ACOG’s newest VBAC guideline changes

In a long overdue updated Practice Guidelines, the American College of Obstetricians and Gynecologists (ACOG) released new guidelines on July 21, 2010 for vaginal birth after cesarean (VBAC).  This will hopefully bring some balance to a growing problem for women’s birth choices and changes on the local level.

For many years, VBACs were offered as standard procedure in most American hospitals.  The former ACOG guidelines recommended that a trial of labor be offered women who fit the criteria as long as a surgical team could be made ‘readily available’.  This generally meant within 30 minutes of determining the need for surgery.  Later, the guideline wording was changed to ‘immediately available’ which would have required that any time a woman was attempting a trial of labor for a VBAC, the surgery team had to be on the premises and ready to perform surgery right away.  There were apparently no supportive studies to justify the wording change, but it quickly became the standard of care and with those two words came many years of women being forced to submit to repeat surgical birth because of the lack of resources to attempt a VBAC.  The new requirement was not practical from the financial or time constraints of the medical facility and physician personnel.  It had nothing to do with the safety issues, but was strictly a financial, time, malpractice and legal issue.

The National Institutes of Health met in March 2010 on the topic of cesarean birth and VBAC and made some recommendations because of the concern over the growing number of cesarean births conducted in our country.  Recent statistics place cesarean birth at around 31% of all births, but many local facilities’ statistics are much higher.  In 1970 the cesarean rate was about 5%.  While a cesarean birth is a life-saving surgery if truly necessary, most experts (including the World Health Organization) agree that the legitimate use of cesarean should be between 10-15% of the birthing population, not the high numbers we are now seeing.  The overuse of induction, medications (including pitocin and epidurals), subjective interpretation of electronic fetal monitors, confinement of laboring women to bed and lack of trust in a woman’s body to birth normally have led to the use of cesarean section in epidemic proportions.  Then because of the lack of VBAC options, women were forced to continue to have repeat cesareans.

The newest guidelines condemn VBAC bans and encourage VBAC as a “safe and reasonable option for most women, including some women with multiple previous cesareans, twins and unknown uterine scars”.  It also states that respect for patient autonomy requires that even if an institution does not offer a trial of labor after cesarean, a cesarean cannot be forced nor can care be denied if a woman declines a repeat cesarean during labor.   The new guidelines also encourage women and their physicians to make a plan for a trial of labor after cesarean (TOLAC) even in institutions where surgical teams may not be ‘immediately available’.  The risk of rupture during a TOLAC is very low, between 0.5% and 0.9%, though circumstances may develop during labor that may require a repeat cesarean delivery.

Women should take the time to educate themselves on their options, discuss and encourage their local care providers and facilities to come into alignment with these newest practice guidelines, and avoid interventions that may lead to a primary cesarean birth unnecessarily. Continued consumer pressure may be the only way real changes in maternity care will occur. For more information, consult International Cesarean Awareness Network at:

http://blog.ican-online.org/

Pit to Distress- disturbing trend

Copied from The Unnecesarean Blog:

Jill from Keyboard Revolutionary wrote about a new term that she recently came across— “Pit to distress.”

“Pit to distress.” How have I not heard about this? Apparently it’s quite en vogue in many hospitals these days. Googling the term brings up a number of pages discussing the practice, which entails administering the highest possible dosage of in order to deliberately distress the fetus, so a C-section can be performed.

Yes folks, you read that right. All that Pit is not to coerce mom’s body into birthing ASAP so they can turn that moneymaking bed over, but to purposefully squeeze all the oxygen out of her baby so they can put on a concerned face and say, “Oh dear, looks like we’re heading to the OR!”

The term is found in this 2006 article in this Wall Street Journal article:

Oxytocin is a hormone released during labor that causes contractions of the uterus. The most common brand name is Pitocin, which is a synthetic version. It’s often used to speed or jump-start labor, but if the contractions become too strong and frequent, the uterus becomes “hyperstimulated,” which may cause tearing and slow the supply of blood and oxygen to the fetus. Though there are no precise statistics on its use, IHI says reviews of medical-malpractice claims show oxytocin is involved in more than 50 percent of situations leading to birth trauma.

“Pitocin is used like candy in the OB world, and that’s one of the reasons for medical and legal risk,” says Carla Provost, assistant vice president at Baystate, who notes that in many hospitals it is common practice to “pit to distress” — or use the maximum dose of Pitocin to stimulate contractions.

It’s also used on this AllNurses forum:

I agree, and call aggressive pit protocols the “pit to distress, then cut” routine. Docs who have high c/s rates and like doing them, are the same ones that like the rapid fire knock em down/drag em out pit routines.

“Pit to distress” appears on page 182 of the textbook Labor and Delivery Nursing by Michelle Murray and Gayle Huelsmann. In this example, the onus is on the nurse to defend the patient from the doctor if he or she sees the order “pit to distress” by immediately notifying the supervisor or charge nurse.

Jill asks the questions, “OBs, do you still think women are choosing not to birth at your hospitals because Ricki Lake said homebirths are cool? Do you still think we are only out for a “good experience?”

I imagine that all of us who have openly questioned the practices of obstetricians in the U.S. have been hit with the same backlash. We must be selfish, irrational and motivated by our own personal satisfaction. We’ve been indoctrinated into a subculture of natural birth zealots and want to force pain on other women or just feel mighty and superior. We fetishize vaginal birth and attach magical powers to a so-called natural entrance to the world.

Nah. It’s stuff like “pit to distress” that made me run for the nearest freestanding birth center. If I had to do it all over again, I’d stay home.

Have you heard this term before? What is your experience with “Pit to distress?”

Before you comment here, please go applaud Jill from Keyboard Revolutionary for blogging about this term and enjoy her brilliant and honest commentary.

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Update on Tuesday, July 7, 2009 at 4:35AM by Jill–Unnecesarean

More discussion of “Pit to distress” on the Internet:

The then labor and delivery nurse who blogs at At Your Cervix wrote this in April of 2007:

I see the wide use of cytotec (misoprostil) for inductions. I see what it does to a woman’s uterus and to her baby. Not to mention – it’s not FDA approved for use as a labor induction agent in pregnant women! I see many, many women being induced with a “hospital made” form of prostaglandin gel to induce labor. I also see a HUGE number of pitocin inductions/augmentations, where pitocin is titrated at such high doses, so quickly, that it’s like we’re trying to blow the baby out of the woman’s uterus.

