The following is from the May 11 Obstetric & Gynocology,
written by Annette Fineberg, MD (OB/GYN) and a response that follows from David
Hayes, MD (OB/GYN)
Obstetrics & Gynecology:
May 2011 - Volume 117 - Issue 5 - pp 1188-1190
Personal Perspectives: An Obstetrician 'b Lament
Fineberg, Annette E. MD
A few weeks ago, during a prenatal visit, a woman pregnant with twins told
me she would love to have a home birth, but did not have the $4,000 cash
required upfront to do so. She was afraid of potential interventions in the
hospital. After a discussion of her fears as well as potential
complications that can abruptly occur in a twin birth, she admitted she would prefer a
hospital birth if she could maintain some control over the situation. This
is not a woman who cares more about the birth experience than the baby, but
she was tempted, and in some ways I can understand her concerns. My
cousin's wife had her twin induction halted at 4 cm because the new obstetrician on
call did not do breech extractions for second twins. Her only option became
cesarean delivery.
I recently received a phone call from a woman 2 hours away who had planned
a home birth for her second baby after having an easy first birth. When the
fetus, which was anticipated to be a little smaller, was found to be a
breech, the midwife sent the woman to the local obstetricians. They would
only deliver the fetus by cesarean delivery. The midwife offered the woman
a home breech birth, but admitted she had only delivered one breech
(stillbirth) in her career. The woman appropriately questioned the safety
of this, and was referred to us. She met the criteria for our vaginal breech
protocol, and had an easy vaginal breech birth in our hospital.
Unfortunately, this is becoming a rarity. A colleague of mine in another
state watched the residents she was supervising emotionally bully a young
woman and her mother into a cesarean delivery. The young woman had a
rapidly progressing active labor with a normal-sized frank breech fetus. Had the
residents been open to the idea, my colleague easily could have taught them
how to deliver a vaginal breech.
The running joke in our community is that the only way to get a vaginal
birth after cesarean delivery (VBAC) is to have the birth at home.
Unfortunately, this is a reality rather than a joke. Our small community
hospital, owing to regional liability insurance constraints, stopped
allowing VBACs in 2002 after many years of successfully offering them. This
has led many women to risk home birth rather than travel to a tertiary care
center to attempt VBAC. I recently counseled a woman against having a
cesarean delivery who had a BMI of 52 and who arrived in active labor at
over 35 weeks of gestation with two previous successful VBACs. I spent the
following months defending that recommendation, despite her considerable
operative risks and high likelihood of success.
Recent news and media excitement about the benefits and increased safety of
home birth over hospital birth have made the former seem like a very
attractive alternative. A growing notion among women in our region, and
perhaps across the country, is that hospitals and obstetricians are a more
risky option than lay-home midwives for birth. Although my initial reaction
is disbelief, perhaps we should look at how we, the obstetricians,
contribute to this trend.
Each of these women deserves an honest discussion about the fetal and
maternal risks of each birthing option. However, our lack of experience as
obstetricians colored by our fear of liability is narrowing women's
choices, and sometimes motivating them to ignore fetal and maternal safety in an
effort not to be coerced into unnecessary interventions. I sense a mounting
tension, because many obstetricians do not have the willingness, time, or
skills to provide maternal choices.
I believe we are at a crossroad in maternity care in this country, and I am
saddened that obstetricians are considered the culprits. Our contracting
skill set as obstetric providers, as well as the prevailing risk-adverse
culture among physicians and hospitals, have given support to home birth.
We can all agree that VBAC, twins, and breech should not be managed at home,
yet we frequently demand complete control of the situation and eliminate
some appropriate choices in the hospital. I understand that it can be very
unnerving to be ultimately responsible for the outcome, as we are, and yet
pushed into situations outside of our comfort zones. However, our
unwillingness to budge in these situations is causing us to lose the battle
regarding what is really important to most obstetricians: safety for
mothers and babies.
Certainly, we can be proud of the dramatic decrease in maternal mortality
in the last century. But, despite the highest per capita expenditure of health
care in the world, infant and maternal mortality rates in the United States
are higher than in all of western Europe. We have the third-highest
cesarean delivery rate in the world. According to a recent study, nearly half of all
primigravidas attempting vaginal delivery are induced, and half of cesarean
deliveries for dystocia are done before 6 cm of dilation, presumably before
active labor. It is amazing how many women begging for elective
induction change their minds when told it doubles their cesarean delivery risk.
We need to draw lines around patient safety, but must they be so rigid?
Most midwives know from experience that Friedman's curve is too strict. A recent
study validates that knowledge. I sincerely hope it is taken seriously. Expectant
management of ruptured membranes at term has been declared unsafe and of no
benefit. The study that settled the question did not account for
the number of vaginal examinations women received, and group B strep was
not treated, both important variables. Most women do go into labor in 24 to 72 hours.
Hayes, MD (OB/GYN)
Obstetrics & Gynecology:
May 2011 - Volume 117 - Issue 5 - pp 1188-1190
Personal Perspectives: An Obstetrician 'b Lament
Fineberg, Annette E. MD
A few weeks ago, during a prenatal visit, a woman pregnant with twins told
me she would love to have a home birth, but did not have the $4,000 cash
required upfront to do so. She was afraid of potential interventions in the
hospital. After a discussion of her fears as well as potential
complications that can abruptly occur in a twin birth, she admitted she would prefer a
hospital birth if she could maintain some control over the situation. This
is not a woman who cares more about the birth experience than the baby, but
she was tempted, and in some ways I can understand her concerns. My
cousin's wife had her twin induction halted at 4 cm because the new obstetrician on
call did not do breech extractions for second twins. Her only option became
cesarean delivery.
