Consenting to Harm: Treatment Options and Informed Consent

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.

Assessing Risk for Birth Settings (and everything else)

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.”

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. here, here, 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.

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.

The Anti-Home-Birthers’ Alternative to Home Birth

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.”

(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.

Research, Change, and the Fallacy of VBAC Bans

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:

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:

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.

 

Lies, Damned Lies, and Cesareans

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.

 

Birth in Brazil–and America

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.

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?

Home Birth and Social Control

There is an interesting paradox in the arguments of some anti-homebirthers.  They argue both that homebirthing is an elitist practice driven by well-educated, wealthy feminists AND that these women do not know, understand, or have easy access to the “truth” about homebirth (because if they did, they would obviously come to the same conclusion as the anti-homebirthers).

Many of the women driving the rise in homebirth are the most capable of finding information on the risks and benefits of homebirth, and if they make a decision that goes against the anti-homebirthers’ beliefs, they certainly aren’t doing it because of a lack of information on risks.  A simple Google search on “home birth” pulls up many sites; some on the first page include a Wikipedia article that has a research review that indicates a higher rate of perinatal death in American homebirths, a Daily Beast story  called “Homebirth: Increasingly Popular, but Dangerous,” and the website Hurt by Homebirth.  It seems that rather than lacking access to the “truth,” some women simply have different interpretations of the evidence and/or different values than the anti-homebirth crowd.

There is, however, a different crowd of women who plan homebirths—or who have homebirths planned for them—who may or may not have accurate information about the risks of homebirth. If they do, it likely doesn’t matter.  Their choice is constrained by a subordination of their own autonomy to God, or in many cases, their husbands or their church leaders.

Some may have heard of the Quiverfull Movement and the Christian Patriarchy Movement.  The overlap between the two groups is substantial.  Those who are “Quiverfull” believe that they must gratefully accept as many children as God gives them, whenever He chooses to give them.  The Christian Patriarchy Movement believes in, well, patriarchy.  Women must always be under the authority of a man; generally this authority passes from father to husband.  The most well known Quiverfull family is the Duggar family of the TV show “19 Kids and Counting.” Kathryn Joyce has an excellent book on the movements, Quiverfull: Inside the Christian Patriarchy Movement.  Two excellent blogs that discuss the ramifications of Quiverfull and Christian Patriarchy are Love, Joy, Feminism, by Libby Anne, who grew up the oldest of 12 in a Quiverfull family; and No Longer Quivering, by Vickie Garrison, who had seven children before leaving the movement.

Because of the movements’ distrust of secular institutions, some in the movements eschew traditional medical care.  In addition, in part because they start families young and have so many children, many of these families are low income but do not believe in using government programs such as Medicaid.  Of course, many members of the movement go to doctors or licensed midwives anyway, and some even sign up for Medicaid.  But many don’t.  In many cases, it is the husband who makes the final decision about the healthcare of his pregnant wife and the circumstances of her labor and birth.  Sometimes these decisions are in response to the guidance of church leadership.

Amy Chasteen Miller, who conducted a study of unassisted childbirth published in Sociological Inquiry, points out that “women make choices about birth within a web of larger social influences.”  For educated, independent women, these choices may come from a feminist sensibility that leads them to reject a paternalistic and technological model of birth.  For other women, birth choices may be “driven by God.”  In some religious communities,

women see childbirth as fully ‘in God’s hands.’  For these women, seeking medical help for pregnancy and birth reflects a breach of faith and an unwillingness to fully trust ‘God’s will.’

In such circumstances, it is unlikely that women are familiar with the scientific literature regarding risks associated with homebirth, but it is also unlikely that knowing and understanding the risks would have any impact on their decision making–if they had any control over the decision.  Miller writes, “For some women, part of surrendering to God is also deferring to their husbands…”  One woman writes, “I asked [my husband] where we should have the baby.”  Another says, “[My husband] knew we needed to do this baby on our own without a professional birth attendant.”  In these families, Miller notes, husbands “played an active role in monitoring, directing, and evaluating the birth process.”

