Research, Change, and the Fallacy of VBAC Bans

It is often noted that change takes time, specifically that it takes about 17 years for research findings to be consistently adopted as practice.  We see that issue frequently in obstetrics, where it often takes longer.  For instance, even though high quality research has shown for more than 20 years that routine episiotomies cause the very tears they were initially hypothesized to prevent, in many hospitals, episiotomy rates remain above 30%, with rates at some institutions being much higher (read more on episiotomy here).

In considering VBAC, however, we can see that change can occur almost instantaneously–in one direction.  The American College of Obstetricians and Gynecologists (ACOG) began recommending restricted use of episiotomy in 2006–more than a decade after research showed the risks of routine use–and many practitioners still aren’t on board.  But when ACOG changed its recommendations regarding vaginal birth after cesarean (VBAC), the practice came to a screeching halt.

ACOG has offered a series of recomendations on VBACs, beginning with Committee Opinions in 1988 and 1994, with Practice Bulletins following in 1995 (#1), 1998 (#2), 1999 (#5), 2004 (#54), and 2010 (#115).  Dr. Hilary Gerber put together an excellent slide show explaining the changes in each set of recommendations, which you can view here.

For most of the twentieth century, when lifesaving cesareans became a real option in hospital births, the common wisdom was “once a cesarean, always a cesarean,” a statement made professionally in 1916 at the New York Association of Obstetricians & Gynecologists.  However, for the next 60 years, cesareans were so rare to begin with that the number of women undergoing repeat procedures was small.  The overall cesarean rate in 1965 was under 5%.  As primary cesareans became more common in the late 1970s and through the 80s, more and more women also underwent repeat cesareans, and by 1990 the overall c-section rate was almost 23%.  At the same time, surgical techniques advanced to make VBACs safer, and in 1990 about 20% of women who had a prior cesarean had a VBAC.

In 1994, ACOG issued a Committee Opinion that said that in the absence of contraindications (primarily classical incision in prior cesarean), women should be encouraged to undergo trial of labor after cesarean (TOLAC) rather than automatically being scheduled for a repeat cesarean.  We know now that most women, especially those with only one prior cesarean, are good candidates for VBAC, and it is estimated that 70% of women undergoing TOLAC can have successful VBACs, but the next year, the VBAC rate was only 27%.  While this was definitely an increase, it hardly indicated that all of the most appropriate candidates for TOLAC were actually going into labor.  The VBAC rate peaked in 1996 at 28.3% and then began to decrease, driven by an article by Michael McMahon et al that linked TOLAC to an increase in maternal complications.

In 1999, ACOG released new, more restrictive recommendations, in part as a response to the McMahon article.  Chief among the changes was what became known as the “immediately available standard”:

VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.

This recommendation was Level C evidence, meaning it was based on clinical opinion, not research trials.  Level A evidence, the level with the highest quality research to back it, still stated in the same bulletin that most women with prior cesareans were good candidates for TOLAC.

The problem with the immediately available standard is that most smaller hospitals can’t meet it.  They may not have an anesthesiologist in house 24/7 or enough OBs that there is necessarily one standing by on the ward, ready to perform surgery.  Even large hospitals may not meet this standard if they cannot guarantee that the available doctors will not be busy with other patients.  The standard was not specifically defined, and rather than be concerned that they weren’t meeting it, many hospitals simply stopped offering TOLACs, requiring patients who had previous cesareans to schedule a repeat surgery.

Here’s what happened:

The line that ends at the top is the overall cesarean rate.  The line that ends in the middle is the primary cesarean rate, and the line that ends at the bottom is the VBAC rate.  In the mid 1990s, the VBAC rate was higher than the overall cesarean rate, but within a year of the 1999 guidelines, VBAC rates were down to what they had been in 1993, the year before less restrictive guidelines were initially recommended.  But it didn’t stop there.  The rate just kept decreasing.

in 2010, ACOG again issued less restrictive guidelines for VBAC.  Dr. Richard Waldman, ACOG’s president at the time, said,

Given the onerous medical liability climate for ob-gyns, interpretation of ACOG’s earlier guidelines led many hospitals to discontinue VBACs altogether. Our primary goal is to promote the safest environment for labor and delivery, not to restrict women’s access to VBAC.

