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Posts Tagged ‘risk’

I used the title “vaccination question” because I don’t consider it a debate. We don’t debate with people outside our family about where we’re going on vacation, whether the kids should go to school or homeschool, or what to have for dinner, even when we receive suggestions, insight, and/or helpful information from others. We take in the information, discuss it, research it more sometimes, and make the choices we feel are right for our family.

We think every family has this right. And I don’t like the notion that some doctors don’t like to discuss all information available about vaccines (and what information is not available) because they are afraid parents won’t make the decision the doctor wants them to make. A big part of my skepticism is that information about risks wasn’t discussed in mainstream medicine until Autism questions forced it into the open. And even if Autism is not caused by vaccines, there are other risks that I was never warned about before vaccinating my older daughter as an infant.

No one said anything about risk – until I met a woman with a vaccine-injured child. She talked about it- you can imagine she talked about it a lot. And I discovered I had a lot of questions that I didn’t know to ask when we first chose to vaccinate. We stopped any vaccination for our oldest after 12 months, declining MMR and Chickenpox at the 12 month visit. (Our younger child has had none.)

Then I started to research online. What I found was that some diseases do pose a serious risk to some children/people- that it’s hard to define who will be affected most seriously. That wasn’t really surprising. And I read about the serious risks of vaccines for some people- and that it’s equally difficult to determine which people will have a serious reaction. I also found that other parents were upset and nervous about vaccinating; about not vaccinating; about the risks to their children from vaccines, from disease, from un-vaccinated children.

As parents we can only make decisions based on the information available. We simply don’t know what we don’t know. My reasons for currently not vaccinating are many. Among them is the idea that I believe the potential risk of damage by vaccines (not just immediate, but long-term health consequences) is greater than the risk of my children suffering long-term damage from illnesses vaccines were created to prevent.

Are there consequences I haven’t considered? Possibly. I’m willing to listen if you have a story to tell me or information to offer. I know I don’t know everything there is to possibly know about vaccines. So if you’ve got something to share, please do.

Incidentally, we were exposed to chicken-pox last week and are waiting for the arrival of spots. Each day, I check the kids and nothing yet. I’ve picked up a homeopathic remedy to use if/when the spots appear and I’m expecting that we’ll go stir crazy in the house before long. (But we may also get some needed organization and laundry done along the way to crazy.)

I’ve still got a lot of questions about vaccination. So on Monday (at 1pm ET) I’m interviewing Barbara Loe Fisher from the National Vaccine Information Center. You can access the show here. You can also call in with questions during the live show, but if you want to simply provide your opinion, I respectfully request you do so here, so that we can have as many questions answered as possible during the hour-long show.

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There are people who really believe that having a baby is inherently dangerous. Maybe more dangerous than extreme sports.

Not just people watching A Baby Story on TV, where women are routinely whisked away in a panic for surgery. Not just people regularly watching women on soap operas faint, only to find out they are pregnant. Not just the drama made for television and the movies, teaching us visually that clearly most women just aren’t up to the job of birth- it’s way too hard, too painful, too scary.

According to some medical providers pregnancy and labor (but especially labor) are accidents waiting to happen. And for these practitioners, the idea of a woman giving birth outside of a hospital setting is selfish and extremely dangerous. For all who believe birth is inherently dangerous, I bring you Birth – an Extreme Sport.

Welcome to the Birth Arena.

First in the line-up is Mary Averagemom. A generally low risk pregnancy, Mary’s fundal measurements were on target with her estimated due date throughout her pregnancy. Her practitioner began discussing induction at her 35 week appointment, to prepare her for this eventuality. He also offered to schedule an elective c-section at the same appointment.

When Mary made an appointment, at about 5 months along, specifically to discuss her written birth plan, her provider reviewed all the items and agreed to all of the options, as long as there were “no complications during labor” and “assuming hospital policy allows it.” This included intermittent EFM (15 min on, 45 min off), no IV, no induction/Pitocin, no epidural, eating & drinking during labor, husband and doula present, squatting for the pushing phase and baby presented to Mary skin to skin at birth.

Hospital policy did deny food during labor, but Mary was told the other requests listed were the doctor’s prerogative. So begins this Extreme Birth– because shouldn’t these be Mary’s prerogative?

