… Documents … allege a midwife ignored and turned down the volume of an echocardiogram alarm that sounded for more than three hours …

The documents also claim Mrs Body was diagnosed and treated for deep vein thrombosis and thrombophilia (blood clotting) …

She alleges the hospital ought to have known her medical history and the risks associated and failed to recognise a natural birth “could not be performed safely”.

The documents show Mrs Body was admitted to hospital at 8am on February 26, 2007, and was monitored at half-hour intervals between 9.30am and 3pm.

Her waters were broken by a doctor about 4pm and at 4.30pm an epidural was administered.

For the past seven months, the state Department of Public Health declined to release a report outlining the trend.

California Watch spoke with investigators who wrote the report and they confirmed the most significant spike in pregnancy-related deaths since the 1930s. Although the number of deaths is relatively small, it’s more dangerous to give birth in California than it is in Kuwait or Bosnia.

“The issue is how rapidly this rate has worsened,” … “That’s what’s shocking.”

… “current trends and evidence suggest that maternal mortality rates may be increasing in the U.S.”

The alert asked doctors to consider morbid obesity, high blood pressure and diabetes, along with hemorrhaging from C-sections, as contributing factors.

… Shabbir Ahmad, a scientist … decided to look closer. He organized … a systematic review of every maternal death in California. It’s the largest state review ever conducted. The group’s initial findings provide the first strong evidence that there is a true increase in deaths – not just the number of reported deaths.

Changes in the population – obese mothers, older mothers and fertility treatments – cannot completely account for the rise in deaths in California …

… scientists have started to ask what doctors are doing differently. And, he added, it’s hard to ignore the fact that C-sections have increased 50 percent in the same decade that maternal mortality increased. The task force has found that changing clinical practice could prevent a significant number of these deaths.

… While the maternal mortality rate among black women is rising, the task force found a more dramatic increase in deaths among white, non-Hispanic mothers …

… In 1996, the maternal death rate in California was 5.6 per 100,000 live births … Between 1998 and 1999, the World Health Organization changed its coding system, which may have increased reporting of deaths. The California rate was 6.7 in 1998 and 7.7 in 1999. Because the number of mothers who die is small, the rate tends to fluctuate from year to year.

In 2003, when California revised its death certificate, the rate jumped to 14.6. And in 2006, the last year for which data is available, the rate stood at 16.9.

… When researchers unveiled their initial findings to a conference of the American College of Obstetricians and Gynecologists in 2007, there were gasps from the audience … The idea that California was moving backward even in an era of high-tech birthing was implausible to some. Confirmation of the trend was noted in the 2008 report …

The state of California has yet to share the report with the public. Researchers say that, after reviewing the report in 2008, officials in the Department of Public Health asked for technical clarifications. Revisions were complete and approved in the first half of 2009 …

… it is important for the public to be aware now that these trends are worsening …

“Even though they tend to be small numbers in terms of maternal mortality, it is important – it’s very important – that these trends be looked at,” she said. “And efforts need to be made to try and reverse them when they are going in the wrong direction.”

Rising C-section birth rate

Nearly one in three babies is now born by C-section. Many scientists have acknowledged that at some point, as the number of surgeries spiral upward, the risks will outweigh the benefits. But the C-section remains a useful tool, and in the middle of labor, doctors say, it’s hard to balance the potential long-term harm against immediate crisis.

Today, doctors face a condition called placenta accreta, where the placenta grows into the scar left by a previous C-section. In surgery, doctors must find and suture a web of twisted placental vessels snaking into the patient’s abdomen, which can hemorrhage alarming amounts of blood. Often, doctors must remove the uterus.

Main said this complication from C-sections has increased eight-to-10 fold in the past decade. Nonetheless, most women survive the ordeal … the rise in deaths is indicative of a larger problem.

“For every maternal death, there are 10 near misses; for every near miss, there are 10 severe morbidity cases (such as hysterectomy, hemorrhage, or infection), and for every severe morbidity case, there is another 10 morbidity cases related to childbirth,” …

Inducing labor before term more common

… Dr. David Lagrew … noticed that a lot of women were having their labor induced before term without a medical reason. And he knew that having an induction doubled the chances of a C-section.

So he set a rule: no elective inductions before 41 weeks of pregnancy, with only a few exceptions. As a result, Lagrew said, the operating room schedules opened up, and the hospital saw fewer babies admitted to the neonatal intensive care unit, fewer hemorrhages and fewer hysterectomies.

