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Tuesday, April 28, 2009

Safety and Normal Birth: Turning A Bitter Historical Truth into a Bright Future

For three decades, birth activists and the obstetrical profession have hotly debated whether ‘normal’ birth is a functional and dependable aspect of our biology or a dysfunctional and harmful ‘patho-physiology’. Both sides agree that life-threatening complications do occur during pregnancy and childbirth but that is where the commonality stops. They are sharply and bitterly divided on the frequency and circumstances surrounding these serious problems and how best to prevent them. Each side is utterly convinced that the other side is utterly wrong.

As a diligent student of the science underpinning this issue, I say that both are off the mark in different ways. Many prospective parents, birth activists and a fair number of midwives do not appreciate the potential for unexpected but nonetheless life-threatening complications to occur, while the obstetrical profession believes that pregnancy and childbirth are nothing less than one disaster after another and anyone (mother or midwife) that even consider laboring and giving birth outside of a well-equipped hospital must be criminally insane.

The connection between Black Swans and Complications -- the high impact of highly improbable events

Before I identify the facts that will allow us to arrive at a reasoned conclusion about the safest, most appropriate and cost-effective model of maternity care, I’m going take a small detour into the general topic of risk – the chance that something serious will go wrong while we are traveling, pregnant, giving birth, serving in the military, etc. Two elements are necessary before we can judge the risky-ness of any event or circumstance: information on what could go wrong in severity and in frequency: how likely we personally are to suffer the impact of an improbable but difficult, painful or life-altering event – illness, injury, crime, bankruptcy, get sued, die, etc?

A lot of research has been done on the psychology of how humans relate to risks and risk-taking and many authors have published excellent articles on the subject. However, the one most useful for our purposes is a book called “Black Swans – The Impact of Highly Improbable Events” by Nassim Nicholas Taleb. It’s s long book, with many important and fascinating ideas, but I will stick to a small handful that help us to understand why humans generally have trouble accurately determining risk and why realistic assessment of risk in pregnancy and childbirth is distorted by both sides. In 20th century America, the nature of childbirth and the ‘proper’ form of care during pregnancy and childbirth has rising to the level of a bitter political controversy, one not much different than unlike partisan politics or opposing religious beliefs. The observations on human behavior described by Nassim Taleb give us some tools to help sort these things out and come to some intelligent conclusions.

Pattern recognition vs. computation: People prefer to get information through patterns (a quick mental picture), rather than arithmetic – always have, always will.

Narrative -- i.e., story form – is a patterned form of communication. Information provided as a narrative helps people simplify and organize lengthy or complex sets of data into story form, which makes it easier to ‘understand’, remember and recount to others.

Narratives always leave out more than they put in and are heavily influenced by the person creating the narrative. The temperament, emotions, style and goals of the individual who constructs a narrative decides which of the raw bits of data to emphasis and which to gloss over or leave out.

Considering the selectivity of the narrative form – what is left out and what is included as a series of personal choices of the story teller -- social scientists question whether distilling information into patterns actually represents a true understanding of the concept or if simplification leaves us with an incomplete or biased idea.

The nature and complexity associated with highly improbable but high impact events can lead even the most well-meaning people into one or more traps – that is, an illogical conclusion fiercely believed to be demonstrable ‘truth’. In regard to most topics, this falls into one of the two extremes: (1) the believe that because you have never encountered a ‘bad’ outcome, that such things are really not a significant issue (2) Because you had a direct or indirectly experience of a bad outcome, that such things are so frequent and so catastrophic, that it is worth ANYTHING – any money, any effort -- to prevent.

For our purposes, it must be noted that birth activist and obstetricians have rather naturally opposite conclusions about the risks of spontaneous birth and the rewards of obstetrical interventions.

Lets return to our topic – childbirth – and look closer at the story that each side tells itself and promotes in the public arena:

Those who believe that childbirth is a safe aspect of our reproductive biology are convinced that complications are the result of poverty, poor healthy and economic deprivation in third world countries. For healthy women with normal pregnancies in wealthy countries such as the US, the problems of pregnancy and childbirth are assumed to be (1) exceedingly so rare or (2) the result of unnecessary, unwanted and unwise obstetrical interventions. This conclusion is that birth would turn out perfectly well, if only those meddlesome doctors would leave things alone and let Mother Nature do her thing unimpeded.

