Birth Story

The writer-humorist Calvin Trillin has said that his idea of alternative medicine is a doctor who was not trained at Johns Hopkins School of Medicine in Baltimore, Md. To the extent that Johns Hopkins is considered the gold standard of medical care, the institution's excellence owes much to its beginnings.

Johns Hopkins

Johns Hopkins, the son of prosperous Maryland Quakers (his first name was his great-grandmother's maiden name), made a fortune investing in America's first important railroad, the Baltimore and Ohio.

In 1867, he established funds for a university and hospital to bear his name, and when he died in 1873, he left $7 million for the two institutions, the largest gift ever bequeathed in America up to that point.

John Shaw Billings, a major in the U.S. army who had distinguished himself as a surgeon in the Civil War, and for his writings on, and criticism of, the care of sick and injured soldiers, created a plan for the hospital that reflected his keen interest in infrastructure, and his assiduous research into the best hospital designs in Europe.

John Shaw Billings

For example, he had the hospital wired for electricity years before it was on the grid. Johns Hopkins was also the first hospital in the country with central heating.

The measures Billings took to prevent the spread of disease throughout the hospital ranged from the horizonal layout of the wards, to the decision not to include elevators, to the elaborate ventilation system that prevented patients from breathing each other's air.

Billings also came up with the idea of a four-year medical school and favored a tough curriculum to weed out all but the best candidates. According the John Hopkins Medicine website, history has not given this remarkable man his due.

Getting the hospital up and running took 12 years. Even though many of the revolutionary ideas the institution embodied were his, Billings decided it was time to move on. He ended his career as director of the New York Public Library.

An early view of the hospital

Opened in 1889, Johns Hopkins Hospital had 17 buildings (three of which remain today, part of a 22-acre campus) and cost $2 million.

Johns Hopkins Hospital had no religious affiliation, which made some people nervous. In 1896, William Wallace Spence, a wealthy Baltimore businessmen, donated a large statue of Jesus Christ that still stands in the rotunda of the Billings Administration Building.

Remember, dear reader, I said there would be tangents. Now we are embarking on a trip to Baltimore, Md., and childbirth will barely be mentioned for a while.

In his groundbreaking 1982 book, The Social Transformation of American Medicine, Paul Starr plumbs the source of mainstream medicine's authority. Simply put, it comes from the public's dependence on the doctor's superior competence, real or perceived.

As the title of Starr's book suggests, doctors were not always able to lay claim to that authority. Indeed, before the germ theory was proved and methods of administering anesthesia devised, making possible the development of effective surgery, physicians had very little to offer. (That didn't keep them from practicing, though.)

But in Baltimore, late in the 19th century, with new technologies and understandings developing rapidly on all sides, events were unfolding that would help solidify the medical profession's authority.

Image by permission  http://creativecommons.org

Taffy Brodesser-Akner's first-person piece in the Los Angeles Times today about her impending birth is a candid, affecting counterpoint to a symposium the National Institutes of Health held last month in Washington, D.C.

With her first baby, born 2 1/2 years ago, Brodesser-Akner endured an emergency Caesarean section after 29 hours of labor, she writes. The experience left her traumatized. Now in the early weeks of her third trimester, waiting to deliver her second child, she is hoping for a vaginal birth after Caesarean, or VBAC.

The VBAC has been the subject of a lot of discussion lately. The NIH held a three-day conference on the topic that encouraged supporters of the VBAC -- and there are many -- by recommending that the VBAC be a more readily available option than it has been in the past.

In her essay, Brodesser-Akner writes, "I agree that women should have the right to try for a VBAC; I'm just not sure if they should try for one. Rather, I'm not sure if I should."

Of women who want a VBAC in a particular pregnancy, she writes, "the more honest and maybe the more uncomfortable way to say it, is that they want to give it a shot. They want a TOLAC, a trial of labor after a C-section."

