A recent Bloomberg News Editorial came across my desk: Hospital Incentives Help Babies Determine Own Birth Dates. In the editorial, a two year project in Washington State showed that hospitals could indeed reduce their elective induction/cesarean rates and subsequently the number of weak babies admitted to the NICU. State health authorities studied health records and revealed that an astounding 15% of the 80,000 births were elective deliveries at 37 - 39 weeks; meaning that 12,000 elective early births took place in Washington State for no medical reason.
It is the assumption of many that health care providers are taught about physiologic birth during their years of training to become physicians or nurses. Sadly, this is not the case. Washington State legislature created a $10 million reward fund to be shared by hospitals that showed marked improvement on statistical data regarding early elective deliveries. Staff education was a part of the plan for many hospitals to reach the goal and partake in the reward. Piggy backing the reward was a decrease in Medicaid payments that hospitals received for uncomplicated Cesareans. But why did it take money to be the incentive to respect human beings and facilitate health pregnancy outcomes?
The evidence is clear and highly available. Anyone now can access the CDC, Cochrane Database or National Institute of Health to find that the US infant and maternal mortality/morbidity rates are higher than ever before despite the fact that the US spends more on health care than many other countries whose statistics in this area are much better. In a nearly 20 year period from 1990 to 2009, the number of near term babies (those born between 37-38 weeks) jumped 8% from 19% to 27% or more than 1/4 of the babies born. Babies who are born at 37 weeks are more likely to die in their first year and are more likely to have health problems.
In the October issue of Seminars in Perinatology*, authors Chauhan and Ananth stated:
Approximately 1 in 4 women in the United States
are induced, with up to 1 in 10-12 being induced for elective reasons.
National guidelines by the American College of Obstetricians and Gynecologists,
the Society of Obstetricians Gynaecologists of Canada, and the Royal College of
Obstetricians and Gynaecologists list 21 indications for inductions; however,
all 3 concur in only 14% women (3 of 21). An induction should be considered
appropriate if it meets the following 4 criteria: (1) concordant with women's
autonomous informed decisions and desideratum; (2) optimizes maternal-fetal
outcomes, including psychological maternal well-being; (3) congruous with
evidence-based medicine; and (4) cost-effective. A meta-analysis of 22
randomized trials noted that membrane sweeping reduces the likelihood of induction. Implementing policies to
prevent elective induction at 37-38 weeks provides conflicting results about the
rate of macrosomia and stillbirth at early term. We argue that a
well-designed randomized controlled trial, with adequate power to demonstrate
whether prohibiting elective induction increases the rate of
stillbirth or complications such as macrosomia, is warranted. Patient education
during their prenatal course is a promising strategy to decrease the rate of induction.
Were their efforts successful? Yes! Elective early deliveries were reduced 77%.This in conjunction with the statement that many hospitals in Washington reduced rates with patient and staff education demonstrates that education is the key to this entire dilemma.
If this doesn't constitute a mandate for childbirth education involving both parents and professionals, I don't know what does.
SP, Ananth CV. Induction of
the United States: a critical appraisal of appropriateness and reducibility. Seminars in Perinatology. 2012 Oct;36(5):336-43.
Hyperemesis gravidarum is a serious and debilitating
disease. Recently, Duchess Kate brought
to light this disease with her pregnancy.
Hyperemesis gravidarum or HG is a condition that typically
peaks during the late first trimester. HG is characterized by persistent and
excessive nausea, and vomiting that far surpasses the frequency of morning
sickness. With both nausea and frequent
vomiting, weight loss of more than 5%, dehydration, dizziness, fainting and
metabolic imbalances are common, including increases in liver enzymes,
increased hematocrit and abnormal thyroid levels. Women with HG often have nutritional deficiencies,
altered sense of taste and sensitivity of the brain to motion. Physical and emotional stress of HG is added
to the physical/emotional stress of pregnancy.
Mullin et al site postpartum implications of PTSD, motion sickness,
muscle weakness and infants with irritability, severe colic and growth
According to the HER Foundation, the Hyperemesis Education
and Research Foundation (www.helpher.org),
thiamine deficiency has been documented in women with HG and may lead to
Wernicke’s Encephalopathy. In the May
2002 issue of Obstetrics and Gynecology,
Spruill and Kuller stated that Wernicke’s Encephalopathy can be positively
impacted by early thiamine replacement, which may decrease the chances of
miscarriage. Women who have had visual
loss due to HG induced Wernicke’s Encephalopahy have been treated with thiamine
replacement and their vision has been restored.
