Let’s say you are CPR certified and the woman next to you on the morning commuter train goes into cardiac arrest.  Is your first thought, I had better let this woman die because if I perform CPR, I might hurt her fetus?  Apparently this is the attitude of many health care providers.
The Society for Obstetric Anesthesia and Perinatology (SOAP) has issued a new consensus statement regarding cardiopulmonary resuscitation (CPR) for pregnant women.  Pregnant women may have special needs regarding CPR, especially later in pregnancy when the size of the fetus compresses veins sending blood back to the heart.
cpr_pregnant
Sometimes a hysterotomy (basically a cesarean, but the idea is to get the fetus out of the woman’s body) is the best way to preserve the woman’s life.  Some might be concerned about hysterotomy because of the concern for the life of the fetus being born prematurely.  We might then ask, what happens to a fetus inside of a woman who has gone into cardiac arrest and dies?  Well, the fetus generally dies too.
One of the things the new guidelines state is the importance of administering care that prioritizes saving the pregnant woman’s life.  Generally when a person goes into cardiac arrest, saving that person’s life is the goal, and it is alarming that it has to be stated that the life of a pregnant woman is equally valuable to the life of any other person who goes into cardiac arrest.
In a Q & A with Brendan Carvalho, Chief of Obstetric Anesthesia at Stanford University Medical Center, Dr. Carvalho notes that pregnancy CPR guidelines are important because pregnancy can increase a woman’s risk for cardiac arrest (and all women, pregnant or not, are at some level of risk).  It is laudable to recognize the normalcy of pregnancy in a woman’s life and determine how to provide appropriate medical treatment.  While Carvalho notes that U.S. maternal mortality has decreased dramatically over the last century, he does not mention that it has increased dramatically over the last two decades, with a rate that is now among the worst in the developed world.  The U.S. rates 60th nationally–59 countries have lower maternal death rates.
Perhaps part of rising maternal mortality stems from an attitude toward pregnant women that their humanity is suspended while they perform as vessels for fetal growth.  Such an attitude has been evidenced in the case of  Marlise Munoz (see here), the Texas woman whose dead body was kept artificially functioning against her wishes and those of her family so that it could serve as an incubator for her fetus. Louisiana has created an official law (which is expected to be signed by the governor) that mandates women’s dead bodies be artificially sustained as incubators for any fetus inside them that has reached 20 weeks.   Pregnant women are routinely criminalized for behavior that is not prosecuted in other adults, such as alcohol consumption or refusing to follow the recommendations of a physician (see here), indicating that pregnant women cannot be accorded basic human rights–the kind of rights accorded to all other adult humans.
Carvalho says,
Caregivers are often reluctant to administer medication to pregnant women because of potential harm to the baby. The consensus statement emphasized that caregivers can use the same drugs they typically give to a nonpregnant patient who has a cardiac arrest. The best thing you can do for baby is to provide the mom the best possible care and not withhold any drugs or procedures that would normally be used managing a critically ill person.
The key word here is person.  What justification would there ever be to intentionally withhold treatment from a critically ill person whose life could be preserved?  If pregnant women were truly viewed as people, no one–not Carvalho, not anyone–would ever have to make this statement.

There has been renewed interest in cesareans in the news (and on this blog) since the release of the ACOG/SMFM consensus statement on preventing primary cesareans in March.  When all health care providers are following best practices, rates of procedures should be relatively similar in patients with similar risk profiles.  This is not so for cesareans, where rates of the procedure in low risk births (singleton, cephalic fetus at term; woman with no health complications) can range from less than 5% to nearly 60% depending on the hospital.

Recently the Contra Costa Times ran a story about the issue in which they quoted Dr. Kirsten Salmeen (whose research interests indicate that she is interested in shared decision making models).  Here is the section of the story in which she comments on practice variation:

Why such profound variations? Should our standards of medical practice be so flexible?

The answer is “complicated” replies Dr. Kirsten Salmeen of the Maternal Fetal Medicine Division at UC San Francisco. She thinks variations in cesarean rates across the country are “likely due to a combination of factors.” That includes differences in patient populations and preferences, provider availability and coverage, hospital and provider culture, access to anesthesia and surgical obstetric services, and the prevailing medico-legal climate.

For example, Salmeen proposed that a difference in rate might depend upon the scope of available obstetrical services. In a hospital staffed with 24/7 obstetric coverage and resourced to provide a C-section when needed, a woman might be allowed more time for labor with a vaginal delivery. In contrast, that may not be as feasible with a solo or small-group provider who’d have to cancel scheduled clinic appointments with many patients in order to wait upon one patient’s labor.

While resource allocation can affect cesareans, in many countries, scant resources mean that women cannot get cesareans that they do need, which is one reason infant and maternal mortality rates are so high in developing nations where hospitals are not universally accessible by birthing women.  It seems preposterous that a lack of resources would lead to more cesareans–it’s how those resources are allocated.

