Getting Started with Canning

World War I Canning Poster,
Image from Wikimedia Commons

We are talking about gardening and canning the goodness from our gardens (or the farmer's market).  Today we address reasons why some people are reluctant to start learning about canning, and how they can get started if they decide to try it.

Canning Safety

A few years ago, I was scared to death to try canning, just like many other people are. I was afraid I might inadvertently kill my family.  But canning's gotten a bad rap over the years, and the science behind canning safety has come a long way.  If you follow the directions, you are unlikely to make your family ill.  The key is to know a few basic principles and to follow recipes carefully, especially in a few key foods.

Safety-wise, what I didn't know then was that high-acid foods, like the jams and jellies most people start with, aren't really that dangerous.  You're not going to get botulism from jams of high-acid fruits.  You might get yeast or mold, but you'll see any spoilage, unlike with botulism, which is odorless and colorless.

So with jams, you'll know if your canned food has gone bad and that you should throw it out. (Throw it all out, because mold extends down into foods beyond what you can see, and can produce mycotoxins which might make you sick).

Botulism, the real thing to worry about, mostly occurs with tomatoes or low-acid products like canned vegetables and meat.  The problem is that if your salsa, canned asparagus, or canned beef has gotten botulism, you might not know it and botulism is dangerous stuff.  Although it's not common, some cases of botulism do occur each year and can be life-threatening.

Jams and preserves are much safer, and that's why they are best for beginners to start with. They are much more forgiving of errors, and spoilage (if any even occurs) will be obvious.

Make no mistake; the other foods can be done safely too, but you need to learn how to do it right (and what prevents botulism). If you want to do tomatoes and/or low-acid foods, get yourself a pressure canner, take a class so you know how to do it safely, and follow tested recipes exactly.

Canning Resources

The other reason people avoid canning is because they think it's really hard. I promise you, canning is not that hard.  It just takes a little practice.

I do suggest canning classes if you can manage it, even just for jams. It's really great to learn the science behind canning so you know proper safety practices, so you practice canning skills in a group where you can learn from each other, and so you have an expert to answer common questions. It's also a great way to find new and unusual recipes.

I first learned how to can from a friend of the family, but she follows old outdated practices (no boiling water bath). Many of the jars of jam we processed went moldy.  While this wouldn't have killed us, it was an awful waste of food.  So I recommend taking a class from trained teachers rather than learning it from a friend or family member, unless you know that person has been properly trained first.

Google your state's name and "extension classes" and many states will have a selection of various canning classes available through the agriculture department of your state university.  They are often offered as "outreach" classes in various communities around the state, so you may not have to travel too far.  Many larger cities also now offer canning classes through local cooking schools, gardening societies, urban homesteading organizations, and other groups.  So there are lots of choices available.  And many extension services have a "preserving" hotline in the summer that you can call if you have questions.

I learned how to can from books (after the disaster with my friend). This summer I took extension classes with my daughter to make sure she knows how to can before she graduates high school, and to brush up on my own skills. The classes were great because I learned some things I didn't know. It was very much worth the time and effort and they really didn't take a lot of time.

Being a geek, I especially liked the dollops of science in the class explaining why things worked and why the safety rules were there. I also really liked the hands-on portion of the classes where we put the lessons to work (especially because they did the prep and the clean-up!). And we got to take home several jars of our homemade jelly/jam, pie filling, and salsa. YUM.

However, if there are no classes in your area or you want to get started on your own, the best place to start is Ball's home preserving books. Ball's Blue Book Guide to Preserving is the classic of the field.  All the recipes are carefully tested and there are instructions on how to can.  I also really like Ball's Complete Book of Home Preserving.  Everyone who cans should own these books as references.

If you are the type of person who learns best by watching instead of reading, you can also find many videos on YouTube etc., demonstrating how to do all this.  Some of the best are from the Ball website, http://freshpreserving.com/getting-started.aspx. 

Personally, my favorite canning book is "Put 'Em Up" by Sherri Brooks Vinton. There are lots of good canning books out there to choose from, but hers has some of the clearest directions and illustrations of the basic canning process I've found, and she has her recipes organized by type of fruit, which makes it easier to use than most books. She also has info on pickling, freezing, and drying, so it's useful on several fronts.

Another good book (and website) is foodinjars.com.  If you don't have many people in your house, she has recipes that are suitable for small-batch canning.  And her website has tons of ideas and info.  I especially like her "it's okay to make mistakes" philosophy.

Generally speaking, you do want to use recipes that have been tested. Again, jams are more forgiving than low-acid foods so there's more room for creativity, but for tomato and low-acid foods you want to be sure to use recipes that have been thoroughly tested for safety, and to follow those recipes exactly.

The best resource for thoroughly tested recipes is Ball's website, freshpreserving.com.  LOTS of good recipes there. Or there's Georgia's National Center for Home Food Preservation, http://nchfp.uga.edu/.  They have a good book, "So Easy to Preserve," available by mail order, plus lots of online resources too.

Summary

Canning is actually a lot easier than it looks at first.  Take it from someone who was scared to death to try it not all that long ago!

Starting with high-acid fruits is the way to go.  It's easy, forgiving, and you won't kill your family. And the fresh taste of summer in the middle of winter will motivate you to come back to do more each year!

If time is an issue for you like it is for many of us, remember that you don't have to preserve everything in sight.  It's not all-or-nothing. Start with something small, like an easy canned jam. You don't need to be canning all summer long unless you want to. Just do what you have time for. It still counts, even if you don't have the giant shelves of canned goods that some people do. It's okay to start slow and easy, and it's okay to just do what you have time for.

If money is an issue, look on Craigslist or Goodwill for used canning equipment. Or go look in the stores right now; lots of canning equipment is on clearance right now because they want to make room for fall stuff.  You can get some great deals that way. But really, you don't need a special pot for canning; just one big enough to handle covering the jars with an inch or two to spare.  An old stock pot is just as good.  Do get the special jar-lifting tongs, the canning rack, the lid-lifter, a good funnel, and such; that will make your life easier.  But that's all you really need if you already own a good stock pot. (Or if you are doing small-batch canning in small jars, you may not even need a stock pot.)

If you still feel uneasy about canning, try making freezer jam instead. (That's what I did.) The Sure-Jell Strawberry Freezer Jam (low-sugar, pink box) is to die for!  Or you can make regular jams and then just freeze them instead of canning.  The trick is to just get your foot in the door.  Eventually you'll get up enough guts to try full-blown canning.

Again, remember that if you want to can vegetables or meats, they have to be done in a pressure canner because they are low-acid foods. (We missed that class this year, so that's a project for next year.) Tomatoes can be done in boiling water bath canners, but only by adding extra acidity with lemon juice or vinegar, and with careful attention to the proportion of acid to non-acid ingredients. In my opinion, tomatoes and low-acid canning are two types of canning where a class is definitely a must.

But for jams, jellies, and preserves, canning is actually pretty easy.  It's mostly a matter of being organized, having the right equipment, getting good fruit, having a reliable resource for questions, and having some good recipes.  Then just take the plunge!  You'll be glad you did.

*What did you can this summer, or what are you hoping to can?  If I have time in the next few weeks, I think I might try Ginger Peach Jam, plus my old stand-bys of applesauce and plum chutney.  That's probably all I'll have time for, besides the Roasted Goodness Spaghetti Sauce (for the freezer) I'm famous for.  How about you?

Garden and Canning Update

Vintage Canning Poster

Let's talk a little about gardening and canning now that we are reaching the height of canning season.

My garden is reaching its peak soon and I am awash with food to preserve. Most we just eat fresh, but some we preserve for later in the year. Yum!

