PUB 460 Lecture 7 - Childbirth.pdf

CHILDBIRTH (IN THE U.S) PUB 460 Dr. Gauri Desai Why Focus on Childbirth (in the US) • 2021 Number of births: 3,664,292 • 2016: >5 million women lived in counties (rural or urban) with neither an obstetrician/ gynecologist nor a nurse midwife, nor a hospital with a maternity unit • Among the 42% of...

CHILDBIRTH (IN THE U.S) PUB 460 Dr. Gauri Desai Why Focus on Childbirth (in the US) • 2021 Number of births: 3,664,292 • 2016: >5 million women lived in counties (rural or urban) with neither an obstetrician/ gynecologist nor a nurse midwife, nor a hospital with a maternity unit • Among the 42% of childbearing women who rely on Medicaid for maternity care coverage, • Many live in states that have not expanded eligibility for Medicaid, i.e., women can gain Medicaid coverage only after becoming pregnant • These women then lose Medicaid coverage about 2 months after giving birth • Early life care is critical for infants, and many postpartum needs persist for a year after birth Scrimshaw, & Backes, E. P. (2020). Birth settings in America : outcomes, quality, access, and choice. The National Academies Press. https://www.cdc.gov/nchs/nvss/births.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fnchs%2Fbirths.htm Why Focus on Childbirth (in the US) • Some women are not eligible for Medicaid because they lack documentation that they are legal residents of the United States • No access to prenatal care • Limited postpartum care for the woman and infant • Many U.S. women lack access to essential maternity care services • Access to prenatal care varies greatly across racial/ ethnic groups • In some subgroups defined by insurance type/ income/ location/ others, overuse of nonmedically indicated care is observed • US has one of the highest rates of caesarean birth among high resource countries at 31.9% percent of all births • C-sections have higher risks and longer recovery times Scrimshaw, & Backes, E. P. (2020). Birth settings in America : outcomes, quality, access, and choice. The National Academies Press. Why Focus on Childbirth (in the US) US has one of the worst maternal and infant outcomes compared to other HICs As a reference, maternal mortality has consistently dropped in most high-resource countries over the past 25 years Scrimshaw, & Backes, E. P. (2020). Birth settings in America : outcomes, quality, access, and choice. The National Academies Press. Why Focus on Childbirth (in the US) With substantial disparities in racial/ethnic groups Scrimshaw, & Backes, E. P. (2020). Birth settings in America : outcomes, quality, access, and choice. The National Academies Press. Why Focus on Childbirth (in the US) BUT, The US continues to outpace its peer countries in the costs of maternity care Scrimshaw, & Backes, E. P. (2020). Birth settings in America : outcomes, quality, access, and choice. The National Academies Press. What is a “good birth”? • The construct in the US is characterized by 3 factors: 1. Agency - the ability to be in control and remain powerful during the birthing process 2. Dignity - refers to being treated with respect and importance by those involved in the birthing process 3. Connectedness - feeling connected and equated to those involved Panazzolo, M. and R. Mohammed (2011). "Birthing trends in American society and women's choices." Race, Gender & Class: 268-283. Birthing Practices in the US Many options and available in terms of location and method • Hospitals - natural birth, a vaginal birth with augmentation, a vaginal birth with epidural, a vaginal birth with augmentation and an epidural, episiotomy, forceps extraction, vacuum extraction, and Cesarean Section • Birth centers – mostly natural birth, but some other options available (similar to those in hospitals) • At home – natural birth, but if complications arise, some basic procedures may be performed Panazzolo, M. and R. Mohammed (2011). "Birthing trends in American society and women's choices." Race, Gender & Class: 268-283. Birthing Practices in the US - Hospitals • Can have the following birth options – 1. Natural birth – free of interventions, woman in full control of process • Recommended for healthy, low-risk pregnancies without serious medical conditions such as diabetes and high blood pressure Pros • Reduced exposure for infants to potentially harmful drugs during labor • Faster recovery for women • Oxytocin released in large amounts, helps with bonding and maternal behaviors Cons – • Extremely painful, although some pain management exercises are available Panazzolo, M. and R. Mohammed (2011). "Birthing trends in American society and women's choices." Race, Gender & Class: 268-283. Birthing Practices in the US - Hospitals 2. Vaginal birth with augmentation – process of stimulating the uterus to increase the