On Giving Birth in Iraq

The Washington Post has a lengthy article on the perils of childbirth in Iraq, "Iraq's Woes Are Adding Major Risks To Childbirth." The piece mentions the state of the healthcare system, road closures, curfews, and violence and doctor kidnapping as barriers to women receiving appropriate care during birth. As a result, it claims, women are resulting to skipping prenatal care, scheduling elective c-sections to avoid being caught out after curfew, and utilizing neighborhood midwives (although I'm not convinced that using midwives should be lumped in the same sentence as avoiding care, which the Post piece does). One obstetrician reports carrying a gun to work, having had the ultrasound machine stolen, and having received 3 death threats. Women also have difficulty arranging to go to the hopsital - "During curfew, ambulance drivers and even police officers sometimes charge women for rides to the hospital, or refuse to take their husbands out of fear that they are suicide bombers, doctors said." Another obstetrician reports an observed rise in birth defects, which she attributes to women skipping prenatal care to avoid going out to see the doctors, ans says that she used to see one baby a week with congenital abnormalities but now sees 5 or 6.

The piece also follows the story of one woman, Ibrahim, who decided to wait until morning to go to the hospital to give birth due to her fears. When she finally arrived, there was no obstetrician or anesthesiologist, and a surgeon has just been kidnapped. Nurses tried to extract the baby with forceps, failed, and told her to go to another hospital. Ambulance drivers refused to take her, resulting in a 30 minute drive. When she arrived at the second hospital, the had an emergency c-section, but the doctors told her that her baby had been killed by the forceps applied at the first hospital. This is no way to give birth, and unfortunately, there are no quick and easy solutions.

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Technorati Tags: childbirth; Iraq
MeSH Tags: Health Services Accessibility; Iraq; Medically Underserved Area; Parturition

20 week appt and ULTRASOUND!

Well, I'm 20 weeks now. Almost 21 according to my ticker!

I went back to the dr. today and had my ultrasound. Before I go into those results, let me just talk about the beforehand prep.

Who the hell's idea was it to take a woman who is pregnant with her THIRD child and already has incontinence problems and have her drink 32 oz of water and then hold it? Hmm? Because that person should be shot.

NO kidding. I actually put a freaking pad on so that I wouldn't pee myself if I accidently coughed, sneezed or laughed hard. Because, hell, even on a good day I can do that. Let alone the times I have my bladder full to the point of wanting to throw up because of it.

My husband thought this whole ordeal was miraclously funny. He would have thought it was really funny had I pee'd all over him, because honest to God there was a flood when I finally did go. And then 15 minutes later when I had to go again.

Cruel and unusual punishment was outlawed in our country a long time ago. I wonder if anyone ever told the ultrasound technicians that.

Okay, that off my chest I can get on to the results. The baby is growing perfectly on target. I was measuring at a due date of May 19. Wow. Very close to my original estimate of an actual due date of May 20. I guess I know when I had sex afterall ;) It's a little surreal to me though to have a baby actually of normal size. My boys were so big (9 1/2 lbs, 23 inches and 8 1/2 lbs, 22 1/2 inches) that a baby measuring normal is a little unusual.

The technician couldn't clearly see the brain or all of the body organs. Apparently, this isn't all that uncommon and nothing for reason of concern. My midwife put it very gently that ultrasound travels best through water and not so great through "soft tissue". Read that "fat". I know...I'm not in denial. So we'll have another ultrasound at 28 weeks to make sure everything is okay.

I got a couple of really cute ultrasound pictures...one of the bottom of the little foot. Awe, I just love baby feet!!!

Oh, yea, and did I forget to mention that we are having A GIRL???? I'm freaking ecstatic and somewhat still in shock even though I was pretty sure I was having a girl. I had a hard time enjoying the ultrasound and the moment because of the fact I had to pee so bad, and the boys were not behaving really well. But I started to get teary eyed. When I went in to go pee, I think more than just that was released. I started to cry. I dryed my eyes and went back in the room to be shown to another room to meet with my midwife. I was bawling by that time. Did I mention I'm emotional? I am on a regular basis. Get me pregnant a third time and it's even worse! The nurse asked me "Are you crying because you're happy???" I nodded. I'm having a girl. How can that not make you happy?

