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Wednesday, January 21, 2015

When the media totally gets it wrong

When the media starts talking about a topic you are acutely aware of or one that's personal to you, you are more aware of when they get it wrong. In my case, birth advocacy and thyroid disease awareness are two subjects that are close to my heart and something I know a lot about.

So it's utterly depressing and maddening when you come across an article that is just so bad and misleading that you want to scream at the top of your lungs.

When the news does a terrible job covering a topic you're
intimately familiar with, it makes you wonder how
they handle all the other stuff.
Photo credit: jayofboy/freeimages
This one - The Daily Mail's "Australian woman gives herself a Cesarean section" - is pretty horrendous. You immediately conjure up images of serious peril; something has gone horribly wrong and she's in dire straits with no sign of help anywhere, right? Wrong!

Apparently, this is an article about a maternal-assisted cesarean (definitely not the same as performing the surgery on yourself, as the Mail implies), something that is verrrrrry slowwwwwwly catching on in the birth community. By slowly I mean probably at a snail's pace, because we still don't hear very much about it. The woman, disappointed over the fact that she could not have a VBAC with the twins she was carrying, decided that she wanted more of an active role in the birth and presented her case to her OB, who - not surprisingly - flatly refused. Apparently after he did more research, (gasp!) he changed his mind. (double gasp!)

"'(The doctor) was quite willing once he realized the risk of infection wasn't as high as he perhaps first thought,' Mrs. Wolffe said.'"

Amazing. An OB that listened the patient, while still yielding to necessary medical intervention, and they both had a positive outcome. I am speechless.

However, that's not the problem. Further down in the article, a video accompanies it captioned 'Live Cesarean: graphic 2013 video of birth broadcast on Twitter." Okay… except that's not the Australian woman's birth they're showing. In fact, it's from a hospital in Texas, something the Mail doesn't exactly explain beforehand and most people from their UK readership didn't pick up on (including, apparently, all the American accents in the room).

How this had anything to do with this woman's birth is beyond me, but it sure makes for great fodder for readers to totally attack her - everything from her looks, to her birthing practices, to a "DIY birth" (which it obviously was not). Some even criticized the weight of the babies, for whatever reason. At any rate, it did nothing to advocate for alternative choices in birth and only made the mother look like a total freak (if you trust the people commenting).

Thanks for totally misleading your readership, Daily Mail. Not that that's anything new, apparently…

Dr. Samadi's commentary on Fox left a lot to be desired,
namely the idea that there is more than one way of
treating thyroid disease - not to mention that many
doctors are neither well-versed in or willing to treat more
complicated cases.
January is Thyroid (Un)Awareness Month
Like bajillions of other Americans, I have thyroid disease, and it's a topic I've written about a lot. I've also basically forced myself to get educated on it in order to understand what was happening to my body, because I found that my doctors were not always that knowledgable. Apparently these guys are no exception.

Dr. David Samadi is apparently one of Fox News' resident doctor experts, which in and of itself isn't bad - except he's a urologist commenting on thyroid disease. Since the two aren't obviously related, I was puzzled why he was weighing in on the subject. While I realize they have time constraints on the broadcast, they really do reflect a serious problem with misinformation and an overall lack of education on the subject, which can often leave patients untreated or improperly medicated.

While I do give him points for mentioning more than just the TSH, it's important to know what to do with the results. Just this week I heard a patient say how enthusiastic their doctor was about ordering tests, even though she'd admitted there were some she had never heard of, but then also admitted she had no idea what to do with the results of the bloodwork. That doesn't help you very much as a patient, but at least she was being honest.

Another expert, NYU Medical School internist Dr. Mark Siegel, gives a very watered-down, extremely over-simplified and perhaps even dismissive explanation. His commentary also left a lot to be desired, and outraged a number of people in the comments who have firsthand experience with the disease.
"Here's the good news…[this] is so treatable… if you have low thyroid, I can give you something called levothyroxine. [It] just replaces the thyroid and you're back to normal. It's a great, great medication." 

