Tell-A-Vision ~ Normal Care for Normal Birth by 2020

2009-04-28T21:47:00.000-07:00

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.....

2009-03-14T17:32:00.000-07:00

In the last year or so, the American Medical Association has adopted an aggressive stance that seeks to limit the provision of healthcare services by non-physician practitioners such as nurse anesthetists, nurse midwives, physician assistant and other 'alternative' healthcare provider.

The following material is commentary on what is called the Flexner Report. It reiterated the 1904 recommendations by the AMA's Council on Medical Education. The ultimate consequence of these policies, which were adopted into law by state medical boards, was to make the practice of medicine into a legal monopoly controlled by the AMA in 1910. Under the outdated "1.0 operating system" installed by the AMA's Council on Medical Education (CME) in 1910, we continue to have an expensive and a profoundly dysfunctional health care system. Its is breaking the bank at home and making it impossible to compete on a level playing field in the global economy.

For example, the manufacturing costs of a car assembled in Canada reflects only $900 of health care expense, while one built in Detroit at a GM plant is weighted down with $4,500. The US now spends 18 % of its entire GDP or $2.2 Trillion dollars a year on health care. Price-Waterhouse-Coopers' has estimated $1.2 trillion of the current $2.2 trillion spent last year is wasted (that's 55 cents of every dollar). Bad as those numbers are, some experts predict health care costs to spike to $4.4 trillion in the next decade, while we continue to waste over half of every dollar spent. If the unproductive health care expenses were eliminated, we would pay off the current federal deficit of $14 trillion with the saving of just 7 years of a cost-effective system of health care.

In spite of these trillions, a 100,000 people die every year of medical mistakes and another 20,000 die because they didn't have health insurance, while 1.3 million mothers have C-sections -- equal to the number of students that graduate from American college each year -- 40% of which are paid for by the federal Medicaid program for the medically indigent.

The AMA latest 'Scope of Practice" resolution is now trying to eliminate the few gains non-MD practitioners have made in the last 25 years. This is exactly the same issue as it was in 1910 and it is still as misunderstood by the public as the CME's Flexner Report-- the false premise of that only an MD is able to provide 'safe' health care.

Next year will be the hundred year anniversary of the Flexner Report. Lets make this centennial anniversary the kick off for the idea of NO MORE of this 100 year-old failed experiment.
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MEDICAL EDUCATION IN THE  UNITED STATES AND CANADA

A REPORT TO
THE CARNEGIE FOUNDATION  FOR THE ADVANCEMENT OF TEACHING
BY ABRAHAM FLEXNER  

INTRODUCTION BY  HENRY S. PRITCHETT,
PRESIDENT OF THE CARNEGIE FOUNDATION
576 FIFTH AVENUE  NEW YORK CITY

Carnegie Foundation BULLETIN NUMBER FOUR
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Excerpts from primary and secondary sources accessed thru the Internet and from Wikipedia

Abraham Flexner 1866-1959): born in Louisville, Kentucky, Flexner was a professional educator specializing in the institutions of higher learning and educational practices in graduate and professional training programs. Some but not all sources identify his brother Simon Flexner to have been trained as an MD and a practicing physician.
Flexner graduated from Johns Hopkins in 1886 and shortly afterwards, opened a preparatory school in Louisville that he owned for 15 years. In 1905 he began his post-graduate studies in education at Harvard and the University of Berlin, To research professional educational systems in other countries, he traveled extensively in England, Germany, France, and Canada. He saw universities not as popular institutions reflecting the desires and whims of society but as intellectual leaders. "Universities must at times give society not what society wants, but what it needs". Later in his life, Flexner also served as first director of the Institute for Advanced Study at Princeton.

As research fellow at the Carnegie Foundation for the Advancement of Teaching in New York City in 1908, Flexner’s first impact on American education took the form of "Germanizing" American medical education. Flexner doubted the scientific validity of all forms of medicine other than biomedicine, deeming any approach to medicine that did not advocate the use of ‘chemical’ treatments such as vaccines to prevent and cure illness as tantamount to quackery. His opinions and policy recommendation as best reflected in a quote by him taken directly from his final report: “If the sick are to reap the full benefit of recent progress in medicine, a more uniformly arduous and expensive medical education is demanded.” 1

After finishing his landmark study of medical education in 1910, Flexner investigated prostitution in Europe. He was also known as an ‘able fund raiser’. Thru his personal and professional relationships with philanthropists he secured a $1.5 million gift from the Rockefeller Foundation’s General Education Board to his alma mater -- the German-oriented Johns Hopkins University.

In 1913 he left the Carnegie Foundation and joined the educational board of the Rockefeller Foundation as assistant secretary. After four years, he was promoted to principal executive officer and ran the operations of the Board for eight years in partnership with its president, Wallace Buttrick. As the resident intellectual and educator on the Board, Flexner's directed millions of dollars of medical education endowments to institution that promoted ‘chemical’ (pharmaceutical) and surgically-oriented medicine in the United States. Over the next 47 years, the Rockefeller’s GEB contributed $96 million to medical schools to Johns Hopkins and other university medical schools that disregarded naturopathy, homeopathy and all other forms of ‘alternative’ medicine (such as midwifery), favoring only those that taught its practitioners to depend exclusively on the use of prescription drugs and surgery.

Overview: Flexner and the Carnegie Foundation for the Advancement of Teaching’ report on Medical Education in the United States and Canada

In 1904 the American Medical Association created an in-house committee known as the “Council on Medical Education”. It developed higher, more restrictive standards for medical education that required additional years of schooling and called for all ‘irregular’ medical schools to be closed down. In 1908 the AMA asked the president of the Carnegie Foundation, Henry Pritchett, to underwrite a major study of medical schools in the United States and Canada. Pritchett was a staunch advocate of medical school reform and chose Flexner, a researcher at the Carnegie Foundation for the Advancement of Teaching, to conduct the survey.

From January 1909 to April 1910, Flexner visited 167 medical colleges and post-graduate programs in the U.S. and Canada seeking data on five points for each school:

(1) entrance requirements and adherence to them
(2) size and training of the faculty
(3) amount of tuition, endowments and fees to support the institution
(4) quality of the laboratories and qualifications of the laboratory instructors
(5) relationships between the school and hospitals used as sites for clinical training

He had “no fixed method or procedure” and used no standard questionnaire. As a layman, he had never by his own admission "[set] foot inside a medical school" and "knew neither anatomy, physiology, nor psychology enough to warrant embarking on a highly specialized bit of experimentation." Although this obviously conflicted with the scientific medicine Flexner claimed to promote, he himself admitted that its "inconsistency never bothered me."
The plan called for Flexner to travel to and comprehensively evaluate each campus of 167 geographically dispersed institutions scattered over the entire North American continent. The actual number of site visits was even greater (175), since some schools maintained separate campuses in different cities. According to the itinerary in his footnotes [see addendum] he would have had only a fraction of a day to travel and evaluate each of the 167 institutions. Although 16 months were allotted to the fieldwork, the majority of the visits occurred in only in eight months.

He made 157 or 90 % in approximately 240 days. His pace was even more amazing in April 1909, when he investigated 31 schools in 30 days in six western states (Colorado, Illinois, Iowa, Missouri, Nebraska, and Utah). Flexner often visited schools when they were not in session and toured some institutions unaccompanied by school officials. On one occasion bribed the janitor to open the laboratories and when he didn’t see any glass bleakers, Bunsen burners or other apparatus, he concluded that the school had no equipment. He never checked with the director or considered other possibilities.
The logistical challenge of visiting multiple schools in such a limited period of time was complicated by returning frequently to his home base in New York, where he stayed for many months at a time. Train travel was fastest but still took one to three days in each direction. Excluding weekends, the train-dependent Flexner would have had only 0.71 of a 12-hour day per school.

Flexner himself admitted that his tour of medical schools was "swift," and that he finished his inspections "within less than a year." His explanation of these methods was his personal maxim of Ambulando discimus or "we learn by going about". His very negative report on American medical education was quickly picked up by the Hurst publishing empire, made into a front-page story and syndicated all across the country. As a result, about half of the medical schools in the United States were forced to close. This included all that taught non-AMA approved methods and nearly all that accepted women and minorities.
As of 2010, the recommendations in the Carnegie Foundation’s “Medical Education in the United States and Canada” will have defined both medical education and medical practice for an entire population of 300 million people for an entire century. However, the underlying research for this power-broker document was undertaken at the request of the AMA. Unfortunately for us all, its conclusions were never been questioned by the public or been reexamined by professionals or policy-makers.
The only exception to the blanket acceptance of an AMA monopoly of healthcare comes from an unlikely source -- the Catholic social theorist Ivan Illich. His 1975 book, Medical Nemesis, he subjected contemporary western medicine to a detailed scrutiny and was the first to introduce the concept of iatrogenic disease to the public. He argued against the routine medicalization of life.

In this context, medicalization is usually defined as “the process by which health or behavior conditions come to be defined and treated as medical issues. The term refers to the process by which certain events or characteristics of everyday life become medical issues, and thus come within the purview of doctors and other health professionals to engage with, study, and treat.” [Wikipedia]

Since 1910 many aspect of our biology, including normal childbirth and anticipated natural death (ex. elderly or terminally ill persons) have become intensely medicalization. Ivan Illich was convinced this caused more harm than good and had turned the entire population of the United States into lifelong patients. Mortality and morbidity statistics in his book also showed the ‘shadow side’ of medicalization, in the shocking extent of post-operative side-effects and drug-induced illness in now rampant in advanced industrial societies that depend solely on drugs and surgery for all their healthcare needs.

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About the Carnegie Foundation's report written by Abraham Flexner on standardization of American medical education

From Wikipedia:

The Flexner Report is a book-length study of medical education in the United States and Canada, written by the professional educator Abraham Flexner and published in 1910 under the aegis of the Carnegie Foundation (available on the web as a Google book). Many aspects of the present-day American medical profession stem from the Flexner Report and its aftermath.

The Report (also called Carnegie Foundation Bulletin Number Four) called on American medical schools to enact higher admission and graduation standards, and to adhere strictly to the protocols of mainstream science in their teaching and research. Many American medical schools fell short of the standard advocated in the Report, and subsequent to its publication, nearly half of such schools merged or were closed outright. The Report also concluded that there were too many medical schools in the USA, and that too many doctors were being trained. A repercussion of the Flexner Report resulting from the closure or consolidation of university training, was reversion of American universities to male-only admittance programs to accommodate a smaller admission pool. This was a reversal of a trend by universities, which had begun opening and expanding female admissions as part of women's and co-educational facilities only in the mid-to-latter part of the 19th century with the founding of co-educational Oberlin College in 1833 and private colleges such as Vassar College and Pembroke College.