Many of the obsetricians that I work with are eager to “get her delivered” as quickly as possible. There is also the “pit to distress” or “make the baby prove itself” – in other words, keep cranking that pitocin up until the baby crumps into fetal distress and the obstetrician does a stat c-section —- all so the doctor can be done, and get out of the hospital. Why wait 12-14 hours for a natural labor, when you can be done in less than an hour?

Our induction rates are through the roof. The nurses are rarely told the unit statistics, and when we are given them, they seem grossly understated. The L&D nurses know how many patients are induced or augmented, day after day, because we are the ones there, admitting the patient, and running their pitocin. We see them in massive amounts of pain from what is a very unnatural process designed to speed up the labor process, thus leading to increased epidural rates due to the higher levels of pain from synthetic oxytocin versus natural oxytocin.

The term was discussed in this Alexian Brothers Medical Center Employee Newsletter

Back in 2006, our tradition, like most maternity units, was to induce mothers when the fetus reached term gestation which was 37-40 weeks gestation. The medication, oxytocin (Pitocin), was administered to high dose levels to affect delivery. At times, the over-zealous use of oxytocin led to uterine hyperstimulation (terminology changed in September, 2008 to tachysystole), where the contractions were occurring too close together to allow the fetus sufficient time to recover before the next contraction would begin. The notion of “Pit to distress” was commonplace back then.

It was mentioned in this Mothering message board thread about Cytotec:

With a reactive baby (either by NST or auscultation) 25 mcg cytotec can be placed in the back of the vagina for cervical ripening 24 hrs prior to hospital induction and the mom sent home to wait, after observing her and baby for an hour. The vast majority (like 90%) will go into spontaneous labor before coming in for their “scheduled” induction. My biggest problem with cytotec is that we just hit moms with it over and over again, and then , surprise,when it does kick in, there’s too much on board, sorta like “pit to distress”.

Pit to distress was mentioned in the comments of the post My Rant on Pitocin on Knitted in the Womb after the blog’s author, a former chemist and doula, was scolded by an anonymous OB nurse for not understanding the difference between microunits and milliliters when it came to dosing Pitocin.

I’m a trained chemist. I hold a bachelors degree in biochemistry, did some course work towards a masters in chemistry, and worked for 6 years in an R&D lab in the specialty chemicals industry. I probably know WAY more about different units of measure than you do. I used “microunits” and “milliliters” in my discussion appropriately.

I’m not sure why I have to resuscitate a newborn to have “been there,” but since it seems to be very important to you, I’ll talk about it. 90% of the time labor should go just fine, with no need for resuscitation—this according to the World Health Organization. Of the other 10%, not all of them would require newborn resuscitation. If you’ve found that a large percentage of the births you’ve been at have required resuscitation, perhaps you should look at the medical interventions that might be causing that. From my end, the only clients I’ve had who had babies who required resuscitation were cases where there had been “Pit to distress.”

The news just broke yesterday of the largest jury award for a medical malpractice case in Ohio history. Miami Valley Hospital was found liable for $31 million in damages, but the parties agreed to settle, according to this Dayton Daily News blog post.

VBAC is safe. VBAC with induction is not, let alone VBAC with Pit to distress.

The lawsuit also identified Dr. Kedrin E. Van Steenwyk and Contemporary Obstetrics and Gynecology as defendants, but the jury found that neither was liable for what happened to the boy.

The boy’s mother, Renetha, was a VBAC patient, meaning she would deliver the boy vaginally, though she had previously had a Caesarian section. That meant she was at a higher risk for a ruptured uterus during labor, which occurred, Lawrence said.

At that point, the mother’s body stopped providing oxygen through the placenta, though the boy was still inside her. He probably went 18 to 20 minutes without oxygen, Lawrence said.

The hospital staff, which knew Renetha Stanziano was a high-risk patient, erred by failing to monitor the labor properly, by failing to diagnosis the hyper-stimulation of her uterus, by inappropriately using the drug Pitocin and by not telling the attending physician of her “inappropriate contraction pattern,” according to the complaint.

The nurses continued to give her Pitocin, even as her contractions escalated to unsafe levels, and “they blew the uterus apart,” Lawrence said.

The boy, called “Leo,” has severe cerebral palsey [sic]. He uses a feeding tube. He cannot speak, is not ambulatory and has trouble holding anything in his hands,” Lawrence said. Though Leo is badly disabled, he is alert and can recognize family members. When he needs something, he communicates by kicking, Lawrence said.

Leo will never be able to work, and Renetha and her husband Douglas are now “24-7 health-care givers,” Lawrence said. After Leo’s birth, Renetha stopped attending college and quit her job at Wright-Patterson Air Force Base to take care of the boy, Lawrence said.

Birth by surgery: The skyrocketing cesarean rate

Medical boon or lawsuit shield? Benefits, risks debated

Story By Mary Beth Pfeiffer

Two weeks before Kristi Ashley gave birth to a son in 2007, an ultrasound exam estimated the baby at a hefty 12 pounds, 10 ounces — too big, her doctor believed, for a safe vaginal delivery. After the child weighed in at 9 pounds, 4 ounces in the delivery room, Ashley came to believe that the planned cesarean section she had, with its attendant pain, long recovery and what she called “emotional damage,” may have been a rush to judgment.

“It’s very hard to go up against your physician, especially at the 12th hour,” said Ashley, 38, of Hopewell Junction. “I think doctors are very quick these days to get scared. They would rather opt for the surgical solution.”

Determined to avoid another surgical birth and aided by a supportive doctor, hospital and birthing coach, Ashley last month did something that has become increasingly rare for post-cesarean women today: She gave birth vaginally, to another son.

In an era of soaring malpractice premiums, technology that sometimes sets off false alarms, physicians pressed for time and mothers-to-be conflicted by fear, cesarean-section birth is soaring to its highest http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_12.pdf“>levels ever.

From 1999 to 2007, the proportion of New York babies born by cesarean section skyrocketed 42 percent. In 1999, just under 1 in 4 babies was born surgically. By 2007, the figure was 1 in 3 — or 34 percent of births — and there is nothing to suggest that the relentless uptick, evident locally as well, is showing any sign of slowing.

In Ulster and Dutchess counties, with cesarean rates in the top sixth of counties statewide, surgical birth rates increased from 1999 to 2007 by 64 percent and 36 percent respectively. Orange ranks in the middle of counties statewide but also saw its section rate rise by 36 percent in that time.

