A few articles
Mar. 12th, 2010 12:41 pm![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
conuly
Another math post
An article about a pretty prolific shoe-thief in Seoul.
Seoul Police Link 1,700 Pairs of Shoes to 2 Feet
By CHOE SANG-HUN
SEOUL, South Korea — In South Korea, where people often remove their shoes before entering homes, restaurants or funeral parlors, it is a nagging problem: people walking off with others’ shoes, either by mistake or, sometimes, intentionally.
Still, Detective Kim Jeong-gu’s jaw dropped recently when he opened the warehouse of an ex-convict in Seoul and found 170 apple boxes packed with 1,700 pairs of expensive designer shoes, sorted by size and brand, and all believed to have been stolen.
“Shoe theft is not unusual here,” Detective Kim, 28, said. “But we gasped at this one.”
The 59-year-old suspect, a former convict identified only by his last name, Park, was a onetime used-shoe vendor who had been convicted twice in the past five years of pilfering shoes and operated around funeral homes, the police said.
Attached to major general hospitals, such facilities have 20 to 40 rooms where grieving families receive guests who bow on the floor in a show of respect for the deceased. They usually arrive in their best shoes and invariably leave them outside. They also linger for a while, eating, drinking and catching up with relatives, old friends or colleagues who have come for the same service.
For Mr. Park, the police said, stealing shoes was a case of if the shoe fits, take it. Last month, Mr. Park, disguised as a mourner dressed in black, strolled into the funeral parlor of the Samsung Medical Center in Seoul, took off his cheap footwear, paid his respects and then slipped on an expensive pair and left.
He hid the shoes behind a tree and returned in sandals. He repeated this twice before he was caught by Detective Kim. The hospital’s security staff members had been scrutinizing images from security cameras after a guest complained about losing a pair of shoes, and they alerted the police when they found Mr. Park behaving oddly, said Chung Jae-hong, a hospital spokesman.
“He admitted stealing three pairs that day,” Detective Kim said. “But he insisted that he had bought the rest of the shoes from used shoe dealers and had intended to resell them. But he could not explain how a jobless man like him, living in a small rented room, could buy so many designer shoes. We believe he stole them all.”
Mr. Park, now behind bars, was not available for comment. Police records showed that he was sentenced to one and a half years in prison in 2005 for stealing shoes, but that the sentence was suspended. In 2008, when he was arrested again and fined $4,300 for the same crime, he was found with 1,200 pairs of shoes.
He was allowed to keep most of them because no one claimed them, and the police could not prove that they all were stolen.
While few shoe thieves operate on the scale of Mr. Park, his is by no means an isolated case. Losing shoes, either to thieves or to drunken people who mistake others’ shoes for their own, has become such a common problem here that many restaurants have shoe lockers for customers or hire “shoe arrangers,” part-timers who keep an eye on the customers’ shoes.
Some places hand out black plastic bags so patrons can keep their footwear with them while dining. Still, most restaurants do not take such precautionary measures, simply putting up a sign: “We are not responsible for lost shoes.”
“It’s distressing when you have a good meal and come out, only to find your brand-new boots gone,” said Weon Yeun-suk, 48, a homemaker in Seoul, who has lost her shoes twice in recent years. “Once, I was all dressed up for Sunday and yet had to cancel everything and walk back home, wearing a pair of oversize men’s rubber sandals provided by the restaurant owner.”
Many people who take others’ footwear while drunk do not bother to return them, said Cho Chang-hyun, 53, who owns a restaurant in Seoul and recently blogged about shoe-snatching.
“This happens quite often in my place,” Mr. Cho said. “Customers who lost their shoes demand compensation, and they overprice their lost shoes. It’s part of the restaurant’s business to negotiate a settlement.
“The worst are customers who came in dirty sneakers and now claim that they have lost expensive leather shoes.”
Mr. Cho recently installed a closed-circuit camera to fight shoe theft.
After catching Mr. Park, officers at the Suseo Police Station in southern Seoul faced a new problem: how to find the owners of the shoes recovered from his warehouse. Few people, or shop owners, take the trouble to report stolen shoes to the police.
Finally, the police came up with what they called the “Cinderella solution.”
For four days last month, they spread out Mr. Park’s footwear on an outdoor basketball court and let anyone who claimed to have lost shoes drop by and try them on — all 1,700 pairs, if they liked. But before doing that, a claimant was required to write down his or her shoe size, design, color and brand to limit the chances of a person’s taking someone else’s pair.