Yes. Well. If you do well on levo, that's your business. Not everyone does, and while some prefer the name brand equivalent, Synthroid, some would rather choose neither and use Armour Thyroid instead - but you usually won't catch a single mainstream physician mentioning that in an article about hypothyroidism. Whether it's intentional or not, Synthroid is usually the only drug mentioned, which misleads patients into thinking Armour has been pulled from the market or simply doesn't exist anymore.

And wouldn't it be great if it were "just" that easy! Just pop a pill and you'll feel like a million bucks in no time. For some, it works great and they're on their way, but for others, it's a constant battle to get a physician to treat them adequately and even take them seriously.

When you catch them screwing up on a topic you're familiar with, it almost makes you wonder what they're telling you about all the other stuff.

Saturday, October 11, 2014

Pinkwashing the breastfeeding and breast cancer studies

It's October, the time of year where you're likely to see a proliferation of those pink ribbons on every item imaginable. You may see pink washing in a number of obvious places, and then in some not so obvious ones.

I saw this meme on FaceBook the other day. Wow, those figures are pretty convincing, aren't they? Or are they? I don't think I would've even noticed had I not just read an article - from a reputable source - that presented very different numbers.

I think I can safely say for all of us that breast cancer is pretty much every woman's worst nightmare. And while it is true, that some studies have found a correlation between reduced risk and duration of total nursing time as well as number of children breastfed, it is not conclusive. Despite everything - the money poured into awareness campaigns and research, "not much research has looked at links between breastfeeding and a lower risk of particular types of breast cancer in particular women."

That also doesn't mean it's an absolute that you won't get breast cancer if you breastfed, long-term or otherwise. I still remember a college professor of mine detecting her cancer literally while she was nursing her baby (who I believe was two at the time). In fact, one of the women commenting on the thread where this was originally shared said she'd been diagnosed with it while nursing her fourth child.

One thing that bugs me a lot about this meme is the complete lack of sources. Where is this information from? The first rule of thumb we learn in any basic composition class is "Always site your sources." When pressed for further data or information, the moderator of the page where this was shared kind of shrugged it off and figured the American Cancer Society would have more information. While I don't think she was the creator of this graphic, she was passing along incomplete information and didn't even realize it.

In fact, the American Cancer Society has something very different to say:
"For every 12 months of breastfeeding (either with only 1 child, or as the total period of a time for several children), the risk of breast cancer decreased by 4.3%, compared to women who did not breastfeed. Risk decreased by 3.4% for each child breastfed, compared to women who did not breastfeed.  This lower risk did not differ by women's age, race, numbers of births, age at birth of first child, family history, or country of residence." - American Cancer Society Expert Voices (click here for full article text)  
Something this meme doesn't address are the types of breast cancer impacted, which can be important - because some studies show that breastfeeding can offer protection from certain types of cancer more than others. As the article suggests, the studies are inconclusive, but so far seem to show more risk reduction for hormone receptor-negative cancers, which are more aggressive. While there is some evidence that breastfeeding can impact rates of hormone receptor-positive cancers, (which are the most common and are 'fueled' by estrogen), in my own reading I found it difficult to determine statistically how much protection was offered, and was concerned that advocacy groups and the general public are simply lumping the two together as one.

It took me awhile, but I was finally able to find the source for this meme's data, a study done in Sri Lanka on a very small group of women (100 cases with cancer, 203 controls). (It's also interesting to note that this study found a correlation between past abortion and cancer rates, but we won't even go there.) Unless you're from Sri Lanka, this could give women a very false sense of confidence.

That's not to say that there isn't some very promising, important data to consider, like these studies:

Delaying childbirth may reduce the risk of an aggressive form of breast cancer - from December 2012. Studies have shown that delaying the age of your first birth by at least 15 years after your first menstrual period could reduce the risk of rare but aggressive triple-negative breast cancer, by as much as 60 percent. While uncommon, it does not depend on estrogen to feed it, and is therefore unresponsive to conventional drugs like Tamoxifen. It accounts for roughly 10-20 percent of breast cancers.

Breastfeeding can reduce the risk of certain types of breast cancers. Recent studies have shown that breastfeeding can reduce the risk for estrogen receptor-negative and progesterone receptor-negative cancers, in women who had three or more children and did breastfeed. Risk was elevated in multiparous women who did not breastfeed. This type of cancer often strikes younger women and has a poor outlook. (The study also showed that in women who never had children, their risk decreased by 40% for hormone receptor-negative cancers, but went up by the same amount for hormone receptor-positive cancer.)

