California Watch: Our Maternal Health en Writer looks for healthiest, happiest approach to childbirth <p>Is natural always better? Bay Area-based writer&nbsp;<a _mce_href="" href="" target="_blank">Nathanael Johnson</a>&nbsp;seeks to answer that very complicated question in his new book, &ldquo;<a _mce_href="" href="" target="_blank">All Natural</a>.&rdquo; In this reported memoir, Johnson, a self-described skeptic, seeks to discover if a more natural approach to life makes one happier and healthier.</p><p>Johnson has written for&nbsp;<a _mce_href="" href="" target="_blank">California Watch</a>, reporting on maternal health and how much medical intervention is really necessary during childbirth. One investigation revealed that for-profit hospitals&nbsp;<a _mce_href="" href="" target="_blank">saw higher rates</a>&nbsp;of cesarean section deliveries, which are more expensive. Data revealed in another story that elective births can&nbsp;<a _mce_href="" href="">increase health risks</a>&nbsp;for the mother and child.</p><p>I spoke with Johnson over the phone and via email, about how a writer tackles a topic with such oppositional viewpoints &ndash; especially when he&#39;s seen both sides of the argument. The interview has been edited and condensed.</p><p><strong>Marie McIntosh:</strong>&nbsp;How much of this book is tied to how you were raised? Did that inform your own reporting while writing the book?</p><p><strong>Nathanael Johnson:&nbsp;</strong>I grew up in a kind of hippie, all-natural family. The book starts with a description of this photo of the family the morning after I was born at home, on Benvenue Avenue in Berkeley. We are all clustered together in this redwood-paneled room, and everything looks so idyllic and warm. It&#39;s a visual metaphor for my early relationship with the idea that what&#39;s natural is healthy. That idea is tenderly knit to my sense of childhood innocence. And then, at the same time, growing up in this family gave me a front row seat on the ways that going all natural can fail. The result is that I&#39;m both deeply sympathetic and deeply skeptical about these ideas of natural birth, natural diets and alternative medicine. A lot of what&#39;s been written about this stuff is polarized &ndash; it&#39;s either totally credulous or totally dismissive. And because I was so fascinated by all the cool nuances in the middle I ended up writing this book.</p><p><strong>MM:&nbsp;</strong>How did&nbsp;the reporting you did for California Watch figure into the genesis of &ldquo;All Natural&rdquo;?</p><p><strong>NJ:</strong>&nbsp;I didn&#39;t know that there was a book here until I started on the reporting I did for California Watch. Because, if everything I found was just a confirmation of conventional wisdom, that wouldn&#39;t have sustained my interest. So when I found out that birth was actually getting more dangerous and that people were being hurt by too much medical care, well, that just felt counterintuitive and unexpected.</p><p><strong>MM:</strong>&nbsp;So, how do you make decisions on these issues when viewpoints seem so polarized?&nbsp;</p><p><strong>NJ:</strong>&nbsp;Just do exhaustive research and get beyond your bubble with scientifically objective information. A big part of this book is focused on this work of uncovering evidence that upset my assumptions and led to pragmatic changes in my life. The problem is, that information only goes so far &ndash; the sum of our ignorance always exceeds the sum of our knowledge. I think (writer) Wendell Berry posed the question best: &quot;How does one act well &ndash; sensitively, compassionately, without irreparable damage &ndash; on the basis of&nbsp;partial&nbsp;knowledge?&rdquo;</p><p>And a big part of acting well, unfortunately, is simple acceptance &ndash; acceptance that we just don&#39;t know. I kept coming across ways that we do ourselves harm by grasping at certainty: C-sections are a good example because you are trading the uncertainty of biological labor for what feels like a sure thing, at least in the moment. But when you look at the big picture it&#39;s clear that having too many C-sections creates more uncertainty and danger than it prevents. Americans are fixers and problem solvers &ndash; you hear about Yankee ingenuity, not Yankee acceptance. But often the most reasonable thing to do is relax into the terrifying uncertainty of life. That&#39;s certainly a hard one for me.</p><p>Read an&nbsp;<a href="" target="_blank">excerpt</a>&nbsp;of Johnson&#39;s new book, &ldquo;All Natural.&rdquo; For more information on the book or where to buy it, click&nbsp;<a _mce_href="" href="">here</a>. He&#39;ll also appear in conversation with Michael Pollan on Jan. 31 at&nbsp;<a _mce_href="" href="" target="_blank">Book Passage</a>&nbsp;at the Ferry Building in San Francisco.</p> Health and Welfare Daily Report Our Maternal Health Tue, 15 Jan 2013 14:05:02 +0000 Marie McIntosh 18782 at Kelly Sue DeConnick/ Flickr An excerpt from Nathanael Johnson's book, 'All Natural' <p>There is, in fact, a vigorous debate over medical intervention in birth, and not just between the fringe and the medical establishment, but within the establishment. No one is suggesting that we revert to the practices of the 1900s, but many clinicians and scientists are warning that the medicalization of birth has gone too far. When I took a closer look at the data, I found one seemingly impossible statistic after another. Progress in reducing the infant mortality rate had advanced through the 20th century, but had stalled in the 21st century. This plateau, &quot;has generated concern among researchers and policy makers,&quot; according to a 2008 brief from the National Center for Health Statistics. &quot;The U.S. infant mortality rate is higher than those in most other developed countries,&quot; wrote the statisticians, &quot;and the gap between the U.S. infant mortality rate and the rates for the countries with the lowest infant mortality [Japan, Sweden, Spain, and others] appears to be widening.&quot; In addition, the numbers of preterm and low birth-weight infants had actually risen (a part of this increase was due to a higher number of twins and multiples, perhaps from the rise of fertility treatments, but the increase remained when researchers only looked at singleton births).</p><p>When it came to the health of mothers, the trends were even more troubling. A paper published in the Journal of Obstetrics and Gynecology noted a marked increase in severe injuries to women during birth: kidney failure, pulmonary embolisms, respiratory failure that required patients to be put on a breathing machine, and more. This increase had occurred between 1998 and 2005, including a 92 percent rise in the percentage of women who needed blood transfusions. Mothers hadn&#39;t become less healthy in that period. The study had adjusted for the effects of hypertension, diabetes, age, and multiple births, but weeding out these problems hadn&#39;t made much of a difference. What did make a difference was controlling for the mode of delivery: &quot;For many of these complications,&quot; the authors wrote, &quot;these increases were associated with the increasing rate of cesarean delivery.&quot; Most disturbing of all, national vital statistics showed that the maternal mortality rate was climbing. This, in particular, seemed too bizarre to be true, and most researchers initially chalked it up to &quot;statistical noise&quot; &ndash; the result, they said, of several states adding a checkbox to death certificates to note if a woman had been pregnant a year prior to her demise. But then the state of California made an inquiry that adjusted for these changes and revealed that there was still a consistent upward trend in maternal deaths. &quot;After several decades of declining rates of maternal mortality in California, rates began to rise in 1999 and proceeded to double in the next seven years,&quot; the researchers reported. Part of this rise was due to the fact that mothers had become older, sicker, poorer, and more obese &ndash; but not all of it.</p><p>The total number of women dying was still minuscule compared to the turn of the century: Maternal mortality had gone from 6 deaths per 100,000 births in 1999, to 14 per 100,000 births in 2006. But more troubling than the total number of deaths was the implication that the best efforts of obstetrical medicine to improve health had perhaps done just the opposite. When the California researchers, speaking at a conference, got to the slide showing a graph of this increase, there were gasps from the audience of obstetricians.</p><p>These numbers hit home when I did the math and found that it had been safer to give birth in 1978 (when I was born), than it would be for Beth to deliver in 2011, if the upward trend continued. The popularization of supposedly safe and reliable techniques like the Caesarean were meant to improve outcomes. In just the last decade, the Caesarean rate had increased from 22 percent to 32 percent, which amounted to half a million additional surgeries each year &ndash; an extraordinary investment of money and medical resources. And yet, when I asked experts what that investment had bought us, they said that there had been no corresponding improvement in the health of mothers or babies. The conventional wisdom has held that, while C-sections may hurt mothers, they reduce the number of babies who might develop cerebral palsy or die due to lack of oxygen. But cerebral palsy rates, like infant mortality rates, have been flat.</p><p>&quot;If you look at the statistics, we don&#39;t see much improvement in the last ten years,&quot; said Debra Bingham, the executive director of the California Maternal Quality Care Collaborative, a partner in the state&#39;s ongoing inquiry on maternal deaths. &quot;What we do see is more women dying, and more women suffering birth-related injuries than we have in decades.&quot;</p><p>I met with Bingham in her office on the Stanford University campus. She had worked for years as a nurse, and then as an administrator of a labor and delivery unit in New York City, before earning her doctorate in public health. Her short, neatly coiffed white hair framed an unlined face that radiated grandmotherly warmth. When I asked why our efforts weren&#39;t improving health, she cleared her throat delicately. Administrators and clinicians were allowing their faith in progress to guide them toward presumptively beneficial technology, Bingham said. What they were not doing &ndash; for the most part &ndash; was allowing the numbers to change their minds when the evidence suggested the technology didn&#39;t help. For example, she said, &quot;Clinicians adopted electronic fetal monitoring with the hope that it would improve outcomes. Even after it became known that continuous fetal monitoring does not improve outcomes clinicians continue to use the technology.&quot;</p><p>Bingham herself had been an early advocate of fetal heart monitors. The rationale for these machines made sense: Watch babies closely enough and you should catch a certain number whose hearts are slowing because they are desperately low on oxygen. She became an expert interpreter of fetal heart rhythms and spent much of her career teaching these skills to nurses. But when the actual data from randomized controlled trials came out, the comparisons among thousands of births showed that the babies who had received continuous heart monitoring were no more likely to survive (nor have less risk for cerebral palsy) than those who had not. The birth industry in the United States basically ignored this evidence, continuing to buy machines for hospitals and routinely using them in every labor (while other countries heeded the science). Years later, after looking at the evidence anew, Bingham began to suspect that in most cases these machines had done more harm than good: They tethered women down (a problem because the inability to move freely can make labor more uncomfortable), they provided fodder for frivolous lawsuits, and they prompted unwarranted surgeries with frequent false alarms of fetal distress.</p><p>Despite the lack of evidence to support them, some traditions in obstetrics perpetuate obstinately, Bingham said. She first began to question these traditions in 1981 after she herself gave birth in the hospital where she worked as a maternity nurse. Another nurse had taken her son away to the nursery shortly after he was born, as was routine. Bingham had done the same thing hundreds of times herself, but this time it felt unmistakably wrong. For months she&#39;d been waiting eagerly to see and hold her newborn baby and, lying there without him, she felt a suffocating loneliness. She still gets emotional thinking about it. She waited anxiously, wondering if her son was crying, trying to hold the contours of his face in her memory until, after two hours, she&#39;d had enough. She walked into the nursery and, despite the entreaties of her coworkers, refused to go back to her room until they agreed that she could take her son with her.</p><p><em>Reprinted from&nbsp;&quot;All Natural&quot; by&nbsp;Nathanael&nbsp;Johnson. Copyright (c) 2013&nbsp;by&nbsp;Nathanael&nbsp;Johnson.