One of the reasons I started this blog was to have a place to put some of the more academic musings I knew I'd be doing over the next two years. I am in the first semester of a masters in public health, focusing on maternal and child health. I knew that I'd be taking advantage of class assignments to learn more about areas I've been interested in since I became a doula four years ago but haven't had the resources or time to explore. Now that I'm a full-time student, with access to the full text of almost any journal you could name, I have the opportunity to tackle some of those areas.
I had to write a couple papers in the last week, and I wanted to share a couple things I learned from the research process from one of them. It was a somewhat open-ended assignment; we could choose a country, and a demographic, for which to pose the question "Is it healthier or safer to be a _______ [pregnant woman, infant, or child] in __________ [country of your choosing] than it was ___ [number of your choosing] years ago?" I chose to fill in my blanks with pregnant woman, the United States, and 25.
One interesting fact I discovered was that the U.S. maternal mortality rate has risen - in fact, doubled - in the past 25 years, and yet we can't actually tell if maternal mortality has changed. Because of a recent focus on better reporting maternal deaths (a hugely important undertaking), the rise in maternal deaths may be entirely due to improved reporting. I couldn't find any research out there untangling the numbers to try to determine what is actually happening out there - if any exists, I'd love to know about it!
Without reliable mortality data, I looked at cesarean rates, which have risen from 22.7% in the early 1980's to 31.1% in 2006. That figure - 31.1% - represents double the maximum cesarean rate recommended by the World Health Organization. If we take this to its logical conclusion, that means that half of all women who undergo a cesarean are having unnecessary surgery.
I also spent some time on the risks of cesarean section - often touted as just as safe as vaginal delivery (so why not schedule yours now!) - one study found deaths after cesarean to be more than triple those after vaginal delivery, in mothers who had similar risk factors. There is also significant risk of health problems associated with the surgery, and those increase with every subsequent cesarean.
All of this was the sad, stark "what", but I was really engaged in going through studies that ask "why?" Because of the way the question was set up, I wasn't exploring the "why" for its own merits, but rather to show that the increase in cesarean does indeed reflect a rise in unnecessary surgeries, and not a response to outside factors (unhealthier mothers, for example). And that turned out to be true; since 1996, cesareans have risen for women in all risk groups, of all ages. I found a lot of speculation on why; the one I think would strike birth activists as most plausible is that the "threshold of risk" has been lowered for c-section - doctors are now more willing to jump to a cesarean for a particular indication than they would in the past - and that it may be linked to malpractice concerns and/or a changing culture of practice. The other one, not called out in the research but by almost any birth activist you talk to, was increasing levels of obstetric "management" of labor. Maybe I can take my next opportunity to search out data around labor management and outcomes...I already know, from writing the other paper on obstructed labor in the developing world, that this is also a very complicated question from a sorting-out-all-the-data perspective.
It's interesting stuff! (To me anyway.) It kind of follows on my last post about misplaced anger over cesareans. Statistically, if you got a cesarean, there's a one in two chance that it wasn't necessary. But unless you go to an ICAN meeting, you won't meet many women who will tell you their cesarean was unnecessary. Maybe it's not so hard to hide the havoc we're wreaking if you create a huge cultural perception of birth as terrifying and dangerous? And then have a third of all mothers ready to tell their story about the c-section they had because their baby was in danger?
I got pretty good feedback on the paper (although I was dinged for my use of semi-colons - I love them, but maybe a little too much) and I'm looking forward to be able to explore more issues like this. If anyone is interested in citations, I'm happy to send them to you or post my list. God I love my full-text access.
Sunday, September 28, 2008
Tuesday, September 16, 2008
Natural birth reflections
There's a reason I have such a hard time waking up for class every morning, and it's probably related to the fact that I go to sleep so late every night. What can I say? I'm a night owl, and the new Daily Show doesn't come on till eleven. But the fact is, too, that I've always done my best writing and thinking late at night. If only the rest of the world ran on my schedule...