History

In the late 19th century, what came to be called modern medicine emerged after a struggle with other forms of medicine such as homeopathy. This new medicine was grounded in antiseptic surgery, the germ theory of infectious disease (which informed a large number of effective public health measures), and the scientific method, including evidence-based medicine and clinical trials. In 1904 the AMA created the Council on Medical Education (CME) whose objective was to restructure American medical education.

At its first annual meeting, the CME adopted two standards: one laid down the minimum prior education required for admission to a medical school, the other defined a medical education as consisting of two years training in human anatomy and physiology followed by two years of clinical work in a teaching hospital. In 1908, the CME asked the Carnegie Foundation for the Advancement of Teaching to survey American medical education, so as to promote the CME's reformist agenda and hasten the elimination of medical schools that failed to meet the CME's standards. The president of the Carnegie Foundation, Henry Pritchett, a staunch advocate of medical school reform, chose Flexner to conduct the survey.

At that time, the 155 medical schools in North America differed greatly in their curricula, methods of assessment, and requirements for admission and graduation. Flexner visited all 155 schools and generalized about them as follows: "Each day students were subjected to interminable lectures and recitations. After a long morning of dissection or a series of quiz sections, they might sit wearily in the afternoon through three or four or even five lectures delivered in methodical fashion by part-time teachers. Evenings were given over to reading and preparation for recitations. If fortunate enough to gain entrance to a hospital, they observed more than participated." The Report became notorious for its harsh description of certain establishments, for example describing Chicago's 14 medical schools as "a disgrace to the State whose laws permit its existence... indescribably foul... the plague spot of the nation."

Recommended changes

When Flexner researched his report, many American medical schools were "proprietary", namely small trade schools owned by one or more doctors, unaffiliated with a college or university, and run to make a profit. A degree was typically awarded after only two years of study. Laboratory work and dissection were not necessarily required. Many of the instructors were local doctors teaching part-time, whose own training left something to be desired. The regulation of the medical profession by state government was minimal or nonexistent. American doctors varied enormously in their scientific understanding of human physiology, and the word "quack" flourished. There is no evidence that the mass of Americans were dissatisfied with this situation.

Flexner looked this situation in the face. Using the Johns Hopkins University School of Medicine as the ideal[1], he boldly recommended that:
Admission to a medical school should require, at minimum, a high school diploma and at least two years of college or university study, primarily devoted to basic science. When Flexner researched his report, only 16 out of 155 medical schools in the United States and Canada required applicants to have completed two or more years of university education (p 28). According to Hiatt and Stockton, by 1920 92% of U.S. medical schools required this of applicants.

The length of medical education be four years, and its content should be what the CME agreed to in 1905.

Proprietary medical schools should either close or be incorporated into existing universities. Medical schools should be part of a larger university, because a proper stand-alone medical school would have to charge too much in order to break even.

Less known is Flexner's recommendation that medical schools appoint full-time clinical professors. Holders of these appointments would become "true university teachers, barred from all but charity practice, in the interest of teaching." Flexner pursued this objective for years, despite widespread opposition from existing medical faculty.
Flexner was the child of German immigrants, and had studied and traveled in Europe. He was well aware that one could not practice medicine in continental Europe without having undergone an extensive specialized university education. In effect, Flexner was demanding that American medical education conform to prevailing practice in continental Europe.
By and large, medical schools in Canada and the United States have followed Flexner's recommendations down to the present day. Recently, however, schools have increased their emphasis on public health matters.

Consequences of the report

To a remarkable extent, the following present-day aspects of the medical profession in North America are consequences of the Flexner Report:

1. A physician receives at least six, and preferably eight, years of post-secondary formal instruction, nearly always in a university setting;

2. Medical training adheres closely to the scientific method and is thoroughly grounded in human physiology and biochemistry.

3. Medical research adheres fully to the protocols of scientific research;[2]

4. Average physician quality has increased significantly;[3]

5. No medical school can be created without the permission of the state government. Likewise, the size of existing medical schools is subject to state regulation;

6. Each state branch of the American Medical Association has oversight over the conventional medical schools located within the state;

7. Medicine in the USA and Canada becomes a highly paid and well-respected profession……….

The annual number of medical school graduates sharply declined, and the resulting reduction in the supply of doctors makes the availability and affordability of medical care problematic. The Report led to the closure of the sort of medical schools that trained doctors willing to charge their patients less. Moreover, before the Report, high quality doctors varied their fees according to what they believed their patients could afford, a practice known as price discrimination. The extent of price discrimination in American medicine declined in the aftermath of the Report;

Western Medicine as a Cartel, AMA and State Medical Boards as legal enforcers

Kessel (1958) argued that the Flexner Report in effect began the cartelization of the American medical profession, a cartelization enforced by the American Medical Association and backed by the police power of each American state. This de facto cartel restricted the supply of physicians, and raised the incomes of the remaining practitioners.

The Report is now remembered because it succeeded in creating a single model of medical education, characterized by a philosophy that has largely survived to the present day. "An education in medicine," wrote Flexner, "involves both learning and learning how; the student cannot effectively know, unless he knows how." Although the report is more than 90 years old, many of its recommendations are still relevant—particularly those concerning the physician as a "social instrument... whose function is fast becoming social and preventive, rather than individual and curative."

Closure of many medical schools

According to Hiatt and Stockton (p. 8), Flexner sought to shrink the number of medical schools in the USA to 31, and to cut the annual number of medical graduates from 4,400 to 2,000. A majority of American institutions granting M.D. or D.O. degrees as of the date of the Report (1910) closed within two to three decades. (No Canadian medical school was deemed inadequate, and none closed or merged subsequent to the Report.) In 1904, there were 160 M.D. granting institutions with more than 28,000 students. By 1920, there were only 85 M.D. granting institution, educating only 13,800 students. By 1935, there were only 66 medical schools operating in the USA.

Between 1910 and 1935, more than half of all American medical schools merged or closed. This dramatic decline was in some part due to the implementation of the Report's recommendation that all "proprietary" schools be closed, and that medical schools should henceforth all be connected to universities. Of the 66 surviving M.D. granting institutions in 1935, 57 were part of a university. An important factor driving the mergers and closures of medical schools was that all state medical boards gradually adopted and enforced the Report's recommendations.

American medicine becomes a less diverse profession

One of the consequences of Flexner's advocacy of university-based medical education was that medical education became much more expensive, putting such education out of reach of all but upper class white males. The small "proprietary" schools Flexner condemned, which were contended to be have been based in generations-old folk traditions rather than relatively recent western science, did admit African-Americans, women, and students of limited financial means. These students usually could not afford six to eight years of university education, and were often simply denied admission to medical schools affiliated with universities.

At the same time, the Report tended to delegitimize existing women doctors and doctors of color. While many such doctors continued to practice, usually within underserviced clienteles, they did so under proscribed circumstances and for less pay. In general, the standardization of medical education advocated in the Report led to the domination of American medicine by well-off white males. It also made it more difficult for people of color, residents of rural areas, and for those of limited means generally to obtain medical care in any form. The Flexner report recommended the closure of several African American medical schools, including the Leonard Medical Center, the oldest four-year medical school in the country for African-Americans. Ironically one of the schools was located in his own hometown of Louisville, Kentucky, Louisville National Medical College.

Impact on alternative medicine

When Flexner researched his report, "modern" medicine faced vigorous competition from several quarters, including osteopathic medicine, eclectic medicine, physiomedicalism, naturopathy and homeopathy. Flexner clearly doubted the scientific validity of all forms of medicine other than biomedicine, deeming any approach to medicine that did not advocate the use of treatments such as vaccines to prevent and cure illness as tantamount to quackery and charlatanism. Medical schools that offered training in various disciplines including eclectic medicine, physiomedicalism, naturopathy, and homeopathy, were told either to drop these courses from their curriculum or lose their accreditation and underwriting support. A few schools resisted for a time, but eventually all complied with the Report or shut their doors.[citation needed]

Impact on osteopathic medicine

Although almost all the alternative medical schools listed in Flexner's report were closed, the American Osteopathic Association (AOA) were able to bring a number of osteopathic medical schools into compliance with Flexner's recommendations. As a result, American osteopathic medical schools today teach from an evidence-based, medicalised, scientific knowledge base. The curricula of DO and MD awarding medical schools differ only minimally, the chief difference being the additional instruction in osteopathic schools of manipulative medicine. This dramatic convergence of osteopathic and biomedical training demonstrates the sweeping effect the Flexner report had, not only in the closure of inadequate schools, but also in the standardization of the curricula of surviving schools.

Comments: The purposeful elimination of midwifery as an independent profession does not even get mentioned as one of the causalities of the Flexner Report – another example of the truism the “history is written by the winners”.

References

UNMC's Flexner's Impact on American Medicine
Beck, Andrew H. (2004), "The Flexner Report and the Standardization of American Medical Education", JAMA: the Journal of the American Medical Association 291 (17): 2139–2140, doi:10.1001/jama.291.17.2139, PMID 15126445
Barzansky, B.M.; Gevitz, N. (1992) (w), http://books.google.co.uk/books?hl=en

Further reading
Beck, Andrew H., 2004, "The Flexner Report and the Standardization of American Medical Education", Student JAMA 291: 2139–40.
Bonner, Thomas Neville, 2002. Iconoclast: Abraham Flexner and a Life in Learning. Johns Hopkins Univ. Press. ISBN 0801871247.
Flexner, A., 1910. Medical Education in the United States and Canada. Carnegie Foundation for Higher Education.
Gevitz, Norman, and Grant, U. S., 2004. The D.O.s (2nd ed.). Baltimore: The Johns Hopkins University Press. ISBN 0-8018-7834-9.
Goodman, John C., and Gerald L. Musgrave, 1992. "How The Cost-Plus System Evolved". Patient Power. Washington, D.C.: Cato Institute,
W67.
Kessel, Reuben, 1958. "Price Discrimination in Medicine", Journal of Law and Economics 1 (Oct., 1958): 20–53.
Starr, Paul, 1982. The Social Transformation of American Medicine. Basic Books. ISBN 0465079350.
Steinreich, Dale, 10 June 2004. "100 Years of Medical Robbery".
Wheatley, S. C., 1989. The Politics of Philanthropy: Abraham Flexner and Medical Education. University of Wisconsin Press. ISBN 0299117502, ISBN 0299117545.

