The Unprivileged Body: Humans Working While Pregnant

Imagine, if you will, a whole community of short people… Given the argument sometimes made in our society that short people are unable to be firefighters because they are neither tall enough nor strong enough to do the job, the question arises: Would all the houses in this community eventually burn down? Well yes, if we short people had to use the heavy ladders and hoses designed by and for tall people. But no, if we (being as smart as short people are) could instead construct lighter ladders and hoses usable by both tall and short people. The moral here should be obvious: It isn’t short biology that’s the problem; it’s short biology being forced to function in a tall-centered social structure.

–Sandra Bem, The Lenses of Gender

So let us then imagine a society of people who spend at least some portion of their lives being pregnant and who also need to have jobs to support their families.  Oh, wait–for almost half of society, this is already the case.  It was the case for Peggy Young when she was let go by UPS because she was not supposed to lift more than 20 pounds–even though her job was mostly lifting envelopes, and she had a colleague who could lift the rare 20 lb-plus package.  Why is it difficult to think that it might be an ordinary expectation that employers would adjust to the needs of pregnant workers for the brief period of their lives that they are pregnant?

When we assume that men’s bodies are the norm, it is easy to see a policy that doesn’t recognize the needs of pregnant workers, a “pregnancy blind” policy as reasonable (UPS had a pregnancy blind policy when Young worked there).  After all, if you can’t get pregnant, you never need accommodations for pregnancy.  But if we assume human bodies are normal, then we know that pregnancy is a condition experienced by almost half of all humans, sometimes on multiple occasions.

We expect that humans need to eat, and thus time to eat is scheduled into normal workdays.  We also assume humans need to urinate, and we provide accommodations for this function.  We do not have a “hunger blind” work policy or a “urination blind” work policy that allows employers to forbid workers who need to eat or pee from holding a job.  Even when some people do not have a need but others do, such as a need for leisure time, we do not institute “leisure blind” policies that allow 15 hour workdays 7 days per week because only some people need some time off from work.  We used to, but we decided (with the help of labor unions) that this was an unfair policy.

Pregnancy is a normal human condition, whether everyone experiences it or not.  Workplaces should expect to accommodate it as they do all ordinary conditions of being human–no matter how inconvenient. And usually it isn’t even inconvenient.

Fertilized Eggs, Women, and the Elephant Fetus

Is this a bowl of eggs or a a bowl of chickens?

The eggs are fertilized, so by the logic of those who believe a fertilized human egg is the equivalent of a human being, this is indeed a bowl of chickens.

And this is a fried chicken:

 

The claim that fertilized eggs are human beings reminds me of the joke (often attributed to Abraham Lincoln),

Q: If you call a tail a leg, how many legs does a dog have?

A: Four, because calling a tail a leg doesn’t mean it is one.

One of the main arguments in Hobby Lobby’s case against providing comprehensive contraception is that  morning after pills and IUDs are abortifacients.  Many have pointed out that morning after pills (which are NOT the same as the pills that actual do induce abortion) work by preventing ovulation, and IUDs generally work by thickening cervical mucus and otherwise creating an inhospitable environment for fertilization to occur.  Olga Khazan offers a concise explanation of the whole thing at The Atlantic.

The only method that could possibly meet any definition remotely connected to abortion is the Paraguard IUD, which when inserted up to 5 days after intercourse, appears to prevent pregnancy in ways that no one has entirely determined.  It is remotely possible that one of these ways could be to prevent the implantation of a fertilized egg.

This hypothetical fertilized egg has not developed into an embryo, much less a fetus, even less a baby (or child, adolescent, adult or senior citizen).  You can see slide show showing the process of ovulation to implantation here.  The passion with which some defend the life of a fertilized egg is mirrored only by the passion with which some defend an elephant fetus as a human being (seriously, click the link–the anti abortion crowd passionately defended the humanity of the elephant fetus).  Just in case you are curious, here is a photo of a fertilized human egg:

And here is a photo of an elephant fetus:

By the logic of the “personhood” movement, the top image is a person and the bottom image is an elephant.