frequency, duration and intensity of contractions after the onset of spontaneous labor • Pitocin, a synthetic version of oxytocin, is usually used • Used to treat delayed labor caused by poor uterine contractions Pros • Faster labor – good for high-risk pregnancies Cons – • Linked to hypertensive episodes, vomiting, postpartum hemorrhage • Increased exposure in infants may impact their central nervous systems Panazzolo, M. and R. Mohammed (2011). "Birthing trends in American society and women's choices." Race, Gender & Class: 268-283. Birthing Practices in the US - Hospitals 3. Vaginal birth with epidural – epidural anesthesia is a local anesthetic that blocks pain in a specific area of the body Pros • Relieves pain but the woman remains alert Cons – • Linked to low blood pressure, headaches, discomfort, and nausea Panazzolo, M. and R. Mohammed (2011). "Birthing trends in American society and women's choices." Race, Gender & Class: 268-283. Birthing Practices in the US - Hospitals 4. Vaginal birth with episiotomy – episiotomy is a surgical incision that enlarges the vagina • Performed when the vagina is not large enough for the baby to push through • Some hospitals no longer offer this option Pros • Needed if the vagina is not large enough for the baby Cons – • Longer recovery period • May/may not cause complications during sexual intercourse Panazzolo, M. and R. Mohammed (2011). "Birthing trends in American society and women's choices." Race, Gender & Class: 268-283. Birthing Practices in the US - Hospitals 5. Vaginal birth with forceps extraction and vacuum extraction – forceps and vacuums are used to extract the baby from the woman's vagina • Performed when the baby is not delivering, or the mother or baby is in distress Pros • Needed if the baby is not coming out • Effective Cons – • May cause bruising of the vagina, bruising of the infant's head, nerve damage • Extreme cases – skull fracture Panazzolo, M. and R. Mohammed (2011). "Birthing trends in American society and women's choices." Race, Gender & Class: 268-283. Birthing Practices in the US - Hospitals 6. Cesarean section – major abdominal surgery where an incision is made through the woman's abdomen and uterus in order to remove the baby • Performed when the baby is not in ideal position for vaginal birth, or is in distress, or if the mother has complications • Used to be performed only in emergency situations, but lately women go for planned cesarean sections Pros • Fastest route of delivery • Mother is awake • Mother does not have to go through labor pains Cons – • • • • • • Losing twice as much blood as a vaginal delivery Risk of surgical damage to the digestive system Increased risk of serious lung problems in infant Increased risk of infection in surgical area Increased risk of hysterectomy Extreme cases - Death Panazzolo, M. and R. Mohammed (2011). "Birthing trends in American society and women's choices." Race, Gender & Class: 268-283. Birthing Practices in the US - Hospitals Factors contributing to high rates of C-sections in the US – 1. Women may choose to go for a C-section to avoid the pain in vaginal deliveries 2. Doctors may take a conservative approach, prioritize patient safety, and recommend C-sections at a higher rate 3. American culture is comfortable with surgeries to a large extent • Celebrities in America are notorious for being "too posh to push.“ • Women like Victoria Beckham, Britney Spears, and Toni Braxton have associated Cesarean sections with status, driving the trend of "designer birth” • Not well supported by research Panazzolo, M. and R. Mohammed (2011). "Birthing trends in American society and women's choices." Race, Gender & Class: 268-283. https://www.theatlantic.com/ideas/archive/2019/10/c-section-rate-high/600172/ Birthing Practices in the US - Hospitals Factors contributing to high rates of C-sections in the US – 4. Cesarean sections are very doctor-friendly • Because it is a surgery, physicians are paid more for a C-section than they are for a vaginal delivery — on average, about 15%more • C-sections are quick and can be planned at a suitable time 5. C-sections are hospital-friendly • Women may take up to 24 hours in a vaginal delivery with natural labor • If labor rooms are scarce, hospitals may prefer C-sections so that more patients can pass through Panazzolo, M. and R. Mohammed (2011). "Birthing trends in American society and women's choices." Race, Gender & Class: 268-283. https://www.theatlantic.com/ideas/archive/2019/10/c-section-rate-high/600172/ Birthing Practices in the US - Hospitals VBAC – Vaginal birth after cesarean • Vaginal delivery of a baby after a previous pregnancy was delivered by cesarean delivery • Previously, pregnant women who had one cesarean delivery would automatically have another • National Institute of