Birth in Brazil–and America

The cesarean rate is Brazil has been high for a long time, and it is getting higher.  In private hospitals, almost all women deliver by cesarean; in public hospitals it’s about half.  According to Ricki Lake, who went to Brazil in the process of filming The Business of Being Born, “There was actually a joke circulating that the only way to have a natural birth in Rio was if your doctor got stuck in traffic.”  Brazil’s childbirth practices have come to attention recently because of Adelir Carmen Lemos de Góes, who on April 1, 2014, was taken by police to have a forced cesarean under court order.  Here’s an account of what happened from The Guardian:

…Brazilian mother Adelir Carmen Lemos de Góes was preparing for her third birth. Despite living in a country with one of the highest caesarean rates in the world (82% for those with private insurance and 50% for those without), she was looking forward to giving birth vaginally after previously having caesareans she felt were unnecessary.  However, in the midst of her labour, six armed police banged on her front door. Despite there being no question of reduced mental capacity, doctors had obtained a court order allowing them to perform a caesarean…Adelir was taken from her home, forcibly anaesthetised and operated on without consent.

Attorney Jill Filopovic writes,

A Brazilian court granted a prosecutor’s request for the appointment of a special guardian. And just in case it was unclear whose life gets prioritized when a woman has a c-section against her will, the judge specified that when there is a ‘conflict of interests of the mother with the child’s life … the interests of the child predominate over hers.’

Filopovic quotes Dr. Simone Diniz, associate professor in the department of maternal and child health at the University of São Paulo: 

In our culture, childbirth is something that is primitive, ugly, nasty, inconvenient….It’s part of Catholic culture that this experience of childbirth should come with humiliation.

The Atlantic subsequently ran a longer piece by Olga Khazan, “Why Most Brazilian Women Get C-Sections,” which, also points to a confluence of attitudes, practices, policies, and norms that lead to a trend toward universal cesarean.  Humiliation isn’t hard to come by in Brazilian obstetrics.  Khazan reports,

Many physicians’ attitudes toward childbirth weave together Brazil’s macho culture with traditional sexual mores….When women are in labor, some doctors say, ‘When you were doing it, you didn’t complain, but now that you’re here, you cry.’

Mariana Bahia, who participated in protests against forced cesarean, noted:

There’s no horizontality between patients and doctors.  Doctors are always above us.

And Paula Viana, head of a women’s rights organization, said,

We have a really serious problem in Brazil that the doctors over-cite evidence [of fetal distress].  They think they can interfere as they would like.

But much of what these various articles says about childbirth in Brazil is eerily similar to what happens in the United States.  Khazan quotes Maria do Carmo Leal, a researcher at the National Public Health School at the Oswaldo Cruz Foundation about birth practices in Brazil:

Here, when a woman is going to give birth, even natural birth, the first thing many hospitals do is tie her to the bed by putting an IV in her arm, so she can’t walk, can’t take a bath, can’t hug her husband. The use of drugs to accelerate contractions is very common, as are episiotomies.  What you get is a lot of pain, and a horror of childbirth. This makes a cesarean a dream for many women.

In the United States, Pitocin induction and augmentation are ubiquitous , and episiotomies, though less common than in Brazil, are still greatly overused.  Almost all U.S. hospitals use IV hydration as a matter of policy (rather than allowing women to eat and drink as they please, which is the evidence based recommendation).  And in the U.S., taking a bath in labor may be impossible, as many hospitals do not provide bathtubs out of a misguided fear of women attempting waterbirths. The website My OB Said What documents a seemingly endless stream of U.S. health professionals’ humiliating comments, such as referring to a pregnant women as a “little girls,” criticizing their weight, or belittling their pain.

Court ordered cesareans occur in the United States as well, as Erin Davenport documents in “Court Ordered Cesarean Sections: Why Courts Should Not Be Allowed to Use a Balancing Test.”  Davenport notes that forced cesareans are generally ordered because of concerns for fetal welfare–as in Brazil, U.S. courts often privilege the rights of the fetus over those of the pregnant woman.

Alissa Scheller created infographics on Huffington Post showing how states’ policies are used to persecute and prosecute pregnant in the name of fetal welfare.

National Advocates for Pregnant Women, whose research supplied much of the information for the above graphic, documents the legal control of pregnant women that occurs in the name of fetal rights, such as prosecuting a woman for murder after a suicide attempt while pregnant (in this case, the baby–born by cesarean–was alive, but died a few days later).

While the cesarean rate in the United States is much lower than in Brazil, a third of U.S. births are by cesarean, more than double the “threshold not to be exceeded” identified by the World Health Organization.  Khazan notes the parallels between Brazil’s medical system and the the system in the U.S.–both incentivize cesareans:

With the higher price of the private system [in Brazil] comes better amenities and shorter wait times, but also all of the trappings of fee-for-service medical care. C-sections can be easily scheduled and quickly executed, so doctors schedule and bill as many as eight procedures a day rather than wait around for one or two natural births to wrap up.

As in Brazil, though some cesareans performed in the U.S. are certainly in the interest of maternal and/or fetal well-being, many are in the interest of the obstetrician’s well-being.  There is still a convenience factor; in addition, OB-GYN Dr. Peter Doelger said doctors and hospitals are protecting themselves by following protocols based a fear of litigation:

So you’re stuck with this situation where we’re doing things, not based on science.  [The increase in C-sections is] really based on protecting the institution and ourselves. And, you can’t blame them. Getting sued is a horrible thing for the physician, a horrible thing for the nurse, and a horrible thing for the institution.

And the woman?  Well as long as the baby is healthy, does she matter?

The Abortion Pill and the Politics of Health

There are two legal ways to have an abortion in the United States, through surgery or medication.  Medication abortions are those induced through taking mifepristone pills (which were called RU486 when they were developed).  Mifepristone is not Plan B (levonorgestrel, a synthetic form of progesterone) or Ella (ulipristal acetate, which suppresses progesterone production). Plan B and Ella have nothing to do with abortion; both stop ovulation in order to prevent pregnancy.  Mifepristone causes the expulsion of an embryo in an established pregnancy, much like a spontaneous miscarriage.