&nbsp;By permission of Rodale Inc. Available wherever books are sold.&nbsp;</em></p> Health and Welfare Daily Report Our Maternal Health Tue, 15 Jan 2013 14:05:02 +0000 Nathanael Johnson 18783 at National C-section rate highest ever, study says <p>More than one in three babies in the U.S. is now delivered by cesarean section,&nbsp;according to a <a href="">study</a> released today by the hospital quality tracking group <a href="" target="_blank">HealthGrades</a>.</p><p>Thirty-four percent of single-baby births in 2009 were done surgically, the highest percentage ever.</p><p>The study &ndash; based on data from 19 states, including California &ndash; reflects the growing popularity of C-sections, whose use increased by more than 50 percent from 1996 to 2007. The study also rates individual hospital performance based on maternal care and gynecologic surgery.</p><p>California ranked eighth among the 19 states in the rate of C-section use, at 32.82 percent.</p><p>&quot;This is a big issue, and this is actually going to come under a lot of scrutiny in the coming year,&quot; said Dr. Elliott Main, chairman of the Department of Obstetrics and Gynecology at California Pacific Medical Center in San Francisco. &quot;A lot of organizations and bodies are going to start paying a lot more attention.&quot;</p><p>While C-sections most often are used when complications arise during labor, the study says changing physician practices, such as inducing labor and a desire by physicians and patients to schedule convenient times for labor, may be leading to the increase. Risk factors that could lead to necessary C-sections &ndash; including obesity, diabetes, multiple births and older pregnant women &ndash; also are more common, though Main says they account for only a small portion of the increase.</p><p>&quot;It&#39;s more an attitudinal issue of doctors and patients not wanting to spend extra time in labor or not wanting to take any perceived extra risk,&quot; he said.</p><p>According to <a href="" target="_blank">quality measures</a> set out by The Joint Commission, a leading health care accreditation group, no data exists to show &ldquo;that higher rates improve any outcomes, yet the C-section rates continue to rise.&rdquo;</p><p>Main echoed that idea.</p><p>&quot;At the end of the day, the C-section rate has risen ... over the past decade, and we don&#39;t have any improved baby outcomes to show for it, so there is a big question of what we are getting for our money,&quot; he said.</p><p>In fact, hemorrhaging from C-sections is one of several possible factors in the state&rsquo;s increased maternal death rate, the subject of a <a href="" target="_blank">California Watch report</a> last year. The number of women in California who died from pregnancy-related complications rose from 5.6 out of 100,000 live births in 1996 to 14 out of 100,000 in 2008. Only about 30 percent of that increase can be accounted for by improvements in the reporting of deaths.</p><p>A <a href="" target="_blank">study [PDF]</a> released this year by the California Pregnancy-Associated Mortality Review Committee, which Main leads, says more research is needed on the relationship between C-sections and maternal deaths.</p><p>&quot;It&#39;s actually a very hard one to tease apart, what the role of C-section is in maternal mortality,&quot; Main said, &quot;but we do know it causes increased morbidity, or complications, so the thought is if you do enough of them, you&#39;re going to see more direct complications.&quot;</p><p>Main said the main risk comes when women have a second, third or fourth C-section. As the procedure&#39;s use increases, more women will have multiple C-sections, meaning the risks will be increasingly present in the future.</p><p>Although cesarean<strong>&nbsp;</strong>sections generally are a safe option for giving birth, The Joint Commission and the Agency for Healthcare Research and Quality both have endorsed reducing their use in certain types of pregnancies, the study says.</p><p>&quot;Part of the problem is that no one has said &ndash; either the medical community or the public or the insurance companies &ndash; that we&rsquo;re doing too many C-sections,&quot; Main said. &quot;In the absence of that kind of pressure, it has floated up like a balloon.&quot;</p><p>In the study&#39;s other findings:</p><ul><li>While the use of C-sections is increasing, the number of hysterectomies is falling. Hysterectomies, surgeries to remove the uterus, still account for nearly 80 percent of all gynecologic surgeries, but the number of hysterectomies has decreased by 31 percent since 2002, mostly thanks to the availability of less invasive treatments.</li><li>The study gave hospitals in the 19 states ratings of one, three or five stars based on maternal care and gynecologic surgery between 2007 and 2009. In California, 57 hospitals received five stars for maternal care, and 117 received five stars for gynecologic surgery.<strong> </strong>To see how a specific hospital fared, search for it <a href=";latitude=37.219688&amp;longitude=-119.7686&amp;regionabbreviation=CA&amp;sortorder=descending" target="_blank">here</a>.</li><li>About 7 percent of women in single-baby labor and 9 percent of women having gynecologic surgery experienced complications while in the hospital. The study estimates that 32 percent of complications during delivery (141,869) and 35 percent of complications during surgery (30,675) could have been prevented if all of the hospitals had performed at the level of the five-star winners.</li></ul><p><span style="font-family: arial,helvetica,sans-serif; font-size: 10pt;"><span face="">&quot;Women can optimize their chances for receiving the highest possible quality of care by researching and comparing the clinical outcomes of hospitals and doctors in their area,&quot; Dr. Divya Cantor, senior physician consultant at HealthGrades, said in a statement.</span></span></p> Health and Welfare Daily Report C-sections maternal health pregnancy women's health Our Maternal Health Tue, 19 Jul 2011 07:05:04 +0000 Emily Hartley 11553 at Mahalie Stackpole/Flickr Death rate from childbirth rises in California <p>The rate of women dying from pregnancy-related complications has increased at a &quot;statistically significant&quot; pace, according to a long-awaited report on maternal deaths released today by the California Department of Public Health.</p><p>African American, low-income and less-educated women had higher deaths rates from complications related to childbirth, according to the report, which also noted &quot;excessive gestational weight gain&quot; and medical problems from C-sections as contributing to maternal deaths.</p><p>&quot;More than a third of pregnancy-related deaths were determined to have had a good to strong chance of being prevented and some causes of death appeared to be more preventable than others,&quot; the report said.</p><p>Researchers had <a href="" target="_blank">described the findings</a> to California Watch in February 2010, but today&#39;s report is the first public release of the numbers. Experts in women&#39;s health had called the trend shocking; the statistics had showed giving birth in California was more dangerous than in Bosnia.</p><p>Today&#39;s report contains some new numbers &ndash; California&rsquo;s maternal mortality rates for 2007 and 2008. The last released rate (from 2006) was 16.9 deaths per 100,000 live births. In 2007, the rate fell to 11, then bounced back to 14 the next year. That&rsquo;s up from 6 in 1996.</p><p>Because these are small numbers, the rate appears to fluctuate dramatically. But the numbers show a &ldquo;statistically significant increase in maternal mortality from 1999 to 2008,&rdquo; according to the report.</p><p>The report suggests that a combination of factors were responsible.</p><p>Better counting of deaths played a part; improved methods of record keeping was responsible for 33 percent of the rise, the report&#39;s authors estimated. In addition, older, heavier and sicker mothers were among those who died from pregnancy-related complications; 60 percent of the victims studied were overweight, and heart-disease was the largest cause of death.</p><p>Social factors such as poverty and the stress of racism also have played a part. African American women were more than four times as likely as white women to die from childbirth, and women who did not finish high school were four times as likely to die as women who made it to college.</p><p>The report also cited the overuse and under-use of medical treatments. Some women, for example, are getting C-sections they don&rsquo;t need, while others do not have access to the C-sections they do need.</p><p>The maternal mortality rate is defined as the number of women who die from a pregnancy-related cause within 42 days of giving birth. A copy of the report <a href="" target="_blank">can be found here</a>.</p><p>For a deeper look at the problem, the report looked at maternal death cases from 2002 and 2003, providing a snapshot of those two years. Here&rsquo;s what they found:</p><ul><li>Number of pregnancy related deaths not reported as such (under counting): 24</li><li>Number of deaths reported as pregnancy related, which reviewers determined were not related (over counting): 14</li><li>Corrected number of deaths directly related to pregnancy: 98</li><li>Of those 98, number in which delays of inadequacy of treatment contributed to death: 41</li><li>Number in which use of ineffective treatments contributed to death: 35</li><li>Number in which Cesarean surgeries contributed to the death: 15</li><li>Number of deaths where obesity or weight-gain was a contributing factor: 18</li><li>Number with multiple preexisting contributing medical conditions: 24</li><li>Number of women who were 30 and older at their death: 57</li><li>Number younger than 30 years old: 41</li></ul><p>Clearly obesity, diabetes, better counting techniques, and the pressures forcing women to put off childbirth until later in life are all contributing to this increase. But those usual suspects do not explain the entire rise.</p><p>The rest are probably explained by changes in society and in hospitals.</p><p>But more important than assigning blame is asking what can be fixed, and how. The report notes 36 out of 98 deaths in which there was a good chance the fatality could have been averted. Out of those 36, the report said that health care professionals had contributed to 35&nbsp; of those deaths. Hospitals or birthing centers were blamed for 27 deaths, while &quot;patient factors&quot; contributed to another 27.</p><p>In other words, there&rsquo;s a lot of room for improvement here all around.<br /> &nbsp;</p><p class="image-full-width" style="width: 600px;"></p><br /> <br /> <p>&nbsp;</p><div><iframe allowtransparency="true" frameborder="0" scrolling="no" src=";layout=standard&amp;show_faces=true&amp;width=450&amp;action=recommend&amp;colorscheme=light&amp;height=80" style="border: medium none; overflow: hidden; width: 400px; height: 80px;"></iframe><script type="text/javascript"> tweetmeme_source = 'californiawatch'; </script><script type="text/javascript" src=""></script></div> Health and Welfare Daily Report C-sections maternal deaths maternal health women's health Our Maternal Health Tue, 26 Apr 2011 16:01:13 +0000 Nathanael Johnson 10038 at Older mothers, obesity, poverty and C-sections were blamed on the spike in maternal deaths. California Department of Public Health Older mothers, obesity, poverty and C-sections were blamed on the spike in maternal deaths. Unnecessary C-sections a $3.5B problem, study finds <p>What would maternity care look like if doctors only intervened when it was medically necessary?</p><p>For more than a year now, I&rsquo;ve been trying to answer that question in terms of the physical health of the mother and child. But for a moment let&rsquo;s forget about increasing maternal mortality and babies in the neonatal intensive care units &ndash; and look at what happens to our national health care bill.</p><p>Intermountain Healthcare released a study yesterday showing that if the U.S. cesarean surgery rate (32 percent of all births at last count) fell to the rate in Intermountain hospitals (21 percent), the country would save $3.5 billion in medical charges each year.</p><p>There are a couple of caveats, which I&rsquo;ll take into consideration below, but first, here&rsquo;s what Intermountain had to say:</p><blockquote><p>Nationally, about one in three births are by C-section &ndash; the most common surgery in U.S. hospitals today. This represents an all-time high, increasing by more than 50 percent since the 1990s. In 2008, Intermountain estimates that 473,592 C-sections in the U.S. were potentially unnecessary. These births result in higher (national) average maternal charges &ndash; $16,671.89 compared to $9,428.08 for a vaginal birth &ndash; and increased medical complications for the mother and baby. (Intermountain&rsquo;s average charges were $9,101.35 for a C-section and $4,964.30 for a vaginal birth.)