I've been thinking lately about the whole "natural childbirth/lactivist/breastfeeding Nazi" vs. "uncaring unthinking overmedicating automaton 'mother'" dialogue (diatribe?) that happens...well...everywhere, but especially on the internet. I have seen it more than once on Tara Parker-Pope's "Well" blog on the NY Times website. My eye is always drawn to the anything related to birth/breastfeeding/etc., and more often than not her posts - regardless of topic - provoke a storm of comments falling on one side or the other.
One of her latest posts was on a small study examining the response of mothers who had recently undergone a cesarean section to the cries of their babies. Brain imaging showed they responded less than women who delivered vaginally. To me, this is an interesting and helpful beginning to a question: do women who have cesareans have a higher risk for postpartum depression? Is that because their natural physiological processes have been altered? As a public health professional-in-training, I think of it in terms of risks. This is not a situation in which every woman who has a cesarean will not be attuned to her baby's cries; this is a situation that increases risk, and which we should be aware of so that we can take better care of moms and babies post-cesarean. This is also a small study, raising more of a hypothesis than a conclusion, that other studies can investigate and build on.
The comments on this post, however, were not tentative or investigative; they were legion and some were very aggressive (or maybe the better word is defensive). Many women who had a cesarean were very upset that someone would label them bad mothers. They offered their own experiences as proof that this phenomenon wasn't real, or at least, couldn't be applied to every woman. They worried that the "natural childbirth nazis" would seize on this as more justification for demonizing cesarean sections, or anything outside the realm of unmedicated vaginal delivery. Once again, as with almost any discussion of cesarean, women said "My cesarean saved my life and my baby's life, and I am so grateful for it."
I always finish reading those comments feeling profoundly sad. I have witnessed normal birth, and I believe that it is a beautiful and empowering experience. I want to help more women understand that birth is not something to be frightened of. It's something to learn about, to embrace, to own, to confront. It's a chance to take control of your health care, your body, and the care of your child. I think these are value-neutral statements; I have a hard time imagining that there are women out there who do not want to be in control of their health care and their baby's health care, who want to be frightened of birth. And yet the community I would like to consider myself part of - the natural birth community - seems to have alienated many women, perhaps the majority, in this country.
I am in the middle of writing a paper on why mothers in this country are less safe and less healthy than they were 25 years ago. We don't think of health care going backwards, but in this case it is. Our cesarean rate is more than twice that of the maximum recommended by the World Health Organization. This is not because there are more high risk women, because cesareans are rising for women in all risk groups. It is not because women are asking for cesarean; surveys have shown that to be a rare phenomenon (outside of Hollywood, at least) The standard of care in the U.S. has changed, to where cesarean is regarded as an equal-risk, no-fault alternative. In doubt? Do a cesarean, everyone's happy, don't get sued. Yet studies have clearly shown that women who undergo cesareans are more than three times as likely to suffer serious consequences as those who deliver vaginally, including death.
Cesarean is absolutely, unquestionably, lifesaving for some people. Hundreds of thousands of women in developing countries die every year because they do not have access. But it can be overused, just as we can overuse antibiotics; the risks can start to outweigh the benefits. And the evidence shows that half the women who undergo cesarean in this country are receiving a medically unnecessary cesarean. Do they all realize it? No, they don't. As a doula, I assure you, they're told, "The baby is too big", "The heart rate is going down", "I'm worried about you and your baby. We need to do this for your safety." The hard part is, women are not able to tell when this is really, really true. Was their labor medically mismanaged into a corner? Or would this have happened anyway?
Many women do not even know that there are even questions they should ask about their cesarean. When they hear people discuss cesarean as something lazy moms do, as something that women get themselves into because they're too ignorant to question their doctors, that half of cesareans aren't necessary and that the pain and recovery time they went through to ensure their baby's safety was just a smoke-and-mirrors facade for the doctor to get to a golf game sooner - of course they're angry. Because these women are not stupid. They trusted medical professionals who promised to take care of them, and came out on the other end alive, with a healthy baby. Millions of women around the world are not so lucky. When they hear the "natural childbirth Nazi" spiel, of course they're upset. Does this mean that some of the hard truths about cesarean aren't real? Of course not. But those of us trying to promote normal birth don't do ourselves - or the mothers of the future - any favors when we alienate women who have undergone cesareans, potentially very dramatic and traumatic experiences, with soaring proclamations about the evils of cesareans and their many terrible side effects.