In her article “My Womb for His Purpose,” Kathryn Joyce tells the story of Carri Chmielewski, a self-described “Homeschooler, Homebirther, Homechurcher,” who had an unassisted childbirth after a complicated pregnancy and suffered an amniotic fluid embolism.  Her baby died.  According to Joyce,

Chmielewski’s husband, who critics charge has erased or hidden much of his wife’s past writing, described her survival as a miracle of God, who spared her even as He took their son.

Melissa, a former Quiverfull daughter who blogs at Permission to Live, was a submissive wife who was active in the web group of Above Rubies, a forum for Quiverfull/Christian Patriarchy mothers.  She says of her prenatal care in the U.S., “I had limited my checkups to only a handful to keep costs down.”  She also got only one of the two recommended shots for her rh-negative blood type and had her children at home.  She could have had comprehensive prenatal care, but her family did not believe in accepting government “welfare” and so went without any insurance at all:

I believed that welfare programs were unnecessary because if every woman just got married to one man and he supported her and her kids there would never be a need for welfare, I believed that Christian rights and privacy were being violated by the government on a regular basis…I remember being on a mommy chat board during my first and second pregnancies and someone started a thread on costs of prenatal care and childbirth. I mentioned that my uninsured home births had cost between six and seven thousand dollars each and felt proud that my costs were so low…

She never mentions anything about her knowledge of homebirth risks, only the “risk” of accepting government assistance.

Anonymous left the following comment at a Recovering Grace post on Quiverfull (ATI is the Advanced Training Institute, a Christian Patriarchy group):

I was an ATI mom for quite a few years and embraced the Quiverfull teachings. After a number of children we had a close call. A home birth and heavy hemorrhaging nearly claimed my life. I was ready to end the child bearing and focus on the children we had, but my husband didn’t agree. Within nine months I was pregnant again. We actually had insurance and I wanted to have the next birth in a hospital, but it was more important to my husband to have a home birth and “prove” his faith. I asked him, “What are you going to do if I bleed to death?” His answer amazed me. “Get a new one.”

This women knew first hand that there were risks to homebirth, ones she did not wish to accept.  Her religion, however, would not allow her to exercise her own autonomy.

According to Birth Junkie, “Born in Zion is a book by Christian ‘childbirth minister’ Carol Balizet, who ‘ministers’ to women during their home births” (I wanted to verify what Birth Junkie writes, but the book is now out of print and is currently selling for $200 per copy, so we’re going to take Birth Junkie’s word for it). She writes of Balizet:

[W]hatever Balizet’s ministry may be, it is certainly not midwifery….her teachings on childbirth are thoroughly unbiblical and even dangerous.  As if all this weren’t bad enough, Balizet believes that to receive any medical care whatsoever is a sin. It is yielding to the “world system” (167) and to the “arm of flesh” (84). Furthermore, taking any drug for any reason is sorcery according to Balizet (171). She refers to people who have never ingested drugs of any kind as “undefiled” and “virgins” (174)….Balizet believes that getting a Caesarean Section is a particularly abominable sin. All women who have had Caesareans have “the same spirit,” the “spirit of Caesar,” who is one and the same with “the Strong Man, the Satanic high prince over the organization and sphere of humanism” because they have “rendered their babies unto Caesar” rather than to God (48). In other words, women with Caesarean scars are idol-worshipers who are demon possessed.

Followers of such a philosophy are likely to be frightened into not seeking appropriate medical care–or bullied into not seeking it by church or family “authorities.”

Vyckie Garrison tells the harrowing story (long but fascinating if you want to read the whole thing) of her belief in her husband’s and God’s authority, and how it impacted her prenatal care and birth.  First she was betrayed by the conventional medical system.  A doctor told her a bone spur made vaginal birth impossible.  When she found out that wasn’t true:

‘Then why have I had three c-sections?’ I wanted to know. Well, it turns out that there really was no good reason–only that the first doctor had run out of patience so declared me to be ‘too small’ to give birth. And because of the first cesarean ~ I had automatically scheduled repeat c-sections for my next two babies.”