Race can also be a factor in hormone receptor-negative cancers: African-American women who had four or more children but never breastfed are 68% more likely to get this type of cancer, compared to women who had only one child but did breastfeed. Studies showed that with each child breastfed, the risk declined. The study also showed that among African-American women who had given birth four or more times, there was slight protection against hormone receptor-positive cancers, regardless of whether they breastfed or not. The same was found for white women.

"The higher incidence of ER-/PR- breast cancer in African American women may be explained in part by their higher parity and lower prevalence of breastfeeding relative to white women." - Julie Palmer, ScD, MPH, senior epidemiologist at the Slone Epidemiology Center and professor of epidemiology at Boston University School of Public Health 

• A Canadian study showed promise for those with a family history of breast cancer - specifically those with the BRCA1 gene (which is more often hormone receptor-negative), stating that breastfeeding for a year could reduce their chance of cancer by 32%, and with "each year of breastfeeding, it reduced their risk by 19%. "With two or more years of breastfeeding, that risk was nearly cut in half. Researchers "calculated that just five women with the BRCA1 gene needed to breastfeed for a year to prevent one developing cancer." It's important to note, however, that these benefits were not observed with women carrying the BRCA2 gene (which is more frequently hormone receptor-positive).  

An earlier US study found, however, that among women with a family history of breast cancer, there was a 59% reduction in risk of getting premenopausal breast cancer, but did not specify which type. (Most likely it is hormone receptor-negative.) The study also noted the duration of breastfeeding did not seem to make a significant impact, and noted "the reduction in risk was similar whether women breastfed for a lifetime total of three months or more than three years." Nor was there a difference noted among women with no family history.

Personally, I think it's important to look at several things when presented with statistics: first, what is their source? Is the study old, and have newer, more accurate studies come out since then? What population did they study? What factors did they include, or exclude?

For instance, an interesting study was conducted by a Chinese researcher at Yale University, which was entirely comprised of Chinese women, mainly because he claimed they have substantially longer breastfeeding rates than the United States. His research (which was published in 2001) looked at three studies conducted in the 1980's, not long after China adopted their infamous one-child policy. Given what we now know about cancer rates and multiparous women and their breastfeeding habits, it is a wonder he could find any woman who had managed to give birth more than once to even do the study. (The one-child policy applies to roughly a third of the population, but the overall parity rate of Chinese women as of 2013 is about 1.5 children, suggesting it has become a cultural standard to have lower birth rates overall.)

While he found a "50 percent reduction in breast cancer risk among those women who breastfed for more than 24 months per child, compared to women who breastfed their children for less than 12 months," it's interesting to note that according to this article, China's breastfeeding rates have "plummeted since the 1970's" when infant formula was introduced. In the 1980's, when these studies were conducted, breastfeeding rates in China were at their lowest.

While this might be good news for Chinese women, it is hard to tell if it correlates to Western women for a number of reasons. Dietary and lifestyle differences can also impact cancer rates, and vary widely between East and West populations. And while this study was published in 2001, as of now roughly 58% of Chinese women exclusively breastfeed their newborns, whereas it drops sharply to around 14% by five months, making it on par with the United States. (And by month six, it nosedives to an alarming 2%.) As of 2013, it was declared that China's breastfeeding rates were "among the world's lowest."

The researcher claimed, "In Chinese society, it is socially acceptable to breastfeed for a long time." Could it really have changed that much in a little more than a decade?

Either way, we need to be careful not only in how we share the data, but how we interpret it. When reading these kinds of statistics, pay close attention to what sources, if any, are listed. Likewise, realize that there could be flaws, unanswered questions or stipulations in those numbers that are not reflected in a meme that merely spews out numbers without proof, leaving the reader with a false sense of confidence and security about a very serious topic. It's important to not take the data as a personal attack as long as it's shared appropriately or dismiss the benefits of breastfeeding for both mom and baby. Likewise, studies should be shared without judgment or hostility. Whether in sharing or interpreting this data, it's so important to get the facts straight and understand the caveats that could seriously impact our understanding of our own level of risk.