The obstetrical profession is diametrically opposed to this thinking. They are convinced that childbearing is an inherently destructive biological process and that life-threatening problems are a basic, count-on-able characteristic of childbearing. Once the genes are passed on to the next generation, the vessel – the female of the species -- becomes expendable, so Mother Nature casually sacrifices women in childbirth with the same disregard for individual wellbeing as She displays towards salmon that die after spawning.

According to the obstetric perspective, complications are more frequent in high-risk pregnancies, but no matter how healthy the mother, how normal her pregnancy, or how spontaneously progressing the labor, distrust of childbirth is justified. This is expressed in the obstetrical truism “Mother Nature is a bad obstetrician”, indicating that depending on normal biology is at one’s own peril. The only defense is to ‘head-em-off-at-the-pass”, via the preemptive use of interventions as a strategy of prevention.

The relative safety of PHB, compared to hospital-based obstetrical care, cannot be meaningful evaluated without addressing the bias on both sides. Such extreme and mutually exclusive views cannot both be true. In all probability, both sides are likely to be wrong in some ways and right in others. This means that so far, neither side has identified the actual dangers associated with childbearing, so that parents, professionals and policy makers could design the best system for maternity care for healthy women, one that is both safe and cost-effective AND meets the practical needs of childbearing families. An undertaking of this magnitude requires is impossible without first developing a deep understanding of the topic.

Irreducible risks and dangers of childbirth in a healthy population

Rule #1: Evaluating the irreducible risks and dangers of childbirth in a healthy population must occur in the context of time and place. Women do not give birth in isolation from their culture, as if they were spinning around in outer space tethered to an oxygen mask. It is no more appropriate to judge the ‘safety’ of childbearing in isolation from modern biological science than any other aspect of our physical wellbeing. Health and longevity for infancy, childhood disease, accidents and injuries, as reflected in morbidity and mortality statistics

In particular, we need to know what happens (how bad and how often) in the absence of all health care services -- when access to science-based maternity care and comprehensive obstetric services are totally absent or they are culturally unacceptable and therefore not used even when obviously needs. Both of these situation frequently occur in third world countries. The same question applies to First World countries with a childbearing population that is generally healthy (over 70% of all births), economically advantaged and has ample access to medical and maternity care and comprehensive obstetrical services.

Extreme Dangers, Dangerous Extremes and the Middle Way:

According to studies and statistical records, the majority of bad outcomes are associated with the two opposites ends of the maternity care spectrum. The greatest risk is associated with under use of medical services – especially the absence of care. The other areas of increased risk is associated with over medicalization, which introduces different hazards and iatrogenic and nosocomial complications and the considerable added expense accompanying this problems. It is the middle of the maternity care spectrum that has the fewest adverse events and best outcomes. This is an articulated model that integrates the classic principles of physiologically-based care, with the best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women.

Here are the principles underlying those observations.

(1) Lack of access to (or ideological rejection of) maternity care and medical services during pregnancy and childbirth accounts for the great majority of maternal-infant mortality and morbidity. Horrific suffering, permanent disability and lost of life is the background risk of childbirth in a pre-scientific world that lacks any capacity to detect or treat obstetrical complications. This is often the case in developing countries, especially sub-Sahara Africia, where maternal mortality ranges from 800 to 1,100 per 100,000 pregnancies. On average, one mother dies for every 90 births.

However, this also applies to the developed world when prenatal care and obstetrical services are unaffordable, unavailable (lack of transportation, etc) or prohibited by cultural beliefs. This latter category includes childbearing women, husbands or other close relatives that reject the use of obstetrical services when a complication has developed. It also applies to labor and birth attendants that have a prejudice against the use of medical services, discourage or deny the applicability of it to a particular situation or fail to recognize an emergent need for medical or surgical intervention.

(2) When compared to evidence-based physiological management, medicalized pregnancy and childbirth services in a healthy childbearing population, which includes the preemptive use of obstetrical interventions, increases maternal mortality and morbidity by statistically significant rates and in some studies, a slight increases infant mortality and morbidity.

