American Heritage Dictionary (my personal favorite) defines treatment in a medical context as

a. The use of an agent, procedure, or regimen, such as a drug, surgery, or exercise, in an attempt to cure or mitigate a disease, condition, or injury.
b. The agent, procedure, or regimen so used.
Notice the terms cure and mitigate.
If we go back to the dictionary, cure is
a. A drug or course of medical treatment used to restore health: discovered a new cure for ulcers.
b. Restoration of health; recovery from disease: the likelihood of cure.
c. Something that corrects or relieves a harmful or disturbing situation:
and mitigate is
a. To make less severe or intense; moderate or alleviate.
Thus, we should expect that any medical treatment should make us better than we would be without it.  Yet reporting on a systematic review in JAMA,  the New York TImes recently ran a piece called “If Patients Only Knew How Often Treatments Could Harm Them.”
Perhaps in these cases, we might want to reconsider using the term “treatment.”
The JAMA review, “Patients’ Expectations of the Benefits and Harms of Treatments, Screening, and Tests,” concludes
The majority of participants overestimated intervention benefit and underestimated harm. Clinicians should discuss accurate and balanced information about intervention benefits and harms with patients, providing the opportunity to develop realistic expectations and make informed decisions.
But where are patients getting this information?  While some may see advertisements for a handful of drugs, for the most part, patients get information on “treatment” from their doctors.  A commentary on the review suggests limiting advertising and changing product labeling to be more transparent (big thumbs up from me on the second one in particular).  It also says that
[A] physician must first understand the risk herself (or himself) and must then communicate it effectively.  It is not clear that physicians do either of these things well.
Addressing OB care, the JAMA article notes that only 9% of women accurately identified the benefits of a trial of labor after cesarean (TOLAC) over an elective repeat cesarean (ERCS), and only 37% accurately identified risks of a TOLAC. Patients also incorrectly identified the benefits of a fetal abnormality scan (90% overestimated the benefits), and 57% could not accurately identify the risks of amniocentesis.
One of the original articles from the review, Trial of Labor After Repeat Cesarean: Are Patients Making an Informed Decision, states
Women in both groups [TOLAC or ERCS] were insufficiently informed about the risks and benefits of TOLAC and ERCS, particularly women in the ERCS group. Specifically, our patients were not familiar with
  • the chances of a successful TOLAC,
  • the effect of indication for previous cesarean section on success,
  • the risk of uterine rupture,
  • the increased length of recovery with ERCS versus TOLAC
  • the increased risk of maternal death, neonatal respiratory compromise, and neonatal intensive care unit admission with ERCS.

In addition, if our patient felt her provider had a preference, she was more likely to choose that mode of delivery, whereas when patients felt their providers were indifferent or if they were unaware of their providers’ preferences, 50% chose one mode and 50% chose the other.

 Note there is no indication that the women who did not feel the provider had a preference were making their own decisions based on accurate information.
Anecdotal evidence indicates that providers rarely provide accurate information–and sometime provide no information, simply saying, “Let’s schedule your cesarean.”  Some examples:
  • Jessica: I was told I need not waste my time trying to attempt a vaginal birth because it would be another long birth that would ultimately end in another section.
  • Jenerra: “I was always told by my doctors that because I had my first c-section that I would have to keep having them, even though my first c-section was the result of an induction gone wrong.”
  • Kiara: I do believe that [my primary cesarean] was the best outcome for everyone, but I knew that I didn’t want that
    experience again. When I discussed this with my OB, she said ‘Oh, we don’t do VBACs in this practice. When you get pregnant again, we’ll just schedule you like a hair appointment. Easy!’
  • Jamie: [My OB said], “You don’t want to VBAC. You don’t need to tear up your little bottom.”
The JAMA article, which is not focused on obstetric care in particular, does not address other common obstetric “treatments.” For instance, many physicians conduct ultrasounds routinely during pregnancy.  A friend of mine said her doctor never measured her fundal height, instead conducting an ultrasound at every appointment, even though there is no indication that having ANY ultrasounds improves pregnancy outcomes.   Other “treatments” for which women may not be adequately informed of benefits and risks include elective inductions,  Pitocin augmentation, and episiotomies, along with any number of other “treatments” offered in prenatal care, labor, and childbirth.
Women often believe they have no say in these procedures at all, as they are often presented as something that is going to occur rather than a choice that the woman can make.  Unfortunately, though ACOG offers excellent guidelines on informed consent, in practice informed consent is rarely more than a women signing a form that she has no time to read, and informed refusal is never on the table at all.  In fact some recent cases have indicated that in some cases doctors override a woman’s informed refusal, as in the case of Rinat Dray’s forced cesarean and Kelly X’s forced episiotomy.
The New York Times report on the JAMA review states:
This study, and others, indicate that patients would opt for less care if they had more information about what they may gain or risk with treatment. Shared decision-making in which there is an open patient-physician dialogue about benefits and harms, often augmented with use of treatment decision aids, like videos, would help patients get that information.
Unfortunately, shared decision making operates as a buzz phrase rather than a practice most of the time.  Perhaps this uninformed approach to “treatment” is why Marinah Valenzuela Farrell, a certified professional midwife, and president of the Midwives Alliance of North America notes in the New York Times series “Is Home Birth Ever a Safe Choice?” that hospitals carry their own risks.
They just don’t inform you about them.