Her Christian OB offered severe limitations on VBAC and laughed at her wish for vaginal birth.  Having embraced the Quiverfull lifestyle, she decided to deliver with Judy Jones, an unlicensed midwife and devout Christian.  Because Vyckie had many complications in her pregnancy (for which she did not seek other care), Judy was at their house frequently.  Vyckie writes,

As ‘part of the family,’ Judy was around to witness the way that Warren dealt with the children…She spent a lot of time talking to me about the importance of upholding my husband’s authority…she always backed him up as ‘head of the home’….the wife should pray for the father of her children–but it’s essential that she never contradict him or do anything which might undermine his rightful authority as protector, provider–and priest in the home.

As the pregnancy progressed, Vyckie’s health worsened:

I was feeling particularly horrible…I told Judy that I really needed help–I really needed to go to the doctor. Judy drove to my house and did the usual check and assured me that–although I was still spilling sugar in my urine (+1,000)–I was okay and the baby was fine….Even though we really didn’t have the money for it, I insisted that I needed to go to the OB/GYN. ‘I can’t handle this anymore–I feel like I’m dying!’  I was laying on the couch and Judy got down on her knees beside me and did what she called a ‘diaphragmatic release,’ in which she put one hand under my lower back and her other hand on my lower abdomen and then waited patiently while the uterine muscles relaxed. It did calm me down, and while we waited, Judy told me a bible story…about the time when the children of Israel were wandering in the desert, and the Lord was providing for their every need…[b]ut the Israelites grew…greedy. ‘They had meat in abundance,’ Judy explained, ‘but they suffered leanness of the soul.’  Leanness of the soul … that’s what happens to those who don’t trust the Lord through their trials–those who seek “worldly” remedies and don’t have the faith to believe that God will never give us more than we can handle.

Eventually, after months of complications and a harrowing labor, she had a hospital transfer and an emergency cesarean.  Her recovery was lengthy, and her mother urged her not to have more children.  Vyckie writes,

But what about God? What did He want? His word made it very plain ~ He wanted to bless us and to use our family for His glory. Who was I to say, “No. Sorry, Lord–but it’s just too difficult for me”?

Now that she has left the movement, Vyckie offers the following reflections on her experience:

Because I had made the commitment to welcome every pregnancy as an unmitigated gift from the Lord, and because I also believed that accepting government assistance in the form of Medicaid was tantamount to trusting Caesar to provide for the health and wellbeing of my babies, I desperately sought an alternative to the expensive surgical deliveries.  I know now that it was absurd for a woman with my health issues and high-risk status to eschew all medical care and trust myself and my unborn baby to an unlicensed ‘lay midwife’ – but I was idealistically motivated, and it made perfect sense to me at the time. In fact, I was absolutely certain that it was God Himself who put the idea in my head and lead me to Judy Jones….Judy’s incompetent, negligent, and abusive pre- and post-natal care…seriously endangered my life and my baby’s life, and left me so physically, emotionally, and spiritually traumatized that I suffered severe PTSD for over a year and still sometimes have nightmares almost seventeen years later.

Rebekah Pearl Anast, the daughter of Christian Patriarchy couple Michael and Debi Pearl, married Gabe, a man who quit his job to study the Bible.  The family lived in a rural home outside Gallup, New Mexico, where their electricity has been turned off because they can’t afford to pay the bill.   Rebekah has 6 homebirths assisted only by Gabe.  She does seem to have enjoyed them (at least the first 4):

Now, I have had 4 “unassisted” homebirths. It did save us 20,000 dollars all told, and has been a thrilling and bonding experience for both my husband and I.

