Birth Story

Often, the annual meeting of a medical group produces a flurry of scientific papers, but the meeting of the American College of Obstetricians and Gynecologists seems more like, say, a bunch of writers  getting together. (I attended the 2009 meeting in Chicago.) As a cohort, OB-GYNs seem to want to find out about the newest approaches, tools and techniques they might put to use in their practices, and perhaps exchange some stories from the trenches as well.

But here's something new for consumers from ACOG, which held its annual meeting in San Francisco this week. The fifth edition of Your Pregnancy and Childbirth: Month to Month was unveiled, along with a new companion website,  www.yourpregnancyandchildbirth.com.

While there are many pregnancy books, this one is "unique in the extent of the medical detail that it covers about all aspects of pregnancy, yet it is designed as an easy-to-read, helpful reference for all of those questions that inevitably pop up," said Hal Lawrence, MD, The College's vice president of practice activities in a press release on the ACOG website.

The latest edition of the book has a new chapter that addresses obesity and eating disorders, another devoted to diabetes during pregnancy, and a third covering other chronic diseases like hypertension, heart disease, celiac disease, lupus, and physical and mental disabilities.

"The majority of women do not experience severe complications, but we felt it was important to give a thorough overview so women will know if something's wrong and when to call a doctor," Dr. Lawrence said.

Another new chapter covers feeding the baby, and includes advice on both breastfeeding and the use of formula.

The American College of Obstetricians and Gynecologists was founded in Chicago in 1951, the latest in a line of associations that has sought to serve the organizational needs of specialists in medicine for women.

By the time the organization was founded, the controversy over whether the two specialties should be practiced separately or together had been largely resolved, which reflected an improvement of the status of obstetrics. (One 19th century proponent of keeping the two disciplines together had characterized obstetrics as "the portal to the temple of gynecology.")

Obstetricians are not the only doctors who deliver babies — family physicians attend about 20 percent of births nationally, and midwives, mostly nurse-midwives, handled about 8 percent of births in 2004. Still, obstetricians deliver the majority of American babies.

ACOG membership is voluntary. The group, now headquartered in Washington, D.C., has 52,000 members, more than 90 percent of board-certified OB-GYNs. Important ACOG activities include the annual meeting, continuing education and the publication of the monthly journal Obstetrics and Gynecology, the so-called Green Journal.

Some of  ACOG's members are specialists in maternal-fetal medicine, gynecologic oncology, reproductive endocrinology, and other areas.

The American College of Obstetricians and Gynecologists begins its annual clinical meeting today in San Francisco. And so, I guess, does the American Congress of Obstetricians and Gynecologists.

Where there was one organization, there now are two, and confusion abounds. I gather that even some ACOG members and staffers aren't sure exactly where the College leaves off and the Congress starts.

Here's "the basic explanation" I got from ACOG's press office when I inquired about the new name on the ACOG website:

The College and the Congress are two separate and distinct legal entities, although they are companion organizations.

The American College of Obstetricians and Gynecologists is a 501(c)(3) organization and its activities include producing the College's practice guidelines and other educational material.

The American Congress of Obstetricians and Gynecologists is a new 501(c)(6) organization that was formed December 31, 2008 and is operational as of January 1, 2010. The Congress focuses on socioeconomic, political, and grievance activities for its members.

Allow me one more post on this last day of Women's History Month about Anne Hutchinson, the midwife in the Massachusetts Bay Colony who was banished to Rhode Island for heresy.

The pregnancy Hutchinson had been carrying during her civil and ecclesiastical trials turned out to have been probably the first hydatidiform mole, or molar pregnancy, in New England, according to a 1959 article in the New England Journal of Medicine.

This freakish obstetrical event, which occurs in about 1 in 2,000 pregnancies in the United States today (it is 10 times more common in Asia), happens when a pregnancy goes awry and turns into a mass of tissue in the uterus. The mass might grow for several months, and lumps of tissue might eventually be "delivered." Such a "birth" event would likely be upsetting to anyone, but given the beliefs of the time, it carried a dark judgment on Hutchinson's state of grace.

She was safe in Rhode Island, but the event was sensational news. Imagine the response of her nemesis, Gov. John Winthop of the Massachusetts Bay Colony, when he heard that not only had Hutchinson attended Mary Dyer's "monstrous birth," but now had also delivered one of her own.

I can't stop wondering how Hutchinson felt about this. Although the austere religion practiced in the Massachusetts Bay Colony never allowed anyone to take salvation for granted, according to Calvinism, God's favorite people should be easy to spot: They prospered in this life as well as the next.

Hutchinson herself had had a comfortable life in England, and even in Massachusetts she was a member of the church, the wife of a prosperous textile manufacturer and the mistress of an elegant home right across the road from Gov. Winthrop's, according to Selma R. Williams in Divine Rebel: The Life of Anne Marbury Hutchinson.

