The process of in vitro fertilization – in which embryos are created outside a woman’s body and then implanted in her uterus — has become increasingly common in the United States. In 2010, 61,564 infants were born using an a form of assisted reproduction technology (ART), and almost all of those resulted from IVF.

A common IVF practice has involved transferring multiple embryos to a woman’s body in one cycle. This was thought to increase the likelihood that at least one embryo would successfully result in a live birth. The average number of embryos transferred at one time is two to three.

While this strategy makes sense theoretically, it is not risk free. Transferring more than one embryo creates a risk for multiple pregnancies, such as twins or triplets, which makes the pregnancy higher risk and increases the risk of premature birth and low birth weight. (Single pregnancies created via IVF are also thought to be at a higher risk for prematurity, low birth weight, and congenital anomalies, though researchers aren’t certain whether this is due to the IVF techniques or the underlying infertility problem.)

Recently, researchers have been studying whether single embryo transfer might be a better option. Some have suggested that birth rates might be similar when single embryos are transferred.

The research has been convincing. In a joint practice committee statement, the Society for Assisted Reproductive Technology and the American Society for Reproductive Medicine concludes that with improving technology, single embryo transfer (SET) is an increasingly better choice for achieving pregnancy while avoiding multiples.

The statement notes that SET may be particularly appropriate for women with the best chance of a good outcome, such as those who are under 35 or on their first or second treatment cycle, and that women ages 35 to 40 could also elect SET if they have “top quality” embryos of the proper stage available for transfer.

The authors also note that the United States has “lagged behind” the rest of the world in focusing on SET. For example, the National Institute for Health and Care Excellence (NICE) in the UK recommends single embryo transfer for most women and no more than two at a time for anyone.

For more on single-embryo transfers, read this excerpt from “Our Bodies, Ourselves.”

Childbirth Connection, a nonprofit organization that produces evidence-based information and resources on pregnancy, labor and birth, and the postpartum period, has released its third major survey on the experiences of childbearing women in hospitals across the United States.

The results of Listening to Mothers III provide insights into numerous issues, including childbirth education; the use and need of government services such as the Special Supplemental Nutrition Program for Women, Infants and Children (WIC); medical interventions during birth; provider choice; and health disparities.

The 2,400 women who completed the online survey were 18-45 years of age, gave birth in a U.S. hospital to a surviving single baby at some point between July 1, 2011 and June 30, 2012, and could participate in English. The research firm Harris Interactive collected the data.

Among the findings, the number one factor driving a woman’s choice of maternity care provider and hospital was acceptance of her health insurance plan. Insurance compatibility ranked higher than  recommendation by a provider, friend or family member, and higher than familiarity due to a previous birth.

Only about half of the women ever saw information that allowed them to compare the quality of potential providers and hospitals, but when they did have that information, 80 percent used it as a factor in their decision.

Pregnant women reported difficulty communicating with their providers at times — 30 percent said that at least once they had let a question go unasked because their provider seemed rushed, and 15 percent reported that their prenatal care provider “always” or “usually” used medical words they did not understand.

The survey provides a variety of data about various medical interventions, including induction, mode of birth, pain relief, labor support.

Close to one-third (31 percent) of survey participants had Cesarean-sections, which is pretty similar to the overall national rate.

There are a number of data points that suggest practices that are not evidence-based or are otherwise problematic, including hospitals not allowing VBAC attempts, somewhat high (17 percent) rate of episiotomy, reports of pubic hair shaving (10 percent for vaginal birth), c-sections performed because the provider had concerns about the baby being too big, and providing formula samples/coupons to moms and bottles with formula or water to babies, even when the moms wanted to exclusively breastfeed.

While it’s not clear how accurately the provider rationale and medical interventions were self-reported by the women, they’re worth a look for women’s perspectives on their care before, during and after childbirth.

The report includes women’s stories about these interventions, and the sometimes-poor communication they experienced with their providers. One respondent commented: “I was not told that I was going to need an episiotomy, and it was done without my permission. I just would have liked to know what an episiotomy was, why it happens, and what it’s like to deal with and take care of after giving birth.”

Another woman reported: “I felt bad because the doctor delivering my baby didn’t give me details. He just told me my baby was in danger and that I needed a c section. I believed him because I care about my baby.”

A companion report, “Listening to Mothers III: New Mothers Speak Out,” will explore postpartum experiences and further explore childbearing and maternity care. It is expected to be released later this month.

The Reproductive Justice: Activists, Advocates, Academics in Ann Arbor (“A3 in A2″) conference taking place this week aims to foster learning, dialogue and collaboration around reproductive justice issues. OBOS Executive Director Judy Norsigian, one of the conference advisory board members, is leading a session on informed consent and moderating Friday’s final panel.

Until recently, the term reproductive justice was used mainly by a relatively small number of people involved with abortion rights and women’s reproductive health (read about its history at SisterSong). The phrasing is more inclusive than abortion rights and takes into account all aspects of women’s ability to control their own reproduction, including social inequalities that affect the ability and right to have or not have children and to parent children in healthy environments.

The term has been discussed, and debated, quite a bit lately. Over at RH Reality Check, Jon O’Brien, president of Catholics for Choice, recently argued why reproductive justice cannot be a substitute for the terms “choice” or “pro-choice,” prompting this response from reproductive justice activists (who, it should be noted, consider Catholics for Choice an ally). Their response notes in part:

Women of color struggled within the pro-choice movement to bring their needs to the forefront, and they also created new organizations built on a broad, intersectional analysis and understanding of reproductive rights and health. The shift from choice to justice does not, as O’Brien says, devalue the autonomy of women who face obstacles. Instead, locating women’s autonomy and self-determination in human rights rather than in individual rights and privacy gives a more inclusive and realistic account of both autonomy and what is required to ensure that all women have it. Advocating for reproductive justice was not counter-posed against being “pro-choice” or supporting abortion rights. Rather, reproductive justice re-framed and included both.

