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LeapFrog Survey Results and Variation in Hospital/Provider practices in northern New Jersey

4/19/2015

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I must have missed this back in February when the results on the Leapfrog group's analysis of early elective delivery between 2010 and 2014 were reported on NJ.com. Here's the info from the Leapfrog group, an organization that monitors hospital performance to enhance information and safety, while "highlighting the variation in quality of care across hospitals."

Leapfrog Maternity Care Fact Sheet
You can search the survey results HERE (search by state, then check out the maternity care results: the results are eyeopening)


So, the good news. Elective delivery rate statewide has dropped from 16% in 2010 to just 4% in 2014. This is largely due to a "hard stop" by many area hospitals where head of ob needs to review any case where induction/csection before 39 weeks is being called for. AND in those years we've seen the teeniest tiniest bit of a drop in the overall csection rate in NJ. Let's hope it's the start of a trend.

The big thing is this tells us CHANGE IS POSSIBLE. When a hospital wants to effect change, it can happen. Everyone got on board with this. Hospitals, obstetricians, March of Dimes. Something as simple as reviewing the reasons for elective early delivery has made a big change in outcome.

The not-so-great news: As usual the blame is shifted to the patient (wanting to fit into a bridesmaid dress), and not the cases of "I'll be going on vacation July 2nd, so we'll schedule your induction/csection for June 30..."

A couple of other things worth noting: Meadowlands Hospital, with an early elective delivery rate of 34.3% (close to ten times what the average for the other reporting hospitals is, with the exception of St. Barnabas) also has a 50% csection rate, one of the highest in the state (cesarean rates: NJ). OK, most of the hospitals nationwide chose not to provide their statistics to LeapFrog, but of those that did, the numbers are mostly in the single digits. Meadowlands' statistics of 34.3% are off the chart.

No reporting of whether the reasons for denying elective early delivery are discussed with the patient. Is it just a shift from "We won't let you go past 40 weeks" to "We won't let you go earlier than 39 weeks," or are the risks of early elective delivery (to the baby) actually discussed? Considering that the risks of elective repeat csection are often glossed over, I'm going to guess no.

Another interesting observation: While early elective delivery has decreased, as reported by the NJ.com article, "New Jersey remains one of 14 states where women are more likely to receive an episiotomy, or small incision, during labor. While the procedure used to be commonplace, it has since fallen out of medical favor because it carries increased risks. Roughly 17 percent of women still receive the incision in New Jersey hospitals - a rate topped only by Alabama, Mississippi and Utah among the states included in the study.

Episiotomy is a small incision made in the perineum, or birth canal, to facilitate delivery. It was once routine in childbirth, but today's medical guidelines recommend it only in a small percentage of cases. That's because it increases the risk of tears, loss of bladder or bowel control, and pelvic floor infections.

"Clearly we have more work to do on the episiotomy rate," said Kelly.

Leapfrog reported that hospitals vary tremendously in the rate of episiotomies, with some hospitals reporting fewer than 1 percent of mothers experience it, while others saying more than 40 percent have it during childbirth."

IN OTHER WORDS: While csections and episiotomies are sometimes absolutely medically warranted, some doctors don't know how to deliver a baby without cutting something. It's either abdominal incision or perineal.

Do your research.
Ask questions.
Know your rights.

Sometimes the only people who really see the differences in hospital practices are DOULAS!!! We need to get this local information out there so women can make an informed decision about their health care. Please share!
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Cesarean and VBAC: Listening to Mothers

4/18/2015

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PictureDeer in the headlights.
I was staring at the ceiling of the operating room, tears running into my ears. My arms had been shaking uncontrollably, and I was worried that when my baby finally arrived I wouldn’t be able to hold him, so the anesthesiologist had given me a shot of “something” and now that something made feel detached, and not in a good way. I felt like I was dying, only I didn’t care. All at once there he was, a cry, a face quickly dangled over the curtain, then whisked away with only a tiny, bloody handprint lingering behind. And then the most painful moment of my 36-hr labor and birth, hearing my son cry from across the room where I could neither see nor touch him. I had felt nothing of the surgery itself, but now the feeling of his separation hurt so much I asked my husband to go to him. “How is he?” I called over, still staring at the ceiling. Tears still in my ears. And my husband called back, “He’s beautiful.” 


This is how I met my son. 6:46pm, February 5, 1999. 

