Wednesday, January 26, 2011

ACOG Weighs in on Homebirth

ACOG issued a statement on homebirth on January 25, 2011.

Here is our "response".  Please feel free to give yours!

ACOG says: "It's important to remember that home births don't always go well, and the risk is higher if they are attended by inadequately trained attendants or in poorly selected patients with serious high-risk medical conditions such as hypertension, breech presentation, or prior cesarean deliveries." 

Childbirth Today: No, homebirths don't always go well but then neither do hospital or birth center births.  To think that location guarantees safety is not supported by the literature.  We do agree that high risk women should be attended by equally adequate providers.

ACOG says: absolute risk of planned home births is low.

Childbirth Today: True!

ACOG says: published medical evidence shows it does carry a two- to three-fold increase in the risk of newborn death compared with planned hospital births.

Childbirth Today: please cite the references.  

ACOG says: A review of the data also found that planned home births among low risk women are associated with fewer medical interventions than planned hospital births.

Childbirth Today: True.

ACOG says: Although The College does not support planned home births given the published medical data, it emphasizes that women who decide to deliver at home should be offered standard components of prenatal care.

Childbirth Today: There will ALWAYS be the population who will decided, through informed decision making that home birth is an option for them.  We hope that instead of putting up more roadblocks for these families, ACOG will work together with other care providers to create an educational and informational highway for families devoid of statements like this one, that could be construed as not presenting the entire picture plus discouraging families from seeking childbirth education, which strengthens their educational foundation.

ACOG says:  It also is important for women thinking about a planned home birth to consider whether they are healthy and considered low-risk and to work with a Certified Nurse Midwife, Certified Midwife, or physician that practices in an integrated and regulated health system; have ready access to consultation; and have a plan for safe and quick transportation to a nearby hospital in the event of an emergency.

Childbirth Today: Research shows that in countries with more midwifery care, maternal mortality/morbidity and infant morbidity/mortality rates are much lower, while our statistics grow worse in spite of rising intervention on births.  Have you read this 2005 study in the BMJ? What about Licensed Midwives or Certified Professional Midwives?  Why leave them out?  

ACOG Says: the risk is higher if they are attended by inadequately trained attendants or in poorly selected patients with serious high-risk medical conditions.

Childbirth Today: women should choose their care providers carefully and wisely, whether they are midwives or physicians.  Women should also choose their location to give birth wisely as well.  The Birth Survey can help!

While statements or opinions such as Committee Opinion #476, "Planned Home Birth," is published in the February 2011 issue of Obstetrics & Gynecology is perfectly fine as an opinion, the reader must be aware that it is only an opinion and only based on limited references...which are not given.  For expectant parents to make full use of informed consent, they should hear other opinions, read CDC statistics and make their own decisions.  After all, childbirth is not an illness.  It is a state of health.  And statistically speaking, few women actually need the care of an obstetrician (who is also a surgeon).  There are some that do and that is why we have obstetric care and hospitals.

The bottom line (no pun intended...well, ok maybe) is that the war between physician/midwife and hospital birth/home birth is not likely to end soon.  And this is one example of why.

Tuesday, January 25, 2011

The Evidence says: Education is the Key ~ Breast is Best

The US Surgeon General held a press conference last week (January 20,2011) announcing a Call to Action for the American public for more education, access  and acceptance of breastfeeding.
In her Call to Action, Dr. Regina Benjamin detailed the plans of her "Call to Action to Support Breastfeeding," which includes greater cultural support of nursing at work, at home, and in the community.
"One of the most highly effective preventive measures a mother can take to protect her child and her own health is to breastfeed," Benjamin said during the briefing.
Mother's milk has been shown to reduce diarrhea, ear infections, pneumonia, and asthma and protect against obesity in babies, while it diminishes the risk of breast and ovarian cancer in moms, Benjamin said.
In a report accompanying the announcement, Department of Health and Human Services Secretary Kathleen Sebelius said that "for much of the last century, America's mothers were given poor advice and were discouraged from breastfeeding, to the point that [it] became an unusual choice in this country."
In her document, Dr. Benjamin presents irrefutable evidence about the benefits of breastfeeding including health benefits, psychosocial benefits, plus economic and environmental benefits.  Following surgeon generals before her, Benjamin endorsed a federal policy on breastfeeding. 