I've already done some berries (strawberry freezer jam, raspberry jelly, and blueberry-lime jam), and cherries (Drunken Cherries, and cherry-amaretto jam), all from my yard.  I froze any blueberries and cherries I didn't get around to canning. Then I took a break.

Now peaches have arrived (from a local farmer, though I hope to plant a peach tree this fall), and my plums are juuuuust about ripe. My daughter and I made some peach/blueberry pie filling, and my husband is making noises about peach butter or ginger-peach preserves. Then, plum chutney!

And since the tomatoes are coming in, I'll be doing my special Roasted Goodness Spaghetti Sauce (frozen, not canned, because it's too hard to get the right amount of acidity for safe canning with all the roasted veggies I put in). That's one of our family's favorites.

I also have frozen a lot of pre-chopped carrots and onions for ease of use in stews and soups later in the year.  We grew a ton of carrots this year.  Some are destined for spaghetti sauce, but many are being blanched and frozen for other stuff this winter.

Have my first eggplant this year; we'll see how that is. We're eating a ton of green beans right now; I may have to freeze some for later. And we harvested a ton of garlic this year! We'll be vampire-free for some time to come, I think.

Our apples are almost ripe, so applesauce season is just around the corner. I have my first Gravensteins this year, so I'm excited about that. Our other apple trees are just starting to bear as well, so I sense a big applesauce season this year!  I love homemade applesauce.

However, I'm most excited over getting my first couple of pluots this year! Pluots are a cross between plums and apricots. Apricots don't grow well in my area, so I grow these instead. They are about 75% plum, but with some of the texture and feel of an apricot. Some people feel that pluots are better than plums for fresh eating. With the right type, I would agree!

I planted some pluot trees several years ago, but never got any before now.  I have several different types for cross-pollination purposes, but the one that fruited first was Dandy-Dapple pluot. WOW, how delicious!  A nice cross between sweet and tart. There are recipes for pluot jam out there, but I don't think many will make it to the jam jar next year.  Too good for fresh eating right off the tree!

Anyhow, enough about my garden.  Let's talk about canning a bit, because it can help preserve all this wonderful goodness for later in the year when very little is fresh, and because it's a good way to put aside food for emergencies or leaner times.  Yet many people are surprisingly reluctant to take up canning.  Why is that?

So in the next week or two, let's talk a little bit about canning and freezing.  It's another way for people of all sizes to pursue "slow food" and Health At Every Size.  And it just tastes good!

*What have you been growing and/or canning this year?

Lowering the Risk for Surgical Site Infections in Fat Folk

Image from Chopra 2010 study, link below

We've discussed prevention of surgical site infections before, often in the context of cesareans, but most recently in the context of Emergency Room visits.

Regardless of type of operation, however, accumulating evidence suggests that antibiotic regimens for "obese" people need to be adjusted.

We in the Size Acceptance Movement have been saying for years that people of size often benefit from larger or weight-based dosing for certain types of antibiotics, longer courses of antibiotics in some cases, and IV antibiotics instead of oral antibiotics for serious infections.

This was based on the anecdotal experiences of many people of size over the years, and as such, was summarily dismissed by many in the medical community.

Here is research that confirms the importance of longer courses of antibiotics and weight-based dosing, and which also suggests that more frequent dosing, administration of antibiotics by IV, and perhaps topical infusion of antibiotics into the wound  itself before closing (instead of just systemically in the IV) seem to improve outcomes.

Of course, different types of antibiotics work differently in the system. This means that some types of antibiotics need different dosing for obese people and some don't.  That's important to remember ─ the need for weight-based dosing is not universal for all drugs.  And to be fair to doctors, research has been slow to differentiate these and to provide easy-to-use guidance to doctors in their prescriptions.

Yet there is some research that addresses this issue now, but as we saw recently in the Emergency Room study, getting doctors to follow this research is difficult. In that study, simple guidelines for dosing for high-BMI patients in the E.R. were readily available, but even so, less than 5% of morbidly obese patients received the proper initial dosage of common antibiotics. And that was at a medical center that specialized in treating obese patients!

Furthermore, another study has shown that hospital pharmacists often do not catch/correct underdosing errors in high-BMI patients.  In that study, less than 1/3 of obese patients received an adequate initial dose of vancomycin, only 1% received the optimum recommended dose, and only about 3% of these underdosing cases were caught and corrected by hospital pharmacists.

Far too often, people of size are still being treated with standard antibiotic dosages instead of dosages tailored to their weight, or antibiotics given too infrequently, orally, or for an insufficient length of time.

When will doctors listen to people of size and learn from our experiences?  Heck, when will they learn from their own research?

What is the barrier to adopting these new regimens?  Why aren't they being utilized far more often?  Why aren't hospital pharmacists or medical supervisors catching more inadequate dosing and raising red flags about it?

It's frustrating that this topic is only now being researched and that many hospitals ─ even those that specialize in treating obese patients ─ have been slow to utilize the new dosing guidelines that do exist.

As people of size, we need to be our own best advocates, both before surgery and when surgical site infections occur, so don't be afraid to bring up this concern with your surgeon, or to ask for a consult with an infectious specialist.  Even with a specialist, you may have to be ready to assertively argue your case, but they are more likely to be responsive to advocacy if you can cite research like the studies below.

Providers, please press hard for more research on the most optimal antibiotic dose and regimens, and press vigorously for more caregiver education about and usage of these regimens.  If there is any question about optimal dosage, please take the time to research the issue, and don't be afraid to explore using a different timing or delivery system.  It could literally be the difference between life and death for some people of size.

Infections can be a significant problem in high-BMI patients. Part of this is because of physiological differences like decreased vascular perfusion in fat tissue, and thus decreased oxygenation.  But an under-recognized part of it is because clinicians are using the wrong dosages and treatment regimens for fat folk.

The most efficient approach to improving outcome in obese patients is still to prevent infection in the first place by using the most effective antibiotic dose and treatment protocols available for our unique needs.


References

Am J Obstet Gynecol. 2010 Mar;202(3):306.e1-9. Extended antibiotic prophylaxis for prevention of surgical-site infections in morbidly obese women who undergo combined hysterectomy and medically indicated panniculectomy: a cohort study. El-Nashar SA, et al.   PMID: 20207249

OBJECTIVE: The purpose of this study was to compare surgical-site infection rates in obese women who had extended prophylactic antibiotic (EPA) vs standard prophylactic antibiotic.
STUDY DESIGN: An electronic records-linkage system identified 145 obese women (body mass index, >30 kg/m(2)) who underwent combined hysterectomy and panniculectomy from January 1, 2005, through December 31, 2008. The EPA cohort received standard antibiotics (cefazolin, 2 g) and continued oral antibiotic (ciprofloxacin) until removal of drains. Regression models were used to adjust for known confounders. RESULTS:The mean age was 56.0 + or - 12.1 years, and mean body mass index was 42.6 + or - 8.4 kg/m(2) (range, 30-86.4 kg/m(2)). The EPA cohort experienced fewer surgical-site infections (6 [5.9%] vs 12 [27.9%]; P less than .001; adjusted odds ratio, 0.16; 95% confidence interval, 0.04-0.51; P less than .001), had lower probability of incision and drainage (3 [2.9%] vs 5 [11.6%]; P = .05), and required fewer infection-related admissions (5 [4.9%] vs 6 [13.9%]; P = .08). CONCLUSION: Extended antibiotic prophylaxis can reduce surgical-site infections in obese women after combined hysterectomy and panniculectomy.

