed and regulated in order to make the option of homebirth as safe as possible.

The statement also calls for evidence-based practices in maternity care, and for the American College of Obstetricians and Gynecologists and the American Medical Association “to strike those resolutions that deny childbearing women the autonomy and rights that medical professionals, educators, and women’s health advocates have historically endorsed.”

OBOS Executive Director Judy Norsigian, who was instrumental in coordinating the creation of the statement, explains further:

“During the past 8 months, while I was meeting with maternity care providers and community groups after the publication of ‘Our Bodies, Ourselves: Pregnancy and Birth,’ I was struck by how many people were deeply concerned about current trends in childbearing. At the same time that women’s birthing options were increasingly being restricted and that obstetric practices were moving more and more in the direction of highly medicalized births for ALL women - even those women without pregnancy and labor complications - our national statistics regarding birth outcomes were far from impressive, especially as compared with other industrialized countries.

As a result of many conversations with health care professionals and women’s health educators/advocates, we embarked upon a rather unusual ‘group writing’ project, the result of which is this ‘Choices in Childbirth’ statement. We hope that this effort will reinforce other national initiatives seeking to establish a greater focus on evidence-based practice and a commitment to sustaining women’s desires for safe childbirth alternatives. Liability concerns now appear to be taking precedence in community after community, rather than the well-being of women and their babies. This is a situation that must be addressed before the morbidity and mortality from unnecessary and inappropriate medical interventions become trends too difficult to reverse.”

The statement concludes:

We recognize the central importance of health care reform proposals now under consideration and urge all maternity caregivers to become involved in debates surrounding these proposals. We support efforts to make maternity care safer by reducing the risk of systems errors that can harm patients and lead to litigation. It is time to create a system that allows women all reasonable choices in childbirth and to encourage practices that produce optimal outcomes for both mothers and babies.

Maternity care providers, public health professionals and childbirth advocates who support the statement are invited to become signatories, and can do so by filling out this online form.

A recent issue of the journal Obstetrics & Gynecology includes an article reporting on a survey of more than 31,000 U.S. women on “sexual problems and distress,” including “low arousal,” “low desire,” and “orgasm difficulties.” Slightly more than 44 percent of the women reported at least one of these “problems,” although only 12 percent reported any “sexually related personal distress.”

As I read the study, I was bothered by the assessment mechanism, such as asking women, “How often do you desire to engage in sexual activity?” Those who reported “never” or “rarely” were categorized as having a sexual problem, but it seems clear that not all of the 38.7 percent of women who responded this way were distressed about it. If they’re not bothered, I wondered, why then is it classified as a “problem?”

In an editorial responding to the study (available only by subscription or payment), Dr. Ingrid Nygaard expresses a similar sentiment:

“It isn’t that I believe that changes in sexual function don’t create substantial distress for some women, but ever since an oft-quoted 1999 study concluded that a whopping 43% of U.S. women between ages 18 and 59 years have sexual dysfunction, I have been suspicious that variations of the norm were morphing into diseases.

…One obvious question was raised by a patient recently, who, not bothered herself by her lack of interest but very bothered by her husband’s distress at her lack of interest, asked, ‘Why am I the abnormal one?’”

Nygaard goes on to urge caution when approaching the issue of sexual dysfunction:

“What’s to be gained by overinflating rates and turning symptoms into diseases? Lots — market shares, provider income, grant support, and so on — that is, fame and fortune. What’s lost is less tangible: an increasing sense held by Americans that no one is actually normal, or entirely healthy, or just fine; and, of course, enormous economic cost to the health care system and to society at large.”

The study’s authors acknowledge that their results show that “sexual problems associated with personal distress” are “much less common than previously published and widely quoted prevalence estimates of about 40% for sexual problems (with unknown presence of distress).”

In her editorial, Nygaard goes on to ask how much of this distress may be related to media depictions of sex, asking “I wonder, at what point does sexual dysfunction represent a societal dysfunction rather than a personal health dysfunction?”

Nygaard concludes: “Balancing the daily media barrage of glamorous, stress-free sex with a realistic message about sexual problems and the potential for treatment will help to decrease the burden experienced by couples who are unable to be ‘as one.’ This article importantly sets the stage for such a conversation.”

While it’s important to not pathologize variations in sexuality, it’s also important to avoid minimizing or ignoring women who DO experience distress about their sexual issues, as 12 percent of the women surveyed did. Nygaard expresses similar concerns, noting that, “These one in eight women who feel stress, frustration, worry, anger, embarrassment, or unhappiness about their lack of sexual interest or enjoyment do indeed meet the criteria of a problem: a source of perplexity, distress, or vexation.”

