Green Maternity Care Part 3 2007

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Green Maternity Care ~
a natural partner with StepItUp2007 in an effort to reduce global warming

NIH wades in the “maternal choice” Cesarean debate and muddies the waters

Don’t look to the Feds to put to put the brakes on our run-away Cesarean rate or re-examine the idea of elective CS as just another way to have a baby. The NIH is has also fallen under the spell of obstetrical politics. In March 2006 the National Institute of Health (NIH) held a three day national conference on what they called “The Maternal Request Cesareans”. A draft recommendation written by two obstetrician-consultants 6 weeks before the conference was adopted essentially unchanged at the close of the conference, which eliminated any public discourse on its criteria or conclusions. Many professional spokespersons for family practice medicine and midwifery were felt betrayed by the NIH’s inability to address the real issue.

The type of scientific evidence chosen by the NIH consultants was double blind studies, also known as randomized control trials (RCT). This type of research requires a control group (which gets no treatment at all) and two other equally matched groups who are randomly assigned to each ‘arm’ of the study. A necessary part of ‘double blind’ studies is that neither practitioner nor patient knows which group each individual is assigned to. Both are also suppose to be ‘blind’ to which type of treatment the patient is getting – either placebo/sham treatment or the real thing. Then the researchers record the number of complications in the two randomly assigned groups and calculate the difference to see who had the best outcomes, i.e. most ‘cures’, least complications.

However, it would be impossible and unethical to do RCT on the elective use of Cesarean, as it would entail flipping a coin to decide whether each mother in the study would be assigned to have a normal birth or to have a Cesarean and EVERYBODY would know what group they were assigned. There is no placebo equivalent of either a Cesarean or a vaginal birth, and of course, it would prevent the childbearing woman from electing to have an elective Cesarean, forcing women who didn’t want a vaginal birth to labor and give birth spontaneously and visa versa.

As could be expected, there were no RCTs on elective cesarean versus vaginal birth (and there never will be). Lacking RCTs, the consultants deemed all the other research to be less compelling or problematic. For example, some studies had small numbers or couldn’t absolutely guarantee that some of the elective Cesarean group didn’t have an unplanned vaginal birth or unreported medical complications. However, the preference for RTCs meant disregarding a large pool of the comparison studies, a standard that is no applied elsewhere in the practice of medicine. Obviously there are many areas of medicine and surgery that can neither be randomized nor blinded and yet, we use the wide swath of data available to determine the best course of action.

But the NIH committee on elective Cesarean chose not to base its recommendations on the broadly-based scientific literature that is available. As a result, they purported to have found no ‘good’ scientific evidence to determine the relative safety of normal vaginal birth vs. elective Cesarean. On the safety of “Maternal Request” cesarean, the NIH was neutral, leaving it up to the ‘consumer’, in consultation with her doctor. This “have it your way” solution has already been made famous by Burger King commercial, but doesn’t seem to be a very good model for spending 5% of our GDP..

Politically speaking, the obstetricians involved in the NIH panel had a vested interest in not looking too closely at the problem. The failure of the NIH to recommend against medically unnecessary CS was welcomed by the obstetrical profession, as it coincided with and supported their efforts to get a unique diagnoses and billing code for the medically unnecessary ‘maternal request cesarean’. This will assure that health insurance carriers and federal Medicaid program compensate OBs for performing medically unnecessary Cesareans.

An additional spin off of the conference’s “have it your way” conclusion was a recent article in an obstetrical trade paper. Under a banner head line that read “Honor her Choice”, the article reported on the NIH maternal request cesarean conference. Citing the NIH conclusion that no credible scientific information was able to determine the issue, representatives of the obstetrical profession saw the NIH’s report as paving the way for a widening use of Cesarean surgery for little or no medical reason.

What actually happened is that those with a hidden agenda have been made into gate keepers and put in charge of what should be an objective and scientific inquiry. Based on objective and scientific criteria Cesarean surgery is and will always be more risky than normal childbirth occurring naturally under physiological principles. However, the issue from the obstetrical end of the equation is not simple or easy.