Magazines, Teens, and Dieting

Hmmm. Is it possible that the girls who were found to have unhealthy food-related behaviors 5 years later were already insecure about their bodies at the time that magazine reading was counted, making them more likely to be interested in reading diet-related things and fluffy, superficial, image-based magazines in the first place? I'm not suggesting that pop culture and media have no influence on adolescent behavior, but am curious to find out if the study really supports the conclusions we're reading in the news outlets, such as the NYTimes piece linked below.

More on this later, after I get a chance to read the entire study.

Citation: van der Berg P, Neumark-Sztainer D, Hannan PJ, Haines J. Is dieting advice from magazines helpful or harmful? Five-year associations with weight-control behaviors and psychological outcomes in adolescents. Pediatrics. 2007 Jan;119(1):30-7. [Abstract]

Reading Diet Articles Could Be Unhealthy - NYTimes, via AP

Technorati Tags: adolescents; body image; dieting; magazines; teens
MeSH Tags: Adolescent; Adolescent Behavior; Body Image; Mass Media; Periodicals

Does Right to Film a Birth Affect Your Hospital Choice?

Over the holidays, I watched the video of my sister-in-law's c-section. I was rather surprised that my brother-in-law was allowed to film it, as so many hospitals now refuse to allow the filming of births, particularly to avoid creating evidence for malpractice suits. This was a c-section resulting from several complications, and the video shows a bit of the preparation, the entire procedure, and the early resuscitation efforts on my nephew, who is fine now, but was floppy, unresponsive, and silent at the time. Meanwhile, I'm told by a colleague that the hospital where I work, which technically allows filming of births in its official policies, does not allow it in practice. I've been thinking that, should I ever become pregnant, having the option to film is both realistically and symbolically important to me. So I ask, would the ability to film a birth affect your or your partner's choice of hospital or other birthing facility? On a related note, does knowing that your chosen facility does not allow filming reduce your confidence in the facility?
(My apologies if the poll looks crazy; this is my first use of addpoll.)

Update: It occurred to me that I should clarify that you don't have to be pregnant or have had a child to respond to this poll - it's about your intentions and what influences them. Also, perhaps I should have added an option for, "No, I think filming a birth is icky." :)
Previous related posts: Hospitals Prohibit Videos of Childbirth; More Bans on Photography and Videotaping During Labor and Delivery

Technorati Tags: birth; childbirth; filming; hospitals; poll; video
MeSH Tags: Delivery Rooms; Motion Pictures OR Photography; Parturition

Would the right to film a birth play a role in your choice of hospital?

• 
  
  No, only my healthcare provider influences my hospital choice for giving birth.


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  No, only my insurance coverage influences my hospital choice for giving birth


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  No, other combined factors influence my hospital choice, but being able to video the birth is not one of them.


• 
  
  Yes, this is a major factor in choosing a hospital


• 
  
  Yes, this is a minor factor in choosing a hospital

view results

Wow...how time flies...

When you're on vacation!

Well, at least a vacation from work! Chuck and I both took off the 3 days between Christmas and New Years so that we could have 11 days off and only use 24 hours of annual leave. It has been ABSOLUTELY wonderful being home together; however, I wish we could have gotten more done. But, considering it is the holidays...and that always means visiting tons of relatives and seeing friends we don't see too often...I should have known better.

One good thing about being off from work is that I've reconnected with my husband. Or at least I feel like I have. Sex is good again. Okay, not to say it was BAD before because when we have it its always good, but it's just never abundant enough for me. Considering we work opposite schedules we don't have too much of an opportunity. Being off together, we've taken lots of opportunities. YAY!

Bad thing is...I realize I really don't want to go back to work. At least not where I am now. I'm dreading going back tomorrow. And in some ways, I'm thinking that maybe I don't want to go back at all. I think I could handle being a SAHM. Even though we could never afford it. I've always thought I would go crazy...but with Zachary in preschool, and me not working nights, I would be having some extra sleep, some alone time with Lucas, and naptimes to myself to catch up on things considering that I got household stuff done while they were up playing. *sigh* All wishful thinking though.