The more important question in terms of shared decision making and informed consent is what women are told when a doctor performs a cesarean.  Are they given the real reasons as outlined by Dr. Salmeen:

  • Does an obstetrician in solo practice say, “Your labor is normal and you and the baby are doing fine but it looks like your birth is going to take several more hours, and I have patients waiting at the office, so is it okay if I just do a cesarean?”
  • Or perhaps in a state with high malpractice claims, the obstetrician says, “Your labor is normal and you and the baby are doing fine, but you had a brief indeterminate fetal heart rate tracing, and if your baby isn’t perfect, you could use that to sue me, so is it okay if I just do a cesarean?”
  • Or perhaps the obstetrician says, “Our culture here at this hospital is to do cesareans on women who don’t really need them, so let’s schedule yours now.”

Somehow, I think not.  Here is a video, intended to be humorous, in which the “OB” convinces a woman to have a cesarean, which “will be way easier” for him:

 

Unfortunately, the kinds of things the actor says are often not that far from things some obstetricians say in real life.

As Dr. Elliott Main (a generally great guy) points out, a doctor can convince pretty much any woman to have a cesarean.  Few women will refuse when a doctor tells them their baby is in danger.

That’s a much easier sell than needing to get back to the office.

 

Rinat Dray was forced to have a cesarean in 2011 at Staten Island University Hospital.  Dray had two previous cesareans and chose a doctor who said he supported her desire for a VBAC and a hospital with (by American standards) a low cesarean rate and a good VBAC rate.  But once she arrived at the hospital in labor, according to Dray (as reported by the New York Times),

The doctor told her the baby would be in peril and her uterus would rupture if she did not [have a cesarean]; he told her that she would be committing the equivalent of child abuse and that her baby would be taken away from her.

She still refused the cesarean, and she was supported in her refusal by her husband and her mother.  The hospital strapped her down and wheeled her into surgery as she begged them to stop.  A note in her medical record by Dr. James Ducey says, “I have decided to override her refusal to have a C-section.”  During the surgery, the doctor punctured her bladder.  You can hear a podcast on RH Reality Check in which Dray discusses her case along with professionals in obstetrics, law, and ethics.

Dray is a Hasidic Jew, which likely means that she wants a large family.  While there are risks to vaginal birth after cesarean, in most cases there are even greater risks to having many cesareans.

In the podcast, Dr. Katharine Morrison, MD, FACOG (Director of Buffalo WomenServices, which I wrote about here) says that she reviewed the record and it did not appear that there was an emergency situation or that a cesarean was needed at all.  But even if a cesarean has appeared necessary to preserve the life or health of Dray or her baby, as Dr. Howard Minkoff, chairman of obstetrics at Maimonides Medical Center in Brooklyn, said in the NYT article, “I don’t have a right to put a knife in your belly ever.”

One would think that a case in which a psychologically stable woman refused surgery and was then strapped down, sliced open, and had her bladder perforated would be apparent to anyone as a horrendous breach of human rights.  (And actually, she was asking them to wait a little longer, not saying she would not agree if she felt a cesarean was truly necessary).

All one has to do to see where a woman falls in the human rights spectrum of many is to read the comments on the New York Times piece.

The comments fall into a number of categories, including some that unequivocally support Dray.

Many, however, unequivocally support the the doctors or the profession of obstetrics.  Here is Northstar5:

If this woman had 2 prior C-sections then the doctors are absolutely right that vaginal delivery was exceedingly risky. I almost laughed when I read that the woman is charging the doctors and hospital for “improperly substituting their judgment for that of the mother.” What?? That’s what they are supposed to do. They are doctors, she is not.

Some defend the doctors doing whatever they like to avoid risks of malpractice:

Attempting a vaginal birth after two c-sections is extremely dangerous and reckless. The physicians involved would likely have been sued regardless of the method of delivery, so I applaud them for at least saving a life in this case.

I’m not sure where the commenters get their medical information, but the doctor agreed in advance to attend Dray at a vaginal birth.  You can read the entire American College of Obstetricans and Gynecologists’ practice statement “Vaginal Birth After Previous Cesarean Delivery,” which specifically says, “women with two previous low transverse cesarean deliveries may be candidates for TOLAC [trial of labor after cesarean].”  I highly recommend that you visit Jennifer Kamel’s website VBACFacts.com and read “13 Myths about VBAC.”  Repeat cesarean and VBAC both have risks.  The newest ACOG obstetric care consensus statement on cesarean points out the risks of cesarean over vaginal birth.  Cesarean nearly quadruples the risk of maternal death, and risks of maternal morbidity and mortality go up with every cesarean.  This would be a particular concern for a woman who wanted a very large family, as many Hasidic women do.  Here is a consent form that clearly lays out the risks and benefits of repeat cesarean and VBAC.