At Vassar Brothers Medical Center in Poughkeepsie, 1,072 babies were delivered via cesarean section in 2008 — two of every five births, for a rate of 40 percent. In Ulster County, Kingston Hospital had a cesarean rate of 40 percent in 2007, the latest figure available, while Benedictine Hospital’s was 35 percent, nearly double what it was in 1999.

Even Northern Dutchess Hospital in Rhinebeck, with a reputation for progressive natural-birthing practices, saw its surgical birth rate soar by 52 percent since 1999 — to 29 percent of all births in 2008.

The World Health Organization calls for a maximum cesarean section rate of http://www.unicef.org/sowc/“>15 percent in any nation in the world. Anything above that “seems to result in more harm than good,” according to a 2006 research summary in the British medical journal Lancet.

Factors hotly debated

Physicians, midwives, childbirth experts and researchers point to a confluence of factors behind the growing rate of cesarean section — factors that are hotly debated both in medical literature and hospital corridors. Some say that more mothers are older, obese, more prone to multiple births and, in particular at Kingston and Vassar Brothers hospitals, less healthy, increasing risks of surgical measures. Others contend that overused interventions to induce and augment labor, manage pain and monitor for fetal distress have driven cesarean rates to unnecessary heights.

All agree that fewer women are opting for once-popular vaginal birth after cesarean, or VBAC, as Ashley did. But some believe doctors emphasize its risk – that the scarred uterus could tear – while minimizing the drawbacks of surgery. VBACs have declined precipitously at five local maternity hospitals; at Northern Dutchess, 17 percent of women who had a previous cesarean gave birth vaginally in 2008, compared to 41 percent in 1999. In 2007, just 3 percent of post-cesarean women birthed vaginally at Kingston Hospital, where the procedure is officially banned. The figure was 33 percent in 1999.

Amid the debate, there is widespread agreement that medical factors are only a part of the story. Cesareans have become so common and accepted that first-time mothers – frightened by societal depictions of overwrought laboring women — sometimes request them simply to avoid labor; doctors, hospitals and insurance companies acquiesce. Moreover, obstetricians, who pay $84,500 a year for malpractice insurance in Ulster and Dutchess and $137,600 in Orange, may see cesareans as a way to avoid lawsuits over injuries to infants from vaginal birth — as well to manage precious time. Obstetricians must attend 54 births just to cover annual malpractice premiums in Westchester County, a medical society study showed; cesareans are undoubtedly quicker and more convenient.

“I see colleagues around me who seem to operate out of fear,” said Dr. Ira Jaffe, a Rhinebeck obstetrician who estimated his cesarean rate at less than 20 percent. “They always have in the back of their mind, ‘How is it going to look in court?’ It’s the defensive medicine.”

“It’s not in the best interest of women and babies to do this many C-sections,” he said.

And the more common cesareans become, the more accepted they are as an alternative way to have a baby. “When you talk to co-workers and friends, so many people have had C-sections,” said Kimberly Revak, 37, of Fishkill, who has had two cesareans, the last with twins in February. “We’re kind of losing that experience” of vaginal birth.

As in Ashley’s case, an ultrasound overestimated the size of Revak’s first baby, putting her at 12 pounds while she delivered at under 9. “It’s easier to go along than to choose the other way and have a problem,” she said.

Telling both sides

For a community of activists who say the cesarean section rate is out of control, the question is whether women like Revak are getting both sides of the story – on one hand that cesarean sections no doubt save lives in high-risk circumstances and are generally safe, but that they contribute in other cases to prematurity, cause respiratory problems in babies and increase maternal bleeding and infection.

“Women are getting cheated by not being encouraged to believe both in their ability to birth and that birth can be a positive experience,” said Christie Craigie-Carter, Hudson Valley coordinator of the International Cesarean Awareness Network, or ICAN, who echoes other mothers who believe they’ve had needless or questionable cesareans at the expense of a core maternal experience: vaginal birth.

Assemblywoman Amy Paulin, a Democrat from Scarsdale in Westchester County, said she is “very alarmed” by the rising cesarean rate.

A Paulin http://www.amypaulin.com/press_rel_detl.asp?id=50“>bill, signed into law last year, requires the state to educate women on birthing procedures, such as the induction of labor and use of pain-numbing techniques like epidurals, that increase risk of cesarean section. Paulin, a three-time mother who had two midwife-attended babies at home, believes that cesareans are often performed for reasons of convenience, fear and liability. “We have a huge problem,” she said.

But while physicians acknowledge room for debate, many accept and even embrace rising cesarean rates, in particular for women having just one or two children, when cesareans are safest. Some noted that planned cesareans generally produced better outcomes than emergency procedures performed after problems arise.

“Is it wrong?” asked Dr. Carla Eng, an obstetrician who delivers babies at Vassar Brothers Medical Center. “It’s hard for me to answer that. The final outcome is to have a healthy baby and a healthy mom.”

“It’s not necessarily a bad trend,” said Dr. Cornelius Verhoest, an obstetrician for 25 years who practices in Fishkill and Poughkeepsie and specializes in urinary disorders. Verhoest, who recently married and is considering fatherhood, said he would encourage his wife to have a cesarean section. He and other obstetricians said the procedure helps avoid potential “pelvic floor disorders” such as urinary incontinence that sometimes follows vaginal childbirth.

“There’s more fevers, wound infections associated with C-section,” acknowledged Dr. John McAndrew, chairman of obstetrics and gynecology at Kingston Hospital, where the cesarean rate hit 43 percent in 2006. “However, it’s safer for the baby.”

Weighing surgical risks

Physicians and researchers concerned with rising cesarean rates take issue with that assertion, which they say fails to weigh the risk that a baby will be damaged or die in vaginal delivery – what drives many decisions to operate – against surgical risks to mother and child.

“In low-risk or no-risk mothers, studies have consistently shown higher morbidity (illness) in infants delivered by cesarean section,” said Dr. Lucky Jain, a pediatrics professor at Emory University School of Medicine in Atlanta who has studied respiratory problems in C-section http://www.ncbi.nlm.nih.gov/pubmed/16549212“>babies. “We have created a monster here without knowing what the long-term impact is.”

