International Cesarean Awareness Network

Education, Support, & Advocacy for Birth Justice & Healing

Increased risk of home birth is "pure fiction"

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The Big Push for Midwives released a statement today in response to publicity surrounding a forthcoming article in the American Journal of Obstetrics and Gynecology that claims to show home birth is unsafe. From the press release:

As New York and Massachusetts moved to pass pro-midwife bills in the final weeks of their legislative sessions, the American Journal of Obstetrics and Gynecology fast-tracked publicity surrounding the results of an anti-home birth study that is not scheduled for publication until September. Described as unscientific and politically motivated, the study draws conclusions about home birth that stand in direct contradiction to the large body of research establishing the safety of home birth for low-risk women whose babies are delivered by professional midwives.

The release further quotes Dr. Michael C. Klein:

“Many of the studies from which the author’s conclusions are drawn are poor quality, out-of-date, and based on discredited methodology. Garbage in, garbage out.” said Michael C. Klein, MD, a University of British Columbia emeritus professor and senior scientist at The Child and Family Research Institute. “The conclusion that this study somehow confirms an increased risk for home birth is pure fiction. In fact, the study is so deeply flawed that the only real conclusion to draw is that the motive behind its publication has more to do with politics than with science.”

Several days ago, Amy Romano at Science and Sensibility expressed her own doubts about the study, highlighting these points:

1. The meta-analysis is compromised by the inclusion of a deeply flawed study that relies on birth certificates and includes preterm births, unplanned home births, and home births attended by unqualified providers. In the only analysis in which the researchers excluded this study, the significant excess of neonatal mortality disappeared.

2. The meta-analysis also includes studies that report on births that took place as early as 1976.

The Big Push notes that the timing of publicity initiated by AJOG is questionable, at best:

“Given the fact that New York just passed a bill providing autonomous practice for all licensed midwives working in all settings, while Massachusetts is poised to do the same, the timing of this study could not be better for the physician groups that have been fighting so hard to defeat pro-midwife bills there and in other states,” said Susan M. Jenkins, Legal Counsel for The Big Push for Midwives Campaign. “Clearly the intent is to fuel fear-based myths about the safety of professional midwifery care in out-of-hospital settings. Their ultimate goal is obviously to defeat legislation that would both increase access to out-of-hospital maternity care for women and their families and increase competition for obstetricians.”

Best of the Birth Blogs – Week Ending July 4th

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Your weekly one-stop for highlights from the birth blogosphere. Visit weekly for the latest on childbirth, especially related to cesarean prevention, recovery, and VBAC. To nominate a blog post to be featured here, email me at blog@ican-online.org.

It’s been a little slow here on the blog so far this summer. Lots going on with family vacations and graduate school for this blogger! I’ll try to keep up and post more often from here on out. Meanwhile, in case you’ve missed what other wonderful birth bloggers have been posting, here are some highlights from the last week:

Do not miss this awe-inspiring video and narrative from midwife and “Spinning Babies Lady” Gail Tully on her Spinning Babies Blog of a second-time VBAC mama’s frank breech homebirth. Those of us in the Twin Cities of Minnesota are so fortunate to have such wonderful midwives who really trust birth.

In case you’ve been reading unsettling headlines about the World Health Organization dumping it’s cesarean rate guidelines, be sure to read Jill’s fact-checking post at The Unnecessarian. Another example of the media gone haywire on childbirth in America.

Speaking of the media, Kmom offers a great analysis on Well-Rounded Mama of a recent Boston Globe op-ed discussing the high costs of cesareans and suggestions on lowering the cesarean rate.

Lastly, Fearless Birth picked up on news of a recent study that shows high protein diets early in pregnancy can help protect mothers from gestational diabetes, something many good midwives have known (without testing mice) for a long time!

Scare tactics & women of size in childbirth

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The New York Times recently published an article titled “Growing Obesity Increases Perils of Childbirth.” The article’s lead states:

As Americans have grown fatter over the last generation, inviting more heart disease, diabetes and premature deaths, all that extra weight has also become a burden in the maternity ward, where babies take their first breath of life.