There are three main restrictions put on medical abortions in the United States:

1. Pills must be provided by a licensed physician (not a nurse practitioner, nurse midwife, or other qualified health practitioner)
2. Pills must be provided through an in-person patient-physician visit
3. Pills must be provided according to the original FDA protocol (much lower doses of the pills have since been found to be effective)

White states have the least restrictive policies, and dark green states have the most restrictive.  You can find an interactive version of this map at the Mother Jones website (the map does have some inaccuracies; Iowa and Arizona in particular currently have stays against some of their restrictions).

Restriction #1: Licensed Physicians 

That the pills can only be provided by a licensed physician is a restriction that is not solely promoted by opponents of abortion. It is a restriction in place in states that receive an “A” from NARAL Pro-Choice America on choice related law (find your state’s laws and grade here).

Physicians often oppose legislation that would allow medical practitioners who are not physicians–including midwives, advanced practice nurses, or pharmacists–to provide care that is within their scope of training.  Doctors often make the same argument that abortion opponents make: that they are trying to keep women “safe”  (e.g. doctors protect women from midwifery care in New York; doctors protect people from receiving primary care from nurse practitioners in Texas; doctors protect people from vaccination by pharmacists in Florida).

In her novel The Handmaid’s Tale, a story of a futuristic society in which the United States is taken over by the Christian Right, the characters identify differences between “freedom to” and “freedom from.” If you haven’t read the book, go get it and read it immediately.  In any case, Aunt Lydia, who trains women to accept their role in the new society, says,

There is more than one kind of freedom…Freedom to and freedom from. In the days of anarchy, it was freedom to. Now you are being given freedom from. Don’t underrate it.

“Freedom to” gives women agency and choice.  “Freedom from” restricts them in exchange for safety and protection.  In the novel, “freedom from” involves wearing burkah-like clothing, not being allowed to read, and bearing children for religious couples with political standing.  This supposedly frees women from rape, responsibility, and thinking.

In any case, the paternalistic “protection” of making physicians the only practitioners who can provide medication abortions seems to have an underlying agenda–moral or financial–that has nothing to do with women’s health.

Restriction #2: In-Person Physician Encounter

Telemedicine is increasingly used to serve rural communities in particular.  Many people in rural areas are far from hospitals and other sources of medical care.  You can see in this map that there are large areas without critical access.

To provide needed care in the Mountain West, St. Luke’s Health System has established a virtual intensive care unit, which monitors 69 critical care beds in 5 hospitals and provides critical care consultation in 5 emergency departments in Idaho.  Here is a video about it:

Critical care is being offered to people on the brink of death through telemedicine, but some states have seen fit to decide that medication abortions offered through telemedicine are dangerous.  Over the past year, this restriction has generated attention in Iowa, where Planned Parenthood has safely offered medication abortions through telemedicine to thousands of women since 2008.  In September 2013, the Iowa Board of Medicine, made up of political appointees, voted to ban telemedical abortions, in addition to imposing other restrictions and requirements.

Delaying access to abortion care narrows women’s options, as medication abortions are only considered safe through the first 9 weeks of pregnancy.  After 9 weeks, a surgical abortion becomes a woman’s only abortion option (see here for a comparison of surgical and medication abortions).  While there are risks and side effects from medication abortions, most of them are uncomfortable or annoying rather than dangerous.  According to the FDA, no deaths have been directly attributed to medication abortions.

As Jill June, President and CEO of Planned Parenthood of the Heartland, said,

It’s evident that this ruling was not based on the health and safety of women in our state – it was based on politics. There was no medical evidence or information presented to the Board that questions the safety of our telemedicine delivery system. It’s apparent that the goal of this rule is to eliminate abortion in Iowa, and it has nothing to do with the safety of telemedicine. The reality is, this rule will only make it more challenging for a woman to receive the safe health care she needs.  Iowa women deserve to have access to the newest medical technologies and all of the heath care services they need, regardless of where they live.

A judge halted Iowa’s ban through a stay until the court case is settled.  The Iowa legislature, which is controlled by Democrats, was unable to pass a bill to instate the restriction through law; however, this restriction is in place in other states.

Restriction #3: The Original FDA Protocol

The Guttmacher Institute offers this chart comparing the original protocols for administering mifepristone pills established by the FDA, and the newer protocols adopted by the World Health Organization (WHO) and the American College of Obstetricians and Gynecologists (ACOG) based on evidence that has emerged since the FDA’s original approval:

Abortion opponents have argued that adhering to the FDA protocols protects women, even though the Agency for Healthcare Research and Quality, a government agency as is the FDA, has published guidelines for mifepristone administration in their National Guidelines Clearinghouse.  The following guideline is level A evidence, the highest and most reliable evidence available:

Compared with the FDA-approved regimen, mifepristone-misoprostol regimens using 200 milligrams of mifepristone orally and 800 micrograms of misoprostol vaginally are associated with a decreased rate of continuing pregnancies, decreased time to expulsion, fewer side effects, improved complete abortion rates, and lower cost for women with pregnancies up to 63 days of gestation based on last menstrual period.

I have argued against non-FDA-approved use of Pitocin to induce labor electively.  However, there is no evidence base for the use of Pitocin for non-medically indicated deliveries.  As you can read in my previous posts (here and here), Pitocin is a high-alert medication with many dangerous side effects.  Its elective use has no known benefit other than convenience.  The new guidelines for mifepristone use, on the other hand, are based on evidence and involve giving a woman less medication rather than more.

That legislators would ignore a large, reliable body of scientific research does not inspire my confidence in their understanding of safety.  If they really care about the health and safety of women and babies, restricting off-label Pitocin use would be a much more effective technique.

It should be noted that while a law was passed in Arizona imposing this restriction and was upheld by a federal judge in Tuscon on April 1, 2014, the 9th Circuit Court of Appeals issued a stay on the legislation on April 2.  Thus, the only state implementing this restriction as of April 2014 is Texas.

If you view yourself as a human rather than a political pawn, you might want to say so.  If you value your freedom to rather than your freedom from, you might consider fighting for that freedom.  And if you are a woman in Texas who cares about her health, you may want to move.

Breastfeeding, Politics, and Digging for Truth

Controversies around breastfeeding surged once again last month with Social Science and Medicine‘s pre-release of Cynthia Colen and David Ramey’s article, “Is Breast Truly Best?  Estimating the Effects of Breastfeeding on Long-term Child Health and Wellbeing in the United States Using Sibling Comparisons.”*  That’s not a very snappy title, so the news sources that picked it up went with the pithier “Breastfeeding Benefits Overstated” (CNN Health) and “Is Breastfeeding Really Better” (New York Times) or with other much shorter versions of the article title.  The article looks at sibling pairs in which one child was breastfed and the other was not.  Statistical comparisons of the children at ages 4-14 on a host of factors showed that the breastfed sibling did not appear to have health, learning, or attachment advantages over the sibling who was never breastfed.