The new guidelines stated not only that most women with a prior cesarean were good candidates for VBAC, but that many women with two prior cesareans were as well.

Here’s what happened:

The rates rose a tiny amount, and remain about half of what they were in 1990.

In 2014, AGOC issued a consensus statement about preventing primary cesareans.  This publication pointed out some of the risks of cesarean over vaginal birth, including a tripling of risk of maternal death.  While some hospitals and doctors have gradually become more receptive to VBAC and have lifted out-and-out bans, some hospitals have instituted new bans since the 2010 and 2014 guidelines were released.

Many providers do not support VBAC and do not present benefits and risks in a way that allows women to make informed decisions.  The website My OB Said What? is full of quotes from doctors misrepresenting VBAC risks:

Attempting a VBAC is comparable in risk to standing your older child out in the middle of a busy highway and hoping she doesn’t get hit by a semi. Maybe the odds of her being hit are low, but you wouldn’t take that risk with your other child, so I don’t understand why you’re willing to risk your unborn baby’s life.

I don’t know where you got the *delusion* that you could VBAC, there was a law that was passed against VBAC’ing after more than one cesarean.

A VBAC is like *jumping off a bridge* in which mortality is close to 90% with a uterine rupture!

When citing risk of “uterine rupture,” many physicians include scar separation in the totals.  Just to clarify, there is a difference between genuine uterine rupture, which is a genuine emergency, and a cesarean scar opening, which is not:

In contrast to frank uterine rupture, uterine scar dehiscence involves the disruption and separation of a preexisting uterine scar. Uterine scar dehiscence is a more common event than uterine rupture and seldom results in major maternal or fetal complications.

So let’s review:

• When VBACs were recommended as safe in 1994, the rate slowly crept up, reaching over 28% in 1996.
• The rate began to go down in 1997 in response to a single article, even before recommendations were issued by ACOG.
• When the “immediately available” standard was introduced in 1999, the rate plunged to its pre-1994 level within a year.
• 10 years after the “immediately available” standard (level C) was introduced, the rate was 8.4%, even though the Level A recommendations still said that most women were good candidates for TOLAC.
• Two years after less restrictive standards were introduced in 2010, the VBAC rate had inched up less than 2 percentage points, to 10.2%.  Many hospitals have continued their de facto VBAC bans, some hospitals have introduced new bans, and many physicians still refuse to perform VBACs.

The problem is (as others have also pointed out), why are hospitals not ready to perform an emergency cesarean?  Isn’t that the whole reason to birth in a hospital–that they are prepared for emergencies?  Uterine rupture is not unique to VBAC–it can happen as a result of  any number of complications, including labor inductions.  A hospital that is not equipped to support a TOLAC is not set up to support birth emergencies.

VBACfacts.com has a list of VBAC myths and corresponding correct information.  here is my favorite:

Myth:  If your hospital doesn’t offer VBAC, you have to have a repeat cesarean.

As Howard Minkoff MD said at the 2010 NIH VBAC Conference, “Autonomy is an unrestricted negative right which means a woman, a person, anybody, has a right to refuse any surgery at any time.” ACOG affirms that “restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will.”

If your hospital does not support VBAC, ask them why they are not properly equipped and staffed to perform emergency cesareans.  Then go elsewhere.

 

Avoid an Unnecesarean

It would be hard to find anyone who doesn’t think the cesarean rate is too high.  The World Health Organization says that a 15% rate “is not a target to be achieved but rather a threshold not to be exceeded.”  Healthy People 2020 goals (see section MICH-7) target reductions in primary cesareans and increases in vaginal birth after cesarean (VBAC) as two primary goals in maternity care. In some situations, the benefits of a cesarean far outweigh the risks, but when the surgery is not needed, it has the small but significant potential to cause severe complications for the woman and her baby, and also affects the woman’s subsequent pregnancies.

