Archive for the ‘Pregnancy & Childbirth’ Category

May 21, 2012

Public Comments Sought in Response to CDC’s Infertility Action Plan

The Centers for Disease Control and Prevention has released a draft of its National Public Health Action Plan for the Detection, Prevention, and Management of Infertility, and will be soliciting public comments until June 15, 2012.

The CDC describes the purpose of the plan as follows:

Addressing both male and female infertility, the plan outlines and summarizes actions needed to promote, preserve, and restore the ability of women in the United States to conceive, carry a pregnancy to term, and deliver a healthy infant. This goal extends beyond simply addressing the inability to conceive but also focuses on reducing the burden of impaired fecundity by promoting behaviors that maintain fertility; by promoting prevention, early detection, and treatment of medical conditions; and by reducing environmental and occupational threats to fertility. Given the public health focus of this action plan, promoting healthy pregnancy outcomes associated with treating and managing infertility is also important, as is improving the efficacy and safety of infertility treatment.

OBOS hopes to comment on the draft plan and will share any useful comments that colleagues will be making. In the meantime you can read the draft and submit your comments to the agency.

To comment, first go to regulations.gov and do a search for CDC-2012-0004. The first result should be the Plan – just click on Submit Comment and complete the form. Note that you do not have to enter your name with your comment, and if you do it will appear on the site.


March 21, 2012

Supreme Court Ruling on Family & Medical Leave Act “Appalling and Dangerous,” Says Deborah Ness

The Supreme Court ruled 5-4 on Tuesday that state government workers may not sue their employers for money for violating a part of the federal Family and Medical Leave Act dealing with personal sick leave.

Debra L. Ness, president of the National Partnership for Women and Families, which drafted and fought to pass the FMLA, called the decision “an appalling and dangerous ruling that simply cannot stand.”

The case was brought by Daniel Coleman, a Maryland state court employee who was fired after requesting a 10-day medical leave. The state argued that federal law could not be applied because states, as sovereigns, are generally immune from lawsuits seeking monetary damages.

The Family and Medical Leave Act of 1993 entitles eligible employees 12 weeks of job-secured leave during any 12-month period for: (A) the birth of a child and to care for the newborn child within one year of birth; (B) the adoption or foster care of a child and to care for the newly placed child within one year of placement; (C) care for a spouse, child, or parent with a serious health condition; (D) a serious health condition that makes the employee unable to perform the functions of the position.

The case hinged on whether the sick-leave provision addressed gender bias. Justice Anthony Kennedy, who wrote the majority opinion, said it did not. He was joined by Chief Justice John Roberts and Justices Samuel Alito and Clarence Thomas. Justice Antonin Scalia agreed with the judgment but did not join Kennedy’s opinion, excerpted below:

Without widespread evidence of sex discrimination or sex stereotyping in the administration of sick leave, it is apparent that the congressional purpose in enacting the self-care provision is unrelated to these supposed wrongs. The legislative history of the self-care provision reveals a concern for the economic burdens on the employee and the employee’s family resulting from illness-related job loss and a concern for discrimination on the basis of illness, not sex. [...] It is true the self-care provision offers some women a benefit by allowing them to take leave for pregnancy-related illnesses; but as a remedy, the provision is not congruent and proportional to any identified constitutional violations.

So since they found no evidence of discrimination or sex stereotyping, the majority found no reason to lift the usual protections against suing a state.

Justice Ruth Bader Ginsburg wrote the dissenting opinion and was joined by Justices Stephen G. Breyer, Sonia Sotomayor and Elena Kagan. From the dissent:

The FMLA’s purpose and legislative history reinforce the conclusion that the FMLA, in its entirety, is directed at sex discrimination. Indeed, the FMLA was originally envisioned as a way to guarantee—without singling out women or pregnancy—that pregnant women would not lose their jobs when they gave birth. The self-care provision achieves that aim.

It goes on to provide an interesting history of the development of the FMLA.

“The best way to protect women against losing their jobs because of pregnancy or childbirth, Congress determined, was not to order leaves for women only, for that would deter employers from hiring them,” said Ginsburg, who took the unusual step of summarizing the dissent from the bench, signaling a major disagreement. “Instead, Congress adopted leave polices from which all could benefit.”

Ness, whose organization led a group of 10 civil and workers’ rights organizations in filing a friend-of-the-court brief in the Coleman case, was outspoken in her criticism of the court’s decision:

Justice Ginsburg noted that “[t]he plurality pays scant attention to the overarching aim of the FMLA: to make it feasible for women to work while sustaining family life. Over the course of eight years, Congress considered the problem of workplace discrimination against women, and devised the FMLA to reduce sex-based inequalities in leave programs. The self-care provision is a key part of that endeavor, and in my view, a valid exercise of congressional power….”

Even Justice Kennedy’s opinion acknowledged that “[d]ocumented discrimination against women in the general workplace is a persistent, unfortunate reality, and, we must assume, a still prevalent wrong. An explicit purpose of the Congress in adopting the FMLA was to improve workplace conditions for women.”

Today’s ruling underscores how tenuous the rights of workers are in this country, and the urgent imperative for the Senate to confirm only those justices and judges who have a demonstrated commitment to equal rights under the law and a real understanding of the impact of their rulings on women, workers and others who struggle to make ends meet.

For more information, view the Kevin Russell’s coverage at SCOTUSblog, including Kevin Russell’s recap of the oral arguments.

Plus: Earlier this year, Judith Lichtman, a National Partnership for Women and Families senior advisor, presented seven specific recommendations to the U.S. Equal Employment Opportunity Commission (EEOC) on what federal agencies can do in response to discrimination based on pregnancy and caregiving. View her full testimony (pdf).


