1.22.2008

Birth: Medical Event or Natural Process?

Imagine if you will, a woman who has just discovered she’s pregnant. If she lives in the United States, one of her first thoughts will likely be that she has to make an appointment with her obstetrician.

From that first appointment the woman usually acquiesces to test after prenatal test throughout the pregnancy. She will likely accept a plethora of interventions throughout her labor and birth that in many cases are, at the very least, uncomfortable or stressful (or both), and in some cases painful. She may be facing a fear of the unknown with courage henceforth unknown to her. She does so for the sake of her baby. She sacrifices privacy, and in some cases dignity, because she believes it will keep her child safe and herself healthy.

What if the vast majority of women and babies are delivered safely because birth is a reasonably safe, healthy, physiological function of the mammalian body? In other words, what if the end result could be the same in a way that focused on the joy and wonder of the process of procreation…not on every possible thing that could, but is not likely to, go wrong?

In the U.S. today, most people assume that medically managing birth makes it safer. It is widely accepted that the interventions in pregnancy and birth serve a purpose…in effect, that they are safe and effective. Does the evidence support these beliefs?

To assess whether birth is safer medically managed as opposed to expectantly managed, I believe we must first examine how obstetricians became the primary caregiver for birthing women. As an experienced childbirth educator, I’ve discussed this with parents, and without exception, the belief has been that birth originally shifted from a midwife monitored event at home to a medically managed hospital occurrence due to safety reasons. That is an erroneous assumption.

According to The Official Plan to Eliminate the Midwife: 1900-1930 (Gibson, n.d.), at the time that birth moved to the hospital, there was little doubt that midwifery was the safer option. Through early professional journals such as Transactions for the Study and Prevention of Infant Mortality (1910 – 1915) we have a unique glimpse into history. She quotes Dr. Ira Wile as saying in 1911, "In NYC, the reported cases of death from puerperal sepsis occur more frequently in the practice of physicians than from the work of the midwives’"(as cited in Gibson, 2006, Part I), and she attributes the following to a Dr. Levy in 1917, "Of the babies attended by midwives, 25.1 per 1000 ... died before the age of one month; of those attended by physicians, 38.2 per 1000 .... died before the age of one month; and of those delivered in hospitals, 57.3 per 1000 died before the age of one month. These figures certainly refute the, which Gibson obtained through Stanford University Medical Library, charge of higher mortality among the infants whose mothers are attended by midwives, and instead present the unexpected problem of explaining the fact that the maternal and infant mortality for the cases attended by midwives is lower than those attended by physicians and hospitals" (ibid.). This, despite the fact that 80 years prior, Dr. Ignaz Philipp Semmelweis had admonished physicians for not washing their hands before attending women after handling cadavers, which he suspected was one reason for their high rate of childbed fever, and subsequently higher mortality rate (CDC, 2001). He was ridiculed.

Midwives would have had no idea their vocation was systematically being eliminated to provide “clinical material”…pregnant women…to obstetricians (as cited in Gibson, 2006, Part II). Even if they had known they couldn’t have done a thing about it. Women didn’t have the right to vote.

Since that time, there has never been a definitive study showing medically managed birth with obstetricians to be safer than expectantly managed birth with trained midwives, though there have been those that have tried (Pang, 2002). The conclusions and methodologies, however, have been called into question (MacCorkle, 2003; Vedham, 2003; Citizens for Midwifery, 2002; Gibson, 2006; Strong, 2000, pp. 222-223). In fact, Jock Doubleday (Doubleday, 2005) has been offering progressively larger amounts of money, with $50,000 being the last offered in December of 2005, for anyone who can provide such a study. The reward has stood unclaimed since he first offered it in 1998.