“There is no evidence that cesarean is safer for the baby,” said Dr. Jed Turk, newly appointed obstetrics and gynecology chairman at Vassar Brothers Medical Center and a proponent of lower cesarean rates. “It is not a good trend.”

To be sure, every obstetrician knows of or has experienced a vaginal birth gone bad; some said that they and other colleagues had been sued more than once. “If anything goes wrong, the first question you’re asked is, ‘Why wasn’t a C-section done?’ ” said Dr. Scott Hayworth, chairman of the New York district of the American College of Obstetricians and Gynecologists, who calls lawsuit fears “the leading cause” of rising cesareans.

In one case reported on VerdictSearch.com, a legal research service, a Suffolk County jury awarded $212 million in 2005 to a boy born in 1998 with brain damage after a delayed cesarean section (the award was later reduced to $10.6 million). In another, a Bronx jury awarded $64 million in 2002 to an 18-year-old woman who suffered cerebral palsy during her vaginal birth.

Locally, an Ulster County case was settled for $3 million in 2006 after a baby boy allegedly suffered brain damage during a vacuum extraction birth in 2001 at the former Mid-Hudson Family Health Institute in Kingston, which had been licensed to perform births.

“Physicians are less risk-tolerant,” said Dr. Michael Rosenberg, president of the 25,000-member Medical Society of the State of New York, echoing several local obstetricians who acknowledged the role of litigation fear. “When a physician is forced to make clinical decisions influenced by the threat of lawsuits, they are not rendering the best medical care to their patients.”

Vaginal birth undoubtedly has risks. One in 5,000 to 10,000 babies suffers permanent shoulder damage, and one in 1,000 suffers moderate to severe brain damage, according to a 2006 http://cat.inist.fr/?aModele=afficheN=18208466“>article in the professional journal Seminars in Perinatology. These injuries, as well as 6,000 stillbirths, could be avoided nationwide if the nation’s 3 million annual vaginal births were performed surgically at term — but that would mean additional costs and maternal and infant complications.

While researchers do not suggest universal cesarean section, momentum currently favors surgical birth – with troubling implications. At least two of New York’s 146 maternity hospitals have rates above 50 percent, and 23 are in the 40s; the state’s rising rates worry health officials.

“C-section is major surgery, which involves a longer recovery time for the mother and can have other significant consequences,” said Barbara McTague, family health director for the state Health Department.

The cost of cesareans in a cash-starved health-care system is just one consequence. A cesarean birth cost the state Medicaid program $7,200 on average for hospital care in 2007 – 49 percent more than a vaginal delivery. The state’s cesarean price tag was $189 million.

Earlier deliveries

Of greater concern may be the effect of cesareans on babies that are increasingly being delivered early. Thirty-six percent of elective cesareans were performed before 38 weeks, according to a http://content.nejm.org/cgi/content/short/360/2/111“>study published in January in the New England Journal of Medicine, producing infants who had high rates of breathing problems, prolonged hospitalization and sepsis, a severe bacterial infection.

As significant, the study found that 10.2 percent of all cesarean-born babies were admitted to neonatal intensive care units, and 4.4 percent suffered from respiratory distress syndrome caused by fluids that are normally wrung from infant lungs during labor and vaginal delivery. Twenty-thousand babies delivered near-term by cesarean section suffer respiratory distress each year, according to a 2006 http://www.ncbi.nlm.nih.gov/pubmed/16549212“>article in Seminars in Perinatology, while death rates of C-section babies before 28 days were nearly triple those of vaginal deliveries, according to a 2006 http://www.ncbi.nlm.nih.gov/pubmed/16948717“>study by researchers at the U.S. Centers for Disease Control in Birth: Issues in Perinatal Care.

Studies have also found 20 percent higher incidence in both childhood-onset http://www.ncbi.nlm.nih.gov/pubmed/18292986“>diabetes and http://www.ncbi.nlm.nih.gov/pubmed/18352976“>asthma among cesarean babies, who have one-third to three-quarters the level of healthy http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1774211“>bacteria in their intestines as vaginally born babies.

“When a baby comes out the normal way, they swallow vaginal mucus en route and get a nice dose of healthy bacteria to jump start their digestion,” said Dr. Joseph Malak, a Poughkeepsie pediatrician who called “surreal” the number of cesarean babies he sees on hospital rounds. “This doesn’t happen when babies come out through an abdominal incision.”

Malak believes that the rising cesarean rate may be linked to “a dramatic increase” in recent years in infants with colic, acid reflux, eczema and milk allergies – effects that, some say, obstetricians do not consider when weighing vaginal versus cesarean birth.

“You hand the baby to the pediatrician and you release the mother from your care,” said Dr. Carol Sakala, who has a doctorate degree in public health and is program director for the research and advocacy group Childbirth Connection, based in New York City. “There’s very little thought to the ongoing consequences.”

While cesarean delivery is safer than ever for the mother, it is not risk-free. According to a 2008 http://www.ajog.org/article/S0002-9378(08)00268-8/abstract”>report in the American Journal of Obstetrics and Gynecology, 2.2 women died for every 100,000 cesarean births – 10 times higher than for vaginal births. “Cesarean delivery is associated with an increased risk of postpartum maternal death,” concluded a 2006 http://journals.lww.com/greenjournal/Abstract/2006/09000/Postpartum_Maternal_Mortality_and_Cesarean.12.aspx“>report in the same journal.

In New York, the rate of maternal mortality rose 70 percent from 1997 to 2007, when 40 women died as a consequence of pregnancy. Researchers say the rise, seen nationally as well, may be related in part to better reporting as well as to rising rates of obesity; one http://www.childbirthconnection.org/pdf.asp?PDFDownload=LTMII_report“>survey found that a quarter of pregnant women were obese. While no link has been proven between rising maternal deaths and rising cesarean rates, a state-sponsored study in 2004 identified three of the major causes of maternal death as embolism, hemorrhage and infection – all of which occur at higher rates in cesarean section.

Growing complications

Indeed, serious obstetrical complications increased by 27 percent from 1998-99 to 2004-05, according to a 2008 report in http://www.ncbi.nlm.nih.gov/pubmed/19155897“>Obstetrics and Gynecology. These included renal failure, pulmonary blood clots, shock, blood transfusion and ventilation — upticks that parallel rising cesarean rates.

