Birth in Brazil–and America

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

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

Attorney Jill Filopovic writes,

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

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

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

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

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

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

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

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

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

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

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

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

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

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

National Advocates for Pregnant Women, whose research supplied much of the information for the above graphic, documents the legal control of pregnant women that occurs in the name of fetal rights, such as prosecuting a woman for murder after a suicide attempt while pregnant (in this case, the baby–born by cesarean–was alive, but died a few days later).

While the cesarean rate in the United States is much lower than in Brazil, a third of U.S. births are by cesarean, more than double the “threshold not to be exceeded” identified by the World Health Organization.  Khazan notes the parallels between Brazil’s medical system and the the system in the U.S.–both incentivize cesareans:

With the higher price of the private system [in Brazil] comes better amenities and shorter wait times, but also all of the trappings of fee-for-service medical care. C-sections can be easily scheduled and quickly executed, so doctors schedule and bill as many as eight procedures a day rather than wait around for one or two natural births to wrap up.

As in Brazil, though some cesareans performed in the U.S. are certainly in the interest of maternal and/or fetal well-being, many are in the interest of the obstetrician’s well-being.  There is still a convenience factor; in addition, OB-GYN Dr. Peter Doelger said doctors and hospitals are protecting themselves by following protocols based a fear of litigation:

So you’re stuck with this situation where we’re doing things, not based on science.  [The increase in C-sections is] really based on protecting the institution and ourselves. And, you can’t blame them. Getting sued is a horrible thing for the physician, a horrible thing for the nurse, and a horrible thing for the institution.

And the woman?  Well as long as the baby is healthy, does she matter?

The Pregnancy Outcome Blame Game

When something goes wrong, we often seek someone to blame.  Sometime the culprit is obvious, as when someone hits you or rams into your car or knocks over your vase.  When things go wrong in a pregnancy, it can be harder to tell what happened.  But having someone to blame is comforting.  Assigning blame allows us to believe that avoiding the blameworthy person’s mistakes will spare us a similarly bad outcome.

Blaming Mothers

People are quick to blame women for any bad pregnancy outcome–miscarriage, preterm birth, still birth, baby with disabilities, baby with genetic disorders, low birthweight baby and on and on and on.  Any choice a pregnant or birthing mother makes, it seems, can be used against her.  A New York Times piece points out that

much of the language surrounding advice to pregnant women as well as warnings is “magical thinking” that suggests that women who do everything right will have healthy babies — and therefore, women who have babies with birth defects failed to do everything right.

Women are blamed for not following a doctor’s orders, even if those orders have no basis in evidence, such as bed rest to prevent preterm birth.

Women may be blamed for not following folk wisdom: some people strongly believe that a pregnant will miscarry if she lifts anything heavier than a frying pan or that her fetus will strangle on its umbilical cord if she raises her arms over her head.

Women may be blamed if they do follow a doctor’s orders if a bad outcome occurs.  Virginia Rutter notes the following case from Paltrow and Flavin’s 2013 article on the criminalization of pregnant women:

A Louisiana woman was charged with murder and spent approximately a year in jail before her counsel was able to show that what was deemed a murder of a fetus or newborn was actually a miscarriage that resulted from medication given to her by a health care provider.

Women may be blamed for choosing a provider or place of birth someone else feels is inadequate.  One mother who planned to birth at home with a registered midwife wrote,

If something does go wrong, with the birth, or otherwise, [my mother] is going to blame me forever, for my “selfishness.” If the baby grows up to have a learning disability or something (for whatever reason), my Mom [who had cesareans] is going to say that it’s all my fault for having a natural birth, that I damaged the baby’s brain.

In fact, blame may be heaped on women for things that others believe have the potential to cause poor pregnancy outcomes, even if the actual outcomes are just fine.  For instance, women are often pilloried for having so much as a sip of wine during pregnancy, even though the evidence of harm in to the human fetus from low to moderate alcohol use is nearly nonexistent.

Women may even be blamed for things that they no longer do, as was the case with Alicia Beltran, who was imprisoned for refusing medical drug treatment while pregnant because she no longer used drugs.