</p></blockquote><p>Intermountain, a nonprofit health care provider based in Utah, has long been a model for national policy makers. President Obama has cited its work. A New York Times Magazine profile by reporter David Leonhardt <a href="" target="_blank">singled it out</a> (especially in obstetrics) as an exemplar. And here at California Watch we have <a href="" target="_blank">looked to its record</a> as an example of what can be accomplished.</p><p>Intermountain&rsquo;s cesarean rate has been driven down by its insistence on delivering babies when they are ready, rather than early.</p><p>But that&rsquo;s not the only cause of Intermountain&rsquo;s low cesarean rate, and here come the caveats. Utah has lower rates in general &ndash; and the reasons for this are not clear.</p><p>The other point of clarification is one that always bedevils calculations on health economics: Intermountain is making its figures based on the amounts it charges, rather than the amounts that patients and insurance companies actually pay.</p><p>If you&rsquo;ve ever examined your bill after a hospital visit, you know that you&rsquo;ll get charged one amount, but your insurance company will often slash that number down significantly. It&rsquo;s a strange system, and it means that every insurance company pays a different amount for the same procedure.</p><p>This makes it nearly impossible to do large-scale calculations like this with any degree of accuracy. Still, you can look at this study as a benchmark. It tells us roughly that there are a lot of dollars to be saved by simply giving mothers better care.</p><p>As policy makers work to reef the sails on our health care system, they should be paying attention to this report, and others (like <a href="" target="_blank">this one</a>), that show that in this particular sector, less is probably more.</p><br /> <br /> <p>&nbsp;</p><div><iframe allowtransparency="true" frameborder="0" scrolling="no" src=";layout=standard&amp;show_faces=true&amp;width=450&amp;action=recommend&amp;colorscheme=light&amp;height=80" style="border: medium none; overflow: hidden; width: 400px; height: 80px;"></iframe><script type="text/javascript"> tweetmeme_source = 'californiawatch'; </script><script type="text/javascript" src=""></script></div> Health and Welfare Daily Report cesarean sections early births health care maternal health Our Maternal Health Wed, 19 Jan 2011 08:06:03 +0000 Nathanael Johnson 8133 at Daquella Manera/Flickr As early elective births increase so do health risks for mother, child <p>The number of women giving birth early &ndash; often for no medical reason &ndash; has increased dramatically over the past two decades, altering the way we bear children and posing new health risks to both mothers and newborns, experts say.</p><p>The average time a fetus spends in the womb has fallen seven days in the United States since 1992, according to researchers and data from the <a href="" target="_blank">Centers for Disease Control and Prevention</a>. Experts call this trend an &ldquo;evolutionarily dramatic event.&rdquo;</p><p>Researchers say shorter pregnancies coincide with a large number of women and doctors now scheduling childbirth for convenience. One study of nearly 18,000 deliveries in 2007 showed that 9.6 percent were early births &ndash; through scheduled inductions or C-sections &ndash; for nonmedical reasons.</p><p>Shortening a pregnancy could affect a baby&rsquo;s lung development, vision, weight, and some fine-tuning of the brain, experts say. Babies born too early often sleep longer than normal and have trouble learning how to breast-feed, causing dehydration and jaundice.</p><p>&ldquo;For every day and every week before 39 weeks, it&#39;s an increasing risk to the baby,&rdquo; said Dr. Bryan Oshiro, vice chairman of obstetrics and gynecology at Loma Linda University. &ldquo;The vast majority of early term babies do fine, but it&#39;s like playing Russian roulette.&rdquo;</p><p>California Watch <a href="" target="_blank">reported in September</a> that women are significantly more likely to experience C-sections at for-profit hospitals across the state. In February, <a href="" target="_blank">California Watch reported</a> that the number of women who die each year from causes directly related to childbirth had more than doubled in California since 1996.&nbsp;</p><p>The rise in deaths during childbirth is an indicator that obstetric health has deteriorated in many important ways, according to the <a href="" target="_blank">California Maternal Quality Care Collaborative</a>, a task force of medical researchers.&nbsp;</p><p>The group has recently focused its efforts on the number of babies delivered for nonmedical reasons before they would naturally arrive. For the most part, the public has been left in the dark; the problem has been confined to articles in medical journals and among maternal health experts.</p><p>The normal length of pregnancy is 40 weeks, although researchers believe induced delivery at a full 39 weeks is probably safe. Women often naturally give birth earlier than this, and in some cases, medical problems require an early delivery. The problems come when babies are born before they are ready.</p><p>Of all births between 1990 and 2006, the number of babies born at 36&nbsp;weeks increased by about 30 percent, and babies born at 37 and 38&nbsp;weeks rose more than 40 percent, according to national vital&nbsp;statistics. There was a corresponding drop in the number of babies&nbsp;born in later weeks. There are now more babies born at 39 weeks than&nbsp;at full term.</p><p>The data examined is considered fresh by academic standards and covers such a long period of time &ndash; 16 years &ndash; that experts say the trend is unmistakable.</p><p>&ldquo;The entire bell curve has shifted,&rdquo; said Dr. Jeanne Conry, California district chairwoman of the <a href="" target="_blank">American Congress of Obstetricians and Gynecologists</a>.&nbsp;</p><p>Some early births are scheduled for the convenience of the mother or doctor; some are judgment calls that require weighing relative risks.&nbsp;</p><p>A California Watch inquiry through the <a href="" target="_blank">Public Insight Network</a>, which solicits observations from people around the country, asked mothers around the country about their experiences with early deliveries. The questionnaire elicited responses from more than 300 women and produced several cases in which mothers said their doctors had pushed for early births.</p><p>One mother, Michelle Van Norman, gave birth to her second child, Christian, 11 days early in 2006, despite no urgency noted on her medical records. The doctor wrote on her chart: &ldquo;This is a pleasant white female in no apparent distress.&rdquo;&nbsp;</p><p>Van Norman, a 31-year old mom, living in Las Vegas, said her doctor didn&rsquo;t seem worried about the delivery date.</p><p>&ldquo;There were no medical reasons for the delivery being early,&rdquo; Van Norman said. &ldquo;He told me the week he could do it and asked me to choose which day was best for us.&rdquo;&nbsp;</p><p>After his birth by C-section, one of Christian&rsquo;s lungs collapsed. He spent three weeks in intensive care and 10 days on a ventilator with six tubes going into his chest. It&rsquo;s unclear what caused Christian&rsquo;s lung to collapse, but this condition is strongly associated with early childbirth.</p><p>&ldquo;The whole experience was horrific,&rdquo; Van Norman said. &ldquo;It didn&#39;t end with the birth it continued for the first year of his life, and we still don&#39;t know if the oxygen deprivation has had any affect on him.&rdquo;</p><p>When Van Norman&rsquo;s surgeon cut the cord, Christian seemed robust. The doctor declined to comment about the case.</p><p>&ldquo;The doctor came in the day after and asked where the baby was,&rdquo; Van Norman said. &ldquo;When I told him, he asked me if I was joking. &hellip; I swore from that day on I would never put another baby through that kind of torture for any reason.&rdquo;</p><p><strong>Raising awareness</strong></p><p>Babies born early through induction or C-section without a medical reason are nearly twice as likely to spend time in the neonatal intensive care unit, researchers say. They also are more likely to contract infections and need the assistance of breathing machines, <a href="" target="_blank">according to a 2009 study</a> in the New England Journal of Medicine and a number of other reports.&nbsp;</p><p>&ldquo;We are finding out that the last weeks of pregnancy really do count,&rdquo; said Leslie Kowalewski, an associate state director for the <a href="" target="_blank">March of Dimes</a>. &ldquo;At 35 weeks, the brain is only two-thirds of what it will weigh at 40 weeks.&rdquo;</p><p>Many organizations are responding with programs designed to eliminate early elective deliveries. Most significantly, chapters of the American Congress of Obstetricians and Gynecologists have begun to notify doctors about the serious consequences of performing early elective births.</p><p>In California, the state <a href="">Department of Public Health</a>, March of Dimes and California Maternal Quality Care Collaborative have released what its authors call &ldquo;<a href="">the Toolkit</a>,&rdquo; which makes the case that, unless medically necessary, cesarean sections and artificial induction of labor before full gestation should be eliminated.</p><p>The state chapter of the American Congress of Obstetricians and Gynecologists has thrown its weight behind this recommendation and is taking measures to see that it is carried out, holding teaching sessions and reaching out to obstetrics leaders at every hospital in the state.&nbsp;</p><p>&ldquo;Nothing on this scale has ever been done before in California,&rdquo; Conry said. At the same time, physicians groups are rolling out the toolkit&rsquo;s guidelines in New York, Florida, Illinois and Texas.</p><p>The authors of the Toolkit note that rates of medically induced labor more than doubled between 1989 and 2004. The increase in deliveries between 37 and 39 weeks &ldquo;has been associated with an increase in obstetrical interventions such as induction of labor and cesarean sections,&rdquo; the Toolkit authors said.</p><p>Lack of knowledge both among clinicians and patients seems to have driven this trend.</p><p>Part of the problem has to do with education, said Kowalewski, one of the authors of the Toolkit. Because we learn that human gestation lasts nine months, many people think that 36 weeks is full term. It&rsquo;s a misconception even within the March of Dimes, which has worked for years to teach people about infants born too early.</p><p>&ldquo;When I started talking about this, members of our own state board said, &lsquo;Wait, what are you talking about, nine times four is 36 right?&rsquo; &rdquo; Kowalewski said. &ldquo;But nine months isn&rsquo;t always a complete pregnancy.&rdquo;</p><p>To complicate matters, doctors start the pregnancy clock at a woman&rsquo;s last menstrual period before becoming pregnant, which is usually about two weeks before conception. All this is confusing enough that when doctors tell women they are at 36 weeks gestation and must wait at least a month before starting labor, they can grow impatient, Conry said.&nbsp;</p><p>&ldquo;We call it tired of being pregnant,&rdquo; she said. &ldquo;Some women have 36 weeks in their heads as the end point, especially when their mother and girlfriends have delivered at 36 weeks and had an easy birth.&rdquo;</p><p>Societal changes also push women to seek an early delivery. Some women schedule births before their due date so they can better plan for taking time off work and flying in family members, Kowalewski said.&nbsp;</p><p>&ldquo;It&rsquo;s at least a weekly discussion, where one of my patients wants to get an induction before 39 weeks,&rdquo; said Dr. John Wachtel an obstetrician and adjunct professor at the Stanford University School of Medicine.&nbsp;</p><p>A little information can change this.&nbsp;</p><p>&ldquo;I haven&rsquo;t met a woman who wasn&rsquo;t willing to continue her pregnancy if given information,&rdquo; said Debra Bingham, an author of the Toolkit and vice president of the <a href="">Association of Women&#39;s Health, Obstetric &amp; Neonatal Nurses</a> in Washington, D.C. &ldquo;I&rsquo;ve had experience with women who clearly didn&rsquo;t understand the risks of an elective induction, but it&rsquo;s also fair to say that there are a lot of doctors, nurses, and childbirth educators who aren&rsquo;t aware of the risks.&rdquo;</p><p><strong>Doctors&rsquo; role</strong></p><p>There are signs that doctors are driving part of the rise in earlier births. Since 1979, the American Congress of Obstetricians and Gynecologists has advised doctors not to do elective inductions before 39 weeks gestation, but early elective deliveries have continued to rise, except in the places where there is a system to hold doctors accountable.</p><p>Deliveries at 37 and 38 weeks account for about 17.5 percent of total births in the United States, according to authors of the Toolkit. &nbsp;</p><p>At <a href="">Intermountain Healthcare</a>, a system of hospitals based in Utah, 28 percent of elective deliveries occurred before 39 weeks until the health system began talking to doctors who were routinely performing early cesarean surgeries and inductions for nonmedical reasons. Now, 3 percent of elective deliveries occur before 39 weeks&rsquo; gestation.