One of the problems with making any assessment of breastfeeding is that it has become a battlefield for Mommy Wars.  One side claims that breastfeeding will guarantee a gifted child who is never ill, and who will always remember to call his mother after graduating from an Ivy League school–plus it will give you an alternative to gas for your car!

The other side retorts that most adults were formula fed and came out just fine, so there can’t possibly be any benefit to breastfeeding, plus it ties women down, shuts fathers out of parenting, and is kind of icky anyway.

The more each side trumpets its point of view, the more entrenched each side becomes. Thus, while many news outlets represented the study’s findings as absolute truth, reporting “breastfeeding [is] no better than bottle feeding,”  Melissa Bartick, MD, who spearheaded the Ban the Bags campaign, referred to the Colen and Ramey study as “sensationalism.”

No one is helped when the main breastfeeding support organization in the U.S. states that a tenet of their philosophy is that “Mothering through breastfeeding is the most natural and effective way of understanding and satisfying the needs of the baby,” implying that mothers who don’t breastfeed can never be as attached to their babies and can never satisfy a baby’s needs the way breastfeeding mothers do.  And no one is helped when the United States is among the only countries in the world that has not implemented a single aspect of the World Health Organization’s International Code of Marketing of Breast-Milk Substitutes because no one wants to stand up to the lobbying of a multi-billion dollar formula industry.  (Just so you know, there’s not much of an industry around breast milk production).

Groups like the American Academy of Pediatrics, the World Health Organization, and health arms of the U.S. government promote the benefits of breastfeeding without much consideration of what benefits there might be in not breastfeeding.  The one-note message of these health groups tends to over-inflate breastfeeding’s benefits and to imply that mothers who breastfeed love their children more or are better mothers than those who do not.

The promotion of breastfeeding to individual mothers without equal or greater promotion of breastfeeding in the culture and structure of society is a recipe for guilt.  Colen and Ramey say,

The line between providing information about the health benefits of breastfeeding and stigmatizing mothers facing structured, valid, and often difficult trade-offs in the care and financial support of their children or in fulfilling their own human potential must be drawn sensitively.

This is a very important point.  In the United Arab Emirates, the belief in breastfeeding’s benefits is mirroring some of the U.S. body politic around pregnant women: legislation was introduced that would compel women to breastfeed.  To force one person to use her body for the benefit of another against her will is a human rights violation.  To pit mothers against their children in the name of “child rights” is unconscionable.  (Seriously, click on the link–it’s mind boggling).

This is the climate in which Colen and Ramey conducted their research.  It is perhaps not surprising that as sociologists, who generally abhor structural inequalities, they conclude that structural changes should take precedence over individual-level breastfeeding promotion:

[A] multifaceted approach will allow women who want to breastfeed to do so for as long as possible without promoting a cult of ‘total motherhood’ in which women’s identities are solely constructed in terms of providing the best possible opportunities for their children and the risks  associated with a failure to breastfeed are vastly overstated.

While I agree with the sentiment of their conclusion, I do think we need to further examine the research process that led to a finding that breastfeeding has no benefit that extends through middle childhood.

Here is a summary of their methods:

• They used the data set from the National Longitudinal Survey of Youth 1979 (NLSY79)
• To determine if a child had been breastfed, they used two questions, both reported by the woman. One asked if the mother had ever breastfed the child (status); the other asked her to estimate how old the child was in weeks when she stopped breastfeeding (duration).
• The full sample included 8,237 children.  The “discordant” sample (siblings groups with one child who had been breastfed and one who had not) included 1,773 children.
• They measured the following outcomes: body mass index, obesity, asthma, hyperactivity, parental attachment, behavioral compliance, and 5 tests of intelligence or academic achievement.
• Outcomes were only investigated for the children from age 4-14.

Let me say emphatically that all studies have flaws and that no one study can address all research concerns.  This is why we have a body of scientific literature, and no one study should absolutely convince us of anything, especially if it is not a large, well-constructed randomized control trial.  Colen and Ramey have made an important contribution to the literature, but it is also important that they and their promotors do not overstate their case.

Current health recommendations are that all children breastfeed exclusively for 6 months.  In the U.S., it is generally advised that children continue to breastfeed in addition to eating food for at least a year.  The World Health Organization recommends at least two years.

The Colen and Ramey study

• had no measure of exclusive breastfeeding at all;
• had no measure of “intensity”–those who reported breastfeeding could have been breastfeeding only once a day while their child consumed primarily formula;
• found no significance for breastfeeding duration in weeks, but did not discuss longer periods of time that would mirror recommendations (for instance, children who breast fed for 6 months and for a year);
• did not discuss the sample sizes for each week of duration (I am guessing that the sample size for each week decreased dramatically as the weeks wore on; it is difficult to find statistically significant differences when the sample size is small);
• did not appear to control for a number of factors that could have been important, such as the financial status of the family at each child’s birth or the child’s place in the birth order.

Colen and Ramey also are not able to examine other crucial health measures, such as the impact on the woman herself (breastfeeding is thought to have heath benefits such as reducing the incidence of diabetes and some cancers) or the impact on the children past age 14 (breastfeeding is thought to have a protective effect against some diseases that emerge in adulthood, such as Crohn’s disease).

Perhaps most importantly, they did not look at what happened to children who never consumed any formula at all, but who were fed according to standard health guidelines for infant feeding.

Ultimately, Colen and Ramey measured what the breastfeeding literature typically calls “any breastfeeding,” meaning the child was fed any breastmilk at all even once.  It is of concern that they conclude (and the reporters report) that the benefits of breastfeeding do not extend into middle childhood, rather than that the benefits of any breastfeeding do not extend into middle childhood.  Though Colen and Ramey concede that there are benefits to breastfeeding for infants, I am not certain that there are any measurable benefits to having been fed a few drops of breastmilk on one occasion.