However, she has so subsumed her own desires to those of her husband that it is unclear whether she knows how to have her own feelings.  Of her relationship to God, her home, and her husband, she says (DH means Dear Husband),

[I]f your worship of God IN ANY WAY short-changes your husband or son, or makes them feel shut out, then IMO, it is not in spirit and in truth….Remember that your husband is your lord….It really helped me to remind myself ‘this kitchen belongs to DH, the food belongs to DH, the meal is all about DH, and both me and our daughter are helpers for DH…’

Rebekah’s entire life is dictated by the whims and desires of her husband, so whatever knowledge she has of the risks of unassisted childbirth are likely to be irrelevant.

There definitely appears to be a group of women homebirthing under questionable circumstances regarding their knowledge and autonomy–but it isn’t privileged feminists beholden to misinformation campaigns of hippie websites.

Time, Money, and Vaginal Birth

New recommendations from both the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal Fetal Medicine (SMFM) seem revolutionary.  Their new joint consensus statement advises abandoning the time restrictions on labor established by misguided adherence to Friedman’s Curve.  Here are some of the new recommendations, which are designed to lower the primary cesarean rate:

• Allowing prolonged latent (early) phase labor.
• Considering cervical dilation of 6 cm (instead of 4 cm) as the start of active phase labor.
• Allowing more time for labor to progress in the active phase.
• Allowing women to push for at least two hours if they have delivered before, three hours if it’s their first delivery, and even longer in some situations, for example, with an epidural.
• Using techniques to assist with vaginal delivery, which is the preferred method when possible. This may include the use of forceps, for example.

Aside from being written as if an epidural is unusual (60%-80% of first time mothers have epidurals), these guidelines have amazing potential to lower the rate of cesareans by justifying longer time for women to labor and reducing obstetricians’ justifications for their “failure to wait.”

The question remains, however, whether these new guidelines really will change practice in any meaningful way.  Even the joint consensus statement from ACOG and SMFM says,

Changing the local culture and attitudes of obstetric care providers regarding the issues involved in cesarean delivery reduction also will be challenging.

They go on to note that systemic change (meaning things like changes in required hospital protocols) is likely to be essential for significant practice change to occur, and they also argue for tort reform (discussed below).

People often say that obstetricians perform cesareans because the reimbursement is higher, and there are studies that indicate that this is true.  Doctors, however, are not always paid more for cesareans, and when they are, the difference is often only a few hundred dollars–not chump change, but probably not the major motivator for those in one of the most highly paid medical specialties.  The increase in birth costs for cesareans is primarily for the hospital resources: the operating room, post-operative care, and a longer hospital stay for the woman and her baby.  Contrary to what some studies have found, according to a conversation I had with Alabama Medicaid officials, when Alabama changed its Medicaid reimbursement a few years ago to be the same for cesareans and vaginal births, officials were disappointed to find it did not reduce the cesarean rate.  Here is a graph based on CDC data from Jill Arnold’s CesareanRates.com:

So what does drive high cesarean rates if it’s not all about the financial greed of physicians looking to make a couple hundred bucks through slice and dice obstetrics?

Some cite malpractice suits as a major motivator.  While malpractice premiums do appear to impact c-section rates, the effect is relatively small.  Rather than actual malpractice suits, according to Theresa Morris’ Cut it Out, it is  fear of them that drives OBs toward cesareans.  According to Childbirth Connection’s comprehensive report, Maternity Care and Libility, ACOG’s 2009 survey of OB practitioners reported that liability fears had led 29% of respondents to increase their use of cesarean and 26% to stop performing VBACs. Here’s another graph from Jill:

In his excellent New Yorker article on “how childbirth went industrial,” Atul Gawande points to the predictability and reliability of cesarean over vaginal birth, which makes doctors likely to choose cesarean over less invasive procedures (such as forceps deliveries) that may be risky in the hands of those without enough training, experience, or practice:

Is medicine a craft or an industry? If medicine is a craft, then you focus on teaching obstetricians to acquire a set of artisanal skills….if medicine is an industry, responsible for the safest possible delivery of millions of babies each year, then the focus shifts. You seek reliability. You begin to wonder whether forty-two thousand obstetricians in the U.S. could really master all these techniques….[O]bstetricians decided that they needed a simpler, more predictable way to intervene when a laboring mother ran into trouble. They found it in the Cesarean section….We have reached the point that, when there’s any question of delivery risk, the Cesarean is what clinicians turn to—it’s simply the most reliable option….Clinicians are increasingly reluctant to take a risk, however small, with natural childbirth.

