Even though caesareans are associated with higher rates of complications than vaginal births, they are becomingly increasingly common. Problems range from infections, including the more serious antibiotic-resistant ones, to blood clots, prematurity, respiratory problems for the baby, and more complications with subsequent pregnancies. There is even a small but measurably higher risk of death for the mother.

Between 2000 and 2006, while the Massachusetts caesarean rate climbed from 16th to 10th highest among all states, the state’s ranking on neonatal mortality has slipped from 4th best to a tie for 9th. Six hospitals in the state have caesarean rates greater than 40 percent for first time mothers, yet none of these hospitals is designated as a high-risk center. So much for the argument that high-risk pregnancies are the reason for these rates.

There are also cost consequences for taxpayers — the caesarean rate for Massachusetts mothers on Medicaid is increasing at a faster pace than among privately insured mothers. Nationally, in 2008, average hospital charges for an uncomplicated caesarean section were $14,894, while such charges for an uncomplicated vaginal birth were $8,919.

In the United States, about one in three births are via c-section, and in some communities the rate is much higher.  Childbirth Connection explains the myriad conditions that have led to the increase, including: low priority of enhancing women’s own abilities to give birth; side effects of common labor interventions; refusal to offer the informed choice of vaginal birth; casual attitudes about surgery and cesarean sections in particular; limited awareness of harms that are more likely with cesarean section; providers’ fears of malpractice claims and lawsuits; and incentives to practice in a manner that is efficient for providers.

In the op-ed, Norsigian and Johnson argue that while the media often focuses on how extreme obesity can raise the risk of having a caesarean, more emphasis is needed on “system-based approaches” — steps that hospitals and obstetricians can take, such as instituting policies that restrict the induction of labor, unless there is a good medical reason, and following the new National Institute of Health recommendations to offer the option of vaginal birth after a caesarean for women who want to avoid repeat surgery.

Finally, they note, hospitals should expand access to nurse-midwifery care:

Enhancing access to midwifery care might well be the most effective approach to safely reducing the overall caesarean rate — and could lead to significant cost savings and improvement in other priority areas such as breastfeeding. It would also address the impending shortage of obstetric providers. The Legislature should pass a bill to expand access to midwifery care in Massachusetts. We must finally make midwives more central in maternity care — as do all other countries whose birth outcomes are superior to ours.

Read the full op-ed here.

Related:
* Vaginal Birth after Cesarean — What the NIH has to say

* ACOG on VBAC: In Their Own Words

The FDA, though, responded to this plan with a letter to the company indicating that their product met the definition of a medical device and would therefore require FDA approval. The agency indicated that they could find no such approval on file, and asked the company to respond within 15 days with either an FDA approval number or an argument for why one shouldn’t be needed.

The House Committee on Energy and Commerce has also jumped into the fray. In a letter [PDF] to the company planning to offer OTC kits, the committee asked for, among other things “All documents relating to the ability of your genetic testing products to accurately identify consumer risk,” and “All documents regarding your policies for processing and use of individual DNA samples collected from consumers.”

This is not the first time, however, that genetic testing has been available to consumers – other companies have been offering what is essentially mail order genetic testing, including testing for BRCA mutations. The Committee also sent letters to two other companies which have been offering these services, such as 23andme.

Aside from issues of FDA approval, the presence or absence of mutations does not tell the whole story of an individual’s health risk. For example, in the case of BRCA1 and BRCA2 mutations, a positive or negative test cannot specifically predict whether or when an individual woman might develop cancer (or determine that she will not develop cancer). As Merrill Goozner of Gooznews on Health explains:

…Mary Claire King discovered that women in families with a history of breast cancer had common mutations of the BRCA1 and BRCA2 genes. But it’s important to remember that you can have the relevant mutations and not develop the disease.

Similarly, the National Cancer Institute explains the limitations of what can be known from a positive or negative test:

A positive test result generally indicates that a person has inherited a known harmful mutation in BRCA1 or BRCA2 and, therefore, has an increased risk of developing certain cancers… However, a positive test result provides information only about a person’s risk of developing cancer. It cannot tell whether an individual will actually develop cancer or when. Not all women who inherit a harmful BRCA1 or BRCA2 mutation will develop breast or ovarian cancer… Having a true negative test result does not mean that a person will not develop cancer; it means that the person’s risk of cancer is probably the same as that of people in the general population.

