Archives for posts with tag: Midwifery

Cosmopolitan (really!) has published an amazing interview with Dr. Katharine Morrison, the physician who worked with the abortion provider Dr. Barnett Slepian, who was murdered by “pro life” activist James Kopp in 1998.  She subsequently took over the Buffalo Women’s Clinic where they practiced.  In the intervening years, she developed an interest in homebirth as a women’s rights issue and decided to open a birth center so that her clinic would truly offer comprehensive reproductive services in a woman-centered environment.  It is only the second birth center in the entire state of New York (the other is in Brooklyn).

Unlike many obstetricians who vociferously oppose homebirth, Morrison has actually witnessed homebirths.  And as has happened with other obstetricians who have taken the initiative to learn about homebirth midwives and attend homebirths, she underwent a conversion.  She says that she went to a meeting led by Certified Nurse Midwife (CNM) Eileen Stewart, who was giving up her homebirth practice because she couldn’t find a collaborating physician.  Morrison recalls,

It occurred to me that, although I had delivered 2,000 to 3,000 women, I had never actually seen a natural birth.

Some obstetricians insist that it is ridiculous to say that OBs are not familiar with natural childbirth.  They will have to take this up with Dr. Morrison.  In any case, she asked Stewart to take on a few clients and agreed to be the collaborating OB.  Here is her response to the experience:

It’s a different culture of birth. A woman isn’t subjected to anything she doesn’t want. She doesn’t need an IV [for drugs or fluids]. She can eat and move around. No one’s checking her every hour. She can go at her own pace, and even have a water birth. There’s no rush to cut the umbilical cord as there is at a hospital. And if labor is progressing slowly, no one’s pressuring the patient to have a C-section, as can happen at a hospital. All of these things were part of my routine in my previous practice. But when I saw this woman-centered care, I was hooked.

Although Morisson is opening a freestanding birth center, not a homebirth service, she observes the similar reactions of those opposed to abortion and those opposed to homebirth:

The same contempt that people have for women choosing to terminate a pregnancy and the person providing that care, I’ve seen for women who want to have natural births and for the women providing them. It’s this idea that these women are selfish and insufficiently caring about these babies.

Women generally care passionately about being good mothers and having babies who will have all of the resources they need to grow to be thriving adults.  How and when to bring a child into the world are two sides of the same coin.  Women’s autonomy in deciding where and how to give birth is just as important as autonomy in deciding whether to give birth at all.

Read the whole interview: “Meet the Doctor Who Opened a Natural Birthing Center in Her Abortion Clinic

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

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

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

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

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

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

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

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

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

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

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

I believed that welfare programs were unnecessary because if every woman just got married to one man and he supported her and her kids there would never be a need for welfare, I believed that Christian rights and privacy were being violated by the government on a regular basis…I remember being on a mommy chat board during my first and second pregnancies and someone started a thread on costs of prenatal care and childbirth. I mentioned that my uninsured home births had cost between six and seven thousand dollars each and felt proud that my costs were so low…
She never mentions anything about her knowledge of homebirth risks, only the “risk” of accepting government assistance.
Anonymous left the following comment at a Recovering Grace post on Quiverfull (ATI is the Advanced Training Institute, a Christian Patriarchy group):
I was an ATI mom for quite a few years and embraced the Quiverfull teachings. After a number of children we had a close call. A home birth and heavy hemorrhaging nearly claimed my life. I was ready to end the child bearing and focus on the children we had, but my husband didn’t agree. Within nine months I was pregnant again. We actually had insurance and I wanted to have the next birth in a hospital, but it was more important to my husband to have a home birth and “prove” his faith. I asked him, “What are you going to do if I bleed to death?” His answer amazed me. “Get a new one.”
This women knew first hand that there were risks to homebirth, ones she did not wish to accept.  Her religion, however, would not allow her to exercise her own autonomy.
According to Birth Junkie, “Born in Zion is a book by Christian ‘childbirth minister’ Carol Balizet, who ‘ministers’ to women during their home births” (I wanted to verify what Birth Junkie writes, but the book is now out of print and is currently selling for $200 per copy, so we’re going to take Birth Junkie’s word for it). She writes of Balizet:

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

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

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

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

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

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

As the pregnancy progressed, Vyckie’s health worsened:

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

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

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

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

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

Rebekah Pearl Anast, the daughter of Christian Patriarchy couple Michael and Debi Pearl, married Gabe, a man who quit his job to study the Bible.  The family lived in a rural home outside Gallup, New Mexico, where their electricity has been turned off because they can’t afford to pay the bill.   Rebekah has 6 homebirths assisted only by Gabe.  She does seem to have enjoyed them (at least the first 4):
Now, I have had 4 “unassisted” homebirths. It did save us 20,000 dollars all told, and has been a thrilling and bonding experience for both my husband and I.
However, she has so subsumed her own desires to those of her husband that it is unclear whether she knows how to have her own feelings.  Of her relationship to God, her home, and her husband, she says (DH means Dear Husband),
[I]f your worship of God IN ANY WAY short-changes your husband or son, or makes them feel shut out, then IMO, it is not in spirit and in truth….Remember that your husband is your lord….It really helped me to remind myself ‘this kitchen belongs to DH, the food belongs to DH, the meal is all about DH, and both me and our daughter are helpers for DH…’
Rebekah’s entire life is dictated by the whims and desires of her husband, so whatever knowledge she has of the risks of unassisted childbirth are likely to be irrelevant.
There definitely appears to be a group of women homebirthing under questionable circumstances regarding their knowledge and autonomy–but it isn’t privileged feminists beholden to misinformation campaigns of hippie websites.

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.

What is an Episiotomy?

To attempt objectivity in definition, let’s start with the dictionary: episiotomy is “an incision into the perineum and vagina to allow sufficient clearance for birth.”  This means the vagina is cut open to make it bigger, ostensibly to make it easier for the baby to come out.  The cut goes in the direction of the anus.

There are two types of episiotomy: midline, in which the cut is made in a straight line toward the anus, and mediolateral, in which the cut is made at an angle toward one side of the anus.

episiotomy

In a review of the procedure, Cleary-Goldman and Robinson note that technically episiotomy refers to the cutting of the external genitalia, and perineotomy more accurately describes what is called episiotomy in American obstetrical practice.  If you are not squeamish, you can do a search on Google Images for episiotomy and see what they look like in photos rather than drawings.  I mean it about the not squeamish part.

A Short History

There is documentation of episiotomy being performed in the 1700s in particularly difficult and prolonged births.  There is also documentation in this era of using support and lubricants (such as hog lard) to prevent tearing of the perineum during birth.  Accounts in the preceding links differ, but episiotomies appear to have been introduced in the United States in the mid 1800s.  The combination of anesthesia, hospital birth, and routine use of forceps served to popularize episiotomies in the late 19th and early 20th centuries.

In 1918, advocating for episiotomy in a journal article, obstetrician Ralph Pomeroy wrote, “Why should we consider it other than reckless to allow the child’s head to be used as a battering ram?”  Obstetrician Joseph B. DeLee published a subsequent article on episiotomy in 1920 and claimed that episiotomy “preserves the integrity of the pelvic floor, forestalls uterine prolapse, rupture of the vaginal-vesico septum, and the long train of sequalae.”  Doctors also preferred the ease of sewing the straight incision of an episiotomy rather than a tear.

The speculations of  Pomeroy and DeLee were absorbed as truth, and episiotomy became routine procedure for physician-attended births, even though there was no actual evidence to support episiotomy’s effectiveness in preserving women’s pelvic function.  The procedure was not widely questioned or tested by anyone in mainstream obstetrics until the 1990s.

What Happens after Episiotomy?

Episiotomy has sometimes been referred to dismissively as a “little snip,” but like mackerel and pudding, the words vagina and snip should exist far, far away from one another.  Episiotomy can have serious health consequences, including

  • Bleeding
  • Tearing past the incision into the rectal tissues and anal sphincter
  • Perineal pain [short and long term]
  • Infection
  • Perineal hematoma (collection of blood in the perineal tissues)
  • Pain during sexual intercourse [short and long term]

Some women recover quickly from episiotomy and do not report lasting problems.  Some women even request an episiotomy to shorten second stage labor–after hours of pushing, anything to hasten the birth may seem a relief.

