Dr. Joyce Brothers
C/O King Features 888 Seventh Ave.
New York City, New York 10019.
RE:
August 9, 2003 ~
“Home birth deserves careful consideration”
Link to
Citations
Critique of Broader Issues
in Obstetrical Care
~ The Final Frontier -- Safe
Maternity Practices for the 21st Century ~
Families
do not seek out home birth because they are indifferent to the safety of
their babies. Quite the contrary. Healthy families choose home-based care
from midwives because it is virtually impossible to get the type of care
they deserve and that is safest -- normal or “physiological” management
of spontaneous labor and birth -- from hospital-based obstetrics.
Our
tort law system, which is 100 years out of date, requires that normal labor
be managed by physicians as a medical condition and childbirth be conducted
or "performed" by obstetricians as surgical procedure. This
prevents medical institutions from utilizing 'normal' or physiological
management. Normal (i.e., non-medical) care is associated with the best
maternal-infant outcomes and, except for obstetrically-dominated areas of
North America, it is the type of care provided around the world by
physicians and midwives in hospitals, homes and birth centers with excellent
results.
In
contrast, organized medicine in the US has prejudiced the issue of safety in
maternity care by distracting us with the rhetorical question “is home
birth safe?” The science-based answer is a resounding “yes” but only
one-half of one percent of women choose this “alternative.” Ninety-five
percent of women want or need to deliver in the hospital. For the last
century this false focus on midwifery has prevented us from looking closely
at the really important question: “Is
our medicalized form of obstetrical care, which defines normal childbirth as
a ‘surgical procedure,’ safe
and appropriate for healthy women with normal pregnancies?”
I
began my professional career as a Labor & Delivery Room nurse in the
1960s. I have
been a close observer for more than 40 years of the struggle by healthy
women to have control over the manner and circumstances of their normal
births. We have gone from the “knock’em out, drag’em out” obstetrics
of the 60s, which included twilight sleep,general anesthesia, episiotomy and
forceps delivery (with a Cesarean rate of only 4%) to the different but equally interventionist style of the last two decades. Now more than
50% of labors are routinely accelerated with Pitocin. Epidural anesthesia is
the new standard. Otherwise normal pregnancies often culminate with
operative delivery -- episiotomy and forceps or vacuum extraction, and
cesarean section. Far too many otherwise healthy babies spend days in the
neonatal intensive care unit as a result. The bill for this interventive
style of care is enormous and yet we still are not getting the safest care.
Cesareans
are now performed for 26% of all U.S. births. Childbearing women are three
times more likely to die from complications of this major abdominal surgery
than from normal vaginal birth. But the problem doesn’t stop there.
Post-cesarean complications include increased rates of infertility, tubal
pregnancies, miscarriage, stillbirth, placenta previa, placenta percreta
(abnormal growth into the wall of the uterus), placental abruptions, uterine
rupture, emergency hysterectomy and the need for extensive blood
transfusions (Ob.Gyn.News
Vol 36, Aug 1, 02, enclosed).
In the last couple of years the obstetrical profession has been promoting
the “maternal-choice cesarean” as safer and better than normal birth (Dr
Ben Harer, past president of American College of Obstetricians, Good Morning America interview, Jun 2000); it is a
warped idea of safety that discounts these many long-term complications.
This includes increased mortality in a post-cesarean pregnancy -- 10% for
women who develop placenta percreta and about 1/2% for newborns. The risks of Cesarean rise with each successive surgery.
(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).
For healthy women with normal pregnancies who choose
home-based midwifery only 10% will want or need interventive obstetrical
care during labor. The over-all Cesarean rate for mothers who planned to
labor and give birth at home is about 4% with approximately 2% forceps or
vacuum extraction. This means nine out of ten women deliver naturally at
home without the risky medical and surgical procedures listed above and
without the downstream complications that can cast a dark shadow over a
future pregnancy. The protective nature of home-based care is one of the
most important reasons people are attracted to out-of-hospital 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
As a professional midwife and spokesperson for the
California College of Midwives, people may assume that I am biased. So let
me tell you about two excellent, well-respected sources that we may turn to
for objective information on this topic. 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 Center Association (MCA)of New York City and conducted by Harris
Poll Interactive.
Maternity Center Association is a well-respected
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 determination of scientifically predicated,
evidence-based practice parameters is derived from the published work of Drs
Ian Chalmers and Murray Enkins. 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 and
is regarded as the bible of evidence-based maternity care.
Resource
1: The Guide to Effective Care
identifies six levels of 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 GEC
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” currently
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.
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.
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 findings 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.” Nornal Vaginal Spontaneous
Delivery 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, labors and births.