Only 60 to 80 percent of women who attempt a VBAC actually get to have that vaginal delivery, Brodesser-Akner writes; the remaining women wind up getting another C-section. And perhaps 1 percent will have a uterine rupture (with a previous low transverse uterine incision, the most favorable for a VBAC; other types of incisions carry more risk), which can threaten the lives of both mother and child.

"When a uterus ruptures...things go wrong fast — and they go wrong big," she writes, adding that a high-risk obstetrician told her that one-quarter of those ruptures end in hysterectomies, brain damage and/or the baby's death.

"As that doctor said to me, 'The risk may be low, but it's 100% when it's happening to you,' she writes.

Brodesser-Akner is right. Every pregnancy is different, and I can assure you from experience that when you find yourself living out that small, shocking statistic, it is 100 percent real. And I am one of the lucky ones.

But why couldn't she be in that 60 to 80 percent of women who have the "normal" birth experience she says she desires? And if she births in a hospital with capable OB/GYNs who perform a good number of Caesareans -- and 24-hour anesthesiology coverage -- she should have the backup she requires in case of an emergency. That shouldn't be hard to find in Los Angeles.

Any birth can take a turn toward the worst-case scenario, and it's impossible to fully predict which ones actually will do so. It is probably all too easy for a woman who had a wretched experience during her last birth to imagine all the things that could go wrong.

But the numbers are with mothers in general; that is, the odds are in their favor. The fact that the pendulum might be swinging back toward a trial of labor in some challenging situations is, I think, a good thing. And I am by no means alone.

I would tell Brodesser-Akner what I tell my own daughters, not only about childbirth but about life in general: Don't let your fears rule your life. Don't be foolhardy, but don't think the cosmos is out to get you, either. I know it's a cliche, but it's true: The most dangerous thing many of us will ever do is ride around in  cars (or worse yet, on bikes), and nobody seems to spend much time worrying about that.

Whatever she decides, I hope Brodesser-Akner has a beautiful birth story to tell this time. It should be one of the best days of her life.

Image by Petteri Sulonen

My favorite book about a mother is To the Lighthouse, by Virginia Woolf. I read it for the first time only recently. I couldn’t believe how powerful it was.

I have had friends who loved To the Lighthouse. They usually admired the character of Lily Briscoe, an artist and independent woman who seems to stand in for Woolf herself in some ways. In the book, Briscoe visits a British family, the Ramsays, at their vacation home on a Scottish island before World War I.

Incredibly, to me now, anyway, my friends never talked about Mrs. Ramsay. I guess I can understand why they didn’t. Lily Briscoe was what we wanted to be at the time, serious women devoted to our art. Or at least that’s what we thought.

Mrs. Ramsay. Woolf doesn’t even give her a first name. Mrs. Ramsay is married to a celebrated intellectual who has come to Scotland with his favorite students. While he marches up and down the beach spouting great thoughts and obsessing about whether his work will live on after him, she is thinking about all the people in her home, her children and guests, and how she might make them happy.

Using the stuff of ordinary life, Mrs. Ramsay pulls off one magical evening in particular, even in spite of a number of glitches, that will stay with all of them for the rest of their lives, tying them with emotion and memories to that time and place.

I don’t want to trivialize a literary masterpiece, but that is what mothers do. Woolf is making that point, of course, that this woman who is almost part of the furniture to the people around her creates the moments that make their lives worth living.

I’m starting to think about Mother’s Day, and I hope you are, too, especially if your mother is still alive. Make that dinner reservation. Plan to give your mother something that will make her happy — flowers, a card, a phone call, a big kiss, or maybe a copy of To the Lighthouse.

Whatever your relationship with your mother, she is the only one you have.

Pregnant women were more likely to die in last year’s outbreak of the so-called swine flu than other people were, the Journal of the American Medical Association reports in the issue published today.

