One for the 'Language Matters' files

Here is a geographer talking about once and future plans for how to redevelop an area:

“The debate about the footprint is history now,” Campanella says. “You can’t reintroduce that question six years later, given that the city, the state and the nation as a whole has already committed recovery dollars to rebuilding houses and fixing utilities. To go back and reopen the wound — it’s too late. The baby’s already born. Maybe next time we could revisit this. I hope there isn’t a next time. But of course there will be.” (emphasis added)

He's from Tulane, talking about the Lower Ninth Ward in Louisiana - the state with the highest cesarean rate, 39.7% in 2010. I was reading this article through quickly (fascinating, by the way) and thought, haha, funny mixed metaphor. Wounds, babies. Except on second thought, I think the metaphor here is a actually a c-section, functioning as the unmarked concept.

Making Birth Seem Like a Battleground

Like the whole world (as represented by my Google Reader and twitter feed) I am so eager to see what comes out of the Home Birth Consensus Summit (statements expected around November 1).

I have been thinking about the disservice the birth community does to itself when we frame the whole thing as a battle or a controversy or an issue completely shaped by the 'sides' that people are on. While Barbara Katz Rothman's midwifery model and medical model is really helpful, it has the unfortunate side effect of making birth seem like a battleground. (Also, though perhaps inescapably, conflates clinician habits with clinician credentials.)

Jill and Rixa were joking about regretting some of the anti-OB rhetoric from earlier periods in their blogs, and I thought it was really big of them to say so -- and that it's important for people to read it. I make this mistake still in my thinking, but I try to counter it:

Just like individual women's health choices and behaviors aren't the only/best way to approach the issue of a flawed maternity care system, individual clinicians' choices and behaviors aren't either. Both matter; both are relevant; both are reflections of many things, including that person's background, experiences, and the community and culture in which they exist.

Taking an individual or a group of individuals to task for their choices and behaviors is easy, and you can throw your whole righteous weight behind it. I've done it in a conversation or six. But it won't solve things.

So where to look instead? Hospitals? Alliances? Professional organizations? Or do we need to go a step further than institutions and try to figure out how to change the entire social context?

And how do we do that?

PS. If you haven't seen it yet, take a gander at Public Health Doula's post with the hilariously awkward title Stages of birth thinking (yes, I need a way better name for this).

Guest Post at Unnecesarean on Hospital Variation in Induction and Cesarean Rates

The lovely Jill asked me if I could write up a guest post for The Unnecesarean - a review of this article on the effect of hospital type (community or university) on labor induction and cesarean rates.

I'm planning to work on a similar topic - the association between different hospital characteristics and their cesarean rates - for a lit review in my Perinatal Epidemiology class. I'm delighted to see articles that look at birth outcomes with exposures other than maternal factors. It'd be easier if every cesarean section were an obvious outcome of a medical or personal factor that made it necessary, but the data just doesn't bear this out. This kind of research is a great step toward figuring out what's going on with the rising c-section rates and I am particularly excited about this lit review because I don't think - fingers crossed, or I don't have a topic - it's been done before, and I love the idea that my classwork could actually mean something to someone.

(Also, my inner feminist is itching to shout 'stop blaming women!' from the rooftops. Guess what? Maybe the 33% cesarean rate isn't because we're fat, or old, or unhealthy.)

Quick Hit on Midwifery Care and Disparities

Prepare yourself for the longest sentence ever:

• In a system where truly collaborative OB-midwifery care is a relative rarity and transfers/transports from home births or birth centers can result in terrible antagonism and poor treatment,

• and therefore many women are summarily (and possibly wisely, in this context) risked out of midwifery care in these settings,

• then to the extent to which midwifery care is associated with better outcomes,

• out-of-hospital midwifery care becomes a means by which the bad and worsening sociological disparities in perinatal health (by race especially, but also by insurance status and income, geography etc.) for both mother and child are exacerbated,

• because exactly those populations who could most benefit from midwifery care are systematically excluded from accessing it,

• due to the bigger problem of the fragmented system of maternity care.

Please, your thoughts?

Navelgazing

Lots of navelgazing lately about what I'm about regarding childbirth.

I would say right now I am mostly trying to hash out a spot somewhere between three angles on the topic:

One. The fact that many or even most aspects of modern American birth are not optimal for healthy mothers and babies, aka the public health angle.

Two. The severe lack of information, choice, and agency most women face in their childbirth experiences, aka the feminist angle.

Three. The devious little inner know-it-all birth nerd that thinks everyone should have a non-interventive birth and breastfeed as long as possible, aka the asshole angle.

Woops! I let that one come out of my virtual mouth. You know, I'm working on this, and I'll be frank and say that I haven't whooped it yet. I can talk big about how both One and Two are problems on a population/society level, not an individual level, but talk to me about a pregnant woman and the asshole wheels start spinning, true story.

In my head, this is wrapped up with a few other issues, which I hope to write about in the short term future:

A. The question of what actions my convictions about these issues compel me to.

B. Issues I seem to have with advocacy. And you know it's true because I once had to get told by a certain BU professor interested in childbirth that "Advocacy is real, you know." Doy!

