The Illusion of Choice…

Yesterday I spent a good portion of my time reading articles and watching news clips that discussed the recent NIH Conference on VBAC (Vaginal Birth After Cesarean).  *sigh* (and that was a HUGE sigh BTW!)

[a side note… I feel like I am so BEHIND… VBAC was the story of Mon, Tue, Wed, Thu…. the news of  TODAY is the Amnesty International paper on maternal mortality.  But I supposed when you recognize that our rising maternal mortality rate is related to our rising cesarean section rate I'm not that behind at all :-)  ]

Moving on….  In a perfect maternity, mother friendly, family-centered, baby-friendly world, there would have been no need for such a conference.  Everyone would know, appreciate and inherently understand, that we are all created equal and everyone, INCLUDING pregnant women, has a right to choose the medical procedures that they will and will not undergo. 

In a perfect world, this would include everything from open heart surgery, to a tonsillectomy; laser eye surgery to plastic surgery, a hysterectomy and everything in between.  Yes in a perfect world, the choice about going under the knife would be the choice of each individual to decide. YES… even pregnant women.

Imagine this perfect world where women are given true information from their providers… where choice is NOT an illusion and they have real options because every hospital, every provider, every midwife, every doctor, every nurse understands that given the right information, women will make the best choice for herself and her family.  In fact, many of those women would choose a VBAC because it is indeed a safe and viable option. 

Alas this is not a perfect world and somewhere between the laser eye treatment and the breast augmentation, women are stripped of the autonomy to make choices about their bodies.  All of a sudden policy makers, insurance providers, hospital administrators, medical organizations and the like begin to think they know what is best.  To me the saddest part about the whole VBAC discussion is this assumption that women are incapable of making decisions for themselves and therefore need the patriarchal powers that be to lay down the law! The funny thing is… the “powers” don’t even know what they want the law to be.  It changes with time and when it changes they enforce the new law with the same enthusiasm as the previous law.

The VBAC discussion always makes me think about my personal career in women’s health.  When I first started working on a labor and delivery unit in 1995, the “law” was Trial of Labor (TOL).  I worked in a hospital that had 100% Medicaid population, and it seems women with Medicaid often have fewer choices than women with private insurance, but that’s a discussion for another day.  In 1995, we forced women to have a TOL.  They did NOT have a choice.  We even induced women with two prior cesarean sections.  Most women didn’t think to protest. They went along with what the almighty resident doctors told them.  There were a few women who cried and told stories of long and scary labors who begged for a repeat section and they too were told NO! No, NO!,  no…  a thousand times no.  None of these women were given a choice.  TOL was the law followed to the letter.

I knew it was wrong and yet in all of my greenness as a labor nurse I felt my hands were tied.  I didn’t really understand the risks/benefit ratio of either option but I KNEW if a woman wanted to have a repeat cesarean… That was a no brainer she should be able to have one….

I left that hospital in 1999 and in 2003 I returned for a short stint.  When I returned I found the law had changed.   I remember being in the triage area and a women presented in active labor 6cm dilated.  This was her fourth pregnancy. Her previous deliveries were vaginal, cesarean, VBAC.  As soon as the resident discovered she had a previous cesarean she shouted for us to quickly move to get her ready for a repeat cesarean. I protested loudly…. WTH! I encouraged the patient to protest.  

The craziest thing about this facility creating a VBAC ban is they actually have in house anesthesia and MDs around the clock and I have personally been there when we have gone from decision to incision in less than 5 minutes. With that in mind WTH??!! is all I could say.

Unfortunately my protesting did not work and she did undergo a repeat cesarean.  Yes the law had changed. We went from forced TOL to forced repeat cesarean section.  Unfortunately what did not change was the fact that women were still denied choice, options, and autonomy.  *smdh*

In 1994, what we did wasn’t right. In 2003 what we did wasn’t right. And today in 2010 what we are doing is NOT right… women have a RIGHT to make a choice about the way she wants to birth.  It is preposterous that anyone can tell a woman how she should birth especially when one choice is NOT necessarily better, safer or the best option for her.  I don’t understand how we got into this situation. When did we allow THEM to take over OUR process!

Tomorrow I will be doing a FREE Pregnancy Teleclass:  The Birth Plan Myth… Perhaps I should have called it the Illusion of Choice, because at the end of the day, when it comes to maternity care in this country, Birth Plan or not… there is little choice.

And the end result……. How about we pause and go read the report from Amnesty International. It says more than a mouthful…

In Birth and Love
Nicole

Published in:  on March 12, 2010 at 10:46 am Comments (2)
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Wordless Wednesday – YES! I’m from New Orleans!