Cesareans have many advantages for doctors.  The payment for attending a cesarean is equal to or greater than attending a vaginal birth.  While even a fast vaginal birth generally takes at least several hours from the time the woman arrives at the hospital,  performing a cesarean takes about an hour.  Cesareans are not risk-free, but the outcomes are predictable.  And scheduling a cesarean is particularly lucrative and convenient for doctors because they can avoid conflicts with office hours and family/leisure time.

Dr. Jonathan Weinstein of Frisco Women’s Health, whose cesarean rate is under 15%, offers the helpful list, Top Ten Signs Your Doctor is Planning to Perform an Unnecessary Cesarean Section on You:

1. Arrives to L&D immediately after office hours and says, “I just don’t think this baby is going to fit”
2. Third Trimester, Routine Office Visit, “I think this is going to be a big baby you should just have a C/S” – Did you know? ACOG has very specific guidelines for when it is appropriate to offer a patient an elective C/S for MACROSOMIA (fancy word for large baby). ‘Prophylactic (elective) cesarean delivery may be considered for suspected fetal macrosomia with estimated fetal weights greater than 5,000 gms (11 pounds) in women without diabetes and greater than 4,500 gms (9.9 pounds) in women with diabetes.
3. “We should induce at 39 weeks your baby is getting too big” – Did you know? According to ACOG, ‘Induction of labor at least doubles the risk of cesarean delivery without reducing shoulder dystocia (rare situation where baby’s shoulder can get stuck at delivery) or newborn morbidity(complications). Suspected fetal macrosomia is not an indication for induction of labor, because induction does not improve maternal or fetal outcomes.’
4. Performs routine ultrasounds at end of pregnancy to see how big your baby is. Did you know? Ultrasounds at the end of the pregnancy can be 1-2 pounds off. Ask some VBAC patients who were talked into a C/S for this, then had a vaginal delivery of a bigger baby the next time.
5. “You have a positive herpes titer (or history of herpes); the baby will get it if you deliver vaginally.” Try some Valtrex for the last month of the pregnancy that is pretty much standard of care now. It prevents outbreaks and allows for a normal vaginal delivery.
6. “Your baby is breech you need to have a C/S” Ever heard of or performed an External Cephalic Version? It really does work.
7. “You have pushed for 2 hours” (with an epidural that prevents you from feeling anything so you are probably not pushing effectively; this is evident on exam because the baby’s head is still perfectly round, but you do not need to know that) it’s just not going to come out.”
8. “I scheduled you for an induction at 39 weeks, it is just soooo… much more convenient for you!” (and so much higher risk of ending in a C/S, especially if you are not dilated when you start the induction). At least 80% of my VBAC patients were induced the previous pregnancy. For whose convenience was the induction?
9. First Visit (7 weeks), “Congratulations you are having twins. I will go ahead and schedule your C/S at 38 weeks, but don’t worry if you go in to labor early I will cut you right away!” Translation, “I am scared out of my mind for you to deliver your babies vaginally because I am not trained on what to do when the second baby is coming, plus it pays more to cut you open. Oh yeah, I don’t have that great a rapport with you because I only spend 2 minutes (fundal height, heart beat and ‘I’ll see you next time’) with you each visit, so I am afraid I will be sued for trying to do the right thing.” (note from Human with Uterus: planned cesarean for twins is not evidence based.)
10. First Pelvic Exam in Office (7 weeks), “Hmm, your pelvis is pretty narrow”
11. Bonus Tip: 38-week visit, “Your blood pressure is a little up today you are probably developing preeclampsia or toxemia. That can cause you to have a SEIZURE! The treatment is to deliver the baby. You need a Cesarean Section this is the quickest way to resolve it. Let’s get you up to L&D NOW!” Translation – Preeclampsia or Pregnancy Induced High Blood Pressure is a pain in the butt. If I induce you, it could take 24 hours or more and then I would have to manage your blood pressure, and put you on Magnesium. This is way too inconvenient. Do not worry you can try to have the baby vaginally next time. Yeah right!

For more information on cesarean/induction for “big baby,” see this post from Evidence Based Birth.