There are many problems with assigning human status to fertilized human eggs (or elephant fetuses).  But the greatest problem comes when a woman becomes not a human being in her own right, but the vessel for the development of potential humans.

Thus, the argument that Hobby Lobby and others with their beliefs make is that it is immoral for a woman to make her body inhospitable to the implantation of a fertilized egg.  We already know that the methods of contraception that they claim prevent implantation actually prevent fertilization in the first place.  But let’s go ahead and pretend that implantation of a fertilized egg might be prevented.

Why is this a problem?  About half of fertilized eggs do not implant even when a woman is not using any form of contraception at all.  By the logic of the anti-IUD crowd, women should be banned from doing ANYTHING that might interfere with implantation of fertilized eggs.  This might include things such as being underweight.  If a fetilized egg is more likely to implant in heavier women, shouldn;t we force all women to be the ideal weight for implantation?  In fact, if a fertilized egg is a person, and that “person” has the indisputable right to grow inside of another person until it decides it can survive on its own, perhaps we should force all fertile women to take drugs that make implantation more likely.

If women use contraceptives, including IUDs, they are actually less likely to expel fertilized eggs because the eggs are less likely to become fertilized in the first place.  Libby Anne at Love, Joy, Feminism has a great explanation of how using birth control is the best way to prevent the deaths of fertilized eggs/zygotes/blastocysts.  And as I have argued, if we really believed fertilized eggs to be human, we would insist on funeral services and other respectful disposal of them instead of allowing them to pass along with ordinary vaginal discharge (the fertilized egg would be expelled before menstruation; implantation occurs about 5 days after ovulation, but menstruation occurs about two weeks after).

Believing that a fertilized egg is a person does not make it so.  Believing that morning after pills and IUDs cause abortions does not make it so.  And believing that a woman is an obligatory vessel not deserving of human rights does not make it so either.

 

CPR for Pregnant Women: Treating the Vessel

Let’s say you are CPR certified and the woman next to you on the morning commuter train goes into cardiac arrest.  Is your first thought, I had better let this woman die because if I perform CPR, I might hurt her fetus?  Apparently this is the attitude of many health care providers.

The Society for Obstetric Anesthesia and Perinatology (SOAP) has issued a new consensus statement regarding cardiopulmonary resuscitation (CPR) for pregnant women.  Pregnant women may have special needs regarding CPR, especially later in pregnancy when the size of the fetus compresses veins sending blood back to the heart.

Sometimes a hysterotomy (basically a cesarean, but the idea is to get the fetus out of the woman’s body) is the best way to preserve the woman’s life.  Some might be concerned about hysterotomy because of the concern for the life of the fetus being born prematurely.  We might then ask, what happens to a fetus inside of a woman who has gone into cardiac arrest and dies?  Well, the fetus generally dies too.

One of the things the new guidelines state is the importance of administering care that prioritizes saving the pregnant woman’s life.  Generally when a person goes into cardiac arrest, saving that person’s life is the goal, and it is alarming that it has to be stated that the life of a pregnant woman is equally valuable to the life of any other person who goes into cardiac arrest.

In a Q & A with Brendan Carvalho, Chief of Obstetric Anesthesia at Stanford University Medical Center, Dr. Carvalho notes that pregnancy CPR guidelines are important because pregnancy can increase a woman’s risk for cardiac arrest (and all women, pregnant or not, are at some level of risk).  It is laudable to recognize the normalcy of pregnancy in a woman’s life and determine how to provide appropriate medical treatment.  While Carvalho notes that U.S. maternal mortality has decreased dramatically over the last century, he does not mention that it has increased dramatically over the last two decades, with a rate that is now among the worst in the developed world.  The U.S. rates 60th nationally–59 countries have lower maternal death rates.