Surg Infect (Larchmt). 2009 Feb;10(1):53-7. Prevention of surgical site infections by an infusion of topical antibiotics in morbidly obese patients. Alexander JW, Rahn R, Goodman HR.  PMID: 19245364 

BACKGROUND: The reported incidence of surgical site infection after abdominal surgery in morbidly obese patients is high (about 15% in most studies), and this is associated with considerable disability and an increased economic burden. Topical antibiotics may reduce the incidence of serious infections. METHODS: Standard techniques for the prevention of surgical site infections were used along with the introduction of kanamycin into the subcutaneous space of morbidly obese patients at the time of closure and allowing it to dwell for 2 h. Eight hundred thirty-seven evaluable patients were followed for the development of site complications for at least six weeks postoperatively. RESULTS: One of the 65 patients with a revisional procedure had a primary deep incisional surgical site infection, as did one of the 772 patients with a primary operation. Secondary deep incisional surgical site infections occurred in four patients, two after spontaneous evacuation of a seroma, one from excessive superficial contamination, and one following separation of a nonhealing surgical site. Additionally, 21 patients had minor surgical site complications including incisional separation and stitch-related infections, which required no significant expenditure of resources. CONCLUSIONS: Prolonged contact (2 h) of topical kanamycin solution with the surgical site greatly reduces the incidence of primary infections in the deep subcutaneous space of laparotomy sites in morbidly obese patients.

Expert Rev Pharmacoecon Outcomes Res. 2010 Jun;10(3):317-28. Preventing surgical site infections after bariatric surgery: value of perioperative antibiotic regimens. Chopra T, et al.   PMID: 20545596    Full free text available here.

Kmom Summary: This paper reviews the surgical site infections (SSIs) that occur post bariatric surgery, and how to prevent SSIs. "This paper sets out to define different types of SSIs that occur following bariatric surgery and to discuss existing literature on the critical aspects of SSI prevention and the appropriate use of surgical antimicrobial prophylaxis for bariatric surgery."   

Important quote: "Most antimicrobial agents do not achieve optimal serum levels when administered orally. Although certain oral antimicrobials have comparable bioavailability with their intravenous formulation, the time to achieve maximum serum concentration is slower due to the need for absorption through the gastrointestinal tract. Intravenous antimicrobial prophylaxis is the most extensively studied route and remains the preferred route of administration."

Obes Surg. 2012 Mar;22(3):465-71. Cefepime dosing in the morbidly obese patient population. Rich BS, et al.  PMID: 22249886

Proper dosing of specific antibiotics in morbidly obese patients has been studied inadequately. However, these data are beneficial as this patient population is at an increased risk to develop postoperative infections. Cefepime is an antibiotic used for the treatment of both gram-positive and especially gram-negative infections; administration of the appropriate dose in the morbidly obese population is crucial. We therefore examined the pharmacokinetics of cefepime in patients with body mass index >40 kg/m(2). Ten morbidly obese patients, with a mean [±SD] estimated glomerular filtration rate of 108.4 ± 34.6 mL/min, undergoing elective weight loss surgical procedures were administered cefepime in addition to standard prophylactic cefazolin and studied. Serial serum cefepime concentrations were analyzed after dosing using a validated high performance liquid chromatography method. Pharmacokinetics and duration above the minimum inhibitory concentration (MIC) were determined using a protein binding value of 15% and a MIC threshold of 8 μg/mL. Mean free cefepime concentrations for t = 30, 120, and 360 min were 69.6, 31.6, and 9.2 μg/mL, respectively. The dosing interval was calculated to maintain the free concentration above the MIC (fT > MIC) for 60% of the interval. This was determined to be 10.12 h, including time for infusion. There was no toxicity. Based on this analysis, an increased dose of 2 g every 8 h is necessary to maintain an adequate fT > MIC throughout the dosing interval. Further studies are necessary to determine the efficacy of this regimen in the settings of active infections and critical illness.

Pharmacotherapy. 2007 Aug;27(8):1081-91.  Antimicrobial dosing considerations in obese adult patients. Pai MP, Bearden DT.    PMID: 17655508

As obesity continues to increase in prevalence throughout the world, it becomes important to explore the effects that obesity has on antimicrobial disposition. Physiologic changes in obesity can alter both the volume of distribution and clearance of many commonly used antimicrobials. These changes often present challenges such as estimation of creatinine clearance to predict drug clearance.

Although these physiologic changes are increasingly being characterized, few studies assessing alterations in tissue drug distribution and the effects of obesity on antimicrobial pharmacokinetics have been published. The available data are most plentiful for antibiotics that historically have included clinical therapeutic drug monitoring.

These data suggest that dosing of vancomycin and aminoglycosides be based on total body weight and adjusted body weight, respectively. Obese patients may require larger doses of beta-lactams to achieve similar concentrations as those of patients who are not obese. Fluoroquinolone pharmacokinetics are variably altered by obesity, which prevents a uniform approach. Data on the pharmacokinetics of drugs that have activity against gram-positive organisms-quinupristin-dalfopristin,linezolid, and daptomycin-reveal that they are altered in the presence of obesity, but more data are needed to solidify dosing recommendations. Limited data are available on nonantibacterials. 

An understanding of the physiologic changes in obesity and the available literature on specific antibiotics is valuable in providing a framework for rational selection of dosages in this increasingly common population of obese patients.

Am J Med. 2008 Jun;121(6):515-8.  Multicenter evaluation of vancomycin dosing: emphasis on obesity. Hall RG 2nd, Payne KD, Bain AM, Rahman AP, Nguyen ST, Eaton SA, Busti AJ, Vu SL, Bedimo R.    PMID: 18501233 Full text available here.

BACKGROUND: There is a paucity of data available regarding the dosing of antimicrobials in obesity. However, data are available demonstrating that vancomycin should be dosed on the basis of actual body weight. METHODS: This study was conducted at 2 tertiary care medical centers that did not have pharmacy-guided vancomycin dosing programs or other institutional vancomycin dosing policies or protocols. Patients who received vancomycin between July 1, 2003, and June 30, 2006, were stratified by body mass index and randomly selected from the computer-generated queries. Patients greater or equal to 18 years of age with a creatinine clearance of at least 60 mL/min who received vancomycin for at least 36 hours were included. RESULTS: Data were collected on a random sampling of 421 patients, stratified by body mass index, who met the inclusion criteria. Most patients in each body mass index category received a fixed dose of vancomycin 2 g daily divided into 2 doses (underweight 82%, normal weight 90%, overweight 86%, and obese 91%).  

Adequate initial dosing (greater than or=10 mg/kg/dose) was achieved for 100% of underweight, 99% of normal weight, 93.9% of overweight, and 27.7% of obese patients (P less than .0001).

Ninety-seven percent of underweight, 46% of normal weight, 1% of overweight, and 0.6% of obese patients received greater than or =15 mg/kg/dose recommended by several Infectious Diseases Society of America guidelines.

Pharmacists also failed to correct inadequate dosing because only 3.3% of patients receiving less than 10 mg/kg/dose had their regimen changed in the first 24 hours of therapy.

CONCLUSION: In this multicenter pilot study, obese patients routinely received inadequate empiric vancomycin using a lenient assessment of dosing. Greater efforts should be undertaken to ensure patients receive weight-based dosing because inadequate dosing can lead to subtherapeutic concentrations and potentially worse clinical outcomes.