My physical recovery was about as good as recovery from major abdominal surgery could be. What I couldn’t shake however, was the feeling that I had failed. That I was hurting in the wrong place. And I was left with a wide range of complicated emotions: joy that my son was born, relief that labor was over, mourning for the loss of a birth experience I had hoped for, guilt that I felt that way, anger at my providers, my husband, myself. I knew women who had struggled for years with infertility; I knew women who had babies who died—how could I even talk about my disappointment at the way my son’s birth went? I was healthy. My baby was healthy. Isn’t that all that matters? 


It’s not all that mattered to me. I was going to avoid the mainstream route and all those unnecessary interventions, and here I had undergone the biggest intervention of all: my body had to be cut open so my son could be born. I was part of the statistics I wanted to avoid. I was embarrassed to share my birth story. Reactions ranged from, “You’re so lucky: you got the baby and none of the pain!” to a look of horror and “I’m so sorry,” to, “Don’t worry, my friend’s daughter had a csection with her first, but her next baby was normal.” I found myself jealous of women who seemingly had no problem giving birth the way nature intended, and jealous even of other women who had cesarean sections that were clearly medically warranted. For months I avoided walking the block where the birth center was, because that was where my baby was supposed to have been born, but instead became the place where I gave up, got in a cab, and headed to the hospital. That was the site of my failure. 


I bought a copy of The VBAC Companion, read it cover to cover, then lent it to a friend who had a VBAC a few months later. But it took me three years until I finally felt ready to try again. I spent most of my pregnancy abroad, then with three months left of my pregnancy returned to the U.S. where I found a supportive care provider and hired a doula. I discovered that in the intervening years ACOG’s guidelines for VBAC changed, becoming more restrictive. I felt like I had to become an expert on VBAC. While uterine rupture is a justifiably frightening prospect, I knew the risk was small, and for me the greatest fear was that of having the same thing happen again: hour after hour of labor only to be labeled “failure to progress.” Ultimately I decided I would rather have a trial of labor followed by an unplanned cesarean than schedule a repeat cesarean ahead of time. 


When I did go into labor a few days before my due date, I used the time-honored coping strategy of denial as long as I could manage, but when my water broke at home and I threw up, it was hard to deny that I was in active labor. We headed to the hospital where an internal exam showed I was dilated 5cm. I had never progressed beyond 4-5cm with my first birth so when I heard 5cm I began crying, convinced it was all happening again. It took my midwife, my doula, and my husband to talk me off that ledge, to assure me that this birth was totally different, and that in fact things were going really fast. I gave birth two hours later, squatting on the hospital bed, feeling completely surrounded in support. The difference between my physical recovery from my csection and my first VBAC was not so much “night and day,” but “night and evening.” It was still hard. But the difference is I felt like myself almost immediately. About two weeks after my daughter was born I attended the presentation of the results of the first Listening to Mothers survey sponsored by the Maternity Care Association in New York City (now known as Childbirth Connections). As I described my experience giving birth while surrounded by my midwife, doula, and husband, the room erupted in applause. I was moved, but at the same time wondered why do we only applaud those births that meet certain conditions? It took me a long time to call my first baby’s birth a birth, to say, “I gave birth by cesarean section.” Because I did. I worked harder to birth that baby than I did in any of my vaginal births. 


When we moved to New Jersey, and I found I was expecting again, I first looked into a home birth and discovered that [HBAC] wasn’t an option in New Jersey as it is in New York. One glance at the cesarean rates for the hospitals closest to me, and I quickly decided to stay with my providers in the city. Our third baby and eighteen months later our fourth were both born by VBAC, and I was deep in the trenches of parenting, with four kids eight and under, trying to maintain an academic career, and homeschooling. Over the years, however, something began to bother me. When talking about my babies’ births to women I met at the playground, at the library, at the pediatrician’s office, again and again, I heard,”Your doctor let you do that?” “I thought that once you have a cesarean it’s not safe to have a vaginal birth any more.” I saw firsthand the huge information gap between women and their providers. While the risks of vaginal birth after cesarean were repeatedly emphasized, risks of repeat cesarean births were minimized, if discussed at all. When I congratulated a woman I knew on the birth of her fourth baby, she said, “Well, I know this one will be our last.” “Hey, you never know…” I began, and she stopped me. “No. This one is our last. It was my fourth csection and my doctor says that’s the limit.” Had VBAC been a possibility for her after her first baby’s birth? I became a doula in 2012 in part because I felt a need to share this information, encourage women to make their own decisions, and support them in these decisions, whatever they might be. 