Two compelling situations made interventionist obstetric the standard of care in the US. The first is a century-long tradition of obstetrics as a surgical specialty.

As a surgical specialty, childbirth is a professional service for which the obstetrician is totally responsible. A physician-surgeon is legally defined as the “captain of the ship”, making him or her liability for everything that happens to the patient while under his/her care. Under these rules, the birth or ‘delivery’ becomes a surgical procedure performed by the birth attendant.

The second situation is blowback for the high malpractice litigation rate for obstetrics as a specialty. This continues to fuel intensive efforts to reduce the litigious risk to obstetricians and hospitals.

There are two major contributors to a small but statistically significant increase in mortality and morbidity in highly medicalized maternity patients.

The first category is systemic problems: lack of continuity of care, an inattentive staff that fail to recognize or respond to a complication and a busy or short-handed staff overwhelmed by the number of patients or deficiencies in the institutional system.

The second category is iatrogenic and nosocomial complications: hospital-acquired and drug-resistant infections, side effects and adverse reactions to drugs, procedures or treatments or synergistic interactions between by drugs and/or treatments.

In the US, an average of seven significant medical and surgical interventions are used every year on each of the 4 million women who give birth. This intervention rate is 2 to 10-fold higher than physiologically-based care. Interventionist obstetrics annually generates 28 million medical or surgical opportunities for medical errors, adverse events, anesthetic accidents, hospital-acquired infections, and unanticipated consequences such as delayed or downstream complications. This sheer volume makes increased maternal mortality inevitable.

The shadow side of medicalization rarely ever makes it into the public press, except as undifferentiated statistics for iatrogenic mortality. This is usually characterized in the media as ‘medical errors’, which account for 100,000 deaths each year. There are no figures for what percentage of that applies to obstetrical care, but 25% of all hospital care is maternity care, obstetrical care generates 8% of all malpractice suits, 50% of which involve the use of Pitocin to induce or speed up labor. Obstetrical training materials developed to teach risk-reduction strategies to nurses, midwives and other professionals recount many vivid examples of preventable ‘adverse events’ occurring during labor and hospital delivery.
The facts of each situation often show how the sheer complexity of medicalized labor triggers unexpected problems.

One recent example was a hospital in the UK that had 10 preventable maternal deaths within a few years, 3 within a few months. One maternal death occurred after bupivacaine, the local anesthetic used in epidurals, was accidentally put in the mother’s IV line in her arm instead of the epidural catheter in her back. A host of precautions and intricate protocols are suggested to prevent such ‘errors’ in the future, but many of them increase the complexity of medicalized care. This unintentionally and unavoidably creates further opportunities for iatrogenic and nosocomial complications.

According to the World Health Organization’s document “Managing Complications in Pregnancy and Childbirth” (2001), the best description of childbirth risk is as follows:

“While most pregnancies and birth are uneventful, all pregnancies are at risk. Around 15% of all pregnant women develop a potentially life-threatening complication that call for skilled care and some will require a major obstetrical intervention…”

Surprise! Both Sides Wrong, Both Sides Are Right:

Turns out birth activists and obstetricians have both gotten it wrong. Blindly ‘trusting birth” is no better than blindly trusting obstetrical medicine. One group leans hard to the starboard while the other leans to port -- together they are destined to make endless circles in the opposite direction. From that perspective, birth activists and obstetricians have a lot in common, which is to say that both gravitate towards ideological extremes.

One side insists that birth is a safe as life gets and that trust in birth makes modern maternity care all but irrelevant. They dismisses the substantial risks to childbearing women when they are isolated from the safety net of modern science -- prenatal care, risk-screening, referral to medical service as indicated, presence of a skilled birth attendant and appropriate access to comprehensive obstetrical care whenever necessary. The other has a century long tradition of defining normal birth as so dangerous that the preemptive use of obstetrical interventions is the only ethical course of action.

interventionist obstetrics as applied to healthy women ignores the unnatural and unnecessary complications associated with these medical and surgical procedures, including Iatrogenic and nosocomial complications and delayed and downstream problems inevitable associated with invasive interventions and surgical procedures.

