Dec 2, 2008

For Dr. Padma

Dr. Padma (back left), Kim Gutschow (back right), and the chowkidar or night watchman at Leh Hospital.


Picture this. The Sonam Norbu Hospital in Leh, Ladakh is one of only two hospitals that serve an area the size of Norway. This area is only home to 250,000 people, making it one of the least populated regions in India, with one of the lowest fertility rates in the nation.

Why so few people? Did I mention the forbidding desert landscape at 12,000 feet above sea level--- some of the lowest precipitation in India? Or the fact that many crops don't or can't grow that high or in such a dry climate? So why all this talk about altitude?

Imagine a hospital where electricity is imminent at times and the back-up generator takes 10 minutes to kick in, depending on how cold it is and whether they guy who is supposed to start it feels like getting out of bed in the middle of the night. Imagine doing a cesarean section by flashlight, as I have heard done in Leh.

Imagine having to beg the anesthesiologist repeatedly to come in just one more night, one more time, for one more emergency obstetric complication, and he is twice your age, and is better friends with your parents than you in a very small town.

Imagine a delivery room where the heating is spotty, the mother lies down on a cold rubber surface that was scrubbed by ice cold water that may or may not have been hauled there in a bucket when the pipes freeze.

And now imagine Dr. Padma, doing her morning rounds, after she has walked the 100 yards from her tiny one bedroom apartment that is in the staff quarters next to the hospital. Always cheerful, always professional, even in the coldest weather, or in the worst mood. She is happy to discuss each patients' progress, give the nurses their instructions one more time, clarify the meds that should and should not be administered, order another ultrasound, and then discuss the latest literature on corticosteroids with me.

She graduated from one of Delhi's most prestigious medical colleges and then left a fellowship at one of New Delhi's finest public hospitals---Safdarjung--- three years ago to return home, to Ladakh, to work at Leh's government hospital. She has never accepted payment under the table for her services as many do in India's public hospitals where the salaries are almost as poor as the infrastructure.

And tomorrow she goes back down to Delhi for another shorter fellowship. Let's hope she returns.

We need more doctors like her in Ladakh. And everywhere in rural India for that matter.

Jul 17, 2008

AMA and ACOG fight home births

Have you heard the news?? According to ABC news (7/11/2008), the American Medical Association (AMA) recently agreed to support proposed legislation that could make having a planned home birth difficult if not impossible.

The AMA agreed to back resolution 205, in which it agreed with a recent ACOG (American College of Obstetricians and Gynecologists) position that home births are not as safe as hospital births. Both the AMA resolution and the ACOG statement on home births (2/6/2008) have come in response to the publicity surrounding the new film, the Business of Being Born. The fact that ACOG feels threatened by the film's open advocacy of home births---when home births only account for under 1% of all births nationwide in the US (the official figure, actual figures may be closer to 2%)----suggests how paranoid ACOG has become of midwives and their support of home births.

Like many of ACOG's practice guidelines or seemingly innocuous educational reports, their "statement on home births" is a highly politicized document, which bears little relationship with evidence-based medicine. Their attack on Lake and Epstein's film is hardly disguised when they say, "childbirth decisions should not be dictated or influenced by what's fashionable, trendy, or the latest cause celebre."

As if women are choosing home births because they are trendy.  It may be because home births are now safer than a hospital birth for the first time, given the current trends towards unecessary interventions, many of which are not evidence-based.  

ACOG might also have noted that childbirth decisions should NOT be influenced by legal issues. Indeed, the epidemic of inductions (up to 60%) and cesareans (30%) within low risk hospital births in the US, may be due to obstetric fears of malpractice than concern for maternal or fetal or neonatal well-being.

ACOG might have noted that childbirth decisions should NOT be influenced by economic issues. They might have noted that hospitals are trying to save money when they use electronic fetal monitoring (EFM, now used in over 90% of all hospital births in America) rather than the intermittent auscultation with a hand-held doppler still used in Europe and the developing world that offers improved neonatal and maternal outcomes over EFM in many low risk births. Click here for the NEJM article on electronic fetal pulse oximetery (which was hoped to be an improvement over EFM but the trial was cancelled when it became clear it was no improvement over a technological method already deemed questionable). Interestingly, Michael Greene's scathing rebuke of EFM in the New England Journal of Medicine (vol 355 Nov 23, 2006) that was picked up by news wires around the country during Thanksgiving week that year, is only available to NEJM subscribers, but you can see the abstract here. 
 
But they ignored the practices prevalent across the US that have contributed to a profound crisis in hospital based obstetrics that the film Business of Being Born so ably unpacks. There are no clear answers to our dilemma, but a fear mongering against the very groups that are trying to improve the birthing outcomes for women is not one.

As for the AMA decision, it is one thing to reject a phenomenon that has been studied, but quite another to reject a phenomenon they have shown almost no interest in. The most recent study of home births in its flagship journal, JAMA, dates to 1980. In other words, for 28 years nobody on the JAMA editorial board has felt the need to address the evidence on home births. Perhaps it is too difficult to study home births or there simply aren't studies out there worth reviewing? Actually there are great studies, but from Canadian or European journals, which DO show an interest in the evidence comparing home and hospital births. One of the more recent and largest studies---from the British Medical Journal (18 June 2005)---found far lower rates of intervention for home births, but comparable intrapartum and neonatal mortality rates (1.7 per 1000) than the average low-risk hospital birth.

Jan 31, 2008

Yeshe, small and thin


Appropos the low birthweight study I discussed in my previous post, our third child, Yeshe, who was born on Dec 30th, 2007, was low birthweight. She was born full term, at home, after a calm, smooth labor. So calm in fact that she was born with her sac intact, what is traditionally referred to as in the caul. Midwives have told me this is a sign of wisdom, psychic insight, and even spiritual teachings, while another friend set me a clipping from an early 20th century memoir that talked about how ship captains would take a caul with them to the sea for good luck. I hope this gift serves Yeshe, which means wisdom in Tibetan, well.

Will Yeshe experience any sequelae of her low birthweight? And how did she come to be low birthweight? I ate like a horse during my pregnancy and gained 35 pounds. Her weight---5 lb, 10 oz---is a mystery as is so much in life.

The question my husband and I recently debated was---should we tell Yeshe that she was low birthweight? Or would we pathologize her by showing this concern? We decided that this information was only relevant on a need to know basis. Sure, she'd get her birth certificate, but unless mentioning her birthweight was relevant to an ongoing health issue, why burden her? Then we thought about our twins---who were born at 26 weeks and are now 3.5. The same strategy could apply---unless they need to know about their prematurity because of an ongoing health issue, why bring it up?

On the flip side, I also think that when they are older---teenagers? in college?---I might talk about their NICU stay, but always keeping in mind that it is MY experience of the NICU that I would be relating, not theirs, which will always remain a mystery to me (and perhaps) them.

What do you think--- where do we draw the line between helpful information and pathologizing our kids? How much is our experience of prematurity as parents relevant to our kids and when and how do we choose to share with them? For more on this topic see the post in The Preemie Experiment.