February 22, 2012

Birth Control, Santorum and the Media: Battle Over Women’s Health Hits Feverish Pitch

You know when you’re feverish and you overhear bits and pieces from the news and it all swirls together in headache-fueled song? That’s how I spent a good part of February. I’m still coming to terms with the fact that covering prenatal testing has been called into question, or that Virginia legislators thought it would be cool to mandate transvaginal ultrasounds for women seeking abortions — at least until Gov. Robert McDonnell saw his VP hopes sink lower every time the word “transvaginal” was mentioned (the Virginia House passed an amended bill today requiring external ultrasounds instead).

At one point I assumed Komen must be behind all of this — a PR maneuver to distract from the Planned Parenthood blowback — but that, too, was the fever talking. Reality was far harsher: Republicans had set the cultural clocks back to 1950.

Consider this bit of political history, courtesy of Ann Gerhart:

“We need to take sensationalism out of this topic so that it can no longer be used by militants who have no real knowledge of the voluntary nature of the program but, rather, are using it as a political stepping stone,” said George H.W. Bush. “If family planning is anything, it is a public health matter.”

Title X, the law he sponsored that still funds family planning for the poor, passed the House by a vote of 298 to 32. It passed the Senate unanimously. A Republican president, Richard Nixon, enthusiastically signed it.

That was 1970.

Cable news channels played into the time warp, inviting almost twice as many men as women onto news programs to discuss women’s access to contraception — a huge topic thanks to a very small group, the U.S. Conference of Bishops. Jennifer Pozner, executive director of Women in Media and News, gives those media figures some depressing context:

The twitterverse seemed shocked to learn that female experts were sought out as commentators only 38 percent of the time on a story about women’s health. As a media critic, I was surprised, too—because that’s actually a higher percentage of women’s voices than typically heard across all news categories, not just in stories involving women’s bodies.

To understand institutional sexism within the media, look no further than the systematic sidelining of women’s perspectives in corporate news and public affairs programming. Women are a paltry 14 percent of all guests on influential, agenda-setting Sunday morning news shows on ABC, NBC, CBS, FOX and CNN—more than half of whose episodes feature no female guests at all (White House Project). The disparity is just as stark in nightly news, where women are 19 and 27 percent of cable and network news sources, respectively (Pew Project for Excellence in Journalism).

A new report from the Women’s Media Center paints a similarly bleak picture.

I’ve been frustrated, too, by the lack of useful information. Often (mostly) male anchors and guests ruminate over the politics of women’s health without bothering to fact-check the pompous statements and accusations, letting misinformation sit uncontested.

But there are signs of relief. While print/online publications and public radio are doing a better job than television at presenting the facts (see Erika Christakis’s smart column in Time magazine on the birth control debate and the rise of unintended pregnancies, and Irin Carmon’s longer analysis in Salon), TV news has shown some improvement.

In the wake of GOP candidate Rick Santorum’s harmful claims, I was grateful to see Marjorie Greenfield, a professor of obstetrics and gynecology at University Hospitals Medical Group and a longtime contributor to “Our Bodies, Ourselves,” address the importance of insurance coverage for prenatal testing Tuesday on MSNBC. She explained the difference between routine screening tests, such as ultrasounds, and more specific diagnostic tests, such as amniocentesis, which can determine whether a fetus has certain genetic conditions. Most women who are offered amniocentesis are carrying healthy fetuses, she said, so in the vast majority of cases, testing provides reassurance.

Greenfield noted that when she discusses amniocentesis to her patients, some are certain they would terminate a pregnancy if the fetus has a genetic anomaly such as Down Syndrome; others are sure they would not. In the middle are women who don’t have a clear position but who want more information so they can decide, with their families and physicians, the best course of action. Families may turn to support groups or specialists to learn how to prepare for a child with particular health challenges, or, if the genetic anomaly is fatal, arrange for hospice care.

Amniocentesis is expensive, often costing several thousand dollars. If it were not covered by insurance, many women would be unable to obtain the facts they need to make informed decisions.

That brings us to class issues that are rarely discussed, even though the intersections of race, class and gender are unavoidable in most any discussion about women’s health. So let’s cheer for Melissa Harris-Perry, a gifted debater, who is now hosting her own two-hour news program Saturday and Sunday mornings on MSNBC. Harris-Perry made her public intellectual name as frequently the only pundit to complicate solely political horse-race debates by providing a broader social context.

Additionally, Pozner notes that Harris-Perry is “the first black progressive woman to ever solo-host her own news and politics show on a major corporate TV news outlet.” And she isn’t giving up her day job — the Tulane professor is also “the first scholar to teach a full course-load during the week, and grill politicians and pundits on live TV over the weekends.”

This past weekend featured a discussion of gender roles and positions of power in religion and in Congress. Harris-Perry started with a wonderfully nerdy look at how schema affects our attitudes and expectations of who gets to be a leader — and the importance of changing the picture. And it might be good to start with our House — and Senate. Consider: Women comprise only 17 percent of the U.S. Senate and 16.8 percent of the House membership.

Harris-Perry also took on Virginia’s anti-women push — three bills that deal women a losing hand, including the aforementioned transvaginal probes for women seeking to have an abortion; Medicaid restrictions that would force poor women to carry pregnancies to term when the fetus has an incapacitating deformity or mental deficiency; and personhood legislation that could criminalize contraception and outlaw abortion.

There is quite a good amount of organizing going on against these and other attacks on women’s rights and health — including a silent protest this week at the Virginia state capitol and this-just-in news about a march on Washington on April 28.

