Tuesday, February 28, 2012

Shameless Plug

So, this blog recently got nominated by readers of about.com as one of the Top Five Pregnancy Blogs this year.

I never quite know how to take something like this; I'm flattered, I'm embarrassed, and I have no idea whether or not to mention it on the blog.  Sounds too much like tooting your own horn to me, so I had decided I wasn't going to mention it.  If folks wanted to vote for me, I wasn't going to object, but I wasn't going to actively solicit votes either.  It's just a little uncomfortable.

I don't do a lot of self-promotion, and I constantly have people telling me that I need to be doing more social networking.  I'm a product of my baby-boomer generation, I guess, and I just find the whole Facebook and Twitter thing annoying and egotistical, not to mention being way too much of a time drain. I'd rather spend my all-too-minimal computer time doing something more substantive. Plus, these contests are often just a way to drive more visitors to the sponsoring organization's webpages.  It's very clever viral marketing, so I'm a bit cynical about participating in that.

And yet, I do feel it's an honor.  I know the author who runs about.com's pregnancy content, and she has consistently worked for women's best interests for years. She's not just out there trying to buy her way into more hits; she really cares about supporting women and giving them good information so they can make informed choices about their care.  This is one way of doing that.

So I got to thinking about this contest as a way to spread the word about the relatively unknown concept of Health At Every Size®, about the need for dignified and respectful treatment for women of size, and about important pregnancy and birthing issues we discuss here that apply to all women, regardless of size.  It's great to work on substantive issues, but it's even better when people actually read your messages about those issues.  It's the difference between preaching to the choir and reaching out to a whole new audience, some of whom may really need to hear those messages.

So it's with some embarrassment but also some grit-your-teeth-and-just-do-it determination that I'm letting folks know about the contest.  If you've found this blog useful at all and are so inclined, just click on the link below and go vote. You can vote now through March 21st. You can only vote once each day, but you can vote more than once.  Don't feel you have to vote, but if you want to, I thank you for helping to raise awareness of these issues to a whole new audience.  Here's the voting link:


I really don't expect the blog to win, as we're up against some really outstanding and social-media-savvy blogs (personally, I voted for The Unnecesarean!). However, if we have a good showing, then perhaps more people who don't know my blog will come and check it out. That's all I'm aiming for.

Thanks for thinking about it.  Shameless-and-embarrassing plug over now.  We return you to our regular programming.

(And yes, I'm still holding my nose and considering the whole Facebook thing. I know you young whipper-snappers don't understand resistance to Facebook, but us old geezers just have a great distaste for the whole concept. Or at least this old geezer does! But I suppose it has its uses. I'll think about it....)

Friday, February 24, 2012

Breastfeeding Helps Lower the Risk for Maternal Heart Disease

Thanks to JC for sharing this picture
February is American Heart Month, a month to raise awareness about the frequency and impact of heart disease in U.S. society.  My colleagues over at the Association for Size Diversity and Health have a new blog post up about lowering your risk for heart disease, whatever your size.

But I have to add that there's one thing that women in particular can do to help lower their risk for heart disease, and that's ─ surprise! ─ breastfeeding, which brings it within the realm of this blog.

So, in honor of American Heart Month, let's discuss how long-term breastfeeding can help lower the risk for heart disease in the mother.

Research has traditionally focused on how breastfeeding may help lower the risk for various problems in a child as he grows up, but until fairly recently, there hadn't been a lot of data on whether it helped lower the risk for various heart risk factors for the mother.

Now, thanks to the Nurses Health Study, the Women's Health Initiative, CARDIA, and other studies, we know that breastfeeding is protective for the mothers as well, especially extended (or long-term) breastfeeding.

Below you will find the abstracts for a number of studies about how breastfeeding lowers the risk for hypertension, metabolic syndrome, diabetes, high fasting insulin levels, and high lipid levels.

Now, of course, there are some caveats to this research.  The overall effect for some factors is not huge, for example, and obviously many people who do breastfeed long-term go on to develop high blood pressure, diabetes, or heart disease.  There are multiple factors at work here, not just breastfeeding.

So it's important to remember that breastfeeding, even long-term breastfeeding, is not a guarantee against heart disease.  But even with these caveats, the findings are encouraging.  Here's something we can do that will really benefit both our babies and ourselves.

Notes on the Studies

Note that the length of breastfeeding time is an important variable which varies greatly among these studies.  Some studies looked at women who breastfed longer than 2 years, some at longer than 1 year, while others only looked at those who breastfed longer than 3 or 6 months.  There's likely a significant difference in risk between those who breastfed for only 3 months vs. those who breastfed for several years! So if anything, the effect might be even stronger.