I once led a community service project for which middle schoolers baked cookies to deliver to a local shelter.  We brought out the ingredients and began giving instructions when one kid asked if they could eat some of the cookie dough.  Another kid immediately said eating cookie dough would give everyone salmonella.  Within seconds, we had two camps of shrieking middle schoolers, one with members who had eaten raw cookie dough all their lives and were just fine, and the other with members that insisted that eating raw cookie dough would lead straight to a week-long date with the toilet followed by certain death.

A Google search on the subject breaks into similar camps, from “Rejoice!  you Probably Won’t Get Salmonella from Eating Raw Cookie Dough” to “Eating Raw Cookie Dough Can Actually Be Deadly.”

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In fact, there is a tiny risk of contracting salmonella from eating anything with raw eggs in it, including cookie dough, but that risk is very small, and the risk of dying from salmonella is even smaller.  There is also a risk of choking on raw cookie dough, or having an unexpected allergic reaction to an ingredient, or eating too much of it and having a stomach rupture.  And there is a risk of getting salmonella from other foods, such as meat or salad greens–in fact, almost any food could be contaminated.

All of this is to say that everyone assesses risks differently, and that people can get very upset when others don’t assess risks the same way they do.

Enter home birth.

In the New York Times’ “Is Home Birth Ever a Safe Choice?” risk assessment is on everyone’s mind.  Two obstetricians who specifically address risk come to two very different conclusions.

In “Emergency Care Can Be Too Urgently Needed for Home Births,” John Jennings, the current president of the American Congress of Obstetricians and Gynecologists (ACOG) writes,

When women decide where to give birth, they should understand the potential risks involved with their options….evidence shows that although the overall risk of serious childbirth complications remains low, there is still a twofold to threefold increased risk of neonatal death associated with home birth.

This line is almost verbatim from ACOG’s 2011 Committee Opinion, “Planned Home Birth,” which says that “it respects the right of a woman to make a medically informed decision about delivery,” but goes on to say that the only risk obstetricians are obligated to share is the neonatal death death risk as determined by the Wax study.  The Wax study, a meta-analysis of a number of other studies, was widely criticized for drawing faulty conclusions from flawed methods (see e.g. herehere, and here).

Like OBs Grunebaum and Chervenak, who I critiqued in my previous post, Jennings, a professor at Texas Tech, suggests that hospitals strive for more home-like settings and partner more with nurse midwives (CNMs).  He also suggests working with patients to create “action plans”–aka birth plans.

Texas Tech OBs attend births at the Medical Center Health System’s Center for Women and Infants.  The hospital reports to the Leapfrog Group, which says that they have made progress on reducing episiotomies (current rate is 12.2%,), but have low adherence to clinical guidelines for high risk deliveries, which would seem to negate the purpose of having a high-risk birth at the hospital.  In their favor, they do appear to have one of the lower primary cesarean rates in the state for uncomplicated births at just over 12% (an uncomplicated or low-risk birth is generally defined as a healthy mother with a single, head-down, vertex fetus).

It’s hard to determine much from the website other than that they have a lot of nice rooms and that they appear not to do skin-to-skin contact at birth (the nurse takes the baby for suctioning).  They have a short video that shows a woman on a gurney with a nurse showing her what look like two English muffins on a headphone cord.  There is a long sequence on the Ronald McDonald Room where a towheaded boy eats cookies, and then a segment on “Family Centered Care,” which shows a nurse holding a baby in the hospital nursery.  Despite Jennings’ apparent promotion of CNMs, no midwives are listed as practicing there, and a search for midwives on the site yields nothing.  There is no information about developing or following an “action plan.”

OBs who say that hospitals should provide home-like setting, employ nurse midwives, and honor birth plans might want to begin at the hospitals where they themselves practice.

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Jennings also says, “As obstetrician-gynecologists, our goal with any delivery is a healthy mother and a healthy baby.” It’s not as if mothers’ and midwives’ goal is mothers and babies who are sick or dead. Jennings definition of “healthy” seems to be “alive.”  Superfluous slicing, dicing, and infections are not even noted.

The problem with assessing risk only in terms of neonatal death is that the risk of neonatal death is very small, while the risk of other birth complications is fairly large.  Jennings’ hospital aside, the national cesarean rate for low risk births is 26.9% (the overall rate is 32.7%).  This varies tremendously by hospital, with some achieving rates below 5% while others have rates that are over 80%.

Aaron Caughey, who is chair of the department of obstetrics and gynecology and the associate dean for Women’s Health Research and Policy at Oregon Health and Science University’s School of Medicine, does not assume that the risks in home birth are automatically unacceptable.  Instead he asks, “In Home Birth, What Risk is Acceptable?

In discussing a recent British report about home birth, Caughey acknowledges  “increased C-sections, episiotomies and epidurals as a reason to avoid in-hospital births”  and “[t]he tradeoff of an increased risk of C-section for a small decreased risk in neonatal morbidity and mortality is not worth it for some women.”  He goes on to emphasize neonatal death risks, but says that women should be educated and assess trade-offs for themselves.

Oregon Health and Science University actually does offer some of the options that other OBs said hospitals should provide.  They have midwives on staff attending births, tout their low C-section rates (which actually aren’t that low, but are below 30%), and offer waterbirth and vaginal breech births.  Even though Caughey chairs the department at a hospital with many “home-like” options, he is the most open to the idea that some women might still choose to birth at home.

