I was reading one of the original publications on the three delays to care in childbirth emergencies this morning, and was struck with an unpleasant thought.
First, let me acquaint any readers who have not heard of them with the three delays. It is a framework for thinking about and dealing with the problems that lead to increased maternal mortality. It has generally been applied to women living in low resource settings.
- The first delay is the wait time between the problem occurring and the woman or those with her recognizing there is a problem. This generally has to do with lack of education and trained birth workers. In areas where poor outcomes are endemic due to multiple effects of poverty, women and their families may consider the signs of a problem to be normal because this happens to nearly everyone.
- The second delay is the wait time between identifying the problem and seeking help. This generally has to do with the costs of seeking care, the low value of women to a society (and her ability to decide for herself to seek care), and the perception of the health system’s ability to provide help.
- The third delay is the wait time between arriving at the place where help is available and receiving that help. This generally has to do with under funding health systems causing lack of staff, supplies and necessary resources to handle emergencies.
What stuck me today was that although this framework was designed for use in low resource settings, I can see reflections of some of the causes of delays in conversations with home birth in the US. I understand that in the US, the maternal mortality rate is not driven by women not having access to care in obstetric emergencies. Yet, I can’t help but wonder if some of the push back against home birth comes from the successful implementation of this framework into the international obstetric community.
I want to explain why this framework was adopted. Prenatal care was supposed to have solved maternal mortality by identifying women at risk and referring them to appropriate resources. While this might work for hypertension issues, that is only one small chunk of the maternal mortality pie-chart. Once the research started to show the failure of prenatal care to predict obstetric emergencies, the momentum changed to improving access to emergency care by making sure facilities with obstetrical services were well distributed, properly staffed, provided with adequate supplies, and able to be accessed when an emergency occurred.
In the United States, most of the country has the emergency services available (but there are geographic pockets with low population levels that are simply under served in all areas of health care). In the minds of decision makers, the existence of emergency obstetric care is evidence the third delay has been dealt with, and it is only the first two delays that could cause problems.
If you look back on the first two problems, these relate to poor decision making by unskilled labor attendants. In the developing world this was most often family members of the woman. In most of the United States, registration or licensing helps to ensure minimum competency of birth attendants for home birth. To some, this serves as evidence that the first two delays have also been dealt with.
So what was the unpleasant thought? When viewing birth from two different paradigms, it is easy for sides to see very different courses of action as appropriate. While homebirth supporters may feel they are expressing faith in the natural process, I can see how practitioners who view birth from a different paradigm could hear something very different in the comments I hear.
So a comment about how it took two days of labor, but the baby finally came out might be seen as evidence the midwife is not trained in the partograph to help identify obstructed labors.
A comment about how a woman had to birth unassisted because she didn’t want a cesarean might be seen as evidence of an inability to recognize risk.
These are just examples. I’m sure you could come up with additional ones. The point is, a paradigm can make a comment be received very differently than it was intended. It makes me wonder what the best way to bridge the various birth paradigms may be.
I have to admit, I wasn’t quite prepared for a new semester to start. It didn’t help that instructors didn’t have readings available until the day of class so I couldn’t be a week ahead (my comfort zone). What really had me not prepared was that I actually spent my break doing something for me. No editing papers for submission, no posters. No credentialing tests to get done. So I ran a marathon.
I use the term ran rather loosely, I walked about 25 miles of it. I intended to take walk breaks so it wasn’t a huge disappointment. I had intended to take a walk break every 8-9 minutes, so it was a little sad. I had made a classic newbie blunder – I over-trained. Not that I was trying to be really fast or beat some time. I just figured I could do a little extra and it would be OK.
My legs are now receiving the rest they so desperately needed, and the experience was not so bad that I won’t go near another marathon. In fact I am planning to run again. So what did I learn from this experience (aside from the importance of not over-training as defined by your running ability?) I learned that the running a marathon metaphor I had been taught to use when explaining why women should prepare for birth is not quite as good as I had always imagined.