The push toward a more comprehensive understanding of reproductive rights has also been adopted by the Unitarian Universalist Association (UUA) of Congregations. Delegates at last year’s General Assembly meeting selected “Reproductive Justice: Expanding Our Social Justice Calling” as the 2012-2016 Congregational Study/Action Issue — meaning congregations and districts are invited to engage and reflect on it, in any way they see fit — and the subject will be the focus of this summer’s GA meeting.

Earlier this year, Billy Moyers invited Jessica González-Rojas, executive director of the National Latina Institute for Reproductive Health, and Lynn Paltrow, founder and executive director of National Advocates for Pregnant Women, to discuss the topic.

“What’s happened is that women are beginning to recognize that what’s at stake is more than abortion,” said Paltrow. “It is their personhood — their ability to be full, equal, constitutional persons in the United States of America.”

For more information: Check out the Reproductive Justice Briefing Book. Produced by the Pro-Choice Public Education Project, it offers a comprehensive look at a variety of topics, including sex education, abortion, adoption, pregnancy, disability, incarceration, immigrants, LGBT issues, race, and class.

First in an occasional series by OBOS staff about their work and their lives.

I was welcomed into the Our Bodies Ourselves family in January 2006, soon after I moved to Boston from India. As a die-hard reproductive justice advocate (and unabashed “Our Bodies, Ourselves” fan), I was euphoric to join the team.

The OBOS Global Initiative, which supports women’s organizations developing and using culturally specific materials based on “Our Bodies, Ourselves,” offered the perfect opportunity to weave together my commitment to women’s rights and cross-cultural movement building.

Eight years later, I have helped shepherd the development of resources based on “Our Bodies, Ourselves” in 12 additional languages (with more in development), and coalesced a global network of social change activists.

I have been privileged to meet, learn from, and grow to love this group of women, each on the frontline of human rights work in her country. I know that OBOS’s partnerships with these visionary and tenacious leaders represent a community of shared interests that is pivotal to protecting the lives of women and girls on the ground.

Beyond OBOS, I nurture my decade-long love affair with reproductive justice by supporting families with newborns. As a postpartum doula trained by DONA International, the oldest and largest doula association in the world, and young mum (and as a child who benefitted enormously from the loving arms of extended family), I am personally affected by and committed to changing the state of postpartum care in the United States — one mummy at a time!

My doula-ing started rather unexpectedly and informally in 2009, with the birth of my niece. Though I have always been acutely aware of the growing global crisis in maternal and postpartum care through my work overseas and at OBOS, being with my sister and her family during and after the birth was transformative — the proverbial eye-opener. I quickly became aware of the awesomeness of their task; a task that really does take a village.

At the time, my goal was simple: to love and provide everything my sister and her partner needed to stay nourished and focused on their baby and each other. From hot meals and daily grocery runs, to endless loads of laundry and late-night, sleepy-eyed banter to keep my sister awake (and laughing) through yet another round of pumping, I did my best and loved (nearly) every moment of it.

OBOS, with its four-decade journey and networks of women’s health activists, has connected me with women who, like me, are drawn to the sides of expectant and new mothers. With these relationships, I am now gaining stride in my doula-clogs.

I thank the families that have let me into their homes and lives; I am honored and humbled by their trust. As OBOS expands its global reach, I thank the women who have become our steadfast co-conspirators in a collective struggle. I am inspired by the fire in their bellies.

And to all of you: I thank you for cheering us on and hope you will remain our committed partners as we plough ahead, forging a global community where women live without fear, with dignity, wrought as a fundamental human right.

Ayesha Chatterjee is the OBOS Global Initiative program manager.

by Miriam Zoll

In an essay recently published in the Wall Street Journal, Sarah Elizabeth Richards, author of the new book “Motherhood Rescheduled,” encourages women to ward off age-related infertility by simply freezing their eggs — like she did.

Between the ages of 36 and 38, Richards spent $50,000 to freeze 70 eggs that she plans to thaw, fertilize, and insert into her uterus when she is 44 or 46.

“Egg freezing,” she said, “stopped the sadness that I was feeling at losing my chance to have the child I had dreamed about my entire life.” Still looking for a mate at almost 40, Richards says she now goes onto Match.com and has the confidence to tell men that she can “have kids whenever I want.”

While Richards’ decision appears to have provided her with a sense of hope and temporary emotional equilibrium, it may prove to be illusory. Sadly, as millions of women, including me, can attest, the vast majority of assisted reproductive technologies fail.

In 2012, of the 1.5 million treatments performed globally, 1.1 million failed: a 77 percent failure rate. In the United States, the overall failure rate was 68 percent. Once optimistic and hopeful about the promise of reproductive science, I endured four failed in vitro fertilization (IVF) cycles, one miscarriage, and two donor egg attempts in which both donors were diagnosed as being infertile.

But it is no wonder that Richards believes she will be able to bear children with her frozen eggs whenever she wants to. A $4 billion industry is driving the public discourse about often unproven discoveries through a lens that focuses attention on the minority of successes rather than the whole messy, complicated story.

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Related: What’s Wrong With Fertility Clinics and Online Advertising

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Growing up in a culture that reveres science, she has been bombarded with overly optimistic and one-sided media stories touting the miracles of creating babies in laboratories. The truth is, many women signing up for treatments do not realize until later the extent to which they are participating in a vast experiment, where evidence-based medicine has yet to establish a reasonable foothold.