I agree with the conclusions of an Agency for Healthcare Research and Quality (AHRQ) review,

A history of breastfeeding is associated with a reduced risk of many diseases in infants and mothers from developed countries. Because almost all the data…were gathered from observational studies, one should not infer causality based on…findings. Also, there is a wide range of quality of the body of evidence across different health outcomes.  For future studies, clear subject selection criteria and definition of “exclusive breastfeeding,” reliable collection of feeding data, controlling for important confounders including child-specific factors, and blinded assessment of the outcome measures will help. Sibling analysis provides a method to control for hereditary and household factors that are important in certain outcomes. In addition, cluster randomized controlled studies on the effectiveness of various breastfeeding promotion interventions will provide further opportunity to investigate any disparity in health outcomes as a result of the intervention.

Colen and Ramey meet only the sibling analysis recommendation.  Ultimately, their article may have done nothing more than to fan the flames of the breastfeeding battles, sending each side further into their own trenches while doing nothing to promote structural changes that might support women’s desire to breastfeed.

*You need a subscription or access to an academic library to get a copy of the full article.

Avoid an Unnecesarean

It would be hard to find anyone who doesn’t think the cesarean rate is too high.  The World Health Organization says that a 15% rate “is not a target to be achieved but rather a threshold not to be exceeded.”  Healthy People 2020 goals (see section MICH-7) target reductions in primary cesareans and increases in vaginal birth after cesarean (VBAC) as two primary goals in maternity care. In some situations, the benefits of a cesarean far outweigh the risks, but when the surgery is not needed, it has the small but significant potential to cause severe complications for the woman and her baby, and also affects the woman’s subsequent pregnancies.

Cesareans have many advantages for doctors.  The payment for attending a cesarean is equal to or greater than attending a vaginal birth.  While even a fast vaginal birth generally takes at least several hours from the time the woman arrives at the hospital,  performing a cesarean takes about an hour.  Cesareans are not risk-free, but the outcomes are predictable.  And scheduling a cesarean is particularly lucrative and convenient for doctors because they can avoid conflicts with office hours and family/leisure time.

Dr. Jonathan Weinstein of Frisco Women’s Health, whose cesarean rate is under 15%, offers the helpful list, Top Ten Signs Your Doctor is Planning to Perform an Unnecessary Cesarean Section on You:

1. Arrives to L&D immediately after office hours and says, “I just don’t think this baby is going to fit”
2. Third Trimester, Routine Office Visit, “I think this is going to be a big baby you should just have a C/S” – Did you know? ACOG has very specific guidelines for when it is appropriate to offer a patient an elective C/S for MACROSOMIA (fancy word for large baby). ‘Prophylactic (elective) cesarean delivery may be considered for suspected fetal macrosomia with estimated fetal weights greater than 5,000 gms (11 pounds) in women without diabetes and greater than 4,500 gms (9.9 pounds) in women with diabetes.
3. “We should induce at 39 weeks your baby is getting too big” – Did you know? According to ACOG, ‘Induction of labor at least doubles the risk of cesarean delivery without reducing shoulder dystocia (rare situation where baby’s shoulder can get stuck at delivery) or newborn morbidity(complications). Suspected fetal macrosomia is not an indication for induction of labor, because induction does not improve maternal or fetal outcomes.’
4. Performs routine ultrasounds at end of pregnancy to see how big your baby is. Did you know? Ultrasounds at the end of the pregnancy can be 1-2 pounds off. Ask some VBAC patients who were talked into a C/S for this, then had a vaginal delivery of a bigger baby the next time.
5. “You have a positive herpes titer (or history of herpes); the baby will get it if you deliver vaginally.” Try some Valtrex for the last month of the pregnancy that is pretty much standard of care now. It prevents outbreaks and allows for a normal vaginal delivery.
6. “Your baby is breech you need to have a C/S” Ever heard of or performed an External Cephalic Version? It really does work.
7. “You have pushed for 2 hours” (with an epidural that prevents you from feeling anything so you are probably not pushing effectively; this is evident on exam because the baby’s head is still perfectly round, but you do not need to know that) it’s just not going to come out.”
8. “I scheduled you for an induction at 39 weeks, it is just soooo… much more convenient for you!” (and so much higher risk of ending in a C/S, especially if you are not dilated when you start the induction). At least 80% of my VBAC patients were induced the previous pregnancy. For whose convenience was the induction?
9. First Visit (7 weeks), “Congratulations you are having twins. I will go ahead and schedule your C/S at 38 weeks, but don’t worry if you go in to labor early I will cut you right away!” Translation, “I am scared out of my mind for you to deliver your babies vaginally because I am not trained on what to do when the second baby is coming, plus it pays more to cut you open. Oh yeah, I don’t have that great a rapport with you because I only spend 2 minutes (fundal height, heart beat and ‘I’ll see you next time’) with you each visit, so I am afraid I will be sued for trying to do the right thing.” (note from Human with Uterus: planned cesarean for twins is not evidence based.)
10. First Pelvic Exam in Office (7 weeks), “Hmm, your pelvis is pretty narrow”
11. Bonus Tip: 38-week visit, “Your blood pressure is a little up today you are probably developing preeclampsia or toxemia. That can cause you to have a SEIZURE! The treatment is to deliver the baby. You need a Cesarean Section this is the quickest way to resolve it. Let’s get you up to L&D NOW!” Translation – Preeclampsia or Pregnancy Induced High Blood Pressure is a pain in the butt. If I induce you, it could take 24 hours or more and then I would have to manage your blood pressure, and put you on Magnesium. This is way too inconvenient. Do not worry you can try to have the baby vaginally next time. Yeah right!

For more information on cesarean/induction for “big baby,” see this post from Evidence Based Birth.

Despite reports that cesareans are performed at maternal request, only about 1% of primary cesareans were requested by the woman.  As a woman cannot perform a cesarean on herself, the skyrocketing rate must be driven by providers.  Providers also say that high cesarean rates are driven by liability concerns. A connection between liability environments and cesarean rates exists, but the effects are small.  A natural experiment in Texas, which underwent tort reform, showed that reductions in liability did not lead to corresponding changes in cesarean rates–cesarean rates went up at roughly the same rate as they did in the rest of the country.  Texas cesarean rates are currently 35.3%, higher than the national average.

We might also generally question the ethics of performing a surgery that is in the best interest of the doctor, not the woman and her child.  When a doctor recommends a risky procedure such as major abdominal surgery, women should always ask for references to evidence (meaning documents they can read, not off-the-cuff statistics).  A woman’s care should be a process of shared decision making, not following someone else’s orders.  A woman’s humanity demands nothing less.

