In 2008, I began creating quilt squares for the Safe Motherhood Quilt Project, created by midwife Ina May Gaskin, to raise awareness about the increasing crisis of American maternal mortality (the U.S. currently ranks 41st in the world in maternal mortality according to the World Health Organization). In November 2009, as Vice President of Florida Friends of Midwives and with the help of the National Organization for Women, I welcomed Ms. Gaskin to Sarasota to speak at an interdisciplinary panel discussion called Maternal Health Care in the 21st Century. Just before her arrival, I finished quilting an entire panel of the Safe Motherhood Quilt, honoring women who have died in pregnancy or childbirth in the US since 1982.
On April 9, Ms. Gaskin will join professionals from all over the world at the groundbreaking, interdisciplinary Healthy Mothers, Healthy Birth Summit in Washington DC, after which she and others will march the Safe Motherhood Quilt from the National Mall to the Capitol steps.
Friends, I would like to attend this summit and bring back to our community the knowledge of the world's experts on how to begin to fix this problem. I would like to march the quilt with Ina May and show the powers that be in Washington DC that this issue is critically important to American mothers. I have shown commitment to improving this community's birth outcomes and will continue to do so in whatever capacity presents itself to be most effective. Due to a hefty investment of time in the non-profit sector, I cannot personally afford the expenses of a trip to Washington at this time.
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If you would like to help me on my journey to Washington DC, I will add your name to a custom-designed T-shirt that I will wear during the march, so you will be walking right along with me. I will also report to you my learnings from the Summit upon my return. Finally, you will be showing Amnesty International, American College of Obstetrics & Gynecology, The White Ribbon Alliance, American College of Nurse Midwives, Midwives Alliance of North America, The Tatia Oden French Memorial Foundation, The Safe Motherhood Quilt Project, International Childbirth Education Association, Doulas of North America, The Organization of Labor Assistants for Birth Options & Resources, and MyBestBirth.com that you support their important work and the mission of this Summit to issue a directive to the US Government to reduce maternal mortality in this country.
Something monumental and potentially life-saving for America's mothers and babies happened last week on the House floor. Congresswoman Lucille Roybal-Allard introduced the Maximizing Optimal Maternity Services (MOMS) for the 21st Century Act (HR 5807), which places a national focus on evidence-based maternity care practices to help achieve the best possible maternity outcomes for mothers and babies. Your Florida colleagues in the House, Congresswoman Debbie Wasserman-Schultz and Congresswoman Kathy Castor, have co-signed this legislation. I am writing to implore you, as a mother, as a taxpayer, as a maternal rights advocate and as your constituent, to sponsor this act.
I have written you before to tell you that the United States currently ranks 41st in maternal mortality, yet we spend significantly more on childbirth than any other industrialized country. Moreover, our nation's 32% c-section rate, high premature birth and labor induction rates, and their subsequent repeat admission rates are all playing a major role in our nation’s escalating health care costs. Hospitalization related to pregnancy and childbirth costs approximately $86 billion each year, the highest hospitalization costs in any area of health care.
The MOMS for the 21st Century Act responds to this crisis by creating a new Health & Human Services focus on the promotion of optimal maternity care, an additional focus area for the Office on Women's Health, and an Interagency Coordinating Committee on the Promotion of Optimal Maternity Outcomes, a widespread consumer education campaign, and a bibliographic database of systematic reviews for care of childbearing women and newborns. Most importantly, it calls for accountability in accurate research and data collection, and the enhancement of an interdisciplinary maternity workforce, including Obstetricians, Certified Nurse-Midwives, and Certified Professional Midwives.
