From InternationalMidwives.org. Click the pic for more info!
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From the category archives:
Midwifery
Must read NYTimes article: Lessons at Indian Hospital About Births by Denise Grady. Photo by Alice Proujansky for the NY Times. Click the pic to go directly to the article.
Note: All quotes are directly from Lessons at Indian Hospital About Births written by Denise Grady for the New York Times.
Don’t miss the excellent multimedia presentation that accompanies the article.
From the New York Times
Saturday’s New York Times featured an article by Denise Grady, Lessons at Indian Hospital About Births. The article focuses on The Tuba City Regional Health Care Corporation in Arizona and its Navajo Nation-run hospital. This hospital is not what many would consider state of the art. It is not shiny and new. It is not as well resourced as the hospitals that routinely win the “Best Hospital in the US” awards, but its maternity care and outcomes are significantly better.
In a country with a national caesarean rate of 31.8 percent, this hospital’s rate is just 13.5 percent. Many physicians would reflexively hypothesize “well, they must not handle the same high-risk population.” Oh yes they do. They have a higher than average percentage of patients with diabetes and high blood pressure, two of the conditions most often resulting in the classification of high-risk pregnancy. Grady’s article shows that the rate of caesarean section in this country is not just about the patient population, it’s about patient care, and also about culture. The culture of a community. The culture of birth. The culture of medical practice in the US. The culture of litigation. All of these things influence the care mothers and babies receive. I am sharing some excerpts from the article here, but you need to read it in its entirety. It begins with the story of a typical birth in Tuba City:
After less than two hours in the maternity ward, with her boyfriend, his mother and a nurse-midwife by her side, Jacquelynn Torivio gave birth to a five-pound, five-ounce son with his grandmother’s dimples and a full head of shiny black hair….It was the kind of birth that many women in the United States could only wish for. Ms. Torivio had a vaginal birth, even though her previous child had been delivered by caesarean section. Because of that prior surgery, many hospitals would not have let her even try to give birth vaginally, but would have required another caesarean.
The article shines a light on the issue of VBAC (vaginal birth after caesarean) which is a hot topic as “even the American College of Obstetricians and Gynecologists has acknowledged that the operation is overused. Though there is no consensus on what the rate should be, government health agencies and the World Health Organization have suggested 15 percent as a goal in low-risk women.” How can maternity care practices and outcomes across the US get closer to those in Tuba City? By heeding the lessons learned there. Below are four that I found particularly compelling. Once you read the whole article, please come back and tell me which lessons resonated most with you.
Lesson 1: Honor birth
In mainstream US culture, birth is simultaneously sequestered from “real life” and overhyped in countless media images of women losing their minds, screaming for epidurals, yelling at their husbands, and barely making it through. Contrast this with the birth culture in Tuba City where “Birth is a joyous affair here, and the entire family—from children to great-grandparents—often go to the delivery room.” Grady explains that in this environment, “many young women have already seen children born by the time they become pregnant, and birth seems natural to them, not frightening.”
In New York City where I live and practice, most hospitals place limits on the number of people who can support a laboring mother, a policy wholly out of sync with a culture like the one described in the article. At the same time, I have seen situations where additional family members were allowed in a hospital room, but because of their own unfamiliarity with and fear of birth they were not able to exude the calm confidence that a laboring woman needs. Both of these situations are out of whack, and a result of a culture that needs to rebuild a healthy relationship with birth.
The cultural dynamics that intersect with birth go well beyond attitudes about the birth event itself. In Tuba City, the larger context of Navajo culture and customs is also taken into account. “Couples often want more than two children, but repeated caesareans increase the risk of each pregnancy, so doctors and patients are motivated to avoid the surgery. Also, Navajos regard incisions as a threat to the spirit, something to be avoided unless necessary.” This kind of culturally competent healthcare should be the standard of care.
