Archives for posts with tag: hospital birth

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

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

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

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

Grunebaum and Chervenak say,

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

cascade of interventions

(see original here)

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

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

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

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

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

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

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

In your own home, you make the rules.

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

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.

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.

Note: there is follow-up to this post with a response from Dr. Paul Burcher.  You can read it here.

Obstetrician Paul Burcher has a column called The Ethical ObGyn at ObGyn.net in which he instructs his fellow OBs, “Don’t Dread the Birth Plan.”  The best thing I can say about it is that not everything he says in this column is offensive.

He starts off citing Frank Chervenak and Laurence McCullough’s concept of “preventive ethics.”  For those of you not familiar with Chervenak, he is an OB, an expert in ultrasonography, and an anti-homebirth crusader.  He is perhaps most famous among homebirth supporters for a clinical opinion he published in AJOG in which he discussed midwife-supported homebirth in terms of “recrudescence” (which basically means resurgence or revival, except it tends to refer to something really bad, like guerilla warfare).  Chervenak also presented an anti-homebirth screed in the IOM Birth Settings Workshop in the Spring of 2013 in which he used vital records (birth certificate) data to make the case that homebirth led to a an enormous increase in stillbirth.  The statistician representing the National Center for Vital Statistics, Marian MacDorman, responded after his presentation that vital records were not a reliable source for making such claims, but he went on to publish the data anyway.  He also wrote the following in response to the ACOG Committee Opinion against homebirth (which he did not feel went far enough):

Obstetricians have an ethical obligation to disclose the increased risks of perinatal and neonatal mortality and morbidity from planned home birth in the context of American healthcare and should recommend against it. Obstetricians should recommend hospital-based delivery and respond to refusal of these recommendations with respectful persuasion.

Note that he is not suggesting that there be a full explanation of the benefit-risk analysis, a shared decision making process, or a consideration of the woman’s values.  There should just be information (that has been questioned by numerous experts) that neonatal mortality increases (and as I have posted before, even with the increase cited by Chervenak, the absolute risk of such a grim outcome is very, very small).  In other words, women should make the choice that he deems to be ethical.  At the time he wrote this recommendation, the hospital where he practices had one of the highest cesarean rates in New York.

But back to Burcher.  Burcher makes a private assessment of birth plans, dividing maternal requests into “of course,” “probably,” and “nonstarter.”  He suggests beginning by placating women with the “of course” items, such as not shaving because the hospital never does that anyway (do any hospitals still do routine shaves?  Even 20 years ago in the middle-of-nowhere hospital where I delivered, it never came up).

Regarding the “nonstarters,” his approach is reasonably respectful.  he suggests asking the woman about why she made the request and seeing if it can be fully or partially accommodated in some other way.  For instance, if a woman planning a VBAC wants to avoid continuous electronic fetal monitoring, but it is not the monitoring she objects to, but rather the restriction of movement, telemetric monitoring could work.  While I still think that women should have the ultimate choice about what is done to their bodies, I also understand that outside forces on physicians could jeopardize their careers if they agreed to processes that went against hospital or practice guidelines.  However, that does not mean that a woman cannot refuse against medical advice (AMA), and if she does, her wishes should be respected.  He does not address this very important ethical issue.

This biggest issue I have with Burcher are the “maybes.”  First of all, if it’s a maybe, it seems like what it should really be is “yes.”  If it is possible, and the woman wants it, what is the debate?  Of course, he is referring to the possibility of complications that would tip a “maybe” to a “nonstarter”–however, he indicates that this is already the case with the “of courses”:

I always tell my patients that my comfort zones may be different than the limits that my partners may have, so I cannot guarantee that the decisions made during prenatal care will all be carried out during labor. As circumstances change, so may our determinations of what is safe and appropriate.

This strikes me as bait and switch.  I read stories from so many women saying that their provider said s/he would support a VBAC, only to insert so many caveats along the way (you must go into spontaneous labor by x date, you must consent to y while in labor, you must deliver in z way) that their support for VBAC revealed itself to be a sham.  So what he is saying is that he cannot guarantee that he will attend the birth, and if one of his partners is there, what has already been determined by him to be perfectly acceptable might be outside the other practitioner’s “comfort zone,”  and therefore the agreed-upon birth plan would be meaningless.  I don’t understand why the doctor’s comfort zone is under consideration, as he is not birthing the baby.  How does the new doctor get the woman to change her informed consent?  By telling her that Dr. Burcher misinformed her?

The woman must have the autonomy to make the final decisions regarding her own care even if the doctor would personally make a different choice.  That is ethical, and that is the  point that Dr. Burcher (and many of his colleagues) seems to miss.

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