Birth Story

The full text of the article "Contemporary cesarean delivery practice in the United States" published on-line in the American Journal of Obstetrics and Gynecology reveals some interesting insights into the particulars of the study. Birth Story published an earlier post this week based on the abstract.

"The national rate of cesarean delivery in the United States has increased more than 50 percent since 1996, to 31.8 percent in 2007," the report states. "This upward trajectory appears likely to continue in the near future."

The study was performed as part of the Consortium on Safe Labor, an initiative of the National Institute of Child Health and Human Development. It used electronic medical records of 228,668 births at 19 American hospitals between 2002 and 2008.

Here are some highlights:

A total of 93 percent of babies who presented "nonvertex" — with any body part other than the head in the lead— came into the world via C-section.

Almost 66 percent of multiples — twins or more — were delivered by cesearean section. Most of these moms did not attempt a trial of labor.

The C-section rate doubled from 21 percent at age 20 to 42 percent after age 35, "mainly due to repeat pre-labor cesarean deliveries."

Half of cesareans performed once labor had begun were because of "failure to progress" or  the belief that the baby's head was too large for the mother's pelvis. More than a quarter were performed because of "fetal distress."

Among women who had had previous deliveries, most C-sections occurred before labor began, and that was true no matter when they delivered.

More than 60 percent of deliveries at 28 weeks gestation were C-sections. That rate went down as pregnancies progressed.

The trial of labor in women with a uterine scar was 48 percent in 1999, 31 percent in 2002, and 29 percent by 2007.

The success rate of vaginal births after cesarean (VBAC) in the study was 57 percent (of the 28 percent of women who attempted a VBAC), "markedly lower" than in "previous large studies," which had ranged as high as 87 percent.

Overall, 84 percent of women with a uterine scar delivered by C-section.

Pre-labor repeat C-sections "have a profound impact on the overall cesarean rate."

"Truly elective" cesareans accounted for 9.6 percent of C-sections before labor commenced, and 2.1 percent undertaken during labor.

The hospitals in the study represented a wide range in rates of C-sections, from 20 to 44 percent.

Nearly 10 percent of the women who participated in the study added more than one delivery to the database; only the first delivery for each was included in the analysis.

Two of the hospitals in the study were non-teaching community hospitals. Nine were teaching community hospitals and eight were university-affiliated teaching hospitals.

In an article in the Aug. 2 issue of the New Yorker, the surgeon/writer Atul Gawande MD considers Americans' ars moriendi, the art of dying — or rather our lack of one. There are some interesting parallels with birth, such as our society's propensity to throw technology at situations that often might be better left to nature, taking its course in its own time.

What I found fascinating was the honesty with which Gawande writes about his own discomfort with talking with patients who are looking to him to guide them through a fundamentally human experience, one his skills as a surgeon don't equip him to handle.

Of the team of physicians treating Sara Monopoli, a young mother dying of lung cancer, Gawande writes:

You’d think doctors would be well equipped to navigate the shoals here, but at least two things get in the way. First, our own views may be unrealistic. A study led by the Harvard researcher Nicholas Christakis asked the doctors of almost five hundred terminally ill patients to estimate how long they thought their patient would survive, and then followed the patients. Sixty-three per cent of doctors overestimated survival time. Just seventeen per cent underestimated it. The average estimate was five hundred and thirty per cent too high. And, the better the doctors knew their patients, the more likely they were to err.

Second, we often avoid voicing even these sentiments. Studies find that although doctors usually tell patients when a cancer is not curable, most are reluctant to give a specific prognosis, even when pressed. More than forty per cent of oncologists report offering treatments that they believe are unlikely to work. In an era in which the relationship between patient and doctor is increasingly miscast in retail terms—“the customer is always right”—doctors are especially hesitant to trample on a patient’s expectations. You worry far more about being overly pessimistic than you do about being overly optimistic. And talking about dying is enormously fraught. When you have a patient like Sara Monopoli, the last thing you want to do is grapple with the truth. I know, because [Monopoli's oncologist, Dr. Paul] Marcoux wasn’t the only one avoiding that conversation with her. I was, too.