Some commenters are completely on the side of the fetus–if the mother’s status is reduced to that of a container, so be it.  Here’s NYC Commuter:

In this case, the hospital and doctors have not one patient, but two. One is an adult who appears competent to make medical decisions. The other is a fetus, at term, who has no voice. The courts have repeatedly affirmed that the state has a duty to protect citizens that cannot protect themselves. If a fetus is believed to be “alive,” then an argument can be made that it must be protected as well. Pregnant women have been forced to receive imprisoned to prevent them from harming their fetuses (e.g. drug abusers), take medication (e.g. for treatable diseases), and even receive c-sections if the baby’s life is judged to be in direct jeopardy.

I have written about the ethics of privileging the well-being of a fetus over an adult woman many times, including here, here, and here.  ACOG also agrees that a woman should have the right to make her own decisions, even if it may negatively impact the fetus.  One recommendation from ACOG’s Committee Opinion, “Maternal Decision Making, Ethics, and the Law” says,

Pregnant women’s autonomous decisions should be respected. Concerns about the impact of maternal decisions on fetal well-being should be discussed in the context of medical evidence and understood within the context of each woman’s broad social network, cultural beliefs, and values. In the absence of extraordinary circumstances, circumstances that, in fact, the Committee on Ethics cannot currently imagine, judicial authority should not be used to implement treatment regimens aimed at protecting the fetus, for such actions violate the pregnant woman’s autonomy.

In addition to wanting to protect the rights of physicians and fetuses over those of pregnant women, many commenters simply condemn Dray as selfish, selfish, selfish.  Here’s Beth Green:

What an incredibly selfish woman putting her unborn child in harms way. She got her several hours of trial-labor and no baby, so according to the standard of care she got a C-section and a healthy baby.

Some also posit that Dray is not only selfish but also psychologically compromised.  Here’s Dave:

This case is not about the “debate over C-sections.” This case is mostly about psychopathology, but there is a larger point. Rinat Dray’s actions harm us all. In her narcissism, she was willing to sacrifice her child to maintain her sense of control. This bears repeating – we are dealing with someone who would rather her child suffer than allow a section. So I’m sure she cannot put herself in the place of others, and she will not understand this, but she makes it all the more difficult to deliver babies in the US. Once all the OB/GYNs suffer these indignities and these lawsuits from those with personality disorders, who will deliver babies safely?

And here’s Reader:

A mother in labor who focuses more on her joy of delivery rather than trying to ensure that she delivers a healthy child who could be stuck with birth defects for up to an average of 7-8 decades thereafter is not rational, is selfish and needs to have her head examined.

What we get above all else if the “all that matters is a healthy baby” trope.  Here is NMY:

I have absolutely no sympathy for this woman at all. Her sense of entitlement is simply galling. She’s having a baby. The most important thing here is to ensure the delivery of a healthy baby, not to satisfy some preconceived notion that she should have a vaginal delivery.

Here’s Jen:

The OBGYNs can’t win. Now they are going to get sued for performing c-sections. It used to be they got sued for not doing the section soon enough. This lawsuit is absolutely ridiculous and I hope the physicians win. Do you want a c-section and a healthy baby or a VBAC and a dead baby? How can any mother refuse a c-section when the physician is telling you the health of your baby is at risk?

Here’s Stephen:

Sorry, but the health of the fetus should trump the intellectual desires of the mother….There are too many C-sections performed to be sure, but isn’t the point of labor and birth to deliver a healthy baby?

Here’s Lynn in DC:

She had this child in 2011 and all of her children are healthy so what’s the big harm here?

Aside from the fallacy of believing that Ms. Dray could not have both a respectful vaginal birth AND a healthy baby, a healthy baby is not all that matters.  A healthy mother matters too.  As in Ms. Dray’s case, having a perforated bladder and the trauma of being strapped down for a surgery that she actively refused did not result in a healthy mother.  Not being dead is not good enough.

 

 

 

The New York Times recently ran an excellent piece on increasing evidence-based medicine in childbirth, Tina Rosenberg’s “In Delivery Rooms, Reducing Births of Convenience.”  One would think that evidence-based practice was not a controversial idea.  But apparently it is–especially in childbirth.

The piece discusses the reasons for hospitals’ varied cesarean rates among low-risk births (healthy women with no prior cesarean and a full term, singleton, vertex fetus).

STV fetus For instance, Los Angeles Community Hospital has a 62.7% rate; up the coast at San Francisco General, the rate is 10.1%.  Remember, these are all low-risk births.

The piece concludes that there are many reasons for the variation, including some not very nice ones, like the convenience of doctors or the fact that most of the fee doctors collect for prenatal care and birth comes from attending the birth (making it worth their while to schedule births for when their partners won’t get the prize). It also discusses various staffing models that may contribute to the rise or fall of cesarean rates.