About 400 people showed up, but only 95 found their shoes.
The police said there was a decent chance that Mr. Park would eventually keep most of those unclaimed shoes.
“But we hope our crackdown will scare away shoe snatchers for a while,” Detective Kim said.
An article about the reduction in c-sections (particularly an increase in VBAC) at a hospital on a reservation
Lessons at Indian Hospital About Births
By DENISE GRADY
TUBA CITY, Ariz. — After less than two hours in the maternity ward, with her boyfriend, his mother and a nurse-midwife by her side, Jacquelynn Torivio gave birth to a five-pound, five-ounce son with his grandmother’s dimples and a full head of shiny black hair.
As she held him, Ms. Torivio’s spirits clearly matched her Hopi name, Nuquahynum — “a feather flying high.”
It was the kind of birth that many women in the United States could only wish for. Ms. Torivio had a vaginal birth, even though her previous child had been delivered by Caesarean section. Because of that prior surgery, many hospitals would not have let her even try to give birth vaginally, but would have required another Caesarean.
The Tuba City Regional Health Care Corporation is different. Its hospital, run by the Navajo Nation and financed partly by the Indian Health Service, prides itself on having a higher than average rate of vaginal births among women with a prior Caesarean, and a lower Caesarean rate over all.
As Washington debates health care, this small hospital in a dusty desert town on an Indian reservation, showing its age and struggling to make ends meet, somehow manages to outperform richer, more prestigious institutions when it comes to keeping Caesarean rates down, which saves money and is better for many mothers and infants.
This week, the National Institutes of Health will hold a conference in Bethesda, Md., about the country’s dismal rates of vaginal birth after Caesarean, or VBAC (pronounced VEE-back), which have plummeted since 1996. “I think it’s the purpose of this conference to see if we can turn the clock back,” said Dr. Kimberly D. Gregory, vice chairwoman of women’s health care quality and performance improvement at Cedars-Sinai Medical Center in Los Angeles.
Tuba City will not be on the agenda, but its hospital, with about 500 births a year, could probably teach the rest of the country a few things about obstetrical care. But matching its success would require sweeping, fundamental changes in medical practice, like allowing midwives to handle more deliveries and removing the profit motive for performing surgery.
Changes in malpractice insurance would also help, so that obstetricians would feel less pressure to perform Caesareans. (The hospital and doctors in Tuba City are insured by the federal government, and therefore insurance companies cannot threaten to increase their premiums or withdraw coverage if they allow vaginal births after Caesarean.) Patients, too, would have to adjust their attitudes about birth and medical care during pregnancy and labor.
The national Caesarean rate, 31.8 percent, has been rising steadily for the last 11 years and is fed by repeat patients. Critics say that doctors are performing too many Caesareans, needlessly exposing women and infants to surgical risks and running up several billion dollars a year in excess bills, precisely the kind of overuse that a health care overhaul is supposed to address.
Even the American College of Obstetricians and Gynecologists has acknowledged that the operation is overused. Though there is no consensus on what the rate should be, government health agencies and the World Health Organization have suggested 15 percent as a goal in low-risk women.
“VBAC” has become a battle cry, with fierce advocates on both sides—women who insist that they should not be forced into surgery versus doctors and hospitals who insist on repeat Caesareans, citing the risks of labor and concerns about liability and insurance.
Originally, the mantra was “once a Caesarean, always a Caesarean” because of fears that the scar on the uterus would rupture during labor, which can be life-threatening for both the woman and the child. But after an expert panel in 1980 declared it safe for many women, vaginal birth after Caesarean had a heyday: in 1996, the rate reached 28.3 percent in women with previous Caesareans.
Then, there were some ruptures, deaths and lawsuits. The obstetricians’ group issued stricter guidelines, and the rate sank. It is now below 10 percent, and some experts think the pendulum has swung too far the other way.
In Tuba City last year, 32 percent of women with prior Caesareans had vaginal births. Its overall Caesarean rate has been low — 13.5 percent, less than half the national rate of 31.8 percent in 2007 (the latest year with figures available). This is despite the fact that more women here have diabetes and high blood pressure, which usually result in higher Caesarean rates.