Gawande had been called in to talk with Monopoli about surgery on a secondary, treatable thyroid cancer. Though he thought she would die long before the thyroid cancer became a serious problem, Gawande relates miserably dancing around the subject of death with her.

Determined to be more honest in talking with patients with a poor prognosis, Gawande tried to communicate the stark truth as he saw it to a woman with advanced colon cancer. After she went on to have a better-than-expected recovery,  she told Gawande that their early conversation had made her feel "as if I'd dropped her off a cliff."

In a long section on the importance and nuance of effective communication, Gawande concludes that "the words you use matter."

It appears that conversation — just words — during a terminal illness might help people avoid medical interventions. Gawande cites a 2004 initiative by Aetna insurance company that allowed terminal patients to proceed with aggressive medical treatment, while at the same time using the emotional supports of a hospice facility. (The two approaches are not typically used together.) The patients' hospital stays decreased by more than two-thirds, and the cost of their care went down nearly a quarter.

"The program’s leaders had the impression that they had simply given patients someone experienced and knowledgeable to talk to about their daily needs. And somehow that was enough—just talking," Dr. Gawande writes.

He writes,

We pay doctors to give chemotherapy and to do surgery, but not to take the time required to sort out when doing so is unwise.... But the issue isn’t merely a matter of financing. It arises from a still unresolved argument about what the function of medicine really is—what, in other words, we should and should not be paying for doctors to do.

My apologies to Gawande for shoehorning his thoughts on death into this ongoing discussion of birth, but I think his honest consideration of a doctor's role in helping people negotiate life's last major threshold is worth thinking about relative to the first.

This is my 75th post, something of a milestone for me, especially as it coincides with roughly six months of blogging — and a change of status.

I was part of a group laid off last week from the Chicago Sun-Times, where I had loved, loved, loved being a features reporter. The economics of print journalism caught up with me, as they have with so many others.

Where do I go from here? This is no idle question for me, and I'm just beginning to work out the answer.

Over the course of the past couple of years, I have enjoyed learning about new media, and now here I am, with both feet in the 21st century. I blog three times a week, I tweet, I even built my own website (with lots of help).

At the same time, I believe in the values of old media — checking facts, maintaining a certain distance from sources, and allowing both sides to have their say in a civil discourse.

Even while I find myself slipping into the conventions of the new, I hang onto my belief that the best journalism serves the reader's need to know about, and understand, the society she lives in.

I think I have picked a great topic to write about, because it seems to me that birth is on the cusp, just like me. Modern medicine knows how to make birth safe, and yet the maternal mortality rate appears to be going up.

Not only that, but I can't help but notice that while 99 percent of American women have their babies in hospitals, most of the voices making themselves heard in books and blogs belong to women who are dissatisfied with and critical of the hospital experience.

And with Caesarean-section rates rising out of all proportion to any statistical need for their use, those voices are gaining an intelligent and often passionate following.

Where do we go from here? I believe that one thing that will help us answer that question is an understanding of how far we have come.

Cartoon by Shel Silverstein

Here perhaps is one clue to the conundrum of why maternal mortality in the United States is relatively high for an industrialized nation, 12.7 deaths per 100,000 births in 2007: Two thirds of the women who died giving birth in New York State between 2003 to 2005 were obese, the New York Times reported on Sunday. The Safe Motherhood Initiative provided the figure.

Obese women are more likely to hemorrhage, have high blood pressure, diabetes, anesthesia complications, blood clots and strokes during pregnancy and childbirth.

Not only that, but very obese women, defined as having a body mass index (BMI) of 35 or higher, are three to four times more likely to experience a Caesarean section with their first baby than other as first-time mothers are, Anemona Hartocollis reports in the NYT story.