The metaphor for those who have never heard it: A person couldn’t run a marathon without training. Childbirth is like running a marathon, you need to train to do it well. There are lots of variations of phrasing, but it basically boils down to: you have to get your body in good shape and have lots of endurance to give birth.
Yes, I did have to build endurance. But that didn’t mean I needed to think about running all the time, and it didn’t mean I needed to practice running every day. And honestly, there was no question about my ability to do a marathon. I had read the statistics on marathon finishers — it turns out that if you actually train you have a pretty low chance of not finishing. That little piece of information surprised me, and kept me motivated. Unlike childbirth, there were not things outside my control that could wreak havoc on my ability to finish. I might fall, or crash into another runner — but really the chances of something happening that could prevent me from finishing was pretty small.
And really, the building endurance was only part of the training. Seems there are people who are quite athletic, but don’t run long distances regularly, who are not able to finish a marathon when they first try because they assumed it was all about strength and endurance. These people end up vomiting, leaving the race due to blisters or chaffing, or overdo it in the beginning and just can’t make it to the end. I learned how often I needed to eat when running — too infrequent and I would be weak, too frequent and I would be nauseous. I learned which clothing causes chaffing, and which outfits keep my skin intact despite sweating in them for six hours. I learned my best strategy for hydration. I learned which shoes do the best at protecting my feet on long runs. All these things I needed to be able to finish I could learn because I was really running during the practice. This doesn’t happen when women practice positions and comfort measures for labor. A teacher might try to simulate pain with pinching or ice cubes, but until you are actually in labor (or running), you cannot be sure what does and does not work. This is probably one of the reasons women say they have an easier time with the second and subsequent labors – they know what to expect and what didn’t work.
I have been challenged to do a triathlon this summer. While my legs rest from running I’ve been working on the swimming and cycling portions. I’ll let you know if this turns out to be a better metaphor for labor.
Just found an interesting site for those who want to improve their ability to understand research articles. I haven’t dug too far into it yet, but seems promising:
Looking for an interesting self-study program during the holiday break? Here is one from the CDC on vaginitis. It is such a common issue for women, midwives need to understand the condition.
At the end of a random self-talk conversation this morning I remembered how awesome I thought it was when the midwives at the birth center taught me to hear the fetal heartbeat with a stethoscope. At the time is seemed so hard, and it took me a few tries. But the more I traveled, the more I realized this method is pretty common in low resource areas. But in the US where you are likely to learn to listen with a fetoscope or dopler, transferring those skills to a stethoscope will take a few adjustments.
Here are some things I had to learn to master listening with the stethoscope:
- It helps if you are already well practiced with a stethoscope. You need to know how to position it properly in your ears to block out the ambient noise.
- You need to already know how to find the baby and identify landmarks. You will have to position the stethoscope over the back near the head, and there is less room for error than with a doppler.
- You need to be willing to press the bell very firmly onto the mother. You will be pushing hard enough to ‘indent’, and you will leave a red ring (that lasts about 5 minutes) where the bell was pressed against the skin.
- You need to already know how to “hear” the heartbeat. The sounds are different than when you use a doppler, and they are more subtle than with a fetoscope. One friend equated it to the difference in listening for the blood pressure sounds between an 18 year old healthy young man and a 90 year old lady – the sounds are there, but they are subtle and you need to learn to hear them.
Hope this lists help you master this skill. If you are just learning how to use a stethoscope and/or to identify fetal parts, it might help to use the stethoscope after you have already found the heartbeat with a doppler. Figure out where you hear it the loudest, and begin your stehoscope search for the heartbeat there. It may also help to try it on women near term the first few times – it can be easier to identify parts and the fetus is squished right next to the abdominal wall.
For those who think their calling may be more on the political activism side of the spectrum, I wanted to take a minute and give you some resources you might not have considered. Most major organizations have advocacy priorities that are set by the national board. For example, if you read at the Royal College of Midwives, you will see a collection of research and briefings that share what the RCM thinks is most important right now.