Throughout her time in the hospital, even with the support of her husband and doula, Mary was bombarded with pressure from staff (nurses and OB) to consent to protocols. Mary refused the unnecessary IV line 4 times before being told she could not decline. Although she had discussed intermittent use of the EFM for monitoring well in advance of labor, (and agreed to 15 minutes of monitoring per hour) she was regularly scolded for detaching the belt and getting out of bed to change position. (The staff did not respond to Mary’s call button at the agreed removal time- another example of ignoring her limited consent.) Pitocin was brought up multiple times (at least 4) although Mary was clear she would not consent to Pitocin during early labor.

When it came time to push, Mary was told not to push(!) because the doctor was delivering another baby down the hall. When pushing did not go according to the count, Mary was scolded and told her wasn’t trying hard enough. (This all followed an argument about the use of the squat-bar on the bed -part of the original birth plan, which the doctor had affirmed agreement to at 8:30 am that morning. It’s extreme that a doctor would attempt to argue with a woman in labor, ready to push, and expect a discussion. Words don’t come easily during pushing and I believe he expected Mary would be unable to defend herself at all and simply yield to his preference- which eventually she did.)

Following “delivery”, minor tears were sewn while baby nursed. Nursing staff refused to speak to Mary after she’d been so difficult. (Doctor also left the room without a word.)

This is extreme treatment. Ignoring consent. Condescension. Mary’s discovery that her doctor had no intention of honoring her birth plan- finding this out during labor!Extreme measures that disregard the definition of CARE for women.

Care- to be concerned or attentive; have thought or regard; with the opposite being indifference. But this “care” was indifferent, and the fact that this is the standard of care, means the standard is indifferent to women.

Contestant number 2:

She’s mom to a young toddler, pregnant with baby number 2, and views birth as a physiologic process designed by God. She’d like to birth in an environment where she is respected, her choices are honored, and no one is trying to rush things along. She’d also like the option of having child #1 present to witness the birth of her younger sibling. Meet Hannah Homebirth.

During her first birth in a hospital, she experienced care like Mary’s. She wants to avoid a repeat of that routine treatment and has chosen a homebirth midwife for prenatal care and to attend the birth.

Hannah read several books about birth during this pregnancy: Henci Goer’s The Thinking Woman’s Guide to Better Birth, Pam England’s Birthing from Within, Ina May Gaskin’s Ina May’s Guide to Childbirth.

She discussed with her midwife reasons a transfer to a hospital might be needed. Which hospital, admissions through ER, the potential reception by staff. Hannah and her husband have discussed reasons to birth at home, concerns, risks with each other & their midwife.

The time for labor came on naturally, 40+ weeks. Hannah drank some water & ate a granola bar. Contractions just begun, a walk around the block brought Hannah into active labor. Doula & midwife arrived to find a relaxed, focused beginning labor. Hannah headed to the birth ball and asked her husband to fill the tub.

The water- the heat and buoyancy- relieved a lot of pressure. Contractions became closer, stronger. Hannah requested no vaginal exam & although the midwife legally had to offer and document findings, the exam was presented as an option. She refused each time, feeling no pressure.

Encouraging words spoken through labor- “You’re doing a great job!” “The baby is doing great” (after intermittent Doppler check.)

Pop! Water bag spontaneously broke at 9:15 pm. (Light on.) A quick check revealed no meconium in the fluid. (Lights back out. Candles flicker.) Relief of darkness & relief at clear fluid.

Time to push. On hands and knees, semi-upright, Hannah roars her baby out slowly. No one else present makes a sound. Once her head is out (and midwife checks for cord), 2 pushes bring her fully into the world. To Hannah’s breast, a beautiful baby girl! 9:45 pm.

Perhaps these are the extremes: from indifference to genuine love. But it’s an extreme worth looking into. I don’t want my birth to be part of someone’s routine. I want my birth to be part of someone’s passion.

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If you heard my recent interview with Henci Goer, you know I’m really interested in women having the information they need to make decisions for their care, especially during pregnancy. I also think women have the right to choose the care they feel most comfortable with, no matter how certain data is interpreted, or by whom, or if there is no data at all. For example, choosing midwifery vs OB care can be based on statistical data of outcomes for certain providers, or it can be based solely on how a woman feels about a particular individual.

When it comes to risks and benefits, it’s up to individual women to discern their own comfort levels, especially about safety, weighing the benefits and the risks based on her individual perspective.

