Consortium for the Evidence-based practice of Obstetrics
Historical Move to Re-define Childbirth
as a 'Surgical Procedure'
What is the
Nature of Birth?
A Force of Nature?
A Normal biological act?
♠ 1911: “For the sake of the lay members who may not be familiar with modern obstetric procedures, it may be informing to say that care furnished during childbirth is now considered, in intelligent communities, a surgical procedure." [1911-D, p. 214]
A Man-Made Process?
A Professional Service?
A Modern Obstetrical Procedure?
Is it a normal biological event in which the laboring woman voluntarily seeks out others to assist her in achieving the goal of a spontaneous delivery because birth is an important developmental process for the mother and her family?
Is it a professional activity and surgical procedure performed by a physician-surgeon on an anesthetized woman in a sterile environment because without obstetrical interventions the woman & baby would die or be permanently damaged?
Addendum (1) Pertinent Historical Background in Three Parts
Introduction: For the last century, society’s relationship with normal childbearing has been tragically flawed because it was based on faulty assumptions. The central and erroneous belief was that childbearing in healthy women was fundamentally and inextricably dangerous. This false assumption was based on the notion that a woman’s reproductive biology is inherently defective, or as Freud would say, biology is woman's (unfortunate) destiny.
For childbearing women, this Freudian concept of unfortunate destiny meant that it was a woman's biological destiny to be sacrificed to a defective anatomy and physiology. This notion gave rise to the idea that normal childbirth had to be made safe by the medical profession through the corrective use of powerful drugs and risky surgeries. The laboring woman would be saved by becoming a passive patient delivered by others. Childbirth was redefined as surgical procedure performed by the doctor on the mother. These unexamined assumptions have continued to dominate our thinking and have driven our health care policies for over a hundred years.
When our current obstetrical system was first developed in the early 1900s, maternal and infant mortality were indeed dreadfully high. The crowded cities of the eastern seaboard were awash with the poorest of the poor as new immigrants crammed into the squalor and filth of tenements without indoor plumbing. The result was tuberculosis, typhoid fever and rickets. Post-slavery racial segregation and Appalachian isolation of poor whites generated the grinding poverty of subsistence farming. Rural families were particularly prone to tetanus, cholera, and horrific injuries from farm machinery.
The ubiquitous backdrop for this human tragedy was the general exploitation and disenfranchised status of all women. In an era with no effective or legal form of birth control, the average married woman had six or more pregnancies while families with 12 to 20 children were not uncommon. Hungry, over-worked women who were suffering from malnutrition had frequent close spaced pregnancies with little or no access to the most basic forms of health care. When their privations resulted in the predictable complications of childbearing, medical science had little to offer and due to economic or geographical barriers, what little it could do was often beyond reach of poor families.
Institutionalized injustices and economic deprivations contributed to a horrific number of childbirth-related preventable deaths and disabilities in the early 20th century. One out of every 500 pregnant women died of pregnancy-related causes before, during or after birth. One third of these deaths were from unsafe or botched abortions. One out of ten babies died at birth or during the first month. In the tenements of NYC, 20% of all children died before their 5th birthday. This huge public health problem was a humanitarian disaster of the first order and by 1910, politicians and public health officials were demanding that the medical profession “do something”.
Unfortunately, the medical profession’s response to the high mortality rate for mothers and babies was to focus a small flashlight on the tiny field of obstetrical emergencies while failing to acknowledge the hugely important public health issue of protection and prevention. It was a double whammy in which organized medicine ignored the pivotal role of poverty, ignorance, exploitation and social injustice while they also failed to take into account the rudimentary and inadequate state of medical science. In 1910, when this plan was first conceived, antibiotics had not yet been discovered, surgery and anesthesia were extremely dangerous and blood typing necessary for safe transfusions was still unknown. The only real help doctors of this era could offer was to mechanically pry open the cervix with rubber balloons ("boogies"), cut an episiotomy and use forceps or a cesarean to remove the baby. Post-operative death from these procedures was 20% in some hospitals. For serious infection or a life-threatening hemorrhage all the medical profession could do was keep the woman heavily drugged until she either died or got better on her own. None the less, doctors sought to bring all childbearing women under the purvey of surgically-trained doctors through the universal medicalization of pregnancy and childbirth.
