Hospitals with Midwives on Staff Have Better Outcomes

Here are two recent studies showing that hospitals with midwives and doctors practicing together ("interprofessional" centers) have better outcomes than hospitals with only doctors. One study is on first-time mothers (nulliparous), and the other study is on women who have given birth before (multiparous), to separate out the possible effects of parity.

In first-time mothers, women were much less likely to be induced or have oxytocin augmentation of labor in interprofessional/collaborative centers. The cesarean rate was 12% lower in interprofessional centers too.

For multiparous mothers (multips), women were again much less likely to be induced or have augmentation of labor in interprofessional centers. The first-time cesarean rate was 36% lower, and the Vaginal Birth After Cesarean (VBAC) rate was 31% higher than in institutions with only doctors. Neonatal outcomes were similar between the two types of centers.

The implication here is that not only do midwives lower the rates of interventions without endangering outcomes, they also influence the hospital culture in a positive way. Doctors who work with midwives tend to be more flexible about interventions, less likely to push a cesarean without need, and more likely to support VBACs.

If you are considering a hospital birth, try to choose a hospital with both doctors and midwives on staff, one with low overall cesarean rates, and strongly consider hiring a doula for professional labor support. Most women can safely be attended by a midwife, so make that your first choice if you can. If a risk comes up that means that you need to see an OB or high-risk maternal fetal medicine (MFM) specialist, the midwife will refer you to one, probably one that is supportive of the parents' birth wishes whenever conditions allow.



References

Birth. 2018 Nov 11. doi: 10.1111/birt.12407. [Epub ahead of print] Midwifery presence in United States medical centers and labor care and birth outcomes among low-risk nulliparous women: A Consortium on Safe Labor study. Neal JL, Carlson NS, Phillippi JC, Tilden EL, Smith DC, Breman RB, Dietrich MS, Lowe NK. PMID: 30417436

...Our objective was to compare labor processes and outcomes for low-risk nulliparous women birthing in United States medical centers with interprofessional care (midwives and physicians) versus noninterprofessional care (physicians only). METHODS: We conducted a retrospective cohort study using Consortium on Safe Labor data from low-risk nulliparous women who birthed in interprofessional (n = 7393) or noninterprofessional centers (n = 6982). .. women at interprofessional medical centers, compared with women at noninterprofessional centers, were 74% less likely to undergo labor induction (risk ratio [RR] 0.26; 95% CI 0.24-0.29) and 75% less likely to have oxytocin augmentation (RR 0.25; 95% CI 0.22-0.29). The cesarean birth rate was 12% lower at interprofessional centers (RR 0.88; 95% CI 0.79-0.98). Adverse neonatal outcomes occurred in only 0.3% of births and were thus too rare to be modeled. CONCLUSIONS: The care processes and birth outcomes at interprofessional and noninterprofessional medical centers differed significantly. Nulliparous women receiving care at interprofessional centers were less likely to experience induction, oxytocin augmentation, and cesarean than women at noninterprofessional centers. Labor care and birth outcome differences between interprofessional and noninterprofessional centers may be the result of the presence of midwives and interprofessional collaboration, organizational culture, or both.

Birth. 2018 Nov 9. doi: 10.1111/birt.12405. [Epub ahead of print] Influence of midwifery presence in United States centers on labor care and outcomes of low-risk parous women: A Consortium on Safe Labor study. Carlson NS, Neal JL, Tilden EL, Smith DC, Breman RB, Lowe NK, Dietrich MS, Phillippi JC. PMID: 30414200

...We sought to use national United States data to analyze the association between midwifery presence in maternity care teams and the birth processes and outcomes of low-risk parous women. METHODS: We conducted a retrospective cohort study using Consortium on Safe Labor data from low-risk parous women in either interprofessional care (n = 12 125) or noninterprofessional care centers (n = 8996). .. women at interprofessional centers, compared with women at noninterprofessional centers, were 85% less likely to have labor induced (risk ratio [RR] 0.15; 95% CI 0.14-0.17). The risk for primary cesarean birth among low-risk parous women was 36% lower at interprofessional centers (RR 0.64; 95% CI 00.52-0.79), whereas the likelihood of vaginal birth after cesarean for this population was 31% higher (RR 1.31; 95% CI 1.10-1.56). There were no significant differences in neonatal outcomes. CONCLUSIONS: Parous women have significantly higher rates of vaginal birth, including vaginal birth after cesarean, and lower likelihood of labor induction when cared for in centers with midwives. Our findings are consistent with smaller analyses of midwifery practice and support integrated, team-based models of perinatal care to improve maternal outcomes.

Midwifey-Led Model of Care Increases VBACs

Some hospitals do not allow Certified Nurse-Midwives (CNMs) to attend VBACs (Vaginal Births After Cesarean). Even in my area, which is generally pretty birth-friendly, there are major hospitals that do not allow CNMs to attend VBACs.

This lack of choice is greatly frustrating to the many VBAC women who want to be attended by a midwife. They feel they have a better chance at vaginal birth with a care provider that specializes in more hands-off model of care. Furthermore, they feel that a prior cesarean should not deprive a woman of her autonomy in choosing how and with whom she gives birth.

Here is recent research from a hospital that implemented a midwifery-led model of care. It compared stats from before and from after the switch to see how the change affected things.

The most striking result was that changing to a midwifery-led model of care increased both the number of women who planned VBACs and the number who actually ended up having a VBAC.

Most importantly, safety outcomes were just as good.

This shows that midwives can safely attend VBACs. Midwifery care is likely a key step in lowering the cesarean rate by preventing automatic repeat cesareans and by improving VBAC rates in those who do labor.

It is time for hospitals to stop restricting women who have had previous cesareans from accessing midwifery care.  


Reference

Birth. 2016 Sep;43(3):200-8. doi: 10.1111/birt.12229. Epub 2016 Mar 18. Evaluating a Midwife-Led Model of Antenatal Care for Women with a Previous Cesarean Section: A Retrospective, Comparative Cohort Study. White HK1, le May A2, Cluett ER2. PMID: 26991669

BACKGROUND: Research is yet to identify effective and safe interventions to increase the vaginal birth after cesarean (VBAC) rate. This research aimed to compare intended and actual VBAC rates before and after implementation of midwife-led antenatal care for women with one previous cesarean birth and no other risk factors in a large, tertiary maternity hospital in England. METHODS: This was a retrospective, comparative cohort study. Data were collected from the medical records of women with one previous lower segment cesarean delivery and no other obstetric, medical, or psychological complications who gave birth at the hospital before (2008) and after (2011) the implementation of midwife-led antenatal care. Chi-squared analysis was used to calculate the odds ratio, and logistic regression to account for confounders. RESULTS: Intended and actual VBAC rates were higher in 2011 compared with 2008: 90 percent vs. 77 percent, adjusted odds ratio (aOR) 2.69 (1.48-4.87); and 61 percent vs. 47 percent, aOR 1.79 (1.17-2.75), respectively. Mean rates of unscheduled antenatal care sought via the delivery suite and inpatient admissions were lower in 2011 than 2008. Postnatal maternal and neonatal safety outcomes were similar between the two groups, except mean postnatal length of stay, which was shorter in 2011 compared with 2008 (2.67 vs. 3.15 days). CONCLUSIONS: Implementation of midwife-led antenatal care for women with one previous cesarean offers a safe and effective alternative to traditional obstetrician-led antenatal care, and is associated with increased rates of intended and actual VBAC.

A Midwife-Laborist Care Model Reduces Cesarean Rates

Here is brand-new research showing that a midwife-physician laborist care model resulted in lower cesarean rates than a private practice OB care model.

This could be one potent way to reduce stubbornly-high cesarean rates on a more widespread basis.

But first, let's start by discussing what a "laborist" is, since many readers may not be familiar with this model of care.

What is a "Laborist"?

More and more hospitals are beginning to implement "laborist" programs in their maternity wards. But what the heck is a "laborist"?

According to the American College of Obstetricians and Gynecologists:

The term laborist most commonly refers to an obstetrician–gynecologist who is employed by a hospital or physician group and whose primary role is to care for laboring patients and to manage obstetric emergencies.