The hospital serves mostly Native Americans — Navajos, Hopis and San Juan Southern Paiutes. Four other hospitals in New Mexico and Arizona, run by the Indian Health Service, also offer vaginal birth after Caesarean to some women (it is not safe for all) and have relatively low Caesarean rates without harming mothers or children, whose health in the first month after birth matches nationwide statistics. Doctors say there is no scientific evidence that Native American women are more able than others to have vaginal births.
“There is a significant lesson here about the ability of most women to deliver vaginally,” said Dr. Jean E. Howe, the chief clinical consultant for obstetrics and gynecology at Northern Navajo Medical Center in Shiprock, N.M.
Nurse-midwives at these hospitals deliver most of the babies born vaginally, with obstetricians available in case problems occur. Midwives staff the labor ward around the clock, a model of care thought to minimize Caesareans because midwives specialize in coaching women through labor and will often wait longer than obstetricians before recommending a Caesarean. They are also less likely to try to induce labor before a woman’s due date, something that increases the odds of a Caesarean.
In the rest of the country, nurse-midwives attend about only 10 percent of vaginal births, though their professional society, the American College of Nurse Midwives, hopes that will grow to 20 percent by 2020.
Dr. Kathleen Harner, an obstetrician in Tuba City, said: “Midwives are better at being there for labor than doctors are. Midwives are trained for it. It’s what they want to do.”
Dr. Amanda Leib, the director of obstetrics and gynecology at Tuba City, said: “I think the midwives tend to be patient. They know the patients well, and they don’t have to leave at 5 to get home for a golf game or a tennis game. As crass as that sounds, I do think it has some influence.”
Donna Rackley, a nurse-midwife in Tuba City, said that at a previous job in North Carolina, doctors who did not want to work late would sometimes set an arbitrary deadline and declare that if a woman did not deliver by then, she would have to have a Caesarean.
“I found myself apologizing to patients,” Ms. Rackley said.
In Tuba City, she said, if labor is slow but there is no sign of fetal distress and the patient wants more time, the doctors will wait.
Something that has led many other hospitals to ban vaginal birth after Caesarean poses less of a problem at Tuba City. The American College of Obstetricians and Gynecologists recommends that an obstetrician and an anesthesiologist be “immediately available” during labor for patients who have had a previous Caesarean in case something goes wrong.
Many hospitals, especially small ones, say they cannot afford to pay these specialists to wait around. But in Tuba City, doctors live on the hospital grounds or just minutes away, and they are immediately available even if they are at home.
Doctors and midwives here earn salaries and are not paid by the procedure, so they have no financial incentive to perform surgery. (Doctors earn $190,000 to $285,000 a year, and midwives $80,000 to $120,000.)
“My colleagues here truly want to practice medicine and help people,” said Dr. Jennifer Whitehair, an obstetrician. “That’s not true everywhere. Here they’re not thinking, how much can I make off this procedure?”
The hospital and doctors are federally insured against malpractice, in contrast to other hospitals, where private insurers have threatened to raise premiums or withdraw coverage if vaginal birth after Caesarean is allowed.
As a result, Dr. Leib said, doctors in Tuba City are free to “think about what’s best for the patient and not what covers our butts.”
Some of Tuba City’s success probably arises from Navajo culture and customs. Couples often want more than two children, but repeated Caesareans increase the risk of each pregnancy, so doctors and patients are motivated to avoid the surgery. Also, Navajos regard incisions as a threat to the spirit, something to be avoided unless necessary.
Birth is a joyous affair here, and the entire family — from children to great-grandparents — often go to the delivery room.
“I’ve had 12 family members in the room,” said Michelle Cullison, a nurse-midwife. “I’ve frankly never seen a place like this. Whoever that woman wants to be there is there. It’s something I would take out to the community.”
Linda Higgins, the head of midwifery at Tuba City, said: “All of a sudden Mom is surrounded by women, and they’re all helping her and touching her.”
As a result, many young women have already seen children born by the time they become pregnant, and birth seems natural to them, not frightening.
Can the rest of the country learn from Tuba City? Doctors say they are intrigued by the model but not sure how transferable it is.
Dr. Gregory said it would not be easy to lower the Caesarean rate because of entrenched practices that raise it, like labor induction, repeat Caesareans and in vitro fertilization procedures that produce multiple births. Obesity also drives up Caesarean rates.
“I believe that a 15 percent rate is possible and not unreasonable — as a researcher,” Dr. Gregory said. “As a clinician, if you factor in patient autonomy and the number of interventions we do, it’s not likely to be possible if we keep doing what we’re doing.”