~ ¨ 1911 “For the sake of the lay members who may not be familiar with modern obstetric procedures, it may be informing to say that care furnished during childbirth is now considered, in intelligent communities, a surgical procedure." [1911-D, p. 214] ~
~ ¨ 1915 …‘The parturient [laboring woman] suffers under the old prejudice that labor is a physiological act,’… and the medical profession entertains the same prejudice, while as a matter of fact, obstetrics has great pathologic dignity ---it is a major science, of the same rank as surgery”. [1915-C; DeLee, MD p. 116]
~ ¨1915 “If the profession would realize that parturition [ childbirth], viewed with modern eyes, is no longer a normal function, but that it has imposing pathologic dignity, the midwife would be impossible of mention."[1915-C; Dr Joseph DeLee, MD p.117]
~ The History and Characteristics of Surgery and Surgical Procedures ~ The original medical definition of “surgery” was to “sever or penetrate human tissue”. Since the discovery of microbes and the development of the germ theory of disease, this definition was expanded to include the use of sterile techniques or entering into a sterile body cavity through a natural body orifice. The mouth, nose, ear, vagina and rectum are not normally ‘sterile’ and thus excluded from that definition. Only three sterile organs can be accessed thru a natural body orifice -- the lungs, the bladder, and the uterus. A medical treatment is functionally a “surgical procedure” if it occurs under general or regional anesthesia and utilizes “sterile” technique. This would apply to changing burn dressings in the operating room or inserting a bronchoscope into the lungs. In the early years of the 20th century, surgical sterility and anesthesia was also applied to “normal vaginal birth”. The idea of surgical ‘sterility’ itself is little more than a 100 years old. It was not until 1881 that a French physician, Dr. Louis Pasteur, established the central role of microbes -- commonly known as ‘germs’ or ‘pathogens’-- in causing illness and infection. On a chalk board at a prestigious medical meeting Dr. Pasteur drew a graphic representation of what the streptococcus bacteria looked like under a microscope -- rectangular microbes that resembled a string of box cars on a train track -- and said “Gentlemen, this is the cause of Childbed Fever”. With this discovery, Dr. Pasteur delivered the fatal blow to the erroneous and dangerous doctrine of ‘spontaneous generation’ -- the theory held for 2000 years that live organisms such as bacteria could arise spontaneously in organic materials. This discovery was a natural development for Louis Pasteur as his father was a vintner and techniques to achieve bacteria-free surfaces are basic to wine making. In order to prevent mold from growing on the fermenting wine, the bottles must be sterilized by boiling and their sterility maintained until filled with wine and sealed. Dr Pasteur also developed "pasteurization", a process by which harmful microbes in perishable food products are destroyed using heat, without destroying the food. It was not until the discovery of anesthesia in the 1840s to control the inevitable pain of surgery and then 40 years later, the germ theory of disease and use of sterile technique to control the infection that surgery became a reasonably effective form of medical treatment. According to history, the first-ever obstetrical operation -- a Cesarean -- was done in first century Rome to extract a living child from its dead or dying mother. Anesthesia made it possible to do Cesareans on living women and sterile technique made it possible for women to survive the operation. Other obstetrical surgeries such as episiotomy and the use of forceps were greatly enhanced by anesthesia and sterile technique. It did not take long for operative obstetrics to become the new “wave of the future” – for the years 1909 and 1910, operative deliveries in one famous NYC hospital were already up to 20% or one out of five births. By the early 1900s, “enlightened” obstetrical care was based on the idea that surgical interventions provided a superior form of care. One of the titans of the obstetrical world in the first decade of the 20th century was Dr. Joseph DeLee. Dr DeLee was famous (or perhaps infamous!) for insisting that childbirth, from the mother’s standpoint, was about as “natural” as falling on a pitchfork. He likewise insisted that every baby’s head was subjected to pathological forces during even the most normal labor by being repeated bashed into the mother’s intact and thus “iron” (according to Dr DeLee) perineum. The take-home message in 1910 was that a “generous” episiotomy saved both mother and baby from the malevolent forces of her “iron” (i.e., intact) perineum and that the routine use of forceps ‘saved’ the baby from being battered and bruised as it was pushed down thru an intrinsically dangerous birth canal by unpredictable forces of nature. For these reasons it was natural to obstetricians of the early 1900s that childbirth should henceforth be considered a surgical procedure. Technically-speaking, childbirth is considered an “operative” delivery when forceps (& now vacuum extraction) are used or a Cesarean section performed. Strangely, the use of episiotomy during childbirth, which impacts only the mother, is not statistically categorized as operative but of course episiotomy is deep surgical incision in the intact perineal skin and supportive musculature, thus it is an fact "operative" delivery. By 1910 it was considered standard to utilize sterile technique, anesthesia, episiotomy and outlet forceps at every birth, to manually remove the placenta (this required the doctor to reach up inside the uterus and sheer the placenta off the uterine wall with his or her fingers) and then suture the perineal wound. These surgical procedures and operative techniques were routinely used 95% of the time and quickly equated to the formal obstetrical “standard of care”. Doctors also assumed that childbirth conducted under these sterile operating room conditions would eliminate the great killer of childbearing women and newborns -- a fatal streptococcal infection of the blood stream known as puerperal sepsis or ‘childbed fever’. It was the streptococcal bacteria which caused septicemia after childbirth that Dr Pasteur used as an example of the germ theory of disease on that famous day in 1881. In the minds of obstetricians 2 decades later, surgical techniques represented a permanent cure for this scourge, one so important to public health that it called for 100% hospitalization and 100% care of childbearing women by obstetrical surgeons.