But then again, during this 11 day period I think we've been sleeping at home for like 4 nights. The rest of the time, we've spent seeing Shannon, Barb and Logan; Matt and Karen; my parents; Chuck's parents. And spending the night wherever we go. We've come home, slept, repacked the bag in the morning and left again. But it's been kinda fun. I had an AWESOME time seeing Matt and Karen....there's something so comfortable with them. Granted, Matt, Chuck and I go WAAAY back but I like Karen too. I guess that's what makes it different. I usually don't like my guy friend's wives or girlfriends. But Karen is cool...easy to talk to, down to earth and smart. I like those traits. We played some game with them and it was so much fun...I honestly can't remember the last time we had couple time and spent time as COUPLES doing interactive stuff. I know Chuck throughly enjoyed himself too.

So, now we start a new year...and I hope we can keep connections with our friends better than we did in the last year. They do a body good.

What Do Physicians Think of On-Demand C-Section?

The "Green Journal" has a lot of interesting articles for January 2007. Among them:

Bettes BA, Coleman VH, Zinberg S, Spong CY, Portnoy B, DeVoto E, Schulkin J. Cesarean delivery on maternal request: obstetrician-gynecologists' knowledge, perception, and practice patterns. Obstet Gynecol. 2007 Jan; 109(1):57-66.
ACOG Fellows (practicing OB/GYNs who are part of a national obstetrics and gynecology organization) were interviewed by mailed questionnaire about elective c-sections. Their findings:
-92.2% reported that their department or practice has no policy on maternal request cesareans. Of those with a policy, 72.2% stated the policy is to support maternal requests.
-53% reported having done c-sections in response to maternal request, "with the majority of those performing them once or twice per month or more rarely"
-58.4% reported an increase in maternal requests for c-sections in the past year.
-When asked about what they would choose if they or their spouse were pregnant (for a term, uncomplicated, head first, single delivery), "Fewer than 20% (n=102, 17.8%) of respondents reported that they would choose or recommend a cesarean delivery on maternal request in this situation, due to concerns for the mother’s (64.8%) or the neonate’s (19.4%) well-being; 15.7% would choose cesarean delivery on maternal request for convenience."
-54.6% believe a woman has the right to c-section on request without any medical indication, and 57.4% would perform one. Those who believed it was a right/appropriate were more likely to say they would perform one.
-The clinicians were asked to agree or disagree with 14 risks and 14 benefits. 0.8% endorsed none of the risks, while 11.8% endorsed none of the benefits.
-"The most frequently endorsed benefit was the reduced risk of perineal damage (76.2%), followed by risk of dystocia or birth trauma (63.4%), pelvic organ prolapse (56.8%), long-term incontinence (54.8%), lacerations (53.9%), and complications from labor (49.6%). "
-"The most frequently endorsed risk was intraoperative risks to the mother such as bleeding and damage to internal organs (93.7%). "
-Female respondants were more negative about the procedure on maternal request than were male respondants.

The article does not include a detailed comparison of the clinician's perception of risk and benefit versus the incidence of these occurances and outcomes in the medical evidence. It would be interesting to see how correct the physicians are in their assessments of risk and benefit. Given the varying percentages, it is clear that not all physicians agree on the risks and benefits of the procedure, and many do not think they should be available on request where there is no medical indication. I think a lot of women tend to take "My doctor says" as some kind of gospel, not realizing that there may be considerable debate about a topic. Something to consider when consulting with your physician about this - he or she may not agree with the doctor just next door.