</p><p>&ldquo;Physicians are data driven,&rdquo; said Daron Cowley, spokesman for Intermountain, which performs about 30,000 deliveries a year. &ldquo;When the data were presented to physicians, practice patterns changed.&rdquo;</p><p>Earlier in his career, Loma Linda University&rsquo;s Oshiro worked for Intermountain as a neonatologist in Ogden, Utah, where he had the defining experience that made him an evangelist for this issue. The head of the neonatal intensive care asked him to look in on a group of babies with problems.&nbsp;</p><p>&ldquo;He said, &#39;You doctors are doing this. These babies are here because you allowed them to be delivered early,&#39; &quot; Oshiro remembered. &quot;That just kind of stopped me dead. It was really clear &ndash; we&#39;re hurting babies, and we can stop it.&quot;</p><p><a href="">MemorialCare Health System</a> in Orange County has achieved similar results by requiring doctors to call their medical director and explain the reasons for an early birth. At Intermountain, these types of changes have led to fewer cesarean sections and $5 million in savings for patients over the past five years, Cowley said.</p><p>Still, Conry, of the American Congress of Obstetricians and Gynecologists, cautions that part of this improvement may be because such systems motivate better record keeping, eliminating births incorrectly coded as &ldquo;elective.&rdquo;</p><p><strong>Weighing the risks</strong></p><p>Often, the decision to deliver early requires weighing risks. Elizabeth Regan of Frankfort, Kentucky, was at 37 weeks gestation when she had her first child in 2001.</p><p>Doctors wrote that Regan went into labor during an exam. But Regan said she merely had a <a href="">Braxton Hicks contraction</a>, something that commonly occurs weeks before birth. Nonetheless, she was rushed off to the operating room, she said.</p><p>Doctors also delivered Regan&rsquo;s second child at 37 weeks gestation, concerned that this baby was too small, according to medical records. A small baby can be a sign that the mother isn&rsquo;t delivering enough nutrients through the placenta, said Dr. Stephen Hall, who advised Regan to deliver early.</p><p>&ldquo;You are trying to make the decision, is the baby safer inside mom while you are waiting for the lungs to mature, or is it better off in the mother&rsquo;s arms, fed by breast milk rather than worrying about the placenta?&rdquo; he said in an interview.</p><p>The problem is that estimates of the baby&rsquo;s size can be off by a pound, Hall said. Regan&rsquo;s baby turned out to be of normal weight, similar to his sister&rsquo;s size at 37 weeks. Both children had trouble breathing &ndash; a common problem in early births &ndash; and were treated with inhalers and steroids. They are now healthy. &nbsp;</p><p>When Regan learned it was possible to deliver vaginally after two cesarean surgeries she decided to try it, but had grown wary of doctors.&nbsp;</p><p>&ldquo;Needless to say, I stayed far away from the hospital and doctors offices at 37 weeks,&rdquo; she said. She carried her third child to 40 weeks when labor began spontaneously and she gave birth to a healthy boy at home.</p><p>Researchers now are finding that some of the medical justifications for early delivery actually don&rsquo;t help.&nbsp;</p><p>Jennifer Penick of Omaha, Neb., had her labor induced at 38 weeks. She said her doctor told her baby was too large. The authors of the Toolkit point out that numerous studies show that babies induced early to limit their growth are actually more likely to get stuck in the birth canal and need a C-section.</p><p>Penick&rsquo;s baby was average size, but her induction turned into a cesarean surgery, she said. Her doctor did not return calls seeking comment.&nbsp;</p><p>Alegent Health, which runs the hospital where Penick delivered seven years ago, has adopted a 39-weeks policy. Penick has since given birth there three more times. As more evidence accrues in support of waiting until at least 39 weeks gestation, medical practice is beginning to change.&nbsp;</p><p>It&rsquo;s easy for doctors to get the impression that delivery a few days early doesn&rsquo;t matter, because complications occur so infrequently, said Bingham, one of the Toolkit&rsquo;s authors.&nbsp;</p><p>&ldquo;It reminds me of all the years of research on seat belt safety,&rdquo; she said. &ldquo;How many times have you actually needed a seat belt? You need to look at the entire population to see the cumulative risk.&rdquo;</p><p>Dr. Elliott Main, lead author of the Toolkit and head of obstetrics at <a href="">California Pacific Medical Center</a> in San Francisco, said problems occur in just one in 33 babies delivered early through elective induction. That&rsquo;s why it&rsquo;s crucial to begin quality-improvement measures, rather than simply relying on the experience of doctors, he said.&nbsp;</p><p>&ldquo;The tendency is to shave a day here and a day there,&rdquo; Main said, &ldquo;and if you get away with it you are going to shave another.&rdquo;</p><p>In the past, the American Congress of Obstetricians and Gynecologists has hesitated to do anything that could restrict the freedom of doctors to choose techniques, said Wachtel, the Stanford professor.</p><p>&ldquo;There&rsquo;s something of a philosophical change where we are not just educating people, but trying to improve outcomes,&rdquo; he said.</p><div>&nbsp;</div><div><p class="image-full-width" style="width: 600px;"></p></div><br /> <br /> <p>&nbsp;</p><div><iframe allowtransparency="true" frameborder="0" scrolling="no" src=";layout=standard&amp;show_faces=true&amp;width=450&amp;action=recommend&amp;colorscheme=light&amp;height=80" style="border: medium none; overflow: hidden; width: 400px; height: 80px;"></iframe><script type="text/javascript"> tweetmeme_source = 'californiawatch'; </script><script type="text/javascript" src=""></script></div> Health and Welfare birth rates early births maternal health Our Maternal Health Sun, 26 Dec 2010 08:05:28 +0000 Nathanael Johnson 7689 at C-section rates vary in low-risk situations <meta http-equiv="REFRESH" content="0;url="> <p>Whoops! This page should shuttle you over to our projects server automatically. If it is not, please go to <a href=""></a>. Health and Welfare C-sections California hospitals maternal health Database Our Maternal Health Sat, 11 Sep 2010 21:09:05 +0000 4609 at For-profit hospitals performing more C-sections <p>For-profit hospitals across the state are performing cesarean sections at higher rates than nonprofit hospitals, a California Watch analysis has found.</p><p>A <a href="" target="_blank">database</a> compiled from state birthing records revealed that, all factors considered, women are at least 17 percent more likely to have a cesarean section at a for-profit hospital than at one that operates as a non-profit. A surgical birth can bring in twice the revenue of a vaginal delivery.</p><p>In addition, some hospitals appear to be performing more C-sections for non-medical reasons &ndash; including an individual doctor&rsquo;s level of patience and the staffing schedules in maternity wards, according to interviews with health professionals.</p><p>Across the state, more women are having C-sections for a variety of reasons: a rise in obesity and the number of older mothers, fear of lawsuits among doctors and hospitals, and a growing cultural acceptance of the procedure. Rather than examine these well-known trends, California Watch looked at why individual hospitals are performing cesarean sections at higher rates than others.</p><p>The statewide database revealed significant differences among 253 hospitals in California. Women, whose pregnancies were deemed to be low-risk, had a 9 percent chance of giving birth by C-section at the nonprofit <a href="" target="_blank">Kaiser Permanente Redwood City Medical Center</a>, for example. At the for-profit <a href="" target="_blank">Los Angeles Community Hospital</a>, women had a 47 percent chance of undergoing a surgical birth. When you factor in moms who needed to have C-sections for medical reasons, the Los Angeles hospital&rsquo;s rate jumps to 59 percent. In Riverside County, hospitals just miles apart had dramatically different rates, even though they serve essentially the same population.</p><p>The numbers provide ammunition to those who have long suspected that unnecessary C-sections are performed to help pad the bottom line.</p><p>&ldquo;This data is compelling and strongly suggests, as many childbirth advocates currently suspect, that there may be a provable connection between profit and the cesarean rate,&quot; said Desirre Andrews, president of the <a href="" target="_blank">International Cesarean Awareness Network</a>, a nonprofit group that would like to see C-sections only in cases of medical need.</p><p>To doctors and other health professionals, the results of the analysis were troubling.</p><p>&ldquo;We take this extremely seriously. The wide variation in C-section rates really is a cause for concern,&rdquo; said Dr. Jeanne Conry, California district chairwoman of the American Congress of Obstetricians and Gynecologists.</p><p>The analysis challenges some common assumptions about C-sections, including that wealthier women are more likely to opt for a surgical birth. Higher C-section rates were found at hospitals catering to all ethnic groups and economic classes. And there was no correlation between C-section rates and the percentage of a hospital&rsquo;s business from low-income or indigent patients receiving Medi-Cal, the state&rsquo;s Medicaid program.</p><p>But of the five hospitals in California with the highest C-section rates, four were for-profit hospitals in poorer parts of Los Angeles County, where the African-American and Hispanic populations are above the state average. Hospitals in Southern California tended to have higher rates than in the north, which may suggest a cultural influence.</p><p>This was the first independent analysis of C-section rates at the 253 hospitals reporting birth statistics to state health authorities from 2005 through 2007 and the first showing for-profit hospitals with higher rates than nonprofit ones. Studies in other countries have shown the same relationship between for-profit health care institutions and C-sections.</p><p>But some hospital officials dispute the notion that their institutions could be pushing C-sections for money. It is &ldquo;a wrong premise,&rdquo; according to Tenet Healthcare representative Rick Black, who said the decision to perform the surgery is made by the doctor and patient, while the hospital exerts no direct influence.</p><p>&ldquo;You don&rsquo;t just come into a hospital and they say, &lsquo;We want to give you a C-section so we can drive up profits.&rsquo; &rdquo;</p><p>Gene Declercq, professor of community health sciences at the Boston University School of Public Health, agrees that hospitals would not explicitly push C-sections for profit. But subtle incentives to increase efficiency could have the same effect.</p><p>&ldquo;There are factors that are attractive to hospitals in terms of training and staff and facilities,&rdquo; he said. &ldquo;It&rsquo;s a lot easier if you can do all your births between seven and 10 in the morning and know exactly how many operating rooms and beds you need.&rdquo; Vaginal births are unpredictable, creating inefficiencies that can hurt the bottom line.</p><p>In 2008, more than 180,000 C-sections were performed in California. It&rsquo;s unclear what percentage of these procedures led to adverse outcomes because some injuries are the result of underlying conditions.</p><p>California Watch previously reported that the state&rsquo;s <a href="" target="_blank">maternal death rate has increased</a> dramatically, and researchers are exploring the possible connection to the rise in C-sections during the same time period. Other media outlets, including ABC&rsquo;s &ldquo;World News&rdquo; and the Los Angeles Times, followed up with reports about this trend. By comparing hospitals with similar demographics, the California Watch analysis revealed that rising C-section rates cannot be completely attributed to changes in patient health and preference.</p><p>&ldquo;If you look at this variation among hospitals, it&rsquo;s clear we can&rsquo;t just blame women,&rdquo; said Debra Bingham, president-elect of <a href="" target="_blank">Lamaze International</a>, a group that promotes natural birth.</p><p>This finding adds to a growing body of studies that explain the rise in C-sections, said Carol Sakala, director of programs at Childbirth Connection, a maternity care advocacy group.</p><p>&ldquo;Much variation in cesarean rates is due to differences in practice style and is unrelated to needs and preferences of childbearing women,&rdquo; Sakala said. &ldquo;The likelihood that a woman will have a cesarean &ndash; with all the short- and longer-term excess risks of surgery to her and her newborn, and excess expense &ndash; is greatly influenced by the hospital she enters to give birth and the caregiver attending her birth.&rdquo;</p><p><strong>Pressure for procedure</strong></p><p>Even at nonprofit hospitals, some women say they felt pressured to have a C-section.