Unfortunately, the frequent pelvic exams associated with laboring in a hospital, combined with episiotomy, forceps, manual removal of placenta and suturing of the perineium, created the ideal conditions to carry hospital pathogens up into the sterile cavity of the uterus where the raw surface of the recently delivered placenta offered bacteria the perfect pathway into the mother’s blood stream.The stress of anesthesia and added blood loss associated with episiotomy, operative delivery and manual removal of the placenta all weakened the mother’s immune system and made her more vulnerable to this lethal infection. The lack of effective antibiotics sealed her fate in all too many cases – in 1918 there were 23,000 maternal deaths, the majority cause by or complicated by streptococcal septicemia. Unfortunately for the childbearing women of the era, surgical birth vastly increased the rate of puerperal sepsis and the rate of maternal deaths. Other Unintended Consequences But this 20th century convention of ‘birth as a surgical procedure’ influenced more that just the way the baby was delivered and went far beyond the singular personal experience of any one childbearing woman, more even than the sum of surgical complications and preventable fatalities. There was an impressive and exhaustive list of special arrangements that had to precede the wholesale provision of childbirth as a surgical service. For the last 100 years these special arrangements have molded and eventually defined the institutions of society in regard to maternity care. More influential than the 30 minutes surgical procedure of “delivery” were the many other areas this new concept impacted -- public opinion, medical education, the design of hospital maternity wards, the rigid, gender-based roles of health care professionals and the dramatically increased professional fees charged for this type of medicalized maternity care. These social changes molded public opinion and national policies for health care so even if an individual woman never personally gave birth under “surgical” conditions, her choices in regard to normal childbearing (i.e., physiological management and non-medicalized birth) were eclipsed by this historical turn of events. First off, birth as a ‘surgical procedure’ changed both the public and the medical profession’s fundamental relationship to childbearing. Doctor, nurse, mother, husband, lay person -- status didn’t matter, as everyone began to see a sharp (if artificial) split between ‘labor’ and ‘delivery’ -- the mother labored but the doctor “delivered”. Attention was directed away from the mother and her labor and instead shined a spotlight on the artificially created, very brief event of “delivery”, during which the obstetrician, instead of the mother, becomes the most essential person in the room and the one credited with bringing about the birth of the baby. Birth as a surgical procedure was (and is) divorced from labor, which was historically characterized by the obstetrical profession as merely the “waiting period”. All of this resulted in a very different expectation of where and how to give birth, and what the proper roles of the two categories of participants were -- the mother and her family, the doctor and his assistants. It also promoted a drastically different type of hospital architecture that isolated the mother and the events of childbirth from all forms of social oversight and accountability. (See Hx Addendum) Maternity Care ~ on a Metaphoric ‘San Andreas Fault’ after the “Big One” With childbirth redefined as a surgical procedure performed by physicians, the hospital quickly replaced the home, the nurse displaced both family and midwifery care during labor, the doctor displaced the midwife during the birth/delivery and his surgical skills displaced the mother’s spontaneous efforts. Under ‘surgical’ conditions, the mother’s central role was reduced to a passive, usually unconscious vessel, out of which a baby was extracted by the physician who then received the accolade of the father for having ‘safely’ delivered his wife of the longed-for son or daughter. While the doctor was giving the good news to the family in hospital waiting room and the family was excitedly admiring the baby in the nursery window while handing out cigars to passing strangers, the mother was sequestered away in the “No-Admittance” labor ward, bleeding from the manually removed placenta, hurting from the episiotomy and vomiting her way out of the fog of anesthesia. Birth as a surgical procedure also leads to an entirely different focus in medical education. Medical students “observed” deliveries -- not labors. They studied interventions, not normal biological processes. They practiced surgical techniques, not methods to avoid the necessity of their use. They dissected cadavers and performed autopsies, which required them (in emotional self-defense) to distance themselves, and objectify the ‘body’ as an inert and unemotional machine. The fashion of surgical dominance spilled over into other areas and influenced nursing school education, which now taught students nurses a surgical