Yet the 2010 diabetes study listed below only looked at women who breastfed longer than 1 month, and they still found an effect.  How much more of an effect might there be if they had followed women who had breastfed far more long-term?  THAT'S where this research needs to go in the future.

I'd also point out that this research is a pretty big condemnation of doctors in past generations discouraging women from breastfeeding.  That just goes to show that even with the best training, doctors can still be misguided, and the medical "standard of care" isn't always best for women or babies.  Doctors are human and sometimes they are misguided....and that can still be true today.

Even now, support for extended breastfeeding is still tepid among many physicians (like the one who told me there were no benefits to breastfeeding beyond about 6 weeks). There are far too many hospitals who only pay lip service to the idea of breastfeeding but whose policies actually impede it.  Much progress remains to be made in promoting breastfeeding, and that's even now, when we know how important it is.

Another vital point is that there is research not just on breastfeeding improving intermediate outcomes (risk factors for heart disease, like diabetes or hypertension), but also for it improving long-term outcomes (i.e., actual incidence of coronary heart disease, not just impact on risk factors).  As the press release for the 2009 study noted:
In their analysis of 89,326 parous women in the Nurses’ Health Study, Stuebe et al found that compared with women who had never lactated, women who had breastfed for 2 or more years had a 37 percent lower risk for CHD after adjusting for age, parity, stillbirth history, early-adult adiposity, parental history, and lifestyle factors. 
The authors note that this protective effect is characterized by a threshold effect at 2 years, as women had a hazard ratio (HR) of 0.87 for CHD if they had breastfed for more than 1 year versus no lactation, compared with 0.77 for 2 or more years. 
Considering the dose-response relationship they found, I wonder what the effect is for those of us who have breastfed far more than 2 years total?  Although my breastfeeding days are sadly over now, I spent about 10 years breastfeeding, cumulatively speaking.  Since I have significant risk factors for heart disease (what with the PCOS, insulin resistance, and a family history of CHD), I'm hoping this helps reduce some of that risk!

In the end, I think it's pretty darn conclusive that breastfeeding is not just good for babies, but for long-term maternal health as well.  We knew that was true for various cancers, but now we know it's true for heart health as well.

To lower the number of heart-related deaths, the CDC has joined together with several other organizations to promote the Million Hearts™ Initiative. They recommend the following ideas to help lower your risk for heart disease (and how refreshing is it that their recommendations are HAES-friendly!):
  • Get up and get active by being physically active for at least 30 minutes on most days of the week.
  • Know your ABCS:
    • Ask your doctor if you should take an Aspirin every day.
    • Find out if you have high Blood pressure or Cholesterol, and if you do, get effective treatment.
    • If you Smoke, get help to quit.
  • Make your calories count by eating a heart-healthy diet high in fresh fruits and vegetables and low in sodium and trans fat.
  • Take control of your heart health by following your doctor's prescription instructions.
To this list, we can now add breastfeeding, especially long-term.  Breastfeeding is not a guarantee against heart problems, obviously, but it does seem to help, and any help to lower the risk for the number one cause of death is very welcome. 

*Please note, posting this research is not meant to make mothers who can't breastfeed feel bad.  Because PCOS can impact milk supply in some women, a number of my readers may well have experienced breastfeeding struggles, and I always want to be sensitive to that fact, even as I highlight the research supporting the benefits of breastfeeding.  I strongly encourage anyone who has struggled with breastfeeding issues to visit MOBI, Mothers Overcoming Breastfeeding Issues, and www.lowmilksupply.org, both of which are incredible resources for both information and support.


*Please note that a number of the following abstracts have links to free full texts of the studies.