The Chinese government really, really wants babies to breastfeed - (a good piece that is particularly damning of the heavy influence of infant formula in the Chinese market) 

Friday, September 26, 2014

A glimpse into 1950s parenting: The A-ha Moment

When we think of typical 1950s parenting, we picture dad coming home from work, belt in hand; mom is perfectly made up and ready for bridge club, remote, distant, and oblivious. But when I came across an article from 1957
in an old magazine I bought at an antique store, it made me smile to think there were parents even then who "got it."

"I wish I had stopped a little oftener to think, "Does this really matter? Is it more
important to them than to me?"
There were the Dr. Spocks and other experts who warned you about the dangers of spoiling your babies, how to introduce solids by four weeks and all kinds of other "advice" that is truly horrifying to think of today. Sometimes you wonder if these "experts" even had children themselves. Even Dr. Spock, in his twilight years, regretted the advice he dispensed and backpedaled on his own message. It's sad that for some, it took a lifetime to realize; for others, like the author of this article, thankfully we stopped to realize a bit sooner that maybe there is more to life than spanking, yelling and rigid, unbending schedules. Hopefully we can all find a happy medium.

Thursday, September 18, 2014

Reply turned post: The Beauty of OB

You often see posts like "Confessions of a Labor Nurse," or "Why You Need Pitocin in Labor" (I think poor Nurse Jenna removed that post a long time ago) and they're supposed to be touchy-feely, feel good pieces that make you come away with a renewed sense that childbirth is such a special time, that your care provider really does care about you and your child and they only want the best for you. Which sometimes comes at a high price, we know. Sometimes an induction, a cesarean, difficult labor and delivery - they all can happen and are often a rite of passage before entry into motherhood. 

It's hard for me not to be cynical about it. But to cut to the chase, sometimes I think the true beauty of OB is that women still want, and manage, to give birth at all after being subjected to the institutional abuses and misuses that are so typical of modern obstetrics. 

That isn't to say I'm critical of lifesaving measures, or that I'm saying, "All cesareans are unnecessary!" I'm more critical of abuse of care and intervention that is misconstrued as good care, when really, it's excessive and sometimes pointless, sometimes causing the problem you're trying to prevent in the first place. 

But I feel like all these posts have an overtone that says, "You should be thankful. Now shut. up."

The author of this article over at Huffington Post is an L&D nurse. I'm not, and I'm not trying to compare my experiences with hers. But as I see so often in these posts, they really don't get to the heart of the matter. They sort of gloss over, or completely miss, whole areas that are often untouched in our culture of women. The idea that women often come home without a baby, or sometimes never come home themselves, is incredibly tragic. No one is arguing with that. Modern obstetrics has saved many lives, both mothers and babies, and yet the place we are in today is proof of how its overuse can taint our perception of things so much we can't see what's really going on. 

Often the women who are missing, shattered or empty, as the writer mentions, are not only the ones who never survive childbirth or come home to an empty crib. They are often women who look normal and whole on the outside, with perfectly healthy children. We cannot discount their experiences and just assume that everything is perfectly normal and right because we can't see anything broken, or lost. If a woman is subjected to horrible treatment in labor, sometimes resulting in physical injury, how many times does an attorney refuse to handle her case if she seeks prosecution? Because she and her baby both appear healthy and happy on the outside? If no one is physically maimed or dead, they don't even want to talk to you. 

The author mentions staying healthy in pregnancy and waiting for active labor as ways to have a healthy delivery, avoiding induction unless for a medical reason. But unless you know what some valid medical reasons are (and more importantly, aren't) anything that comes out of your doctor's mouth is therefore a 'medical reason' and before you know it, the Pitocin is flowing. Staying healthy is relative, unless you're an illicit drug or alcohol user, and even the healthiest, most informed women can still be subjected to dubious care at times. Oftentimes it never seems to be enough. And often has nothing to do with you and everything to do with an impatient, overbearing care provider who is set in his/her ways and refuses to change. 

