Sunday, September 26, 2010

Sarasota Licensed Midwives Week: Oct. 4-8

At the next Sarasota City Commission meeting, Monday, October 4th at 6:00 pm, Mayor Kelly Kirschner will proclaim October 4-8 Sarasota Licensed Midwives Week. The first full week in October is annually proclaimed Florida Licensed Midwives Week by the office of the Governor, coinciding with National Midwifery Week, which recognizes certified nurse-midwives.

This proclamation will pay tribute to the skilled, individualized care that licensed midwives offer women and their families throughout the childbearing cycle. It will signify the strong contribution licensed midwives make to the health and well-being of our community's mothers and babies through appropriate care and treatment in all phases of childbirth.

The Midwives Model of Care™ is based on the fact that pregnancy and birth are normal life events. The application of this model has been proven to reduce to incidence of birth injury, trauma, and cesarean section. The Midwives Model of Care includes:
  • monitoring the physical, psychological and social well-being of the mother throughout the childbearing cycle;
  • providing the mother with individualized education, counseling, and prenatal care, continuous hands-on assistance during labor and delivery, and postpartum support;
  • minimizing technological interventions; and
  • identifying and referring women who require obstetrical attention.
I am so proud to live in a city that recognizes the value and service our midwives provide. I know that many people reading this blog share this sentiment, and I encourage you to bring your families to City Hall next Monday evening and show your support for this proclamation. Contact your local media, your elected officials, and most importantly your midwives, and communicate how important their service is to you. Spread the word about the overwhelming body of evidence supporting the safe, cost-effective, nurturing model of care these practitioners offer our families.

Saturday, September 25, 2010

Healthy Start Coalition Annual Meeting

On Thursday, September 23, the Healthy Start Coalition of Sarasota County held their annual meeting. In attendance were many of our community's midwives, obstetricians, hospital staff, health department officials, leaders of health care organizations, families, educators, legislators and more.

Healthy Start Board of Directors co-chair Shara Abrams began the meeting by reminding guests of the uncertainty of the past year, with the Florida legislature coming dangerously close to eliminating all Healthy Start Coalitions. She also announced new Fetal and Infant Mortality Review (FIMR) Coordinator Beth Rubin. Jennifer Highland, Healthy Start Executive Director, then took the podium and gave an overview of Healthy Start (now in its twelfth year) and its services. She too spoke about the near-elimination in the legislature, as well as the downward shift in incoming young families to our community. Jennifer talked about some of the improvements made over the last year, despite the reduction in budget, including the addition of a Spanish speaking Certified Lactation Consultant to the care coordination team.

Jennifer went on to describe the Service Delivery Plan (SDP) 2010-2015, issued by Healthy Start this summer. I had the privilege of joining the Planning and Evaluation Committee of Healthy Start just in time to watch this incredibly thorough document's creation. The SDP identifies key risk factors and trends affecting pregnant woman and infants, and uses those to set forth an activity plan for the next five years. The statistics and research compiled to create these initiatives came from a variety of measures and sources, all referenced and double-checked, resulting in a comprehensive and thoughtful outline of steps. The SDP identified the following as the most affective negative trends in Sarasota County:
  • smoking;
  • substance abuse;
  • obesity;
  • maternal infections;
  • unplanned pregnancies;
  • high cesarean section delivery rate leading to unnecessary pre-term births;
  • sub-optimal breastfeeding rates;
  • and significant maternal and infant health disparities among African-Americans.
The SDP's plan of action outlines nine initiatives to execute during the next five years:
  1. Implement "Right from the Start" and "text4baby" campaigns, both of which target pre/interconception, pregnancy, and infant health.
  2. Promote uniform counseling messages and the "5 A's Approah" for women at risk of continuing tobacco use during pregnancy or between pregnancies.
  3. Improve screening for drug abuse among pregnant women, and advocate for routine drug screening and treatment.
  4. Provide education to the community and enhance Healthy Start services to reduce the hazards of obesity during pregnancy.
  5. Improve public awareness of the risks of maternal infections during pregnancy and the importance of prevention and adherence to treatment protocols.
  6. Offer updated family planning education to Healthy Start, MomCare and Healthy Families clients.
  7. Improve public awareness of the dangers of elective C-sections prior to 39 weeks of gestation.
  8. Improve breastfeeding rates among Healthy Start and Healthy Families clients by working along the continuum from pregnancy through the postpartum phase.
  9. Increase and sustain education and support for preconception, interconception and pregnancy health for high risk African-American pregnant women.
After introducing two women who have been positively impacted by Healthy Start--one through taking advantage of its services, and one by recognizing high need and taking the path toward the field of obstetrics--Jennifer passed the microphone to Sarasota Mayor Kelly Kirschner, one of two keynote speakers for the morning.