Obstetricians are the people most likely to see the rare birth disaster, and understandably, such emergencies make an impression.  Because even a low-risk birth can go wrong, many OBs see low-risk home births as risky, and Caughey pretty obviously believes hospital births are the better choice–which is absolutely his prerogative.  At least he doesn’t imply that women who make different choices than he would simply don’t know what they are doing.

Home and hospital births, however, are often compared to each other with little consideration of circumstances.  For instance, home-to-hospital transfer rates for women who have had a previous birth are far lower than they are for women having a first birth–in the largest home birth study done in the United States, transfers were three times more common among first time mothers–22.9%–vs. 7.5 % for women who had birthed before.  As mentioned above, the risk of an unnecessary C-section is very high at some hospitals and almost unheard of at others.  Some hospitals are not even equipped to do on-the-spot emergency cesareans, resulting in bans on vaginal birth after cesarean.  Thus, a woman might want to consider more than just home vs. hospital, but individual circumstances–does her pregnancy have elevated risk?  Does the hospital available to her offer evidence-based care?  What are the skill levels of the various practitioners available at the hospital or at home?

Even the Wax report acknowledges

Planned home births were associated with fewer maternal interventions including epidural analgesia, electronic fetal heart rate monitoring, episiotomy, and operative delivery. These women were less likely to experience lacerations, hemorrhage, and infections. Neonatal outcomes of planned home births revealed less frequent prematurity, low birthweight, and assisted newborn ventilation.

It is presumptuous for obstetricians to offer only neonatal death rates when giving women information about risks of home vs. hospital births. While the risk of neonatal death is a very serious one, it hardly ever happens.  Wax estimates the risk to be about 2/1,000 for home births vs. a little less than 1/1,000 for hospital birth.  On the other hand, a hospital with an 80% cesarean rate for low-risk births would give a woman an 800/1,000 chance of having a cesarean vs around 50/1,000 if she births at home.

Women take the lives of their babies very, very seriously.  It is almost certain that every mother loves her baby more than any obstetrician does.  With accurate facts about all aspects of birth, women are capable of doing their own risk assessments, and they have the right to choose even high risk home births, despite the opinion of you, an obstetrician, or anyone else who doesn’t agree with her choice.

For the record, I have eaten raw cookie dough all my life and am just fine, but you don’t have to have any.  As for the service project, we had bought pasteurized eggs, and all of the kids enjoyed cookie dough to their heart’s content.

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In February, the New York Times ran six short pieces on home birth in its “Room for Debate” online feature.  I am going to discuss each of the pieces in posts over the next few days.

One of the featured pieces is titled “Home Birth is Not Safe,” written by two doctors who have made a number of anti-home-birth contributions to the medical literature.  Their NYT bio line says,

Amos Grunebaum is the director of obstetrics and Frank Chervenak is the obstetrician and gynecologist-in-chief at New York-Presbyterian Hospital, Weill Medical College of Cornell University.

Their work brings up a number of interesting issues to consider about home birth safety, but they also appear to conduct their research with an anti-home-birth agenda–Chervenak has written articles stating that it is unethical for MDs to participate in home births in any way and that it is the professional responsibility of all health workers to forcefully persuade women to birth in hospitals.  All birth data in the United States has limits, but Grunebaum and Chervenak’s use of vital records data to draw sweeping conclusions about home birth outcomes has been broadly criticized (e.g. here, here, and here).

Grunebaum and Chervenak say,

[i]n our research we have found that in the United States at least 30 percent of home births are not low-risk and that two thirds of home births are delivered by midwives who are not properly credentialed.

While I have argued that a woman has the right to birth wherever she chooses, regardless of risk, one might ask why a woman at high risk would choose to give birth at home when she has a hospital as an alternative.  Some women may be compelled to do so for religious reasons (and may not have full control of their choices), but it is also true that some well-educated, well-informed women also make the choice to have high-risk births at home.

Grunebaum and Chervenak acknowledge some of the problems with hospital-based obstetrical care that drive women to seek out home births even when their medical profiles indicate that they may need the kinds of medical interventions that are only available in a hospital-based setting.  They particularly note high numbers of “unnecessary C-sections” and lack of “compassionate care” in hospital births.

They propose as a solution that “the profession [of obstetrics] should strive for home-like hospital births.”

We know from his bio that Chervenak is in charge of the obstetrics unit at NY Presbyterian-Weill Cornell Medical College (NYP-WC).  If women are to shun home birth in favor of hospital birth, a good hospital environment must already be in place.  Let’s take a look at what he and his colleagues are doing to reduce unnecessary C-sections, provide compassionate care, and strive for home-like settings.

New York state now requires hospitals to report certain data, including C-section rates.  NYP-WC’s is 31.6%, a smidge below the national average, but hardly indicative of a culture that is eschewing unnecessary C-sections.  For the last year reported, there were only 38 VBACS at NYP-WC.

NYP-WC’s episiotomy rate is a whopping 25.7%.  Episiotomy is rarely necessary, and this rate is far, far above the home birth rate of under 2%.  According to a 2005 JAMA review by Katherine Hartmann and her colleagues, a national episiotomy rate of less than 15% should be “immediately within reach”–10 years later, NYP-WC is not on board, even though the national rate was already close to 15% by 2010.  Nearby Bellevue Hospital has a rate around 2%.   Compassionate care should not include cutting gashes in women’s vaginas for no reason.