Childbirth is safer than it was 100 years ago (Johanson, Newburn, & Macfarlane, 2002). Undoubtedly, it is safer to give birth in the U.S. than it is in many places throughout the world. However, to assume that if obstetricians now attend birth, then improved outcomes must be due to that development alone is a fallacy that does not take into account improved nutrition, sanitation, disease control, birth control or any number of other variables. It is a spurious correlation. There are many contributing factors to improved health and well-being in the childbearing year (Wagner, 1994). In fact, countries that enjoy the modern advancements mentioned above in addition to midwifery care have the best outcomes in the world (Strong, 2000), and “…there is never a doctor in the room” (Wagner, 1994, pp.124). Where exactly does modern obstetrical management place the U.S. in comparison to the rest of the world? There are 42 countries with lower infant mortality rates (Central Intelligence Agency, 2006) and 29 countries where fewer mothers die (World Health Organization, 2004, pp.23).

While this may be surprising to some, certainly, it is not to suggest that the practice of obstetrics is unnecessary. We need surgeons and experts in pathology for a small number of cases that might be deemed high risk, such as mothers who have pre-existing medical conditions or mothers with addictions. The evidence suggests that number should be a very small percentage (Johnson & Daviss, 2005; Declercq, Skala, Corry, Applebaum, & Risher, 2002).

In essence, the system under which the U.S. currently operates might be like hiring a cardiologist as a personal trainer. Could heart attack deaths be reduced by having surgeons immediately available in the event that a normal, but strenuous, activity turned tragic? It’s very likely. However, would a game of tennis be imminently more difficult, if not impossible, if mobility were restricted by an assortment of electrodes and devices strapped to the player to assess every biological function and make the job of the cardiologist easier?

If this seems like an absurd analogy, consider this: the image that most of us have of birth is of a woman in bed, usually on her back, pushing out her baby, possibly with her feet in stirrups, or her legs being pulled toward her ears by herself, her partner or a nurse. Now, look at the following two pictures. The picture on top is the reproductive anatomy of an upright female. The picture on bottom has been turned as if the model were on her back.




Free clip art from http://www.arthursclipart.com/medical/reprobw.htm

The path the baby follows is called the ‘curve of Caras’. It becomes apparent in the second picture that, on the back, the mother would be pushing her baby uphill. Why? Is there some physiological reason that mothers are expected to lay on their backs? No. The reason mothers are restrained to bed is so that the monitors can be hooked up and so that the doctor can sit comfortably at the end of the bed.

Women are told throughout pregnancy to avoid laying on their backs because oxygenation to the uterus can be impeded by the weight of the baby resting on the vena cava (major blood vessel). Does the position suddenly become safe in labor? No. This position is detrimental to babies, and it creates pain for the mother because the weight of the baby rests on her tailbone (Lamaze, 2005). The position also makes the pelvic outlet considerably smaller by resting the mother’s weight on the tailbone, this flexing it inward. It makes the final stage of labor much harder than it needs to be. It almost guarantees the perineum (area between the vagina and anus) will tear (Walsworth & French, 1998). Therefore, episiotomies are done to prevent tears. This means healthy perineal tissue is cut to prevent tears that would be unlikely to occur if the mother were not in a position that creates conditions for tears. Does it work? Think about it. If you try to rip a piece of whole fabric, it remains strong. If you first cut the fabric a tiny bit, it rips easily. The same is true of the human flesh. Fourth degree lacerations (where the perineum rips through to the rectum) happen almost exclusively with episiotomies (Goer, 1995).

All of this so the baby could be continuously monitored, and for the convenience of the provider, without any regard for how it impedes the process of birth, the danger it introduces into the process, or the comfort of the mother. It is not supported by evidence as safe, is not backed by common sense or evidence as effective for, well, anything. Yet it is a nearly universal intervention.

At this point, it might be argued that by constantly monitoring the baby, we can avert a terrible tragedy by knowing moment by moment what the state of the baby is. Except that what the evidence says is that the routine use of continuous electronic fetal monitoring does nothing but increase the rate of surgical birth without any improvement in outcomes (Goer, 1995; Wagner, 1994).

The act of giving birth becomes more difficult, and in some cases impossible, due to the assortment of wires and devices meant to assess every biological function.

Each obstetrical intervention was created for a specific medical indication for which, when used appropriately for that indication, it is effective. Unfortunately, instead of being used selectively in exclusively pathological (abnormal) situations, many interventions are used routinely within a healthy population, in part due to the litigious environment in which physicians must operate (Carpenter, 2004).