Mayor Kirschner framed his message by sharing his personal journey with maternal and infant health--his oldest child, Bodhi, was born at 27 weeks gestation and spent three and a half months in intensive care. Kirschner's wife, Tracy, is a Certified Nurse Midwife who suffered a grand mal seizure as a result of sudden eclampsia during her pregnancy. After Bodhi's birth by emergency c-section, the couple watched by his side as Bodhi literally struggled for survival, using machines to help him breathe. Mayor Kirschner's message was clear: this was a necessary c-section, and the bill for Bodhi's care exceeds half a million dollars. His treatment, albeit appropriate and one for which the Kirschners are grateful, comes with repercussions today. The cesareans and resultant NICU admissions that are NOT necessary must be eliminated if we are to improve outcomes and healthcare costs.

Kirschner cited the recent Health News Florida article that connected high c-section rates and populations with high Hispanic percentages. Kirschner challenged some of these correlations, saying Florida has been home to Puerto Ricans, Brazilians, Chileans and others for decades, and that their presence here can't explain the sharp c-section increase. He focused instead on a hospital in Guadalajara, Mexico, that requires a second opinion, a documentation of reason, and monitoring and follow-up with the obstetrician when a c-section is suggested. Kirschner also reminded the Healthy Start members that while convenience, lack of VBAC access, fear of litigation, obesity and more are often called out as reasons for the high c-section rates, the highest increase is currently in women 25 and under--indicating that a lack of informed consent is perhaps the true culprit.

Mayor Kirschner summarized his message, inspired by Dr. Albert Bandura, by saying that a belief in self-efficacy is the foundation for change. We--mothers, fathers, families, policy makers, maternity care providers, hospitals, legislators, insurors--have to understand that to improve the practice of childbirth today, through a return to normalcy and appropriate care, is to reduce a high-cost impact tomorrow, both fiscally and physically.

Florida Representative Keith Fitzgerald was the second keynote speaker of the morning, and he continued Mayor Kirschner's sentiments with a plea to those present to get involved in their state government. He very honestly described the near-elimination of Healthy Start from a legislative perspective, which was enlightening to say the least: he said that the Coalitions were never intended to be eliminated, but rather cut in funding; however, proposing elimination allowed the Coalitions to rally, and allowed the State to then "save" the slice of the pie (albeit a smaller piece), making all parties look heroic. As these sorts of games continue to be played, it is more important year after year that consumers and advocates make their voices heard. Representative Fitzgerald adjourned with a strong message: It's up to YOU.

Jennifer Highland returned to the podium to present annual awards from Healthy Start for Volunteer of the Year (Liz Murphy), Business Partner of the Year (Sarasota Architectural Salvage), Community Partner of the Year (United Way 211), Family of the Year, the Mission Award (Shelley Rence), and the Lawton Chiles Award (Barbara White, Cyesis founder).

Jennifer then thanked outgoing Board of Directors members for their service, including six-year co-chair Jenna Norwood, who passed the "silver rattle" to incoming chair Shara Abrams. I am very honored to have been nominated and elected to the 2010-2011 Board of Directors for Healthy Start, along with many people whom I have respected in this community for years, and several new faces as well. Joining the board as honorary members are Representative Fitzgerald, Representative Ron Reagan, Ed Chiles, and outgoing director of Maternal Fetal Medicine at Sarasota Memorial Hospital, Dr. Washington Hill.

The mission of Healthy Start is to improve the health and well-being of pregnant women, infants and young children. I am privileged to join this group in this capacity, for I truly believe there is no organization in our community better poised to improve birth outcomes.

Tuesday, September 21, 2010

Florida C-Sections Driven by Culture?

I had the pleasure of a phone interview with Sarasota Health News editor David Gulliver, working on a story for Health News Florida examining possible contributing factors to Florida's "stubborn" cesarean section rates. The story, originally posted here, follows in its entirety:

A report from California last week found a statistically significant link between high rates for cesarean-section births and the for-profit status of hospitals. Health News Florida ran a similar analysis and found no such association.

Our analysis of the 116 Florida hospitals that delivered babies in 2009, both in overall rates and in rates of c-sections where there were no medical complications, found similar results in non-profits and for-profits. See complete list.

The overall rate statewide of around 39 percent, about seven percentage points above the national average, shows differences tend to be geographic. That didn't come as news to Tampa OB-GYN Robert Yelverton, a member of the Florida Perinatal Collaborative.