Planned home births are generally attended by midwives.  Both certified professional midwives (who cannot attend hospital births) and certified nurse midwives (who most commonly work in hospitals) subscribe to “The Midwives Model of Care.”  The American College of Nurse Midwives summarizes this philosophy of care on its website–some notable components include:

  • Complete and accurate information to make informed health care decisions
  • Self-determination and active participation in health care decisions
  • Acknowledg[ing] a person’s life experiences and knowledge
  • […] therapeutic use of human presence and skillful communication
  • Watchful waiting and non-intervention in normal processes
  • Appropriate use of interventions and technology for current or potential health problems

Grunebaum and Chervenak brag that “we have a midwife teach our residents at NewYork-Presbyterian.”  However, they do not employ midwives to attend births.  Zero births at NYP-WC are attended by a midwife.  In addition, because they are a teaching hospital, NYP-WC has many births attended by residents whom the woman may not even know.  No one invites complete strangers into their home to attend their births.  Most women who have home births are seeking the Midwives Model of Care, but though Grunebaum and Chervenak acknowledge that CNMs can safely attend hospital births, they choose not to offer this option.

The hospital’s maternity unit has a “Patient and Visitor Guide: During Your Stay” that lays out standard processes and procedures on the unit, gives prospective patients an overview of what to expect, and lays out hospital and maternity unit policies.

The guide begins by saying that the hospital offers “Family Centered Care,” though what this means is not explained other than to say that rooming-in with the baby is encouraged.

They proceed to say that the woman’s care team may involve “your attending obstetrician, who is often your personal obstetrician or the doctor who admitted you, …[and] other medical or surgical specialists, as well as fellows or residents…[and] a pediatrician.”  But that’s just the doctors!  They say that the nursing staff is “constantly present” and indicate that there will be many nurses involved in care.  Other people involved in the hospital birth experience are care coordinators, unit clerks, physician assistants, lactation consultants, social workers, dieticians, nutrition assistants, housekeepers, patient escorts, and volunteers.  There is also a Rapid Response Team for emergencies.

I don’t know about you, but I’m not sure that many people could fit in my house.

The Labor and Delivery Unit is described as “comfortable, family-friendly, [and] private with soothing natural light.”  The birthing rooms are

spacious and light-filled birthing rooms [that] combine comfort with leading-edge technology. All suites are private and equipped with a special multi-positioned birthing bed, as well as state-of-the-art equipment for monitoring and delivering your baby. Your progress will be monitored regularly throughout labor, and your nurses will help you explore which comfort measures work best for you.

My home has a queen sized bed.  The most leading-edge technology in it is my iPhone.

Then we move on to pain management, and the real trouble starts.  Many women choose home birth because they want to be able to access a wide variety of non-pharmacological pain management strategies.  In my research, a frequent complaint from women who were not interested in epidurals was the pressure from hospital staff to have an epidural.  Here is what the guide says about pain management (emphasis mine):

The intensity of discomfort during labor and delivery varies from person to person. Some women may manage well with relaxation and breathing techniques. However, most women choose some type of pain relief. The majority of women receive analgesia (relief from pain without losing consciousness) from an anesthesiologist….The most effective methods for relief of labor pain are regional anesthetics in which medications are placed near the nerves that carry the painful impulses from the uterus and cervix, lessening pain and facilitating your participation in your delivery. Our anesthesiologists commonly use an epidural, spinal, or combined spinal-epidural to minimize pain.

Nothing is mentioned other than relaxation, breathing, and calling the anesthesiologist.  However, in home settings (and even at other hospitals) many women choose “pain relief” from any number of options that do not require an anesthesiologist, such as walking, changing position frequently, sitting on a birth ball, taking a warm shower, or submerging in warm water.  They may also get pain relief assistance from massage or from non-drug-based interventions such as acupuncture.  This is not a complete list.  It should be noted that all of these other options could be made available at home–the only one that could not is the anesthesiologist.  No mention is made of the risks of anesthesia nor of what can be done in the event that the epidural or spinal doesn’t work.  Choosing pain relief does NOT have to mean choosing an epidural–unless you are at this hospital, where according to the state more than 85% of women have epidurals (and that doesn’t include spinals and other medical methods).

Many of NYP-WC’s policies and standard procedures would preclude use of most pain relief options anyway.  Here’s what happens once a women is admitted to her birthing room:

your nurse will assess your blood pressure, pulse, and temperature, and place you on a fetal monitor. The nurse will monitor you throughout your labor and help you explore which comfort measures work best for you. An intravenous line may be placed to give you medication and fluids. You may also receive ice chips to help quench your thirst. Do not eat any food without your physician’s permission.

Not only are these policies not home-like, they aren’t even evidence based:

  • According to the Cochrane Reviews, continuous electronic fetal monitoring (EFM) in low-risk births increases a woman’s risk of an unnecessary C-section. Because the risks-benefits ratios of EFM and intermittent auscultation, in which a health care provider listens to the fetal heart rate with a Doppler or fetoscope at regular intervals, are similar, Cochrane recommends that women be given information and then choose for themselves.
  • IV fluids can also lead to complications, such as too much fluid in the mother or newborn.  In addition, having an IV in place is conducive to starting a cascade of interventions, as having the IV in place makes it easier to begin a Pitocin drip.
  • The Cochrane Review on eating and drinking in labor concludes, “Since the evidence shows no benefits or harms, there is no justification for the restriction of fluids and food in labour for women at low risk of complications.”

cascade of interventions

(see original here)

Only two people can be with the woman in labor.  Last I checked, I was allowed to have whoever the heck I want in my house.