Similar decisions are made by individuals all the time. For example- the option to drive or walk to the store:

I live less than 2 miles from my local grocery store. A sidewalk exists on one of the 3 roads that I need to travel. The speed limit on the roads without sidewalk is 30 mph, but enforcement is nil and generally cars travel about 40 mph. Because I live in Florida, the weather is generally nice enough to walk 90% (or more) of the time.

Benefits to Walking:

  • Walking is great cardio exercise.
  • Carrying my groceries will help me save money b/c I may not be able to carry “extras”
  • Ecological benefit- less pollution
  • Save money on gas
  • Fewer miles on car/less maintenance needed
  • Safer than driving

Risks to Walking:

  • Possibility of getting hit by car where there is no sidewalk
  • I could trip/fall
  • May take time away from other necessary activities

Benefits to Driving:

  • Faster
  • Can carry as much as I want/need to buy
  • Safer than walking

Risks to Driving:

  • Possibility of car accident (3 left turns to get to store)
  • Danger of navigating the cars backing out of parking spots
  • May spend too much money due to no limits on carry weight

If you read closely, you’ll notice each option is “safer” than the other, as listed under benefits. That’s because there is a risk of injury in both cases, and ways to be safer in both cases. I could walk on the grass shoulder; wear a seat belt; wear reflectors; drive defensively. I’m sure somewhere I could find statistics that define the probability of accidents for walking vs. driving this distance under various conditions and make a statistical comparison.

But even with a thorough review of the statistics, I get to choose which feels safer to me. Even if the data “clearly show” a greater chance of injury for one option, the benefit of speed (or a smaller carbon footprint) might outweigh the risk.

Choices should be offered to women for childbirth with the full understanding that women are ultimately responsible to choose, and that women have the right to choose for themselves, no matter how others interpret the benefits and risks involved.

After all, risks and benefits cannot always be measured and statistically defined. In birth, it’s more personal than that.

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I’m going to get a bit political today. If you’re not into that, skip this post. There is so much going on about healthcare reform in the media and I can’t help but notice there isn’t much mention of improving the sorry state of pregnancy-related care and maternal/fetal outcomes. No one is talking about the continued restriction of valid childbirth options for women with a history of c-section. Yes, I’m talking about VBAC.

VBAC, short for vaginal birth after cesarean, is a valid healthcare option for pregnant women in low risk categories. According to Childbirth Connection.org:

If you do not have a clear and compelling need for a cesarean in the present pregnancy, having a VBAC rather than a repeat c-section is likely to be:

  • safer for you in this pregnancy
  • far safer for you and your babies in any future pregnancies”

Most OB’s and hospitals that refuse to support VBAC do so citing concerns about uterine rupture. And while this is a possibility, educating women about risks and benefits is vital to informed consent of patients. To be vital, informed consent requires patients (in this case women) the option of informed refusal. It is the right of every person to make healthcare decisions personally. Each pregnant woman, therefore, should also have the same right to choose what she will and will not accept as part of her individualized care. She can choose to accept or refuse induction, epidural, ultrasound, fetal monitoring, IV. She has the right to change her mind, even during labor.

Let’s look at the risks associated with uterine rupture during VBAC (from this article at ChildbirthConnection.org):

“What is the added likelihood that the scar will give way (uterine rupture) during a VBAC labor?
Best research suggests that an extra 27 women experience a ruptured uterus in every 10,000 VBAC labors, compared with planned c-section deliveries. Thus, nearly 400 women would need to experience surgical birth to prevent one instance of uterine rupture during VBAC labors. While the scar giving way usually requires an urgent cesarean, loss of the baby is much less common (see next paragraph).
Added likelihood for a woman with a known low-transverse (horizontal) scar: MODERATE for scar rupture compared with planned repeat c-section.”

“What is the added likelihood that the baby will die as a result of the scar giving way (uterine rupture) during a VBAC labor?

Best research suggests that about 1.4 extra babies die due to problems with the scar in every 10,000 VBAC labors, compared with planned c-section deliveries. Thus, over 7,000 women would need to experience risks of surgical birth to prevent the death of 1 baby from scar problems during VBAC.
Added likelihood for a woman with a known low-transverse (horizontal) scar: LOW for death of the baby around the time of birth compared with repeat c-section.”