Perhaps part of rising maternal mortality stems from an attitude toward pregnant women that their humanity is suspended while they perform as vessels for fetal growth.  Such an attitude has been evidenced in the case of  Marlise Munoz (see here), the Texas woman whose dead body was kept artificially functioning against her wishes and those of her family so that it could serve as an incubator for her fetus. Louisiana has created an official law (which is expected to be signed by the governor) that mandates women’s dead bodies be artificially sustained as incubators for any fetus inside them that has reached 20 weeks.   Pregnant women are routinely criminalized for behavior that is not prosecuted in other adults, such as alcohol consumption or refusing to follow the recommendations of a physician (see here), indicating that pregnant women cannot be accorded basic human rights–the kind of rights accorded to all other adult humans.

Carvalho says,

Caregivers are often reluctant to administer medication to pregnant women because of potential harm to the baby. The consensus statement emphasized that caregivers can use the same drugs they typically give to a nonpregnant patient who has a cardiac arrest. The best thing you can do for baby is to provide the mom the best possible care and not withhold any drugs or procedures that would normally be used managing a critically ill person.

The key word here is person.  What justification would there ever be to intentionally withhold treatment from a critically ill person whose life could be preserved?  If pregnant women were truly viewed as people, no one–not Carvalho, not anyone–would ever have to make this statement.

Lies, Damned Lies, and Cesareans

There has been renewed interest in cesareans in the news (and on this blog) since the release of the ACOG/SMFM consensus statement on preventing primary cesareans in March.  When all health care providers are following best practices, rates of procedures should be relatively similar in patients with similar risk profiles.  This is not so for cesareans, where rates of the procedure in low risk births (singleton, cephalic fetus at term; woman with no health complications) can range from less than 5% to nearly 60% depending on the hospital.

Recently the Contra Costa Times ran a story about the issue in which they quoted Dr. Kirsten Salmeen (whose research interests indicate that she is interested in shared decision making models).  Here is the section of the story in which she comments on practice variation:

Why such profound variations? Should our standards of medical practice be so flexible?

The answer is “complicated” replies Dr. Kirsten Salmeen of the Maternal Fetal Medicine Division at UC San Francisco. She thinks variations in cesarean rates across the country are “likely due to a combination of factors.” That includes differences in patient populations and preferences, provider availability and coverage, hospital and provider culture, access to anesthesia and surgical obstetric services, and the prevailing medico-legal climate.

For example, Salmeen proposed that a difference in rate might depend upon the scope of available obstetrical services. In a hospital staffed with 24/7 obstetric coverage and resourced to provide a C-section when needed, a woman might be allowed more time for labor with a vaginal delivery. In contrast, that may not be as feasible with a solo or small-group provider who’d have to cancel scheduled clinic appointments with many patients in order to wait upon one patient’s labor.

While resource allocation can affect cesareans, in many countries, scant resources mean that women cannot get cesareans that they do need, which is one reason infant and maternal mortality rates are so high in developing nations where hospitals are not universally accessible by birthing women.  It seems preposterous that a lack of resources would lead to more cesareans–it’s how those resources are allocated.

The more important question in terms of shared decision making and informed consent is what women are told when a doctor performs a cesarean.  Are they given the real reasons as outlined by Dr. Salmeen:

• Does an obstetrician in solo practice say, “Your labor is normal and you and the baby are doing fine but it looks like your birth is going to take several more hours, and I have patients waiting at the office, so is it okay if I just do a cesarean?”
• Or perhaps in a state with high malpractice claims, the obstetrician says, “Your labor is normal and you and the baby are doing fine, but you had a brief indeterminate fetal heart rate tracing, and if your baby isn’t perfect, you could use that to sue me, so is it okay if I just do a cesarean?”
• Or perhaps the obstetrician says, “Our culture here at this hospital is to do cesareans on women who don’t really need them, so let’s schedule yours now.”