Apparently, Princess Aiko isn't going to school because of bullying, or something. Interesting article, I thought.
A Jostled Princess, a Heavy Crown
By MARTIN FACKLER
TOKYO — When an official at the Imperial Household Agency suddenly announced last week that 8-year-old Princess Aiko was refusing to go to school because of bullying, he did more than just disclose a mundane problem facing a member of Japan’s ancient and secretive monarchy.
He also added a new twist to one of the most riveting but mysterious dramas in Japan, the seven-year depression and seclusion of Aiko’s mother, Crown Princess Masako, the Harvard-trained former diplomat. Aiko is the only child of Princess Masako and her husband, Crown Prince Naruhito, and is widely known to be one of the few sources of joy for the troubled crown princess.
The episode has once again put Princess Masako’s unhappy story into the harsh glare of Japan’s tabloid press. The news media here portrayed her 1993 wedding as the fairy-tale marriage of a commoner to a prince but then grew increasingly critical of her inability to bear a male heir for the Chrysanthemum Throne. The mounting pressure is widely seen as contributing to what appears to have been a breakdown.
Since last week’s announcement, Princess Masako, 46, has emerged to take her daughter to school and even to sit with Aiko in her second-grade classroom. Some commentators speculated whether her mother’s problems had made Aiko overly sensitive or emotionally frail.
The question now is whether the report that her daughter was bullied will make Japanese more sympathetic to the princess’s plight, or only add to the criticism of her. Some said Aiko’s troubles might even feed growing calls by conservatives for her father, 50, to step aside as the successor to his father, Emperor Akihito, 76.
“Many people won’t want such an unhealthy family to become emperor and empress,” said Akira Hashimoto, a former schoolmate of Emperor Akihito who has written several books about the imperial family. “If Aiko’s problems continue, this will only put more pressure on the crown prince.”
The renewed attention began on Friday, when the Imperial Household Agency’s grand master, who manages the affairs of the crown prince and his family, said at a regular news conference that Aiko was staying home because of stomachaches and anxiety attacks. The grand master, Issei Nomura, then revealed that the agency believed that the princess had suffered “violent acts” by boys in her elementary school, though he did not elaborate.
The apparently unscripted outburst was unprecedented from someone in the usually tightlipped inner circles of Japan’s tradition-bound imperial family, and it immediately set off a frenzy of coverage in the Japanese media. Some reports have criticized the grand master for overreacting to a common problem faced by parents of other social classes.
However, the harshest words have been reserved for Tokyo’s elite Gakushuin Primary School, which was created more than a century ago to educate Japan’s prewar aristocracy. Tabloid weeklies have reported in scandalized tones how the school had allowed students to run, yell in class and tussle on the playground — roughhousing common at other schools but unacceptable at a school patronized by the imperial family.
Responding to the grand master’s comments, a director at the school, Motomasa Higashisono, said that Aiko was scared after two boys nearly collided with her by accident as they rushed down the hallway to get lunch.
“My understanding is that we have heard nothing about any acts of violence or bullying directed at Her Highness Princess Aiko,” Mr. Higashisono said. Still, there has been talk of whether the incident may prompt the imperial family to cut its ties to the school.
In an indirect way, the saga has also added to concerns of some conservatives about whether Prince Naruhito is fit to take the throne. Some court watchers, like Mr. Hashimoto, have begun to ask how the crown prince would be able to fulfill his duties as emperor with his wife incapacitated and now his daughter unable to attend school on her own.
Naruhito has also shared the blame for his wife’s failure to have a boy, which prompted a politically charged debate about whether to break with centuries of tradition and allow a woman to assume the Chrysanthemum Throne, one of the world’s oldest hereditary monarchies. This debate was halted three years ago when the wife of the crown prince’s younger brother, Prince Akishino, bore a son, ensuring a male successor for at least one more generation.
Others, however, said the school incident might have the opposite effect of making the public feel more compassion for Princess Masako. They said it could make the crown princess seem less distant if she was seen as a concerned mother facing her child’s bullying, an all-too-common problem in Japan’s high-pressure educational system.
“This will impress upon the public psyche that Princess Masako has problems just like the rest of us,” said Takeshi Hara, a professor specializing in the monarchy at Meiji Gakuin University here. “This could generate more support for her and the crown prince.”