Link to a modern day example of the AMA-type relationship with maternity care provided to healthy women as the property of obstetricians, who misused their power to close down nurse midwifery services in hospital all across the country.

Tomorrow -- Excerpts from TWILIGHT SLEEP :
~ A Simple Account of New Discoveries in Painless Childbirth
By Henry Smith Williams, B. Sc, MD, LLD ~ 1914

2008-04-03T09:53:00.000-07:00

http://womenshealthnews.wordpress.com/2008/04/01/nations-largest-hospital-to-ban-vaginal-birth-ny-state-likely-to-follow/

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."

2008-03-28T17:01:00.000-07:00

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.

2008-03-17T15:38:00.000-07:00

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.

Childbirth 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

2008-03-16T17:43:00.000-07:00

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

2008-02-03T11:14:00.000-08:00

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 www.normalbirth.org 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. [ChildbirthConnection.org]. 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

2007-05-25T13:40:00.000-07:00

The Wisdom of Industrializing Biological Systems

Read the New Yorker article first :

“THE SCORE - How childbirth went industrial”

Click here for a web link to the original New Yorker article . Published October 09, 2006

Part Two -- What happens when you attempt to industialize our normal biology?

The last section of this 3-part essay focused on the industrialization of biological systems. A substantial list of unintended consequences is associated with mass production techniques of any kind, whether for farming, ranching, egg production or systemizing care for normal childbirth.

However, we can’t overlook the historical dangers associated with childbirth. Obviously the absence of professional care does not, by itself, make normal childbearing better or any safer. This distrubing realization resulted in the development of a traditional system for providing maternity care that has existed since the dawn of humankind. As recorded by 5,000 year-old Egyptian Hieroglyphics, the principles of physiolgoical care for normal childbirth were acknowledged and utilized by trained midwives as a formal discipline as long ago as 3,000 BCE. This means that midwifery truly is the world's oldest profession. But we wouldn't be debating the pros and cons of industrializing the care for normal birth if midwifery care were 'perfect'.

At the cusp of the 21st century the big question is whether industrialized childbirth results in the greatest level of safety, patient satisfaction and cost-effectiveness? Dr Gawande refers to these practices as the “obstetrical package”, a term that describes the medicalization of normal maternity care as purposefully developed by the medical profession over the course of the 20th century.

The question so far unaddress is the fundamental nature of childbirth in a healthy population. What is the optimal management for this healthy cohort? Is childbirth a normal and reasonably dependable aspect of our reproductive biology or it it, as the author of older obstetrical text books insisted, a "nine-month disease that requires a surgical cure"? Is it really a ‘disaster waiting to happen’? The obstetrical profession asserts that it is only ‘normal’ in retrospect. Is that a useful way to relate to the care of childbearing women?

Today's essay (part 2) focuses on the biological nature of childbirth and its relationship with the right (or wrong!) use of gravity and the most frequent historial complication of normal birth. The classical or more frequent complication of childbirth as always been an inability by the mother to push the baby out under her own powers, a problem that gave rise to the first use of obstetrical instruments (forceps) that could make up for Mother Nature's failures without having to sacrific the life of either mother or baby.

From there we will look at how the industrialization of childbirth fits in the modern day picture of maternity care, starting with that first tool of obstetrical industrialization - obstetrical forceps. Our modern romance with obstetrical technology starts with the propriety development of forceps by the Chamberlain family in the late 1600s. Unfortunately, use of forceps eventually became a routine accompaniment of obstetrical practice for all childbirth, even when the mother was healthy and there was no 'dystocia' or disproportion between the size of the baby and her pelvis.

Identifying the basic nature of childbirth

When it comes to industrialized childbirth, it is obvious that the current system for providing care to healthy women has a variety of problems. No matter what the obstetrical profession or Dr. Gawande may believe, the majority of childbearing women are healthy and at the end of nine months, they are enjoying a normal pregnancy. Practically and statistically-speaking, normal childbirth in healthy women does not benefit from the routine use of medical procedures or surgery.

But for all the faults of a systematized approach to childbirth, a disturbing reality must constantly be acknowledged: Pregnancy and childbirth complications can and do occur, even for women with no obvious problems or risk factors. The industrialized childbirth of the early 1900s was fueled by this disturbing reality. Its worthy goals were the complete elimination of all preventable complications and ‘bad outcomes’ in pregnancy and childbirth.

In THE SCORE, Dr Gawande stated flatly that: "For thousands of years, childbirth was the most common cause of death for young women and infants". This was presented as an undisputed ‘common sense’ fact. And yet, for all the certainty of Dr G’s assertion, we do not actually know if it is true: Was childbirth was the most common cause of death for our ancestors? It certainly seems plausible. Without credible evidence to the contrary, the American public has always assumed that the obstetrical definition of childbirth as serial killer of young women and newborn babies was a sad fact of a woman’s life before the 20th century. In the minds of most Americans, only the development and wide-spread deployment of modern obstetrics has been able to stop the carnage of Mother Nature gone mad.

Childbirth – Normal Biology or Gender-specific Curse?

It is the belief that childbirth is a dangerous and dysfunctional aspect of female biology that underlies the philosophy of industrial obstetrics. Fear-based beliefs that medical and surgical interventions are necessary in every normal childbirth is what generated the policies and practice of 20th century obstetrics. As for those mothers who somehow delivered without having such interventions, well, the official explaination is that they were "just lucky this time", aluding to the idea that the narrowly missed catastrophy would fall next time uless they took the appropriate evasive action. The obstetrical profession has always believed that nosocomial (hospital-based) or iatrogenic (practitioner-based) harm that resulted was far outweighed by the ‘obvious’ benefits and therefore, neither the theory nor the practice of routine obstetrical intervention required any further study.

The obstetrical profession’s fear of childbirth gave rise to the second central belief -- that childbearing women can only be saved thru the universal application of the “obstetrical package”. The confluence of these concepts decides what the ‘rules of the factory floor’ are in 2007. Regrettably, one can predict that factor-floor childbirth will inch forward, year by year, towards what is believed to be the ultimate mechanism of obstetrical reliability – the progressive elimination of vaginal birth.

The active verb ‘to give birth’ will eventually be replaced by a purely obstetrical vocabulary, in which the obstetrician is the means of production, the baby is the product and the parental- consumers are compliant, complacent, well-insured and grateful.

Looking at Historical Documents for Clues

Just for the sake of argument, let’s assume that the process of childbirth, with its propensity for unexpected problems, was a bad mistake by Mother Nature. If this is the case, analysis of vital records and birth certificate data over the last century should be able to easily document the superiority of industrialized obstetrics. Statistics comparing the maternal-infant outcomes of medical versus physiological management would demonistrate that the higher the rate of intervention (i.e., use of the obstetrical package) lowered the morbidity and mortality and conversely, failure to employ the “pre-emptive strike” would be accompanied by very high rates of complications and fatalities.

Were that the case, industrialized obstetrics would clearly be associated with dramatically improved outcomes.

However, this hypothesis is not substantiated by world-wide scientific literature or the obstetrical history included in Dr. Gawande’s account. As readers will recall, Dr G. described how the level of mortaility of mothers and babies was just as high in 1940 as it was in 1910, when obstetrics first imposed a medical and surgical model on normal childbirth. Here is an excerpt of that section of THE SCORE in Dr G's own words:

"By the early twentieth century, the problems of human birth seemed to have been largely solved. Doctors could avail themselves of a range of measures to insure a safe delivery: antiseptics, the forceps, blood transfusions, a drug (ergot) that could induce labor and contract the uterus after delivery to stop bleeding, and even, in desperate situations, Cesarean section. By the nineteen-thirties, most urban mothers had switched from midwife deliveries at home to physician deliveries in the hospital.

But in 1933 the New York Academy of Medicine published a shocking study of 2,041 maternal deaths in childbirth. At least two-thirds, the investigators found, were preventable. There had been no improvement in death rates for mothers in the preceding two decades; newborn deaths from birth injuries had actually increased. Hospital care brought no advantages; mothers were better off delivering at home.

The investigators were appalled to find that many physicians simply didn’t know what they were doing: they missed clear signs of hemorrhagic shock and other treatable conditions, violated basic antiseptic standards, tore and infected women with misapplied forceps. The White House followed with a similar national report. Doctors may have had the right tools, but midwives without them did better. " [end excerpt]

This is hardly a affirmation for the 'tools' of industrialized childbirth.

Instead, physiologically-managed labors and births using classical non-medical methods and often occurring in non-medical settings, have maternal-infant outcomes equivalent to those of the obstetrical package, but with a rate of maternal and infant interventions two to ten times lower. If childbearing biology was indeed just a bad mistake of Mother Nature, this would be impossible. [Click here for ObGynNews report the BMJ study - June 2005].

Historical records and contemporary experience both give good reason to question the cultural belief that all childbirth is a disaster waiting to happen. However, attitudes and behaviors of physicians and midwives in many other industrialized countries do not reflect that belief, nor do they depend on policies such as the pre-emptive strike to manage normal childbirth. And yet, the cost of maternity care in these countries is far less than in our own and the maternal-infant outcomes in these countries are far better than the US. The experience of community midwives in the US and abroad is also the very opposite of these ideas. [see CNM studies by Patricia Anderson, CNM on the cost effectiveness of planned home birth attended nurse-midwives - AJNM]

As for the historical record, anthropology researchers report strong evidence that many aboriginal societies, living lives undisturbed by civilization, have remarkably good health, with little or no discernable heart disease, cancer, diabetes, dental decay, etc. In those cultures, childbirth is neither greatly feared nor frequently complicated. Obviously, we can never know for certain what childbirth for early humans was like. But there are intriguing historical clues that call into question the 20th century obstetrical conclusions that our childbearing biology is normally abnormal.

Historical Support for Alternative Theories

An example of ‘simpler times’ can be found in the historical records of the early settlers of Colonial American. A detailed bibliography of John Adams provides an interesting record of the dozens of large families of the founder of our country and their wives during the American Revolution and early years of the new American government. In these accounts, which span the 50 years before, during and after the Revolution, more children and women of childbearing age died from virulent forms of influenza and TB and from epidemics of small pox, cholera and typhoid fever than childbirth-related complications.

