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Study: Home Birth With Midwife as Safe as Hospital Birth
Posted 9/3/2009 8:20 PM
By Amanda Gardner, HealthDay
Having your baby at home with a registered midwife is just as safe as a conventional hospital birth, a new study says.
In fact, planned home births of this kind may have a lower rate of complications, according to the study published in the Sept. 15 issue of CMAJ.

Even though the study was conducted in Canada, where attitudes toward midwifery are more accepting than in some other countries, the findings may help to calm an ongoing controversy in the United States and elsewhere.

The American College of Obstetricians and Gynecologists is opposed to home births, as are certain organizations in Australia and New Zealand. More organizations in Great Britain are supportive and Canadian provinces are currently transitioning to midwifery, said study lead author Patricia Janssen, director of the Master of Public Health Program at the University of British Columbia.

Janssen, a registered nurse who has midwife training though not certification, said: “People who function as independent midwives are not necessarily tightly regulated [in the U.S.] depending on which state you’re in, so there may not be a guarantee that they have had an adequate level of training or a certified diploma or anything like that. And they may not be monitored and regulated by a particular professional college.”

The controversy has resulted in a lack of clear regulation and licensing requirements in the United States, said Dr. Marjorie Greenfield, associate professor of obstetrics and gynecology at University Hospitals Case Medical Center in Cleveland.
According to Greenfield, the National Association of Certified Professional Midwives does have a certification process but many states don’t recognize it. “If you’re a woman who wants to have a home birth, how do you determine if this person has appropriate qualifications?” she said.

The authors of the new study compared three different groups of planned births in British Columbia from the beginning of 2000 to the end of 2004: home births attended by registered midwives (midwives are registered in Canada), hospital births attended by the same group of registered midwives, and hospital births attended by physicians. In all, the study included almost 13,000 births.

The mortality rate per 1,000 births was 0.35 in the home birth group, 0.57 in hospital births attended by midwives, and 0.64 among those attended by physicians, according to the study.

Women who gave birth at home were less likely to need interventions or to have problems such as vaginal tearing or hemorrhaging. These babies were also less likely to need oxygen therapy or resuscitation, the study found.

The authors acknowledge that “self-selection” could have skewed the study results, in that women who prefer home deliveries tend to be healthier and otherwise more fit to have a home birth.

Janssen said she hoped “this article will have a major impact in the U.S.” But there is a definite “establishment” bias against home births. And the issue is an emotionally charged one, she said.

“There is a political and economic issue about controlling where birth happens, but also a deep belief by physicians that it’s not safe to have your baby at home,” Greenfield said. “Doctors see every home-birth patient who had a complication, but we don’t see the ones that have these beautiful, fabulous babies at home who may breast-feed better or have less hospital-acquired infections. There may be medical benefits,” she added.

“Midwifery needs to be regulated. It can’t be under the radar because then it’s dangerous,” Greenfield said. “There has to be a regulatory process and a licensure process [to protect] women who are going to choose home birth anyway.”

Article in the Wall Street Journal

Healthier Births and Babies—With Midwives

Modern American obstetrics is great at reacting to catastrophe, but less skilled at preventing it

By Nathanael Johnson
Something has gone wrong with the way that we handle birth in this county. After nearly a century of progress, deliveries are now getting more dangerous rather than less so. The number of women who go into shock during childbirth has more than doubled in the past decade, and those who suffer kidney failure rose 97%. Globally, we are tied with Belarus in maternal mortality.
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After a century of progress, deliveries are getting more dangerous rather than less so.

As we look for solutions, we’d be well served to examine a remarkable 1920s success story that has almost been forgotten. The key was taking a more personal approach, with a focus on prenatal care, in the style of British midwives. While Americans treated birth as a medical event performed on the mother, British midwives learned that birth was a physical event, performed by the mother.

In 1923, Mary Breckinridge started the Frontier Nursing Service in rural Appalachia. At that time, nine women died for every 1,000 births in the U.S.—a rate 100 times higher than we see today. And in these deep hollows, where people were cut off from medical care, the risk for pregnant women was even greater. Breckinridge changed all that when her horseback midwives began riding out into mountain snowstorms to deliver babies by candlelight.

Within a decade, the astonishing impact of that care was apparent. (Breckinridge recruited Louis Dublin, vice president and statistician at the Metropolitan Life Insurance MET +1.71% Company, to do the numbers; the results were published in 1932.) The women the Frontier Nursing Service cared for, who were desperately poor and usually gave birth at home, were 10 times less likely to die in childbirth than the average American at the time. The nation as a whole wouldn’t catch up until the 1950s, after the widespread acceptance of antiseptic and the discovery of antibiotics.