I recently received a phone call from a woman 2 hours away who had planned
a home birth for her second baby after having an easy first birth. When the
fetus, which was anticipated to be a little smaller, was found to be a
breech, the midwife sent the woman to the local obstetricians. They would
only deliver the fetus by cesarean delivery. The midwife offered the woman
a home breech birth, but admitted she had only delivered one breech
(stillbirth) in her career. The woman appropriately questioned the safety
of this, and was referred to us. She met the criteria for our vaginal breech
protocol, and had an easy vaginal breech birth in our hospital.
Unfortunately, this is becoming a rarity. A colleague of mine in another
state watched the residents she was supervising emotionally bully a young
woman and her mother into a cesarean delivery. The young woman had a
rapidly progressing active labor with a normal-sized frank breech fetus. Had the
residents been open to the idea, my colleague easily could have taught them
how to deliver a vaginal breech.
The running joke in our community is that the only way to get a vaginal
birth after cesarean delivery (VBAC) is to have the birth at home.
Unfortunately, this is a reality rather than a joke. Our small community
hospital, owing to regional liability insurance constraints, stopped
allowing VBACs in 2002 after many years of successfully offering them. This
has led many women to risk home birth rather than travel to a tertiary care
center to attempt VBAC. I recently counseled a woman against having a
cesarean delivery who had a BMI of 52 and who arrived in active labor at
over 35 weeks of gestation with two previous successful VBACs. I spent the
following months defending that recommendation, despite her considerable
operative risks and high likelihood of success.
Recent news and media excitement about the benefits and increased safety of
home birth over hospital birth have made the former seem like a very
attractive alternative. A growing notion among women in our region, and
perhaps across the country, is that hospitals and obstetricians are a more
risky option than lay-home midwives for birth. Although my initial reaction
is disbelief, perhaps we should look at how we, the obstetricians,
contribute to this trend.
Each of these women deserves an honest discussion about the fetal and
maternal risks of each birthing option. However, our lack of experience as
obstetricians colored by our fear of liability is narrowing women's
choices, and sometimes motivating them to ignore fetal and maternal safety in an
effort not to be coerced into unnecessary interventions. I sense a mounting
tension, because many obstetricians do not have the willingness, time, or
skills to provide maternal choices.
I believe we are at a crossroad in maternity care in this country, and I am
saddened that obstetricians are considered the culprits. Our contracting
skill set as obstetric providers, as well as the prevailing risk-adverse
culture among physicians and hospitals, have given support to home birth.
We can all agree that VBAC, twins, and breech should not be managed at home,
yet we frequently demand complete control of the situation and eliminate
some appropriate choices in the hospital. I understand that it can be very
unnerving to be ultimately responsible for the outcome, as we are, and yet
pushed into situations outside of our comfort zones. However, our
unwillingness to budge in these situations is causing us to lose the battle
regarding what is really important to most obstetricians: safety for
mothers and babies.
Certainly, we can be proud of the dramatic decrease in maternal mortality
in the last century. But, despite the highest per capita expenditure of health
care in the world, infant and maternal mortality rates in the United States
are higher than in all of western Europe. We have the third-highest
cesarean delivery rate in the world. According to a recent study, nearly half of all
primigravidas attempting vaginal delivery are induced, and half of cesarean
deliveries for dystocia are done before 6 cm of dilation, presumably before
active labor. It is amazing how many women begging for elective
induction change their minds when told it doubles their cesarean delivery risk.
We need to draw lines around patient safety, but must they be so rigid?
Most midwives know from experience that Friedman's curve is too strict. A recent
study validates that knowledge. I sincerely hope it is taken seriously. Expectant
management of ruptured membranes at term has been declared unsafe and of no
benefit. The study that settled the question did not account for
the number of vaginal examinations women received, and group B strep was
not treated, both important variables. Most women do go into labor in 24 to 72 hours.
The Cochrane systematic review concludes that, because
the differences in outcome are not substantial, women need to be given the
appropriate information to make a decision. This very rarely occurs in the hospital setting.
the differences in outcome are not substantial, women need to be given the
appropriate information to make a decision. This very rarely occurs in the hospital setting.
The Term Breech Study closed the door on vaginal breech delivery even for the
lowest-risk women in most obstetricians' minds (including the residents I
mentioned above). This, despite the opinion of the College that it may be
appropriate in carefully selected situations. In any case, vaginal breech delivery is not completely
avoidable, and should not be relegated to the history books with vaginal
delivery for previa and high forceps.
mentioned above). This, despite the opinion of the College that it may be
appropriate in carefully selected situations. In any case, vaginal breech delivery is not completely
avoidable, and should not be relegated to the history books with vaginal
delivery for previa and high forceps.