</p><p>Rebecca Zavala, 29, a teacher and makeup artist in Ventura, was one.</p><p>Zavala consented to have her delivery induced a week early because the baby&rsquo;s head seemed large and because the doctor was about to leave for vacation.</p><p>Zavala went to the nonprofit <a href="" target="_blank">Santa Monica-UCLA Medical Center</a>, where nurses gave her drugs to dilate her cervix and start the contractions. After four hours, in which labor progressed slowly, Zavala&rsquo;s doctor broke her water and turned up the drug, stimulating contractions.</p><p>&ldquo;It felt like there was this monster on top of me all of a sudden,&rdquo; Zavala said. &ldquo;It was terrifying. I was totally unprepared for anything like that.&rdquo;</p><p>Shortly thereafter, her doctor informed Zavala that her baby was showing signs of distress and recommended a C-section. Zavala agreed. Nurses congratulated Zavala on being an accommodating patient.</p><p>But Zavala said she felt manipulated. Her doctor hadn&rsquo;t told her that induction increased the likelihood that she&rsquo;d have a C-section, and that C-sections came with health risks, she said. Now that she is pregnant again, she has learned that most hospitals are unlikely to allow a woman with a prior C-section to give birth naturally.</p><p>&ldquo;She told me nothing,&rdquo; Zavala said of her doctor, noting that the doctor left for her vacation shortly after the delivery.</p><p>The hospital could not discuss the specifics of the case due to patient privacy, but responded with the following statement:</p><p>&ldquo;Many factors go into the decision to perform a C-section delivery, with mother and baby safety foremost among them. Our policy requires physicians to obtain informed consent from patients undergoing C-sections. The process, which we followed completely, involves discussing the risks, benefits and alternatives to the procedure, and documenting that the discussion occurred and the patient opted to proceed.&rdquo;</p><p>Zavala&rsquo;s doctor did not wish to comment for attribution. Zavala did sign the consent but said it was impossible for her to interpret and assess the issues laid out in small print. Santa Monica-UCLA Medical Center has one of the highest rates of C-section deliveries in the state, ranking 15<sup>th</sup> out of 253 hospitals, for women whose pregnancies are deemed to be low-risk.</p><p>For some, a C-section can have devastating consequences.</p><p>After Heather Kirwan had been in labor for a few hours her doctor at <a href="" target="_blank">Rancho Springs Medical Center</a> in Murrieta urged her to have a C-section, warning that the baby was too big for her birth canal. She reluctantly agreed to the procedure, but now questions that decision.</p><p>&ldquo;She ended up being a 5-pound, 12-ounce baby,&rdquo; said Kirwan, 26, a manager for The Home Depot who lives in Murrieta. &ldquo;So that was obviously a lie.&rdquo;</p><p>A year and a half later, Kirwan was pregnant again, but the doctors found that the embryo was developing outside the uterus. Before her C-section, Kirwan said no one had warned her that C-sections increase the risk of this life-threatening condition, called ectopic pregnancy. And if it were listed in her lengthy consent form at the time of her first delivery, Kirwan said, no one bothered to point it out.</p><p>The doctors removed the embryo, along with one of Kirwan&rsquo;s ovaries and fallopian tubes. She has been unable to conceive since.</p><p>&ldquo;I&rsquo;ve been trying for years and years, and I still can&rsquo;t get pregnant. It&rsquo;s very heartbreaking,&rdquo; Kirwan said. &ldquo;I just want people to know the risks.&rdquo;</p><p>In a <a href=" " target="_blank">recently published study</a>, the Centers for Disease Control and Prevention showed that a 27 percent increase in severe maternal injuries in the United States between 1998 and 2005 was associated with higher rates of cesarean sections.</p><p>Kirwan&rsquo;s doctor and Rancho Springs Medical Center didn&rsquo;t respond to requests for comment. The hospital&rsquo;s C-section rate is among the state&rsquo;s lowest, ranking 207<sup>th</sup> out of 253 medical centers.</p><p>&nbsp;</p><p><strong>Searching for a link</strong></p><p>Medical experts have been unable to pinpoint exactly why some hospitals perform far more C-sections, or &ldquo;operative deliveries,&rdquo; than other medical facilities.</p><p>In June, a group of scientists writing in Obstetrics &amp; Gynecology, the journal of the American College of Obstetrics and Gynecology, found clear evidence of &ldquo;substantial regional variation in the use of cesarean delivery that cannot be explained by patient illness or preferences.&rdquo;</p><p>Another analysis of C-section rates noted that the variation among hospitals seems to defy a rational pattern. That 2007 study, in the American Journal of Obstetrics &amp; Gynecology, concluded that the &ldquo;rates of operative delivery in the United States are highly variable and suggest a pattern of almost random decision making.&rdquo;</p><p>Yet, one important factor has always loomed over the debate about the rise in C-sections: the bottom line. In California, hospitals can increase their revenue by 82 percent on average by performing a C-section instead of a vaginal birth, according to a 2007 analysis by the Pacific Business Group on Health.</p><p>The group &ndash; a coalition of business, education and government agencies &ndash; estimated that average hospital profits on an uncomplicated C-section were $2,240, while profits for a comparable vaginal birth were $1,230.</p><p>California Watch examined the births least likely to require C-sections, those in which mothers without prior C-sections carry a single fetus &ndash; positioned head down &ndash; at full term, and found that, after adjusting for the age of the mothers, the average weighted C-section rate for nonprofit hospitals was 16 percent, while for-profit hospitals had a rate of 19 percent.</p><p>That may seem like a small percentage gap to the casual observer, but medical experts consider it a significant difference. It means women are 17 percent more likely to have a C-section if they give birth at a for<strong>-</strong>profit hospital. (When calculated without weighting averages by number of patients<strong>,</strong> the difference is slightly larger.)</p><p>&ldquo;That&rsquo;s a decent<strong>-</strong>sized difference,&rdquo; said Boston University&rsquo;s Declercq.</p><p>Less than one in five maternity hospitals in the state is a for<strong>-</strong>profit institution, but among the 15 hospitals with the highest rates of C-sections, 10 are for-profit facilities. Among the 15 hospitals with the lowest rates, none are for-profit medical centers.</p><p>A few obstetricians, like Dr. Jeffrey Phelan<strong>,</strong> director of quality assurance for obstetrics at <a href="" target="_blank">Citrus Valley Medical Center</a> in West Covina believe that a higher C-section rate might be beneficial, especially in preventing infant brain injuries. In rare cases, when a baby&rsquo;s oxygen supply is cut off during birth, the baby may suffer brain damage. Because C-sections allow greater obstetrical control, Phelan says this problem might be alleviated by eliminating vaginal birth altogether.</p><p>However, most researchers agree that the rising number of birthing surgeries has done nothing to improve the health of mothers or babies, while exposing them to side effects. The accumulation of this data led <a href="" target="_blank">The Joint Commission</a>, the nation&rsquo;s top hospital accreditation organization, to announce this year that it would begin using low-risk C-section rates to measure hospital quality.</p><p>Dr. David Lagrew, medical director of <a href="" target="_blank">Saddleback Women&rsquo;s Hospital</a> in Orange County, spends about half his time delivering babies and says the change is welcome.</p><p>&ldquo;The big problem<strong>,</strong> of course<strong>,</strong> is that cesarean section has a number of downsides, such as increasing the maternal death rate, infections, blood loss, a lot of complications long term that we are just now beginning to understand,&rdquo; he said.</p><p><strong>Clinical practices and local leaders</strong></p><p><a href="" target="_blank">Citrus Valley Medical Center&rsquo;s</a> 29.3 percent low-risk C-section rate is the highest of any nonprofit maternity hospital in California. The reason for these C-sections is often listed as &ldquo;failure to progress,&rdquo; but the nurses have another name for it<strong>:</strong> &ldquo;failure to wait.&rdquo;</p><p>This is particularly a problem at Citrus Valley<strong>,</strong> where nurses have been written up for insubordination after asking doctors to give their patients more time or complaining to administrators about doctors rushing to perform C-sections, according to Nancy Carder, nursing practice representative for the <a href="" target="_blank">California Nurses Association</a>.</p><p>But Phelan said there is no drive for speed at Citrus Valley, only a drive for safety.</p><p>&ldquo;I&rsquo;ll put our perinatal safety record up against anyone in the state, and in the nation<strong>,</strong> for that matter,&rdquo; he said. &ldquo;We&rsquo;ve seen continued improvement over the years. Whether higher C-section rates are a part of that, I don&rsquo;t know.&rdquo;</p><p>Phelan acknowledges that he may be part of the reason there are so many C-sections at Citrus Valley. A lawyer as well as a doctor, he has written about obstetric liability, and testified in malpractice cases. He acknowledges that his advice about avoiding lawsuits &ldquo;has an impact.&rdquo;</p><p>All hospitals operate under the same malpractice rules in California, but they react to the threat of lawsuits differently. &ldquo;In published studies and case reports, the biggest reason for the variations has been shown to be clinical practices and local leaders,&rdquo; said Bingham, of Lamaze International.</p><p>The ultimate cause of the high C-section rate, Phelan contends, is patient choice.</p><p>&ldquo;I think<strong>,</strong> to a large extent<strong>,</strong> consumers want to have elective cesarean deliveries,&rdquo; he said.</p><p>But Citrus Valley labor and delivery nurses said it doesn&rsquo;t make sense that more patients would prefer C-sections at their hospital compared with others nearby. According to several nurses, it&rsquo;s often the doctors, not the patients, who make the choice.</p><p>The reason people often don&rsquo;t know the risks associated with C-sections is that they crop up years later, said Aaron Caughey, chairman of the Department of Obstetrics &amp; Gynecology at Oregon Health &amp; Science University.</p><p>The first C-section is very safe for the mother and it&rsquo;s unclear if it lowers the risk to the baby, but it may also cause a small increase in the risk of future stillbirths, while increasing the risk of maternal injury in subsequent pregnancies, he said.</p><p>Caughey&rsquo;s research predicts that if the C-section rate continues to increase at its current rate<strong>,</strong> it will cause 1,620 more hysterectomies and 50 more maternal deaths each year in the United States by 2020.</p><p>&ldquo;When there is a bad outcome on the third pregnancy, people don&rsquo;t think, &lsquo;Oh, it was the first C-section eight years ago,&rsquo; &rdquo; he said. &ldquo;We kind of forget to look back.&rdquo;</p><p><strong>Divide in the Inland Empire</strong></p><p>The problem exposed by the variation in C-section rates is clearly illustrated by two nonprofit hospitals in the Inland Empire.</p><p><a href="" target="_blank">Riverside County Regional Medical Center</a> in Moreno Valley is on the eastern rim of the Los Angeles Basin, where the coastal smog piles up against the desert mountains. <a href="" target="_blank">Hemet Valley Medical Center</a>, just 22 miles away, sits at the base of the same mountains, in the same haze.</p><p>And yet, between 2005 and 2007<strong>,</strong> Hemet Valley had one of the highest C-section rates in the state<strong>,</strong> 28.7 percent for low-risk pregnancies, while Riverside County Regional had one of the lowest at 9 percent.</p><p>Riverside County Regional abuts a subdivision for doublewide trailers. Hemet Valley is on a bedraggled commercial strip. In Hemet Valley&rsquo;s medical service area, 15.5 percent of the people live below the poverty level. For Riverside County Regional, that number is 15.4 percent. The ethnic makeup of the two areas is similar. Doctors at both hospitals practice under the same malpractice laws.</p><p>So why are women more likely to undergo a C-section in Hemet Valley? For Jerri Randrup, vice president for communications and marketing at Hemet Valley, the difference is a mystery. The hospital had to enter bankruptcy a few years ago, but that hasn&rsquo;t affected the quality of care, she said.</p><p>&ldquo;I can&rsquo;t tell you what we were doing in the past,&rdquo; said Randrup, noting that the hospital&rsquo;s rate had fallen in 2009. &ldquo;But what I can tell you is there is a team in place that is very focused on quality care and patients, following standards and getting our nurses trained.