The following graph (Wildner, 2006) illustrates some of these. It shows the percentage of women who will experience the selected interventions under different caregivers, with no substantial difference in outcomes.


If we can obtain virtually the same results without performing them, why are they being done? How many of these common procedures proven safe and are they effective?

Two interventions deserve special consideration. These are procedures deemed ‘elective’, which is a bit misleading, because a woman may ‘elect’ to have them, but should she ‘elect’ to refuse them, they may be performed under court order (Irwin & Jordon, 1987).

These two procedures, induction of labor and cesarean section, while they are extremely important life-saving measures when used for medical indication, are perfect examples of obstetrical technology gone awry when used for convenience.

The World Health Organization suggests that induction is medically indicated no more than 10% of the time (as cited by The Coalition for Improving Maternity Services, 2003). Yet, according to the Listening to Mothers survey, (
Declercq, et al, 2002) 55% of mothers were induced, even though there is acknowledgement that induction increases risk (Baxley, 2003; Rubin, 2006) and the chemical agents, such as Cytotec, used for elective induction are not approved by the FDA for such use (Haire, 2001; Physician’s Desk Reference, 2003). In fact, not only is Cytotec not approved for elective induction, it carries a serious warning not to use it for induction at all (U.S. Food and Drug Administration, 2005), which does not seem much of a deterrent to the American College of Obstetricians and Gynecologists (ACOG) or the American Academy of Family Physicians who “…supports the safety and effectiveness of vaginal misoprostol (Cytotec) for cervical ripening and labor induction” (Weaver, 2006) contrary to the scientific evidence.

The Centers for Disease Control, (CDC, 1993) and the World Heath Organization, (as cited by The International Cesarean Awareness Network, 2004) recommend rates of surgical birth not to exceed 12-15%. The U.S. is currently at 29.1% (Dress, 2005), meaning at least half of these surgeries are medically unjustified. Obstetricians contend (
Rubins, 2003) that the increase is due to ‘maternal request’ surgeries, to avoid such things as urinary incontinence later in life, or sometimes due to fear of pain, supposedly the case with Britney Spears. Yet, vaginal birth is not a factor in urinary incontinence (Albers, 2003; ACOG, 2005), despite what some doctors may suggest (Healy, 2006). If women are requesting surgery over natural birth, which some sources doubt (Lamaze International, 2006), then one would wonder if they are being apprised of the significant risks (Thornton, 2006). Risks that are perhaps worth taking if the life of mother or baby are compromised…but not worth introducing where none previously existed.

People often say that in the end, all that really matters is that the mother and baby are okay. Is that really all that matters?
What if the mother and baby could have been safe without adding insult to injury?

While some authors merely tell women they should expect care with no basis in science (
Murkoff, Eisenberg, & Hathaway, 2002) others defend over-treating in order “To be sure that not even one baby will be harmed during delivery” (Tuteur, 1994; Part III-Common Obstetrical Practices). Is that a realistic goal? Is it being realized? Not as evidence by the many people who have studied obstetrical management versus midwifery attended pregnancy and birth for the last 25 years or so (CIMS, 2003; Johnson & Daviss, 2005; Enkin, Marc, Keirse, Renfrew, & Neilson, 1995; Gibson, 2003; Goer, 1995, 2002; Wagner, 1994, 2003; Stewart, 1981; Keefe, 2001; Tillett, 2005). If success is measured by results, the U.S. obstetrical system could do better. In those 25 years, infant mortality has actually worsened, (Kristof, N., 2006) and maternal mortality has remained unchanged (CDC 1998; CDC, 2003).

While this may seem an indictment of an entire system it truly isn’t. It is a call for reformation. Obstetrics have at their disposal the most advanced technology in the world. However, when you have a hammer, everything looks like a nail. By transferring care of healthy women and babies to midwives, only the actual ‘nails’ reach the ‘hammers’ through a referral from midwives, guardians of normalcy. Obstetricians are then able to use their considerable skills to benefit the women who really need their help. Under this new paradigm that views birth as a natural process, health care costs would be reduced, (Druley, 1998) maternal satisfaction would increase, (Villagran, L., 2006) outcomes would improve and obstetricians would get the recognition and respect they deserve for doing the job they were trained to do. Everyone wins.