style for childbirth and prepared them to be good technicians who carefully served the hospital system and faithfully carried out the doctor’s orders. While the ratio of midwifery caregiver to mother has always been (and remains) one midwife to one mother, the ratio of nurse to laboring patients (that is patients plural) is one nurse to several labor patients – anywhere from two to six women in all stages of labor, plus new admissions, emergency surgeries and covering for other nurses while they take meal breaks. This made labor room nursing a very different entity from the traditions of midwifery care. Nurses primarily administered potent drugs while “waiting” for the mother to be completely dilated so she could be prepared for ‘delivery’ and of course, the nurse assisted the doctor during the surgically conducted procedure of childbirth. The obstetrical care system itself, that is the needs of the doctors and the hospital, were the central focus of L&D nursing. The Surgical System ~ a galaxy light-years away in its own orbit Labor and delivery was organized around ideas of surgical sterility which first required admission to an acute care hospital and second required isolation of the “patient” within the hospital. Laboring women were hidden way behind those ubiquitous swinging doors with a sign that read “No Admittance -- Authorized Personnel Only” in big black letters. Surgical procedures required special preparations of the mother’s body (pubic shaving and enemas) and administration of sleeping pills, narcotics and other drugs that altered her consciousness. As a ‘pre-op” patient she was NPO – non per os or ‘nothing by mouth’, no food or water. In some hospitals, IV fluids were given if the labor was unusually long. The narcotic and amnesic drugs, combined with the L&D protocols, restricted her to lying horizontal a hospital bed, listening to other women in the labor ward moan and cry out with each contraction. She was isolated her from friends and family and prevented from walking about or socializing during labor. Under these circumstances the drugs were a blessing, even though they depressed newborn respirations. Needles to say, virtually all of the standard techniques of midwifery care, such as psychological support, walking and right use of gravity, were impossible in this medialized environment devoted to assembly-line childbirth surgery. Birth as a surgical procedure also required a specially trained professional staff, special clothing for the staff and special arrangements for changing clothes -- a place where doctors and nurses could exchange street clothes for special OR clothing. It required a variety of other special preparations and rituals for the staff such as a surgical cap to hide the hair, shoe covers to hide the feet, a surgical mask to block exhaled air and a prolonged form of hand washing called a “surgical scrub”. The OR team (surgeon and scrub nurse) were all required to perform a ritualized cleaning of nails and scrubbing of fingers, hands and forearms for 5 full minutes with a special antibacterial soap, rinsing hands with fingers pointing up so that the water (and germs from skin) flowed off the fingers and hands and water dripped off the elbows. Then the scrubbed hands and arms must be dried with a sterile towel while being held in this fingers-up, elbows down position. The last steps in this particular ritual were special techniques for physicians and scrub nurses to don sterile OR gowns and gloves without ‘breaking technique’ -- that is, scrubbed and dried hands must be kept directly in front of the body, in sight and above waist level at all times, and touch nothing that isn’t itself sterile, all surfaces must be keep dry, etc. With hands in this stilted position, the doctor and scrub nurse must each don a sterile “doctor’s” gown and surgical gloves (while the circulating nurse tied their gowns, as scrubbed hands can’t go behind the body or out of sight). One of the most “special” aspects of birth as a surgical procedure was the special location designed for the surgical procedure of “delivery” -- an operating or ‘delivery’ room itself. The operating room of an acute care hospital functions under special rules, which included restricted access and the ability to maintain sterility of the environment (no cloth or other type of porous surfaces, sealed flooring, etc) and non-sparking electrical equipment. It also required very special furnishings -- stretcher, operating table, operating room lights, instrument table, surgical instruments, drugs, equipment cabinets, oxygen, anesthesia machine, etc. Next was the need for a special OR staff -- circulating nurse and “scrub” nurse, other assistants and on occasion, specially trained nursery nurses and the most “special people” of all -- licensed physician-surgeons as obstetrician, anesthesiologist and sometimes a pediatrician. Physicians and physician-extenders (Physician Assistants or certified nurse midwives acting under the authority of an MD) were (and still are) the only people with the special technical skills and legal authority to provide surgical procedures of any