All this, however, came at a cost: The hospital had to take a cut in revenue for reducing the procedures it performed. Lagrew doubts that any hospital has increased its C-section rate in pursuit of profit, but he does note that the first hospitals to adopt controls on early elective inductions have been nonprofits.

According to a report issued by the advocacy group Childbirth Connection, “Six of the 10 most common procedures billed to Medicaid and to private insurers in 2005 were maternity related.” On average, a C-section brings in twice the revenue of a vaginal birth. Today, the C-section is the single most common surgical procedure performed in the United States.

“If all these guys were losing money on every C-section, well, what’s the old saying? Whenever they tell you it’s not about the money, it’s about the money,” Lagrew said.

And while Foley said she’s pleased with how her home birth went, and that she would do it again, the issue of the safety of out-of-hospital birth is up for debate.

Statistics show that while the desire for a less sterile, more intimate birth experience is growing, most mothers in the U.S. still have their babies in a hospital. It’s the prudent choice, safer if something goes wrong, experts say.

But it isn’t a simple call.

Family history, health of the mother and fetus, available and trusted midwives and personal preference all weigh in the decision.

On average, only 1 percent of all births in the U.S. are conducted out of hospitals annually …

Tori Kropp, a perinatal registered nurse at San Francisco’s California Pacific Medical Center, says it’s safer to give birth in a hospital.

… hospital births have gotten a bad rap due, in part, to the efforts of home-birth proponents, such as TV personality Ricki Lake.

Lake’s 2008 documentary “The Business of Being Born,” ignited a fire storm by implying many common medical practices may be doing new mothers more harm than good.

Through education and outreach Kropp strives to correct what she says is “misleading” information promoted by Lake’s film. ”

After about 6 hours of active labor, with the help of a direct-entry midwife, Foley gave birth to her son in an inflatable pool filled with water, which is described as a water birth.

… “Pregnancy and childbirth are normal, healthy events in a woman’s life and interventions, such as cesarean sections, should be used only when medically necessary, Winkler said. “Women choose to come to the birthing center for freedom of choice.”

But Winkler cautioned that women who have chronic diseases, such as kidney disease, high blood pressure or diabetes are “safest when (giving birth) at the hospital.”

Planned home births may have a low rate of complications …

Among 13,000 planned births studied, researchers found that the mortality rate was similarly low – less than one in 1,000 – among women who gave birth at home with a midwife, women who gave birth in a hospital with a midwife, and women who gave birth in a hospital with a physician.

… “Birth is safe. It is safe to give birth out-of-hospital when a woman is healthy and having a normal pregnancy,” Winkler said.

But Kropp says even if a woman is healthy, there is still the possibility of complications in childbirth.

Excess weight in and of itself also sharply increased a woman’s risk of pre-eclampsia …

Women have more difficulty delivering very large babies, while these newborns are also at risk of suffering injury during birth, including shoulder dislocation. While women who are overweight or obese are known to run a greater risk of having very large babies and experiencing other pregnancy complications, it has been difficult to separate out the effects of a mother’s weight from those of gestational diabetes …

This led them to investigate whether BMI … a standard measure of weight in relation to height used to gauge how fat or thin a person is — might influence pregnancy risks and fetal and newborn health, independently of a woman’s blood sugar levels.

… women with BMIs of 42 or greater … were at more than triple the risk of having an excessively large baby, compared to the thinnest women in the study …

The heaviest women’s risks of having a C-section were more than doubled, while their likelihood of pre-eclampsia was 14-fold greater than for the leanest women …

… dietary changes can effectively treat gestational diabetes for more than 90 percent of women with the condition.

“… treating gestational diabetes going forward is going to continue to be beneficial,” the researcher said. “We have much less evidence at this point as to how to neutralize or reduce the impact of overweight on pregnancy outcome.”

… mothers should only have a C-section for medical reasons, according to the authors of the World Health Organisation study.

Women who chose a caesarean over a natural birth were 10 times more likely to be admitted to intensive care and suffer severe bleeding.

… “I do get women who ask for a C-section, often because they’ve got a pathological fear of childbirth, fears of pelvic floor problems in later life or have been sexually abused earlier in life, so they choose to have a C-section to avoid any genital tract trauma which would remind them of what’s happened.”

