Each year, Lamaze International presents awards to the best and brightest in childbirth education and advocacy at its annual conference. We are thrilled to announce that for the first time, bloggers will be considered for the annual Lamaze Media Award. Increasingly, bloggers are shaping the conversation about birth, highlighting the need for maternity care reform, and reaching childbearing women with critical messages about safe and healthy birth practices. Be recognized for your unique voice and important impact in childbirth education and advocacy.

The winner will receive:

• Publicity in communications to Lamaze members, the public, and the media
• One free registration to the 2009 Annual Conference in Walt Disney World, FL, where the award will be presented
• Up to $500 reimbursement for travel to the 2009 annual conference

Nominations are due by June 15 and should be sent to amyromano@lamaze.org. You may nominate yourself or another blogger.

Please include:

• The name and URL of the blog
• The direct link to a post that best exemplifies blog content that supports the Lamaze mission
• The credentials of the main blogger(s)
• A summary of the traffic and influence of the blog (e.g., monthly site traffic; links from other influential blogs or the mass media)

Researchers are finding that unborn mice exposed to the same waves that the little handpiece emits through that cold gel the technician has squirted on a pregnant belly end up experiencing a derailing of their developing brain cells. The Yale researchers cited here conclude: “The effect of this slight disruption remains unknown. More testing is underway.”  So then, why are so many of us submitting our unborn to a most-often unnecessary procedure that might derail activity in a busily developing little brain? We need to be asking our doctors: “Is this procedure absolutely medically necessary?” And then ask “Why?” – that little word that so many of us don’t often like to have to deal with. The Yale research team suggests that, for now, we step away from the scanner unless there’s a clear and present need. It just might be worth waiting until after the birth for “baby’s first picture.”

I was struck (as I always am) by how important birth is for women. How transforming it is meant to be. And how absolutely wonderful it can be. In this short film I was also struck by how many of the women and their men are health care providers themselves, including physicians and anethesiologists. 

Debate is going on among doctors groups on the feasibility and necessity of prenatal testing for thyroid imbalance in pregnancy. If a pregnant woman’s thyroid isn’t functioning as it should, it can under-produce (hypothyroidism) or over-produce (hyperthyroidism), and that may lead to pre-eclampsia, premature birth, miscarriage, or impaired intelligence in her infant.

Most doctors’ groups haven’t yet endorsed universal prenatal thyroid screening. They wonder if the benefits would justify the expense of testing in roughly 6.4 million pregnancies each year and educating doctors to read results that are tricky to interpret. There was a recent thyroid association symposium to consider the most recent research, and what it will lead to remains to be seen.

I get a little paranoid about hidden agendas behind sweeping proclamations like these. A recent op-ed piece in the Times had me wondering if I should eat those local-farm pork chops that my little health market sells here in Ann Arbor. A couple of days later a little disclaimer appeared, tucked into the bottom of the page: An Op-Ed article last Friday about pork neglected to disclose the source of financing for a study finding that free-range pigs were more likely than confined pigs to test positive for exposure to certain pathogens. The study was financed by the National Pork Board.

Hmmm. Things are never quite what they appear these days. This is why using our innate womanly wisdom about how we care for our pregnant bodies has kept the human race around all those centuries before Vitamin D and thyroid scares, soft cheese and nail polish alerts, and much, much more that has gotten some of us so scared we’re forgetting how to breath into our pregnancies and trust our bodies.

Cochrane reviews synthesize all of the research on a particular topic, and because the reviewers bring together and analyze all of the data from many studies, the study population gets very big. Big populations yield greater statistical power and often (but not always) more reliable findings.

Prior to this Cochrane review there was a large body of literature on movement in labor, including a good sized U.S. randomized controlled trial. There was even another systematic review! But this body of research never consistently supported the hypothesis that movement improved labor and birth outcomes. Now we have a Cochrane review, which is the gold standard for evidence-based practice.  So we can put the evidence-based “stamp of approval” on freedom of movement.

But, were we any less justified in endorsing freedom of movement before the Cochrane? Although studies have given us inconsistent results as to whether movement shortens labor or decreases the need for c-section, a few conclusions have been loud and clear from the literature since researchers began looking at maternal position and movement:

1. Women prefer to move around, primarily because they experience less pain when they can move.
2. Women who stay in bed usually do so because they are connected to machines or IV lines, and/or because a health care provider tells them to.
3. Movement and walking are not harmful to the woman or the baby.