“It looks like there’s an association,” said the study’s author, Dr. Susan Meikle, an obstetrician and medical officer at the National Institutes of Child Health and Human Development. She and others argue that indicators like maternal mortality and illness should be dropping if, indeed, more cesareans are a good thing. “Where’s the benefit from the increase?” she asked.

In its 2006 review of optimal cesarean rates, the British medical journal Lancet, for one, showed “no reductions” in mother or child illness or death in populations with cesarean rates above 15 percent.

“There is an awful lot of lying to women about cesarean,” said Dr. Marsden Wagner, former director of women’s and children’s health for the World Health Organization and author of several books on childbirth. “All of those thousands of women who are getting unnecessary cesareans in New York state are at double or more risk of dying and the babies are at risk of dying.”

The argument over cesarean’s benefits is perhaps most pointed when it comes to vaginal birth after cesarean; many doctors fear that the scarred uterus will tear, resulting in hemorrhage and loss of oxygen to the infant.

“There’s a real risk,” said Dr. Maureen Terranova, obstetrics chief at Northern Dutchess Hospital. “They have to be willing to accept that 1 percent risk of uterine rupture.”

“When it occurs, it can be catastrophic,” said Kingston Hospital’s McAndrew, who has seen uteruses so thin in surgery that the baby is visible. “That’s the thing that makes us reluctant to tread in that water.”

Melissa Ptacek, 47, of Garrison in Putnam County, said it took her years to recover from a uterine rupture from which her daughter – now a normal 11-year-old – had to be resuscitated. “I wouldn’t want anyone to go through what I had to go through,” she said.

In a study published in the http://content.nejm.org/cgi/content/abstract/351/25/2581“>New England Journal of Medicine in 2004, 124 women suffered uterine rupture among 17,898 who attempted vaginal birth after cesarean — a rate of 0.7 percent. Seven babies suffered brain damage, including two who died. A 2000 research http://www.google.com/search?hl=en&q=%22Evaluation+of+Cesarean+Delivery%22&b”>summary by the American College of Obstetricians and Gynecologists put the risk of rupture in vaginal birth at 0.2 to 1.5 percent for most women with one prior cesarean. In an advisory that subsequently sent cesarean rates climbing, the organization recommended that post-cesarean vaginal births only be attempted in hospitals “with physicians immediately available to provide emergency care.”

Proponents of vaginal birth after cesarean say the risks of rupture must be balanced against the downsides of surgical birth. “The conversation about VBAC doesn’t touch on dozens of other concerning outcomes that favor vaginal birth,” said Sakala of Childbirth Connection, noting that cesareans make breastfeeding difficult, lead to adhesions and cause significant pain for up to six months. More than 7,000 repeat cesareans would be needed to save the life of one baby from a ruptured uterus, she said, citing a 2004 British Medical Journal http://www.bmj.com/cgi/content/abstract/bmj.38160.634352.55v1“>study.

Other proponents argue that not all ruptures are catastrophic and some have actually been caused by labor-enhancing medications, called http://content.nejm.org/cgi/content/abstract/345/1/3“>prostaglandins, whose dangers for post-cesarean women are now recognized.

http://www.poughkeepsiejournal.com/article/20090329/NEWS01/903290311/1006

Childbirth Without Choice

by Pamela Paul

Posted February 20, 2009 | 03:20 PM (EST)

It would seem perfectly natural that a woman could give birth naturally if she wants to. Guess what? She can’t.

An increasing number of hospitals in this country are refusing to offer women the option of delivering the way nature intended, if she had a cesarean section the first time around (and guess what — chances are she has because the 31% of all births are now C-sections — up 50% in 10 years).

I wrote an article in this week’s issue of Time magazine called “The Trouble With Repeat Cesareans”on the subject of women’s diminishing patient’s rights. I won’t repeat the story here, since you can link to it here, but will give some of the back story for those who want more:

This was a story I’ve been wanting to write for a long time. The short version is, doctors and hospitals are no longer allowing many women to have a vaginal birth after cesarean (or VBAC, pronounced “vee-back”) because the “medicolegal” costs are too high. Or, as one ob-gyn put it when I asked why she and other doctors no longer allow VBACs, “”It’s a numbers thing. It is financially unsustainable for doctors, hospitals and insurers to engage in a practice when the cost of doing business way exceeds the payback. You don’t get sued for doing a C-section; you get sued for not doing a C-section.”

Now, I think most of us realize that many hospitals are for-profit institutions and that doctors need to make money too, increasingly hard in this era of managed care. It is nonetheless tough to hear a physician talk about medical care in such bare-bones financial terms. So, um, we can’t get the most appropriate care because it costs too much? What’s especially galling is that VBACs are actually a much less expensive “procedure” (if childbirth can be termed that way) than cesarean sections, which are major abdominal surgery and require days more in the hospital. The costs the doctor is referring to are the malpractice insurance costs passed on to doctors. And those costs aren’t even reasonable, but are largely in response to a few high-profile cases of VBACs gone awry dating back 10 years, many of which involved a labor-induction drug called Cytotec, which is no longer used during vaginal births after cesarean.

Meanwhile, according to the International Cesarean Awareness Network (ICAN), out of 2,849 hospitals with labor and delivery wards nationwide, 28% have total outright bans on VBAC and an additional 21% have de facto bans in that they say they’ll do it but none of the doctors on staff will do it. That’s half of American hospitals, but the numbers are probably much worse. Many of the rest will allow what’s often termed “Cinderella VBACs” (a term coined by Henci Goer ) — “yes, you can have a VBAC as long as you have it Monday – Friday, between 8 am and 5pm and you aren’t over 40 weeks and we don’t think your baby is too big”.

Moreover, even if the hospital allows VBACs, it doesn’t mean that all the doctors there are willing or eager to perform them. Take my own case. After I had a cesarean with my first child, I made a point to find a new practice that was VBAC-friendly. (I would have stayed with my first doctor, but my insurance switched, a whole other story). The practice I eventually signed up was very encouraging, telling me that VBACS had a 60-80% success rate and that their particular practiced boasted a 75% success rate. All good. Right?

Except, when I hit the 6 month point, my doctor said to me casually, “OK, let’s schedule your C-section now.”

“Excuse me?”

“Oh,” he said, “You know, you only have a 13% chance of success with your VBAC.” He went on to explain that since I had reached the “pushing” phase of my first labor, my chances of a successful VBAC were dismally low and therefore it made no sense to attempt one.