The Institute also recommends genetic counseling prior to testing in order to discuss the risks and benefits of such testing and the implications of a positive or negative result. The debate over whether over-the-counter genetic testing is appropriate without such counseling is likely, I think, to follow along similar lines as the debate over the elimination of required counseling for HIV testing since the availability of over-the-counter testing. Although the specifics and rationale are a little different, both discussions include a component of whether consumers can fully utilize or react to results without further counseling or intervention.

The bloggers at Genetic Future and Genomics Law Report have more.

Some resources specific to women:

The bill would make it illegal for Certified Professional Midwives — midwives who who are specially trained to deliver babies in out-of-hospital settings– to practice.

Right now, the Midwives Alliance of North America (MANA) categorizes the current situation in Mississippi for non-nurse midwives as “Legal by Judicial Interpretation or Statutory Inference” – in other words, interpreted to be legal but not explicitly provided for in the current law.

The organization provides some documentation from the previous MS Attorney General who concluded in 1991 that, “By its express terms, the practice of medicine as defined in Miss. Code Ann. Section 73-25-33 specifically excludes the practice of midwifery. Thus, it is the opinion of this office that those persons otherwise not licensed as nurses may engage in the practice of midwifery without licensure as a physician and for compensation.”

The current bill, which would add language to explicitly make non-CNM midwives illegal, passed the state House on February 9th and has been referred to Public Health and Welfare committee in the state Senate, whose members bill opponents are contacting. That committee consists of: Hob Bryan, Chairman; Alan Nunnelee, Vice-Chairman; Terry C. Burton; Eugene S. Clarke;Bob M. Dearing; Joey Fillingane; Hillman Terome Frazier; Billy Hewes; W. Briggs Hopson III; John Horhn; Cindy Hyde-Smith; Gary Jackson; Kenneth Wayne Jones; Tom King; Chris McDaniel; Nolan Mettetal; Willie Simmons; Bennie L. Turner; Lee Yancey. Contact information for each Senator is linked from this Senate roster.

MANA is encouraging supporters of Certified Professional Midwives who live in Mississippi to contact their state Senators. Tell them that you do NOT support making Certified Professional Midwives illegal, and ask them to vote NO on HB 695.

In other birth-related legislative news, the American Association of Birth Centers is asking supporters to contact their Senators and Representatives to support the Medicaid Birth Center Reimbursement Act (H.R. 2358 / S. 1423). For further information, see our previous post and information provided by AABC.

• Cervical cancer screening should begin at age 21 years (regardless of sexual history). Screening before age 21 should be avoided because women less than 21 years old are at very low risk of cancer. Screening these women may lead to unnecessary and harmful evaluation and treatment.
• Cervical cytology screening is recommended every 2 years for women between the ages of 21 years and 29 years. Evidence shows that screening women every year has little benefit over screening every other year.

Older guidelines from ACOG and other groups varied but tended to suggest that women start screening at age 18 or 21, or at the onset or within 3 years of the onset of sexual activity, whichever came first, and often recommended yearly screening.

The new guidelines also suggest that women women 30 and older should be screened for cervical cancer whether by conventional or liquid PAP test once every 2 years, instead of annually, and after 3 consecutive negative tests be screened once every 3 years. Women with certain risk factors such as a history of cervical dysplasia or cancer, HIV, other causes of immunosuppression, or exposure to the drug DES may need more frequent screening.

Unchanged in the guideline is that women who have undergone total hysterectomy no longer need a Pap test, and that women ages 65 and older can discontinue cervical cancer screening if they have three consecutive negative Pap tests and no abnormal tests in the previous 10 years.

The American Cancer Society issued a statement that the revised ACOG guidelines “aren’t very different than the guidelines currently outlined by ACS, which were last updated in 2002;” they’re also very similar to the recommendations issued in 2003 by the USPSTF. Medical News Today provides a freely available summary of the guideline.

The first paragraph succinctly describes the progression:

In the beginning there was sex. And sex begat skill, and skill (or its absence) begat judgment, and judgment begat insecurity, and insecurity begat doctors’ visits, which begat treatments, which have flourished into a multibillion-dollar industry, so that sex between men and women is today almost inconceivable without the shadow of disorder, dysfunction, the “little blue pill” or myriad other medical interventions designed to bring sex back to some longed-for beginning: a state of certified healthfulness, the illusion of normal.

