Scares Doctors? A: Hospital! --
TIME Magazine, Cover Story, May 1, 2006
Interview of Dr. Don Berwick, President, Institute for Healthcare Improvement (IHI) & expert in medical errors and other aspects of nosocomial.
Note: Two of the scientific papers cited below contain very good data but
and hard to read. In both cases, I have excerpted the most important information and included it with the citation link.
What Every Pregnant Woman Needs to know about Cesarean Section ~ 2004 Maternity Center Association - Childbirth Connection -- you can get a free download, but have to register, which is free
"EFM as a Public Health Screening Program: The Arithmetic of Failure" ~ by Dr David Grimes
Electronic fetal monitoring has failed as a public health screening program. Nevertheless, most of the
four million low-risk women giving birth in the United States each year continue to undergo this screening.
The false association between the routine use of continuous of electronic fetal monitoring (EFM) and high rates of Cesarean Section as a strategy to prevent Cerebral Palsy and other neurological damage -- citations from (
[a) Am. College of Obstetrician & Gynecologists (ACOG) Task Force on Neonatal Encephalopathy & Cerebral Palsy, 2003
[b) September 15, 2003 edition of Ob.Gyn.News; [c] and August 15, 2002 report in Ob.Gyn.News.
Cesareans not safe or effective for preventing pelvic problems:
Having identified that the ‘prophylactic’ use of Cesarean is unable to prevent cerebral palsy in babies, elective C-section is often promoted as a prophylactic procedure whose value lies in reducing pelvic floor problems later in the woman’s life. However, reputable research also does not support the use of elective Cesarean surgery as either a safe or a reliable method to achieve this goal.
In an article entitled “Elective Cesarean Section: An Acceptable Alternative to Vaginal Delivery?”, Dr Peter Bernstein, MD, MPH, Associate Professor of Clinical Obstetrics & Gynecology and Women's Health at the Albert Einstein College of Medicine, reported on the failure of the obstetrical profession to practice evidence-based medicine as it applies to this topic. Addressing the popular notion that pelvic floor damage and incontinence were the inevitable result of normal birth (to which cesarean surgery was the proposed remedy), Dr Bernstein observed:
“...these adverse side effects may be more the result of how current obstetrics manages the second [pushing] stage of labor. Use of episiotomy and forceps has been demonstrated to be associated with incontinence in numerous studies. Perhaps also vaginal delivery in the dorsal lithotomy position [lying flat on the back] with encouragement from birth attendants to shorten the second stage with the Valsalva maneuver [prolonged breath-holding], as is commonly practiced in developed countries, contributes significantly to the problem.” Click here for rest of article
Judging a System by its Results
Ultimately, a maternity care system is judged by its results
-- the number of mothers and babies who graduate from its ministration as healthy, or healthier, than when they started.
Medicalizing healthy women makes normal childbirth unnecessarily and artificially dangerous and is unproductively expensive. Our current system of routine obstetrical intervention for healthy women must be reevaluated and reformed. But unlike many of the problems facing us in the 21st century that defied our best efforts – curing cancer, ending terrorism, reversing global warming, figuring out how to afford healthcare, etc.,— we know what to do about this problem. The scientific literature clearly demonstrates that physiological management is the safer and most cost-effective form of care for a healthy population.
For many centuries, the normal, non-surgical care of pregnancy and normal birth has been called ‘maternity’ care. The origin of this word is ‘maternal’ and describes care organized around the needs of the mother and her strong desire to protect her unborn or newborn baby. One small step towards a more functional system would be to use the term maternity care instead of ‘obstetrical’ when providing care to healthy women during a normal pregnancy or childbirth. This simple correction would help everyone realize that childbearing is primarily about the mother and baby and not primarily about the professions or professionals that provide that care.
Efforts to rehabilitate our maternity care system must start by listening to childbearing women and their families as a class of experts in the maternity experience. Because physiological management has never been a part of obstetrical education in the US, medical educators must learn and teach the principles of physiological management to med students.
A newly formulated national maternity care policy would integrate physiological principles with the best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women. All categories of birth attendants would use these methods when providing care to healthy women with normal pregnancies. Only then will family practice physicians, obstetricians and professional midwives be able to enjoy a mutually respectful, non-controversial relationship. Under this logical system, the appropriate form of care for any individual mother-to-be (physiological vs. medical) 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 (physician, obstetrician, midwife). At present, who the woman seeks care from (physician/obstetrician vs. midwife) determines how she is cared for. This is illogical.
It’s inappropriate to use a surgical billing code for normal spontaneous childbirth. A professional billing code must be configured for physiologically-based care which encompasses the entire intrapartum period as a continuum. This would fairly reimburse professional birth attendants for the time they spend supporting the normal process of labor, birth and the immediate postpartum/neonatal period. Prevention must be valued equally with intervention as the proper role of the professional maternity care provider. Methods that reduce the need for medical intervention and surgical procedures benefit the childbearing woman and her family, third party payers, the economy, the environment and the goals of a humane society.
The question is simply this: How much longer will we be content to use an expensive, pathologically-oriented and outmoded 19th century system for our healthy 21st century population?
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