Yet c-sections also pose real risks, as this table from the joint consensus statement indicates:

Table 1. Risk of Adverse Maternal and Neonatal Outcomes by Mode of Delivery
Outcome	Risk
Maternal	Vaginal Delivery	Cesarean Delivery
Overall severe morbidity and mortality*†	8.6%	9.2%*
	0.9%	2.7%†
Maternal mortality‡	3.6:100,000	13.3:100,000
Amniotic fluid embolism§	3.3–7.7:100,000	15.8:100,000
Third-degree or fourth-degree perineal laceration||	1.0–3.0%	NA (scheduled delivery)
Placental abnormalities¶	Increased with prior cesarean delivery versus vaginal delivery, and risk continues to increase with each subsequent cesarean delivery.
Urinary incontinence#	No difference between cesarean delivery and vaginal delivery at 2 years.
Postpartum depression||	No difference between cesarean delivery and vaginal delivery.
Neonatal	Vaginal Delivery	Cesarean Delivery
Laceration**	NA	1.0–2.0%
Respiratory morbidity**	< 1.0%	1.0–4.0% (without labor)
Shoulder dystocia	1.0–2.0%	0%
Abbreviations: CI, confidence interval; NA, not available; NICU, neonatal intensive care unit; OR, odds ratio; RR, relative risk.

(Note that cesarean’s near-quadrupling of maternal death risk is not causing a call to ban non-medically essential cesarean).

Another factor in physician preference for cesarean–one that is closely tied with money–is time.  As one prominent obstetrician once told me, the money itself isn’t the issue–what’s a couple hundred dollars to someone whose salary is well into six figures?  It’s time.  A cesarean takes 40 minutes.  A vaginal birth can drag on for hours and hours, and the timing is completely unpredictable.

This report on Maternity Care Payment Reform from the National Governors Association explains that the optimum timing possible with cesarean is personally convenient as well as financially lucrative–but not because of the payment for the cesarean itself:

[P]lanned cesarean deliveries have lower opportunity costs for obstetricians and facilities. For facilities, spontaneous vaginal deliveries may be more difficult to plan and manage compared to scheduled cesarean deliveries. With a planned cesarean delivery, hospitals can schedule operating room time and ideal hours for nursing staff. For providers, scheduling a cesarean birth ensures that they will be the ones to perform the delivery and they will not have to transfer care and associated payment to a colleague or be delayed from office or other hospital duties.11 In addition to securing reimbursement, having scheduled births allows providers more time to schedule billable procedures.

Even in vaginal births, the emphasis many obstetricians put on time is obvious.  Elective inductions allow for births to be scheduled at the physician’s convenience (and while this may sometimes be convenient for the pregnant woman also, you can bet that she does not get to pick a time that would be inconvenient for her doctor).  ACOG guidelines on labor induction and augmentation discuss the reduction in labor time that can occur with Pitocin administration in positive terms (without any indication that this is preferred by laboring women).

In my tours of hospital labor units, it has not been uncommon for every laboring woman on the board to have a Pitocin drip to “help them along.”  A friend of mine–one who was amenable to a highly medicalized birth and had an epidural in place–said her obstetrician walked into the room when she had dilated to 10 centimeters and said, “Okay, you have two hours to push this baby out and then I’m going to have to do a cesarean.”  This did not even meet old time guidelines, which indicated a three hour pushing time for first time mothers who had an epidural.