To fully understand the risks associated with VBAC and make an informed decision women must also comprehend the risks to mother and baby for repeat cesarean birth. (From this article at ChildbirthConnection.org)

“Extra risks associated with cesarean section: Current research suggests that cesarean section has the following disadvantages in comparison with vaginal birth:

Physical problems in mothers: Compared with vaginal birth, cesarean section increases a woman’s risk for a number of physical problems. These range from less common but potentially life-threatening problems, including hemorrhage (severe bleeding), blood clots, and bowel obstruction, to much more common concerns such as longer-lasting and more severe pain and infection. Even after recovery from surgery, scarring and adhesion tissue increase risk for ongoing pelvic pain and for twisted bowel.

Hospitalization of mothers: If a woman has a cesarean, she is more likely to stay in the hospital longer and is at greater risk of being re-hospitalized.

Emotional well-being of mothers: A woman who has a cesarean section may be at greater risk for poorer overall mental health and some emotional problems. She is also more likely to rate her birth experience poorer than a woman who has had a vaginal birth. {Note: This risk is reduced somewhat for planned cesarean birth.}

Early contact with, feelings toward babies: A woman who has a cesarean usually has less early contact with her baby and is more likely to have initial negative feelings about her baby.

Breastfeeding: Recovery from surgery poses challenges for getting breastfeeding under way, and a baby who was born by cesarean is less likely to be breastfed and get the benefits of breastfeeding.

Health of babies: Babies born by cesarean are more likely to:

  • be cut during the surgery (usually minor)
  • have breathing difficulties around the time of birth
  • experience asthma in childhood and in adulthood.

Future reproductive problems for mothers: A cesarean section in this pregnancy puts a woman at risk for future reproductive problems in comparison with a woman who has a vaginal birth. These problems may involve serious complications and medical emergencies. The likelihood of experiencing some of these conditions goes up sharply as the number of previous cesareans increases. These problems include:

  • ectopic pregnancy: pregnancies that develop outside her uterus or within the scar
  • reduced fertility, due to either less ability to become pregnant again or less desire to do so
  • placenta previa: the placenta attaches near or over the opening to her cervix
  • placenta accreta: the placenta grows through the lining of the uterus and into or through the muscle of the uterus
  • placental abruption: the placenta detaches from the uterus before the baby is born
  • rupture of the uterus: the uterine scar gives way during pregnancy or labor.

Concerns about babies in future pregnancies: A cesarean section in this pregnancy can affect the babies of future pregnancies. Studies have found that they are more likely to:

  • be born too early (preterm)
  • weigh less than they should (low birthweight)
  • have a physical abnormality or injury to their brain or spinal cord
  • die before or shortly after the birth”

When women are fully informed of the risks associated with repeat cesarean and VBAC, they should each have the opportunity to choose which risks they are willing to take. When a doctor refuses to “allow” his patients to attempt VBAC, s/he is taking away a fundamental right of women to determine the direction of their healthcare.

According to ACOG’s Committee Opinion #321 from November 2005, respecting patient’s autonomous decision making is a fundamental ethical obligation:

“Requiring informed consent is an expression of respect for the patient as a person; it particularly respects a patient’s moral right to bodily integrity, to self-determination regarding sexuality and reproductive capacities, and to the support of the patient’s freedom within caring relationships.”

“The ethical requirement for informed consent need not conflict with physicians’ overall ethical obligation to a principle of beneficence; that is, every effort should be made to incorporate a commitment to informed consent within a commitment to provide medical benefit to patients and thus respect them as whole and embodied persons.”

“[Even if] a woman’s autonomous decision [seems] not to promote beneficence-based obligations (of the woman or the physician) to the fetus, … the obstetrician must respect the patient’s autonomy, continue to care for the pregnant woman, and not intervene against the atient’s wishes, regardless of the consequences.“(emphasis mine)

“The obstetrician must keep in mind that medical knowledge has limitations and medical judgment is fallible” and should therefore take great care “to present a balanced evaluation of the expected outcomes for both [the woman and the fetus].”

So how can it be true that women have the right to make autonomous choices regarding their healthcare, including care during pregnancy and childbirth, yet doctors choose to ignore and even ban valid healthcare options for these same women?

This is about women’s rights. A woman doesn’t stop having the right to bodily integrity because she is pregnant. She maintains the right to independent thinking, personal preference, and choice throughout the 40+ weeks gestation. Choosing to bring a child into the world doesn’t limit my right to individualized care or informed consent. In fact, choosing to bring a life through my body has made me more focused on what is appropriate and acceptable risk to me and my baby- and this is a very personal choice.

I should always have the final say about what is ok and not ok for my body, and any baby residing within it. And that’s what I teach my girls.

Who does your body belong to?

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