Lesson 2: Midwives are the professionals best equipped to manage labor and normal birth
In Tuba City,
“Nurse-midwives…deliver most of the babies born vaginally, with obstetricians available in case problems occur. Midwives staff the labor ward around the clock, a model of care thought to minimize caesareans because midwives specialize in coaching women through labor and will often wait longer than obstetricians before recommending a caesarean. They are also less likely to try to induce labor before a woman’s due date, something that increases the odds of a caesarean.
In the rest of the country, nurse-midwives attend about only 10 percent of vaginal births.
Dr. Kathleen Harner, an obstetrician in Tuba City, said: “Midwives are better at being there for labor than doctors are. Midwives are trained for it. It’s what they want to do.”
This description of how midwives practice is true in New York City as well, and in contrast to the care received by patients of ob/gyns. I try to prepare my doula clients who choose an ob/gyn as their provider that they will likely not spend much time in the labor room until they are actually pushing the baby out. Hospitals are not really for labor, they are for birth, which is reflected by the practice of active management that is typical on most maternity wards in this country. Although ob/gyns are expert at high-risk and surgical birth, for which they are the provider of choice hands down, their training does not focus on evidence-based management of normal labor and delivery. As I reflect on my time as a labor and delivery RN, and now as a doula, I realize I have never once seen an ob/gyn talk a woman through a contraction, or recommend a position, or comfort technique to help her manage the pain. I have seen midwives do all of the above, often. This attention to the whole process allows the laboring mother to be more than just her fetal heart rate and contraction strip, and the whole picture can be taken into consideration as her labor and birth unfold. The rates of interventions and caesareans for midwives vs. ob/gyns prove that this makes a difference in outcomes.
Lesson 3: Take away the profit motive for increased interventions and procedures in healthcare
Tuba City’s doctors and midwives, “earn salaries and are not paid by the procedure, so they have no financial incentive to perform surgery.” Author Denise Grady quotes Dr. Jennifer Whitehair, an obstetrician who says, “My colleagues here truly want to practice medicine and help people. That’s not true everywhere. Here they’re not thinking, how much can I make off this procedure?”
This just makes good sense. I think we all want to know that as patients, we are receiving care based on what is the absolute best for our health and wellbeing. Period.
Lesson 4: If we are going to create true healthcare we have to learn from those who have better outcomes, and then make necessary changes
In the US, the maternal death rate is the highest it has been in decades, and our maternal mortality ranking world-wide was #41 in 2005 (based on the research of The World Health Organization, UNFPA,the United Nations Population Fund, UNICEF (the United Nations Children’s Fund), the UN Population Division and The World Bank). As in Tuba City, the nations of Denmark and Sweden utilize the midwifery model as the primary model of maternity care, and they rank in the top 8 world-wide in maternal mortality.
We need to learn from these success stories. Grady offers a lot to think about on the matter:
“As Washington debates health care, this small hospital in a dusty desert town on an Indian reservation, showing its age and struggling to make ends meet, somehow manages to outperform richer, more prestigious institutions when it comes to keeping caesarean rates down, which saves money and is better for many mothers and infants.
Tuba City will not be on the agenda, but its hospital, with about 500 births a year, could probably teach the rest of the country a few things about obstetrical care. But matching its success would require sweeping, fundamental changes in medical practice, like allowing midwives to handle more deliveries and removing the profit motive for performing surgery.
Changes in malpractice insurance would also help, so that obstetricians would feel less pressure to perform Caesareans. (The hospital and doctors in Tuba City are insured by the federal government, and therefore insurance companies cannot threaten to increase their premiums or withdraw coverage if they allow vaginal births after Caesarean.) Patients, too, would have to adjust their attitudes about birth and medical care during pregnancy and labor.”
I am incredibly appreciative of Denise Grady for writing Lessons at Indian Hospital About Births with a journalist’s attention to detail, and a storyteller’s voice. Her compelling report helps bring into awareness the important issues of mothers and babies that affect our communities and country as a whole. I’m also thrilled that her editor at the NY Times supported this work, and lastly, I am thankful to the people of Tuba City and the Navajo Nation for showing us a better way. Here’s hoping we are willing to go there.