Freedom of movement is the thing that would happen if women did not have any interaction with a health care system or provider in labor. In other words, it’s the default state of affairs. Anything that we do in the name of “health care” to improve upon this normal unfolding of things is referred to as an “intervention”. In scientific research, researchers compare a control group, which should represent the default/normal, with an experimental group, which represents the intervention. The burden of proof should be on the intervention.

Somehow, things have gotten turned around, and the normal condition is now the “experiment” and the intervention is the “control”. In addition to being irrational, this is a set-up to perpetuate conventional obstetric care, which imposes unhealthy and unfounded restrictions on women in labor. This is because in “intervention versus control” research, you have to show that the intervention performs significantly better, otherwise the control condition remains standard practice. While many of us believe that encouraging a laboring woman to move when and how she wants to is healthier and safer than making her stay in bed, waiting for evidence that it produces better health outcomes is putting a burden of proof on normal birth that has never been applied to routine intervention. Besides, lack of evidence of harm, less pain, and maternal satisfaction are valid and important outcomes in and of themselves, and provide the justification we need to reject routine policies and practices that restrict maternal movement.

BTW, I’ve had my nose in the literature on mobility in labor for a while and am bringing it all together in a session at the Lamaze International Annual Conference in Orlando this October. The session is titled, “Optimizing Labor Progress: What the Research Does and Does Not Tell Us”.  Save the date!

Citation: Lawrence A, Lewis L, Hofmeyr GJ, Dowswell T, Styles C. Maternal positions and mobility during first stage labour. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD003934. DOI: 10.1002/14651858.CD003934.pub2

The American College of Obstetricians and Gynecologists (ACOG) came out against home birth in 2006. They argued that unexpected complications can occur in labor and birth, so the hospital is the safest bet. Despite the existence of a good sized body of literature on home birth, ACOG emphasized the lack of evidence that home birth is safe, concluding that, by default, a policy of universal hospitalization is the optimal way to organize maternity care. ACOG’s statement reads:

Studies comparing the safety and outcome of U.S. births in the hospital with those occurring in other settings are limited and have not been scientifically rigorous. The development of well-designed research studies of sufficient size, prepared in consultation with obstetric departments and approved by institutional review boards, might clarify the comparative safety of births in different settings. Until the results of such studies are convincing, ACOG strongly opposes out-of-hospital births. (Out-of-hospital births in the United States, ACOG 2006)

OK, so now we have an enormous study with the statistical power to detect important differences in perinatal mortality. Will ACOG change their tune?

Some obstetricians may (and to be sure, there are a good number of OBs who already support home birth and home birth midwives), but ACOG as a professional body will most certainly stick to their guns. A closer look at their statement reveals their bias. ACOG pledges to oppose planned home birth unless and until there are large, well-designed studies on the safety and outcomes a) of U.S. births, b) prepared in consultation with obstetric departments, and c) approved by institutional review boards. This is a carefully constructed catch-22.

Planned home birth accounts for less than 1% of all births in the United States. In order to construct a U.S. study the size of the new Dutch study, every single woman planning a home birth in the United States would have to be enrolled in that study for the next eight years. In addition, we would need reliable databases collecting data about perinatal death based on where a woman planned to give birth, something that the Netherlands has but the U.S. lacks. Even if these hurdles were overcome, obstetric departments and institutional review boards present another barrier. If the dominant view in our maternity care system is that home birth is unsafe, obstetric departments and IRBs would be unlikely to willingly participate in research on hundreds of thousands of babies being born at home.

ACOG will say that a study in the Netherlands does not apply to U.S.-style maternity care, a claim that has some merit. Because conventional obstetric management holds sway in the U.S., out-of-hospital midwifery is seen as a fringe alternative and poorly integrated into our system here. Contrast that with the Netherlands, where all healthy women are cared for by midwives, and about a third of babies are born at home. Midwives are not just integrated in the system, they run the system. Home birth is certain to be less safe in a system that marginalizes women who choose to give birth at home and the professionals who attend them there.

A couple of generations ago, obstetricians led a charge in the U.S. to move birth into the hospital without any a priori evidence that hospital birth was any safer. Now that home birth is all but extinct, the “lack of evidence” on planned home birth in the U.S. serves to bolster ACOG’s position. The U.S. is not fertile ground for home birth research because a professional organization looking out for the power and financial interest of its members has run home birth underground and failed to provide the complementary specialist services that ensure continuity of care and safety when complications arise.