Then come the comments.

Apparently, some believe that merely presenting evidence about safe and healthy childbirth practices deprives women of choices.  Here’s “Janet”:

My body – my choice. Period.
If in the current medical environment I can elect cosmetic surgery, then I can elect a C-section. No further discussion necessary.
Stop subjugating women by dictating how to deliver.

There are authoritative statements based on supposition or speculation.  “PPippins” had a lot to say in the comments, including this:

Natural birth is not complication free: it harms mothers and babies. Where is the outrage about the babies who die or are damaged during natural births? What of the mothers who suffer unspeakable trauma and damages, require subsequent surgeries, become incontinent? No one ever has anything to say about them.

Of course, all of these things can happen during cesareans, medicated childbirth, operative vaginal deliveries–any birth has risks.  Evidence, however, shows that vaginal birth is safest for women (cesarean more than triples the risk of maternal death), and that two years after birth, there is no statistical difference in incontinence between women who birthed vaginally vs. by cesarean.

There are attacks on people who support natural childbirth.  “Kirsten” is sure there is a conspiracy:

Whoever selected the comments with the green checkmarks was clearly a natural childbirth advocate like the author of the article. It is sort of a religion that they try to indoctrinate you into in many birth education classes. I’m appalled that the NYT is promoting such a poorly supported opinion. A low cesaren rate has nothing to do with the maternal and fetal mortality rates and that is why it is wrong to do what the author did and rate hospitals according to their cesarean rates. Also, the author claimed that the acog supports a 15 percent cesarean rate while linking to a natural childbirth propaganda site. Bait and switch. There is no such acog recommendation.

Actually, ACOG did set a target of a 15% cesarean rate among low risk mothers as part of the Healthy People 2010 goals (the goal was not met).  Cesarean is most certainly tied to maternal mortality and morbidity (and has some elevated risks for infants as well).  While there are definitely those who advocate for natural/physiologic birth, I have never heard any natural childbirth advocate say that women should be forced to have an unmedicated vaginal birth.

Then, there are the anecdotes.  My heart goes out to any woman who loses a child–having a stillborn or infant death is a terrible and traumatic thing.  Certainly there are isolated cases in the U.S. in which a cesarean should have been performed and was not.  This does not mean that all women should have cesareans, just as the fact that some women die as a result of cesarean does not mean that no woman should ever have one.  It’s hard to present facts this way to a woman suffering from such a terrible loss, so we’ll just say it here, and if you want to read the anecdotes, go read the comments on the article.  I’m not going to exploit anyone’s pain.

Finally, there are the arguments that the process of birth doesn’t matter–only the outcome.  And the outcomes we care about set the bar at being alive, and possibly healthy:

The only thing that would tell us about safety is mortality rates (both perinatal and maternal, adjusted for the risk profile of the patient population).
Ms. Rosenberg has sadly fallen into the mind set of the natural childbirth community, which values process (vaginal birth) over outcome (live mother and live baby).
Would you judge a cancer center by how much chemotherapy is “necessary” or “unnecessary” or would you judge it by how many cancer patients survived? Would you judge the treatment of heart disease by how many people got angioplasty vs. how many had surgery, or would you judge it by how many people survived and thrived after hospitalization.
The goal in obstetrics is NOT to maximize vaginal deliveries. The goal is to maximize babies’ lives and brain function and mothers lives.

Of course, as noted in the links above, overuse of cesarean surgery does not contribute to the goal of life, especially for mothers.  Let me respond twofold:

  1. If a hospital has equal or better survival rates by doing fewer heart surgeries or less chemotherapy, I think that’s a great way to assess the quality of care.
  2. By the logic of this comment, as long as you are alive (and maybe physically healthy and not brain damaged), nothing that happens to you can possibly matter.  Were you sexually harassed?  Did you lose your job?  Did your house burn down?  Well, you are alive and healthy, and that’s the only way we can assess your life.  By this logic, no one should ever have a wedding ceremony and reception because you are just as married if you make a quick (and very low cost) trip to the courthouse.  Why does it matter how you got to your married state if you are ultimately married?  Plus, you would be alive whether you had a nice wedding or not, so who cares?

If the commenter doesn’t care about her life experiences, that’s fine.  She can have superfluous cesareans and no wedding and be thrilled with her live state after she loses her job and her house burns down.

But for some of us, the quality of our life experiences does matter.

Plus, at San Francisco General, with its high risk, low income population and 10% term, singleton, vertex cesarean rate, there have been no maternal deaths in the last 5 years, and perinatal mortality is less than half of the national average.

Which just goes to show, having good experiences and being alive are not mutually exclusive.

