Alarming increase in maternal mortality rate

Tues, 2.2.10 By Lilian Kim, available from http://abclocal.go.com/kgo/story?section=news/health&id=7254194

Women across California are dying during childbirth in alarming numbers. Three times as many expectant mothers have died in just the past decade. But why? That's the question California Watch, a project of the Center for Investigative Reporting, is asking.

The number of deaths is relatively small, but still the spike in the maternal death rate is alarming to those in public health. In fact, it is more dangerous to give birth in California than it is in Kuwait or Bosnia.

Tatia Oden French died in childbirth nine years ago after having an adverse reaction to the drug used to induce her.

"She was about two weeks overdue and her doctor wanted to induce her," said French's mother, Maddy Oden of Oakland. "They ultimately did an emergency c-section and she died and the baby died."

Turns out, more pregnant women in California are dying from causes directly related to pregnancy. It has caught the attention of the State Department of Public Health which formed a group to investigate. What they found was surprising.

In 1996 for instance, the maternal death rate in California was 5.6 per 100,000 live births. Since then, it has steadily gone up. In 2006, the maternal death rate was 16.9 per 100,000 live births.

"We haven't seen these rates of maternal death since the 70s," Christine Morton of California Maternal Quality Care Collaborative said. "You don't expect childbirth outcomes to go backward. That's concerning."

Morton is on the committee investigating the higher death rate. She says they are still reviewing the data so it is too soon to point to causes. But she says some of the increase is attributable to better reporting on death certificates. The rest is likely the result of a variety of factors.

An important point is that many deaths were the result of hemorrhage.

"We do know that c-sections have risen dramatically in the last 10 years," Morton said. "We know that with more c-sections there's more likelihood of placenta abnormalities that can cause problems including hemorrhage."

The task force has already taken action. It is working with hospitals to improve response to hemorrhages and to be more cautious with inductions.

It is something Oden says is a good idea.

"I personally believe from my research and my experience that a lot of it has to do with the interventions that are not necessary at the time in birth," she said.

The task force is also looking into morbid obesity, high blood pressure and diabetes as possible contributing factors.

http://www.theage.com.au/opinion/its-a-womans-right-to-choose-how-she-births-20090715-dlgs.html
It's a woman's right to choose how she births
Monica Dux
July 16, 2009 - 12:00AM

Changes that will effectively outlaw supported home births are paternalistic.

IN FIVE months' time, if my pregnancy progresses without complication, I will birth my second child at home, attended by two registered private midwives. If I'd become pregnant a mere six months later, this carefully researched, intensely personal decision would have been far more tenuous.

From the middle of next year, if the draft legislation establishing a new national registration scheme for health professionals becomes law, midwives will be required to hold indemnity insurance and midwives in private practice — those who typically attend home births — will be unable to access this insurance. This means that, with the exception a few small home-birth support programs run out of public hospitals, home birthing will effectively be outlawed.

In a recent interview on Radio National's Life Matters, Dr Hilary Joyce, the new president of the National Association of Specialist Obstetricians and Gynaecologists, dismissed the significance of this ban by pointing out that only a small percentage of women in Australia choose to give birth at home. And yet, she complained, the issue is given a disproportionate voice in the media.

The assumption underlying her argument — that minority rights are unimportant and can be casually overridden — is both offensive and antithetical to the fundamental values of a liberal society. But Joyce's emphasis on the small number of women directly affected by the legislation also obscures a deeper problem. It is not only the rights of the minority who undertake home birth that are at stake here. This is an issue that impacts on all women.

In the past century we have seen a profound shift in the status of women, from being virtual chattels owned by husbands or fathers, to the attainment of full citizenship and (supposedly) equal rights with men. This hard-won legislative and cultural change has allowed women greater freedoms, but it has also given rise to an expectation of physical dignity, and of ownership over our own bodies, as epitomised in liberal abortion provisions and stricter sexual assault laws.