An article about a pretty prolific shoe-thief in Seoul.
Seoul Police Link 1,700 Pairs of Shoes to 2 Feet
By CHOE SANG-HUN
SEOUL, South Korea — In South Korea, where people often remove their shoes before entering homes, restaurants or funeral parlors, it is a nagging problem: people walking off with others’ shoes, either by mistake or, sometimes, intentionally.
Still, Detective Kim Jeong-gu’s jaw dropped recently when he opened the warehouse of an ex-convict in Seoul and found 170 apple boxes packed with 1,700 pairs of expensive designer shoes, sorted by size and brand, and all believed to have been stolen.
“Shoe theft is not unusual here,” Detective Kim, 28, said. “But we gasped at this one.”
The 59-year-old suspect, a former convict identified only by his last name, Park, was a onetime used-shoe vendor who had been convicted twice in the past five years of pilfering shoes and operated around funeral homes, the police said.
Attached to major general hospitals, such facilities have 20 to 40 rooms where grieving families receive guests who bow on the floor in a show of respect for the deceased. They usually arrive in their best shoes and invariably leave them outside. They also linger for a while, eating, drinking and catching up with relatives, old friends or colleagues who have come for the same service.
For Mr. Park, the police said, stealing shoes was a case of if the shoe fits, take it. Last month, Mr. Park, disguised as a mourner dressed in black, strolled into the funeral parlor of the Samsung Medical Center in Seoul, took off his cheap footwear, paid his respects and then slipped on an expensive pair and left.
He hid the shoes behind a tree and returned in sandals. He repeated this twice before he was caught by Detective Kim. The hospital’s security staff members had been scrutinizing images from security cameras after a guest complained about losing a pair of shoes, and they alerted the police when they found Mr. Park behaving oddly, said Chung Jae-hong, a hospital spokesman.
“He admitted stealing three pairs that day,” Detective Kim said. “But he insisted that he had bought the rest of the shoes from used shoe dealers and had intended to resell them. But he could not explain how a jobless man like him, living in a small rented room, could buy so many designer shoes. We believe he stole them all.”
Mr. Park, now behind bars, was not available for comment. Police records showed that he was sentenced to one and a half years in prison in 2005 for stealing shoes, but that the sentence was suspended. In 2008, when he was arrested again and fined $4,300 for the same crime, he was found with 1,200 pairs of shoes.
He was allowed to keep most of them because no one claimed them, and the police could not prove that they all were stolen.
While few shoe thieves operate on the scale of Mr. Park, his is by no means an isolated case. Losing shoes, either to thieves or to drunken people who mistake others’ shoes for their own, has become such a common problem here that many restaurants have shoe lockers for customers or hire “shoe arrangers,” part-timers who keep an eye on the customers’ shoes.
Some places hand out black plastic bags so patrons can keep their footwear with them while dining. Still, most restaurants do not take such precautionary measures, simply putting up a sign: “We are not responsible for lost shoes.”
“It’s distressing when you have a good meal and come out, only to find your brand-new boots gone,” said Weon Yeun-suk, 48, a homemaker in Seoul, who has lost her shoes twice in recent years. “Once, I was all dressed up for Sunday and yet had to cancel everything and walk back home, wearing a pair of oversize men’s rubber sandals provided by the restaurant owner.”
Many people who take others’ footwear while drunk do not bother to return them, said Cho Chang-hyun, 53, who owns a restaurant in Seoul and recently blogged about shoe-snatching.
“This happens quite often in my place,” Mr. Cho said. “Customers who lost their shoes demand compensation, and they overprice their lost shoes. It’s part of the restaurant’s business to negotiate a settlement.
“The worst are customers who came in dirty sneakers and now claim that they have lost expensive leather shoes.”
Mr. Cho recently installed a closed-circuit camera to fight shoe theft.
After catching Mr. Park, officers at the Suseo Police Station in southern Seoul faced a new problem: how to find the owners of the shoes recovered from his warehouse. Few people, or shop owners, take the trouble to report stolen shoes to the police.
Finally, the police came up with what they called the “Cinderella solution.”
For four days last month, they spread out Mr. Park’s footwear on an outdoor basketball court and let anyone who claimed to have lost shoes drop by and try them on — all 1,700 pairs, if they liked. But before doing that, a claimant was required to write down his or her shoe size, design, color and brand to limit the chances of a person’s taking someone else’s pair.