Likewise, the authors note that existing medical conditions, including depression, thyroid problems, anxiety, and urinary incontinence, may be associated with distress for some these women.

For more information on how the medicalization of sexuality can harm women, see the OBOS article “Female Sexual Dysfunction: A Feminist View.”

Good morning, readers! By now you all know that Barack Obama is our President-Elect. However, a number of specific reproductive health issues were up for a vote in this election - RH Reality Check has great coverage of the fate of anti-choice ballot initiatives in this election (links below), and Feministing has a good summary.

The stand-out negative of the election? Prop 8 — the California ballot proposition to amend the state’s Constitution to eliminate any rights to same-sex marriage, officially designating marriage as “between a man and woman”  — has passed.  You can find out more here.

The Center for Reproductive Rights has issued a call on “President-Elect Barack Obama to champion women’s reproductive freedom and equality and restore America’s leadership on these issues.” In their letter [PDF], the Center asks for reproductive health policies guided by science, not ideology, judicial appointments that support established rights, and support of reproductive rights and health in foreign assistance programs.

Most of us are expecting long lines at the polling place on election day. Here are a few websites providing information that may be useful to you as you prepare to vote.

How to take kids to the voting booth on Election Day - tips from an AP writer

Election Day Resources for Voters with Disabilities - Information from the National Disability Rights Network

Know Your Voting Rights - ACLU - state-by-state guide to voting rights; they also have a hotline for questions or voting problems - 1-877-523-2792

Election Protection - Voter rights protection

Project Vote Smart - All kinds of info on voting. Also has directory of contact information for local election offices around the country.

Citizen Media Law Project - Information on documenting your vote.

Urban Voter’s Survival Guide - A checklist of steps to take prior to election day.

Voting Rights During Foreclosure - Good starting place on this topic at Ballotpedia, although you may want to verify locally.

As for me, my Election Day survival kit is going to include a cell phone, numbers for reporting problems, a snack, and maybe some water and reading material. And I’m bringing a buddy!

If you need more convincing of what’s at stake in this election, head over to RH Reality Check and read The Future of Sexual and Reproductive Health.

PS-You may have heard that a number of companies are offering free treats or beverages to voters on Election Day. I just learned this morning that this includes Babeland stores in New York and Seattle, who are giving out free sex toys to voters!

The Center for Gender and Health Equity has released a policy paper on U.S. foreign assistance and its implications for women and reproductive rights, entitled, “Making U.S. Foreign Assistance Work: Sexual and Reproductive Health and Human Rights as Key to Global Development [PDF].”

The authors explain that “many NGOs are preparing to give input to Congress’s considerations for reforming the 1961 Foreign Assistance Act,” but that “overhauling the Foreign Assistance Act will achieve nothing unless policy makers embrace the principle of advancing human rights, specifically by prioritizing the wellbeing, rights, and empowerment of women.” In examining the Millennium Development Goals, they argue that goals of reducing child mortality and poverty, improving maternal health, improving access education, combating HIV/AIDS and other diseases, and other goals all depend on Goal 3, which specifically calls for gender equality and the empowerment of women.

The authors also note that other organizations such as Oxfam have made proposals with important recommendations for reform, but that these existing recommendations “fail to address sexual and reproductive health and rights and women’s equality, even though these have been identified as critical components to global development.”

Among the topics and U.S. activities discussed in the report as hindering the achievement of development goals are prohibitions against prostitution, the Global Gag Rule, the withholding of UNFPA funds, and the push for abstinence-based programs. CHANGE proposes 6 specific reforms, including:

“Eliminate restrictions (including the Mexico City Policy, Anti-Prostitution Loyalty Oath, and denial of funding for UNFPA) and unnecessary reporting requirements, and fund comprehensive sexual and reproductive health programs that integrate HIV prevention based on human rights and public health best practices, allowing communities to determine what interventions meet their needs.”

Other recommendations include the creation of cabinet-level posts on global development and women, aligning U.S. foreign assistance with ICPD Programme of Action and the Millennium Development Goals, greater transparency in U.S. foreign policy goals on sexual and reproductive health, affirming the sexual and reproductive rights of all people, and getting funding directly into the hands of grassroots groups and women.