And this is where ICAN comes in. A grassroots non-profit organization founded in 1982, ICAN’s mission is to improve mother-baby health by providing education and information about cesareans, their prevention, recovery, and VBAC. Nearly 44% of all births in Bergen County in 2011 were by cesarean. I looked around at the many parenting support groups in Bergen County—in a state with one of the highest csection rates in the country, in a county with one of the highest csection rates in the state, there was no place women could go for information and support about cesarean birth and VBAC. My experiences speaking with women showed they weren’t getting this information from their providers. Trish and I got together, hit it off, and on a hot, muggy evening last June we had our very first ICAN of Bergen County meeting. What an honor it was to gather with a handful of women and hear their stories, and know we’re not alone. For many women it’s the only place where they can get emotional support and information. And here I’d like to encourage you to consider becoming a member of ICAN. There are various membership levels for both individuals and professionals. Wouldn’t it be great to see a symposium of this kind become an annual event? This can only be possible with ongoing support, and as a non-profit ICAN relies on donations. Suggest ICAN as a resource to your friends and colleagues, and please join us, if you think you might benefit form an ICAN meeting. Here in Bergen County we meet the second Tuesday of every month in Dumont (our next meeting is May 12th at 7pm). 


ICAN meetings are a safe place for women to share information and experiences relating to cesarean birth and vbac. Although loosely focused on various topics (recovering from cesarean, planning a vbac, choosing a care provider), the fundamental structure is of sharing: stories, information, compassion. While most meetings are limited to parents who have given birth by cesarean, others are open to providers and other family members.  What we do not do: we don’t tell women what they should be feeling. We don’t blame the mother (you didn’t use the right care provider, you didn’t eat right during pregnancy, you didn’t hire a doula, you must have had emotional issues you didn’t work through, you didn’t try hard enough). We’re not here to tell women that they should not have had a csection or should pursue a VBAC. We’re here to listen, to act as a sounding board for women to express their own emotions, often complicated, surrounding the births of their babies. Because if we tell a woman, “You shouldn’t feel that way,” we are invalidating her feelings. If we tell her, “The only thing that matters is a healthy baby,” it can further complicate her nagging sense that, while a healthy mom and baby may be the most important thing, it’s not the only thing that matters. And if we assume that everyone who has a cesarean must be traumatized by the experience, we diminish the experiences of women who feel good—even great—about their cesareans, who feel like they were informed and supported every step of the way, and that they made the right decision for them? 


While ICAN supports the reduction of unnecessary cesareans, and supports those women who have experienced cesarean birth, without judging whether her cesarean was necessary or not (because we all know there’s a lot of gray area here), in many cases a cesarean is the safest way for that baby to be born. We can make that experience more positive and provide the woman the information she needs beforehand to make the decisions that are right for her. And once the baby is born, we can listen. We can offer support and change our practices to reflect women’s experiences. Do not assume that just because a woman had a cesarean birth that she has had a traumatic experience. Likewise, do not assume that just because she and her baby are healthy (or that the cesarean was medically warranted and/or planned) that she has not had a traumatic experience. The only one who can tell you if the experience was traumatic for her or not is the woman herself. And often the deciding factor is how supported she felt during the pregnancy, birth, and postpartum. Birth is not a failure. It’s time to stop using terms like “failed VBAC.” It’s time to stop saying a woman was “sectioned.” It’s time to stop calling babies “csection babies” and”vbac babies.” It’s time to start calling a cesarean section what it is: a birth. And it’s time to start acting that way, so women can exercise their options: choosing their support partners, having arms free to facilitate skin-to-skin contact in the OR, bringing in their own music to listen to, having a birth photographer capture the event, breastfeeding as soon as possible, not being separated from the baby unless there is a medical need (and, no, routines are not the same things as needs). And—please—don’t take the baby out of the mother’s sight unless you really need to. She might never forget that. And it’s time to present the relative risks of both VBAC and repeat elective csection honestly and fairly, allowing the woman to make her own decision, withholding judgment and offering only support. 


So what’s the appropriate response when learning that a woman has given birth by cesarean? Congratulations! The next: Would you like to tell me about your baby’s birth? Then let her tell her own story. She may need to tell this story over and over again. But let her tell it.
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    Homeschooling mom of four: think Tarantino meets Little House. Doula, Childbirth Educator, Bereavement Doula, and Lactation Counselor. 

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