The website My OB Said What? is full of anecdotes about practitioners who value their own time over the normal progression of  labor.  A few examples:

• “Well she pushed for over two hours, I would have just sectioned her.”– OB  who was not caring for the mother during labor, after learning of the mother’s vaginal birth. 
• “But then we’ll be here ALL DAY!” – OB, with wild flinging of arms into the air,  in response to the suggestion that breaking the bag of water be delayed until a mother being induced  continued to dilate more then the current 2 CM of dilation she was at.
• “You can’t pay me enough to sit here waiting for you to deliver to make up the time lost with my children.” –OB commenting on Twitter.
• “You’ll have to be pushing by 1, I have some place to be at 2 this afternoon.” –OB to woman on Pitocin induction who was also having her membranes ruptured at 2cm dilation.

Some doctors also feel a therapeutic mandate to “do something,” which is often counterproductive in a normal labor.  Obstetrician and ethicist Paul Burcher notes that a “therapeutic imperative” is essentially another term for “the inertia that prevents physicians from abandoning ineffective therapies because no better alternative yet exists.”  Burcher is writing about bed rest, but as with threatened miscarriage, the current “better alternative” in a normal labor is to do nothing at all.  As Dr. Burcher says,

It takes courage to do nothing, but when we have nothing of benefit to offer we must refrain from deluding ourselves and harming our patients.

Here’s hoping that ethics will trump time and money and lead to genuine change in practice.  But given the historic difficulties obstetricians have with implementing evidence based practice and the slow obstetric response to reducing (rather than increasing) intervention, given the average time it takes to put an innovation into routine practice, we may have at least 17 years to wait.

The Right to High-Risk Homebirth

There is a sense in the United States that a woman has a right to give birth in the hospital.  In fact, most people can’t imagine giving birth anywhere else.  Fewer than 2% of births in the U.S. occur outside of a hospital.  Hospitals are required to accept birthing women–even undocumented immigrant women receive emergency Medicaid to cover the cost of a hospital birth.  Insurance policies often do not cover homebirth but they are required to cover hospital birth.  While some state Medicaid programs cover homebirth (e.g. Washington), most do not.  But does a woman have the same right to birth at home that she does to birth at a hospital?

Working through ACOG and its journal, Obstetrics and Gynecology (aka The Green Journal), obstetricians vociferously push their view that homebirth is dangerous.  While there certainly may be dangers in birthing at home, recent studies have relied on birth certificate data to indicate dangers.  Marian McDorman, a senior statistician with the National Center for Vital Statistics, has said repeatedly (most recently in the Daily Beast) that vital records data are not appropriate for research: “There are quite a few limitations in using that data for that kind of analysis.”  Vital Statistics reports are descriptive in nature for this reason.

In a recent workshop I attended on linking Vital Statistics data with Medicaid claims, the statistician leading the workshop pointed out  flaws in a recent study of Apgar scores and neonatal seizures in home, hospital, and birth center births.  Among the flaws:  hospital birth certificates are generally filled out within 24 hours (while for home births, they are generally filled out later), thus truncating the time during which a seizure could  be reported for a hospital birth.  A senior statistician for the state of Washington also pointed out that homebirth midwives reliably fill out every field in the birth certificate while most hospitals rarely do.

It is hard to tell whether hospital birth is really safer than homebirth (or vice versa) for low risk births.  Politics take over the debate, and women are left with rhetoric rather than information.  For high risk births, however, there is some agreement from both sides that the intrapartum and neonatal death rates* are higher when a woman births at home.

High risk births include breech presentation, vaginal birth after cesarean (VBAC), maternal complications such as preeclampsia or gestational diabetes, and multiple gestations (e.g. twins).  While women in these circumstances are more likely to be subjected to interventions in the hospital that may be unnecessary, they and their babies have a lower risk of dying in the hospital.  These high risk conditions sometimes result in complications that simply cannot be handled adequately at home and may not present in such a way that a hospital transfer can occur in time.

Death is the ultimate negative outcome in medicine.  Long term disability for the infant or woman is also  a poor outcome.  While medicine acknowledges short term morbidities such as maternal hemorrhage or neonatal respiratory distress, these are generally not taken particularly seriously as long as everyone appears to be all right in the long run.

The question is then, should women who are well informed of the risks and benefits of home vs. hospital birth be allowed to choose where to birth?

