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.

There is more than one way of looking at this, I know, but I believe I cheated death when I survived an amniotic fluid embolism during my younger daughter's birth in 1997. These extra 13 years, and counting, seem like a stupendous lagniappe tacked onto the lifetime I was meant to have.

That might be why, every so often, an event comes along that reduces me to a heap of gratitude for the medical advances, the professional competence, the technology — and the luck — that saved me. My older daughter's college graduation last week was one of those events.

Nora had just turned 10 when Maeve was born. She had not enjoyed being an only child, and was thrilled about the prospect of welcoming a new baby into our family. I had spent 4 1/2 months on bedrest, punctuated by a couple of terrifying bleeding incidents, which Nora had suffered through along with her dad and me. We were all relieved when the pregnancy reached term, and I went into Prentice Women's Hospital for a scheduled induction.

That fall Friday was a holiday from school, and Nora was off picking apples with friends in a far suburb, hoping that when she came home she would meet her new sister or brother.

She came back instead to a phone call from her dad, telling her about Maeve, who by that time was swaddled up in Prentice's high-risk nursery. Nora wanted to talk with me, but her dad said I had had a rough time and couldn't come to the phone. At the time he was talking with her, he still didn't know if I would live or die.

What if I hadn't survived? Both my girls would have been motherless, but Maeve wouldn't have known anything else. Nora would have suffered a devastating loss.

That didn't happen, of course. Because I have been there these 13 years, I know the scrapes Nora has been through, the joys, the disappointments, the accomplishments. Success in school never came easily to her, but last week, she graduated cum laude from DePaul University in Chicago.

I don't want to take credit for Nora's successes, but I do believe that mothers make a difference in their children's lives. I am proud of the wonderful young woman my daughter has become, and I am grateful that I have been there to see it.

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.

Amber Strocel is one of my favorite bloggers. A Vancouver, B.C. "crunchy granola mom" (and engineer), Strocel writes with equal aplomb about the pleasures of domesticity and more serious issues like Internet privacy.

Strocel also writes a good bit about childbirth, and one recent post got me thinking. In “Scare Tactics,” Strocel considers which kinds of stories about birth and breastfeeding women should share, in particular with pregnant women.

As anyone who has ever been pregnant knows, that bump is a powerful magnet for women who had a 78-hour labor, or whatever, and believe you need to hear a blow-by-blow description, complete with sound effects.

“I don’t see much value in sharing horror stories,” Strocel wrote, adding that during a discussion she shared on Twitter, others had disagreed, saying they thought “negative stories can prepare women” for the possibility of problems with birth or breastfeeding.

Strocel relates that during the birth of her first child, precipitated at 34 weeks by an infection, she experienced severe hemorrhaging, which required surgery and a blood transfusion.

“I was actually not all that afraid of labour when I was pregnant the first time around… Being armed with someone else’s story of severe blood loss wouldn’t have changed anything for me,” she writes. “Thinking about it, I believe there’s a difference between sharing a horror story that scares someone out of her pants, and useful information that you can use to avoid problems.”

Strocel offers an example of the latter: "If I had a very negative experience with a health care provider, I might share that with someone who was considering seeing the provider."

I agree that would be useful information, but the key would be to catch a woman before she had committed to that provider. By the time other people know a woman is pregnant, she has usually settled on a birth attendant.

In fact, I’m not sure any birth stories have utility for a pregnant woman. Let's think about a really positive one. Would hearing about supermodel Gisele Bundchen’s painless water birth really be encouraging to the average mortal? No pressure, girlfriend, but Gisele had zero pain.

I suspect one reason why people deluge pregnant women with birth stories is that we assume they have some interest in a topic we don't actually get to talk about that much.

The birth story occupies a place very near the heart of the narrative of most mothers’ lives. I have two birth stories myself. One tells of a vaginal delivery in a hospital that required foiling an obnoxious resident itching to perform a Caesarean-section; the other is a near-miraculous survival story.

I hardly ever tell these stories out loud. They are great stories, full of colorful characters, conflict and drama but, practically speaking, who can I press them on? The people who are willing to listen to me use words like “vagina” and “transfusion” do not include, for example, my brother-in-law.