“The MOMS for the 21st Century Act makes overdue reforms to our nation’s maternity care system to better ensure that providers and mothers have the best information available when making serious maternity care decisions,” Congresswoman Lucille Roybal-Allard said last week. “The fact is we have a maternity care system in the United States that has not traditionally adhered to evidenced-based practices. For example, there is widespread over use in our country of maternity practices, such as elective Cesarean sections and scheduled inductions. These procedures are beneficial and needed only in limited situations. When used routinely and indiscriminately and without medical necessity, these and other practices expose women and infants to unnecessary risks at high cost. On the other hand, credible science-based research tells us non-invasive maternity practices...produce considerable improvement in maternity outcomes, such as healthier moms and babies. Yet these cost-effective evidence-based practices, which have no detrimental side effects, are significantly underused in our country.”
As a consumer, I will do everything possible to offer you the utmost support from my community in sponsoring the Maximizing Optimal Maternity Services (MOMS) for the 21st Century Act (HR 5807). I look forward to hearing your response on this issue and will follow up with your legislative aides by telephone. Thank you for your service and your attention.
The very next day after the refreshing revision to ACOG's VBAC guidelines were released, my new favorite Congresswoman Lucille Roybal-Allard (D-California) introduced the MOMS (Maximizing Optimal Maternity Services) for the 21st Century Act on the House floor. Special thanks to Kathy Castor (D-Florida) for co-signing the legislation (Ms. Castor has been vocal in our own state about the correlation between our high c-section rate and premature birth). This has been a very exciting week along the path to healthier American birth! The following is from Congresswoman Roybal-Allard's office, describing her reason for the introduction and what she hopes it will achieve (including accountability for data collection, interdisciplinary maternity care including midwives, pregnancy and labor support including doulas and nutrition education, and more).
The United States spends significantly more on childbirth than any other industrialized country, but ranks far behind almost all developed countries in healthy child birth results for both mothers and babies. To address this national tragedy, Congresswoman Lucille Roybal-Allard introduced the Maximizing Optimal Maternity Services for the 21st Century Act which places a national focus on evidence-based maternity care practices to help achieve the best possible maternity outcomes for mothers and babies.
“Each year, more than 4 million women give birth in the United States. Caring for them and their babies plays a major role in our nation’s escalating health care costs. In fact, hospitalization related to pregnancy and childbirth costs approximately $86 billion each year, the highest hospitalization costs in any area of health care. Tragically, in spite of all the money we spend, the United States continues to rank far behind nearly all developed countries in perinatal outcomes, with childbirth continuing to present significant risks for mothers and babies, particularly in communities of color,” said Congresswoman Lucille Roybal-Allard, who co-founded the Congressional Study Group on Public Health and chairs the Congressional Hispanic Task Force on Health. “The MOMS for the 21st Century Act, which I introduced, addresses these disparities in our nation’s maternity health care system by making key reforms to improve the health and well-being of mothers and their babies in our country while bringing down maternity care costs.”
The Maximizing Optimal Maternity Services for the 21st Century Act (HR 5807) creates a national focus on maternity care by establishing an Interagency Coordinating Committee charged with promoting medical practices proven to provide the healthiest results for mothers and babies. The legislation authorizes a public awareness media campaign to educate the public about the best-proven maternity care practices. The legislation expands federal research on best maternity practices. The bill also authorizes data collection to pinpoint specific geographic areas of the country that lack maternity care providers.
Finally, the measure puts in place a concerted effort to create a more culturally diverse and interdisciplinary maternity care workforce. It establishes loan repayment programs for providers in maternity care shortage areas. It authorizes grant programs for maternity professional organizations to recruit and retain minority providers. It also calls for the development of core curricula across maternity professional disciplines to better ensure that providers are better trained and able to inform patients about all of their maternity care options.