Somehow, I think not.  Here is a video, intended to be humorous, in which the “OB” convinces a woman to have a cesarean, which “will be way easier” for him:

 

Unfortunately, the kinds of things the actor says are often not that far from things some obstetricians say in real life.

As Dr. Elliott Main (a generally great guy) points out, a doctor can convince pretty much any woman to have a cesarean.  Few women will refuse when a doctor tells them their baby is in danger.

That’s a much easier sell than needing to get back to the office.

 

VBAC vs. Forced Cesarean: Facts, Opinion, and Informed Consent

Rinat Dray was forced to have a cesarean in 2011 at Staten Island University Hospital.  Dray had two previous cesareans and chose a doctor who said he supported her desire for a VBAC and a hospital with (by American standards) a low cesarean rate and a good VBAC rate.  But once she arrived at the hospital in labor, according to Dray (as reported by the New York Times),

The doctor told her the baby would be in peril and her uterus would rupture if she did not [have a cesarean]; he told her that she would be committing the equivalent of child abuse and that her baby would be taken away from her.

She still refused the cesarean, and she was supported in her refusal by her husband and her mother.  The hospital strapped her down and wheeled her into surgery as she begged them to stop.  A note in her medical record by Dr. James Ducey says, “I have decided to override her refusal to have a C-section.”  During the surgery, the doctor punctured her bladder.  You can hear a podcast on RH Reality Check in which Dray discusses her case along with professionals in obstetrics, law, and ethics.

Dray is a Hasidic Jew, which likely means that she wants a large family.  While there are risks to vaginal birth after cesarean, in most cases there are even greater risks to having many cesareans.

In the podcast, Dr. Katharine Morrison, MD, FACOG (Director of Buffalo WomenServices, which I wrote about here) says that she reviewed the record and it did not appear that there was an emergency situation or that a cesarean was needed at all.  But even if a cesarean has appeared necessary to preserve the life or health of Dray or her baby, as Dr. Howard Minkoff, chairman of obstetrics at Maimonides Medical Center in Brooklyn, said in the NYT article, “I don’t have a right to put a knife in your belly ever.”

One would think that a case in which a psychologically stable woman refused surgery and was then strapped down, sliced open, and had her bladder perforated would be apparent to anyone as a horrendous breach of human rights.  (And actually, she was asking them to wait a little longer, not saying she would not agree if she felt a cesarean was truly necessary).

All one has to do to see where a woman falls in the human rights spectrum of many is to read the comments on the New York Times piece.

The comments fall into a number of categories, including some that unequivocally support Dray.

Many, however, unequivocally support the the doctors or the profession of obstetrics.  Here is Northstar5:

If this woman had 2 prior C-sections then the doctors are absolutely right that vaginal delivery was exceedingly risky. I almost laughed when I read that the woman is charging the doctors and hospital for “improperly substituting their judgment for that of the mother.” What?? That’s what they are supposed to do. They are doctors, she is not.

Some defend the doctors doing whatever they like to avoid risks of malpractice:

Attempting a vaginal birth after two c-sections is extremely dangerous and reckless. The physicians involved would likely have been sued regardless of the method of delivery, so I applaud them for at least saving a life in this case.

I’m not sure where the commenters get their medical information, but the doctor agreed in advance to attend Dray at a vaginal birth.  You can read the entire American College of Obstetricans and Gynecologists’ practice statement “Vaginal Birth After Previous Cesarean Delivery,” which specifically says, “women with two previous low transverse cesarean deliveries may be candidates for TOLAC [trial of labor after cesarean].”  I highly recommend that you visit Jennifer Kamel’s website VBACFacts.com and read “13 Myths about VBAC.”  Repeat cesarean and VBAC both have risks.  The newest ACOG obstetric care consensus statement on cesarean points out the risks of cesarean over vaginal birth.  Cesarean nearly quadruples the risk of maternal death, and risks of maternal morbidity and mortality go up with every cesarean.  This would be a particular concern for a woman who wanted a very large family, as many Hasidic women do.  Here is a consent form that clearly lays out the risks and benefits of repeat cesarean and VBAC.