About 400 people showed up, but only 95 found their shoes.
The police said there was a decent chance that Mr. Park would eventually keep most of those unclaimed shoes.
“But we hope our crackdown will scare away shoe snatchers for a while,” Detective Kim said.
An article about the reduction in c-sections (particularly an increase in VBAC) at a hospital on a reservation
Lessons at Indian Hospital About Births
By DENISE GRADY
TUBA CITY, Ariz. — After less than two hours in the maternity ward, with her boyfriend, his mother and a nurse-midwife by her side, Jacquelynn Torivio gave birth to a five-pound, five-ounce son with his grandmother’s dimples and a full head of shiny black hair.
As she held him, Ms. Torivio’s spirits clearly matched her Hopi name, Nuquahynum — “a feather flying high.”
It was the kind of birth that many women in the United States could only wish for. Ms. Torivio had a vaginal birth, even though her previous child had been delivered by Caesarean section. Because of that prior surgery, many hospitals would not have let her even try to give birth vaginally, but would have required another Caesarean.
The Tuba City Regional Health Care Corporation is different. Its hospital, run by the Navajo Nation and financed partly by the Indian Health Service, prides itself on having a higher than average rate of vaginal births among women with a prior Caesarean, and a lower Caesarean rate over all.
As Washington debates health care, this small hospital in a dusty desert town on an Indian reservation, showing its age and struggling to make ends meet, somehow manages to outperform richer, more prestigious institutions when it comes to keeping Caesarean rates down, which saves money and is better for many mothers and infants.
This week, the National Institutes of Health will hold a conference in Bethesda, Md., about the country’s dismal rates of vaginal birth after Caesarean, or VBAC (pronounced VEE-back), which have plummeted since 1996. “I think it’s the purpose of this conference to see if we can turn the clock back,” said Dr. Kimberly D. Gregory, vice chairwoman of women’s health care quality and performance improvement at Cedars-Sinai Medical Center in Los Angeles.
Tuba City will not be on the agenda, but its hospital, with about 500 births a year, could probably teach the rest of the country a few things about obstetrical care. But matching its success would require sweeping, fundamental changes in medical practice, like allowing midwives to handle more deliveries and removing the profit motive for performing surgery.
Changes in malpractice insurance would also help, so that obstetricians would feel less pressure to perform Caesareans. (The hospital and doctors in Tuba City are insured by the federal government, and therefore insurance companies cannot threaten to increase their premiums or withdraw coverage if they allow vaginal births after Caesarean.) Patients, too, would have to adjust their attitudes about birth and medical care during pregnancy and labor.
The national Caesarean rate, 31.8 percent, has been rising steadily for the last 11 years and is fed by repeat patients. Critics say that doctors are performing too many Caesareans, needlessly exposing women and infants to surgical risks and running up several billion dollars a year in excess bills, precisely the kind of overuse that a health care overhaul is supposed to address.
Even the American College of Obstetricians and Gynecologists has acknowledged that the operation is overused. Though there is no consensus on what the rate should be, government health agencies and the World Health Organization have suggested 15 percent as a goal in low-risk women.
“VBAC” has become a battle cry, with fierce advocates on both sides—women who insist that they should not be forced into surgery versus doctors and hospitals who insist on repeat Caesareans, citing the risks of labor and concerns about liability and insurance.
Originally, the mantra was “once a Caesarean, always a Caesarean” because of fears that the scar on the uterus would rupture during labor, which can be life-threatening for both the woman and the child. But after an expert panel in 1980 declared it safe for many women, vaginal birth after Caesarean had a heyday: in 1996, the rate reached 28.3 percent in women with previous Caesareans.
Then, there were some ruptures, deaths and lawsuits. The obstetricians’ group issued stricter guidelines, and the rate sank. It is now below 10 percent, and some experts think the pendulum has swung too far the other way.
In Tuba City last year, 32 percent of women with prior Caesareans had vaginal births. Its overall Caesarean rate has been low — 13.5 percent, less than half the national rate of 31.8 percent in 2007 (the latest year with figures available). This is despite the fact that more women here have diabetes and high blood pressure, which usually result in higher Caesarean rates.