 

Image The cesarean rate is Brazil has been high for a long time, and it is getting higher.  In private hospitals, almost all women deliver by cesarean; in public hospitals it’s about half.  According to Ricki Lake, who went to Brazil in the process of filming The Business of Being Born, “There was actually a joke circulating that the only way to have a natural birth in Rio was if your doctor got stuck in traffic.”  Brazil’s childbirth practices have come to attention recently because of Adelir Carmen Lemos de Góes, who on April 1, 2014, was taken by police to have a forced cesarean under court order.  Here’s an account of what happened from The Guardian:

…Brazilian mother Adelir Carmen Lemos de Góes was preparing for her third birth. Despite living in a country with one of the highest caesarean rates in the world (82% for those with private insurance and 50% for those without), she was looking forward to giving birth vaginally after previously having caesareans she felt were unnecessary.  However, in the midst of her labour, six armed police banged on her front door. Despite there being no question of reduced mental capacity, doctors had obtained a court order allowing them to perform a caesarean…Adelir was taken from her home, forcibly anaesthetised and operated on without consent.

Attorney Jill Filopovic writes,

A Brazilian court granted a prosecutor’s request for the appointment of a special guardian. And just in case it was unclear whose life gets prioritized when a woman has a c-section against her will, the judge specified that when there is a ‘conflict of interests of the mother with the child’s life … the interests of the child predominate over hers.’

Filopovic quotes Dr. Simone Diniz, associate professor in the department of maternal and child health at the University of São Paulo: 

In our culture, childbirth is something that is primitive, ugly, nasty, inconvenient….It’s part of Catholic culture that this experience of childbirth should come with humiliation.

The Atlantic subsequently ran a longer piece by Olga Khazan, “Why Most Brazilian Women Get C-Sections,” which, also points to a confluence of attitudes, practices, policies, and norms that lead to a trend toward universal cesarean.  Humiliation isn’t hard to come by in Brazilian obstetrics.  Khazan reports,

Many physicians’ attitudes toward childbirth weave together Brazil’s macho culture with traditional sexual mores….When women are in labor, some doctors say, ‘When you were doing it, you didn’t complain, but now that you’re here, you cry.’

Mariana Bahia, who participated in protests against forced cesarean, noted:

There’s no horizontality between patients and doctors.  Doctors are always above us.

And Paula Viana, head of a women’s rights organization, said,

We have a really serious problem in Brazil that the doctors over-cite evidence [of fetal distress].  They think they can interfere as they would like.

But much of what these various articles says about childbirth in Brazil is eerily similar to what happens in the United States.  Khazan quotes Maria do Carmo Leal, a researcher at the National Public Health School at the Oswaldo Cruz Foundation about birth practices in Brazil:

Here, when a woman is going to give birth, even natural birth, the first thing many hospitals do is tie her to the bed by putting an IV in her arm, so she can’t walk, can’t take a bath, can’t hug her husband. The use of drugs to accelerate contractions is very common, as are episiotomies.  What you get is a lot of pain, and a horror of childbirth. This makes a cesarean a dream for many women.

In the United States, Pitocin induction and augmentation are ubiquitous , and episiotomies, though less common than in Brazil, are still greatly overused.  Almost all U.S. hospitals use IV hydration as a matter of policy (rather than allowing women to eat and drink as they please, which is the evidence based recommendation).  And in the U.S., taking a bath in labor may be impossible, as many hospitals do not provide bathtubs out of a misguided fear of women attempting waterbirths. The website My OB Said What documents a seemingly endless stream of U.S. health professionals’ humiliating comments, such as referring to a pregnant women as a “little girls,” criticizing their weight, or belittling their pain.

Court ordered cesareans occur in the United States as well, as Erin Davenport documents in “Court Ordered Cesarean Sections: Why Courts Should Not Be Allowed to Use a Balancing Test.”  Davenport notes that forced cesareans are generally ordered because of concerns for fetal welfare–as in Brazil, U.S. courts often privilege the rights of the fetus over those of the pregnant woman.

Alissa Scheller created infographics on Huffington Post showing how states’ policies are used to persecute and prosecute pregnant in the name of fetal welfare.

Image

National Advocates for Pregnant Women, whose research supplied much of the information for the above graphic, documents the legal control of pregnant women that occurs in the name of fetal rights, such as prosecuting a woman for murder after a suicide attempt while pregnant (in this case, the baby–born by cesarean–was alive, but died a few days later).

While the cesarean rate in the United States is much lower than in Brazil, a third of U.S. births are by cesarean, more than double the “threshold not to be exceeded” identified by the World Health Organization.  Khazan notes the parallels between Brazil’s medical system and the the system in the U.S.–both incentivize cesareans:

With the higher price of the private system [in Brazil] comes better amenities and shorter wait times, but also all of the trappings of fee-for-service medical care. C-sections can be easily scheduled and quickly executed, so doctors schedule and bill as many as eight procedures a day rather than wait around for one or two natural births to wrap up.