kind, including normal childbirth defined as a surgical event. The special role for the mother relative to a surgical ‘delivery’ was to be especially passive, compliant, horizontal, pushed thru space on a conveyance such as a stretcher or special type of intensive care bed. In order for the doctor to properly perform the ‘delivery’ the mother had to be positioned on a operating room table (or specially equipped bed) in lithotomy stirrups. She would be naked from the waist down, with her buttocks hanging slightly off the table over empty space. This unstable position on the delivery table required special restraints -- the mother’s arms were confined by leather cuffs at each side so she wouldn’t fall off the high narrow delivery table or touch any of the sterile drapes, her legs were strapped into the lithotomy stirrup on each side of the table. Since these all these surgical functions were strictly segregated from the public, the very architectural design of the hospital was deeply changed by this re-defining of care for normal childbirth. Birth as a surgical procedure meant that women labored in a different setting and under different conditions than they “delivered”, hence the now familiar expression “the Labor and Delivery Room”. What had been an integrated maternity ward (with mother’s laboring, giving birth and recovering in the same place) was now divided into four separate classifications – (1) labor room, (2) operating/delivery room, (3) postpartum hospital room for the new mother, (4) nursery care for the new baby. The childbearing woman (and eventually her baby) experienced musical beds and conveyances as she went by wheelchair from hospital admitting desk to her labor bed, then by stretcher to the delivery table, by stretcher again to a recovery room or temporary holding area until she regained consciousness and then she was rolled out via stretcher to her to postpartum bed. During this time her baby had already been sent to the nursery to reside for several days in a cot (or incubator). Needless to say, this plethora of specialty arrangements added greatly to hospital overhead and thus greatly increased the basic cost of maternity care. Patients (or third party payors) were billed for the special staff and surgical environment by the quarter hour and for the patient room and nursery by the day. These special services also provide an excellent opportunity for professionals to charge a very handsome fee for the advanced technical skills associated with the surgical procedure of ‘delivery’. Fast Forward --> Childbirth in the Year 2003
While the use of twilight sleep and general anesthesia is rare today, the contemporary obstetrical standard in the United States is still a surgical model for normal childbirth, with a philosophy and a style of care remarkably faithful to the 1910 model, only now days we usually bring the delivery room to the mother through surgically equipped LDR rooms that have special (and especially expensive) motorized labor beds which turn into a waist-high delivery “table” with stirrups at the press of a button.
Epidurals have replaced general anesthesia but childbearing women are still required to be NPO (no food or drink) with the exception of ice chips and they are still immobilized in bed during labor. The 21st century woman is now held hostage in bed by the ½ dozen (or more) the medical devices that she is hooked up to -- IV fluids and Pitocin administration equipment, 2 continuous electronic fetal monitoring leads, epidural anesthesia catheter and administration pump, automatic blood pressure cuff, Foley catheter, pulse oximetry, and for many, an oxygen mask when the inevitable signs of fetal distress are noted, the frequent result of a supine position and the depressive effect of multiple drugs.
Obviously maternal mobility, right use of gravity and other aspects of physiological management are still not a recognized part of obstetrical care. Meeting the social and psychological needs of the mother are still not acknowledged to have any real importance in regard to safe, satisfying and non-surgical outcomes.
The physician is still the “captain of the ship” and the nurse is still a “borrowed servant”, loaned to the physician by the hospital as his assistant. The labor room nurse is out of the labor room 79% of the time, serving the “system” instead of the mother. According to this study of L&D nursing, only 6% of the nurse’s time is devoted to the personalized care of the mother.
Normal childbirth is still conducted as a ‘surgical procedure’ (complete with a surgical billing code that charges by the quarter hour) that must be performed by and billed for by a licensed physician (or physician extender). It is still the nurse’s job to keep the mother from pushing so that the baby will not be born spontaneously before the physician arrives, as the doctor can’t bill for the surgical procedure of ‘delivery’ if he wasn’t scrubbed in and the hospital can’t bill for the nurse’s services as a birth attendant since she is not a licensed practitioner. This makes an “easy” birth a big problem for everyone but the new mother.
