Archive for the ‘Pregnancy & Childbirth’ Category

April 25, 2013

How Can We Help Teen Mothers Avoid and Cope With Postpartum Depression?

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.

April 17, 2013

“Can We See the Baby Bump, Please?”: Film on Commercial Surrogacy in India Screens in Boston

Can We See the Baby Bump, Please

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.

April 9, 2013

The Saga of Michael Klein: A Poem in Praise of a Pristine Perineum

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.


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). 

March 27, 2013

What Explains Variation in Cesarean Rates Between Hospitals?

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,, 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.

March 4, 2013

Hospitals Clamp Down On Dangerous Early Elective Deliveries

By Phil Galewitz | Kaiser Health Newskaiser health news logo

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

Now, with pressure on doctors and hospitals from the federal government, private and public insurers and patient advocacy groups, the rate of elective deliveries before 39 weeks is dropping significantly, according to latest hospital survey from The Leapfrog Group, a coalition of some of the nation’s largest corporations that buy health benefits for their employees.

The national average of elective early deliveries fell to 11.2 percent last year from 14 percent in 2011 and 17 percent in 2010. Nearly 800 U.S. hospitals report their data to Leapfrog, about a third of U.S. facilities offering maternity services.

“This data shows more hospitals are responding to the evidence,” said Cindy Pellegrini, senior vice president of the March of Dimes, which has been educating women and working with hospitals and doctors to lower early delivery rates. “This means babies are being born healthier and having a better start in life, and have a much greater likelihood of avoiding health consequences later on in life.”

Babies born before 39 weeks are more likely to have feeding and breathing problems and infections that can result in admissions to neonatal intensive care units than those who are born later, studies show. The elective deliveries can also cause developmental problems that show up years after birth.

Inducing labor early also carries risks for mothers because it increases the chances they will need cesarean sections.

Since 1979, the American College of Obstetricians and Gynecologists has recommended against deliveries or induced labor before 39 weeks unless there is a medical indication, such as the mother’s high blood pressure or diabetes or signs that the fetus may be in distress.

Still, an estimated 10 to 15 percent of U.S. babies continued to be delivered early without medical cause, according to a report last year by the Department of Health and Human Services.

Leapfrog Chief Executive Officer Leah Binder said she’s encouraged by the latest figures, but says rates are still too high at many hospitals — with some as high as 40 percent. “This is a move in right direction, but more needs to be done,” Binder said.

Leapfrog wants to see rates no higher than 5 percent of all deliveries, a target achieved by nearly half of the reporting hospitals – up from 39 percent of hospitals in 2011.

State averages varied from a high of 26 percent in Pennsylvania to a low of 5.9 percent in Massachusetts and New York. Only states with at least 10 hospitals reporting data were counted toward a state average.

One reason some hospitals have been slow to lower their rate is a reluctance to pressure doctors to change their practice, she said.

Some rural hospitals may also have higher rates because doctors in solo practice sometimes schedule to deliver babies early to stagger their workload. Women who are unaware of the higher risks may also ask to deliver early out of convenience.

Average Early Elective Delivery Rates
State averages for states with more than 10 hospitals reporting
State 2011 Avg. 2012 Avg.
Alabama 22.5%
Arizona 19.5% 9.5%
California 11.3% 8.8%
Colorado 11.8% 7.4%
Florida 13.2% 18.2%
Georgia 16.1% 14.8%
Illinois 13.7% 7.2%
Indiana 11.3%
Maine 11.9% 6.9%
Massachusetts 9.6% 5.9%
Michigan 9.2% 7.9%
Nevada 17.1% 10.7%
New Jersey 11.7% 12.1%
New York 19.8% 5.9%
North Carolina 7.8%
Ohio 7.6% 7.9%
Pennsylvania 26.2%
South Carolina 19.4% 10.4%
Tennesee 14.9% 18.2%
Texas 17.3% 18.3%
Virginia 12.5% 13.1%
Washington 14.9% 7.2%
Wisconsin 20.6%
Individual Hospitals
Rates of early elective deliveries by hospital from The Leapfrog Group

Some of the most dramatic improvements last year came from states such as South Carolina and Illinois where business groups and insurers have exerted pressure to decrease high-risk deliveries. In Illinois, the rate has been cut almost in half to about 7 percent through efforts by organizations such as the Midwest Business Group on Health.