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Necessary cesarean sections can be life saving for mama and baby, but like any surgery, they carry risks. A cesarean section is a major abdominal surgery, and taking steps to decrease the likelihood that you will have one is incredibly important. You may think there is nothing you can do to influence this outcome, but indeed there is. Here is a short list of some of the best ways to boost your odds of a normal vaginal delivery.
1) Deliver in a setting with a reasonable cesarean section rate. If you deliver in a hospital with a 40% cesarean section rate, there is a 40% chance that you will have a cesarean section. For NYC mamas you can research the cesarean section rates (as well as episiotomy rates, epidural rates, rates of midwife assisted births, etc…) for New York county here, and Brooklyn (King’s County) here.
2) While you’re at it, research to find a provider with a cesarean section rate you can live with. Midwives often have lower cesarean section rates than ob/gyns, even when adjusted for the fact that ob/gyns take higher-risk patients. While ob/gyns are specialists in high-risk pregnancies, midwives are specialists in normal physiological birth. So if you’re not sure what kind of provider you would like, definitely look into these highly skilled birth professionals.
3) Hire a doula. Research shows that women with doulas are 50% less likely to have a cesarean section. Want more info? Here’s my Doula 411.
4) Avoid induction. Induction increases the risk of a cesarean section significantly. Tons more info on induction here.
5) Stay healthy. You need to exercise regularly (everyone loves prenatal yoga!) and be well rested, fed, and hydrated throughout your pregnancy to be at the top of your game for the big day. Staying healthy is also important because if you do end up having a cesarean section, it will decrease your risk of complications and increase your ability to heal quickly and completely. Want some tips for how to stay healthy in pregnancy? Check out this post: Tips for a Holistic Pregnancy and Birth.
6) Educate yourself. Take a childbirth education class with your birth partner, watch videos like The Business of Being Born and Orgasmic Birth (both available on Netflix), read a book by Ina May Gaskin. All of these things will help you make the best decisions for your birth and empower you to trust in the process.
Based on the recommendations of the World Health Organization, Lamaze International has created a similar list of ways to support normal birth (much of which you saw echoed above). To find out more visit the Lamaze International website.
Lamaze Care Practices That Support Normal Birth:
- Labor begins on its own
- Freedom of movement throughout labor
- Continuous labor support
- No routine interventions
- Spontaneous pushing in upright or gravity-neutral positions
- No separation of mother and baby with unlimited opportunities for breastfeeding
Here’s wishing you a healthy, happy birth!
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All photos from NBC.com
Note: If you missed The Office birth episode (The Delivery Parts 1 and 2) you can watch the whole thing on NBC by clicking here.
I’m a huge fan of The Office, and have always been enamored with the Pam and Jim love story. I was, nonetheless, trepidatious of tonight’s hour-long episode, “The Delivery Part 1 and 2.” Television and film portrayals of labor and delivery are notoriously inaccurate and often play into our society’s fear of birth. Every pregnant mama I work with has mentioned the need to get media images of birth out of her psyche to trust in the process. I do understand that the goal of TV and film is to entertain, but I also know that accurate portrayals of the birth process can be just as entertaining, and probably even more so. With all of that in mind, as I sat down to tonight’s very-special-episode of The Office I decided to blog and watch, providing my doula/L and D RN two cents in terms of what they’re getting right, and what is for fictional portrayals only. Here we go…
#1) Pam and Jim need a doula! They would be able to call her up and get reassurance that with contractions that are irregular and even 7 minutes apart, there is still plenty of time to labor at home (or at the office in this case) before heading to the hospital. Early labor is best done where a mama can move around free from IVs and monitors, and eat and drink as she pleases.
#2) Pam: “I’m not really in labor, I’m near labor.” Excellent description of early labor! When contractions are irregular they can come and go. A+
Pam "contrapting."
#3) Michael: “Contraptions! She’s contrapting!” No. But really funny.