The Obstetrical Escape Clause – an explanation of ‘when in doubt, cut it out’

‘When in doubt, cut it out’ is a phrase coined and frequently used by contemporary obstetricians. As a policy, it is a hedge against litigation. It pairs the obstetrician’s safety to the performance of a cesarean. The expression describes an informal protocol that predictably results in the decision to do a Cesarean whenever the doctor has any doubt. If something seems wrong or might go wrong or even that the obstetrician can’t absolutely guarantee that everything is all right, then cut the baby out before you are sorry you didn’t do it sooner. It is action that expresses the obstetrician’s personal fear and reflects the depth of the profession’s anxiety over the life-wrecking effects of malpractice litigation and the unfair burden that all obstetricians feel themselves to be working under.

This experience is so deep and so visceral that it can to liken to being terrorized, the same kind of irrational reaction any American might have if confronted by an Osama Ben Laden look-alike with a suspicious bulge under his jacket. Obstetricians are terrified by the specter that they might make a mistake, might miss some little subtle sign, not act fast enough and wind up with an “adverse event” that would ruin their career. Each childbearing family only faces the anxiety associated with childbirth a few of times in their whole life. However, obstetrician finds themselves facing this dreadful responsibility every day of the week for 20 or 30 years. Adverse events -- the official term for a bad outcome-- often lead to being sued, which is experienced by an obstetrician as a potentially fatal disease.

The current malpractice ‘crisis’ began in 1910 with the obstetrical profession’s historical promise to childbearing families that if they chose obstetricians, instead of midwives, they would be guaranteed a good outcome. This was half wishful thinking and half a genuine belief in the strict rationalism of western science. The new frontier of ‘modern’ medicine was expected to quickly redefine life in the 20th century, sweeping away millennia of superstition and human helplessness in the face of disease. This was only 3 decades after the discovered the germ theory, which ended 2000 years of belief in spontaneous regeneration – the false notion that life, in the form of infectious agents, could generate from inorganic matter.

In the field of medicine, cracking the code for infection was a scientific leap functionally equal to the invention of air travel, telephones and computers rolled into one. In all honesty, perhaps only the sequencing of DNA will ultimately have a bigger impact on human healthy than the germ theory did. In 1910 it seemed perfectly logical to the medical profession (and to many others) that a scientific obstetrics would ultimately be able to eliminate the complications historically associated with childbirth. The idea was simple -- medically manage all labors, aggressively respond to any hint of trouble (the pre-emptive strike) and conduct ‘the delivery’ under general anesthesia as a surgical procedure. Families were assured that a sterile environment and sterile technique would eliminate infection. It was assumed that a generous episiotomy would preserve the mother’s pelvic floor, thus eliminating “female troubles” later in her life. And the routine use of forceps would shorten the pushing phase, thus saving the baby from the stress of labor while also protecting the baby’s brain from being pounded on the mother’s “iron perineum”. What’s not to like?

Unfortunately, the assumed superiority of medicalized childbirth was only a hypothesis, an untested theory, one that turned out to be wrong. In a ideal world, obstetricians would have learned from the unexpected complications, asking hard questions, reexamining assumptions, correcting unrealistic ideas. But their belief in the ideal of science was so seductive that clear vision was replaced by a blind spot. When problems arose, the obstetrical profession redoubled their efforts and tried harder. They were absolutely sure they were on the right tract, if only they used interventions more liberally, with greater frequently and earlier in the course of events, then all would be well.

Despite these valiant efforts, perfect control over Mother Nature never materialized. This wouldn’t have wrecked such havoc if it weren’t for the unrealistic expectations of the public so the carefully cultivated by obstetrical profession. Failure was built into the promise of a perfected system. Since no system is ever perfect, the expectation of perfection poisoned the water. When something went wrong during childbirth, as it inevitably did from time to time, people began to blame the obstetrician for doing something wrong. Bad outcomes were no longer ascribed to bad luck or bad genes – instead they were the doctor’s fault.

The obstetrical profession’s inability to deliver on this impossible promise created an independent cause of action – grounds for a malpractice law suit --each time mother or baby died or was left with a permanent disability. The family was unable to distinguish between ‘adverse events’ caused by nosocomial or iatrogenic mistakes and those that were genuinely unpredictable and unpreventable. Whatever the origin of the tragedy, they believed that they had been tricked, lulled into a false sense of security and then victimized by carelessness, callous disregard, negligence or incompetence of their doctor. They went home mad, distrusted doctors and were generally unhappy with the medical profession.

Despite this distress, obstetrical lawsuits were not a big problem in regard to childbirth for the first 50 years. One reason was the virtual impossibility of getting one obstetrician to testify against another obstetrician. Without a supply of ‘expert witnesses’, it was all but impossible to win malpractice cases and as a result, lawyers wouldn’t take malpractice cases.