Instead, although it is not easy, I would encourage us to - in my public health mindset, tonight - talk about risks. It's hard, sometimes, to remember about risks when you're not dealing with the concept every day. Risk is not about something happening to everyone. It's about accepting the size of the possibility that it might happen to you. I wear my bike helmet as I travel to school because I accept the size of the possibility that I might have an accident where I need it. I don't travel in an armored car with bodyguards, because I don't accept the size of the possibility that I will need those accoutrements.
I think our proclamations are a way of trying to hammer home the risks of medically overmanaged birth to a populations that has come to perceive it as routine and safer. But we end up creating people who just don't believe us - because of the hype. "I had an epidural and I was so happy, I didn't feel a thing. I'm not some kind of martyr." "My mother formula fed my and my three brothers and we're all healthy and smart. Why go through the torture of breastfeeding?" "I had a cesarean and I felt better within a few days. I heard women screaming in pain down the hall; I'm so glad I didn't go through that." It ends up backfiring, because there are always people - usually the majority - who fortunately escaped those increased risks, and we sound shrill and punitive. I think we need to work on helping people understand risk better, as well as showing them how much better the quality of a properly managed birth can be - "The Business of Being Born" does a beautiful job of showing births of women who are in control and not afraid. And then we need to step back. There are many paths to that empowerment; do I believe some are healthier and safer than others? Absolutely. But every woman has to make her own - informed, educated - decisions. We need to trust her. Maybe then we'll see less defensiveness and anger on this message boards.
I've been thinking lately about the whole "natural childbirth/lactivist/breastfeeding Nazi" vs. "uncaring unthinking overmedicating automaton 'mother'" dialogue (diatribe?) that happens...well...everywhere, but especially on the internet. I have seen it more than once on Tara Parker-Pope's "Well" blog on the NY Times website. My eye is always drawn to the anything related to birth/breastfeeding/etc., and more often than not her posts - regardless of topic - provoke a storm of comments falling on one side or the other.
One of her latest posts was on a small study examining the response of mothers who had recently undergone a cesarean section to the cries of their babies. Brain imaging showed they responded less than women who delivered vaginally. To me, this is an interesting and helpful beginning to a question: do women who have cesareans have a higher risk for postpartum depression? Is that because their natural physiological processes have been altered? As a public health professional-in-training, I think of it in terms of risks. This is not a situation in which every woman who has a cesarean will not be attuned to her baby's cries; this is a situation that increases risk, and which we should be aware of so that we can take better care of moms and babies post-cesarean. This is also a small study, raising more of a hypothesis than a conclusion, that other studies can investigate and build on.
The comments on this post, however, were not tentative or investigative; they were legion and some were very aggressive (or maybe the better word is defensive). Many women who had a cesarean were very upset that someone would label them bad mothers. They offered their own experiences as proof that this phenomenon wasn't real, or at least, couldn't be applied to every woman. They worried that the "natural childbirth nazis" would seize on this as more justification for demonizing cesarean sections, or anything outside the realm of unmedicated vaginal delivery. Once again, as with almost any discussion of cesarean, women said "My cesarean saved my life and my baby's life, and I am so grateful for it."
I always finish reading those comments feeling profoundly sad. I have witnessed normal birth, and I believe that it is a beautiful and empowering experience. I want to help more women understand that birth is not something to be frightened of. It's something to learn about, to embrace, to own, to confront. It's a chance to take control of your health care, your body, and the care of your child. I think these are value-neutral statements; I have a hard time imagining that there are women out there who do not want to be in control of their health care and their baby's health care, who want to be frightened of birth. And yet the community I would like to consider myself part of - the natural birth community - seems to have alienated many women, perhaps the majority, in this country.
I am in the middle of writing a paper on why mothers in this country are less safe and less healthy than they were 25 years ago. We don't think of health care going backwards, but in this case it is. Our cesarean rate is more than twice that of the maximum recommended by the World Health Organization. This is not because there are more high risk women, because cesareans are rising for women in all risk groups. It is not because women are asking for cesarean; surveys have shown that to be a rare phenomenon (outside of Hollywood, at least) The standard of care in the U.S. has changed, to where cesarean is regarded as an equal-risk, no-fault alternative. In doubt? Do a cesarean, everyone's happy, don't get sued. Yet studies have clearly shown that women who undergo cesareans are more than three times as likely to suffer serious consequences as those who deliver vaginally, including death.