“The MOMS for the 21st Century Act makes overdue reforms to our nation’s maternity care system to better ensure that providers and mothers have the best information available when making serious maternity care decisions,” Congresswoman Lucille Roybal-Allard said. “The fact is we have a maternity care system in the United States that has not traditionally adhered to evidenced-based practices. For example, there is widespread over use in our country of maternity practices, such as elective Cesarean sections and scheduled inductions. These procedures are beneficial and needed only in limited situations. When used routinely and indiscriminately and without medical necessity, these and other practices expose women and infants to unnecessary risks at high cost. On the other hand, credible science-based research tells us non-invasive maternity practices such as prenatal smoking cessation programs and centering of pregnancy group prenatal care, produce considerable improvement in maternity outcomes, such as healthier moms and babies. Yet these cost-effective evidence-based practices, which have no detrimental side effects, are significantly underused in our country.”
A longtime advocate on behalf of mothers, infants and children, the congresswoman has been honored by the March of Dimes and the Association of Maternal and Child Health Programs. Both awards recognize the congresswoman’s authorship of the Newborn Screening Saves Lives Act, which was signed into law in 2008. Enactment of the Newborn Screening Saves Lives Act established national newborn screening guidelines intended to make comprehensive newborn screening widely available throughout the country. The law also provides federal funding to educate parents and health care professionals about the importance of newborn screening, and improves the systems for follow-up care for infants identified with an illness through the newborn screening tests. In addition, the law requires the Centers for Disease Control and Prevention to ensure the quality of laboratories involved in newborn screening, and establishes a system for collecting and analyzing data that will help researchers develop better detection, prevention and treatment strategies.
Amnesty International Executive Director Larry Cox issued the following statement in support of the "MOMS for the 21st Century Act," introduced Wednesday evening in the House of Representatives by Rep. Lucille Roybal-Allard, (D-CA):
"Amnesty International commends Rep. Roybal-Allard for her commitment to improving the outcomes and disparities in maternal health in the United States. Access to good quality maternal health care is a right, not a privilege. It is shameful that as a nation we have neglected this right for so many women for so long. Amnesty International is grateful for Rep. Roybal-Allard's leadership and her recognition of the terrible human cost of this failure. We stand behind this significant legislative effort to ensure that all women have access to the maternal health care they need.
"The "MOMS for the 21st Century Act," if passed, will require the U.S. government to live up to its obligation to address this problem by developing a coordinated approach to maternal care that will improve women's access to quality, evidence-based care and will begin to address maternal health disparities. This is a first step to reducing the needless loss of women's lives that tragically affect so many families in the United States and preventing the complications that have risen steadily for decades.
The preliminary data for births in 2008 has been released by the CDC's National Center for Healthcare Statistics. Florida has risen to an all-time high 38.2% cesarean section rate. Sarasota Memorial Hospital's c-section rate for the same year was 41.7%, a slight increase from their 2007 reported data of 41.3%.
These numbers are simply dangerous. As they continue to increase (up over 50% in the last decade), so do our maternal mortality rates. These are a few facts taken from the Independent Childbirth Education Association:
-The World Health Organization (WHO) states that no region in the world is justified in having a cesarean rate greater than 10 to 15 percent.
-A cesarean section poses documented medical risks to the mother's health, including infections, hemorrhage, transfusion, injury to other organs, anesthesia complications, psychological complications, and a maternal mortality two to four times greater than that for a vaginal birth.
-An elective cesarean section increases the risk to the infant of premature birth and respiratory distress syndrome, both of which are associated with multiple complications, intensive care and burdensome financial costs. Even mature babies, the absences of labor increases the risk of breathing problems and other complications.
-Cesareans can delay the opportunity for early mother-newborn interaction, breastfeeding and the establishment of family bonds.
-The four most common medical causes contributing to the increase in cesarean section rates in North America are: routine repeat cesareans; dystocia (non-progressive labor); breech presentation; and fetal distress. Some reports suggest that more careful diagnosis and management of dystocia could halve the primary section rate. Combined with fewer cesareans for breech presentation (along with more cephalic versions), careful diagnosis of fetal distress and active encouragement of VBAC, these efforts have resulted in lowering cesarean rates to less than 12% in various parts of the world.
-Cesarean rates are influenced by non-medical factors. Rates are higher for women who have private medical insurance, are private rather than public clinic patients, are older, are married, have higher levels of education and are in a higher socio-economic bracket.