The National Intitutes of Health held a conference on the topic in spring of 2006, and released a statement, downloadable as a PDF. An Agency for Healthcare Research and Quality abstract on the topic states, "Virtually no studies exist on CDMR, so the knowledge base rests chiefly on indirect evidence from proxies possessing unique and significant limitations. Furthermore, most studies compared outcomes by actual routes of delivery, resulting in great uncertainty as to their relevance to planned routes of delivery. Primary CDMR and planned vaginal delivery likely do differ with respect to individual outcomes for either mothers or infants. However, our comprehensive assessment, across many different outcomes, suggests that no major differences exist between primary CDMR and planned vaginal delivery, but the evidence is too weak to conclude definitively that differences are completely absent." Essentially, they state that they find no evidence for differences between planned vaginal birth and planned c-section, but that the available evidence is too limited to make a real conclusion.

Technorati Tags: c-section; cesarean; elective; maternal request
MeSH Tags: Cesarean Section; maternal request (keyword; in a combined search, try adding "elective" and "on demand")

Down Syndrome Screening For All Pregnant Women?

The American College of Obstetrics and Gynecology has released a new practice bulletins for OB/GYNs that recommends Down Syndrome screening for all pregnant women before 20 weeks of gestation, regardless of the woman's age. In the past, this screening has been recommended for women 35 and older, but have changed in part because of the development of newer, less invasive tests (compared to amniocentesis) for the condition, and also because they assert that 35 is not a hard and fast cutoff age for risk. The publication is not freely available to the public, but here are some summary points:

The bulletin lists several methods of screening, but states that "It is not practical to have patients choose from among the large array of screening strategies that might be used," and recommends that physicians review the evidence before deciding which strategies to offer the woman.

Doctors are instructed to discuss false-positive rates (the chances that a test will detect a problem which does not exist), advantages, disadvantages, limitations, risk, and benefits so the patient can make an informed decision.

The bulletin also gives the following factors that affect the choice of a screening test: gestational age at first prenatal visit, number of fetuses, previous obstetric history, family history, availability of nuchal translucency measurement, test sensitivity and limitations, risk of invasive diagnostic procedures, desire for early test results, and options for earlier termination.

The guideline does not estimate how many additional women <35 might benefit from this screening, or otherwise discuss the implications of the change. Presumably, women under 35 who undergo the screening and receive information regarding a possible Down Syndrome diagnosis will need additional care in terms of pregnancy options; the Washington Post article linked below also mentions that babies born with this chromosomal abnormality may need specialized care when born that may affect hospital selection.

Citation: American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 77: screening for fetal chromosomal abnormalities. Obstet Gynecol. 2007 Jan;109(1):217-27.
Down screening urged for all pregnant women - CNN
Group Recommends Down Syndrome Testing - AP via Washington Post

Resources (note that these may not have been updated to reflect the new ACOG recommendation):

Prenatal testing and diagnosis - National Down Syndrome Society

Down Syndrome: what you need to know when you're pregnant - American Academy of Family Physicians

Down Syndrome: finding out your child has Down Syndrome - American Academy of Family Physicians

Is it possible to breastfeed my baby who was born with Down Syndrome? - La Leche League

Birth Defects & Genetics: Down Syndrome - March of Dimes

Down Syndrome - National Institute of Child Health and Human Development

On December 1, ACOG also released revised recommendations for women's health screening and care, including (quoted from the release):

"HIV Testing: Routine HIV testing should be offered to women ages 19 to 64 regardless of personal risk factors, following the new Centers for Disease Control and Prevention (CDC) guidelines.

Preconception Care: Ob-gyns should encourage women of childbearing age to develop a reproductive health plan to help conscientiously assess the desire for a child or children or desire not to have children.

Colorectal Cancer Screening: Women age 50 and older should be screened for colorectal cancer using one of five recommended screening strategies.

HPV Vaccine: ACOG recommends that HPV vaccination be offered to all girls and women 9 to 26 who have not previously been vaccinated.

Meningococcal Vaccine: ACOG now recommends that adolescents not previously immunized receive meningococcal conjugate vaccination before entry into high school. Older women at high risk also should receive the vaccine."
See the press release for more complete details.

Technorati Tags: ACOG; colorectal cancer; Down Syndrome; HIV; HPV; meningitis; preconception; pregnancy; screening; vaccines;
MeSH Tags: Colorectal Neoplasms; Down Syndrome; HIV; Meningococcal Vaccines; Papillomavirus Vaccines; Preconception Care