Blaming Providers 

Some OBs openly acknowledge that their colleagues find it difficult to change practice in response to new scientific information–or even old scientific information.  Some examples are recommending bed rest, performing routine episiotomies, and using Pitocin for elective induction of labor.  However, when a woman or her infant develops a complication from one of these routinely prescribed interventions, the physician is rarely blamed for the poor outcome.  In fact, the doctors are often lauded in such circumstances for doing “all they could.”

Doctors  claim that women demand potentially harmful procedures, such as elective inductions or cesareans. Ashley Roman, MD, a maternal fetal medicine specialist at NYU Medical Center said,  “I have definitely seen an increase in C-section requests, even when there is no real medical justification behind it.” But the Listening to Mothers III survey found, “Despite much media and professional attention to ‘maternal request’ cesareans, only 1% of respondents who had a planned initial, or ‘primary,’ cesarean did so with the understanding that there was no medical reason.”

ACOG actually sanctions elective cesareans (albeit reluctantly).  In a 2013 Committee Opinion on elective surgery, ACOG concludes, “Depending on the context, acceding to a request for a surgical option that is not traditionally recommended can be ethical.”  Though their 2013 Committee Opinion on maternal request cesarean says vaginal birth should be recommended, it provides parameters for performing an elective cesarean.

Doctors sometime behave as if they are helpless to say no in the face of maternal request for elective medical procedures, such as cesareans or early inductions.  The director of women’s services at one hospital with a high early induction rate said,

A lot of the problem was the fear among our physicians that if they didn’t do what the patient asked, they’d go find another doctor. It was a financial issue.

Women, however, report that physicians consistently offer elective inductions and cesareans.  On the Evidence Based Birth Facebook page, Megan posted, “I was ‘offered’ an induction at 39 weeks at every visit starting at 34 weeks.”  At The Bump, user Ilovemarfa wrote, “I was induced with my son when I went overdue by over a week and he was estimated to be about 10 lbs 5 oz. My doctor offered me a c section due I possible high birthweight…” Her baby weighed 8lbs 9 oz.  Note that a prophylactic cesarean is only supposed to be considered if the baby is estimated to weigh at least 11 pounds.

Physicians may act as if they are doing women a favor by offering elective procedures.  For instance Emily on Baby Gaga posted,

I’m due [in two weeks]. I went to the doctor today. Last week I wasn’t dilated, but now I am 3 cm. He said if I don’t have the baby by my next appointment, I could pick a day, and they would induce me. No medical reason.

Or the provider may state that the procedure will be done, without any discussion or informed consent process.  On the Evidence Based Birth Facebook page, Becca reported, “[My]care provider did routine 36 week ultrasounds. [I] was told I was going to have a ‘Texas sized baby’ and would be induced if labor didn’t start…before 40wks.”   Dana was told at 29 weeks that “All first time moms need an episiotomy.”

In their Committee Opinion on Maternal Decision making, ACOG recommends,

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.

Despite their acceptance of elective interventions and a professional ethics opinion stating that women’s decisions should be respected, physicians sometimes threaten or persecute women when they refuse interventions–whether they are evidence based or not.  At the blood-pressure-raising website My Ob Said What?, a woman who told her OB that she refused to schedule a routine C section for her twin pregnancy (not evidence based) reported that she was told,

If you do that, then we’ll have to get social services involved and believe me, you don’t want that, Cookie.”

Another said she was told,

If you don’t agree to the cesarean section, we will call Child Protective Services and they will take the baby away for someone to be a real parent.”

A woman in Florida “was ordered to stay in bed at Tallahassee Memorial Hospital and to undergo ‘any and all medical treatments’ her doctor, acting in the interests of the fetus, decided were necessary.”  She was not even allowed to ask for a second opinion (bed rest is not evidence based).

One woman pointed out that doctors are not “reported to social services for child endangerment every time they try to induce a baby who’s not ready to be born, just for their own convenience” but that “if a mother did something for her own convenience that landed her child in the hospital, there sure as hell would be…lots of tough questions, lots of shaming.”

As stated earlier, when bad outcomes happen because of a physician’s choices, people often praise the doctor’s heroic efforts, even if the dangerous situation was caused by the physician.