The legislative squeezing-out of home birth represents a serious regression in this reform process. Given that the new laws will effectively make private midwife-assisted home birth illegal, the Federal Government is acting to deprive most women of the ability to make a fundamental choice about their own bodies; the choice to birth in a non-medicalised environment.

Birthing is an extremely intimate, uniquely visceral, sometimes terrifying physical experience. There is much that will inevitably be out of a woman's control during her confinement, so allowing her to birth in the place in which she is most comfortable is fundamental to maintaining both her personal dignity and her sense of ownership over the experience.

Just as adequate abortion rights are important for all women, not just those with unwanted pregnancies, so the fundamental right to birth in the way one chooses is an issue for us all. In this respect the proposed legislation is a setback for all women, not just those who would take up the option of a home birth if it was offered to them.

If we truly live in a society where women are granted ownership of their own bodies, and if home births, properly supported, are a safe option, then why shouldn't women have the right to choose that option?

Many assume that this is the crux of the matter; that home births are simply unsafe. But the facts suggest otherwise. International studies, and experience in countries such as the Netherlands and Britain, have conclusively demonstrated that for uncomplicated pregnancies, home births carried out with proper support are just as safe as hospital births. At a time when our public hospitals are in the grip of a very real crisis the decision to give birth at home, with proper support and preparation, seems not just reasonable but prudent.

Yet, all too often, those who favour home birth are presented as a fringe group of maternal kooks, the sort of women who recklessly put ideology before health and safety. Of course, there is a long tradition of dismissing troublesome, non-compliant women as kooky, and of deriding their views as irrational or even childish; a tradition that is implicitly continued in the proposed scheme.

Such a paternalistic provision, effectively telling women what is and isn't good for them, cuts to the heart of women's collective dignity and autonomy. While women were once routinely patronised in this way, the contemporary assumption is that those bad old days are behind us. Sadly, this does not appear to be the case when it comes to birthing.

Monica Dux is co-author of The Great Feminist Denial, published by Melbourne University Press.

Lessons in Labour (Hannah Dahlen) 20 April 2009

http://www.abc.net.au/unleashed/stories/s2543589.htm

The front page of the Daily Telegraph ran the sensational headline recently 'Four dead in home birthing'. The article went on to say that at least four babies had died 'during homebirths in the past nine months' and a further four babies had suffered brain damage. This was presented as 'fact' although it remains unconfirmed to date.

The facts we have from the latest Australian Institute of Health and Welfare (published in 2008), indicate that 708 women had planned homebirths in Australia in 2006 (0.3%) and there were no deaths reported amongst these births. In this same year 2730 babies died - most of them in Australian hospitals. While we must remain committed to trying to reduce these deaths, the reality is this rate has remained unchanged for nearly 15 years, despite a doubling in the caesarean section rate.

What has been missed in this debate is the difference between a planned home birth for a woman with a low risk pregnancy attended by a competent midwife who is well networked into mainstream services (supported by evidence as safe), and a birth at home where there is no professional care or where the woman has risk factors in her pregnancy (supported by evidence as less safe).

To put some balance into this argument the following issues need to be considered.

Firstly, the intervention rates during childbirth have sky-rocketed over the past ten years in Australia, leaving many women traumatised and fearful. A first time mother in Australia now has a greater chance of having surgical intervention during her birth than of not having it. Miranda Devine's mocking disregard for the emotional trauma that stems from this reality was evident in her article 'A home birth is not a safe birth'.

Secondly, options of care for childbearing women remain limited with around three per cent of women able to access continuity of midwifery care.

Thirdly, around 130 maternity units have shut down in Australia over the past 10 years, many of these in rural and remote Australia, leaving women with little option but to travel great distances from family and community to give birth. The rising incidence of 'roadside births,' is the unintended consequence of such actions.

Fourthly, privately practicing midwives have not been able to obtain affordable insurance since 2000, leading many to stop practicing, with the remaining midwives practicing uninsured and without visiting rights to hospitals. Midwives cannot even order routine blood tests or ultrasounds and often find it difficult to obtain the results for the women they care for, causing delays in appropriate management.