"We know it's higher in hospitals below (Interstate) 4, in general," he said. "We’re attempting to find funding to study that."

That suggests a demographic difference linked to the culture of the community. Ten of the 12 Florida hospitals with the highest rates of cesarean section delivery are in Miami-Dade County, where 62 percent of residents claim Hispanic ancestry.

“It’s sort of a cultural phenomenon,” said Dr. Rafael Perez, an obstetrician on the South Miami Hospital executive committee, where 61 percent of births are c-section.

Florida's highest c-section rate is at Kendall Regional Medical Center, where almost two-thirds of babies are delivered via that way. All Miami-area hospitals except two that are part of the public system deliver about half of babies by c-section.

The findings echo a 2006 state report that found women of Hispanic ethnicity had a higher c-section rate than women of other backgrounds.

While culture may explain why Florida's rate is far above the national average, it doesn't explain the inexorable increase, from 26.2 percent in 2000 to to 41.2 percent in 2009.

The Florida Department of Health, working with physicians and other groups in the Florida Perinatal Collaborative, has been working for more than two years on a report on the reasons for preterm delivery, in which c-section is often implicated. That report may be ready by the end of the year, said DOH epidemiologist William Sappenfield, MD.

In the meantime, physicians, parents and healthcare advocates point at a variety of causes, and sometimes at each other.

“It’s becoming an epidemic, and it’s being swept under the rug,” said Laura Gilkey, a Sarasota mother and advocate for natural childbirth.

Se habla espanol?

Florida experts have noted the link between Hispanic ethnicity and c-section rates before. A 2006 study by the Agency for Health Care Administration found that Hispanic women were the most likely to deliver by section.

That tendency surfaces in examinations of other countries. A Centers for Disease Control study found c-section rates of 45 percent in Puerto Rico in 2002, nearly double the mainland United States’ rate at the time. And some Central and South American countries have even higher c-section rates -- like Brazil’s 70 percent.

South Miami’s Dr. Perez said about two-thirds of his patients are Hispanic, and they have a different approach to childbirth. They are eager to attempt natural birth, said, but also quick to abandon it if they sense problems. “They have a fear of complications,” he said.

But mothers in general have changed, he said. He is seeing more older mothers, often using fertility treatments. “The people coming to see us now are not the same as the ones in the ‘50s and ‘60s,” Perez said. “They are delivering one baby, later in life, and they want it to be perfect,” he said.

About a quarter of his patients have c-sections, he said. Of them, about half attempt labor first. But his other patients’ choices illustrate some of the controversy surrounding cesarean sections.

No more VBACs

About half of Perez’s c-sections were likely from the outset, because of complications or because the mother had a prior c-section. Obstetricians have become reluctant to allow mothers to deliver vaginally after c-sections, a procedure known as VBAC. Studies show that in slightly less than 1 percent of cases, it can cause the mother’s uterus to rupture.

The American College of Obstetrics and Gynecology in July said the sharp decline in VBACs was a major cause of rising c-section rates. It issued new guidelines on when the procedure is safe, to persuade more doctors to perform it.

Doctors may still have doubts. VBACs are successful only about 70 percent of the time, so many end up with a c-section anyway, Perez said. In the rare uterine rupture, a medical team must anesthetize the mother and deliver the baby in a 10-minute window before lack of oxygen causes brain damage.

That illustrates another incentive for c-sections: Physicians’ fears of malpractice lawsuits.

“The first thing the lawyer is going to tell you, when you have a baby with a neurological impairment, is ‘Why did you do a VBAC?’” Perez said. “These kinds of lawsuits go into the millions of dollars, and that weighs heavily,” he said.

A handful of his patients will choose a cesarean delivery from the start, he said. Physicians, researchers and childbirth advocates have targeted those elective c-sections as the most dangerous.

ACOG guidelines tell members to avoid performing elective c-sections before 39 weeks of gestation, but difficulties in estimating fetal growth can result in babies born weeks before they reach full-term. This is the focus of the ongoing Perinatal Collaborative study.

“You absolutely cannot predict with certainty the gestational age of the fetus,” said Jennifer Highland, a registered nurse and director of the Sarasota County Healthy Start Coalition.

Incorrect age estimates result in elective c-sections performed too early, leading to health problems for infants. “It is the number one reason why our prematurity rates are going up,” Highland said.

Babies born in planned c-sections ended up in neo-natal intensive care units almost twice as often as those delivered vaginally, and had twice the risk of pulmonary problems, according to a 2006 study published in the American Journal of Obstetrics and Gynecology.

“We’re electing to put those risks on the baby, for no good reason,” Highland said.

Convenience a factor?