Am J Obstet Gynecol. 2009 Feb;200(2):138.e1-8. Epub 2008 Dec 25. Duration of lactation and incidence of myocardial infarction in middle to late adulthood. Stuebe AM, et al.   PMID: 19110223
OBJECTIVE: We assessed the relation between duration of lactation and maternal incident myocardial infarction. STUDY DESIGN: This was a prospective cohort study of 89,326 parous women in the Nurses' Health Study. RESULTS: During 1,350,965 person-years of follow-up, 2540 cases of coronary heart disease were diagnosed. Compared with parous women who had never breastfed, women who had breastfed for a lifetime total of 2 years or longer had 37% lower risk of coronary heart disease (95% confidence interval, 23-49%; P for trend < .001), adjusting for age, parity, and stillbirth history. With additional adjustment for early-adult adiposity, parental history, and lifestyle factors, women who had breastfed for a lifetime total of 2 years or longer had a 23% lower risk of coronary heart disease (95% confidence interval, 6-38%; P for trend = .02) than women who had never breastfed.
CONCLUSION: In a large, prospective cohort, long duration of lactation was associated with a reduced risk of coronary heart disease.
Obstet Gynecol. 2009 May;113(5):974-82. Duration of lactation and risk factors for maternal cardiovascular disease. Schwarz EB, et al.   PMID: 19384111
OBJECTIVE: To examine dose-response relationships between the cumulative number of months women lactated and postmenopausal risk factors for cardiovascular disease.
METHODS: We examined data from 139,681 postmenopausal women (median age 63 years) who reported at least one live birth on enrolling in the Women's Health Initiative observational study or controlled trials. Multivariable models were used to control for sociodemographic (age, parity, race, education, income, age at menopause), lifestyle, and family history variables when examining the effect of duration of lactation on risk factors for cardiovascular disease, including obesity (body mass index [BMI] at or above 30), hypertension, self-reported diabetes, hyperlipidemia, and prevalent and incident cardiovascular disease.
RESULTS: Dose-response relationships were seen; in fully adjusted models, women who reported a lifetime history of more than 12 months of lactation were less likely to have hypertension (odds ratio [OR] 0.88, P<.001), diabetes (OR 0.80, P<.001), hyperlipidemia (OR 0.81, P<.001), or cardiovascular disease (OR 0.91, P=.008) than women who never breast-fed, but they were not less likely to be obese. In models adjusted for all above variables and BMI, similar relationships were seen. Using multivariate adjusted prevalence ratios from generalized linear models, we estimate that among parous women who did notbreast-feed compared with those who breast-fed for more than 12 months, 42.1% versus 38.6% would have hypertension, 5.3% versus 4.3% would have diabetes, 14.8% versus 12.3% would have hyperlipidemia, and 9.9% versus 9.1% would have developed cardiovascular disease when postmenopausal. Over an average of 7.9 years of postmenopausal participation in the Women's Health Initiative, women with a single live birth who breast-fed for 7-12 months were significantly less likely to developcardiovascular disease (hazard ratio 0.72, 95% confidence interval 0.53-0.97) than women who never breast-fed.
CONCLUSION: Among postmenopausal women, increased duration of lactation was associated with a lower prevalence of hypertension, diabetes, hyperlipidemia, and cardiovascular disease.
Am J Epidemiol. 2011 Nov 15;174(10):1147-58. Epub 2011 Oct 12. Duration of lactation and incidence of maternal hypertension: a longitudinal cohort study. Stuebe AM, et al.  PMID: 21997568
Never or curtailed lactation has been associated with an increased risk for incident hypertension, but the effect of exclusive breastfeeding is unknown. The authors conducted an observational cohort study of 55,636 parous women in the US Nurses' Health Study II. From 1991 to 2005, participants reported 8,861 cases of incident hypertension during 660,880 person-years of follow-up. Never or curtailed lactation was associated with an increased risk of incident hypertension. Compared with women who breastfed their first child for ≥12 months, women who did not breastfeed were more likely to develop hypertension (hazard ratio (HR) = 1.27, 95% confidence interval (CI): 1.18, 1.36), adjusting for family history and lifestyle covariates. Women who never breastfed were more likely to develop hypertension than women who exclusively breastfed their first child for ≥6 months (HR = 1.29, 95% CI: 1.20, 1.40). The authors found similar results for women who had never breastfed compared with those who had breastfed each child for an average of ≥12 months (HR = 1.22, 95% CI: 1.13, 1.32). In conclusion, never or curtailed lactation was associated with an increased risk of incident maternal hypertension, compared with the recommended ≥6 months of exclusive or ≥12 months of total lactation per child, in a large cohort of parous women.
Am J Med. 2010 Sep;123(9):863.e1-6. Lactation and maternal risk of type 2 diabetes: a population-based study. Schwarz EB, et al.  PMID: 20800156