The American Academy of Pediatrics recommends that Moms begin breastfeeding as soon as possible following the baby's birth. Newborns should be nursed on demand or whenever they show signs of hunger including mouthing, sucking or rooting behaviors or increased awake/alert states. Crying is considered a late hunger cue. Newborns typically need to nurse between 8 to 12 times a day, until satisfied. There are growth spurts at 2 weeks, 6 weeks, 3 months where Baby may nurse more vigorously and more often. This is not a sign that milk production is decreasing. Nursing infants should not be given any supplements (water, glucose water, formula, etc.) unless there is a medical indication. Supplements are rarely needed when breastfeeding is properly accomplished. Pacifiers and bottles should be avoided -- at least until breastfeeding is well established to avoid nipple/flow confusion.
As birth professionals, regardless of if you are a physician, midwife, nurse, childbirth educator, doula or related professional, it is our duty to present the facts about breastfeeding.  Plus, in the event that a new mother absolutely wishes to breastfeed, she must be given adequate instruction for the safety of her baby.  Benjamin acknowledged that research indicates that the marketing of substitutes for breast milk has a negative effect on breastfeeding practices, noting that women who receive commercial discharge packs that include formula are less likely to be breastfeeding exclusively at 10 weeks postpartum than are women who do not receive them.
We encourage you to print out the Surgeon General’s Press Release, Fact Sheet and the entire Report, via the direct links below.  These documents will be further evidence that education about the benefits of breastfeeding will increase the numbers of American babies who are breastfed, and this will unequivocally benefits our society as a whole.

Read the Surgeon General’s Press Release  Click here 
Read/print the Fact Sheet
Download the entire Surgeon General’s Report

Friday, January 21, 2011

Guest Blogger: Donna Walls RN, IBCLC

Our Second Guest Blogger of 2011 is Donna Walls RN, IBCLC.  She has had many years of experience helping mothers and babies breastfeed. She lives in Dayton Ohio and works as a nurse and Lactation Consultant. If you would like to be a Guest Blogger at Childbirth Today, email us at!

Many new mothers worry about their milk supply. Do I have enough milk for my baby? In the first days after birth¸ it’s the number one question mothers ask.  In  reality for the vast majority of women, the answer is yes. There is only a very small, less than 1% chance, that a woman’s breasts lack enough glandular tissue to provide adequate breast milk for her infant.

There are some issues that can create concerns; early introduction of contraceptive hormones or some anti-depressants, unnecessary supplementation in the first days of life, infant suck problems such as tongue-tie, and exposures to environmental endocrine disruptors such as plastics and pesticides.

So what can we do to ensure a good milk supply?
Nurse your baby as soon as possible after birth, preferably within the first 60 to                      90 minutes after birth and make sure the latch is comfortable, feeling only a tugging, pulling sensation on the nipple. If you feel the latch is not good ask your nurse or lactation consultant for assistance.

Keep your baby with you in the hospital and spend as much time as you can skin to skin. Babies love the calming closeness of skin to skin and smelling the milk in your breasts can encourage early feedings.

Nurse your newborn on demand¸ whenever they show signs of hunger such as mouthing motions, restlessness, fussing sounds. Offer the breast- if they are hungry they will eat and if not, they won‘t! Forcing feedings in the first 24-28 hours is not necessary and may interfere with the natural rhythm of breastfeeding.  Colostrum is very concentrated and provides the newborn with all the nutrients they need in fewer feedings.

 Most newborns will have some shorter “snacking” feedings and some longer “meals”. They commonly eat in clusters of feeds, usually followed by a stretch of sleep. This cluster or feeding frenzy period is normal and not a sign that the mother doesn’t have enough milk- no supplementation is necessary. Establishing this request and supply system of communication between mother and baby sets the stage for a good milk supply.