As in Brazil, though some cesareans performed in the U.S. are certainly in the interest of maternal and/or fetal well-being, many are in the interest of the obstetrician’s well-being.  There is still a convenience factor; in addition, OB-GYN Dr. Peter Doelger said doctors and hospitals are protecting themselves by following protocols based a fear of litigation:

So you’re stuck with this situation where we’re doing things, not based on science.  [The increase in C-sections is] really based on protecting the institution and ourselves. And, you can’t blame them. Getting sued is a horrible thing for the physician, a horrible thing for the nurse, and a horrible thing for the institution.

And the woman?  Well as long as the baby is healthy, does she matter?

There are two legal ways to have an abortion in the United States, through surgery or medication.  Medication abortions are those induced through taking mifepristone pills (which were called RU486 when they were developed).  Mifepristone is not Plan B (levonorgestrel, a synthetic form of progesterone) or Ella (ulipristal acetate, which suppresses progesterone production). Plan B and Ella have nothing to do with abortion; both stop ovulation in order to prevent pregnancy.  Mifepristone causes the expulsion of an embryo in an established pregnancy, much like a spontaneous miscarriage.

There are three main restrictions put on medical abortions in the United States:

  1. Pills must be provided by a licensed physician (not a nurse practitioner, nurse midwife, or other qualified health practitioner)
  2. Pills must be provided through an in-person patient-physician visit
  3. Pills must be provided according to the original FDA protocol (much lower doses of the pills have since been found to be effective)

Image

White states have the least restrictive policies, and dark green states have the most restrictive.  You can find an interactive version of this map at the Mother Jones website (the map does have some inaccuracies; Iowa and Arizona in particular currently have stays against some of their restrictions).

Restriction #1: Licensed Physicians 

That the pills can only be provided by a licensed physician is a restriction that is not solely promoted by opponents of abortion. It is a restriction in place in states that receive an “A” from NARAL Pro-Choice America on choice related law (find your state’s laws and grade here).

Physicians often oppose legislation that would allow medical practitioners who are not physicians–including midwives, advanced practice nurses, or pharmacists–to provide care that is within their scope of training.  Doctors often make the same argument that abortion opponents make: that they are trying to keep women “safe”  (e.g. doctors protect women from midwifery care in New York; doctors protect people from receiving primary care from nurse practitioners in Texas; doctors protect people from vaccination by pharmacists in Florida).

In her novel The Handmaid’s Tale, a story of a futuristic society in which the United States is taken over by the Christian Right, the characters identify differences between “freedom to” and “freedom from.” If you haven’t read the book, go get it and read it immediately.  In any case, Aunt Lydia, who trains women to accept their role in the new society, says,

There is more than one kind of freedom…Freedom to and freedom from. In the days of anarchy, it was freedom to. Now you are being given freedom from. Don’t underrate it.

“Freedom to” gives women agency and choice.  “Freedom from” restricts them in exchange for safety and protection.  In the novel, “freedom from” involves wearing burkah-like clothing, not being allowed to read, and bearing children for religious couples with political standing.  This supposedly frees women from rape, responsibility, and thinking.

In any case, the paternalistic “protection” of making physicians the only practitioners who can provide medication abortions seems to have an underlying agenda–moral or financial–that has nothing to do with women’s health.

Restriction #2: In-Person Physician Encounter

Telemedicine is increasingly used to serve rural communities in particular.  Many people in rural areas are far from hospitals and other sources of medical care.  You can see in this map that there are large areas without critical access.

hospital access

To provide needed care in the Mountain West, St. Luke’s Health System has established a virtual intensive care unit, which monitors 69 critical care beds in 5 hospitals and provides critical care consultation in 5 emergency departments in Idaho.  Here is a video about it:

Critical care is being offered to people on the brink of death through telemedicine, but some states have seen fit to decide that medication abortions offered through telemedicine are dangerous.  Over the past year, this restriction has generated attention in Iowa, where Planned Parenthood has safely offered medication abortions through telemedicine to thousands of women since 2008.  In September 2013, the Iowa Board of Medicine, made up of political appointees, voted to ban telemedical abortions, in addition to imposing other restrictions and requirements.

Delaying access to abortion care narrows women’s options, as medication abortions are only considered safe through the first 9 weeks of pregnancy.  After 9 weeks, a surgical abortion becomes a woman’s only abortion option (see here for a comparison of surgical and medication abortions).  While there are risks and side effects from medication abortions, most of them are uncomfortable or annoying rather than dangerous.  According to the FDA, no deaths have been directly attributed to medication abortions.