At the Institute of Medicine Birth Settings Workshop, I chatted with a number of Certified Professional Midwives (CPMs), the kind of midwives who generally attend births only outside of a hospital.  I asked if they were willing to attend high risk home births, such as breech births.  They replied that the choice of birth setting was entirely up to the woman.  They explain the risks thoroughly, and if the woman still chooses to birth at home, they will attend her.

ACOG’s official position is remarkably similar: a woman may make choices that entail risk, even if the doctor does not agree, and should not be prosecuted or persecuted for her choices (though that doesn’t mean the doctor should provide the care). Among their recommendations in their Committee Opinion, “Maternal Decision Making, Ethics, and Law,” is

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.

ACOG’s Committee opinion, “Planned Home Birth” even reluctantly acknowledges a woman’s right to birth at home:   “Although the Committee on Obstetric Practice believes that hospitals and birthing centers are the safest setting for birth, it respects the right of a woman to make a medically informed decision about delivery.”  (Though they do not support physicians’ attending home births.)

In an ironic twist, ACOG supports physicians who actively act in ways they believe are not in the best interests of a woman’s health as long as they explain the risks to the woman and she still wants the procedure.  While they are not obligated to perform the procedure, ACOG’s Committee Opinion, “Elective Surgery and Patient Choice,” says it is ethical for the physician to perform operations such as ovary removal or cesarean section on patient request.

In addition, as Marian McDorman has pointed out, even in high risk situations, the absolute risk of a bad outcome from homebirth is very small.  I would point out that in contrast, the absolute risk of unnecessary clinical intervention in hospitals (and associated morbidities), including administration of high alert medications such as Pitocin and unnecessary cesarean surgery, is very, very high.  In the case of a woman wishing to have a VBAC, the chance of of cesarean in a given hospital may be 100%, even if the woman meets ACOG criteria for safe VBAC.

Personally, I would choose to birth at the hospital if my pregnancy indicated that my birth would be high risk.  But that is my choice.  I would not want someone to force me to birth at home because that person thought that the relative risk of morbidity at the hospital was higher than that of death at home, or because hospital birth in the U.S. is outrageously (and unnecessarily) expensive, or because some hospitals cannot be trusted to act in the woman’s best interests as a matter of policy, or because U.S. hospital births have among the worst maternal and infant outcomes in the developed world.

A practitioner does not have to attend a high-risk homebirth (or any homebirth), just as a practitioner is not obligated to perform a maternal request cesarean.  But if it is not wrong to put a woman and infant at risk from unnecessary surgery because the woman believes that is the best decision for herself, then why is it wrong to support a woman in homebirth if she believes that is the right decision?

We need to separate ethics, which are often personal, from the law, which is universal.  As long as a woman’s body is her own, she has the right to determine where it should be, when she is giving birth, and always.

*The intrapartum rate refers to deaths during labor and delivery; the neonatal rate technically refers to the first 28 days, but it is often truncated to refer to the first 24 or 48 hours.  A study should explain which definition it is using.

Informed Refusal

Medical practice has many issues around informed consent, with many procedures being routinely performed with no shared decision making process, no informed consent, or no permission at all.  Rebecca Dekker of Evidence Based Birth wrote than in her training as a nurse,

I was taught to say, ‘I am going to listen to your lung sounds now.’ My instructors told me that the patient would be less likely to refuse if I simply stated what I was doing, instead of asking permission. I practiced that way– and even taught nursing students that way– for several years. (emphasis mine)

This seems relatively innocuous when it involves listening to lung sounds, but has more onerous implications for pregnancy and childbirth.  Training to make statements is training for practitioners to say, “I am going to cut an episiotomy now” or “I need to do a cesarean.”  It may be true that the procedure is a good idea, but it is not acceptable to tell a woman that you are going to do something to her body.  A woman needs to have to opportunity not only to consent to a procedure, but also to refuse it.