Doctors say some parents press for early deliveries for convenience or to avoid pain. Healthy childbirth advocates say some doctors also do so out of convenience. Perez said he educates his mothers about the risks.

“Babies should be born at 39 weeks,” he said. “Delivering at 38, 37 weeks -- that is not a good medical decision.”

Reducing those early c-sections -- the goal of initiatives by March of Dimes, hospital accrediting group the Joint Commission, and others -- may improve outcomes, but will not significantly change c-section rates, he said.

Despite those concerns, Perez sees cesarean deliveries as an advance in obstetrics and a safe choice for most women

“You have to ask a philosophical question: Are c-sections that bad?” he said. “Nowadays, a c-section is one of the safest procedures, because we do so many of them.”

That’s where physicians and advocates differ. C-sections carry significantly higher risks of infection and surgical injuries, and slightly higher risks of death or blood clots leading to stroke. “You don’t want to have surgery unless you have to have surgery,” Highland said.

Gilkey, the Sarasota mother, has two children. Both were 10 pounds at birth, both delivered at a birthing center with a midwife. In one birth, the midwife resolved a case of shoulder dystocia, allowing the natural delivery to proceed. “That never would have happened in a hospital,” she said.

While she believes hospital deliveries are best in some cases, the experience turned her into an advocate for natural childbirth. “Where birth is concerned, we live in a culture of fear,” she said.

Friday, September 17, 2010

Informed Consent and Refusal: Bring Ruth Home

When I learned, just this morning, the story of Ruth Light--the Illinois baby that was taken from her parents and put into foster care because of alleged neglect (her parents refused a cesarean birth due to breech presentation and opted for a homebirth which resulted in a happy healthy baby girl)--I was heartbroken and very, very angry. I just sent this letter to the Illinois State Attorney. I will be gathering more evidence to support a second letter and encourage anyone reading this to do the same.

Rock Island County
State's Attorney's Office
Fourth Floor - Courthouse
210 - 15th Street
Rock Island IL 61201

Dear Mr. Terronez,

My name is Laura Gilkey. I am a Florida mother of two home-born children. Both of my boys weighed ten pounds at birth, and one was born with shoulder dystocia--all of these would have speculatively pointed me, in a hospital setting, toward a surgical birth. However, with the skilled help of my licensed midwives and the tried-and-true Gaskin maneuver, both of my boys were born safely and easily into my arms, and are as healthy as can be today--just like Ruth Light. The Lights chose to refuse a cesarean birth for their breech baby, which is perfectly within their legal right of informed consent and informed refusal (1).

I am very concerned for the future of our society when a government agency deems it appropriate to remove a healthy baby from the care of her loving parents during the most critical time in her development. During a baby's first moments, days, weeks and months, it is absolutely critical to her physical and emotional development (2)--and to her mother's (3)--to have the benefit of maternal bonding and breastfeeding (4). To remove that benefit from Ruth because someone somewhere didn't agree with her decision isn't neglect on the part of the Lights, but on the part of the state.

Mr. and Mrs. Light are well-researched folks who made an evidence-based decision to birth Ruth at home. Ruth is a healthy baby girl that was not neglected. To return Ruth to the home where she was lovingly born is the right, legal, and just decision.

I look forward to hearing your timely response.

Laura Gilkey
Informed Consent and Refusal Subcommittee, Coalition for Improving Maternity Services

Monday, September 6, 2010

LTE: Birth Centers' Gentle Options

I was beyond thrilled to read this letter to the editor from Ryan Stanley in the opinion pages of yesterday's Sarasota Herald-Tribune. I learned from Ryan that her original letter had been edited for length; the following is the letter in its entirety. You may read the edited version here.

Citing a newly released study, Denise Grady (“Majority of Cesareans are Done Before Labor”, August 30, 2010) explains that the increased use of labor inducing drugs, the tendency of doctors to give up on labor too soon and the failure to allow vaginal births after C-Sections are all factors contributing to our nation’s alarming 32 percent Caesarean rate. It is especially clear from this study that if you are a new mom giving birth in a hospital you have a 44 percent chance of receiving labor inducing drugs and thereafter a 50 percent chance of having a C-Section before labor even begins.

As a new mom who chose to give birth in a free standing birth center, I am shocked by these new findings. Based on this new research, I fear that had I chosen to give birth in a hospital, I would not have been afforded the gentle, drug and intervention free birth I so desired.

I feel blessed to live in a community with two free standing birth centers and a number of skilled licensed midwives, doulas and independent childbirth educators. I encourage all women, especially those concerned with the rising Caesarean rate, to seek out their services and to demand that their labors be allowed to progress naturally and without unnecessary interventions.