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Updated ~ Wednesday February 16, 2011 01:34

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Consortium for the Evidence-base practice of Obstetrics
C.E.O. is dedicated to bringing science-based maternity care to all childbearing women
and promoting public debate on our national maternity care policy

Preserving the health of already healthy mothers and babies is the primary role of maternity care.

Flat earth obstetrics is the belief that medical and surgical interventions are
 necessary in every normal childbirth, despite evidence that such a policy is harmful.
The term is derived from the insistence by religious and political leaders during 
the Dark Ages that the earth was flat despite evidence to the contrary. 

a thousand letters in a hundred days  To MAria Shriver
Letter-writing campaign starts on Mothers' Day,
May 9th, 2004 thru August 19th, 2004

"Motherhood ~ 24/7 on the front lines of humanity.
Are you man enough to try it?" - Maria Shriver

 Printer-Friendly PDF ~ appreciated Instructions & Address for Mothers' Day letters

Reading time approximately15-20 minutes

Assume as a given that no one in the obstetrical profession is purposefully making childbirth hard for women. Medicalized childbirth is well intentioned.  However, interventionist obstetrics does not acknowledge the normal biology of spontaneous childbearing nor meet the practical needs of healthy women and their babies.  

Problem: The uncritical acceptance of an unscientific premise -- surgical obstetrics for normal childbirth in healthy women with normal pregnancies

Solution: A science-based care maternity based on physiological management --  safe, cost-effective and mother-baby-father friendly. This would result in a single, evidence-based standard for all healthy women used by all maternity care providers -- family practice physicians, obstetricians, and professional midwives.

Physiological: …"..in accord with, or characteristic of, the normal functioning of a living organism”
                                                 (Stedman’s Medical Dictionary definition of “physiological” – 1995)

The scientific basis for physiological management of  pregnancy and normal childbirth is supported by a consensus of the scientific literature. Physiological management is actually protective for both mothers and babies, reducing the episiotomy / operative delivery rate (and associated complications), from approximately 72% to approximately 5% with an identical, or even slightly improved perinatal mortality rate. It is efficacious -- that is, both safe and cost effective.

In order to bring science-based maternity care to all childbearing women, we must bring an end to "flat earth obstetrics". True mastery in normal childbirth services means bringing about a good outcome without introducing any unnecessary harm. Interventionist obstetrics is an  “expert” system that has failed most in the very area it was supposed to have the most mastery and expertise -- "the optimal conduct of the many normal cases".

Our present system of obstetrics for normal childbirth does not do well in this regard. The scientific literature -- vital statistics records, textbooks and published research -- all make it clear that routine obstetrical interventions and conducting normal birth as a surgical procedure are more dangerous for healthy women than the use of normal or 'physiological' principles.  

For the last century, an unscientific form of Interventionist obstetrics has dominated maternity care in the United States, to the detriment of childbearing women and the taxpaying public. In spite of spending more money that any other country in the world, the United States is 30th in maternal mortality and 22nd in perinatal mortality. The five countries with the best outcomes spend only a fraction of the money we do. They all have national maternity care policies that depend on physiological management.

In the US, organized medicine has purposefully dismantled the infrastructure for providing physiologically-based maternity care over the last hundred years and replaced it with interventionist obstetrics. Medical and surgical interventions originally intended to treat life-threatening complications are routinely used on healthy women with normal pregnancies, without having been proven safe or more effective than physiological management. This unregulated medical experiment introduces artificial risk and serious complications. In the last three decades the medicalization of childbirth has expanded exponentially. Institutional memory of "normal" childbirth is now absent for obstetricians, the nursing profession and medical educators.

Defensive medicine rules the day. This creates an asymmetrical burden of risk that falls unfairly on the childbearing woman, in which the mother is exposed to the actual pain and potential harm of medical and surgical interventions in order to reduce the risk of litigation for the obstetrician. Premature and/or artificial termination of normal pregnancy by induction, surgical incisions, instruments or cesarean section has become the statistical norm. Childbirth for healthy women in 21st century America is typically accompanied by the routine use of continuous electronic monitoring (93%), inducing or speeding up labor with artificial hormones (63%), epidural anesthesia (63%), episiotomy, instrumental delivery and/or cesarean surgery (72%). 