#4) This get-to-the-hospital-at-midnight-for-the-extra-day-in-the-hospital plan is not necessarily a great idea. Hospitals are best for acute injury and life-threatening illness. For most other situations being in the hospital increases risk of infection and illness or injury caused by being in the hospital in the first place. I say get out of there as soon as you are safely able.
#5) Along those lines, a lot of people make critical decisions based on insurance. If you are able to avoid this please do. You will be happiest if you deliver with whomever’s practice and philosophy best matches yours, and in the venue (home or hospital) that will support the birth experience you seek.
#6) Kelly: “Did you know that labor can last weeks, and then they take your insides out and just plop them on a table, and sometimes epidurals don’t work and you can poop yourself?” My response in order: Not exactly but kind of (early labor warm up contractions can be felt for weeks by some), the uterus is placed on mamas belly during a c-section–but not plopped on a table, and true, and true. All of which would be well supported by a doula who would do her best to provide you with the informational, emotional, and physical support to help you feel a-ok about whatever your labor may bring. (Even the pooping, which sounds horrible but I promise you, it isn’t. Your excellent nurse will whisk it away and you won’t even know it happened.)
#7) To pick up with the point of when to leave for the hospital if you choose a hospital birth, leaving when contractions are every 5 minutes is generally better than when they are every 7, and many practitioners even recommend 3 minutes. The general recommendations go something like this: “Leave when the contractions are 4 minutes apart, and last for one minute, for one hour.” They call this “411″ and some midwives and docs recommend 511, some 411, and others 311. As a doula, I support my client in leaving whenever she wants, however, for my mamas who want to stay home as long as possible, I work with them to stay home until we see signs that mama’s entering transition territory.
#8) Jim: “Why don’t I just run you down to the hospital and we’ll get you a quick check.” I totally understand Jim’s reaction here as this is all unknown to him. At this risk of sounding like a broken record, this is where a trained birth professional can really help keep everything calm, cool, and collected. And although this may be different around the country, in most NYC hospitals there is little to no chance of a “quick check.” Priority is given to women in active labor or in emergent situations, and Pam would likely spend a lot of time in the waiting room in triage, where she would be less comfortable and perhaps progress more slowly. Also, in many situations once you’re in the hospital they will try to keep you there and then begin “active management” of labor, which means interventions to try to speed it along. Staying home as long as possible (or having a homebirth) is your best shot at being on the time table that is best for you and your baby, not the time table preferred by the hospital.
Curious about the Early Labor Baking Project? Click the pic for the scoop.
#9) In her early labor Jim is trying to give Pam room to “listen to her body’s signals,” which is right on (good job Jim!), but just not quite yet. In early labor, distraction is the name of the game just like Pam says. If Pam and Jim were my doula clients I would have helped them create an appropriate Early Labor Plan which helps with the distraction factor early on. I may even recommend they consider an Early Labor Baking Project which can be both distracting and delicious. Of course, none of that would make for Must See TV…
#10) Kelly: “Oh my god Pam, you are a warrior.” Yep, all laboring mamas are. More impressive than Olympic athletes and marathon runners. Hands. Down.
#11) Michael’s labor induction tips:
- Stimulate the nipples: True–releases oxytocin, causing uterine contractions.
- Walk around: Yes! I recommend a good 3 – 4 mile walk to my mamas who want to get things going.
- Eat spicy food: Maybe, can’t hurt. Some say eggplant parmesan is a good food for labor too (I’ve heard it’s actually the basil and oregano that do the trick).
#12) Jim: “Let’s go to the hospital…let’s go now.” Oh Jim…I will say that I’m not sure who I am of more use to in early labor, the mamas or the papas. 99.9% of men have never seen a woman give birth before, let alone witnessed a number of births with myriad variations on normal. It is totally natural that they would feel better being someplace with people around who did know about birth. The thing is, that is not what is best for mama most of the time. The cervix needs an environment of safety, privacy, and calm to properly dilate, and hospitals rarely offer much of that particular combo. A doula and/or a midwife who will join the couple in their home during this time allows papa to be a wonderful supportive partner, and know that there are other people with the experience to judge if everything is as it should be.