Some commenters are completely on the side of the fetus–if the mother’s status is reduced to that of a container, so be it.  Here’s NYC Commuter:

In this case, the hospital and doctors have not one patient, but two. One is an adult who appears competent to make medical decisions. The other is a fetus, at term, who has no voice. The courts have repeatedly affirmed that the state has a duty to protect citizens that cannot protect themselves. If a fetus is believed to be “alive,” then an argument can be made that it must be protected as well. Pregnant women have been forced to receive imprisoned to prevent them from harming their fetuses (e.g. drug abusers), take medication (e.g. for treatable diseases), and even receive c-sections if the baby’s life is judged to be in direct jeopardy.

I have written about the ethics of privileging the well-being of a fetus over an adult woman many times, including here, here, and here.  ACOG also agrees that a woman should have the right to make her own decisions, even if it may negatively impact the fetus.  One recommendation from ACOG’s Committee Opinion, “Maternal Decision Making, Ethics, and the Law” says,

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.

In addition to wanting to protect the rights of physicians and fetuses over those of pregnant women, many commenters simply condemn Dray as selfish, selfish, selfish.  Here’s Beth Green:

What an incredibly selfish woman putting her unborn child in harms way. She got her several hours of trial-labor and no baby, so according to the standard of care she got a C-section and a healthy baby.

Some also posit that Dray is not only selfish but also psychologically compromised.  Here’s Dave:

This case is not about the “debate over C-sections.” This case is mostly about psychopathology, but there is a larger point. Rinat Dray’s actions harm us all. In her narcissism, she was willing to sacrifice her child to maintain her sense of control. This bears repeating – we are dealing with someone who would rather her child suffer than allow a section. So I’m sure she cannot put herself in the place of others, and she will not understand this, but she makes it all the more difficult to deliver babies in the US. Once all the OB/GYNs suffer these indignities and these lawsuits from those with personality disorders, who will deliver babies safely?

And here’s Reader:

A mother in labor who focuses more on her joy of delivery rather than trying to ensure that she delivers a healthy child who could be stuck with birth defects for up to an average of 7-8 decades thereafter is not rational, is selfish and needs to have her head examined.

What we get above all else if the “all that matters is a healthy baby” trope.  Here is NMY:

I have absolutely no sympathy for this woman at all. Her sense of entitlement is simply galling. She’s having a baby. The most important thing here is to ensure the delivery of a healthy baby, not to satisfy some preconceived notion that she should have a vaginal delivery.

Here’s Jen:

The OBGYNs can’t win. Now they are going to get sued for performing c-sections. It used to be they got sued for not doing the section soon enough. This lawsuit is absolutely ridiculous and I hope the physicians win. Do you want a c-section and a healthy baby or a VBAC and a dead baby? How can any mother refuse a c-section when the physician is telling you the health of your baby is at risk?

Here’s Stephen:

Sorry, but the health of the fetus should trump the intellectual desires of the mother….There are too many C-sections performed to be sure, but isn’t the point of labor and birth to deliver a healthy baby?

Here’s Lynn in DC:

She had this child in 2011 and all of her children are healthy so what’s the big harm here?

Aside from the fallacy of believing that Ms. Dray could not have both a respectful vaginal birth AND a healthy baby, a healthy baby is not all that matters.  A healthy mother matters too.  As in Ms. Dray’s case, having a perforated bladder and the trauma of being strapped down for a surgery that she actively refused did not result in a healthy mother.  Not being dead is not good enough.

 

 

 

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?

