Mama's Got a Plan:

Maternity Care, Health Insurance, and Reproductive Justice

Tag Archives: evidence basis


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Separation anxiety

C

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You wouldn’t cut the rope of someone rappelling down a mountain, would you? The umbilical cord fulfills a similar lifeline function for a newborn: it delivers oxygenated blood to the baby until Junior’s lungs expand and begin to function. With her usual wisdom, Nature has provided this backup because she knows that newborns do not always breathe immediately. So why the widespread and persistent belief that the cord must be cut, or at least clamped, immediately after birth?

The medical record

A 2012 article1 describes the origin of early cord cutting:

The first records of cutting before placental delivery hail from the 17th century. It has been suggested that changes in third stage management accompanied the emergence of male midwives; it became normal practice to deliver women in bed, thereby decreasing the likelihood of spontaneous delivery of the placenta …

In other words, the prone position demanded by new-fangled male birth attendants caused a slower or problematic delivery of the placenta, which then dispensed with the need to wait for the placenta to cut the cord. It makes as much sense as anything else. Providers also believed there to be little benefit in preserving the umbilical cord because the blood flow was so brief:

The contribution of the umbilical arteries was considered to be minimal as it was thought that arterial flow stopped within 25–45 s[econds]. However, no explanation for this cessation of flow was provided …2

One reason that practitioners might have believed blood flow to stop within 45 seconds after birth is that by clamping and cutting the cord immediately after delivery of the newborn, they caused it to stop! Other scientific rationales for early cord cutting included:
  • The desire to prevent analgesic or anesthetic medications administered to the mother from reaching the infant. Of course, these medications would already have crossed the placenta to the prenate* in utero, but it’s hard to argue with a harm reduction approach.
  • As early as 1938, placental and umbilical cord blood began to be used in transfusions.1 The value of this particular blood was recognized again in the 1990s after the function of stem cells became better known. Costly services offering “cord blood banking” cropped up; they persuaded anxious new parents to collect this blood and store it against the possibility of their newborn developing diseases years in the future for which stem cells might be the cure.
  • Newborn resuscitation in contemporary medicine is facilitated by very specialized tools. The baby is typically removed to a surface on or near a crash cart; an intact umbilicus is a hindrance to this removal. 
  • The outdated belief that blood from an uncut cord will flow backwards, out of the newborn, continues to find traction among medical professionals.
  • One also cannot discount the effect of institutional inertia, the perceived need to preserve hospital routines that promote speed and consistency (which then frees up expensive and in-demand physician time), and an inclination on the part of some medical professionals to invest the results of their early medical education with a carved-in-stone quality.
Whatever the rationale, premature clamping and cutting of the cord causes one very distinctive harm: It deprives the newborn of approximately one-third of its total blood volume. This puts the infant at risk for iron deficiency, which in turn may have neurological consequences.3 With many young children in the United States already at risk for iron deficiency from other causes, such as premature birth or lead poisoning, the need to transfuse as much blood as possible into the newborn seems particularly important. That’s the roundup on premature cord cutting from the medical community. But really …

We blame Hollywood

Fictional representation of birth on the silver screen and TV always features:
  • labor beginning with water breaking (8% in reality!) and sudden, immense pain
  • birthing person screaming in pain
  • the phrase (directed at male partner) “You did this to me”
  • whether in or out of hospital, birthing person lying on her back
  • someone telling birthing person to PUSH (or occasionally “don’t push!”)
  • and, of course, immediate clamping and cutting of the umbilical cord following birth of baby
The photo below, that shows an elevator birth in a 2004 episode of Joan of Arcadia, is typical of precipitous birth depicted onscreen. For whatever reason, people seem to fixate on the shoelace. Even Embezzler Home Birth Dad, who surely should know better, feels the need for one. With such depictions so ubiquitous, it’s hardly surprising that parents, first responders, and even medical providers believe that immediate clamping and cutting of the cord is an urgent necessity. Fortunately, care of the cord following a precipitous birth is remarkably simple: Do nothing.  Want to know more? The 2016 article How to Deliver a Baby (If You Absolutely Have To) provides an excellent set of instructions for supporting a birthing person through a birth in an unplanned location at an unplanned time. We take issue with the headline “You birthed a baby!” since it seems to attribute that accomplishment to the person assisting, rather than to the one who has just produced a new person, but in the face of so much otherwise sound information, we’ll forgive the article’s editors that small oversight.
*Prenate. We use this term, coined by Rebecca Todd Peters4 as a neutral descriptor of the being in utero.