As I think about these stories, though, it occurs to me that even though the near-death experience is more dramatic, the birth of my first daughter is more satisfying, more reassuring, more the kind of narrative prospective parents are looking for: A family overcomes obstacles to have the experience it was hoping for (more or less). It was certainly more pleasant to live through.

I'm not sure it is the more helpful of the two stories. Knowing what it takes to live through a calamity — in our case, speedy access to a competent surgeon and anesthesiologist, and plenty of blood — seems to me to be extremely useful information.

But perhaps the stories we mothers like best are the ones where the fair damsel saves herself.

We're in the thick of the 50th anniversary rumination on "the Pill," which has been blamed for precipitating "the sexual revolution" -- it was hardly the only impetus -- and has probably played a role in lowering maternal mortality as well. In May 1960, the U.S. Food and Drug Adminstration began the process of allowing the pharmaceutical maker G.D. Searle & Company to market its drug Enovid as the first oral contraceptive.

A hundred million women worldwide use oral contraceptives now; where the average American women had 3.6 children in 1960, she now has 2. That's an important figure for our maternal mortality statistics, as the more children a woman has, the more likely she is to die in childbirth.

Margaret Sanger, who coined the term "birth control," was driven first to become a nurse and then to make disseminating birth-control information her life's work after watching her mother's 18 pregnancies contribute to her death at age 50.

When Sanger began her crusade, the Comstock Law of 1873, an anti-obscenity measure, made it illegal to publish information about birth control, and she was arrested more than once.

In 1936, ruling in U.S. vs. One Package of Japanese Pessaries, Judge Augustus Hand of the U.S. District Court of Appeals in New York exempted birth control devices from restriction under the Comstock Law, which had been absorbed into the Tariff Act of 1930. This was the first step toward making birth control legal. The case came out of Sanger's importation of a shipment of "pessaries," in this case essentially a diaphragm, for distribution through the birth control clinics she had fielded since 1916.

Working with the wealthy philanthropist Katharine Dexter McCormick, Sanger formed the organization that would become the Planned Parenthood Federation of America. (In the spring of 1960, Sanger was 80 and McCormick was 84.)

The researchers John Rock and Gregory Pincus, working first independently and then together, developed an oral contraceptive that they tested in Puerto Rico to get around laws that persisted against birth control on the American mainland.

There have been some great recent stories about the Pill at 50 in the press. I thought Time magazine did a nice job of summing up the pre-Pill atmosphere, the history and today's landscape, and PBS has a useful timeline on birth control from "The American Experience" on its website.

Flashing back to a time when people were arrested for sharing information on birth control is pretty chilling, especially given the fact that it wasn't very long ago.

As Sanger put it, “No woman can call herself free who does not own and control her own body.”

Image from Wikimedia Commons  http://creativecommons.org

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.

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

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.

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.

Bring on the party hats!

I started my blog on Jan 3, full of trepidation about whether I would be able to keep up with posting three times a week about pregnancy, childbirth, medical history, maternal mortality, etc. After all, I have a job, a family, a dog, and on and on.

But I can do this! And I've learned a lot!

What's next?

My most popular post so far was "Birth in Haiti." You could've knocked me over with a feather.

My own favorites were the two posts I wrote after interviewing Robbie Goodrich, who lost his wife, Susan, last year to amniotic fluid embolism. Robbie was kind enough to talk with me while planning a big birthday celebration for his son, Charles Moses, and honoring Susan's memory on the anniversary of her death.

Career adviser Penelope Trunk tells bloggers not to succumb to the temptation to start that second blog. Penelope, you read my mind! I have been thinking how much fun it would be to lighten up a little, loosen up the voice, write about something else besides the point in childbirth at which bliss and safety concerns intersect.

But you know what? Penelope is right. "Birth Story" is my topic, because for 12 years, since I survived an amniotic fluid embolism during my younger daughter's birth, I have been fascinated with extreme childbirth. So I am going to stay with the difficult stories, the life-saving innovations and all those mixed emotions.

I enjoy the immediacy of blogging, and "meeting" other bloggers, many of whom are moms as well. I've settled into a Monday/Wednesday/Friday publishing schedule. And I'm still finding my voice.

So now we'll embark on the next leg of the journey. Maybe every couple of months I'll drop in a totally irrelevant picture like the one above and celebrate a little, just like today!