What if I notice my milk supply diminishing after it is well established?
First go back to the basics. Make sure you are nursing, pumping or hand expressing at least 8-10 times a day, remember milk production is request and supply, so the more you ask you breasts to do, the more they produce!

Many foods and herbs have also been shown to enhance milk supply. Many mothers notice an increase in supply with a daily bowl of oatmeal or adding brewer’s yeast tablets to food. Traditional cultures have used barley, anise, garlic, dill, caraway and alfalfa to assist mothers in making milk for their babies.

Herbal medicines taken as teas, tinctures or capsules have also been used successfully for increasing milk supply. Some of the most common herbs used are: fenugreek, fennel, blessed thistle, goat’s rue, hops, marshmallow and nutritive herbs such as nettle, spirulina or kelp.

The drug Reglan can be prescribed for increasing supply. This drug was originally used for gastrointestinal upset but has been shown to improve lactation.

Monday, January 17, 2011

Illinois Hospital Bans Elective Deliveries Before 39 Weeks

Edward Hospital in Naperville is one of six Illinois medical centers chosen to be part of a March of Dimes pilot program calling for a halt to elective deliveries before 39 weeks of pregnancy.

According to hospital officials, a critical part of the success of this program is patient education.  In the article that appeared in the Beacon News on January 15, "As our culture shifted toward a more relaxed attitude about delivering early, it was apparent education was needed by both patients and medical staffs."

The obvious solution to the patient education need is childbirth education!  However, the education for medical staff may be a little more tricky.  Due to the limited OB curricula in nursing schools and residency programs, few nurses or physicians are trained (and therefore skilled in) the art of supporting women through what is known as physiologic birth.  Physiologic birth, formerly known as natural childbirth or normal birth, involves honoring the mechanics and hormonal responses of the body for birth, limiting interventions and medications, and enhancing the physiologic/mind/spiritual link between mother and baby.  Even though the number of interventions in childbirth has increased exponentially in the past decade in the U.S., the U.S. maternal and infant mobidity/mortality has NOT improved; rather those statistics have gotten progressively worse.  It becomes clear that an increase in intervention during childbirth does NOT improve outcomes.

Some call this hands off method of childbirth the midwifery model of care.  Rather than label it and cause a riff in the maternity profession, call it what it is....physiologic birth.  Stop quibbling.  And honor physiologic birth for reducing the admissions of near-term/preterm infants into the NICUs.

The article goes on to make these points:
"Based on data, hospitals participating in the 2011 March of Dimes project can expect to reduce pre-term births and admissions to the NICU by 15 to 20 percent, Crouse said. That is significant from both a health and cost perspective. The typical hospital bill for a full-term baby is about $2,000, he added. That can be 10 times higher when a baby is in the NICU."
We applaud all of the hospitals who are joining with the March of Dimes in this endeavor!  Seventeen Illinois hospitals applied to be part of the March of Dimes program. Others that were selected are Decatur Memorial Hospital, St. Elizabeth’s Hospital in Belleville, St. Joseph Hospital in Breese, Katherine Shaw Bethea Hospital in Dixon and the University of Illinois Hospital at Chicago. Also participating are five hospitals in California, Texas, New York and Florida.

Monday, January 10, 2011

Guest Blogger: Jodi Hitchcock

We welcome Jodi Hitchcock, MSW as our first Guest Blogger of 2011!  If you would like to be a Guest Blogger in 2011, email us at!

Living in the North East, the passage into a new year is often a bittersweet one.  After the hustle and bustle of the holiday shopping, eating, visiting and overall merriment, we enter into the dreaded long months of winter in its fullest.  Although we have had a substantial amount of snow and cold for several weeks now, it does not seem as foreboding when you are in the midst of the holiday cheer.  Come January 1st, winter feels as though it will never end.