Legally Human–and Pregnant

Wisconsin has the dubious distinction of being one of three states (along with Minnesota and South Dakota) that allow civil commitment of pregnant women for mental health and substance abuse treatment (you can find your state’s policies here).  In an ironic twist, it is very hard for pregnant women to voluntarily enroll in appropriate substance abuse treatment–many programs will not accept pregnant women, and specialized programs are few and far between (and often have no room).  Only four states prohibit discrimination against pregnant women seeking treatment in publicly funded programs–none of them are states that allow civil commitment.  So when the state of Wisconsin forced 28 year old Alicia Beltran into substance abuse treatment under the “cocaine mom act”–even though she was not abusing any substances at the time–she was held for 78 days in a treatment center, received no medical care, and was forced to take a drug that helps people withdraw from their drug of abuse–even though she had already finished withdrawing from Percocet before entering treatment (verified by drug tests).  She was also not allowed to have a lawyer to represent her at her commitment hearing (she requested one), but the court appointed representation for her fetus.

People in Wisconsin also took notice of the case of Marlise Munoz in Texas. Munoz’s body was kept artificially alive after she was declared brain dead (which is the clinical definition of dead) so that she could incubate her fetus against her previously stated wishes and the wishes of her family.  A judge finally ruled that a law stating that life support could not be withdrawn from a pregnant woman, regardless of her wishes, did not apply in Munoz’s case because Munoz was already dead.    

Understandably, some in Wisconsin are concerned that pregnant people are not being accorded the same human rights as other people.  As a result, three new bills are being introduced, the “Pregnancy Protection Package,” sponsored by Rep. Chris Taylor, D-Madison and Rep. Terese Berceau, D-Madison (as reported here):

• Assembly Bill 860 ensures pregnant women who have allegedly used drugs have the right to an attorney before being detained.
• Assembly Bill 861 requires a pregnant woman’s advanced medical directives to be respected, just like any other patient’s.
• Assembly Joint Resolution 111, affirms that “pregnant women be afforded all the rights of non-pregnant people.”

Here is a part of ACOG’s Committee Opinion on substance abuse and pregnancy:

Seeking obstetric–gynecologic care should not expose a woman to criminal or civil penalties, such as incarceration, involuntary commitment, loss of custody of her children, or loss of housing. These approaches treat addiction as a moral failing. Addiction is a chronic, relapsing biological and behavioral disorder with genetic components. The disease of substance addiction is subject to medical and behavioral management in the same fashion as hypertension and diabetes. Substance abuse reporting during pregnancy may dissuade women from seeking prenatal care and may unjustly single out the most vulnerable, particularly women with low incomes and women of color. Although the type of drug may differ, individuals from all races and socioeconomic strata have similar rates of substance abuse and addiction.

Many people would love to have mental health or substance abuse treatment, but cannot get it.  In other cases, people who are a genuine danger to themselves or others cannot be committed to treatment involuntarily.  Pete Early’s book Crazy details his agonizing quest to get treatment for his young adult son, who was delusional and ultimately broke into someone’s home and was criminally prosecuted.  Early points out that not allowing family members or qualified medical professionals to mandate treatment for the severely mentally ill means that we populate our jails with people who are in desperate need of treatment.  They do not get better in jail, where one psychiatrist is generally responsible for hundreds of severely mentally ill prisoners.

The concern for receipt of mental health treatment for pregnant women generally has nothing to do with the health or well being of the woman.  In the case of Bei Bei Shuai, pregnant and depressed, Shuai’s suicide attempt led not to mental health treatment, but to 435 days in jail and a trial for murder (the baby was born alive by cesarean but died two days later).  It is also notable that fetal protection laws directed against pregnant women are unlikely to help the fetus either — as Beltran noted, she spend her entire 78 days in “treatment” with no prenatal care.  Inadequate prenatal care is a known risk factor for poor pregnancy outcomes for the baby as well as the woman.

Rather than criminalizing pregnant women for legal behavior or criminalizing health conditions only for pregnant women, perhaps we should make sure that all people have access to needed health care, including care for mental health and substance abuse.  And perhaps we should make sure pregnant women have at least as much right to consent and refusal for treatment as people who are actively hallucinating.  And perhaps we should recognize that if we are going to allow for anyone to have advance directives, it is not acceptable to say that pregnant women have no say over their own bodies if the state wants to use those bodies as incubators.