Eur J Clin Pharmacol. 1998 Oct;54(8):621-5. Vancomycin dosing in morbidly obese patients. Bauer LA, Black DJ, Lill JS.   PMID: 9860149 

OBJECTIVES AND METHODS: Vancomycin hydrochloride dosing requirements in morbidly obese patients with normal renal function were computed to determine the dose of vancomycin necessary to achieve target steady-state peak and trough concentrations and compared with a normal weight population.  RESULTS: Morbidly obese patients [total body weight (TBW) 165 kg, ideal body weight (IBW) 63 kg] required 31.2 mg x kg(-1) x d(-1) TBW or 81.9 mg x kg(-1) x d(-1) IBW to achieve the target concentrations. Normal weight patients (TBW 68.6 kg) required 27.8 mg x kg(-1) x d(-1) to achieve the same concentrations. Because of altered kinetic parameters in the morbidly obese patients (obese: t1/2 = 3.3 h, V = 52 L, CL = 197 ml x min(-1); normal: t1/2=7.2 h, V=46 L, CL=77 ml x min(-1), 20 of 24 patients required q8h dosing (1938 mg q8h) compared with q12h dosing (954 mg q12h) in all normal weight patients in order to avoid trough concentrations that were too low for prolonged periods. There was a good correlation between TBW and CL, but only fair correlation between TBW and V. CONCLUSION: Doses required to achieve desired vancomycin concentrations are similar in morbidly obese and normal weight patients when TBW is used as a dosing weight for the obese (approximately 30 mg x kg(-1) x d(-1)). Shorter dosage intervals may be needed when dosing morbidly obese patients so that steady-state trough concentrations remain above 5 microg x ml(-1) in this population. Because of the large amount of variation in required doses, vancomycin serum concentrations should be obtained in morbidly obese patients to ensure that adequate doses are being administered. Dosage requirements for morbidly obese patients with renal dysfunction require further study.

Surgery. 2004 Oct;136(4):738-47. Perioperative antibiotic prophylaxis in the gastric bypass patient: do we achieve therapeutic levels? Edmiston CE, et al.    PMID: 15467657

BACKGROUND: Perioperative surgical antibiotic prophylaxis requires that therapeutically effective drug concentrations be present in the tissues. METHODS: Patients undergoing Roux-en-Y gastric bypass for morbid obesity were given 2 g cefazolin preoperatively, followed by a second dose at 3 hours. Thirty-eight patients were each assigned to 1 of 3 body mass index (BMI) groups: (A) BMI=40-49 (N = 17); (B) BMI=50-59 (N=11); (C) BMI > or= 60 (N=10). Multiple timed serum (baseline; incision, 15, 30, 60 minutes; prior to second prophylactic dose; and closure) and tissue (skin, subcutaneous fat, and omentum) specimens were collected and cefazolin concentration analyzed by microbiological assay. RESULTS: No significant difference was observed in intraoperative fluid replacement or blood loss among BMI groups. Serum antimicrobial concentrations exceeded resistance breakpoint (32 microg/mL) in 73%, 68%, and 52% of BMI groups A, B, and C, respectively. No significant difference in cefazolin concentration was observed in mean incisional skin and closure tissue specimens in groups A, B, and C. A significant decrease in cefazolin concentration was noted in closure adipose (p=.04), initial (p=.03) and closure omentum (p=.05) tissues in groups B and C compared with A. Over 90% of serum samples exhibited therapeutic concentrations covering 53.8% of gram-positive and 78.6% of gram-negative surgical pathogens. However, therapeutic tissue levels were achieved in only 48.1%, 28.6%, and 10.2% of groups A, B, and C, respectively. CONCLUSIONS: Pharmacokinetic analysis suggests that present dosing strategies may fail to provide adequate perioperative prophylaxis in gastric bypass patients.

Am J Emerg Med. 2011 Dec 12. Underdosing of common antibiotics for obese patients in the ED. Roe JL, Fuentes JM, Mullins ME.  PMID: 22169576

BACKGROUND: Obesity is a growing problem in the United States. Obesity alters the pharmacokinetic profiles of various drugs. Although there are guidelines for dose adjustments for many of the antibiotics commonly used in the emergency department (ED), they are seldom used. METHODS: This is an institutional review board-approved retrospective study at an American Society of Metabolic and Bariatric Surgery Center of Excellence and a level I trauma center with annual ED volumes of more than 80 000 visits. Data were retrospectively collected from ED pharmacy records during a 3-month period in 2008. Any first dose of cefepime, cefazolin, or ciprofloxacin administered in our ED to a patient recorded as both more than 100 kg and with a body mass index greater than 40 kg/m(2) was compared with our hospital guidelines and found to either adhere or not adhere to those guidelines. RESULTS: There were 1910 orders found to meet the study criteria: 775 orders for cefepime, 625 orders for cefazolin, and 510 orders for ciprofloxacin. Adherence rates for first dose of cefepime, cefazolin, and ciprofloxacin administered, respectively, were 8.0%, 3.0%, and 1.2%. CONCLUSION: Emergency physicians frequently underdose cefepime, cefazolin, and ciprofloxacin in obese patients. Underdosing antimicrobials presents risk of treatment failure and may promote antimicrobial resistance. Education is necessary to improve early antibiotic administration to obese patients.

Obese Patients Undertreated for Infection in the Emergency Room

The following study shows just how badly obese patients are underdosed with antibiotics in the Emergency Room (E.R.).

Terri of the FattiesUnited blog brought this study to the attention of the fatosphere briefly several months ago, just as I was about to write a post about this study too, so I put the post on the back burner.

However, in writing an upcoming post on treating Surgical Site Infections in people of size, I came across the study again and decided it was important enough to be highlighted once more.  Any of us can end in the Emergency Room at any time, regardless of size.  But those of us who are fat need to be aware of the possibility of underdosing and to be able to advocate for ourselves as needed.  Perhaps sharing the full details of this study will help in that process.

In this study, the initial antibiotic dosages of "morbidly obese" folks (BMI over 40) who visited the E.R. and were prescribed 3 common antibiotics were analyzed retrospectively for a 3-month period.  The doses were compared with internal hospital guidelines for antibiotic dose adjustments for obese folks.

Less than 5% of morbidly obese patients were given the correct antibiotic dose for their weight.

That's right, more than 95% of high BMI patients were underdosed with antibiotics, putting them at significant risk for serious complications.

The study notes:

Although there are guidelines for dose adjustments for many of the antibiotics commonly used in the emergency department (ED), they are seldom used...Underdosing antimicrobials presents risk of treatment failure and may promote antimicrobial resistance. Education is necessary to improve early antibiotic administration to obese patients.

Study Details

This study was done as a quality improvement review at an urban Level I trauma center with an emergency medicine residency.

In the study, pharmacy records were collected retrospectively to identify the initial dose of cefazolin, cefepime, or ciproflaxin given in the E.R. to patients with a BMI greater than 40 and who weighed more than 100 kg.

These three drugs were chosen because they are used so frequently and because, unlike many antibiotics, there are readily-available guidelines for dosing obese folks without having to do a bunch of complicated extra calculations first.  The guidelines are distributed in a handbook each year to every resident and are also always available on the hospital's internal website, so there was no excuse for not knowing or not checking the recommended dosages.

The study looked at only the initial dose given (and to be fair, any additional dose within 4 hours, as sometimes doctors self-correct dosing when they have a chance to look up the guidelines).

This attention to the initial dose is important because the first dose of antibiotics is the most important in knocking down an infection.  According to the study, the effectiveness of this class of antibiotics (cephalosporins) is proportional to the amount of time kept above the Minimum Inhibitory Concentration (MIC). If the initial dose does not achieve MIC, then the patient may develop resistance to the antibiotics, not to mention serious complications, longer hospital stays, or even death.

In the study, there were 1,910 orders that fit the criteria in the 3-month study period. Of these, only 4.6% of the antibiotic orders were dosed appropriately for morbidly obese patients.

For cefepime, the adherence rate was 8%.  For cefazolin, the adherence rate was 3%, and for ciproflaxin the adherence rate was only 1.2%.

This is an appallingly poor adherence rate to readily-available, simple dosing guidelines. The study notes this and emphasizes how important it is to ensure adequate dosing in morbidly obese patients:

Attaining therapeutic dosing in [morbidly obese] patients is especially important.  Obese patients present a greater risk of infection and a higher morbidity and mortality associated with infection than does the general population.  Subtherapeutic dosing increases the risk of treatment failure, unnecessary escalation to broader-spectrum antibiotics, and selection of resistant pathogens...Because early antibiotic administration reduces mortality in life-threatening infections, meeting proper dosing guidelines in the [Emergency Department] should be of the highest priority.