This feeling was never more intense for me than the first winter after I had given birth.  My first birth experience, my daughter who was born in October 2000 at 36 weeks gestation and after a very traumatic delivery, left me feeling a range of physical and emotional pain I had never felt before.  At that time, given what I had been through, my family, friends and doctors all dismissed what I was experiencing as “normal” and “to be expected”.  As a 23-year-old first time mom, who was I to question all of these wise and worldly individuals?  They told me it was normal… so it must be normal!  It was ok that I cried constantly, that I felt overwhelmed by the needs of my new premature baby and that I could not sleep without horrible dreams of her delivery (yet all I longed to do was sleep).  It was “normal” that I was absolutely terrified to walk down the stairs with my baby because I was certain my arms would go limp and she would tumble down the stairs.  I was living a nightmare… that I was assured was “normal”.  I wanted desperately to feel the sun on my skin and to breathe fresh air.  Unfortunately, where I live, sun is MIA for about 6 months of the year… and I was right at the start of that 6 months.  Bundling up my new baby for a crisp walk was not an option since she was considered to have a weakened immune system and she had difficulty maintaining her body temperature.  So in we stayed… a prisoner in my own home is how I felt.  I loved my baby, I think, but I also resented how her birth had left me feeling.

At that point in my life, I had vaguely heard of postpartum depression (in news reports of Andrea Yates-the mother who killed her 5 children *).  I knew that I was not capable of harming my baby, so the thought that I could be experiencing the same thing that she had never crossed my mind.  My doctors never mentioned it or screened for it… so it all must be normal, right?  WRONG!!  After 2 more children… and each postpartum period worse than the others… I finally got what I had desperately needed in the beginning; answers, a diagnosis, acknowledgement that what I was feeling was not normal and most importantly, treatment. 

As a social worker, I have been able to use my horrific personal experiences by dedicating my career to the perinatal population.  I have spent the past 6 years researching, studying and working with women and families who have experienced perinatal mood disorders (PMD’s).  My goal is to help eliminate the shame, the judgment and the fear of those suffering from PMD’s and to help educate the perinatal professional community so that women are able to receive help as soon as possible.  I am excited to spend 2011 as a guest blogger on the Child Birth Today site and I hope to offer some insight, both personally and professionally, on perinatal mood disorders.  

*I now know that Andrea Yates did not have postpartum depression, but did have postpartum psychosis.  This is a much more severe mental illness that can lead to infanticide and/or suicide and is extremely rare.

About the Author: 

Jodi K. Hitchcock, MSW is a mother of 4 amazing children (ages 10, 8, 6 and 16 months) and the stepmother to a wonderful 14 year old.  She currently works 24 hours a day as a stay-at-home mom to those lovely children.  In addition, Jodi works as an independent consultant providing perinatal support, education and outreach to mothers, couples and families experiencing PMD’s.  In addition, she conducts training seminars and provides outreach education to other perinatal professionals.  After experiencing a variety of PMD’s during and after her pregnancies, Jodi is able to provide a unique combination of personal and professional knowledge to the people she works with.  Jodi especially loves to work with pregnant women who are experiencing or are at risk to experience a PMD so that she may empower them through education and prevention techniques so that they may have the best possible birth experience!

Tuesday, January 04, 2011

The Evidence Says: Friedman’s Curve Essential to Reducing Cesarean Rate

For nearly 60 years, the (Dr. Emanuel) Friedman’s curve has been the gold standard by which maternity care givers have managed a woman’s labor.  It is one of the very first things that physicians and nurses learn in school.

The curve, depicted in graph form, shows the progress of labor where cervical dilation and fetal descent are plotted on a vertical axis.  Along the horizontal axis is the element of time.  Like a mathematical graph, the Friedman’s curve is divided into stages and phases of labor.  When there is a disparity in the slope of the curves, labor is termed dysfunctional.

Studies done during the first decade of this century demonstrate that the parameters to determine if labor is progressing need to be expanded.  The reasons for expansion may be the increase in medical technology, specifically the rise in epidural anesthesia and subsequent inactivity during labor which can prolong the labor.  A study published in 2004 in the Journal of Obstetrics, Gynecology and Neonatal Nursing (Cesario, S. Reevaluation of Friedman’s Labor Curve: a pilot study.  2004 Nov-Dec; 33(6):713-22) suggested  “With the availability of technology to assess maternal and fetal well-being, labor should be allowed to progress past the rigid 2-hour time limit for the second stage of labor artificially imposed on women in some childbirth settings. More emphasis should be placed on the nursing assessment techniques used to reassure the family and health care practitioners that labor is progressing safely and the nursing interventions that may have an impact on the length of each stage of labor.”