Our mission has become more difficult in the last 20 years as mothers have
become older, heavier, and of lower parity. Many women, admittedly, do have unrealistic
expectations. Although I am eternally grateful for the obstetric skills I
learned in residency, I have been amazed in my 14 years of practice to see
much of the dogma I also absorbed disproven with experience and patience
(both my own, my colleagues', and the midwives I have worked with in the
hospital setting).
Collaborative practice with midwives is a good start, but in order for
obstetricians to be more than providers of cesarean deliveries (a thankless
and, in most cases, technically simple procedure) we need to have
conversations with our patients that are not one sided and allow for true
informed consent. Many of the obstetric disasters we have all seen and
which
color our perspective (which David Grimes has called "numerators in search
of denominators"of are at least in some part iatrogenic if examined deeply
enough. That failed induction for convenience with early artificial rupture
of membranes and chorioamnionitis. The first cesarean delivery done at age
15 after 2 hours of pushing with an epidural that then leads to the fifth
cesarean years later, and then accreta and life-threatening hemorrhage, are
both typical examples. We need to recognize and own those aspects of
obstetric management that are driving our skyrocketing cesarean delivery
rate but having no positive effect on maternal or infant morbidity and
mortality.
Admitting what is truly evidence based versus what is tradition and culture
is a good start. It is essential that we offer real choices to our
patients.
We need to recover and disseminate the skills that make obstetrics an art
and a privilege. Seek out mentors skilled in forceps, vaginal breeches, and
breech extractions before it is too late. Then learn to be patient, so that
you very rarely need to use them.
------------------------------
And a reply:
become older, heavier, and of lower parity. Many women, admittedly, do have unrealistic
expectations. Although I am eternally grateful for the obstetric skills I
learned in residency, I have been amazed in my 14 years of practice to see
much of the dogma I also absorbed disproven with experience and patience
(both my own, my colleagues', and the midwives I have worked with in the
hospital setting).
Collaborative practice with midwives is a good start, but in order for
obstetricians to be more than providers of cesarean deliveries (a thankless
and, in most cases, technically simple procedure) we need to have
conversations with our patients that are not one sided and allow for true
informed consent. Many of the obstetric disasters we have all seen and
which
color our perspective (which David Grimes has called "numerators in search
of denominators"of are at least in some part iatrogenic if examined deeply
enough. That failed induction for convenience with early artificial rupture
of membranes and chorioamnionitis. The first cesarean delivery done at age
15 after 2 hours of pushing with an epidural that then leads to the fifth
cesarean years later, and then accreta and life-threatening hemorrhage, are
both typical examples. We need to recognize and own those aspects of
obstetric management that are driving our skyrocketing cesarean delivery
rate but having no positive effect on maternal or infant morbidity and
mortality.
Admitting what is truly evidence based versus what is tradition and culture
is a good start. It is essential that we offer real choices to our
patients.
We need to recover and disseminate the skills that make obstetrics an art
and a privilege. Seek out mentors skilled in forceps, vaginal breeches, and
breech extractions before it is too late. Then learn to be patient, so that
you very rarely need to use them.
------------------------------
And a reply:
Friday, May
13, 2011 at 6:26AM
By David Hayes, MD
I am encouraged by Dr. Fineberg's recognition and admission that
the current standard of practice of obstetrics in the United States is
in fact lamentable. I am encouraged that she has felt the need to make
a public declaration of her concern over the disconnect between the
information available in the obstetrical literature (not to mention the
midwifery literature – which obstetricians rarely even concede
exists) and the routine practices in virtually every hospital in the
country.
I appreciate that she understands and delineates at least portions of
the various chains of events that lead to an increase in the number of
unnecessary cesarean deliveries. I appreciate that she describes the
role that dogmatic adherence to the long discredited Friedman curve,
overly aggressive management of rupture of membranes at term, and the
irrational discontinuance of performing and even training future
obstetricians to perform vaginal breech deliveries plays in driving up
the numbers of these unnecessary cesarean deliveries.
I am positively thrilled that she recognizes and calls out the extent
to which obstetricians routinely ignore the doctrine of informed
consent, except to pay lip service to the satisfy the legal requirements
for their own protection.
But then, just when I think she might scale those rarified heights and
suggest that we actually consider those options that make prenatal care
and delivery safer for mothers and their babies in virtually every
developed country on the planet, she retreats squarely inside the
obstetrical dogma.
"A growing notion among women in our region, and perhaps across the
country, is that hospitals and obstetricians are a more risky option
than lay-home midwives for birth. Although my initial reaction is
disbelief, perhaps we should look at how we, the obstetricians,
contribute to this trend."
Perhaps? Really? Yes, perhaps we should!
Consider first the state of obstetrics in our self-proclaimed best
medical system in the world:
"The United States' rate for maternal mortality is 1 in 2,100
– the highest of any industrialized nation. In fact, only three
Tier I developed countries – Albania, the Russian Federation and
Moldova – performed worse than the United States on this indicator.