Despite reports that cesareans are performed at maternal request, only about 1% of primary cesareans were requested by the woman.  As a woman cannot perform a cesarean on herself, the skyrocketing rate must be driven by providers.  Providers also say that high cesarean rates are driven by liability concerns. A connection between liability environments and cesarean rates exists, but the effects are small.  A natural experiment in Texas, which underwent tort reform, showed that reductions in liability did not lead to corresponding changes in cesarean rates–cesarean rates went up at roughly the same rate as they did in the rest of the country.  Texas cesarean rates are currently 35.3%, higher than the national average.

We might also generally question the ethics of performing a surgery that is in the best interest of the doctor, not the woman and her child.  When a doctor recommends a risky procedure such as major abdominal surgery, women should always ask for references to evidence (meaning documents they can read, not off-the-cuff statistics).  A woman’s care should be a process of shared decision making, not following someone else’s orders.  A woman’s humanity demands nothing less.

Cesareans Are Us: Mississippi

I am a big fan of Jill Arnold’s cesareanrates.com, and I encourage you to visit.  Here is Jill’s report on Mississippi cesarean rates.

River Oaks Hospital, which is just outside of Jackson, has the highest cesarean rate in the state of Mississippi:  57.2%.  Just for reference, the national rate is 32.8%,  the average for Mississippi is 38.3%, and the World Heath Organization says that 15% is a “threshold not to be exceeded” because maternal and infant health do not improve when rates rise higher.  To be fair, River Oaks handles many high risk cases from around the state, but the WHO threshold is supposed to cover even high risk populations.  A rate nearly four times the maximum threshold seems excessive.

According to March of Dimes Peristats, the VBAC rate in Hinds County (where River Oaks is located) was 4.3% in 2010, meaning that among women who have already had at least one cesarean, only 4.3% who had another baby in 2010 birthed vaginally.  According to the Jackson chapter of the International Cesarean Awareness Network, River Oaks does “allow” VBAC, though there were fewer than 200 VBACs in the entire state in 2010.

So let’s look at what happens at River Oaks.  The homepage for their Labor and Delivery Center features three links: planning a pregnancy, healthful pregnancy and cesarean.  Hmm….  Here is their list of possible reasons a woman would need a cesarean at their hospital (followed by my commentary):

There are several conditions which may make a cesarean delivery more likely. These include, but are not limited to:

• Abnormal fetal heart rate. The fetal heart rate during labor is a good sign of how well the fetus is handling the contractions of labor. The heart rate is monitored during labor…If the fetal heart rate shows there may be a problem, immediate action can be taken… A cesarean delivery may be necessary.

We know from my past post on Florida that fetal monitoring is not recommended for a normal labor, and that the evidence suggests that fetal monitoring does not lead to better outcomes for infants but does lead to higher cesarean rates.  In normal labors, the best evidence suggests that the baby’s heart rate be monitored by intermittent oscillation (using a hand-held Doppler at regular intervals).

• Abnormal position of the fetus during birth. The normal position for the fetus during birth is head-down, facing the mother’s back. However, sometimes a fetus is not in the right position, making delivery more difficult through the birth canal.

It is true that head down facing back is the most common position and that other positions tend to make births more difficult.  However, according to ACOG committee opinion, a skilled practitioner can deliver some breech babies vaginally (a sideways baby who won’t turn has to be delivered by cesarean).  Unfortunately, many practitioners do not have the skills for safe vaginal breech delivery.   A posterior (“sunny side up”) baby can  be delivered vaginally and does not require unique obstetrical skill.  Breech and posterior babies can often be turned, and posterior babies especially often turn themselves late in pregnancy or during labor, making a planned cesarean  unnecessary.

• Labor that fails to progress or does not progress normally

“Normal labor” has changed.  Many doctors rely on the outdated Friedman’s curve, developed in 1954.  It  does not fit with the  labor progression of contemporary women, who labor under different conditions (e.g. not heavily sedated).  “Active labor” used to be diagnosed at 3 cm of cervical dilation; current thought is a woman should reach 6 cm before being considered in “active labor.” However, many hospitals and many individual physicians still cling to the outdated norms. As women now labor more slowly, this leads to many cesareans for “failure to progress.”