Bed Rest in Pregnancy Part I: What’s the Evidence?

This may shock you, but there is no evidence that bed rest does anything to prevent preterm birth or help with any other health condition of pregnancy, including placenta previa, pre-eclampsia, preterm premature rupture of membranes (pPROM), or shortened cervix.

Really, truly.  No evidence that bed rest helps.  And this has been known for a long time.

Preventing Preterm Birth

 (image from Babble)

The American Congress of Obstetricians and Gynecologists (ACOG) published the following recommendation in 2003, which was reaffirmed in 2012:

Bed rest and hydration have not been shown to be effective for the prevention of preterm birth and should not be routinely recommended.*

Got that?  Not effective.  Should not be routinely recommended.

In fact, a study of women with shortened cervix by Grobman et al showed that bed rest increased risk for preterm birth.

The Cochrane Collaboration, which sets international standards for evidence based medicine by reviewing randomized control trials (considered the “gold standard” in medical research), says of bed rest for preterm labor,

Due to the potential adverse effects that bed rest could have on women and their families, and the increased costs for the healthcare system, systematic advice of bed rest for preventing preterm birth should not be given to pregnant women.

The World Health Organization reports on the largest known randomized control trial of bed rest for preventing preterm labor:

For the purpose of comparing the effects of bed rest to no bed rest, 432 women allocated to bed rest at home were compared with a control group …422 had received no intervention. Incidence of preterm birth prior to 37 weeks was similar in both groups.

Here are the conclusions on the efficacy of bed rest from a series of articles posted on Medline:

Bed rest is used extensively to treat a wide variety of pregnancy conditions, at substantial cost but with little proof of effectiveness (Goldenberg, et al).

We should not assume any efficacy for bed rest. (Glaziou and Del Mar)

Mitigating Medical Conditions in Pregnancy

There is no evidence base for bed rest for conditions other than preterm birth risk either.  Here is what ACOG guidelines say about bed rest for hypertension/pre-eclampsia (high blood pressure in pregnancy):

There is little evidence of the efficacy of nonpharmacologic management of hypertension in pregnancy.  Whether bed rest is efficacious requires more research, including larger trials, and the risks of immobilization for long periods of time (e.g. thromboembolic events [blood clots, etc]) must also be addressed.

Update: I have a full post on preeclampsia here.

On placenta previa, for which hospital bed rest is often prescribed, Cochrane says,

[T]here are only trials of cervical cerclage (‘tying’ the cervix), and the effects of hospitalisation. The review found that cervical cerclage may reduce very premature births, although the evidence was not strong. There is little evidence of advantages or disadvantages to hospitalisation.

Regarding threatened miscarriage, and multiple gestations (e.g. twins or triplets), and preeclampsia, in addition to preterm labor, Drs. Bigelow and Stone of Mount Sinai School of Medicine in New York write,

Although the use of bed rest is pervasive, there is a paucity of data to support its use. Additionally, many well-documented adverse physical, psychological, familial, societal, and financial effects have been discussed in the literature. There have been no complications of pregnancy for which the literature consistently demonstrates a benefit to antepartum bed rest.

The evidence is unwavering.  There is no known benefit of bed rest in pregnancy.  Even if bed rest has no associated harms, if it has no benefit, why bother?  When we have two options with equal outcomes, one involving living life normally, and one involving a major life alteration that is inconvenient, expensive, and boring, why would anyone choose the latter?

But, in fact, bed rest does have harms–lots of them.  Read Part II and Part III .

*All emphasis in quotes throughout the post is mine

Update: WebMD has a new piece on bed rest for preventing preterm birth that actually provides evidence based information here.

Yet Another Way to be a Bad Mother (even while pregnant!)

There is another article in the tiresome littany of obesity handwringing about how mothers are responsible for the lifelong eating habits of their offspring.  Why only mothers?  Aren’t fathers and other caregivers also responsible for what children eat?  Perhaps, but the problems outlined in this article focus on pregnancy and breastfeeding.  So guys, you’re off the hook until later.

Under the headline Bad Eating Habits Start in the Womb, Kristin Wartman argues in the New York Times that children develop their food tastes in utero and in very early infancy, and that past toddlerhood, these tastes are nearly impossible to change.

The research Wartman cites comes from the Monell Center, which describes itself as “the world’s only independent, non-profit scientific institute dedicated to basic research on taste and smell.”  They appear to do some interesting work, such as looking for ways to detect disease through the sense of smell.  Gary Beauchamp, the director of the center says of developing tastes,

It’s our fundamental belief that during evolution, we as humans are exposed to flavors both in utero and via mother’s milk that are signals of things that will be in our diets as we grow up and learn about what flavors are acceptable based on those experiences.  Infants exposed to a variety of flavors in infancy are more willing to accept a variety of flavors, including flavors that are associated with various vegetables and so forth and that might lead to a more healthy eating style later on.

This, of course, is different from infants exposed to a variety of flavors in old age.

Note the word “might.”  There is no conclusive evidence that fetuses and newborns are being set up for lifelong obesity because of what their mothers eat.  While it seems plausible that a mother’s eating patterns may help a developing fetus/infant to accept a wider variety of flavors, that does not necessarily have anything to do with obesity.  If I eat nothing but tofu and kale, does that mean my kid’s limited exposure to tastes will create a junk food junkie?  Or does it sentence the kid to an inability to tolerate anything other than tofu and kale?

It’s not just variety though.  Mothers who eat processed foods are creating budding addicts. Jessica Gugusheff, who conducts research with the FOODplus Research Centre in Australia writes,

When someone is addicted to drugs they become less sensitive to the effects of that drug, so they have to increase the dose to get the same high.  In a similar way, by having a desensitized reward pathway, offspring exposed to junk food before birth have to eat more junk food to get the same good feelings.

Wartman, in a feat difficult to accomplish, manages to excoriate both formula feeding and breastfeeding moms–the formula feeders don’t expose their kids to variety, since formula always tastes the same.  But the breastfeeders are exposing their kids to all the junk they eat themselves, thus setting up the kid’s lifelong quest for a food high.