Unless her baby is born precipitously before the doctor arrives, the mother is still expected to be prone and passive during delivery, which is assumed to be accomplished by the doctor while the mother lies on her back in some version of a lithotomy position. The physician will still be “scrubbed in” and wearing a surgical gown, scrub cap, shoe covers and face mask (with splash guard), with ready access to an array of gleaming surgical instruments at his side. And the mother still assumes, for the most part, that she could not have ‘done it’ without the physician’s advanced technical skills and thus is grateful to the doctor for ‘delivering’ her. And as soon as the physician puts in the last stitch, removes his gloves and writes post-op orders, his/her official duties as a surgeon are completed and the mother’s post-delivery recovery will revert back to the nursing staff.~ The Final Frontier -- Safe Maternity Practices for the 21st Century ~ The last and most crucial question in regard to the issue of an “appropriate” standard of care is whether or not modern day obstetrics for healthy women is a “superior” system that rightly displaces the traditional practice of midwifery. If that be the case, obstetrically-based practice would logically replace the non-medicalized from of care used by midwives and thus the obstetrical profession would have earned the right to define the “appropriate” standard of care for California licensed midwives. There are two excellent, well-respected sources that we may turn to for an objective determination on this question. The first is a scientifically researched publication known as ‘A Guide to Effective Care in Pregnancy and Childbirth’ and the second is a survey of contemporary maternity care practices entitled “Listening To Mothers” that was commissioned by the Maternity care Association of New York City and conducted by Harris Poll Interactive.
(1) The determination of scientifically predicated, evidence-based practice parameters is based on the published work of Drs Ian Chalmers and Murry Enkins, the bible of evidenced-based maternity care entitled ‘A Guide to Effective Care in Pregnancy and Childbirth’(GEC). It is a compilation of all pregnancy and childbirth related studies published in the English language in the last 30 years.
The Guide to Effective Care identifies six levels effectiveness/efficacy, ranging from the positive end of ‘clearly beneficial’ (category 1) to the negative end (category 6) of ‘likely to be ineffective or harmful’. Using the preponderance of available evidence, Drs Chalmers and Enkins rated each ‘standard’ maternity-care practice and regularly used medical/ surgical interventions for safety and efficacy. Based on these categories, the G E C cautions that:
"Practices that limit a woman's autonomy, freedom of choice and access to her baby should be used only if there is clear evidence that they do more good than harm"
"Practices that interfere with the natural process of pregnancy and childbirth should only be used if there is clear evidence that they do more good that harm"
As measured by the 6 categories established by Guide to Effective Care, the “standard of care” presently provided by obstetricians is extremely discordant when measured by scientific principles (both in practice and in interpretation of scientific studies) and evidence-based practice parameters. Contemporary obstetrics reverses the recommended safe practices, with those identified as most beneficial and least likely to cause harm (List #1) being the last or least used and those identified as most likely to be ineffective or harmful (List #6) being the primary or routinely used methods. This vastly increases the number of medical and surgical interventions used and the complications occurring, both immediately and downstream.
(2) “Listening to Mothers: Report of the First National US Survey of Women’s Childbearing Experiences” by the Maternity Center Association ~ October 2002, as conducted by the Harris Interactive Polling Service. This is a survey of healthy mothers with normal pregnancies (no premies, multiple gestations, no sick mothers) who gave birth in the last 24 months. The full report (some 60 pages long) is available on the Internet at www.maternitywise.com).
Our second source is an important national survey from an impeccable source -- the well-respected Maternity Center Association (MCA) of New York City, a non-profit organization established in 1918. It promotes safer maternity care and develops educational materials for expectant parents on ‘evidenced-based’ maternity practices -- that is, policies that are based on a scientific assessment of the safety and effectiveness of commonly used methods and procedures.
The Maternity Center Association documented a significant gap between scientific evidence and standard obstetrical practice. Healthy, low-risk women in the United States often receive maternity care that is not consistent with the best research. According the MCA, many people are not aware of the following major areas of concern:
~ The under-use of certain practices that are safe and effective
~ The widespread use of certain practices that are ineffective or harmful
~ The widespread use of certain practices that have both benefits and risks without
enough awareness and consideration of the risks
~ The widespread use of certain practices that have not been adequately evaluated for
safety and effectiveness
According the MCA's ‘Listening to Mothers’ survey, the majority of childbearing women did not receive the safer and more satisfactory type of care delineated in the top 3 categories (those established as beneficial) and instead were exposed to a plethora of practices in the bottom 3 categories which were rated as of unknown or unproven effectiveness, unlikely to be effective or known to be harmful.
This document notes that in the last 24 months there were virtually NO ‘natural’ births occurring in hospitals. This entire population of childbearing women was subjected to one or more major interventions. The only women who had a normal birth without medical or surgical interventions were those who had their babies in a domiciliary setting – home or free-standing birth centers.
