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Tuesday, October 24, 2006

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.

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.

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.


Laura Bentz said...

Thank you for this response.

I *knew* there was something about the rhetorical approach, of the article, that was at the root of my "problem" with it. Thank you for taking the time to begin to unravel his assumptions.

I look forward to reading more.

WiseWoman said...

Thank God we have you to write sanely
about this, Faith. So many people
sent me the N.Yer article and I couldn't even read past the first
paragraph, let alone fashion a reply.
I was very glad to read your words.
Gloria Lemay, Vancouver BC

Aimee Crane, Traditional Midwife said...

Thank you for your thoughtful response to the doctor's quasi-intellectual survey of obstetrical care in America. We in the normal birth community must call these docs on their fast-and-loose treatment of the facts, and demand evidence-based medicine from them. I only wish that your response correcting the myriad inaccuracies would get the same play in the media as the original drivel. I, too, look forward to your next installment. Give 'em Hell!

faith gibson said...

I was so pleased to find that a few of you were actually reading the critique of the New Yorker article. I will be continuing the point by point rebutal, but babies are falling out of the sky this week and now i'm way behind.

Good to hear from Gloria L. in Vancouver.

I do hope you all are sending at least a small note/email to the editor of the NYer, so that they will offer us "equal time".

faith ^O^

Dr. Leonid Gavrilov, Ph.D. said...

Thank you for your interesting post!
I thought perhaps you may find this related post about new article by Atul Gawande interesting to you:
Longevity Science: The Way We Age

faith gibson said...
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faith gibson said...
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