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In Pregnancy, Doctors' Focus is on Baby, Not Mom

Oct. 17, 2018 -- The birth of Stephanie Portell’s first child was a breeze. The delivery was so swift and easy, she says, she really pushed only once. So she headed into her second pregnancy a few years later expecting a similar experience. Instead, she almost died.

“I had one beautiful moment with my second son, right after he was born and was laid on my chest. But after I handed him back to the nurse and went to the recovery room, I realized something wasn’t right,” the mother of two explains.

Her stomach was cramping with pain like she’d never felt before. The nurses weren’t concerned and told her that was common with second pregnancies. But then Portell felt lightheaded when she tried to stand up. The last thing she remembers before blacking out is the terrified looks on her family’s faces -- including her 4-year-old son -- as a nurse yelled, ”She won’t stop bleeding. Get the doctor in here now.”

Portell’s uterus wasn’t contracting properly after delivery. She was in and out of the hospital for more than a week, hemorrhaging and passing blood clots. Ultimately, she required several blood transfusions to get back on the road to good health and never did find out what caused it all. Several years later, she still looks back at the experience, astonished and confused about how it all unfolded and went on for so long.

“The medical staff didn’t listen to me, and they made mistakes over and over and over again for no apparent reason,” Portell says. “Everyone is always so focused on the baby. But I think a lot of women like me, who have gone through something terrifying during childbirth, are amazed how little is known about how to care for moms.”

What More Can Be Done for Mothers?

Experts say there has long been concern that obstetrics has focused on babies’ well-being almost to the exclusion or certainly to the detriment of moms, and many hope and believe that tide is starting to turn.

More research can provide more answers, and a National Institutes of Health-led task force has just recommended research into pregnant women and nursing mothers for the Department of Health and Human Services. The task force found there’s not enough information to “guide the care and treatment of pregnant women in several areas,” and it called for more research aimed at finding new drugs to treat pregnancy-related conditions. The group says more needs to be known, for example, about the dosing of medications approved for the general population, which might not apply to pregnant and nursing women.

Dana Gossett, MD, chief of obstetrics, gynecology, and gynecologic subspecialties at the University of California, San Francisco, urges pregnant women to do research and check data to compare things that matter to them, like C-section rates among doctors and hospitals in their area.

“Many institutions publish their C-section and episiotomy rates. These are not perfect markers of quality, because some groups of women are higher risk than others and some hospitals may care more for at-risk populations, but it is a reasonable place to start in asking a provider’s philosophy on these issues and how they think it might be related to your individual case,” Gossett explains.

She also says you should consider using a midwife (a person trained in childbirth) or a doula (someone trained in labor support) and says both can help women with low-risk pregnancies make better labor and delivery decisions.

Maternal Health -- What We Do and Don’t Know

There are almost 4 million births a year in the United States, and despite all the advances that have been made in medicine, there are still many mysteries about the health of women during pregnancy and childbirth. From maternal mortality, to diabetes, pain management, cesarean sections (C-sections) and more -- there is still a lot that isn’t scientifically understood or standardized, and harrowing childbirth stories are heartbreakingly common.

A 6-month investigation by National Public Radio and the website ProPublica finds the United States has the worst rate of maternal deaths of any developed country. The latest data from the CDC, released in 2014, finds 50,000 women a year have what’s called severe maternal morbidity, which involves unexpected outcomes of labor and delivery that can cause short- and long-term health problems, including the need for blood transfusions and hysterectomies.

“Science and research in obstetrics lags behind research in other areas like cardiology by at least a decade and was hindered for a long time by ethical concerns about doing research among pregnant women,” Gossett explains. “This did pregnant women a real disservice because we have less data than we would want.”

“We are still learning,” agrees Alan Peaceman, MD, chief of maternal fetal medicine in the department of obstetrics and gynecology at Northwestern University outside Chicago.

Several new studies are looking to change that by providing clear scientific data aimed at finding the best treatment and care for women during pregnancy and childbirth.