The basic stats for healthy women reflect the following routine medicalizations of normal birth:
93% continuous electronic fetal monitoring;
86% IV fluids and denial of oral food and water;
74% immobilized or confined to bed due to physician preference,
hospital protocols or the limitations imposed by multiple medical
devices (EFM, IVs, epidural catheter, Foley bladder catheter, etc);
71% push and deliver with mother lying flat on her back;
67% artificial rupture of membranes;
63% epidural anesthesia,
63% Pitocin induced or accelerated uterine contractions;
58% gloved hand inserted up into the uterus after the delivery
to check for placenta or remove blood clots;
52% bladder catheter;
24% Cesarean delivery (12.6% planned/12.4% in labor;
11% operative – one-half forceps the other half via vacuum extraction.
In a population that was essentially healthy (95% +/-), an astounding 55% of women had some form of surgery performed – episiotomy, forceps, vacuum extraction or Cesarean section. Using the classical definition of operative delivery (CS+ forceps/vacuum extraction) the rate for 2002 for California would be 38% or 2 out of five or twice the operative deliveries reported by physicians in the early 1900s who merely performed operative procedures on one out of five.
Please note these statistics are for healthy women at term with normal pregnancies. Intervention rates would be much higher for women with premature labor, multiple pregnancies or frank medical complications.
The finding of Maternity Center Association survey are consistent with data from the CDC’s National Center for Health Statistics Vol. 47, No 27, The Use of Obstetric Interventions 1989-97, which documents a steady annual increase since 1989 in each of these interventions. A press release dated June 6, 2002 based on the NCHS report “Births: Preliminary Data for 2001”; NVSR Vol. 50, No. 10. 20 pp. for the year 2001 http://www.cdc.gov/nchs/releases/02news/birthlow.htm), documents a 24.4% CS rate. Statistics for the year 2002 show an even higher Cesarean rate – 26.1 in the US and 26.8 in California.
Childbearing women are three times more likely to die from the immediate operative, post-operative or downstream complications of Cesarean surgery than from normal vaginal birth. These dangers don’t go away with the mother’s successful recovery from surgery as potentially-lethal problems and difficulties extend into the immediate postpartum period, post-cesarean reproduction and post-cesarean pregnancies, labor and birth.
Following Cesarean delivery there is an increased rate of serious postpartum depression, low self-esteem and breastfeeding failures. Complications of post-cesarean reproduction include a higher rate of infertility, tubal pregnancies and miscarriage. (Ob.Gyn.News ‘Elective C-Section Revisited’ Dr. L. Elaine Waetjen; August 1 2001 • Volume 36 • Number 15) Babies in post-cesarean pregnancies suffer a higher rate of fetal demise and stillbirth. (Ob.Gyn.News ‘C-Section Linked to Stillbirth in Next Pregnancy’ May 15 2003 • Volume 38 • Number 10) Mothers in post-cesarean pregnancies face a significant increase in placenta previa and placenta percreta (abnormal growth into the wall of the uterus) as well as uterine rupture, emergency hysterectomy and the need for extensive blood transfusions (Ob.Gyn.News Vol 36, Aug 1, 02). The rate of emergency hysterectomy within 14 days of giving birth is 13 times higher for women delivered by Cesarean surgery. (Obstet Gynecol. 2003 Jul;102 (1):141-5. Route of delivery as a risk factor for emergent peripartum hysterectomy)
These delayed and down-stream complications elevated mortality in post-cesarean pregnancies -- 10% for women who develop placenta percreta and about 1/2% for newborns. The risks of Cesarean rise with each successive surgery as the operation becomes more technically difficult as a result of surgical adhesions. (Ob.Gyn.News Vol 36, Mar 1, 01 & Vol 36, Sept 15, 01; Elective Cesarean: An Acceptable Alternative to Vaginal Delivery? Peter Berstein, MD, MPH).
By contrast, only 10% of the healthy women with normal pregnancies who choose home-based midwifery transfer to obstetrical hospital care during labor. The over-all Cesarean rate for mothers who planned a homebirth is about 4% with approximately 2% forceps or vacuum extraction. [Outcomes of Planned Home Births in Washington State" by Dr Pang, MD et al, ACOG journal, August 2002] This means nine out of ten women deliver naturally at home without the risks of the medical and surgical procedures listed above and without fear of downstream complications, which can cast a dark shadow over a future pregnancy. The protective nature of physiological care is one of the most important reasons people seek out community-based midwifery. Letters to Editor, ACOG Green Journal (Obstetrics and Gynecology) Jan 2003; Safety of Alternative Approaches to childbirth – PhD – Stanford University, Dr. Peter Schlenzka, 1999
The Maternity Center Association’s recommendation was for “more physiological and less procedure-intensive care during labor and normal birth”. The beneficial practices identified by the Guide to Effective Care are protective and reduce medical and surgical interventions, At present these are absent for the majority of women giving birth in this country under obstetrical management. These helpful practices are based on the physiological management of labor and birth, which requires a respect for the normal biology of reproduction and a commitment not to disturb that natural process. The elements of success for normal labor and spontaneous birth are the same for home or hospital and include the tried and true methods of non-pharmaceutical pain management and promotion of a spontaneously progressive labor.
