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 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).
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:
- 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.
- 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.
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:
- Pills must be provided by a licensed physician (not a nurse practitioner, nurse midwife, or other qualified health practitioner)
- Pills must be provided through an in-person patient-physician visit
- Pills must be provided according to the original FDA protocol (much lower doses of the pills have since been found to be effective)
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.
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:
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?
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)
But immersion in water during birth has been associated with multiple benefits during the birth (not just labor). These include:
- less perineal trauma and vastly lower rates of episiotomy
- Lower rates of 3rd and 4th degree tears
- lower rates of obstetric intervention (amniotomy, oxytocin, epidural, or
- operative delivery)
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.”
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.
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.
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.
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.