The only current independent effort to track the health of all women going through treatments remains largely invisible to patients who might sign up to have their health — and that of their offspring — tracked over time.

The voluntary Infertility Family Research Registry is based at the Dartmouth Hitchcock Medical Center and is funded in part by the American Society for Reproductive Medicine (ASRM). To date, the vast majority of large fertility centers in the United States are not displaying the registry’s placard in their waiting rooms, greatly reducing the potential benefits such a long-term study would provide. [Ed note: Our Bodies Ourselves is actively encouraging infertility clinics and centers across the country to promote awareness of the Infertility Family Research Registry.]

Richards’ desire to protect her ability to bear a biological child is heartfelt, and her willingness to undergo egg freezing procedures that were considered experimental at the time speaks to her commitment — and her panic — to try anything to preserve that opportunity. But her statement that this decision was “the best investment” she ever made is premature, to say the least.

The general public knows virtually nothing about the failure and success rates of vitrification — a new flash-freezing technique that has been used to preserve the eggs of women younger than 30 who are facing life-threatening illnesses. While an estimated 1,000 babies have been born from this technology worldwide, there is virtually no data that tells us if these live births were the result of 3,000 or 10,000 trials.

We have no idea how many miscarriages or still births may have ensued, and there are few, if any, long-term infant health studies evaluating how flash freezing half of a child’s DNA might affect that child later in life. The one study Richards cites found that 900 babies exhibited no more risk of birth defects than babies conceived naturally by young mothers, but is one study really enough?

Apparently the ASRM believed it was proof enough for them to lift the “experimental” label from the still young procedure last fall. The ASRM Practice Committee said it was not yet ready to endorse widespread use of egg freezing for elective use. However, while randomized controlled studies were rare, the committee did find sufficient evidence to “demonstrate acceptable success rates in young, highly selected populations.”

Citing a lack of data on safety, efficacy, cost-effectiveness, and potential emotional risks, their report states, “Marketing this technology for the purpose of deferring childbearing may give women false hope and encourage them to delay childbearing. Patients who wish to pursue this technology should be carefully counseled.”

As would be expected, once the ASRM decision became public, their caution about women’s age and infant health was obscured and eventually obliterated by the dust kicked up by a stampede of panicked but hopeful 30- and 40-something women running to the nearest fertility clinic to have their eggs harvested for future use — for anywhere between $10,000 and $15,000 per harvest, or more.

One must wonder why the ASRM felt so compelled to provide a stamp of approval for a procedure still lacking in reliable safety and efficacy data. As legal scholars Debora Spar and Naomi Cahn have written in their books, “The Baby Business” and “Test Tube Babies,” respectively, in the context of an unregulated industry in the United States, it is virtually impossible to separate the medical and market forces at play when new techniques and procedures are advertised to potential clients.

The blurred boundaries between fertility clinics wanting to provide patients with safe, evidence-based procedures while also needing to generate business to meet their bottom lines puts that much more pressure on consumers to know what they are signing up for. But when evidence and information is scarce, biased, or non-existent, well-heeled consumers like Richards feel they have no choice but to close their eyes, write a check, and jump off that technological cliff called “hope.”

For Richards’ sake, I hope she succeeds. If not, she may well join the ranks of millions of men and women who, since the first IVF baby was born in Britain 35 years ago, have experienced involuntary biological childlessness as a result of delaying parenthood and relying on science for last-minute miracles.

Miriam Zoll is an award-winning writer and an international health and human rights advocate and educator. She is the author of “Cracked Open: Liberty, Fertility and the Pursuit of High Tech Babies” and is on the board of Our Bodies Ourselves. This article was originally published at RH Reality Check, and is reprinted with permission.

Although there is a fair amount of information and research available on postpartum depression in general, very little of it seems to focus specifically on the needs or care of teen mothers.

A pilot study published in the American Journal of Obstetrics and Gynecology in March attempts to fill in this gap — and it shows some promising results.

First, the authors explain why the risks of PPD in teens are important:

PPD puts adolescent mothers and their children at risk during an already challenging time in their lives, and this hardship may be a major determinant of poor outcomes for these young mothers and their children. Untreated, depression is associated with school dropout, suicide, and substance use. Among adolescent mothers, evidence suggests that depression may prevent them from engaging in health-promoting behaviors for their infants and themselves.

The study is based on a randomized controlled trial of the REACH program (Relax, Encourage, Appreciate, Communicate, Help), which is designed to help expectant mothers develop stress management and other skills. The program was offered as structured therapy during pregnancy, followed by a postpartum “booster” session.

Participants in the therapy group used interpersonal therapy to work on effective communication skills, conflict management, improving their social support systems and building healthy relationships, and goal setting. They, as well as the control group, received a handbook of typical pregnancy and postpartum/newborn health information. A total of 106 teens age 17 or younger and without pre-existing mental health issues were randomized to the therapy or control groups.

The researchers looked for major depressive episodes within the six months after birth. Although only 12.5 percent of the REACH teens developed postpartum depression, compared with 25 percent of the control teens, the results were not statistically significant, as the study was fairly small and very few teens (19) overall developed postpartum depression. A larger study may be needed to better determine the utility of the program.

Despite a lack of clear effect, the study highlights a need for further investigation into the postpartum mental health needs of teens. As the authors explain:

Although validated treatments for adolescent depression exist and include interpersonal therapy, cognitive behavioral therapy, and antidepressant medication, teen mothers with mental health problems are mostly under treated. To date, only one published report of 2 small open-trial pilot studies addressed treatment for depression in pregnant adolescents. Despite the potentially high burden of depression to young women and their families, studies on the prevention of PPD in pregnant adolescents are virtually nonexistent.