A woman in the U.S. is more than 7 times as likely as a woman in Italy
or Ireland to die from pregnancy-related causes and her risk of
maternal death is 15-fold that of a woman in Greece."(1)
And:
"Similarly, the United States does not do as well as most other
developed countries with regard to under-5 mortality. The U.S. under-5
mortality rate is 8 per 1,000 births. This is on par with rates in
Latvia. Forty countries performed better than the U.S. on this
indicator. At this rate, a child in the U.S. is more than twice as
likely as a child in Finland, Greece, Iceland, Japan, Luxembourg,
Norway, Slovenia, Singapore or Sweden to die before reaching age
5."(2)
The women who are increasingly asking for out of hospital care are
doing so because they are informed, intelligent, and empowered women who
are concerned about their health and the health of their baby. Indeed,
the international human rights organization Amnesty International took
the extraordinary step just last fall of issuing a report in which they
referred to the "maternity health care crisis in the USA" in
calling world wide attention to the state of obstetrical care in the
U.S.(3) The only people who seem not to see it are the obstetricians
who are at the root cause of it.
Any thinking woman who bothers to look should be disturbed by what she
sees. There is something very wrong here. Part of the problem
certainly arises from the for-profit health care system that even now
makes access to health care impossible for millions of Americans. But
the problem is much deeper than even that. The statistics cut squarely
across racial and socio-economic lines and there is no indication that
it can all be accounted for by access.
Yes, women are increasingly avoiding the medical model of childbirth
and the hospital setting for deliveries. They are fully capable of
reading and of obtaining good, accurate information. They are well aware
that the decisions their obstetricians are making on their behalf often
are not supported by the literature and do result in worse outcomes.
They do understand the problems endemic in the US obstetrical system.
And as a result they are well aware, if Dr. Fineberg is not, that their
risk of morbidity and mortality is significantly lower when delivering
their baby with a skilled birth attendant in their own home than it is
in any hospital in the United States.(4, 5, 6, 7) The fact is, 90% of
births in the US could be accomplished at home, at lower cost, with
better outcomes, and with more satisfied moms and babies.
We debate the causes, bemoan the rise in cesarean delivery rates, but
through it all we are missing a hugely important fact – a fact that
is not lost on a generation of intelligent, educated women. Outcomes
are better in a home birth attended by a skilled birth attendant than a
hospital birth attended by ANY attendant, midwife or obstetrician.hos
Until we admit that basic premise, we will make no progress.
Physicians are admonished to "first do no harm." In practice
that implies we should do nothing unless we have evidence it may
improve an outcome. Yet for the vast majority of things we do in
obstetrics, we do not have that evidence. In fact we often have
evidence to the contrary. We routinely order continuous monitoring that
has shown no benefit at all to fetal morbidity and mortality but
dramatically increases the rate of unnecessary interventions thereby
dramatically increasing maternal morbidity and mortality. We, without
thinking, perform or order invasive cervical exams that have very poor
prognostic value, have never been shown to improve any index of
maternal or fetal morbidity, yet have been shown to increase the risk
of fetal and maternal infection. Indeed, we routinely order or perform
dozens of procedures in every labor and delivery unit in the country
that have no proven benefit and in many cases fly in the face of
evidence in our own literature that they worsen maternal and fetal
outcomes.(8)
I cannot agree more with Dr. Fineberg's observation that "each
of these women deserves an honest discussion about the fetal and
maternal risks of each option." But she should not stop with that
discussion. After that discussion is held, each of these women
deserves a birth attendant that respects and supports her regardless of
the option she chooses. That is where the U.S. obstetrical culture has
utterly failed its clientele. We, as obstetricians, have entirely lost
sight of the fact that our first obligation in ethical medical
decision-making is to respect patient autonomy. We routinely order and
perform procedures against our patients' wishes, often exploiting
the vulnerability of our patients, enforcing our authority through
intimidation, fear mongering, and occasionally even obtaining court
orders that are virtually always invalid and overturned when it is too
late.
I found Dr. Fineberg's statement "This is not a woman who cares
more about the birth experience than her baby" very telling and
typical of the condescending attitude that has gotten us where we are
today. They do care about their delivery experience, not entirely in
the sense that they are looking to make a spiritual or emotional
connection to one of the defining experiences of womanhood (although
that is certainly much more important than the dismissive derision
implied by the statement). They care about it also because they want
control over, or at the very least input into, the decision making
process involving their life, their health, and their baby. They care
about it because they do not trust their obstetrician to make the
decision that's in their patient's best interest, rather than
their own. They care about it because they know the hospital protocols
being blindly followed with little reason are not necessarily
applicable to their particular situation.
In my experience, no mother cares more about the "birth
experience" than they do their baby. It is precisely because they
care about their baby and their life that they are making the
completely rational decision to avoid a hospital birth at all costs.
Many of them are avoiding hospital births because they have had
hospital births, because they have been bullied into unnecessary
inductions, which failed, because they've had "emergency"
c-sections and suffered through difficulties in bonding, breast
feeding, post partum depression, because they have been treated with
condescension and had their own wishes about their own bodies overruled
with coercion and fear tactics that were completely inappropriate.
There are many reasons we should encourage home deliveries attended by
qualified birth attendants: it's more comfortable and convenient;
it's less expensive; we should respect patient autonomy. But there
is one reason why we cannot ethically avoid it — it is safer. The
outcomes, for mothers and babies, are simply better.