She mentions the case of a teenage mother who was induced, with no success, and then sectioned. As a result, she hemorrhaged and her uterus was removed. They lamented, rightfully so, over the fact that she would never have any more children. Do they ever lament over how some teen mothers are degraded and insulted because they're young and often unmarried? Or do they consider for a moment that this young mother's complications were caused in part because of the induction, which carries a risk of postpartum hemorrhage? Why do these happy sunshine articles never, ever candidly discuss what goes on behind closed doors, the whispered conversations or blatant remarks when they don't think a patient is listening - or when they don't care if they are? 

Yes, it's great to do all the "right" things in your pregnancy to encourage the best outcome possible. And sometimes, those things happen despite your best efforts. But when you look at these figures, it's hard to see the "beauty" in OB, only the ugly side that makes it seem like the deck is stacked against you. 

For the original graph and accompanying post, click here
Source:,  Rebecca Dekker, PhD, RN, APRN 

Thursday, May 22, 2014

Birth History: Death in Childbirth

In the days of our great-grandmothers and beyond, childbirth was often a dreaded, formidable time. Hospitals were usually avoided as places where only sick people went, usually never to return. The possibility of death while giving birth loomed over a woman as she came closer to her due date, overshadowing any joy of her upcoming arrival.

Among the greatest risks to a woman in childbirth were childbed fever, toxemia and postpartum hemorrhage; the last two of which are still a major cause of maternal deaths worldwide today.

Childbed fever, or puerperal fever, is an infection of the female reproductive organs and was one of the most common causes of death in childbirth prior to the early 20th century. It frequently took the mother's life within days of giving birth and was extremely painful. And it was almost entirely caused by the hygiene practices of the birth attendant - which included midwives and physicians.

It's important to make this distinction, because many times people tend to think of midwives of that time period as uneducated, inept, or practicing witchcraft in an unsanitary, ramshackle house. While there were some that did, there were many who were very capable, some even experiencing fewer deaths than their physician counterparts.

A Lysol ad from 1937, referencing
infection control both in hospital births
and those that take place at home. 
It is also worthy of noting that, unlike with neonatal mortality rates, maternal deaths were more likely to happen among women in higher socioeconomic classes: likely because they were more apt to go to hospitals to give birth or have the finances to pay for a private physician.

Dr. Ignaz Semmelweis is often credited with understanding how childbed fever was transmitted: he theorized, correctly, that midwives and physicians were spreading the streptococcus pyogenes bacteria through improper hand washing from patient to patient. He proposed that physicians wash their hands in a chlorine solution prior to delivering a child, an idea that offended fellow doctors. Despite his repeated attempts to educate healthcare workers on proper hygiene, they often ignored his requests and refused to believe they were, in fact, contributing to the problem - even as maternal deaths were decreasing among those who practiced Semmelweis' hand washing guidelines.

When he first introduced the protocols in a Vienna obstetrical clinic in 1847, the rate of childbed fever deaths in the doctors' wards was three times higher than that of the midwives' wards.

Decades before Semmelweis' work, physician Alexander Gordon made similar observations as early as 1790. His ideas were not well-received and he was essentially run out of practice. Later, physician Oliver Wendell Holmes came to the same conclusions, only to be equally rebuffed and ignored.

It literally took decades - roughly half a century - before physicians started admitting that perhaps they were indeed the cause of infection and deaths in so many women. And even then, it wasn't until around the 1930s when cases finally started to become scarce, due in part to better hygiene practices, more sanitary birthing conditions and the introduction of antibiotics and sulfa drugs. During Semmelweis' work in Austrian maternity wards, handwashing alone led to a dramatic lowering of maternal deaths.

It was 1925 when my great-grandmother delivered her last babies, a set of twins, at home. The doctor was called in - who I later discovered had questionable hygiene practices. Even then, after much was known about controlling the spread of infection, obviously some continued to disregard it. In my opinion, it's not enough to say "Women died in childbirth before modern obstetrics. You should be thankful your physician does X, Y, Z to make sure you and your baby is safe." Most of us know that maternal deaths were far more common, but do we understand why? One birth blogger who spent an unusual amount of time criticizing the natural birth movement wrote about 'those headstones in a graveyard of all those mothers and infants who had died because of natural childbirth.' (Paraphrasing a bit here, as it's been a few years ago since I read that. But still, that was the gist of the message.) One thing I have noticed: when discussing maternal deaths, many sources will completely gloss over the cause, as if it was just an unfortunate problem that happened for no reason.