We explored the relationships between lactation and risk of type 2 diabetes in a well-characterized, population-representative cohort of women, aged 40-78 years, who were members of a large integrated health care delivery organization in California and enrolled in the Reproductive Risk factors for Incontinence Study at Kaiser (RRISK), between 2003 and 2008. Multivariable logistic regression was used to control for age, parity, race, education, hysterectomy, physical activity, tobacco and alcohol use, family history of diabetes, and body mass index while examining the impact of duration, exclusivity, and consistency of lactation on risk of having developed type 2 diabetes. RESULTS: Of 2233 women studied, 1828 were mothers; 56% had breastfed an infant for greater than or =1 month. In fully adjusted models, the risk of type 2 diabetes among women who consistently breastfed all of their children for greater than or =1 month remained similar to that of women who had never given birth (odds ratio [OR] 1.01; 95% confidence interval [CI], 0.56-1.81). In contrast, mothers who had never breastfed an infant were more likely to have developed type 2 diabetes than nulliparous women (OR 1.93; 95% CI, 1.14-3.27) [corrected]. Mothers who never exclusively breastfed were more likely to have developed type 2 diabetes than mothers who exclusively breastfed for 1-3 months (OR 1.52; 95% CI, 1.11-2.10).
CONCLUSIONS: Risk of type 2 diabetes increases when term pregnancy is followed by less than 1 month of lactation, independent of physical activity and body mass index in later life. Mothers should be encouraged to exclusively breastfeed all of their infants for at least 1 month.
Diabetes. 2010 Feb;59(2):495-504. Epub 2009 Dec 3. Duration of lactation and incidence of the metabolic syndrome in women of reproductive age according to gestational diabetes mellitus status: a 20-Year prospective study in CARDIA (Coronary Artery Risk Development in Young Adults). Gunderson EP, et al.  PMID: 19959762 
OBJECTIVE: The objective of the study was to prospectively assess the association between lactation duration and incidence of the metabolic syndrome among women of reproductive age.
RESEARCH DESIGN AND METHODS: Participants were 1,399 women (39% black, aged 18-30 years) in the Coronary Artery Risk Development in Young Adults (CARDIA) Study, an ongoing multicenter, population-based, prospective observational cohort study conducted in the U.S. Women were nulliparous and free of the metabolic syndrome at baseline (1985-1986) and before subsequent pregnancies, and reexamined 7, 10, 15, and/or 20 years after baseline. Incident metabolic syndrome case participants were identified according to National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) criteria. Complementary log-log models estimated relative hazards of incident metabolic syndrome among time-dependentlactation duration categories by gestational diabetes mellitus (GDM) adjusted for age, race, study center, baseline covariates (BMI, metabolic syndrome components, education, smoking, physical activity), and time-dependent parity.
RESULTS: Among 704 parous women (620 non-GDM, 84 GDM), there were 120 incident metabolic syndrome case participants in 9,993 person-years (overall incidence rate 12.0 per 1,000 person-years; 10.8 for non-GDM, 22.1 for GDM). Increased lactation duration was associated with lower crude metabolic syndrome incidence rates from 0-1 month through greater than 9 months (P < 0.001). Fully adjusted relative hazards showed that risk reductions associated with longer lactation were stronger among GDM (relative hazard range 0.14-0.56; P = 0.03) than non-GDM groups (relative hazard range 0.44-0.61; P = 0.03).
CONCLUSIONS: Longer duration of lactation was associated with lower incidence of the metabolic syndrome years after weaning among women with a history of GDM and without GDM, controlling for preconception measurements, BMI, and sociodemographic and lifestyle traits. Lactation may have persistent favorable effects on women's cardiometabolic health.
Obstet Gynecol. 2007 Mar;109(3):729-38. Lactation and changes in maternal metabolic risk factors. Gunderson EP, et al.   PMID: 17329527
METHODS: This 3-year prospective study examined changes in metabolic risk factors among lactating women from preconception to postweaning and among nonlactating women from preconception to postdelivery, in comparison with nongravid women. Of 1,051 (490 black, 561 white) women who attended two consecutive study visits in years 7 (1992-1993) and 10 (1995-1996), 942 were nongravid and 109 had one interim birth. Of parous women, 48 (45%) did not lactate, and 61 (55%) lactated and weaned before year 10. The lactated and weaned women were subdivided by duration of lactation into less than 3 months and 3 months or more. Multiple linear regression models estimated mean 3-year changes in metabolic risk factors adjusted for age, race, parity, education, and behavioral covariates.
RESULTS: Both parous women who did not lactate and parous women who lactated and weaned gained more weight (+5.6, +4.4 kg) and waist girth (+5.3, +4.9 cm) than nongravid women over the 3-year interval; P<.001. Low-density lipoprotein cholesterol (+6.7 mg/dL, P less than .05) and fasting insulin (+2.6 microunits, P=.06) increased more for parous women who did not lactate than for nongravid and parous women who lactated and weaned. High-density lipoprotein cholesterol decrements for both parous women who did not lactate and parous women who lactated and weaned were 4.0 mg/dL greater than for nongravid women (P less than .001). Among parous, lactated and weaned women, lactation for 3 months or longer was associated with a smaller decrement in high-density lipoprotein cholesterol (-1.3 mg/dL versus -7.3 mg/dL for less than 3 months; P less than .01).
CONCLUSION: Lactation may attenuate unfavorable metabolic risk factor changes that occur with pregnancy, with effects apparent after weaning. As a modifiable behavior, lactation may affect women's future risk of cardiovascular and metabolic diseases.