-Cesarean sections are sometimes performed for other than maternal or fetal well-being, such as avoidance of patient pain, patient or provider convenience, provider legal concerns or provider financial incentives.
What if instead of a slight increase each year in c-section rates, Sarasota Memorial Hospitaland our community worked toward a slight decrease?
With only a reduction of 2.2% per year, we can put our obstetric community at the forefront of health care reform by achieving a very healthy model, saving taxpayers literally millions of dollars, and educating women and families in the process.
It has been done, and it is being done right now in other parts of the country. New Jersey, the only state in the nation with a higher c-section rate than Florida, is launching the "Worst to First 2010" campaign, in which seven hospitals have agreed to re-educate their staffs to achieve 10%-15% c-section rates. And on Staten Island, one hospital is taking powerful measures to create drastically different outcomes than its nearest competitor. The two New York hospitals sit just five miles apart and serve an almost identical demographic, yet one has the highest c-section rate in the city, and the other, the fourth lowest. Why? Because Staten Island University Hospital does not allow unnecessary inductions for first-time pregnancies at any point before the 41st week, since they are a main cause of c-sections. They also do not allow elective cesarean deliveries upon maternal request.
Therefore, it is with great hope, excitement and the vision of a long journey ahead, that Born in Sarasota introduces 20% / 2020, an initiative to encourage elected officials, hospital staff, maternity care practitioners and consumers to reduce Sarasota's epidemic cesarean section rates to 20% by the year 2020.
How can we expect obstetricians, our hospital, and our consumers to undergo this change?
1 : Engage our community in an educational campaign about the benefits of spontaneous labor and the risks of cesarean sections that are not medically necessary, to mothers, to babies, and to future pregnancies.
2 : Explicitly describe the difference between maternal request elective cesarean section, physician ordered elective cesarean section, and true emergency surgery. Increase transparency in billing codes so that maternal request elective cesareans are accurately reflected in medical billing.
3 : Increase access to Vaginal Birth After Cesarean. Arm consumers and practitioners with the latest evidence and legislation.
4 : Make informed consent and informed refusal a respected right of the maternity care consumer. Make the public acutely aware of the Patients' Bill of Rights.
5 : Develop a localized cost-savings analysis that will illustrate to the Sarasota County Public Hospital Board and to the taxpayer that a reduction in c-section will not only improve outcomes but save millions of dollars and reduce readmission rates.
6 : Encourage independent childbirth education classes regardless of maternity care provider. Aside from good health and low risk assessment, prenatal education (including includes thorough education of the childbirth process, inspiring real-life examples, pain-coping mechanisms that do not require medical intervention, and hands-on labor preparation techniques) is the most critical element to avoiding surgical birth. These classes also explore in full detail the risks and benefits of common obstetric interventions such as c-section, labor induction, episiotomy and epidural anesthesia.
7 : Reduce the high-risk population by engaging the childbearing public in a campaign about pre-pregnancy and prenatal nutrition, including the risks of obesity and high blood pressure at birth.
8 : Maintain continued demand for transparency in statistics, at the provider and facility levels. Encourage and advertise The Birth Survey at all maternity care provider offices and facilities in our community.
9 : Increase access and use of Licensed Midwives for low-risk, healthy pregnant women. Using midwives at homes and in Birth Centers safely and cost-effectively reduces intervention rates.
10 : Introduce a feedback system by which physicians receive detailed information about the c-sections they have performed, coupled with voluntary adoption of more aggressive protocols for inducing and augmenting labor. In one California hospital, this measure alone HALVED the c-section rate.
Born in Sarasota would appreciate your feedback on how to best execute this ten-step model toward healthier birth outcomes. It will take the entire community of consumers, physicians, midwives, doulas, hospital administrators, legislators, insurance agents and policy makers to make this happen. But we can save mothers and babies in the process. We want to hear from you!