The hospital serves mostly Native Americans — Navajos, Hopis and San Juan Southern Paiutes. Four other hospitals in New Mexico and Arizona, run by the Indian Health Service, also offer vaginal birth after Caesarean to some women (it is not safe for all) and have relatively low Caesarean rates without harming mothers or children, whose health in the first month after birth matches nationwide statistics. Doctors say there is no scientific evidence that Native American women are more able than others to have vaginal births.
“There is a significant lesson here about the ability of most women to deliver vaginally,” said Dr. Jean E. Howe, the chief clinical consultant for obstetrics and gynecology at Northern Navajo Medical Center in Shiprock, N.M.
Nurse-midwives at these hospitals deliver most of the babies born vaginally, with obstetricians available in case problems occur. Midwives staff the labor ward around the clock, a model of care thought to minimize Caesareans because midwives specialize in coaching women through labor and will often wait longer than obstetricians before recommending a Caesarean. They are also less likely to try to induce labor before a woman’s due date, something that increases the odds of a Caesarean.
In the rest of the country, nurse-midwives attend about only 10 percent of vaginal births, though their professional society, the American College of Nurse Midwives, hopes that will grow to 20 percent by 2020.
Dr. Kathleen Harner, an obstetrician in Tuba City, said: “Midwives are better at being there for labor than doctors are. Midwives are trained for it. It’s what they want to do.”
Dr. Amanda Leib, the director of obstetrics and gynecology at Tuba City, said: “I think the midwives tend to be patient. They know the patients well, and they don’t have to leave at 5 to get home for a golf game or a tennis game. As crass as that sounds, I do think it has some influence.”
Donna Rackley, a nurse-midwife in Tuba City, said that at a previous job in North Carolina, doctors who did not want to work late would sometimes set an arbitrary deadline and declare that if a woman did not deliver by then, she would have to have a Caesarean.
“I found myself apologizing to patients,” Ms. Rackley said.
In Tuba City, she said, if labor is slow but there is no sign of fetal distress and the patient wants more time, the doctors will wait.
Something that has led many other hospitals to ban vaginal birth after Caesarean poses less of a problem at Tuba City. The American College of Obstetricians and Gynecologists recommends that an obstetrician and an anesthesiologist be “immediately available” during labor for patients who have had a previous Caesarean in case something goes wrong.
Many hospitals, especially small ones, say they cannot afford to pay these specialists to wait around. But in Tuba City, doctors live on the hospital grounds or just minutes away, and they are immediately available even if they are at home.
Doctors and midwives here earn salaries and are not paid by the procedure, so they have no financial incentive to perform surgery. (Doctors earn $190,000 to $285,000 a year, and midwives $80,000 to $120,000.)
“My colleagues here truly want to practice medicine and help people,” said Dr. Jennifer Whitehair, an obstetrician. “That’s not true everywhere. Here they’re not thinking, how much can I make off this procedure?”
The hospital and doctors are federally insured against malpractice, in contrast to other hospitals, where private insurers have threatened to raise premiums or withdraw coverage if vaginal birth after Caesarean is allowed.
As a result, Dr. Leib said, doctors in Tuba City are free to “think about what’s best for the patient and not what covers our butts.”
Some of Tuba City’s success probably arises from Navajo culture and customs. Couples often want more than two children, but repeated Caesareans increase the risk of each pregnancy, so doctors and patients are motivated to avoid the surgery. Also, Navajos regard incisions as a threat to the spirit, something to be avoided unless necessary.
Birth is a joyous affair here, and the entire family — from children to great-grandparents — often go to the delivery room.
“I’ve had 12 family members in the room,” said Michelle Cullison, a nurse-midwife. “I’ve frankly never seen a place like this. Whoever that woman wants to be there is there. It’s something I would take out to the community.”
Linda Higgins, the head of midwifery at Tuba City, said: “All of a sudden Mom is surrounded by women, and they’re all helping her and touching her.”
As a result, many young women have already seen children born by the time they become pregnant, and birth seems natural to them, not frightening.
Can the rest of the country learn from Tuba City? Doctors say they are intrigued by the model but not sure how transferable it is.
Dr. Gregory said it would not be easy to lower the Caesarean rate because of entrenched practices that raise it, like labor induction, repeat Caesareans and in vitro fertilization procedures that produce multiple births. Obesity also drives up Caesarean rates.
“I believe that a 15 percent rate is possible and not unreasonable — as a researcher,” Dr. Gregory said. “As a clinician, if you factor in patient autonomy and the number of interventions we do, it’s not likely to be possible if we keep doing what we’re doing.”