Do you have a political leaning in your call? Check out the national organizations that work around birth – think organizations of nurses, midwives, doctors; and think about international organizations such as Lamaze and La Leche League. Check out the advocacy sections of their website and see if you can find a current need to help fill.
I’ve decided to dig deeper into infertility for one of my class papers. It is paper number three in a series of short essays on the mechanisms that lead to different health outcomes. The previous two focused on disparities in cesarean and how stress doesn’t affect breastfeeding. The essays are limited to three pages in APA format, which gives just about enough space to describe the situation before you need to start your concluding paragraph–no messing around with flowery words here. The limitations mean you focus on a very small piece of the puzzle.
For my infertility paper, I am focusing on the smallest piece — the microbial ecosystem that inhabits the genital tract. While the known details are interesting, it is the unknowns that are fascinating. For example, women with BV have a higher preterm birth rate and early pregnancy loss rate and are less likely to achieve conception with assistive reproductive technologies. Unfortunately, we can’t really say why…yet. And as interesting as the mid-vaginal microbes are, there apparently exists a controversy over whether or not the uterus is a sterile environment.
Me, I’m very clearly on the non-sterile side of the debate. The cervical os opens monthly, and we know it is possible for pathogenic bacteria such as chlamydia and gonorrhea to ascend all the way up to the tubes. Why would we assume the good microbes would not also make the trip? This view is also supported by the evidence that babies who are born via cesarean after the bag of waters has broken appear to have the same microbial gut colonization as babies born vaginally — current evidence suggests only babies who do not have time in the uterus without the protection of the amniotic sac have a different gut colonization. Based on this, I’m proposing that better understanding of uterine microbial ecosystems can help explain some of the 10% of infertility cases that are currently labeled as “unknown reasons.”
Excuse me now, I need to do a bit more research so I can make recommendations of possible collection techniques to obtain uterine microbe samples (without too much human DNA) for 16S rRNA sequencing and can finish this paper.
I hadn’t realized it had been a month since I shared about concepts. I completed the assignment, and hopefully did a good job communicating what I found. As expected it was different, but not difficult, and very eye opening.
I chose to look at the concept of “elective” as we use it to describe an elective induction. I knew there were problems with the use of the word, and I wanted to learn how to highlight those problems. As expected, my analysis found multiple meanings of the word, which leads me to today’s reminder: always ask questions about everything you read.
The problem with multiple meanings is that we are talking about very different things–things that could even be the opposite of each other–and we make the assumption that we are talking about the same thing. What was the most disturbing to me is that for the assignment I was limited to peer-reviewed scientific literature; I was only looking at published research. This wasn’t disagreement by pregnant women about what was a legitimate reason for an induction. This wasn’t disagreement among health care providers. This was disagreement among scientists trying to determine what the risks and benefits of the procedure may be.
What questions should you be asking when you read? Basically, what was the methodology (the boring science part of the study). So, if you wanted to know about how eating carrots affects pregnancy you need to ask yourself, “Who did they include, and who did they exclude as carrot eaters?” Did they only include women who are otherwise healthy, or did they only include women who are having a particular issue with pregnancy? You need to know how they measured “eating” carrots. Did a woman count as a carrot eater if she at a carrot once, or did she need to eat them every day, or did she need to eat a certain total amount of carrots? You need to understand why this particular population was selected, and what that means about how they are defining a carrot eater or not a carrot eater. Were women chosen because they visited a dietitian during pregnancy, or recruited through a cooking class, or were they chosen because they happened to be the women using a particular clinic? Where women are recruited might make a difference in what the “normal” diet is, and you need to be able to decide if that difference is meaningful.
Chances are you know what a concept is…something that represents something that isn’t physical. Like “democracy” or “faith.” And chances are you could list a few concepts that relate to childbirth. In case you are feeling lazy, I can list a few:
- natural childbirth
- continuous support
- elective induction
- woman-centered care
I’m sure you get the idea.