Bibliography

  1. Candice L Downey and Susan Bewley, “Historical Perspectives on Umbilical Cord Clamping and Neonatal Transition,” Journal of the Royal Society of Medicine 105, no. 8 (August 2012): 325–29, https://doi.org/10.1258/jrsm.2012.110316.
  2. I Boere et al., “Umbilical Blood Flow Patterns Directly after Birth before Delayed Cord Clamping,” Archives of Disease in Childhood – Fetal and Neonatal Edition 100, no. 2 (March 2015): F121–25, https://doi.org/10.1136/archdischild-2014-307144.
  3. Judith S. Mercer et al., “Effects of Delayed Cord Clamping on 4-Month Ferritin Levels, Brain Myelin Content, and Neurodevelopment: A Randomized Controlled Trial,” The Journal of Pediatrics 203 (December 2018): 266-272.e2, https://doi.org/10.1016/j.jpeds.2018.06.006.
  4. Rebecca Todd Peters, Trust Women : A Progressive Christian Argument for Reproductive Justice (Boston, Massachusetts: Beacon Press, 2018).
  5. Judith S. Mercer and Debra A. Erickson-Owens, “Rethinking Placental Transfusion and Cord Clamping Issues:,” The Journal of Perinatal & Neonatal Nursing 26, no. 3 (2012): 202–17, https://doi.org/10.1097/JPN.0b013e31825d2d9a.

Image credits 

All images are shared under a Creative Commons license, unless otherwise noted. Where required by license, changes to the image are noted.
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Viral flight


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An Epidemic of Home Birth?

As if the U.S. maternity care system didn’t have enough challenges to deal with – a spot of obstetric violence here, a 4-fold racial disparity in maternal mortality there – now there’s that dang Coronavirus! It should come as no surprise that both hospitals and pregnant people might now find themselves with qualms about the practice of giving birth in hospitals.

One potential objection is that healthy people about to give birth might be wary of doing so in a place filled with sick people with a highly contagious disease. The other concern, from the hospital’s point of view, is that facilities and providers might well be strained to the maximum by the exigencies of caring for pandemic patients.

As a result, even parents-to-be who would not have chosen home birth before might find themselves considering it now. It’s not a bad idea! A majority of pregnant people are healthy and are good candidates for home birth. (For comparable safety data on place of birth, see our post here for starters. For more recent data, see the just-released Birth Settings in America report or this summary.) We won’t pretend that hospital-based experts recommend home birth, but others have weighed in on the benefits of separating out healthy mothers and babies from COVID-19 sufferers. None of this is news: in past epidemics, some pregnant hospital patients have switched their planned place of birth.

In order to make out-of-hospital birth possible for many families, however, appropriate providers must be found to attend those births. The good news is that midwives, particularly Certified Professional Midwives, are currently practicing in almost every state. How those states facilitate access to that care is another matter. CPM practice is legally authorized in 35 states, but each state has different views on CPM scope of practice, Medicaid coverage, and many other issues. In the remaining states, CPM practice exists on a spectrum from unregulated to illegal status. 

If ever there were grounds for support of these maternity care providers who specialize in out-of-hospital care, the COVID-19 pandemic provides it. States must use the emergency police powers available to them to facilitate access to CPMs, and hospital-based medical providers must turn to the important work that only they can do and stop opposing what pregnant people want: the option to give birth in the place of their choosing, attended by a provider of their choice.