On Wednesday, March 24th, the State of Florida's Agency for Health Care Administration will move to permanently ban Vaginal Birth after Cesarean (VBAC) in Florida birth centers. Currently, women who choose to give birth normally after surgery must do so in a hospital that will allow it, which encompasses only half of those in the state, or at home with a Licensed Midwife and physician consult sign-off. VBAC's are currently not permitted in birth centers, but only because of a 'de facto ban' due to outdated language in the regulations. After a request that the language be updated to include legalized VBAC's at birth centers with Licensed Midwives and physician consultation, the State used the opening to move to make VBAC's illegal in state licensed birth facilities.
This is a dangerous proposition. The State has evidenced already this year its assumed position as medical surrogate, in the January case of a Tallahassee woman who was confined to a hospital bed and subsequently court-ordered to have a c-section. This sort of treatment completely negates a patient's right to informed consent. Further, if the State feels women should have VBAC's in hospitals, then by the same medical surrogate token, they should mandate that AHCA hospitals allow women adequate trial of labor and welcome VBAC's. If fewer than half of Florida hospitals 'allow' VBAC, and fewer than 1% of obstetricians 'allow' VBAC candidates as patients, and Florida women are limited in their choice of birth place and care provider...well, you do the math. Our primary c-section rates aren't getting any lower (Florida's average is around 37%). The best way to begin to chip away at these epidemic and very dangerous numbers is to increase the VBAC percentages. Women who attempt to VBAC are successful over 75% of the time without necessity for intervention, yet at Sarasota Memorial Hospital, for example, only 1 to 3 women have successful VBAC's each month. Why? Because they cannot find supportive care providers. Many providers, pressured by insurance and medical malpractice concerns, scare (for lack of a better word) women into believing they are making an unsafe choice (read this thorough comparison to learn for yourself). While it is true that a uterine rupture (the primary concern of providers hesitant to accept VBAC patients) can be a devastating obstetric event, it occurs in fewer than 1% of VBAC candidates, and is responded to by emergency c-section--a procedure our hospitals are fully equipped to execute effectively. For those undergoing repeat c-sections, rates of serious placental complications, infections and NICU admission for the babies of those sections are rising rapidly. Women should and are legally obligated to receive balanced information that includes the risks and benefits of VBAC as well as the risks and benefits of repeat surgery. Allowing the pursuit of VBAC at home or at a state licensed birth center with a Florida Licensed Midwife will keep healthy, safe options open for Florida's families, and will dramatically reduce taxpayers' investment in unnecessary surgery.
There is virtually no difference in medical equipment between a birth center and the gear of a homebirth midwife. If the state considers VBAC with a Licensed Midwife at home safe, it is literally contradictory to ban VBAC's in birth centers. Many women would feel more comfortable in a birth center than in their homes, for a variety of reasons, and should be offered this opportunity. Physician consultations for VBAC's take into account several factors regarding the woman's previous surgery(s) and current health risk factors. Once again, we should be striving toward a collaborative model, one in which normal, healthy woman can choose the safe, cost-effective, nurturing care of midwives, and be reassured that obstetricians are available to provide their expertise and intervention if necessary--and only if necessary.
For these reasons, I urge you to sign the following petition and make your voices heard in support of legalizing VBAC's in Florida's licensed birth centers:
To: Florida Agency Health Care Administration
While we recognize the need to change outdated language in the rule, it is our position that the state consider similar language to that of F.S. 467. Such language would work to insure the patient received competent care from a licensed practitioner and respects the right of the patient to make an informed decision. We ask the State of Florida to remain a regulatory body and not take on the role of medical surrogate.
