Wednesday, July 29, 2015

Correlation, Causation, & Skepticism

I recently read this article about mother’s weight gain during pregnancy and connection with childhood obesity, and I just can’t keep my Medical Anthropologist mouth shut.

Title: When mom gains too much weight during pregnancy, her child is more likely to be obese

Researchers in Greece: “conducted telephone interviews using a standardized questionnaire collecting information on the mother's age at pregnancy, amount of weight gained during pregnancy, pregnancy exercise level, smoking status, alcohol consumption and the body mass index of the child at the age of eight.”

And they came to the conclusion: “that the amount of weight gained throughout pregnancy, the   level of physical activity and smoking status was strongly associated with obesity in children. Moderate exercise during pregnancy was found to lower the risk of a child becoming overweight or obese in childhood, even after adjusting for the other maternal and child characteristics.”

So what’s the big deal?
First I want to say that while there MIGHT be a correlation between pregnancy weight gain and childhood obesity, that certainly does not mean there is a causal relationship between the two.  Said another way: Gaining too much weight in pregnancy might NOT cause childhood obesity.

In my professional opinion, there are so many other factors that could contribute to childhood obesity that were not looked at in this study.  Things like lifestyle, diet, current activity levels, genetics, and so many more that were not considered.  Perhaps moms who gain excess weight in pregnancy are more likely to be overweight in the first place and to continue that same lifestyle after pregnancy thus passing it on to their offspring.  Additionally, this was a retrospective study that asked mothers to recall very specific information about their pregnancy 8 years after the fact.  I have a 7 year old, and I honestly have a really hard time remembering specifics about my pregnancy with her. 

This is the problem with inflammatory headlines like this.  While they might get a lot of attention, the specious connections they are touting are not always accurate or whole pictures of what is actually happening and the risks involved. 

The point: Don’t freak out over every new claim that blames pregnant mothers for the outcomes of their children.  It isn’t always the mother’s behavior when their child was in utero that has long term effects. While that certainly is part of the picture, the whole picture is much more complicated than a simple headline can explain.

Wednesday, July 15, 2015

The Birth of Avery.

This birth story is shared with permission. Saturday, July 11 marked the three year anniversary of the first birth I attended as a doula.

I met Avery's mother the month before he was born. Another doula referred me to her. I called her as soon as I read the message, I was calling to set up an interview, doing all the things just as they were supposed to be done. Whatever that even means. Her mom answered: "the doula is on the phone!!!!" Wait what!? I am not your doula yet, you have to interview me! I didn't say that,but that's what went through my head. We set up a meeting for the next day, I was in a hurry, she was dues soon and we had much to do. I jabbered like a crazy person at our first meeting, going around in circles about this and that. She was young. Sixteen in fact. I had questions, who is in charge at the birth. Her? Her mother? I needed answers! Not really,but I harassed more seasoned doulas anyway.

I jumped a mile any time my phone made a peep. Is is Jme? Is she in labor? The day before the birth she called me to say her OB wanted to induce. I panicked. What's wrong? Is everything ok!? I raged and punched a wall a few times after we got off the phone. What kind of doctor wants to induce a perfectly healthy woman? The baby is fine. The mother is fine. Leave.Her. Alone. After I drove myself crazy for a while. I got myself to sit down and shut up. It's her birth,not mine. I am there to support,not run the show. 

The induction was set for the next day. I had to get myself together and be prepared for a potentially very long birth. I was scrambling to figure out what to put in my doula bag. I was flat broke so I couldn't by any gadgets or any "official" doula tools. I feel very silly about all this now, as I don't really use anything from my bag these days. I packed my honey bear,Moby wrap, a sandwich,phone charger,and my manuals from my doula training. I was ready as I could get. I didn't sleep at all. I was up two hours before my alarm. 

I rode to the hospital with Jme and her family. I noticed she was having contractions the whole time we were in the car. This was very exciting! Maybe her labor would take off and there would be no need for induction. Labor picked up right away, after checking in and getting settled in a room. The nurse came in and broke her water, and we were off. I was officially at my first birth. Labor picked up steadily and a stream of visitors was in and out all day. Jme labored beautifully, she was in her own space, immune to the chaos going on around her. There wasn't a lot for me to do and I didn't know what to make of that. Shouldn't I be DOING something? The answer was no, as a doula I don't always have to be doing something. Sometimes my presence is enough. Eventually she was laboring on the birthing ball and I was doing the doula's bread and butter-the double hip squeeze. At that precise moment I was a doula. Doing doula things. 