But that all changed in the early 1960s, when a Supreme Court decision redefined “community standard”. Under the new rule, it was no longer a geographical place but as the entire profession of medicine as practiced in the United States. For the first time, a lawyer suing a doctor in New York could import expert witnesses from California and easily prevail in court, since the experts were getting paid a lot of money to favor the plaintiff’s claim.

The ‘perfect storm’ that turned into the malpractice crisis consisted of three elements. First was the historical promise that, compared to the physiological care of midwives, obstetrical care was ‘value added’ and would dependably prevent complications and make childbearing safer and better, even for women who didn’t have any risk factors. The second element was the fundamental inability of obstetrics to make normal birth better or to actually predict and prevent all complications and the unfortunately increase in problems from nosocomial and iatrogenic causes. The proverbial ‘nail in the coffin’ was the Supreme Court decision, providing an endless supply of expert witnesses to testify against any physician fingered by the plaintiff’s attorney. At that point, the genie couldn’t be put back in the bottle. Like a hurricane forming in the moist warm waters of the Gulf, the modern malpractice suit took on its modern form and emerged with a vengeance.

Fueled by the success of the first 100 cases, it burst into flames by 1976 and ever since the medical profession has been trying to put out the fire. Sadly, the malpractice crisis has become a permanent epidemic that remains impervious to all the efforts to beat it back into submission. While ‘defensive medicine’ is the norm in every aspect of medical practice, no where is it more aggressive than in regard to medicalized childbirth. Modern obstetrics is totally organized around reducing the risk of malpractice litigation. Of course, this brings us right back to the obstetrical escape clause – when in doubt, cut it out.

Seen in this light, it should come as no surprise that obstetricians generally assume that such a policy is equally beneficial to the mother and baby. This reflects, in part, the historical notion that normal birth is fundamentally dangerous and that it has no particular advantage for mothers and babies, so why not just get the baby out the ‘easy’ way’? Don’t we all wish there was an ‘easy way’, one that eliminated the birth attendant’s anxiety over litigation, was convenient, inexpensive, painless and not only safe in the strict sense, but also psychologically satisfying for mother and baby and free from any downstream complications?

While hope springs eternal in the human breast, Cesarean is not and never will be the answer to this prayer.

Cesarean surgery can be life-saving in the face of life-threatening complications, it also can be life-threatening in the absence of life-threatening complications. This applies to both mother and baby. Cesareans performed for any reason are strongly associated with additional maternal deaths, higher medical costs at the time of delivery and the delayed and downstream complications. These include emergency hysterectomies, secondary infertility, tubal pregnancies and miscarriages, as well as placental abnormalities. Women who give birth by Caesarean section run twice the risk of having a stillbirth at the next pregnancy. [Health Editor UK Jeremy Laurance 28 November 2003] These are human as well as economic disasters.

Many obstetricians believe these complications are mostly associated with emergency Cesareans. They see elective C-sections, which, in theory, would eliminate the need to perform emergency C-sections, as a winning strategy that simultaneously prevents both emergency C-sections and all the problems they see associated with normal birth.

That argument brings up enough questions that several researchers have recently studied the independent risk of Cesarean surgery when performed on healthy women with no pregnancy or labor-related complications. The focus of this research is to identify the rate of morbidity and mortality in women who have completely elective cesarean (no maternal illness, medical problem, surgery performed before labor, etc). A number of they studies has recently been published and identify what common sense would predict – that childbirth surgery, regardless of the reason or lack of reason, is still surgery and still associated with surgery-related complications.

One study done in France established that elective cesarean delivery in healthy women either before onset of labor or in early labor was associated with increased risk of maternal death from complications of the surgical procedures -- anesthesia, infection, and venous thromboembolism [potentially fatal blood clots]. [Postpartum Maternal Mortality and Cesarean Delivery, C. Deneux-Tharaux, MD, MPH, et al, Obste& Gynecol Sept 2006] The rate of postpartum death was 3.6 times higher after cesarean than after vaginal delivery

The reasons for increased maternal mortality were the same short list that has been associated with surgery for a hundred years -- anesthesia complications, infection and post-operative blood clots. We will never be able to eliminate the independent surgical risk of Cesarean without eliminating the essential elements of surgery – incising the body -- which mandates the use of anesthesia and carries the potential for hemorrhage, infection and blood clots. But unlike general surgery, Cesarean surgery also impacts on an unborn or newborn baby.