Cesarean is absolutely, unquestionably, lifesaving for some people. Hundreds of thousands of women in developing countries die every year because they do not have access. But it can be overused, just as we can overuse antibiotics; the risks can start to outweigh the benefits. And the evidence shows that half the women who undergo cesarean in this country are receiving a medically unnecessary cesarean. Do they all realize it? No, they don't. As a doula, I assure you, they're told, "The baby is too big", "The heart rate is going down", "I'm worried about you and your baby. We need to do this for your safety." The hard part is, women are not able to tell when this is really, really true. Was their labor medically mismanaged into a corner? Or would this have happened anyway?
Many women do not even know that there are even questions they should ask about their cesarean. When they hear people discuss cesarean as something lazy moms do, as something that women get themselves into because they're too ignorant to question their doctors, that half of cesareans aren't necessary and that the pain and recovery time they went through to ensure their baby's safety was just a smoke-and-mirrors facade for the doctor to get to a golf game sooner - of course they're angry. Because these women are not stupid. They trusted medical professionals who promised to take care of them, and came out on the other end alive, with a healthy baby. Millions of women around the world are not so lucky. When they hear the "natural childbirth Nazi" spiel, of course they're upset. Does this mean that some of the hard truths about cesarean aren't real? Of course not. But those of us trying to promote normal birth don't do ourselves - or the mothers of the future - any favors when we alienate women who have undergone cesareans, potentially very dramatic and traumatic experiences, with soaring proclamations about the evils of cesareans and their many terrible side effects.
Instead, although it is not easy, I would encourage us to - in my public health mindset, tonight - talk about risks. It's hard, sometimes, to remember about risks when you're not dealing with the concept every day. Risk is not about something happening to everyone. It's about accepting the size of the possibility that it might happen to you. I wear my bike helmet as I travel to school because I accept the size of the possibility that I might have an accident where I need it. I don't travel in an armored car with bodyguards, because I don't accept the size of the possibility that I will need those accoutrements.
I think our proclamations are a way of trying to hammer home the risks of medically overmanaged birth to a populations that has come to perceive it as routine and safer. But we end up creating people who just don't believe us - because of the hype. "I had an epidural and I was so happy, I didn't feel a thing. I'm not some kind of martyr." "My mother formula fed my and my three brothers and we're all healthy and smart. Why go through the torture of breastfeeding?" "I had a cesarean and I felt better within a few days. I heard women screaming in pain down the hall; I'm so glad I didn't go through that." It ends up backfiring, because there are always people - usually the majority - who fortunately escaped those increased risks, and we sound shrill and punitive. I think we need to work on helping people understand risk better, as well as showing them how much better the quality of a properly managed birth can be - "The Business of Being Born" does a beautiful job of showing births of women who are in control and not afraid. And then we need to step back. There are many paths to that empowerment; do I believe some are healthier and safer than others? Absolutely. But every woman has to make her own - informed, educated - decisions. We need to trust her. Maybe then we'll see less defensiveness and anger on this message boards.
Sunday, August 24, 2008
Birth trauma shouldn't be a secret, but it is
Do you read Postsecret? Every Sunday a new set of secrets, mailed in anonymously on postcards, goes up. This week one of the secrets had to do with an unnecessary c-section (scroll down about halfway to see it). I noticed this woman mentioned that her son is healthy...a lot of women hear "as long as you have a healthy baby, whatever happened to you doesn't matter". But I think deep down they suspect that they DO matter. And I loved, loved, loved that on this website that millions of people read, they posted a response to that secret directing this woman to ICAN. I hope it serves to educate more women about unnecessary c-sections long before they have to deal with the prospect personally.
Friday, August 22, 2008
Trying again
I haven't done as much posting in this blog as I'd planned. That's not to say I can't think of anything to post - I think of things to talk about all the time! I've just put so much time and effort and thought into the posts I've written so far that to write another one like that feels exhausting to me. I think I need to dial that thoroughness back a notch. So if you feel like I'm not citing something or not thinking something through, ask and I shall expound, but otherwise I'm going to try to be a little more casual.