Published in:  on February 24, 2010 at 12:40 am Leave a Comment
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A Heavy Situation…

That STAT of the Week from the National Health and Nutrition Examination Survey, NCHS posted at the beginning of the week stated that in 2007-2008, approximately 34% of U.S. adults (32% of men and 36% of women) were obese.  It is not news that we have a serious weight and obesity problem in this country. 

Aside from the general population, according to the CDC, more than 56% of women of childbearing age are overweight or clinically obese.  I want you to know that being obese before and during pregnancy comes with MULTIPLE problems.  If you are currently overweight or obese and planning to get pregnant it is IMPERATIVE that you do what you can to lose weight BEFORE you even think about pregnancy.  Your health, the possibility of healthy pregnancy, the health of your future infant, and in fact both of your LIVES depend on it.

Unfortunately, there are many women who may believe that they are simply a “little over weight” when in fact their weight has reached the definition of clinically obesity.  Clinical obesity is defined by a   measurement we call Body Mass Index or BMI.  BMI is calculated based on a formula using your height and weight.  While your BMI is important to your overall general health it becomes even more crucial when you are thinking about bearing children.  The risks of obesity in pregnancy are numerous and I am simply going to give you a quick overview, a very small tip of the iceberg.

First it is important to know that overweight and obese women have a more difficult time even getting pregnant in the first place. Once pregnant, there is then an increase risk of miscarriage.  Additionally, obese women are more likely to have an infant with a birth defect of the spine, abdominal wall, and heart.  Unfortunately, the more obese you are, the more difficult it can be for your provider to visual some of these birth defects with ultrasound examination.

As pregnancy progresses, overweight and obese women are at increased risk of pregnancy complications including gestational diabetes, pregnancy induced hypertension and pre-eclampsia, all of which are connected to an increased risk for still birth.  In some studies obesity has been associated with a 5 fold increase risk of a still birth infant. 

Because of the various pregnancy complications, obese women are more likely to need a medical induction before their infants are full term.  Induction and prematurity are associated with a HOST of additional problems and complications: from the “simple” extra length of stay in the hospital to the worse and unthinkable increased risk of mortality.  Women who are overweight and obese have an increased risk for cesarean birth and then have increased risks for complications related to the surgery.

Do you know if you are obese???  You may think you are simply a bit overweight and in reality you may be clinically obese.  If you want to find out check out this calculator and learn what your BMI is. 

If you are overweight or obese, get some help with your weight loss NOW. You do not have to do it on your own. There are many community programs out there that want to help all of us optimize our lives.  If you are considering a weight loss surgery be sure to understand the implications that this will have on future pregnancies and understand the importance of delaying pregnancy until well after your initial weight loss is accomplished.

This information is not meant to scare you, however if it does scare you into weight loss then I am not unhappy about that.  I know that weight loss is not an easy thing. However I hope this information will encourage you to do whatever you can to make it happen BEFORE pregnancy.  After you are pregnant it is much too late.  I know someone out there needed to hear this message today and I hope it moves you to action.

In Birth and Love,
Nicole

Published in:  on January 22, 2010 at 7:01 am Comments (3)
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Never Underestimate the Power of YOU!!

“It is YOUR body and only you know what you can handle.”   Hmmmmmm…. ???

That quote is a status update I placed on the Your Birth Right facebook fan page Monday evening. It was initially written by a fan/reader who mentioned that while she supports women who want a natural birth she had a very satisfying birthing experience with an epidural.  She said, (and I agree with her) that every woman has to choose the experience that is best for them based on the information they have.  She ended her post by saying “It is YOUR body and only you know what you can handle.” 

Initially I was like…. “YES,” however when I woke up the next morning I re-evaluated that phrase and realized in actuality, we often DON”T know what we can handle until we are faced with the situation, or the challenge. 

Monday night, after using that statement for a status update, I watched some coverage of the Haiti tragedy.  While watching, I saw a story about a women, who had been trapped SEVEN days beneath rubble, without food or water. SEVEN days!!!  On day seven she was rescued and as she was pulled from the rubble to safety she smiled, she cried, and she sang LOUDLY songs of praise!! After a brief examination she was sitting upright in a truck with rescue workers and her husband riding along to a safer place. She was smiling the entire time and unless you had seen the rescue yourself, you would not have believed she was a woman who was trapped for seven days!!! It was remarkable to say the least.

Who among us, if asked, would say:   “Yes, ABSOLUTELY I could survive SEVEN days after an earthquake trapped beneath unmovable rubble, without food or water and with rescue nowhere in sight”  Yea… right.  How much strength, faith, fortitude, and power did this woman have?  LIMITLESS….  Did she know she had this amount of strength and power prior to her personal experience? Probably not.