The authors go on to cite another study which found that when the perioperative dose of cefazolin was doubled to 2g in obese patients, the postoperative infection rate dropped from 16.5% to 5.6%.  This shows that increased dosages of this antibiotic in heavier patients do result in improved outcomes.

Interestingly, there is recent data (Pevzner 2011) on cesareans in morbidly obese patients suggesting that even a doubled, 2g dose of cefazolin may not be enough, and that further research is needed to figure out the most effective perioperative dose in this group.  What implications this has for E.R. usage is unknown but suggests doses bigger than 2g may also need to be considered. Research needs to be done to find the optimal dose for each size.

Concluding Thoughts

Sooner or later, people of every size end up in the E.R., especially as they age.  Different populations present different care challenges; obese people present a unique subset whose care challenges are often under-recognized and under-addressed.

Bottom line, the best care protocols for obese people are yet to be determined because research on the topic has been woefully inadequate.  Furthermore, even when the best care protocols are known, they are often not followed by medical personnel.  Therefore, it is critical as people of size that we know about key care issues in our own care and how to advocate for ourselves when we interact with medical personnel.  

One of the most understudied areas in the care of obese patients is optimal medication dosage.  Research shows that obese patients (and especially morbidly obese patients) are often dosed inappropriately with a variety of drugs, from chemotherapy to anti-coagulants to antibiotics, and this may be correlated to poorer outcomes among these groups.

Clearly, it is imperative that more research and physician education be done on appropriate medication dosage for people of size as quickly as possible.

In this study, only initial antibiotic dosing at the Emergency Room was examined, using only common antibiotics with easily-available dose adjustments.  Even so, less than 5% of the morbidly obese patients were given dosages that adhered to the internal guidelines of the hospital.

One has to wonder how adequate the dosing was in very fat patients for the rest of their hospital stays and how that impacted their outcomes.

Ironically, this was in a hospital that is a regional referral center for fat patients and is recognized as a Bariatric Surgery "Center of Excellence" (ugh).  That makes the findings even more alarming.

If a teaching hospital that specializes in the treatment of very fat people doesn't routinely use the correct antibiotic dosing in their E.R., what are the underdosing rates in community hospitals that don't specialize in fat patients at all?

This study has lessons both for people of size and for the medical community.

Fat people should know that if they end up in the E.R. for an infection of some sort, they need to ask their physician to check into adjusted antibiotic doses for weight.  Not every type of antibiotic needs dose adjustment, mind ─ it all depends on how they are designed to work in the body.  But this study indicates that you may really have to push your physician to find out about dose adjustments and to use them when they are indicated.

Most physicians truly want their patients to get better, so it's really OK to ask about whether weight-based dosing is needed for you. However, don't be afraid to ask for a consult with an infections specialist if you feel your E.R. doctor is not attentive to your concerns, or to involve the hospital's Patient Advocate in getting your concerns heard.  There are measures in place to help patients advocate for their own needs, and you don't have to go it alone.

But the first step is self-education, to know where the potential issues may lie, to know to ask questions about dosages, and to feel empowered enough to do so.

For medical professionals, the associated lesson is that they must aggressively press for better research on optimal medication dosage in obese patients, and to continue to push for more physician education and accountability on these matters.

*Next post.....other ways to improve response to infections in people of size, including IV antibiotics, more frequent dosings, and topical infusions.



References

Am J Emerg Med. 2011 Dec 12. Underdosing of common antibiotics for obese patients in the ED. Roe JL, Fuentes JM, Mullins ME.  PMID: 22169576

BACKGROUND: Obesity is a growing problem in the United States. Obesity alters the pharmacokinetic profiles of various drugs. Although there are guidelines for dose adjustments for many of the antibiotics commonly used in the emergency department (ED), they are seldom used. METHODS: This is an institutional review board-approved retrospective study at an American Society of Metabolic and Bariatric Surgery Center of Excellence and a level I trauma center with annual ED volumes of more than 80 000 visits. Data were retrospectively collected from ED pharmacy records during a 3-month period in 2008. Any first dose of cefepime, cefazolin, or ciprofloxacin administered in our ED to a patient recorded as both more than 100 kg and with a body mass index greater than 40 kg/m(2) was compared with our hospital guidelines and found to either adhere or not adhere to those guidelines. RESULTS: There were 1910 orders found to meet the study criteria: 775 orders for cefepime, 625 orders for cefazolin, and 510 orders for ciprofloxacin. Adherence rates for first dose of cefepime, cefazolin, and ciprofloxacin administered, respectively, were 8.0%, 3.0%, and 1.2%. CONCLUSION: Emergency physicians frequently underdose cefepime, cefazolin, and ciprofloxacin in obese patients. Underdosing antimicrobials presents risk of treatment failure and may promote antimicrobial resistance. Education is necessary to improve early antibiotic administration to obese patients.

Surgery. 2004 Oct;136(4):738-47. Perioperative antibiotic prophylaxis in the gastric bypass patient: do we achieve therapeutic levels? Edmiston CE, et al.  PMID: 15467657

BACKGROUND: Perioperative surgical antibiotic prophylaxis requires that therapeutically effective drug concentrations be present in the tissues. METHODS: Patients undergoing Roux-en-Y gastric bypass for morbid obesity were given 2 g cefazolin preoperatively, followed by a second dose at 3 hours. Thirty-eight patients were each assigned to 1 of 3 body mass index (BMI) groups: (A) BMI=40-49 (N = 17); (B) BMI=50-59 (N=11); (C) BMI > or= 60 (N=10). Multiple timed serum (baseline; incision, 15, 30, 60 minutes; prior to second prophylactic dose; and closure) and tissue (skin, subcutaneous fat, and omentum) specimens were collected and cefazolin concentration analyzed by microbiological assay. RESULTS: ...Over 90% of serum samples exhibited therapeutic concentrations covering 53.8% of gram-positive and 78.6% of gram-negative surgical pathogens. However, therapeutic tissue levels were achieved in only 48.1%, 28.6%, and 10.2% of groups A, B, and C, respectively. CONCLUSIONS: Pharmacokinetic analysis suggests that present dosing strategies may fail to provide adequate perioperative prophylaxis in gastric bypass patients.

Obstet Gynecol. 2011 Apr;117(4):877-82. Effects of maternal obesity on tissue concentrations of prophylactic cefazolin during cesarean delivery. Pevzner L, et al.  PMID: 21422859

OBJECTIVE: To estimate the adequacy of antimicrobial activity of preoperative antibiotics at the time of cesarean delivery as a function of maternal obesity. METHODS: Twenty-nine patients scheduled for cesarean delivery were stratified according to body mass index (BMI) category, with 10 study participants classified as lean (BMI less than 30), 10 as obese (BMI 30-39.9), and nine as extremely obese (BMI 40 or higher). All patients were given a dose of 2 g cefazolin 30-60 minutes before skin incision. Antibiotic concentrations from adipose samples, collected after skin incision and before skin closure, along with myometrial and serum samples, were analyzed with microbiological agar diffusion assay. RESULTS: Cefazolin concentrations within adipose tissue obtained at skin incision were inversely proportional to maternal BMI (r=-0.67, P<.001)...Although all specimens demonstrated therapeutic cefazolin levels for gram-positive cocci (greater than 1 microgram/g), a considerable portion of obese and extremely obese did not achieve minimal inhibitory concentrations of greater than 4 micrograms/g for Gram-negative rods in adipose samples at skin incision (20% and 33.3%, respectively) or closure (20.0% and 44.4%, respectively)... CONCLUSION: Pharmacokinetic analysis suggests that present antibiotic prophylaxis dosing may fail to provide adequate antimicrobial coverage in obese patients during cesarean delivery.