References

Albers, L., Sedler., K, Bedrick, E., Teaf, D., Peralta, P., (2006, June). Factors related to genital tract trauma in normal spontaneous vaginal births. Birth, 33
(2), 94. Retrieved January
28, 2007, from Ovid database.

ACOG, (2005).
Vaginal birth not associated with incontinence later in life. ACOG press
Release. Retrieved February 13, 2007, from
http://www.acog.org/from_home/publications/press_releases/nr11-30-05-1.cfm

Baxley, E., (2003). Labor induction: A decade of change. American Family Physician, 67(10).
Retrieved January 27, 2007, from http://www.aafp.org/afp/20030515/editorials.html

Carpenter, D., (2004 November). Safe deliveries. H&HN: Hospitals & Health Networks, 78(11), 56-60. Retrieved February 13, 2007 from EBSCOhost database.

Central Intelligence Agency, (2006, June 13). The World Fact Book: Rank order, infant Mortality rate. Retrieved January 24, 2007, from
https://www.cia.gov/cia/publications/factbook/rankorder/2091rank.html

Centers for Disease Control and Prevention, (2003, February). Pregnancy-related mortality
surveillance: United States, 1991-1999. Morbidity and Mortality Weekly Report, 52.
Retrieved January 25, 2007 from
http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5202a1.htm

Centers for Disease Control and Prevention, (2001, March-April). Ignaz Philipp Semmelweis
(1818-65) Emerging Infectious Diseases 7(2). Retrieved January 25, 2007, from
http://www.cdc.gov/ncidod/eid/vol7no2/cover.htm

Centers for Disease Control and Prevention, (1998, September 4). Maternal mortality: United
States, 1982-1996. Morbidity and Mortality Weekly Report, 47(34). 705-7. Retrieved
January 24, 2007, from http://www.cdc.gov/mmwr/preview/mmwrhtml/00054602.htm

Centers for Disease Control and Prevention, (1993, April). Rates of cesarean delivery: United
States1991. Morbidity and Mortality Weekly Report, 42(15), 285-289. Retrieved January 25, 2007 from http://www.cdc.gov/mmwr/preview/mmwrhtml/00020285.htm

Citizens for Midwifery, (2002, February 11). “Planned” home birth study misrepresented in the press. Retrieved January 24, 2007, from http://www.mana.org/WAHomeBirthStudy.pdf

The Coalition for Improving Maternity Services, (2003). Problems and hazards of induction of
labor: A fact sheet. Retrieved January 26, 2006,
from http://www.motherfriendly.org/Downloads/induct-fact-sheet.pdf

Declercq, E.R., Skala, C., Corry, M.P., Applebaum, S., Risher, P., (2002, October). Listening to
mothers: Report of the first national U.S. survey of women’s childbearing experiences. Maternity Center Association, New York. Retrieved February 15, 2007 from http://www.childbirthconnection.org/article.asp?ck=10397

Doubleday, J. (2005). The unequivocal safety of home birth. Retrieved
February 11, 2007, from http://www.spontaneouscreation.org/SC/NWNM2006/TheUnequivocalSafetyOfHomeBirth.htm

Dress, C., (2005). Record high cesarean rate in USA contradicts best practices for birth. Medical News Today. Retrieved January 25, 2007, from http://www.medicalnewstoday.com/medicalnews.php?newsid=34017

Druley, L., (June, 1998). The Childbirth Monopoly. Mother Jones. Retrieved January25, 2007,
from http://www.motherjones.com/commentary/columns/1998/06/druley.html
Enkin, M., Keirse, M., Renfrew, M., Neilson, J. (1995). A guide to effective care in pregnancy & childbirth (2nd ed.). Oxford. Oxford Medical Publications.