Obstetrical medicine rejects out of hand the "social" model of childbirth used world-wide to the great advantage of childbearing families. While publicly promoting itself as virtuous beyond compare, the obstetrical profession is frequently disrespectful and dismissive of the concerns of childbearing women and their families. It does not provide truly informed consent and resorts to threats of legal force if parents do not quickly comply with obstetrical advice for risky medical and surgical interventions that frequently turn out to be unwarranted.

The obstetrical profession has recently begun promoting the 'maternal choice', or medically unnecessary cesarean as the ideal form of childbirth. Scheduled surgery permits the practice of 'daylight obstetrics' while maximizing the physician's time and economic compensation. Many doctors predict that within the next 10-15 years, scheduled cesarean delivery will replace spontaneous vaginal birth as the obstetrical standard. Unfortunately, this major abdominal surgery is also associated with a 2 to 4-fold increase in preventable maternal deaths and many delayed or 'downstream' complications..

Maternal mortality associated with vaginal birth is rare -- only one out of 16,666. To put this number in perspective, auto accident fatalities for women of childbearing age are one out of 5,000, so it is more than 3 times safer to give birth normally than to travel in a car. However, when cesarean sections are performed, the maternal death rate jumps to 1 out of 3,225 or six times more dangerous than normal vaginal birth.

To put elective cesarean in perspective, consider that terrorist-related deaths for Israeli citizens is only one per 10,000, making scheduled cesarean surgery three times more dangerous to childbearing women than living in the midst of the Israeli-Palestine conflict and 6 times more dangerous than normal birth. In addition, there are serious, sometimes fatal problems for babies delivered by cesarean, such as surgical lacerations, surgery-related prematurity and respiratory distress.

To assume that normal biology is itself dangerous is a serious misunderstanding of normal childbearing. This regrettable attitude by the obstetrical profession culminates in the politics of the 'pre-emptive strike' and the hair trigger. For healthy women, the greatest risk associated with normal labor and birth is not the rare unpreventable complication of normal biology but the frequent preventable complications stemming from the routine use of electronic monitors, IVs, immobilizing laboring women in bed, routine use of uterine stimulants to accelerate labor, narcotics, anesthesia, surgical procedures and surgical instruments. Obstetrical intervention makes normal childbirth into a war zone for healthy women and their babies.

Instead of the "optimal conduct of the many normal cases" as proclaimed by the obstetrical profession as its forte, interventionist care routinely exposes healthy mothers and babies to unnecessary physical and mental suffering and increased rates of preventable death and disability. A medical care system that over treats three-quarters of its patients (3 million each year) is both expensive and dangerous. For a profoundly wasteful and dysfunctional system, obstetrical reformation is long overdue.

Consider this: If planes landing at US airports crashed  five times more often than when they landed at airports in England, Japan or Sweden, we would demand an inquiry of our air traffic control system, since the laws of aerodynamics are the same worldwide. Each year in the US about 8 million mothers and babies 'fly' the united service of interventionist obstetrics. Only a fraction -- under  30% -- need and benefit from highly medicalized obstetrical management. Isn't it time to inquire why the universal 'laws of normal childbirth,' which are the same worldwide, are being routinely suspended by American obstetricians and, as a result, American mothers and babies are crash landing at an alarming rate?   

The Better Way: Evidence-based Maternity Care

Preserving the health of already healthy mothers and babies is the primary role of maternity care. Approximately 70% of pregnant women in the United States are healthy and have normal pregnancies. That is about 3 million normal births annually.

Physiological principles provide the safest and most cost-effective form of maternity care. According to the World Health Organization (WHO), it is the preferred standard for healthy women. WHO refers to this as the "social" model of childbirth. In the US, it known as "family-centered" or "mother/ baby/ father-friendly" maternity care.

These protective and preventive methods include a commitment not to disturb the natural process. This minimal-intervention approach includes continuity of care, patience with nature, one-on-one social and emotional support, non-drug methods of pain relief and the right use of gravity. Obstetrical intervention is reserved for complications or if the mother requests medical assistance.

The scientific basis for physiological management of  pregnancy and normal childbirth is supported by a consensus of the scientific literature. Physiological management is actually protective for both mothers and babies, reducing the episiotomy / operative delivery rate (and its associated complications), from approximately 72% to approximately 5% with an identical, or even slightly improved perinatal mortality rate.