From an article on, current definitions of labor protraction and arrest may be too stringent, Dr. Jun Zhang of the National Institute of Child Health and Human Development, in Bethesda, Maryland said at the 2002 annual meeting of the Society for Maternal-Fetal Medicine. "And the long-accepted Friedman curve may not be an accurate description of normal labor progression, according to a new analysis of data from 1,329 nulliparous women aged 18-34 undergoing singleton, vertex presentation deliveries following spontaneous labor," said Dr. Zhang.

Based on the speed of overall labor progression and current cervical dilation, Dr. Zhang and his colleagues calculated the expected traverse time for the cervix to reach the next centimeter and the expected rate of cervical dilation at each phase of labor. "Our curve is very different," Dr. Zhang said, pointing out that on his curve the average was 5.5 hours for progression from 4 cm to 10 cm, compared with 2.5 hours on the Friedman curve.

"We also didn't see a deceleration phase," he said, noting that in 1978 Friedman modified his curve, but the distinctive sharp upturn remained, as did the deceleration phase. "Our data suggest that most women enter active labor at different times, mostly between 3 cm and 5 cm dilation, and even in the active phase the speed of progression varies from person to person," he further explained. The median time for cervical dilation to progress from 4 cm to 5 cm in the present study is 1.7 hours. And for fetal descent, it could take 3 hours to progress from station +1 to +2, and an additional half hour from station +2 to delivery, he added. "Therefore, the definition of protracted descent or arrested descent appears to be too stringent in current practice," according to Dr. Zhang.  Read more

Dr. Zhang again calls into question the use of the Friedman’s curve in 2006 and refines insight into labor progress, the diagnostic criteria for labor protraction and arrest disorders.

And in December of 2010, Zhang again questions existing practice by the study gathering data from over 62,000 birthing women.  Their conclusions were as follows:

"Judging whether a woman is having labor protraction and arrest should not be based on a research definition of an average starting point or average duration of labor," the researchers write. Instead, an upper limit of what is considered 'normal labor' should be used in patient management. "As long as the labor is within a normal range and other maternal and fetal conditions are reassuring, a woman should be allowed to continue the labor process."
The differences they observed could be due to the fact that women giving birth are older and heavier, on average, than they were when Dr. Friedman's labor curves were developed, the researchers note; "these factors are known to affect labor progress and duration."
Therefore, based on several large studies and over a decade of research, the evidence says that the rate of cervical dilation accelerated after 6 cm, and progress from 4 cm to 6 cm was far slower than previously described. Allowing labor to continue for a longer period before 6 cm of cervical dilation may reduce the rate of intrapartum and subsequent repeat cesarean deliveries in the United States. Clinging to the original Friedman’s Curve may “cause” an increase in cesarean section.


"The Length of Active Labor in Normal Pregnancies," by Leah I. Alberts,CNM,PhD: Melissa Schiff, MD; and Julie G. Gorwoda, CNM,MSN. Obsterics & Gynecology. 87(3):355.359, March 1996.

“Contemporary patterns of spontaneous labor with normal neonatal outcomes” by Jun Zhang MD and others.  Obstetrics & Gynecology. 2010 Dec;116(6):1281-7.