In May of 2012, the HER Foundation held their first annual
Hyperemesis Gravidarum Awareness Day. The
purpose of the Day was to further the goals of their organization: finding a cure for HG, helping to develop a
universal treatment protocol with proactive components, eradicating
maternal/fetal mortality due to HG, and
the complications; provide education and support and resources. HER works along side many entities to further
research and disseminate information. The University of Southern California has
an excellent professional information page titled “Symptomatology and Outcomes
of Women with Hyperemesis Gravidarum as Reported in a Large Registry”. To access this pdf, click here. USC also has a pdf titled “Secular Trends in
Treatment of HG” – click here to access.
Not only is HG devastating, but so are the statistics. According to www.motherisk.org, NVP or nausea and
vomiting during pregnancy afflicts more than 80% of the pregnant woman
population with 0.5%- 2.0% of pregnant women having HG. This translates into an estimated 285,000
annual hospital discharges for US women with HG. An estimated 36% of women quit their job due
to HG, and only 28% return to the workforce.
The cost of an inadequately managed HG woman is estimated at
Treatments for HG may include a multitude of therapies including both complementary/alternative therapies and traditional therapies. These therapies may include accupressure, psychological counselling, IV hydration at home or in a hospital setting, Vitamin B-6, Ginger, antiemetics, sea sickness bands. If additional nutritional support is needed, a PICC line (peripherally inserted central catheter used for prolonged therapies) may be used.
The Duchess of Cambridge
While doulas and childbirth educators may see expectant
mothers after the incident of HG has passed, the psychosocial impact may
continue throughout the pregnancy and well into motherhood. Meighan found that women suffering from HG
may not benefit from regular prenatal education efforts and so postpartum
follow-up by the doula, childbirth educator or a postpartum doula may be
needed. However, in our classes or in
prenatal meetings with clients, mentioning HG might be an opening for helping
with postpartum issues or even helping friends/relatives of that woman who may
encounter HG. Spreading evidence-based
education plays a vital role in dealing with HG.
Chitra & Lath. Wernicke’s Encephalopathy with visual
loss in a patient with Hyperemesis
Gravidarum. Journal of the Association of Physicians in India. 2012 May;
Meighan & Wood. The impact of Hyperemesis Gravidarum on
Maternal Role Assumption. JOGNN 2005 Mar-April; 34 (2): 172-9.
Mullin, P. M., Ching, C.,
Schoenberg, F., MacGibbon, K., Romero, R., Goodwin, T. M., & Fejzo, M. Risk
factors, treatments, and outcomes associated with prolonged hyperemesis
gravidarum. Journal of Maternal-Fetal and Neonatal
Medicine. 2012 June 25(6), 632-636.
Spruill & Kuller.
Hyperemesis gravidarum complicated by Wernicke’s Encephalopathy. Obstetrics
and Gynecology 2002 May: 99 (5 Pt 2): 875
Last week, I found out that one US hospital had abandoned their efforts to achieve Baby Friendly status because of artificially inflated economic number presented to them. After 30+ years in this business, I thought I'd seen everything and had become accustomed...almost complacent...to this type of corporate attack on our mothers, babies and future societies. Oh, but wait. This angered me more than I can tell you. Fast forward to today when I viewed the trailer to the powerful new film, "Bottled Up - The Film". With an advisory board that includes IBCLCs, MDs, and PhDs plus moms who breastfed, this film is one that will shake the newborn world like "The Business of Being Born", rocked the birth world. As I watched this trailer, I was cheering that someone now shows the real dirty little truth about the business of formula companies and the cultural shift to bottlefeeding rather than the best food - breastmilk. Yet when I heard Bill Maher say that breastfeeding was a private function like masturbating or "pissing" - I got mad. View the trailer on their website here: http://www.bottledupthefilm.com/bottled-up-the-film/ It will encourage and empower you. And it could make you angry. What are we doing to future generations...for the almighty buck and for convenience?