Reliable scientific evidence establishes physiological management as the safest and most cost-effective form of maternity care. Scientifically-speaking, this is not a controversial finding. The scientific literature is neither lacking nor incomplete, nor the subject of methodological disputes. To become familiar with this body of knowledge is to redefine the politics of this controversy. The real question is how best to care for healthy women with normal pregnancies. The choice is between 'more of same' --- the ever-escalating, ever-more-expensive model of obstetrical intervention --- or actively engaging the public in the reformation of our maternity care policies and rehabilitation of obstetrical practices.

Purpose and Plan:

For society, flat earth obstetrics is an economic issue. Most Americans are not directly affected by this dysfunctional system -- that is, we aren't presently expecting a baby and do not have to worry that we will become a casualty of over treatment. However, we are all negatively impacted by the economic damage resulting from artificially inflated maternity care costs. The current practice of obstetrics misdirects scarce economic and human resources that could more properly be used to treat the ill, the injured and the elderly. Seventy percent of maternity care expenses (equal to 2.4% of our total GNP) are artificially inflated by unneeded medicalization and preventable complications.

The bill for this failed medical experiment is passed on to the public and to employers through the increased cost of health insurance and the Medicaid tax burden. Economists identify our inflated health care costs (as compared to other countries) as a major reason why many industries are outsourcing manufactured goods and replacing service jobs with off-shore workers. This means that every American has a stake in reforming our maternity care policies so the United States can remain competitive in a global economy. Worldwide, the global economy depends on the use of physiological principles and low-tech, low-cost methods for providing normal birth services. To remain competitive in a free market economy, the US must also utilize these efficacious forms of maternity care to meet the needs of healthy families. 

Scientific, humanist and economic factors all call for the rehabilitation of obstetrics as it is applied to healthy women with normal pregnancy. This would make way for a science-based system -- maternity care that is safe, cost-effective, family-friendly and physiologically sound. A rehabilitated policy would integrate the classic principles of physiological management with the best advances in obstetrical medicine.  This would create a single, evidence-based standard for all healthy women used by all maternity care providers -- GPS, family practice physicians, obstetricians, and professional midwives.

Recovering of institutional memory & reestablishing physician expertise in physiological management: To create single, evidence-based standard for all practitioners would require the obstetrical profession to recover its institutional memory of normal childbirth and to reestablish physician expertise in physiological management and socially-based childbirth services. In a rehabilitated maternity care system, physicians who provide care to a healthy population would be required to either:

• utilize the successful strategies of physiological management themselves

• cede the care of healthy women to those who do,

• or obtain truly informed consent for substituting medicalized obstetrical care with its well-documented dangers

Fully informed consent would require true transparency relative to the documented consequences of medicalized labor and normal birth conducted as a surgical procedure.  Scientifically correct information must be routinely provided to healthy women on the short and long-term limitations and complications resulting from the medicalization of labor – i.e., drugs, anesthesia, and medical interventions and procedures that abnormally limit mobility or confine the laboring women to bed. The benchmark for transparent informed consent should be this same level of information about complications that is reported to physicians in the scientific literature and obstetrical trade papers

Failure of EFM and CS to prevent cerebral Palsy: Informed consent as provided by obstetricians must identify the well-documented failure of continuous electronic fetal monitoring (EFM) and increased use of cesarean section to reduce the rate of cerebral palsy and other neurological disabilities. According to the scientific literature, there has been no change in the incidence of cerebral palsy since the advent of fetal heart rate monitoring. The increasing use of cesarean delivery triggered by worrisome fetal monitoring data has not resulted any reduction in the CP rate. In an attempt to identify babies at high risk for CP, a  non-reassuring heart rate pattern as picked up by EFM has a 99.8% false positive rate.  A physician would have to perform 500 C-sections for abnormal EFM tracings to prevent a single case of cerebral palsy."   

Management strategies determined by health status of the childbearing woman: Under a rehabilitated system, management strategies would be determined by the health status of the childbearing woman and her unborn baby in conjunction with the mother’s stated preferences, rather than by the occupational status of the care provider (family practice physician, obstetrician or midwife). At present, who the woman seeks care from (obstetrician vs. FP physician or midwife) determines how she will be cared for. This illogical situation must be corrected.