Another lesson learned in this study was that teens preferred individual therapy sessions over the planned group sessions, so sessions were adjusted to be one-on-one. The researchers also took care to specifically design the REACH program to be culturally appropriate for a diverse group of racial and ethnic backgrounds.

Update: A second public event has been added, also co-sponsored by Our Bodies Ourselves: “Systemic Violence or Informed Consent? The Politics of New Reproductive Technologies and Medical Experimentation in India” is the theme of the program at MIT on Tuesday, April 23, which will include the film screening and remarks by Sama’s co-founder, Sarojini N. The event will take place in MIT Bldg. 5, Room 217, at 7 p.m.

The rise of commercial surrogacy has led to numerous concerns and conversations involving women’s health and medical ethics. On Monday, April 22, Our Bodies Ourselves will sponsor a screening of “Can We See the Baby Bump, Please?” — a documentary film about commercial surrogacy in India that explores the ethical challenges.

The screening will take place at Boston University’s Bakst Auditorium at 5 p.m. and is free and open to the public. Co-sponsors include the Health Law, Bioethics and Human Rights Department of the School of Public Health and the student-led Health and Human Rights Caucus.

From film director Surabhi Sharma’s website:

The global reach of medical tourism and commercial surrogacy spawns a range of clinics and practices across big cities and small towns in India. Anonymous, often with limited choice, woman’s labour is yet again pushed into the background. A whiff of immorality, the absence of regulation and the erasure of the surrogate’s experience collude to produce a climate of callousness. May we see the baby bump please? meets with surrogates, doctors, law firms,agents, and family in an attempt to understand the context of surrogacy in India.

The film was commissioned by the Sama Resource Group for Women and Health in New Delhi (view Sama’s blog for more on the film and a recent study on commercial surrogacy).

Sarojini N., the director and co-founder of Sama, will attend the screening and discuss her organization’s recent research on surrogacy practices, and strategies to address medical malpractice and the exploitation of women hired to be gestational mothers.

In 2012, Judy Norsigian, OBOS founder and executive director, traveled to Kathmandu to lead a workshop with Sarojini and Renu Rajbhandari, founder of the Women’s Rehabilitation Centre, OBOS’s Global Network partner in Nepal, on the growing popularity of cross-border surrogacy arrangements. Their presentation included effective strategies that could be used to educate and empower women.

“Already a booming business in India, where estimates suggest that 25,000 couples a year travel to arrange surrogacy contracts and there are about 1,000 surrogacy centers, this practice is soon expected to extend to Nepal, where poor women with limited economic opportunities will likely be attracted by the prospect of earning money by bearing children for others,” wrote Norsigian.

Read about her experience and learn more about the growing market in cross-border reproductive health care.

by Allison Saran

Some of the world’s greatest medical discoveries never receive the attention they deserve. For Canadian physician Michael Klein, the attention came late, but it’s been growing ever since.

And thanks to one very humorous and talented fan, Klein’s work is immortalized in rhyme.

Dr. Jerry Kruse, the newly named executive associate dean of the School of Medicine at Southern Illinois University School of Medicine, where he had been chair of the department of Family and Community Medicine, has a flair for writing poetry and limericks – often under the pseudonym of Dr. Kreuss, which, yes, rhymes with “Seuss.”

Kruse’s talents were on full display last December at the annual meeting of the North American Primary Care Research Group. In the video above, he pays tribute to Klein, who is widely known for his landmark randomized control trial that showed routine episiotomies during childbirth (an incision on the perineum and the posterior vaginal wall during second stage of labor) cause an increase in the very complications they aim to prevent.

Klein believed that women given routine episiotomies experienced deeper perineal tears than women who were not given episiotomies. Though his study confirmed this, it was initially met with resistance within the medical community. In 1992, eight years after the original request for publication in an accredited journal, Klein’s findings were finally published.

Once released, the study caused a medical, and thus cultural, shift. Routine episiotomy was slowly abandoned by medical caregivers (“scissors were thrown to the floor with disdain,” notes Kruse in his poem) and with that, severe perineal injuries declined.

The results of Klein’s trial helped to decrease episiotomies not only in Canada, but throughout the world. In his opening remarks, Kruse credits Klein with “improving the lives of millions of women.”

In “The Saga of Michael Klein,” billed as the story of Klein’s “search for truth regarding episiotomy,” Kruse begins with a description of Klein’s holistic obstetric practice. Klein had advocated that women in labor should not be treated as if they have a disease, and that the first intervention during labor often leads to a cascade of other interventions, disrupting a natural process.

Here’s an excerpt:

Michael knew in his heart, way deep down inside
That obstetrical knowledge was not well applied.
“Technology’s great, for those who are ill,
But for those who are healthy it’s really no thrill
To be strapped down and poked, and scared stiff as a board.
This just isn’t right!” his fervent voice roared.

One thing more than others, did gnaw at his heart,
Made his blood boil, and stung like a dart.
He just couldn’t stand it, to see a long slice,
A cut, an epis – what a terrible vice,
Disruption of skin for no reason at all,
A snip with the scissors that starts very small
But rips and extends as the baby comes through
Tears into the sphincter and up the wazoo.
A third, then a fourth, oh my what a mess
“They must like to sew,” was his only guess.

So Michael rose up, and he raised his right hand
And opened his mouth, and took a firm stand:
“I’ll study this problem,” he said with a shout,
“And when I am finished there won’t be a doubt
That these cuts are no good—the whole world will see—
This idea’s a good one, they’ll have to agree.
I’ll start up a randomized, single-blind study
And I’ll work with Michel who’s my very good buddy
And we’ll put ole’ McGill right here on the map.
This study of perineal trauma’s a snap.