The causal relation between breastfeeding and lower rates of obesity is controversial in any case.  Though there is a correlation, as the World Health Organization concludes in their 2013 meta-analysis:

[T]he meta-analysis of higher-quality studies suggests a small reduction, of about10%, in the prevalence of overweight or obesity in children exposed to longer durations of breastfeeding. Nevertheless, it is not possible to completely rule out residual confounding because in most study settings breastfeeding duration was higher in families where the parents were more educated and had higher income levels.

It is important not to oversell any particular food or feeding method.  Kids who breastfeed from moms with poor nutrition, formula feed, or eat a lot of junk in childhood generally come out just fine–and some kids fed “ideal” diets struggle with obesity.  Still, I don’t think many would argue that breastfeeding is usually best or that a diet based on fresh foods close to their natural state is preferable to processed foods full of fat, salt, and sugar.  So how do we get people to eat these foods–Do we ban advertising of low-quality foods?  Do we facilitate the promotion of high quality foods?  Do we stop farm subsidies for corn and redirect them to organic broccoli?  Or do we restrict people’s access to foods and blame them for eating them or feeding them to their kids?  Wartman says,

[R]egulating processed food products and infant formula, and creating clear warning labels to deter parents from feeding their children potentially harmful foods may be our best shot.

I am all for banning the advertising of infant formula and of the marketing of junk food to children (including the marketing of child-focused junk foods to anyone.  You may think this is paternalistic, so brief tangent: when I worked in a daycare in a housing project, a young mom told us that she had fed her infant his first solid food.  What was it, we asked.  The answer: Cheetos.  Because they have real cheese.  There was also a trend in this community to sell baby bottles with the Pepsi logo on them.  Guess what the moms started putting in the bottles…).

 (actual ad from the 1950s)

But warning labels on foods with unrestricted marketing are just a guilt trip. Because what parents need is more guilt.  That will make them better parents.  They can expend energy worrying about warning labels rather than, say, taking their kids to the playground.  Or advocating for more green space.  Or making tofu-kale smoothies.  Or any number of things that, unlike guilt, would lead to better nutrition and less obesity.

Advertising and Public Health: Who Wins the Infant Feeding Debate?

The public health community is a great advocate for breastfeeding–and why not?  Breastfeeding is not only the normal way mammals feed their young, it’s the ideal way, and it’s almost free.

On the other hand, some human mothers struggle with breastfeeding, sometimes because they don’t get the support they need, they have severe postpartum depression, they need to take incompatible medications, they have been sexually abused, or a whole host of other reasons.  Sometimes it just doesn’t work out, and the most important thing a baby needs is loving parents.  The risks associated with formula feeding are relatively slight compared to its benefits for many families.  Guilt tripping women about formula feeding is shameful.

That said, companies spend about 8 billion (yes, billion) dollars per year marketing infant formula, and they also have a trade group, the International Formula Council (IFC), that does lobbying and other advocacy on behalf of manufacturers. The IFC also sets up sham maternal advocacy sites to press the idea that breastfeeding advocates want to take away the right to bottlefeed.  In contrast, La Leche League International (LLL), the best-known breastfeeding advocacy group, has an annual budget of about 3.5 million.  I find La Leche League’s philosophy falls into demagoguery, especially regarding gender and parenting, but that’s what the breastfeeders have.  LLL is certainly a David to the Goliath IFC.

The American Public Health Association (APHA) has been a great supporter of breastfeeding, and they created a new policy statement on the topic at their 2013 annual meeting.  Their press release states that their Breastfeeding Call to Action (emphasis mine):

Continues APHA’s strong support of breastfeeding and recognizes efforts to increase breastfeeding rates and narrow breastfeeding disparities as fundamental public health issues. Calls for increasing access to lactation services, especially among under-served populations, and making sure such services are properly reimbursed. Also urges restricting infant formula marketing practices that can discourage breastfeeding, promoting breastfeeding in developing nations to help decrease HIV infection rates and endorsing the breastfeeding actions outlined in the 2013 federal “Report of the Secretary’s Advisory Committee on Infant Mortality.”

The thing is, there is already a policy on formula marketing practices from the World Health Organization.  It’s official title is the WHO International Code of Marketing of Breast-Milk Substitutes (the WHO Code for short), and it was published in 1981.  The United States was the only member nation in the world that did not vote to adopt the code, and it wasn’t until 1994 that President Clinton finally signed on.  The U.S. Breastfeeding Committee has a quick version of the WHO Code:

• NO advertising of breast milk substitutes directly to the public.
• NO free samples to mothers.
• NO promotion of products in health care facilities.
• NO company “mothercraft” nurses to advise mothers.
• NO gifts or personal samples to health workers.
• NO words or pictures idealizing artificial feeding, including pictures of infants on the products.
• Information to health workers should be scientific and factual.
• All information on artificial feeding, including the labels, should explain the benefits of breastfeeding, and the costs and hazards associated with artificial feeding.
• Unsuitable products, such as condensed milk, should not be promoted for babies.
• All products should be of a high quality and take into account the climatic and storage conditions of the country where they are used.

The IFC and its members try to portray the WHO Code as discriminatory against mothers who have to or choose to formula feed.  For instance, a press release on one of their websites links to a Cafe Mom piece, “Formula Restrictions are Unfair to New Moms.”  What is the unfair restriction?  China is banning the use of pictures of babies on formula containers (see bullet 6 above).  While the piece makes the important point that bullying or guilt-tripping mothers about their feeding choices is  asshole behavior, I don’t understand how following this aspect of the code qualifies as “bullying.”  The author refers to it as “[t]he latest strike in the war against moms who don’t want to breastfeed.”

                           

Let me explain something.  There is almost no advertising for breastfeeding.  There is no product placement, there are not free goody bags from the breastfeeding fairy, there are no samples delivered to your door.  If a baby needs formula, parents know where to find it.  They don’t need cute pictures or slick ads to be able to pick up a can of formula and follow the directions for its preparation.  All formula sold in the United States has to meet safety and health standards.  The advertised additives that many name brands throw in are, in the words of pediatrician David Paige, “chemical soup.”  Touting the benefits of these additives through advertising doesn’t help anyone but those profiting from the sale of brand-name formulas.

I do agree that the bullet “All information on artificial feeding, including the labels, should explain the benefits of breastfeeding, and the costs and hazards associated with artificial feeding” is controversial.  Certainly if a woman wanted to breastfeed and then saw “risks” touted on her baby’s best alternative food, it could cause unwarranted guilt.  That’s wrong.