A number of women’s health groups have formed the Coalition to Protect Women’s Healthcare. It’s new, and it will be interesting to see where it goes. Member groups are organizing visibility events this week at the district offices of members of Congress — especially those who have been promoting religious employer exemptions. You can visit the site for facts about contraception and sign a pledge calling for insurance coverage of birth control, no matter where women work.

Visit Pinterest much? Check out The War on Women page, started by Hello Ladies, for a running catalog of stories and images (love the description: “Ladies, we are under attack. Stay informed. Stay vocal. Run for office.”).

And there’s much needed humor, and not just from the typically awesome Jon Stewart and Stephen Colbert. See The Second City’s Network take on contraception hearings below.

Laughter really is the best medicine.


January 9, 2012

Get Karen to Haiti! Support Local Midwives Serving Women in Earthquake-Ravaged Region

Weeks after the Jan. 12, 2010 earthquake decimated Haiti’s health infrastructure, Karen Feltham, a certified nurse midwife and nursing instructor at Binghamton University, traveled to Fond Parisien, Haiti, to provide support for pregnant and laboring women at a local birth center.

Two years later, she is returning — leaving today to spend 10 days working alongside the two local Haitian midwives that staff the HCM Maternity Clinic, a birth center that serves more than 2,000 women a year. While the midwives provide the best care possible under difficult conditions, outcomes for mothers and babies could be improved with additional training and support.

Karen’s trip is sponsored by Circle of Health International, which works with local health care providers in crisis- and disaster-struck regions to ensure access to quality reproductive, maternal and newborn care. Like all COHI volunteers, Karen is donating her time, and COHI is fundraising to cover the transportation to Haiti (about $800 in airfare and local travel) and room and board on the compound where the birth center is located (about $300).

Here’s where you come in. For as little as $10, you can help send Karen to Haiti. Want to donate more? Please do so! Numerous gifts are available as perks for donors who can offer $20, $35, $50 or more.

Circle of Health International - images from Haiti

Training drills like the one shown (left) help ensure safer births in unsafe times. Women in areas of crisis or disaster often struggle to secure basic reproductive health care. The Fond Parisien Birth Center (right) serves more than 2,000 women a year, providing critical care.

It’s all part of the Get Karen to Haiti campaign that Our Bodies Our Blog and other bloggers involved in improving maternal health are participating in for the next two weeks. Hillary Boucher and Jeanette McCulloch at BirthSwell have more information about the collaborative effort.

Your donation can make a huge difference. According to COHI:

Birth Centers like the one at Fond Parisian provide a model of care for other areas in Haiti and around the world, where maternal mortality is at the highest rate in the Western Hemisphere, with 630 deaths per 100,000 live births (compared to 11 deaths per 100,000 births in the US).

The midwives at the Fond Parisien birth center have received training in supporting women in low-risk births, providing care in common emergencies, and are developing protocols for when to transfer to other emergency medical facilities. But unlike their peers in the U.S. and in other industrialized societies, they do not have access to the latest research or journals, conferences where they can share skills, or even family support.

Karen took a moment as she was preparing for her trip to talk with Our Bodies Our Blog about her birth philosophy and why she’s returning to Haiti now (see below). Her goals are specific:

* Review existing protocols for managing emergencies and deciding when to transfer to the local hospital. Provide clinical support and skill-building where it could improve outcomes for Haitian women and their babies.

* Run emergency drills using improved protocol for complications most likely to be seen at the clinic, including shoulder dystocia and postpartum hemorrhage.

* Improve monitoring processes so that the clinic can evaluate their existing protocols and make improvements based on evidence, not just anecdotal understanding.

We hope you’ll consider supporting Karen’s efforts in Haiti and visit COHI’s Facebook page to follow along on Karen’s journey. You can learn more about COHI’s efforts in Haiti on its website.

* * * * * * * * * *

Our Bodies Our Blog: You first visited Haiti after the earthquake. How did that experience affect you and your commitment to expanding access to evidence-based care?

Karen Feltham: Arriving in Haiti, especially Port Au Prince, was overwhelming. I kept thinking of how long the earthquake lasted, counting in my head and imagining the earth shaking and the buildings falling — the world changing in 30 seconds. What was that like? Homes become rubble, the living-dead. It has changed everything for me, in a way. Anything can happen, in any instant. It might sound funny, but I run through worst-case scenarios in my head and with my family. Where will you go? Where will we meet?

Witnessing the work of countless NGOs and volunteers was inspiring, as well as a bit maddening. There was (and is) really good work happening in Haiti. There are excellent providers and logisticians providing great, life-changing (and life-providing) services. And that is inspiring.

At the same time, I think that there is a feeling of, “Anything is better than nothing.” I have seen that lead to a neglect of clinical standards.

OBOB: Why are you returning now?

KF: The organization that I volunteer with (Circle of Health International) is completing their work there and turning over the operation of the clinic to a local organization. This is a nice opportunity to re-connect with midwife colleagues who I had worked with previously. My goals for the trip are to run emergency obstetric care management drills, review core competencies, and always to reinforce and encourage the midwifery model of care.

Also, skilled birth attendants at delivery (and fewer pregnancies) definitely lower the maternal mortality rate. The international community is expecting quite a bit from newly trained midwives, and midwifery is a tough job. In the United States, a licensed midwife is more likely to begin independent practice with the benefit of collaboration and experienced colleagues. And so, I feel a commitment to providing something similar to this midwife team.

OBOB: How does your birth philosophy inform your volunteer efforts?

KF: I absolutely believe in the power of kindness and how it can be transformative, even revolutionary. Think of what women bear, here and elsewhere — assault, abuse, submission. I can’t change a country’s infrastructure, health care and education policies. But I can listen. I can provide the most gentle pelvic exam and the most respectful atmosphere.