Over-treatment is not better than under-treatment -- excesses are bad for mothers and babies, whatever their origins.

As long as this issue is seen in the extremes of black and white, right/wrong, good/bad, doctor versus midwives or hospital versus midwife, the long process of reconciliation will remain beyond our grasp. The point of balance lies in the middle of the spectrum, an articulated model of maternity care that integrates the best of physiologically-based principles of management and comprehensive obstetrics.

If a balanced model of maternity care is ever to be more than a pie-in-the-sky pipe dream, we must re-evaluate the language used by each side and consider whether either one matches with facts. The idea of childbirth as so benign that rejecting all health and maternity care made childbirth safer does not stand up to scrutiny. This is amply documented by the mortality statistics from 3rd world countries, which clearly demonstrates that childbirth in a non-scientific, non-technological society has a high potential for death and disability. It is also clearly evident in the well-researched history of the religious group in Indiana that eschewed all forms of health or maternity care, even when obvious life-threatening complications developed.

However I take equal exception to the idea so often repeated that being born is the most dangerous thing that ever happens us as human being. I don’t argue with the numbers, but the perspective is skewed. The notion of birth as unparallel danger exists in isolation from the broad experience of history and from the reality of daily life. We human beings exist within fragile biology of bodies – that has never been a ‘safe’ or stable place to be if judged by complete freedom from illness, injury or death. We reasonably rely on modern biological sciences to keep small health problems from becoming tragedies. Nonetheless, we don’t think about, or talk about, normal life as “the most dangerous thing that ever happens to us”.

From infancy to old age, humans have always faced both common-place and unusual or unexpected dangers. The simplest aspects of daily life could suddenly result in a potentially fatal injury or infection – stumble or step on a sharp stick. A long list of diseases, from kidney failure to brain tumors, befell earlier generations just as much as now, only there were no effective medical treatments. Every period of history and every geographical location that lacked the ability to diagnosis and treat disease and injury meant that sudden death or slow painful demise were everyday facts of life. Turn-of-the-century cemeteries are filled with the graves of whole families who died of diphtheria, typhoid fever, or small pox. This was often the consequence of a minor illness or a transient problem that we would avoid by simply making a late-night trip to the ER for stitches, an x-ray or a prescription for antibiotics.

Until approximately 150 years ago, contagious illness and injuries with contaminated wounds was the most frequent cause of death. Until the work of Louis Pasteur was published in 1881, no one knew about the world of micro-organisms – microscopic bacteria and other germs. Personal hygiene was merely a personal preference, some held in distain by most people, including physicians. There was little in the way of public sanitation after the Roman Empire fell and along with it, societal valuing of cleanliness for its own sake . Historical records of my own ancestors ascribe the untimely death of my great-great-great grandfather (1840s) to walking barefoot to the barn, stubbing his toe on a stick that he himself had whittled earlier in the day, and developing a fatal septicemia (probably a bacterial infection from the barnyard animals). According to anthropologists, life expectancy in primitive cultures was only 35 years.

However, these same problems can easily apply to modern life when customary health care services are cut off (like the aftermath of Hurricane Katrina) or when people are forced by family or choose based on religious beliefs to turn their back on the biological sciences and the use of medical services when indicated.

Reintegrating Our Thinking about Childbirth back into the Biological Sciences

It’s not helpful to focus on childbearing as separate from the general fragility of human life by singling out pregnancy and childbirth as many times more dangerous, as if they existed in isolation from modern scientific knowledge, and the principles practice of modern medicine. We don’t apply this narrow focus to the other stages and phases of human life. Across the board, modern life – pregnancy, birth, infancy and all the subsequent stages of development are orders of magnitude safer as a result of universal education and modern biological science -- sanitation, nutrition, preventative medical care and emergency services for illness and injury.

Characterizations that portray maternity care and skilled birth attendants as unnecessary, since we need only ‘trust birth’, and those that promote childbirth as monstrously dangerous are both at crossed-purposes to the humanitarian interests of society.

Continued later in the week.....

2 comments:

懷念 said...

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踢人 said...

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