Monday, February 20, 2012

Your Body Is Not A Lemon

Image from BodyLoveWellness.com

Sadly, in our society, pregnancy is often used as a time to make women feel neurotic or guilty about their bodies.

However, pregnancy is an incredible opportunity for body love and body image healing.  It offers a tremendous chance to do many years' worth of healing, compressed into a short amount of time.

Instead of hating on your body, try embracing your body instead. Marvel that the miracle of growing a new baby can occur in a lush body as well as a sparse one.  Give yourself credit for all the things your body is doing right.  Embrace the changes that pregnancy and birth bring to your body, for they are the Tiger Stripe Emblems of Honor that mark your experiences as a mother.

Remember this, for it is as true as true gets: Your body is not a lemon.  
You are not a machine. The Creator is not a careless mechanic. Human female bodies have the same potential to give birth well as aardvarks, lions, rhinoceri, elephants, moose and water buffalo.  
Even if it has not been your habit throughout your life so far, I recommend that you learn to think positively about your body.
~Ina May Gaskin, midwife and author of Ina May's Guide to Childbirth

Tuesday, February 14, 2012

"You and the Baby are About 85% Likely To Die on the Table"

The hype around the risks of pregnancy and obesity is so extreme at times that some doctors have developed an exaggerated fear of the possibilities of deadly complications in "morbidly obese" women.

In particular, some have begun to routinely tell very fat women  that they are quite likely to die during pregnancy or birth.  This is their way of bullying them out of further pregnancies or at least scaring them into massive weight loss.

Sigh. Here we go again.  We've seen the Dead Mama Card before.

Some women of size have been told that they are so fat, they'll surely have a heart attack and die during labor, that they or their baby will probably not survive a pregnancy, that choosing to be pregnant while fat is committing suicide by pregnancy, or they have been pointedly asked about their funeral arrangement preferences before surgery.

There was yet another blood pressure-raising example of this from My OB Said What?!? recently, where one OB said to a "morbidly obese" mother:
I can't believe I have been put in this position!  I absolutely resent that I am now responsible for your life and delivering this baby, you have no right thinking you can safely deliver a child when you are so overweight.    
In the comments section on the My OB Said What?!? website, the original poster gave some more details behind the case. The mother weighed in the upper 200s in her pregnancy and had had a healthy pregnancy.  At one week overdue, she had a slow leak of her amniotic fluid (normally not a big deal, but in this case it had leaked out enough that contractions were pressing on the baby's umbilical cord and interfering with his heart rate).  They took her back for a cesarean, where the on-call OB began to berate the patient and her husband with the above statement ─ and more:
This was the LEAST of the horrible things he said to my husband and I.  He lectured my husband so severely that my big tough husband started to cry.  He told us that I and the baby were about 85% likely to die on the table during the surgery and it was all hubby's fault because I am SO fat. 
What the hell.....??!!!  Where does this doctor get off treating a patient, ANY patient, no matter her risk factors, like this?

Now, up to a point, I can understand the on-call OB feeling put on the spot at having to do what he perceived as risky surgery on a larger-sized person.  This wasn't his patient, but because he was on-call, he ended up having to the surgery on a patient whose risks he was uncomfortable with.  Fair enough, even though really, that's the nature of being on-call for another doctor's patients.

But this doctor had such an exaggerated sense of fear around the pregnancy and cesarean of this woman of size.  An 85% chance of dying during the surgery?  Really?  What orifice did he pull that statistic from?

Did he really believe that statistic, or was he just trying to scare and bully this woman?  Or maybe a little of both?

Now, to be fair, some research does suggest that obesity is over-represented as a risk factor in the very few women in developed countries who die during pregnancy or birth.  It does look like it is a risk factor for some cases of maternal mortality and near-misses. And that's a legitimate cause for concern.

However, the part that gets ignored by the media is that obesity usually is a co-factor along with other factors like low socioeconomic status, non-white ethnicity, cesarean surgery, pre-eclampsia, or receiving substandard medical care (like inadequate prophylaxis against blood clots, or faulty intubation during general anesthesia).

But of course, it is often obesity only that gets the focus instead of seeing it as just one of several co-factors, and rarely do authorities seriously examine how substandard care for obese women contributes to maternal mortality.

And of course, the only cure is always seen as pushing weight loss before pregnancy instead of the more uncomfortable task of looking at how poor care for obese women has impacted outcomes. Far more effective would be studying how to improve care in obese women (by improving blood clot prophylaxis, by improved recognition of pulmonary embolisms, by more careful follow-up postpartum, by doing fewer damn cesareans in women of size in the first place).