I started graduate school in maternal and child health this week. I'll be getting a master's in public health. "What can you do with an MPH?" everyone asks me. Well, sometimes I worry about that myself. I have a lot of interest in direct service, and an MPH often leads more towards policy, research, and program development. But the truth was, I was tired of working crap jobs and an MPH was the quickest way to get myself to a way more interesting level. I still contemplate other degrees like an MSW or even - still - midwifery, but an MPH will always be useful to me and it does have a very broad applicability when I'm out looking for interesting work.
I'm already glad I'm doing it on maternal and child health, vs. something more general like health behavior. The subjects we discuss in class already catch my ear - terms I'm already familiar with from doula work, issues I already am very curious about. So far I seem to be the only one in my entering cohort so devoted to birth issues - there's more of a family planning and child health focus. But I think that's OK. It just needs I mean to push myself to really seek out opportunities to explore those issues through my classes, and that there won't be a lot of competition for that area!
One class that seems like it will be great is international issues in MCH. Dealing with high maternal mortality in developing countries is something that I've been very interested in for a while. While maternal deaths in developing countries stem - in part - from lack of medical care, the challenge is to respond creatively with only appropriate medical care. A developing country cannot (and should not) provide an OB for every woman. Rather, one needs to train midwives to handle uncomplicated birth, and make OB services available and accessible for the 15% of women who will require them. The readings are already very interesting. It's astounding, and depressing, that reducing death rates for mothers and children is not that hard - we know how to do it effectively - and yet not happening.
I started graduate school in maternal and child health this week. I'll be getting a master's in public health. "What can you do with an MPH?" everyone asks me. Well, sometimes I worry about that myself. I have a lot of interest in direct service, and an MPH often leads more towards policy, research, and program development. But the truth was, I was tired of working crap jobs and an MPH was the quickest way to get myself to a way more interesting level. I still contemplate other degrees like an MSW or even - still - midwifery, but an MPH will always be useful to me and it does have a very broad applicability when I'm out looking for interesting work.
I'm already glad I'm doing it on maternal and child health, vs. something more general like health behavior. The subjects we discuss in class already catch my ear - terms I'm already familiar with from doula work, issues I already am very curious about. So far I seem to be the only one in my entering cohort so devoted to birth issues - there's more of a family planning and child health focus. But I think that's OK. It just needs I mean to push myself to really seek out opportunities to explore those issues through my classes, and that there won't be a lot of competition for that area!
One class that seems like it will be great is international issues in MCH. Dealing with high maternal mortality in developing countries is something that I've been very interested in for a while. While maternal deaths in developing countries stem - in part - from lack of medical care, the challenge is to respond creatively with only appropriate medical care. A developing country cannot (and should not) provide an OB for every woman. Rather, one needs to train midwives to handle uncomplicated birth, and make OB services available and accessible for the 15% of women who will require them. The readings are already very interesting. It's astounding, and depressing, that reducing death rates for mothers and children is not that hard - we know how to do it effectively - and yet not happening.
Thursday, July 31, 2008
iDelivery
Wow.
For serious, people. Your doctor can monitor your contractions and fetal heart tones from their iPhone! Real time! Talk about hands-on medicine!
So my post on evidence-based medicine is a little long in coming (it's in draft form) but in the meantime I wanted to share. Looking up medical PDA applications for my mom (there are a lot) I came across something I think says a lot about the way you might deliver with a doctor.
As a doula and someone who talks with women about pregnancy and birth, I hear so many women say "I trust my doctor," or "I like my doctor," when contemplating birth choices. They believe that this will be enough to give them the healthy, normal birth experience they want. I know that there are many fabulous doctors out there - I haven't been able to work with many of them, but I know that there are doctors who practice more like our conception of midwives, than some certified nurse-midwives do! (And I have worked with some of those CNMs - never assume that because someone is a "midwife" that they have a certain standard of practice.)