There was nothing mystical about this improvement. The midwives simply understood that, instead of focusing narrowly on the birth, they needed healthy families to produce healthy babies. They treated snakebites, fevers and men shot in feuds. They made frequent house calls—18 prenatal visits and 12 postpartum checkups were standard for an uncomplicated pregnancy.

Today, there are a few modern Breckinridges. Among low-income minority women in Washington, D.C., 15% give birth before term, and 14.5% of their babies are dangerously small. But when those women work with the midwives at the Family Health and Birth Center, the preterm birthrate is just 5%, and the rate of low-weight babies is 3%.

The standard response to health problems in the U.S. is more: more hospitals, more highly skilled surgeons, more access to the top technology. But we know for sure that at least some of the increasing danger of birth has been driven by the medicalization of the process. For example, a rare but often deadly condition where the placenta grows into a scar left by an earlier C-section has increased fivefold since the 1980s.

Of course, the idea that increased medical care is causing harm is controversial. Many argue that the benefits of C-sections outweigh these complications and that the real reasons that birth has gotten riskier have to do with a changing population; women are giving birth later in life, they are more likely to be obese, more likely to have heart disease. All of this is true. The profile of the American mother has changed, and she’s much more likely to have a C-section. We should be trying to solve all these problems, and midwives are uniquely equipped to address them.

The great strength of American-style obstetrics is in reacting to catastrophe. But we’re terrible at preventing catastrophes before they happen. While our traditional obstetric mode is reactive, the style of midwifery demonstrated by the Frontier Nursing Service is proactive. A low-tech, high-touch approach has been shown to effectively lower rates of C-sections and early births in several modern cases. Moreover, this personal, coaching approach is the most effective way to address chronic problems like obesity and diabetes.

Facing these chronic problems head on would have profound effects, lasting long beyond delivery. Birth is one of those inflection points where it is possible for people to change their lives, and midwives can assist in that process. Thundering in on horseback, as in Breckinridge’s day, is optional.

—Mr. Johnson is the author of “All Natural: A Skeptic’s Quest to Discover If the Natural Approach to Diet, Childbirth, Healing, and the Environment Really Keeps Us Healthier and Happier,” to be published this month by Rodale Books.A version of this article appeared January 19, 2013, on page C2 in the U.S. edition of The Wall Street Journal, with the headline: Healthier Births and Babies—With Midwives.

Fetal Lungs Protein Release Triggers Labor to Begin

We’ve long known that a mammal’s lungs are the last organ to develop inutero before it is baby’s time to exit. Disrupting this normal process (and initiating/inducing labor to start before a baby triggers labor on his/her own) frequently causes a cascade of complications – from difficulty in latch, poor breathing, increased infection, decreased immunity, under development, failure to thrive, and an increase in SIDS.

Now, University of Texas Southwestern Medical Center at Dallas researchers have found that it is in fact the fetal lungs themselves which provide the signal to initiate labor.

Drs. Carole Mendelson, Jennifer Condon and Pancharatnam Jeyasuria published findings that a substance secreted by the lungs of a developing fetus contains the key signal that initiates labor.

The protein released from the lungs of a developing mouse fetus initiates a cascade of chemical events leading to the mother’s initiation of labor. This research, which has implications for humans, marks the first time a link between a specific fetal lung protein and labor has been identified, said Mendelson, professor of BioChemistry and Obstetrics and Gynecology and senior author of the study. Their research appears in the Proceedings of the National Academy of Sciences and is currently available online here.

The initiation of term labor is carefully timed to begin only after the embryo is sufficiently mature to survive outside the womb. Previous studies suggested that the signal for labor in humans may arise from the fetus, but the nature of the signal and actual mechanism was unclear. In this study, researchers found that the key labor triggering substance, surfactant, is essential for normal breathing outside the womb.

“We found that a protein within lung, surfactant, serves as a hormone of labor that signals to the mother’s uterus when the fetal lungs are sufficiently mature to withstand the critical transition from life in fluid to airbreathing,” said Mendelson.

“No one really understands what causes normal or preterm labor. There may be several chemical pathways that lead to labor, but we think that this surfactant protein, which is also produced by the fetal lung in humans, may be the first hormonal signal for labor to begin,” reported Mendelson, who is also co-director of the North Texas March of Dimes Birth Defects Center at UT Southwestern.