So when I woke up Tuesday morning, I reexamined that quote… “It is YOUR body and only you know what you can handle.”  Hmmmmmm??? Yes… It is YOUR body….. but I am reminded through the struggle and power of that Haitian Woman, and in fact all of the Haitian people struggling for survival…. NO we often DON’T know what we can handle.  We have no idea how strong we are.  We are so much stronger than we know and much stronger than we may ever realize.

In birth as in life, when we are faced with a challenge, with an opportunity, with a situation that on another day, we may have thought we were too weak to handle… when we are actually put into the extraordinary situation, by Devine Design we have the power to face the music and create a melody never heard before.  We make it happen because we are so much stronger than many of us have ever imagined and we can handle much more than we know.

Through the years, I have heard about and read countless stories of unbelievable strength and courage. Through my involvement in birth I have personally witnessed the shift to empowerment many times in many women, who doubted their ability to handle labor.  So on second thought, I would have to say… NO, we don’t really know what we can handle.

When I was a little girl, my mother had a great tote bag that said “Never underestimate the power of a woman!” I loved it and the older I got the more I “got it” and so today I say… “

Never underestimate the power of a woman AND never underestimate the power of YOU!!”

In Birth and Love
Nicole

Wanna help the women and infants of Haiti…. send a text message with HAITI to 501 501 to donate $10 or a message of Yele to 501 501 for a $5 donation. For more information about Yele Haiti you can visit their website at http://yele.org

Published in:  on January 20, 2010 at 8:44 am Comments (3)
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Ain’t I a woman… A look at Maternal and Infant Mortality

On Friday there was a lot of buzz about Secretary of State, Hillary Clinton’s speech commemorating the 15th anniversary of the International Conference on Population and Development that took place in Cairo Egypt, September 1994. 

I finally took the time to really sit down and listen to her speech.  Secretary Clinton mentioned the original goals of the ICPD conference which included:  All governments making access to reproductive health care and family planning services a basic right, “dramatically” reducing infant, child, and maternal mortality and increasing educational opportunities substantially for girls and women. 

These were no small goals to put forth in 1994 and they seem to have been more than the ICPD could handle as Secretary Clinton admits that unfortunately, while the goals “remain critical” they also “remain unfilled.”

As I listened to the 20 minute talk I tried my best to remain optimistic. I certainly believe that these goals should indeed be a part of the global human rights agenda and the United States should be a part of the solution.  At the same time I watched and thought that this was another speech of promises and wondered what is going to happen dramatically in the next 5 years (the year 2015 was the original target date for reaching the goals) that failed to happen in the last 15.  While the speech may have been motivational for some, as Secretary Clinton pledged the United States continued support for global improvements in women’s health care, I couldn’t help getting a little annoyed as I listened to her complete her speech.  Before I tell you exactly what got my feathers ruffled let me first give you some of the grave statistics women in other parts of the world face due to a lack of maternity and family planning services. 

It is estimated that half a million women die each year due to birth related causes.  According to a maternal mortality report published by WHO:

“Of the estimated total of 536,000 maternal deaths worldwide in 2005, developing countries accounted for 99% (533,000) of these deaths.  Slightly more than half of the maternal deaths (270,000) occurred in the sub-Saharan Africa region alone, followed by South Asia (188,000). Thus, sub-Saharan Africa and South Asia accounted for 86% of global maternal deaths.”

In spite of the goals set at the Cairo convention, between 1990 and 2005 maternal mortality at the global level decreased less than 1% annually.

The international infant mortality rates are just as grim.  According to a 2002 report from the Guttmacher Institute,   ”Each year, about 7.5 million babies born in Sub-Saharan Africa, Asia, Latin America, and the Middle East and North Africa die before their first birthday. “

 The international infant mortality rate for developing countries is 61. Meaning 61 babies die for every 1,000 live births.  In many places the rates are much higher than that average and in some of the worst areas more than 1 in 10 infants dies before age one.

WOW!!! This is crucial, and I can’t even begin to imagine what that looks like, or feels like for a community, for a country, for a people and for those women!  I won’t even begin to pretend I have any idea to know what that is like. 

That being said, I have felt the pain of maternal and infant mortality that is taking place at unacceptable rates right here in the good ole U S of A.  While I have compassion for the women of the world I hurt directly and feel the pain for the women in my own back yard.  While the maternal and infant mortality rates in our country are a far cry from the horrific rates in developing countries I am still reminded that we have a lot of work to do right here at home ESPECIALLY in the African American community. 