But when women tell me things like "I like my doctor," I get an uncomfortable feeling. That you like your doctor is great, but that should only be the first item on your list. Like this person? Okay, check. Now let's ask: What are their intervention rates? What will they allow you to do and not do in labor? Under what circumstances? What's their c-section rate? What percentage of women in their practice deliver without medication? Would they be willing to deliver a breech baby vaginally?...etcetera.
When women say "I trust my doctor," do they trust them because they've gone through all the above questions with their doctor, or because they assume that all doctors practice identically and their doctor's training will be all they need?
And in the end, if you like them and trust them, is your doctor even in the room for more than a few minutes at the end to catch the baby? Because they could always be tracking you down in the cafeteria, or from the comfort of their own bed, with this:
For serious, people. Your doctor can monitor your contractions and fetal heart tones from their iPhone! Real time! Talk about hands-on medicine!
More information here, if you want it.
All I have to say is, if I'm ever in the position of needing an OB, my first question might well be "Will you be turning me into an iPhone application, or treating me like an actual person?"
Monday, July 7, 2008
Informed Choice: The Gold Standard
After I wrote my last post, where I discussed the rights of women to make decisions about their medical care and have those decisions honored, I got a link to a statement from a Canadian OB/GYN who is responding to statements from the American Medical Association (AMA) and American College of Obstetricians and Gynecologists (ACOG).
A bit of background: Ricki Lake, the TV talk show host, gave birth to her second child at home and decided that she wanted to make a documentary about our country's maternity care system and the alternatives available. The result was The Business of Being Born, which was released theatrically and on DVD in the past year. I have met more than one pregnant woman who decided to switch from hospital care to a home birth after seeing this movie. It's been screened all over the country and in hospitals, and it's gotten a decent amount of media attention.
This, apparently, requires action from our country's medical authorities. Both ACOG and the AMA released statements opposing home birth. ACOG's called for births to take place only in the hospital or birthing centers, and the AMA's supported that resolution. ACOG calls home birth "fashionable" and "trendy" (as someone noted, this is probably a big surprise to the Amish, who aren't generally called "trendy" yet have chosen home birth for generations). Why? It might have something to do with the fact that this movie is actually influencing women's choices, and that means less business for the OB/GYNs (although with home birth at less than 1% of the total births in this country, it's going to take a lot of screenings for that to truly tip the balance).
There are plenty of doctors who are not on board, however. Dr. Andrew Kotaska, noted Canadian researcher and Clinical Director of Obstetrics and Gynecology at Stanton Territorial Hospital, issued the following response. I wanted to repost it not just because it shows that there is opposition within the profession, but because of his statements about patient choice:
I would invite ACOG to join the rest of us in the 21st century. Modern ethics does not equivocate: maternal autonomy takes precedence over medical recommendations based on beneficience, whether such recommendations are founded on sound scienctific evidence or the pre-historic musings of dinosaurs. In the modern age, the locus of control has, appropriately, shifted to the patient/client in all areas of medicine, it seems, except obstetrics. We do not force patients to have life-saving operations, to receive blood transfusions, or to undergo chemotherapy against their will, even to avoid potential risks a hundred fold higher than any associated with home birth. In obstetrics, however, we routinely coerce women into intervention against their will by not "offering" VBAC, vaginal breech birth, or homebirth. Informed choice is the gold standard in decision making, and it trumps even the largest, cleanest, RCT. [my emphasis]
Science supports homebirth as a reasonably safe option. Even if it didn't, it still would be a woman's choice. ACOG and the AMA are, by nature, conservative organizations; and they are entitled to their opinion about the safety of birth at home. As scientific evidence supporting its safety mounts, however, (to which BC's prospective data is a compelling addition) they will be forced to accede or get left behind. The concerning part of this proposed AMA resolution is the "model legislation."
If ACOG and the AMA are passive-aggressively trying to coerce women into having hospital births by trying to legally prevent the option of homebirth, then their actions are a frontal assault on women's autonomy and patient-centered care. Hopefully the public and lawmakers realize the primacy of informed choice enough to justify Deborah Simone's words: "We don't need to be angry or even react to these overtly hostile actions from the medical community. We just need to keep doing what we do best; the proof is always in the pudding." It is sad to see the obstetrical community still trying to earn itself a wooden club as well as the wooden spoon; if the resolution passes, it is sad to see the politico-medical community helping them.