What does it say about our attitude toward the humanity of women that we have to generate laws that say that ordinary human rights extend to them whether they are pregnant or not?

Time, Money, and Vaginal Birth

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:

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:

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:

• “Well she pushed for over two hours, I would have just sectioned her.”– OB  who was not caring for the mother during labor, after learning of the mother’s vaginal birth. 
• “But then we’ll be here ALL DAY!” – OB, with wild flinging of arms into the air,  in response to the suggestion that breaking the bag of water be delayed until a mother being induced  continued to dilate more then the current 2 CM of dilation she was at.
• “You can’t pay me enough to sit here waiting for you to deliver to make up the time lost with my children.” –OB commenting on Twitter.
• “You’ll have to be pushing by 1, I have some place to be at 2 this afternoon.” –OB to woman on Pitocin induction who was also having her membranes ruptured at 2cm dilation.

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.

A Little Light Reading

I am away for a bit and leave the following to stimulate your mind and feminist sensibilities in my absence:

Updates on Marlise Munoz (see Living Wills are Not for Incubators)

• from the New York Times
• from the UK edition of the Huffington Post
• from Salon
• from RH Reality Check

Recent Thoughts on enforcing the Contraceptive Mandate (see Contraception and Forced Pregnancy and Reproductive Health, Undue Burden, and the Church of the Holy Cinder Block)

• from Ruth Marcus at the Washington Post
• from Salon
• from RH Reality Check

New Abortion Restrictions (see Questions from Priests for Life and “Hard’ Questions about Abortion)

• from Feministing (with map)
• from the Washington Post (with chart)
• from Salon

 

Procrustean Obstetrics: Narrowing the Range of Normalcy

Procrustes took in lodgers on the road to Athens, but they had to fit his proffered bed.  If the prospective lodgers were too short, he stretched them, and if they were too tall, he cut as many inches as necessary from their legs. As a result, according to Encyclopedia Brittanica, “The ‘bed of Procrustes,’ or ‘Procrustean bed,’ has become proverbial for arbitrarily—and perhaps ruthlessly—forcing someone or something to fit into an unnatural scheme or pattern.”

Enter American Obstetrics.

Human beings generally are within  a range of normalcy.  As such, we do not expect everyone to be exactly the same height or weight.  We don’t say that everyone should have exactly the same blood sugar reading, and we accept a range of blood pressure readings as healthy.  A woman could be 5 feet or 6 feet tall–we might think that one woman was short and the other tall, but we probably wouldn’t consider either to be abnormal–certainly not to the point that we would medically intervene to change her.  There is an average, to be sure, but there is a range around that average that is considered “normal.”

But that range, in the mind of an obstetrician, may become very, very small.

A friend of mine, pregnant with twins, had one twin who was substantially smaller than the other.  As the pregnancy came close to 36 weeks gestation, the OB ran some tests to see if the smaller twin was suffering from intrauterine growth restriction.  The numbers came back within the normal range, but the doctor didn’t like them because they were on the low side of normal.  She told my friend that a cesarean was necessary, and as a result, the larger twin, not ready to be born, spent a week in the NICU with respiratory problems.

The length of a normal, healthy pregnancy can vary by as much as 5 weeks, but new definitions recommended by the American College of Obstetricians and Gynecologists (ACOG) have narrowed the definition of  normal gestation to a 2 week window.  Only babies born at 39-41 weeks are “term”:

Recommended Classification of Deliveries From 37 Weeks of Gestation

• Early term: 37 0/7 weeks through 38 6/7 weeks
• Full term: 39 0/7 weeks through 40 6/7 weeks
• Late term: 41 0/7 weeks through 41 6/7 weeks
• Postterm: 42 0/7 weeks and beyond

As Linda Hunter observes, accurately calculating a due date from the first day of the last menstrual period (LMP)  depends on “the woman’s accurate recall of her LMP; the regularity of her cycles; the presence of early or light bleeding; and other factors, such as oral contraceptive use or breastfeeding that could influence ovulation timing.  There can also be some variation in the actual timing of ovulation, even in the presence of a seemingly normal 28-day menstrual cycle.”  And many women do not have 28 day cycles, though the due date is generally calculated the same way regardless.