I am an obstetrician. I too lamented when, at the behest of risk
averse pediatricians, my local hospital stopped allowing trials of labor
in women with prior cesarean deliveries. But I did more than just
lament. I studied the data carefully. I looked closely at the real risks
and who might be appropriate candidates, and I began doing VBACs at
home. I have done this for several years and had many successful VBACs
and no complications. I know the obstetricians reading this are quaking
in their boots, but there is no rational reason to. In one classic
study, 3 of the 17,898 women undergoing a trial of labor after cesarean
died, while 7 of the 15,801 women undergoing a repeat C/S died(9) It is
likely that the trial of labor morbidity and mortality would have been
even lower had the study participants refrained from inducing or
augmenting labor. But even those numbers are roughly half of the 2 in
10,000 risk that a woman will be killed in an automobile accident during
the period of time she is pregnant.(10)
Furthermore, other studies suggest that while around 5/10000 serious
uterine ruptures may occur during a trial of labor, around 2/10000
uterine ruptures occur prior to the onset on labor. In other words, any
pregnant woman who has had a prior C/S is at increased risk of uterine
rupture even if she elects a repeat C/S. And as we well know, there are
many other consequences of cesarean delivery that may be life
threatening. Why then are we not approaching performing a C/S with even
a fraction of the trepidation that we approach normal vaginal
deliveries?
A woman choosing to have a home VBAC rather than be forced to have a
repeat C/S in her local hospital is making a rational decision given the
data we have available, a decision which we should be prepared to
support if we cannot offer her a better alternative. I have delivered
several hundred VBACs in the past several years without incident. In the
same time frame, my local hospital has lost at least 3 mothers during
or shortly following cesarean deliveries.
U.S. obstetricians have already come to the crossroads and have taken
the wrong path. It can be fixed, but they need to start having honest
and open discussions among themselves about the real maternal and fetal
risks, about the rampant rate of unnecessary induction which leads to
unneeded cesarean delivery, about the continued use of continuous fetal
monitoring, restricted movement, withholding of nutrition, unneeded
augmentation of labor, artificial rupture of membranes, epidural
anesthesia and even multiple cervical exams, none of which have any
proven benefit and all of which contribute to increased morbidity and
even mortality.
Less than two per cent of what is routinely done on labor and delivery
units in the US has been shown to have any positive benefit. Over 15%
has been shown to have demonstrably adverse impact. ACOG continues to
spout, with no evidence, the tired old line that delivery is safer in
hospitals or birth centers joined at the hip to hospitals.(11) At the
same time, every EU member country is actively seeking to increase the
numbers of home deliveries, increase the numbers of midwife managed
pregnancies, and work to ensure there is a seamless interface between
home delivery practices and the hospital system. In the US, virtually
all medical boards and obstetrical societies, and most obstetricians
and hospitals, are actively hostile to the idea of home delivery and to
the practitioners and pregnant women who choose it.
Our maternal and infant mortality rates continue to climb. We continue
to do the same things and expect different outcomes. Is it because of
the "risk averse culture of doctors and hospitals"? Partly,
yes. But it is also pressure from their peers that prevents
obstetricians from actually practicing the evidence based medicine we
have and from even considering the vast realms of international EBM and
midwifery EBM. Obstetricians who attempt to practice based on the
literature rather than the "local standard of practice" run a
very real risk of losing their hospital privileges and possibly even
their medical licenses. If they practice according to the "local
standard of care" they almost invariably must violate all four of
the accepted principals of medical ethics: patient autonomy,
beneficence, non-maleficence, and justice.
We have the information to fix this problem. When we address the
culture of peer pressure, the local "standards of care" that
bear no resemblance to what the literature supports, when we recognize
that many (including some among the top leadership and most recognized
names in obstetrics) are more interested in procuring their positions,
promoting their ideology, protecting their power, and preserving their
market share than they are in really addressing the problems, improving
maternity care, and truly supporting their patients, then and only then
can we start to make headway towards creating a model of maternity care
that is both world class and genuinely supportive of its clientele.
David Hayes, MD has been offering home births since 2005 and has
attended exclusively home births for the last three years. He is
closing his practice this month to devote his energies to the
international humanitarian aid organization, Doctors Without Borders
<_http://www.doctorswhttp://
(http://www.
This post is featured as one of a series of posts
<_http://www.theunnechttp://
_ (http://www.theunnecesarean.
<_http://www.theunnechttp://
(http://www.theunnecesarean.
by OB-GYNs in response to the May 2011 article, An Obstetrician'b
Lament, by Dr. Annette Fineberg.
BIBLIOGRAPHY
1. WHO. Trends in Maternal Mortality: 1990 to 2008. (Geneva: 2010).
whqlibdoc.who.whqlibdoc.who.<
2. UNICEF. The State of the World's Children 2011.
(New York: 2010) Table 1, pp.88-91. www.unicef.org/(New York
statistics.php
3. Deadly Delivery; The Maternal Health Care Crisis In The USA,
Amnesty International Publications, Nov 2010 Index: AMR 51/007/2010
ISBN: 978-0-86210-ISBN:
4. Patricia A. Janssen PhD, Lee Saxell MA, Lesley A. Page PhD, Michael
C. Klein MD, Robert M. Liston MD, Shoo K. Lee MBBS PhD. Outcomes of
planned home birth with registered midwife versus planned hospital
birth with midwife or physician., CMAJ 2009. DOI:10.1503/birth with
5. de Jonge A, van der Goes B, Ravelli A, Amelink-Verburg M, Mol B,
Nijhuis J, Bennebroek Gravenhorst J, Buitendijk S. Perinatal mortality
and morbidity in a nationwide cohort of 529 688 low-risk planned home
and hospital births. BJOG 2009; DOI: 10.1111/j.1471-and hospital
02175.x.
6. Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwife-led versus
other models of care for childbearing women. Cochrane Database of
Systematic Reviews 2008, Issue 4. Art. No.: CD004667. DOI:
10.1002/14651858.10.1002/110.
7. Kenneth C Johnson, Betty-Anne Daviss: Outcomes of planned home
births with certified professional midwives: large prospective study in
North America
BMJ 330 : 1416 doi: 10.1136/bmj.BMJ 330 :BMJ 330 : 1416 doi: 10.1136/bmj
8. Vincenzo Berghella, MD; Jason K. Baxter, MD, MSCP; Suneet P.
Chauhan, MD. Evidence-based labor and delivery management, American
Journal of Obstetrics & Gynecology, NOV 2008, pp 445 – 454.
9. Landon, MB, et.al. Maternal and perinatal outcomes associated with
a trial of labor after prior cesarean delivery. NEMJ Volume
351:2581-2589 December 16, 2004 Number 25
10. National Highway Traffic Safety Administration, Fatality Analysis
Reporting System. www-fars.nhtsa.Reporting SysReporting
11. AMERICAN MEDICAL ASSOCIATION HOUSE OF DELEGATES, Resolution: 205,
annual meeting 2008.
I am encouraged by Dr. Fineberg's recognition and admission that
the current standard of practice of obstetrics in the United States is
in fact lamentable. I am encouraged that she has felt the need to make
a public declaration of her concern over the disconnect between the
information available in the obstetrical literature (not to mention the
midwifery literature – which obstetricians rarely even concede
exists) and the routine practices in virtually every hospital in the
country.
I appreciate that she understands and delineates at least portions of
the various chains of events that lead to an increase in the number of
unnecessary cesarean deliveries. I appreciate that she describes the
role that dogmatic adherence to the long discredited Friedman curve,
overly aggressive management of rupture of membranes at term, and the
irrational discontinuance of performing and even training future
obstetricians to perform vaginal breech deliveries plays in driving up
the numbers of these unnecessary cesarean deliveries.
I am positively thrilled that she recognizes and calls out the extent
to which obstetricians routinely ignore the doctrine of informed
consent, except to pay lip service to the satisfy the legal requirements
for their own protection.
But then, just when I think she might scale those rarified heights and
suggest that we actually consider those options that make prenatal care
and delivery safer for mothers and their babies in virtually every
developed country on the planet, she retreats squarely inside the
obstetrical dogma.
"A growing notion among women in our region, and perhaps across the
country, is that hospitals and obstetricians are a more risky option
than lay-home midwives for birth. Although my initial reaction is
disbelief, perhaps we should look at how we, the obstetricians,
contribute to this trend."
Perhaps? Really? Yes, perhaps we should!
Consider first the state of obstetrics in our self-proclaimed best
medical system in the world:
"The United States' rate for maternal mortality is 1 in 2,100
– the highest of any industrialized nation. In fact, only three
Tier I developed countries – Albania, the Russian Federation and
Moldova – performed worse than the United States on this indicator.
A woman in the U.S. is more than 7 times as likely as a woman in Italy
or Ireland to die from pregnancy-related causes and her risk of
maternal death is 15-fold that of a woman in Greece."(1)
And:
"Similarly, the United States does not do as well as most other
developed countries with regard to under-5 mortality. The U.S. under-5
mortality rate is 8 per 1,000 births. This is on par with rates in
Latvia. Forty countries performed better than the U.S. on this
indicator. At this rate, a child in the U.S. is more than twice as
likely as a child in Finland, Greece, Iceland, Japan, Luxembourg,
Norway, Slovenia, Singapore or Sweden to die before reaching age
5."(2)
The women who are increasingly asking for out of hospital care are
doing so because they are informed, intelligent, and empowered women who
are concerned about their health and the health of their baby. Indeed,
the international human rights organization Amnesty International took
the extraordinary step just last fall of issuing a report in which they
referred to the "maternity health care crisis in the USA" in
calling world wide attention to the state of obstetrical care in the
U.S.(3) The only people who seem not to see it are the obstetricians
who are at the root cause of it.
Any thinking woman who bothers to look should be disturbed by what she
sees. There is something very wrong here. Part of the problem
certainly arises from the for-profit health care system that even now
makes access to health care impossible for millions of Americans. But
the problem is much deeper than even that. The statistics cut squarely
across racial and socio-economic lines and there is no indication that
it can all be accounted for by access.
Yes, women are increasingly avoiding the medical model of childbirth
and the hospital setting for deliveries. They are fully capable of
reading and of obtaining good, accurate information. They are well aware
that the decisions their obstetricians are making on their behalf often
are not supported by the literature and do result in worse outcomes.
They do understand the problems endemic in the US obstetrical system.
And as a result they are well aware, if Dr. Fineberg is not, that their
risk of morbidity and mortality is significantly lower when delivering
their baby with a skilled birth attendant in their own home than it is
in any hospital in the United States.(4, 5, 6, 7) The fact is, 90% of
births in the US could be accomplished at home, at lower cost, with
better outcomes, and with more satisfied moms and babies.