As Jill June, President and CEO of Planned Parenthood of the Heartland, said,

It’s evident that this ruling was not based on the health and safety of women in our state – it was based on politics. There was no medical evidence or information presented to the Board that questions the safety of our telemedicine delivery system. It’s apparent that the goal of this rule is to eliminate abortion in Iowa, and it has nothing to do with the safety of telemedicine. The reality is, this rule will only make it more challenging for a woman to receive the safe health care she needs.  Iowa women deserve to have access to the newest medical technologies and all of the heath care services they need, regardless of where they live.

A judge halted Iowa’s ban through a stay until the court case is settled.  The Iowa legislature, which is controlled by Democrats, was unable to pass a bill to instate the restriction through law; however, this restriction is in place in other states.

Restriction #3: The Original FDA Protocol

The Guttmacher Institute offers this chart comparing the original protocols for administering mifepristone pills established by the FDA, and the newer protocols adopted by the World Health Organization (WHO) and the American College of Obstetricians and Gynecologists (ACOG) based on evidence that has emerged since the FDA’s original approval:

Screen Shot 2014-04-02 at 10.00.16 PM

Abortion opponents have argued that adhering to the FDA protocols protects women, even though the Agency for Healthcare Research and Quality, a government agency as is the FDA, has published guidelines for mifepristone administration in their National Guidelines Clearinghouse.  The following guideline is level A evidence, the highest and most reliable evidence available:

Compared with the FDA-approved regimen, mifepristone-misoprostol regimens using 200 milligrams of mifepristone orally and 800 micrograms of misoprostol vaginally are associated with a decreased rate of continuing pregnancies, decreased time to expulsion, fewer side effects, improved complete abortion rates, and lower cost for women with pregnancies up to 63 days of gestation based on last menstrual period.

I have argued against non-FDA-approved use of Pitocin to induce labor electively.  However, there is no evidence base for the use of Pitocin for non-medically indicated deliveries.  As you can read in my previous posts (here and here), Pitocin is a high-alert medication with many dangerous side effects.  Its elective use has no known benefit other than convenience.  The new guidelines for mifepristone use, on the other hand, are based on evidence and involve giving a woman less medication rather than more.

That legislators would ignore a large, reliable body of scientific research does not inspire my confidence in their understanding of safety.  If they really care about the health and safety of women and babies, restricting off-label Pitocin use would be a much more effective technique.

It should be noted that while a law was passed in Arizona imposing this restriction and was upheld by a federal judge in Tuscon on April 1, 2014, the 9th Circuit Court of Appeals issued a stay on the legislation on April 2.  Thus, the only state implementing this restriction as of April 2014 is Texas.

If you view yourself as a human rather than a political pawn, you might want to say so.  If you value your freedom to rather than your freedom from, you might consider fighting for that freedom.  And if you are a woman in Texas who cares about her health, you may want to move.

The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) released a joint statement on laboring and birthing in water, Committee Opinion #594: Immersion in Water During Labor and Delivery.  You can read the whole opinion here.  While they concede that laboring in water reduces pain, reduces use of epidurals and other pharmaceutical pain relief, and shortens labor, they come down against birthing in water. Their arguments are a little odd.

First, they make no universal recommendations that water submersion be available to laboring women.  The benefits are obvious–there are no side effects from water as pain relief, women like it, and it shortens labors without increasing risk or pain (as Pitocin augmentation does when it is used to shorten labor).  As both epidurals and Pitocin augmentation are ubiquitous at births attended by obstetricians, even though both carry risks, why would they not recommend that water submersion be available to all women as an alternative?

waterbirth 2

Their statement against birthing in water is based on what are called “case reports.”  These are generally considered the lowest form of scientific evidence–if you could even call them scientific.  A case report is essentially a statement that someone saw something happen, but with no scientific comparison or exploration of alternative explanations.  Thus, if a baby had a bad outcome after a water birth that could be attributed to the water birth, a case report may assume it is attributable to the water birth.  This is a bit like saying, “My Aunt Myrtle went out walking in a blue hat and she fell down, so wearing blue hats must make people fall down,” or “My friends didn’t vaccinate their kids and the kids have not died of whooping cough.”

Ultimately, the opinion concludes,

The safety and efficacy of immersion in water during the second stage of labor have not been established, and immersion in water during the second stage of labor has not been associated with maternal or fetal benefit. (emphasis mine)

waterbirth 1

But immersion in water during birth has been associated with multiple benefits during the birth (not just labor).  These include:

I am not sure why these would not be considered evidence of benefit.

The committee opinion itself says,

[T]he only difference in maternal outcomes from immersion during the second stage was an improvement in satisfaction among those allocated to immersion in one trial.

Apparently, women’s satisfaction with their birth experience is not worthy of consideration as a benefit.

This dismissal of women’s experience is mirrored in other recommendations.  For instance, ACOG’s recommendation on management of labor states,

Patients should be counseled that walking during labor does not enhance or improve progress in labor nor is it harmful.

Why bother telling the patient anything if this is the case?  Why not “counsel” her to do whatever makes her feel most comfortable?