For many women, however, episiotomy (which, after all, is a deep cut into the genitals) is traumatic and has long-term effects.  In nearly all cases, an episiotomy is not necessary, meaning that these women suffer while accruing no medical benefit.

Evidence

(See here for a brief explanation of a randomized control trial.)

In 1992, a group of Canadian physicians published the results of a randomized control trial in Current Clinical Trials showing that there was “no evidence that liberal or routine use of episiotomy prevents perineal trauma or pelvic floor relaxation.”  In addition, they found that almost all severe perineal trauma occurred among women who had median (midline) episiotomies, and that among women who had already had at least one vaginal birth, those who had episiotomies were much more likely to tear and needed more stitches on average than women who did not have episiotomies.

In 1993, a group of Argentine physicians published the results of a randomized control trial in the Lancet.  Their randomized control trial of 2606 women showed that routine episiotomy (rather than “selective” episiotomy) increased risk of severe perineal trauma.  Those in the routine group also showed higher rates of ” posterior perineal surgical repair, perineal pain, healing complications, and dehiscence.”  The study concluded that “[r]outine episiotomy should be abandoned.”

A 1995 study published in the Canadian  Medical Association Journal found that “Physicians with favo[rable] views of episiotomy were more likely to use techniques to expedite labour, and their patients were more likely to have perineal trauma and to be less satisfied with the birth experience.”  This study also found that the doctors who liked episiotomy had difficulty following study protocols about when to perform the procedure and were more likely to diagnose fetal distress and perform cesareans than their counterparts who did not have favorable views of episiotomy.

Some physicians still try to justify performing episiotomy to prevent tears, but tearing was shown to be preferable to episiotomy in a 2004 Scandinavian randomized control trial: “Avoiding episiotomy at tears presumed to be imminent increases the rate of intact perinea and the rate of only minor perineal trauma, reduces postpartum perineal pain and does not have any adverse effects on maternal or fetal morbidity.”

A 2012 Cochrane Review did not find significant differences between midline and mediolateral episiotomy–both were generally worse than avoiding an episiotomy altogether: “Women [who did not have episiotomies] experienced less severe perineal trauma, less posterior perineal trauma, less suturing and fewer healing complications at seven days (reducing the risks by from 12% to 31%); with no difference in occurrence of pain, urinary incontinence, painful sex or severe vaginal/perineal trauma after birth.”

Current American College of Obstetricians and Gynecologists (ACOG) guidelines note that “routine episiotomy does not prevent pelvic floor damage leading to incontinence” and recommend against routine use of episiotomy.  The guidelines note that median (midline) episiotomy is associated with anal sphincter injuries but that mediolateral episiotomy is “associated with difficulty of repair, greater blood loss, and, possibly, more early postpartum discomfort.”

The Royal College of Midwives (RCM, in the United Kingdom) offers the following evidence based reasons for episiotomy:

  • Aid the delivery of the presenting part when the perineum is tight and causing poor progress in the second stage of labour
  • Allow more space for operative or manipulative deliveries, such as forceps, shoulder dystocia or breech delivery (NICE, 2007; RCOG, 2005)
  • Prevent damage of the fetus during a face or breech presentation, or during instrumental delivery
  • Shorten the second stage of labour for fetal distress (Sleep, 1995) or maternal medical condition
  • Accommodate issues associated with female genital mutilation to the benefit of both mother and baby (Hakim, 2001).
  • Episiotomy is contraindicated when there is a high head. In these circumstances, descent will not be assisted.