Employers and insurers have gotten involved partly to reduce health costs, since stays in neonatal intensive care units can average well over $60,000.

This year, the South Carolina Medicaid program and BlueCross BlueShield of South Carolina stopped reimbursing providers for performing early deliveries without medical cause. In 2012, the state, working with the March of Dimes and other groups, asked hospitals voluntarily to reduce their rate of early deliveries. The rate of early elective deliveries in South Carolina hospitals fell to 10 percent last year from 19 percent in 2011, the Leapfrog data show.

“We are pleased to see these improved health outcomes,” said Kim Cox, spokeswoman for the South Carolina Department of Health and Human Services.

Texas Medicaid stopped paying for early elective deliveries in 2011, and New York and New Mexico are considering similar actions, according to state officials.

Some hospitals are moving on their own. Boston Medical Center reduced its rate to 5.3 percent last year from 22.5 percent in 2011 by reminding doctors that delivering babies even one or two days before 39 weeks would not be allowed without medical cause. The hospital also informed women about the policy during prenatal care.

“All of the nurses, midwives and doctors on Labor and Delivery are aware that decreasing elective deliveries prior to 39 weeks is an important goal for our service,” said Dr. Ronald Iverson, director of quality improvement for OB/GYN at Boston Medical Center.

Provided by Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

February 28, 2013

Delivery of “Our Bodies, Ourselves” to Members of Congress Launches on Capitol Hill

Erin Thornton, Judy Norsigian, Rep. Jim McGovern, and Christy Turlington Burns

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.

NWHN interns Allyson Reddy and Grace Adofoli with Judy Norsigian and Rep. Chellie Pingree

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!

Erin Thornton, Christy Turlington Burns (holding the film “No Woman, No Cry”) Rep. Gary Peters, Judy Norsigian, Allyson Reddy, and Grace Adofoli

February 7, 2013

New Study Shows Excellent Outcomes in Birth Centers

More than 9 out of 10 women (94%) who entered labor planning a birth center birth achieved a vaginal birth

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.

January 18, 2013

Fixing Persistent Liability Concerns in Maternity Care: We Can Do It!

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

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.

January 16, 2013

When Pregnancy is a Crime: Arrests, Forced Interventions in the Name of Public Health

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.

November 16, 2012

Savita Halappanavar’s Death from Being Denied an Abortion Leads to Shame and Searching

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

September 21, 2012

Pregnant Workers Fairness Act Introduced in Senate

Senators Bob Casey (D-Penn.) and Jeanne Shaheen (D-N.H.) this week introduced the Pregnant Workers Fairness Act to provide pregnant workers with legal protection against discrimination, similar to protections provided by the existing Americans with Disabilities Act (which does not cover pregnancy).

Many women need simple accommodations like being allowed to sit while working or additional bathroom breaks, and these are not protected under existing laws. As an example, one pregnant worker was reportedly fired for carrying a water bottle and drinking from it while working, as it was against store policy prohibiting eating or drinking while working.

Casey remarked:

Pregnant workers face discrimination in the workplace every day, which is an inexcusable detriment to women and working families in Pennsylvania and across the country. This legislation will finally extend fairness to pregnant women so that they can continue to contribute to a productive economy while progressing through pregnancy in good health.

The bill was also introduced in the House earlier this summer by Rep. Jerry Nadler (D-N.Y.) and has more than 100 cosponsors. Not much has happened on it, though, except referrals to various committees — prompting RH Reality Check’s Sheila Bapat to remark that the bill was “going nowhere fast.”

