An Obstetrician's Hope
By David Hayes, MD | May 13, 2011
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)
“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.(4) 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.