Note that in the case of shoulder dystocia, the episiotomy is justified only to give the practitioner more room to perform necessary maneuvers.  Episiotomy does not, in itself, help with shoulder dystocia.  As the obstetrical nurse and midwife who blogs at Birth Sense explains:

Many physicians will openly admit that episiotomy does nothing to help facilitate the delivery of a baby with shoulder dystocia, because it is not a tissue problem, but a bone problem. The shoulder is stuck behind bone, and cutting the woman’s perineal tissue does not resolve the problem. Then why do it? Most physicians I’ve spoken with admit it is simply a matter of protecting themselves legally: by cutting a large episiotomy, they can show they’ve done everything they could possibly do to try to deliver the baby.

A recent study by Paris et al concluded episiotomy does not appear to reduce brachial plexus injuries (a rare paralysis associated with shoulder dsytocia):

There were a total of 94,842 births, 953 shoulder dystocias, and 102 brachial plexus injuries. The rate of episiotomy with shoulder dystocia dropped from 40% in 1999 to 4% in 2009 (P = .005) with no change in the rate of brachial plexus injuries per 1000 vaginal births.

Despite the evidence, shoulder dystocia is still commonly cited on popular consumer websites as a reason for episiotomy.

Overall, there are sometimes good reasons to perform episiotomy for the safety of the woman, the fetus, or both.  However, as Kim Gibbon of the RCM notes,

Consent is required for episiotomy, as it woud be for any surgical procedure. Women must be given a full explanation of the nature of the procedure and the situations under which its use will be proposed (Carroli and Belizan, 1999). Ideally, this should occur in the antenatal period so that the woman’s consent can be sought and documented at this stage. Further explanation should be given to the woman when a decision to use episiotomy is made to provide reassurance and confirm consent.

Current Practice

The Leapfrog Group has begun reporting episiotomy rates as one of its maternity care measures.  Unfortunately, reporting is voluntary at the hospital level, so there is only data for a limited number of hospitals (information on how to find the information on the Leapfrog site is at the bottom of the  page *).  Just looking at the data that is available shows enormous variations in practice.  For instance, among the four campuses in the Baptist Memorial Hospital system in Mississippi, rates range from a low of 1.5% at the De Soto campus to a high of 38.8% at the Golden Triangle campus.  Cesarean rates at all four campuses are similar (32% to 35%), so it appears that women who are not good candidates for vaginal birth (as well as a good number who are) have already been eliminated at all campuses.  Skin elasticity is unlikely to vary much by region, so why the variation in episiotomy rates?

A report on the evidence for episiotomy by the Agency for Healthcare Research and Quality (AHRQ) states,

Wide practice variations suggest that episiotomy use is heavily driven by local professional norms, experiences in training, and individual provider preference rather than variation in the physiology of vaginal birth.

Evidence indicates that many doctors have been slow to change practice regarding episiotomy, and that doctors who have not already changed may be increasingly reluctant to do so.  Like recommendations for bed rest, tradition or a “feel good” factor for the doctor may trump actual health outcomes.

Consistent with the findings of the Canadian study of physicians and their views on episiotomy (cited in the previous section), some hospitals with high rates of episiotomy are less likely to adhere to evidence-based maternity practice overall.  For instance, South Miami Hospital (of the Baptist Health South Florida network) has an episiotomy rate of 33.1%.  They also have the highest cesarean rate in the state (62%) and have not reached Leapfrog goals for early elective deliveries (induction or cesarean before 39 weeks for no medical reason).

The AHRQ report appears to give the most accurate reason for continued use of episiotomy at high rates: provider preference. One obstetrician quoted in the New York Times said that during her residency, “Fifty percent of the episiotomies I’ve done were because my supervising staff wanted to go back to bed.” According to this Times story, the quoted doctor has a colleague, who “‘loves epis’ and cuts them during almost every vaginal birth.”