“The Saga of Michael Klein” concludes with a clear message: Never give up on your cause if the research is true and good can come of it.

Klein’s quest is one of many that healthcare providers and birth advocates have completed to make birth healthier and safer for all women. No matter if you are a doctor, midwife, nurse, pregnant woman, or just someone who cares about childbirth, “The Saga of Michael Klein” encourages you to laugh – and to carry the hope of bettering birth.

Ed. note: You can view the full poem in Family Medicine journal (October 2012), along with a complete bibliography.

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Allison Saran is a senior at Brandeis University, majoring in anthropology and public health. She is a keen advocate for evidence-based birth and is excited to continue her studies at the Yale School of Nursing (CNM speciality). 

While cesarean rates (which reached an all-time high in 2007) are known to vary widely by state, they also vary quite a bit by hospital. One common explanation for this has been that different hospitals have different c-section rates because they see different types of patients – patients who are sicker or healthier, or more likely to have complications requiring cesarean.

In an article published in PLOS ONE, researchers report findings from a study designed to look at other factors that influence cesarean rates. The authors looked at birth certificate and hospital discharge data in Massachusetts to determine which factors were linked to cesarean rates at each hospital.

The researchers focused on first births of single, non-breech births in Massachusetts hospitals from the beginning of 2004 through the end of 2006. They report that at the hospital level, the percent of cesarean deliveries varied between 14.0 percent and 38.3 percent (average of 26.4 percent). Then they adjusted for health and sociodemographic factors, like labor induction and maternal age, that are linked to higher rates of cesarean.

They found, predictably, that individual risk for cesarean varied by demographic, socioeconomic, pregnancy, and preexisting medical conditions. After they adjusted for these factors, though, there was still significant variation in rates between hospitals that could not be explained by those medical and personal risk factors.

While the authors did not set out to explain why this variation occurred, they note that it has been observed in other studies (such as in Arizona, and in military hospitals), and that contributing factors may include liability- and insurance-related factors, whether a woman delivers at a teaching hospital, the provider’s approach to delivery, hospital practices related to labor induction and augmentation, and others. They conclude that additional research is needed on hospital characteristics to figure out what is driving variability between hospitals and reduce the influence of non-clinical factors on women’s risk of cesarean delivery.

Finding out the rate of cesarean sections at any given hospital can be difficult, as is understanding why the rates are high in any given situation. At her  website, CesareanRates.com, consumer advocate Jill Arnolds attempts to bring together the available statistics, allowing users to compare cesarean rates by state and by individual hospital.

If you’re interested in finding out more about what you can do increase your chances of having a vaginal birth, see this tip sheet from Childbirth Connection.

By Phil Galewitz | Kaiser Health News

For decades, doctors have been warned about the dangers of delivering babies early without a medical reason. But the practice remained stubbornly persistent.

Last fall, following a sex-ed road trip with The Ladydrawers to deliver “Our Bodies, Ourselves” to former Rep. Todd Akin (of “legitimate rape” fame), Our Bodies Ourselves launched Educate Congress, a campaign to deliver the book to all members of Congress and key administration officials.

The basic premise: Everyone deserves access to accurate information concerning women’s reproductive and sexual health — especially those who write the laws.

Today OBOS kicked off delivery of the book, as Judy Norsigian, OBOS executive director and one of the original authors of “Our Bodies, Ourselves,” hand-delivered copies of the newest edition to about 20 legislators and staff members.

The point was made that the problem isn’t just poorly chosen words; rather, a lot more needs to be done to advance evidence-based health policy.

Norsigian walked the halls of Capitol Hill with Christy Turlington Burns, founder of Every Mother Counts, and EMC’s executive director, Erin Thornton. They submitted EMC’s petition to female members of Congress, asking them to support policies that protect the health and well-being of girls and women around the world, especially those that will reduce infant and maternal mortality rates.

Doing this on the day that the House finally passed the Violence Against Women Act made it particularly poignant.

Thanks to Allyson Reddy and Grace Adofoli, interns at the National Women’s Health Project, the book launch was a success. More books will be delivered in the coming weeks, until every member of Congress has, in their office, up-to-date information they can rely on when drafting bills that have a real impact on girls and women.

A big thank you to the supporters of Educate Congress! And a special shout out to fellow road-trippers Anne Elizabeth Moore, Rachel N. Swanson, Nicole Boyett and Sara Drake; Congress scheduler Christina Knowles; everyone who participated in the making of the Educate Congress video, especially Paul Noble and Anthony Cupaiuolo (bro!); and Malcolm Woods, who helped organize the Educate Congress launch at the National Press Club and kept the word going on Twitter (with the aid of “The West Wing” staff). All of you made this happen!

According to the CDC, in 2009, 98.9 percent of all U.S. births were in hospitals, while only 1.1 percent took place elsewhere.

Many women, however, wish to give birth in an environment that is more homelike, or want to reduce their likelihood of experiencing many of the interventions that have become very common in hospitals, such as continuous electronic fetal monitoring, induction of labor, and cesarean section.

Of the non-hospital births documented in 2009, 27.6 percent (just over 12,000 births) took place in freestanding birth centers – an option for women interested in giving birth with trained professionals outside of hospital obstetrics units. At birth centers, midwives generally provided prenatal, birth and postpartum care.

Now, there’s a large new study showing that birth centers are a safe option for both mothers and babies, reaffirming safety findings from previous research.

The study, published in the Journal of Midwifery & Women’s Health, looked at data from U.S. birth centers to assess outcomes for women and babies, including the need for a hospital transfer, mode of birth, complications, and deaths from 2007 through 2010.