This is a very timely discussion, as tomorrow begins the first conference from the National Institutes of Health on VBAC issues. The conference will address the following key questions:
--What are the rates and patterns of utilization of trial of labor after prior cesarean, vaginal birth after cesarean, and repeat cesarean delivery in the United States? --Among women who attempt a trial of labor after prior cesarean, what is the vaginal delivery rate and the factors that influence it? --What are the short- and long-term benefits and harms to the mother of attempting trial of labor after prior cesarean versus elective repeat cesarean delivery, and what factors influence benefits and harms? --What are the short- and long-term benefits and harms to the baby of maternal attempt at trial of labor after prior cesarean versus elective repeat cesarean delivery, and what factors influence benefits and harms? --What are the nonmedical factors that influence the patterns and utilization of trial of labor after prior cesarean? --What are the critical gaps in the evidence for decision-making, and what are the priority investigations needed to address these gaps?
I am hopeful that the findings of this conference will further support the safety, cost-effectiveness and good common sense of allowing women to make their own informed decisions about VBAC, and will encourage the practitioners in attendance to do everything possible to combat the primary c-section rate. We wouldn't be holding conferences or discussing legislation regarding VBAC policies if the primary c-section rate were at an appropriate, healthy level.
Today is Brad Augsburger's birthday, and he is receiving the sweetest gift of his thirty-five years: watching his wife move out of the ICU and into a regular recovery room. That is expected to happen later today. Colleen has been waking up slowly, eating and drinking tiny bits at a time and being up for half-hour stretches. This is great news. We could so easily be coping with a different outcome.
Last night, I had the uncanny experience of learning the story of Katy Hayes, a Texas mother of three who is fighting the same rare Streptococcal A bacterial infection that Colleen is overcoming (this woman's baby was born just 5 days before Kaya). As Colleen was giving birth to Kaya, Katy was in surgery for the removal of several septic organs. She remains unconscious, is still on a ventilator, and is undergoing dialysis. Just yesterday, her husband Al had to make the heartbreaking decision to allow her doctors to amputate her hands and feet, because the bacteria was attacking the tissue in her extremeties. Without amputation, her team of doctors warned that the bacteria would spread fatally.
I cannot underscore enough the importance of routine postpartum visitation and care. I am very grateful for the close observation of Colleen's midwives, family members and postpartum care team. Her warning signs were noticed immediately, and she was admitted to Sarasota Memorial Hospital in time to avoid a very bad outcome. I am also extremely grateful to the team of physicians and nurses that has worked around the clock to literally save Colleen's life. This is an example of collaborative care between midwives and doctors, and for that, on so many levels, I am grateful.
Baby Kaya, his siblings, and his daddy have been sustained by the most incredible community here in Sarasota, one that I attribute greatly to the two birthing centers here, their midwives, and their family of families. Mothers have pumped their milk to ensure Kaya's healthy beginning on this earth. The Augsburgers and their care team have been fed every night from a different family, and their food train is booked through mid-March. They have received donations of fresh produce, baby items and food delivery from local businesses. Brad would like to extend deep gratitude to those that have donated money while he is unable to work. He does not expect to be able to work again until April, so donations are still being graciously accepted so this family of five can reunite, heal, and care for each other, worry-free.
This next phase of recovery will be a long one, but a joyous one. More info on a benefit coming soon!
The Joint Commission, the organization that accredits and certifies more than 17,000 health care organizations and programs in the United States, has issued a Sentinel Event Alert focused on Preventing Maternal Death. Joint Commission accreditation and certification is recognized nationwide as proof of a health care facility's adherence to certain performance standards. More importantly, its accreditation has become a condition of licensure, and subsequently, of Medicaid reimbursement.
Unfortunately, current trends and evidence suggest that maternal mortality rates may be increasing in the U.S., despite the rarity of the incidence of maternal death – deaths that occur within 42 days of birth or termination of pregnancy. Since 1996, a total of 84 cases of maternal death have been reported to The Joint Commission’s sentinel event database, with the largest numbers of events reported in 2004, 2005 and 2006. According to the National Center for Health Statistics of the Centers for Disease Control and Prevention, in 2006, the national maternal mortality rate was 13.3 deaths per 100,000 live births.