Recognizing  and protecting the ethical and constitutional rights of competent adult women to have control over the manner and circumstances of pregnancy and normal birth.

Hospital labor and delivery units must be staffed by professional midwives to assures that physiological management remains the standard used by all practitioners and is taught to medical students. This system frees obstetricians from many "routine" duties, thus permitting them to be the highly trained experts their education prepared them to be. This plan will require economic incentives for current L&D nurses who wish to retrain for hospital-based midwifery practice to do so at minimal expense to themselves: 

Standard arrived at through an interdisciplinary process. This interdisciplinary process must include the traditional discipline of midwifery as an independent profession and must integrate the input of childbearing women and their families into the process. It is especially important to include testimony from those families who had complications following episiotomy, instrumental delivery or cesarean surgery or who found it virtually impossible to arrange for a subsequent normal labor and birth after a cesarean (VBAC).

Mutually respect: In the reformed or social model of maternity care system, professional midwives, family practice physicians and obstetricians would all enjoy a mutually respectful, non-controversial relationship.

The only way the healthcare system can meet the needs of our healthy childbearing population, while remaining competitive in the global economy, is to implement the social model for pregnancy and childbirth care as the basis for our national maternity care policy.

To implement our plan to end flat earth obstetrics and replace it with the social model of childbirth, we are embarking on a campaign to educate California First Lady Maria Shriver about this dismal state of affairs and ask for her help to reform our maternity care system.  We are starting this campaign on May 9th, Mother's Day.  

Our goal is a thousand letters in the next hundred days (thru August 17th).  Please read the document called "Instructions" (hyperlink below) for important additional information.

To access the scientific literature that is background or "proof of principle" for reforming of our maternity care policy, scroll down to the navigational short-cut immediately below.

To become a member of the Consortium, or a "designated ambassador", email your name or your organization's name to info@ScienceBasedBirth.com.

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a thousand letters in a hundred days !
Campaign starts on Mothers' Day, May 9th, 2004 thru August 19th, 2004

(3) Action Plan, instructions & mailing address for Maria Shriver

(3-b) Printer-Friendly PDF ~ purpose, instructions & address
for letter to First Lady Maria Shriver

(4) Archive of letters to California First Lady Maria Shriver 

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Navigational short cut to scientific Literature on these topics

Scientific Citations from obstetrical sources for Physiological Management  of Normal Labor & Spontaneous Birth		What Every Pregnant Woman Needs to know about Cesarean Section ~ 2004 Maternity Center Association
"Continuous labor support" — a systematic review finding important benefits and no known downsides		"Listening to Mothers" — for the first time, hear what women nationwide are saying about their childbearing experiences.
The Medicalizing of Normal Childbirth	Ultrasound Limitation  & Inappropriate Use of Sonogram Findings	Risks & Complications of Elective Induction	Episiotomies / Forceps / Incontinence
The Cesarean Connection & Electronic Fetal Monitoring	The Politics of Cesarean Surgery ~ what doctors are saying to each other	Cesarean Surgery ~ Immediate & Downstream Complications	Post-Cesarean Pregnancy, Abnormal Placentation & VBAC-related complications
Cytotec/misoprostal Complications & Deaths	Consequences of Epidural	(1)  Postpartum Depression ======================== (2)  Post Traumatic Stress Syndrome	Neonatal complication of maternal procedures / epidural fever, vacuum, CS
Step by step photos of Cesarean surgery	Photos demonstrating single versus double layer closure of cesarean incision	Technical problems of performing a repeat Cesarean	Photos ~ Forceps & episiotomy
Court Ordered Cesareans	General Information on Maternal Mortality	Index page for Maternal / Infant Deaths / Maternal Mortality Quilt Project organized by Ina May Gaskin
Safer Childbirth? M. Tew

 

Position Paper ~ May 9,Mothers' Day, 2004  (2) reading time 25 min

C.E.O White Paper 2004 (1) reading time 35 min Printer-Friendly PDF Version  of White Pager 2004

Click on the Picture to Return to Index Page

Bridal Vale Falls,
Yosemite, April 2004
www.ScienceBasedBirth.com

A-C.E.O ~ The American College of Evidence-based Obstetrics ~
For physicians who wish to re-establish the scientific foundation of  their profession
and reclaim their expertise in the use of physiological management for normal birth

Wednesday February 16, 2011 01:34