If my touch is the first that a newborn feels, then I promise to make it a gentle one. If my voice is the first that she hears, then let it be welcoming. This is what I can bring, a reminder that excellent clinical skills are essential, but that kindness is life-changing. At least that’s what I think, and it’s the best that I can offer.

OBOB: You’ve identified three goals for your time in Haiti. Can you give readers a sense of how those goals will be achieved?

KF: I’m not sure how each day will unfold. One must be very flexible in these situations. But I’m certain that each day will be very full. My volunteer partners and I will run through management of the obstetric emergencies; postpartum hemorrhage and shoulder dystocia — the “what-ifs.” It’s so valuable to run through what everyone does in these situations, and then do it again.

Also, each day will include conferencing with the midwives, which involves reviewing clinical cases and addressing whatever concerns that they might have, along with symptoms, diagnoses, and procedures they have questions about.

OBOB: Have you incorporated into your teaching at Binghamton any experiences or lessons learned from working alongside midwives in Haiti and Nicaragua?

I guess that every experience influences every other, even in subtle ways.

I teach at the Decker School of Nursing at Binghamton University in both the graduate and undergraduate programs. I love working with nursing students! They are amazingly good people. One of the courses that I teach is in global nursing. So many students are interested in really making a difference but don’t know where to begin. I try to share a bit of my own experience and encourage each individual student to find their own way. I believe in the ripple effect of good work.

Also, one thing I try to do intentionally with students is to blur the line between “us” and “them.” Haiti and Nicaragua are very far away, and it’s easy to think that the people, clinicians and patients are so very different from us. I try to refer to clinical cases that I have seen elsewhere and good clinical work and speak to the shared experience between provider and patients that happens everywhere.

Health care is what happens between midwife (and doctor and nurse) and patient. It doesn’t happen at the upper levels of the bureaucracy. It’s the thing that takes place between two people. And that is true in Ithaca, N.Y., Fond Parisien, Haiti and Managua, Nicaragua.


December 13, 2011

Susan Wood Issues Response to Sebelius’s Overruling of Emergency Contraception Access

Last week, we wrote about a controversial decision by HHS Secretary Kathleen Sebelius, who overruled the FDA’s decision that emergency contraception should be made available over the counter to women of all ages.

On Friday, former FDA official Susan Wood issued her response to the move in the Washington Post, rejecting Sebelius’s claim that more data is needed on safety and label comprehension for the youngest of possible emergency contraception users:

…this type of age restriction, and worries about the use of medicines by teenagers, have not been applied to other products…Indeed, for no other over-the-counter medication has the FDA ever required extra data for a particular age group. (This extra data on younger teenagers was provided to the FDA in the latest application by the company.)

But somehow, the prescription requirement for Plan B — which is very safe and impossible to overdose on — remains in place for those younger teens who are in the unfortunate situation of being at risk of pregnancy and who need emergency contraception immediately.

Wood also notes that because the age restriction remains, access for older women remains restricted – emergency contraception is available without a prescription for those over 17, but is still behind a pharmacy counter.

Wood previously served as assistant FDA commissioner for women’s health and director of the Office of Women’s Health. She resigned in 2005 because of past politically motivated delays in emergency contraception approval, stating at that time:

I can no longer serve as staff when scientific and clinical evidence, fully evaluated and recommended for approval by the professional staff here, has been overruled.

Now, Wood calls out Obama for breaking his promise to the American people by allowing this overruling:

In his scientific integrity memo, the president stated: “When scientific or technological information is considered in policy decisions, the information should be subject to well-established scientific processes, including peer review where appropriate, and each agency should appropriately and accurately reflect that information in complying with and applying relevant statutory standards.”

In overturning the well-considered, scientifically based decision of the FDA, Sebelius and the Department of Health and Human Services certainly did not “appropriately and accurately reflect” the available scientific information…The president should stand by the principles of scientific integrity and restore science to its rightful place. He should support the FDA commissioner and direct the secretary to allow the agency to do its job. By doing so he will fulfill the promise of that beautiful day in March 2009 when he pledged that science would trump politics, not the other way around.

If you would like to write President Obama to object to Sebelius’s action and remind him to remember his promise about scientific integrity, you can contact the White House directly via this online form.


November 29, 2011

Why is the Cesarean Section Rate So High?

A recent Boston Globe Magazine feature “The C-Section Boom,” written by obstetrician Adam Wolfberg, discusses the high rate of cesarean sections as well as the variable rate between providers and facilities, possible reasons for the high rate, and potential approaches for reduction.

Wolfberg believes that the factors that contribute to the high rates include doctors’ convenience, fear of litigation, overdiagnosis of fetal distress, and previous cesareans. One particular statement laid out the power dynamic operating in many birth situations with a clarity I’ve rarely seen:

The truth is, an obstetrician can persuade almost any patient at any time that a caesarean is the best choice. I could have told this woman that the transient dips in the heart rate concerned me and that I recommended surgery to prevent her baby from being harmed. Few patients, hearing those words, would refuse.

Letters in response to the piece point to issues not fully explored by Woflberg. In her letter with Gene Declerq, a professor in Maternal and Child Health and the assistant dean for doctoral education at the Boston University School of Public Health, OBOS co-founder and director Judy Norsigian writes that while Wolfberg says previous cesareans often lead to future cesareans, he does not describe changes in the official ACOG position (2010) on previous cesareans, which presumably will allow for more vaginal births – and which potential patients could benefit from being aware of.

Wolfberg also doesn’t really discuss potential adverse health effects of cesarean, focusing instead on institutional costs as a downside. Another letter-writer, Beth Shearer, raises these concerns and advises doctors to be as wary of surgical risks during unnecessary surgery as they might be of the legal risks of not doing cesareans.