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, that negatively influence 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 helpful practices are absent for the majority of women
giving birth in this country under obstetrical management. Safe and
beneficial 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.
While
physiological management of labor reduces the requests for pain meds or
epidural anesthesia, it does not mean that hospitalized mothers cannot
receive pharmaceutical analgesia. The only down-side of
physiologically-based care is that hospitals can’t bill as much for the
nurse’s or midwife’s professional services as they can for medical or
surgical procedures preformed
by physicians. This means that normal birth is not as profitable to the
medical establishment. In a tight economy like ours, the cost savings from
normal or “non-medical” management should be turned into a plus.
In
particular, the obstetrical community’s 30-year romance with continuous
electronic fetal monitoring (EFM) should be carefully scrutinized. According
to the summary of Neonatal Encephalopathy and Cerebral Palsy by the ACOG
Task Force on brain damage and cerebral palsy, page 4:
Since
the advent of electronic fetal heart rate monitoring, there has been no change in the incidence of cerebral palsy.
Abnormal fetal heart rate patterns have a high
false-positive rate and are poor
predictors of the subsequent development of cerebral palsy. … A low
5-minute Apgar score is a poor
predictor of later neurologic dysfunction and cerebral palsy.
Approximately 75% of children
with CP have normal Apgar scores at
birth.
For
example, a prominent obstetrician researcher on continuous EFM acknowledged
that a thousand laboring women
have to have continuous EFM applied to their entire labors to save one baby from fetal distress and neurological damage.
Electronic fetal monitoring of 1,000 women would increase the CS rate by
approximately 100 additional
surgeries
[ObGynNews Vol 36, 11-15-01 Dr. Anthony Vintzileos, MD].
Another
obstetrician-expert calculated that a physician would have to perform 500
Cesareans section based on non-reassuring EFM patterns to prevent a single case of cerebral palsy. However, he
acknowledged that the long term consequences and complications of those 500
surgeries would be at least one case of cerebral palsy in a subsequent
pregnancy, as well as serious, potentially fatal, complications for these
mothers. As he put it
“Performing
CS for abnormal FHR patterns in an effort to prevent cerebral palsy is
likely to cause at least as many bad
outcomes as it prevents”. [Dr Gary Hankins, MD; ObGynNews 4-15-02, Vol 37].
Listening
to fetal heart tones with an electronic Doppler or hand-held stethoscope every
half hour for one full minute immediately after a contraction (called
Intermittent auscultation or ‘IA’) is equally effective as continuous
EFM, with a greatly reduced CS rate. Thankfully, intermittent
auscultation (IA) unhooks healthy mothers from machines and replaces
faceless electronics with the warm hand of a friendly helpful nurse or
midwife. Equally important, it makes physiological management possible as it permits laboring women
to move around, change positions frequently, walk, use showers or deep water
for pain relief and make “right use of gravity” to reduce the need for
Pitocin, anesthesia and operative delivery.
Organized
medicine complains that Intermittent Auscultation is “impractical as it
requires one-on-one nursing care” and that it “isn’t being taught any
more.” (ObGynNews
Vol 37, Oct ½].
Of course, doctors could teach or use IA if they wanted to. They don’t.
The dirty little secret is that
hospitals bill at $400 an hour for
continuous EFM, which applies to the entire five to 40 hours of labor
for the 3,790,000 women who give birth in hospitals each year (93% of annual
births). That makes it a cash cow, as
it is the single most frequently used intervention in normal birth.
EFM’s only consistent contribution to maternity care is to elevate the
Cesarean section rate.
So
dare I suggest that your newspaper consider devoting time and space to an
inquiry on why the majority of childbearing women do not receive the safer
and more satisfactory type of care established as beneficial in the Guild to Effective Care and recommended
by the Maternity Center Association? Laboring women are instead routinely
exposed to a plethora of practices in the bottom three categories rated as of
“unknown or unproven effectiveness, unlikely to be effective or known to
be harmful.”
Can
we count on your paper for a thoughtful, unbiased inquiry into this
important topic? This scandal is hidden in plain sight, impatiently awaiting
the application of common sense. The documentation is massive and impeccable
and traces from the early 1900s to this new millenium. Do you perhaps have a
bright ambitious reporter on your staff that is looking for a unique
opportunity to investigate something of great importance to society, someone
who wouldn’t mind being recommended for a Pulitzer Prize in investigative
journalism?
Faith
Gibson, LM, CPM
Executive Director,
California
College of Midwives, State Chapter,
American College of Community Midwives
3889 Middlefield Road
Palo Alto, Ca 94303
650 / 328-8491