So to get back to Clinton’s speech….  I was actually taken aback to hear her say

“Every woman everywhere deserves high quality care.  Not only at her most vulnerable hour but at every single stage of life. That’s our goal and that’s our responsibility.  It’s also a matter of simple equity and fairness.  I’ve been in many places in many parts of the world where the rich, the educated, the well off, the connected, the powerful, the elite had access to every single form of healthcare, and yet it was denied.  Denied by law, denied by culture, denied by taboo denied by regulation denied by resources to the vast majority of women in the same societies.  That is unacceptable. “

And so in the well known words of Sojourner Truth, I ask on behalf of the African American women who die from child birth related causes at rates 2-4 times the rate of white women nationwide.  ”Ain’t I a woman?” and don’t I deserve high quality care not only in my most vulnerable hour but at every single stage of my life? 

I ask on behalf of little black babies who die at rates 2-4 times the rate of little white babies:  Where is the high quality care? The rates are so deplorable in fact in some African Americans communities, the infant mortality rate mirrors the rates found in DEVELOPING nations.

Clinton mentioned visiting places where the rich, the connected, and the powerful had better health care access. I wonder if one of the countries she visited was the United States??  Perhaps as she and the rest of our national leaders are travelling the world making health care assessments they should look into their own back yard where in Washington DC the infant mortality rate for black babies is nearly two and half times the national average at 16.95. (That’s nearly 17 babies per 1,000 live births who DIE) 

In fact the 2005 statistics show that the infant mortality rate for African American infants in TWENTY-TWO states is more than TWICE the national average of 6.87! Secretary Clinton said it’s a “matter of simple equity and fairness.” Where is the equity and fairness in that?

In case you are not getting the point here, let me contrast this another way…  The infant mortality rate for white infants nationally is 5.73 (lower than the national average of 6.87) In 10 states white infants have a mortality rate greater than the national average. The highest rates are found in West Virginia with a rate of 7.93 deaths per 1000 live births.

Compare those numbers to these:  EVERY state with reported data for black infants shows an infant mortality rate GREATER than the national average.  The LOWEST black race specific rate is 8.18 (higher than the highest statistic for white infants.) The rates at the state level go as high as 18.89 deaths per 1000 live births!  It is well known that in pockets of the country, county rates are even higher.    

Once at a high of 47.02, since 1940 the national infant mortality rate has definitely declined.  In spite of this national decline, the black/white disparity has always been there. The data showed then and continues to show now that African American babies still die at TWICE the rate of white infants. And so I ask again… WHERE is the equity and fairness in that?

The African American community also bears the burden of the maternal mortality statistics in our country.  In general the rates are low, however it is well noted that African American women die at twice the rate of the national average and at THREE TIMES the rate of Caucasian women from child birth related causes.   

As I gathered this statistical information, I also uncovered a bit more than I had bargained for.  I was not prepared for the discovery that our maternal mortality rate is slowly rising!! Yes you read that correctly… RISING!

It is duly noted that some of the rise is because of changes in our reporting systems that took place in 1999 and 2003.  In fact, changes continue to take place as states revise their death certificates to include a separate question about pregnancy.  I am then forced to wonder…  Are the numbers we currently use possibly just a tip of the ice berg.  As the data continues to be collected and changes are made at the state level, how much will the numbers rise. 

We must also remain cautious not to assume all of the rise is related to data collection changes.  In 2003, the maternal mortality rate was 12.1 deaths per 100,000 live births in the United States.  In 2005 that number had risen to 15.1.  Here’s the kicker…. The 2005 rate for Caucasian women 11.1. The rate for African American women 36.5.  This is more than THREE times the rate of Caucasian women!  The disparity here is mind blowing and is absolutely unacceptable. 

The health disparities between white and black Americans are not new. They have been on the debate table for decades and unfortunately, in the maternal child health arena nothing has changed.  The level of disparities has NOT changed in SIXTY years!!!

“If we believe that human rights are women’s rights and women’s rights are human rights then we cannot accept the ongoing marginalization of half the world’s population.  We cannot accept it morally, politically socially or economically” — Secretary Clinton

Hopefully “WE” also believe that ALL women are human and “WE” cannot accept the ongoing marginalization of 13% of this country’s population.  It’s past time to reverse these trends in this country.  It is deplorable and we cannot accept it morally, politically, socially, or economically. 

Understanding that we can’t fix a problem until we know we have one, my goal here was to introduce you or re-introduce you to the problem and encourage you to bring this information into your conversations.  Next  up… discussions for solutions.

References:
National Vital Statistics Reports, Volume 56, Number 10, April 2008
Maternal mortality and related concepts. National Center for Health Statistics. Vital Health Stat 3(33). 2007.
Maternal mortality in 2005 : estimates developed by WHO, UNICEF, UNFPA, and the World Bank. WHO. 2007
Guttmacher Institute – Issue in Brief – Family Planning Can Reduce High Infant Mortality Levels – April 2002
Published in:  on January 12, 2010 at 11:22 am Leave a Comment
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