"There clearly has been no decrease in maternal mortality in recent years, and we are not moving toward the U.S. government’s Healthy People 2010 target of no more than 3.3 maternal deaths per 100,000 live births,” says William M. Callaghan, M.D., M.P.H., senior scientist, Division of Reproductive Health, Centers for Disease Control and Prevention.
The leading causes of maternal death are: hemorrhage, hypertensive disorder, pulmonary embolism, amniotic fluid embolism, infection, and pre-existing chronic conditions (such as cardiovascular disease). (Research) also indicated a four-fold increased risk of pregnancy-related death for black women, and increased risks for older women and women with no prenatal care. The numbers of deaths related to hemorrhage are declining, while deaths attributable to other medical conditions – including cardiovascular, pulmonary and neurologic problems – have significantly increased.
Several studies determined that from 28 to 50 percent of maternal deaths were preventable. In 2008, Hospital Corporation of America (HCA) looked at individual causes of maternal deaths among 1.5 million births within 124 hospitals in the previous six years. According to the HCA study, the most common preventable errors are:
-Failure to adequately control blood pressure in hypertensive women -Failure to adequately diagnose and treat pulmonary edema in women with pre-eclampsia -Failure to pay attention to vital signs following Cesarean section -Hemorrhage following Cesarean section
“Pregnancy is a known major risk factor for venous thrombosis and pulmonary embolism. HCA now advocates for the universal use of pneumatic compression devices for all pregnant women undergoing Cesarean section.” Unlike nearly all other adult patients undergoing major surgery, pregnant women undergoing Cesarean delivery have traditionally not received prophylactic measures for the prevention of venous thromboembolism afforded similar surgical patients who lack this risk factor.
Each case of maternal death needs to be identified, reviewed, and reported in order to develop effective strategies for preventing pregnancy-related mortality and severe morbidity. To this end, The Joint Commission encourages participation by hospital physicians, including obstetrician-gynecologists, in state-level maternal mortality review and collaboration with such review committees in sharing data and records needed for review. The following suggested actions can help hospitals and providers prevent maternal death:
1.Educate physicians and other clinicians who care for women with underlying medical conditions about the additional risks that could be imposed if pregnancy were added; how to discuss these risks with patients; the use of appropriate and acceptable contraception; and pre-conceptual care and counseling. Communicate identified pregnancy risks to all members of the health care delivery team.
2.Identify specific triggers for responding to changes in the mother’s vital signs and clinical condition and develop and use protocols and drills for responding to changes, such as hemorrhage and pre-eclampsia. Use the drills to train staff in the protocols, to refine local protocols, and to identify and fix systems problems that would prevent optimal care.
3.Educate emergency room personnel about the possibility that a woman, whatever her presenting symptoms, may be pregnant or may have recently been pregnant. Many maternal deaths occur before the woman is hospitalized or after she delivers and is discharged. These deaths may occur in another hospital, away from the woman’s usual prenatal or obstetric care givers. Knowledge of pregnancy may affect the diagnosis or appropriate treatment.
Additional suggested actions for hospitals and providers to take for patients identified as high-risk (for example, those with pre-existing medical conditions such as hypertension, diabetes, morbid obesity):
4.Refer high-risk patients to the care of experienced prenatal care providers with access to a broad range of specialized services.
5.Make pneumatic compression devices available for patients undergoing Cesarean section who are at high risk for pulmonary embolism.
6.Evaluate patients who are at high risk for thromboembolism for low molecular weight heparin for postpartum care.
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This is a huge step in the right direction. However, two of the four main preventable causes of maternal death result from cesarean sections. In light of research showing the correlation of elective cesareans to increased maternal death, what seems glaringly missing from the Joint Commission's suggested course of action is a campaign to educate patients (and physicians!) on the risks of elective cesarean section surgery. Instead of education, the Joint Commission suggests the universal use of pneumatic compression devices and prophylactic embolism prevention for women who undergo c-section surgery.