&rdquo;</p><p>There&rsquo;s no mystery for Guillermo Valenzuela, vice chairman of obstetrics at Riverside County Regional, who is on call about twice a month to deliver babies. &ldquo;These things don&rsquo;t happen by accident,&rdquo; he said.</p><p>Valenzuela attributes his hospital&rsquo;s low rate to doctors working in shifts. Shift workers have no financial incentive to hurry a delivery along: The doctor is paid the same and can end a shift regardless of whether he or she delivers 10 babies or simply monitors the early stages of labor. The system increases accountability, he said.</p><p>By contrast, most doctors, who must be there when the baby arrives to make their fee, face a dilemma unknown to shift workers: either wait hours for a vaginal delivery or perform a C-section.</p><p>&ldquo;If I come in in the morning, look over the charts and see that one of the patients just had a C-section without medical indication,&rdquo; Valenzuela said, &ldquo;you can bet that I&rsquo;m going to start asking questions.&rdquo;</p><p>Other hospitals rely on a similar system. Kaiser Permanente hospitals use this shift-work model and generally have lower C-section rates. Dr. Tracy Flanagan<strong>,</strong> who regularly delivers babies and is director of women&rsquo;s health at Kaiser Permanente Northern California, has worked under both systems and understands how the forces of time can affect a physician in private practice.</p><p>&ldquo;You are sitting in labor and delivery for 12 hours and she&rsquo;s barely making progress, and your family is yelling at you wondering when you are going to come home,&rdquo; Flanagan said. &ldquo;There&rsquo;s tremendous pressure. In addition<strong>,</strong> you know that you will get paid the same or more for doing a C-section. Our medical system makes it hard to do the right thing. That&rsquo;s a big reason I moved over to Kaiser.&rdquo;</p><p>Kaiser also addresses this issue by hiring midwives, who are able to conduct births more cheaply than doctors. Midwives participate in the majority of Kaiser births.</p><p>Last spring, The Joint Commission, the principal body that evaluates hospitals in the United States, instituted a standard designed to prevent frivolous C-sections. The Joint Commission wrote that hospitals with low C-section rates &ldquo;have infant outcomes that are just as good, and better maternal outcomes. &hellip; Many authors have shown that physician factors, rather than patient characteristics or obstetric diagnoses, are the major driver for the difference in rates within a hospital.&rdquo;</p><p>This pressure from an organization with the power to remove a hospital&rsquo;s accreditation should make a difference, said Lagrew, of Saddleback Women&rsquo;s Hospital. More hospitals are working to reduce C-sections by limiting medical interventions like induction of labor and hiring shift-work doctors or midwives who can afford to be more patient with long labors.</p><p>Though some hospitals have yet to respond, the pendulum is starting to swing back, Lagrew said.</p><p>&ldquo;The great debate is what should the C-section rate really be?&rdquo; he said. &ldquo;With things getting more complicated, as far as obesity and older women, it shouldn&rsquo;t be 10 percent probably &ndash; but it shouldn&rsquo;t be 50 percent<strong>,</strong> either. You want to find the sweet spot.&rdquo;</p><br /> <br /> <p>&nbsp;</p><div><iframe allowtransparency="true" frameborder="0" scrolling="no" src=";layout=standard&amp;show_faces=true&amp;width=450&amp;action=recommend&amp;colorscheme=light&amp;height=80" style="border: medium none; overflow: hidden; width: 400px; height: 80px;"></iframe><script type="text/javascript"> tweetmeme_source = 'californiawatch'; </script><script type="text/javascript" src=""></script></div> Health and Welfare Our Maternal Health Sat, 11 Sep 2010 21:05:07 +0000 Nathanael Johnson 4069 at How the C-section story came together <p>Working with California Watch, I first broke the story on a rise in <a href="">maternal death rates</a> in February. After consulting with California Watch editors <a href="/user/robert-salladay">Robert Salladay</a> and <a href="/user/mark-katches">Mark Katches</a>, I decided to delve deeper into the area of cesarean sections, which have been rising during the past several years.</p><p>I started by looking at what information the state already had. The most interesting thing I found was that California&rsquo;s Office of Statewide Health Planning and Development had done <a href="">a statistical analysis</a> comparing C-section rates at California hospitals and noted that the wide variation in rates could indicate that some hospitals were performing unnecessary surgeries. To refine this point, the state focused on those C-sections most likely to be unnecessary.</p><p>The state data excluded deliveries in which C-sections might be medically justified: instances in which the woman had a prior C-section, twins, breech babies and babies delivered before term (which covered babies induced early due to diabetes, heart disease, eclampsia and other complications). The state data also excluded births that resulted in the death of the baby.</p><p>Finally, it adjusted these rates for maternal age because older mothers are more likely to require a C-section. The patients remaining after making all these exclusions were women who were most unlikely to need a C-section for medical reasons. This &ldquo;low-risk&rdquo; rate formed the foundation of my analysis.</p><p>Before delving into the data, I asked two experts in the field, Debra Bingham, president-elect of <a href="" target="_blank">Lamaze International</a>, and Dr. Elliott Main, principal investigator for the <a href="" target="_blank">California Maternal Quality Care Collaborative</a>, how to best analyze this variation between hospitals. They suggested I look for correlations between the low-risk C-section rate and other factors, such as type of insurance, and hospital quality measures. I also spoke with experts at the <a href="" target="_blank">Robert Wood Johnson Foundation</a>, <a href="" target="_blank">Kaiser Family Foundation</a> and <a href="" target="_blank">California HealthCare Foundation</a>.</p><p>With the help of California Watch intern <a href="" target="_blank">Timothy Sandoval</a>, I combined the numbers from the state&rsquo;s C-section analysis, from 2005 to 2007, into a single Excel spreadsheet. Entering data by hand, we then added information on hospital characteristics and finances. Most of this information came from the state, but I also used federal data from patient surveys about hospitals, as well as data from the <a href="">Dartmouth Atlas of Health Care</a>, an academic research organization. I also made public records requests, which resulted in disclosure of Medicare fees paid for C-sections.</p><p>California has about 430 hospitals and medical centers. Of that total, nearly 260 hospitals reported birthing statistics to the state during the timeframe analyzed.</p><p>After looking over this spreadsheet I excluded from the analysis five hospitals with significant missing data: <a href="">Valleycare Medical Center</a> in Alameda County; <a href=";rop=MRN">Kaiser Permanente Antioch Medical Center</a> in Contra Costa County; <a href="">Selma Community Hospital</a> in Fresno County; <a href="">Martin Luther King Jr. Hospital in Los Angeles County</a>; and <a href="">Rideout Memorial Hospital</a> in Yuba County. Martin Luther King Jr. Hospital shut down in 2007, leaving significant gaps in its data. The four other hospitals were missing C-section data for most of the three years (2005-07).</p><p>I then began looking for statistical correlations between the low-risk C-section rates and various hospital characteristics. To do this, I used the Pearson&rsquo;s correlation function in Excel, which shows if there is a linear relationship between two columns. The formula yields a correlation coefficient between -1 and 1. A perfectly linear correlation is indicated by a coefficient of + or -1, while 0 indicates no correlation. So, for instance, if hospitals with higher low-income patients (i.e. patients utilizing Medicaid and indigent assistance)rates always had higher C-section rates, the Pearson&rsquo;s coefficient would be close to 1.</p><p>But, as it turned out, the percentage of a hospital&rsquo;s low-income patients was not correlated with C-section rates. The formula yielded a correlation coefficient of 0.1. The graph comparing C-section rates with low-income patient care rates looks like a random cloud of dots, rather than a straight line.</p><p>Those dots tightened into something resembling an oval when I compared C-section rates related to a hospital&rsquo;s exclusive breast-feeding rate: The formula produced a coefficient of -0.3, a weak inverse correlation.</p><p>Next, I wanted to see if either for-profit or nonprofit hospitals were more likely to perform C-sections, but because one column contained words (e.g., nonprofit) rather than numbers, I couldn&rsquo;t run Pearson&rsquo;s formula. Instead, I calculated the average low-risk C-section rate for nonprofits and compared that to the for-profit average. I included all hospitals that don&rsquo;t earn money for investors or private owners in the nonprofit set (that is, all hospitals run by nonprofits, charities, tax districts, cities and counties). This division left me with 48 for-profit and 205 nonprofit hospitals.</p><p>The average low-risk C-section rate was higher at for-profit hospitals by 3.7 percentage points. This difference was found to be statistically significant using a two-tailed T-test: (t = 3.72, p &lt; 0.001, d.f. = 251).</p><p>I shared this result with Gene Declercq, professor of community health sciences at the <a href="">Boston University School of Public Health</a>. Declercq, who is nationally recognized for his work with birth statistics, asked to see the spreadsheets. After looking over the work, Declercq said the methodology was fair and complied with standard practice. Declercq said I should weight the averages by number of births, so that small hospitals wouldn&rsquo;t have an outsized importance in my analysis.</p><p>To weight the averages, I multiplied low-risk C-section rates by the average number of births at each hospital from 2005 to 2007, and then divided by the average number of births per hospital. After weighting the averages for number of deliveries per hospital, the difference was 2.78 percentage points, meaning that a pregnant woman walking into a for-profit hospital is 17 percent more likely to receive a C-section than a pregnant woman walking into a nonprofit hospital.</p><p>Declercq also pointed out that, although I had included county demographic information, a report with better access to data would have controlled for demographic factors (such as higher rates of poverty and obesity in some areas) specific to the particular C-section patients at each hospital. Because the 48 for-profit and 205 nonprofit hospitals are scattered throughout the state, it&rsquo;s probably safe to assume that for-profit hospitals are no more likely than nonprofit medical centers to be in areas of high obesity. But a more thorough analysis would quantify and exclude these confounding demographic factors. We decided against doing that and simply focused on county demographic information.</p><p>California Watch&rsquo;s Agustin Armendariz converted the most useful numbers in the spreadsheet to a visual format accessible on the web. California Watch&rsquo;s Chase Davis checked the math and statistical calculations. California Watch copy editor Austin Fast also double-checked the math.</p><p>Most of the work I did for this story was not statistical, but instead comprised old-fashioned telephone and shoe-leather reporting, visiting hospitals at both ends of the spectrum and interviewing researchers, hospital administrators, doctors and nurses. I put out a call for women who believed they had received an unnecessary C-section through online groups, doula organizations, childbirth educators and the advocacy group <a href="">International Cesarean Awareness Network</a>. The two women quoted in the story were both associated with this last group.</p><p>On the question of the profits hospitals make from C-sections, I <a href="">relied on a report [PDF]</a> from the California Pacific Business Group on Health. I checked the estimates in that report in off-the-record interviews with insurance company representatives. Insurance companies declined to openly reveal the amounts they paid to specific hospitals for C-sections and vaginal deliveries, but they provided representative reimbursement amounts without naming hospitals.</p><p>Each person and hospital mentioned in the story was given the opportunity to comment.</p><p><em>Nathanael Johnson is a freelance contributor to California Watch.