Fifthly, there are very few financial rebates women can access for midwifery care, and they pay between $3000-5000 dollars for this service. Some women clearly cannot afford it.

The ramifications of these issues are: more traumatised women due to interventions during birth; fewer options of care - especially continuity of midwifery care; fewer experienced, networked midwives available to attend women privately; and no access for women to a hospital birth under a private midwife. The result has been increasing numbers of unattended births and more women with high-risk pregnancies seeking midwifery care at home.

The rise in the numbers of unattended births is ironically being seen in two countries - Australia and the USA - both with the highest intervention rates in birth and limited access to continuity of midwifery care.

The answer to all this is not to demonise women but to stop and consider our responsibility as a society to mothers and babies. It is time we made our maternity care system accountable and really listened to what women are telling us. Over 400 submissions from women to the government, as part of the National Maternity Review should not be dismissed as irrelevant, as Miranda Devine seemed determined to do. It is time to make birth safe, physically, emotionally, culturally and spiritually.

Never before in history have women been able to reap the benefits of safe and satisfying birth like we can now. We need to give women access to choice and continuity of care, where midwives and doctors are willing and able to work together respectfully. We need to begin to reconstruct our maternity system with women, their babies and families at the centre - not the health professionals and their inevitable turf wars.

In the United Kingdom they have made an effort to do just this, with a joint statement on home births produced by the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives. In this joint statement they say, "The Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG) support home birth for women with uncomplicated pregnancies. There is no reason why home birth should not be offered to women at low risk of complications and it may confer considerable benefits for them and their families. There is ample evidence showing that labouring at home increases a woman's likelihood of a birth that is both satisfying and safe, with implications for her health and that of her baby."

In Scotland they are now urging mothers to give birth at home. In the Netherlands where 30 per cent of babies are born at home, and the caesarean section rate is less than half ours (14 per cent versus 31 per cent), both private insurance companies and government health funds cover only midwives or general practitioners and home birth; or short stay hospital births (anything more women pay for), for low-risk pregnancies.

Financial support for care from an obstetrician is only available to women with high-risk pregnancies. For women with low-risk pregnancies in the Netherlands, outcomes of planned home births are as good or better than the outcomes of hospital births. The often misquoted Bastian study of homebirth in Australia between 1985 and 1990 showed, "while homebirth for low risk women can compare favourably with hospital birth, high risk home birth is inadvisable and experimental."

The Bastian study provided what we call low-level evidence - the study design was retrospective (looking back at what had been done), it included births by non-registered and registered midwives and it used a number of methods to collect the data (eg searching newsletters for death notices). The one study you will never hear the medical profession quote is the USA home birth study. This was a prospective study (gathering data as it happens) looking at 5418 low risk women who planned a home birth with midwives in the USA and Canada in the year 2000. There was no difference between the numbers of babies dying at home or in hospital, but the intervention rates were significantly lower amongst homebirth women.

The largest study done to date in the world was published this month and showed that out of more than 500,000 births in the Netherlands there was no difference in outcomes for babies of planned homebirths and babies of planned hospital births. What all this research indicates is homebirth is safe for low risk women under the care of competent, networked midwives who work in collaboration with mainstream maternity services.

Recent media has revealed the hazard of ignoring this evidence.

Whatever your beliefs about home birth, the facts are this - never in history, and in no country on earth, has homebirth ever been eradicated. There are two potential responses to this fact. One, we put in place supportive, safe, collaborative systems of care that respect a woman's right to choose her place of birth and care provider, like they have in the UK and the Netherlands, or two, we bury our heads in the sand and hope it will all go away.

This last choice is the one we have made to date in Australia and it is clearly not working. It's time to take the proverbial 'log' out of our own eye and seriously consider where we have let women down in the maternity system we currently make available to them, before we try to pick the 'spec' out of our sister's and criticise the choices some may make.