One sex therapist interviewed for the piece argues that sexual concerns should not necessarily be medical concerns, that sex is “…more like dancing or cooking. Yes, you do it with your body. You dance with your body, too. That doesn’t mean there’s a department of dance in the medical school. You don’t go to the doctor to learn to dance.”

The author refers to a couple of resources on the topic for further exploration, including the new documentary “Orgasm, Inc.” by Liz Canner, which examines the role of pharmaceutical companies in creating a market for drugs for “female sexual dysfunction.” Also mentioned is the book “The Technology of Orgasm: ‘Hysteria,’ the Vibrator, and Women’s Sexual Satisfaction” by Rachel Maines, which further details the history of physician approaches to “hysteria” and women’s sexuality. Readers may also want to check out “Passion and Power: the Technology of Orgasm,” a film inspired by Maines’s work.

One line in The Nation piece I couldn’t let pass without sharing: “Sears marketed a home vibrator with attachments for beating eggs, churning butter, operating a fan.” Now that’s a multi-purpose tool!

The report examines U.S. prison nursery programs, which allow incarcerated women to keep their newborns with them in prison for a finite period of time, and community-based residential parenting programs, which allow women to serve criminal justice sentences with their infants in a non-prison setting. Both types of programs are intended to promote bonding and parenting skills, and potentially reduce recidivism.

The report describes the scope of the problem of parenting for incarcerated women thusly:

Between 1977 and 2007, the number of women in prison in the United States increased by 832 percent. According to data released by the Bureau of Justice Statistics (BJS), in 2004 four percent of women in state prisons and three percent of women in federal prisons were pregnant at the time of admittance. In 1999, BJS reported that six percent of women in local jails were pregnant at the time of admittance. As the number of women in prison has skyrocketed over the past 30 years, states have had to consider what it means to lock up women, many of whom are pregnant or parenting.

Among the findings regarding prison nurseries:

• Nine states – California, Illinois, Indiana, Ohio, Nebraska, New York, South Dakota, Washington, and West Virginia – currently have or will soon open prison nurseries.
• The amount of time infants are allowed to remain in prison nurseries ranges from 30 days to 18 months.
• The largest prison nursery program in the country has capacity for up to 29 mother/child pairs. Some programs have much smaller capacities, such as the Decatur Correctional Facility in Illinois, which has room for just 5 pairs.
• All of the prison-based programs provide educational programming in child development and parenting skills.
• All states with prison nursery programs only allow this arrangement when the child is born in state custody.
• In general, only women who committed crimes and who do not have a past history of child abuse or neglect are accepted into the programs.
• Mothers are often required to sign waivers releasing the facility from any responsibility if their children become sick or injured.

The authors also describe community-based facilities, in which women serve their sentences in a residential setting. The women are usually allowed to leave to attend doctor and social service appointments and other community programs, and often receive drug or alcohol abuse treatment. Children in this program are usually not infants born in custody, but small children brought by their mothers into the programs.

The authors also note – in addition to the overall lack of programs to deal with pregnancy, motherhood, and incarceration – a lack of standards for the treatment of pregnant women under criminal justice supervision and for the health care or housing needs of the  infants.

Finally, the organization makes three recommendations:

• 1) Increase use of community corrections and reduce reliance on incarceration;
• 2) Enhance program features that promote overall family well-being in prison nurseries and community-based residential parenting programs;
• 3) Fund scientific research, participatory action research, and program evaluations of prison nurseries and community-based residential parenting programs to reveal best practices and the potential benefits of system reforms.

The conditions – chronic fatigue syndrome, endometriosis, interstitial cystitis, irritable bowel syndrome, temporomandibular joint disorders (TMJ), and vulvodynia – disproportionately or solely affect women.  All are poorly understood, and many who suffer from these conditions are misdiagnosed and receive inappropriate treatment.

While the OCA website does not yet have a lot of detail, the partnered organizations are:

• Chronic Fatigue and Immune Dysfunction Syndrome Association of America
• Endometriosis Association
• Interstitial Cystitis Association
• International Foundation for Functional Gastrointestinal Disorders
• TMJ Association
• National Vulvodynia Association

The Overlapping Conditions Alliance will advocate for funding to research the common underlying mechanisms and risk factors for these conditions, so that preventive strategies and more effective treatments can be developed.

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

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

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

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

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

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