Andrew Kotaska
Yellowknife
---
Next post answers Seth's second question: Why is there a gap between the evidence base and medical practice? Part of the answer lies in a conversation I had with my parents (both doctors) just a couple of days ago. Stay tuned!
A bit of background: Ricki Lake, the TV talk show host, gave birth to her second child at home and decided that she wanted to make a documentary about our country's maternity care system and the alternatives available. The result was The Business of Being Born, which was released theatrically and on DVD in the past year. I have met more than one pregnant woman who decided to switch from hospital care to a home birth after seeing this movie. It's been screened all over the country and in hospitals, and it's gotten a decent amount of media attention.
This, apparently, requires action from our country's medical authorities. Both ACOG and the AMA released statements opposing home birth. ACOG's called for births to take place only in the hospital or birthing centers, and the AMA's supported that resolution. ACOG calls home birth "fashionable" and "trendy" (as someone noted, this is probably a big surprise to the Amish, who aren't generally called "trendy" yet have chosen home birth for generations). Why? It might have something to do with the fact that this movie is actually influencing women's choices, and that means less business for the OB/GYNs (although with home birth at less than 1% of the total births in this country, it's going to take a lot of screenings for that to truly tip the balance).
There are plenty of doctors who are not on board, however. Dr. Andrew Kotaska, noted Canadian researcher and Clinical Director of Obstetrics and Gynecology at Stanton Territorial Hospital, issued the following response. I wanted to repost it not just because it shows that there is opposition within the profession, but because of his statements about patient choice:
I would invite ACOG to join the rest of us in the 21st century. Modern ethics does not equivocate: maternal autonomy takes precedence over medical recommendations based on beneficience, whether such recommendations are founded on sound scienctific evidence or the pre-historic musings of dinosaurs. In the modern age, the locus of control has, appropriately, shifted to the patient/client in all areas of medicine, it seems, except obstetrics. We do not force patients to have life-saving operations, to receive blood transfusions, or to undergo chemotherapy against their will, even to avoid potential risks a hundred fold higher than any associated with home birth. In obstetrics, however, we routinely coerce women into intervention against their will by not "offering" VBAC, vaginal breech birth, or homebirth. Informed choice is the gold standard in decision making, and it trumps even the largest, cleanest, RCT. [my emphasis]
Science supports homebirth as a reasonably safe option. Even if it didn't, it still would be a woman's choice. ACOG and the AMA are, by nature, conservative organizations; and they are entitled to their opinion about the safety of birth at home. As scientific evidence supporting its safety mounts, however, (to which BC's prospective data is a compelling addition) they will be forced to accede or get left behind. The concerning part of this proposed AMA resolution is the "model legislation."
If ACOG and the AMA are passive-aggressively trying to coerce women into having hospital births by trying to legally prevent the option of homebirth, then their actions are a frontal assault on women's autonomy and patient-centered care. Hopefully the public and lawmakers realize the primacy of informed choice enough to justify Deborah Simone's words: "We don't need to be angry or even react to these overtly hostile actions from the medical community. We just need to keep doing what we do best; the proof is always in the pudding." It is sad to see the obstetrical community still trying to earn itself a wooden club as well as the wooden spoon; if the resolution passes, it is sad to see the politico-medical community helping them.
Andrew Kotaska
Yellowknife
---
Next post answers Seth's second question: Why is there a gap between the evidence base and medical practice? Part of the answer lies in a conversation I had with my parents (both doctors) just a couple of days ago. Stay tuned!
Friday, June 27, 2008
Balancing the rights of women, and best outcomes for babies
OK, after a lot of writing and thinking I've started to answer Seth's three questions (see my last post for what those questions were, and what they were about). I'm going to address the first and last questions today, and the middle question tomorrow.
When women become pregnant, they have two choices: terminate the pregnancy, or be pregnant for nine months and give birth. You cannot pop a fetus out as soon as you realize it's there and give it someone else to handle. If it's going to continue, the mother is going to have to offer it a space in her body and, in whatever way she chooses, her life.