Obesity is not only hard on mothers, but it may also pose problems for their infants. Babies born to obese women are almost three times as likely to die within their first month of life than those born to women with BMIs within the normal range. Obese women are also nearly twice as likely to have a stillborn baby, Hartocollis reports.

About one in five women are obese when they become pregnant, according to data from the Centers for Disease Control in Atlanta, Ga. Obesity is gauged by a BMI of at least 30. A woman who stands five-foot-seven inches tall and weighs about 195 pounds has a BMI of 30.

Preterm births in the United States went up steadily from 1981 to 2006, but now they seem to be going back down, according to a new report from the National Center for Health Statistics in Hyattsville, Md.

This is the first two-year downturn in nearly three decades, the report states.

The peak year for preterm births was 2006, when they accounted for 12.8 percent of all births. The rate in 2008 was 12.3 percent.

A preterm birth is one that occurs before 37 weeks of gestation. Babies born before this point are more likely to have serious health problems compared with infants born later in pregnancy. Even babies just shy of 37 weeks are more likely to have "neurodevelopmental problems," or to die before they turn one year old, than are babies born at term, the report states.

Preterm rates appear to be falling among women of all age groups younger than 40, among all ethnic groups, in all types of deliveries and in most parts the country. Several states saw a flat rate of preterm births over the last two years, but only Hawaii experienced an increase. The decrease was similar for singleton and multiple births.

However, the report notes that "the U.S. preterm birth rate remains higher than in any year from 1981 to 2002, with large differences still evident by race and Hispanic origin. Further research is necessary to explain the factors behind the current downturn and to develop approaches to help ensure its continued decline."

In 1899, John Whitridge Williams, whose name lives on in the definitive textbook on pregnancy and childbirth, succeeded Howard Kelly as the head of obstetrics at Johns Hopkins Medicine.

Kelly had split off baby-catching from the more interesting (to him) department of gynecology, which he continued to head up.

Williams, a Baltimore native, came from a medical family -- his mother's forebears had been doctors for 160 years. He trained at the University of Maryland, and then in Vienna, Berlin, and other European cities, which exposed him to a different way of looking at medicine.

Williams' Obstetrics, first published in 1903, and still in print today, came out of Williams' desire to render everything about pregnancy and birth in scientific terms. The first edition contained more than 1,000 references to other medical publications.

Williams wrote five additional editions of the book before he died in 1931, of complications from abdominal surgery.

The departments of obstetrics and gynecology were finally reunited at Johns Hopkins School of Medicine in 1960.

The 23rd edition of Williams' Obstetrics was published in 2009.

"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

I notice that the American College of Obstetricians and Gynecologists is gearing up for its annual clinical meeting May 15 through May 19 in San Francisco.

The 2009 annual meeting was in Chicago, and I attended as many sessions as I could -- I don't want my ideas about what is going on in obstetrics to stop with my own birth experiences. (Sadly, I won't be able to attend the San Francisco meeting.)

I learned a lot last May, but one thing stayed with me in particular, Dr. Robert Wachter's keynote address.

Robert Wachter MD

Dr. Wachter,  chief of the medical service at the University of California at San Franciso, among other titles, is one of the founders of the hospitalist movement, and an expert in patient safety.

He spoke about efforts to improve safety since 1999, when the Institute of Medicine released its landmark report, To Err Is Human, which revealed that as many as 98,000 people were dying from medical mistakes every year.

Dr. Wachter's message is important for the birth story because obstetricians are the doctors most often sued for malpractice. A 2003 ACOG survey showed that 76 percent of OB-GYNs have been sued at least once.

Many of them would say that if anything ever goes wrong with a birth, they are sued whether the mishap was their fault or not. Dr. Wachter agreed that "the blame game" is "not productive."

He said, "Medicine is too complex to be error free." Some other complex industries have better safety records, though, he said, often because they have developed "systems thinking," standardizing procedures and accepting that some mistakes are a natural part of the process.

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.