Pregnant women represent only about 1 percent of the population of the United States, yet they accounted for 5 percent of deaths from the H1N1 flu between April and August of 2009, according to an analysis of data from the Centers of Disease Control in Atlanta, Georgia, by Alicia M. Siston, Ph.D., of the CDC, and colleagues.

Taking antiviral drugs soon after they became ill greatly helped pregnant women who were hospitalized.

Of 788 pregnant women who were reported to the CDC to have become ill with H1N1 virus between April and August, 30 died. That was 5 percent of all swine flu deaths for the period. Of 509 women who were hospitalized, 115 were so sick they were admitted to intensive care units.

If they had waited four days after the onset of symptoms to go to a doctor, pregnant women were six times more likely to wind up in an ICU than if they sought treatment after only two days.

Pregnant women should be vaccinated against H1N1, and should be treated quickly with antiviral drugs if they do become sick, the authors recommended.

Two-thirds of the women who died in the final tally for the year were in their final trimester of pregnancy. “Changes in the immune, cardiac, and respiratory systems are likely reasons that pregnant women are at increased risk for severe illness with influenza,” the authors wrote.

The latest figures on global maternal mortality, which I've written about in the last two posts here on Birth Story, are encouraging. But are they correct?

The new figures, in a study funded by the Bill and Melinda Gates Foundation, are much more positive than the ones the World Health Organization came up with in 2006. Advocate groups fear that the brighter statistics will slow down progress on making birth safe for women in developing countries.

The New York Times columnist Nicholas Kristof, who has made a specialty of chronicling the dire state of women in the world's least prosperous areas, wrote in his blog "On the Ground" on April 16 that "when women die in childbirth in poor countries, nobody keeps track, and so all these figures are very rough estimates."

Imagine that. A mother dies, and nobody even writes it down.

I am a regular reader of Kristof's column, as he consistently mines the rich vein of human interest stories about indigent women.

Kristof has done some great video work on "On the Ground."  Video gives a face -- and a voice -- to the actual women who are living the difficult lives he writes about.

I would recommend taking a look at Kristof's videos from eastern Congo, although some of them are terribly upsetting, as many of these women have been brutalized in the political unrest there.

Here is one video that is simply illuminating, "What Are You Carrying?"

"Women have long delivered for society, and, slowly, society is at last delivering for women. This is a moment to celebrate—and accelerate," The Lancet editor-in-chief Richard Horton wrote in a commentary that accompanied the publication of a new survey on global maternal mortality the British journal published on Monday.

Four factors associated with maternal mortality are moving in a good direction in many areas of the world, according to the study published this week, which was discussed in the previous post here on Birth Story.

First, the global total fertility rate (TFR), which reflects births per woman, has come down considerably, from 3.7 children in 1980, to 2.6 in 2008. That is a good thing, as the TFR is closely associated with maternal mortality.

Secondly, per capita income is also up, especially in Asia and Latin America. When families have more money, women get more nourishing food, and are more likely to get access to medical care.

Women are also more likely to get some education than they were 30 years ago, which bodes well for a society in which mothers can give birth in a safe environment. Women 25 to 44 years of age in sub-Saharan Africa had 1.5 years of school in 1980, but now have 4.4 years of school on average.

And lastly, women are more likely to have skilled birth attendants in 2008 than they were thirty years ago. "Some large countries such as India have witnessed quite rapid increases in skilled birth attendance in recent years," the study reports.

Scratch that last post.

It appears that societies around the world are working to improve the survival rate for mothers in birth after all -- and that their efforts are working.

Even as I was tapping out Monday's post, The Lancet was publishing a new study online that shows that maternal mortality has actually been dropping dramatically in many countries.

"The overall message, for the first time in a generation, is one of persistent and welcome progress," Lancet editor-in-chief Richard Horton wrote in a commentary that accompanied the study.