Also conveniently ignored in the media hype is that the risk of dying during pregnancy is actually extremely small, even in women with risk factors. 

So this doctor telling this woman that she (and her baby) had an 85% chance of dying during the c-section is total and unadulterated bullsh*t.  

As I said, either this doctor has a distorted-in-the-extreme sense of risk around c-sections in obese women, or he is trying to bully this woman ─ or more likely, a bit of both.

Typically, what docs like this are trying to do is shock fat women into either losing massive amounts of weight (usually through weight loss surgery....funny how that surgery is not seen as "too risky" eh?), or to frighten them out of ever daring to have a baby again.

This kind of over-the-top scare tactic is a major exaggeration of the risks around obesity and pregnancy and is a new form of Medical Bullying.  It's trying to scare women of size out of having babies, rather than giving nuanced and evidence-based counseling about possible risks and reasonable ways to mitigate those risks.

There are so many ways that this type of tactic is wrong, but one of the things that bugs me most is that they are trying to become the gate-keepers for who is "allowed" to procreate, and they have deemed fat people unworthy of procreating.  This far exceeds their mandate as physicians, and worse, it smacks of eugenics.

It's deeming some types of risk factors (like type 1 diabetes) as worthy of having babies despite the risks, and other types of risk factors (obesity) as unworthy of having babies.

But it's not up to doctors to decide which patients with which risk factors should procreate.  

Rather, it is up to the couple to look at their particular risks and make an informed decision about having children or not. Reasonable risk counseling is appropriate, medical bullying through risk hyperbole is not.

Thankfully, most care providers do not use extreme tactics like this with women of size, but the fact that some do (and get away with it) is a terrible stain on the medical profession.  I've said it before but I'll say it again.....this is a unique and insidious form of eugenics and IT MUST STOP.

**I have a more in-depth piece about obesity and maternal mortality in the works, but seeing this entry on My OB Said What?!? necessitated a quicker response.  Stay tuned for more on this topic in the future.

Monday, February 6, 2012

Induction Math: The Importance of the Bishop Score

Image from Relay Health, as displayed on http://www.med.umich.edu/

Yet another study shows that inducing labor increases the risk for a cesarean, especially in first-time mothers with an unripe cervix (one that has not done much dilating and effacing yet).

In the study, they specifically looked at cesarean rates among induced mothers with an unripe cervix.  They found that cesarean rates were particularly high among first-time mothers who were induced with an unripe cervix, but the risk was also elevated for mothers with prior vaginal births who were induced on an unripe cervix.  

This is why it is absolutely vital to ask your provider about your Bishop Score before agreeing to induce labor.

The Bishop Score

The Bishop Score is a measure of how soft and ripe your cervix is before labor. It can help predict whether or not your body is ready for labor, and whether or not an induction is likely to succeed or fail.

A vaginal exam is done and the care provider evaluates the degree of:
  • cervical dilation (how far the cervix has opened so far)
  • cervical effacement (how thinned out the cervical walls are)
  • cervical consistency (how soft or firm the cervix is)
  • cervical position (whether the cervix is pointing forwards or backwards relative to the vaginal walls)
  • fetal station (how far down the baby is in the pelvis)
[If you need further explanation about the terminology above, you can find an excellent explanation and great illustrations here.]

Each factor is "graded" on a scale of 0-2 or 0-3.  The maximum possible score is 13. This all adds up to what some doulas call "induction math".

The exact cut-offs used differs by source, but generally a score of 5 or less indicates the woman is unlikely to go into labor spontaneously at that time, and that an induction is likely to fail (result in a cesarean).

A score of 8 or more indicates that an induction is more likely to succeed.  A score of 9 or more indicates the woman will likely go into labor on her own very soon.

Sometimes care providers use modifications of a Bishop Score to help predict likelihood of successful induction.  One point may be added to the score for the existence of pre-eclampsia or for every previous vaginal birth.  One point is often subtracted for a "postdates" pregnancy, being a first-time mother (or for no previous vaginal births), or preterm prelabor rupture of membranes.

The Bishop Score is just one tool for predicting a woman's response to induction.  Obviously, other factors matter as well.

The Influence of Fetal Position

One often-overlooked factor is fetal position ─ which way a head-down baby is facing in utero.  Most babies face either occiput anterior (back of the head towards mother's belly; baby looking at mother's back) or occiput posterior (back of the head towards mother's back; baby looking at mother's belly).

Often a low Bishop Score is associated with a posterior baby, which is a less ideal position for birth.  In this position, the the baby's head is not putting pressure as efficiently on the cervix, so there is less cervical effacement or dilation, and the cervix is often posterior (pointed towards the lower vaginal wall and hard to reach during a vaginal exam).  When the baby rotates to anterior, the Bishop Score often changes dramatically because the physics of the baby's pressure changes.