</em></p> Health and Welfare maternal health Our Maternal Health Sat, 11 Sep 2010 20:04:00 +0000 Nathanael Johnson 4075 at Downloadable C-section primers <p>Check out our downloadable primers for a brief description of the C-section story, a look at the five hospitals with the highest cesarean rates regionally, a Q&amp;A with an expert, and a list of recommended resources. Also available in <a href="">Spanish</a>. &nbsp;</p> Our Maternal Health Sat, 11 Sep 2010 19:20:05 +0000 Ashley Alvarado 4616 at As world improves, pregnancy-related deaths rise in U.S. <p>A massive new analysis of worldwide maternal mortality shows that deaths are down significantly around the globe &ndash; but in the United States, deaths are up to 17 per 100,000, compared to the last U.S. estimate of 12 per 100,000.</p><p>This suggests that California&rsquo;s most recently reported rate of 19 per 100,000 is not an outlier or a fluke, but a representation of a national problem.</p><p>This <a href="" target="_blank">study</a>, which comes from the <a href="" target="_blank">Institute for Health Metrics and Evaluation</a> at the University of Washington, is much more powerful than previous analyses. The team spent two years assembling a dataset three times larger than the set of numbers used to make previous estimates.</p><p>&ldquo;Just to give you some perspective,&rdquo; said Christopher Murray, one of the study&rsquo;s co-authors, &ldquo;a sample that&rsquo;s 5 percent larger is a big deal in public health.&rdquo;</p><p>So 300 percent must be a really big deal. In addition, the team was able to fix biases that had been present in previous estimates and apply the newer statistical methods.</p><p>There&rsquo;s a bedeviling confounder in U.S. maternal mortality numbers: We haven&rsquo;t done a very good job of counting deaths in the past, so undoubtedly part of any increase is due to better reporting. This report doesn&rsquo;t ask how much of the increase is real, but even if 100 percent of the rise were attributable to better counting it would be cold comfort.</p><p>The fact remains that a lot of mothers have died in this country who probably would have been fine if they had lived in Italy (which has the lowest rate, 3.9 per 100,000), Sweden, or Albania.</p><p>This new information also provides a correction for the <a href="" target="_blank">story on maternal deaths</a> California Watch published in February: We said (based on the U.N. estimates) that California&rsquo;s rate was higher than that of Kuwait or Bosnia. This study estimates that Kuwait&rsquo;s maternal mortality rate is significantly higher (26.1 per 100,000), though Bosnia (at 11.8 per 100,000) still has California beat.</p><p>&ldquo;We&rsquo;ve done as much as we can to make those countries comparable,&rdquo; Murray said.</p><p>And the power of this analysis is most evident in the margins of error for each of the country rates &ndash; before, when it was hard to tell if some governments were cooking the books, the uncertainty intervals were much wider.</p><p>Now it is possible to compare Slovakia (5 to 9 deaths per 100,000) with the U.S. (15 to 19 per 100,000), with confidence. The U.S. ranks 39th overall, tied with Macedonia.</p><p>While the poor U.S. performance is troubling to public health scientists, it&rsquo;s not entirely surprising.</p><p>&ldquo;The U.S. doesn&rsquo;t rank so well in any health outcome, so we&rsquo;re pretty sure that finding is robust,&rdquo; Murray said. &ldquo;We are ranked around 40th for young and middle-aged mortality too. The thing about maternal mortality is it&rsquo;s totally preventable &ndash; there&rsquo;s no excuse for these rates.&rdquo;</p><p>These findings offer an opportunity to researchers to learn from the success of countries like Egypt, where the rate dropped 8 percent per year. What was Egypt doing right?</p><p>It also reaffirms the great medical mystery of our time: What is the U.S. doing wrong?</p> Health and Welfare Daily Report maternal deaths maternal health Our Maternal Health Tue, 13 Apr 2010 07:07:00 +0000 Nathanael Johnson 1721 at Flickr photo by Munroe Photography AUDIO: Experts weigh in on maternal mortality rates <p><a href="">LISTEN</a> to doctors Elliott Main and Aaron Caughey and reporter Nathanael Johnson discuss the rise in maternal mortality in California on KQED&#39;s Forum program.</p><p><a href=""></a></p><p>&nbsp;</p><p><a href="">LISTEN</a> to reporter Nathanael Johnson and producer Michael Montgomery investigate what&#39;s driving the rise in maternal mortality rates on KQED&#39;s radio magazine, The California Report.</p><p><a href=""></a></p> Health and Welfare maternal deaths maternal health Our Maternal Health Mon, 08 Feb 2010 18:37:14 +0000 Michael Montgomery 1031 at More women dying from pregnancy complications; state holds on to report <p>The mortality rate of California women who die from causes directly related to pregnancy has nearly tripled in the past decade, prompting doctors to worry about the dangers of obesity in expectant mothers and about medical complications of cesarean sections.</p><p>For the past seven months, the state Department of Public Health declined to release a report outlining the trend. &nbsp;</p><p>California Watch spoke with investigators who wrote the report and they confirmed the most significant spike in pregnancy-related deaths since the 1930s. Although the number of deaths is relatively small, it&rsquo;s more dangerous to give birth in California than it is in Kuwait or Bosnia.</p><p>&ldquo;The issue is how rapidly this rate has worsened,&rdquo; said <a href="" target="_blank">Debra Bingham</a>, executive director of the <a href="" target="_blank">California Maternal Quality Care Collaborative</a>, the public-private task force investigating the problem for the state. &ldquo;That&rsquo;s what&rsquo;s shocking.&rdquo;</p><p>The problem may be occurring nationwide. The Joint Commission, the leading health care accreditation and standards group in the United States, issued a &ldquo;<a href="" target="_blank">Sentinel Event Alert</a>&rdquo; to hospitals on Jan. 26, stating: &ldquo;Unfortunately, current trends and evidence suggest that maternal mortality rates may be increasing in the U.S.&rdquo; &nbsp;</p><p>The alert asked doctors to consider morbid obesity, high blood pressure and diabetes, along with hemorrhaging from C-sections, as contributing factors.</p><p>In 2007, the <a href="" target="_blank">U.S. Centers for Disease Control and Prevention</a> reported that the national maternal mortality rate had risen, but experts such as <a href="" target="_blank">Dr. Jeffrey C. King</a>, who leads a special inquiry into maternal mortality for the American College of Obstetricians and Gynecologists, chalked up the change to better counting of deaths. His opinion hasn&rsquo;t changed.</p><p>&ldquo;I would be surprised if there was a significant increase of maternal deaths,&rdquo; said King, who has not seen the California report.</p><p>But Shabbir Ahmad, a scientist in California&rsquo;s Department of Public Health, decided to look closer. He organized academics, state researchers and hospitals to conduct a systematic review of every maternal death in California. It&rsquo;s the largest state review ever conducted. The group&rsquo;s initial findings provide the first strong evidence that there is a true increase in deaths &ndash; not just the number of reported deaths.</p><p>Changes in the population &ndash; obese mothers, older mothers and fertility treatments &ndash; cannot completely account for the rise in deaths in California, said <a href="" target="_blank">Dr. Elliott Main</a>, the principal investigator for the task force. &nbsp;</p><p>&ldquo;What I call the usual suspects are certainly there,&rdquo; he said. &ldquo;However, when we looked at those factors and the data analyzed so far, those only account for a modest amount of the increase.&rdquo;</p><p>Main said scientists have started to ask what doctors are doing differently. And, he added, it&rsquo;s hard to ignore the fact that C-sections have increased 50 percent in the same decade that maternal mortality increased. The task force has found that changing clinical practice could prevent a significant number of these deaths.</p><p>One maternity expert who was not involved in the report, <a href="" target="_blank">Dr. Thomas R. Moore</a>, chair of the Department of Reproductive Medicine at UC San Diego, said about the data: &quot;This could be a sentinel finding, and I could see other states taking a closer look and finding the same thing.&quot;</p><p><strong>Low numbers, high consequences</strong></p><p>Despite the increase in the mortality rate, pregnancy is still safe for the vast majority of women.</p><p>In 2006, 95 California women died from causes directly related to their pregnancies &ndash; out of more than 500,000 live births. That&rsquo;s a small number by public health standards. If California had met the goal set by the <a href="" target="_blank">U.S. Department of Health and Human Services</a> to bring the state&rsquo;s maternal mortality rate down to a level achieved by other countries, the number of dead would be closer to 28.</p><p>It&rsquo;s not clear who is most at risk, but researchers have long known that African-American mothers are between three and four times more likely to die from pregnancy-related causes than the rest of the population. That racial association is not stratified by socio-economic status: Even high-income black women are at a greater risk.</p><p>While the maternal mortality rate among black women is rising, the task force found a more dramatic increase in deaths among white, non-Hispanic mothers. There is not yet enough data to show if the risk of death is associated with poverty.</p><p>What&rsquo;s certain is that each maternal death shatters families. That cold sum &ndash; 95 dead &ndash; represents 95 stories of people such as <a href="" target="_blank">Tatia Oden French</a>. In 2001, she was newly wed and had just finished her doctorate in psychology. She was about to have a baby girl she would name Zorah Allie Mae French.</p><p>&ldquo;She&rsquo;s the type of person that just walked into the room and lit it up,&rdquo; said her mother, Maddy Oden.</p><p>During the labor, Maddy Oden was at home in Oakland, waiting for a call announcing the birth of her granddaughter. Instead, she needed an emergency C-section. &ldquo;I woke up at 4 in the morning, and I knew that something was wrong,&rdquo; Oden said.</p><p>Then the phone rang. French was in trouble. Powerful contractions had forced amniotic fluid into her bloodstream, stopping her heart and killing the baby. When Oden got to her daughter at an Oakland hospital there was only one thing she could do: &ldquo;We said a prayer,&rdquo; Oden said, &ldquo;and I closed her eyes.&rdquo; &nbsp;</p><p>Oden lost the subsequent lawsuit: The doctor had not deviated from the standard of care.</p><p>Rather than track down the cause of every death and assign blame, the California task force is focused on finding solutions. And Bingham and Main have found that doctors and nurses are eager to help after seeing the numbers.</p><p>In 1996, the maternal death rate in California was 5.6 per 100,000 live births, not far from the national goal of 4.3 per 100,000. Between 1998 and 1999, the World Health Organization changed its coding system, which may have increased reporting of deaths. The California rate was 6.7 in 1998 and 7.7 in 1999. Because the number of mothers who die is small, the rate tends to fluctuate from year to year.&nbsp; &nbsp;</p><p>In 2003, when California revised its death certificate, the rate jumped to 14.6. And in 2006, the last year for which data is available, the rate stood at 16.9. &nbsp;</p><p>The best estimates show that less than 30 percent of the increase is attributable to better reporting on death certificates. Even accounting for these reporting and classification changes, the maternal death rate between 1996 and 2006 has more than doubled, Main said.</p><p><strong>Not yet public</strong></p><p>When researchers unveiled their initial findings to a conference of the American College of Obstetricians and Gynecologists in 2007, there were gasps from the audience, according to participants at the San Diego event. The idea that California was moving backward even in an era of high-tech birthing was implausible to some. Confirmation of the trend was noted in the 2008 report written by 27 doctors and researchers. The report was described in detail to California Watch.</p><p>The state of California has yet to share the report with the public. Researchers say that, after reviewing the report in 2008, officials in the Department of Public Health asked for technical clarifications. Revisions were complete and approved in the first half of 2009, according to Ahmad. &nbsp;</p><p>Al Lundeen, the department&rsquo;s director of public affairs said, &ldquo;There was no effort to hold that report back. It just needed some more revisions.&rdquo;</p><p>Researchers say that it is important for the public to be aware now that these trends are worsening. Diane Ashton, the deputy medical director for the <a href="" target="_blank">March of Dimes</a>, has seen the numbers. She says they demand a concerted response. &nbsp;</p><p>&ldquo;Even though they tend to be small numbers in terms of maternal mortality, it is important &ndash; it&rsquo;s very important &ndash; that these trends be looked at,&rdquo; she said. &ldquo;And efforts need to be made to try and reverse them when they are going in the wrong direction.