Laborists are based on the "hospitalist" concept from other medical fields. A hospitalist is a physician that only works in the hospital and does not have care responsibilities elsewhere. Their focus is on hospitalized patients, not private patients.

A hospitalist might work up patients admitted to the hospital from the emergency room, get information from all the patient's doctors, order tests, look for potential cross-reactions between medications, and develop a plan of care for the patient's hospital stay, release, and after-care. The patient's main doctor collaborates with the hospitalist, but having a hospitalist assigned to a patient assures the patient of having a doctor immediately available if necessary, as well as someone who will coordinate care between various providers.

Basically, a laborist is a hospitalist in the OB-GYN field.

There are several different laborist models around so details can differ, but generally a laborist stays in the hospital and is in charge of consulting on patients in labor during his/her work shift. He/she would not be responsible for any other other duties or office hours, but instead manages whatever issues come up during that shift, including emergencies.

If a minor problem occurred, the woman's regular care provider and the laborist would consult on how to manage it. If there was an emergency that required immediate response, the laborist would handle it. If a c-section was needed, the laborist would do it (or would do it in conjunction with the woman's care provider). If a woman in labor came into the E.R. without an assigned physician from that hospital, the laborist would take the case. In addition, if the emergency room had an E.R. patient with a gynecological problem, the laborist would consult.

In the non-laborist model of care, a private OB group covers its own patients when they are in labor. This means that doctors must juggle covering office hours, meetings, and routine appointments with managing patients who are in labor. If there is an emergency, the doctor must drop everything to run over to the hospital and respond to the crisis. Regular patient appointments must often be rescheduled or covered by colleagues back at the office because of the unpredictable nature of labor.

Like hospitalists, the laborist care model is a rapidly expanding model of care. One survey showed that about 40% of the U.S. hospitals surveyed had moved to a laborist model, and this number is likely to increase over time.

That means it's time to have a more in-depth look at the pros and cons of laborist programs.

Advantages and Disadvantages of Laborists 

The biggest advantage of having a laborist is that an obstetric surgeon is always right at hand in the hospital, ready to intervene at a moment's notice if a true emergency occurred. 

This is HUGE in the field of obstetrics where sudden emergencies sometimes do occur. Most birthing women are surprised to learn that most hospitals don't have a doctor always on hand, ready to intervene. Thus there can be a critical delay while waiting for a physician to arrive from off-campus.

Private duty OBs juggle regular office hours with monitoring their patients in labor. They are usually on-call at a nearby office or home within a certain number of minutes, but that is not the same as being at the hospital 24/7. Having a laborist always on duty means that someone is always available right away on those rare occasions when immediate action is needed.

Another big advantage of laborist care is a more humane life-style for the care providers involved. In hospitals with laborist models, care providers have more off-duty time, more time with their families, and less need to juggle laboring patients with office hours. In a profession where stress contributes mightily to burn-out and substance abuse issues, a more sane schedule is a tremendous advantage for both care providers and the mothers they attend.

Laborists also offer business advantages. Hospitals with laborist programs have been able to reduce their malpractice premiums and do not have to hold as much money in reserve for possible liability claims. This means that even though laborists cost extra money in salaries, their overall effect often saves a hospital money.

One potential disadvantage of laborist care is less personal care. A woman might not be attended by her personal caregiver during labor. Many women feel strongly about having a personal relationship with a caregiver she knows and trusts, one who has a deep understanding of her medical history and birth preferences. A laborist model has the potential to decrease this. This is a real and substantial disadvantage.

However, the reality of hospital birth is that many caregivers already do not attend their own patients because they are part of large group practices. The mother gets whomever is on duty in the group on the day she goes into labor. Those caregivers who do promise to be there for a woman's labor often do so by inducing her when they are on duty, exposing the mother and baby to all the risks of induction and perhaps raising the risk for cesarean.

Additionally, most laborist models do allow the regular caregiver to attend a particular patient's birth if desired. It doesn't keep them from attending births, it just gives them more flexibility to balance other duties with births. And having a laborist working in conjunction with the regular caregiver might just ease some of the time constraints that caregivers feel and give the mother more opportunity to get the birth outcome she wants.

Possible Effect on Cesarean Rate

One VERY important potential advantage of having a laborist is hopefully lowering both the primary and repeat cesarean rate, while also increasing VBAC access. 

Because a private practice OB has dual duties with office hours and births, the constraints on their time may make them more quick to move to a cesarean. A laborist may have more patience to wait out a long labor because they don't have to rush off to other appointments, and they might be more willing to try alternatives (like mobility in labor, manual repositioning of the baby, etc.) when labor is "stuck." In this way, a laborist may help prevent primary cesareans, which in turn will help prevent many repeat cesareans in the future.

In addition, the current rules of many hospitals make it hard for many care providers to attend Vaginal Births After Cesarean (VBACs). Many hospitals demand that a doctor and anesthesiologist must be IN the hospital with a VBAC patient at all times, making it hard for caregivers to manage regular office hours and VBAC patients. This has resulted in many doctors refusing to attend VBAC mothers, forcing most of them into repeat cesareans.

Having a laborist on duty should boost the willingness of care providers to support VBAC patients.

This could be very important, since about one-third of U.S. hospitals have official VBAC bans, and many more have de facto VBAC bans. Many women are being forced into surgery they do not want or need by the "immediately available" VBAC criteria. Laborists can provide the 24/7 coverage needed to satisfy part of that criteria and may help bring VBAC back to many hospitals.

What Does the Research Say?

The theory has been that if laborists were added to hospitals, some lives would be saved, the quality of life of OBs would improve, and the cesarean rate would go down. But has the laborist model achieved this?

The research so far does seem to support this. In one study from Nevada, the cesarean rate dropped from 39% to 33% when a full-time laborist model was adopted ─ and this was during a period when the cesarean rate was rapidly increasing everywhere else.

[However, it's important to point out that even with the laborist model, the Nevada study still had a fairly high cesarean rate, over 30%, suggesting that there is still room for improvement.]

In 2013, three studies on laborist models were presented at a meeting of the Society of Maternal-Fetal Medicine. All three showed improvements with a laborist model of care, as summarized here:

Hospitals that employed laborists saw about a 15% decline in induction of labor and preterm deliveries after adjustment for other factors compared with centers that do not employ that OB equivalent of a hospitalist, Sindhu Srinivas, MD, of the University of Pennsylvania in Philadelphia, and colleagues reported.  

In a separate study, hospitals that provided 24-hour coverage through use of laborists or other means saw a similar reduction in cesarean delivery rates, with a more than twofold increase in attempted vaginal birth after a prior cesarean, said Yvonne Cheng, MD, PhD, of the University of California San Francisco and colleagues.

...In the third study, Allison Allen, a medical student at Oregon Health & Science University in Portland, and colleagues looked at a computer simulation comparing probabilistic scenarios for two events that require urgent delivery -- umbilical cord prolapse and major placental abruption -- at laborist and nonlaborist hospitals. In a theoretical cohort of 100,000 pregnant women, employment of laborists at hospitals with a volume of 1,000 deliveries a year would be expected to result in 83% fewer stillbirths, 17% fewer cases of major neurologic injury, and 13% fewer neonatal deaths.

So indeed, it does seem that a laborist model should save lives, lower the cesarean rate, and improve access to VBAC. Most OBs agree that it also brings a bit more sanity into their busy schedules and more time for family life.

All of this speaks strongly in favor of a laborist model of care. But what if that model of care could be improved on even further?

One hospital in California asked whether it could lower the cesarean rate even more by using both OBs and midwives in its laborist model.

Midwifery/Laborist Model of Care

Midwifery care has been shown numerous times to lower intervention rates and often c-section rates. Integrating midwives into a laborist care model might make for a particularly potent combination for reducing cesarean rates.

In this study from a community hospital in Marin, California, using both midwives and OBs as laborists helped lower the cesarean rate substantially compared to those handled in private OB practices.

In the study's private practice care model (also called an "out-of-hospital" model), a large practice of 18 OBs and 2 CNMs (Certified Nurse-Midwives) practiced together and handled 57% of the births during the 5-year study period.

In the collaborative midwife-laborist care model (also called an "in-hospital" model), a group of 20 CNMs and 25 OBs practiced together. They handled 42% of the births during the same study period. In this care model, both a midwife and an OB were on duty as laborists 24 hours a day. The care for most patients was midwife-led, with the OB laborist called in as the woman's risk factors and situation dictated.