The hospital does not allow videorecording of the birth.  At home, you could live stream your birth if you were so inclined.

Rooming in is offered but not required.  Obviously at home, there is no nursery staffed by nurses.  In addition, rooming in is the standard for Baby Friendly Hospitals, as non-medically necessary separations can negatively impact breastfeeding.

One of the things many women appreciate most about their home births is the freedom to move around and to birth in any position they choose.  An acquaintance of mine who had an accidental home birth said that although she hadn’t planned it, she liked the experience, especially because “no one made me get on the little table.”  Another acquaintance said that as she was birthing, her OB asked that she get on her back for each contraction because, the OB said, “that’s the way I prefer to deliver.” Still another friend said that although there was a squat bar available in her birthing room, her OB refused to let her use it and threatened to leave if she would not lie on her back.

Notably, NOTHING is said in the guide about freedom of movement or position during labor or birth.  If a woman is tethered to a monitor and has an epidural, her movement would be curtailed even if hospital policy did not restrict her.

Finally, in the “Patient Responsibilities” section, the guide lists this “responsibility” (all emphasis mine):

Follow the treatment plan recommended by the health care team responsible for your care and the care of your baby. This group may include doctors, nurses, and allied health personnel who are carrying out the coordinated plan of care, implementing your doctor’s orders, and enforcing the applicable Hospital rules and regulations.

In your own home, you make the rules.

If Grunebaum and Chervenak want women to choose their hospital’s maternity care over a home birth, they’ve got a lot of work to do.

Sociological Images addressed two issues that have been pet peeves of mine for a long time, namely the sexualization of breast cancer and the sexualizing of breastfeeding.  The piece compares the admonishment of the author’s sister-in-law for allowing her “breast to fall out” when she fell asleep nursing on a plane and this 2012 ad for breast cancer awareness:

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To create momentum to fund breast cancer research, breast cancer has been both feminized/infantilized through pink marketing, and sold as a way for men to save body parts to which they want to preserve sexual access.  Breast cancer awareness is all about the breasts.  Hence, you see bumper stickers that say

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or

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As if what is being preserved through breast cancer research and treatment are breasts, not human lives.  It is hard to imagine a campaign to raise awareness of testicular cancer that promoted blue teddy bears and selling beer with blue ribbons on it, along with bumper stickers saying “save the wienie beanies” or “save the family jewels” or “save the nuts” (which is what we are if we think such a campaign would ever occur).

While the 2012 ad featured in Sociological Images does include partial faces, many breast cancer awareness ads do not:

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While it is possible for nubile young women to get breast cancer, most women who get breast cancer look more like this:

Portrait of a happy nurse and patient

Bodies and breasts getting cancer treatment, even when headless, look more like this:

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and despite the blonde locks on the tatas model, many women battling breast cancer do not have hair, having lost it to chemo treatments:

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Somehow, these sexy tata images, including apparently naked women (or women’s torsos), are okay to display because they are for the higher purpose of fighting breast cancer, and perhaps more importantly, preserving breasts so men can be titillated by them (yes, titillated, haha).

While it may be possible to find breastfeeding a baby sexy, usually it is fairly dull.  Most women-infant pairs look something like this while breastfeeding:

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though many new mothers don’t look this good on a regular basis.

But the media also tends to portray breastfeeding as an activity of a breast rather than a human:

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even when the intent is not remotely sexual:

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But many photos of breastfeeding women are sexualized.  Beautiful women with no postpartum paunches wear attractive bras or negligees or form-fitting tops and pull the top down (rather than wearing a loose shirt and lifting it up from the bottom):

mother breast feeding her child, focus on the child

  While some women do feed their babies this way, usually it’s not the first-line choice for feeding in the presence of strangers.

Somehow, this image gets translated to the typical breastfeeding women, who is chastised for allowing her breast to show, or sometimes merely because she is breastfeeding, even if no one can see anything at all other than fabric:

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No one excoriates women for having cancer in public.

The problem with breasts is, apparently, that they are attached to women.  Women need to go out in public to work, shop, get sunshine, see other people, and all of the reasons that human beings generally leave the privacy of their homes.  And when they go out, they take their breasts with them.  And when a woman gets cancer, the pain and fear are experienced by a human being, not a breast.

It’s fine to think breasts are sexy.  it’s not so fine to define them as separate from the women who have them.

It is often noted that change takes time, specifically that it takes about 17 years for research findings to be consistently adopted as practice.  We see that issue frequently in obstetrics, where it often takes longer.  For instance, even though high quality research has shown for more than 20 years that routine episiotomies cause the very tears they were initially hypothesized to prevent, in many hospitals, episiotomy rates remain above 30%, with rates at some institutions being much higher (read more on episiotomy here).

In considering VBAC, however, we can see that change can occur almost instantaneously–in one direction.  The American College of Obstetricians and Gynecologists (ACOG) began recommending restricted use of episiotomy in 2006–more than a decade after research showed the risks of routine use–and many practitioners still aren’t on board.  But when ACOG changed its recommendations regarding vaginal birth after cesarean (VBAC), the practice came to a screeching halt.