This weekend, I read Harriet A. Washington’s “Medical Apartheid,” which documents the shocking history of abuse and unethical practices in the conduct of medical research on black Americans. While many of you may have heard of the Tuskegee syphilis experiment, Washington’s work is much more comprehensive, outlining and tying together events from slavery to recent decades.

While reading this work, I wondered how we can “ask hard questions of the physicians who are recruiting in your community,” as Washington urges. It seems that we often only learn of these incidents long after they have occurred, such as through reading this text, and we should keep an eye not just on ethical problems of studies recruiting in our own communities, but wherever medical research is conducted. How do we know what research is being done across the country, before it is reported in the news or books?

One possibility is to examine trials listed in the freely available database of trials funding by the National Institutes of Health (and some other entities). For example, a search for terms such as “prison” and “incarcerated” can give us a clue about the types of research being done in this vulnerable population, and we can at least see a summary of the rationale and who is being included and excluded from the research. The clinicaltrials.gov advanced search does not provide for easy searching by the study’s population group, but keyword searching for terms such as “prison,” “african american,” “low income” and “pregnant” may be useful.

It’s not the neatest method in the world, but a search of the database for “african american” returned at least one study that raised questions, although it is one that has already been completed (with no reporting publications available). The study, “Metabolism of Nicotine and Cotinine in Pregnant African-American Women,” focused on the use of the nicotine patch in pregnant smokers. Reading the summary, I wondered why they focused on this population (has any plausible biological explanation been offered?), why they enrolled pregnant women who “cannot quit smoking within 7 to 10 days after receiving counseling” (is that a reasonable expectation?), and why they applied nicotine patches to these women after preventing them from smoking for 48 hours, enough time for the nicotine levels in their bodies to drop significantly. It seems that they wanted to study how the substances from the patch were metabolized, but I have to wonder if, after a pregnant woman has been without nicotine for 2 days, whether it might be more ethical to help her continue on that path rather than slapping a nicotine patch on her for up to a day (even though it wouldn’t serve the research goal). The summary does not give any indication of whether the women were further assisted with smoking cessation after the end of the trial.

Although further details might be warranted for critique of this specific study, they are not available in a publication, and this example suggests the kinds of questions and concerns that might be raised through keeping an eye on descriptions of federally funded research. It would be a very big job to independently monitor the numerous existing trials, but this, perhaps, is one place to start.

The U.S. Preventive Services Task Force has updated its statement on breastfeeding promotion following a review of the evidence, and recommends that “health care settings use strategies that work with women and families both before and after delivery to encourage and support breastfeeding.” The previous review, published in 2003, did not address prenatal support and had found insufficient evidence for interventions such as counseling by primary care providers.

The Task Force is part of a government agency and focuses on better informing healthcare providers by reviewing evidence of effectiveness and developing recommendations for clinical services. Its recommendation in this case is Grade B, meaning that “There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.”

In the recommendation, the reviewers note that there is evidence that breastfeeding may have health benefits for women and children, and that interventions to support breastfeeding have been found to increase the rates of initiation, duration, and exclusivity of breastfeeding, while the harms of such interventions are thought to be minimal.

The commentary on these potential harms specifically addresses the empowerment of women to make informed choices. The reviewers explain (emphasis added):

“No studies identified for the USPSTF reported harms from interventions to promote and support breastfeeding. Nonetheless, there are potential harms, such as making women feel guilty. Breastfeeding interventions, like all other health care interventions designed to encourage healthy behaviors, should aim to empower individuals to make informed choices supported by the best available evidence. As with interventions to achieve a healthy weight or to quit smoking, breastfeeding interventions should be designed and implemented in ways that do not make women feel guilty when they make an informed choice not to breastfeed.”

The reviewers also note that additional research is needed on issues such as exclusive vs. partial breastfeeding, costs and cost benefits of interventions to promote breastfeeding, the effectiveness of compliance with the World Health Organization’s Baby-Friendly Hospital Initiative in the United States, the effects of individual components of breastfeeding support, and “to allow the tailoring of interventions to the needs of individual women and families.”

The agency’s Recommendation Statement is freely available online, and links to supporting documents are provided here.

Earlier this month, Congress passed and the President signed into law the Prenatally and Postnatally Diagnosed Conditions Awareness Act, a bill “to amend the Public Health Service Act to increase the provision of scientifically sound information and support services to patients receiving a positive test diagnosis for Down syndrome or other prenatally and postnatally diagnosed conditions.”