In this study, women who were cared for in the private OB practice model had more cesareans than those under the care of midwife-laborist model, 31.6% vs. 17.3%. 

That's a HUGE difference. Even after adjusting for confounders, the women in private practice care had twice the risk for cesarean. They also had more inductions and more epidurals.

The midwife-laborist care model was effective for first-time mothers as well as multips. "NTSV" stands for Nulliparous, Term, Singleton, Vertex, and basically means first-time mothers, at full-term, with only one baby, and that baby is head-down. Many researchers feel these low-risk NTSV births are the best target for lowering overall cesarean rates because every primary cesarean prevented in NTSV mothers usually means that a repeat cesarean for a later birth is also prevented.

In this study, 29.8% of NTSV births in the private practice model ended in cesarean, whereas only 15.9% of NTSV births in the midwife-laborist care model ended in cesarean. That's a very important difference.

The difference was also clear in NTSV cesareans where medical judgment plays a critical part of when to move to a cesarean (such as interpreting abnormal fetal heart tracings or dealing with slower labors). In this situation, the private practice model had a 28.1% cesarean rate, versus a 15.6% cesarean rate in the midwife-laborist care model. The authors suggested that the difference may well have had to do with less competing demands for the care provider's time and as a result, more patience in labor.

The midwife-laborist care model was also helpful for mothers who had had a prior cesarean. 71.3% of women with prior cesareans had another cesarean in the private practice model, whereas 41.4% of women with prior cesareans seen in the collaborative care model had another cesarean.

This was probably both a reflection that midwives tend to be more supportive of offering VBACs, as well as the fact that 24-hour laborist care enabled more providers to meet the "immediately available" requirement without having to cancel regular office hours. So while the study did not have specific data on the "trial of labor" or success rates in each group, it's likely that midwife-laborist care model did significantly expand VBAC access at the hospital.

One item I'd particularly like studied in the future is whether a midwife-laborist care model could lower the cesarean rate in women of size. In the study, the authors did not have information on Body Mass Index and could not analyze for its effect. However, they pointed out that the midwife-laborist care model had far more Latina patients than the private OB care model. They noted that Latinas tend to have a higher prevalence of obesity than white women in the U.S. and that if that trend also held true in the study, the midwife-laborist care model "should" have had higher cesarean rates. <roll eyes> Yet the midwife-laborist care model actually had LOWER cesarean rates, despite a population that was probably heavier.

[Hmmmm. Maybe how an "obese" woman's labor is managed makes a big difference? Maybe differing expectations of normalcy make a difference? Maybe midwives should be handling more women of size? Sounds like this is a topic ripe to be studied in further detail, doesn't it?]

The authors concluded:

In this study, we observed a consistent pattern of a higher use of cesarean delivery among women cared for under a private model compared with women cared for under a midwife/laborist model...Based on our findings, the implementation of obstetrician-midwife laborist programs may also have a positive impact on reducing the rate of cesarean deliveries in the United States.

This is a study that deserves to be replicated to see if other hospitals can achieve similarly dramatic results. Heaven knows we need to reduce the amount of non-indicated cesareans we are doing in the U.S., and reducing that rate should help prevent some of the alarming downstream outcomes of a too-high cesarean rate, like placenta accreta, placenta previa, placental abruption, and cesarean scar pregnancies.

I'd also love to see researchers particularly focus on whether a midwife-laborist program can decrease the unacceptably high risk for cesarean among women of size, and thereby decrease their risks for downstream complications too.

Summary

These studies show that a full-time laborist care model can be part of a program to help reduce cesarean rates at the hospital level.

If having a laborist on duty at all times can help lower cesarean rates, make VBAC more accessible, save a few lives, and help make caregivers' lives more humane, then it's a win-win situation all around. Research shows that most women are satisfied with the care received under a laborist care model, despite some care providers' fears that they would not be.

Laborist care models seem like a winning innovation so far, but the California study shows that a midwife-laborist care model is worth looking at even more closely.

Note that the OB laborist program in Nevada reduced its cesarean rate from 39% to 33%, yet the midwife-laborist program in California reduced its cesarean rate from 31% to 17%.

This suggests that a midwife-laborist model of care is even more potent at reducing cesarean rates than an OB laborist model of care.

More research is needed to confirm these results, but this preliminary research is very promising. If hospitals are serious about lowering cesarean rates, then it's time they looked into a midwife-laborist model of care.


References

Am J Obstet Gynecol. 2015 Apr;212(4):491.e1-8. doi: 10.1016/j.ajog.2014.11.014. Epub 2014 Nov 13. Two practice models in one labor and delivery unit: association with cesarean delivery rates. Nijagal MA1, Kuppermann M2, Nakagawa S3, Cheng Y4. PMID: 25446697

OBJECTIVE: The objective of the study was to examine the association between labor and delivery practice model and cesarean delivery rates at a community hospital. STUDY DESIGN: This was a retrospective cohort study of 9381 singleton live births at 1 community hospital, at which women were provided labor and delivery care under 1 of 2 distinct practice models: a traditional private practice model and a midwife-physician laborist practice model. Cesarean rates were compared by practice model, adjusting for potential sociodemographic and clinical confounders. Statistical comparisons were performed using the χ(2) test and multivariable logistical regression. RESULTS: Compared with women managed under the midwife/laborist model, women in the private model were significantly more likely to have a cesarean delivery (31.6% vs 17.3%; P < .001; adjusted odds ratio [aOR], 2.11; 95% confidence interval [CI], 1.73-2.58). Women with nulliparous, term, singleton, vertex gestations also were more likely to have a cesarean delivery if they were cared for in the private model (29.8% vs 15.9%; P < .001; aOR, 1.86; 95% CI, 1.33-2.58) as were women who had a prior cesarean delivery (71.3% vs 41.4%; P < .001; aOR, 3.19; 95% CI, 1.74-5.88). CONCLUSION: In this community hospital setting, a midwife-physician laborist practice model was associated with lower cesarean rates than a private practice model.

Am J Obstet Gynecol. 2013 Sep;209(3):251.e1-6. doi: 10.1016/j.ajog.2013.06.040. Epub 2013 Jul 29. Implementation of a laborist program and evaluation of the effect upon cesarean delivery. Iriye BK1, Huang WH, Condon J, Hancock L, Hancock JK, Ghamsary M, Garite TJ. PMID: 23904102

...In a tertiary hospital staffed with private practice physicians, data were retrospectively reviewed for 3 time periods from 2006 through 2011. The first period (16 months) there were no laborists (traditional model), followed by 14 months of continuous in-hospital laborist coverage provided by community staff (community laborist), and finally a 24-month period with full-time laborists providing continuous in-hospital coverage. The primary hypothesis was that full-time laborists would decrease cesarean delivery rates. RESULTS: Data from 6206 term nulliparous patients were retrospectively reviewed. The cesarean delivery rate for no laborist care was 39.2%, for community physician laborist care was 38.7%, and for full-time laborists was 33.2%. With adjustment via logistic regression, full-time laborist presence was associated with a significant reduction in cesarean delivery when contrasted with no laborist (odds ratio, 0.73; 95% confidence interval, 0.64-0.83; P < .0001) or community laborist care (odds ratio, 0.77; 95% confidence interval, 0.67-0.87; P < .001). The community laborist model was not associated with an effect upon cesarean delivery. CONCLUSION: A dedicated full-time laborist staff model is associated with lower rates of cesarean delivery. These findings may be used as part of a strategy to reduce cesarean delivery, lower maternal morbidity and mortality, and decrease health care costs.

Other discussions of various "laborist" models:

• http://www.acog.org/About-ACOG/ACOG-Departments/Practice-Management-and-Managed-Care/The-Laborist---A-Flexible-Concept
• http://contemporaryobgyn.modernmedicine.com/contemporary-obgyn/news/user-defined-tags/hospitalists/debating-laborist-model-care-0?page=full
• http://www.medpagetoday.com/MeetingCoverage/SMFM/37437
• http://www.the-hospitalist.org/article/the-laborist-movement/
• http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Patient-Safety-and-Quality-Improvement/The-Obstetric-Gynecologic-Hospitalist

Nice Is Not Enough: Questions for Interviewing a Maternity Care Provider

Many women want to choose their pregnancy care provider carefully, but aren't sure what questions to ask when interviewing doctors or midwives. 