Bra Recycling: Passing on the Wealth

Motherwear Great Support Nursing Bra
(Sizes to 50K)

I was so thrilled to find this organization that recycles bras and passes them along to other women around the world in need of a good bra.  The URL is www.brarecycling.com 

If you're like me, you have bras in your drawers that you don't wear very often.  You may have tried a new style or design and found you didn't like it very well, or the fabric/color didn't suit you, or you've changed sizes.  It always sits very poorly with me to waste perfectly good clothes, but I didn't figure that Goodwill or other such organizations would accept such an intimate item as lingerie, so I have quite a few just languishing in my drawers.  But now there's a place to donate!

This is especially important for those of us who are a special size.  It's so hard to find good plus-size clothes second-hand; imagine how hard it is to find good bras in our size when money is an issue!  They are so expensive to buy new.

So if you wear a larger band size (more than about 42 or so), a larger cup (D or more), have a mastectomy or post-surgery bra, or have some nursing bras you no longer need, I hope you will especially consider donating to this group.

Below is more information about the company and where to send the bras.  Some communities also have drop-off sites where you can drop off the bra instead of having to pay shipping costs; info about that can be found here. And here is a link to the donation paperwork you need to fill out.

[I should probably add the disclaimer that I know nothing about this group or its validity as a charity.  Caveat Emptor. However, they do have a page that discusses which charities they donate the bras to, if you want to do more research.]



From the company's "about" page:

What is The Bra Recyclers all about?

• We are a textile recycling company focused on doing our part to recycle and reuse bras (textiles) that unnecessarily go to landfills
• We buy and sell recycled bras, which are re-distributed through exporters and organizations to developing countries around the world
• We have created and support a network of Bra Recycling Ambassadors who assist us in providing deserving women with used or unused bras as they transition back to self-sufficiency

What Type of Bras Are Needed?

• Bras in good condition; Clasps and straps need to be functional
• All sizes and styles of bras
• Special needs bras, post breast surgery and maternity bras

Recovering and Recycling Your Bras

We make it easy for you to recover and recycle all of the old or new bras sitting in your lingerie drawers waiting to be worn by a deserving woman in your community. Just follow 4 easy steps:

• Wash It. All bras should be washed.
• Tag It. Fill out Bra Recycling Form.
• Box It. Place your bras in a box or large envelope.
• Drop It Off or Mail It to:

The Bra Recyclers
3317 S. Higley Rd, Ste 114-441
Gilbert, AZ 85297

Summer Fluff: The Bobs

Here's a little musical fluff to brighten up your summer day.  Anybody else here a fan of The Bobs?

I've seen The Bobs perform a few times over the years, and I love their off-beat virtuosity. They are an a capella group with a twist.  And they are awesome.

I'm a big fan of a capella music (just vocals, no instruments) and doo wop music in general.  However, this is not your grandma's a capella music.  They've been called "New Wave A Capella" and they specialize in very off-beat, often humorous songs, either covers of other material or original songs written by members of the group. They merge pop, blues, and jazz, often utilize non-traditional harmonies, and generally push the envelope of a capella music in a major way. They describe themselves on their website in the following way:

The Bobs (prat)fall outside a cappella traditions, landing in a hot tub of humor and vocal prowess. What other band can headline The American Songbook series, open for Frank Zappa and The Dead, and perform for 700 million people on the Emmy Awards?

The Bobs were founded in 1981 but hit the big time in 1984:

Matthew Stull and Gunnar Madsen founded The Bobs in 1981 in Berkeley, California, and were quickly joined by bass singer Richard Greene and über-alto Janie Scott. They performed in the San Francisco area until a 1984 Grammy nomination for their unique vocal cover of the Beatles’ “Helter Skelter” catapulted them into a national and international tour schedule.

As is common in many groups, they have rotated through several different singer line-ups over the years. MatthewBob and RichardBob are the longest-serving members of the group, and are currently joined by DanBob and AngieBob. (Yes, all the members have "Bob" in their psuedo-names.) More information (including upcoming concerts and how to buy their albums) is available at their website, The Bobs.

If you ever get the chance to see them in person, take it!  They're famous for their show patter, so it's usually a very entertaining show.  If you are very traditionally-minded in your music preferences, you might not enjoy some of their songs (which can be pretty offbeat harmonically), but generally speaking, the humor and the sheer virtuosity with which they perform is enough to win over most people.

Here are a few videos of some of their more wide-appeal songs to get you started.

The first is "There Ain't Nobody Here But Us Chickens."  It's a cover of an old Louis Jordan song, and it's straightforward and fun.  Check out the cool scatting by DanBob Schumacher.



Here is "The Tight Pants Tango", a tribute to the dancing that happens when your cell phone rings when ensconced in the pocket of pants that are far too tight.



Here is a link to another video of "The Tight Pants Tango". You can't see everyone, so it's not as good a video, but it's got all the lyrics listed, so some might enjoy looking at that one instead.

Finally, for cat fans everywhere, a very bizarre but funny song called "Fluffy's Master Plan for World Domination" about how cats are plotting to take over the world. It's a fan's amateurish video of The Bobs soundtrack, mind, but it's still fun.  Enjoy!

CesareanRates.com: Transparency in Maternity Care

www.cesareanrates.com 

There's a new website out that I've been wanting to highlight for a while.  Now, as the author struggles to finance her work on the site, it's even more important that I publicize the site.

The site is called cesareanrates.com and it has the cesarean rates for most of the states in the U.S. and the provinces in Canada.

Most importantly, not only does it have the cesarean rates by state/province, it also has the cesarean rates by individual hospital.

Earthy-birthy types who read my blog probably already know about this wonderful resource, but others may not.  It makes for very interesting reading and I recommend the site.

Having cesarean rates available by hospital is incredibly useful information.  If you live in an area where you have the choice of more than one hospital, you can see which ones have very high baseline cesarean rates and which ones don't.

Such information has to be interpreted with caution, of course, since some hospitals have higher loads of high-risk patients who might be expected to have higher cesarean rates. This is a legitimate concern.  However, even among hospitals that serve higher-risk patient populations, cesarean rates can vary widely. So while caution has to be used when viewing this data, it still can be useful to the consumer.  Some hospitals really do have a strong climate of overutilization of cesareans, and consumers should have access to that information before choosing to become a customer of that hospital.

So let's talk a little bit more about the variations in cesarean use and the importance of transparency in cesarean rates for quality control purposes.

Image Use Disclaimer: I received express permission from creator Jill Arnold of The Unnecesarean to use the cesareanrates.com images. If you want to use them, please ask her permission first.

Variations in Cesarean Utilization

One of the attitudes we have to fight against all the time in Cesarean Awareness advocacy is the common public perception that cesareans are only done when necessary.  In other words, most people assume that if a woman had a cesarean, it was usually because she needed it and it saved her or her baby's life.

Yes, cesareans can be life-saving, and there is no doubt that having them available is a wonderful thing.  Absolutely no argument there.

However, while cesareans mostly used to be used only when truly needed, there are many cesareans being performed today that are not medically indicated.  And the strong regional variations in cesarean use just reinforce this.

Below is a chart from Jill's site of the ten hospitals with the highest c-section rates in Florida.

Now look at a chart from Jill representing the ten hospitals with the highest c-section rates in Utah.

So the hospital with the highest cesarean rate in Florida has a rate TWICE as high as the hospital with the highest cesarean rate in Utah.