Meanwhile, the CDC’s preliminary birth data for 2010 shows the first – tiny – decline in the U.S. cesarean rate in more than a decade, after reaching an all-time high. From 32.9% to 32.8% of all births. And the rate actually went up for Black (35.4% to 35.5%) and Hispanic (31.6% to 31.8%) women. Here’s what the overall rate looks like over the last fifteen years:

graph of increasing cesarean rate since 1996 from CDC data


November 18, 2011

More Discussion of Nitrous Oxide in Labor

The November/December issue of the Journal of Midwifery & Women’s Health has an article on nitrous oxide by Judith Rooks, a nurse-midwife and epidemiologist who has long advocated for making nitrous oxide available as a pain relief option for U.S. women in labor.

Nitrous oxide (N2O) is a gas that a laboring woman can breathe in through a mask.  It works very quickly, taking effect in about a minute, and wears off quickly.  Because it is administered by the laboring woman herself, it allows her to obtain a short burst of relief only when needed, as an alternative to an epidural. It is the most commonly used form of analgesia in the United Kingdom.

However nitrous oxide is not widely available in the U.S., despite the endorsement of various childbirth advocacy organizations, including the American College of Nurse Midwives.

In her article, Rooks reviews the research and literature on the safety and risks of nitrous use. She discusses questions around high and low doses of the gas, labor progress, maternal and fetal/newborn effects, and occupational hazards.  She notes that:

Because N2O/O2 labor analgesia does not have adverse effects that could threaten the safety of the mother or fetus, laboring women who use it do not need routine intravenous access, continuous electronic fetal monitoring, or other procedures that are intrusive and restrict the mother’s freedom of movement during labor. Nitrous oxide labor analgesia is safe for the mother, fetus, and neonate and can be made safe for caregivers.

The review points out several health concerns,  including that women who have had recent ear surgery (because of potential vomiting and inner ear pressure issues) and women who at increased risk of vitamin B12 deficiency may need special review before using nitrous, and that workplaces should take care to make sure the appropriate safety measures are taken to limit birth workers’ exposure. She also points to the need for additional research on issues like brain effects and occupational exposure in birth settings.

Although it’s only available to members, the American College of Nurse-Midwives also covered nitrous oxide in their recent Quickening newsletter. In it, they speak to Michelle Collins, CNM at Vanderbilt, who was instrumental in pushing for nitrous to be an option there. Collins explains several reasons women might choose nitrous: to take the edge off contractions, reduce anxiety, relieve discomfort while waiting on an epidural or during other procedures, or simply to delay epidural and keep more time available when the woman can be mobile.

Collins shares that in one month this summer, “35 women used the nitrous during labor at Vanderbilt, and of those, 22 used it as their sole analgesia. The remain­ing 13 used it and later had an epidural.”

For more on this topic, see this previous post with further discussion from Judith Rooks.


November 3, 2011

Finally, Some Consensus on Home Birth: The Nine Statements of Agreement

At an historic Home Birth Consensus Summit in Virginia last month on “The Future of Home Birth in the United States: Addressing Shared Responsibility,” a group of 68 national and international experts developed nine key common ground statements that provide a foundation for continued dialogue and collaboration across sectors in the maternity care field.

The statements were posted this week at homebirthsummit.org, along with comment about the scope and context of the meeting. The site also includes information about why the summit was necessary and the process involved in reaching consensus. Action plans relating to these statements will be posted soon.

As one of the participants in the three-day summit, I was impressed with our collective commitment — despite different perspectives and areas of disagreement about out-of-hospital birth — to a common goal of improving maternal and newborn care for families choosing to give birth at home or in freestanding birth centers.

Mark Sloan, a pediatrician and writer who attended the summit, briefly explains the history of home birth in United States, offering context for why the summit marks a significant moment: “The representatives of all the major midwifery organizations — MANA (Midwives Alliance of North America) and ACNM (American College of Nurse-Midwives) — as well as ACOG (American College of Obstetricians and Gynecologists), FIGO (International Federation of Gynecology and Obstetrics), and the AAP (American Academy of Pediatrics) sat together in the same room to discuss home birth for probably the first time in history.”

One of the agreed-upon statements emphasized our belief that “collaboration within an integrated maternity care system is essential for optimal mother-baby outcomes. All women and families planning a home or birth center birth have a right to respectful, safe, and seamless consultation, referral, transport and transfer of care when necessary. When ongoing inter-professional dialogue and cooperation occur, everyone benefits.”

The ninth and last statement reads: “We recognize and affirm the value of physiologic birth for women, babies, families and society and the value of appropriate interventions based on the best available evidence to achieve optimal outcomes for mothers and babies.”

Other statements address improving the current liability system, the licensure of maternity care professionals, increased participation by consumers in multi-stakeholder initiatives, and the creation of an equitable maternity care system without disparities in access, delivery of care, or outcomes. See below for the full list.

The remarkable collegiality and constructive dialogue among the stakeholders present enabled the group to develop these nine core principles as well as commit to a variety of future collaborations. This is an important first step towards achieving improved outcomes for childbearing women and their families in this country.

As Saraswathi Vedam, director of the Division of Midwifery at the University of British Columbia and chair of the Home Birth Consensus Summit Steering Committee, noted: “When you have an issue as controversial as home birth, there are always going to be differences of opinion among various types of providers, policy-makers and even among consumers. But all of us recognize that for women who choose home birth, it’s our shared responsibility to work toward policies that will make that choice as safe as possible.”