Here are some general questions that some care providers* have suggested asking any provider you are considering during your pregnancy and birth.

1. How do you define “normal birth”?
2. Can you give me an example how you typically manage a normal birth?
3. How would you feel if I disagreed with you about a procedure you recommended during labor or birth?
4. How long will you “allow me” to wait if I go overdue?
5. What position(s) will you allow me to use when giving birth?
6. How do you feel about IVs and continuous fetal monitoring?
7. How do you feel about a woman eating and drinking in labor?
8. What are your thoughts on pain relief in labor?
9. How do you feel about cesareans?

Some childbirth educators would substitute different questions here and there from this list but it's a reasonable basic list to start with. Adapt as necessary for your own personal situation and concerns.

Also pay close attention to the provider's response to your questions. Of course, care providers have limited amounts of time to answer questions at most visits so it's important to be considerate and concise when you ask questions, but if they are impatient with your questions or dismissive of your concerns, that's a sign you might want to look elsewhere.

There are other additional questions you might want to ask if you are a woman of size, but more on that in future posts. If anything, women of size need to be even more vigilant in asking questions of potential care providers because size bias is so prevalent in maternity care. But for now, the above questions are a reasonable start to the process.

Sample Answers to These Questions

So what are reasonable answers to the above questions? It really depends on the type of birth you are looking for and how interventive you want your care provider to be.

Some people want a totally natural birth, and some want all the interventions and machines that go PING that technology can give them. Neither approach is right or wrong; it's more a matter of what you prefer and the unique needs of your pregnancy.

However, it's far more difficult to find a provider truly supportive of natural birth than a provider that routinely uses lots of technology and interventions. So the slant of this post is going to lean more in the direction of finding someone supportive of natural birth, but readers should not infer any judgment of their own personal preferences. Again, adapt the questions to your own personal needs and preferences.

1. How do you define "normal birth"? 

To some care providers, "normal" birth means just about anything (including significant amounts of interventions), whereas to others it means an undisturbed, spontaneous labor resulting in a vaginal birth without any interventions. You can get some idea of a care provider's attitude towards birth and interventions by what they think of as "normal" in birth.

2. Can you give me an example how you typically manage a normal birth?

To some care providers, typical management includes inducing labor at 39 or 40 weeks, mandatory IV, epidural by 4 cm dilation, and active management of care (breaking the waters early in labor, aggressive management of contractions with oxytocin, etc.). To other care providers, induction is used only when medically indicated (concern over blood pressure, baby not growing well, etc.), IVs are not mandatory, epidurals are completely up to the mother's choice, and routine interventions in labor are not utilized unless medically indicated.

Again, neither is inherently right or wrong, just different ways of looking at and managing labor. By asking the question of how the care provider typically manages normal birth, they can begin to understand where the caregiver falls on the continuum of intervention.

3. How would you feel if I disagreed with you about a procedure you recommended during labor or birth?

This is an important question because it speaks to the caregiver's respect for patient autonomy and how they prefer to interact with patients. Some care providers never want their dictates questioned. Others give education on the pros and cons of procedures and make strong recommendations based on their training and knowledge, but respect the mother's right to choose for herself.

It's important to also point out that women vary greatly in their desire for informed decision-making. Some prefer to leave all the decision-making up to the care provider and don't want to be "burdened" with having to make those choices. Others want to be very involved in the decision-making. The question is designed to help you figure out which style of care you prefer, and whether that aligns with the care style of the provider you are interviewing.

4. How long will you "allow me" to wait if I go overdue?

There is a great deal of controversy about the safest time for women to go into labor. There is a small but significant risk for stillbirth as gestational age increases, but this risk has to be weighed against the significant risks of inducing labor earlier, which may increase the risk for harm from strong drugs or may increase the risk for cesarean. Current research varies quite a bit on whether a pregnancy should be induced to lower the risk for stillbirth or other poor outcomes. There is no "right" answer here, only an answer that reveals to you what your care provider routinely does.

Many care providers induce labor right at 39 or 40 weeks, some wait till 41 weeks, some wait till 42 weeks, some wait even longer as long as the baby's status is reassuring. Some prefer inducing earlier but will respect the mother's decision to wait if baby looks okay. The point is to know your care provider's preferences on this very important point and to explore how flexible they are about it.

5. What position(s) will you allow me to use when giving birth?

Most hospital births occur with the mother either flat on her back, propped up with her legs in stirrups, or with the mother pulling back on her knees ("supine" or "lithotomy" positions). This is our cultural expectation of birth, and nearly all media images of birth show this position.

In other cultures, however, many other birth positions are used, including kneeling, squatting, side-lying, hands-and-knees, and asymmetrical positions, and these labor positions have distinct advantages. Some providers are very comfortable allowing the mother to labor in positions like these, while other providers restrict the mother to only the typical hospital positions. The question is designed to help you find out how your provider feels about birth positions.

Be careful how you word the question, though. Many care providers tell you that they will "let" you labor in whatever position you want, but fail to reveal that when it comes time to actually push out the baby they want you in the usual positions. Many providers are extremely uncomfortable attending a birth in a position other than supine or lithotomy and will pressure you to change positions, even though there is quite a bit of evidence for the benefit of upright and other positions in birth.

Some women don't care about what position they give birth in or are uncomfortable experimenting with different positions. Others are adamant about having the freedom to move as their bodies dictate, especially as the baby emerges. The important thing is to find a provider that is comfortable with your preferences, so be sure to ask ahead of time about not only labor positions, but also what position they want you in for when the baby is actually coming out.

6. How do you feel about IVs and continuous fetal monitoring?

It is important to establish your provider's preferences about routine interventions like IVs and continuous fetal monitoring.

Some providers are fine with women laboring without an IV. Others mandate an IV for all their patients, while still others strike a middle course and only request that a heplock be placed so that emergency access would be faster if an IV became needed.

Although continuous fetal monitoring has not been shown to improve outcomes in low-risk women, it is still extremely common in nearly all hospitals. However, some providers are more flexible than others about when it starts, whether intermittent monitoring can be used instead, and whether mobile monitoring is allowed.

7. How do you feel about a woman eating and drinking in labor?

Some care providers and hospitals have strict rules about whether a woman is "allowed" to eat food or drink during labor, despite a lack of evidence showing harm from this practice. Many allow only ice chips to be used during labor. It is important to understand your caregiver's policies before labor.

8. What are your thoughts on pain relief in labor?

Women vary greatly in their wishes towards pain relief during labor. Some prefer to go natural, some want an epidural "in the parking lot," some would rather take a wait-and-see-if-it's-needed approach.

Some care providers are very respectful of a woman's wishes about pain management in labor. However, some practically mandate that all their patients receive an epidural, while others can be judgmental about any use of pain medications. Still others know many "tricks" to help women lower their need for pain relief in labor but are supportive of whatever the woman chooses at the time.

Respect for one's wishes regarding pain management during labor plays a strong role in women's satisfaction with their birth experience. It is vitally important to find a care provider who is aligned with your preferences and who will be supportive of your choices.

9. How do you feel about cesareans?

Some providers truly believe that vaginal birth is dangerous and that cesarean birth is to be preferred. Others believe that cesareans are to be avoided at virtually any cost. Most providers fall somewhere in between, but most tend to "lean" one way or the other. Obviously, every caregiver is supportive of cesareans when they are truly life-saving but their attitudes towards other cesareans (and the current cesarean rate in first-world countries) can be revealing about their underlying philosophies of birth and likelihood to use a cesarean.

Beware: Nice Is Not Enough

Don't let a care provider's bedside charm and personality supercede your own commonsense about interventions. A care provider can be really charming, caring, and nice and still have a 50+% c-section rate and a 40+% episiotomy rate, which will do far more harm than good in the long run.

Just because they are "nice" doesn't mean you are going to get care from them that doesn't put you at risk for more complications. 

One midwife told the story of the following doctor on her blog:

What is the definition of a “good doctor”? I once knew a physician whom everyone believed was a “good doctor”. Let’s call him Dr. Wonderful. He had a very high cesarean rate, a high episiotomy rate, a high forceps/vacuum rate, and yet his patients adored him. Why?