ACOG has offered a series of recomendations on VBACs, beginning with Committee Opinions in 1988 and 1994, with Practice Bulletins following in 1995 (#1), 1998 (#2), 1999 (#5), 2004 (#54), and 2010 (#115).  Dr. Hilary Gerber put together an excellent slide show explaining the changes in each set of recommendations, which you can view here.

For most of the twentieth century, when lifesaving cesareans became a real option in hospital births, the common wisdom was “once a cesarean, always a cesarean,” a statement made professionally in 1916 at the New York Association of Obstetricians & Gynecologists.  However, for the next 60 years, cesareans were so rare to begin with that the number of women undergoing repeat procedures was small.  The overall cesarean rate in 1965 was under 5%.  As primary cesareans became more common in the late 1970s and through the 80s, more and more women also underwent repeat cesareans, and by 1990 the overall c-section rate was almost 23%.  At the same time, surgical techniques advanced to make VBACs safer, and in 1990 about 20% of women who had a prior cesarean had a VBAC.

In 1994, ACOG issued a Committee Opinion that said that in the absence of contraindications (primarily classical incision in prior cesarean), women should be encouraged to undergo trial of labor after cesarean (TOLAC) rather than automatically being scheduled for a repeat cesarean.  We know now that most women, especially those with only one prior cesarean, are good candidates for VBAC, and it is estimated that 70% of women undergoing TOLAC can have successful VBACs, but the next year, the VBAC rate was only 27%.  While this was definitely an increase, it hardly indicated that all of the most appropriate candidates for TOLAC were actually going into labor.  The VBAC rate peaked in 1996 at 28.3% and then began to decrease, driven by an article by Michael McMahon et al that linked TOLAC to an increase in maternal complications.

In 1999, ACOG released new, more restrictive recommendations, in part as a response to the McMahon article.  Chief among the changes was what became known as the “immediately available standard”:

VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.

This recommendation was Level C evidence, meaning it was based on clinical opinion, not research trials.  Level A evidence, the level with the highest quality research to back it, still stated in the same bulletin that most women with prior cesareans were good candidates for TOLAC.

The problem with the immediately available standard is that most smaller hospitals can’t meet it.  They may not have an anesthesiologist in house 24/7 or enough OBs that there is necessarily one standing by on the ward, ready to perform surgery.  Even large hospitals may not meet this standard if they cannot guarantee that the available doctors will not be busy with other patients.  The standard was not specifically defined, and rather than be concerned that they weren’t meeting it, many hospitals simply stopped offering TOLACs, requiring patients who had previous cesareans to schedule a repeat surgery.

Here’s what happened:

cesarean VBAC graph

The line that ends at the top is the overall cesarean rate.  The line that ends in the middle is the primary cesarean rate, and the line that ends at the bottom is the VBAC rate.  In the mid 1990s, the VBAC rate was higher than the overall cesarean rate, but within a year of the 1999 guidelines, VBAC rates were down to what they had been in 1993, the year before less restrictive guidelines were initially recommended.  But it didn’t stop there.  The rate just kept decreasing.

in 2010, ACOG again issued less restrictive guidelines for VBAC.  Dr. Richard Waldman, ACOG’s president at the time, said,

Given the onerous medical liability climate for ob-gyns, interpretation of ACOG’s earlier guidelines led many hospitals to discontinue VBACs altogether. Our primary goal is to promote the safest environment for labor and delivery, not to restrict women’s access to VBAC.

The new guidelines stated not only that most women with a prior cesarean were good candidates for VBAC, but that many women with two prior cesareans were as well.

Here’s what happened:

primarycesvbactbl

The rates rose a tiny amount, and remain about half of what they were in 1990.

In 2014, AGOC issued a consensus statement about preventing primary cesareans.  This publication pointed out some of the risks of cesarean over vaginal birth, including a tripling of risk of maternal death.  While some hospitals and doctors have gradually become more receptive to VBAC and have lifted out-and-out bans, some hospitals have instituted new bans since the 2010 and 2014 guidelines were released.

Many providers do not support VBAC and do not present benefits and risks in a way that allows women to make informed decisions.  The website My OB Said What? is full of quotes from doctors misrepresenting VBAC risks:

Attempting a VBAC is comparable in risk to standing your older child out in the middle of a busy highway and hoping she doesn’t get hit by a semi. Maybe the odds of her being hit are low, but you wouldn’t take that risk with your other child, so I don’t understand why you’re willing to risk your unborn baby’s life.

I don’t know where you got the *delusion* that you could VBAC, there was a law that was passed against VBAC’ing after more than one cesarean.

A VBAC is like *jumping off a bridge* in which mortality is close to 90% with a uterine rupture!

When citing risk of “uterine rupture,” many physicians include scar separation in the totals.  Just to clarify, there is a difference between genuine uterine rupture, which is a genuine emergency, and a cesarean scar opening, which is not:

In contrast to frank uterine rupture, uterine scar dehiscence involves the disruption and separation of a preexisting uterine scar. Uterine scar dehiscence is a more common event than uterine rupture and seldom results in major maternal or fetal complications.

So let’s review:

  • When VBACs were recommended as safe in 1994, the rate slowly crept up, reaching over 28% in 1996.
  • The rate began to go down in 1997 in response to a single article, even before recommendations were issued by ACOG.
  • When the “immediately available” standard was introduced in 1999, the rate plunged to its pre-1994 level within a year.
  • 10 years after the “immediately available” standard (level C) was introduced, the rate was 8.4%, even though the Level A recommendations still said that most women were good candidates for TOLAC.
  • Two years after less restrictive standards were introduced in 2010, the VBAC rate had inched up less than 2 percentage points, to 10.2%.  Many hospitals have continued their de facto VBAC bans, some hospitals have introduced new bans, and many physicians still refuse to perform VBACs.