Apparently, Princess Aiko isn't going to school because of bullying, or something. Interesting article, I thought.
A Jostled Princess, a Heavy Crown
By MARTIN FACKLER
TOKYO — When an official at the Imperial Household Agency suddenly announced last week that 8-year-old Princess Aiko was refusing to go to school because of bullying, he did more than just disclose a mundane problem facing a member of Japan’s ancient and secretive monarchy.
He also added a new twist to one of the most riveting but mysterious dramas in Japan, the seven-year depression and seclusion of Aiko’s mother, Crown Princess Masako, the Harvard-trained former diplomat. Aiko is the only child of Princess Masako and her husband, Crown Prince Naruhito, and is widely known to be one of the few sources of joy for the troubled crown princess.
The episode has once again put Princess Masako’s unhappy story into the harsh glare of Japan’s tabloid press. The news media here portrayed her 1993 wedding as the fairy-tale marriage of a commoner to a prince but then grew increasingly critical of her inability to bear a male heir for the Chrysanthemum Throne. The mounting pressure is widely seen as contributing to what appears to have been a breakdown.
Since last week’s announcement, Princess Masako, 46, has emerged to take her daughter to school and even to sit with Aiko in her second-grade classroom. Some commentators speculated whether her mother’s problems had made Aiko overly sensitive or emotionally frail.
The question now is whether the report that her daughter was bullied will make Japanese more sympathetic to the princess’s plight, or only add to the criticism of her. Some said Aiko’s troubles might even feed growing calls by conservatives for her father, 50, to step aside as the successor to his father, Emperor Akihito, 76.
“Many people won’t want such an unhealthy family to become emperor and empress,” said Akira Hashimoto, a former schoolmate of Emperor Akihito who has written several books about the imperial family. “If Aiko’s problems continue, this will only put more pressure on the crown prince.”
The renewed attention began on Friday, when the Imperial Household Agency’s grand master, who manages the affairs of the crown prince and his family, said at a regular news conference that Aiko was staying home because of stomachaches and anxiety attacks. The grand master, Issei Nomura, then revealed that the agency believed that the princess had suffered “violent acts” by boys in her elementary school, though he did not elaborate.
The apparently unscripted outburst was unprecedented from someone in the usually tightlipped inner circles of Japan’s tradition-bound imperial family, and it immediately set off a frenzy of coverage in the Japanese media. Some reports have criticized the grand master for overreacting to a common problem faced by parents of other social classes.
However, the harshest words have been reserved for Tokyo’s elite Gakushuin Primary School, which was created more than a century ago to educate Japan’s prewar aristocracy. Tabloid weeklies have reported in scandalized tones how the school had allowed students to run, yell in class and tussle on the playground — roughhousing common at other schools but unacceptable at a school patronized by the imperial family.
Responding to the grand master’s comments, a director at the school, Motomasa Higashisono, said that Aiko was scared after two boys nearly collided with her by accident as they rushed down the hallway to get lunch.
“My understanding is that we have heard nothing about any acts of violence or bullying directed at Her Highness Princess Aiko,” Mr. Higashisono said. Still, there has been talk of whether the incident may prompt the imperial family to cut its ties to the school.
In an indirect way, the saga has also added to concerns of some conservatives about whether Prince Naruhito is fit to take the throne. Some court watchers, like Mr. Hashimoto, have begun to ask how the crown prince would be able to fulfill his duties as emperor with his wife incapacitated and now his daughter unable to attend school on her own.
Naruhito has also shared the blame for his wife’s failure to have a boy, which prompted a politically charged debate about whether to break with centuries of tradition and allow a woman to assume the Chrysanthemum Throne, one of the world’s oldest hereditary monarchies. This debate was halted three years ago when the wife of the crown prince’s younger brother, Prince Akishino, bore a son, ensuring a male successor for at least one more generation.
Others, however, said the school incident might have the opposite effect of making the public feel more compassion for Princess Masako. They said it could make the crown princess seem less distant if she was seen as a concerned mother facing her child’s bullying, an all-too-common problem in Japan’s high-pressure educational system.
“This will impress upon the public psyche that Princess Masako has problems just like the rest of us,” said Takeshi Hara, a professor specializing in the monarchy at Meiji Gakuin University here. “This could generate more support for her and the crown prince.”
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Date: 2010-03-13 01:38 am (UTC)