Dr. Steven Clark, medical director for women and newborn services for HCA, says in the Alert that "the only cause of maternal death amendable to nationwide systematic prevention efforts is pulmonary embolism." I urge Dr. Clark to take this statement further. Any maternal death that resulted from an unnecessary intervention or surgery was preventable. Proper nationwide systematic prevention efforts MUST include universal prenatal education about risks of and treatment following obstetric interventions.
On Friday, October 30th, Ina May Gaskin presented a closed clinical conference to the medical staff of Sarasota Memorial Hospital. Her presentation was entitled "Combining the Best of Modern Obstetrics with Respect for Nature and Traditional Midwifery Approaches." Ms. Gaskin has been internationally credited with reintroducing legalized direct-entry midwifery in the United States. The presentation is available via podcast on the SMH Continuing Education website. View a PDF of the accompanying power point presentation, in both English and Spanish, here.
Her objectives were threefold: to explore the knowledge base and skills common to traditional midwifery; to understand the need for both modern obstetrics and (authentic) midwifery; and to build positive relationships between the two professions (especially with regard to home birth midwives). Present at the conference were SMH Director of Maternal-Fetal Medicine Dr. Washington Hill; Sarasota County Health Department OB/GYN Dr. John Abu; Licensed Midwives Christina Holmes and Alina Vogelhut; and several members of the hospital staff and the community, including childbirth educators, nurses and retired physicians.
In her introduction, Ms. Gaskin told attendees "I just want to show what someone who births at home teaches us," and proceeded to show still images of the dancing birth of her own grandchild. She then discussed everything from her world-famous Gaskin maneuver for delivering babies with shoulder dystocia, to the rapid decline in vaginal breech birth, to the benefits of allowing the baby to clear his or her own air waves. She talked about the 1-2% c-section rate at her renowned midwifery center, The Farm, in Summertown, Tennessee. "We did allow eating and drinking during labor; we never would have had such a low c-section rate had we not." When discussing positive, unmedicated, ecstatic birth experiences, Ms. Gaskin said, "We can only achieve that if we keep the labor room calm and sweet...because we find the mother's feelings really do matter a lot."
Ina May Gaskin then gave those present a brief history of American midwifery and its resurgence, and talked about her own tutelage from a family physician, and subsequent collaboration with several obstetricians. She asked the question, "How do we then lower a c-section rate when it is up so high?" She suggested alternative methods for labor induction, specifically discussing her concerns about the use of misoprostol for induction, a drug which has never been approved by the FDA for this purpose and has been directly linked to an increase in amniotic fluid embolism, a potentially fatal condition for both mother and baby. She also discussed alternatives to medical pain relief, different positioning and movement, and the need to reverse an overall "cultural unfamiliarity" with unmedicated birth.
In conclusion, Ina May Gaskin talked about the need for healthy relationships when transferring patients from midwifery care to the hospital. "Above all, what the women who come to us (midwives) want, if we have to take them to hospital, is that they don't want to be punished or judged for having made that choice. That's probably the number one thing that needs to be conveyed."
Dr. Washington Hill, Medical Director, Labor & Delivery, SMH with Ina May Gaskin
Born in Sarasota is a collective of thoughts, articles, birth stories, events, and evidence in action supporting healthy, normal childbirth in our community. We are dedicated to promoting choices in mother-friendly maternity care practices and providers, informed consent for our pregnant families, and increased support of normal childbirth.
Do you have a birth story or birth photos to share? Please submit them here! Sharing your birth experiences will help empower others!
I believe that the current paradigm of maternity care in the United States must be shifted away from the medically invasive model and back to the embrace of birth as a natural, healthy process, one in which intervention should be used appropriately and with absolutely transparent informed consent. Without such a shift, our mothers and babies will continue to have unnecessarily poor outcomes, and we will lose our primal reverence for birth as a sacred event.
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