Ultrasound screening is generally more accurate at estimating gestational age than using the LMP, but this method also has limits.  Hunter reminds us that screening is only reliably accurate if done in the first trimester.  In addition, she says, “Ultrasound’s accuracy depends greatly on the skill of the person performing the examination and the quality of the images, not to mention the size of the patient and the fetal position.”  She notes that ultrasound dating is useful because many women’s due dates are estimated too early under the LMP method, and thus many women undergo unnecessary inductions for “postdate” pregnancies (late term or post term, according to the new definitions) that are actually still well within the “term” range.

Even within the two week window, many OBs push for induction as soon as a woman reaches 39 weeks.  The average pregnancy length has become shorter and the range of gestational age at birth narrower as induction has more frequently been used to force women’s bodies to conform to obstetrical definitions of term.  In the past decade, the average length of pregnancy has decreased from 40 to 39 weeks, in part because of scheduled inductions and cesareans to make women’s pregnancies fit an increasingly narrow definition of “normal.”

Perhaps the most egregious narrowing of the normal window comes from Friedman’s curve.  Friedman observed the labors of women in the 1950s, and came up with a”normal” trajectory for a labor to progress (click to enlarge):

As Rebecca Dekker at Evidence Based Birth explains, Friedman’s curve is now obsolete.  Women are no longer heavily sedated in labor.  Their size is different, their nutrition is different, their lifestyles are different, and most women labor much longer now than they did during the time of Friedman’s observations.  Here is a graph that shows Friedman’s curve against the typical labors of contemporary women (click to enlarge):

Despite the historical changes, many OBs cling to Friedman’s curve as the definition of “normal” labor, and give women Pitocin and other drugs to try to make an uncomplicated labor conform to Friedman’s curve.  If the woman’s body still does not conform, she may wind up with a cesarean for “failure to progress,” even though her labor was progressing fine.

A debate has now arisen over diagnosis of gestational diabetes (and I’m sure this debate will continue).  New standards proposed would lead to nearly 20% of pregnant women being diagnosed with gestational diabetes.  Although the NIH issued a consensus statement that the old standards should remain for now, some doctors are now concerned by blood sugar readings that were considered perfectly normal by everyone just a few years ago.  It should be noted that women experience many negative effects with a diagnosis of gestational diabetes, including “constant worry and anxiety over their baby, self-blame and guilt, and more medicalization throughout the prenatal care and delivery,” all of which, like gestational diabetes itself, can lead to negative health consequences.

The narrowing range of obstetric normalcy mirrors other areas in which women are expected to conform to a narrow standard–and literally to cut their bodies to conform:

There are many ways to be a human being and to grow one.  In the words of Dr. Anne Marie Jukic,

[N]atural variability may be greater than we have previously thought, and if that is true, clinicians may want to keep that in mind when trying to decide whether to intervene on a pregnancy.

Women do not need to be cut open because their bodies do not follow a line on a graph.  They do not need to be shamed and blamed for numbers a doctor doesn’t like.  They do not need to be given medications to force their functions to fit a preconceived idea of what is normal.  Perhaps instead someone could observe the woman and her fetus and see if both appeared to be healthy and developing well, and intervene only when an actual problem arose.

Fitting into a Procrustean version of obstetrics that dictates increasingly narrow ranges of normal does not benefit women or babies–and rejecting such a model would allow more women to emerge from pregnancy and birth physically and psychologically intact.