In humans the signaling protein, called surfactant protein A, or SP-A, also helps immune cells, called macrophages, fight off infections in the lungs of children and adults by gobbling up bacteria, viruses and fungi that infiltrate the lung airway.

“Women who go into preterm labor frequently have an infection of the membranes that surround the fetus, and the number of macrophages in the wall of the uterus increases with the initiation of preterm labor. When women go into labor in their own time, at term, they also have an increase in macrophages in the uterus,” Mendelson said.

This led the researchers to investigate whether there was a connection between what happens during normal labor at term and in infected mothers who go into early labor.

Mendelson continued, “This also raised the question: If bacterial infection can cause increased macrophage infiltration of the uterus in preterm labor, what is the signal for the enhanced macrophage migration to the uterus at term?”

In mice, the developing fetal lung starts producing SP-A at 17 days gestation; full-term delivery occurs at 19 days. The developing human fetus starts producing SP-A in increasing amounts after 32 weeks of a 40+week normal gestation, at which time the baby’s lungs are essentially developed. As the fetus “breathes” amniotic fluid in the womb, the protein is released into the fluid.

“The SP-A protein binds to macrophages in the amniotic fluid, macrophages that come from the fetus itself,” said Dr. Jennifer Condon, a postdoctoral researcher in BioChemistry and the study’s lead author.

The macrophages, activated by the protein, make their way through the amniotic fluid to the wall of the uterus. Once embedded there, they produce a chemical that stimulates an inflammatory response in the uterus, ultimately leading to labor.

Researchers also found that injecting a pregnant mouse with SP-A before day 17 of the pregnancy caused the mouse to deliver early. Injection of pregnant mice with an antibody that blocks SP-A function caused them to deliver late. This would cause us to believe that women who carry babies post 42 weeks (as is common in some family lines) may do so because the necessary SP-A function is happening at later date in gestation (starting at 34 weeks instead of 32 weeks, for example).

Identifying the receptors on the macrophages to which the SP-A protein binds will be the next step, Mendelson said. “We think that bacteria may be binding to the same receptor on the macrophages to cause preterm labor in women. The bacteria mimic the function of SP-A, initiating the chemical reactions that lead to premature labor. If we knew more about this receptor on amniotic fluid macrophages, we may be able to design therapies or inhibitors to block preterm labor.”

Other researchers participating in the study were Dr. Pancharatnam Jeyasuria, a research fellow in internal medicine and former fellow Julie Faust, now a medical student at Texas A&M University.

The research was funded in part by the National Institutes of Health and the Texas Higher Education Coordinating Board.

Dr. Bill Sears talks about getting baby to sleep:

Dr. Bill Sears talks about Juice Plus

Vaccine Excipient & Media Summary
Excipients Included in U.S. Vaccines, by Vaccine
This table includes not only vaccine ingredients (e.g., adjuvants and preservatives),
but also substances used during the manufacturing process, including vaccine-production media,
that are removed from the final product and present only in trace quantities.
In addition to the substances listed, most vaccines contain Sodium Chloride (table salt).
Last Updated February 2012
All reasonable efforts have been made to ensure the accuracy of this information, but manufacturers may change product contents before that information is reflected here. If in doubt, check the manufacturer’s package insert.

Routine Induction at 41 Weeks? Not According to ACOG!

I had yet another student this week being told she HAS to induce at 41 weeks. Unfortunately, 41 weeks has become the absolute cut-off for the vast majority of OBs these days.

Pitocin used for routine induction at 41 weeks.

Not even ACOG gets behind the arbitrary 41 week cut-off.

First off, nobody HAS to do anything, and I absolutely cringe when it is presented as something the patient has no choice in. Believe it or not, hospital policies/preferences and the LAW are two completely separate things, yet I hear of so many women going in for their induction against their will because “my doctor won’t let me go past 41 weeks.” Unless they have a gun to your head (in which case… call 911 – you’ve got bigger problems than induction at the moment!), it’s not a matter of them “letting” you do anything. Proper care should be a matter of discussing your options, and deciding from all of those options which is the best route in your individual situation.

But here is the most interesting little well-kept secret on the subject of the 41 week cut-off rule that so many OBs seem to cling to: ACOG, The American Congress of Obstetricians and Gynecologists, doesn’t even recommend routine induction at 41 weeks. In Practice Bulletin 55 (September 2004, Reaffirmed 2009) they cover the subject of Management of Postterm Pregnancy. You can find their official recommendations below. If you’re looking at the actual PDF of the bulletin, skip to page 5, where it says “Recommendations.” I’ll break down the recommendations given in the bulletin, because some of the terminology is confusing if you’re not aware of how ACOG already defines other terms.