Furious at the bait-and-switch (doctors love, love, love C-sections — in and out in an hour! No messy labor! No pesky doulas or family members hanging around!), I asked him to produce the study that said so. It turns out that the study, which dated back to 1999, was contradicted by several later studies, all of which showed a significantly higher rate of success — between 40-60%. One study showed no difference in success rates at all, no matter where the first labor ran into trouble.

The doctor on call when I ended up giving birth on Thanksgiving weekend, was, needless to say, very much put out by my inconveniencing him. His revenge? He refused to talk to me while I was in labor, and didn’t answer his pager when I was ready to push. So that’s an example of a hospital that allows VBAC and supposedly pro-VBAC doctors for you. The truth is, doctors who are truly VBAC-friendly are few and far between. The good news is, I gave birth, via VBAC, to a perfectly healthy little boy and had a much quicker, easier recovery than I did with my C-section (which was hell, but another story).

I’ll end with this story, much more dramatic than mine: After giving birth to her first child via cesarean, Alexandra Orchard, a CPA in Colorado Springs, was told her second baby measured too large to be delivered vaginally. “My doctor said, ‘You’re not only risking her life, you’re going to break her collarbone when you push her out,'” Orchard recalls. Through tears, she scheduled a second cesarean. “I was in so much pain after each surgery that I don’t even remember when I met my children.” With her third child, Orchard was determined to get a VBAC, but her doctor refused. Orchard researched the risks and with the help of a midwife, labored for 30 hours and gave birth at home to a daughter, now almost two years old. Orchard is apprenticing to become a midwife because, she says, “I don’t want my daughter to have to fight like I did.”

Are Feminists finally catching on that birth is an important issue?

I’ve never considered myself a feminist in the stereotypical way, but having been involved in women centered care for several years has certainly made me more aware of women’s issues in a newly enlightened way.  Much has been said about how the traditional feminist movement has by and large ignored birth issues.  It has been wondered out loud that if the feminist movement ever really caught on and truly understood the disparity of care and the authoritarian manner that many women must endure during pregnancy and birth, the issue would have been settled long ago.

This past week I heard Judy Norsigian, Executive Director of Our Bodies Ourselves speak to a group of mostly women medical students. I’m assuming many of them may be planning on becoming obstetricians.  The original book, a groundbreaking text for women, published in 1973, was a feminist statement concerning women having knowledge about and control over their own bodies. Our Bodies Ourselves has just this year published a book delving into the current state of affairs concerning pregnancy and birth.  I have not yet purchased or read the book, so I can’t speak for everything included in the book, however I was very encouraged to hear Norsigian address the runaway cesarean rates nationwide, mentioning that in many places the rates are astronomical.

Norsigian also relayed to these up-and-coming medical students the results of Listening to Mothers II, published by Childbirth Connection.   Childbirth Connection is a non-profit organization dedicated to improving maternity care and providing access to evidence-based information for women.  Their Listening to Mothers landmark surveys provided the first real glimpse nationwide into the disparity between what has been reported to be women’s pregnancy and birth experiences and what is actually happening in hospitals across the country.

In the first survey it reported that:

  • 94% of the women had electronic fetal monitoring (even though the official stance of the ACOG says intermittent monitoring is just as effective, and constant monitoring usually confines the woman to the bed and in one position)
  • 83% had IVs (again it makes it difficult to remain mobile)
  • 76% had epidurals (no more mobility with this one either, as well as a long list of possible side effects)
  • 56% had bladder catheters (usually as result of the epidural, but puts them at risk for infection)
  • 41% attempted induction (this has begun to be a big issue because of the number of iatrogenic premature births, it also contributes to the rising cesarean rates)
  • 47% has their births augmented with pitocin (I have to believe that number is higher!)
  • 47% had their bag of waters artificially ruptured
  • 22% used narcotics
  • 32% ended up with a surgical birth (cesarean, which has contributed to our unacceptable and rising maternal mortality rates)
  • 25% had their vaginas cut in order to ‘assist’ the birth (studies show you are more likely to suffer a 3rd or 4th degree tear with an episiotomy)
  • 28% were staff directed in their pushing
  • 17% endured someone putting pressure on their belly for delivery
  • only 63% roomed in with their babies
  • only 39% of babies actually got to stay with their moms for that first golden hour
  • 38% of babies who were supposed to only be breastfed were given formula or water (both detrimental to breastmilk supply and even one bottle of formula can start a negative autoimmune response)
  • 44% of babies were given pacifiers (even though current recommendations by lactation consultants suggest this is detrimental to establishing good breastfeeding supply and latch)

Our Bodies Ourselves has issued a statement signed by physicians, midwives and women’s health advocates who support safe choices in childbirth as of November 2008.  They are urging the following:

  1. That communities preserve the option of vaginal births after cesarean (called VBACs). There is substantial evidence that this is the absolute safest choice for most women, yet many hospitals are bowing to pressure from insurance companies and area standards of practice.  This option has got to become available for women in every location.
  2. That options for hospital-based midwifey care (CNMs and CMs) be made available in all communities across the country. With a rising cesarean rate, less women are getting to take advantage of this alternative.  For complicated reasons,  many CNMs are having to choose to practice with very similar medical protocols and interventions as obstetricians, making them not much of a choice.  But there are also some really good ones out there.  Women need to be educated about their options and the interventions in pregnancy and childbirth in order to make a truly informed choice.
  3. That Certified Professional Midwives (CPMs) be licensed and regulated in order to make the option of homebirth as safe as possible. While I agree with the licensing aspect of this recommendation the ‘regulation’ part is flawed in many ways.  While it is true that the CPM is a highly educated and trained individual and this is now considered the “gold standard” for certification for homebirth midwives, it ignores the rich history and excellent outcomes of other traditional midwives.  The regulation aspect can also place undue burdens on midwives.  Those burdens limit women’s choices.  Some states place boundaries around the CPM in which she is not allowed to provide care for VBACs, twins, breeches and other variations of births.  If more and more physicians and hospitals are requiring cesarean deliveries for these variations of normal, what other options does a woman have?  Some states license the CPM but do not allow her to attend births and administer life-saving medications, which her training has instructed her to know how to use.  Her hands are tied in an emergency situation.  Other states place a burdensome provision requiring the midwife work in a supervised or collaborative relationship with a physician.  This can be impossible to find, as many a cooperative physician have been pressured by their peers to drop the midwife or face persecution by their medical community.  The Midwifery Model of Care is evidence-based, but it will never be a medical model of care and shouldn’t be.  Otherwise, there is no discernable difference for women to truly have a choice between the way in which both approach the process of birth.  Midwives will always see birth as a natural event and physicians will always see birth as a disease process they must ‘fix’.

