To put it bluntly: we suck at having babies over here in the big red, white, and blue.
Not like 4th place suck, not even like 10th place suck, I’m talking like 31st.
And that is just a general composite score. When we break it down into parts we hit 46th for maternal health and 40th for children’s well being. If you want to go even further and look at our specific infant mortality rate we sit at 61st.
To put the icing on the cake we have also recently discovered that not only does our infant mortality rate suck, it’s getting worse!
Even more crazy to think that we spend more money on obstetrical care compared to any other industrialized country in the world.
Apparently you DO NOT get what you pay for.
So what in the heck is going on?
The vague answer to that (because these things are never so simple) can be found in looking at what the top 5 countries are doing that we are not and vice versa, what we are doing that they are not. (The rest of the vague answer can come in comparing what we both do and examining the difference in outcomes, but we will get to that later.)
Who are the top 5?
Finland, Norway, Sweden, Iceland, and the Netherlands have pretty much taken the cake for the past 15 years. The Scandinavians seem to know how to get it done.
On a side note, I will also be bringing Australia into our discussion as they have consistently sat in the top ten over the last decade or so. We have some interesting similarities with them such as high cesarean rates but they seem to be coming out with better outcomes and I think we have some things to learn from there.
What are the differences?
Over the past 12+ years studying birth and maternity care I have learned that the major differences in the way we care for women through pregnancy, birth, and postpartum pretty much boils down to:
- Pain Management Options
- Nutrition education
- Maternity Leave
- Postpartum Support + Education
This is probably one of my most favorite subjects to talk about so I am so excited for us to open up a discussion on it.
Over the next few months we will be taking a closer look at the above mentioned topics and hatching out the details so that we, as responsible consumers, stay informed on the approach of care that we should be receiving.
In light of our fun Mother’s Day Contest where I quizzed you on the recent change in ACOG’s guidelines, we will start looking at:
Have you ever noticed that a lot of gals get induced? In general about 22 % of women in the United States are induced somewhere between 38 to 41 weeks gestation. Back in the 1990s it was around 10%.
The catch is, that number comes from a national survey done in 2006. Many people argue that it is grossly underreported, varies widely by area, and has experienced a sharp increase over the last few years.
A study lead by Dr. Deborah Ehrenthal looked at a pool of 24,679 women and found 44% of them were induced and in the Listening to Mothers Survey done by the Childbirth Connection nearly 41% of women said that induction was attempted by their care-provider.
The reason there has been A LOT of attention on inductions these days is because of the current focus on decreasing our high cesarean rate of 32%.
Numerous studies have tied the dramatic increase of c-sections with the two-fold increase in inductions. Especially affected by the risk are first-time mothers who are twice as likely to end up with a cesarean when induced too early.
As was stated before, our infant and maternal mortality rate has been going up instead of going down alongside the increased use of interventions so there is reason to believe we are not using them appropriately.
After several publications of research and public pressure, ACOG finally released their revised guideline emphasizing the importance of waiting until 41 weeks to induce unless medically necessary.
Why did we think it was ok to induce before 41 weeks?
Well the “new” guidelines actually use to be the “old” guidelines. Up until the early 1980’s it was commonplace for a woman to go to the 42-week mark. I myself was a two-week “overdue” baby. Most people don’t know that the definition, straight from the American College of Obstetrics and Gynecology, of a truly post-term pregnancy is one that hits 42 weeks and beyond (not the “due date” that they give you!)
Why we began to trend to earlier inductions is a bit of a mystery considering that the rest of the industrialized world has always stuck to the protocol of inducing between 41 and 42 weeks. It is considered by many as the sweet spot to garner the best outcomes for mama and baby.
There were several recommendations of practice that were published around the time when inductions began to increase in an effort to better our infant mortality rates. The data emphasized the importance of keeping baby in until the 39th week mark unless absolutely necessary. The recommendation came from strong evidence that shows trips to the NICU decrease dramatically when following these guidelines.
I don’t think ACOG ever had the intention when publishing and supporting this info but, unfortunately, the way this information perhaps began to be interpreted by practitioners and the public alike was that once a gal hit 39 weeks she was considered full term and it would be totally safe to induce.
It may have just been one of those things that snowballed. Sadly medicine and science fall victim to trends and fads just like everything else.
What are the stats elsewhere?
It is INSANELY difficult to find specific inductions stats overseas. One, because the majority of the studies are published in the native language and two, because the definition of induction of labor as well as the way we record it varies widely country by country.
Of the bits that I have been able to pick up I have found most of the countries that we talked about above do consistently have a lower number in induction rates. For example I found one study that put a Swedish hospital at a 12% induction rate and another showing some hospitals in Finland with a 17-20% rate of induction.
Data from the UK is easier to pull up and I found rates ranging between 12-17% Even though they don’t make the top 5, they do have a lower cesarean rate of 25.5% compared to our national average of 32%.
It is easy to look at the numbers above and think that, yes, these countries have lower induction rates and they also have lower cesarean rates so there must be something there.
However, one of the things that I continue to notice study after study is not so much when we induce but how we induce in the United States that may make all the difference.
A key difference that is not getting attention
As with any piece of research, as soon as one finding is published, it is immediately followed by another that “proves” the opposite. It’s sort of sciences dirty little secret: statistically you can just about prove anything.
There was a study published in April by Khalid Khan of Queen Mary University of England that concludes that we actually have it all wrong: elective inductions at term or post term decrease cesareans and fetal complications.