The study is referred to as the National Birth Study II (NBSII); the research is an update of the National Birth Center Study conducted by Judith Rooks and colleagues and published in 1989.

The study gathered data from member organizations of the American Association of Birth Centers; 79 birth centers took part, with 59 of those sending data for the complete study period. The analysis included 15,574 women who planned and were eligible for a birth center birth at the onset of labor.

What does “eligible” mean in this context? Pregnancies considered medically low-risk: single-baby deliveries; pregnancies that went to full-term; and no breeches or medical/obstetric risk factors that required cesarean, continuous electronic fetal monitory, or labor induction.

Among the findings:

• Of the women admitted to the birth center in labor, 87.6 percent did give birth there. The rest (12.4 percent) were transferred to the hospital. Most of the transfers were considered non-emergencies and occurred because of prolonged labor or arrest of labor. Just 1.9 percent of women or newborns required emergency transfer. Women who had never given birth before accounted for most (81.6 percent) of the transfers.
• A few women (4.5 percent) planned to give birth at a center but were not able to, for issues such as breech, premature membrane rupture, or the woman’s choice.
• Most of the births (92.3 percent) for all women who planned a birth center birth were head-first, spontaneous vaginal births. The mode of birth data includes women who transferred to a hospital as well — 1.2 percent ended up with an assisted vacuum or forceps birth, and 6.1 percent ended up having a cesarean birth.
• There were no maternal deaths.
• Women can mostly expect care from Certified Nurse-Midwives at AABC birth centers. Most of the care providers in the study were CNMs (80 percent, in 63 of the birth centers); Certified Professional Midwives or Licensed Midwives provided care in 11 of the centers (14 percent). In five of the centers, care was delivered by mixed teams of these providers.

There are some things the study can’t tell us, such as the outcomes at non-AABC birth centers and at AABC centers that don’t report their data to the AABC registry, and outcomes for women attempting vaginal birth after a prior cesarean (because most birth centers do not support it).

The NBSII study found a rate of 6.1 percent for cesareans. The authors looked at the cost savings related to reducing cesareans, and conclude, “Had this same group of 15,574 low-risk women been cared for in a hospital, an additional 2,934 cesarean births could be expected.”

They base this comparison on national rates of cesareans in low-risk women, currently reported at 26.5 percent (derived from data reported on birth certificates).

“Given the increased payments for facility services for cesarean birth compared with vaginal birth in the hospital,” the researchers wrote, “the lower cesarean birth rate potentially saved an additional $4,487,524. In total, one could expect a potential savings in costs for facility services of more than $30 million for these 15,574 births.”

I had some questions about whether the 26.5 percent figure was the best comparison group (versus older data with a lower rate), so I emailed the study authors, who responded: “It is not a perfect comparison, because this pool of low-risk women from birth certificate data may not be as stringently selected as women screened for birth center eligibility. But it is the best estimate we have for low-risk women being cared for in hospitals.” [We can discuss this issue in more detail in the comments if anyone is interested.]

Without a perfect comparison, we can still safely assume that the rate of cesarean is pretty low for women who qualify for AABC birth center births. It’s also fair to assume that very few women at AABC birth centers require emergency transfer to a hospital, and that the vast majority (almost 80 percent) of women who qualify for birth center care do end up giving birth there and being discharged to home.

There were no maternal deaths recorded in the study, and low fetal/neonatal death rates — the researchers found an intrapartum fetal mortality rate for women who were admitted to the birth center in labor of 0.47/1,000, and a neonatal mortality rate excluding lethal anomalies of 0.40/1,000. From this, we can conclude that AABC birth centers are a reasonably safe choice for low-risk women.

On Feb. 13, the American Association of Birth Centers and the American College of Nurse-Midwives are holding a Congressional briefing focused on the role of midwives and birth centers in potentially affecting health care costs and outcomes (such as cesarean rates). More information and registration are available here.

For more information, here a Q&A about the study. Visit Science & Sensibility for an interview with one of the study’s authors.

Plus: “It took more than two decades of labor,” writes Julie Deardorff in the Chicago Tribune, “but Illinois is finally poised to permit its first free-standing birth center, an alternative model of care for low-risk pregnant women who want to deliver in a homey environment with a reduced chance of medical interventions.”

Read about the pilot program and steps supporters took, along with the Illinois Department of Public Health, to negotiate with hospitals and doctors.

by Carol Sakala, Director of Programs, Childbirth Connection

One of most commonly cited barriers to improving maternity care is the risk of providers and hospitals being held liable for bad outcomes. Whether it is reining in overuse of tests and procedures, honoring women’s preferences, or increasing interdisciplinary collaboration, good ideas often cannot move forward once the issue of liability is raised.

If we cannot make progress toward more evidence-based, woman-centered care because of liability concerns, then the liability system is functioning poorly. But what are the aims of a high-functioning liability system? Is it just to avoid lawsuits and hold liability insurance premiums down?

In our new report, Maternity Care and Liability, we hold 25 possible liability reforms up to a framework that addresses the needs and interests of all of the system stakeholders: those who deliver care, those who pay for care, and most importantly, the women and newborns who receive care.

We developed this framework based on maternity care and liability studies and with the input of clinicians, legal scholars, consumer advocates, policy makers, and others. For each possible reform, we asked whether it does or would likely:

• promote safe, high-quality maternity care that is consistent with best evidence and minimizes avoidable harm
• minimize maternity professionals’ liability-associated fear and unhappiness
• avoid incentives for defensive maternity practice
• foster access to high-value liability insurance policies for all maternity caregivers without restriction or surcharge for care supported by best evidence
• implement effective measures to address immediate concerns when women and newborns sustain injury, and provide rapid, fair, efficient compensation
• assist families with responsibility for costly care of infants or women with long-term disabilities in a timely manner and with minimal legal expense
• minimize the costs associated with the liability system

The proposed framework has the potential to move discourse and policy forward. When options for reform are held up to criteria in the framework, many that have been widely implemented do not appear to meet any of the criteria. Most notably, the best available evidence shows that tort reforms fare poorly against these aims, despite the fact that they are the most widely advocated and enacted liability reforms.