Summit participants included obstetricians, family physicians and midwives, non-professionals serving in advocacy roles, insurers, attorneys, ethicists, administrators, policy makers, researchers, and others with expertise in epidemiology, public health, midwifery, obstetrics, pediatrics, nursing, sociology, medical anthropology, law, and health policy research.

We invite your comments on the statements below.

STATEMENT 1
We uphold the autonomy of all childbearing women.

All childbearing women, in all maternity care settings, should receive respectful, woman-centered care. This care should include opportunities for a shared decision-making process to help each woman make the choices that are right for her. Shared decision making includes mutual sharing of information about benefits and harms of the range of care options, respect for the woman’s autonomy to make decisions in accordance with her values and preferences, and freedom from coercion or punishment for her choices.

STATEMENT 2
We believe that collaboration within an integrated maternity care system is essential for optimal mother-baby outcomes. All women and families planning a home or birth center birth have a right to respectful, safe, and seamless consultation, referral, transport and transfer of care when necessary. When ongoing inter-professional dialogue and cooperation occur, everyone benefits.

STATEMENT 3
We are committed to an equitable maternity care system without disparities in access, delivery of care, or outcomes. This system provides culturally appropriate and affordable care in all settings, in a manner that is acceptable to all communities.

We are committed to an equitable educational system without disparities in access to affordable, culturally appropriate, and acceptable maternity care provider education for all communities.

STATEMENT 4
It is our goal that all health professionals who provide maternity care in home and birth center settings have a license that is based on national certification that includes defined competencies and standards for education and practice.

We believe that guidelines should:

allow for independent practice
facilitate communication between providers and across care settings
encourage professional responsibility and accountability, and
include mechanisms for risk assessment.

STATEMENT 5
We believe that increased participation by consumers in multi-stakeholder initiatives is essential to improving maternity care, including the development of high quality home birth services within an integrated maternity care system.

STATEMENT 6
Effective communication and collaboration across all disciplines caring for mothers and babies are essential for optimal outcomes across all settings.

To achieve this, we believe that all health professional students and practitioners who are involved in maternity and newborn care must learn about each other’s disciplines, and about maternity and health care in all settings.

STATEMENT 7
We are committed to improving the current medical liability system, which fails to justly serve society, families, and health care providers and contributes to:

inadequate resources to support birth injured children and mothers;
unsustainable healthcare and litigation costs paid by all;
a hostile healthcare work environment;
inadequate access to home birth and birth center birth within an integrated health care system, and;
restricted choices in pregnancy and birth.

STATEMENT 8
We envision a compulsory process for the collection of patient (individual) level data on key process and outcome measures in all birth settings. These data would be linked to other data systems, used to inform quality improvement, and would thus enhance the evidence basis for care.

STATEMENT 9
We recognize and affirm the value of physiologic birth for women, babies, families and society and the value of appropriate interventions based on the best available evidence to achieve optimal outcomes for mothers and babies.


October 25, 2011

Comparing ACOG VBAC Guidelines

Last year, the American College of Obstetricians and Gynecologists released new guidelines on vaginal birth after cesarean (VBAC). ACOG’s stance on VBAC is considered extremely important, because it can have a strong influence on whether hospitals and individual providers are willing or able to offer VBAC as an option. The organization’s 2004 statement is widely considered to have drastically reduced the availability of VBAC in the United States.

The 2010 guideline place a greater emphasis on women’s right to be part of the decision-making process and to refuse cesareans, and indicated that women with two previous low transverse incisions, carrying twins, or with single previous cesarean with an unknown type of incision may be candidates for a trial of labor.

One thing that has always bothered me about from a research perspective is how ACOG guidelines are treated once they are updated. Once a new version is out, the old guidelines are essentially disappeared from all the online sources. As I wrote after speaking to an ACOG rep about this issue, it makes it really difficult to compare the old and new version if one wants to see them side by side and compare documents/changes. Immediate removal is probably great for clinicians and liability reasons, but it’s not so great for historical research and understanding changing policies and influences on birth practices over time.

Childbirth Connection has released a document that gives a very basic overview of changes related to VBAC in the 2010 ACOG practice bulletin compared to the 2004 VBAC and 2006 induction of labor for VBAC documents. While this comparison doesn’t have the full details, caveats, and discussion of having the ACOG documents in hand side-by-side, it’s a good starting point for understanding what has changed.


October 1, 2011

The flood of relief I felt at that moment, and the power that came from the sense of not being alone, really did change my life …

by Ruth Bell Alexander

In late 1969, a couple of months away from delivering my first baby (my son, who is now 41), I was 25 years old, living out in the country suburbs of Boston 3,000 miles away from my family, with a husband who went off to Cambridge every weekday for work.

It was a pretty lonely existence. I knew almost no one. But when my husband came home one day and told me he had met some people at work who knew about a women’s group that was starting, my life began to change. They were offering a class after hours at MIT about women’s issues. I remember the class being called Women and Their Bodies, but that’s with 42 years hindsight, so I may be wrong about the original title.

I do remember with startling clarity that although I knew only one person there, and even she I knew only barely, the roomful of women I walked into was very welcoming. The “class” was presented in a series of lectures about topics that ranged from women’s “roles,” to women’s work, health, legal issues pertaining to women, etc. — one topic per week for 12 weeks.

Each week had a “presenter,” and everyone in the room was invited to ask questions, offer comments, and discuss the issue at hand. I remember the Pregnancy class most clearly of course, and most specifically I remember raising my hand, with some trepidation, to ask about nightmares. During my pregnancy I had been having troubling nightmares, one of the issues that led me to brave the New England winter nights to drive 20 miles into Cambridge for the class. So I raised my hand and asked, “Has anyone experienced nightmares during pregnancy?”