&rdquo;</p><p><strong>Rising C-section birth rate </strong></p><p>Nearly one in three babies is now born by C-section. Many scientists have acknowledged that at some point, as the number of surgeries spiral upward, the risks will outweigh the benefits. But the C-section remains a useful tool, and in the middle of labor, doctors say, it&rsquo;s hard to balance the potential long-term harm against immediate crisis.</p><p>Today, doctors face a condition called <a href="" target="_blank">placenta accreta</a>, where the placenta grows into the scar left by a previous C-section. In surgery, doctors must find and suture a web of twisted placental vessels snaking into the patient&rsquo;s abdomen, which can hemorrhage alarming amounts of blood. Often, doctors must remove the uterus.</p><p>Main said this complication from C-sections has increased eight-to-10 fold in the past decade. Nonetheless, most women survive the ordeal. The point, says Catherine Camacho, deputy director of the state&rsquo;s <a href="" target="_blank">Center for Family Health</a>, is that the rise in deaths is indicative of a larger problem. &nbsp;</p><p>&ldquo;For every maternal death, there are 10 near misses; for every near miss, there are 10 severe morbidity cases (such as hysterectomy, hemorrhage, or infection), and for every severe morbidity case, there is another 10 morbidity cases related to childbirth,&rdquo; Camacho wrote in an e-mail. &nbsp;</p><p>Other factors are contributing to the rise in deaths, but the researchers in California are most interested in the areas where they have control, such as the high C-section birth rate: It&rsquo;s easier for doctors to improve medical care than to fix more intractable problems like poverty and obesity.</p><p><strong>Inducing labor before term more common </strong></p><p>In 2002, <a href="" target="_blank">Dr. David Lagrew</a>, the medical director of the Women&rsquo;s Hospital at Saddleback Memorial Medical Center in Orange County, noticed that a lot of women were having their labor induced before term without a medical reason. And he knew that having an induction doubled the chances of a C-section.</p><p>So he set a rule: no elective inductions before 41 weeks of pregnancy, with only a few exceptions. As a result, Lagrew said, the operating room schedules opened up, and the hospital saw fewer babies admitted to the neonatal intensive care unit, fewer hemorrhages and fewer hysterectomies. &nbsp;</p><p>All this, however, came at a cost: The hospital had to take a cut in revenue for reducing the procedures it performed. Lagrew doubts that any hospital has increased its C-section rate in pursuit of profit, but he does note that the first hospitals to adopt controls on early elective inductions have been nonprofits. &nbsp;</p><p>According to a report issued by the advocacy group <a href="" target="_blank">Childbirth Connection</a>, &ldquo;Six of the 10 most common procedures billed to Medicaid and to private insurers in 2005 were maternity related.&rdquo; On average, a C-section brings in twice the revenue of a vaginal birth. Today, the C-section is the single most common surgical procedure performed in the United States.</p><p>&ldquo;If all these guys were losing money on every C-section, well, what&rsquo;s the old saying? Whenever they tell you it&rsquo;s not about the money, it&rsquo;s about the money,&rdquo; Lagrew said.</p><p>The California task force isn&rsquo;t waiting to determine the ultimate cause of these deaths. It has started pilot projects to improve the way hospitals respond to hemorrhages, to better track women&rsquo;s medical conditions and to reduce inductions &ndash; as Lagrew did at Memorial Care.</p><p>Although the state hasn&rsquo;t released the task force&rsquo;s report, the researchers and doctors involved forwarded data to the national Joint Commission, which issued incentives for hospitals to reduce inductions and fight what it called &ldquo;the cesarean section epidemic.&rdquo; &nbsp;</p><p>&ldquo;You don&rsquo;t have to be a public health whiz to know that we are facing a big problem here,&rdquo; Bingham said.</p><p><br /> &nbsp;</p> Health and Welfare maternal deaths maternal health Our Maternal Health Wed, 03 Feb 2010 02:22:54 +0000 Nathanael Johnson 957 at CHART: Tracking maternal mortality rates <p>California&rsquo;s maternal mortality rate has increased over an 11-year-period from 1996 through 2006, the most recent data available. The national maternal mortality rate was 13.3 per 100,000 in 2006.</p><center><table width="50%"><tbody><tr><td><b>Year </b></td><td><b>Rate</b></td></tr><tr><td>1996</td><td>5.6</td></tr><tr><td>1997</td><td>9.1</td></tr><tr><td>1998</td><td>6.7</td></tr><tr><td>1999</td><td>7.7</td></tr><tr><td>2000</td><td>10.9</td></tr><tr><td>2001</td><td>9.7</td></tr><tr><td>2002</td><td>10.0</td></tr><tr><td>2003</td><td>14.6</td></tr><tr><td>2004</td><td>11.7</td></tr><tr><td>2005</td><td>11.7</td></tr><tr><td>2006</td><td>16.9</td></tr></tbody></table></center><p>&nbsp;</p><p>&nbsp;</p><center></center><p>&nbsp;</p><p>Source for chart: <a href="">State of California Department of Public Health, California Birth and Death Statistical Master Files</a></p><p>Source for national death rate: <a href="">Centers for Disease Control</a></p> Health and Welfare maternal deaths maternal health Our Maternal Health Tue, 02 Feb 2010 22:36:05 +0000 Nathanael Johnson 983 at Q&A: Pregnancy-related deaths explained <p><b>How do doctors report maternity-related deaths?</b></p><p>In 2003, California put a new checkbox on death certificates asking if the deceased was pregnant within one year of death. This caught a certain number of deaths that would have slipped through the cracks previously. The codes used on the death certificate also changed slightly in 1999. Most importantly, the World Health Organization, which controls these codes, added definitions for obstetric death.</p><p><b><b><b>Why isn&rsquo;t the rise in deaths simply attributable to better reporting? </b></b></b></p><p>Basically, the rise is too big. Doctors are seeing a greater than 300 percent increase between 1996 and 2006. Part of that is certainly attributable to better reporting, but how much? Donna Hoyert at the U.S. Centers for Disease Control and Prevention, Division of Vital Statistics found that the change in reporting codes resulted in about a 13 percent increase.</p><p>The checkbox issue is a little more complex, however, because every state asks slightly different questions on the death certificates. What Hoyert found was an across-the-board increase between 2002 and 2003. In states that asked about pregnancy on the death certificate in a single year &ndash; 2002 or 2003 &ndash; there was a 20 percent increase in maternal mortality. In states that had a question or a checkbox both years, there was a 40 percent increase in maternal mortality.</p><p>Note that collection practices hadn&rsquo;t changed in either example. The difference, 20 percent vs. 40 percent may reflect the fact that states with better collection of data are better able to see changes. So how much is caused by the addition of the checkbox? You can get an idea by comparing states with a checkbox both years (40 percent increase) to states that instituted the checkbox in 2003 (53 percent increase).</p><p>Considering this information, Dr. Elliott Main has estimated that 30 percent of the rise can be attributed to better reporting. That leaves 70 percent that could be caused by changes in population and changes in hospitals.</p><p><b><b><b><b><b>What about the various definitions: pregnancy-related mortality, maternal mortality, and pregnancy-associated mortality? </b></b></b></b></b></p><p>Pregnancy-associated mortality lumps in all deaths (including women who die in car crashes) of any mother who dies within one year of pregnancy. So, that&rsquo;s not a very useful measure.</p><p>Maternal-mortality refers to all deaths directly relating to pregnancy and birth within 42 days. This misses women like Nancy Lim, who was injured during a cesarean section in 1993, and died from complications of that injury some nine months later. The numbers are slightly lower, but this is the most commonly used measure. California Watch used maternal-mortality numbers to show how the California rate had increased to 16.9 in 2006. This is the most conservative method of counting maternal deaths. Using that rate, California Watch determined that 95 women died in 2006.</p><p>A second method &ndash; called pregnancy-related mortality &ndash; catches some deaths missed by the maternal-mortality rate. Pregnancy-related mortality counts all deaths directly relating to pregnancy and birth within a year of birth (or the end or pregnancy). If you applied that method to California, there were 108 pregnancy-related mortalities in 2006. And the California pregnancy-related death rate was 19.2 per 100,000 that year.</p><p><b><b><b><b><b><b><b>What exactly is the California Maternal Quality Care Collaborative? </b></b></b></b></b></b></b></p><p>It&rsquo;s a group founded by the California Department of Public Health and the California Perinatal Quality Care Collaborative. It includes state agencies, nonprofits, professional organizations (like the American College of Obstetricians and Gynecologists), universities (it&rsquo;s based at Stanford), and health care systems (like Kaiser Permanente and Sutter Health). The group is funded through multiple sources, including some state money and support from Stanford University.</p><p>The task force formed in 2004 and began conducting the maternal mortality review in 2006.</p><p><b><b><b><b><b><b><b><b><b>What exactly is this review that California is conducting and what does it have to do with the report referenced in the story? </b></b></b></b></b></b></b></b></b></p><p>It&rsquo;s called the California Pregnancy Associated Mortality Review, and it&rsquo;s the first in the state. Researchers carefully went through all the administrative data &ndash; the numbers from vital statistics &ndash; to see if this rise in deaths was meaningful. They found that, if anything, poor reporting had been hiding the problem and they put together the report referenced in the story. It was meant as a call to action.</p><p>Then they began a much larger review. Researchers are checking all the maternal death certificates against baby birth certificates to make sure no women are missed. And then they are examining the medical records of every woman who died after or during a pregnancy. So far, the researchers have completed analysis of the years 2002 and 2003, and information from that data informs the story.</p><p><b><b><b><b><b><b><b><b><b><b><b>Why haven&rsquo;t we heard about this before? </b></b></b></b></b></b></b></b></b></b></b></p><p>For one thing, everybody in obstetrics knows that maternal mortality is a problem in poor countries and that, since the 1930s, it&rsquo;s been getting better every year in rich countries. So, any evidence to the contrary is hard to swallow.</p><p>There&rsquo;s also the fact that these deaths are so rare that a doctor will probably go his or her entire career without seeing a death: it&rsquo;s impossible for individuals to see the trend. In fact, you need a population the size of California&rsquo;s or bigger to get statistically relevant information. Looking at the entire U.S. population would provide even better information, but the national data is messy because every state collects data differently.</p><p>Finally, when a mother dies it is often so painful for the family that people don&rsquo;t talk about it. California Watch was able to find only four relatives of mothers who had died from pregnancy related causes who were willing to talk. California Watch obtained a list of women who had died within one year of pregnancy from the state in 2007, and with this information, we were able to contact about a dozen family members of women who had died from representative causes, but not one of them wanted to share their story.</p><p><b><b><b><b><b><b><b><b><b><b><b><b><b>How much of this problem is caused by cesareans? </b></b></b></b></b></b></b></b></b></b></b></b></b></p><p>There are many, many studies with many different results. On the face of it, cesareans look like they are clearly more dangerous. More women and infants die during or after cesarean delivery than vaginal delivery. But that conclusion is confounded by what&rsquo;s called sampling error: the sample of women in the C-section group are at a higher risk than the sample of the women in the vaginal-delivery group because some of them are getting cesareans as a last-ditch effort in an emergency, and others are getting cesareans because they have some underlying risk factor.</p><p>So what&rsquo;s the upshot of all this? For a healthy woman, a C-section is pretty safe. The consensus is that it may be slightly more dangerous than vaginal birth. But if you look at the second third and fourth births after that C-section, the risks go up dramatically. That&rsquo;s because with every new surgery there is more internal scarring, more risk of placenta problems.</p> Health and Welfare maternal deaths maternal health Our Maternal Health Tue, 02 Feb 2010 18:32:56 +0000 Nathanael Johnson 981 at