Tort Law – One Size Does Not Fit All
Due to the restriction of tort laws on individual physicians, doctors cannot independently implement common sense recommendations as provided by the MCA or the Guide to Effective Care. At present, obstetricians are forced to provide care that is of the same quality as is the statistical norm for other obstetricians, even when that institutionalizes sub-optimal care as the 'standard.' As can be seen from these numbers, the majority of doctors impose a daunting array of interventions that are (to quote the authors of the G.E.C, p. 265) ‘ineffective, inefficient or counter-productive,’ while failing to use many measures that have been documented to shorten labor, increase the mother’s satisfaction and self-esteem while reducing the frequency and severity of postpartum depression. According to the tenets of tort law, what constitutes the ‘standard’ is initially established by the profession itself (as reflected in contemporary ACOG policies) and the numerical majority of practices used by obstetricians which establish the “customary practice”. Illogical as it sounds, failure to utilize these harmful interventions is to provide ‘substandard’ care according to the conventions of tort law.
Practically speaking, what this means is that childbearing women who are strongly committed to a spontaneous labor and a ‘normal’ birth and/or wish to avoid the ‘ineffective, counter-productive or harmful’ methods of medical management must go outside the obstetrical care tort system. Unless or until A_COG changes its formal policies which currently define medicalized birth as the official "standard of care" for obstetricians, physicians are no more able to comply with the mother’s unique request for physiological (i.e., non-medical) management any more than an airline pilot or bus driver can permit a passenger to change the course of the company’s scheduled travel or otherwise take exception to company protocols.
In response to the constraints placed on physicians by tort law as it pertains to obstetrical practice, a small number of childbearing women purposely choose to contract with non-physicians to provide non-medical, physiologically-based care as provided under the midwifery model of care. Tort law as it pertains to the competence and due diligence of the professionally licensed midwife would be determined by the historical standards applying to the distinct calling of community-based midwifery.
The basic problem with the current form of obstetrical care in the US is the uncritical acceptance of an unscientific method – medically interventionist care for healthy women with normal pregnancies and normal birth as something to be 'performed' by physician-surgeons as a surgical procedure. The consequence of a hundred years of faulty assumptions about normal birth is the dysfunctional aspect of so-called ‘modern’ obstetrics. This has produced a 21st century version of a medical Dark Ages -- Flat Earth Obstetrics -- in which contemporary medicine has forgotten or ignored the traditional knowledge base and physiological principles necessary for normal labor and safe, spontaneous birth. The routine interference in normal labor has so disturbed the natural process that “failure by design” is the result. Given the faulty design of obstetrical care, abnormal labors can be anticipated for the majority of healthy women. The high number of dysfunctional labors associated with medicalization reinforces society’s false assumption that our normal biology is defective and medical interventions are necessary all the time.
And yet all reliable sources – historical and contemporary science both – tell us that the medicalization of normal childbearing always adds unnecessary and abnormal dangers to normal childbirth in a healthy woman. The opposite of medicalization --physiological management -- is actually protective for mothers and babies as it reduces the operative delivery rate from approximately 37% (70% when episiotomy is included) to under 5%. This reduces immediate and long-term complications that are associated with surgical delivery. Interventionist obstetrics for a healthy childbearing population with its 37% operative rate, is neither safe nor cost effective.
While the history, politics and circumstance of this issue is complex, the important questions are simple and straight forward:
Why does the obstetrical profession consistently fails to teach, learn or utilize physiological management for healthy women?
Why does A_COG promote the risky procedure of ‘maternal choice’ Cesarean as safer and better than normal birth?
Why doesn't A_COG define physiological management as the official standard of care for healthy women?
Why, when provided with corrective information, does the obstetrical profession consistently fails to take corrective action?
Why doesn’t the American public realize that the basic creed of medicine -- “In the first place, do no harm” -- is no longer being advocated by many leaders in the obstetrical profession?
Addendum – (1) Pertinent Historical Background in Three Parts
(2) “Remarks on the Employment of Females as Practitioners in Midwifery” - 1820
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