Part 5 ~ Ongoing critique ~ 12-17-06

THE SCORE - October 9, 2006
How childbirth went industrial

Read First Web link to THE SCORE

New Study added ~ 11/29 blog reposted on 12-17-2006

I imagine readers (including me) must be tired of my personal story and my personal opinions about the dangers associated with medically unnecessary Cesarean surgery. So I’d like to go back to the New Yorker article and revisit the actual words of Dr Gawande on the topic of Cesarean as the all-purpose cure for everything associated with pregnancy and birth.

After revisiting these assertions in THE SCORE, I have copied excerpts of several recently published studies that, strangely enough, seem to diametrically oppose the lovely fantasy that Cesarean surgery and other obstetrical excesses can lead the way to inexpensive, risk-free, pain-free childbirth.

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“If obstetrics wasn’t to go the way of phrenology or trepanning, it had to come up with a different kind of ingenuity. It had to figure out how to standardize childbirth. And it did.

…. there’s also no getting around C-sections. 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. …… These were the rules of the factory floor.

A measure of how safe Cesareans have become is that there is ferocious but genuine debate about whether a mother in the thirty-ninth week of pregnancy with no special risks should be offered a Cesarean delivery as an alternative to waiting for labor.

The idea seems the worst kind of hubris. How could a Cesarean delivery be considered without even trying a natural one? Surgeons don’t suggest that healthy people should get their appendixes taken out or that artificial hips might be stronger than the standard-issue ones. Our complication rates for even simple procedures remain distressingly high.

Yet in the next decade or so the industrial revolution in obstetrics could make Cesarean delivery consistently safer than the birth process that evolution gave us.

Currently, one out of five hundred babies who are healthy and kicking at thirty-nine weeks dies before or during childbirth—a historically low rate, but obstetricians have reason to believe that scheduled C-sections could avert at least some of these deaths. Many argue that the results for mothers are safe, too.

Scheduled C-sections are certainly far less risky than emergency C-sections—procedures done quickly, in dire circumstances, for mothers and babies already in distress.

One recent American study has raised concerns about the safety of scheduled C-sections, but two studies, one in Britain and one in Israel, actually found scheduled C-sections to have lower maternal mortality than vaginal delivery.

Mothers who undergo planned C-sections may also (though this remains largely speculation) have fewer problems later in life with incontinence and uterine prolapse.”

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OBSTETRICAL AND GYNECOLOGICAL SURVEY
Volume 61, Number 12 2006 CME REVIEW ARTICLE

CHIEF EDITOR’S NOTE: This article is part of a series of continuing education activities in this Journal through which a total of 36 AMA/PRA Category 1 Credits can be earned in 2006.

Public Health Implications of Cesarean on Demand

Lauren A. Plante, MD, MPH Assistant Professor, Obstetrics & Gynecology and Anesthesiology, Thomas Jefferson University, Philadelphia, Pennsylvania

Cesarean rates have been rising in the United States. Recently, there has been an upsurge of interest in “cesarean on maternal request” in the absence of any medical indication, a phenomenon that will further increase the cesarean rate. This trend may not be benign on a population basis, and reliable data are lacking. This article reviews reasons for the increasing cesarean rate, describes maternal and neonatal consequences likely to accrue with a policy of cesarean on demand, and explores larger implications for public health.

Target Audience: Obstetricians & Gynecologists, Family Physicians

Learning Objectives: After completion of this article, the reader should be able to state that there continues to be a rise in the cesarean delivery rate in the United States and summarize that cesarean delivery on maternal request (CDMR) is contributing to this rise without data to indicate a decrease in maternal and fetal mortality and morbidity, possibly with a large population cost.

Synopsis of conclusions of Cesarean-related mortality and morbidity associated with a 5% annual increase in patient requests for non-indicated [medically-unnecessary] Cesarean surgery in the US:

* A total of 14 to 32 more maternal deaths
* A total of 5000 to 24,0000 more surgical complications
* A total of 4000 to 6000 more postoperative infections
* A total of 2200 more postpartum readmissions to the hospital
* A total of 200 to 300 additional venous thromboses [potentially fatal blood clots]
* A total of 33,000 more neonatal intensive care unit admissions
* A total of 8000 more cases of neonatal respiratory complications
* A total of 930,000 more hospital days for women, infant length of stay not calculated
* Between $750 million and $1.7 billion in healthcare expenditures
* Higher rates of hospital occupancy
* Longer waiting times for elective operations of all kinds
* The potential for an overall increase in medical error related to higher hospital
occupancy rates.

Doesn’t this makes you want to run out and have a couple elective Cesareans?

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Postpartum Maternal Mortality and Cesarean Delivery

Catherine Deneux-Tharaux, MD, MPH, Elodie Carmona, MPH, Marie-Hélene Bouvier-Colle, PhD,and Gérard Bréart, MD

OBSTETRICS & GYNECOLOGY VOL. 108, NO. 3, PART 1, SEPTEMBER 2006

OBJECTIVE: A continuous rise in the rate of cesarean delivery has been reported in many countries during the past decades. This trend has prompted the emergence of a controversial debate on the risks and benefits associated with cesarean delivery. Our objective was to provide a valid estimate of the risk of postpartum maternal death directly associated with cesarean as compared with vaginal delivery.

METHODS: A population-based case–control study was designed, with subjects selected from recent nationwide surveys in France. To control for indication bias, maternal deaths due to antenatal morbidities were excluded. For the 5-year study period 1996–2000, 65 cases were included. The control group was selected from the 1998 French National Perinatal Survey and included 10,244 women. Multivariable logistic regression analysis was used to adjust for confounders.

RESULTS: After adjustment for potential confounders, the risk of postpartum death was 3.6 times higher after cesarean than after vaginal delivery (odds ratio 3.64 95% confidence interval 2.15– 6.19).

Both prepartum and intrapartum cesarean delivery were associated with a significantly increased risk.

Cesarean delivery was associated with a significantly increased risk of maternal death from complications of anesthesia, puerperal infection, and venous thromboembolism [potentially fatal blood clots].

The risk of death from postpartum hemorrhage did not differ significantly between vaginal and cesarean deliveries.

CONCLUSION: Cesarean delivery is associated with an increased risk of postpartum maternal death. Knowledge of the causes of death associated with this excess risk informs contemporary discussion about cesarean delivery on request and should inform preventive strategies. (Obstet Gynecol 2006;108:541–8)

LEVEL OF EVIDENCE: II-2

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Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America

José Villar et al; for the WHO 2005 global survey on maternal and perinatal health research group* www.thelancet.com Published online May 23, 2006

Summary

Background Caesarean delivery rates continue to increase worldwide. Our aim was to assess the association between caesarean delivery and pregnancy outcome at the institutional level, adjusting for the pregnant population and institutional characteristics.

Methods: For the 2005 WHO global survey on maternal and perinatal health, we assessed a multistage stratified sample, comprising 24 geographic regions in eight countries in Latin America. We obtained individual data for all women admitted for delivery over 3 months to 120 institutions randomly selected from of 410 identified institutions.

Findings: We obtained data for 97 095 of 106 546 deliveries (91% coverage). The median rate of caesarean delivery was 33% (quartile range 24–43), with the highest rates of caesarean delivery noted in private hospitals (51%, 43–57). Institution-specific rates of caesarean delivery were affected by primiparity, previous caesarean delivery, and institutional complexity.

Rate of caesarean delivery was positively associated with postpartum antibiotic treatment and severe maternal morbidity and mortality, even after adjustment for risk factors. Increase in the rate of caesarean delivery was associated with an increase in fetal mortality rates and higher numbers of babies admitted to intensive care for 7 days or longer even after adjustment for preterm delivery. Rates of preterm delivery and neonatal mortality both rose at rates of caesarean delivery of between 10% and 20%.

Interpretation: High rates of caesarean delivery do not necessarily indicate better perinatal care and can be associated with harm.

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Voluntary C-Sections Result in More Baby Deaths
September 5, 2006 | New York Times
By NICHOLAS BAKALAR

Original study -- September 2006 - Birth: Issues in Perinatal Care

A recent study of nearly six million births has found that the risk of death to newborns delivered by voluntary Caesarean section is much higher than previously believed.

Researchers have found that the neonatal mortality rate for Caesarean delivery among low-risk women is 1.77 deaths per 1,000 live births, while the rate for vaginal delivery is 0.62 deaths per 1,000. Their findings were published in this month's issue of Birth: Issues in Perinatal Care.

The percentage of Caesarean births in the United States increased to 29.1percent in 2004 from 20.7 percent in 1996, according to background information in the report.

Mortality in Caesarean deliveries has consistently been about 1½ times that of vaginal delivery, but it had been assumed that the difference was due to the higher risk profile of mothers who undergo the operation.

This study, according to the authors, is the first to examine the risk of Caesarean delivery among low-risk mothers who have no known medical reason for the operation.

Congenital malformations were the leading cause of neonatal death regardless of the type of delivery. But the risk in first Caesarean deliveries persisted even when deaths from congenital malformation were excluded from the calculation.

Intrauterine hypoxia — lack of oxygen — can be both a reason for performing a Caesarean section and a cause of death, but even eliminating those deaths left a neonatal mortality rate for Caesarean deliveries in the cases studied at more than twice that for vaginal births.

"Neonatal deaths are rare for low-risk women — on the order of about one death per 1,000 live births — but even after we adjusted for socioeconomic and medical risk factors, the difference persisted," said Marian F. MacDorman, a statistician with the Centers for Disease Control and Prevention and the lead author of the study.

"This is nothing to get people really alarmed, but it is of concern given that we're seeing a rapid increase in Caesarean births to women with no risks," Dr. MacDorman said*

Part of the reason for the increased mortality may be that labor, unpleasant as it sometimes is for the mother, is beneficial to the baby in releasing hormones that promote healthy lung function. The physical compression of the baby during labor is also useful in removing fluid from the lungs and helping the baby prepare to breathe air.

The researchers suggest that other risks of Caesarean delivery, like possible cuts to the baby during the operation or delayed establishment of breast-feeding, may also contribute to the increased death rate.

The study included 5,762,037 live births and 11,897 infant deaths in the United
States from 1998 through 2001, a sample large enough to draw statistically significant conclusions even though neonatal death is a rare event. There were 311,927 Caesarean deliveries among low-risk women in the
analysis.

Dr. Michael H. Malloy, a co-author of the article and a professor of pediatrics at the University of Texas Medical Branch at Galveston, said that doctors might want to consider these findings in advising their patients.

"Despite attempts to control for a number of factors that might have accounted for a greater risk in mortality associated with C-sections, we continued to observe enough risk to prompt concern," he said.

"When obstetricians review this information, perhaps it will promote greater discussion within the obstetrical community about the pros and cons of offering C-sections for convenience and promote more research into understanding why this increased risk persists."

Caesarean doubles risk of stillbirth for next child
By Jeremy Laurance, Health Editor
28 November 2003 © 2003 Independent Digital (UK) Ltd

Women who give birth by Caesarean section run twice the risk of having a stillbirth at the next pregnancy, researchers reported yesterday.

Although the risk of a later stillbirth remains low, at about one in 1,100, doctors say the finding could redefine the nature of the debate about Caesareans, which have more than doubled in the past 20 years. Concern about Caesareans has previously focused on the immediate potential risks to mother and child. Problems with the development of the placenta in subsequent pregnancies have been noted but this is the first time Caesareans have been linked with an increased risk of stillbirth.

Most Caesareans are carried out to avoid the complications of a vaginal delivery, especially involving a breech baby, and the small additional risk of a stillbirth in a future pregnancy is unlikely to affect the decisions. But an increasing number are performed at the request of the mother, and not for a clinical reason. A survey in 2001 by the Royal College of Obstetricians and Gynaecologists found 7 per cent of Caesareans were at maternal request, amounting to about 2,400 a year.

Nowadays, more than 20 per cent of births are Caesarean, up from 9 per cent in 1980, and obstetricians [???] say pressure from patients for Caesareans is intensifying.

Gordon Smith, from the department of obstetrics at the University of Cambridge, and colleagues who carried out the study, said in The Lancet: "If women are being counseled about Caesarean birth with no clear obstetric advantage, such as Caesarean section for maternal request, the possible effect on the risk of unexplained stillbirth in future pregnancies should be discussed."

The authors studied data for 120,000 births in Scotland between 1992 and 1998, and found the risk of a stillbirth from 34 weeks gestation was 1.77 per 1,000 women who had had a previous Caesarean compared with 0.89 per 1,000 for other women. The risks of a breech baby dying in a vaginal birth are put at 8.9 in 1,000 and the risk of a later stillbirth are said to be less than one in 1,000. Therefore, the new findings are "unlikely to influence the decision to have a Caesarean in a breech pregnancy," they said.

But the findings could influence the choices women make in subsequent pregnancies - and increase Caesareans. If the risk of a stillbirth in a subsequent pregnancy is increased from the 34th week onwards, women may decide they want to deliver the baby early by Caesarean. Many women are advised to have a second Caesarean because of the small extra risk of the womb rupturing along the old scar, which is put at 0.45 per 1,000 deliveries.

The researchers said the risk of a stillbirth from the 39th week of pregnancy was greater than double this risk in women who had previously had a Caesarean, at 1.06 per 1,000. "The current data suggest that an additional benefit of planned repeat Caesarean delivery at 39 weeks gestation may be to reduce the risk of unexplained stillbirth." They said their results cannot be explained by any of the usual factors affecting stillbirths, such as smoking, social deprivation or the age of the mother.

Prophylactic Cesarean At Term

The following paper, published in 1985, is an example of how far the perspective and agenda of the obstetrical profession is from the expectations of the public and genuine interests of childbearing women. Below are excerpts from an article published NEW ENGLAND JOURNAL OF MEDICINE, May 1985, by George B. Feldman, MD, Jennie A. Friedman, MD entitled Prophylactic Cesarean Section at Term?

This article brings into sharp contrast how much we need unbiased investigative reporting by media to explore these conflicts of interest. It is an example of just how much the media has been asleep at the wheel for the last century. When Dr Gawande made much the case for ‘prophylactic’ Cesarean as a way to save more babies in the 2006 New Yorker article, it was not the first time the idea had been circulated.

In 1985 the Doctors Feldman & Friedman also made the “case” for Cesarean on demand and began promoting the idea that a 100% scheduled or “prophylactic” cesarean become the norm for all women. With few exceptions, nobody noticed in 1985 and surely no one with any clout publicly objected. This tested out the waters and told the powers-that-be that eventually the obstetrical agenda to eliminate normal birth will prevail. By the time the people figure out what’s happening, no one will be able to stop this steamroller.

As with the general tone of the New Yorker article, this drastic idea is presented as a ‘preemptive strike’ to protect the baby from the ‘dangers’ normal labor and birth. It changes the professional focus of obstetrics to simply determining when fetal lung maturity is achieved so that the CS can be scheduled before the mother goes into spontaneous labor (gasp!) and gives birth naturally (yuk!).

These obstetricians boldly make a statistical case for cesarean surgery as “saving” babies with only a little “excess” or “extra maternal mortality” and opine that the “low cost of excess maternal mortality” may be a price worth paying.

Prophylactic Cesarean Section at Term? Excerpts

Feldman GB, Friedman JA; N Engl J Med 1985;312:1264-1276

Here is a short excerpt:

p. 1266 ….the number of extra women dying as a result of a complete shift to prophylactic cesarean section at term would be 5.3 per 100,000…. This may be the proper moment to recall that the number of fetuses expected to suffer a disaster after reaching lung maturity is between 1 in 50 to 1 in 500. … if it could save even a fraction of the babies at risk, these calculations would seem to raise the possibility that a shift toward prophylactic cesarean section at term might save a substantial number of potentially healthy infants at a relatively low cost of excess maternal mortality.

We probably would not vary our procedures if the cost of saving the baby’s life were the loss of the mother’s. But what if it were a question of 2 babies saved per mother lost, or 5 or 10 or (as our calculations roughly suggest) as many as 36 or 360? …. Is there some ratio of fetal gain to maternal loss that would unequivocally justify a wider application of this procedure? [editor note: with its increased maternal deaths?]

p. 1267….is it tenable for us to continue to fail to inform patients explicitly of the very real risks associated with the passive anticipation of vaginal delivery after fetal lung maturity has been reached? If a patient considers the procedure and decides against it, must she then be required to sign a consent form for the attempted vaginal delivery? [emphasis added]

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Once again we are back to the strangely familiar words of Dr Gawande in his 2006 New Yorker article, words and ideas that track exactly with Drs Feldmen and Friedman.

“….. one out of five hundred babies who are healthy and kicking at thirty-nine weeks dies before or during childbirth—a historically low rate, but obstetricians have reason to believe that scheduled C-sections could avert at least some of these deaths. Many argue that the results for mothers are safe, too.”

Am I the only one disturbed by the idea of eliminating normal birth based on unexamined and unscientific criteria and the weakly modified verbs such as “reason to believe” “could avert at least some of these deaths”? Would you fly on an airline that claimed to “believe” that “at least some” of their planes “could” land safely?

Am I the only one that sees gender politics here reminiscent of the last century’s attempt to gloss over the right of adult, mentally-competent women to control their fertility or to terminate a pregnancy that threatened their own lives and exposed existing children to the possibility of being orphaned?

Isn’t this just another round of the dubious abstract theory of ‘buying us better babies’, no matter what the risks, who is hurt or how much it costs? This theory readily gives rise to the notion that a pregnant woman’s value is simply as fetal container. She is expected to demur without question to ‘professional advice’ and to willingly sacrifice her or suffer permanent disability on the mere possibility that obstetrical profession “believes” they “could avert at least some” of the dangers? As for idea that the maternal request Cesarean is the highest expression of reproductive “choice”, I’d have to point out that women ask for Cesareans for the same reason that smokers buy cigarettes – a huge industry has spent a ton of money to convince them that it’s desirable. Medically-unnecessary Cesareans are to healthy childbearing what cigarettes are to healthy lung function. As with cigarette smoking, some people do indeed benefit but it is not the smoker or the in this case, not the childbearing family or society.

At the risk of sounding like a broken record, can you say “physiological package” for healthy women with normal pregnancies?

Now tell me again why investigative journalists are so disinterested in this, the most important untold story of the 20th century?

Copy of My Official Letter to the New Yorker

Ongoing Comments on THE SCORE – published 2006-10-09

Web Access to Original Article

I am a former labor and delivery room nurse, mother of three and a grandmother. While my ovaries are honorably retired, my daughters are still of childbearing age. My first grandson was a breech baby born by electively scheduled cesarean. My daughter’s recovery took nine miserable months. Three years later his younger brother was born spontaneously. Her recovery was night and day different.

I also am a professional midwife who provides care to healthy women. Our practice uses the science-based principles of physiological management. Our cesarean rate is under 4%. Physiological management of childbirth is preventative – that is, associated with the lowest rate of mortality and morbidity for both mothers and babies. Its methods are also protective of the mother’s pelvic floor. This model of normal birth care is both safe and cost-effective. It is the standard used worldwide by family practice physicians, midwives and obstetricians in countries with much better maternal-infant outcomes than the US.

The obstetrical package – the centerpiece of ‘industrialized’ childbirth glowingly described by Dr Gawande – is associated with high levels of drug and anesthetic use, episiotomy, instrumental delivery (associated w/ stress incontinence), cesarean surgery, reduced rates of breastfeedingand increased number and severity of complications. When applied routinely, as it is in the US, to healthy women with normal pregnancies (70%), it is the opposite of evidence-based care. The obstetrical package for a healthy population – including the casual use of cesarean -- is not healthier, safer, cheaper or better for society than physiologic birth.

Nonetheless the author of the THE SCORE, along with many in the obstetrical profession, is promoting the notion that routinely scheduled cesareans are somehow safer and better than normal birth. But the science is unequivocal – the liberal or elective use of c-section does NOT improve perinatal outcomes. In addition to immediate surgical problems for the mother, other serious complications of cesareans are displaced to future pregnancies [1,3,4,5]. The notion that increased levels of morbidity and mortality are justified in pursuit of safety is an oxymoron.

Without ever establishing proof of efficacy, Cesarean section has become the most commonly performed surgery in the US. In 2005 it was 29% of all births. In 2003, 1.2 million cesareans cost $14.6 billion. [2] Forty percent of all maternity care is paid for by state and federal Medicaid programs; the other 60% is billed to employer-sponsored health insurance. Like all business expenses, the added cost of elective cesarean is incorporated into the price of goods and services and then passed on to us. For example, automakers add $1500 for employee health insurance to the cost of every car manufactured in the US. If more births are by elective, unnecessary surgery, that cost will rise even more rapidly, making America ever less competitive in a global economy.

So when I read articles such as THE SCORE, I feel like Alice in Wonderland. I have fallen down a rabbit hole into a land where professionals engage in double-speak and investigative journalism has been replaced by faith-based reporting. In this war on women’s biology, truth is also a victim.

Decades of medical and surgical interventions (i.e., the obstetrical package) used routinely on all childbearing women has resulted in unnecessary morbidity in otherwise normal vaginal birth. According to the Listening to Mothers surveys by the Maternity Center Association of NYC, over 90% of low-risk healthy women have seven or more significant intervention in a normal hospital birth and 47% are exposed to one or more surgical procedures or instrumental delivery. [3b]

The lack of obstetrical support for normal biology, paired with the sequelae of serious interventions, makes dismal statistics for vaginal birth. As a result, C-section starts to look pretty good --- like it’s not that much more dangerous. Why not “have it your way”, especially since Cesarean surgery is convenient for obstetricians, profitable for hospitals and makes interesting copy for newspapers on a slow news day?

The answer lies in the research circulated by doctors for other doctors, which tells quite a different story. According to insider information easily available to obstetricians [2], the sequelae of cesarean surgery include a grim list of intra-operative and post-op complications. In addition there is a whole new category of delayed and downstream complications unique to post-cesarean reproduction, which result in a total of 33 Cesarean-related ‘route of delivery’ complications, compared to only 4 route-of-delivery risks for spontaneous vaginal birth. [3a]

According to a preponderance of scientific literature, cesarean delivery more than doubles the rate of maternal death when compared to normal vaginal birth. An excellent study just published in September 2006 (file attached) found a 3.5 fold increase in the deaths of healthy women who had elective cesareans performed before onset of labor [4]. Anesthesia, infection (3 times higher following cesarean), and fatal blood clots (9 times higher following cesarean) were the big killers – the same complications that accompany all forms of surgery.

In addition to increased fatalities, these adverse events can also result in serious disability or permanent neurological damage for the new mother. [1] Cesarean increases the incidence of intra-operative hemorrhage and blood transfusions, and has a 13 times greater emergency hysterectomy rate than vaginal delivery. Post-operative complications include prolonged surgical pain, diminished mobility, bowel obstruction and difficulty breastfeeding.

Should a cesarean mother want to have another baby, she faces a secondary infertility rate of 6%, and an increased rate of ectopic pregnancies and miscarriages. Mothers in post-cesarean pregnancies have higher rates of serious placental problems, including placenta previa (placenta over the cervix) and placenta accreta or percreta (implanted in or through the wall of the uterus). Placenta percreta requires a hysterectomy at delivery and carries a maternal mortality rate of 7 to 10 % -- even in the very best, most well-equipped hospitals, in an operating room full of the most experienced surgeons. In addition, the likelihood of placental anomalies rises with each subsequent pregnancy, making it the dangerous gift that keeps on giving. [1]

Additional risks to fetuses and newborns in post-cesarean pregnancies include increased fetal demise & stillbirth rates and, in subsequent births, mortality and morbidity due to uterine rupture. For the baby, being born by any cesarean, primary or repeat, increases the rate of operative lacerations, respiratory distress, admission to the NICU, exposure to serious iatrogenic complications such as infection and drug errors in the special care nursery, decreased breastfeeding and increased rates of asthma in childhood and as an adult. [1]

Then there is the huge economic drain on our health care system. Cesareans cost 2 to 4 times more than normal hospital births, a figure that doesn’t count surgical anesthesia, special care nursery charges or any of the delayed and downstream problems described above. The costs of infertility treatments are enormous, as is the expense of mandatory repeat cesareans -- mandatory because most OBs are no longer allowed by their malpractice carriers and/or their hospitals to perform VBACs (vaginal birth after cesarean).

Unfortunately, THE SCORE did nothing to advance our understanding of this complex topic or promote a truly science-based debate. As with claims of WMDs, an informed public should demand evidence before taking drastic actions with permanent and potentially-harmful consequences. The alternative is to institutionalize dangerous and expensive practices without any public oversight or proof of benefit.

A letter by a family practice physician published just this week (Nov 7th) in the Canadian Medical Association Journal entitled “Not Safer and Not Cheaper”, sums up how the scientific data was manipulated and describes the many egregious consequences, personal as well as economic:

“ … in their economic analysis, [they] looked only at immediate costs, thus vastly underestimating the real costs of elective cesarean for breech or any birth. Since most women will have more than one birth, the presence of a uterine scar will expose women to increases in placenta previa and placenta acreta,⁵ ectopic pregnancy,⁶ abruption,⁵ infertility,⁷ stillbirth⁸ and excess hospital readmissions because of the cesarean⁹ and adhesion-related intestinal obstruction.¹⁰ All of these costs have been ignored.

This analysis led to headlines in the popular press that cesarean births are both safer and cheaper. This lack of nuance fuels societal views that increasingly suggest that cesarean section is just another way of giving birth; in addition, it undermines the confidence of a generation of women who are coming to believe that they cannot give birth without massive technological assistance.”

CMAJ • November 7, 2006; 175 (10); Michael Klein, MD Centre for Community Child Health Research, BC Child and Family Research, Institute, Vancouver, BC http://www.cmaj.ca/cgi/content/full/175/10/1243-a

We are long overdue for a robust public discourse about the routine use of the infamous ‘obstetrical package’ on healthy women. As for the obstetrical profession’s official distain and disregard for the preventative and protective principles of physiological management, well, the facts are plentiful. Just follow the money.

Personally, I would encourage the New Yorker to provide equal time and a rematch over this very biased and misleading article. The future of normal birth hangs in the balance.

Faith Gibson, LM, CPM
Exec Director, American College of Community Midwives
Palo Alto, CA 94303
_________________________________________________________________

[1] Ob.Gyn.News – www.obgynnews.com --The Leading Independent Newspaper for the Obstetrician /Gynecologist (search back issue archive by date, topic or title)

Elective C-section Revisited; Dr. Elaine Waetjen; August 1, 2002

C-Section Linked to Stillbirth in Next Pregnancy, 05/15/03

Maternal Morbidity Rises Sharply with Repeat Cesareans, 03/15/05

Prior C-Section Assoc. with Worse Outcomes – ICU Admit, postpartum infection, 03/01/05

Study Shows Elective Cesarean Riskier than Vaginal Delivery, 05/01/04

Asthma Associated with Planned Cesarean, 05/14/03

Cesarean Birth Associated with Adult Asthma, 06/15/01;

Steep Rise Seen in “No [Medical] Risk Primary C-Sections, 01/01/05

Offering C-Section ‘On Demand’ Can Be Ethical: ACOG, 12/01/03

Cesarean Rate Portends Rise in Placenta Accreta, 03/01/01

Placental Invasion on the Increase – hike in C-Section may be responsible, 01/15/03
Placenta Previa, C-Section History Up Accreta Risk, 09/15/01

[2] August 02, 2005 WASHINGTON (Reuters) The most common U.S. hospital procedure is the Caesarean section, with 1.2 million of the operations done each year, according to a government report. Caesarean sections cost $14.6 billion in total charges in 2003, the report from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project found. The report, which can be found on the Internet at http://www.hcup.ahrq.gov/, lists the other top five in-patient hospital procedures

[3a] "What Every Pregnant Woman Needs to Know about Cesarean Section", a systemic review of the scientific literature by the Maternity Care Association of NYC;
[3b] Listening to Mothers Surveys (2002, 2004, 2006) @ www.maternityWise.org
281 Park Ave S New York, NY 10010 (212) 777-5000

[4] Postpartum Maternal Mortality and Cesarean Delivery; C. Deneux-Tharanux, MD et. Al; Obstetrics and Gynecology, Vol 108, No 3, September 2006 (file attached)

[5] A July 2003 report by the ACOG Task Force on Neonatal Encephalopathy & Cerebral Palsy
Internet access to supportive documentation www.sciencebasedbirth.com/CEO%20SSB/Synopsis_CEO_mission_2004.htm#scientific%20Literature

Continuation of my commentary on the New Yorker article ~

Part 2 – corrected and republished on 10-26-2006
___________________________________________

I’m a part-time scholar in the history and politics of midwifery and obstetrics. One of my areas of expertise in obstetrical history is the period from 1820 to 1935. I have a considerable library of classic obstetrical textbooks and archival copies of the original documents from this period. Information from those documents disproves many of the crucial facts about obstetrical history as presented by Dr. Gawande.

Unfortunately for all of us, the facts used by Dr Gawande are either wrong or used in a misleading manner. His tactics were scare-tactics, a strategy that discourages public debate or any individual questioning of the practices and policies institutionalized by the American College of Obstetricians and Gynecologists (ACOG). Typifying the biology of childbirth as inherently dangerous makes people passive and politically ineffective. Since September11^th, 2006, fear-mongering has become something of a national pastime. But there is no rational reason to make the normal biology of childbirth into yet another terrorist plot or a gender-specific WMD.

Dr Gawande is factually incorrect to conclude that:

• each and every childbearing woman through out the history of the human species has been just seconds from disaster at all times
• only the ‘obstetrical package’ stands between the modern mother-to-be and catastrophe
• if women wind up with an unwanted C-section, the Cesarean hasn’t anything to do with the style of obstetrical management –Mother Nature is just a bitch
• as long as the baby is healthy, it really doesn’t matter that its born by major abdominal surgery or that you can’t breastfeed it

This makes the obstetrical package like a planned plane crash -- all that counts is that you can walk away from the wreckage with all your limbs intact. That is really a sad, if not actually perverted, vision of the best we can do for the 70% of healthy mothers giving birth in the 21^st century.

Missing the Point – effective strategies for labor

But aside from the substitutive criticism, there was a particular place in the article that I thought was the most striking example of having missed the point. I wondered if I was the only one who saw that connection. Since a midwifery client of mine told me she had just read the New Yorker article, I ask her what she saw as most representative of a fundamental misunderstanding. She blurted out “when her husband went to sleep while she (the physician-mother-to-be) was having strong painful contractions, leaving her in pain in the middle of the night all by herself”.

I had the same reaction – the obstetrical ‘package’ was unable to provide care to the mother at this most critical junction -- its not part of the ‘package deal’. Obstetricians don't attend labors and they certainly don't make house calls or send other knowledgeable professionals in their stead. Then, with either hubris or arrogance, the obstetrical profession uses the negative consequences of that built in failure (or as they say in Silicon Valley -- it’s not a bug – it’s a feature!) as an example of why ascending levels of obstetrical intervention, including the most extreme of those interventions -- Cesarean section -- are always warranted.

Of course, the narrative of this mother in labor has nothing to do with the official merits of the either the article or the obstetrical package. However, it was used by the author to exemplify how, despite the ‘best of circumstances’, mothers or babies will, with great frequency, need to be ‘rescued’ by C-section.

But lets fact it -- if a pregnant physician (with all the ability to control events that we ascribe to physicians) who didn’t want any interventions and wished to have a natural birth with fairies in a forest bower has, instead, the ‘book’ thrown at her, up to and including an unplanned C-section, then Freud must have been right all along – female biology is destiny (a desperately defective one) -- and obstetrics is our only salvation from the cruel fate of Mother Nature.

It not my intention to dishonor the birth experience of Elizabeth Rourke, the young mother/physician described in the article. Should she ever read this blog, I apologize for making public comments about so important and private a matter. Actually I believe that any C-section that has already taken place was ‘necessary’ -- at that time, with those particular individuals and under those specific circumstances, it was the necessary thing. As with all “water under the bridge” situations, we learn from it (doctors included) and move on.

So I want to re-contextualize my comments as addressing the general circumstance that Elizabeth Rourke’s situation was to exemplify, but not Elizabeth as an individual mother. It is most unkind to second guess events that one was not present for, especially involving people one does not personally know. I think she earned and should be awarded the Perinatal Purple Heart for bravery above and beyond the call of duty. Every mother deserves a Perinatal Purple Heart.

Physiological Management ~ not the absence of medical interventions

In that regard, I have to mention that physiological management is not simply the absence of medical interventions. Being at home alone in the middle of the night with no physical, psychological or social support services, no way to access how you are doing, no witnesses to your pain and your valiant efforts to cope, is neither ‘natural’ or normal. When a mother experiences labor as unending unendurable pain, her mind and her body start working against each other and she will not be able to make progress unless or until she receives appropriate social and emotion support or effective drugs.

Functionally speaking, what makes a bodily process “physiological”, rather than simply biological, is the interplay between the psychological and emotional state of the individual and the targeted body organ – think erection (or the let-down reflex for breast milk) and you’ll have no trouble getting the picture. The big problem with the industrialization of childbirth is that the current ‘obstetrical package’ offers no specific training, experience or skills in physiological management – i.e, the mind-body events of labor and childbirth.

This means that modern interventionist obstetrics has little more to offer healthy women with normal pregnancies than kidney dialysis has to contribute to those with healthy kidneys. The contemporary problem with obstetrics for a healthy population is that obstetrics is all about the obstetrician, not the mother or the physiological process. Also missing from obstetrics is active concern for the social and economic consequence of policies that promote the routine use of the expensive, pre-emptive strike and its many complications -- immediate, delayed and downstream. It’s the ‘gift’ that keeps on giving.

For the professional practitioner of normal birth, physiological management is not a passive state. In fact, it is just the opposite – it is an activity and a rather arduous and intellectually-discerning one at that. It is a ‘contact’ sport that uses continuous physical proximity, physical touch and intimacy skills, more than a tad of mothering and an occasional Dutch Uncle- football coach “only you can push your baby out normally, so open your eyes and look at me, focus your energy and just push a little bit more” pep talk. You have to love your mothers like they were your daughters, love being a birth attendant, pray fervently and then work wholeheartedly like your prayers meant nothing at all.

When the mother is having serious trouble coping or is not progressing in labor, it requires the full-time presence of the primary care provider (physician, midwife or labor attendant) through out the remainder of the labor. This includes the latent and early 1^st stage if that is where the problem first showed up. It is important to build into everyone’s expectations – mother, father, midwife, family, etc – an acknowledgment that most contemporary women experience 4 to 48 hours of a “warm-up” phase. This is an irregular labor pattern of varying lengths and strengths – too much labor to be ‘normal’ but not enough to expect progressive change.

Warm-up Labor ~ Why it’s OK and How to Cope

However, prodromal labor should not be thought of as an inherently dysfunctional state. In many instances, a long prodromal phase seems to prepare the mother for a briskly active labor and straightforward birth. It is a period with important contributions in the social, psychological and biological realms. The mother gets to make the mental changeover from just being pregnant to “moving day” for the baby – being in labor. She gets to ‘practice’ her coping techniques, while the father and other family get involved and focused on the mother, as they should.

While I don’t have facilities to do endocrine research, I do have a hypothesis generated by close observations over a long time – the prodromal and latent phases of labor seem to trigger the mother’s biology to start building up the necessary hormones of labor – oxytocin to progress labor, beta endorphins to make the pain of labor tolerable and adrenal hormones to help the mother push during 2^nd stage and prepare the baby for independent respirations at birth.

From that standpoint, the physiological contribution of the warm-up phase is equally, if not more, important than the social and psychological contributions. I am convinced that the biological evolution of normal labor and birth, as a successful and straightforward event, actually benefits from and is programmed for this “warm up the mother / build up the hormones” phase.

Natural Birth in the Natural World

I have carefully interviewed women from non-industrialized cultures (Thailand, Laos, Vietnam, etc) about normal birth in their country. When queried, they report that labor in a first time mother is “maybe 3 or 4 hours”. However, when probed deeper they describe that pregnant women at term have many hours or even a couple of days “warning”, during which time she is expected to go on with her normal life.

In agricultural societies, the on-going demands of family or farm take precedence over early labor until such as time as the uterine contraction pattern is overwhelming --so long, so strong and so close together (3-4 minutes apart and a minute long) that the mother can’t do anything else. Then she must fully attend to giving birth, which tends to occur in less than 6 hours from this point. This is the only part of that long period that is officially acknowledged as “labor”. The biological gift of this is a mother who usually gives birth when she and her unborn baby are physically strong, well nourished and well hydrated, which is ideal.

Initially, the most effective coping style for the early end of warm-up labor is called distraction. The mother and rest of family are encouraged to go on with their normal life during waking hours as a strategy to distract her from the early crampy and often anxiety-provoking aspects of her experience. During the night time, the coping strategy of “distraction”' means turning off the lights and resting in bed, even though she will be awakened regularly by contractions.

If she can’t tolerate laying down during a contraction (most women find lying on their back while in labor to be intolerably painful), then midwives and other labor attendants suggest that she prop her self up in a comfy chair and doze between contractions, while incorporating the next style of coping during each contraction – paying attention and using her labor breath.

One that I find to work well is a pattern of 6 to 10 breaths in a one minute period, in which the mother takes a little short inhalation each time (2-3 seconds), followed by a slow, steady relaxed exhalation (6-10 seconds). Physiologically speaking, each exhalation is similar to letting the air slowly out of an inflated balloon or singing a long musical note. According to my Pacific Rim sources, this is similar to the contemplation breathing of Tibetan monks. At the end of the contraction, the mother returns gives a big sigh, relaxes herself, and returns to the low energy style of rest.

Being in Control – Not a Characteristic of Labor or Birth

I frequently provide care to older, highly educated 1st time mothers, who lead incredibly busy and stressful lives. In particular, these women seem to seem to actually benefit from a longer a warm-up phase. The sleep deprivation naturally associated with it seems helpful to women who have a hard time giving up control.

For the female of the species, labor and sex are typically a “you’re-not-in-control” experience. Both benefit from ‘surrendering’ oneself to the biology of the moment and riding (as opposed to fighting) the waves of sensation. For most (but not all) women, as they get farther and farther out on the sleep derivation scale, the psychic stiffness slowly ebbs away. They get too tired to fight, soften slowly and eventually surrender. Some may have 60 hours of warm-up, 8 hours of latent labor and as few as two hours of active labor.

Alas, for some, sleep deprivation only makes everything worse. These moms will need an epidural before they can function again and labor progress.

However I remember one client who fit the general description of a high stress life, who went from 5 centimeters of cervical dilatation to delivery in 43 minutes. This was after 74 hours of “yes/no, maybe-baby-day, maybe-not” labor. Her first contraction was 3 am Wednesday morning. Early active labor set in at 11 pm Friday night. Saturday morning at 4:48 am her water broke and she was 5 cms. At 5:31 am – exactly 43 minutes later -- the 8 pound baby was born. I’ve seen a lot of deliveries, but a photo-finish birth like hers still stands out in my mind. Spontaneous biology, yes – bring it on!

Industrial Responses to Human Physiology – not a good fit

For the rest of the childbearing population, the prodromal phase is where industrialized childbirth prematurely hospitalizes women. This is especially a problem for 1st time mothers. Their care providers don’t make house calls, the mother can’t tell what is happening to her and she can't cope at home all alone. Hospitalization and the obstetrical package is the only help and only hope available to her. For a large percentage of contemporary women, the warm-up/prodromal phase is where the trolley goes off the track, triggering the cascade of unwanted obstetrical interventions and ultimately ending in an operative delivery 24 to 48 hours before the baby would have naturally have arrived.

This phase often includes painful, close together but brief contractions that make it difficult to sleep normally, so obviously that is a big factor. Midwives make daily (or twice daily) house calls during this period of time and remain at the mother’s home when appropriate. There are strategies to help women get thru this period – dozing in the bathtub is a favorite – and I always use the example of being sleepy on a transatlantic flight. You can’t lie down and you can’t stay awake, but you really want to go to Europe, so you figure out how to work with it. We endeavor to find ways to prop the mother up, airplane-style, so she can take a series of micro naps between each contraction. Mind you, this is not the same as being ‘comfortable’ in labor – there is no ‘comfortable in labor’ position until the baby is in the mother’s arms, while we are awaiting delivery of the placenta (thank goodness for the 3rd stage of labor!).

The prodromal phase is particularly hard if the mother starts labor already at the skinny end of sleep deprivation. This was obviously the case described in the New Yorker article, as the mother-to-be was a resident at Mass General. According to Dr Gawande, she worked up to the day she went into labor. Considering the long hours required of medical residents, one can assume that she was suffering from massive and chronic sleep deprivation. She readily admitted that it was extreme sleep deprivation -- more than the pain of labor -- that triggered her grudging request for an epidural. Mind you, this was coupled with the fact that few other options were offered by the hospital staff or available in the hospital environment.

The obstetrical package doesn’t routinely offer active support for the physiologic process. Instead it depends on the sequential use of various interventions. The contemporary obstetrical package as provide to healthy women consists of:

1. Admission to a labor room bed - 99%
2. Continuous electronic fetal monitoring - 93%
3. Administration of intravenous fluids - 86%
4. Being confined to the bed during labor - 71%
5. Giving birth on your back - 74%
6. Artificial rupture of membranes - 67%
7. Labors induced or artificially accelerated - 63%
8. Epidural anesthesia - 63%
9. Gloved hand inserted into the uterus after birth - 58%
10. Bladder catheterizations – 52%
11. Episiotomies - 35 %
12. Cesarean section - 29 %
13. Instrumental delivery forceps or vacuum (12 %)

(*Listening to Mothers Survey- 2002, except C-section rate taken from 2005 stats)

An astounding 76% of healthy women with normal pregnancies (70 % of all pregnancies) who are having babies in the system of industrialized childbirth will experience some form of operative procedure, if you just count the rate of episiotomies, forceps and Cesarean section. Artificial rupture of membranes and manual exploration of the uterus after delivery are both technically surgical procedures for billing purposes, but I did not included them in these statistics.

As for Elizabeth Rourke’s choice to not to have effective labor support at home, I can appreciate that neither she nor any other mother wants to “be paired with someone who might be annoying”. However, that’s another of the many good reasons for having a practitioner relationship with a midwife as the designated labor attendant. You start out by working with the midwife during the prenatal period. If she turns out to be annoying, you find a different one long before you are in labor.

Elements of Success for normally progressive labor

As for what a skilled and experienced labor attendant does for a mother with a painful non-progressive labor, it starts with strategies for calming her by first addressing and defusing the anxiety and fear. Vaginal exams, while kept to a minimum, are necessary to get a bench mark, judge progress, inform management decisions and keep everybody attached to reality. They are also necessary to get the mother to the hospital at the right time - not too soon, not to late, but just right (6 cms).

In the mean time, the midwife must provide effective non-drug methods to manage the mother’s pain and reduce it to a tolerable level. This usually includes touch relaxation and/or walking around, being upright and mobile, making right use of gravity, having access to a hot shower or warm, deep-water tub, etc, and lots of encouragement. I tell the mother to think of this as “doing labor a half-hour at a time”. It helps everyone to keep focused on the moment and away from the “what ifs” - what if something is wrong, what if this goes on all night, what if I can’t take it any more, what if I loose it – this list never ends well.

When the going get tough, it means that someone -- midwife, husband or family friend -- must breathe with her through each and every contraction. Face-to-face, one-on-one support by an experienced midwife or labor attendant and the continuing presence of an encouraging husband is the functional norm under these circumstances.

Contrast the dynamics of that description with being alone in a dark & empty house at 2:30 AM after being in labor all day, husband sleeping soundly in the other room, as one is gripped by the 500^th labor pain, no end in sight, no help, no hope. Midwives call this the “Kill me now” phenomenon. By that point women will agree to anything, no matter how much it diverges from their plan or violates their body.

For women who are overwhelmed by their current stage of labor, the process of labor support is highly reminiscent of talking someone who is afraid of heights down from the tallest branch of a swaying tree. It is an art form, an all-encompassing activity like writing, where every word, every minute matters. It is also vital that the husband /father/ partner repeat to her frequently and ardently (if not passionately!) that he knows she “can do it”, that he is confident in her and her ability to cope, that he is there to help her, that he believe she has what it takes to give birth to their baby and that whatever happens, they’ll deal with it together, etc.

Husbands & Fathers -- the Secret Weapon Against Discouragement

I cannot emphasis enough how important it is for men to overcome the idea that they “can’t know what its like” and therefore have no “right” to say anything definitive or take a stand on the general desirability of a normal biological process (as contrasted with blasting caps, salad tongs or a toilet plunger to pull the baby out).

Fathers also can’t permit themselves to give in to the idea that their wife’s experience of labor is the rightful role of the obstetrician. It’s not -- he or she won’t be there until the very end. If, by chance, they come before the baby is on the perineum, well, lets fact it -- doctors still don’t ‘do’ labor. Last but not least, husbands must divest themselves of the idea that the ‘proper’ role for the husband is to defer to the obstetrical ‘wisdom’ of the system – the “hey, I’m not gonna tell the doctor how to do his business” or that “how can I (a non-physician) tell if something’s wrong? I’ll just stay way back and watch”.

No, no, no, no! To the mother, the husband is the most important person in the room. If he gives away his natural power, her “rock of Gibraltar” in the hospital system will transfer to obstetrical technology, and she will become unnaturally dependent on drugs and obstetrical interventions.

Childbirth is about making functional families, so let’s help all the family members to be empowered at this crucial time. Bonding is not just for mothers and babies; it’s also between husbands and their wives and sometime between mothers and daughters or between the mother and her sister or other family member. Fathers and families are going to live with the mother and baby for a life time – the staff is going home after 8 hours and will never see any of you again. In a few years the OB is going to give up his birth practice and just see gyn patients, so he doesn’t have to be on call on weekends or get up at night to do deliveries. So fathers and families unite --take back your power and your rightful place – right in the thick of things!

Athletic Coping -- Not Usually an Effective Coping style

While every woman’s process for coping with labor is unique, ‘coping’ styles that are highly energetic, even athletic, do not work, physiologically-speaking. I’m describing a labor with lots of rapid striding about the room, dramatically writhing and moaning with every contraction, desperately grasping the hand (or other body parts) of those nearby, perhaps attempting to bite themselves or others -- the word ‘panic’ should give you the picture. This is the psychological equivalent of a trickle bleed -- it places an absolute duty on the birth attendant to respond effectively.

Just as the constant loss of a small amount of blood multiplied by many hours is a devastating form of hemorrhage, so is the leaking away of the mother’s physical and psychological resources (her spirit), while the labor-retarding, pain-enhancing effects of fight or flight hormones are constantly being secreted into her blood stream and sabotaging her progress. The responsible practitioner cannot stand by and permit the mother’s labor to self-destruct like this. If the birth attendant (midwife or physician) cannot satisfactorily return the mother to a state of calm and achieve a progressive labor pattern in a reasonable time through the above listed methods, then analgesic drugs or epidural anesthesia will be just as necessary as oxytocin would be for a postpartum hemorrhage.

The good news is that timely use of these medical interventions can reduce the likelihood that operative delivery will be needed.

The High Price of Labor without Physiological Labor Support

For women without access to physiologically-sound methods to support and advance labor (even if the mother herself rejected the help of a labor attendant), the risk of a painful but non-progressive labor, persistent posterior fetal position and operative delivery is disproportionately high. Obstetricians won’t tell you this but mothers know.

The author of a new book on childbirth, written from the perspective of a new mother, was interviewed today (10/24/06) by Terry Gross on NRP. Tiny Cassidy researched and wrote “Birth- a History of How We Were Born” after an experience similar to the one facing Elizabeth Rourke. Ms Cassidy described needing active and effective labor support for a long slow and painful labor with a posterior baby. What she received however was the standard medical care, the obstetrical package if you will, in which a busy nurse repeatedly stock her head in the door and asked kept asking if she was “ready for her epidural yet”. Under these circumstances, a mother, who was in pain and exasperated, will eventually say yes. In far too many cases, the posterior baby gets stuck in an undeliverable position. Like Elizabeth, Tiny Cassidy wound up with an unplanned and unwanted C-section.

Gender Politics

However, that kind of dysfunctional labor is not the destiny of our gender. No – it’s a social deficiently in our maternity care system, an educational failure in teaching the public about normal birth and the elements for success and a policy failure at the highest levels of government. It is not the mother’s personal fault, it is ours, collectively, as a society.

We are a society that does not provide the elements for successful childbirth. To a great extent, this is because we do not value the mother’s experience of normal labor and spontaneous birth. Instead, a woman’s interest in normal birth is dismissed as either naive or selfishly hedonistic. I still haven’t figured out why doctors consider not having narcotics drugs or anesthesia (and their associated risks) to be a selfish or hedonistic act on the mother’s part – personally I consider it a very brave thing to do.

But in the industrialized model of birth, the medical-industrial complex values efficiency and reliability more than any aspect of the mother’s experience. The obstetrical package is constructed to get the job done in the least amount of time, with the largest number of billable units and no uncompensated services, nothing that doesn’t have a billing code. There is no billing code for physiological management. Time spent with the mother, ‘merely’ providing a supportive presence, represents uncompensated services.

An example of how much this colors our entire relationship to ‘modern’ birth can be seen in how we talk about it. We don’t even speak of the mother delivering her baby. We say the doctor delivered her baby. The mother’s role is first to be passive, then to be appropriately appreciative. Over the course of the 20th century, women have permitted childbirth to be ‘industrialized’, with little more that an occasional whimper of protest. As a result, we let normal birth become the property of the obstetrical profession. They have chosen to industrialize it, borrowing ideas like ‘standardization’ and assembly line thinking from manufacturing and the agri-business – all in pursuit of the obstetrical ‘product’, defined here in the 21st century as the unborn and the “wellborn” infant (Williams Obstetrics, 1970 edition).

Prior to the baby being the identified ‘product’, the obstetrical package was geared towards providing the mother with a pain-free labor that she would not even remember, and then being ‘knocked out’ for the birth. The very earlier version of the obstetrical package was configured in the desperate hope of simply preventing maternal deaths from ‘childbed fever’ -- an all too common complication of laboring and giving birth in the bio-hazardous environment of a hospital before the discovery of antibiotics.

Ever since it was originally conceived, the design of obstetrical package has depended on an unequal ‘division of labor’ – that is, the professional activities associated with caring for women under obstetrical management. Continuity of care (such as provided by midwives sand old country doctors) was replaced by the ‘hand-off’, in which the unfinished ‘product’ (the mother in labor) is handed from one low or mid-level medical personnel to another. This is accompanied by move, conveyor belt style (via hospital gurney) to different wards, each with a separate staff of nurses -- labor room, delivery room, recovery room (mom), nursery (baby), hospital room. Each hospital employee has just small or brief part in the overall process. The laboring woman is provided ‘pre-op’ care by the labor room nurse until she is readied for her ‘op’ – the surgical procedure of vaginal delivery or cesarean section. Then the obstetrician is called and comes in to receive the finished product, which is pushed into his hands by the mother or pulled out with forceps, vacuum or Cesarean section – it doesn’t matter too much to an obstetrical surgeon which it is, except that the CS is often faster and easier to control.

Then the parents thanks the obstetrician, who turns the ‘post-operative’ care of mother and new baby over to the two different hospital assembly lines – one for the mother and one for the baby. They will wind though the system for many hours, eventually be reunited. After a few days, the mother will be put in a wheel chair, the baby placed in her arms and they will both be deposited at the back door of the ER door, ready for dad to bring the car around and take them home – the happy product of the American obstetrical package. In the six to 12 8-hour shifts that she was a patient on the OB floor, she will have been cared for by at least a dozen different nurses, doctors and other incidental hospital personnel. But none of them had the time and very few had the inclination to get to know her on a personal level. Bonding with your caregivers is not part of the obstetrical package. The modern maternity ward is just a revolving door in the industry known as the ‘baby business’, with moms coming and going all the time.

On the “shop floor” of Industrial Childbirth

The industrialized childbirth means our fate as healthy childbearing women is decided by the market forces, in combination with obstetrician preference. Sometimes this is just the personal preferences of the doctor on duty and other times it reflects policies and protocols handed down from on high – hospital administrators, insurance companies, ACOG practice policies, etc. For the last decade, the hot new thinking of the policy makers has been the idea of eliminating the messy, unpredictable, time-consuming, miserable hours, often unprofitable business of normal birth.

To that end, a significant minority of American obstetricians have developed a personal preference for performing Cesareans. These same obstetricians are working hard to convince all the rest of us, including the lay public, medical profession in general, insurance companies and the government, that C-section should be welcomed as the new standard for the 21st century.

The only question left was how to make the idea of operative obstetrics into a functional reality. Since June 2000 there has been a steady stream of public relations and propaganda campaigns of various sorts. In 2000, Dr Ben Harer, then president of ACOG, appeared on Good Morning American with Diane Sawyer and introduce the American public to the incredible idea of Cesarean as safe and better than vaginal birth. Mark Twain once remarked that “Only fiction must be credible”.

The talents of Dr Gawande are just the most recent of these incredible efforts. THE SCORE is the first time that an extensive and comprehensive article (8600 words) has been published in a magazine with such an outstanding reputation and wide circulation. Its placement in the New Yorker is a real coup. In addition, Dr Gawande does a masterful job of laying the necessary foundation for the total industrialization of childbirth. Unintentionally or otherwise, he covered all the bases, leaving the average reader with a feeling of certainty – the idea that childbirth is one less thing to worry about. Now there is a new ‘medical miracle’ – the scheduled Cesarean at 39 weeks, how lucky for us all.

Unfortunately, Dr Gawande’s writing talents have been used to spin the notion of birth as an industrial function of obstetrics into a high wall that distracts us and blocks out our view of normal childbirth. This acerbates the loss of critical institutional memory; it hides dangerous practices and policies; it agues against public discourse; it stands fore square against any critical review; it foils any attempt to correct individual excess; it diminishes the chance that the obstetrically-defined policies that currently define our national maternity care system will be debated, reviewed and rehabilitated.

Too bad, because in another decade, there will be no one left who remembers childbirth “BC” - Before Cesarean.

Personally, I’d like to see the New Yorker magazine offer equal time and a ‘rematch’ –opportunity for a robust public discourse consistent with the New Yorker’s singular reputation in the literary world and a real service to childbearing families and to the rest of society who, directly or indirectly, picks up the tab.

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Log on again in a few days for the next episode of this incredible story…..

Comments on NewYorker Article "THE SCORE ~ The Industrialization of Childbirth"

About me:

I am a mother of three, grandmother of two, former ER and L&D nurse, birth educator, web wife and presently a professional midwife with a small private practice on the San Francisco peninsula.

I am also a naturally opinionated person. In particular, I have a lot of opinions about normal birth and interventionist obstetrics as applied to healthy women with normal pregnancies. I am frustrated by the unwarranted cost of contemporary obstetrics, the absence of internal consistency and a cavalier attitude that often ignores scientific evidence. I object to policies that promote or result in medically-unnecessary Cesarean sections.

However, you would be wrong to think that I am ‘anti-obstetrician’ or anti-modern medicine. In fact, I have personally benefited by the expertise of a compassionate and very skilled ObGyn physician who diagnosed and performed fertility surgery many years ago so I could have children. None the less, I am convinced that we need to dramatically reform our national maternity care policies so that they are evidence-based, internally consistent, cost-effective and “mother-baby-father-friendly”.

World-wide, the scientific standard of care for healthy women with normal pregnancies is based on the principles of physiological management -- patience with nature, the full-time presence of the primary birth attendant during active labor, absence of arbitrary time limits, upright and mobile mother, social and emotional support as the mother requests, non-drug methods of pain relief (including access to hot showers and deep water tubs), right use of gravity, etc. These low cost, high-touch methods are used around the world with far better outcomes and far less expense. Our national maternity care policies should identify physiological management as the universal standard to be used by all birth attendants and in all settings – by midwives, family practitioners, or obstetricians and in hospitals, homes or birth centers.

Given these natural proclivities, the article by Dr Gawande really got a lot of my attention. I believe it calls for a point by point commentary. I will be writing and posting a well-researched, science-based commentary on each major topic, stretched out over the next couple of weeks. Unlike the New Yorker article, I will provide original sources – either citations, direct quotes or extensive excerpts from the original documents. These historical and contemporary resources speak for themselves.

So without further preamble, here goes.

THE SCORE
by ATUL GAWANDE
How childbirth went industrial
Issue of 2006-10-09

Atul Gawande, M.D. M.P.H Surgeon, General and Gastrointestinal Surgery, Endocrine Surgery Unit. Division of General and Gastrointestinal Surgery. ...

What is THE SCORE and why would anyone be interested in reading someone’s comments about it?

This New Yorker article about obstetrics (October 9th, 2006) was elegantly written and interesting. In light of the 30% and climbing C-section rate, it certainly is “timely”. Its author is a surgeon, although not an obstetricians. Dr Gawande comes across as good natured guy who is well-versed on the historical and contemporary practice of obstetrics and what he characterizes as its bright and promising future.

He provides a compelling account of how the profession got from the bad old days of the 19th century to the extraordinary success of its modern-day practitioners. He is candid about a particular problem with obstetrical practice that came to light in the early 1930, but assures us the profession learned its lesson from these problems and promptly fixed them. The “warts and all” style of story telling gives the reader every good reason to believe that he is a trustworthy and well-intentioned commentator, happily passing his wisdom on to us.

The picture he paints of obstetrics is a surgical specialty populated by doctors with an extraordinary ingenuity in their field. According to him, 20th century obstetrics made having a baby immeasurable safer by figuring out how to standardize childbirth. Dr Gawande describes this noble pursuit as the “industrialization of childbirth”. The birth-related services provided by obstetricians are identified as the “obstetrical package”. After nearly a hundred years of improving that ‘package’, Dr Gawande’s credits it with saving more lives each year that any other aspect of modern medicine. In his words: “… nothing else in medicine has saved lives on the scale that obstetrics has.”

Dr Gawande eventually gets around to telling us about new trends and cutting-edge developments obstetrics. As for the nature of their brave new world, Dr Gawande assures the reader that the “industrial revolution” in obstetrics is in the process of making Cesarean delivery consistently “safer than the normal biological process of childbirth”. He concludes by giving credence to the idea of elective Cesarean as the 21st century replacement for normal birth.

In describing the theory behind the liberal use of Cesarean, he says: “…. our deep-seated desire to limit risk to babies is the biggest force behind its prevalence; it is the price exacted by the reliability we aspire to. …. if medicine is an industry, responsible for the safest possible delivery of millions of babies each year, then … You seek reliability.

His revisionist history proudly touts the courage of the obstetrical profession to ignore the limitations and lack of creativity in evidence medicine. Or Dr Gawande’s puts it:

“In obstetrics .. if a strategy seemed worth trying doctors did not wait for research trials to tell them if it was all right. They just went ahead and tried it, then looked to see if results improved. Obstetrics went about improving the same way Toyota and General Electric did: on the fly, but always paying attention to the results and trying to better them. And it worked.”

The only line I personally agreed with was when he admitted that: Obstetricians did few randomized trials, and when they did they ignored the results.

As a former L&D nurse and current provider of maternity care, I enjoyed reading this article. Upon deeper reflection however, I realized that many of the crucial facts (especially those with political overtones) weren’t factual. The style of the article is misleading. If I were pregnant or planning on having a baby, his graphic accounts of rare complications and blow-by-blow descriptions of gruesome obstetrical procedures would convince me that I should either adopt, be knocked out or schedule a C-section. Amazingly, he managed to pair at least one catastrophe-related word to a birth-related topic in every sentence of a 1200 words section on birth complications.

It seems probable that someone provided Dr Gawande with cherry-picked information and a lot of encouragement for slanting the story in favor of the obstetrical agenda. His conclusions read like a ‘product placement’ for the obstetrical profession – a carefully constructed narrative designed to look like a public service announcement -- but in fact, it is a very well placed infomercial.
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Next post – Commentary on the labor and birth narrative, turned apology for an unplanned C-section and how the principle of physiological management care dramatically reduce similar unwanted intervention.

www.collegeofmidwives.org

www.sciencebasedbirth.com