Image credits 

All images are shared under a Creative Commons license, unless otherwise noted. Where required by license, changes to the image are noted.

  • Frame 1: The cityscape image is by Ricinator.
  • Frame 2: The car racing to the hospital is from a photo on  ph.
  • Frame 3: The ultrasound scene is by artistraman. The busy hospital exterior is a cropped version of a photo by PAspecialNHCL. 
  • Frame 4: The messy dining room is by Hans. The pregnant woman is by readingruffolos. The child with fingers in his nose is by ranjatm. 
  • Frame 5: The bedroom is from pxfuel. The doctor is by OpenClipart; the image is in the public domain. The hand reaching for the button is selected from an image from pxfuel. Helper midwife is cropped from a photo from AllGo. The red carrying cases at her feet are by Dids. The wall portrait is by pxfuel, as is the children’s drawing. At the head of the bed, the map of licensed states is from The Big Push for Midwives; a larger copy is included in the blog text above. The primary midwife is by Tosha Noakes.


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Weed whacking

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The last few years have seen an increase in states working to decriminalize recreational marijuana use by adults. Apparently, the U.S. Surgeon General believes that only illegal status was preventing pregnant people from puffing their nine months away, because this year he issued a strong warning against marijuana use during pregnancy.

This cartoon addresses criminalization of marijuana use rather than a generalized warning, but the fact is that laws that criminalize drug use during pregnancy and issue special penalties for it already exist and women are being charged under them. Furthermore, even in decriminalized states, mothers still face consequences for marijuana by way of the child welfare system; sanctions can include one that many mothers would rate even worse than the loss of their liberty: the loss of their child. These repercussions seem vastly disproportionate to the drug-using behavior, considering the following facts:

  • The effects of marijuana use during pregnancy are often overstated in the absence of concrete data.
  • The effects of marijuana use during pregnancy are often confounded with other substance use – including alcohol and tobacco, which are far more dangerous to the baby than any illicit drug.
  • The effects of marijuana use during pregnancy are often confounded with socio-economic status and with disparate effects by race, including uneven enforcement, uneven consequences, and uneven expectation of privacy. Indeed, the effects of intervention itself in the form of child welfare agencies cannot be classified as benign; certainly, separating babies from their mothers in the first hours of life isn’t good for either party.

Sanctions, whether threatened or real, scare pregnant people away from prenatal care. When so many things in our lives are bad for babies (job loss, environmental pollution, violence against women), this fixation with a substance whose harm hasn’t even been fully established looks like just another way to criminalize pregnancy. In addition, when marijuana use is legal, punishing users might serve as the bridge to criminalizing tobacco and alcohol use. Or consumption of runny cheese! Or hot tub use. … Or living in a neighborhood where the water has been turned off, homes have been foreclosed upon, and the factory next door belches a queasy-making smoke that the municipality assures residents is Perfectly Safe. 

If we want pregnancy to result in healthy babies and healthy mothers, perhaps we might concentrate on known dangers and support parents in ways that don’t involve a) a jail cell, or b) the threat of separation on the single most important day in a brand-new person’s life.

Suggested reading

Image credits 

All images are shared under a Creative Commons license, unless otherwise noted. Where required by license, changes to the image are noted.

  • Frame 1: “Reefer Madness” poster (“drug-crazed abandon!”) is from Wikimedia Commons. The image is in the public domain.
  • Frame 2: Policymaker and scientist/doctor are by Mohamed Mahmoud. RJ Truthteller is borrowed from another cartoon that states the image source.
  • Frame 4: Pregnant woman is by Thiago Borges. Health Department is by Michael Rivera; the image was cropped.
  • Frame 5: The photo is by Patricia Deal, and is in the public domain. Because this photo portrays a real person, we wish to emphasize that the pregnant woman pictured did not speak the words we put in her mouth. In no way do we wish to suggest that the circumstances suggested by those words apply to her.