On the other hand, various reforms have the potential to be win-win-win solutions for women and newborns, providers, and payers. Strategies are needed both to prevent harm and ensure that it is rare and to respond appropriately to harm or claims of harm when they occur. For preventing negligent injury and related lawsuits, these reforms include rigorous quality improvement programs and shared decision making initiatives.

A series of recent reports clarifies the “business case” for quality improvement initiatives: successful programs with strong leadership are achieving better care, better health outcomes, and rapid substantial declines in liability claims, payouts, and premiums. Among redress approaches, disclosure and apology programs were the most promising, but have not yet been evaluated in maternity care.

The report includes summary tables with the full list of more promising and less promising strategies assessed and their demonstrated or plausible impact on the various areas addressed in the framework.

To achieve the high-performing maternity care system that stakeholders need, we cannot allow longstanding liability concerns to continue to rankle. By seeking guidance from the best available evidence about the nature of liability problems in maternity care and the effectiveness of possible solutions, we can move constructively beyond belief and entrenched positions.

It is time to pilot and evaluate the most promising strategies and scale up those that are effective, beginning with routine maternity care quality improvement initiatives. They have the potential to transform the quality and value of maternity care, and to ensure that maternity care work offers the joy and honor that draws talented, passionate individuals to the profession and keeps them caring for women, babies, and families.

For the full report, a set of 10 fact sheets, links to three related open-access Women’s Health Issues articles and an invited commentary from legal scholars Sara Rosenbaum and William Sage, and other resources, please visit http://transform.childbirthconnection.org/reports/liability.

This entry was originally posted at Transforming Maternity Care and is republished with permission.

Carol Sakala, director of programs at Childbirth Connection, is a long-time contributor to “Our Bodies, Ourselves.” She has worked on maternity care issues as an advocate, educator, researcher, author, and policy analyst for more than 25 years, with a continuous focus on meeting the needs of childbearing women and their families.

Although this January marks the 40th anniversary of the landmark Supreme Court decision legalizing abortion, we know that there is still much work to be done to ensure reproductive justice for all women.

The Guttmacher Institute reports that 2012 saw the second highest number of abortion restrictions enacted in a single year; the Center for Reproductive Justice addresses each state in this report.

Among the provisions ultimately defeated were “fetal personhood” bills in Mississippi and Oklahoma. But the notion that fetuses should be protected from the women carrying them has resulted in the restriction and punishment of women across America.

Lynn Paltrow, executive director of National Advocates for Pregnant Women, and Jeanne Flavin, a professor of sociology at Fordham University and chair of NAPW’s board, have put together an extremely interesting and important study: “Arrests of and Forced Interventions on Pregnant Women in the United States, 1973–2005: Implications for Women’s Legal Status and Public Health.”

Paltrow and Flavin (who is also the author of the 2008 book “Our Bodies, Our Crimes: The Policing of Women’s Reproduction in America“) tried to identify and examine U.S. cases from 1973, the year of Roe v. Wade, through 2005, in which a medical or government authority tried or succeeded in stripping a woman’s autonomy because of pregnancy. The study appears in the Journal of Health Politics, Policy and Law.

These cases could have involved threat of or actual arrest, incarceration, or increased prison/jail time; detention in a hospital, treatment program, or mental institution; or forced medical intervention. Descriptive detail of several cases is provided, along with summary statistics on the findings.

Looking at legal, medical and other sources, Paltrow and Flavin analyzed 413 cases, which they speculate are “a substantial undercount,” because cases were difficult to identify and some sources referred to additional cases.

The data reveals substantial racial, income and geographic disparities. While almost every state had multiple cases, the regions with the most were the south (56 percent) and midwest (22 percent). These cases disproportionately targeted black women (52 percent of cases overall, and 72 percent of cases in the south), and 71 percent involved low-income women (enough so that they qualified for indigent defense).

Most women who faced criminal charges were charged with felonies; a greater percentage of black women (85 percent) were charged with felonies than white women (71 percent).

The authors explore how these disparities are interlinked with disparities in drug laws, disproportionate application of criminal laws, and outdated stereotypes about cocaine use (such as the “crack baby” myth).

The vast majority of the cases — 84 percent — involved allegations of illegal drug use. In the remaining cases, “women were deprived of their liberty based on claims that they had not obtained prenatal care, had mental illness, or had gestational diabetes, or because they had suffered a pregnancy loss.”

Although concern for the health of the fetus/infant is typically offered as a reason for increased scrutiny or detainment of pregnant women, in 64 percent of the cases there was no reported health issue cited in the allegation.

Chillingly, most cases were reported by people in so-called “helping professions”: health care providers (41 percent), social workers (12 percent), and hospital, child protective services, or police personnel (17 percent). Health care providers reported black women at a higher rate (48 percent) than white women (27 percent).

As the authors point out:

Due in part, no doubt, to the strong public health opposition to such measures, no state legislature has ever passed a law making it a crime for a woman to go to term in spite of a drug problem, nor has any state passed a law that would make women liable for the outcome of their pregnancies. Similarly, no state legislature has amended its criminal laws to make its child abuse laws applicable to pregnant women in relationship to the eggs, embryos, or fetuses that women carry, nurture, and sustain. No state has rewritten its drug delivery or distribution laws to apply to the transfer of drugs through the umbilical cord. To date no state has adopted a personhood measure, and no law exists at the state or federal level that generally exempts pregnant women from the full protection afforded by federal and state constitutions.