He made each woman who came to him feel special. He was handsome and charming, and would treat each woman as if she were the only patient in the world that mattered to him. This is not necessarily a bad thing–I believe each patient should feel special and important to her provider. However, when this perception of being special clouds a woman’s judgment, it is time to have a reality check.

Dr. Wonderful would visit his patient after whatever unnecessary procedure he did, sit by the bedside, take her hand, and very regretfully tell her how sorry he was that she needed ___________ (insert the procedure of your choice), but if he had not done it, ___________ would have happened (insert catastrophe of your choice). So he very reluctantly had heroically intervened to save her life, or the life of her baby. The woman would be trembling with gratitude toward this marvelous physician by the time he left the room. None of his patients could ever believe that any of these procedures were unnecessary.

This bait-and-switch tactic is very common among some care providers. They know how to manipulate patients into going along with what they think is best and/or what is most convenient, even when the actual research doesn't support these interventions as best practice. 

Most women think that if their doctor recommends a procedure to them, it must be necessary, and who are they to question the doctor's judgment? But most don't realize how much interventions vary from caregiver to caregiver. Nor are most given adequate information about the pros and cons of most procedures.

The point is not that all interventions are "bad" or must be avoided, but that the benefits and risks of proposed interventions should be discussed thoroughly and true patient autonomy respected, not manipulated. 

If you are sure you want a hospital birth but you'd like to try and find a provider who is more friendly to natural childbirth and patient autonomy than most, the midwife above summarized one strategy for scoping out the possibilities:

I suggest that women who are planning hospital birth call their local [Labor and Delivery] unit, and ask to speak to a nurse who enjoys helping women who want unmedicated birth. Then ask that nurse for names of doctors [or midwives] that she thinks are most likely to support you in your goals.

Last, and perhaps most important, don’t be fooled by a charming bedside manner. Make sure there is substance behind it.

Amen to that. "Nice" is wonderful, but some care providers use it as a way to convince women into all kinds of risky interventions as a way to lower the risk for being sued or because it's more convenient for him/her. 

In particular, many women of size are just so grateful just to find a doctor who doesn't yell at them about their weight that they fail to ask further questions about the provider's rates of interventions that increase the risk for cesarean (a high induction rate, inducing for suspected big baby, etc.). 

I've been there done that myself and gotten burned, so learn from my mistakes.

Don't fall for "nice" over substance. Nice is a good start, but you still have to ask further questions.

Ask for Specific Intervention Rates

It's really important to ask a provider's intervention rates, especially his/her intervention rates for first-time moms.

What's his/her induction rate, cesarean rate, episiotomy rate? 

Also observe how the provider responds to questions about these things. That's as telling as the actual intervention rate.

For example, "I only do them when necessary" is not a helpful answer; for some docs, interventions like these are seen as "necessary" 60% of the time, and that rate presents far more risk than benefit. 

For example, episiotomy rates should be quite low; if it's not, the provider is not practicing evidence-based medicine, which has clearly shown routine episiotomy to be more harmful than helpful. 

Many doctors say they "only do episiotomies when necessary" --- but if they find it "necessary" 40% of the time, there is something wrong with their definition of "necessary."

Moral of the story: Actual numbers are important for evaluating a provider.

Primary cesarean rates (cesareans in first-time moms or mothers who have never had a cesarean before) is another benchmark by which you can judge providers. Women who have not had cesareans before should not have a very high rate of cesareans during labor; if they do, it suggests that the doctor has a low threshold for surgery or encourages a lot of interventions that lead to more cesareans.

(Of course, if a provider regularly provides care to many high-risk women, the cesarean rate is going to be higher than a provider who mostly sees only low-risk women.....but generally speaking a high cesarean rate is a red flag.) 

It's also helpful to ask how the care provider feels about cesareans. 

If they have a high cesarean rate but are defensive about that, they'll likely say something that minimizes the impact of cesareans and ridicules the mother for caring. 

Watch out for comments like, "The real priority is a healthy baby" or "A healthy baby is more important than the delivery method".....as if that justifies any intervention the doctor uses, as if the mother's outcome is of no importance, and as if the mother questioning things means she doesn't really care about her baby over herself.

Of course the priority is a healthy baby, but a healthy mother is also a priority, and one recovering from unnecessary surgery is not a healthy mother. Nor should a woman be ridiculed for caring about avoiding a cesarean or an episiotomy whenever possible. 

A provider that avoids the question of intervention rates by blaming the mother, brushing off her concern, or making her feel selfish for caring is a giant red flag.

Beware care providers that "don't know" their cesarean rate, or who subtly deride anyone who asks questions about cesarean or episiotomy rates. All providers should have a general idea of their cesarean and episiotomy rates. If they don't, that suggests that they don't think these rates are important or aren't concerned about their use.

Also ask when/why the provider would want to induce labor. If they routinely induce labor if the baby is thought to be  "big," that's another tremendous red flag.  Research shows that inducing early for a "big baby" actually increases the cesarean rate, but despite the evidence, many providers still induce early for a big baby anyway.  [This is one major factor driving the high rate of cesareans in women of size.]

If you interview a provider and they would induce early for a big baby, this is a huge red flag.

Many providers also routinely induce labor at 39, 40 or 41 weeks, and research is mixed on the pros and cons of this practice. 

Particularly for women of size (whose pregnancies tend to last longer), inducing labor early or right around term "just in case" probably leads to more cesarean risk and a whole host of other potential complications. You may want to find a provider who is more willing to wait and not rush things as long as mother and baby are doing well.

Conclusion

You can have the "nicest" doctor or midwife in the world, and he or she can still coax you straight down the path to a cesarean or episiotomy you don't need by engaging in unnecessarily high rates of interventions with dubious benefits.

Being nice is just not enough. You have to ask careful questions when interviewing a care provider, you have to ask for specific intervention rates, and it's very important to watch for the classic red "alarm" flags.

What questions were most helpful to you when you were interviewing providers? What questions do you wish you had asked? What advice do you have for other pregnant women looking for maternity care providers?


*July 2014 Update: These questions were originally shared in a much longer article ("In Search of Dr. Right: 11 Questions to Ask" by The Midwife Next Door) on another website, and I gave credit and linked to that article in my original post in 2010. Sadly, the original link has since been compromised and now goes to an extremely undesirable site, so I have stripped out all those links and am re-posting this article without them. The questions are helpful so I am keeping the post; but it's important to note that it originally arose from another's work.

Supersized Women and Cesareans: A Tale of Two Cities

Although most care providers mean well when caring for high-BMI women, one consistent blind spot has been providers recognizing how the  high level of interventions used with many high-BMI women influence outcome.

In other words, are poor outcomes only due to "obesity" or do some poor outcomes reflect the interventive way that obese women are often managed in pregnancy and birth?

This is a particularly relevant question for the high cesarean rates found in "morbidly obese" women (BMI of 40 or more).  If a high-BMI woman is perceived as ultra high-risk, and is therefore subjected to increased rates of interventions (like inductions, early epidurals, and a lower threshold for surgery), does the resulting high cesarean rate really reflect problems with obesity itself, or with the way obese women are managed?

Here are two studies of cesarean rates in women of size that demonstrate that iatrogenic (provider-caused) influences can have a very strong effect on cesarean rates, and that a high cesarean rate in morbidly obese women is NOT just about the obesity itself.

These two studies examined cesarean rates in "super obese" women (BMI of 50 or more), one from Kentucky and one from the U.K.  The Kentucky study found a super-high c-section rate, and the U.K. study did not.

Yet the two studies basically were looking at very similar study groups, women with a BMI of 50 or more. If cesarean rates really are tightly tied to obesity and obesity alone, shouldn't the cesarean rates in these two studies be similar?

In the Kentucky study, women with a BMI over 50 had a whopping 56% cesarean rate. Compare that with the British study that found a 30% cesarean rate in women with a BMI over 50.

The Kentucky cesarean rate was nearly DOUBLE the rate of the British group, even though the size of the women was similar. 

This strongly suggests that management of labor around the pregnancies of supersized women differed and highly influenced the resulting cesarean rate, and that it's NOT just about a woman's size, but also her care provider's management.