The state of Tennessee (and I’m sure others) has a state midwifery board, much like most state’s medical boards, which oversees and supervises the midwives in that state.  In cases of misconduct or malpractice, they have the authority to hold peer review and remove the right to practice.  But this is a body of PEERS, all who have an understanding of what it is to practice authentic and skilled midwifery.

Placing midwives under the ‘regulation’ of the medical system is a bit like having a fox in the hen house.  In other countries, midwives are seen as part of the team, not necessarily the competition.  Midwives handle the majority of low risk mothers and births and physicians use their skills where it really matters; on the high risk pregnancies and babies.  Their is a cooperative effort and collaborative effort, because the physicians see that as their role.  But in this country, where an accident of history almost wiped out the influence of midwives in this country, we are not yet at that place.

To place midwives under the regulation of the medical system is to continue the status quo and that’s not a choice women should be happy about.  To only legitimize the CPM and not the hundreds of other traditionally trained and skilled direct entry midwives is to also limit women’s choices.  It’s something the feminists should think long and hard about.

Crunching numbers

I was finally able to get some figures to try and determine what the cesarean section rate is running with my local hospital.  It’s difficult to get an exact number because of the way they have their figures broken down.  You have to get the actual birth rate from one site for a calendar year and the hospital gives you its cesarean rate for a calendar year, but between the two it looks like we are running around a 50% cesarean rate here.  A surgical nurse told me recently he t hought it might even be higher because he saw so many of them.

Either way….that is criminal.  HALF of the women in this area are not allowed to birth their babies vaginally?  High intervention rates, high induction rates, high epidural rates, and across the board denial of VBACs have resulted in this soaring rate.

My childbirth classes are geared to those intending to have a hospital birth.  I try to teach them how to avoid an unnecessary cesarean birth, coping techniques for a natural birth and the many advantages of natural birth.  If I can save a few women from the trauma, recovery from major surgery and psychological scarring of surgical birth, it’s worth my time.  Some of them learn too late the consequences of their choices in birth.

I recently tried to help an expectant mom achieve a vaginal birth after a cesarean birth for her first child.  I’ve never seen a mom want something so much and work so hard to attain it.  She was a warrior and as long as she and the baby were both fine, I continued to fight with her for her goal.  But ruptured membranes for too many hours, a posterior baby that wouldn’t turn anterior, a large baby and a marginal pelvis combined with a dysfunctional labor were more odds against us than we could fight.  She ended up in a transfer with her uterus still intact and baby still in good shape.  But she had another cesarean.  It was hard emotionally on us both.  I knew she had done everything she could possibly do and I knew I had also, but it just wasn’t going to happen.  I know that the cesarean was necessary and I’m glad that eventually she will know it was the only way to safely deliver her child.

When she and her family arrived at the hospital they were treated as criminals for having attempted a VBAC.  Every person they encountered was rude and misinformed about the statistics concerning VBAC safety (a nurse told them there was a 99% rupture rate!).  The OB on call lied to her and said her uterus was ruptured and that’s what you get when you use an illegal midwife.  When she was finally able to get her actual surgical records, she discovered there was no rupture at all.  This same OB told another VBAC homebirth transfer several years previous to this that he had done a vertical incision just so she would never try something that stupid again.  Again, she was smart enough to request her actual surgical records and discovered only the external incision was vertical, the actual uterine incision was transverse.  This same hospital was doing VBACs themselves until just a year and a half ago, when pressure was put on them by other hospitals in the region, and insurance companies. It had nothing to do with good science or the vast body of medical studies that have shown us there is only a 0.05% chance of rupture, meaning there is a 99.05% chance of NOT rupturing!  It had everything to do with community standards, which are frequently not based on medical evidence.

Is it any wonder some women want to run away?

ACOG State Legislative Update–Who’s afraid of a few “lay” midwives?

The ACOG recently published their yearly state legislative update. The main topic was those troublesome ‘lay’ midwives and home birth. While the document is full of the typically misinformed information and erroneous assumptions about midwives, it has the flavor of someone who is afraid–very afraid. Let me quote from the document and set the record straight.

The report first mentions that home birth bills are on the rise in states across the country, fueled by state midwifery guilds and MANA (Midwives of North America) and its credentialing organisation, NARM (North American Registry of Midwives). It complains that because of Republican majorities in states and the crafting of a model bill by The American Legislative Exchange Council (ALEC) that many of these bills are not only being introduced, but passed. They are afraid of the trend of conservative lawmakers who lump home schooling and home birthing together.

Interesting…I home schooled my children back in the day when we were considered pioneers and many states still considered us lawbreakers. The question of the day was “what kind of quality education could they possibly get?” and “what will you do about socialization?”. Funny, no one asks those questions much anymore. Home schooling has been around long enough now for people to see the fruit, and the educational outcomes from many public schools and accompanying issues with negative peer pressure has made many a doubter look longingly over to the other side of the home school fence. Perhaps home birthing will enjoy the same awakening if enough people buck the system to embrace birth as a normal event?

To quote again from the document: “The ‘lay midwives’ internal philosophy on state regulation and licensure appears to have shifted. In the past, their position on licensure reflected the dominance of midwives who did not want to be regulated, opposed state licensure, and defended within their individual guilds the right to stay unlicensed and practice underground. While there are midwives who still do not want to be regulated and who do not support the current licensure campaign, for the most part you don’t see them speaking publicly against licensure in the legislature or elsewhere. Even the nurse-midwives no longer can be counted on to speak publicly against home birth or lesser trained midwives.”

Excuse me while I take a moment to laugh out loud at this one. Even the nurse-midwives have turned coat and can’t be counted on to speak out against home birth? Maybe a good portion of them are simply tired of following obstetrical authoritarian’s non-evidenced based protocols and have had enough of a glimpse over the fence at the outcomes of their home birthing sister midwives to just decide not to say anything at all. Some of them have home birth practices of their own. I recently attended a Christian midwifery conference and there were midwives in attendance of every persuasion–‘lay’ midwives, CPMs, CNMs, whatever you call yourself. No one wore a name tag with their credentials, just our names. You know what sifted to the top? Not a title—wisdom (experience+knowledge), knowledge, skill. No matter what your title, you learned a few new things from someone who had put something solid into practice and knew that it worked. CNMs learned from CPMs and vice versa. It was quite refreshing.