Sometimes practitioners do not even say what they are going to do–they just do it.  Sometimes they tell the woman after it has been done, as in this case from My OB Said What?:

‘I gave you an episiotomy.’ – OB to mother after birth. Nothing was mentioned about an episiotomy being needed during the birth, and when the mother screamed in pain when the OB touched her, both the OB and the L&D nurse insisted the OB was just ‘stretching’ her.

Or this one

‘We will go ahead and schedule your cesarean section now.’ —OB to mother with two prior cesareans, at the mother’s 10 week prenatal appointment, after the mother indicated that she wanted to have a VBAC.

Sometimes the practitioner doesn’t tell tell woman anything, and she finds out what happened by reading her chart or talking about her case with a different practitioner, as in this report from Cookieparty at Community Baby Center:

I remember my OB saying he was stitching me and I was like oh I must have torn. He didn’t even tell me he did [an episiotomy], I found out later that day or the next day I think, when one of the nurses was tending to it. [It] pissed me off!

Instruction on “Patient Rights” from The Birth Place of UCLA Medical Center make it sound that their belief is that women do not have the right to refuse what health practitioners want to do in any case.  Their responsibility is to follow the rules and cooperate (emphasis mine):

Patient Responsibilities
As a patient, you have the responsibility to:

• Treat those who are treating you with respect and courtesy.
• Be considerate of the rights of other patients and hospital personnel.
• Observe the medical center’s rules and regulations, including the Visitor and No Smoking policies.
• Be as accurate and complete as possible when providing information about your medical history and present condition, including your level of pain.
• Cooperate fully with the instructions given to you by those providing your care.
• Fulfill the financial obligations of your health care, know your insurance benefits and eligibility requirements, and inform the hospital of changes in your benefits.
• Provide a copy of your Advance Directive (Durable Power of Attorney for Healthcare) if you have one.

In their Committee Opinion “Elective Surgery and Patient Choice,” the American College of Obstetricians and Gynecologists (ACOG) says that OBGYNs may perform unnecessary surgeries upon a woman’s request, including cesareans, as long as the woman is adequately informed of the risks and alternatives and the OBGYN believes the surgery is not an undue health threat:

Performing cesarean delivery on maternal request should be limited to cases in which the physician judges that it is sufficiently safe, given the specifics of the woman’s pregnancy and setting, and has had the opportunity for thorough and thoughtful conversation with the patient.

In their Committee Opinion “Maternal Decision Making, Ethics, and the Law,” ACOG points out

• Appellate courts have held…that a pregnant woman’s decisions regarding medical treatment should take precedence regardless of the presumed fetal consequences of those decisions.
• [M]ost ethicists also agree that a pregnant woman’s informed refusal of medical intervention ought to prevail as long as she has the ability to make medical decisions
• [I]n the vast majority of cases, the interests of the pregnant woman and fetus actually converge.
• Because an intervention on a fetus must be performed through the body of a pregnant woman, an assertion of fetal rights must be reconciled with the ethical and legal obligations toward pregnant women as women, persons in their own right….Regardless of what is believed about fetal personhood, claims about fetal rights require an assessment of the rights of pregnant women, whose personhood within the legal and moral community is indisputable.

Two of the main conclusions of this committee opinion are

• Coercive and punitive legal approaches to pregnant women who refuse medical advice fail to recognize that all competent adults are entitled to informed consent and bodily integrity.
• Court-ordered interventions in cases of informed refusal, as well as punishment of pregnant women for their behavior that may put a fetus at risk, neglect the fact that medical knowledge and predictions of outcomes in obstetrics have limitations.

However, the obstetric community continues to bully women into acquiescing to procedures that the obstetric team wishes to perform, and women are still persecuted for refusing procedures both legally and socially, even when these procedures are not evidence based.

Even when medical professionals do explain risks and benefits to a procedure, they often expect a woman to draw the same conclusion that they do regarding what should be done.  The flip side of informed consent, however, is informed refusal.  Women not only have the right to know what their options are, they have the right to choose the option they believe is right, regardless of what their health practitioner believes.