As the day went by Jme was caught up in labor, she wasn't saying a much and the contractions were requiring all of her attention. She wasn't responding to all of the commotion in the room, hearing Avery's heartbeat on the monitor was meditative for her. I noticed that she was shaking through each contraction, I whispered "are you feeling pushy?" Yes. She was. Then what I like to call the baby swat team swooped in. Doctor,tech,more nurses. It was a bright sunny afternoon,what's that spotlight doing there? Avery was earthside after very little time pushing, he wasn't Avery yet. The name hadn't been decided yet. Avery? Alekzander? Every family member had an opinion, everyone wanted to hold him. 

A mother,baby,and a doula were born that day. Though it took me a bit longer to not be the over excited new doula. 

Wednesday, July 8, 2015

Birth Doulas: How Support Could Change Childbirth in America

Birth Doulas:
How Support Could Change Childbirth in America
That first moment, when a woman and her newborn lock eyes and a child imprints upon its mother is unforgettable.  That beautiful, intense, instantaneous love that a mother feels for a person that she is only first meeting, but whom she has "known" for much longer, is incomparable.  The birth of a child is an experience like no other in a woman's life.  Ensuring that this occasion is as positive an event as possible should be taking precedence in society, should it not?  Sadly, American culture has begun to devalue mothers and the childbirth process, treating it as an everyday occurrence.  The emphasis once put on its importance seems to have waned.
Several factors have contributed to society's desensitization of the effects of birth on mothers, infants, families and even society itself.  One of those reasons is how birth has changed over time.  Birth used to happen at home, where a woman was comfortably surrounded by those that loved her, and attendant that knew how to deliver children this way-a way mentally and physically safe and healthy.  Now majority of births are occurring in hospitals, with very expensive and impersonal care that is designed to make the jobs of medical staff simpler, not to better accommodate a birthing woman or her unborn child.  A certified professional midwife named Ina May Gaskin (2003) wrote, “Most Americans are unaware that women ever die from cesarean operations, particularly when those surgeries are scheduled, rather than emergencies…Few people have any way of knowing that most maternal deaths take place in hospitals or that unnecessary surgery can actually cause a death” ( p. 288).  Another factor is the increased usage of pain medications (such as epidural analgesia), scheduled births, like inductions of labor (choosing a baby’s birthdate), augmentation of labor (using medical intervention to speed up the labor process), and cesarean sections.  This creates the feelings of a well-planned and uncomplicated event-but that is not the case at all.  Each of these choices comes with risks to both mother and child.  All too often these risks are under-explained, and their severity is underestimated.
High Mother and Infant Mortality Rates
The general public would likely be shocked to know the reality of death in childbirth. Americans take solace in the mere thought of living in such a privileged society.   Rachel Ward is the director of research at Amnesty International, a human rights organization.  Ward is the author of Deadly Delivery: The Maternal Health Care Crisis in the USA, which was published in 2011, and she understands the need for these facts to be brought to light.  Ward (2011) found that the World Health Organization’s recommended rates are nearly half as much as the current U.S rates, since there has been a sharp rise in cesareans and inductions performed in the past 25 years. (p.78).  Drug-induced labors are an estimated 23%, and the national cesarean rate at 32%.
Many organizations agree that interventions are too high, yet attempts to get them down have been unsuccessful.  Ward went on to elaborate on the risks of these interventions. In summation, she found induction of labor is related to higher risk of hemorrhage and cesarean sections in primigravida mothers (2011).  Cesareans carry their own set of significantly increased risks when compared to spontaneous vaginal birth, such as hysterectomy, kidney failure, pulmonary embolism, infection, and death (p. 78).
Rachel Ward is not alone.  Published by Francine Coeytaux, Debra Bingham, and Nan Strauss, Maternal Mortality in the United States: A Human Rights Failure (2011) also refers to the overuse of technology in childbirth.  Over the past 12 years, there has been a 56% increase in the amount of surgical births in the United States, and a sharp incline of births in which Pitocin was administered.  While there are no studies proving better outcomes, data exists showing misusing these procedures caused maternal and infant mortality rates to rise.  America is a country where access to medical care is just as big an issue as the over exposure to procedures where pregnancy and birth are concerned.  
                Moreover, these interventions are also quite expensive, and are contributing to higher maternity care costs across the board.  The same study describes how these interventions aren’t just limited to maternity care.  Performing inductions and cesarean sections when they are not advisable to improve outcomes leads to higher risk of hysterectomy (and further expenditures) in the future.
A Birth Doula’s Ability to Reduce Intervention
A birth doula is a professional support person for women and families before, during, and immediately after childbirth. A doula is trained and educated in methods of physical and emotional comfort, and has information to help women make informed decisions about maternity care. A doula may be a lay person, have taken special training, and/or be certified through organizations like ICEA, CAPPA, and DONA. While some effects are immeasurable, many clinical studies have found that doulas have a major impact on outcomes for both mother and child. 
Hodnett, Gates, Hofmeyer and Sakala (2012) showed continuous labor support to be effective in reducing the need for interventions such as pain medications/epidural analgesia, labor induction or augmentation with synthetic oxytocin (Pitocin), vacuum extraction and forceps deliveries (pp. 1-2).  All of which carry hazards to both mother and child. Risks range from mild, like chills, to more life-threatening problems like shoulder dystocia, brain damage, and hemorrhage.  Lower incidences of abuse, postpartum depression, and generally shorter, uncomplicated labors were also reported. Mothers in the study reported more pleasant feelings about their birth experiences in the doula attended group.  Perhaps more importantly, there are no known risks to mother and/or child from doula attended births.  Dr. John H. Kennell, MD is one of the founders of Doulas of North America.  Dr. Kennell (1998) once said, “if a doula were a drug, it would be unethical not to use it.”
Conclusions and Future Study