Next point in the ACOG document says: “The term direct entry is used to refer to midwives who enter the profession of midwifery directly without earning a nursing degree. Both certified professional midwives (CPMs) and certified midwives (CMs) are considered direct-entry midwives, although their level of education and training varies markedly. CPMs are largely self-taught and their training is typically through aprenticeship. CPM was the title chosen by MANA and NARM in the mid-1990s for their credentialed direct entry midwives. By comparison, CMs must undergo three years of university-affliated training, and while there is no nursing prerequisite, these direct-entry midwives must complete the same science requirements and sit for the same certification exam as a nurse-midwife. ….More states are adopting the CPM credential as a requirement for midwifery licensure, and not the CM credential which both ACOG and ACNM recognize. Of the roughly 21 states that license midwives to attend home births, all use the CPM credential. By their lack of training and because they do not work collaboratively with hospital-based obstetric providers, CPMs are the least qualified midwives to attend a home birth.”

So much is wrong in that one paragraph, I hardly know where to start. True that all midwives who enter the field without first becoming a nurse are called direct entry. It is odd that both the ACOG and ACNM recognize and approve of this route, as long as you can pass the certification exam and will work collaboratively with a hospital-based obstetric provider (can you say CONTROL?). But if you get an equal didactic education somewhere other than their own hallowed halls and your clinical experience occurs in a home birth setting, then you are seen as decidedly inferior. Anyone who calls the process to become a CPM a ‘lack of training’ has not actually seen the hoops you must jump through, nor understood the knowledge required to pass both the clinical and written exams. In this situation, I think ‘lack of training’ can be interpreted “we can’t control them!”. And the last time I looked, CPMs and CNMs were using many of the same textbooks to obtain their education. Much has been said about the apprenticeship model recommended to receive the clinical training necessary for certification as a CPM. Because a physician must go through an internship before he/she is allowed to practice independently, I fail to see much difference. Both models offer the opportunity for hands-on experience under the supervision of a person with infinitely more experience and knowledge. It is an ideal way to learn how to apply your book knowledge into practical terms. They call it internship, we call it apprenticeship. A rose is a rose is a rose.

“To bolster their case for licensure, midwives like to cite European countries’ experience with midwives and home birth. This may play well with an uninformed public, but the analogy is flawed. The conditions that make home birth relatively safe in some countries–the Netherlands for example–do not pertain to much of the US. The Netherlands is a geographically small, densely populated country where everyone lives within 20 minutes of a hospital.”

Very misleading statement! Yes, it is a small, densely populated country, but everyone does not live within 20 minutes of a hospital, as reported. The hospital situation in the Netherlands is not at all like the US. There is not a hospital in every town, and even in towns with hospitals, because of the dense population, the traffic alone sometimes prohibits speedy arrival at a hospital. Most are operated by the government or universities, not privately owned, so there really aren’t that many hospitals. Every city and village doesn’t have a hospital, yet the Netherlands enjoys a MUCH better infant mortality rate than the US. Most of their births occur in their homes and are attended by non-nurse midwives because they treat pregnancy and birth as a normal event, not a medical emergency. Usually only the high risk pregnancies are encouraged to birth in their hospitals with obstetricians. Hmmmm, OK so if home birth is safe in that country only because they live so close to a hospital and we’ve blown that theory out of the water, we’ll have to assume their statistics are better than ours for other reasons. Could it be that perhaps if you treat birth as a normal event and you don’t induce, augment, confine, over-monitor and otherwise harass a laboring woman, things just might work better? That would be a hard one for the ACOG to swallow.

“In their recent testimony to state legislators, midwives have been citing a 2005 study on the safety of home births by direct entry midwives in the US. (Johnson KC, Daviss B. Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ 2005;330;1415) This study concluded, “certified professional midwives achieve good outcomes among low risk women without routine use of expensive hospital intervention.” ACOG continues to assert that studies comparing the safety and outcome of births in and out of the hospital are problematic, not scientifically rigorous, and unconvincing.”

In other words, they see the proof, but they just can’t wrap their minds around it. They believe what they want to believe.

“…in Missouri, ‘lay’ midwife bills get introduced year after year. These bills have been stopped–up to now–mainly by deft political maneuvering and hardball tactics employed by the State Medical Society, not by any persuasive testimony about comparative safety or quality of care.”

Quite an admission, wouldn’t you agree? They go on to discuss how nurse-midwives have previously been their front-line defense against these bills, but now they are a fickle ally. Maybe there is a growing respect between the two sets of professional women, in which the knowledge each possesses is no longer mistrusted.

“Physician back-up for midwives and out-of-hospital deliveries is a growing concern in some states. …In 1993, California licensed midwives to do home deliveries under physician supervision. But implementing regulations for the 1993 law were only recently finalized after years of wrangling over key issues including the physician supervision requirement in the authorizing legislation. Medical liability insurers in the state were refusing to cover physicians who back-up midwives and midwifery proponents in the legislature threatened to waive the requirement for physician supervision altogether.”

It was the ACOG who got the requirement for physician supervision thrown in at the last minute. With the liability insurers already refusing to cover physicians who backed up midwives, it created a situation impossible to abide by for CA midwives. Or was that the idea….?

It’s slightly amusing that this review refers to legislative handbook developed by MANA as being full of “lobbying advice, tactics and propaganda”. Is everyone aware that the ACOG is basically a lobbying organization for the advancement of obstetricians and gynecologists? Isn’t this a little like the pot calling the kettle black?

Lastly, the document mentions the problem of hospitals refusing to do VBAC (vaginal birth after cesarean) deliveries as being one of the reasons many women are seeking out other alternatives, including home birth with midwives. The most up-to-date studies all support VBAC attempts as being the safer approach to subsequent births in the majority of situations. Yet hospital after hospital have closed out this option, choosing to bow under the pressure of regional medical standards and insurers demands, rather than evidence-based studies. What are women to do who don’t wish to undergo major surgery to birth their babies again, especially when the number of primary unnecessary cesareans is so unreasonably high? They go to the only sane choice available–they turn to highly skilled, highly educated home birth midwives.

Honestly? They sound a little worried.