ACOG’s Practice Bulletin on labor induction makes no note of maternal pain or preferences, except in cases of fetal demise, where it indicates that “patient preference” may be a consideration.  The only mention of “discomfort” is in reference to membrane stripping, but it is not indicated that potential discomfort should be a consideration when deciding whether or not to do the procedure.

So who benefits if water birth is prohibited?  The AGOG/AAP opinion indicates a number of potential harms to the infant, including drownings, near drownings, and respiratory distress.  However, they also note that the Cochrane Review on water birth did not come to the same conclusion:

Morbidity and mortality, including respiratory complications, suggested in case series were not seen in the 2009 Cochrane synthesis of RCTs, which concluded that, “there is no evidence of increased adverse effects to the fetus/neonate or woman from laboring in water or water birth.”

waterbirth 3

They suggest however, that the randomized control trials (RCTs) were not large enough to pick up on “rare but potentially serious outcomes.”  This is the same reasoning given by the the chief of obstetrics at Massachussetts General Hospital, Michael Greene, for ignoring the results of a large randomized control trial that showed the safety of planned vaginal birth for twins.  Basically, he said, he wanted to keep practicing the way he always had and saw no compelling reason to change.

It is frustrating to see physicians making bold statements against something women want when not only is there no scientific evidence to support their view, the most rigorous evidence that exists actually comes to the opposite conclusion.  Both doctors and midwives in the United Kingdom endorse water birth, stating that basic safety should be practiced and that the people attending the birth should be properly trained:

Both the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives support labouring in water for healthy women with uncomplicated pregnancies. The evidence to support underwater birth is less clear but complications are seemingly rare. If good practice guidelines are followed in relation to infection control, management of cord rupture and strict adherence to eligibility criteria, these complications should be further reduced.

The United Kingdom has better birth outcomes than the U.S.  Though water birth itself likely has nothing to do with that, it does seem like an American focus on a process that has, as ACOG and AAP acknowledge, no scientific evidence of harm, is misplaced.

This leads to the consideration of who does benefit from a policy of banning water birth.  Most doctors have not been trained in how to perform water births and may have never seen one.  Nancy Shute writes on NPR’s health news site,

[I]t’s hard not to get the sense that this also may be a bit of a battle for control over the birthing process.

hospital birth

Barbara Harper, founder of Waterbirth International,  teaches all over the world. This is her official response to the ACOG/AAP opinion:

There are no bad outcomes, nothing that would lead ACOG to issue this statement at this time. Doctors see that women want options that are out of their comfort zone, educational scope and experience and it pushes the envelope for freedom of choice and human rights. It is a basic human right to birth without drugs or intervention or interference of any kind. If that can be integrated into a hospital setting, great. But, it still makes doctors nervous because their training demands that they ‘do’ something at a birth instead of sit by and knit or take the photos. This is why I have titled my new book, ‘Birth, Bath and Beyond.’ Waterbirth gives you the ability to watch birth happen, relax with it, witness the miracle – and it changes the way you approach all other births after you experience it. Waterbirth equates liability in the litigious world that we live in. Waterbirth challenges the conventional ‘security oriented/risk management’ approach to maternity care.  The science behind waterbirth, coupled with the experience of at least a quarter of a million women who have done it, will dictate policy and not the opinion of any organization, even ACOG and the AAP.

As a commenter on the NPR piece, Erin Shetler, says,

There are risks and benefits of every type of birth intervention, including water births. But you don’t see ACOG coming out with news releases about the risks of epidurals (increased C-section rate), vacuum extraction (cephalatoma in a newborn’s brain), induction (increased risk of uterine rupture and fetal distress), episiotomy (increased likelihood of third- or fourth- degree tearing) and other common practices because these are risks they feel comfortable taking. The risk of infection increases with every pelvic exam during labor, but that doesn’t stop most doctors from doing several. Some of the drugs used for induction are very commonly used “off-label,” meaning that their use is not approved by the FDA. Look up the facts. No matter what kind of birth you like or endorse, coming out against water births because they have a few risks while staying mum and/or endorsing other interventions is disingenuous at best.

It’s worth noting that there are doctors and hospitals that do support water births, so this committee opinion is not universal.

If ACOG wants to develop a committee opinion that is truly in the interests of women’s health and not the physician’s bottom line or comfort zone, they might issue strongly worded opinions against practices with no scientifically established benefits and well established harms, such as pregnancy bed rest.

Plus, women don’t like bed rest.  Perhaps that should be worthy of consideration as well.

 

Updates

Barbara Harper on “Why Pediatricians Fear Waterbirth.”  Her evidence-based review points out misinterpretations and misrepresentations of research in the ACOG/AAP statement.

American Association of Birth Centers (AABC) Position Statement on waterbirth.  AABC has a long record of conducting waterbirths safely.

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