Child Health and Development research shows that among appropriate candidates, about 75% of VBAC attempts are successful • VBAC should take place in a hospital that can manage situations that threaten the life of the woman or her fetus. • Some hospitals may not offer VBAC because hospital staff do not feel they can provide this type of emergency care. https://www.nichd.nih.gov/health/topics/labor-delivery/topicinfo/vbac https://www.acog.org/womens-health/faqs/vaginal-birth-after-cesarean-delivery Birthing Practices in the US - Hospitals VBAC – Vaginal birth after cesarean • How the C-section Became America's Most Common Major Surgery (16:53): https://www.youtube.com/watch?v=SWPip1lIu5Q&ab_channel=TheNewYorker • Why is the c-section rate in the U.S. so high (2:39)? https://www.youtube.com/watch?v=iKKVRaPAFrc&ab_channel=NYUPress Birthing Practices in the US – Birth Centers What is a birth center? • Health care facility for childbirth where care is provided in the midwifery and wellness model • It is freestanding, and not a hospital • Recommended for low-risk pregnancies • Usually, the emphasis is on a more natural birthing process https://www.birthcenters.org/ https://americanpregnancy.org/healthy-pregnancy/labor-and-birth/birth-centers/ Birthing Practices in the US – Home births • Involves the participation of trained midwives or nurse-midwives in cases of low-risk, healthy pregnancies • Pros of home births – • Comfort • Cost • Cultural practices • Lack of access to transportation or facilities • Dissatisfaction with institutionalized care • Home Birth Can Be Appealing, But How Safe Is It? NPR clip (4 mins): • https://www.npr.org/sections/health-shots/2019/03/11/700829719/home-birth-can-be-appealing-but-how-safe-isit#:~:text=Nationwide%2C%20planned%20home%20births%20have,infant%20death%20as%20hospital%20births.&text=Pla nned%20home%20births%20end%20up,247%20per%201000%20hospital%20births). YouTube video [6:06]: https://www.youtube.com/watch?v=xHWvSPhENtk&ab_channel=Healthc areTriage https://americanpregnancy.org/healthy-pregnancy/labor-and-birth/home-birth/ https://www.mayoclinic.org/healthy-lifestyle/labor-and-delivery/in-depth/home-birth/art-20046878 Birthing Practices in the US – Home births • Women may be transferred to a hospital if needed • The following are some of the reasons women are transferred: • The mother feels exhausted and does not want to continue • Premature rupture of membranes • High blood pressure • No progress with labor • Fetal distress • Cord prolapse • Hemorrhage https://americanpregnancy.org/healthy-pregnancy/labor-and-birth/home-birth/ Trends in Out of Hospital births Trends in Out of Hospital births Midwife vs. Doula • Midwife: a trained medical professional (can be a woman or man). • They play a key role during the birthing process. Midwives have various levels of training. • Some midwives are registered nurses, while others have a bachelor degree with specialized training • Certified nurse-midwives can do many of the same things as doctors: • perform gynecological exams & provide prenatal care • administer pain medications & give labor-inducing drugs • monitor the fetus using electronic equipment • order an epidural • perform an episiotomy • deliver a baby vaginally • resuscitate a baby • stitch tears https://www.healthline.com/health/pregnancy/doula-vs-midwife#midwife Midwife vs. Doula • Doula: Term comes from a Greek word meaning “a woman who serves”; men can also be doulas • A doula takes the nurturing role that family and community used to play in the birth process • Emotional, informational, and physical support during pregnancy, birth and the immediate postpartum period • Offers nonmedical techniques during labor, such as breathing, massage etc. • Not all doulas go through a certification process. • If a doula seeks certification training, it usually includes didactic training and assisting during live births. • Certification is typically not required but may vary by state. https://www.healthline.com/health/pregnancy/doula-vs-midwife#midwife https://bellhousedoulas.com/blog/whats-difference-doulamidwife/#:~:text=So%2C%20What%20is%20the%20Difference%20Between%20a%20Midwife%20and%20a%20Doula%3F&text=Midwives%20provide%20medical%20care%20for,and%20the%20immediate%20postpartum%20period. Risk of neonatal mortality by birth setting Scrimshaw, & Backes, E. P. (2020). Birth settings in America : outcomes, quality, access, and choice. The National Academies Press. Housekeeping  Short HW and case study HW open – due 9/21, 1:00 pm  Final project – pdf of instructions, link to shared excel sheet on Brightspace in folder titled “Final project” Question Bank 1. Describe any two reasons behind the increased rate of C-sections in the US. 2. What is a birth center? 3. What might be some pros of home births?