Come on, are the uteri of women in Utah really that much more efficient as the uteri of women in Florida? No, of course not.  The fact is that cesarean rates are highly variable by region, by hospital, and by doctor, and many of these variations are not explainable by demographic differences or risk caseload.

Even within one regional area with similar demographics and patient risk profiles (and eliminating cesareans for indications like breech, thought to be "necessary" by some providers), cesarean rates can vary widely.

While doctors like to blame women for high c-section rates (the overused "women are too old or too fat" or "women are requesting these cesareans" arguments), the truth is that provider practice patterns have far more influence on cesarean rates than factors attributable to women themselves.

The Childbirth Connection, an organization devoted to improving maternity care, confirms this trend:

The cesarean rate varies broadly across states and areas of the country, hospitals, and maternity professionals. Most of this variation is due to "practice style" rather than differences in the needs and preferences of childbearing women.

In other words, your chances of "needing" a cesarean at one hospital in your area may be quite different than your chances of "needing" a cesarean in a different hospital in your area.  Even if you fall into a supposedly "high-risk" category, your chances of "needing" a cesarean can vary widely, depending on who you see and their practice patterns around birth.

While some cesareans truly are prudent and at times even life-saving, many cesareans performed today are not.  Women deserve to know which hospitals have high rates of cesarean utilization and which do not, so that they can make informed choices about where they go to birth, should they choose to have a hospital birth.

Caveats

I would like to tell you that hospital-level cesarean rates area available for all 50 states, but alas, that's not true.  Last I checked Jill's site, the following states did not have hospital-level information about cesarean rates available:

• South Carolina
• North Carolina
• Georgia
• Arizona
• Connecticut
• Hawaii
• Idaho
• Iowa
• Kansas
• Michigan
• Missouri

Why is this information not available uniformly? The reasons vary. Some states don't think consumers are interested in this information and so don't provide it. Or pencil-pushers decide that providing cesarean rates to the public is not a Department of Health budget priority.  A few states have decided that health consumers have no right to this information and refuse to release hospital-level cesarean rates, despite many requests to do so.

There is information in each of the links above on how to contact these states directly to request that this information be made public.  Sometimes, if a state gets enough requests, they make providing hospital-level cesarean rates more of a priority.  (We were able to do this recently in my state.)

On the other hand, sometimes states actively refuse to provide hospital-level cesarean rates because doctors have actively campaigned to keep these rates private, on the grounds that the public is not smart enough to understand the concept of mitigating factors (like a high-risk caseload, etc.).  Or they simply don't want the bad publicity for their hospitals.

This is ridiculous.

As health consumers, we deserve to have public health information about various hospitals and their quality of care.  And we deserve this information for maternity-related care as well as basic overall care.  

The Importance of Transparency

Transparency is a HUGE up-and-coming issue in healthcare.  As one quality watchdog group notes:

You may not realize there are differences in the quality of care provided by different hospitals. Hospitals are busy and complex places. Every day, hundreds of patients are receiving hundreds of different procedures. Medical mistakes are a leading cause of death each year, causing more deaths each year than car accidents, breast cancer and AIDS. 

There is good news! Hospitals can take steps to prevent mistakes and protect patients from unnecessary injury. Even better, there is information available to help you determine the quality of your local hospitals.

More and more, groups such as consumerreports.org and the Leapfrog Group have begun to document basic information on Quality of Care measures, such as which hospitals have high rates of hospital-acquired infections, which have poor overall patient safety, and which have high rates of medical mistakes or medication errors.

However, these quality monitoring efforts are in their infancy.  Some hospitals participate voluntarily, but some actively resist any attempt to shine a spotlight more closely on care practices. Yet experience shows that when substandard results are highlighted and a program is developed to address these issues, outcomes can be improved.

It is important to be careful when comparing results from different hospitals, but even with this caution in mind, transparency in Quality of Care measures can be useful in improving care and patient outcomes.

Transparency and Participatory Medicine are concepts whose time has come.

How does this translate to maternity care?  In maternity care, substandard care translates to high rates of maternal or neonatal infections, high rates of early scheduled deliveries, higher-than-average deaths, and a too-high cesarean rate.

Some hospitals would argue that a high cesarean rate is not a sign of substandard care. The World Health Organization disagrees, noting that high rates of non-medically indicated cesareans translate into a higher rate of adverse maternal outcomes, including admission to Intensive Care Units, blood transfusions, hysterectomies, and maternal deaths. Other risks include blood clots, wound infections, anesthesia accidents and other problems.  Clearly, overuse of cesareans has risks.

There is an ongoing argument over what the "most optimal" cesarean rate should be, but that's beside the point.  Whatever the "ideal" rate is, women deserve to know the baseline cesarean rate of their hospital of choice, and how that compares to other hospitals.  Then it is up to them which hospital they choose.

Final Thoughts

CesareanRates.com is a powerful new tool for healthcare consumers.

One of the many useful things on the website is the listing of the cesarean rates of all the U.S. states (both alphabetically and by highest-to-lowest rates). There is also a graph showing the increase in cesarean rates over time in the U.S.  Rates from the Canadian Provinces are available as well.

I like the Top Ten slideshow, where slides from several representative states list the hospitals with the highest cesarean rates in those states.  You'll see that quite a few hospitals have c-section rates around 50%-60%, while other states' rates are not nearly so high. This is a good micro-demonstration of how much variation there can be in cesarean rates from hospital to hospital and state to state.  (Click on the page number on the bottom to freeze a particular state's slide.)

Another useful thing is a state-by-state listing of the VBAC ban policies of individual hospitals.  This information can already be obtained from the International Cesarean Awareness Network’s VBAC Policy Database but it's useful to have it all in one place with the hospital-level cesarean rates.

You can read more here about why Jill Arnold created this new site:

CesareanRates.com is a snapshot of online cesarean rate reporting in the United States as of January 2012. The site compiles the most current hospital-level data accessible to the public online, whether reported directly by a state’s department of health or gathered from state hospital association web sites via pull-down menus. The initial goals of the site are to a) show the (poor) quality and inaccessibility of hospital-level information available to the public, b) to assess whether there is public demand for this information and c) to work toward establishing a precedent for hospital data transparency.

How might this site be useful for a typical healthcare consumer?  Jill elaborates on that question here:

As with everything pregnant people can get their hands on, it is one of many tools. Everyone makes decisions differently and weighs things based on their unique experiences, values, preferences and education. For example, a 60% total cesarean rate might trigger a different reaction for different people. A woman that passionately wants to avoid an unnecessary cesarean section might be deterred from giving birth there, while one hoping for an elective primary section might infer something about the culture of the hospital and seek a provider that delivers babies there. Another person might try to evaluate what exactly that means and start investigating why it is so high, while someone else might not care one way or the other where they give birth as long as they are with a care provider they like. 

Ideally, it would be nice to see the site used by pregnant people for the purpose of seeking preference-sensitive care and opening up dialogue with their provider about what they can expect at the hospitals at which their provider has privileges.

If you want to know more about how cesarean rate information is reported. watch the following short video on the technical aspects of such data collection.



Go, check out www.cesareanrates.com. If you get an additional moment, go to its Facebook Page and "like" it as well.  Blog about it and pass on the link so more people know about this invaluable resource.

And if you can, donate to the author so she can continue carrying on this work.

Thank you, Jill, for your hard work on this site.  Brava!


References

Health Aff (Millwood). 2006 Sep-Oct;25(5):w355-67. Epub 2006 Aug 8. Geographic variation in the appropriate use of cesarean delivery. Baicker K, Buckles KS, Chandra A.   PMID: 16895942

There is enormous geographic variation in the use of cesarean delivery: For births over 2,500 grams, adjusted cesarean rates vary fourfold between low- and high-use areas. Even for births under 2,500 grams, high-use counties have rates that are double those of low-use ones. Higher cesarean rates are only partially explained by patient characteristics but are greatly influenced by nonmedical factors such as provider density, the capacity of the local health care system, and malpractice pressure. Areas with higher usage rates perform the intervention in medically less appropriate populations-that is, relatively healthier births-and do not see improvements in maternal or neonatal mortality.