A prime example is use of Pitocin without medical indication (you can read more about Pitocin here and elective induction here).  Some doctors who want to rush a birth or generate a reason to perform a cesarean practice something called “Pit to distress.”  Nursing Birth has an in-depth explanation with examples, but the short version is as follows:

• A doctor starts Pitocin to induce labor or augment it (speed it up).
• The dose is raised until the woman is contracting strongly and regularly.
• The doctor orders that the dose keep going up, even though the woman’s contractions are already strong (at least 3 in 10 minutes).
• The uterus becomes “tachysystole,” meaning there are more than 5 contractions in 10 minutes.
• In many cases, not enough oxygen gets to the fetus under these conditions, the fetus goes into distress, and the mother is rushed to the operating room for an emergency cesarean that “saves” her baby.

Many times, the woman has no idea that the physician ordered that her Pitocin dose be raised, so she doesn’t realize that the doctor caused the fetal distress.  All she knows is that the baby was in distress, and that her doctor saved the baby from a potentially terrible outcome.

Even when bad outcomes occur, lawsuits are not common.  Despite the hype around liability, it doesn’t seem to impact practice the way doctors say it does.  After tort reform passed in Texas, limiting physician liability, the cesarean rate continued to go up at more or less the same rate as the rest of the country.  As one obstetrical nurse said, though physicians and nurses fear lawsuits, “hospital staff are rarely criminally prosecuted for their actions or inactions.”

Blame, Fate and Social Control

Certainly there may be someone to blame when a pregnancy or birth has a bad outcome.  But there may not be.  Blaming a doctor is frightening–it encourages people to question someone they need to trust with their lives–and their babies’ lives.  Fate can be even scarier–no one controls fate.  And in looking someone to blame, it seems society is often more interested in the social control of pregnant women than in rooting out the real culprit.  There may be those who escape unscathed, but nobody wins in this blame game.

Elective Inductions: Be Thankful not to Have One

I have written previously about problems with Pitocin overuse (and about widespread overuse of other medical procedures in birth).  Now that the holidays are almost upon us, it seems wise to revisit the Pitocin issue.

Pitocin is a synthetic form of oxytocin, a natural hormone that promotes bonding and also causes cervical dilation and labor contractions.  Using Pitocin interferes with the body’s natural output of oxytocin, doesn’t effectively dilate the cervix, and prevents the body’s release of endorphins that naturally alleviate pain.  There are sometimes good reasons for inducing labor with Pitocin (for instance, if the baby must be born right away for health reasons).  In many cases, however, good reasons are not in the equation when the Pitocin comes out.

In 1990, fewer than 10% of women underwent labor induction.  Now, estimates indicate that up to 40% or more of labors may be induced.  As scheduled cesarean rates have also gone up dramatically in that same period (see this graph), we know that the proportion of women planning a vaginal birth who are induced has gone up even more.  If you doubt that large numbers of births are being scheduled, see this graph that shows that births are disproportionately on Tuesday-Friday, with an extraordinary dip on weekends.

Doctors like to indicate that elective inductions are primarily done at maternal request.  While some women definitely do request inductions, pregnant women cannot induce themselves with Pitocin.  Doctors seem to have no problem enforcing non-evidence-based practices that women don’t want, such as not eating in labor, but act as if they are helpless in the face of induction requests.

Some doctors also have selective memory when it comes to their own induction practices.  According to mothers, childbirth educators, and nurses, it is usually doctors who are encouraging inductions.  As one childbirth educator said,

[A]n increasing number [of women] are being encouraged by their physicians to have labor induced. Threats of “your baby is getting too big” or “your blood pressure is a bit high” or “going past your due date is dangerous” and seduction with “your baby is ready, let’s get on with it” are almost routine.

Even some doctors acknowledge that elective induction is often physician driven.  Dr. Vivien von Gruenigen writes,

Health care providers may request a patient to have an elective induction of labor and the “fee for service” model is a factor.  This routine is common for physicians in solo practice with needed time off call or impending vacation.  In addition, many physicians in group practice schedule elective inductions when they are on call for the purpose of financial gain.