In the U.K., policy makers called obstetricians on the absurdity of their “lack of evidence” claims when the national government set out to reform the maternity care system in the early 1990s. I love this quote from a British policy-maker, shared by Eugene Declercq in his 1998 article, ‘Changing Childbirth’ in the United Kingdom: Lessons for U.S. Health Policy:

To consider it safer, or even to have a consensus view, is not the same as having evidence . . . are you not saying that you have made a policy on the basis of safety which was not justified on the statistics when they did exist, and now you say there is not any possibility of getting statistics? Is that not putting women into a trap?” (House of Commons Health Committee 1991b: 210–211).

Today, the debate in the U.K. has moved on from whether to offer access to home birth to how to make sure there are enough midwives to meet the demand.

We need more and better research on home birth. We can use data from the Netherlands to determine the safety of home birth in systems that support and integrate home birth midwifery. After all, it is the only place left with a maternity care system that lends itself to home birth safety research, and national registers to conduct that research soundly. In the U.S., we must study how we can reform our maternity care system to provide access to midwife-led care in all settings, and best practices for caring for the women who rightly and inevitably will continue to desire birth at home.

In research and policy-making, these differences are called “practice variation,” and in obstetrics there is plenty of it. Some variation in practice across settings or providers makes sense – women or their babies may have different needs depending on their health status, risk factors, or preferences. But what’s troubling is that a lot of practice variation arises from factors that have nothing to do with women or their babies, and everything to do with the approach to care. Do women know that their risk of episiotomy may be as much as 7 times higher if they go to a private OB practice rather than a public clinic? Do low-risk first-time mothers know that the hospitals where women are most likely to be induced or admitted early in labor have c-section rates 3 times higher than other hospitals that restrict those practices? (And how do they know which hospitals those are, anyway?) Do women who have had a cesarean know which hospitals restrict or deny access to VBAC?

A new study published in the current issue of The European Journal of Obstetrics, Gynecology, and Reproductive Biology illuminates another troubling consequence of practice variation. Researchers studied the outcomes of over 3500 full-term babies born to low-risk, first-time mothers in 138 French maternity units. Thirty-four were “level 1” units, where there are no special facilities for caring for sick neonates, and babies needing such care are transferred to other facilities. Sixty-six were “level 2” units, where special care nurseries are available to care for some sick newborns as well as preterm babies born at or beyond 32 weeks. The remaining 38 units had intensive care units capable of caring for very sick and preterm babies, and had 24/7 availability of neonatologists. The researchers were careful to compare apples with apples. In addition to restricting their analysis to healthy mothers with full-term babies, they used statistical adjustments to control for other factors that could affect outcomes like the mother’s age, the mode of birth, and the baby’s gestational age and birthweight.

The results they reported show that the level of hospital is itself a risk factor for a baby being admitted for special or intensive care. Babies born in the level 1 hospitals were most likely to stay with their mothers after birth. Babies born in level 2 hospitals were twice as likely to be admitted for special or intensive care, a difference that was statistically significant. Babies born in level 3 hospitals were also more likely to be admitted to special or intensive care, but the difference was not statistically significant.

I am not aware of any US studies looking at the association between the presence of a NICU and the likelihood that a full-term baby born to a healthy mother will be admitted there. However, in our market-based health care system, NICUs are major money makers for hospitals. Admission to the NICU drives costs way up for consumers and payers, and is a dismal way for a baby to start life. We know that optimal maternal and newborn wellbeing occur when mothers and babies stay together in the hours and days after birth, so the goal of a functioning health care system should be to keep as many babies with their mothers as possible, without compromising safety or wellbeing.

NICUs should be there for the babies who need them. Babies should not have to be there for the NICUs that need them.

Citation: Le Ray, C., Zeitlin, J., Jarreau, P. H., Breart, G., Goffinet, F., & for the PREMODA study group. (2009). The influence of level of care on admission to neonatal care for babies of low-risk nullipara. European Journal of Obstetrics, Gynecology, and Reproductive Biology, doi: 10.1016

A systematic review synthesizes all of the literature on a given topic, using rigorous criteria for which studies will be included. For instance, Cochrane systematic reviews are typically confined to randomized, controlled trials in which there is no evidence that the randomization process has been intentionally subverted. For this reason, Cochrane reviews are considered the “gold standard” of evidence.