Bapat also clarifies why the the Pregnant Workers Fairness Act matters, even though a Pregnancy Discrimination Act has existed since 1978:

There are laws that protect pregnant women from discrimination, but they have not been interpreted to protect women seeking adjustments to their work responsibilities. The Pregnancy Discrimination Act (PDA) was passed over 30 years ago and prevents discrimination “on the basis of pregnancy, childbirth and related medical conditions.” But the PDA is interpreted to only protect women who are pregnant but not hindered in job performance due to pregnancy or women who cannot work at all and need leave.

National Advocates for Pregnant Women has an online guide to laws affecting pregnancy discrimination in employment, which is a great starting point for understanding existing protections and the gaps in current laws, such as the ADA and the Family and Medical Leave Act.

The National Women’s Law Center has been working to promote passage of the Act, and has a number of useful posts at their blog for learning more. Excellent posts in the series include “It Shouldn’t Be A Heavy Lift: Pregnant Workers Fairness Act Introduced in Senate,” and “The Pregnant Workers Fairness Act: What It Means for Low-Wage Working Women.”

September 21, 2012

Ley de Equidad para Trabajadoras Embarazadas Presentado en el Senado

Escrito por Rachel. Traducido del orginial en inglés Sept. 21, 2012.

Los senadores Bob Casey (Demócrata, Pennsylvania) y Jean Shaheen (Demócrata, New Hampshire) presentaron introdujeron la Ley de Equidad para Trabajadoras Embarazadas esta semana para extender protecciones legales a trabajadoras embarazadas contra la discriminación, protecciones a las que provee el Acta de Americanos con Descapacidades (que no cubre el embarazo) .

Muchas mujeres embarazadas necesitan arreglos sencillos en el trabajo: el permiso de trabajar sentadas, o descansos de baño mas frecuentes. Pero estos arreglos no están protegidos bajo las leyes actuales. Como ejemplo, una trabajadora fue despedida después de cargar y beber agua de una botella, ya que el negocio donde trabajaba tenia una regla prohibiendo empleados de comer y beber durante el trabajo.

Dijo Casey:

Trabajadoras embarazadas enfrentan discriminación en el trabajo todo los días, lo que es un detrimento sin excusa a las mujeres y familias trabajadoras de Pennsylvania y por toda la nación.  Esta ley finalmente extenderá equidad a las mujeres embarazadas para que puedan continuar a contribuir a una economía productiva mientras que progresan con un embarazo sano.

La ley se presentó en la Cámara de Representantes previamente en este verano por el Rep. Jerry Nadler (Demócrata Nueva York) y tiene más de 100 copatrocinantes. Sin embargo, no ha progresado mucho, menos ser referida a varios comités– provocando el comentario de Sheila Bapat de RH Reality Check, “ la ley no estaba yendo a ningún lugar.”

Bapat también nos clarifica las razones por la cuales la Ley de Equidad para Trabajadoras Embarazadas tiene importancia, aunque una Acta contra Discriminación en el Embarazo ha existido desde 1978:

Ya existen leyes que protegen mujeres embarazadas contra la discriminación, pero no han sido interpretado en términos de proteger mujeres que buscan modificaciones a sus responsabilidades en el trabajo. El Acta contra Discriminación en el Embarazo (PDA) se aprobó hace 20 años, y previene la discriminación “a base de embarazo, parto, y condiciones médicas relacionadas.” Pero esta ley ha sido interpretada a proteger solamente a las mujeres que están embarazadas pero que no necesitan modificaciones en su trabajo para continuar, o mujeres embarazadas que ya no pueden seguir trabajando y que necesitan baja por maternidad.

Defensores Nacionales para Mujeres Embarazadas tiene una guía a las leyes que afectan la discriminación contra las mujeres embarazadas en el trabajo en la red  un buen punto de partida para comprender las protecciones que ya existen y los huecos en las leyes actuales, como el Acta de Americanos con Descapacidades y el Acta de Baja Médica y de Familia (“ADA” y “FMLA” en sus siglas ingleses”.