In Which My Law Professor Sets a Question To Rest

Since I've had one session of my Public Health Law class, I now know everything about the law. In particular, the professor (unwittingly - this was not his particular topic) set up some tenets that relate to the periodic internetz question of the supposed 'alegal' status of midwives in states without laws about midwives, as follows:

1. In the United States, everything is legal unless it's illegal.

2. "Can [someone] be sued for [something]?" is never a meaningful question, because the answer is always yes, yes s/he can. (You can try it: Can I be sued for picking my nose? Yes I can.)

Rather, the meaningful question is "Can [someone] be successfully sued for [something]?" (Can I be successfully sued for picking my nose? No, probably not.)

3. QED, dudettes.

PS. I am being sassy. But I am also rather sure - 92%, say - that my conclusions here are correct. Please tell me I'm wrong if you know better.

Short labor, long labor

I have been thinking about the use of length of labor as an outcome of interest in scholarly papers about birth. If you search length of labor on Google Scholar, all 8 relevant hits on the first page assume that shorter is better.*

(Molly wrote a post about this from a birth story or personal perspective - that some women may find fast labors more frightening, and that her very long labor was wonderful for her.)

I'm not sure length of labor makes any more sense as a study outcome in populations, either. Is this really the ideal curve?

sciencey drawing

In a medical birth setting, providers are invested in speeding labor up; many common interventions serve this purpose. Since all of these interventions will not have been withheld in studies, the data is going to be a little warpy (technical term). This is like the data conundrum in looking at average length of gestation. Many women gestate their babies for much shorter than the norm, but few will remain pregnant way longer than the norm because they'll be induced to prevent it. Similarly, many labors will be much shorter than the norm, and few will be much longer than normal. (We can separate out labors/pregnancies that are shorter than normal because of medical interventions, needed or not, and those that are shorter than normal just because that's what that woman's body is doing, pathological or not.)

Why the professional bias toward shorter labors? My guess is because of the relationship between length of labor, failure to progress, and eventual cesarean section. It sounds dumb to say it, but short labors never fail to progress. Long labors do often result in c-sections, but as ever, it's important to think of cesarean as a medical decision, rather than a medical outcome. In some long labors, a c-section is really called for. In other cases, it's not - more time is what's needed.

Using 'length of labor' as a measurable outcome in published studies fails to distinguish these cases (and ignores overly short/precipitous labors) by looking at average length of labor and assuming that shorter means better. Women's experiences contradict this blanket statement; it seems like common sense does too.

Does anyone know of other writing or thinking on this topic?

PS. If you enjoy reading about babies and epidemiology and curves and stuff, try this out. It will either blow your mind or put you to sleep.

*(It took me like 30 seconds to realize that "Optimal length of labor contracts" was not a relevant hit. I'm thinking I've never heard the use of 'labor contracts' to refer to contractions ... then realize it's from an economics journal. Oh.)

2001-2010 Achievements in Maternal and Infant Health

Well, I'm only about three months behind on this, but the CDC's MMWR (Morbidity and Mortality Weekly Report - most exciting periodical EVAR) published a list of ten great public health achievements between 2001-2010.

Maternal and Infant Health

The past decade has seen significant reductions in the number of infants born with neural tube defects (NTDs) and expansion of screening of newborns for metabolic and other heritable disorders. Mandatory folic acid fortification of cereal grain products labeled as enriched in the United States beginning in 1998 contributed to a 36% reduction in NTDs from 1996 to 2006 and prevented an estimated 10,000 NTD-affected pregnancies in the past decade, resulting in a savings of $4.7 billion in direct costs.

Improvements in technology and endorsement of a uniform newborn-screening panel of diseases have led to earlier life-saving treatment and intervention for at least 3,400 additional newborns each year with selected genetic and endocrine disorders. In 2003, all but four states were screening for only six of these disorders. By April 2011, all states reported screening for at least 26 disorders on an expanded and standardized uniform panel. Newborn screening for hearing loss increased from 46.5% in 1999 to 96.9% in 2008. The percentage of infants not passing their hearing screening who were then diagnosed by an audiologist before age 3 months as either normal or having permanent hearing loss increased from 51.8% in 1999 to 68.1 in 2008.

Quoted from here with citations removed for readability.

So to summarize, in the last 10 years we've made gains in preventing neural tube defects (the best-known disorder in this category is spina bifida) by fortifying grains with folic acid, and we've done a better job screening for diseases at birth, allowing earlier treatment. The data about hearing screening is actually quite surprising to me - I would not have guessed that so recently, there was so much room for improvement. Of all the things you need to catch early! So I was glad to see that.