#13) Pam held her ground even though Jim wanted to leave. Not all mamas are able to do this, and in part because they’re scared too. This is an important thing to discuss as a couple ahead of time. Birth should be about supporting mama in what she needs, and anything that may get in the way of that (including a birth partner’s own nerves or fear) needs to be figured out in advance.
Jim and Pam before baby made three.
#14) Pam: “There’s no rush to get to the hospital. I’m fine. I’ll get there. And if I don’t get there, I don’t get there.” Wow. Pam’s composure is amazing, but rare in a first time mama, so don’t feel bad if you’re not quite so confident. I love this portrayal though, it is so different than the typical terrified and frantic mother-in-labor image. I hope the tone stays like this!
#15) Not being able to walk or talk through a contraction is indeed a sign that Pam has moved from early labor to active labor.
#16) Ummm…oops. To go directly from active labor (can’t talk during contraction) into signs of transition (Pam’s expression that she can’t do it) is not particularly realistic. Though the timing is off, a woman’s sense of overwhelm is virtually universal, and I believe that emotional state gives way to the surrender necessary to fully open up and eventually push the baby out. The best thing to say to a mama in this moment? “You are doing it! You’re doing so good!” (Because she is!)
#17) Contractions are now 2 minutes apart, keep breathing everyone. A lot of my clients like to keep track of their contractions with this iPhone app called Contraption Contraction Master.
#18) You should not attempt to measure dilation with a metal tape measure. Just so you know.
#19) Jim: “Pam’s ten inches dilated now. Sorry, sorry meters. Centimeters. And she’s fully effaced. Which, ah, I don’t know what that is.” Perhaps Jim and Pam didn’t take childbirth education classes, because those are certainly terms that we cover. Taking childbirth education classes with your partner is incredibly important in terms of gaining the knowledge needed to be empowered in a the brand new situation. You will learn cool things like this: Cervix Lingo: Effacement What? Dilation Who?
#20) RN: “Daddy, she’s ready to push.” How do you know you ask? Rectal pressure. It feels like you have to have a bowel movement, but in fact what you’re feeling is the baby’s head. If you have an epidural you may not feel this, although you very well may. With an unmedicated birth you will absolutely know when you’re ready to push.
Babies come in their own time Michael!
#21) Michael during Pam’s pushing, “Can we have an ETA?” Not really. The average is from a few minutes to 3 hours of pushing. First time mamas like Pam usually take on the longer side. This is a-ok as it is important that mama and baby have time to work together for optimal fetal positioning and so that mama has time to open up and stretch.
#22) And finally, a beautiful baby girl was born and Pam looks fresh and pretty in a gown and robe. The fresh and pretty part is absolutely true. Every woman I have seen give birth looks unbelievably beautiful right after, it is amazing. None of them have a robe on however. A gown maybe, or a tank, or a belly band worn as a tube top. This is all preferable as you want lots of skin-to-skin contact for bonding and breast feeding.
****Postpartum
#23) When Pam is unsure if the baby is latching or getting anything (what she would be getting is colostrum by the way) and the nurse offers to take her away to the nursery that was just not very helpful. A doula or RN would ideally help ensure that the baby is latching correctly. When mom and baby need a break, it is best to stay close and enjoy skin-to-skin contact and just getting used to each other, and then try again in a bit. Here’s a good video about getting started with breastfeeding, and here’s one specifically about latching.
My conclusions? Not bad! I am pleasantly surprised by how well the writers finessed this episode. Pam was quite empowered, and there were no “emergency” twists and turns. There was also no hint that she couldn’t handle the intensity, or scenes of her screaming for an epidural, which TV shows often portray. All in all I have to say nicely done NBC and The Office, and congratulations fictional Pam and Jim!
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