But what happens when the trials that make up a systematic review themselves have flaws or limitations? We end up with Cochrane reviews that can mask problems in the literature, and we can inadvertently put the evidence-based “stamp of approval” on a practice that still needs to be studied further. This is referred to as the “garbage in, garbage out” phenomenon, and we see plenty of it in the obstetric literature.

One kind of garbage that Cochrane reviews rarely address is crossover. This is when some of the participants randomized to the “control group” (e.g., no intervention) end up getting the intervention that is being tested. This problem is rampant in trials of induction, pain relief, and episiotomy, among others. Some women randomized to “expectant management” end up getting induced; some women randomized to “non-epidural pain management” end up getting epidurals; some women randomized to “conservative use of episiotomy” end up getting episiotomies, and so on.  This makes it much more difficult to use our statistical toolbox to discover differences between the two groups, and as a result we see smaller differences, or even no difference. The “evidence-based” conclusion then becomes “there’s no difference is unwanted outcomes, so the intervention is harmless.” But “no difference” can also mean “this study wasn’t big enough to find a difference” or, in this case, “there was too much crossover to detect a true difference.”

The crossover problem usually drives me crazy because it often serves to perpetuate medical-model bias and medical-model practices. But this week I had an “ah ha” moment when I discovered a crossover-of-sorts problem in the 2008 Cochrane systematic review of midwife-led care. This review was released to fanfare within the birth community. Finally, the enormous body of literature on midwifery had been synthesized by Cochrane reviewers and the conclusions were firmly in favor of midwife-led care! The results were, indeed, unusually impressive. While the conclusions of many Cochrane reviews are couched in tentative language and call for more research, the reviewers here concluded decisively, “Midwife-led care confers benefits and shows no adverse outcomes. It should be the norm for women classified at low and high risk of complications” (p. 17). Still, when I looked a little closer, I was perplexed that some of the differences the Cochrane reviewers found were small or even non-existent. What? No difference in c-sections? Only a small difference in episiotomy? What’s going on here?

Crossover is the culprit, and this time it means that the good news just gets better! It turns out, of the 11 trials comprising over 12,000 women, in all but 1 of these trials (with only 318 participants), some or all of the women in the control groups were actually cared for by midwives. The difference was that that these midwives were supervised by physicians, or they shared their client caseload with physicians. The Cochrane reviewers were not interested in comparing midwives versus doctors. They took it for granted that midwifery care itself is safe, effective, and satisfying. This is, after all, a global consensus, to which the United States remains in stubborn and lonely opposition. Working from the assumption that midwives are an important part of the maternity care system, the question becomes how should we organize that system? Who should coordinate the care of childbearing women – midwives or doctors? Midwife-led care means that women receive their primary maternity care with the midwife, and the midwife engages an obstetrician or other consultant when some aspect of the woman’s or baby’s care falls outside of the scope of independent midwifery practice. This stands in stark contrast to the typical arrangement in the United States, when midwives are supervised by obstetricians or employed by hospitals, and obstetric protocols and productivity standards drive midwifery practice. 

Women often believe that going to an obstetrician practice that employs midwives is getting “the best of both worlds.” The Cochrane review of midwife-led care in fact tells us that such arrangements are ineffective, inefficient, and may be hazardous to the health of women and babies.

Citation: Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwife-led versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub2.

But on the other hand, I want to say, “Gees, how obvious is it that ‘mothers who experience too many interventions feel a lack of control’?” “Studies have shown” can be an awfully worn out phrase, but it turns out Ms. Clarke is right to use it here.

The challenge lies smack in front of us: How can we better encourage today’s pregnant woman to take responsibility for her body, her pregnancy, her birth experience, by finding out more about those interventions and interruptions waiting for her inside the hospital, to seek out the facts about what “studies have shown” when the interventions get foisted onto her while she labors, and both she and her baby experience avoidable distress and complication. There’s a heck of a lot of (mis)information out there swirling around pregnancy and birth, from internet to TV to magazine to bookstore, and a lot of fears are being fueled by that misinformation.

My next door neighbor texted me Saturday to say her son’s partner had just delivered a 9 ½ pound girl at home after an undisturbed water labor. Present at the intervention-free birth were the midwife, the father, the mother; and then, of course, baby Sarie joined them right before lunch. My neighbor said it was a hushed, holy, joyful setting to step into once she‘d gotten their call. Since then, there’s been a quiet flow of meals and flowers as a new family gets to know each other. Me thinks this might be what Ms. Clarke has in mind when she brings up issues of control and the lack there-of.