Many "overdue" babies are actually posterior babies whose positions are simply not putting the most efficient kind of pressure on the cervix to thin and dilate, and so the body wisely does not go into labor yet.  Forcing the issue by inducing labor when the baby is posterior (or has other malpositions) tends to result in long, hard labors that often end in a c-section.

[This is a pet peeve for me, because it is the story of my first c-section....induced at 40 weeks despite a very low Bishop Score (the OB told me I had a "horrible" cervix) and a malpositioned baby.  Small wonder I ended up with a cesarean!]

So if your Bishop Score is low, it may not just be that your body is not "ripe" for labor, it may also be that the reason you are not ripe is because the baby is not in a great position for labor.  For that reason, it may be wise to delay inducing until the baby is in a more favorable position for labor.

Seeing a pregnancy chiropractor and getting adjusted may help encourage the baby to get into a better position for labor, which in turn might lessen your chances for a cesarean.  (This is what was key for me in my VBACs.)

Induction Triples the Risk for Cesarean in First-Time Mothers

In the 2011 study listed below, the charts of women who were induced with a Bishop score of less than 7 were studied.

Those first-time moms who were induced with a Bishop score less than 7 had a whopping 42% cesarean rate.  

This shows just how important it is to have a nice ripe cervix before inducing labor, and especially so in first-time moms, whose cervices have never dilated before.

Sometimes a doctor will try to reassure you that it doesn't matter if your cervix isn't ripe; they use drugs that help ripen the cervix before starting the induction drugs.  And it's true that these drugs can help at times.

However, even with cervical ripening methods, many inductions still fail.  Cervical ripening drugs are simply not a panacea for preparing the body for birth when it's not ready.  They work best when the baby is in good position and the body is close to being ready but not quite there yet.  Cervical ripening methods are very unlikely to help in women with very low Bishop Scores.

Now, if the cervix has dilated before, induction is more likely to work. Women who had had vaginal births before had a much lower cesarean rate after induction in this study, 14%.  Still, this was nearly double the cesarean rate of those multips who went into labor spontaneously.  

Obviously, cervical ripeness matters, even in women who have had vaginal births before.

Take-Home Points About Induction

Additional research confirms that cervical ripeness is one of the key factors in whether or not an induction will work.  Here are some take-home lessons from the 2011 study:
  • Whenever possible, wait to go into labor spontaneously
  • If induction is being considered, try to avoid inducing if your Bishop Score is less than 7
Other general bits of wisdom about inductions:
  • Try to see a provider who is not induction-happy and won't induce automatically at a certain gestation.  This is especially important for women of size, because many providers induce "obese" women at extremely high rates (a 50-60% induction rate is common in many recent studies).  This is a direct but under-acknowledged factor in the very high cesarean rate in women of size.
  • Question whether an induction is truly necessary in your case.  Many inductions are done routinely, simply because it is convenient for the provider or protocol to induce by a certain gestational age.  However, you don't have to agree to this intervention.  Discuss the pros and cons of the induction vs. waiting with the provider, and see if you can negotiate for more time.  
  • If you are contemplating an induction, ask about your Bishop Score before agreeing to the induction.  If at all possible, try not to induce before you have a favorable Bishop Score. 
  • If you are contemplating induction, ask about your baby's position before agreeing to the induction.   If the baby is not anterior, consider delaying the induction.  Seeing a well-trained pregnancy chiropractor may help encourage the baby to get into an easier position for birth.
  • If a medical condition makes induction necessary even with an unripe cervix, look into ways to increase cervical ripeness before the induction.  This can include acupuncture, herbs, and cervical ripening agents.  Consider the pros and cons of each choice carefully for your situation, and remember that gentler methods generally need a longer time to be effective.  Don't wait to the last minute to try the more gentle methods of cervical ripening if you are very likely to face induction.
  • Be sure your provider allows adequate induction time before resorting to a cesarean.  Recent research has shown that many providers move to a cesarean too soon in an induction; allowing just a few more hours (provided mother and baby are doing well ) may result in a vaginal birth after all.
  • Remember, induction doesn't automatically mean you're going to have a cesarean; many women who are induced do end up having a vaginal birth.  Go in with a positive attitude, try to remain as mobile as possible, and be sure to have professional labor support (a doula), who can often help maximize your chances even during an induction.  However, because an induction does increase the chances for cesarean, be prepared for any possibility and have a cesarean birth plan ready if one becomes necessary.
Induction is more and more common these days.  This is why it is important for all women to be informed birth consumers and learn more about their choices around induction.  The Bishop Score is an important ─ and often overlooked ─ part of this discussion.