We debate the causes, bemoan the rise in cesarean delivery rates, but
through it all we are missing a hugely important fact – a fact that
is not lost on a generation of intelligent, educated women. Outcomes
are better in a home birth attended by a skilled birth attendant than a
hospital birth attended by ANY attendant, midwife or obstetrician.hos
Until we admit that basic premise, we will make no progress.
Physicians are admonished to "first do no harm." In practice
that implies we should do nothing unless we have evidence it may
improve an outcome. Yet for the vast majority of things we do in
obstetrics, we do not have that evidence. In fact we often have
evidence to the contrary. We routinely order continuous monitoring that
has shown no benefit at all to fetal morbidity and mortality but
dramatically increases the rate of unnecessary interventions thereby
dramatically increasing maternal morbidity and mortality. We, without
thinking, perform or order invasive cervical exams that have very poor
prognostic value, have never been shown to improve any index of
maternal or fetal morbidity, yet have been shown to increase the risk
of fetal and maternal infection. Indeed, we routinely order or perform
dozens of procedures in every labor and delivery unit in the country
that have no proven benefit and in many cases fly in the face of
evidence in our own literature that they worsen maternal and fetal
outcomes.(8)
I cannot agree more with Dr. Fineberg's observation that "each
of these women deserves an honest discussion about the fetal and
maternal risks of each option." But she should not stop with that
discussion. After that discussion is held, each of these women
deserves a birth attendant that respects and supports her regardless of
the option she chooses. That is where the U.S. obstetrical culture has
utterly failed its clientele. We, as obstetricians, have entirely lost
sight of the fact that our first obligation in ethical medical
decision-making is to respect patient autonomy. We routinely order and
perform procedures against our patients' wishes, often exploiting
the vulnerability of our patients, enforcing our authority through
intimidation, fear mongering, and occasionally even obtaining court
orders that are virtually always invalid and overturned when it is too
late.
I found Dr. Fineberg's statement "This is not a woman who cares
more about the birth experience than her baby" very telling and
typical of the condescending attitude that has gotten us where we are
today. They do care about their delivery experience, not entirely in
the sense that they are looking to make a spiritual or emotional
connection to one of the defining experiences of womanhood (although
that is certainly much more important than the dismissive derision
implied by the statement). They care about it also because they want
control over, or at the very least input into, the decision making
process involving their life, their health, and their baby. They care
about it because they do not trust their obstetrician to make the
decision that's in their patient's best interest, rather than
their own. They care about it because they know the hospital protocols
being blindly followed with little reason are not necessarily
applicable to their particular situation.
In my experience, no mother cares more about the "birth
experience" than they do their baby. It is precisely because they
care about their baby and their life that they are making the
completely rational decision to avoid a hospital birth at all costs.
Many of them are avoiding hospital births because they have had
hospital births, because they have been bullied into unnecessary
inductions, which failed, because they've had "emergency"
c-sections and suffered through difficulties in bonding, breast
feeding, post partum depression, because they have been treated with
condescension and had their own wishes about their own bodies overruled
with coercion and fear tactics that were completely inappropriate.
There are many reasons we should encourage home deliveries attended by
qualified birth attendants: it's more comfortable and convenient;
it's less expensive; we should respect patient autonomy. But there
is one reason why we cannot ethically avoid it — it is safer. The
outcomes, for mothers and babies, are simply better.
I am an obstetrician. I too lamented when, at the behest of risk
averse pediatricians, my local hospital stopped allowing trials of labor
in women with prior cesarean deliveries. But I did more than just
lament. I studied the data carefully. I looked closely at the real risks
and who might be appropriate candidates, and I began doing VBACs at
home. I have done this for several years and had many successful VBACs
and no complications. I know the obstetricians reading this are quaking
in their boots, but there is no rational reason to. In one classic
study, 3 of the 17,898 women undergoing a trial of labor after cesarean
died, while 7 of the 15,801 women undergoing a repeat C/S died(9) It is
likely that the trial of labor morbidity and mortality would have been
even lower had the study participants refrained from inducing or
augmenting labor. But even those numbers are roughly half of the 2 in
10,000 risk that a woman will be killed in an automobile accident during
the period of time she is pregnant.(10)
Furthermore, other studies suggest that while around 5/10000 serious
uterine ruptures may occur during a trial of labor, around 2/10000
uterine ruptures occur prior to the onset on labor. In other words, any
pregnant woman who has had a prior C/S is at increased risk of uterine
rupture even if she elects a repeat C/S. And as we well know, there are
many other consequences of cesarean delivery that may be life
threatening. Why then are we not approaching performing a C/S with even
a fraction of the trepidation that we approach normal vaginal
deliveries?
A woman choosing to have a home VBAC rather than be forced to have a
repeat C/S in her local hospital is making a rational decision given the
data we have available, a decision which we should be prepared to
support if we cannot offer her a better alternative. I have delivered
several hundred VBACs in the past several years without incident. In the
same time frame, my local hospital has lost at least 3 mothers during
or shortly following cesarean deliveries.