I think the most important thing to remember when reading the recommendations below, is that “postterm” does not mean “past your due date.” ACOG considers “postterm” to be a pregnancy that has extended to, or beyond, 42 weeks (“term” is considered 37-42 weeks) as defined in the very first sentence of the bulletin, on page 1. So when they’re talking about management of postterm pregnancy, they’re referring to those pregnancies that have reached 42+ weeks.

The recommendations in bold are taken directly from the bulletin, and my plain-English explanation is in regular font.

  • Women with postterm gestations who have unfavorable cervicescan either undergo labor induction or be managed expectantly.
    Women who go past 42 weeks (postterm) who have a cervix that is not showing signs of being ready for labor (not softening, effacing, dilating) can either be induced or managed expectantly (closely watched, but not intervening until there is a sign that something [baby’s heart-rate or movement, or mom’s blood pressure, for example] are no longer in the normal, low-risk range.).
  • Prostaglandin can be used in postterm pregnancies to promote cervical ripening and induce labor.
    Prostaglandin (usually Cervidil® or Cytotec® – I am NOT a fan of cytotec, but that’s a whole different post!) can be used to soften, and “prep” the cervix, and can sometimes cause contractions, as well. Again, based on the first recommendation of either induction orexpectant management, prostaglandin administration is an option, not an absolute.
  • Delivery should be effected if there is evidence of fetal compromise or oligohydramnios.
    Delivery (doesn’t specify whether by induction or cesarean, as once true complications arise it needs to be taken on a case by case basis) should be caused to happen if there is evidence that the baby is no longer doing as well in the womb (often diagnosed by unfavorable heart-tones or decreased fetal movement) or abnormally-low amniotic fluid levels.

There is NOTHING in there about routinely inducing at 41 weeks, or anytime before 42 weeks, for that matter. It’s all about either inducing after 42 weeks, continuing to watch the mom and baby carefully, or inducing if there is some medical indication that baby seems to be in danger.

In the next section, there are further recommendations based not necessarily on evidence, but admittedly on consensus and expert opinion:

  • Despite a lack of evidence that monitoring improves perinatal outcome, it is reasonable to initiate antenatal surveillance of postterm pregnancies between 41 weeks (287 days; EDD +7 days) and 42 weeks (294 days; EDD +14 days) of gestation because of evidence that perinatal morbidity and mortality increase as gestational age advances.
    There is no evidence that more in-depth testing (non-stress test [NST], biophysical profile [BPP]) produces better outcomes, but it is still reasonable to begin doing these at 41 weeks because there is an increase in complications the further past your due date you get. This is a case where even though it hasn’t been shown to help, they feel like they have to do something.
  • Many practitioners use twice-weekly testing with some evaluation of amniotic fluid volume beginning at 41 weeks of gestation. A nonstress test and amniotic fluid volume assessment (a modified BPP) should be adequate.
    Many OBs do twice-weekly NSTs and amniotic fluid volume checks past 41 weeks. Note that it doesn’t go so far as to say that theyhave to… just that many do.
  • Many authorities recommend prompt delivery in a postterm patient with a favorable cervix and no other complications.
    Many OBs routinely induce moms at 42 weeks if their cervix seems ready, even if they are not experiencing complications. So this would be routine induction at 42 weeks if the cervix is favorable (not 41 weeks). Notice it isn’t worded as an official recommendation, just what many experts in the field recommend, which seems to leave it up to discretion, especially in light of the very first official recommendation of either inducing or managing expectantly.

Notice that in all of the recommendations, there is NOTHING in there about inducing routinely (without medical cause) at 41 weeks. The entire body of the recommendations above focuses on 42+ week induction options (or just continuing to watch closely and NOT inducing at 42 weeks!), as well as monitoring options beginning at 41 weeks. There is NOTHING about routine induction at 41 weeks.

If you are being pressured to induce right at 41 weeks and you’d prefer not to, this practice bulletin can be a very helpful piece of information when discussing WHY you’d prefer to give your baby a little more time to pick its own birthday! I’ve had more than one student use this information with an OB who was 100% set on induction at 41 weeks. Of course, no matter what, the decision is up to the patient… but it’s much less stressful when your provider can look at the recommendation and support you in your decision!

ACOG Practice Bulletin Number 55 (September 2004 / Reaffirmed 2009) – Management of Postterm Pregnancy

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