Remembering this brings tears to my eyes even now at age 67, because my question was met with such loving responses that I felt embraced by the warmth and power of the experience and a deep connection to every woman in that room. No one patted me on the head and told me not to worry, as my doctor had done. No one scoffed at me. Instead, they listened and they responded from their hearts. And several of them had nightmares during their pregnancies, and they told me it was a fairly common experience for pregnant women to have strange dreams.

The flood of relief I felt at that moment, and the power that came from the sense of not being alone, really did change my life. The course ended after my baby was born, but I remember being at the last class when anyone there who wanted to participate in the writing of the lecture series into a book was invited to come to the next meeting.

I did show up at that next meeting and I have been involved with the OBOS collective since then. Happy 40th Anniversary, “Our Bodies, Ourselves.”

Do you remember when you first read “Our Bodies, Ourselves”? Take part in OBOS’s 40th anniversary by sharing how “Our Bodies, Ourselves” made a difference in your life. View more stories and submit your own.


October 1, 2011

OBOS was my midwife — always informative, always encouraging me to hear and express my own voice …

by Maura Ann Dowling

In 1986 I was a senior in college, had just ended a relationship with my boyfriend who had anger management challenges from some unresolved issues in his past. Then I found out I was pregnant. My parents were very concerned with image — so this was not an event they were able to open their hearts to for many months.

Fortunately I owned a copy of “Our Bodies Ourselves,” because my mother had planted a seed in me to question the medical establishment, and one of my professors in college was part of the generation of 1968 in France and she had raised my feminist consciousness. Neither my mother nor my professor had the ability to advise me in this, so OBOS gave me that mentoring supportive voice that I needed.

For me, an abortion was not an option. I always knew I would carry my pregnancy to term and raise the baby on my own. And OBOS continually gave me the women’s wisdom I needed. I was 24 at the time but looked about 17 — and when I went to physicians’ offices, I noticed the disconnect between what I wanted to be a positive nurturing pre- and post-natal experience.

Just the forms I filled out asking for the “father’s name” even before my name was appalling. Then the “meet-the-doctor-naked-in-a-paper-gown” was uncomfortable. And then the insistence on ultrasounds and tests that I didn’t agree with. All through this OBOS was my midwife — always informative, always encouraging me to hear and express my own voice.

I declined prenatal tests with 30 percent failure rates. I requested to meet and speak with my physician clothed and with questions about their practice. I discussed natural childbirth and what reasons would cause them to use medical interventions. Once I was faint on the examining table and the female physician asked if I always acted this way! I changed physicians four times through my pregnancy because of the way they handled my taking the lead in me and my baby’s care.

Through all of this, my family went through all manner of projecting judgment and fear on to me — my father didn’t speak to me for four months, my mother made inquiries into an unwed mother’s home, my brother asked why I wasn’t getting an abortion, my Godmother told me I could never wear a white dress at a wedding in future. OBOS validated me while my family heaped their shame on me.

I kept up a full-time course load, and waitressed part-time until I was eight months pregnant. Then the physician I had come to trust told me my baby was breech and that she would schedule me for a C-section. After I had gotten dressed and met her in her office, I knew enough to ask questions because of my intense reading of OBOS. Formulating the question in the heat of the moment was very challenging because this news came at me so suddenly.

I managed to ask why we wouldn’t wait until I went into labor to plan the C-section, because then we would have a clear indication that the baby was ready to be born.

Her response stunned me. She asked, “Why would you want to go into labor — it’s no fun.”

I drove straight home and pulled out OBOS. I searched for some answer — this didn’t feel right. My father stopped by, he was speaking to me now and I told him what had happened. He was an HR executive, and he told me that the major medical health insurance I had paid a physician a higher rate on a C-section than a natural birth.

Since midwives were discussed, I decided I needed advice from one. I obtained a phone number of a midwives association in the New York City area where I was — and when I discussed what had transpired with the midwife, she asked how I knew to call them. I told her about OBOS! She was so supportive of me and encouraged me for standing up for myself — then she gave me three physician’s names and why she thought they were worth a try in my case. She did warn me that changing physicians at almost nine months was tricky due to the way insurance pays.

The second physician’s office took me in for an appointment. My mother went with me and told me I was being vain to avoid a C-section. I reached behind her seat in the car and handed her a copy of “The Silent Knife” that OBOS had recommended and told her the page number to read where they described a C-section step-by-step. My mother had been an RN so I knew she would understand after she read — she did, and she stopped resisting my medical choices. The new physician was willing to discuss ways for the baby to adjust position before birth, as well as manual ways to change her position and he reassured me that a C-section would be a last resort.

By the time I had an ultrasound to check, the baby had moved with the exercises. My former physician called me to see why I was terminating our relationship, and when I explained she went on the fear-path, telling me how big my baby was. I just quoted something from OBOS and told her I felt natural childbirth was the right path for me to pursue.

My beautiful daughter, Maia, was born a few days later after a long and vigorous labor with no drugs or surgery. I spent one night in the hospital (my choice) and took her home, and we were a champion nursing team. She lost 2 ounces, and then gained weight at a robust clip. She was born on a Monday and then on Wednesday evening my mother and aunt babysat for a couple of hours so I could go to my feminist economics class where I got so much positive support along with my trusty OBOS.

My daughter and I thank you — all of you past and present! And for many years now my daughter and her father have cultivated a deep and growing relationship. We are a family that started with bumps, but have found resolution, love and peace.

Do you remember when you first read “Our Bodies, Ourselves”? Take part in OBOS’s 40th anniversary by sharing how “Our Bodies, Ourselves” made a difference in your life. View more stories and submit your own.