*Thanks to Holistic NYC Doula for the term "induction math" and for her excellent posts on the topic of the Bishop Score.


Acta Obstet Gynecol Scand. 2011 Oct;90(10):1094-9. doi: 10.1111/j.1600-0412.2011.01213.x. Epub 2011 Jul 21. Induction of labor and the risk for emergency cesarean section in nulliparous and multiparous women. Thorsell M, et al.   PMID: 21679162
OBJECTIVE: To assess the risk for emergency cesarean section among women in whom labor was induced in gestational week ≥41 and to evaluate if parity and mode of induction affected this association.
DESIGN: Hospital-based retrospective cohort study.
POPULATION: Singleton pregnancies delivered after ≥41 gestational weeks at Danderyd Hospital, Stockholm, Sweden, during 2002-2006.
MATERIAL AND METHODS: Of 23 030 singleton pregnancies meeting the entry criteria, 881 were induced with a Bishop score of less than 7. Obstetric outcome was assessed through linkage with the Swedish Medical Birth Registry and a local obstetrical database containing information from patients' medical files. Results were adjusted for body mass index, age and the use of epidural analgesia.
MAIN OUTCOME MEASURE: Risk for emergency cesarean section.
RESULTS: Among women who were induced, the proportions delivered by emergency cesarean section were 42% for nulliparous and 14% for multiparous. Compared to spontaneous onset, this corresponded to a more than threefold increase in risk for nulliparous women (OR 3.34, 95% CI 2.77-4.04) and an almost twofold increase in risk for multiparous women (OR 1.94, 95% CI 1.24-3.02). There was no significant difference in risk for emergency cesarean section between the two methods of induction (PGE(2) and transcervical catheter).
CONCLUSIONS: Compared to spontaneous onset of delivery, induction of labor is associated with an increased risk for emergency cesarean section both among nulliparous and multiparous women. When labor is induced, the high risk for emergency cesarean must be kept in mind.
Clin Obstet Gynecol. 2006 Sep;49(3):564-72. Preinduction cervical assessment. Baacke KA, Edwards RK.   PMID: 16885663 
The rate of labor induction is increasing in the United States. Methods for quantifying cervical factors have been developed to identify patients who may benefit from cervical ripening before induction. The first cervical scoring systems used digital examination. More recently, cervical ultrasound and testing for the presence of fetal fibronectin have been suggested to evaluatecervical readiness for labor induction, but neither of these methods provides a significant improvement over digital examination. The Bishop score, the most widely used digital examination scoring system, still is the most cost effective and accurate method of evaluating the cervix before labor induction.
Obstet Gynecol. 2005 Apr;105(4):690-7. Bishop score and risk of cesarean delivery after induction of labor in nulliparous women. Vrouenraets FP, et al.  PMID: 15802392 
OBJECTIVE: To quantify the risk and risk factors for cesarean delivery associated with medical and elective induction of labor in nulliparous women.
METHODS: A prospective cohort study was performed in nulliparous women at term with vertex singleton gestations who hadlabor induced at 2 obstetrical centers. Medical and elective indications and Bishop scores were recorded before labor induction. Obstetric and neonatal data were analyzed and compared with the results in women with a spontaneous onset of labor. Data were analyzed using univariate and multivariable regression modeling.
RESULTS: A total of 1,389 women were included in the study. The cesarean delivery rate was 12.0% in women with a spontaneous onset of labor (n = 765), 23.4% in women undergoing labor induction for medical reasons (n = 435) (unadjusted odds ratio [OR] 2.24; 95% confidence interval [CI] 1.64-3.06), and 23.8% in women whose labor was electively induced (n = 189) (unadjusted OR 2.29; 95% CI 1.53-3.41). However, after adjusting for the Bishop score at admission, no significant differences in cesarean delivery rates were found among the 3 groups. A Bishop score of 5 or less was a predominant risk factor for a cesarean delivery in all 3 groups (adjusted OR 2.32; 95% CI 1.66-3.25). Other variables with significantly increased risk for cesarean delivery included maternal age of 30 years or older, body mass index of 31 or higher, use of epidural analgesia during the first stage oflabor, and birth weight of 3,500 g or higher. In both induction groups, more newborns required neonatal care, more mothers needed a blood transfusion, and the maternal hospital stay was longer.
CONCLUSION: Compared with spontaneous onset of labor, medical and elective induction of labor in nulliparous women at term with a single fetus in cephalic presentation is associated with an increased risk of cesarean delivery, predominantly related to an unfavorable Bishop score at admission.