Consumer First, Patient Second

One of our BBN members passed along this article, which talks about why it's important to find the right doctor for your birth. My experience in urban India is that women and couples have to do a great amount of self-advocacy in order to get accurate information, assert their birth preferences (assuming there are some!), and have some amount of control over their delivery. This is a crucial exercise for having a satisfying birth experience.

Here's an excerpt from the article, which speaks to what we in the Bangalore Birth Network have been discussing for awhile now:

If [physicians'] parameters of care include routine epidurals, episiotomies for all their patients, routines IVs, etc. then that is their place of comfort in giving care. If you don’t want any of those things, you’d be much better off finding a different physician than trying to convert this one to your way of thinking, because you’re asking them to take themselves out of their comfort zone to care for you. It’s important that as consumers of healthcare, women understand the pressures that come to bear upon care providers.

Click here to read the entire article.

Exercise During Pregnancy Benefits Babies

If anyone - your doctor, your mother-in-law, etc - tells you that it's not good to exercise while pregnant, think again! A new study found that moderate exercise - that is, moderate intensity aerobic exercise for 30 minutes, at least three times a week - has cardiovascular benefits for the baby as well as for the mother. Read more about it here.

Delayed Cord Cutting Benefits Babies

In most hospital settings, doctors routinely clamp the umbilical cord as soon as the baby is born, cutting off blood and oxygen flow from the placenta to the baby. However, waiting until the cord has stopped pulsating (just a few minutes) allows the baby to get his or her maximum blood flow and iron stores, and makes the placenta less bulky and thus easier to detach from the uterine wall.

A new study out of Canada, recently published in the Journal of the American Medical Association, challenges the common practice of immediate cord cutting. Read more about it here.

Dais in India, and I'd guess other Traditional Birth Attendants around the world, are quite puzzled and sometimes even appalled at immediate cord cutting. Here's an excerpt from Hearing Dais' Voices, a publication by Matrika:

"The practice of not cutting the cord until the placenta is delivered is common in all the areas we have studied. Doctors, health workers and anthropological literature report the custom throughout the country. Dais have the utmost respect for these parts of the female body usually considered as waste products by the bio-medical system or highly polluting by the Brahmanic religious texts. Dais consider the infant-cord-placenta as a package. They have been together for nine months with cord and placenta functioning to nurture the fetus -- why should they be severed too quickly? The placenta is considered 'another mother' to the baby. Sometimes this afterbirth is buried with rituals and prayers for the well being of the infant. It is believed that how the placenta-cord-sac is handled influences the child's health in later life."

IMBCI

The International MotherBaby Childbirth Organization (IMBCO) has just come out with their International MotherBaby Childbirth Initiatve (IMBCI): 10 Steps to Optimal Maternity Services Worldwide. It's based on the results of a survey of birth and breastfeeding organizations in 163 countries and on input from IMBCO's Technical Advisory Group, international representatives, and from birth experts all over the world who participated in its construction.

It would be great if the Bangalore Birth Network could use this in our advocacy work and to help hospitals improve their maternity care.

Step 1: Treat every woman with respect and dignity.

Step 2: Possess and routinely apply midwifery knowledge and skills that optimize the normal physiology of birth and breastfeeding.

Step 3: Inform the mother of the benefits of continuous support during labour and birth, and affirm her right to receive such support from companions of her choice.

Step 4: Provide drug-free comfort and pain relief methods during labour, explaining their benefits for facilitating normal birth and avoiding unnecessary harm.

Step 5: Provide evidence-based practices proven to be beneficial.

Step 6: Avoid potentially harmful procedures and practices that have no scientific support for routine or frequent use in normal labour and birth.

Step 7: Implement measures that enhance wellness and prevent illness and emergencies.

Step 8: Provide access to evidence-based skilled emergency treatment.

Step 9: Provide a continuum of collaborative care with all relevant health care providers, institutions and organizations.

Step 10: Strive to achieve the BFHI 10 Steps to Successful Breastfeeding.

"Nutritional Supplements" for Newborns

I just visited a client who was told to give her healthy, exclusively breastfeeding newborn a supplement called ViSyveral. It occurs to me that this might be routine at hospitals around Bangalore, though it's the first time I've heard of it. Please note that babies do not need anything other than breastmilk for the first 6-9 months (not even water). This "nutritional supplement" has the following information on the box:

"May be administered by mixing in water, sweetened formula, fruit juices, desserts or water, cereals, soups, desserts or any other liquid or semi-liquid food."

"Ingredients: liquid glucose, sucrose, vitamins, gum acacla, coconut oil, sodium bicarbonate, disodium EDTA and antioxidants."

"Contains added flavours and class II preservatives."

?!?!?