Martha Ballard, a midwife who practiced for 30 years in rural parts of the New England colonies, delivered 3,000 women during this same period. The detailed diary of her midwifery practice became the subject of academic study in the 1990s. The author searched the birth and death records of the day in order to determine the accuracy of Martha Ballad’s information. According her personal diary and cross-referenced official records, there was not a single maternal death recorded among the births she attended.

Nonetheless, childbirth in centuries past is of little help to us today, in our own very different and highly developed civilization. So I will stipulate the obvious. In the distant history of the human species, in a world with NO emergency medical or surgical services, in which entire populations were subjected to floods, forest fires, pursuit by wild animals and periodic starvation, childbirth was an additional serious danger to a significant number of childbearing women and infants.

Optimal management of Childbirth in the 21st Century

Does the industrialization of obstetrics provide optimal management of Childbirth in the 21st Century? Is the standardization of childbirth helpful to the majority of the contemporary childbearing population – that very important 70% who are healthy and have normal pregnancies?

What happened when the traditional social and professional structures that supported physiological management of normal birth for five thousand years were purposefully dismantled and eliminated during a 10-year period of time (1910-1920) and replaced by an expensive and capital-intensive childbirth ‘industry’? What is the nature of this new idea – the unopposed, unexamined ‘industrialization’ of American childbirth? Has childbirth been industrialized in other developed countries and if not, what is their experience with normal birth?

A comment by a contemporary obstetrician is instructive:

“... The hallmark of obstetrical quality is the prevention of the rare disaster rather than the optimal conduct of the many normal cases” [Dr. Brody 1981]

By its very nature, industrialized birth must be influenced by economic factors above everything else. In order to maintain economy of scale, industrialized childbirth must try to fit individuals into predetermined norms. This applies to hospital patients and hospital staff alike. In an effort to predictably provide good outcomes or defend itself against unpredictable bad outcomes, it generates a medially aggressive process that revolves around the mentality of the ‘pre-emptive strike’. Its methods require the routine use of medical procedures – intensive care hospitalization, aggressive obstetrical management of labor, immobilization in bed, liberal use of drugs, anesthetics, episiotomy, operative delivery, etc.

Seventy percent of the time, these medical and surgical procedures are not done because the laboring woman actually has a present-tense complication or even a high likelihood of developing one, but ‘just in case’. The rare future possibility trumps the actuality of the moment. Since there is a rather lengthy list of rare but possible complications in the index of every obstetrical textbook, the list of ‘just in case’ maneuvers is likewise lengthy. Whether one is being medically treated for a heart attack or ‘treated’ for normal labor, the medical ministrations are remarkably similar, at least as defined by the serious looking hospital personal coming and going from the room, the number of medical devices attached to the patient and the many different charges appearing on the patient’s hospital bill.

The unexamined issue for the 21st century is what does it mean to eliminate physiological childbearing and then standardize ‘normal’ childbirth care predicated on these ‘worst case’ scenarios? What impact do these policies have on healthy childbearing women? One of the characteristics of industrialization - automobile manufacturing for example - is that the actual product itself doesn’t have a role in the industrialized process -- it is simply a passive part of the system, acted upon by others, like a toy doll being assembled.

In the industrialized model of modern childbirth, there is no active role for the childbearing woman. Her duties are restricted to being a good patient – passive and compliant. Surgical delivery by Cesarean Section renders the mother totally inert and virtually irrelevant, as the entire process can go on without her even being conscious.

What is the impact of this learned helplessness on society? What public policies and individual actions are appropriate? What should we do personally?

Above all, where exactly is the delicate line in which a society balances the benefit of new technologies and new ideas, while protecting the integrity and quality of our personal lives?

So far, the quality of the public debate on these important topics has been very poor. One of the reasons is that the near universal lack understanding of normal biology and normal physiological care for normal birth among the public. And despite anyone’s understanding, the question still remains as to whether or not childbirth had always been and remains fundamentally dangerous.

Earlier in this series, I addressed many of the issues of labor, especially the psychological and social aspects and normal or non-medical methods to help women cope with the stress and pain of labor. But the basic mechanics of getting a baby thru the cervix, into the birth canal and out into the world is still the best kept secret of the 20th century.

Biology 101 – Bones and Body Parts of Normal Birth

The childbearing pelvis – that is, the internal bones that the baby must pass through -- normally creates a hollow space shaped like a lower-case letter “j”. Most people erroneously think of the birth canal as a straight chute (lower-case letter ‘l’), going straight down thru the lower half of the mother’s body.

In other words, if the mother was lying down and you were watching her from the side, her baby would pass through the pelvis and out of her body the same way a train comes out of a tunnel – a straight cylindrical object passing thru a straight cylindrical container.

But this idea is not anatomically correct. Imagine instead that you are looking at an upright pregnant woman from the side and that she will labor and give birth in this same upright posture. If you had x-ray vision, you would see that the long stem of the ‘J’ tracks with the mother’s lower spine and the curved foot of the letter ‘j’ bends forward to track with the lower half of the birth canal.

What this means is the pelvic outlet -- last 1/3 of the journey – bends at a 60-degree angle, which requires that the baby to go around a corner and emerge into the world going forward (into its mother’s arms!). If instead it were to go straight down towards the floor (the “I” theory of the childbearing pelvis), it would be extremely hard for the mother to reach it and the baby might be injured as it fell to the ground. Not doubt this “frontal delivery” is an important survival characteristic, as 99.99% of human history predates hospital obstetrics, which meant it was the mother herself who was responsible for ‘catching’ her baby.

Childbirth has been designed by biological selection to be successful all by itself, independent of any other person or medical interventions.

Were you to look down into the pelvis from the top, you would notice that the big triangle-shaped bone of the lower spine -- the sacrum and coccyx -- encroaches into the pelvic outlet about an inch or so. In this regard, the pelvis is like a hollow bowl with smooth walls on three sides but slightly bent in on the fourth side, making it impossible for anything that is the same size and shape as its circumference to pass through unimpeded.

However, in the second or pushing stage of labor, after the baby is squeezed out of the uterus thru the cervix and starts its trek down into the birth canal, you would see something remarkable happen. In pregnancy the sacrum and coccyx are movable and able to be pressed back out of the way by the baby’s head, as it descends deeper into the birth canal and gets closer and closer to being born. Think of those little pet doors that open and move out of the way as the dog or cat passes throught. The human sacrum also is jointed or hinged where it join to the lower end of the spine and it to move slightly to provide more room for the baby to pass.

In addition, the hormones of pregnancy soften the cartilage that hold the two sides of the pubic bone together, so these pelvic joints become unusually elastic. This permits the pelvis to also stretch and widen side to side, which can give the baby an extra 1-2 centimeters of room to negotiate its passage into the world.

This is graphic of a mother giving birth without the added benefit of gravity, while lying on her back.The baby must first negotiate its way under the pubic bone by rotating its head from sideways to an up / down orientation.

Then the crown of the baby's head spins under the public arch and will be born pointing up, towards the ceiling.

Gravity – What a concept!

Childbearing women, when left to their own devices, almost universally chose to be mobile during labor and to assume some form of upright position during the birth of the baby. The right use of gravity naturally stimulates effective uterine contractions, helps dilate the cervix and assists the baby to descend through the bony pelvis. To help the birth process move along, women are encouraged to walk around during labor. Being upright and mobile during contractions also diminishes the mother’s perception of pain, perhaps by stimulating endorphins. On the rare occasions that require the mother to lie down, midwives also noted that the labor was much slower and the mother had to push longer and harder to get the baby out. Sometimes she wasn’t able to deliver unless or until she got back up into a gravity-friendly position.

For a laboring mother, is lying down can reduce the pelvic size by almost a third, while simultaneously requiring the mother to push her baby up hill, and around a 60-degree bend. Not only does this requires that she defy gravity, but she must do this with the doorway partially blocked, reducing the aperture of the pelvis. When the mother is bearing her own weight on her back and lower spine, such as lying with her legs held up in stirrups, the sacrum cannot move back out of the baby's way.

If the baby is small or the mother’s pelvis is big, the normal forces of labor and extra effort by the mother can overcome this impediment. However, when the mother is on her back, the baby must still emerge at an angle heading upwards, towards the ceiling. Obviously this is a lot harder and takes a lot longer than it would if gravity were used to benefit mother and baby.
Regardless of the answer to that, how did our ancestors manage this central aspect of human reproduction – labor, birth and the new baby? So let’s take a little excursion into the biology and sociology of birth. In order to do that we also have to acknowledge the role what really is the world’s oldest profession – midwives as helpers and guardians of mothers and babies.

Giving Birth with Grace and Gravity

Historically childbearing women themselves were the best (and only!) source of information about the biology and physiology of pregnancy and normal childbirth. For thousands and thousands of years, women gave birth normally with the support of their extended families and the help of experienced older women. For healthy women in safe surroundings, pregnancy and birth was generally successful for them and their babies. We know this statement is true because the human species has survived (and in fact, thrived) into the 21st century. Anyone alive in the 21st century is a direct descendent of women who were successful at giving birth normally, without the need for forceps or cesarean surgery.

Eve 2.0 ~ Nature's program for normal birth

Midwifery as an organized body of knowledge and set of technical skills preceded the modern discipline of medicine by more than 5,000 years.

From the get-go of the human species, older experienced women always helped younger, inexperienced women during the hours of labor and during the moments of birth. This also included caring for the new mother afterwards, as she learned to breastfeed and take care of her new baby. Experienced assistance of this kind (Eve 2.0!) eventually became known as “midwifery”. Those women caregivers who developed specialized skills in managing childbirth and dealing with the needs of new mothers and babies were known as ‘midwives’. In the old world language of England, the word ‘mid’ meant “with” and the word ‘wife’ referred to “woman”. Thus a ‘midwife’ was someone who was ‘with woman’ during the events of childbearing.

“The practice of midwifery dates back to the beginning of human life in this world. At this supreme moment of motherhood it is probable that some assistance has always been required and given. Its history runs parallel with the history of the people, and its functions antedate any record we have of medicine as an applied process. To deny its right to exist as a calling is to take issue with the eternal verities of life.” Dr. Josephine Baker, M.D. 1911-G, page# 232

The first record of midwifery as an established discipline can be found in the hieroglyphics of ancient Egypt in 3,000 BC. The first mention of midwives in Western culture (perhaps prophetically) is a story in the Old Testament of political intrigue and civil disobedience. The book of Exodus records the clash between the Egyptian Pharaoh, who ordered his midwives to kill all the first-born sons of the enslaved Hebrew population. The Egyptian midwives, at great risk to their own lives, declined to carry out such orders. When these midwives were called before the Pharaoh to explain why they did not do as directed, they answered that the Hebrew women, unlike the Egyptian women, were “lively upon the birth stool” and delivered before the midwives arrived.