There are a lot of opinions on when "life" for the fetus begins (conception? forty days? month seven?) and a lot of opinions on how this bears on the mother's rights to control what's going on inside her body and in her life. But bear with me when I say that in the end, people seem to fall along a spectrum of positions. One extreme is "the mother has the right to do whatever she wants with anything to do with her body", and the other extreme is "the mother's body is now the host to the fetus and is always less important than the fetus' survival". There are laws being argued all along this spectrum. Does a woman have a right to a late-term abortion if her health is threatened? Should she be charged with child endangerment if she takes drugs in the ninth month?
This pairs the first and last questions very nicely:
1. If the obstetrician truly believed there was a serious risk to not performing a C-section, did he do the wrong thing? Did the hospital director? Did the judge? Did the sheriff?
3. To what degree, if any, should the best outcome for the unborn child be taken into account if it is contrary to the wishes of the mother? (Whether the two actually are in conflict is not the issue for this question.)
On one end of this spectrum, the obstetrician has acted correctly. The obstetrician sees a situation in which he feels the mother is endangering her child. He goes to the hospital director and the judge, and explains why he believes this - because she is laboring after having had a previous cesarean, she has a higher risk for uterine rupture. If her uterus ruptures, the baby could die. While some states permit parents to decline care for their children - even lifesaving care - based on personal religious beliefs, this mother isn't basing her decision on Christian Science or other religious beliefs rejecting medical care. In the doctor's view, she should be legally forced to give her baby the best medical care possible.
This is where we come back to the fact that the baby is not a discrete entity. To provide Mrs. P's baby with the perceived best care, they will need to force this woman to lie down on a table, submit to anesthesia, and have her uterus cut open. She will then need to have it sewn up and undergo the long, painful healing process from major abdominal surgery. While a repeat cesarean poses risks to the mother (although a uterine rupture would also risk her life, this does not seem to be a factor in the legal decision), the perceived risk to the baby is considered more important.
This woman, who had been offered and refused to consent to a procedure, saw the law used to physically enforce one doctor's opinion - that for the benefit of her child, her body and her wishes about her body were completely irrelevant. If we believe that this is true - that when it comes to the health of the baby, women's bodies are second priority - then we could agree the doctor acted correctly. Suffice it to say that I don't fall on that end of the spectrum. In the last question, we're asking to what degree the baby's health should be taken into account. I believe that a woman who understands the risks and benefits of her choices is taking the best outcome for her child into account already. Doctors may disagree, but ultimately it's the mother's decision. Why? Because it's her body. No one should be forced to undergo medical procedures without their consent. If we accept this, it's a slippery slope to so many other infringements on women's rights.
I think looking at the medical evidence makes this even clearer. When Mrs. P refused a cesarean on behalf of herself and her child, she was indeed placing her child at a slightly higher risk - but only slightly. Some parents refuse to vaccinate their children, which carries a small, but real risk of serious illness and death. Parents who don't vaccinate may have to put up with a lot of forms to fill out when it comes to school enrollment, but they are not arrested and forced to vaccinate their children.
Childbirth Connection reviews the evidence and states that:
"Best research suggests that about 1.4 extra babies die due to problems with the scar in every 10,000 VBAC labors, compared with planned c-section deliveries. Thus, over 7,000 women would need to experience risks of surgical birth to prevent the death of 1 baby from scar problems during VBAC.
Added likelihood for a woman with a known low-transverse (horizontal) scar: LOW for death of the baby around the time of birth compared with repeat c-section."
(Click here for the original statement and more research on VBAC versus repeat C-section from Childbirth Connection.)
Many, many hospitals and doctors permit women to attempt VBACs; this doctor was certainly not acting in lockstep with every other medical professional. Rather, he was acting on a personal bias about the risk of VBACs. Why did he feel justified in sending a sheriff to this woman's house, arresting her, and strapping her to an operating table? Maybe because so many people consider women - especially in the area of reproduction - nothing but vessels. In that worldview, it's all right to force a woman to have a c-section, or forbid her from having an abortion, or live with the consequences of botched abortions and dead women. It's all the same. And that's why this story makes me physically ill.
Subscribe to:
Posts (Atom)