These drops are problematic on many levels for a newborn. For starters, the directions might be confusing to some. We shouldn't be feeding newborns anything besides breastmilk, especially not desserts, soups and fruit juices! Secondly, look at the first two ingredients: SUGAR! Is it a mystery why there is a global epidemic of obesity? For more on sugar's effect on children's development and how to reduce your child's intake, click here. Don't forget that formula isn't really anything like breastmilk; click here for more on what's problematic about infant formula. Finally, food preservatives have been linked to childhood hyperactivity, and I don't even want to think about the chemicals in "added flavours"!

Readers Respond to New York Times Article About Doulas

A couple of weeks ago, the New York Times ran this pretty negative article about doulas and lactation consultants. I wanted to post the letters to the editor that were published a week later.

New York Times
March 9, 2008
Letters in Defense of Doulas

To the Editor:

Re "And the Doula Makes Four," by Pamela Paul (Sunday Styles, March 2): I recently gave birth to my son with the assistance of an experienced doula, without an epidural and other interventions that I had hoped to avoid. Your article, in emphasizing negative experiences with doulas who seem to be acting inappropriately and outside their scope, does a disservice to parents. Medical literature has demonstrated that with a qualified doula, a mother is likely to have a shorter labor with fewer complications, including a lower chance of Caesarean section.
Diana Graham, M.D.Raleigh, N.C.

***

To the Editor:

Your article reported that "44 percent of women described the relationship between their hospital nurses and doulas as hostile, resentful and confrontational." In fact, this study - which surveyed a total of nine women from a single hospital in north-central Alabama - found that four women described their nurses as behaving that way. The doulas, on the other hand, were described as "calm," "respectful" and "the best investment I have ever made in my life." In my experience as a doula, the vast majority of nurses welcome doulas' respectful support and nonmedical role. I can only hope doulas will become more widely available so every woman who wants one can have this kind of support during childbirth.
Dorian Solot
Albany
The writer is a birth doula certified by DONA International, a
professional organization that provides training and certification as
well as information for prospective clients.

***

To the Editor:

It seems Americans do more research on car purchases than on medical providers and hospitals. I did my research and had an amazing doula for the birth of my first child. When my second son was born, we had trouble with breast-feeding. A certified lactation consultant saved our breast-feeding relationship. While I am sure there are bad doulas and lactation consultants, I believe the majority are excellent and much needed in our over-medicalized birth environment and pro-formula society.
Corinne Griswold
North Granby, Conn.

Being Born: Films from Around the World

In today's Friday Review section of the Hindu, there's a great review of the films screened at the Bangalore Birth Network's film festival, entitled "Being Born: Films from Around the World." It was held during the first weekend of February and featured The Business of Being Born. We had a great turn-out and interesting discussions after each screening. Stay tuned for more BBN events! Read the Hindu article here.

Birth, A Play by Karen Brody

I love the idea of performing this in Bangalore. If you're interested in being part of the organizing committee, please let me know! Click here for more.

Open Letter to Christina Aguilera from Jennifer Block

Christina Aguilera has scheduled her cesarean. Read a letter to her from Jennifer Block here.

Wagner Article: Being Seduced to Induce

Being Seduced to Induce: What Women Should Know About Their OBs

By Marsden Wagner M.D.

Women will only agree to caesarean section if they are convinced it is safe for them and their baby. One of the first efforts of obstetricians promoting caesarean section has been to take the scientific evidence on risks of caesarean section and torture the data until it confesses to what they want it to say.

One example: Obstetric hype in popular and professional magazines says research shows 60% of women who have vaginal birth have urinary and faecal incontinence. But a careful reading of the research papers they refer to reveals something very different. The hype lumps all women with vaginal birth together instead of doing what the researchers did – dividing them into risk groups. When analysis of risk was done, they found that women at high risk for urinary and faecal incontinence have had large numbers of births; have had babies weighing over ten pounds at birth; and most importantly, have been the victims of unnecessary, aggressive obstetric interventions during their labour and birth.

What are these aggressive, invasive obstetric interventions that have been proven scientifically to cause permanent damage to the pelvic floor and urinary tract and also lead to more otherwise unnecessary caesarean section? One example is the use of powerful and dangerous drugs to start or accelerate labour, a practice that has doubled during the past 10 years. These drugs make labour abnormal with violent contractions that can damage the uterus and pelvic floor. The only reason women agree to such induction is because they are not told the truth about the drugs, for example that Pitocin (oxytocin), a drug used for decades to induce labour, doubles the chance the woman will have urinary incontinence in the future. By withholding such facts doctors seduce to induce.

Induction with drugs is not the only aggressive, invasive intervention that is frequently used in vaginal birth and is associated with damage to the urinary system, pelvic floor and rectal areas. Episiotomy has been scientifically shown to result in more pelvic floor damage than a natural tear. When an effort was made in the 1980s to reduce caesarean section in the United States, the rate of using forceps or vacuum extractor to pull the baby out went up—some doctors just can’t stop doing invasive interventions. And there is good data that using forceps or vacuum to pull the baby out has more risk of pelvic floor damage than any other form of birth.