Everyone thinks of him or herself as a rational being who is somehow immune from the influences of advertising.  Each of those people is delusional.  Consumers actually have more trust in advertising now than ever.  Jean Kilbourne has some great work on the ways advertising influences us all.  I once argued at a presentation on food advertising that teaching children media literacy skills could help combat ads, and the presenters laughed.  They said that as adults who studied food advertising for a living, watching ads for Dairy Queen Blizzards still made them all want to run out and buy one immediately. Which of the two cans pictured above would you buy? Why would formula corporations spend 8 billion dollars if that investment had no return?

There is no reason for formula to be marketed at all.  If people need it, they need it–they shouln’t need to be persuaded.  The message should be out that formula is the safest alternative to breastmilk, and families should be taught to prepare and feed formula safely.  Past that, what’s to market?  All formula marketing has the potential to discourage breastfeeding.  We should stop it.

We do not need to fight for the right of formula companies to make a profit.  The only people who should win in the infant feeding debate are parents and their babies.

Maternal Mortality: Why are we Paying for It?

According to Reuters, “Merck for Mothers” will provide $6 million to U.S. programs in 10 states and three cities aimed at decreasing the number of women who die as a result of being pregnant or giving birth.  Pharmaceutical companies are not usually on my love list, but let’s take a look at why Merck is bringing their initiative to the U.S.

Other beneficiaries of this program include Zambia (440 maternal deaths per 100,000) and Uganda (310 maternal deaths per 100,000).  So why is the U.S., with a comparatively paltry 17.8* maternal deaths per 100,000, on the list?

While maternal mortality has been reduced in both Zambia and Uganda even before Merck’s interventions, rates of maternal mortality in the United States are rising.   In fact, they have doubled in the last 25 years.  In Zambia, 85% of people earn less than a dollar a day and most women give birth in rural communities with no hospital resources and often no trained attendants.  In contrast, nearly 99% of U.S. births occur in hospitals under the care of a physician or certified nurse midwife, the U.S. poverty line is $11,490 for a single person, and federal Medicaid guidelines mandate that states pay for the prenatal care and births of all women at or below 185% of the poverty line (the threshold can go up to 400% of the poverty line at the discretion of states).

Despite

• the relative wealth of people in the U.S., even among the poor
• having  the most expensive maternity care in the entire world by a large margin
• paying for pregnancy and birth care for lower-income women,

the U.S. has even worse maternal mortality rates among vulnerable populations.  Among African American women, the rate is triple that of whites.  The overall rate and the disparities are so bad that Amnesty International published a devastating report, “Deadly Delivery,” which points out that

Maternal deaths are only the tip of the iceberg. During 2004 and 2005, more than 68,000 women nearly died in childbirth in the USA. Each year, 1.7 million women suffer a complication that has an adverse effect on their health.

The United States has among the worst maternal mortality rates of any developed nation–worse than many nations with much lower human development scores, such as Slovenia, Croatia, and Bulgaria.  In 1990, our maternal mortality rates were only slightly higher than those of the two countries with the highest human development scores, Norway and Australia.  The other two countries’ maternal mortality has gone down in the interim, and our rates are now three times theirs.

Some will argue that the higher rate is a product of better reporting (for instance, there is now a “pregnancy” box on death certificates).  In response, Dr. Edward McCabe, medical director of the March of Dimes, says,

We’re getting better data, yes, but what these data are telling us is that we have an unacceptably high rate of pregnancy-related mortality.

The Reuters report says that “the leading maternal killers include cardiovascular disease, venous thromboembolism, hemorrhage, hypertension and sepsis.”  As the report notes, deaths from cardiovascular disease in women of childbearing age are bizarre.

Though the Merck program will focus on limited regions–not the whole country–they will also work through ACOG on a national level to standardize practices in potentially-fatal obstetric emergencies.  As Dr Mary D’Alton of Columbia University Medical Center says, “Variability is the enemy of safety.”

Amnesty’s “Deadly Delivery” report cites overuse of cesarean as a primary contributor to maternal mortality and morbidity.  The World Health Organization does not recommend an ideal cesarean rate, but says that 15% should be considered a “threshold not to be exceeded.”  The current U.S. rate is nearly 33%.  According to a paper published in Health Affairs, cesarean rates  “vary tenfold across hospitals, from 7.1 percent to 69.9 percent.” Among women with low-risk pregnancies (usually considered a term, singleton, head-down fetus in a mother without health complications), “cesarean rates varied fifteenfold, from 2.4 percent to 36.5 percent.”

It is unfortunate that the responsibility for investigating the quality of hospital-based maternity care and the evidence base of doctor’s practices falls to individual women.  If Merck’s initiative can generate some consistency, I say bring it on.

*estimates vary considerably around this number, but this is what is in the Reuters report.

Low Tech, Low Cost, and Easy to Use–Will it Have a Chance?

An Argentinian Car Mechanic, Jorge Odón, has devised a way to help birth a stuck baby based on a nifty trick for getting a cork out of a bottle, which you can see in this video:

You really have to watch the video to understand how it would work–otherwise the description sounds like you are putting a bag over the baby’s head, and we all know where that leads.  Here’s a picture of the Odón Device:

Yes, it looks like you are putting the baby in a blender.  Seriously, watch the cork video and it will make much more sense.  Although the video will not explain why a baby in the process of being born is wearing a striped romper.

Anyone who has read this blog knows that I am not in favor of “devices,”  and many devices concocted for use in birth seem like something out of a horror movie (the one in the link even generated a petition).  What intrigues me about this one is that it has the potential to replace dangerous devices (or surgery) that may be necessary in many cases.  The Odón, if it actually works, could replace the use of forceps and vacuum extractors, both of which carry significant risks, including incontinence, tissue and nerve damage, and pelvic prolapse for the woman and skull fracture, cranial bleeding, and seizures for the baby.  Because of the risks involved in instrumental delivery, and because many U.S. doctors no longer have sufficient practice to do instrumental deliveries safely, cesareans are a more common solution to slow progress or a stuck baby in second stage labor.  As Atul Gawande notes in his excellent New Yorker article ,

Forceps have virtually disappeared from the delivery wards, even though several studies have compared forceps delivery to Cesarean section and found no advantage for Cesarean section. (A few found that mothers actually did better with forceps.)