            Citizens of the United States are spending more money than necessary on maternal/fetal healthcare.  There is also a needless and preventable amount of maternal and fetal mortality/morbidity.  By providing continuous labor support to mothers and families, both costs and risks of injury and death can be driven down.  It is advisable for doulas to become an integral part of the maternal/fetal support team for each birthing woman, for the sake of cost and safety. Heidi Rinehart is a former obstetrician for Amnesty International, she says, “What works is not flashy, not expensive, but it’s human intensive” (as cited in Deadly delivery: the maternal health care crisis in the US, 2010, p. 92).

Wednesday, July 1, 2015

Informed Consent in Maternity Care

Informed consent is the process where a healthcare provider discusses any procedure before it happens with a patient.  This includes discussing all the risks, benefits, and alternatives with the patient.  Informed consent is not only a discussion, but also typically involves some paperwork.  Some of this paperwork is signed during the pre-registration process, and even more is signed while you are in labor depending on the procedures that are being suggested for intervention or augmentation. 

So what’s the big deal about informed consent in maternity care? Not all providers are equal when it comes to the informed consent discussion.  We’ve even seen some providers who are absolutely horrible at it, even performing procedures without ever getting consent.  This has recently come to a BIG discussion in the birth community, with the case of a California woman who clearly did not consent to episiotomy while her provider proceeded to cut her. This woman is now suing her doctor for assault and battery in a landmark case!

Here are some great links for informed consent in maternity care:
1.      Research paper on informed consent & access to evidence-based research
2.      North American Registry of Midwives statement oninformed consent
4.      Use of the word ALLOWED when it comes to informed consent
5.      What the American Congress of Obstetrics & Gynecology has to say about informed consent

We always encourage our clients to do research about the procedures that might be suggested to them during pregnancy and birth.  We also encourage clients to be prepared for the informed consent conversations that will inevitably come up during the course of their care. The best way that you can approach conversations with your provider is by remembering the acronym B.R.A.I.N.


Ask these questions:
What are the benefits of this procedure?
What are the risks?
Are there any alternatives?
What is my intuition saying?
What happens if we do nothing?

As your doulas, we can also help you by talking about the research that we have done. We regularly try to keep up with the maternal medicine research that is constantly evolving, and we can tell you what we’ve found.  What we can’t do, is have the conversation with your provider for you or make the decision for you.

We want to help you make the best decisions for your care.  We want to make sure that the most recent evidence-based research is being used in your care as well.  We want you to have the best birth experience ever, but as doulas it is not our place to make decisions for you.  You have to be an active participant in your care, and being an informed consumer is one step along that path.  Providers have an ethical responsibility to utilize good informed consent procedures, but you also need to be a good healthcare consumer.  Being a good consumer means asking questions and making sure