Mothers’ reports from My Ob Said What? indicate that time is indeed  more important to some doctors than the integrity of women and their vaginas.  One mother reports questioning why her OB performed an episiotomy and was told, ““Why did I just do an episiotomy? I did an episiotomy because you would have been pushing for another 20 minutes!”  A friend of mine had an OB who told her, “Which do you think is easier for ME to sew up–a straight cut or a jagged tear?” (my friend switched practitioners).  A study by Webb and Culhane found that obstetrical procedures such as episiotomies increased at peak times in Philadelphia hospitals, to the detriment of women:

The fact that incidences of 3rd or 4th degree lacerations are high at roughly the same times that procedure use is high is consistent with what is known about the risks associated with episiotomy and vacuum/forceps use, and suggests that efforts to influence the timing of births through more liberal use of obstetric interventions may increase the morbidity associated with vaginal delivery.

Although rates of episiotomy have decreased drastically overall, some doctors do still perform them routinely, as this doctor indicated to a first-time mom who requested not to have one: “Well, we’ll see. I find that pretty much all of my first time mothers require an episiotomy.”

In addition, like the woman above, many women do not consent to episiotomies, but are cut anyway.  After one woman told her OB she did not want an episiotomy and preferred to tear (which is evidence based according to the Scandinavian study cited above), her OB told her, “I’m just giving you an episiotomy anyway.”  Another woman commented at the Chicago Tribune,

When I was pushing out my third child, my doula nudged my husband and told him that the OB was preparing to cut an episiotomy. The OB had not asked me if it was ok, and hadn’t even mentioned it. My husband piped up and said, “My wife doesn’t want an episiotomy.” He said that twice. The OB ignored him and injected me with the lidocaine. I finally clued in and shouted “I do not consent to an episiotomy” two times before the OB put her scissors down. Two times!! The kicker is that I didn’t tear. Not one bit. The episiotomy would have been completely unnecessary.

A 2005 comprehensive review in the Journal of the American Medical Association (JAMA) concurs with the above comment (emphasis mine):

The goals for quality of care must remain focused on both optimizing safety for the infant and minimizing harm to the mother. Given that focus, clinicians have the opportunity to forestall approximately 1 million episiotomies each year that are not improving outcomes for mothers.

While women sometimes successfully sue for episiotomies that are botched, as with cesarean (see this December 23, 2013 post), it is difficult to win a suit for an episiotomy performed without consent.  Generally, a doctor argues that the procedure was in the best interest of the fetus, and the woman’s rights cease to matter.

But women do matter.  Their pain matters.  Their sexual pleasure matters.  And most of all, their informed consent to what is done to their own bodies matters.  Practitioners may want to believe that they know better than their patients and can therefore slice and dice as they please.  They may believe that it is acceptable to sacrifice women’s bodily integrity to their own convenience.  Such a stance turns a woman into an object, a vessel who can be treated in any fashion as long as her body yields a healthy baby.  Women and those who love them must stand for a woman’s right to be human in childbirth — and always.

*To do a comparison of episiotomy rates at hospitals, click the Leapfrog Group link.  On the Leapfrog page, select “state” in the search by menu, select your state, and accept the terms of use.  On the next page, click the “Maternity Care” tab.  If there are any green bars in the “rate of episiotomy” column, click the blue question mark, and the rate will come up in a new window.

There appears to be an ongoing effort to pit obstetricians and midwives against one another as if the two can’t both play important parts in optimizing pregnancy and birth outcomes and women’s reproductive health.

A couple of years ago, Time magazine published a piece called, “Doctors Versus Midwives: The Birth Wars Rage On.”  Wars?  Really? What is this, the sequel to Monsters vs. Aliens?  How can doctors and midwives be at war when every licensed, practicing midwife has to work with an obstetrician as back up for births that exceed her scope of practice?  And when many states require midwives to work under the direct supervision of a physician?  So how do these midwives practice if they are spending all of their spare time laser blasting obstetricians?  Or hiding from the obstetricians who want to laser blast them?

And even though physicians’ organizations do sometimes fight against licensure of midwives or expanding midwives’ scope of practice, many obstetricians include midwives in their own practices or work with them side by side in hospitals, birthing centers, and even at homebirths (4 to 5% of homebirths are attended by obstetricians).  Again, working together like this is hard to do for people trying to kill each other.