A recent study of nearly six million births found that the risk of death for newborns delivered by elective Caesarean is much higher than previously believed. Newborn mortality for elective Cesarean in the cases studied was more than twice that for vaginal births. One explanation offered was 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.” [Voluntary C-Sections Result in More Baby Deaths * New York Times September 5, 2006 ]

When it comes to Cesarean section, the only way to circumvent the lethal dangers of anesthesia would be to figure out a way to get the baby out with having to cut in to the mother’s body. To prevent the hemorrhage and blood clots associated with CS, one must figure out how to get the baby out without the cutting of tissue, organs, blood vessel and other structures. To prevent the associated infection would require inventing a way to withdraw the baby without having to put anything in the mother’s sterile abdominal cavity and uterus. Infection is the result not only of carrying bacteria into sterile body parts but also the assault that surgery itself represents to the immune system, and the general stress to the mother, which makes it less able to fight off infection.

By now, most readers will have realized that it is already possible to accomplish all of the above listed goals – a dependable method to eliminate the risks anesthesia, hemorrhage, blood clots and infection. We can get the baby out without cutting into the mother’s body, without cutting organs or tissue, risking blood clotting problems or without introducing potentially infecting materials into sterile body cavities. This ’new’ idea is called normal vaginal birth and it’s been around forever.

Americans are uniformly grateful for the life-saving abilities of obstetrical medicine. But appropriate gratitude can’t hide that fact that we have outgrown our 1910 system of industrialized maternity care and the illogical notion that normal maternity care should be conducted as a strict obstetrical model. As an obstetrical event, normal birth becomes a surgical procedure performed by a physician, instead of a spontaneous biological event in which the mother gives birth normally with the support of her professional caregivers, who are careful not to disturb the normal process.

The 19^th century reductionist view of childbirth generated a host of unintended consequences. This started with the centuries-old conflict surrounding the clinical training of obstetricians and the ethical issues generated by the need for a large and steady supply of teaching cases. Other problems included epidemic level of nosocomial and iatrogenic complications in the first half of the 20th century, inappropriate and indiscriminate use of technology and obstetrical interventions in the second half of the century. More recently, the malpractice crisis was added to the list and now the move to replace normal birth with Cesarean surgery as the 21st century standard of care. To this lengthy list of human burdens, we now have to add the resource hungry, “gas guzzling” aspect of a medicalized maternity care system

The relationship of the obstetrical model to normal childbirth has changed very little since being standardized in 1910. Even though the health of the childbearing population in the 21st century is generally excellent, medicalized maternity care still applies a fixed set of interventions to both low and high risk women. As a result, obstetrical interventions have sky-rocketed all out of proportion to the number of complicated pregnancies. Twentieth century obstetrics plays an important role for those with complications of pregnancy and childbirth, but it is unable at any price to make normal childbirth safer for those who are already healthy.

The current obstetrical ‘package’ is associated with an ever-increasing Cesarean section rate. This results in additional maternal deaths, higher medical costs at the time of delivery and from the delayed and downstream complications of surgical birth, which include emergency hysterectomies, secondary infertility, tubal pregnancies and miscarriages, as well as placental abnormalities and stillbirth in subsequent pregnancies. These are human as well as economic disasters.

Ultimately, our success in the global economy is dependent on the US having an efficient and functional maternity care system that matches the rest of the world. We don’t have that at present. Mastery in normal childbirth services means bringing about a good outcome without introducing any unnecessary harm. Our present system of obstetrics for normal childbirth does not do this very well, as evidenced by our 90% intervention rate for healthy women and our 30% Cesarean section rate. As an “expert” system, obstetrics has failed most in the very area it was supposed to have the most mastery and expertise -- preserving the health of already healthy mothers and babies.

The sad fact is simply that our 1910 system of medicalized maternity care has never been reexamined, or held accountable for either scientific or economic integrity. It’s appropriate to question the wisdom of using a surgical specialty to provide care to a healthy population. Were we to do that, many of the conditions that lead to excessive levels of obstetrical intervention – particularly the overuse of induction and Cesarean surgery -- will become clear, permitting us to reverse the current upward spiral of costly obstetrical interventions.

Green Maternity Care ~
a natural partner with StepItUp2007 in an effort to reduce global warming