We can't tell for sure from these particular studies why the cesarean rates in women of size in these two places are so different, but it's a good bet that it's NOT because the uteri of British women are that much more efficient than those of Kentucky women. No, the contrast in rates is much more likely to be due to differences in care, attitudes, and interventions.

A couple of strong possibilities spring to mind.

First, midwives are the most prevalent form of care provider for most women in the U.K., whereas most women in the USA get their care from OBs.  Research shows that on the whole, midwives tend to have lower cesarean rates, even when the risk profiles of patients are similar.  So perhaps the cesarean rate is lower because more of the "super obese" women in the U.K. had access to midwifery care.  If so, this is yet another reason to be alarmed about the move towards restricting fat women's access to lower-tech birthing alternatives and midwifery care.

Second, we don't know that much about the types of intervention, induction rates, and threshold for surgical intervention in each study.  My guess is that the Kentucky study had very high induction rates (which tends to lead to higher cesarean rates), a higher rate of interventions, and a lower threshold for doing a cesarean in labor.

I would love to see more research that focuses on why there can be such different outcomes in "morbidly obese" women.  We need to really shine a spotlight on differing management protocols and how they impact cesarean rates ─ and particularly so in women of size.

Interestingly, the Kentucky study notes that pitocin augmentation in labor led to lower cesarean rates in these women, although this difference did not rise to statistical significance.  They speculated, therefore, that "a qualitative or quantitative deficiency in the hormonal regulation of labor exists in the morbidly obese parturient."

This is a theory that is often bandied about in obstetric research (without any supporting proof, but often accepted as gospel anyhow). Yet if this were true, why were 70% of British women able to birth vaginally? It's far too easy and convenient to blame fat women's hormones instead of looking more closely at your own management practices instead.

It's time for doctors to stop scapegoating obesity alone for high cesarean rates in women of size, and long past time for them to start examining more closely how their own biases and high-intervention protocols negatively influence outcomes in this group.

This is not an emotionally comfortable thing to study, because care providers are human and no one wants to acknowledge that their own biases and management can affect outcome so strongly.  I understand that.

But if care providers are truly interested in improving outcomes in "obese" women, then this is the kind of work that MUST be done.  

The contrast between these studies shows that most very fat women CAN give birth vaginally....if caregivers would just stand aside and let them. It's time to take off the blinders and see how management protocols can  influence that.



References

Am J Perinatol.  2011 Jun 9. [Epub ahead of print] Extreme Morbid Obesity and Labor Outcome in Nulliparous Women at Term.  Garabedian MJ, Williams CM, Pearce CF, Lain KY, Hansen WF.  PMID: 21660900

Source: Department of Obstetrics and Gynecology, University of Kentucky, Lexington, Kentucky.

We examined the prevalence of cesarean delivery (CD) among women with morbid obesity and extreme morbid obesity. Using Kentucky birth certificate data, a cross-sectional analysis of nulliparous singleton gestations at term was performed. We examined the prevalence of CD by body mass index (BMI; in kg/m (2)) using the National Institutes of Health/World Health Organization schema and a modified schema that separates extreme morbid obesity (BMI ≥50) from morbid obesity (BMI ≥40 to less than 50). Bivariate and multivariate analyses were performed. Multivariate modeling controlled for maternal age, estimated gestational age, birth weight, diabetes, and hypertensive disorders. Overall, 83,278 deliveries were analyzed.

CD was most common among women with a prepregnancy BMI ≥50 (56.1%, 95% confidence interval 50.9 to 61.4%). Extreme morbid obesity was most strongly associated with CD (adjusted odds ratio 4.99, 95% confidence interval 4.00 to 6.22).

Labor augmentation decreased the likelihood of CD among women with extreme morbid obesity, but this failed to reach statistical significance. We speculate a qualitative or quantitative deficiency in the hormonal regulation of labor exists in the morbidly obese parturient. More research is needed to better understand the influence of morbid obesity on labor.

BJOG. 2011 Mar;118(4):480-7. Planned vaginal delivery or planned caesarean delivery in women with extreme obesity. Homer CS, Kurinczuk JJ, Spark P, Brocklehurst P, Knight M.  PMID: 21244616

Source: National Perinatal Epidemiology Unit, University of Oxford, UK.

OBJECTIVE: To compare the outcomes of planned vaginal versus planned caesarean delivery in a cohort of extremely obese women (body mass index ≥ 50 kg/m(2)). 

DESIGN: A national cohort study using the UK Obstetric Surveillance System (UKOSS). 

SETTING: All hospitals with consultant-led maternity units in the UK. 

POPULATION: Five hundred and ninety-one extremely obese women delivering in the UK between September 2007 and August 2008. 

METHODS: Prospective cohort identification through UKOSS routine monthly mailings. 

MAIN OUTCOME MEASURES: Anaesthetic, postnatal and neonatal complication rates. 

RESULTS: After adjustment, there were no significant differences in anaesthetic, postnatal or neonatal complications between women with planned vaginal delivery and planned caesarean delivery, with the exception of shoulder dystocia (3% versus 0%, P = 0.019). There were no significant differences in any outcomes in the subgroup of women who had no identified medical or antenatal complications. 

CONCLUSIONS: This study does not provide evidence to support a routine policy of caesarean delivery for extremely obese women on the basis of concern about higher rates of delivery complications, but does support a policy of individualised decision-making on the mode of delivery based on a thorough assessment of potential risk factors for poor delivery outcomes.

Open Thread: What Do You Want To Tell Caregivers?

I'm speaking next week to a group of midwives (and possibly some doctors) about caring for women of size.

I'll be presenting lots of facts and figures and discussing research studies, but I'm also there to represent the voice of consumers, specifically of women of size.

So what in particular do you think is most important for these caregivers to know about caring for women of size?  How do you want to be treated? How do you not want to be treated?

How should caregivers responsibly discuss risk with women of size?  How can they improve outcomes in women of size? What do you most wish you could say to your own caregivers about the care you received during your pregnancies (or if you were to have one)?  About your gynecological care?  What constitutes good care in women of size?

This is an open thread; please feel free to add your comments.  However, remember that caregivers will be reading this thread in the future and we want to promote constructive dialogue about improving care in women of size.  Please keep comments constructive and helpful, even as you make the points you feel need to be made.

I hope this will generate some interesting dialogue and give some thought-provoking feedback to caregivers.

*P.S. Logistical note: For those who asked.....by no means am I done with the PCOS series.  It just went on hiatus for a bit while I worked on some major deadlines on other projects.  It will be a periodic series. Stay tuned!

Waterbirth Video of Plus-Sized Mom

A (plus-sized) reader of my blog sent me the link to the video of her recent waterbirth.  This seems like the perfect complement to last week's post about a new waterbirth study, plus it's a lovely, cheery story for Christmas week. 

Not only is this awesome because it's waterbirth─ the coolest thing ever! ─ but it's waterbirth in a woman of size, something some care providers and some facilities do not "permit."  (Actually, women of size are the perfect candidates for waterbirth, since it can help us be more mobile in labor and pushing.)

But this mom didn't let rules against waterbirth in women of size stop her ─ she found a place and a provider that was amenable to waterbirth for her, regardless of size. 

This was her fifth child.  She had had vaginal births with all her prior children in the hospital, but with some significant interventions (forceps, big episiotomy, a near c-section with the fourth one because she wasn't progressing fast enough for them...even after 3 prior vaginal births!).  She was determined to change things for the next baby. 

She had a boy, 9 lbs. 12 ozs., 22.5 inches long, a size many doctors would freak out over (and some would mandate a c-section for) ─ but she had him naturally and easily with the mobility that the water offered. 

Here are her words about her story (slightly edited):

I avoided seeking out a midwife for my previous births because of size issues, but I went for it and called tons of midwives, wearing my heart on my sleeve as I brought up the issue of weight. I found a wonderful midwife, had a healthy pregnancy and had my baby at home in the water.

I am still on cloud nine. It was one of the most amazing accomplishments of my life. 

I want to help as many moms as possible develop the courage for the birth they want. Waterbirth, long sigh, was so wonderful. Compared to straps around my tummy that didn't fit, cutting into my skin (literally) at the hospital on a bed I could barely move in....