Inductions are usually performed without true informed consent.  Pitocin is not FDA approved for elective induction of labor and carries a black box warning because it is a high alert medication (prone to errors in administration that lead to catastrophic consequences).  It appears that very few women are told that they are receiving a high alert medication that is being used “off label.”

One suggested consent form for elective induction includes the following for women to acknowledge:

• An increased risk of the need for cesarean section (surgical abdominal birth)
• I have also discussed the use of cervical “ripening agents” with my physician and I understand their separate risks of: a. Excessive stimulation of the uterus to the point that my fetus may become compromised and require emergency delivery, either vaginally or abdominally. b. I also understand that rarely the uterus may rupture under these circumstances, and cause death of my fetus and severe hemorrhage or death to myself.
• An increased risk that instruments may be used to accomplish a vaginal delivery if necessary.
• I also realize that if I have a cesarean birth, I am likely to require cesarean births for all of the children I may have in the future, and that each of these will incur the usual risks associated with cesarean section that I might have avoided had I had this birth vaginally.
•  I acknowledge that there may be an increased risk for the need of blood transfusion, and I give my full consent to receive blood and blood products as necessary unless specifically stated here:

I have never met a lay woman who was aware of all of these risks, even if she had undergone an elective induction.

Marilyn Curl notes that elective deliveries spike before holidays–but that women do not always realize that the induction is elective:

Few doctors want to be pacing the halls on Thanksgiving or Christmas, waiting for a mother to deliver, so it’s not uncommon to see a surge of women with normal pregnancies being told that there might be an issue and that they should consider scheduling the delivery, coincidentally, right before a holiday.

Jill Arnold has a whole post about the pre-holiday induction phenomenon at The Unnecesarean.

Aside from  the health risks, there are many other disadvantages to a pre-holiday induction, namely that there are so many of them being done that the obstetric wards are likely to be overcrowded.  Robin Elise Weiss notes that

• Trying to schedule an induction just before Christmas ensures a hugely busy and overworked staff because of everyone else doing the same thing.  I’ve personally seen women laboring in the halls or having very long wait for services like epidural anesthesia because of it.
• When you have a baby in the week before Christmas (with lots of other women), you’ve also got a crowded postpartum floor.  This means longer waits for being seen by pediatricians, getting pain medicationss, etc.
• Being in the hospital in a crowded induction season can mean that you have to share resources in the hospitals that are already spread thin, like the lactation consultant, breast pumps, birth certificate clerks, etc.

At a recent PCORI conference, consensus opinion was that elective induction of labor before 41 weeks was one of the most important issues facing perinatal care today.  As Deborah Bingham pointed out, we don’t give people with normal blood pressure medication for high blood pressure, because that would be dangerous; similarly, we should not be giving healthy pregnant women medication designed for rushing a birth in a medically dangerous situation.  And it certainly shouldn’t be done by tricking women into thinking an induction is necessary because of a big baby or other concern that is not an indication for induction.

Not even before Thanksgiving or Christmas.

Update: you may also want to read Public Service Post: The Bishop Score

When Nothing is Better than Something

Alice Dreger and her partner Aron Sousa have a piece in Virtual Mentor, the American Medical Association’s ethics journal, about science and evidence in labor and birth.  This is very similar that to another piece that Dreger published in The Atlantic last year.  I highly encourage you to read the full article(s), but I want to highlight a few things Dreger and Sousa say here.

They point out

Many well-intentioned obstetricians still employ technological interventions that are scientifically unsupported or that run counter to the evidence of what is safest for mother and child.

These include (according to the AMA article) routine use of continuous electronic fetal monitoring (EFM) in most hospital settings, routine use of episiotomy by some obstetricians, not providing (or even suggesting) doulas as a matter of routine practice, and routine use of epidurals for pain relief (see my post on choice in technological and scientific pain relief options here).

In response, Dreger and Sousa propose that

we believe it would be better to think of childbirth not in terms of “natural versus medical” but rather “scientific versus unscientific.”

In her Atlantic article, Dreger also notes

Many medical students, like most American patients, confuse science and technology. They think that what it means to be a scientific doctor is to bring to bear the maximum amount of technology on any given patient. And this makes them dangerous. In fact, if you look at scientific studies of birth, you find over and over again that many technological interventions increase risk to the mother and child rather than decreasing it.