“The practice of midwifery is as old as the human race. Its history runs parallel with the history of the people and its functions antedate any record we have of medicine as an applied science. Midwives, as a class, were recognized in history from early Egyptian times.” Dr. Hardin, M.D.1925-A; p. 347

During the first 5,000 years of recorded history, the discipline of midwifery was empirically-based and organized around meeting the practical needs of laboring women. These universal needs are primarily psychological, emotional, and social. The care of midwives included ‘patience with nature’, the right use of gravity and a commitment not to disturb the natural process. Again, we must accept as fact that this was a successful strategy, as the human species has survived and thrived under the care of their midwives.

No medical drug or devise, no surgical instrument or procedure ever developed by medical science has been able to make birth better or safer in healthy women with normal pregnancies than spontaneous labor and normal birth attended by an experienced birth attendant.
These protective methods are what we now refer to as “physiological management” – that is, “…in accord with, or characteristic of, the normal functioning of a living organism”.

The classic principles of physiological management include a basic trust in biology and support for the normal process of labor and birth. It is a tradition that restricts the use of interventions to abnormal situations only. This non-interventive approach recognizes the mother’s need for physical and psychological privacy and to feel safe from unwanted intrusions and the prying eyes of strangers. Physiologic care encourages the mother to walk around at will and to be upright and mobile during both labor and birth. It also includes continuity of care by individuals known to the mother, one-on-one social and emotional support, non-drug methods of pain relief (such as movement, touch and warm water), patience, and the right use of gravity.

“...that trained midwives surpass the record of physicians in normal deliveries has been ascribed to several factors. Chief among these is the fact that the circumstances of modern practice induce many physicians to employ procedures which are calculated to hasten delivery, but which sometimes result in harm to mother and child. On her part, the midwife is not permitted to and does not employ such procedures. She waits patiently and lets nature take its course.” [1931 Testimony on midwifery care, White House Conference on Child Health and Protection by the Committee on Prenatal and Maternal Care]

The Birth of Industrialized obstetrics: FORCEPS – Microcosm of Difficulties to Come
The first act of the industrial childbirth revolution was the invention of obstetrical forceps in 1650. According to historians, the first functional pair of forceps was due to the ingenuity of an English family of doctors – patriarch William Chamberlen, sons Peter I and Peter II and grandson, Peter III. It was William Chamberlen’s accurate knowledge of the bony pelvis and his understanding of the mechanics of normal childbirth that permitted him to design the first obstetrical instrument that would permit a physician to forcibly extract a living baby out without causing it permanent harm or death.

For centuries physicians had been looking for a method or instrument that would permit them to extract the baby in cases of obstructed or ineffective labor. The obvious question is why it took so long to design something like forceps and why didn’t anybody come up with alternative methods until the vacuum extraction was developed in the 1970s? What is so special about the anatomy of the childbearing pelvis? Unfortunately, the use of force to get an undamaged baby out is very much harder than it looks. In order to understand what was so remarkable about the Chamberlen intervention, readers refer back that primer in the bony anatomy of childbirth and the simple physiology of normal childbirth earlier in this essay and entries on this blog.

In general, the successful extraction of a live baby from the birth canal without hurting either mother or baby required a functional understanding of the “J” shape of the pelvic canal and the simple fact that when a mother is lying down, a physician using any form of physical and mechanical force (root of the word “forceps”) would have to be pull the baby around the 60 degree angle of the pelvis. In order to accomplish this, the angle of the pull is straight up towards the ceiling. Unless the doctor is suspended from the ceiling, this would be a very difficult maneuver. The 60-degree angle and the need to exert force going upward are just two issues that the design of obstetrical forceps had to overcome.

Using William Chamberlen’s original pair of forceps as a push-off point, successive generations of the Chamberlen family developed and refined their designs over the next century. It should be noted again that the operative word in forceps is ‘force’. Whether the use of force is a blessing or a curse depends on many factors.

While obstetrical forceps are potentially a life-saving technology, their history is a disturbing story marked by intrigue, unbridled competition, ego-centricisim, personality cults, gender politics and old-fashioned greed. William Chamberlen’s life-saving invention was kept as a family secret for more than a hundred years.

The surreptitious use of the forceps was accomplished by tying one end of a bed sheet around the neck of the doctor and covering the lower half of the mother’s body with the other end. The box containing the forceps was slipped under this visual tent and the forceps taken out and inserted into the mother vagina by “touch”. No one in the room, not even the mother, knew what they looked like or exactly how they worked.

The invention of forceps was the first time in the history of obstetrics that a manufactured instrument became the personal or ‘intellectual’ property of its doctor-developer. Unfortunately, this proprietary relationship with an obstetrical invention led to a host of abuses. Due to the unwillingness of the Chamberlens to make their discovery available to the public, it is conservatively that estimated that during the 17th and 18th century hundreds of thousands of babies who could have been successfully delivered by forceps (had the technology been in the public domain) instead died as a result of obstructed labors. After 4 to 6 days of useless labor, the baby would die and the mother was often left with severe and permanent damage to the tissue of her pelvis (fistulas) and life-long incontinence.

While forceps were designed to rescue babies that otherwise would have been permanently damaged or died, the use of instrumental delivery by the medical profession gradually become more and more indiscriminate, based on obstetrical fashion instead of medical need. In particular, forceps were used excessively on wealthy patients who didn’t need them while being withheld from maternity patients whose babies would die with help, all because the family could not pay the large professional fee.

Forceps in the 20th Century

In early 20th century American, this enthusiasm turned into an irrational exuberance, as forceps become central to the routine practice of obstetrics. Normal birth was characterized as a dangerous mistake of Mother Nature, whereas forceps were portrayed as making birth safer and better. This was the forerunner of today’s identical claim by the obstetrical profession that Cesarean section being better and safer than normal birth. As they say, ‘the more things changes, the more they stay the same’.

In the early years of the 20th century, a famous obstetrician of that era (Dr. Joseph DeLee) was infamous for defining the biology of birth as a patho-physiology -- no more ‘normal’ for the mother’s perineum than “falling on a pitchfork”. Even worse, the poor baby’s head was being used as a “battering ram on the mother’s iron perineum”. His solution was the routine use of episiotomy (incidentally giving rise to an entire century of unnecessary episiotomies!) and forceps to save the mother and baby from what he defined as the pathological effects of normal birth.

From 1910 to the 1940s, they were routinely used at all physician-attended births. As late as the 1970s, low or “outlet” forceps deliveries were still the norm in the South and more rural parts of the US. They were used routinely where I worked in the L&D as last as 1976 (Orange Memorial Hospital and Holiday Hospital in Orlando, Florida).

Ultimately, forceps changed the nature of maternity care, tipping it away from physiological management by midwives and general practice physicians and towards the male-dominated profession of obstetrics. The use of forceps became the single most important element of obstetrical practice and virtually eliminated physiologically-based maternity care, since instrumental delivery must be accompanied by the use of anesthesia and episiotomy.

Traditionally, maternity care had been a personal service between two people of the same social status who had an on-going relationship and lived in geographically proximity. But midwives were not permitted to use forceps, which was a restricted practice of medicine. Thus the idea of ‘market share’ was introduced, making obstetrics into an economic adventure shaped and dominated by market forces.

The obstetrical profession took on the mantle of being the source of all knowledge about normal reproduction and the only credible source of wisdom about proper care during childbirth. To their way of thinking, this equated to a medical version of “manifest destiny”. Newspapers and women’s magazines picked up this drum beat and soon the lay public was socialize to the idea that more intervention in birth was, well, more better. The manifest destiny of industrialized childbirth in the US had been born. Within a single generation, virtually all childbirth services were reorganized around hospitals, physicians, obstetrical interventions, with forceps at the top of the list.

Intellectual Property Versus the Normal Anatomy of Childbearing

For mothers who are too tired to push or for whom the baby is in distress, the use of obstetrical forceps to extract the baby can be life-saving. That puts the invention and use of forceps in the pantheon of modern medicine, both as a humanitarian advance and as an aspect of the ‘industrialization’ of maternity care. Unfortunately, the thing that has distinguished the use of obstetrical forceps was not any form of humanitarian concern.

I could not possibly improve on the historical account of the invention, the politics and the lasting consequences than to simply provide the original words of obstetrical historians.

Before providing the test of these historical excerpts, I must mention that ‘obstetrics’ is a 20th century word. From the time of the Ancients until the last 1900s, the word midwifery was almost synonymous with the idea of maternity care, regardless of the gender or status of the practitioner – midwife or physician.

The obstetric forceps: a short history and descriptive catalogue

by BRYAN M. HIBBARD,

The introduction of forceps into obstetric practice is variously described as one of the great advances in obstetric care, or alternatively as an example of the brutal use of new instruments whose only purpose was to advance the cause of man-midwifery.

The latter view was held by many eighteenth-century midwives who saw their business slipping into the hands of medical practitioners, and sometimes by modern historians reacting against what they see as the subsequent domination of childbirth by men, with their persistent tendency to intervene unnecessarily in a physiological process.

…any obstetrician worth his salt had to have a pair of forceps to his name. Witowski, whose Histoire des accouchments was published in Paris in 1887, described mid-nineteenth-century obstetricians as "possessed with an incredible ardour for inventing instruments sometimes dangerous, often useless, but always ingenious".

If you had your name attached to an instrument, you were tempted to use it whenever it was necessary and often when it was not; and your students learnt to do the same.

"Give me a pair of Kiellands and a pair of Wrigleys and I am content" was, as I remember it, the received obstetric wisdom in the 1950s,….

The past proliferation of forceps does, however, provide an important clue to past practice. The massive intervention in normal or slightly delayed labours, which was such a feature of obstetric practice from the mid-nineteenth century to the 1930s, stimulated the production of new designs. In the hands of an experienced practitioner, forceps could relieve an enormous amount of distress and save maternal and infant lives. Their misuse, which admittedly occurred on a grand scale

BRYAN M. HIBBARD, The obstetric forceps: a short history and descriptive catalogue of the forceps in the Museum of the Royal College of Obstetricians and Gynaecologists, London, Royal College of Obstetricians and Gynaecologists [27 Sussex Place, London NWl 4RG], 1988, 8vo, pp. iii, 69, £2.00.