I want to help any mom of any size to achieve the birth she wants - I didn't have that courage for my other births and its a big regret. This was my fifth birth and first home/waterbirth.

My first son was a hospital birth with a very 'old school' obstetrician. I was induced. He only saw me in labor to break my water and he barely darkened the doorway when I started pushing. He mostly waited in the hallway. The nurse finally called him over because she felt my pushes were inadequate - he almost immediately said we needed forceps. My son was born via forceps with a very intense episiotomy.

The next three births followed, with some changes - new doctors, new hospitals, more interventions that I felt weren't needed. My fourth birth they 'threatened' a c-section because I was not progressing to their liking. I didn't get said c-section but I was left very frightened by the threats. I told my husband before I was even home that if we were blessed with another baby I was not going to any hospital. 

I had to face my fears of finding a midwife who would accept me even though I am a plus size mom. I called many midwives before I even knew if I wanted to get pregnant again. I felt so strongly about a homebirth that if it was not an option, it would have affected my choice to even get pregnant again. I found a wonderful Midwife...and I achieved the birth I knew I wanted. My homebirth healed many disappointments from the past. And I was so much more comfortable than I was with any pain-relieving techniques offered at the hospital.

Even though my body may not be [what] want many women would want, I LOVE my body. It brings me so much joy. With my body I shared love with my husband, grew a healthy baby and birthed him naturally in the safety of my home. That is indescribable joy.

Here is the video of her birth:



*Reposted with permission from http://rubyslippersx3.blogspot.com/

Words of Sense in the Boston Globe: Now Apply Them to Women of Size

Check out this great new op-ed opinion in The Boston Globe from Judy Norsigian (of Our Bodies, Ourselves) and Dr. Timothy R. B. Johnson (Bates professor and chair of the Department of Obstetrics and Gynecology at the University of Michigan).

In the op-ed, the authors discuss the high costs of cesareans, both financial and medical, and the non-medical factors that lead to more cesareans. 

Even though caesareans are associated with higher rates of complications than vaginal births, they are becomingly increasingly common. Problems range from infections, including the more serious antibiotic-resistant ones, to blood clots, prematurity, respiratory problems for the baby, and more complications with subsequent pregnancies. There is even a small but measurably higher risk of death for the mother...

There are also cost consequences for taxpayers — the caesarean rate for Massachusetts mothers on Medicaid is increasing at a faster pace than among privately insured mothers. Nationally, in 2008, average hospital charges for an uncomplicated caesarean section were $14,894, while such charges for an uncomplicated vaginal birth were $8,919.

In the media, most of the blame for the increasing cesarean rate has been placed on the mothers, rather than on doctor practices and medico-legal concerns.  Mothers are blamed for being too old, too fat, too high-risk......supposedly that's why the cesarean rate is rising.  But the article quickly skewers this reasoning:

Between 2000 and 2006, while the Massachusetts caesarean rate climbed from 16th to 10th highest among all states, the state’s ranking on neonatal mortality has slipped from 4th best to a tie for 9th. Six hospitals in the state have caesarean rates greater than 40 percent for first time mothers, yet none of these hospitals is designated as a high-risk center. So much for the argument that high-risk pregnancies are the reason for these rates.

Now, I would like to have seen more from the authors addressing (and questioning) the issue of obesity "causing" high cesarean rates, but I love how succinctly they suggest commonsense options for improvements in the overall cesarean rate (emphasis mine).

What can we do to lower the caesarean rate? Considerable media attention has focused on how extreme obesity can raise the risk of having a caesarean, but more emphasis is needed on these system-based approaches:

• More hospitals need to institute policies that restrict the induction of labor, unless there is a good medical reason...
• Obstetricians and hospitals should follow the new National Institute of Health recommendations to offer the option of vaginal birth after a caesarean for those women who want to avoid repeat surgery...
• Hospitals could expand access to nurse-midwifery care. In Boston, statistics for hospitals that care for women facing the same risk of complications show that hospitals with nurse-midwifery services tend to have lower caesarean rates than those without a significant midwifery presence.

These suggestions are so common-sense that they have a big "DUH" factor.....yet they are not routinely used in many hospitals. 

The induction rate today is completely out of control....and it's not all "inductions of convenience" just because the mother is tired of being pregnant, as some doctors claim.  For the most part, doctors are behind the epidemic of inductions these days, for reasons of fear, of convenience, and because they are in denial about the very real risks of induction.  WE MUST STOP INDUCING LABOR SO OFTEN.

Denying women the right to VBAC is a violation of human rights, pure and simple.  No one should be forced into surgery they don't want or need.  Everyone, including pregnant women, has the the right to bodily autonomy and the right to informed consent/refusal.  Even ACOG's own position paper says that women have the right to make their own decisions on their medical care.  This should include the right to choose a VBAC and/or refuse a planned repeat cesarean:

Once a patient has been informed of the material risks and benefits involved with a treatment, test or procedure, that patient has the right to exercise full autonomy in deciding whether to undergo the treatment, test or procedure or whether to make a choice among a variety of treatments, tests, or procedures.  In the exercise of that autonomy, the informed patient also has the right to refuse to undergo any of these treatments, tests, or procedures...Performing an operative procedure on a patient without the patient's permission can constitute "battery" under common law.  In most circumstances this is a criminal act...Such a refusal [of consent] may be based on religious beliefs, personal preference, or comfort.  --ACOG Committee Opinion #237, June 2000

Finally, access to midwifery care should be the right of every woman, but more and more hospitals, doctors, and insurance companies are closing down midwifery-friendly hospitals, phasing out nurse-midwifery practices, and trying to restrict/outlaw out-of-hospital midwifery.  Midwifery is a more economical choice and has equivalent or better outcomes for most women and babies....yet it is not available to many women, and some authorities are trying to actively cut off access for still more women.  This makes NO financial or ethical sense!

In particular, I would like to see the above systematic suggestions applied to women of size.  Women of size are routinely induced at extremely high rates, and are increasingly being denied access to VBACs and to midwifery care.  Let's see if restricting inductions, allowing (and encouraging!) VBACs, and expanding access to low-intervention midwifery care might lower the rate of cesareans in "obese" (and "extremely obese") women as well. 

If these suggestions work as systematic solutions for lowering the cesarean rate in all women, they should help lower the cesaran rate in women of size too.  Funny how folks have blinders on in applying these suggestions to "obese" women, though, eh?

Choosing a Birth Care Provider - Which Type?

Some online friends of mine wrote this article for their local paper.  I gave feedback and helped during the editing process, and liked the final product so much I thought I'd share it here on my blog.  I offer it for those of you who are scratching your heads over figuring out how midwives and doctors differ. 

Again, I emphasize that no one type of provider is suitable for all women.  Some women prefer high-tech care with lots of tests and/or an epidural in the parking lot.  Some women prefer low-tech care, with minimal or no tests and birth as natural as possible.  Others want something in between.  There's nothing wrong with any of these types of births as long as you are clear on what you want and why.

Some women prefer that their doctors do all the decision-making, while other women prefer to be partners in their decision-making.  Some women prefer to birth in the hospital, and some prefer to birth outside the hospital (at a birth center or at home).

There no one "right" way to give birth for everyone. But if they explore their feelings, most people find they have ideals about how they want to be treated in pregnancy and birth, how they picture birthing their babies, and what kind of care they are looking for.  When I teach childbirth classes, I always encourage parents to explore the spectrum of possibilities and consider what fits best with their ideals.  In time, they usually find the right path (and provider) for them.

It's important to remember that the care provider's job title does not necessarily mean they practice in that same care model.  In other words, some doctors actually follow the hands-off tenets of the midwifery (physiological) model of care, while some midwives are high-tech and interventive like the medical (technological) model of care.  Although job titles and degree letters give you generalized clue to their practice style and philosophy, it's not a guarantee of anything.  You always have to ask questions.

Readers of the blog know that I tend to favor midwifery (as does the following article; fair warning) and have usually had my best experiences with midwives, but one of the worst experiences I ever had was with a homebirth midwife who was actually a high-intervention OB in sheep's clothing...at home, no less.  I also have met OBs who are very hands-off and low-tech.You can't tell someone's philosophy solely from their job title; interview carefully to see what their real pattern of practice is like.