I have heard many women say that they want to birth where “everything” is available.  But the problem with having “everything” there is that it becomes very hard not to use it.  Obstetricians seem to view things like fetal monitors, Pitocin, and scalpels the way most people view potato chips and brownies.  If you know they are there, you want them.  You need them.  Even if you know they are bad for you (or your patient)–must…have…now!

None of this information is particularly new.  The scientific evidence has been around, sometimes for decades.  When it comes to things like episiotomy or bed rest during pregnancy, even ACOG got on board long ago with practice guidelines indicating that these interventions should be used only in unusual circumstances.  But that doesn’t mean obstetricians actually practice according to ACOG guidelines.

Dreger and Sousa say,

[Obstetricians apply technological interventions that are not evidence based] not because a well-informed pregnant woman has indicated that her values contradict what is scientifically supported, a situation that might justify a failure to follow the evidence. They do so out of tradition, fear, and the (false) assumption that doing something is usually better than doing nothing.

Interestingly, when women want to decline these interventions, whether there is a scientific rationale for them or not, they are often punished.

Insisting on science based practice should not be controversial.  But as has been evident in obstetrics for hundreds of years, (e.g. the Chamberlen forceps), technological secrets bring power.  Whether the technology works as practiced is irrelevant to preserving that power.

 

Updates:

read about evidence and elective induction here

read about evidence regarding bed rest in pregnancy here

Homebirth Wall Street Journal Style and Considering Risk

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

Pitocin, Because it’s Good for…Someone?

There has been a great kerfuffle in the blogosphere recently about Pitocin, as a recent study (cited below) indicates a correlation between induction and augmentation of labor (both done with Pitocin) and autism.  Note that this is a CORRELATION, meaning that it appears that when one incidence goes up (use of Pitocin for induction or augmentation), so does the other (autism).  That does not mean that we have any certainty that one CAUSES the other.  Lot’s of things that have nothing to do with one another can be statistically correlated, such as climate change and women’s rights or availability of high-quality chocolate and the rise in U.S. wage gaps.

Let’s be clear at the outset: administration of synthetic Oxytocin (Pitocin) to a pregnant woman can be a wonderful thing.  It can improve health outcomes for a woman and for her baby.  It can prevent a woman from hemorrhaging.  It can potentially prevent stillbirth for babies who show no signs of being born even though the uterine environment is deteriorating.  It can help a woman to have a vaginal birth when it is necessary for a baby to be born earlier than planned, as when a woman has pre-eclampsia.

However, as with most drugs, it is best not to take Pitocin if it isn’t needed.  Some say that oxytocin is naturally produced by the body, so it’s fine to give it to pregnant/laboring women.  But lots of hormones and other substances are naturally produced by the body–estrogen, testosterone, red blood cells–and having too much of any of these in one’s system is harmful.  That’s why we don’t generally take hormones or get blood transfusions unless there is a specific medical indication that they are needed.

The FDA has a black box warning on Pitocin.   Pitocin is a high alert medication.  Pitocin is specifically NOT indicated for elective induction of labor.  Guidelines for augmentation of labor are not clear–though the Friedman curve has been widely discredited in the contemporary obstetric environment, it is often still used to determine an appropriate speed of labor.  Obstetric articles regarding augmentation often tout faster labor time as a benefit, without assessing whether that is what the woman prefers–her pain level, her satisfaction with her ability/inability to move around, her overall experience of labor an birth–or whether faster labor produces better outcomes.

The issue around autism and Pitocin is less whether Pitocin use and autism have a causal relationship than the question of why women are being given Pitocin in the first place.  If there is any potential for harm, and the drug is not needed, why is it being administered at all?

A woman is not a scientific experiment, nor is her laboring body obligated to conform to s schedule that does not increase benefits to her health or those of her infant.

JAMA Pediatrics research article on Pitocin and Autism

Overview of Pitocin

Institute for Safe Medication Practices list of high alert medications

Evidence Based Birth on Pitocin augmentation

Also on this blog: Elective Inductions: Be Thankful not to Have One and Public Service Post: The Bishop Score