Perhaps then we will all see more clearly, and hopefully respond more wisely.

Hospital, home births 'no difference' April 16, 2009

http://news.theage.com.au/breaking-news-national

/hospital-home-births-no-difference-20090416-a8ej.html

Midwives found to aid babies' survival
Kate Benson Medical Reporter
October 10, 2008

WOMEN who are cared for by midwives rather than GPs or obstetricians are less likely to lose their babies within the first six months of their pregnancies, an international review of mat-ernity services has found.

Researchers gave no reasons for the shock finding, taken from an analysis of 11 trials involving more than 12,200 women in four countries, but a spokeswoman for the Australian College of Midwives, Hannah Dahlen, said women who were seen by the same midwife during pregnancy, labour and birth usually felt more supported and less anxious, leading to reduced risk of miscarriage.

That explanation has frustrated the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, which says its members provide the same level of continuous care to their patients and could not be held accountable for miscarriages or stillbirths that occurred so early in pregnancy.

"One third of women see private obstetricians and we all give continuity of care," the college's president, Christine Tippett, said yesterday.

"I am on call 24 hours a day, seven days a week and I deliver about 90 per cent of my women. I think it is drawing a very long bow to link miscarriages before 24 weeks with continuity of care. Most miscarriages occur because of foetal or chromosomal abnormalities and there is no evidence to suggest the mode of care makes any difference."

The analysis, which is the largest undertaken in the world, also found that women in midwife-led models of care were less likely to be admitted to hospital during pregnancy, have instrumental deliveries, episiotomies or require analgesia and were more likely to have spontaneous vaginal births, feel in control during labour and better able to initiate breastfeeding.

Dr Dahlen said the analysis, published by the Cochrane collaboration, considered the gold standard of assessing medical evidence, proved that midwife-led models of care had no adverse outcomes and many benefits.

"If this was a tablet, it would be mandatory that all women have it, but instead we have to deal with all this shroud waving by obstetricians. Now we know the evidence for their claims just isn't there," she said.

The Australian College of Midwives has long argued that better use of midwives would reduce the national caesarean rate, now at 31 per cent, cutting the number of people taking up operating theatres and beds in wards. However, the analysis showed there was no significant difference between the two groups when it came to caesareans, despite a recent Australian study which indicated surgery in midwife-led care occurred 4 per cent less often than under medical models.

"Not many people realise that women having babies accounts for the largest single use of our hospitals every year, so if we want to ... look after people on waiting lists, we should be looking at how we can provide good primary care to healthy pregnant women instead of channelling them into surgical theatres in their tens of thousands," the Australian College of Midwives vice president, Chris Cornwall, said.

The analysis also showed there was no significant difference between the two groups when it came to foetal deaths after six months gestation, length of labour, induction, intervention, premature births and admissions to neonatal intensive care units.

http://www.un.org:80/apps/news/story.asp?NewsID=28150&Cr=UNFPA&Cr1  
UN-Endorsed Initiative to Train Midwives Could Save Hundreds of Thousands of Lives

22 September 2008 - With half a million women dying in pregnancy or childbirth every year, the United Nations Population Fund (UNFPA) and the International Confederation of Midwives (ICM) have launched an initiative which could help cut mortality by about 75 per cent by training midwives in developing countries.
"By investing in midwives and universal access to reproductive health, millions of lives can be saved and we can reach Millennium Development Goal 5, to improve maternal health," UNFPA Executive Director Thoraya Ahmed Obaid said in a news release today, referring to one of eight goals that seek to slash a host of social ills by 2015. Beyond the deaths millions more women suffer long-lasting harm due to lack of care.

By investing in midwives and universal access to reproductive health, millions of lives can be saved

An additional 334,000 midwives are needed, according to the UN World Health Organization (WHO). The UNFPA-ICM programme will increase the number of births attended by professional midwifery providers and develop the foundations for a sustainable midwifery workforce in selected developing countries.