Yet her life in America was one catastrophe after another. Hutchinson was a deeply religious woman. Did she feel God's presence so strongly that she was able to dismiss the evidence others saw of His disfavor? Or was she constitutionally unable to listen to people she judged unlikely conduits of the word of God? In any event, she spoke her mind, she stood for what she believed in, and she moved us all forward.

The Society for Maternal Fetal Medicine held its annual conference in Chicago last week, and I went to a few sessions. The physicians, who specialize in the health of mothers and their babies, spent up to six days in meetings, so I got a canape-size serving compared to theirs.

Research teams from all over the country, and from other countries as well, reported on their investigations into conditions that jeopardize mothers' and babies' health in pregnancy.  Several important findings came out of the meeting. Here are just a few:

* A simple new urine test with a cool name, the "Congo Red Dot Test," appears to be able to predict and diagnose preeclampsia, a condition that can kill mothers and babies, cause birth defects, and is a major contributor to pre-term birth. A research team from the Yale University School of Medicine found that the test accurately predicted preeclampsia in 347 women in their study. Preeclampsia symptoms include hypertension and protein in the urine. The condition affects 5 to 10 percent of pregnancies. It is commonly treated by delivering the baby.

* One of every three pre-term births is caused by a "silent" infection inside the uterus. Now it appears some women and babies are genetically more susceptible to inflammatory infections, according to a study led by Roberto Romero MD, Chief of the Perinatology Research Branch at the National Institute of Child Health and Human Development. The study won an award from the March of Dimes, a nonprofit group that works to prevent birth defects, premature birth and infant mortality.

At the SMFM meeting, the Yale U. School of Medicine also presented the results of a couple of other investigations that might lead to a decrease in preterm births as well.

What do women need when birth becomes difficult? The Averting Maternal Death and Disability program has identified a handful of intervention capabilities that should be in place for emergencies wherever babies are born.

These "signal functions" include having personnel on hand who are trained to administer drugs by injection -- antibiotics, anticonvulsants and "oxytocics," which can start or speed labor -- manually remove the placenta and other "products of conception" not leaving the body spontaneously, and perform assisted vaginal delivery -- with forceps, for example.

AMDD, a major initiative of the Mailman School of Public Health at Columbia University in New York City,  has worked with UNICEF and other partners for 20 years to bring down maternal-mortality rates in the developing world.

Its directive, issued in 1997, cites two additional interventions that might be necessary to save lives -- Caesarean section and blood tranfusion. These two go beyond the basics of a birth center -- in some parts of the world they are strictly wish-list items -- but they can often make the difference between life and death, as they did in our case.

AMDD doesn't include anesthesiology in its signal functions, although surgery is difficult without it.

We in the United States might view these interventions as humdrum, or even as irksome or worse if they become part of our own birth story, but behind the development of each one of them are amazing tales.

One big surprise of the WHO survey of Asian births was that "operative vaginal delivery" -- the use of forceps or vacuum -- had the highest death rate for mothers of any method.

Ninety-seven women died during the 108,000 surveyed births. Of those, 53 died during spontaneous vaginal births, as would be expected, given that those were the majority of births (75,000 deliveries), for a rate of less than .1 percent.

However, of 3,465 OVD births, nine mothers died, a rate of nearly .3 percent. In a commentary that accompanied the WHO report in the medical journal The Lancet, the editors called the figures "a sobering reminder of the dangers of operative deliveries," although they noted that most OVDs are "high-risk situations that cannot be easily avoided."

Twenty-three of the 16,500 mothers having Caesaean sections "with indications" during labor died (more than .1 percent), and one woman died of the 554 having elective C-sections during labor (a rate of nearly .2 percent).

The report also found that women undergoing elective Caesarean section were  far more likely to spend time after the birth in intensive care than women whose births were spontaneous.

The irony is that while many unnecessary C-sections are being performed in some areas, women in other areas who desperately need them are not able to get them, the WHO report notes.

The use of prenatal ultrasounds rose 55 percent for both high-risk and low-risk mothers in Ontario, Canada, between 1996 and 2006, according to a population-based study of nearly 1.4 million women published in the Canadian Medical Association Journal this week.

More than one-third of women delivering “singleton” babies had three or more outpatient ultrasounds during their second and third trimesters. Nearly twenty percent of prospective mothers had more than four ultrasounds in the second and third trimesters.

Two ultrasounds are generally recommended in uncomplicated pregnancies -- one in the first trimester, and another in the second, the report states.

The researchers, from Toronto-area facilities, led by John J. You MD, ventured that their findings are consistent with evidence accumulating in other health fields that "interventions most beneficial to high-risk individuals are frequently directed at low-risk populations."

Reasons for this, in the case of obstetrics, include... "the practice of defensive medicine, the desire to reassure a patient that her pregnancy is progressing normally, patient demand and even the 'entertainment' value of seeing one's fetus."