In a recent article in Slate, Laura Helmuth concludes,

For individual simple, low-risk births, having a home birth overseen by a highly trained midwife isn’t necessarily a clearly terrible decision. But when you take a world-historical look at childbirth, it’s not midwives and cozy home births that get credit for making maternal death such an unthinkable outcome today. One of the great victories of modern times is that childbirth doesn’t need to be natural, and neither does the maternal death rate. It’s modern medicine for the win. Doctors may have killed a lot of women in the first part of the 20th century, but they can save your life today.

Note that Helmuth does not out-and-out condemn homebirth (though she certainly doesn’t provide a ringing endorsement).  However, Helmuth, while lauding advances that have indeed made birth safer, does not note that (1) the vast majority of midwives practice exclusively in hospitals and  (2) that the Cochrane review of the most recent research indicates that pregnant women have better pregnancy outcomes when their care is provided by a midwife and recommends that most women receive their prenatal and birth care from a midwife.  The Cochrane review also points out the important role obstetricians can play in high-risk situations.  That does not mean that birthing with an obstetrician when her/his high level of expertise is superfluous is safer.

Anti-homebirth activist and blogger Amy Tuteur (a former obstetrician) responded to Helmuth’s piece with a post with the gleeful title, “Obstetricians for the Win!”  I’m not sure what they won.  I guess the good graces of Laura Helmuth?  I doubt most obstetricians know who she is.

Tuteur is convinced that the technocratic model of childbirth (rather than a model based on actual science) is the savior of womankind.  In her post on Helmuth’s piece, she says

Not surprisingly, as technology drove down rates of maternal and perinatal mortality, women flocked to hospitals to give birth. Midwifery has never really recovered.  But midwives have fought back, mainly by pretending that the massive decreases in maternal and perinatal mortality didn’t actually occur, and that childbirth was always as safe as it is today.

Tuteur does not appear to have read the original article, which notes that obstetricians killed a lot of women by promoting technology not based in science, that they sold women a bill of goods regarding their skills, and successfully pushed midwifery to the sidelines even when hospital outcomes were consistently worse than homebirth outcomes.  Women flocked to hospitals before they became places where birth was safe. In one of her many posts denigrating those who do not agree with her adherence to a technocratic model of childbirth, Tuteur makes her argument (which is repeated throughout her blog) that midwives, doulas, and others with humanistic and/or scientific approaches to childbirth are only in it for the money:

Midwives, doulas and childbirth educators can only make money from births that involve minimal or no technology… The promotion of “normal” birth is a marketing strategy, no more and no less… NCB [Natural Childbirth] advocates recognize that increasing their profits involves creating a demand for their product. They are no different from the myriad of other purveyors in the marketplace who imply that their products will lead to social success and approbation. “Buy PearlyWhite toothpaste and you will get the girl!” translates to “Have a normal birth and you will be happier, empowered and have healthier children!”

I don’t particularly like the term “normal birth” myself, as concern about women’s bodies deviating from established “norms” (e.g. the stubborn adherence to Friedman’s curve for determining “normal” labor time) is what makes contemporary obstetrics such a mess.  Most midwives actually use the term physiologic birth, and while individual midwives may detour from practice guidelines, practice guidelines for midwives do not eschew technology or interventions when there is a demonstrated need for them.  The idea that “NCB advocates” are in it for the money is laughable.  On average, the salary of a certified nurse midwife is about a quarter to a third of that of an obstetrician.  Certified Professional Midwives (CPMs) earn less, and a doula may earn as little as a minimum wage worker.  While obstetrics requires substantially more investment in training, the payback is huge.  And even obstetricians say that it is OBs who feel financially threatened by midwives, not the other way around.

The British obstetricians and midwives have practiced together for a long time, and British OBs don’t seem threatened by midwives.  Here is the Royal College of Obstetricians and Gynecologists’ response to the Cochrane review on midwifery.  Basically it says all women should have access to midwifery care but should see an obstetrician if they need to.

So who wins in this manufactured “war” between doctors and midwives?  Somehow I don’t think it’s women.