El Centro Nacional de Ley de Mujeres (National Women’s Law Center) está promoviendo la aprobación de la ley, y tiene varias entradas útiles en su blog para profundizar conocimiento sobre el tema. Entradas excelentes incluyen “It Shouldn’t Be A Heavy Lift: Pregnant Workers Fairness Act Introduced in Senate,” y “The Pregnant Workers Fairness Act: What It Means for Low-Wage Working Women.”

July 25, 2012

Live in Massachusetts? Take 2 Minutes to Support Bill Regulating Certified Professional Midwives

Our Bodies Ourselves has partnered with The Big Push for Midwives in support of this important legislation. Please take a moment to learn how you can help improve the health of mothers and infants in Massachusetts. Thank you! – Judy Norsigian, OBOS Executive Director


If you care about mothers and babies, the Commonwealth needs your help TODAY to PASS HB 4253, An Act Relative to Certified Professional Midwives.

We have just a few days left to pass this important legislation that will regulate Certified Professional Midwives.

Currently, there is no state oversight, which means ANYONE — even an 18-year-old car mechanic — can hang out a shingle and practice as a midwife. Hairdressers must be licensed to practice in Massachusetts, but midwives do not.

Should a “cut and color” be regulated and have professional practice requirements while MA midwives currently have none?

How to Help

    You can find contact information for your representative here:
  • GIVE them an update on the bill, HB 4253 — An Act Relative to Certified Professional Midwives — and let them know the bill is now with the House Ways and Means committee.
  • ASK them to contact Chairman Dempsey’s office (617-722-2990) (representing Haverill and Chair, House Ways & Means Committee) to REQUEST that HB 4253 BE RELEASED TO THE HOUSE FLOOR FOR A VOTE ASAP.
  • ASK them to then support the bill when it reaches the House Floor.
  • URGE them to tell their colleagues to support the bill on the House Floor.
    The calls will take TWO minutes or less. Please pass this on to friends, family, neighbors and anyone else to also make calls. We need to flood the State House!

Want to do even more?
PLEASE reach out to Massachusetts HOUSE LEADERSHIP (see listing at the end of this message), letting them know:

  • This bill is important to you
  • That this bill is being supported by House leaders

Also, we will be at the State House on Wednesday and Thursday afternoons this week (7/25 and 7/26). Please join us! Drop a quick email to Ann Sweeney at ann AT, and we’ll let you know where to rendezvous with us.

Please help us in spreading the word and passing this legislation into law! Keep the calls coming! We need EVERYONE to call to get this done! Make a difference! Make it count!

Thank you for your support!
- Ann Sweeney (Mass Friends of Midwives)
ann AT
- Miriam Khalsaak (Mass Midwives Alliance)
akmidwife AT


To help out even more:
CALL more Massachusetts House Leadership

Other Important Representatives in House Leadership to call:
Rep. Haddad—very supportive—617-722-2600
Speaker DeLeo—he is aware of the bill—seems to understand need for it—617-722-2500
Rep. Reinstein—very supportive and a co sponsor—617-722-2180
Rep. Moran (Boston and Brookline)—supportive and a co-sponsor— 617-722-2006
Rep. Story (Amherst)—very supportive—617-722-2012
Rep. Donato—seems supportive—617-722-2040
Rep. Mariano—has always supported licensure bills—617-722-2300
Rep. Jones—aide seems supportive—617-722-2100
Rep. Rushing—617-722-2783
Rep. Bradley—617-722-2520

July 20, 2012

Prosecuting Pregnant Women

This year, you may have seen news on the case of Jennie Linn McCormack, an Idaho woman who was arrested for obtaining RU-486 from the internet and inducing her own abortion, apparently a felony under Idaho law even though abortion and RU-486 themselves are legal. Jennie was reported to police by a friend she confided in about her experience.