The act focuses on increasing knowledge and resources, articulating the following purposes:

• increase patient referrals to providers of key support services for women who have received a positive diagnosis for Down syndrome, or other prenatally or postnatally diagnosed conditions, as well as to provide up-to-date information on the range of outcomes for individuals living with the diagnosed condition, including physical, developmental, educational, and psychosocial outcomes;
• strengthen existing networks of support through the Centers for Disease Control and Prevention, the Health Resources and Services Administration, and other patient and provider outreach programs; and
• ensure that patients receive up-to-date, evidence-based information about the accuracy of the test.

Services authorized by the act may include a telephone hotline for those seeking support with regards to diagnoses, creation of a registry of those willing to adopt children with diagnoses such as Down syndrome, further education of health care providers on the issues, and expansion of other support programs.

A joint response issued by the Disability Rights Education and Defense Fund, Generations Ahead, National Women’s Health Network, Reproductive Health Technologies Project, and World Institute on Disability called the law “a positive step toward providing better information and support to pregnant women and new mothers whose fetus or newborn is diagnosed with a disability.”

The organizations also note that “With Democratic Senator Edward Kennedy as an original co-sponsor, the Act does not include anti-choice language nor restrict the ability to obtain an abortion, even though it was authored by Kansas Republican Senator Brownback, a staunch opponent of abortion.”

For further reading on this issue, our OBOS web content provides additional discussion of the politics of prenatal testing and disability rights.

A number of bloggers have written over the past month about a new requirement that immigrants seeking permanent legal status in the United States must receive the HPV vaccine. The requirement is troublesome for a number of reasons, including the lack of an opt-out provision (in contrast to requirements for U.S. citizens), the expense of the series, the lack of significant public health risk posed by omitting this vaccine, and the vulnerability of the affected population.

This requirement originates in the CDC’s vaccination recommendations, which become mandatory for those seeking legal residency. These vaccines are typically for readily infectious diseases such as meningitis, polio, hepatitis, and measles. When the CDC adopted the HPV vaccine (currently only the Gardasil brand shot is available) into its recommendations, that triggered their requirement for immigrants.

Recently, the Wall Street Journal ran a piece on the controversy generated by this requirement, and noted that the CDC claims it never really intended the effect on immigrant populations. According to the piece:

“A CDC spokesman said the experts on the immunization committee didn’t realize their decision would affect tens of thousands of immigrants. However, a government official said the cervical vaccine’s inclusion on the list might be reviewed.”

I would have expected that considerations about the meaning of vaccine recommendations - of what actually happens as a result - might have been part of the decision-making process. Perhaps the CDC will be more alert in the future as to the actual implementation effects of their recommendations. A U.S. Citizenship and Immigration Services spokesperson interviewed by WSJ explained that the mandate is “a statutory requirement. It’s based on CDC recommendations.”

Read additional perspectives on this topic via:

• RH Reality Check
• Feministe
• WoC PhD

The Food & Water Watch program of Democracy in Action alerted us to a public comment period that is closing on Wednesday, October 15 and is collecting comments on the USDA’s child nutrition and WIC programs for consideration prior to the 2009 reauthorization of the programs. Democracy in Action is asking individuals to submit comments requesting that hormone-free and organic milk be among the options in the federal school breakfast and lunch program, and has an action page set up for submitting comments on this topic.

OBOS has written about the topic of rBGH in milk previously - see our web content and this previous post for background information.

The reauthorization will also address WIC, a program intended to improve the nutrition of pregnant and lactating women and their young children - the agency has specifically requested comments regarding the Farmers Market Nutrition Program for provision of fresh fruits and vegetables.

We’ve written previously that, while increasing access to fresh produce is a good thing, the WIC provisions for this (expected to occur mid-2009) are likely inadequate to truly make a difference for women and their families - they’ll add a mere $8/month in vouchers for use at farmers markets. Your comments on the WIC provisions for fresh fruit and veggies can also be submitted prior to Wednesday.

To comment, view Docket FNS-2008-0011at Regulations.gov - click on the HTML or PDF icon beside “Views” to read the request for comments, and click on the yellow icon beside “Add Comments” to submit your suggestions. Comments are due by Wednesday, October 15.

Since the publication of “Our Bodies, Ourselves: Pregnancy and Birth,” OBOS has become increasingly involved in the movement to reform childbirth practices. We have become vocal in criticizing the highly medicalized births that have become the norm for most women and advocating for changes, including increased access to midwifery care and birth centers and the reversal of hospital bans on vaginal births after cesarean (VBAC).