Several bloggers, including ICAN’s own Kmom have blogged in reaction to this piece, highlighting the ways that it misrepresents the risks and evokes fear surrounding childbirth for women of size.

An excerpt from The Well Rounded Mama‘s response:

It’s not that the possible risks of “obesity” and pregnancy should never be discussed with women of size.  Of course they should.  Women deserve to be informed of the possible risks.

However, this article was full of distortions and worst-case scenarios, and it implied that experiences such as stroke during pregnancy are extremely common in fat women.

Anyone reading these types of articles might well conclude that virtually no fat woman has ever had a healthy pregnancy or a healthy baby, that the only way to have a healthy pregnancy is to lose vast quantities of weight first, and that the vast majority of fat women experience major complications and have unhealthy babies. And that simply doesn’t jibe with the experiences of most fat mothers.

Yes, women of size are at increased risk of some complications. But the article distorts the magnitude of that risk and presents weight loss and highly interventive care as the only paths to a healthy pregnancy.

In fact, many women of size have healthy pregnancies and healthy births…..you can read many of these stories on my website.  I was one of them. I somehow managed to have four healthy babies at a much higher starting weight than the woman in the article. Despite being larger than her, I never had diabetes, I never had pre-eclampsia, I never had kidney problems, and I never had a stroke. And I know many more fat women just like me, in all sizes of fatness, who had healthy pregnancies and babies, in all sizes of fat. But THAT part of the obesity story doesn’t get publicized.

It’s not that you cannot discuss the possible risks of obesity in pregnancy with women. But it needs to be done in a fair and balanced way. This article was not well-balanced, it didn’t discuss the possible risks in a reasoned and calm manner, nor did it acknolwedge that many women of size can have healthy pregnancies and babies.

Sensationalistic articles like this are done to shame and scare women out of pregnancy, or into compliance with draconian interventions like weight loss surgery, lack of weight gain during pregnancy, extreme prenatal testing, unnecessary inductions, or planned cesareans.  Postpartum, they try to shame women into emphasizing weight loss at any cost, despite the fact that long-term research shows that nearly all diets will fail, many of the women with weight loss surgery will experience nutritional complications, and that weight loss attempts are one of the major factors in weight gain over the long run. Approaches like this will likely just worsen the problem, not improve it.

Please visit Kmom’s blog to read the full post. She very thoughtfully and methodically addresses the article’s misleading information.

Only 2% of cesareans requested by moms

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A new study in British Columbia has found that, contrary to what some doctors and media reports might contend, the growing cesarean rate is not driven by maternal demand. This is similar to previous findings from the Listening to Mothers study in which only one out of over 1,300 mothers in the study reported requesting her cesarean without medical indication.

As reported in the Vancouver Sun:

The study, which examined all deliveries in B.C. between 2004 and 2007, suggests regional disparities are due to differences in doctors’ approaches and lack of resources — not because women are requesting them or their medical conditions require them more in certain communities.

Researchers at the University of British Columbia’s School of Population and Public Health, found that the number of caesarean births ranged from a high of 27.5 per cent in South Vancouver Island, to 22.1 per cent in Vancouver, to a low of 16.1 per cent in East Kootenay.

Only a small proportion of C-sections — two per cent — were performed because mothers requested them. The wide variation remained even after researchers accounted for medical conditions and maternal characteristics that could necessitate an assisted birth, such as smoking, weight gain, diabetes and high blood pressure.

ICAN of Lower Mainland co-leaders Mieke Bray and Elodie Jacquet were quoted in the news article.

Mieke Bray had a caesarean last May due to a complicated birth. She was two weeks overdue, and tried a synthetic hormone to induce labour at B.C Women’s Hospital.

Shortly after, Bray’s placenta detached from her uterine wall. Bleeding excessively, she was rushed to the operating room for an emergency C-section. Fifteen minutes later, her second son, Tait, was born.

“It never occurred to me that I would get a C-section,” said Bray, 34, whose first child was born naturally. “I do yoga, I’m a vegetarian, so I’ve always lived a naturopathic lifestyle.”