• Baby is too large to be delivered vaginally

The medical term for a large baby is “macrosomia,”  but the condition is often called simply “big baby,” which always sounds to me like the character in Toy Story 3:

Hopefully, most macrosomic babies don’t look like that.  In any case, practice guidelines

do not support prophylactic cesarean delivery for suspected fetal macrosomia with estimated weights of less than 5,000 g (11 lb)

Yes, you read that right.  ELEVEN POUNDS.  Rebecca Dekker at Evidence Based Birth has some great information on macrosomia.

• Placental complications (such as placenta previa, in which the placenta blocks the cervix and presents the risk of becoming detached from the uterus too soon). Premature detachment from the fetus is known as abruption.

Placenta previa is a situation in which cesarean is life saving for women and babies.  Please, if you have have placenta previa, follow your doctor’s advice regarding cesarean (but do not go on bed rest).  Abruption may or may not require cesarean, but it is absolutely reasonable that it be considered.  The placenta, however, separates from the uterine wall, not the fetus.  These people scare me.

• Certain maternal medical conditions (such as diabetes, high blood pressure, or human immunodeficiency virus [HIV] infection)

Sometimes conditions like high blood pressure can mean that the baby needs to be delivered early to preserve the life and health of either the baby or the pregnant woman.  In these cases, an induction can often be tried first.  The choice of induction vs. cesarean for a maternal or fetal medical condition should always be made with the full informed consent of the woman.  I have no idea if that’s the case at River Oaks, but given their cesarean rate, I doubt it.

• Active herpes lesions in the mother’s vagina or cervix

Yes, if the infection is active, cesarean is a good choice.  The chance of herpes transmission to the infant during vaginal delivery is up to 50%.  However, if the woman has been receiving prenatal care, the herpes infection can be treated in advance, which should allow for vaginal delivery in most cases.

• Twins or other multiples

I have posted on vaginal birth vs. cesarean for twin delivery.  A new, high-quality study shows that planned cesarean does not improve outcomes for twins as long as Twin A is head down.  In response, the chief of obstetrics as Mass General wrote an opinion piece saying that doctors should plan cesareans for twins anyway.  That appears to be the River Oaks philosophy.

• Previous cesarean delivery

According to ACOG’s practice bulletin on VBAC, the vast majority of women with one prior cesarean are appropriate candidates for VBAC, as are some women with two prior cesareans.  Probability of successful VBAC ranges from 60-80%.  ACOG says that risks and benefits should be discussed, counseling on VBAC should be documented in the medical record, and the ultimate decision should lie with the woman.  According to the River Oaks website,

A woman may or may not be able to have a vaginal birth with a future pregnancy, called a vaginal birth after cesarean (VBAC). Depending on the type of uterine incision used for the cesarean birth, the scar may not be strong enough to hold together during labor contractions.

Who knows what kind of uterine incisions the docs there are using, because apparently the only way to get a VBAC is to come in pushing and have the baby before they can cut you.

• There may be other reasons for your doctor to recommend a cesarean delivery.

Perhaps it is 4:30 on Friday.

There is more non-evidence-based care featured on their website, including this video featuring babies who bottlefeed and do not room-in with their mothers (fine if that’s what the woman wants, but not a message that promotes best practices).

River Oaks does not appear to be the place to have a baby if you want a vaginal birth and evidence based care.  But you can go make them some money if you want.

Note: this is my second piece on a hospital with the highest cesarean rate within a state.  You can read the post on Florida here.

Performing Surgery for Fun–or Not

On Facebook today, the organization Improving Birth posted this question:

What happens when a mom plans a VBAC with a fully supportive doctor, but then at birth gets an unsupportive doctor who refuses to “perform” a VBAC? Do you think the provider is “forced” to attend a vaginal birth, or is the woman “forced” to have surgery?

I approached this question in my post on rights, so let’s explore it.

Let’s look at the doctor’s side first:

The doctor wants to perform surgery on a woman who doesn’t want surgery.  Her original doctor says it is safe for her to forego the surgery.  Professional guidelines say that forgoing the surgery is perfectly fine as long as some basic conditions are met (and let’s assume they are, since the first doctor agreed the surgery was not necessary and the doctor in question appears not to have reassessed the situation).  Essentially, the doctor is arguing that is is the doctor’s personal preference to perform the surgery, and that the pregnant woman is forcing the doctor not to perform unnecessary surgery.

By this logic, I am forced not to perform surgery on people all day every day.  I am also forced not to do all kinds of other things to them, even if I feel like it.  Even if I am qualified to do things to people, I am “forced” not to do them.  No one has ever let me perform CPR or the Heimlich maneuver or a substance abuse treatment intervention on them just because I felt like it.  And I am qualified to do all of those things and have nifty certificates to prove it.

The doctor feels “forced” to attend a vaginal birth.  But this doctor does not have to ignore practice guidelines.  The doctor does not have to practice obstetrics.  The doctor does not even have to be a doctor.  This doctor could quit and go home.  This doctor could probably even decide to be “sick” and some other doctor would be found.

As for the woman:

She chose a doctor who agreed with standard practice guidelines indicating that she did not need surgery.

Another doctor showed up who apparently wanted to perform surgery whether it was needed or not.

If the doctor refuses to provide care for a vaginal birth, and there is not other doctor available, what choices are available to the woman?  Will the labor and delivery nurses assist her birth?  Can the woman deliver unassisted in the hospital?  Can she leave without signing AMA papers (as she was only refusing the advice of one doctor, but not the advice of her original doctor or of the hospital or of professional guidelines)?  Is there any qualified birth attendant available who can assist?

The woman cannot decide not to be pregnant.  She cannot decide that she will not go into labor and give birth.  She cannot get someone else to do these things for her.  If she goes home, they will still happen.

Is the woman’s choice compromising her life and health and that of her baby by either having an unattended birth or having an unnecessary surgery?  In such a case, it appears that she is forced to make  a bad decision, no matter what she chooses.

The commenters on Improving Birth’s question are champions of the autonomy and agency of women.  Here are a few of their comments–I recommend liking Improving Birth’s page on Facebook:

I think the provider should do his job, or find someone that can. As a mom has a right to decline any procedure that is not medically needed. At that time just because the doctor doesn’t want to do a vbac, does not make a csection medical needed.

Her body, her decision!

What happens when a patient with a cancer diagnosis needs to be seen by another doctor for a day? Or a patient with diabetes? Or someone who is getting occupational therapy for intellectual disability? When the regular provider is temporarily unavailable and a certain treatment plan or protocol has been worked on, all reasonable accommodations should be made to keep to that plan. On-call doctors should not get to say they will not help a mom planning on VBAC continue with her and her primary doctor’s plan.

I don’t think I would want a doctor at my birth who was “forced” to be there. But neither should a woman be “forced” to have unwanted surgery (whether it’s “necessary” or not!). The hospital I believe has an obligation to provide the care that a woman wants – if this doctor is unwilling to attend a vbac then the hospital should be finding one who IS willing to attend. Here in Australia the woman wouldn’t have a doctor there anyhow, unless something went wrong – it would just be midwives.

We have years of case law that competent people can refuse care, and it is an EMTALA violation to deny care to a woman in active labor, even if she is refusing surgery.

Doctors don’t “preform” a VBAC, mother’s give birth. This should not even be an issue, it is sad that it is.

Rights

There has been a lot of discussion in the pregnancy and birth world about the Irish case of Aja Teehan, who wanted to have a homebirth after cesarean (HBAC).  Irish midwives are professionally prohibited from attending homebirths that are considered too risky, and vaginal birth after cesarean (VBAC) risks a woman out of homebirth.

The question posed was whether the woman had the RIGHT to homebirth.  This leads to some interesting questions about rights and whose rights they are.

In pregnancy and birth, there are several interested parties who may or may not have “rights” in various health-related decisions.  These people include the woman, the man who impregnated her, the person who will be raising the child with her, the fetus/infant, and the practitioners providing reproductive health care and medical services.

For instance, there are rights around getting pregnant.  Here we might ask

• Does a woman have the right to get pregnant?
• Does she have the right not to get pregnant?
• Does a practitioner have the right to refuse assisted reproductive technologies to a woman who the practitioner does not want to serve (for instance because she is single or a lesbian, or because she already has several children)?

During pregnancy

• Does a woman have a right to terminate a pregnancy?
• Does a fetus have a right to reside in a woman’s body until its gestation is completed?
• Does a man who has impregnated a woman have a right to demand that she continue the pregnancy?  Or that she not continue the pregnancy?
• Does a woman have the right to continue a pregnancy that will result in a child who will suffer?  What about a child who will present costs to society or the state?
• Does a woman have the right to medical treatment for her own health conditions while pregnant?
• Does a woman have the right to engage in behavior that could potentially harm a fetus she intends to birth?

During labor and birth

• Does a woman have the right to refuse to birth in the way her practitioner thinks best?
• Does a woman have the right to refuse birth interventions a practitioner believes to be optimal?  Does she have the right to refuse interventions that are standard hospital policy?
• Does a practitioner have the right to refuse to attend a woman who will not follow the practitioner’s medical advice?
• Whose rights to life and health should predominate in the birth process: the woman’s or the infant’s?

The links in the questions above are not all-encompassing, but are examples of issues implicit in these questions.  May we always remember that a woman is a human being whether there is a fetus in her uterus or not.

Permission and Punishment

Mothers are often expected to be joyfully self-sacrificing.  When I taught college students, I was perpetually surprised that they saw Shel Silverstein’s book The Giving Tree as a beautiful allegory about the satisfaction that mothers feel in turning themselves from thriving, powerful, productive beings into stumps in order to satisfy the whims of their children.

Pregnancy is a training ground for this.  Pregnant women are expected to give up autonomy as others work in what they feel are the best interests of the fetus.  If women don’t comply, they are punished.

Legal punishment of pregnant women has been extensively documented by National Advocates for Pregnant Women , but the conditioning of women to behave passively and properly often operates in much less formal channels.

Take popular sources of information on pregnancy, birth, and health.  Many discuss what a woman might or might not be allowed to do or what hospitals/health practitioners may or may not let her do.

For instance, a Web MD article on labor says,

“As your contractions get stronger, you may…not be allowed to eat or drink. Some hospitals let you drink clear liquids. Others may only allow you to suck on ice chips or hard candy.”

It is not illegal for a woman to eat or drink while pregnant.  In fact, a Cochrane review on eating and drinking in labor concludes, “women should be free to eat and drink in labour, or not, as they wish.”  So what is the reason for having a hospital policy determine what a laboring woman will be “allowed” to eat or drink?

Another WebMD article provides a list of questions women should ask about labor and delivery.  These include:

• Are showering and bathing allowed during labor?
• Does this birth center/hospital allow water births?
• How many people are allowed to be with me during labor and delivery? How many people are allowed to be with me during a cesarean delivery?
• Are eating and drinking allowed during labor?
• Is video taping allowed?
• Can my partner cut the umbilical cord?

Here’s a quote from the Mayo Clinic’s web article on vaginal birth after cesarean (VBAC):

“It’s also important to keep in mind that some hospitals don’t allow VBACs. Anesthesia must be available at all times in case a C-section becomes necessary, and not all hospitals can afford this luxury. Talk to your health care provider early in your pregnancy to make sure VBACs are allowed where he or she does deliveries.”

What they don’t mention is that is is not legal to force a woman into a cesarean against her will. (And why would anyone give birth in a hospital that was not equipped to do an emergency cesarean?)

Still another WebMD article on labor and delivery says,

“If an emergency arises, your doctor has a responsibility to ensure both your safety and your baby’s safety. You may still be allowed to share in some decisions, but your choices may be limited.”

When does a woman give up her right to make decisions about what happens to her body?  What happens if she chooses to make her own decisions anyway?

Websites also present what health practitioners might or will do to women in labor or giving birth, without presenting these interventions or procedures as things a woman can choose or refuse.

Here’s the Mayo Clinic on amniotomy, which can cause labor to become more intense and painful and raises the chance that the woman or her infant will develop an infection:

“If your health care provider believes the amniotic sac should be opened during active labor — when your cervix is at least partially dilated and the baby’s head is deep in your pelvis — he or she might use a technique known as an amniotomy to rupture the membranes. During the amniotomy, a thin plastic hook is used to make a small opening in the amniotic sac. The procedure might cause some discomfort.”

Nowhere does it say that this should be discussed with the person who will undergo the procedure and face the risks it involves (this is not say there are never good reasons for doing an amniotomy, just that this is not a decision that should be made at the sole discretion of a person not actually getting the amniotomy).

In an article on poor treatment of women during labor and birth, Henci Goer quotes an obstetrician who says in his written materials,

“The decision as to whether and when to perform [a cesarean] is made at my discretion and it is not negotiable, especially when done for fetal concerns.”

ACOG actually has a committee opinion addressing women’s autonomy.  In what I have found typical for ACOG, the official policy is more liberal, flexible, and supportive of women’s autonomy than most actual practice seems to be.  The committee opinion states,

“Efforts to use the legal system to protect the fetus by constraining pregnant women’s decision making or punishing them erode a woman’s basic rights to privacy and bodily integrity and are not justified.”

In reality, when women resist a practitioner’s interventions, question their recommendations, or do not behave in the way the practitioner desires, they are often threatened or punished, both legally and more infomally.

Goer notes, “Women frequently are denied their right to make informed decisions about care and may be punished for attempting to assert their right to refusal. ” One women she interviewed said,

“[The obstetrician]  informed me that IF I got an epidural and IF I made progress over the next two hours, he would let me continue. If not, he would [cesarean] section me stat.”

A medical malpractice site in Illinois documents a case of an obstetrician who felt entitled to punish a birthing woman in a number of ways:

“[Dr.] Pierce, who was filling in for [the plaintiff’s] doctor, arrived at the hospital four hours after she got there, scolded her for not calling first, and wouldn’t give her any pain medicine. He is accused of telling a nurse that the patient deserved to feel pain for failing to let them know that she was coming to the hospital.”  (The physician also forced the woman to birth in an awkward position, told her to shut up, and forced her husband to hold her down while he put in stitches, among other things).

There was this widely documented case:

A woman in New Jersey refused a c-section during labor. She gave birth vaginally, and the child was healthy. But the baby was taken away and placed in a foster home, because the woman allegedly “abused and neglected her child” by refusing the c-section.

Anecdotes abound in mothers’ discussions on various websites. From the What to Expect forums:

“Actually I have had a bad experience with my first child. I brought a birth plan and it seemed like the nurses were punishing me for it! They were super rude and making really mean comments.”

“I have heard stories of people and even read about these things happening in some of the books I have read that OB drs and labor nurses will often be rude and mean to those coming in with birth plans. That nurses will often do things to punish women who come in with birth plans such as constantly bugging them about doing things they said they don’t want to do, messing up IV’s on purpose so it hurts more, insisting on monitoring. My cousin even had a nurse tell her that if she didn’t submit to what the drs and nurses wanted, they would strap her down to the bed, give her a sedative, and report her as mentally unsound so they could hold her baby for 72 hours in the nursery away from her with even the possibility of them being able to take her baby away entirely!”

From Mary-Rose MacColl’s website:

“Some of the women I met had appalling experiences and sometimes chilling stories to tell about contemporary maternity care. Some were punished or abused or neglected by obstetricians or midwives just because they wanted something their carers didn’t like – to hold their babies straight after birth, to save their cord blood, or – like the woman Freedman met at the barbecue – to avoid an injection of synthetic oxytocin to deliver the placenta, or not. “

Pregnant women are human beings who don’t leave their own humanity at the door while they incubate a fetus.  But they may be punished for acting like it.

 

See also: The Pregnancy Outcome Blame Game