They came up with a 12% decrease in chance of cesarean delivery with women who were induced compared to women who were left to let nature take it’s course.
I have a bit of an issue with the study because it piles low and high risk women together, first time mothers with “veteran” moms, and has a broad defintion of a pregnancy being at term between 37 and 42 weeks, but what jumped out at me is where they found that women who were induced with prostaglandin E2 (I will explain below what that means) experienced a reduction of cesareans and women who were induced by oxytocin-aka Pitocin combined with amniotomy-aka breaking your waters did NOT experience a lower cesarean rate.
Hooking you up to Pit and breaking your waters is much the standard mode of induction for many obstetrical practices here in the U.S.
So I did a little sleuthing.
Turns out, most of the top rated countries don’t use Pit that much.
What do they do?
All the top rated countries follow, with some slight variations, the guidelines issued by the World Health Organization which go something like this:
If a woman goes into 41 weeks the midwife (because midwives attend the majority of births in all these places) will discuss stripping your membranes (where your care-provider kind of lifts up the bag of waters from the walls of your uterus during a vaginal exam.) Some may bring it up at 40 weeks, some may have you come in three days in a row in your 41st week, however it goes, this is usually the first approach to getting things going.
Next is to place low-dose vaginal prostaglandin E2s. This can be an out-patient procedure where they send you home for the night, other practices may have you stay at the hospital. They come in the form of gel (Prepadil) or a tampon-like insert (Cervadil).
More often than not, just the placement of the cervical softeners and stripping of the membranes will start up contractions, but if not, then the third recommended step is to hook up Pitocin to stimulate the uterus.
The WHO guidelines do not recommend breaking your waters until much later in established labor, around the 6 cm mark.
They also advise clear across the board that induction by only breaking your waters is strongly not recommended as it poses too much of a risk such as cord prolapse, fetal distress, and infection- all which translate into a cesarean.
Why do we use Pit so much?
Once again I think we are swimming in “trending” being the answer to that question.
The bottom line is Pitocin is a great drug for induction IF it is used on a woman with a favorable cervix.
That last part is the key that perhaps our obstetrical community has not taken seriously enough.
It is not that other countries do not use Pitocin but they do seem to use it much more conservatively than we do and there is a major focus on making sure the cervix is in a favorable position before attempting its use.
So whats a girl to do?
- First and foremost do not assume that your care provider has read the new guidelines…..or is privy to following them. Simply by waiting to be induced until 41-42 week mark will exponentially take you out of the risk of cesarean group. Most women will go into spontaneous labor by then and if they do not they will most likely have a softened cervix by that time. Have this conversation early in your pregnancy! Straight up ask them how long they will “let” you go, and what their routine approach to inducing is. If it’s not what you were expecting to hear, bring them a print-out from ACOG’s web and see if they will be open to following the guidelines. If they are not, well, it might be time to find somebody else.
- If your pregnancy is trucking along just fine and you have no complications coming up, keep that baby in there til’ at least the 41 week mark, especially you first time mamas. And let me tell you, it’s easy to say yes to that now, but once the last weeks of pregnancy hit, you will come to completely understand how it can be so tempting to get induced. Last weeks of pregnancy are a bitch. You can’t sleep, you can’t breathe, you can’t bend over. Beached whale feeling can mess with your patience, you have been warned.
- If you are approaching the 41-week mark consider making your first step be stripping your membranes at each visit. It is not a fun procedure, and can cause some bleeding and discomfort afterwards but for women who want to try a non-pharma intervention it might be a good tradeoff.
- If nothing has happened and it looks like you need to encourage baby out, take special heed to your Bishop score. If your bishop score is below a 6 consider insisting on getting cervical ripeners. If your bishop score is above a 6 (some practices say that first time mothers should ideally be above an 8 before inducing with Pit) you may have three options. After weighing the risks and benefits, you could:
One, get **cervical ripeners anyways with the hopes that it may trigger your uterus to labor. Two, you could opt for getting Pitocin right away, or three, you could do nothing. There is no law that states you have to have your baby by 42 weeks. If, after reading the risks, you just really feel it’s not for you then know that you don’t have to. Sign a consent form. If your care-provider just can’t handle that, find another one.
- It might be very tempting to want to try to break your waters as that is a non-pharma approach but save it as a last resort or until you are much further along in labor. That bag of waters serves as a cushy saftey net for your baby during the rigours of labor, let it pop on it’s own.
- Finally, don’t get hung up on the statistics. They are just generalizations. Sometimes inducing before 41 weeks is the best, other times letting nature take it’s course is the best. The best method of induction varies woman to woman. Do your research and then make the decision that is ultimately best for YOU and YOUR circumstance.
**cervical ripeners are not recommended in women who have had a previous cesarean or any sort of surgery to the uterus due to the increase risk of uterine rupture. Also, there is a type of off-label cervical ripener called Cytotec (misoprostol). It is a prostaglandin E1 (not an E2 like Cervadil and Prepadil) and has been linked to more maternal deaths than I care to share. The fact that it is not illegal is beyond me. The World Health Organization supports the use of misoprostol and I completely disagree with their stance but we will get into that another day.
So, what do you think? What has been your experience with inductions? Do these findings surprise you?
As always, remember that this should not be taken as medical advice but as information for you to open up a discussion with your care provider!
Some further reading to churn your brain juice is:
Hugs and kisses to you all!