A series of papers published in October 2018 looks at why the number of babies born through C-sections almost doubled globally between 2000 and 2015 -- from 12% to 21% of all births. These levels are far higher than the 10% to 15% the World Health Organization says is thought to be needed for medical purposes, and the U.S. rate is even higher, at 25% of births. The authors call on health care professionals, hospitals, women, and families to opt for a C-section only when it is medically required, stressing that the procedure is not without risks. The report says maternal death and disability are higher after C-sections than vaginal births.

Another new study, published Oct. 9 and funded by the National Institutes of Health, seeks to clarify when it’s best for a woman to push during labor. This has long been a matter of debate in the field of obstetrics. Some doctors believe women should push as soon as they are fully dilated at 10 centimeters, while others suggest it’s better to let women rest a bit and wait an hour before pushing.

This new study, carried out at six U.S. hospitals and involving more than 2,400 first-time pregnant women, seeks to end the debate. It finds both approaches to pushing have similar rates of vaginal deliveries, which Gossett says will likely surprise many people.

“The hypothesis or rationale for ‘laboring down’ was, if you let women wait, their body will push the baby lower, and when they start pushing, that will be a more favorable position, and they won’t have to push so hard and it will lower the C- section rate. But this study shows that is false,” she explains. “Vaginal deliveries are the same in both groups, and the amount of time women spent actively pushing was only a small amount longer in the push [early] group.”

The study also revealed downsides when women waited to push. Their rates of infections were higher (9.1%, compared with 6.7%) and they had more hemorrhages after birth (4.0%, compared with 2.3%).

“Moms who waited did worse,” Gossett says.

Clarity has also just come on the question of whether it is safe to restrict calories in pregnant women who are overweight or obese. Many doctors have been concerned about how this might affect the health of both babies and mothers. The question is an important one since the majority of U.S. women of reproductive age are overweight or obese, which raises the chances of stillbirth, diabetes, preeclampsia, hypertension, and more. Pre-pregnancy weight can also cause early delivery.

But a study published Sept. 24 finds it is safe to limit calories in women when it is done in a carefully controlled and monitored setting.

Learning Along the Way

Experts say these new studies add to an ever-increasing body of evidence about the best ways to care for women during pregnancy and childbirth. But it can still be a complicated area, in part because of compliance by doctors.

“We find compliance with data and guidelines is not necessarily universal,” Gossett says, citing the difference in C-section rates from one institution to the next as an example of that.

“People are interpreting guidelines and clinical scenarios differently and responding differently,” she says. “Guidelines do need to be put into the context of an individual patient, but we should only be deviating if something is really unique about a patient and the standard doesn’t apply.”

Others say this is a field that has long relied on tradition over science, and that requires doctors to shift their thinking.

“Obstetrics was traditionally taught as an apprenticeship based on experience and information passed down, but without a whole lot of science involved. Most of medicine was practiced that way, but obstetrics probably longer than it should until we started doing randomized clinical trials,” Peaceman explains. “What we are finding now is that when longstanding dogmas are actually tested, a surprising number of them turn out to not be true or to have other adverse consequences we aren’t measuring.”

Another thing worth noting is that up to 40% of all deliveries take place in hospitals that have fewer than three babies born each day. That’s important, as in general, the more procedures a hospital does, the more “practice” they have- that includes knowing what to do, and also being up to date on research developments.

“We are learning all the time,” Peaceman says. “It’s as much a message for physicians to be on guard against putting too much stock in untested dogma. Until the studies suggest or prove a benefit, we should be cautious with what we are recommending or not have as much confidence that there is only one way to do things.”

As for Portell, whose sons are now 5 and 9, she says she not going to risk her health again by getting pregnant a third time. “Even though I physically can, I wouldn’t. I don’t feel it would be safe because I don’t know what was wrong and doctors didn’t seem to know how to handle me,” she explains.

“I am so thankful I escaped death,” she says. “Not everyone is as lucky as me.” 

WebMD Article Reviewed by Hansa D. Bhargava, MD on October 17, 2018
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