Am J Obstet Gynecol. 2007 Jun;196(6):526.e1-5. Variation in the rates of operative delivery in the United States. Clark SL, et al.   PMID: 17547880

OBJECTIVES: This study was undertaken to examine the national and regional rates of operative delivery among almost one quarter million births in a single year in the nation's largest healthcare delivery system, using variation as an arbiter of the quality of decision making. STUDY DESIGN: We compared the variation in rates of primary cesarean and operative vaginal delivery in facilities of the Hospital Corporation of America during the year 2004. RESULTS: In 124 facilities representing almost 220,000 births during a 1-year period, the primary cesarean and operative vaginal delivery rates were 19% +/- 5% (range 9-37) and 7% +/- 4% (range 1-23). Within individual geographic regions, we consistently found variations of 200-300% in rates of primary cesarean delivery and variations approximating an order of magnitude for operative vaginal delivery. CONCLUSION: Within broad upper and lower limits, rates of operative delivery in the United States are highly variable and suggest a pattern of almost random decision making. This reflects a lack of sufficient reliable, outcomes-based data to guide clinical decision making.

Obstet Gynecol. 2010 Jun;115(6):1201-8. Regional variation in the cesarean delivery and assisted vaginal delivery rates. Hanley GE, Janssen PA, Greyson D.   PMID: 20502291

OBJECTIVE: To examine regional variations in rates of primary cesarean delivery and assisted vaginal delivery in the population of British Columbia, while adjusting for the maternal characteristics and conditions that increase the likelihood of operative delivery. METHODS: Using data from the British Columbia Perinatal Database Registry, we studied all deliveries in British Columbia between 2004 and 2007, excluding women who had a previous cesarean delivery (n=116,839)...RESULTS: Crude primary cesarean delivery and assisted vaginal delivery rates varied markedly across the Health Service Delivery Areas ranging from 16.1 to 27.5 per 100 deliveries, and from 8.6 to 18.6 per 100 deliveries, respectively. The most common indication for cesarean delivery was dystocia, which accounted for 30.0% of all cesarean deliveries and varied more than fivefold across regions. After controlling for maternal characteristics and conditions known to increase the likelihood of cesarean delivery and assisted vaginal delivery, adjusted cesarean delivery rates varied twofold, ranging from 14.7 to 27.6 per 100 deliveries, while adjusted assisted vaginal delivery rates varied by more than twofold, ranging from 6.5 to 15.3 per 100 deliveries. CONCLUSION: Our results illustrate substantial regional variation in the use of cesarean delivery that cannot be explained by patient illness or preferences. This variation likely reflects differences in practitioners' approaches to medical decision-making.

Birth. 2005 Sep;32(3):170-8. Cesarean delivery in Native American women: are low rates explained by practices common to the Indian health service? Mahoney SF, Malcoe LH. PMID: 16128970

BACKGROUND: Studying populations with low cesarean delivery rates can identify strategies for reducing unnecessary cesareans in other patient populations...METHODS: We used a case-control design nested within a cohort of Native American live births, > or = 35 weeks of gestation (n = 789), occurring at an Indian Health Service hospital during 1996-1999... RESULTS: The total cesarean rate was 9.6 percent (95% CI 7.2-12.0). Nulliparity, a medical diagnosis, malpresentation, induction, labor length > 12.1 hours, arrested labor, fetal distress, meconium, and gestations < 37 weeks were each significantly associated with cesarean delivery in unadjusted analyses. The final multivariate model included a significant interaction between induction and arrested labor (p < 0.001); the effect of arrested labor was far greater among induced (OR 161.9) than noninduced (OR 6.0) labors. Other factors significantly associated with cesarean delivery in the final logistic model were an obstetrician labor attendant (OR 2.4; p = 0.02) and presence of meconium (OR 2.3; p = 0.03). CONCLUSIONS: Despite a higher prevalence of medical risk factors for cesarean delivery, the rate at this hospital was well below New Mexico (16.4%, all races) and national (21.2%, all races) cesarean rates for 1998. Medical and practice-related factors were the only observed independent correlates of cesarean delivery. Implementation of institutional and practitioner policies common to the Indian Health Service may reduce cesarean deliveries in other populations.

Prior Vaginal Birth Decreases the Risk for Uterine Rupture in VBAC

Here's an entry in the no-duh Olympics.  You would think this didn't need to be pointed out, but sadly, to some folks it does.

Most caregivers know that once a woman has had a VBAC, she is at decreased risk for rupture  (the scar coming apart) in any future pregnancies.

The risk is never zero, mind.....once a cesarean, always a risk to some degree, whether you choose VBAC or repeat cesarean, which is why it's important to avoid that first cesarean whenever possible.....but a prior vaginal birth (either before or after the cesarean) does seem to lessen the risk for rupture.

However, once in a while, we in ICAN (the International Cesarean Awareness Network) hear about some ignorant caregiver telling women that they can only have one VBAC and then must have all repeat cesareans, or that the risk for rupture remains just as high each time, even after you've already had a VBAC. Wrong!

For all the Homer Simpson caregivers out there who need a primer on this topic, here's a research review that clearly shows that the risk for uterine rupture is significantly decreased in women who have had a prior vaginal birth.  D'oh!

This is another reason why it is so important to prevent cesareans whenever possible.  A vaginal birth is protective against so many complications, including one of the most serious, uterine rupture.  Even if a cesarean becomes truly necessary in a particular pregnancy, it is strongly to everyone's advantage if the woman has had a vaginal birth first, or if she has a vaginal birth (VBAC) afterwards. In most cases, it is more risky to expose them to successive cesareans, particularly multiple repeat cesareans.

Yet research shows the primary cesarean rate rising, and the VBAC rate dropping.

Graph from U.S. National Center for Health Statistics

Don't get me wrong.  I don't hate cesareans. It is wonderful to have life-saving technology and surgery available when truly needed, and there certainly are cases where a cesarean makes more sense. But don't underestimate the power of nature.

On a population-wide basis, vaginal birth offers the most benefits to most mothers and babies. We evolved to give birth vaginally, and we circumvent that casually at our peril.

This research points out yet again that it is to most birthing women's advantage to have a vaginal birth in their history. Most of the time, unnecessary primary cesareans and routine repeat cesareans should be avoided if possible.


Reference

Arch Gynecol Obstet. 2011 Nov;284(5):1053-8. Risk of uterine rupture in women undergoing trial of labour with a history of both a caesarean section and a vaginal delivery. de Lau H, et al. PMID: 21879334

PURPOSE: To determine the risk of uterine rupture for women undergoing trial of labour (TOL) with both a prior caesarean section (CS) and a vaginal delivery.

METHODS: A systematic literature search was performed using keywords for CS and uterine rupture. The results were critically appraised and the data from relevant and valid articles were extracted. Odds ratios were calculated and a pooled estimate was determined using the Mantel-Haenszel method.

RESULTS: Five studies were used for final analysis. Three studies showed a significant risk reduction for women with both a previous CS and a prior vaginal delivery (PVD) compared to women with a previous CS only, and two studies showed a trend towards risk reduction. The absolute risk of uterine rupture with a prior vaginal delivery varied from 0.17 to 0.46%. The overall odds ratio for PVD was 0.39 (95% CI 0.29-0.52, P less than 0.00001).

CONCLUSION: Women with a history of both a CS and vaginal delivery are at decreased risk of uterine rupture when undergoing TOL compared with women who have only had a CS.