Its focus will be on training midwives, developing practice standards, and strengthening national midwifery associations. It is estimated that skilled attendance at delivery, backed up by emergency obstetric care, could reduce the number of women dying in pregnancy and childbirth by about 75 per cent.

Every year half a million women die in pregnancy or childbirth and 10 to 15 million women suffer serious or long-lasting illnesses or injuries. In addition, 3 million newborns die during the first week of life and another 3 million are stillborn. Many of these deaths and disabilities could be prevented if all births were attended by midwives.

The $9-million initiative will start in 11 of the hardest-hit countries with the highest levels of maternal deaths and disability and the lowest rates of births attended by skilled workers - Benin, Burkina Faso, Burundi, Côte d'Ivoire, Djibouti, Ethiopia, Ghana, Madagascar, Sudan, Uganda and Zambia. It will then expand to include 30 countries and, if funding permits, even more.

The three-year project is funded by the Netherlands and Sweden and will be implemented by ICM and UNFPA offices in the selected countries.

"We need some strong advocates who can call on governments to invest in much needed midwives," ICM President Bridget Lynch said. "But we also need to work with governments to ensure the scaling up and quality of midwifery services. They need to take ownership."

http://www.telegraph.co.uk/news/newstopics/politics/health

/3023808/Home-births-still-rare-despite-Government-pledge.html

Home births still rare despite Government pledge

The number of women giving birth at home has slumped in the space of two generations, a Government report will say this week.

By Patrick Sawer
Last Updated: 12:46AM BST 21 Sep 2008

Research by the Office for National Statistics (ONS) will highlight how the proportion of deliveries taking place at home fell from one in three in 1955, to just one in 40 by 2006.

While home births have undergone something of a renaissance in the past few years - with celebrities such as Charlotte Church and Davina McCall opting to give birth at home - the report will demonstrate just how far the level remains below what it was in the Fifties and Sixties.

The Government has promised that by next year, all women in England should be given the option of where to have their baby. However, a shortage of midwives often means that women are not offered a home birth, or have it cancelled at the last minute and are forced to go into hospital.

There was a significant increase in home births in 2006, when 18,953 deliveries took place at home compared with 17,277 the year before. Yet despite the rise, only 2.5 per cent of deliveries in 2006 were at home, compared with 30 per cent in the Netherlands.

Mary Newburn, head of policy research at the National Childbirth Trust, said; "It's very pleasing to see that home birth rates are now on the increase, allowing women and their partners greater choice. However, many women around the UK still find it difficult to access a home birth. There is a lack of balanced information available to enable them to make an informed choice about where to have their baby.

"Low midwifery staffing levels mean that too often the option of a home birth is either not being offered or services end up being withdrawn at short notice."

Home births began to decline during the first half of the 20th century as middle class women increasingly turned to doctors rather than midwives for their maternity care, while poorer women found greater privacy, better facilities and more chance for rest in hospitals than in their overcrowded homes.

As hospital birth became the norm, the public began to view home birth as a less "advanced" option. Many doctors discouraged home birth, believing it to be less safe.

Today's advocates of home birth claim that labour progresses well in surroundings where the mother feels relaxed, has greater privacy and is free to move around.

Women giving birth at home are more likely to have one-to-one care from a midwife they know and who has contributed to their antenatal care. Advocates claim these factors can help labour develop normally, reducing the risk of "failure to progress", fetal distress and the associated medical interventions.

The Nursing and Midwifery Council concluded in 2006 that "research over the last couple of decades suggests that home birth is at least as safe as hospital-based birth for healthy women with normal pregnancies".

Ms Newburn added: "Government policy states that women should be offered the choice of planning birth at home, in a midwifery-led unit or a consultant-led unit. If the Government's choice guarantee for England is to be implemented by the end of 2009, considerable work must be done to increase access to home birth."

The national figures, to be published next Thursday in the ONS's Population Trends journal, mask a wide gulf between different areas. In Middlesbrough just 0.4 per cent of births take place at home, while in West Somerset the proportion is 14 per cent.