Obstetricians have turned birth into a surgical procedure and done damage to women’s bodies and now suggest the solution is to promote yet even more radical and aggressive surgery; caesarean section. The solution is less unnecessary invasive surgical procedures during birth, not more.

[Re: the Midwifery Today E-News article, Issue 3:23]: The two obstetricians tried to say that vaginal birth can damage a woman, but they never pointed out the ways in which caesarean section can do harm not only to the woman but to the baby as well. The following excerpt from my article “Choosing Caesarean Section” in The Lancet of November 11, 2000, reviews some of the dangers associated with caesarean section, the alternative to vaginal birth that some doctors are trying to promote:

‘In addition to the increased risk the woman will die with an elective caesarean section, there are other risks for the woman including the usual morbidity associated with any major abdominal surgical procedure—anaesthesia accidents, damage to blood vessels, accidental extension of the uterine incision, damage to the urinary bladder and other abdominal organs.1 Some of these risks are common: 20% of women develop fever after caesarean section, most due to iatrogenic infections requiring diagnostic fever evaluation for both woman and baby.1

There are also risks women carry to subsequent pregnancies due to scarring of the uterus including decreased fertility, increased miscarriage, increased ectopic pregnancy, increased placenta abruptio, increased placenta previa.1,2, 3 Recently in the United States the widespread use of the unapproved drug misoprostol (Cytotec) for labour induction has created a new risk of caesarean section in subsequent pregnancies. Women attempting VBAC (Vaginal Birth After Ceasarean) who are given misoprostol have a rate of uterine rupture of 5.6% compared with a rupture rate of 0.2% for women attempting VBAC not given misoprostol, a 28-fold increase in risk of uterine rupture.4 For women choosing caesarean section, all of these risks exist in all of their subsequent pregnancies even if the original caesarean section was not an emergency. The increased risks of ectopic pregnancy, abruptio placenta, placenta previa and ruptured uterus are all life threatening to both woman and baby.

For whatever reasons women choose caesarean section, very few are clearly informed about foetal risks. In an emergency caesarean section where the baby has developed a problem during the labour, the risks to the baby of doing the caesarean section will likely be outweighed by the risks to the baby of not doing it. In an elective caesarean section where the baby is not in trouble, the risks to the baby from doing a caesarean section still exist, meaning the woman who chooses caesarean section puts her baby in unnecessary danger. That some women are choosing caesarean section strongly suggests women are not told these scientific facts.

The first danger to the baby during caesarean section is the 1.9% chance the surgeon’s knife will accidentally lacerate the foetus (6.0% when there is a non-vertex foetal position). (5) Obstetricians may be less aware of this risk — in one study only one of the 17 documented foetal lacerations was recorded by the obstetrician doing the surgery.5 A much more serious risk to babies born by caesarean section is respiratory distress. Many reports in the scientific literature document the caesarean section procedure per se is a potent risk factor for respiratory distress syndrome (RDS) in preterm infants and for other forms of respiratory distress in mature infants.1 RDS is a major cause of neonatal mortality. The risk of newborn RDS is greatly reduced if the woman is allowed to go into labour prior to the caesarean section. Another serious risk to the baby born by caesarean section is iatrogenic prematurity (the baby is premature because the caesarean section was performed too early). Even with repeated ultrasound scans, the standard deviation for estimating gestational age is large, creating errors in judging when to do an elective caesarean section. Doing the elective caesarean section after the woman goes into spontaneous labour would markedly reduce this risk as well. A vast literature documents the increased mortality and morbidity, including neurological disability, associated with premature birth.’

So beware. Surgeons try to sell surgery. Never forget that obstetricians are, after all, surgeons. Women must be extremely cautious in the face of this hard sell and get the facts from those who do not have a vested interest in surgery.


Thanks to Leila McCracken and www.birthlove.com

For more about Dr. Wagner.

1. Wagner M, 1994. Pursuing the Birth Machine: The Search for Appropriate Birth Technology, Sydney, Australia: ACE Graphics.
2. Enkin M, Keirse M, Renfrew M, Neilson J, 1995. A Guide to Effective Care in Pregnancy and Childbirth, 2nd ed, Oxford University Press.
3. Goer, H, 1999. The Thinking Woman’s Guide to a Better Birth. Putnam, New York: Penguin.
4. Plaut M, Schwartz M, Lubarsky S, 1999. “Uterine rupture associated with the use of misoprostol in the gravid patient with a previous caesarean section,” Am J Obstet Gyn 180:1535-42.
5. Smith J, Hernandez C, Wax J, 1997. “Fetal laceration injury at cesarean delivery,” Obstet & Gynecol 90:344-6.


First published in byronchild/Kindred, issue 1, March 02