And then there’s the case of Bei Bei Shuai, who ingested rat poison in an attempt to commit suicide. This was believed to lead to the death of her 8-month fetus, and Shuai was charged with murder, due to laws that make murdering pregnant women a double-homicide. Such laws were designed to apply to individuals who attack pregnant women, not to women themselves. Lynn Paltrow of National Advocates for Pregnant Women points out the inequality of cases like these:

‘The principle seems established for now that if you do something intended to end your pregnancy … that is murder,’ said Paltrow. ‘A suicide attempt will be treated as a public health problem for everyone except pregnant women and for them it will be treated as a crime.’

Reacting to cases like these, Soraya Chemaly at VitaminW provides 10 Tips for Staying out of Jail When You’re Pregnant, highlighting the absurdity of the actions pregnant women would have to take to avoid any possibility of endangering a fetus. For example:

Instantaneously upon conceiving end any addiction you may have. Even though you may have tried before,your pregnancy gives you superhuman abilities that mortals do not have. Don’t be fooled into thinking that substance abuse is a health issue.


Cure yourself of any illnesses. If you need to take medications regularly or have cancer treatments stop. These may chemically endanger your fetus.

Chemaly’s piece provides a lot of great links to examples where pregnant women with addictions, who ingested other harmful substances, who attempted suicide, or simply confided their doubts about a pregnancy to a healthcare provider have been subjected to investigation and prosecution.

The National Advocates for Pregnant Women focuses much of their work on issues of this nature, such as prosecution of pregnant women with drug addictions, and is a good source to follow for further news and discussions. They have written on the
Bei Bei Shuai case, and on women’s own personhood (which is often neglected in discussions of “fetal personhood” and related laws).

There is also a recent piece on TruthOut on their work, Criminalizing Pregnancy: How Feticide Laws Made Common Ground for Pro- and Anti-Choice Groups, which includes perspectives from the group and presents several relevant cases, such as that of a woman with an addiction who was jailed for two months in order to supposedly prevent drug use. As the author asks:

So, here’s the question: Should pregnant women who use these products be locked up until they deliver and monitored to ensure that they abstain? What about those who refuse to wear seat belts? How about women who defy doctor’s orders and don’t stay in bed, or continue to have sex after being told not to?

Stop snickering and rolling your eyes – it’s not as preposterous as it sounds.

What *is* preposterous is the notion that every action of pregnant women should be policed for its potential effect on the fetus, and that jailing women for such things is an appropriate measure rather than a gross violation of women’s human rights.

For additional reading, see the New York Times’s recent Magazine piece, The Criminalization of Bad Mothers.

June 14, 2012

New AHRQ Info for Consumers and Public Comment

The federal Agency for Healthcare Research and Quality (AHRQ) has released a draft report for public comment, Vaginal Birth After Cesarean: Developing and Prioritizing a Future Research Agenda.

Through interviews with clinicians, consumer advocates, research funders, and others, and review of the evidence gaps identified in the 2010 VBAC conference, the report team came up with a lot of ideas for future research on VBAC. They then prioritized them, to highlight what they think are the top 10 most important questions for future research. These priorities are meant to guide researchers in focusing their projects and also may influence funding for such projects.

The ten priorities include: examining how institutional and other policies affect availability and safety of trial of labor after cesarean; barriers to providing safe trial of labor; maternal and infant outcomes; the effect of legal liability on practices; long-term complications, and other issues. The complete list with explanations is available in the report PDF.

An opportunity for public comment is available before the report and its priorities are finalized. To submit your comments, use this online form to enter your comments on each section or upload a document with all of them. The deadline for submitting comments is Jun. 22.

AHRQ has also released a new summary for consumers on treating chronic pelvic pain. These summaries present an overview of the condition and options, and what the researchers found from looking at the available evidence on treatment methods, with guidance for making decisions about therapy. Unfortunately, the findings were that “very little is known” about effective ways to treat chronic pelvic pain, with there being very little evidence that either medicines or surgeries really help.