The problem is (as others have also pointed out), why are hospitals not ready to perform an emergency cesarean?  Isn’t that the whole reason to birth in a hospital–that they are prepared for emergencies?  Uterine rupture is not unique to VBAC–it can happen as a result of  any number of complications, including labor inductions.  A hospital that is not equipped to support a TOLAC is not set up to support birth emergencies.

VBACfacts.com has a list of VBAC myths and corresponding correct information.  here is my favorite:

Myth:  If your hospital doesn’t offer VBAC, you have to have a repeat cesarean.

As Howard Minkoff MD said at the 2010 NIH VBAC Conference, “Autonomy is an unrestricted negative right which means a woman, a person, anybody, has a right to refuse any surgery at any time.” ACOG affirms that “restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will.”

If your hospital does not support VBAC, ask them why they are not properly equipped and staffed to perform emergency cesareans.  Then go elsewhere.

 

firefighter4x-383x254

Imagine, if you will, a whole community of short people… Given the argument sometimes made in our society that short people are unable to be firefighters because they are neither tall enough nor strong enough to do the job, the question arises: Would all the houses in this community eventually burn down? Well yes, if we short people had to use the heavy ladders and hoses designed by and for tall people. But no, if we (being as smart as short people are) could instead construct lighter ladders and hoses usable by both tall and short people. The moral here should be obvious: It isn’t short biology that’s the problem; it’s short biology being forced to function in a tall-centered social structure.

–Sandra Bem, The Lenses of Gender

So let us then imagine a society of people who spend at least some portion of their lives being pregnant and who also need to have jobs to support their families.  Oh, wait–for almost half of society, this is already the case.  It was the case for Peggy Young when she was let go by UPS because she was not supposed to lift more than 20 pounds–even though her job was mostly lifting envelopes, and she had a colleague who could lift the rare 20 lb-plus package.  Why is it difficult to think that it might be an ordinary expectation that employers would adjust to the needs of pregnant workers for the brief period of their lives that they are pregnant?

When we assume that men’s bodies are the norm, it is easy to see a policy that doesn’t recognize the needs of pregnant workers, a “pregnancy blind” policy as reasonable (UPS had a pregnancy blind policy when Young worked there).  After all, if you can’t get pregnant, you never need accommodations for pregnancy.  But if we assume human bodies are normal, then we know that pregnancy is a condition experienced by almost half of all humans, sometimes on multiple occasions.

We expect that humans need to eat, and thus time to eat is scheduled into normal workdays.  We also assume humans need to urinate, and we provide accommodations for this function.  We do not have a “hunger blind” work policy or a “urination blind” work policy that allows employers to forbid workers who need to eat or pee from holding a job.  Even when some people do not have a need but others do, such as a need for leisure time, we do not institute “leisure blind” policies that allow 15 hour workdays 7 days per week because only some people need some time off from work.  We used to, but we decided (with the help of labor unions) that this was an unfair policy.

fired-for-pregnancy-375x250

Pregnancy is a normal human condition, whether everyone experiences it or not.  Workplaces should expect to accommodate it as they do all ordinary conditions of being human–no matter how inconvenient. And usually it isn’t even inconvenient.

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I read a comment once about depression as a “minor” side effect of taking oral contraceptives: depression is a minor side effect that merely ruins the entire quality of a woman’s life.  While pretty much everyone feels sad once in a while, depression is not the same as situational sadness.  Here is some basic information on depression from the National Alliance on Mental Illness (NAMI):

Major depression is a mood state that goes well beyond temporarily feeling sad or blue. It is a serious medical illness that affects one’s thoughts, feelings, behavior, mood and physical health….Without treatment, the frequency and severity of these symptoms tend to increase over time….[symptoms include] depressed mood (sadness), poor concentration, insomnia, fatigue, appetite disturbances, excessive guilt and thoughts of suicide. Left untreated, depression can lead to serious impairment in daily functioning and even suicide, which is the 10th leading cause of death in the U.S.

Fortunately depression is treatable, and one main component of treatment is often taking selective serotonin reuptake inhibitors (SSRIs), which include commonly prescribed antidepressants such as Zoloft and Prozac.  Treatment for depression not only impacts quality of life, but life itself.

Imagine my surprise, then, to read New York Times writer Roni Caryn Rabin‘s comparison of giving up prescribed antidepressants to giving up smoking.  And imagine how much more surprising it was when she compared giving up antidepressants to giving up brie.  Yes, brie, as in a single type of gourmet cheese.

brie

I’m sure that anyone who has ever confessed to loving brie more than life was being hyperbolic.

The piece goes on to quote Barbara Mintzes, an associate professor at the University of British Columbia School of Population and Public Health:

If antidepressants made such a big difference, and women on them were eating better, sleeping better and taking better care of themselves, then one would expect to see better birth outcomes among the women who took medication than among similar women who did not.  What’s striking is that there’s no research evidence showing that, [but on the contrary] when you look for it, all you find are harms.

Who is harmed by the continued use of antidepressants, you might ask?  After all, if they were harming the woman, wouldn’t she have stopped taking them on her own?  Wouldn’t it be likely that she would have stopped taking them before she became pregnant?