Bray admits that the C-section saved her life, but she still found the experience traumatic.

Elodie Jacquet, 28, also had a caesarean last July. She had planned a home birth, but as she went into labour, her baby’s heartbeat began decelerating. After being induced, Jacquet’s baby got stuck in her pelvis and could not turn.

“They said, ‘I’m sorry but we’re going to have to give you a C-section,'” said Jacquet. “I didn’t want one, but I wanted whatever’s best for my baby.”

Soon after, baby Liam was born. Seeing that he was healthy, Jacquet wondered if the induction and the following caesarean was really necessary.

Dr. Friedman on "The peril of multiple c-sections"

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Dr. Alex Friedman from the Hospital of the University of Pennsylvania published an article in yesterday’s Philadelphia Inquirer detailing his own experience with the serious risks of multiple cesareans:

The worst surgical case of my residency came when we delivered my patient’s baby by cesarean – her ninth cesarean birth.

The baby came out fine, but for the mother we suspected one of most feared complications in obstetrics – that her placenta had burrowed deep into the muscle of the uterus.

To get oxygen and nutrients to the fetus, the placenta needs to attach just a few millimeters deep into the uterus. We worried that hers had gone much farther and might eat through the entire thickness of the uterus, keeping it from shrinking back to its normal size after delivery and causing a massive hemorrhage.

We gave a gentle tug on the umbilical cord. Usually the placenta peels off with such gentle pulling, but hers remained stuck – an ominous sign.

Importantly, Friedman notes:

The case points out a fundamental truth about surgical delivery: a first cesarean for most women leads to a cesarean with every pregnancy. And while a first section is quick, easy to perform, and rarely complicated, each repeat surgery carries greater risk.

Why the greater risk? Friedman explains:

Repeat C-sections pose more risk than a first section for many reasons. One factor concerns anatomy. When a doctor performs a first cesarean, the layers of tissue look and feel very different from each other. These visual cues and textures guide the surgeon, indicating exactly where to cut…

The surgeon loses the advantage of good anatomy after the first section. The tissue undergoes scarring, toughens, and blends together as it heals. The variations in color and texture disappear. The intestines and bowel sometimes stick to the healing wound, putting them in harm’s way the next time surgery is performed.

These changes in anatomy due to previous cesarean surgery can lead to serious complications.

A study from 2006 published in the journal Obstetrics and Gynecology compared C-section complications in more than 30,000 patients. Risks of requiring a large blood transfusion, incurring a bladder injury, needing to be on a ventilator, and ending up in intensive care all increased significantly with the number of sections after the first.

The study also showed greater risk for my patient’s complication. Scarring on the inside of the uterus after a cesarean causes the placenta to attach abnormally in future pregnancies. During a first section, the risk of this complication was less than 1 in 400. After a sixth section, the risk ballooned to more than 1 in 15.

Ultimately, Dr. Friedman’s patient survived, but only after a risky hysterectomy that left the OR awash in blood and the mother in the ICU for several days.

My patient lost three times the entire blood volume of a normal person, sixteen liters in all. Only a massive transfusion kept her alive. Anesthesiologists pumped in 51 units of red blood cells and seven six-packs of platelets.

Sadly, Friedman notes what so many of us cesarean moms know:

More and more women are finding themselves on the C-section path. Almost one in three babies was delivered by cesarean in 2007, the most recent year for which data are available, an increase of more than 50 percent from a decade earlier.

At the same time, it’s becoming harder for mothers to avoid repeat surgery. The number of vaginal births after a C-section fell by two-thirds, to fewer than 10 percent, over the same time period. This year, the National Institutes of Health estimated that since 1996, one-third of hospitals and one-half of doctors who offered vaginal births after a C-section no longer do so.

As Friedman’s experience demonstrates, the stakes in this quandary are incredibly high:

With a first cesarean, the up-front costs – a few more days in the hospital, a longer recovery – may seem reasonable. Only in retrospect can the true costs become apparent.