The number of maternal deaths per year worldwide has been tallied at 500,000+ in 2005, based on United Nations survey published in 2007. However, the new study, which was conducted by researchers at the University of Washington and the University of Queensland in Brisbane, Australia, and funded by the Bill and Melinda Gates Foundation, shows deaths to have fallen from 526,300 in 1980 to 342 ,900 in 2008. That's good news.

Not only that, but taking out deaths from HIV/AIDS, which has emerged as a major factor in global maternal mortality, the figure would have been 281,500 in 2008.

More than half of maternal deaths are concentrated in six countries-- India, Nigeria, Pakistan, Ethiopia, the Democratic Republic of Congo, and Afghanistan, which has the highest maternal mortality rate in the world, this survey states. (Italy has the lowest rate, according to this report.)

The United States, Canada, Denmark and Norway are among the prosperous nations that are experiencing increases in maternal mortality (less than 1 percent for the U.S.). More comprehensive reporting could account for the increase, the researchers noted.

Not everyone is excited by the new survey's findings, Horton wrote in his commentary.

"Even before the paper ... was submitted to us, we were invited to “delay” or “hold” publication," by some members of  what Horton calls the "global health community" who fret that the relatively rosy picture the new study paints will lead to a flagging interest in working to make birth safer around the world.

Horton dismisses those worries, but expresses concern that the figures in the new report are so different from those in the 2007 UN survey.

"A process needs to be put in place urgently to discuss these figures, their implications, and the actions, global and in country, that should follow," he writes.

So it appears that MDG5, the Millennium Development Goal that has to do with improving birth safety for moms is, after all, alive and well.

"This new evidence suggests there is a much greater reason for optimism than has been generally perceived, and that substantial decreases in the (maternal mortality rate) are possible over a fairly short time," the report states.

Image by Petteri Sulonen

The world is seeing progress on such worthy goals as ending hunger and extreme poverty, conquering pervasive health menaces like AIDS and malaria, achieving universal primary education and ensuring environmental sustainability.

However, of the eight Millennium Development Goals the United Nations and partner organizations set in 2000 for achievement by 2015, lowering the number of the world's women who die in childbirth is the farthest from being met, according to UN Population Fund Executive Director Thoraya Ahmed Obaid, speaking at a meeting last fall  in Addis Ababa, Ethiopia.

"Women’s lives, dreams and rights have not been given the priority attention they deserve,” Obaid said.

"We know what works and needs to be done," Obaid said -- education, medical supplies and services that include prenatal care, the availability of skilled birth attendants and emergency obstetrical care.

But while funding for other health goals has risen significantly during this period, money tagged to improve reproductive health has remained static, Obaid said. And so the birth story continues to be a tragic one in 500,000 families throughout the world every year.

“It would cost the world $23 billion per year to stop women from having unintended pregnancies and dying in childbirth, and to save millions of newborns. This amounts to less than 10 days of global military spending. Instead, the world loses $15 billion in productivity each year by allowing mothers and newborns to die,” she said.

See more recent post, which contradicts this one!

One of the points Dr. Robert Wachter made in his speech at the ACOG meeting in May, 2009, was that everybody makes mistakes. True, people can wind up dead when doctors make mistakes, but everybody else makes mistakes, too.

To illustrate his point, Dr. Wachter showed a video from the BBC, "The Wrong Guy," the tale of two men named Guy who were waiting in reception areas in the BBC's London offices on the same day in 2006.

One was there to interview for a job.  The other, an expert on information technology, had been scheduled to hold forth on the network's News 24 program about a ruling in Apple Corp.'s suit against Apple Inc. The Beatles' music company and the computer firm had previously agreed to stick to their own businesses. But then came iTunes, and Apple Corp. sued Apple Inc. for alleged encroachment on its music brand.

A London judge ruled in Apple Inc.'s favor and the BBC invited tech expert Guy Kewney on to chat about the ruling. But it was Guy Goma, the unwitting job applicant, who was summoned from the waiting room for the interview.

The look on "the wrong Guy's" face when he catches on to who they think he is is priceless!