Maybe a little of both? Today, I came across a study in the March issue of the Journal of Clinical Endocrinology & Metabolism. The researchers report the findings of a small study of the association between maternal blood levels of vitamin D and the risk of having cesarean surgery. They measured the vitamin D blood levels of 253 women within the first 3 days postpartum, conducted interviews about habits such as prenatal vitamin use and alcohol consumption, and gathered personal, medical, and labor and birth information from medical records. After controlling for many variables that could affect cesarean risk, the researchers reported two significant findings:

• Women who were severely vitamin D deficient were almost 4 times more likely to have cesarean surgery.
• The lower a woman’s vitamin D level, the higher her cesarean risk.

This is pretty compelling stuff. But how useful is this study, really? When I analyzed the study, I noticed a few problems that make me wonder if the association between vitamin D and cesarean is that straightforward after all.

• First, although the differences seem large, the numbers were small. Four times the risk sounds like a lot, but is it four times a small risk or four times a large risk? The magnitude of the excess risk changes accordingly. Unfortunately, the researchers do not report the data in a way that lets us calculate how vitamin D deficiency changes a woman’s risk in absolute terms. 
• Second, the researchers do not analyze the effect of prior births. Women who have given birth previously are much less likely to have a primary cesarean. They may also have different vitamin D levels, if pregnancy, lactation, and inter-pregnancy interval affect them. It is clear from the study report that women with prior births were included, but the researchers make a serious omission by not reporting results separately for women who have and have not given birth before. This flaw alone could discredit the entire study, and should have prevented the peer-reviewed journal from publishing it.
• Third, the labs were drawn after the women gave birth. Does the mode of birth affect vitamin D levels? We don’t know. The authors themselves caution that the difference in IV fluids given before cesareans versus during labor might dilute vitamin D in the blood and cause artificially low vitamin D in women having cesareans. The researchers could have controlled for total IV and oral fluid intake as well as postpartum blood loss, but they did not.
• Finally, and more importantly, this study tells us nothing about how to avoid cesareans that may be related to vitamin D deficiency. Should we test women in pregnancy? Which women? When in pregnancy? If a woman is vitamin D deficient, will nutritional interventions or supplementation improve her blood levels, and will these higher blood levels in turn reduce the cesarean risk? Are there risks to any of these tests or interventions? These are the clinical questions that matter, but this study is not designed to answer any of them. Even assuming the association is real and not a statistical fluke, we need plenty more research before we should change the way we care for women in pregnancy.

The kinds of methodological problems we see in this study are common, and sometimes they are difficult to avoid because of logistical or cost limitations or simple human error. But in this case, the authors show some evidence of bias, as well.  For one, they say that their study would have been stronger if they had only looked at cesareans performed for slow labor progress. (This is because vitamin D can affect muscle performance, which is the proposed rationale for a correlation between vitamin D levels and cesarean risk.) But they discount the findings of another study that did in fact look only at cesareans in obstructed labors and found no association with vitamin D levels. The reason they discount the study is that it was conducted in an area with much higher vitamin D deficiency (Pakistan). In fact, this higher prevalence of vitamin D deficiency would make it statistically easier – not harder – to detect clinically important differences. That’s one of the first things I learned in my first research methods class!

Another red flag for bias? One of the study’s four authors is a paid consultant to none other than Quest Diagnostics, the company that made me listen to an ad for vitamin D blood testing while I was on hold.

Debunking this study doesn’t mean that vitamin D deficiency is harmless or that there aren’t other potential public health benefits to preventing and treating vitamin D deficiency in pregnant women. But we need a lot more information before we start blaming the increasing cesarean rate on vitamin D. It’s tempting in the face of a cesarean epidemic to assume that women’s bodies are deficient in something or another, or to just assume that women are asking for it. These theories direct attention away from the systemic problems that keep the cesarean rate marching higher and higher. My client’s former provider who drew her vitamin D levels in early pregnancy may have thought she was doing the right thing to help prevent a cesarean. But that is a major leap from the evidence as it stands now. And there are many things that the typical American maternity care provider could change about his or her practice that could safely prevent cesareans. The problem is: changing these things is a lot harder than checking a new box on the lab slip.

Citation: Merewood, A., Mehta, S. D., Chen, T. C., Bauchner, H., & Holick, M. F. (2009). Association between vitamin D deficiency and primary cesarean section. The Journal of Clinical Endocrinology and Metabolism, 94(3), 940-945.