Well, it turns out that the “harms” of taking antidepressants accrue only to the fetus–maybe.

Among the possible harm that the article lists are autism, attention deficit hyperactivity disorder (ADHD), lower language competence at age 3, preterm birth, birth defects, a lung disorder, REM sleep disruption, and lower birthweight and Apgar scores.

The problem is, most studies were of low scientific quality.  In some of the studies, when further controls were used, many of the negative outcomes were associated with having a mother with depression, whether or not she took antidepressants.

The article does not distinguish between different SSRIs–although these drugs all impact seratonin, they have different chemical formations.  The only concession to this that the article makes is to note that Paxil in particular is associated with birth defects, but information about Paxil strongly recommends against using it in pregnancy, and the FDA changed Paxil’s labeling and pregnancy category in 2005.

Many women actually do give up antidepressants in pregnancy.  For instance, one study of over 100,000 women in the UK found that “Only 10% of women treated before pregnancy still received antidepressants at the start of the third trimester. In contrast, 35% of nonpregnant women were still treated after a similar time period.”  The study does not indicate whether women who continued using antidepressants had different outcomes.

Rabin’s piece does quote Dr. Roy Perlis, an associate professor of psychiatry at Harvard Medical School and author of a study that found a connection between fetal antidepressant exposure and ADHD. Depite this research, he says,

The downside of these studies is that it ends up scaring women away from treatment…the severity of the depression or anxiety can make it very hard for [women] to take care of a child, and is such that their life is at risk if they’re not treated.

The article then closes with an implication that Dr. Adam Urato, a maternal-fetal medicine specialist at Tufts Medical Center, thinks women should stop using antidepressants in pregnancy in favor of non-drug options such as counseling, exercise, and bright light therapy.  I am in favor of all of these things as first line treatments, but if they are not sufficient, what should a pregnant woman do?

The response from pregnant women and young mothers who read this piece doesn’t indicate that Rabin’s information was helpful.  Isn’t it bad enough to be depressed without being shamed for seeking treatment?

Alexis, the mother of a 7-week-old, says

Well I guess I’m a horrible person and mother…Now I feel guilty about the drug that I was prescribed following a suicide attempt 2 years ago, a drug that literally saved my life.

Rachel, currently pregnant, writes

OMG, I am totally freaking out! I have been taking Prozac for symptoms of anxiety for the last few years. When I became pregnant, my ob/gyn, my current therapist, a past therapist whom I consulted, and my prescribing doctor all assured me, in no uncertain terms, that it would be better for my baby if I stuck to this regimen than if I were to discontinue it. Now I am about to start my second trimester, and I read here, also in no uncertain terms, that all my doctors were wrong! Now what am I supposed to do?! Help!!!

On a brighter note, unlike many articles that generate sympathy primarily for the fetus at the expense of the woman, many commenters here point out the deficits in Rabin’s presentation and her argument.  A number of them  are physicians or nurses, and many are also outraged at the comparison of antidepressant use to smoking and eating cheese.

Here’s Nicole:

As an obstetrician I am mortified that this article starts off by comparing quitting smoking and not drinking alcohol to weaning off SSRIs, and it blames the mother for staying on them while barely mentioning that it can’t happen without providers like me who do the prescribing.

And Alabama Doc:

First, medication for a serious brain disorder is nothing whatsoever analogous to buying cheese…There is muddling of several separate issues here, with the assumption that the women and their doctors are using an ineffective medication just for… what, a lifestyle preference? Yes, we have evidence that non-medication treatment can be highly effective for mild to moderate depression and that there may be no clear benefit of SSRIs for mild depression. For severe depression, however, medication appears to have significant benefit. Notice how all the discussion of risks/ benefits centered around the infant and really nothing was said about the mother? Is the mother’s life so unimportant?

and Caroline Cylkowski, Nurse Practitioner:

Shame on NYtimes for publishing an article completely based on pseudoscience. The author cites the opinions of one MFM doctor and one public health researcher as the basis for her argument. What is scary is that pregnant mothers, who already worry that everything they do might harm their future child, will read this this and discontinue their antidepressants. Antidepressants are not optional medications. The disease they treat has debilitating and sometimes life-threatening consequences.

In contrast to Rabin’s piece, sources from medical institutions take a very different tone.  For instance, Massachusetts General Hospital points out

Many women may consider stopping medication abruptly after learning they are pregnant, but for many women this may carry substantial risks.  Decisions regarding the initiation or maintenance of treatment during pregnancy must reflect an understanding of the risks associated with fetal exposure to a particular medication but must also take into consideration the risks associated with untreated psychiatric illness in the mother. Psychiatric illness in the mother is not a benign event and may cause significant morbidity for both the mother and her child; thus, discontinuing or withholding medication during pregnancy is not always the safest option.

The MGH site goes on to point out that each medication is different and some carry more risks than others.  They identify several antidepressants that appear to have no association with birth defects and point out that symptoms of neonatal withdrawal from antidepressants are generally mild and disappear within a few days.

What is perhaps most disheartening about Rabin’s piece is the addition of women’s legitimate medical treatment to the Pregnancy Outcome Blame Game.  Major causes of birth defects include environmental contamination and domestic abuse.  Major causes of preterm birth are racism and lack of prenatal care.  But these require broader social intervention to mitigate.  How much easier to blame individual women for poor birth outcomes, especially when they are too depressed to defend themselves.

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