Archives for posts with tag: Episiotomy

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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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.

 

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

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

Attorney Jill Filopovic writes,

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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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?

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

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

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

Ultimately, the opinion concludes,

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

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

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

The committee opinion itself says,

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

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

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

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

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

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

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

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

waterbirth 3

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

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

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

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

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

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

hospital birth

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

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

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

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

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

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

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

 

Updates

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

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

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.

Lithotomy-Now-300x230

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.

The debate is on.

At long last, the Midwives Alliance of North America’s (MANA) homebirth data has been published in a peer reviewed academic journal, the Journal of Midwifery and Women’s Health.

The study is descriptive, meaning it can only speak to the women included in the data and cannot be generalized to the population at large.*  That being said, the data indicates that homebirth for LOW RISK women (no prior cesarean;  no gestational diabetes or pre-eclampsia; a singleton, vertex, term fetus) is not only safe regarding mortality, but is much, much safer regarding sources of maternal morbidity such as cesarean, instrumental delivery, administration of Pitocin, epidural use, and episiotomy.  Here is a summary from Citizens for Midwifery that includes all of the births, not just the low risk ones.  I have highlighted some notable points:

  • High rate of completed home birth (89.1%): Primary reason for transport was “failure to progress.” Transfer for urgent reasons, such as “fetal distress” was rare.
  • High rate of vaginal birth (93.6%)
  • High rate of completed vaginal birth after cesarean (VBAC; 87.0%)
  • Low intrapartum and neonatal fetal death rate overall: 2.06 per 1000 intended home births (includes all births); 1.61 per 1000 intended home births excluding breech, vbac, twins, gestational diabetes, and preeclampsia. 
  • Cesarean section rate of 5.2% 
  • Less than 5% used pitocin or epidural anesthesia
  • Low rate of low APGAR scores
  • Extremely high rate of breastfeeding (97.7%) at 6 weeks

Even for those in the “healthy baby is all that matters” club, the data don’t have much to condemn low risk homebirths.  And for those of us who think that a woman’s physical and mental health are crucial measure of the “success” of a birth, the data indicate that low-risk women who want to birth at home, for the most part, may be better off doing so.  

It is important to note that most of the births in the MANA registry are attended by Certified Professional Midwives (CPMs).  While many obstetricians accept the professional capacities of Certified Nurse Midwives (CNMs) (who usually practice in hospitals), they generally disparage the credentials of CPMs, even when they don’t know what the requirements are for earning the CPM title. (See information on the different kinds of midwives here.)

As reported in the Huffington Post, Dr. Jeff Chapa, director of maternal fetal medicine at the Cleveland Clinic, who reviewed the new study, said that low-risk women having a home birth “can feel good in that they’re probably going to be OK,” but that the study had not affected his views on home birth because “the bottom line in all of this is you can’t predict who is going to have an issue or a complication.”

The silly thing about Chapa’s comment is that if the maternal, infant, and fetal death rates among low risk women are more or less the same for hospital or home birth, there is no indication that a fatal “issue or complication” could be avoided by going to the hospital.  It is possible that some complications are unavoidable regardless of the setting.  It is also possible that the hospital could prevent some complications while causing others–thus there is no overall advantage to birthing in either setting.

Given that the homebirthing women avoided many procedures that result in complications, it seems that the argument could be made that the hospital is actually less safe for low risk births.  When obstetricians discuss birth outcomes, they often focus on a healthy baby and sometimes a healthy mother.  But what does this mean?  Is a baby who spends a week in the NICU “healthy” if it goes home healthy?  Is a mother “healthy” if she develops post-traumatic stress disorder from a forced cesarean?

Many morbidities don’t enter into calculations of the risks of hospital birth.  In many cases, unnecessary procedures conducted in hospitals are touted as positive, even when they have no positive effect.  Few acknowledge that doctors sometimes cause the problems that a heroic intervention solves, as evidenced by the horrifying practice of “pit to distress.”  Pit to distress NEVER happens at a home birth.

As Melissa Cheyney, a medical anthropologist and lead author of the study, said

 We need to start focusing on who might be a good candidate for a home or birth center birth and stop debating whether women should be allowed to choose these options.

On the other hand, as Miriam Perez, the Radical Doula, points out, very few women birth at home–fewer than 1%, and we should be far more focused on the outcomes in U.S. hospital births:

Whether you think midwifery and home birth are viable alternatives or not, it’s hard to ignore the statistics that say what we’re currently doing isn’t working. We should be able to guarantee better (not perfect, but better) outcomes for parents and children. If I were to play the blame game, I’m going to look to where almost everyone is giving birth — the hospital.

She concludes,

Let’s focus our scrutiny on the system that is failing us, and figure out how we can make it better. A few things that would help greatly in this matter: transparency about c-section rates from hospitals, an independent body investigating deaths from pregnancy-related causes, and real pressure on the obstetrics community to follow their own advice on practicing evidence-based medicine.

If obstetricians and the medical community really care about maternal child health, then rather than railing against homebirths, they should focus on making birth as safe as possible for women and infants, wherever the woman chooses to birth.

To paraphrase Jesus, who had a lot of great things to say if you actually pay attention to them, it is always wise to remove the plank from your own eye before you go after the speck in your neighbor’s.

*In order to say something about homebirth for all women, the women in the sample would have had to be selected randomly.  They were not.  All of them chose homebirth.  In addition, they are not representative of all women who homebirth–only women whose midwives submitted data to MANA are included, which means 70-80% of homebirths are NOT included in this data.

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