So, why is this important? Because when you read research about concepts, you need to be very careful about how those concepts are defined. For example, is an induction for post-dates at 41 weeks an elective induction? Is scheduling one-to-one nursing care the same as continuous support? Is it a natural childbirth if the woman chooses to use oxytocin, or if she has a vacuum assisted birth?
For researchers, the decisions about what “counts” and what “doesn’t count” when measuring these things matters because if your definition isn’t correct you could be measuring the wrong thing. There is also potential for misunderstanding on the part of the reader, especially if the reader does not have access to the full article and can only see the abstract. If the authors make a statement such as “our results show home birth is safe” (or “not safe”), you need to be able to look at the inclusion and exclusion criteria to see how they defined a home birth. Was it any birth that didn’t happen in the hospital? Was it only planned home births? Did it include women with risk factors that would ordinarily prevent them from choosing home birth? If you just assumed the researcher thought about home birth the same way you did, you could be making assumptions the actual research doesn’t support.
Some of the concepts in the birth world are big and hard to measure. Think for example of mobility in labor. Do you count it as mobility if the woman has the freedom to move, but chooses to stay in bed? What if the only walking she does is to the bathroom? How much walking would a woman need to do for you to count her as “mobile” during labor? Or would she not have to walk at all, but simply change her position as much or as little as she wanted? See, these are not always easy things to measure. In reality, you might want to measure different aspects of the same concept. How much women do walk when a policy promoting mobility is put in place is a great question. How does labor change when women spend at least 10 minutes of every hour walking is another great question.
So the next time you read a research paper or the abstract, ask yourself if what they are measuring is a concept. Then try to figure out how close you think they came to actually capturing the effect it has on labor, and what other ways the concept could be measured.
One of the courses I am taking this semester is about determinants of health. We look at things both within the individual, and within the environment, and how they interact to affect health. A very interesting topic, and very challenging to integrate the research on a topic into a three page essay. But integrate I must.
For the next paper, I’ve decided to look at race and ethnicity and its effects on cesarean. I know enough epidemiology to know that when you adjust for risk factors African American and Latina American women are more likely to give birth via cesarean than their Caucasian American neighbors. It isn’t a small increase either – check out this study which is pretty representative of the epidemiology all over: http://www.ncbi.nlm.nih.gov/pubmed/23281861
What the adjusted odds ratio means is that when we control for all the things that we know affect having a cesarean (like social or medical risks), we end up with this number. In the case of African American women, that number is 1.54 – so an African American woman with no risk factors for cesarean is 54% more likely to give birth via cesarean than a Caucasian American woman with no risk factors in the next room.
Does this surprise you?
What about the result that African American women have a 2.19 adjusted odds ratio of having a cesarean for non reassuring fetal heart tracings. This means that if two women are in labor in rooms right next to each other (this was data from one hospital system), the African American woman has more than twice the risk of being told she has non-reassuring fetal heart tracings and that she needs a cesarean than the Caucasian American woman in the next room. Does this seem biologically possible to you?
There are potential social factors that cannot be adjusted for – for example, are Caucasian American women and African American women likely to use different practitioners for their care – and therefore the choice of practitioner is affecting the rate of cesarean?
Another idea is the effect of racism on the actual health of the woman – do the effects of racism and the chronic stress of that racism reduce the capacity of an African American woman’s body to handle the additional stress of labor?
Or is it more obvious than that? Are our healers and care institutions still making decisions based on racism – deciding African American women are either too lazy, too unhealthy, too unfit, too complaining, too controlling, too loud, too sexual, too poor, too proud…. (you get the idea) to give birth naturally and so the decision to cesarean is made faster, easier, with less compelling data?
I don’t know what the answer is. I don’t think I’ll find it in the literature, but if I do I’ll let you know. In the mean time, consider what your advocacy group for physiological childbirth looks like – and if the increased cesarean risk for racial minorities is something your advocacy group speaks against.