You know what I would have been gladder to see? Gains in lowering the maternal and infant mortality rates, and gains in prevention of low birth weight and prematurity. Namely, the same gains made from 1900-1999, except that those rates have stabilized and in some cases gone back up. Worse, there are awful, large and growing racial/ethnic disparities in all four of these areas. It's such an insidious process for an overall reduction in mortality/morbidity to disguise a growing disparity. My sense is that we're really far from a wide awareness and acknowledgement of this process (which I bet happens in lots of other areas besides maternal and child health).

Don the Imagination Hat

This post is inspired in part by Jill's "Lamenting the System" series at The Unnecesarean.

In late elementary and middle school I used to say I wanted to be an obstetrician, and if I put on my imagination hat, I can think about what it might have been like for me to have been an obstetrician when I came to learn about midwifery and physiologic birth.

I think I would have reacted in one of two ways: denial, or identity crisis.

Imagination Hat from here. 

I sometimes feel like trying to change current obstetrics so massively is a project similar to trying to make the oceans more user-friendly, when you should just be swimming in a river instead. ... That metaphor definitely sucked, but what I'm trying to say is: midwives.

Or like this: given the goal of all birth-related professionals providing optimal care to support physiological birth, and the reality of two (economically) competing professions that (at least to some extent) define themselves in opposition to each other, is it more realistic:

1. to try to get them to become more similar to each other, aiming to have both types of practitioners meet a single EBM standard (remember we have our imagination hats on)

2. to try to sort out separate spheres for them, eliminating or reducing the competition but perhaps dramatically shifting the number of practitioners in each (imagination hats I say!)

In scenario #1, we have something like midwives and midwives+ (who can provide surgical birth procedures when called for). We also have a style of practice that is completely unique within medicine (for all the talk about zebra hoofbeats and watchful waiting, at heart medicine is about acting to fix pathology; it is also not about preventative care and not about holistic health) and hence to get this kind of practitioner is going to require a total retooling of medical education for OBs. (The topic brings to mind Robbie Davis-Floyd on obstetrics education. Saying this makes me feel like a broken record, but I can't deny how big an impact Birth as an American Rite of Passage had on me.)

In scenario #2, we have midwives in charge of nearly all births from the get-go (home or hospital), with care transferred to OBs when there's a need for surgery. Of course, the sticking point here is that there are currently some 52,000 OB/GYNs and maybe (very rough) something like 10,000 midwives (in the US I mean). Because midwives have lower patient loads than OBs, this ratio would need to flip dramatically in order for all women to have access to midwifery care. The number of needed OBs would shrink while the number of needed midwives would skyrocket.

Frankly, both scenarios seem wildly unrealistic. I do acknowledge that there are doctors who provide care that looks very much like the midwifery model, but I think it's acknowledged that this is a personal choice and not a result of their training. In fact, obstetricians who practice like midwives probably experience a lot of censure from their colleagues, e.g. see here. And of course, a profession (especially one with a powerful trade organization) will not allow a huge shift in provider responsibilities without a fight.

Thoughts? Questions on this structure-less ramble? More recent stats on provider numbers? Anything? Shout it out in the comments.

My Birth Junkie Birth

Something bloggy and exciting happened this last week.  Jill at The Unnecesarean posted the 2007 Cesarean rates in the US, and I was inspired to create an accompanying visual.  I spent a while looking for a web app that would take a straightforward data set like that and generate a colored map, but didn't find anything.  So I put my mad Paint skills to work and made one myself, then sent it to her.  She posted it a few days later and it was then reposted on the ICAN blog.  How cool is that!

I later found this site which could have done the same thing, but my hand-made original was prettier anyway.

I'm using Jill's version of my map graphic, because she had the good sense to add a title and source!

Am Anfang

Before class today I popped up to the 12th floor library and checked out a book that At Your Cervix recommended, Midwifery and Childbirth in America by Judith Pence Rooks.  I'm a little nervous about my first birth-related book.  I have a bad habit of obsessing over a topic, then checking out a stack of books and never reading any of them - losing interest because the effort involved in continuing to learn is too great.  I'll keep you updated on progress.

In other news, class was fun.  This was the session I'd sat in on last semester, so the material was familiar.  We covered the Health Belief Model and the Theory of Reasoned Action, both in much simpler form than Wikipedia presents.  The professor is making the argument that most public health interventions are based on these or similar models, which are inaccurate representations of human behavior.  One of the texts for the class is Dan Ariely's Predictably Irrational, which I read after sitting in last semester.  I am definitely willing to buy that we should stop depending on human behavior to be rational.  What I haven't heard yet is an example of a successful intervention based on a model that takes this into account.

It also occurred to me to wonder if you get better results from these models for health behaviors that are less dependent on broad issues (socioeconomics, social inequity, lack of access, etc.).  The only example I can think of at the moment is hand-washing, say in the US, so we can assume the presence of clean water, bathrooms with soap in public places, and so forth.  Also assume with me for the moment that hand-washing habits are not greatly shaped by fundamental, underlying factors like those mentioned above.  Can you motivate people to adopt better hand-washing habits using one of the models above?  Is it that the models just completely don't capture behavior-related decision making, or is it that behavior-related decision making is usually so much more complicated and tied to all these other things?