U.S. obstetricians have already come to the crossroads and have taken
the wrong path. It can be fixed, but they need to start having honest
and open discussions among themselves about the real maternal and fetal
risks, about the rampant rate of unnecessary induction which leads to
unneeded cesarean delivery, about the continued use of continuous fetal
monitoring, restricted movement, withholding of nutrition, unneeded
augmentation of labor, artificial rupture of membranes, epidural
anesthesia and even multiple cervical exams, none of which have any
proven benefit and all of which contribute to increased morbidity and
even mortality.
Less than two per cent of what is routinely done on labor and delivery
units in the US has been shown to have any positive benefit. Over 15%
has been shown to have demonstrably adverse impact. ACOG continues to
spout, with no evidence, the tired old line that delivery is safer in
hospitals or birth centers joined at the hip to hospitals.(11) At the
same time, every EU member country is actively seeking to increase the
numbers of home deliveries, increase the numbers of midwife managed
pregnancies, and work to ensure there is a seamless interface between
home delivery practices and the hospital system. In the US, virtually
all medical boards and obstetrical societies, and most obstetricians
and hospitals, are actively hostile to the idea of home delivery and to
the practitioners and pregnant women who choose it.
Our maternal and infant mortality rates continue to climb. We continue
to do the same things and expect different outcomes. Is it because of
the "risk averse culture of doctors and hospitals"? Partly,
yes. But it is also pressure from their peers that prevents
obstetricians from actually practicing the evidence based medicine we
have and from even considering the vast realms of international EBM and
midwifery EBM. Obstetricians who attempt to practice based on the
literature rather than the "local standard of practice" run a
very real risk of losing their hospital privileges and possibly even
their medical licenses. If they practice according to the "local
standard of care" they almost invariably must violate all four of
the accepted principals of medical ethics: patient autonomy,
beneficence, non-maleficence, and justice.
We have the information to fix this problem. When we address the
culture of peer pressure, the local "standards of care" that
bear no resemblance to what the literature supports, when we recognize
that many (including some among the top leadership and most recognized
names in obstetrics) are more interested in procuring their positions,
promoting their ideology, protecting their power, and preserving their
market share than they are in really addressing the problems, improving
maternity care, and truly supporting their patients, then and only then
can we start to make headway towards creating a model of maternity care
that is both world class and genuinely supportive of its clientele.
David Hayes, MD has been offering home births since 2005 and has
attended exclusively home births for the last three years. He is
closing his practice this month to devote his energies to the
international humanitarian aid organization, Doctors Without Borders
<_http://www.doctorswhttp://
(http://www.
This post is featured as one of a series of posts
<_http://www.theunnechttp://
_ (http://www.theunnecesarean.
<_http://www.theunnechttp://
(http://www.theunnecesarean.
by OB-GYNs in response to the May 2011 article, An Obstetrician'b
Lament, by Dr. Annette Fineberg.
BIBLIOGRAPHY
1. WHO. Trends in Maternal Mortality: 1990 to 2008. (Geneva: 2010).
whqlibdoc.who.whqlibdoc.who.<
2. UNICEF. The State of the World's Children 2011.
(New York: 2010) Table 1, pp.88-91. www.unicef.org/(New York
statistics.php
3. Deadly Delivery; The Maternal Health Care Crisis In The USA,
Amnesty International Publications, Nov 2010 Index: AMR 51/007/2010
ISBN: 978-0-86210-ISBN:
4. Patricia A. Janssen PhD, Lee Saxell MA, Lesley A. Page PhD, Michael
C. Klein MD, Robert M. Liston MD, Shoo K. Lee MBBS PhD. Outcomes of
planned home birth with registered midwife versus planned hospital
birth with midwife or physician., CMAJ 2009. DOI:10.1503/birth with
5. de Jonge A, van der Goes B, Ravelli A, Amelink-Verburg M, Mol B,
Nijhuis J, Bennebroek Gravenhorst J, Buitendijk S. Perinatal mortality
and morbidity in a nationwide cohort of 529 688 low-risk planned home
and hospital births. BJOG 2009; DOI: 10.1111/j.1471-and hospital
02175.x.
6. Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwife-led versus
other models of care for childbearing women. Cochrane Database of
Systematic Reviews 2008, Issue 4. Art. No.: CD004667. DOI:
10.1002/14651858.10.1002/110.
7. Kenneth C Johnson, Betty-Anne Daviss: Outcomes of planned home
births with certified professional midwives: large prospective study in
North America
BMJ 330 : 1416 doi: 10.1136/bmj.BMJ 330 :BMJ 330 : 1416 doi: 10.1136/bmj
8. Vincenzo Berghella, MD; Jason K. Baxter, MD, MSCP; Suneet P.
Chauhan, MD. Evidence-based labor and delivery management, American
Journal of Obstetrics & Gynecology, NOV 2008, pp 445 – 454.
9. Landon, MB, et.al. Maternal and perinatal outcomes associated with
a trial of labor after prior cesarean delivery. NEMJ Volume
351:2581-2589 December 16, 2004 Number 25
10. National Highway Traffic Safety Administration, Fatality Analysis
Reporting System. www-fars.nhtsa.Reporting SysReporting
11. AMERICAN MEDICAL ASSOCIATION HOUSE OF DELEGATES, Resolution: 205,
annual meeting 2008.
WOW, WOW, WOW, for lack of better words. This makes me want to run around my living room shouting YES!! Thank you for sharing such a great article! <3
ReplyDelete