Now a new report has been released that highlights the many shortcomings of the U.S. maternity care system. “Evidence-Based Maternity Care,” a report by Childbirth Connection in conjunction with the Milbank Memorial Fund and the Reforming States Group, focuses on the reality that many common maternity care practices are not based on the most reliable evidence of what is safe and effective.

The report addresses a range of maternity cares issues in the United States, including costs, geographic and institutional variation in practices, and current barriers to improving care. It also addresses specific interventions and concludes with a series of policy recommendations.

The report raises the following important points:

• Financial and other external forces have a large impact on the maternity care that is provided in the United States. This means that the kinds of care mothers and babies receive are often not based solely on what is best for them.
• Becoming informed and being actively involved in making maternity care decisions can dramatically influence the health outcomes and experiences of mothers and babies.
• For women without established problems, having skilled, dedicated support for their innate capacities to give birth (“physiologic childbirth”) will generally be the path to effective care with the least harm. Relying routinely on external procedures, drugs and other interventions during labor and birth can expose women and babies to avoidable harm.

Rather than focusing solely on the idea of overused interventions such as labor induction, epidurals, and cesareans, the report also suggests a list of interventions that may be underused. The authors list midwifery care, smoking cessation interventions, ginger for nausea and vomiting, upright positioning during labor, and interventions related to postpartum depression among several other examples. In other words, the report does not simply argue what not to do, but suggests things to do to potentially improve maternity care, and does not limit these to traditional medical services (such as prescription drugs for morning sickness).

Among the barriers to improving maternity care, the authors discuss the current payment system, malpractice concerns, the use of specialty care, reliance on expert opinion in the absence of solid evidence, lack of provider skill for aspects of labor such as coping support and vaginal breech birth, the slowness with which new evidence is adopted by providers, industry pressure (such as distribution of formula samples), and other challenges. The review of each of these issues provides an interesting overview of the U.S. maternity system and the challenges a woman may face when interacting with that system.

Finally, the review provides four policy recommendations, focused on increasing knowledge and use of evidence-based maternity care, supporting research, reforming the reimbursement system, and requiring performance measurement, reporting, and improvement.

The report has the potential to be an important tool for childbirth advocates and allies as we work to improve legislation and other policies that impact maternity care. As Childbirth Connection Director Maureen Corry states, it is the hope of the authors that “clinicians, health systems, payers, policymakers, consumers and the media” each take a role in implementing the recommendations in order “to ensure that all mothers and babies receive safe, effective and satisfying maternity care.”

The Childbirth Connection website has an overview of the report as well as the full 113-page report (PDF). USA Today also has coverage of the report that focuses on the high economic costs of the failure to incorporate evidence-based practices.

The New York Times recently published a special series to help individuals advocate for their own health. The series included information on reliable health information websites, patients’ use of the Internet for self-education about their symptoms and diagnoses, how to understand a medical research report, what FDA approval really means, and several other topics.

Importantly, the Times pieces represented a largely positive take on patients becoming informed and active in their own healthcare, recommending that people seek second opinions when needed and become informed about what constitutes reliable medical evidence by gaining a basic knowledge of good study design. One physician interviewed, with regards to the tendency to go online for additional information, said:

“We have to acknowledge that patients do this research. It’s important that instead of fighting against it, that we join them and become their coaches in the process.”

The pieces make a stark contrast to the historical (and sometimes current) experiences of many women, who may have experienced hostility and condescension from physicians who took a more paternalistic approach. Taken as a whole, the Times pieces encourage individuals to learn and understand, rather than leaving everything to the doctors.

In touching on the estrogen problem as well as the reliability of research, the pieces also remind us that women have too often been on the receiving end of medical practices and traditions that have not been well-supported by the evidence. From individual practices such as previously routine episiotomies and hormone replacement to broader policies such as those that discourage hospitals from allowing vaginal births after a cesarean, individual women may receive care in environments that don’t support the reliance on evidence, questioning and self-education the Times pieces recommend.

For further details, visit any of the following articles from the Times (or this section page):

• You’re Sick. Now What? Knowledge Is Power.
• Searching for Clarity: A Primer on Medical Studies
• What’s Behind an F.D.A. Stamp?
• You Can Find Dr. Right, With Some Effort
• Applying Science to Alternative Medicine

Of course, OBOS has been recommending that women become informed about and advocate for better healthcare for quite a long time - see our content on Navigating the Health Care System for examples, as well as any of the full OBOS books.