October 1, 2011

Midwives are the guardians of normal and natural birth …

by Whitney Pinger

As a young teen in the 1970s, OBOS taught me that women’s health was ours, and that we did not have to give up or strength and power.

I learned that midwives are the guardians of normal and natural birth and that is what I have come to incarnate.

I have been learning to be a midwife since I opened my first copy of OBOS … my journey took me many places but I am now the Director of Midwifery at The George Washington University.

I was an OBOS Women’s Health Hero in 2010.

My entire life has flowed from OBOS.

Do you remember when you first read “Our Bodies, Ourselves”? Take part in OBOS’s 40th anniversary by sharing how “Our Bodies, Ourselves” made a difference in your life. View more stories and submit your own.


September 15, 2011

Fertility Preservation and Egg Freezing for Healthy Women

Freezing eggs for future use (“oocyte cryopreservation”) is an experimental procedure created to help preserve fertility for women undergoing toxic cancer therapies. Research regarding fertility preservation is growing, sparked largely by the increase in survival rates for people with cancer.

Unfortunately the medications used to stimulate egg production carry some health risks, and the high water content of eggs means that egg  freezing is far more difficult and unpredictable than freezing sperm or embryos. The full risks and effectiveness of egg freezing are not clear.

While women about to undergo cancer treatment may be willing to accept these risks, concerns are being raised because some fertility clinics are offering egg freezing as an option for healthy women who wish to delay childbearing.

The American Society for Reproductive Medicine (ASRM) has said offering healthy women egg freezing should only be done as part of scientific experiments with oversight from Institutional Review Boards. In a document outlining “essential elements for informed consent” for this procedure, the ASRM outlines the following risks and concerns, among others:

  • Medical risks associated with ovarian stimulation and egg retrieval
  • The high likelihood that women who undergo this procedure before age 35 will never to use the frozen eggs
  • Costs for medications, monitoring, retrieval, storage, and future use
  • The possibility that a facility will close or lose or damage the eggs, and that different facilities may have differing success rates

The organization also raises concern about possible chromosomal or developmental abnormalities in offspring; they say that while these effects have not been demonstrated, the available data is based on a relatively limited number of successful pregnancies from the method.

In contrast to a recent NPR headline, “Egg Freezing Puts The Biological Clock On Hold,” the ASRM has advised, “At the present time, neither ovarian tissue nor oocyte cryopreservation should be marketed or offered as a means to defer reproductive aging.”

Aside from safety and effectiveness concerns, the procedure is currently an option only for those women with considerable disposable income – costs run higher than $10,000 for a round of egg collection, plus annual storage costs.

For further reading, check out this piece at Biopolitical Times, “Oocyte Cryopreservation: The Next Wave of Assisted Reproductive Technology, or Marketing Ploys for Career-oriented Women?” from the National Women’s Health Network, and our web content on egg donation (which requires similar stimulation and egg harvesting procedures).


September 12, 2011

Women of Sierra Leone Still Struggle to Access Care

Sierra Leone has one of the worst lifetime maternal mortality rates in the world, at 1 in 8 – compared with 1 in 4,800 in the United States. A government program implemented last year is meant to help address this situation, which Amnesty International calls a “human rights emergency,” by providing free healthcare to pregnant and breastfeeding women, as well as to children under age 5.

Amnesty International has released a report describing serious challenges that still exist for women and girls trying to access this care. They report problems such as a lack of needed drugs; women being asked to pay for drugs and “consumables” such as needles that should be free; poor record-keeping that affects the delivery of care; corruption; and lack of sufficient monitoring and oversight. Women who are denied care that is supposed to be freely provided have no effective means of complaint, as one interviewee describes:

My baby was crying a lot, and had fever. Hospital had no drugs for him. Need to pay money. They chased me away. I don’t know how to complain.

Amnesty International’s report provides several recommendations for improving the health care system and more effectively delivering required care to Sierra Leone’s women, and asserts that it is necessary to address underlying problems beyond access:

It is crucial that authorities are able to respond to lack of facilities, nonavailability of drugs, systematic bad practices, corruption and other challenges. The government must ensure that women are informed of their right to redress and available complaint mechanisms and are able to participate in the monitoring and accountability processes. Monitoring and accountability bodies must have a strong mandate, be adequately resourced and be accessible, independent, and transparent and able to recommend remedies to improve delivery of health services…. [Accountability] requires transforming the underlying, untenable situation that gives rise to widespread maternal mortality, not just restoring a prior equilibrium.

The organization is asking supporters to send a message to Sierra Leone’s Minister of Health calling for actions to ensure that emergency obstetric services are properly provided, health systems and providers are aware of their responsibilities for the free care program, and systematic attention to problems of out-of-stock and diverted drugs.

Further reading: this Washington Post piece from 2008 explores maternal mortality in Sierra Leone.


September 7, 2011

Registration Open for Southern Black Midwives and Healers Summit

Registration is now open for the Southern Black Midwives and Healers Summit, themed “Reducing Maternal and Infant Mortality by Building Community Leadership.”

From the program description:

This is an action and solution-oriented leadership development event designed to reduce health disparities, improve breastfeeding rates and build capacity in the Southeast region of the United States. Our goal is to increase the number of midwives, doulas and healers so they can empower families…Midwives, doulas, birth workers, community members and all those committed to reducing health inequities in the SE region will have the opportunity to collaborate with ideas and skills to create leaders and advocates in their communities to ensure improved birth outcomes.

The International Center for Traditional Childbearing organizes the summit, to be held in D’Iberville, MS on October 14-16 this year.

Relatedly, ICTM has a page up on the history of Black midwives, including a video series, “The Legacy of the Black Midwife.”