It seems women and babies may be likely to do even better with the Odón Device, though it has not been widely tested yet, and it has specifically not been tested on women with confirmed obstructed labor (the condition for which the device is designed).  A New York Times article explains the perspective of Dr. Meraldi of the Word Health Organization (WHO):

About 10 percent of the 137 million births worldwide each year have potentially serious complications… About 5.6 million babies are stillborn or die quickly, and about 260,000 women die in childbirth. Obstructed labor, which can occur when a baby’s head is too large or an exhausted mother’s contractions stop, is a major factor.  In wealthy countries, fetal distress results in a rush to the operating room. In poor, rural clinics…if the baby doesn’t come out, the woman is on her own.  Although more testing is planned on the Odón Device, doctors said it appeared to be safe for midwives with minimal training to use.

The device is estimated to cost about $50 to make.

Doctors have readily adapted–and refused to give up–high-tech, costly processes that do not work or cause unnecessary harm, such as fetal monitoring, prophylactic cesarean for twin births, and elective induction.  At the same time, doctors have  actively resisted low or non-technical processes that are both helpful and low-cost or free, such as freedom of movement in labor, doulas, and water for pain relief.

It remains to be seen

1. if the new device is safe and effective
2. and if it is, whether U.S. physicians will be willing to give up lucrative surgeries for a $50 device that can be used by a layperson and is based on a parlor trick
3. or if it will be enthusiastically embraced and used on all birthing women whether they need it or not.

Let’s hope that women (and their babies) are ultimately the ones who benefit.

Your Way–as Long as it’s Our Way: Florida

Jill Arnold is updating the stats at CesareanRates.com, and according to her new tables, South Miami Hospital has the highest cesarean rate in Florida: 62%.  This is nearly double the national average and 4 times the “threshold not be exceeded” identified by the World Health Organization.  Let’s investigate.

Women have babies at the hospital’s Center for Women and Infants.  Their patient brochure begins, “The philosophy toward childbirth at South Miami Hospital encourages your individuality and supports family involvement.”  Such a statement indicates that the woman can call the shots in her own birth–an admirable goal as long as she is given evidence-based information to make choices.  Except it turns out that she doesn’t actually have a lot of choices.  Nor are routine hospital practices based on evidence.

For instance, here are some example from the “Frequently Asked Questions” page (all emphasis and commentary is mine):

3 Q:  Will I be able to walk or use my birthing ball when I am in labor?
A:  We encourage you to discuss this with your physician as you will want to be familiar with your doctor’s practices.

Um…what are the doctor’s birth ball practices?  Should the woman expect to have to share?

6. Q:  Will I be able to eat in labor? How soon will I be able to eat after the baby is born?
A:  While in labor, it is recommended that you have only ice chips. The presence of food in the stomach may cause nausea and vomiting. In the event you should need anesthesia for your labor, vomiting could cause aspiration of food to the lungs, a condition that is dangerous to you. If you deliver vaginally, you will be able to eat once your recovery is complete.  (…)

“It is recommended” by whom?  There is no evidence base for denying women access to food and drink in labor.  A Cochrane review on the subject notes that depriving women of food and drink leads to longer and more painful labors and concludes, “women should be free to eat and drink in labour, or not, as they wish.”  And when would “recovery be complete”?  Isn’t common wisdom that it takes about 6 weeks to recover from a vaginal birth?  That’s a long time to survive on ice chips.

9. Q:  What is a fetal monitor? Do you have wireless monitors in the labor rooms?
A:  The fetal monitor is used to determine the baby’s well-being prior to birth.  It provides a continuous printed record for the evaluation of uterine activity and the baby’s heart response.  Your obstetrician may decide to use an external or internal monitor. Baptist Hospital does have wireless monitors. These monitors are used when appropriate and available.

Continuous monitoring has been shown to raise the risk of cesarean without producing superior maternal or infant outcomes and it is not recommended for low risk women–not even an initial test strip.  In addition, if the wireless monitor is not available, the woman’s movement would be restricted, which would also go against evidence based practice.  Internal monitoring can be painful and introduces risk of infection.  According to Rebecca Dekker at Evidence Based Birth, “evidence clearly demonstrates that the best option for most women and babies is intermittent auscultation” (meaning using a handheld doppler at intervals throughout labor).  Note that the best practice is not mentioned as an option.  Whoops.

11. Q:  Do you have a Jacuzzi?
A:  Use of the Jacuzzi is based on room availability. In early labor, some patients enjoy relaxing in the Jacuzzi. Use of the Jacuzzi will depend on many circumstances revolving around your labor. Your physician will need to approve its use.

It’s interesting that the question is “do you have a Jacuzzi,” but the answer is about all the reasons a woman won’t be able to use one, even though there is a strong evidence base for laboring in water.

It’s also interesting that a physician would need to approve women’s evidence based requests, while the hospital will require women to follow non-evidence based routines.  This does not seem particularly encouraging of individuality.  Or of health.

Women are told they to be admitted at 3 centimeters’ dilation because that is when they are in active labor, even though the most current recommendations state that women should not be considered in active labor until 5-6 cm.  Early hospital admission tends to lead to unnecessary cascades of  intervention that increase birth costs and can lead to cesarean.

Even regarding non-medical issues, South Miami places limits on what women (or their families) can do.  For instance, their video and photography guidelines have some practical information–tripods shouldn’t be used because they get in the way; doctors and nurses should give their permission before being photographed or video recorded.  But the guidelines, which state that “the birth of a baby is an exciting time” also state that no one is actually allowed to photograph or videotape the birth:

1. For vaginal births, videotaping and photographing are permitted, but only after the birth, and when the baby is dried, cleaned and alert.
2. Videotaping is not allowed during a C-section delivery. Photographs may be taken only after the baby is dried, cleaned and alert.

Since a baby should go skin-to-skin with the mother directly after birth and remain with her there for about an hour, it may be a long time before anyone can get a picture of the baby.  Unless South Miami is not following evidence based recommendations about skin-to-skin contact.  Hmm…

We require labels on food packaging to give nutritional information.  It seems we might benefit from hospital labeling to get health information.  If a woman chooses to abide by non-evidence based practice, that is her right.  But it is disingenuous for a hospital to proclaim that it supports a woman’s individuality in childbirth–as long as her individuality fits their mold.

 

You can read the second in this series, an analysis of  the Mississippi hospital with the highest cesarean rate, here.