Archives for posts with tag: Pitocin

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.

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

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

Attorney Jill Filopovic writes,

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Image

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

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

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

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

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

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

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

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

waterbirth 2

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

Ultimately, the opinion concludes,

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

waterbirth 1

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

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

The committee opinion itself says,

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

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

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

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

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

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

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

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

waterbirth 3

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

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

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

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

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

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

hospital birth

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

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

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

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

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

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

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

 

Updates

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

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

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

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

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

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

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

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

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

Image

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

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

lawsuit csec

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The 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.

The Choosing Wisely campaign was begun in order to reduce unnecessary use of medicine and medical procedures.  Non-medically indicated use is unsafe for patients as well as being expensive.  Not only are there costs involved in the medicine or procedure itself, but there are also costs in treating side effects and other health consequences.

The American College of Obstetricians and Gynecologists (ACOG) has a list they made for the Choosing Wisely campaign, “Five Things Physicians and Patients Should Question.”  The top two items on the list are about elective induction of labor (these two items also made the American Academy of Family Physicians list).  The first warns against scheduling a delivery (cesarean or induction) before 39 weeks unless there is a clear medical indication.  Here is the text of the second:

Don’t schedule elective, non-medically indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable:  Ideally, labor should start on its own initiative whenever possible. Higher Cesarean delivery rates result from inductions of labor when the cervix is unfavorable. Health care practitioners should discuss the risks and benefits with their patients before considering inductions of labor without medical indications.

This is similar to the information I provided in my posts on Pitocin and elective inductions.  Before 41 weeks, unless there is a clear medical indication, labor should begin on its own.  Note the caveat that if an elective induction is to occur, the cervix should be “favorable.”  A laywoman might ask what this means.  A favorable cervix is soft, effaced and dilated.  But really the standard that physicians use for determining whether a woman’s body is ready to labor is the Bishop score.

In 1955, Dr. Edward Bishop published a paper (subscription needed to get text) on elective induction of labor in which he looked at the likelihood of induction success based on several factors: fetal position, cervical softness, cervical effacement, cervical dilation, and the “station” of the fetus (how far it was engaged in the woman’s pelvis).  We might question the ethics of inducing labor without medical indication, but Dr. Bishop did find that if the baby was anterior and the cervix was soft,  higher levels of effacement, dilation and engagement made elective inductions likely to work and labors were more likely to be shorter.  This chart from Preparing for Birth sums it up:

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Bishop’s scoring system is still used and has some accuracy at predicting the likelihood of an induction’s success.  Some doctors use a simplified score that just looks at effacement, dilation, and station.

Here are some graphs from Intermountain Healthcare’s care process model on elective induction:

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You can see that higher Bishop scores lead to higher likelihood of a successful induction, and that the higher the score, the shorter the labor.

Nulliparous women (first time mothers) are especially likely to have cesareans when they have lower Bishop scores.  It is important to note, however, that even with a favorable Bishop score, nulliparous women are much more likely to have a cesarean than they would be if labor began on its own, and they are more likely to have operative deliveries (forceps or vacuum).

Dr. Gene Declercq of Boston University and colleagues run a wonderful site call Birth by the Numbers and produced this chart with data from Listening to Mothers III:

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This data does not imply that an induction cannot be successful, that no one should have an epidural, or that a cesarean might not be necessary for reasons having nothing to do with inductions or epidurals.  But the data do give credence to the idea of choosing wisely.  Taking Pitocin to start labor in an uncomplicated pregnancy before 41 weeks is akin to taking high blood pressure medicine when your blood pressure is normal (credit Debra Bingham).  The Bishop score may help to determine if the medicine will not hurt you, but why take it in the first place?  If you do want to go the induction route, however, your Bishop score is a tool to let you know how likely an elective induction is to lead to unnecessary major surgery.

All inductions should be done with full informed consent and should not be scheduled around a care provider’s office hours, vacation time, or child’s birthday party.  The well being of the pregnant woman and her fetus and the woman’s informed choice should be the only considerations.  A woman is a human being and not a vessel to be manipulated for the convenience of others.

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.

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