Monday, January 03, 2011

The Evidence says: Childbirth Education Is A Vital Part of Maternity Care

The Healthy People 2020 initiative for Maternal Child Health is supported by clinical recommendations from the US Preventive Services Task Force (USPSTF).  The USPSTF is an independent panel of non-Federal experts in prevention and evidence-based medicine and is composed of primary care providers (such as internists, pediatricians, family physicians, gynecologists/obstetricians, nurses, and health behavior specialists).
The USPSTF conducts scientific evidence reviews of a broad range of clinical preventive health care services (such as screening, counseling, and preventive medications) and develops recommendations for primary care clinicians and health systems. These recommendations are published in the form of "Recommendation Statements."
In reading through the Healthy People 2020 initiatives, it is plain to see that many of the initiatives could be accomplished with comprehensive childbirth education classes, taught by certified childbirth educators, and enthusiastically and positively promoted by physicians and midwives early in the pregnancy of every woman.
The very fact that Healthy People 2020 initiative MICH-12 calls for an increase in the proportion of pregnant women who attend a series of prepared childbirth classes is proof enough that childbirth education classes are important.  Numerous studies (available with abstracts) are listed on the US National Library of Medicine/National Institutes of Health website, extolling the virtues of childbirth education classes in improving maternity care.  However, not all providers of childbirth education classes devote curriculum to the dissemination of evidence-based information.
The U.S. maternity care system, with the escalating cesarean section rate, increase in near term newborns from an increase in elective inductions,  and a standard of maternity care that is intervention based rather than health based, is truly at a cross roads.  We can no longer sit back and debate whether maternity care is evidence-based.  We have seen that over and over again, in most cases, it is not.
Judith Lothian wrote in the winter 2009  issue of the Journal of Perinatal Education, “It is a challenge to present the “best evidence” when hospitals provide care that is decidedly not evidence-based. Childbirth educators and nurses too often feel pressured to encourage women to comply with hospital policies and routines or are pressured to withhold information or present information in ways that do not challenge women's prior thinking. Our mandate to assist women in making informed decisions, including making them aware of their right to informed refusal, creates never-ending dilemmas for many childbirth educators (as well as many nurses, midwives, and physicians). It is extremely difficult to move from principles to practice!
What can be done to “fix” this seemingly impossible situation?
We need only to take a brief visit back to the 1960s and 1970s when maternity care faced similar challenges. 
1)      Childbirth education must be taken back by certified childbirth educators (either nurses or non-nurses).  Not all nurses have the qualities to be an educator; conversely, not all educators need to be nurses.  Medical schools and nursing schools prepare the students for crisis intervention and rarely prepare students to work with the laboring female body in a physiologic manner.  To this end, those who teach childbirth education absolutely must be trained and certified by organizations who will give them the knowledge of physiologic birth.
2)      Childbirth education must be community based so that the freedom of sharing unbiased, evidence-based information is preserved.  Fear of job loss is evident in areas where childbirth education is taught by hospital employees.  Failure to conform to non-evidence based mandates ultimately result in sanctions or job loss.
3)      Childbirth education must be taught with a standard of credibility, excellence and adherence to the evidence, regardless of the organization of certification.
4)      Childbirth education must have at its core the right of every pregnant women to base her decision-making during pregnancy, birth and parenting on informed consent.  With journals dedicating entire issues to informed consent, numerous conference devoting speakers to teach about informed consent and federal acts/professional practice guidelines defining and mandating informed consent, the inconvenient truth is that not every American woman has the opportunity to exercise this right during childbearing.
5)      Childbirth education must strongly advocate for women as it did in the 1960s and 1970s.  Childbirth education must NOT be adversarial. We must use a variety of marketing strategies to campaign for healthier mothers and babies through evidence based maternity care.  We must shine the light of truth on the fact that U.S. maternity care is not evidence based; that it is based on old information, convenience and intervention. 

Contact your certifying organization and ask them what their Strategic Plan for 2011 entails. This is the best way to know if your organization is working toward this goal.  Then, take these five “musts” and see how you can incorporate them into your community.

Sunday, January 02, 2011

The Evidence Says...Returns!

Early in 2010, I began a series of blogs called "The Evidence Says".  It examined several widely known practices and the differences between the practices and the evidence.

Several readers have asked me to do the series again this year...with different topics.  So in the next few weeks, we will take a look at some of the Healthy People 2020 initiatives and how they will impact hospital practices.  We'll also look at the facts surrounding both the initiatives AND the practices ~ how do the current practices differ from the research?

It will be interesting to read...and research!

Happy New Year all!