Gibson, F., (n.d.). Comprehensive review & critique on the Pang-Benedetti study on home-based birth. American College of Community Midwives. Retrieved January 24, 2007, from http://collegeofmidwives.org/news01/ACOG%20%20Hm%20Brth%20Study%20Aug%2002.htm

Gibson, F., (2003). Critique of broader issues in obstetrical care: The final frontier. Safe maternity practices for the 21st century. American College of Community Midwives. Retrieved January 24, 2007, from http://www.collegeofmidwives.org/Citations%20or%20text%2002/Dr%20Brothers%208-page%20critique%2003.htm

Gibson, F., (2006). The official plan to eliminate the midwife: 1900-1930. Part I. The story of the hundred year war against midwives. The American College of Community Midwives. Retrieved January 25, 2007 from http://www.collegeofmidwives.org/safety_issues01/rosenbl1.htm

Gibson, F., (2006). The official plan to eliminate the midwife: 1900-1930. Part II. Motives of the medical establishment for the suppression of independent midwifery. The American College of Community Midwives. Retrieved January 25, 2007 from http://www.collegeofmidwives.org/safety_issues01/rosenbt2.htm

Goer, H., (2002). The assault on normal birth: The OB disinformation campaign. Midwifery
Today, Autumn,10. Retrieved January 26, 2007, from
http://www.midwiferytoday.com/articles/disinformation.asp

Goer, H., (1995). Obstetric myths versus research realities: A guide to the medical literature.
Westport, Connecticut. Bergin & Garvey.

Haire, D., (2001). FDA approved obstetrics drugs: Their effects on mother and baby. Alliance for the Improvement of Maternity Services. Retrieved February 2, 2007 from
http://www.aimsusa.org/obstetricdrugs.htm

Healy, B., (2006, June). Birthing by appointment. U.S. News and World Report. Retrieved
January 24, 2007 from
http://www.usnews.com/usnews/health/articles/060612/12healy.htm

International Cesarean Awareness Network, (2004, March).
ICEA Position statement and
review: Cesarean birth and VBAC. International Journal of Childbirth Education,
19(1), 31-40. Retrieved February 12, 2007 from EBSCOhost database.

Irwin, S., Jordan, B., (1987, September). Knowledge, practice, and power: Court-ordered
cesarean sections. Medical Anthropology Quarterly, Special Issue on Obstetrics in the United States 1(3) 319-334. Retrieved January 25, 2007 from http://www.lifescapes.org/Papers/COCS%20Hahn%201987.htm

Johanson, R., Newburn, M., Macfarlane, A., (2002). Has the medicalisation (sic) of childbirth
gone too far? British Medical Journal, 324(7342), 892–895. Retrieved January 28, 2007, from http://www.pubmedcentral.gov/articlerender.fcgi?artid=1122835

Johnson, K.C., Daviss, B., (2005, June 18). Outcomes for planned homebirths with certified
professional midwives: Large prospective study in North America. British Medical Journal, 330(7505), 1416. Retrieved January 23, 2007 from http://bmj.bmjjournals.com/cgi/reprint/330/7505/1416.pdf

Kristof, N., (2006 January). Health care? Ask Cuba. Op-ed piece, New York Times.
Retrieved January 25, 2007 from http://www.nytimes.com/2005/01/12/opinion/ 12kris.html?ex=1263272400&en=c7ea472ff9651976&ei=5090


Keefe, C., (2001). Overview of maternity care in the U.S. Citizens for Midwifery. Retrieved
February 2, 2007, from http://www.cfmidwifery.org/pdf/OverviewofMatCareApr2003.pdf

Lamaze International, (2005). Non-Supine (e.g., upright or side-lying) positions for birth.
Care Practice Papers. Retrieved February 12, 2007, from http://www.lamaze.org/MediaProfessionals/CarePracticePapers/tabid/90/Default.asp

Lamaze International, (2006). The problem with ‘maternal request’ cesareans. Retrieved
February 12, 2007, from http://www.lamaze.org/institute/advancing/docs/elective_cesarean_ethics.pdf

MacCorkle, J., (2003).
Homebirth under fire: What the headlines don't say.
Mothering,117(March/April). Retrieved February 2, 2007 from
http://www.mothering.com/articles/pregnancy_birth/homebirth/under-fire.html

Murkoff, H., Eisenberg, A., Hathaway, S., (2002, April). What to expect when you’re expecting, (3rd ed.). New York, NY: Workman Publishing Company.