The Wall Street Journal published a piece on the ubermoms of Brooklyn who want to homebirth.  As a feature story, the piece made a number of interesting observations specific to New York, such as how birth noises might impact neighbors in tightly packed apartment buildings, potential issues with a hospital transfer for a laboring woman in a fifth-floor walk-up, and the desire for homebirth in the Orthodox Jewish community because Cesareans pose a risk to having large families.

Whenever homebirth is mentioned, people go berserk about risk.  The comments in the WSJ piece are full of lines like, “Please do not have you children at home… If someothing (sic) happens, you will live with your guilt for the rest of your life” ; and “People are fools.”  Others point out that women want to homebirth because the Cesarean rate in most New York City hospitals is around 40% and it is very difficult to have an intervention free labor and birth in these hospitals even if the there are no complications.

Two ways of considering risk are looking at relative risk and absolute risk.

Relative risk considers the risk of one choice vs. another.  For instance, your risk of choking to death on a piece of meat or a raw carrot chunk is much higher than your chance of choking on a spoonful of pudding washed down with a swig of Coke.

Absolute risk considers how likely it is that each event will actually happen.  Continuing with the example above, you might consider your risk of developing tooth decay vs. death by choking.  In considering such choices, you might ask, what is my  risk of dying by choking to death vs. my  risk of tooth decay?  You might decide that, though death is a very serious risk, the very tiny  risk of death is less serious that the much higher risk of tooth decay.

We make decisions with poor relative risk profiles all the time because the absolute risks are small.  Sometimes this is done for convenience; for instance, we often ride in cars rather than walking.  Sometimes we do it for pleasure; we might choose to go mountain climbing rather than staying at a nature center watching videos of mountain climbing.  And studies show that we often assess risk poorly, living in fear of rare events like school shootings and terrorist attacks while blithely driving or taking showers without a skidmat.

The article points out that relative risk statistics indicate that the chance of infant death is about three times higher in a home birth than in a hospital birth (this statistic, based on the infamous Wax study, has been widely disputed, but for the sake of argument, we’ll proceed as if it is accurate).  However, the chance of death during a birth is very, very small (statistics on neonatal death consider all deaths by 28 days after birth; infant mortality counts all infants who die in the first year of life–these are different statistics from deaths during birth or in the few minutes afterward).  According to the Wax study, among babies without birth defects, the chance of death at a homebirth was .15%, or 1.5 per 1000 births.  As statistician Marian F. MacDorman says in the article, “the absolute risks of home birth are very low, no matter how you slice it.”

Weigh that against the chance of a cesarean at a hospital birth (approximately 400 per 1000 according to the article; the World Health Organization says 150/1000 is a “threshold not to be exceeded”). And according to the article, the chance of unwanted birth interventions in the hospital is close to 100%, meaning almost 1000/1000.  These interventions can include everything from administration of Pitocin to continuous electronic fetal monitoring, to artificial rupture of membranes, all of which have risks of their own, especially when used without indication.

With honest information, a woman can decide whether the relative risk of death in homebirth vs hospital birth (if the statistic is even accurate) is worth the absolute risk of major abdominal surgery or of unnecessary intervention that can cause pain, infection, loss of autonomy, neonatal complications, or even maternal or infant death.  It is completely legitimate for a woman to make a decision based on her own assessment of the risks, and that includes her right to assume the risks of either home or hospital birth, as well as consideration of risk to herself as well as her baby.

Wall Street Journal article: http://online.wsj.com/article/SB10001424127887323639704579016902834439742.html

Wax study abstract (look at the results as well as the conclusion): http://www.ajog.org/article/S0002-9378(10)00671-X/abstract

Complete text of the Wax study: http://dhmh.md.gov/midwives/Documents/Wax-etal.pdf

Overview of critiques of Wax study: http://www.scienceandsensibility.org/?p=2551

World Health Handbook on Monitoring Obstetric Care (see p. 25):  http://www.who.int/reproductivehealth/publications/monitoring/9789241547734/en/index.html

Book about Americans’ poor risk assessment: http://www.amazon.com/Culture-Fear-Americans-Minorities-Microbes/dp/0465003362

%d bloggers like this: