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Thursday, April 03, 2008

republished from: Today at Our Bodies Our Blog

Nation’s Largest Hospital to Ban Vaginal Birth, NY State Likely to Follow

Posted by Rachel on April 1, 2008

New York City’s St. Sister Mercy General Regional Hospital, which is the nation’s largest hospital and presides over more births than any other facility, announced today that it would no longer offer vaginal deliveries. Hospital spokesperson John Smith stated, “We were on track to reach a 75% c-section rate within the year, and believe that women unnecessarily suffer when they attempt labor with a very small chance of being successful in our facility. Because most of our patients will eventually need repeat cesareans anyway, we believe that we are getting them off to the best possible start. We are encouraging other hospitals to adopt the same policy.”

The hospital is also letting go its team of certified nurse midwives, banning doulas, and banishing fathers back to the waiting room. According to Smith, “Given our new policy of cesarean birth for all women, we feel that support personnel are not needed for our patients, and simply get in the way of the physicians’ work.”

Asked about women who arrive at General unexpectedly in labor and whether they can offer informed consent to a mandatory c-section and implicitly agree to this by showing up at the hospital, Smith responded, “These women have a 75% chance of having a c-section to begin with - we all know that women are less capable of giving birth vaginally than they were just 20 years ago. We simply can’t treat unplanned patients any differently, or it would encourage women to just drop in when they’re in labor, and that would be a nightmare. We’ll bring in the machine that goes “ping,” and that will let us know they need a cesarean anyway, and proceed from there.”

At least one General patient agrees with the new policy. Consulted following her own primary cesarean, Jane Downt said, “I’ve always thought that birth would be so much easier if women’s bodies were designed differently, if they could just pop open a little panel and remove the baby. A c-section is just like that, opening a window into the body to pull the ‘bun out of the oven,’ so to speak.”

Women’s health, birth, and reproductive rights advocates, along with an aging hippie community in the city, have reacted strongly to the decision. One activist responded, “General had a very high c-section rate, and the CNMs were the only thing keeping it from reaching 100% already [the hospital banned VBAC five years ago]. They already insist that all women take home formula samples, even those who aren’t yet pregnant, keep the lights very bright, and allow women to leave the hospital without calling Child Protective Services if those women don’t plan to breastfeed. This is just another appalling new development, and it will drive women into their homes for birth.”

Smith responded, “The last thing we want women to do is give birth at home. To that end, we have proposed legislation that would ban pregnant women from being in their homes, or other homes or shelters, from week 30 of pregnancy until the birth. We believe in general that the safest way to give birth is not to do so at all, so we are working on a long-term plan to prevent any babies from being born in New York State. We just have to work out a feasible plan that will accommodate the rush of women eager to have their fertility and reproduction controlled by the State. We hope the visionaries in Washington, D.C. will take note of our leadership, and implement similar plans for the Nation.”

*Mark it on your calendar

Update: Now that the holiday has passed, I feel the need to explicitly point out that this was an April Fools’ piece, not intended so much to be funny, but to seem plausible on a quick read and play around with some of the stereotypes and extreme rhetoric that tends to surround birth discussions.

This entry was posted on April 1, 2008 at 8:10 am and is filed under Access, Rights, & Choice, Birth, Pregnancy, Women's Health. . You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.

Responses to “Nation’s Largest Hospital to Ban Vaginal Birth, NY State Likely to Follow”

Jim Voorhies Says: 
April 1, 2008 at 8:38 am
"I’m sure this trend toward C-sections is just a way of avoiding having to get right back into the fields and pick."

Friday, March 28, 2008

In a perfect world, healthy childbearing women would have reliable access to science-based birth care. They would never be forced to choose between an obstetrician and a midwife or between a hospital and a planned home birth in order to get the appropriate, physiologically-managed maternity care they are seeking. In the mean time, the controversy is almost exclusively focused on PHB and midwives, while little or nothing is being done to rehabilitate our national maternity care policies. An example of the asymmetrical nature of childbirth politics is the Homebirth Debate blog.

For the last 18 months, Dr. Amy Tuteur, a retired Ob-Gyn physician and mother of 4 has been hosting the Homebirth Debate blog. According to Dr. Tuteur’s bio, she practiced obstetrics in Massachusetts and was an assistant professor of obstetrics at Harvard. She also provided backup for planned home birth (PHB) midwifery at one time during her obstetrical career.

Many readers are already familiar with the regular topics discussed on the Homebirth Debate blog. In general, it insists that hospital birth is orders of magnitude safer than PHB. It may be a legal choice from the parents’ standpoint, but regular HBD bloggers believe that compared to hospital-based care, PHB is an irresponsible and unsafe choice that risks preventable death to both mother and baby. According to Dr. Tuteur, not a single study published in the last half century has ever been able to establish that:

(a) PHB for healthy women with normal pregnancies who have had appropriate prenatal care, are (b) attended by an experienced birth attendant (c) with appropriate access to medical services for complications or if requested by the mother (d) is a safe or responsible choice

In that vein, Dr. Tuteur also claims that no credible research has *ever* identified any unnecessary risk (iatrogenic or nosocomial complications) to be associated with the universal medicalization of normal birth -- hospital-based obstetrics that includes the routine or ‘pre-emptive’ use of medical and surgical intervention as the standard of care for healthy women.

Dr. Tuteur assures her readers that any ‘natural birth’ advocate who says otherwise is either personally deluded or, if they are birth educators or provide any birth-related services, such as labor attendants or midwives, they are misleading a gullible lay public.

The HBD blog expresses unbridled contempt for:

(1) Unattended Childbirth and the often ill-informed advise dispensed by its UC Internet user groups;
(2) untrained, unregulated lay midwives;
(3) the formal direct-entry education, clinical training and certifying exam for CPMs
(4) all forms of PHB and to a great extent, OOH birth in free-standing birth centers

One assumes that HBD bloggers want to influence on our national maternity care policies and practices in a positive direction. However, conflating these four quite different topics makes it unnecessarily confusing and argues against coming up with concrete plans for improvement. The waste land of Internet user groups will always defy the best effort of society and government to control, whether the topic is unattended childbirth, unconventional religion, dieting or white supremacy. No blog can eliminate the faulty thinking that may be promoted on various Internet sites.

My own direct experience as both a L&D nurse in the obstetrical ‘system’ and now licensed midwife who attends both PHB and planned hospital births, constantly reveals disturbing and potentially dangerous practices institutionalized in our obstetrical model of care over the last century. Sadly, being in a hospital L&D unit is no a guarantee of a perfect outcome. Babies and even mothers die in hospitals, sometimes from complications that could not be neither be predicted or successfully treated, no matter where the mother was or who provided care and sometimes from routine hospital practices that are inherently risky and introduce unnecessary dangers.

Complications caused by human error are known as ‘iatrogenic’ - actions or omissions by the physician or medical staff – and ‘nosocomial’, complications associated with institutional care, such as being given the wrong drug or contracting a drug-resistant infections like MRSA. Opportunities for iatrogenic harm include the obstetrical practice of routinely inducing labor at 40 or 41 weeks in healthy women with no medical reason. Cesarean section rate for first time mothers who are induced before their cervix is ‘ripe’ is 35%.

Unless or until our maternity care system is rehabilitated, the elimination of PHB would certainly put healthy women in an impossible situation. Any thoughtful person who has access to the scientific literature acknowledges that PHB is associated with a specific set of risks. While relatively rare in a healthy population with good prenatal care, risks for women who labor or give birth at home are real and when they occur, they can be life threatening.

For example, maternal seizure caused by a fulminating pre-eclampsia (high blood pressure), an umbilical cord accident or prolapse or a uterine rupture in a VBAC mother are much less likely to result in serious morbidity or fatality when the laboring woman is in the L&D unit of a tertiary hospital. Homes, independent birth centers, small and medium-sized community hospitals -- any place that cannot provide 24-7-365 blood banking services and operating rooms staffed around the clock by obstetricians (or obstetrical residents) and anesthesiologists -- cannot provide instant access to surgical delivery. It would be foolish to argue that emergency obstetrical services did not makes childbirth safer for those women with certain types of complications.

However, it must be noted that the ever-escalating rate of Cesarean surgery is not a safe way to use hospital services. Reducing medically-unjustified Cesarean sections can only be done by first questioning and then making changes in business-as-usual hospital obstetrics. The obstetrical profession’s bitterly argues the safety of ‘permitting’ VBAC labor in or out of the hospital but the very best way to prevent uterine rupture is to prevent the original, often unnecessary Cesarean that forever leaves the mother with scarred uterus and unnecessarily vulnerable to this catastrophic complication.

In addition to our skyrocketing Cesarean section rate and the astronomical expense, there are a host of other problems associated with using ‘industrialized’ obstetrics on healthy women. The obstetrical profession’s rejection of physiologically-based management of normal labor and birth and its replacement with the routine use of the pre-emptive strike is a cost-inefficient, illogical policy that needs to be reevaluated and rehabilitated.

These complex questions are inter-related with the history of American obstetrics and the long tradition of midwifery. The current form of PHB is a consequence of the irreconcilable conflict between these two very different models of maternity care. In a perfect world, healthy women would never be forced to choose between an obstetrician and a midwife or between a hospital and a planned home birth in order to get physiologically-managed maternity care.

So why the extreme difference of opinion on what the scientific literature has to say about interventionist obstetrics and PHB? Why the level of vitriol over these diverging opinions? Is there a ‘best answer’ and if so, what is it? What would it take to implement ‘optimal’ birth practices? How can healthy childbearing have reliable access to science-based birth care? What would it take for the US to develop a single standard of care for all healthy women based on the physiological management of normal childbirth? What kind of educational changes would be needed so this universal standard would used by all birth attendants (OBs, family practice physicians and professional midwives) and in all birth settings (hospital, home and independent birth centers)?

This Normal-Birth blog will devote a series of posts to the topics discussed on the Homebirth Debate blog. According to the HBD blog, PHB disasters occur with disturbing frequency, attributed in part to the OOH (out-of-hospital) location and partly because Dr. Tuteur believes the direct-entry (i.e., non-nurse) education for CPM midwives is substandard. If these claims can be substantiated, it would lead responsible people to seriously question the care of CPM midwives and PHB as a reasonable or responsible choice. For the next few weeks, we will try to take the different aspects of this controversy and see what we find.

The first topic will be the presence of formally untrained and unregulated midwives in the United States.

Monday, March 17, 2008

How Normal Childbirth
Got Trapped on the
Wrong Side of History

The perfect storm
that turned healthy women
into the patients of a surgical specialty
and normal childbirth into a surgical procedure

The Last and Most Important UNTOLD Story of the 20th century By Faith Gibson, LM, CPM

Excerpts from unpublished manuscript
Chapter One ~> A Time Traveler

I am a time and place traveler who watched the 20th century history of childbirth unfold, decade by decade. I experienced it first-hand as a labor and delivery room nurse, childbearing woman, a professionally licensed midwife and liaison to the California Medical Board representing the legal and legislative issues of California licensed midwives.

As a curious person with lots of questions about what I saw, I have studied everything that came into my hands on the history of maternity care, normal childbirth, and the practice of obstetrics through the ages. At 64 years of age, I have now dedicated the last stage of my professional life to telling what I describe as “the last and most important untold story of the 20th century”. The best-kept secret in modern times is how and why normal childbirth in a healthy population became the property of a surgical specialty and what the current costs and consequences of that are.

The best place for me to start this story is where it started for me – with the life-changing experiences I had as a virginal 18 year-old nursing student in a racially segregated hospital in the South and later as graduate nurse working in the labor & delivery room of that same segregated hospital. I characterize this as the ‘Dark Ages of the Deep South’. Due to a two-tiered (unequal) system of medical apartheid, I got to closely observe and directly participate in two entirely different systems, side by side, in the same hospital, at the same time, with the same staff and the same type of patients but totally different management style and outcomes, different as day and night.

It was a naturally-occurring, one of a kind scientific study of two contrasting types of childbirth management. One was a profoundly interventionist model characterized as “knock’em out, drag’em out” obstetrics. This is style of obstetrical management introduced by Doctors DeLee and Williams in 1910 and was used on our white maternity patients, with only minor modifications, for the next fifty years. For our black mothers, the counterpoint to intense obstetrical intervention was a lazier-fair system, the classic physiological management provided by family-practice physicians and midwives in other parts of the world. In 1961, it all depended on whether the mother was black or white.

hildbirth in Black and White

In our segregated southern hospital, Caucasian mothers were sent to the all-white labor ward on Five-North. On admission they were isolated from their family, asked to take everything off (we meant everything!) and get in a hospital gown. Then the mother’s clothes, eyeglasses, weddings rings and other jewelry, any dentures, braces, crutches (or artificial limbs) were placed in a brown paper bag and given to her husband in the waiting room. Fathers were not allowed in the labor and delivery area, so he was encouraged to go home, as he would not be able to see his wife until well after the baby was born. This was often 24 to 36 hours later.

Then newly admitted white patients were subjected to the traditional obstetrical ‘prep’. Because poor women in the early 1900s sometimes had pubic lice, hospital policy in the 1960s still required our white labor patients to have their pubic hair lathered up and shaved off. Because physicians in the early 1900s believed that infection following childbirth (childbed fever or puerperal sepsis) was sometimes the result of ‘autogenesis’ – that is, bacteria in the mother’s own vagina or intestines -- our labor patients were still being given a large soapsuds enema on admission. This was sometimes repeated every 12 hours if they weren’t in good labor. Once the admission rituals were concluded, laboring women were routinely medicated with 3 grams of barbiturates -- a double dose of sleeping pills -- and put to bed.

As labor progressed they were injected every 2-3 hours with a narcotic mixture known as “twilight sleep” – large and frequently repeated doses of morphine or Demerol, a tranquilizer drug and scopolamine. Scopolamine is a potent hallucinogenic drug that causes short-term memory loss and permanent amnesia of events occurring under its influence. Under these powerful drugs some women became temporarily psychotic and fought with the staff, sometimes even biting the nurse. If left unattended, medicated patients often fell out of bed and chipped their teeth or broke an arm. To keep drugged women from getting hurt, the hospital required a nurse to stay right at the bedside through out the entire labor.

Whenever the nurses were too busy to be able to stay with each patient full time, our white mothers were put in four-point restraints, with arms and legs attached to the rails at the four corners of their bed. These were the same heavy leather restraints used in the locked psychiatric wards of the hospital. They forced women to labor while lying flat on their back, a position that reduces blood flow to the uterus and placenta, making labor extremely painful and often causing fetal distress. Because labor was more painful when women were on lying on their back, the obstetricians in our area believed that labor was more effective when women were on their back, so they saw the use of leather restraints as an effective method for advancing the labor. A decade later, when we were no longer routinely using wrist restraints, some of our OBs asked the nurse to be sure the mother was kept on her back so that labor would be more effective. 

When the time came to give birth, our white mothers were moved by stretcher to an OR-type delivery room and put in stirrups. Then their pubic region was scrubbed again and painted with Mercurochrome and they were put to sleep with general anesthesia. In the late 1950s and early 1960s, the third leading cause of childbirth-related maternal death was the complications from obstetrical anesthesia. After the mother was unconscious, a “generous” (!) episiotomy was done, and the delivery room nurse instructed to provide “fundal pressure” (standing on a stool at the side of the delivery room table and pushing hard on the top of the uterus to press the baby down farther in the birth canal).  Simultaneously, the obstetrician used ‘low’ forceps to pull from below until the baby was finally extracted. This was followed by the manual removal of the placenta and suturing of the episiotomy wound.

For white babies that arrived under the standard obstetrical management, respiratory depression was the inevitable result of the narcotic drugs, anesthesia, anti-gravitational positions for pushing and the use of fundal pressure and forceps. The well-known effect of drugs and anesthesia was to obliterate the newborn’s normal gag reflex (all general anesthesia has this effect). Since the early 1900s, it has been the standard of care to vigorously suction the newborn’s nose and throat with a bulb syringe and repeat anytime there was a concern about the baby’s ability to breathe or any signs of choking. One of my jobs as a nurse in the all-white Five North delivery room was to resuscitate the many depressed babies who did not spontaneously breath at birth. As a consequence of general anesthesia and/ or the use of obstetrical instruments, a significant number were never able to breathe on their own. One of the reasons for high mortality rate of the era was these iatrogenic factors.

For the obstetrician, routine care for white patients usually ended with the infamous “husband stitch”. Double entente comments often accompanied this, as the doctor added a few extra perineal sutures to make sure the mother’s vagina was tight as a virgin’s again for her husband. Doctors explained that some of their new fathers complained that: “Ever since the baby was born, having sex with my wife is like walking into a warm room”. Our doctors apparently felt responsible for preventing this type of marital dissatisfaction.

After finishing his handiwork and removing his surgical garb, the obstetrician walked over to the waiting room and announced to the family that: “It’s a boy!” or “It’s a girl”. He would congratulate the father with a handshake and bask briefly in the family’s appreciation of his skill in safely delivering their baby, then send the relatives over to the nursery window for their first look at the newest arrival.

For the new mother, obstetrical management in the all white unit ended by being wheeled, still unconscious from the effects of anesthesia, to the recovery room. There she would lie on a stretcher for a couple more hours, retching and vomiting her way back to a dim consciousness before she finally asked “What did I have?” White mothers were always the least important person in this process and the very last to know about their own birth.

The Other Half of the Story – Labor on One South

As a student nurse, my head was still swimming from all this when I rotated off Five North to One South, the all-black ward. Oddly enough, the maternity care for black mothers was remarkably simple, straightforward, non-interventive, and in my uninitiated 18 year-old opinion, infinitely more humane. It met the mother’s psychological needs and made right use of gravity. Biologically speaking, it was both safe and effective. As judged by the number of newborns who did not need resuscitation at birth, it was vastly more successful than the medicalized version visited on their Caucasian counterparts upstairs on Five North. Frankly, all this was a big relief to me. It troubled me to be used an agent for a process that appeared to harm mothers and babies.

One South was a segregated ward in the basement of our hospital. The all-black ward was one of the oldest and most crowded wings in the hospital complex, shoe-horned in between the huge kitchen, industrial-sized boiler room and hospital laundry. One South had no labor ward or labor room nurse to care for black mothers, so black labor patients were just admitted to their postpartum beds in an old-fashioned four-bed ward. There were no admission rituals, no pills, no rules that said that black women had to labor in bed on their back.

In contrast to the restrictive policies and tight control in the all-white labor ward on Five North, the labors of our black mothers were not accelerated with Pitocin or any other drugs. Nor were they given ‘twilight sleep’ drugs for pain because there were only two staff nurses. They were already responsible for 40-plus other patients and had no time to labor-sit with drugged and combative women having hallucinations and trying to climb or fall out of bed. But in our segregated society, what black women in labor wanted (or didn’t want) just didn’t count. However, there were many unintended advantages to this system of purposeful neglect.

Left to fend for themselves, black labor patients moved around the big room, cheered on and cheered up by the older and more experienced women in the four-bed ward. This provided a useful source of encouragement and tips on how to cope with labor pain. Because they were undrugged and unencumbered, black mothers in labor were able to walk about freely, change positions at will or take themselves to the bathroom and sit on the toilet as the baby descended in the pelvis and they began to feel pushy. In particular, black mothers avoided lying down in bed, preferring to stand and hold on to the foot of the bed as they swayed or squatted during contractions. As a naive student nurse, I remember asking one young black mom why she didn’t just lie down in the bed so she would “be more comfortable”. She looked at me like I was a total idiot and in an irritated voice said: “ …’cause it hurts too bad when you lay down!”

By an accident of race, these childbearing women were the beneficiaries of racial policies based in prejudice which co-incidentally shielded them from narcotics and artificial hormones drugs to speed up labor or being forced to push in anti-gravitational positions. The labors of our black mothers were undisturbed and with rare exception, the physiological process unfolded as Nature intended.

Eventually one of our black maternity patients would start to make deep-throated guttural noises -- the unmistakable sounds of pushing. One of the floor nurses would grab a stretcher and help the mother lay down on it. Then we raced the stork through the hall to the elevator, hoping to make it to the 5th floor delivery room before the baby made its entrance. It was my frequent pleasure, as an impressionable student nurse, to ‘catch’ their precipitously born babies in the elevators that traversed the vertical and political distance between One South and Five North.

These normal births were managed physiologically by the nurses, which is to say, the mother gave birth spontaneously, pushing her baby out under her own powers. And wonder of wonder, these babies immediately breathed on their own, since their mothers had not been given narcotics or anesthesia and no artificial, forcible or mechanical means were used to accelerate the labor or pull the baby out. There was no painful episiotomy, no bleeding from a perineal incision, no forceps, no fundal pressure, no bulb syringe thrust repeatedly down the baby’s throat, no manual removal of the placenta. These lucky babies were enthusiastically embraced by their undrugged and fully conscious new mothers, who beamed proudly and proclaimed: “Look what I did!”

By today’s legal standards these black mothers were actually receiving “substandard” care. Racial prejudice and discrimination of the era had institutionalized what would be considered legally negligent treatment. Yet, they clearly were getting the better end of the deal. The nurses just talked these black mothers through the last couple of pushes and their babies just slipped out, with little fuss.

Had anyone in our hospital or our town or any researcher at the CDC been paying attention to this impromptu study of two opposing styles of birth management, the winner would clearly been the black moms on One South. They enjoyed the safer, physiologically managed labors and normal spontaneous births, while being protected from the routine indignities and painful interventions that were the norm five floors above. 

Our black labor patients were not subjected to the labor-retarding effects of social isolation or immobilized on their backs with four-point psychiatric restraints. They did not have their memory erased by scopolamine or their labor slowed down by narcotics, no routine use of forceps damaged to the mother’s pelvic floor or her baby’s cranium. The new mother was not debilitated by the slowly healing episiotomy that made it hard to sit and difficult to care for a new baby. Their babies were not exposed to intrauterine narcotics and the resulting fetal distress, nor did they need to be resuscitated. This no doubt contributed to increased IQ points and, according to three Scandinavian studies, a reduced the incidence of drug addiction as young adults. It was clear to me that Mother Nature knew what she was doing.

A Practical Application of our Black-White Study –an “N” of one

When expecting my first baby, I took my lesson in childbirth out of that same book. In an attempt to avoid the detrimental effects of these interventions, I asked my obstetrician if I could have the same kind of care that our black mothers received. He smiled and kindly suggested that I just stay out of the hospital until the baby was ready to be born because “that’s what hospitals are for -- drugs and anesthesia”.

As a good and faithful nurse I did as I was instructed to do by my doctor. I labored at home as long as possible, hoping against hope to have a nice nurse-managed birth on a stretcher in that same elevator on the way up to the Five North delivery room. As luck would have it, I misjudged by just a few miles. While my husband drove the family car, I gave birth in the back seat of our Renault to a lovely baby girl, just five blocks before we turned into the hospital driveway. It was one of the most surreal moments in my life – to be the first person after God to welcome and hold my brand new daughter. That was the second milestone along the road to my eventual career in midwifery.

My L&D Time Warp – 1910 to 1976

Historically speaking, the policies and the process for providing obstetrical care to the white population of our hospital in the 1960s were pristinely unchanged since 1910, except for replacing the chipped white paint on the OR-style delivery table for shinny new chrome and substituting safer cyclopropane anesthesia for the much more dangerous chloroform and drip-ether. On my last day of work in the L&D unit of that hospital in August of 1976, the obstetrical protocols still included routinely confining the mother to bed, medicating her with narcotics and scopolamine during labor and giving general anesthesia for delivery. Normal birth was still conducted as a surgical procedure that included episiotomy, forceps, manual removal of the placenta and sutures. It still ended with the mandatory separation of mother and baby and the unconscious mother was still the last to know ‘what she had’.

As a L&D nurse, I worked as hard as I could for years to rectify the tension between the two opposing models of maternity care used by every hospital in our part of the state. But I was utterly unable to make the 1910 version of obstetrics move even a tiny millimeter towards the physiological model that served our black moms so well. It finally became obvious that normal childbirth was permanently trapped on the wrong side of history, at least in Orlando, Florida. I threw in the towel and asked to be transferred to the ER, where I worked as emergency room nurse for the next several years. I was too traumatized by being the agent of the ‘new’ obstetrics to ever again be employed in a system that required me to do things I knew were harmful, humiliating and painful. Eventually I joined a domestic Peace Corps project was doing community development work and moved to the project in North Carolina.

Relieved of these onerous duties, I was able to get a better perspective on the issue and to study the problem without so much emotional angst. What I discovered was heartening, as it provided logical reasons for why and how the ‘new’ obstetrics came to be at odds with the fundamental nature of maternity care, which is to make normal childbirth safer and more satisfactory for healthy mothers and their unborn/newborn babies. My study brought me insight, a rational plan to address the immediate problems and a set of principles for restoring balance and rehabilitating our national maternity care policies. 

One of the most simple and central issues is the current use of a surgical billing code for physiological childbirth. Normal birth needs its own specific billing code. A physiological code would once again acknowledge that childbirth is a continuum. Continuity of care by the primary birth attendant during active labor, the birth and the first hour or two of the new baby’s life is a biological imperative for safe childbirth. Fair compensation for birth attendants, via a physiologic billing code, is an economic imperative for birth attendants and institutions and the lynch pin to making the system work for everyone.

~> Next topic will focused on the recent discussion on Dr. Tuteur’s Homebirth Debate blog

Sunday, March 16, 2008

So far, this Normal-Birth blog has been a forum for articles published in the New Yorker and the New York Times that impacted on our 20th century American habit of medicalizing (or as one author put it “industrializing”) maternity care for normal childbirth.

In a perfect world, healthy women with normal pregnancies would not be forced to choose between an obstetrician and a midwife or between hospital and planned home birth. Regardless of the category of caregiver or planned place of birth, they would be able to get acceptable, appropriate, accessible and affordable maternity care.

The core issue for the 21st century is the appropriate use of physiological management versus a national maternity care policy that promotes the inappropriate and medically-unjustified use of obstetrical interventions in the care of healthy women who do not want or need them.

Some in the obstetrical profession continue to promote Cesarean surgery as the de facto standard of care for the 21st century. You might say that normal birth itself is on the endangered species list and women who insist on having at least the opportunity for a normal (non-medicalized) labor and a spontaneous birth are accused of engaging in the ‘extreme sport’ of biological childbirth to the detriment of their unborn babies.

I will continue to utilize this little corner of cyberspace as a safe place for people to comment on and grapple with the needless and ever-escalating medicalization of normal childbirth and all the problems associated with such a model. The rules of debate apply, which is a focus on the exchange of ideas and not the personhood of the speaker. Honorable people can have divergent opinions based on different interpretation of same data. In addition, different values inevitably bring participants to different conclusions.

For any blogger who is not sure what that means, it is the old-fashioned Golden Rule – don’t do (or say) to others what you would not want said or done to you. Love does not kill to save. Killer conversations include sarcasm, name-calling, and a basic attitude of contempt for the other person (as distinct from rejecting ideas you believe to be wrong) Also, please no text message / email abbreviations for Rolling on the Floor Laughing or similar derogatory cross-talk aimed at a third person. Such posts will be deleted from this blog.

Please also note that the blog is not per se devoted to the topic of midwifery in its many forms (lay, licensed direct-entry and certified nurse midwifery), nor is it devoted to promoting either home or hospital birth as a universal national policy.

Although I am a midwife, I see the problems of childbearing women and normal birth itself are a much higher priority than those of midwifery. I don’t think that the difficult issues that all midwives faces today (nurse midwives included) can be corrected until the fundamental problem with our national maternity care policy is adequately addressed.

The core issue is an obstetrical Dark Ages of a 100-years duration that has devalued and eliminated the principles of physiological care by defining them as not appropriate to be included in a medical school education or permitted to be used in obstetrical practice. It was (wrongly) assumed that physiological management was ‘women’s work’ and as such, it was old-fashioned, inferior and inadequate to the problems of childbirth at the end of the 19th century. It must be remembered that the discovery of antibiotics and many of the diagnostic tools that allow us to detect and correct problem pregnancies were decades away. Detrimental effects of poverty, overwork, forced childbearing, close–spaced pregnancies, high parity and general status of public health in the U.S. was very low when compared to Europe and other developed countries.

Many of the decision make in the early 1900s were genuine attempts to address these problems at a time when so-called "modern medicine" was still in its infancy and had few effective tools. The issue for us now, in the first decade of the 21st century, is to reassess these historical decisions and reevaluate the principles, policies and practices that inadvertently gave rise to our contemporary form of care -- the universal application of interventionist obstetrics as the standard of care for healthy women.

Until we rehabilitate our national maternity care policy, these long-standing conflicts will be un-resolvable. Advancing levels of medicalization by the obstetrical profession are in sharp contrast to the persistent pull towards physiologically-based care by a growing number of vocal women who are deeply disenchanted and distressed by business-as-usual obstetrics. This highly unstable political situation poisons any attempt to reconcile the conflict between the disciplines of medicine and midwifery.

So here is the first installment of a chapter from an unpublished manuscript. While this chapter describes events that took place decades ago, I can testify to how the fundamental issue remains pristinely unchanged – narcotics, general anesthesia and routine use of forceps have morphed into epidural, vacuum extraction or Cesarean section, but it is still a system that fails to acknowledge the mother as the central and primary ‘actor’ in the events of childbirth, the one who gives birth. Instead, normal birth continues to be defined, as it has since 1910, as a surgical procedure ‘performed’ by an obstetrically-trained specialist. The identified role of new mothers is to be appropriately grateful afterwards.

How Normal Childbirth
Got Trapped on the
Wrong Side of History

 The perfect storm
 that turned healthy women
 into the patients of a surgical specialty
 and normal childbirth into a surgical procedure:

The Last and Most Important UNTOLD Story of the 20th century

Notes on Vocabulary ~

Linguistically, childbirth is a slippery sloop as soon as the word ‘child’ is separated from the word ‘birth’. I specifically use the word “childbirth” to encompass the whole biological process of laboring and giving birth as a continuum of activities that originate with the mother. As a biological category, it is the mother who gives birth, which includes being pregnant and the entire physiological process of laboring, including the birth of the baby. After the fact, the baby is said to have been born and the occasion is said to be the baby’s ‘birthday’.

The qualitative difference we have created in our minds and in our medical system between ‘labor’ and ‘birth’ is one of language rather than biology. Only in language, hospital architecture and obstetrical billing codes, does a bright line between ‘labor’ and ‘birth’ actually exists. Biologically-speaking, labor is the on-going process of uterine contractions that dilates the cervix and helps (along with the mother’s abdominal muscles and her voluntary efforts) to push her baby down into her pelvis and through the birth canal. As the mother labors to push her baby out, the baby's head will finally slip over her perineum and out into the world. During these few minutes, we say the mother is “giving birth” and after the baby is free of its mother’s body, we say the baby was born -- a passive state of affairs from its perspective. But the reality of laboring and giving birth is a process that lies on a continuum and remains intrinsically intertwined.

However, language and obstetrical billing codes do allow the last few minutes of labor -- those moments when the baby is being born -- to be renamed ‘the delivery’ and subsequently categorized as a separate activity or ‘procedure’ performed by the birth attendant (instead of the mother) and controlled by institutional policy. When the act of giving birth is defined as a medical procedure, hospitals have a legal right to refuse to perform the ‘procedure’ of vaginal birth. Currently, the definition of childbirth as a ‘procedure’ is used to deny some women the fundamental right to give birth normally, which is reflected as a hospital policy that forbids the procedure of vaginal delivery when the mother-to-be has had a previous Cesarean, or her baby is breech, is thought to be bigger than average, is a twin pregnancy, the baby is overdue, etc. In these cases, hospital policy requires that obstetricians on staff perform the invasive surgical procedure of Cesarean section. The take-home message is that words surrounding childbirth are a big deal and it matters how they are defined and who does the defining.

One last linguist note: There is no such stand alone verb as “birthing”, unless you are quoting dialogue from the Civil War movie “Gone with the Wind”, when the maid tells ‘Miss Scarlet’ that she “don’t know nothin’ ‘bout birthin’ no babies!” In real life, the active verb is “to give” and ‘birth’ is the object of that action. The mother is the source and giver of the energetic efforts that produce the baby. Birth is what happened, passively, to the baby.

Having been born myself at one time, I am grateful to my mother for all her hard work. Having given birth three times myself (preceded by painful fertility surgery), I remember all that hard work! Out of respect for all the women who gave birth gazillions of time over the untold millennia of to the human species, I decline to diminish the mother’s central role and cheat her out of this accomplishment by using a linguistic short-cut that skips over the ‘giving’ and substitutes the bastardized passive verb: birthing. I encourage others to likewise remember and honor the verb: To Give Birth.

Tomorrow -- excerpts from Chapter One

Sunday, February 03, 2008

Commentary in response to
New York Times' November 25th Editorial
on the High Cost of Health Care
Faith Gibson ~ February 3, 2008

Originally posted on on December 31, 2007

The New York Times’ op-ed piece on “The high Cost of Healthcare” (11-26-07) was excellent. However, it failed to mention the most frequent, most expensive and most misunderstood healthcare issue in the US – the unnecessary medicalization of normal childbirth for 3 million healthy women every year. For the last hundred years, the US has had a policy of using interventionist obstetrics as the primary source of maternity care for healthy women. The core of this obstetrical system – normal birth as a surgical procedure -- was developed in 1910 to prevent hospital epidemics of childbirth-related infections in a pre-antibiotics era. Since one-fifth of our annual healthcare budget is spent on maternity care, no effort to reform our national healthcare system can afford to ignore our expensive habit of medicalizing normal childbirth.

This issue has nothing to do with the appropriate use of obstetrical intervention to treat the 30% of women who develop complications. It’s obvious that modern obstetrical medicine is indispensable to modern life. As a mother, I have personally benefited from these medical miracles; as a maternity care provider, I greatly respect the life-saving skills of the obstetrical profession. The question is the wisdom, safety, and economic impact of routinely using invasive obstetrical interventions on a healthy population.

Ninety percent of women who become pregnant every year in the US are healthy; seventy to eighty percent are still enjoying a normal pregnancy nine months later. While the ratio of ill health and pregnancy complications in 2007 is many times less than it was in the early 1900s, the number and frequency of obstetrical interventions has sky-rocketed all out of proportion over the last century. As American women have become progressively healthier, the operative delivery rate in the in the US has inexplicably risen with every decade. We seem to have lost sight of the basic purpose of maternity care, which is to preserve the health of already healthy women. Mastery in this field means bringing about a good outcome without introducing unnecessary harm or unproductive expense.

Out of the approximately four million babies born each year, nearly three-quarters of all obstetrical care goes to pregnant women who are healthy and have normal pregnancies. The medical intervention rate for this healthy population is 99%, with an average of seven significant medical procedures performed during labor on millions of healthy childbearing women every year. More than 70% of these new mothers will have one or more surgical procedures during birth – episiotomy, forceps, vacuum or Cesarean section. Over 2 million operative deliveries are performed each year in the US on this healthy population of women [a]. For the last two decade, Cesarean section has been the most commonly performed hospital procedure in the US [b]. In 2006, it was 31% of all births or 1.3 million Cesarean surgeries, equal to the total number of college students that graduate each year, with a price tag of approximately15 billion dollars.

One reason for the ever-increasing Cesarean rate is three decades of ever increasing obstetrical intervention in so-called “normal” vaginal births, a situation heavily influenced by the malpractice litigation issue. Since 1970, at least one major intervention has been added to the standard of care every couple of years. One by one, old and new medical procedures and restrictive protocols have been added to the labor woman’s experience. You can’t put a laboring woman in bed and hook her up to seven (or more) IV lines, electrical leads, tubes, automatic blood pressure cuff, pulse oximetry, catheters, and other equipment without profoundly disturbing the normally spontaneous biology of labor. Each new intervention or drug introduces an independent risk, which is then multiplied by the aggregate of unpredictable interactions with one another. Every single invasive procedure increases the likelihood that a new mother will become infected with a drug-resistant bacteria such as MRSA (the Methicillin-Resistant Staphylococcus Aureus), a problem that already results in 90,000 nosocomial (hospital-acquired) infections every year.

Despite meticulous professional attention, ever higher intervention rates, and the huge amount of money spent on the American way of birth, we are still unable to match the better outcomes enjoyed by industrialized countries that use low-intervention maternity care systems. They achieve this laudable accomplishment by training physicians and professional midwives to manage childbirth physiologically, while reserving obstetrical interventions for women with complications and those who request medical interventions. Cost-effective maternity care systems spend only a half to a third of what we do, while they enjoy a vastly superior outcome. At last count, the US was an embarrassing 32nd in perinatal mortality and ignoble 30th in maternal mortality.

During the 20th century there has been a steady improvement in maternal-infant outcomes around the world. Many assume this was the result of medicalizing normal childbirth in the richest countries, particularly the US. However, it turns out to be the result of an improved standard of living, general access to medical care and preventive use of people-intensive, low-tech maternity care. This describes the prophylactic use of the eyes and ears and knowledge base of maternity care professionals who are able to screen for risk and refer for medical service as needed. This is the best ‘medicine’ for normalizing childbirth in a healthy population. As the medicalized model is currently configured in the US, it’s virtually impossible for any obstetrician or nurse midwife to provide physiologically-based care or for any mother have a truly physiological birth. If we are to successfully compete in the global economy of the 21st century, we must develop a cost-effective maternity care system that relies on physiological practices for healthy women.

Unfortunately obstetrics in the US has turned its back on physiological childbirth for a hundred years. When combined with the unwarranted use of interventionist obstetrics, this disturbs the biological functions that make a normal childbirth possible. Millions of pregnant women are spending the many hours of their labor lying in bed while an extensive array of counterproductive and medically-unnecessary procedures are done to them. The word for this is iatrogenesis. The obstetrical response to the increased morbidity that accompanies excessive intervention in vaginal birth is to propose the ultimate iatrogenic intervention – electively performed Cesarean surgery. There is a move within the obstetrical profession to promote electively scheduled Cesarean for healthy women as the preferred standard of care for the 21st century.

Replacing normal, low-risk biology with scheduled abdominal surgery is being promoted as better, safer and more economical, a two-for-one special that is suppose to be buying us better babies while saving the mother’s pelvic organs from the horrors of normal birth. It’s also being described as a gender rights issue and part of a woman’s “right to choose”. Renamed as the ‘maternal-choice’ Cesarean, medically unnecessary C-section is identified as the ultimate expression of control by women over their reproductive biology. Unfortunately, claims of improved safety or lowered cost do not square with the facts. What we are not being told is that the scientific literature identifies many of the complications of Cesarean to be the same complications that Cesarean surgery was suppose to save us from. One recent study from France identified a 3½ times greater maternal mortality rate in electively scheduled Cesareans in healthy women with no history of health problems or complications during pregnancy. Another study on the elective or non-medical use of Cesarean surgery documented an increased mortality and morbidity for newborns.

The Medical Leadership Council (an association of more than 2,000 US hospitals), in its 1996 report on cesarean deliveries, concluded that the US cesarean rate was:

“medicine’s equivalent of the federal budget deficit; long recognized as [an] abstract national problem, yet beyond any individual’s power, purview or interest to correct.”

That’s pretty grim -- a disjointed, economically-strapped and liability-burdened obstetrical system unable to help itself. I guess it’s up to consumers and (one hopes) investigative journalists to take on the problem. If the US is to successfully compete in the global economy of the 21st century, we will have to develop a cost-effective maternity care system that relies on physiological practices and is suitably “green”, that is, has a much smaller carbon footprint than our current system. Obviously, we can’t eliminate the excessive use of Cesareans without providing an effective alternative -- a plan that safely reduces the inappropriate reliance on technology, medical intervention and surgical delivery while meeting the physical, emotional and psycho-social needs of childbearing women. To bring about the necessary changes, we must initiate a robust public dialogue and reassess the unproductive methods that have captivated everyone’s imagination for the last hundred years.

Science-based Maternity Care for 21st Century

A consensus of the scientific literature identifies the physiological management of normal birth as the safest and most economical type of maternity care for healthy women. It’s the one used by countries with the best maternal-infant outcomes. Stedman’s Medical Dictionary defines physiological as: “…in accord with or characteristic of the normal functioning of a living organism”. When providing care to a healthy childbearing population, physiological care should be the foremost standard used by all birth attendants and in all birth settings.

Physiological care is a not passive or neglectful, it’s not just abstaining from the unnecessary use of medical interventions. It’s an active process for preserving maternal-fetal wellbeing that requires a technical body of knowledge and specific skills for addressing the physical, biological, and emotional needs that women face during labor. This model is always articulated with the healthcare system and includes the appropriate use of obstetrical interventions for complications or at the mother’s request.

Physiological management during labor and birth is associated with the lowest rate of maternal and perinatal mortality. It is protective of the mother’s pelvic floor and has the fewest number of medical interventions, the lowest rate of anesthetic use, obstetrical complications, episiotomy, and operative deliveries. For women who choose physiologically managed care, the C-section rate ranges from 4 to 10 percent, which is three to seven times less than medicalized childbirth [British Medical Journal June 2005]. Millions of health care dollars can be saved every year on the direct cost of maternity care and a reduction in post-operative, delayed and downstream complications associated with Cesarean surgery. []. This is a hugely important savings to employers who pay for employee health insurance, for taxpayers who underwrite government-financed programs for the indigent and for the uninsured who must pay out of pocket.

A non-interventive approach to normal childbirth is careful not to disturb the natural process and to provide for appropriate physical and psychological privacy for the laboring woman. Its principles include patience with nature and continuity of care as provided by the primary caregiver throughout active labor. It acknowledges the mother's right to control her environment and to direct her own activities, positions & postures during labor and birth. This may require changing institutional policies that interfere with the physiological process. To help achieve these goals, evidence-based maternity care employs one-on-one social and emotional support and an absence of arbitrary time limits. Women are encouraged to move around during labor, to walk, change positions, be in the shower, etc. Being upright and mobile during contractions also diminishes the mother’s perception of pain, perhaps by stimulating endorphins. It takes into account the positive influence of gravity on the stimulation of labor. Right use of gravity helps dilate the cervix and assists the baby to descend down through the bony pelvis.

Physiologically-based maternity care for normal childbirth serves the needs of healthy families far better than our expensive and inflexible high-tech model, which is two to ten times more expensive than it should be. For example, a medically managed but otherwise totally normal vaginal birth in the San Francisco Bay area is about $32,000. In addition to the large initial cost, many common obstetrical interventions result in costly downstream complications, such as damage to the mother’s pelvic floor following episiotomy or instrumental delivery. Having had a Cesarean means a future risk of placental abnormalities, stillbirth, and emergency hysterectomy in a subsequent pregnancy.

Physiological management is misunderstood by the American medical profession, who tend to think of it as incompetent, negligent or substandard care and a horrible waste of their extensive and expensive medical education. We have a dysfunctional system because the default setting for childbirth in the US for the last hundred years has been obstetrical intervention. As a result, obstetricians see a disproportion number of complications and readily assume that the biology of birth is itself defective. The assumption that childbirth is pathological creates a negative feed back loop that appears to justify an ever-increase level of medicalization. The obstetrical profession rarely acknowledges any causal relation between increasing rates of intervention and a rising levels of problems. Unfortunately, the 20th century legal standard for obstetrical care locks every obstetrical care provider into the same system and forces them to use the same invasive protocols, even when they personally know that physiological management is more appropriate to the situation.

Our 1910 system of medicalized maternity care has never been reexamined by modern scientific standards, or asked to account for its economic impact. To date, the most important untold story of the 20th century is how and why normal childbirth in a healthy population became the property of a surgical specialty and what the current costs and consequences of that are.

Judging a System by its Results

Ultimately, a maternity care system is judged by its results -- the number of mothers and babies who graduate from its ministration as healthy, or healthier, than when they started. Medicalizing healthy women makes normal childbirth unnecessarily and artificially dangerous and is unproductively expensive. But unlike many of the problems facing us today that have so far defied our best efforts– cancer, terrorism, affordable healthcare for aging baby-boomers, etc— we know how to make a maternity care system for healthy women be safe and cost-effective. As a national maternity care policy, physiological principles should be integrated with the best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women.

The question is simply this: How much longer will we be content to use an expensive, pathologically-based 19th century system for our healthy 21st century population?

Reference numbers refer to information on the Addendum {PDF version}.
Topics either include the citation directly or a numbered bibliography