Puerperal fever is still a risk of childbirth today, but in many cases we have different names for it. Although rare, it does still claim the lives of women. No longer known as 'childbed fever,' it is not unusual for women to develop fevers during labor, which are usually treated with imminent delivery, cesarean section (which alone can increase risk of infection) and antibiotics at the first sign of a problem. Chorioamnionitis, an inflammation of the fetal membranes, is caused by a bacterial infection that tends to occur in longer labors. Among the risk factors are repeated vaginal exams and internal fetal monitoring.

It is true that in many ways, modern obstetrics has saved countless lives of both mothers and babies. But you have to have some perspective on the reasons why many women died -  reasons that were primarily iatrogenic in nature - death brought about by the very people who were supposed to save them.

Childbirth in Early America - Digital History
British maternal mortality in the 19th and 20th centuries - National Center for Biotechnology Information
The Attempt to Understand Puerperal Fever in the Eighteenth and Early Nineteenth Centuries: The Influence of Inflammation Theory: National Center for Biotechnology Information

Saturday, May 17, 2014

Birth History: A Dysfunctional Culture

May is Pregnancy Awareness Month, and while I've covered some of these topics before, I've been planning to put them together in more of a series for quite some time now. There is so much to learn while pregnant, and it can get quite overwhelming when you're faced with decisions that range from the mundane to the life-changing. So much of how our medical community views pregnancy, however, is still deeply rooted in old traditions and practices, some of which were, and continue to be, groundbreaking in the field of obstetrics. Some, on the other hand, not so much.

I once heard someone say how hard can it be? You go to the hospital and push out a baby. If only it were that easy. And if you go behind the scenes much, it's probably never been that easy, for reasons that are often not clear to us until we experience childbirth ourselves. Even then, without some historical perspective, we may not realize just how dysfunctional maternity care in this country still remains, probably a century later.

Many maternity care practices were nothing short of barbaric and humiliating, yet were seen as standard practice and therefore somehow acceptable. Whether it's having your hands tied down in labor, being given pain medication that you feel you don't want or need (as we see in Peggy Vincent's Baby Catcher) or given prophylactic episiotomies and forceps births (we'll get to that later), it's all been considered status quo in "modern" obstetrics. And yet, as we see with new guidelines on episiotomy, VBAC and other protocols, it can be painfully slow to implement these changes.

You can't begin to understand the 'typical' mindset towards birth today unless you understand its history. It is a bright spot in some places, in others very dark and tarnished.

You might want to read:

Birth: The Surprising History of How We Are Born

Friday, March 28, 2014

Buffalo offers nation's first abortion clinic/birth center in one facility

By now you've probably heard about the nation's first abortion clinic and birthing facility all rolled into one, located in Buffalo, New York. Not surprisingly, it hasn't been without controversy.

At first, the idea of it did bother me. But I began to realize that to me, at least, that's not even the issue.

When talking about this groundbreaking facility, many people - both those who are pro-choice and pro-life - focus primarily on the abortion aspect. The fact that it's opening a door, albeit a small one, to women who want to 'birth outside the box' has pretty much gotten lost in the discussion.

Some articles, like this one, do touch on the birth aspect but in a very general sense. Of course the writers at Cosmo probably have no idea what it's like to give birth here. But this area, which comprises an eleven-county region, has, according to the Yellow Pages, at least six facilities that offer abortion, which no doubt translates into dozens of care providers. How many freestanding birth centers do we have in the area? One. How many in the entire state? Three.

Three freestanding birth centers in the entire state. 

Image: Fernando Audibert/stock.xchng
I'm sure there are other states that have zero birth centers in them. But I bet even those states offer abortions, even those that "set limits" on doing them. But they're still doing them. Where are those places that have tons of freestanding birth centers? Or hospitals that are truly, instead of just on paper, designated as 'mother and baby friendly?' Why is the outrage over lack of access to home births, birth centers and non-traditional birth in general seemingly boxed into a very small corner and only discussed by relatively few people in comparison?