I usually suggest that prospective parents interview several types of care providers, including some OBs, some CNMs, and some homebirth midwives.  Reflecting on these interviews usually helps clarify their choices for them.  Most people come away with a clearer idea of the type of care (and care provider) they prefer.

Here then is the article.  I hope you find it helpful.


Choosing a birth provider can be difficult

By Christa Billings and Amy Poe
From the Portland Tribune, Mar 25, 2010
http://www.portlandtribune.com/opinion/story.php?story_id=126946379588406800
Regarding Peter Korn’s article “Natural birth? Nope, C-Section rates on rise” (Feb. 18), one of the most important decisions new parents are faced with is choosing a birth provider. It is also one of the most difficult and confusing decisions to make.

The truth is that there is no one perfect location or type of provider for all women. We all come to our births with our own experiences, beliefs, personal health and genetics, and each mother has to come to know her own needs in order to choose the most optimal provider and setting for her birth.

There are two basic models of maternity care: the physiological (midwifery) model and the technological model (obstetrics). Each has its own advantages.

The physiological/midwifery model recognizes birth as a natural event. Care is centered on the woman and baby as a pair, and each pair is recognized to have its own set of experiences and unique health considerations. In this model, the birth providers spend a considerable amount of time with the parents, getting to know their physical and emotional needs and providing them with important information on their pregnancy and birth choices.

While the midwifery model emphasizes the partnership between the mother and provider in the birth process, the technological model views the birth provider as the expert whose job it is to control and manage the pregnancy, labor and birth. Normal birth is narrowly defined, and the provider is trained to treat any deviation from normal as a pathology needing intervention. The provider relies heavily on testing, monitoring and technological intervention in assessing and controlling the situation.

Statistically, both models of care can and do result in healthy babies most of the time. The primary differences between the two models are the type of care the mother receives during the pregnancy and her role in the actual birth – whether she is the active decision-maker (in partnership with her provider), or whether she delegates the control of her labor to an expert.

Naturally, it is always important to check the credentials and references of any provider you are considering, be it a direct-entry midwife, certified nurse-midwife, naturopath, family practice doctor, or obstetrician. But it is just as important to understand which model of care the provider practices, and whether that is compatible with your own beliefs about birth.

It’s important to realize that the provider’s title does not guarantee which model of care they practice. Midwives can order the same labs and screening tests as doctors, and some are very technology-oriented. Conversely, an OB-GYN may firmly believe in the normalcy and diversity of birth, and have a low technological intervention rate.

Midwifery care is a natural, holistic and wellness-oriented view of pregnancy and birth. Midwifery care focuses on the pregnancy as normal and healthy, rather than pathological. Most midwives believe in a proactive approach to wellness. They try to prevent complications in the first place by emphasizing healthy behaviors. If complications do arise, they take steps to work with you and your baby to deal with them instead of treating a complication like a disaster waiting to happen.

Time and patience can be one of the biggest benefits of midwifery care. Many doctors have strict time limits for labor, after which a cesarean is performed. Midwives believe that if the mom and baby are not in distress and all vital signs are reassuring, there is no need to hurry a birth. Every woman’s body and birth are different, and not all strictly adhere to a “typical” labor curve. Many babies come out naturally if given a bit more time and patience.

Many women have heard of midwives but are unaware of research showing improved outcomes with midwives. Examples include the interspecialty differences in the obstetric care of low-risk women, on the Web at www.ncbi.nlm.nih.gov/pubmed/9096532, and the outcomes of planned hospital birth attended by midwives compared with physicians in British Columbia, on the Web at www.cmaj.ca/cgi/content/full/181/6-7/377.

Midwives are experts in normal birth, and most births proceed normally, with good outcomes, if allowed a little time and patience. However, sometimes more intervention is needed, and midwives are trained to recognize when intervention or technology is needed. At that time, they have obstetric colleagues to whom they refer their clients, while still following up to assure continuity of care. It is at those times that we can be grateful for the surgical skills and capabilities of our obstetricians and hospitals.

Not only does midwifery care lead to fewer infections, inductions, episiotomies, vacuum/forceps extractions and cesarean sections, but midwives also tend to the emotional, spiritual, and health and nutritional needs of the mother from the start of the pregnancy through labor and birth and for several weeks after the baby is born.

Choosing your type of birth provider is a critical choice in your care. Oftentimes, parents spend more time researching and picking out nursery décor than they do choosing a provider who meets all their needs. For some women, an OBGYN is the right type of provider and for others it is a midwife. Taking the time to do your research on choosing the right provider for you can have an effect on the outcome of your birth.

Christa Billings of Beaverton, and Amy Poe of http://www.birthmatters.info/

Midwives Do Gyn Care Too

Let's talk today about gynecological care. Specifically, who do YOU see for GYN care?

The reason this is on my mind is because I recently stumbled across Kate Harding's original post on "Why Don't Fat Women Get Checked for Cancer of the Nasty Bits?" I don't know how I missed the original post but I did.

If you haven't read it yet, it's a post well worth reading, especially if you are a healthcare provider or are not a woman of size yourself.

It can help you gain some insight into the negative contacts women of size have had with the medical profession and why we can be so reluctant to go to the doctor. It may also shed light on why we don't get screened as often for cancer, or why our cancer may be more advanced by the time it is discovered.

Definitely a post worth reading.

However, as I read the comments on the post, I thought it was telling how not ONE person talked about using a midwife for GYN care instead of an OB.

Midwives Do Well-Woman Care Too

Newsflash: Midwives don't just catch babies. They do well-woman and GYN care too.

And chances are you'll get better treatment with them.

Although not universally perfect on fat-acceptance issues by any means, most midwives are far more size-friendly than most OBs. And even if they don't perfectly "get" size acceptance issues and HAES, most midwives will take far more time and care with you than most doctors will, and most midwives listen to your perspective and work with you on healthcare issues more than doctors will.

Why is an OB the automatic go-to when women think about getting well-woman care? Do people not know that midwives are perfectly competent at doing regular well-woman and GYN care? Why don't more women automatically go to a midwife for such care?

Most Certified Nurse-Midwives (CNMs) are covered by insurance, are well-trained and experienced in doing well-woman and GYN care, and work in a practice with OBs so that if something comes up that needs to be seen by a specialist, they can refer you to a person within their own practice group.

Most homebirth midwives (who can have various letters after their names, but who are most often Certified Professional Midwives/CPMs and/or Licensed Midwives/LMs in the USA) do GYN care as well. Some are covered by insurance, some are not.

The advantage of CPMs/LMs is that they are likely to be able to take even more time and care with you than OBs and CNMs, because their time is not so tightly controlled by insurance guidelines. Some are also trained in certain birth control methods (like cervical cap) that most doctors (and even many CNMs) are not.

The disadvantage of CPMs/LMs is that you may have to pay out of pocket (or at least out of network) for your care. Some women feel the extra time and support is well worth the extra money. Financially, I wish it were a realistic choice for all women....but if you can't do the out-of-pocket or out-of-network thing for a CPM/LM, you can usually get coverage for a nurse-midwife.

For years, I got all my pap smears and breast exams etc. from an OB-GYN office. I just thought that's where you went. I tried to get a female doctor (or a female nurse-practitioner) for these exams, but I went through an OB-GYN most of the time.

I did not realize until after I'd had kids that I could use a midwife for my well-woman care. Doh!

Now I go see either the nurse-practitioner at my family doctor's practice, or I go see the CNMs associated with my local hospital. I'd really prefer to use a CPM, frankly (and I do on occasion), but generally speaking I don't because of insurance coverage. (Sad, because the best care I ever got was from a CPM.)

I find I get MUCH more woman-friendly care by seeing midwives, and much more size-friendly care too.

That's not to say that all midwives are automatically size-friendly (clearly some are not, and I have heard a few bad stories), and of course, not all OBs are fat-phobic. There are good doctors out there too, so let's not knock them all. The good ones deserve our business too.

But generally speaking, you are more likely to find woman-friendly care and size-friendly care from a midwife than you are from an OB.

The Take-Away Message?

Challenge the dominant paradigm that means GYN care = a visit to an OB. Consider going to a midwife instead.

They're not just for catching babies!