The Dirty Secret of the Doctors Chamberlen:

The use of forceps to deliver babies has had a long twisted history. As far back as the twelfth century there were instruments described in such a way as to only be useful in removing babies that had died. The use of obstetrical forceps to effect delivery to save the child didn't come into prominence until the mid eighteenth century. Over a century later than it should have.

Power, fame, and greed all played a role in keeping this instrument a secret, so that those with the knowledge [of forceps] could claim that they alone could deliver patients when everyone else had failed. But before we condemn the foul secrecy that was used for personal gain, the secret of omission that was responsible for countless of thousands of babies' deaths for over a hundred years.

In 1813, a woman found an old hidden trunk which described and contained the invention of the Chamberlen family--the obstetrical forceps. In this trunk was evidence indicating that Peter Chamberlen, who died in 1631, was the first to use the technique. In fact, he claimed to be the one who could handle the impossible cases.

Along with his brother, they became prominent practitioners with the secret, and used their success to control the instruction of midwifery in England. Peter's nephew, also named Peter, was the first Chamberlen to actually become a doctor. He maintained the secrecy, assuring his success and prominence, and was the attendant at births of the royal family, who alone benefitted from his solution for difficult births.
Had any of the future monarchs died at their deliveries, like the "little people," because of not using forceps, history might be vastly different

Dr. Chamberlen, armed with his secret, issued his own "Cry of Women and Children as Echoed Forth in the Compassions of Peter Chamberlen." After his death, his son, Hugh, tried to sell the family secret to a French physician, Mauriceau, claiming he could deliver even the most difficult cases in minutes. Mauriceau tested him by assigning him a woman in labor who was a dwarf, and he failed.

Hugh Chamberlen translated Mauriceau's book into English, he wrote in the preface of how, "My father, brothers, and myself (though none else in Europe as I know) have by God's blessing and our own industry attained to and long practiced a way to deliver women...without (harm) to them or their infants."

He later sold his secret in Holland, where the Medical-Pharmaceutical College of Amsterdam was given the sole privilege of licensing physicians, for a huge amount of money, to use the secret technique of the Chamberlens. Finally, someone with scruples bought the privilege and went public, but it seems he himself was sold only one part of the forceps pair, meaning that either he was defrauded by the Medical College or Chamberlen had done it to them. Meanwhile, babies suffered the consequences of this thievery.

Hugh Chamberlen's son, also named Hugh, was a friend of the Duke of Buckingham, and because of this his statue stands today in Westminster Abbey. He's the one who finally freed the obstetrical forceps for general use at the beginning of the eighteenth century, ending the countless needless infant deaths that his family's secret had caused. About the same time, a Dr. De la Motte addressed the Paris Academy of Medicine, [and] stated how he felt about anyone who might invent a successful instrument like that, and what should happen to him should he keep it secret for is own profit:

"He deserved to be tied to a barren rock and have his vitals plucked out by vultures."