In other words, nothing about existing law should make women subject to such persecution. They also note that public health groups have observed that targeting pregnant women may lead to women avoiding medical care or having unwanted abortions to avoid increased and punitive scrutiny.

Paltrow and Flavin also highlight these cases in the context of proposed personhood laws, which would give fetuses individual rights and potentially could lead to increased prosecutions of women. They authors note that they have identified “more than two hundred cases initiated against pregnant women since 2005 that also overwhelmingly rest on the claim of separate rights for fertilized eggs, embryos, and fetuses.”

Opponents to personhood laws have cautioned that such measures could lead to forced medical interventions on pregnant women along with possible punishment for miscarriages and stillbirths. While personhood proponents often dismiss these warnings as scare tactics, the research shows there is good reason to be concerned.

Paltrow and Flavin conclude with a call for change:

In light of these continued efforts and our findings, we challenge health care providers, law enforcement and child welfare officials, social workers, judges, and policy makers to examine the role they play in the arrests and detentions of and forced interventions on pregnant women. We call on these same people to develop and support only those policies that are grounded in empirical evidence, that in practice will actually advance the health, rights, and dignity of pregnant women and their children, and that will not perpetuate or exacerbate America’s long and continuing history of institutionalized racism.

Finally, our study provides compelling reasons for people who value pregnant women, whether they support or oppose abortion, to work together against personhood and related measures so women can be assured that on becoming pregnant they will retain their civil and human rights.

The whole article is well worth a read if you can get a copy. The abstract is freely available online.

The story of Savita Halappanavar, who died last month as a result of Ireland’s abortion ban, has sparked much debate over Ireland’s abortion laws and, in a broader sense, the issue of access to reproductive health care.

Savita went to a hospital in Ireland while experiencing severe back pain. The medical staff diagnosed her with miscarriage of a fetus with no chance of survival, but refused to perform an abortion because they detected a fetal heartbeat.

Several days passed before the heartbeat ceased and removal was allowed. But by this point, Savita had developed an infection that led to her death.

This is a tragic example, but one that unfortunately is quite predictable when women are unable to obtain legal abortion care. Abortion has been banned in the Republic of Ireland since 1983 by constitutional amendment, but traces back to an 1861 law. According to the Irish Family Planning Association, more than 4,000 women living in Ireland traveled to England and Wales for abortions in 2011, because the service is not legally available in Ireland.

Earlier this year, The Guardian reported that despite apparent declines in this number, more women may simply be disguising their home country, as “The number of women contacting a charity that helps people in Ireland seek abortions in Britain is set to double for the third year in a row.” (For more on the history of abortion law in Ireland, see this timeline, and “Ireland’s abortion ban: a history of obstruction and denial.”)

Here are some of the articles and analysis stemming from Savita’s death:

• Justice for Savita — Jessica Valenti gets to the bottom line for The Nation: “It’s not just our lives and health that are in danger, but our human dignity.”
• Hospital Death in Ireland Renews Fight Over Abortion – Douglas Dalby at The New York Times writes of a state of Irish politics that will not be entirely unfamiliar to U.S. readers: “Given the divisiveness of the abortion issue in Ireland, which has prompted two bitterly fought referendums, successive governments have avoided passing any legislation.”
• Death in Ireland is a Wake Up Call to Fight Bans on Later Abortion Here at Home – Susan Yanow at RH Reality Check contemplates the U.S. implications and concludes: “We have a sobering lesson to learn from Ireland — when doctor’s medical judgement is compromised by restrictive abortion laws, it is women’s health and women’s lives that suffer.”

Several writers have referred to the “X case” in covering this story. This was a controversial 1992 Irish Supreme Court case in which a 14-year-old girl expressed suicidal thoughts after being raped by a neighbor and becoming pregnant as a result. The girl planned to have an abortion elsewhere, but was prevented from doing so. The court eventually ruled that women have the right to seek abortions in life-threatening situations, including possible suicide.

Despite this 20-year-old ruling, Irish legislators have not passed a law to codify this right, leaving women in dangerously uncertain territory.

A Choice Ireland spokesperson explained:

Today, some twenty years after the X case we find ourselves asking the same question again — if a woman is pregnant, her life in jeopardy, can she even establish whether or not she has a right to a termination here in Ireland? There is still a disturbing lack of clarity around this issue, decades after the tragic events surrounding the X case in 1992.

Ireland’s Deputy Prime Minister Eamon Gilmore has said that the government would act “to bring legal clarity to this issue as quickly as possible.”

See also these additional commentaries on the failure to pass relevant laws after the X case to make abortions clearly legal in life-threatening situations.

Emer O’Toole writes at The Guardian about the struggles of pro-choice activists in Ireland, pointing to the culpability of doctors, legislators, journalists, and others in perpetuating the lack of justice in abortion laws. She issues an apology to Savita’s family that is also a call to action to supporters of abortion rights:

To her family, I want to say: I am ashamed, I am culpable, and I am sorry. For every letter to my local politician I didn’t write, for every protest I didn’t join, for keeping quiet about abortion rights in the company of conservative relations and friends, for becoming complacent, for thinking that Ireland was changing, for not working hard enough to secure that change, for failing to create a society in which your wife, your daughter, your sister was able to access the care that she needed: I am sorry. You must think that we are barbarians.

Related: Study Examines How Inability To Obtain Abortion Care Affects Women’s Lives