I'm sure it wouldn't be hard to find a number of pro-choice people who think home birth is dangerous, VBACs are reckless, and that hospital birth is the safest option for pregnant women. The sheer volume of abortion facilities tells me that even with limitations, there is probably more access to abortion than there's ever been.

However, if you're giving birth in Western New York, you may have obstacles depending on what kind of birth you want. While Buffalo is indeed a major city, there are also outlying rural areas that are up to an hour away from the city. One hospital has gone on record as saying they'd "get a court order at 2 a.m." if they had to, to prevent you from having a VBAC, but it's hard to say if that's true or just a scare tactic. If you're giving birth in that hostile environment, you may not be emotionally strong enough to take that chance.

Other options include a home birth, which not everyone is totally comfortable with. I know some who've birthed in their midwife's home close to the hospital, but again, the midwife can only see so many patients.

I've heard people say they labored in the parking lot outside the hospital, knowing they'd be hooked up to monitors if they went in too early. Others willingly drive an additional 45 minutes to an hour away in another county to give birth at a "friendlier" hospital with a lower cesarean rate (but a much higher rate of births attended by midwives). Judging from the data, it's quite clear in a number of areas that evidence-based practices are not being performed.

So far several of our hospitals still allow VBAC, but in my experience it was hard to find overwhelming support from doctors (and even midwives) when choosing one (and the numbers speak for themselves). Many women, I'm sure, are easily swayed not to even bother attempting one if their doctor isn't enthusiastic about it. Besides myself, I know only a handful of women who've VBACed. The rest just look at you like you're crazy.

It saddens me deeply that among my friends and acquaintances, most of us have had cesareans, some multiple times. I myself have had two. Among the three women I've talked to recently, I realized that between us, we had ten cesareans total. If I widen that scope, it racks up pretty quickly - to the point where vaginal birth seems to be somewhat of an anomaly.

Why? One reason is likely because of inductions. That one act - inducing labor - can trigger a domino effect that can make your chances of vaginal birth slim, at least around here. I've known women who were induced simply because of their geographical distance from the hospital, with the doctor joking, "You don't want to give birth on the New York Thruway."

Here's how a few facilities in the Western New York region (which comprises eleven counties) stack up: (For the sake of boredom we'll look at two counties.)
Data is from 2012. Note the rate of induction, 
which is substantially higher than both state and local averages 
(down only slightly since 2011).  This hospital serves a number of rural
women in outlying areas surrounding the city. VBAC rates are much lower
than the already predictably low state average. The cesarean
rate actually increased slightly in that time period. 
When I first gave birth, it was at this hospital, and not a very happy experience. Maybe things have improved a little since then?

Across town, induction rates are just as bad, as compared to
state averages. Relatively few births (22 in all) were
attended by a midwife. Episiotomy rates dropped only slightly
from 2011, as did the cesarean rate. 
Located in a fairly remote area, your choices are
further limited in neighboring Niagara County. We can
reasonably assume the VBACs (and probably all breech
births in this entire data set) were unintentional. Still higher than
state average episiotomy rates persist, more than half of
women have labor augmented (which increased from 2011),
cesarean rates are high (which also increased, from 35.5%) and for
some odd reason, they had a relatively high rate of
cesareans performed under general anesthesia. No births
were attended by midwives. 
The c-section rate went up from 51.4% in 2011. There
were no births attended by midwives in both 2011 or 2012.
According to the ICAN VBAC policy database,
VBACs are banned at this facility, and they have one
of the highest cesarean rates in the state.  
A rather alarming episiotomy rate (that was 42.9% in 2011).
"We don't often deliver babies, but when we do,
they're mostly by c-section." 

It's such a hurdle, to essentially change the birth climate of an entire city, and even more so, the entire region - and like anything else, when change finally happens, it's often painstakingly slow. I bet most women in need of an abortion would know where to find one, but for a normal, let alone natural birth, they'd probably have to search, maybe even fight for it. With the overwhelming number of clinics throughout the state (New York City alone has dozens) that serve those who wish to have an abortion, it still seems clear that that is their primary focus, not how to have a happy childbirth. If we're going to recognize reproductive rights, we can't ignore the needs of the laboring mother.