Dr Kliman said Epworth Freemasons had about 20 mother-requested caesareans out of 3500 deliveries a year.

“I tell them it is not necessarily an easy way out,” he said.

“They have risk of haemorrhage, infection and more discomfort after the procedure.”

Vice-president of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, Michael Permezel, said …”If a woman said, ‘I want a C-section’ and had no understanding of the risks, I think most doctors may decline the request,” Prof Permezel said.

The package, called “Getting it right at the very beginning”, has been shortlisted for the “Research into Practice” category of the 2010 Royal College of Midwife Awards.

… “Not only have we had very positive feedback from the women who received the care, but midwives have also seen the benefits.”

11 per cent gave birth without any pain relief and 21 per cent used paracetamol to take the edge off the pain … and more women used natural pain relief like a birthing pool or bath.

Of the group that received the care package, 73 per cent had a normal birth, without any clinical interventions. The Caesarean Section rate was 13.5 per cent.

This compared with a 37.5 per cent normal birth rate for the women who didn’t have the early targeted support, and a Caesarean Section rate of 37.5 per cent.

The care package is a set of six proven actions which work in harmony to benefit the outcome of the labour and give women a positive birth experience.
* L – Look and Listen;
* A – Assess maternal observations;
* T – Time;
* E – Encouragement;
* N – Non-pharmacological pain relief;
* T – Telephone

Rochelle Allan, who wanted a home birth and did not want to be induced, was nearly 14 days overdue when she missed an obstetrics appointment.

… the police were sent to Ms Allan’s home on Friday to conduct a “welfare check” because the midwives could not reach her by telephone.

… the actions of the hospital staff will not be investigated because they had the best intentions and were concerned for Ms Allan.

… a woman should be able to make her own birth choices without someone looking over her shoulder.

“The hospital, they’re service providers, they’re not a regulatory body for pregnant women,” …

“These checks … they’re not mandatory, so it’s entirely up to that woman if she chooses to attend those hospital checks or not.”

Mrs Willicombe and her husband … are now suing the … Hospital … for failing to monitor the baby …

Misoprostol is only licensed … for the treatment of stomach ulcers. Under official guidelines … it should not be used to induce labour unless as part of a clinical trial.

… the drug … is cheaper than other methods to induce birth …

Belinda Phipps, chief executive of the National Childbirth Trust, said she was “absolutely incredulous” that any hospital would give the drug to women …

She said: “This drug is not licensed for use in labour, and the NICE guidance is categorical on that point. In this country, misoprostol should only be used in labour if the baby is already dead, or after the birth, because otherwise the risks are simply too great.”

Mrs Willicombe was not informed the drug was only recommended for use in clinical trials – and nor was she told that she was taking part in any trial.

“I just remember them being very reassuring and saying this drug is fine,” …

… Mrs Willicombe … was not properly monitored and was treated in a room unsuitable for what should have then been classified a high-risk birth.

Within 10 minutes of being given the drug … her waters broke – almost certainly naturally because it was too soon for the Misoprostol to take effect. About four hours later, she was given a second dose leading to contractions which then became more frequent …

… The mother-to-be was moved from the maternity ward to the delivery suite but then placed in a room … without proper monitoring equipment … The midwife then ordered Mr Figus to hit the alarm button. A team of doctors raced in to deliver the baby, the first time Ms Willicombe realised her dream of a first child was turning into her worst nightmare.

“She just came out blue and lifeless,” recalled Ms Willicombe, “She was completely floppy. They held her up very briefly for us to see her and then took her away to resuscitate her … she … suffered severe brain damage due to a lack of oxygen … we agreed to take her off the ventilator. Three days later she died.”

… a coroner in east London concluded Sofia had died of natural causes as a result of neglect.

Their lawyer … said: “It appears clear that Mrs Willicombe received substandard monitoring during her labour with Sofia. This substandard monitoring also needs to be put in to the context of the use of an unlicensed drug which is known to have the side effect of uterine hyperstimulation. It appears that Sofia’s death could have been avoided, had the monitoring been appropriate.”

… inducing labor introduces a risk of 1 to 2 cesareans per 25 inductions that might have been avoided by waiting for spontaneous labor to begin.

… C-sections are major surgeries, and carry risk of infection, bleeding, blood clots, and injury to other organs …

… all labor induced groups faced increased risk for C-section, except for those women delivering after 39 weeks.