conclusion of historial text
~~~~~~~~~~~~~~~~~~~
No doubt the development of forceps were as exciting to the medical profession in the 17th and 18th century as our contemporary enthusiasm for computer technology and the Internet have been to us in the 20th century. It is human nature to embrace technologies that allow us to control the here-to-fore uncontrollable, and it is particularly sweet when it gives us a personal or economic advantage over everyone else.

For the last century however, the concept of ‘balance’ between the needs of maternity patients and the obstetrical profession has been largely ignored in the US, a time when the use of obstetrically-managed childbirth care became the social norm. There are approximately 4 million births each year, more than 90% of which are obstetrically managed.

And yet, there has been little public debate, no public oversight based, no scientific monitoring of the large pantheon of obstetrical interventions and technologies. We have no objective scientific body that can provide evidence-based guidance to develop cost-effective national maternity care policies. It seems that the practical needs of childbearing mothers and the system for providing maternity care to healthy women have both fallen into a cultural blind spot.

Like many areas of modern life, maternity care for healthy women can be organized in two diametrically opposed ways. One is sustainable, socially–conscious, cost-efficient and has a small carbon footprint. The other, refereed to by Dr G. as the ‘obstetrical package’ -- is associated with a large carbon footprint and ever-increasing economic, ecological, and humanitarian burden.

Unfortuantely, the current obstetrical status quo is unsustainable -- industrialized childbirth for a healthy population fails the cost-benefit test. The status quo is also unacceptable in that it fails to meet the practical needs of the childbearing population. But the good news is that unlike war, terrorism, global warming and many other ills facing America today, we do know what to do about this problem. It’s called physiological management. The use of its prinicples can be of benefit to all categories of childbearing women, even those with high-risk pregnancies. It can be used by all categories of birth attendants – obstetricians, family practice physicians and midwives. It works wherever the mother wants or needs to be – home, hospital or independent birth center.

The missing link is YOU!

For more on “Green Maternity Care”, visit http://www.normalbirth.org/.

Part Three:

The Next Wave of Industrialization –

18th century Medical School and Clinical Training

2007-03-12T01:50:00.000-07:00

What happens when you 'industrialize' social biological aspects of life - part one of 3-part essay.

If you have not read the New Yorker article “THE SCORE - How childbirth went industrial” the following critique will be of limited value.

Here is web access to this New Yorker article on the internet. It was originally published October 09, 2006

A brief excerpt from THE SCORE, by Dr Gawande:

“The question facing obstetrics was this: Is medicine a craft or an industry?
If medicine is a craft, then you focus on teaching obstetricians to acquire a set of artisanal skills —… maneuver[s] for the baby with a shoulder stuck, ...for the breech baby, the feel of forceps... You do research to find new techniques. You accept that things will not always work out in everyone’s hands.

But if medicine is an industry, responsible for the safest possible delivery of millions of babies each year, then the focus shifts. You seek reliability. …Clinicians are increasingly reluctant to take a risk, however small, with natural childbirth.
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.
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.
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. [emphasis added]

An Alternative Thought: part one of a three-part essay ~

“Obstetrics has been rated as the least scientifically-based specialty in medicine” [Dr. Ian Chalmers 1987].

It is not my intention to impeach the well-earned prestige of physicians or to disregard the many valuable contributions of modern medicine. As an L&D nurse, I was profoundly gratefully each and every time obstetrical medicine was able to save the life or prevent permanent damage to mothers or babies suffering from the complications of childbearing.

I am personally grateful to a wonderfully sympathetic obstetrician-gynecologist. Without his astute diagnostic and surgical skills in 1962, I would not have been blessed with the ability to become pregnant with my wonderful children. That would also have deprived me of my grandchildren, which surely is one of the best parts of being a parent.

But when it comes to the ‘industrializing’ of normal birth, I am not a fan. I’m aghast at the comments of Dr. Gawande, which promote the idea of obstetrics as an ‘industry’. Instead of the individual skill of the physician, now it’s the industrial “rules of the factory floor” that decide the kind of care provided by obstetricians. Obstetrics is all about what is best for obstetricians, instead of what serves the basic biological safety of childbearing and practical needs of mothers and babies.

Dr Gawande believes that the greatest good for society is to be achieved by passively permitting the ‘obstetrical industry’ to eliminate the biology of spontaneous vaginal birth and replace normal birth with assembly-line Cesarean sections, as is already being done in Mexico City, where all birth is an elective surgical procedure scheduled at 15 minute intervals, Mon-Fri, 8am-5pm. Dr Gawande argues that the industrial revolution in obstetrics could “make Cesarean delivery consistently safer than the birth process that evolution gave us.”

This is clear vote of “no confidence” by the obstetrical profession, who publicly describe our evolutionary biology is as a defective and undependable system, while obstetrical interventions -- particularly Cesarean section -- are pictured as the better and safer route. However, that is a false and misleading claim which is overwhelmingly refuted by the scientific literature. Having major abdominal surgery is not in the best interest of childbearing women. A paper recently published paper by Department of Obstetrics and Gynecology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA, entitled “Vaginal birth after caesarean section versus elective repeat caesarean section: assessment of maternal downstream health outcomes” concluded that:

“The results of our analysis suggest that the downstream consequences of multiple caesarean sections must be incorporated into patient counseling regarding VBAC, especially in women who are considering additional children.

Specifically, for women who desire multiple children after a single caesarean, a strategy encouraging VBAC will result in fewer cumulative hysterectomies than an elective repeat caesarean section strategy.

Our results should also be taken into consideration when making policies about the mode of delivery after one prior caesarean section: they suggest that if the ‘pendulum’ continues to swing away from VBAC, the incidence of placenta praevia and placenta accreta, and their associated morbidities, will continue to rise sharply.”

Industrialized Childbirth

Industrialized childbirth is a capital-intensive system for turning the normal biology into a mass produced “product” of the obstetrical profession.

In 20th century terms, industrialization is a capital-intensive system which does a fine job of producing affordable cars, computers, cell phones and Nike athletic shoes. But the object of industrialization is to make a profit by making things cheaper and more readily available. That is not the same thing as making things better or safer.

We generally believe the quality of being ‘industrious’ is a valuable character trait – that is, focused and consistent energy, applied to achieve a socially valuable goal. But what happens when that quality of industry – in this case, large-scale assembly-line methods -- are grafted onto social and biological processes? Over the course of the 20th century, we have seen our schools, childcare, hot meals, family farms, family fishing businesses, forest management, animal husbandry and many other aspects of our lives become standardized, mass-produced, franchised, out-sourced or contracted out to the lowest bidder. Do assembly-line methods as applied to biology and sociology make our lives better, worse or just different?

One example of this conundrum can be found in the traditional practice of agriculture and animal husbandry. The heavy industrializing of these biological systems has virtually obliterated the individual farmer or family-based fishing business. Now called the agri-business, huge mechanized farms replace family farms. In doing so, society exchanged individual initiative, personal responsibility and ecological balance of the family farm – all planet friendly ‘green’ characteristics, with a small carbon foot-print -- for a high volume, assembly-line industry. By trading quality for quantity, mass production techniques injected a high level of bio-hazard. Recently, E-coli contaminated spinach was shipped all over the US from a single grower in California, resulting in the deaths of several people, including a two-year old child.

Cattle ranching, chicken and hog farms, milk and egg production have also been revamped to make for high volume methods. However, aggregating so many animals together is highly stressful and disruptive to live stock. Worse yet, industrial levels of animal waste, aggregated together in a confined space, create a biologically toxic situation of mammoth proportions. To realize the full impact of this, contrast the biological waste generated by a dozen chickens on a couple of acres of land with what happens when you use the industrialize the same few acres with a 100,000 chickens in tightly packed pens. When this natural ecological balance is ignored, the result is thousands of pounds of manure that contaminate the water and a nauseating stench that pollutes the air. Overflowing hog lagoons in North Carolina and tight-packed cattle pens in California are just two examples this industrial-strength problem.

Without the constant use of prescription drugs, factory farms animals become sick and die. Factory farming and ranching both depends on the pharmaceutical industry to stay in business. Growth hormones increase milk production, force chickens to lay more eggs and fatten cattle. Antibiotic-laced animal and chicken feed is required to overcome the potentially-fatal infections from crowded pens. The blow-back from the industrial use of antibiotics in animal husbandry is an increase in the number of virulent, drug-resistant bacteria and contamination of ground water with large quantities of antibiotics that are excreted in animal urine. Unfortunately, there are many other instances of this sort of industrial ‘blow-back’.

Does the agri-business have anything to do with the baby-business?

Few people think of industrialized childbirth as having anything in common with factory farming or hormone-enhanced egg and milk production. But it has more in common than one would think, starting with the capital-intensive structure of the hospital-industrial business (buildings, expensive equipment, sterile supplies, etc) and the need to maintain its economy of scale thru the economical use of space and staff time.

In order to have some control over the patient census, hospitals must have an orderly flow of patients that matches the number of beds and staff available at any one time. For labor and delivery units, that means control over the timing of labor, at least for some percent of the patient population. This inevitably puts pregnant women on the ‘clock’, as the hospital is reimbursed at a much higher rate for performing medical and surgical procedures than the rate for the simple use of the labor room and the nursing staff.

For example, 5 women in labor for 24 hours each (a total of 5 deliveries in that 24 hrs period) is not nearly as profitable as 15 women who, thanks to speeding up labor through the use of artificial hormones (Pitocin, etc), are able to be ‘delivered’ in just eight hours and whose care requires only one shift of nurses. The hospital reimbursement for 15 deliveries in 24 hours is much greater than the reimbursement for only 5 deliveries. Even though the hospital can recover additional fees for the prolonged use of the labor room, it ties up the very foundation of the industrialized model -- scarce real estate and employees, in this case, 3 shifts of nurses. This is a net loss compared to the billable units in the additional 10 deliveries, especially if 30% of them are Cesarean sections, which are billed at an even higher rate per minute of time.

To understand the industrial childbirth perspective better, I have included the following remarks from a well-known obstetrician who conducted a study on elective inductions. He is quoted in ObGynNews as recommending the off-label use of an ulcer drug (generic name misoprostol or “Cytotec”) and the elective induction of labor:

“Oral misoprostol is far and away the most cost effective labor induction method”, Dr. Arthur S. Maslow asserted at a meeting on ob.gyn, gynecologic oncology, and reproductive endocrinology.

“It's a great agent. It works very, very efficiently. It's very safe. We've had no complications, no uterine ruptures. And it's ungodly inexpensive: 27 cents per tablet. At the most we use two or three tablets,” Dr. Maslow said at the meeting, sponsored by the Geisinger Health System.

“The best part about it is that you can block-schedule your nurses so that you have enough on hand. With a 90% successful induction rate within 8-10 hours, if we start our inductions at 7 a.m., we know that we're going to have X number of patients in labor being admitted by 4 p.m.

That's helped our hospital tremendously,” said Dr. Maslow, director of maternal and fetal medicine at the Geisinger Health System in Danville, Pa.

…. we make them [maternity patients being induced] walk for 2 hours. They can stay in the hospital, go to the mall, I don't care. Just don't rest them during an induction. You're killing your hospital financially if you do that, just killing them. It's not fair to the hospital …” Tips on Labor Induction Using Oral Misoprostol - Study of 2,200 elective inductions; Ob.Gyn.News; April 1 2004 • Volume 39 •

Cytotec is not the only drug that is frequently employed to hasten labor in a medicalized attempt not to ‘kill your hospital financially’. Another artificial hormone known as prostaglandin gel (made from pig semen) is also used to ‘ripen’ the cervix, so that labor can be induced. Unlike Cytotec, it costs about $400 a dose.

However, induction also requires the use of yet another drug “Pitocin” -- an artificial form of the natural hormone oxytocin. According to various sources, between 50% and 80% of all labors are either induced or artificially sped up with one or more of these powerful drugs. Perhaps it is not just a co-incidence that 50% of all malpractice cases brought against obstetricians involves the use of these labor inducing or accelerating drugs

From the standpoint of hospital staffing ratio and insurance reimbursement, electively scheduled Cesarean sections are even more advantageous. One large hospital in Michigan is replacing half of its labor rooms with operating rooms, in anticipation of a 50% CS rate by the time their new unit opens in 2011. [University of Ann Harbor, 2006]

Bio-hazards – Nosocomial blow-back

Another similarity between the agri-business and the birth business is that doing business on an industrial scale inevitably results in a bio-hazardous environment in. Aggregating sick people or healthy childbearing women or healthy infants together in hospitals has always been a bio-hazardous nightmare. The very early hospitals were thought to be places to avoid at all costs, since few people left them alive. The word for hospital-acquired infections, errors or other hospital-related patient harm is “nosocomial”. [for historical perspective, read “The Cry and the Covenant” by Morton Thompson, 1949].

Not a new problem

As long ago as 1881, a professor of obstetrics at the Edinburgh Maternity Hospital in Scotland lamented the infectious dangers of aggregating pregnant women and babies in institutional settings and the virulent nature of the nosocomial disease in hospitalized women known at the times as childbed fever.

Before the widespread understanding of the germ theory, doctors couldn’t figure out what was causing maternity patients to become septic, but they did realize that it was provoked by aggregating childbearing women together in an institutional setting. It was common knowledge among doctors and the lay public that maternal deaths were several times higher when women delivered in hospitals than when they gave birth at home. This was even safer for women to deliver precipitously on the doorstep of hospital before any medical care could be given (no vaginal exams or exposure to dirty linens, etc), than to deliver after being admitted to the hospital.

In a paper presented to the Edinburgh Obstetrical Society Session in 1881 on “the systematic use of antiseptics on midwifery [i.e., maternity] patients”, the author (an obstetrical professor) provided details about the nosocomial risk of childbed fever in institutional environment [i.e., hemolytic septicemia]. A frequent topic among obstetricians was whether they should move all their healthy maternity patients back out of hospitals in order to eliminate these nosocomial deaths. Ultimately, he and other obstetricians concluded that the training medical students required that the medical profession perpetuate hospital-based maternity care, which provided unlimited access to the necessary ‘clinical material’ (teaching cases). Here is an excerpt from 1881:

“…. concerning the question of maternal deaths, it must be admitted that the diminution of maternal mortality is the main object of our art. These maternal deaths during childbed … have been shown … to be striking in their frequency. In our own hospital I … find that out of 10,043 women who have delivered in it, almost 2 percent or nearly 1 in 50 have died.

I speak of prevention rather than cure because …in its presence we are nearly powerless or at least not in a position to rely with certainty of the efficacy of any of the means employed. If we are comparatively unable to cope with puerperal fever once established, it becomes our duty to be all the more anxious to adopt any precaution which may offer a reasonable hope of preventing it.

Since the opening of the [new Edinburgh maternity] hospital, there have been 12 deaths.., 10 have taken place from this cause [puerperal sepsis]. What I believe to have been the origin of the disease, viz, is the want of a separate mortuary and the performance of post-mortem examinations in the hospital. Since that report, the fault has been remedied and the hospital thoroughly and repeatedly disinfected.

Notwithstanding all this, the deaths from puerperal fever have continued. Yet during that period there has not been recorded a single case of death from a similar cause in the extern practice [i.e. labor and birth in the mother’s home]…

This brings us back to the old question long ago worked out by Sir J. Simpson, … and others of home versus hospital practice and of the greatly increased mortality of hospital as compared with home.

….. To me it seems sufficiently established that maternity hospitals must exist, as much for the benefit of women at a time when they most need shelter and assistance, as for the clinical instruction which the medical student can receive there and there only.

It must be borne in mind that the majority of the intern cases [hospital instead of home] are single women who have been seduced, and who, apart from their mental condition, …. have previous to admission, been in straitened circumstances and badly nourished, and are consequently specially liable to be quickly and gravely affected by any septic influence under which they may be brought.

The present Maternity Hospital being a necessity and puerperal fever having been shown to exist there, and to have been the direct cause of death in 1 out of every 32 women and as all needful sanitary improvement have been made, it becomes necessary to look for the prevention of this scourge by means apart from the building itself.

What then is the nature of this disease, which has proved fatal in our new hospital to one out of every 32 women who have been delivered here? And is it feasible to suppose that it can be prevented? I do not believe that we can hope to prevent puerperal fever entirely…. but I feel certain that by strict attention to antiseptics we shall be able to reduce its occurrence to a minimum and render its presence in hospital practice, where I have just said it is most common, a rarity. [Edinburgh Obstetrical Society Session 1880-1881 “On the systematic use of antiseptics in midwifery practice”; emphasis added]

The Germ theory of Contagion

Nosocomial infections were greatly reduced after the discovery of pathogenic bacteria (germs) and the role of different kinds of microscopic organisms in causing infectious disease. In 1881, French physician Louis Pasteur drew a picture on a chalk board at a prestigious medical meeting in France of what streptococcus bacteria looked like under a microscope. Pointing to his picture of rectangular microbes that resembled a string of boxcars on a train track, he made his now famous pronouncement “This, gentlemen, is the cause of Childbed Fever”. The discovery of micro-organisms established as a scientific certainty the role of bacteria in causing infections. The dramatic pronouncement by Dr Pasteur permanently influenced the practice of medicine and surgery all across the world and actually is the foundation of medicine as a scientifically-based discipline.

For the previous 2 centuries, obstetricians had been frustrated by their inability to prevent nosocomial infections. Their considerable medical skills permitted them to use forceps or even perform a Cesarean to save the baby, only to have the mother (and perhaps the baby also) become infected with childbed fever and die a few days later from hemolytic septicemia. The discovery of pathogenic bacteria as the source of infectious disease was enormously exciting to the medical profession. Finally there was something tangible, something that could be seen under the microscope and killed by strong chemicals and exposure to heat. An understanding of the germ theory and the principles of antiseptic and aseptic techniques provided doctors with a way to prevent wholesale epidemics, thus making hospitals into a place of healing instead of a place to die.

Over the course of the next 30 years, this single event changed the practice of medicine from a hit and miss art form to a budding science with unlimited potential. Dissemination of the germ theory particularly influenced the way normal childbirth was conducted. For the first time the medical profession understood that anything which touched an infected person would be contaminated by pathogens and thus it became a source of contagion. This eventually was describes as the 'vector', a mathematical term for the place where two lines cross. In this case, it describes a remote point for the transmission of disease, in which the two infected people never personally had any contact with one another and yet the pathogen from one infected person found its way to healthy person who also became infected and thus was a second victim. This contagious chain of events could go on endlessly and result in massive epidemics.

Using the science of microbiology and employing a generous dose of Yankee ingenuity, the obstetrical profession threw itself into approximately 30 years (1880-1910) of antiseptic and aseptic-based remodeling of building and of innovative ideas about medical care. Hospitals were striped of all ‘fu-fu’ – rugs, curtains, upholstered furniture, etc. Strict house keeping standards were imposed, with frequent dousing of the walls and floors with Lysol. Stainless steel replaced wood and fabric and institutional green become the color du jour. Delivery rooms were tiled floor to ceiling; equipment was stainless steel or chrome for easy disinfecting. Rules for hospital visitors were very strict, with even more draconian restrictions for visitors to the maternity floor. Children under 16 were totally barred from the maternity ward.

Nosocomial Infections stubbornly persist

However, eliminating nosocomial infections was more difficult than anticipated. As reported by the professor from Edinburgh in 1881, simply disinfecting the building was not able to provide the hoped for rate of zero infections. The enemy was an invisible pathogen hundreds of times smaller than the period at the end of this sentence. This meant that nosocomial infections had as many sources as the employees of the hospital had fingers -- nurses, medical students and attending physicians all had multiple opportunities to spread deadly bacteria. An innocent error, a minor mistake, carelessness or wanton disregard anywhere along the institutional chain of events could result in contamination and contagion.

All it took was one incidence of unwashed hands, an improperly cleaned piece of equipment, a contaminated surgical instrument, an unsterilized bed sheet, a dirty bedpan, a broken sterilizer, an outdated antiseptic, a sneeze or a cough – anyone or anything in this great institutional smorgasbord could be the harbinger of a fatal error. Janitors, central supply clerks, nurses, housecleaning, all were equally likely to be guilty. Eliminating nosocomial infections is the archetypical Herculean effort, cleaning the stable out each and every day, for each and every patient and relative to each and every items used – linens, instruments, other equipment -- only to be back to square one the very next minute.

“...in 1921 the maternal death rate for our country was higher than that of every foreign country for which we have statistics, except that of Belgium and Chile.”[1925-A; HardinMD, p.347]

"Maternal mortality in the country when compared with certain other countries, notable England, Wales and Sweden is, according to Howard, is "appallingly high and probably unequaled in modern times in any civilized country".

“The ‘International Year Book of Care and Protection of Children’ gives emphasis to the fact that the Untied States has still a higher rate of maternal mortality than any other of the principal countries of the world …. Twenty five thousand women die in the United States every year from direct and indirect effects of pregnancy and labor. Three to 5% of all children die during delivery and thousands of them are crippled.” [1925-A p. 350]

Iatrogenic contributors to nosocomial infection

The elimination of nosocomial infections was a high priority of the obstetrical profession in the late 19th and very early 20th century. By 1910 hospital buildings had been remodeled, hospital policies forbid visitors who might themselves be ill and antiseptic principles were routinely used by the staff. In theory, this should have stopped cross-contamination dead in its tracks.

Despite these aggressive measures, hospital-acquired infections continued to be the most frequent cause of maternal-infant death. After much sole searching, leaders in the obstetrical community had to admit that doctors themselves were part of the problem. A well-known obstetrician and author (Joseph DeLee) lamented the continued high rate of nosocomial infections associated with hospital childbirth. In his 1924 obstetrical textbook, Dr DeLee identified the role of doctors in a hospital setting as a vector for these infectious diseases and recommends additional changes in hospital policies to reduce infection:

“Without doubt the physician carries the greatest danger of infection to the confinement [labor] room. The germs in the air, in the bed clothes, in the patient’s garments, even those of the vulva, may be the same … as those he [the doctor] brings with him, but the former are not virulent ….

The physician comes in daily contact with infections disease, pus, and erysipelas cases, and his person, clothes and especially his hands may carry highly virulent organisms.”

The air in the ordinary home does not contain any virulent bacteria, but this cannot be said of general hospitals admitting pus cases, pneumonia cases, and tonsillitis patients into the same wards with maternity patients. That under these circumstances puerperal infection may originate has been amply demonstrated to the author. The maternity case should be in a part of the general hospital absolutely isolated from the rest of the wards, best in a detached pavilion of its own as the older obstetricians have always taught.” [Obstetrical textbook Dr DeLee p. 294]

Patient harm is described as “iatrogenic” (instead of nosocomial or hospital-based) when it is the direct result of actions (or inactions) by a medical professional. The obstetrical profession had to admit that many maternity deaths were actually iatrogenic complications. One way that this came to light was by comparing physician-attended birth with those attended by midwives. Contrary to expectations, puerperal septicemia in mothers who had their babies delivered by midwives was rare.

“In New York City, the reported cases of death from puerperal sepsis occur more frequently in the practice of physicians than from the work of the midwives”. [Dr. Ira Wile, 1911-G, p.246]

But among themselves, doctors also admitted that it wasn’t just hospitalization that increased rates of childbirth septicemia. The more manipulations done during labor the more infections. Common obstetrical procedures and manipulation included vaginal exams, rubber bogies gradually filled with water to pry open the cervix, and other use of ‘artificial, forcible or mechanical means’ to advance the labor or bring about the birth. The included all surgical procedures – episiotomy, forceps, Cesarean section, etc – which greatly increased the rate of morbidity and mortality.

Here is how the problem was describes by Dr. DeLee [p. 292-293]:

“Let the [mother’s] natural immunities be broken down, as by severe hemorrhage, shock, eclampsia, etc or let a new virulent bacterium be introduced; let the accoucheurs [archaic word for obstetrician] in his manipulation carry too many of the vaginal bacteria up into the uterus (a procedure not entirely avoidable), or let him, by his operations, bruise and mutilate the parts too much, or let him break up the protective granulation referred to, and the germs will rapidly invade the system, producing a disease know as puerperal infection, termed by the older writers as child-bed fever.

The asepsis of the patient therefore consists mainly in the preservation of her immunities by sustaining her strength, procuring a normal course of labor, avoiding the necessity for operative interferences, and conducting these with the least possible amount of damage.”

Hospital epidemics finally halted, discovery of antibiotics has unintended consequences

It was not an easy or instantaneous transformation, but eventually the systemic use of antiseptics, aseptic technique and eventually, sterile supplies, eliminated epidemics outbreaks of puerperal sepsis in hospital maternity wards. Obstetricians ascribed their success to the hospital policy of conducting of labor and birth under conditions of surgical sterility, as a “surgical” procedure. It was the Holy Grail of obstetrical practice, but in spite of flawless sterile technique, individual cases puerperal septicemia continued to kill a small percentage of new mothers.

With the discovery of antibiotics during WWII, it was assumed that finally the danger of hospital contagion was a thing of the past. Antibiotics were administered ‘prophylacticly’ to hospital patients in the mistaken belief that these drugs would “nip it in the bud”, should an errant germ gain entrance. With this powerful new weapon against virulent bacteria, doctors felt free to intervene as much as convenient, assuming that should the mother develop signs of infection, they could just order a shot of penicillin and the problem would magically fade away.

Unfortunately, that idea was wrong. Hospital-acquired infections tend to be the most virulent and antibiotic-resistant forms of bacteria and drug therapy can no longer be counted on to cure them. Hospitals do their very best to keep contamination and contagion away from laboring women, but the need to sterilized absolutely everything that a labor patient or newborn baby comes in contact with is extraordinarily expensive and only partly effective, as human systems that require inhuman perseverance frequently break down despite everyone’s best efforts.

The longer someone is a patient in a hospital and the more procedures performed (skin punctured or instruments inserted into body cavities, etc) the higher the rate of nosocomial diseases. These antibiotic-resistant pathogens tend to become incorporated into the normal flora (the nose, throat and alimentary tract) of hospital workers. Once these infections are under way, they are not easily treated. Nosocomial infections are responsible for about 20,000 deaths in the U.S. per year. Approximately 10% of American hospital patients (about 2 million every year) acquire a clinically significant nosocomial infection. [Supplemental Lecture (98/05/09 update) by Stephen T. Abedon (abedon.1@osu.edu]

Three-part essay ~ End of part one -

Stay tuned for part two -- Identifying the basic nature of childbirth, the right (and wrong) use of gravity and the role of obstetrical forceps in the earliest attempts to industrialized childbirth by taking a short-cut. Forceps were originally intended to rescue babies whose mothers couldn't physically give birth naturally, but soon became the 18th and 19th equivilent of "elective Cesarean", that is, the idea that man-made tools and interventions could somehow make birth "better" than old-fashioned biology.

2006-12-17T02:07:00.000-08:00

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.

=================================

“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?

================

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]

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

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?

2006-11-15T13:18:00.000-08:00

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 onlyat immediate costs, thus vastly underestimating the real costsof elective cesarean for breech or any birth. Since most womenwill have more than one birth, the presence of a uterine scarwill expose women to increases in placenta previa and placentaacreta,⁵ ectopic pregnancy,⁶ abruption,⁵ infertility,⁷ stillbirth⁸and excess hospital readmissions because of the cesarean⁹ andadhesion-related intestinal obstruction.¹⁰ All of these costshave been ignored.

This analysis led to headlines in the popular press that cesareanbirths are both safer and cheaper. This lack of nuance fuelssocietal views that increasingly suggest that cesarean sectionis just another way of giving birth; in addition, it underminesthe confidence of a generation of women who are coming to believethat 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

2006-10-26T16:55:00.000-07:00

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…..

2006-10-24T12:20:00.000-07:00

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.

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