Pang, J., Heffelfinger, J., Huang, G., Benedetti, T., Weiss, N., (2002). Outcomes of planned home births in Washington State: 1989–1996. Obstetrics & Gynecology, 100. 253-259

Physician’s Desk Reference, (2003 February). CYTOTEC® (Searle) misoprostol tablets. Retrieved February 2, 2007 from http://www.drugs.com/data/_pop3.cfm?htm=76000319.htm&bn=MISOPROSTOL&pageid=0&type=pdr&pop=1

Rubin, R., (2003). More moms opt to go c-section births, study finds. USA Today. July 21, p. 5d.Retrieved February 2, 2007 from http://www.usatoday.com/news/health/2003-07-20-cesarean_x.htm\

Rubin, R., (2006 March). ‘Increasing intervention' shifting births earlier: A few weeks has abig effect. Electronic version, USA Today. Retrieved February 15, 2007 from http://www.findarticles.com/p/articles/mi_kmusa/is_200603/ai_n16233838

Stewart, D., (1981). The five standards for safe childbearing. The case for homebirth. Marble Hill, MO: Napsac Reproductions.

Strong, T., (2001). Expecting trouble: The myth of prenatal care in America. New York and
London: New York University Press.

Thornton, P., (2006, April 8). New study confirms cesarean risks. Medical News Today. Retrieved February 2, 2007 fromhttp://www.medicalnewstoday.com/medicalnews.php?newsid=41247

Tillett, J., (2005, April-June). Obstetric rituals: Is practice supported by evidence? Journal of Perinatal & Neonatal Nursing, 19(2), 91-3. Retrieved February 2, 2007, from
Ovid database.

Tuteur, A., (1994). How your baby is born. Ziff-Davis Press, California.
Retrieved electronic chapters February 7, 2007, from http://www.askdramy.com/

U.S.
Food and Drug Administration, (2005, May). Misoprostol (marketed as Cytotec) information: FDA alert–Risks of use in labor and delivery. Retrieved February 2, 2007 from http://www.fda.gov/cder/drug/infopage/misoprostol/default.htm

Vedham, S., (2003 March). Home birth versus hospital birth: Questioning the quality of the
m evidence on safety. Birth, 30(1). 57-63. Retrieved February 11, 2007 from EBSCOhost database.

Villagran, L., (2006 June). A different path for childbirth: Growing number of women choose
nurse-midwives to deliver their babies. ABC News. Retrieved February 2, 2007, from http://abcnews.go.com/Business/BusinessOfLife/story?id=2042314&page=1

Wagner, M., (1994). Pursuing the birth machine: The search for appropriate birth technology.
Camperdown, NSW, Australia. ACE Graphics.

Wagner, M., (2003). Revealing the real risks: Obstetrical interventions and maternal mortality. Mothering, May/June(118) 48. Retrieved February 2, 2007 http://www.mothering.com/articles/pregnancy_birth/birth_preparation/risks.html

Walsworth, D., French, L., (1998 December). Minimizing trauma to the genital tract in childbirth. Journal of Family Practice, 47(6). 411-2. Retrieved February 8, 2007, from http://www.findarticles.com/p/articles/mi_m0689/is_6_47/ai_53509876

Weaver, S., (2006, February). FPIN's clinical inquiries: Vaginal misoprostol for cervical ripening in term pregnancy. American Family Physician, 73(3). Retrieved February 14, 2007 from http://www.aafp.org/afp/20060201/fpin.html

World Health Organization, (2004). Maternal mortality in 2000: Estimates developed by
WHO, UNICEF, and UNFPA. Retrieved February 8, 2007 from http://www.who.int/reproductive-health/publications/maternal_mortality_2000/index.html

2 comments:

Debbie said...

Thank you so much for this excellently referenced summary of birth in the United States. We are working on legislation to legalize Certified Professional Midwives in my state and this is such useful information!

Wendy CPM said...

Really well said, with lots of references to back up your statements. Thank you for a brilliant summary!