The following is from the May 11 Obstetric & Gynocology,
written by written by Annette Fineberg, MD (OB/GYN) and a response
that follows from David Hayes, MD (OB/GYN)
Obstetrics & Gynecology:
May 2011 - Volume 117 - Issue 5 - pp 1188-1190
doi: 10.1097/AOG.0b013e31820c9cab
Personal Perspectives
An Obstetrician's Lament
Fineberg, Annette E. MD
Article Outline <javascript:showOutline()>
<javascript:showHide('ej-
article-box-text2',%20'img2')> Collapse Box
Author Information
>From the Department of Women's Health, Sutter West Medical
Group, Davis,
California.
See related articles on pages 1179 and 1183.
Corresponding author: Annette E. Fineberg, MD, Department of
Women's Health,
Sutter West Medical Group, 2020 Sutter Place # 203, Davis, CA
95616; e-mail:
finebea@....
Financial Disclosure The author did not report any potential
conflicts of
interest.
A few weeks ago, during a prenatal visit, a woman pregnant with
twins told
me she would love to have a home birth, but did not have the
$4,000 cash
required upfront to do so. She was afraid of potential
interventions in the
hospital. After a discussion of her fears as well as potential
complications
that can abruptly occur in a twin birth, she admitted she would
prefer a
hospital birth if she could maintain some control over the
situation. This
is not a woman who cares more about the birth experience than the
baby, but
she was tempted, and in some ways I can understand her concerns.
My cousin's
wife had her twin induction halted at 4 cm because the new
obstetrician on
call did not do breech extractions for second twins. Her only
option became
cesarean delivery.
I recently received a phone call from a woman 2 hours away who had
planned a
home birth for her second baby after having an easy first birth.
When the
fetus, which was anticipated to be a little smaller, was found to
be a
breech, the midwife sent the woman to the local obstetricians.
They would
only deliver the fetus by cesarean delivery. The midwife offered
the woman a
home breech birth, but admitted she had only delivered one breech
(stillbirth) in her career. The woman appropriately questioned the
safety of
this, and was referred to us. She met the criteria for our vaginal
breech
protocol, and had an easy vaginal breech birth in our hospital.
Unfortunately, this is becoming a rarity. A colleague of mine in
another
state watched the residents she was supervising emotionally bully
a young
woman and her mother into a cesarean delivery. The young woman had
a rapidly
progressing active labor with a normal-sized frank breech fetus.
Had the
residents been open to the idea, my colleague easily could have
taught them
how to deliver a vaginal breech.
The running joke in our community is that the only way to get a
vaginal
birth after cesarean delivery (VBAC) is to have the birth at home.
Unfortunately, this is a reality rather than a joke. Our small
community
hospital, owing to regional liability insurance constraints,
stopped
allowing VBACs in 2002 after many years of successfully offering
them. This
has led many women to risk home birth rather than travel to a
tertiary care
center to attempt VBAC. I recently counseled a woman against
having a
cesarean delivery who had a BMI of 52 and who arrived in active
labor at
over 35 weeks of gestation with two previous successful VBACs. I
spent the
following months defending that recommendation, despite her
considerable
operative risks and high likelihood of success.
Recent news and media excitement about the benefits and increased
safety of
home birth over hospital birth have made the former seem like a
very
attractive alternative. A growing notion among women in our
region, and
perhaps across the country, is that hospitals and obstetricians
are a more
risky option than lay-home midwives for birth. Although my initial
reaction
is disbelief, perhaps we should look at how we, the obstetricians,
contribute to this trend.
Each of these women deserves an honest discussion about the fetal
and
maternal risks of each birthing option. However, our lack of
experience as
obstetricians colored by our fear of liability is narrowing
women's choices,
and sometimes motivating them to ignore fetal and maternal safety
in an
effort not to be coerced into unnecessary interventions. I sense a
mounting
tension, because many obstetricians do not have the willingness,
time, or
skills to provide maternal choices.
I believe we are at a crossroad in maternity care in this country,
and I am
saddened that obstetricians are considered the culprits. Our
contracting
skill set as obstetric providers, as well as the prevailing
risk-adverse
culture among physicians and hospitals, have given support to home
birth. We
can all agree that VBAC, twins, and breech should not be managed
at home,
yet we frequently demand complete control of the situation and
eliminate
some appropriate choices in the hospital. I understand that it can
be very
unnerving to be ultimately responsible for the outcome, as we are,
and yet
pushed into situations outside of our comfort zones. However, our
unwillingness to budge in these situations is causing us to lose
the battle
regarding what is really important to most obstetricians: safety
for mothers
and babies.
Certainly, we can be proud of the dramatic decrease in maternal
mortality in
the last century. But, despite the highest per capita expenditure
of health
care in the world, infant and maternal mortality rates in the
United States
are higher than in all of western Europe. We have the
third-highest cesarean
delivery rate in the world.1
<
http://journals.lww.com/greenjournal/Fulltext/2011/05000/An_Obstetrician_s_
Lament.25.aspx#P24> According to a recent study, nearly half of
all
primigravidas attempting vaginal delivery are induced, and half of
cesarean
deliveries for dystocia are done before 6 cm of dilation,
presumably before
active labor.2
<
http://journals.lww.com/greenjournal/Fulltext/2011/05000/An_Obstetrician_s_
Lament.25.aspx#P25> It is amazing how many women begging for
elective
induction change their minds when told it doubles3
<
http://journals.lww.com/greenjournal/Fulltext/2011/05000/An_Obstetrician_s_
Lament.25.aspx#P26> their cesarean delivery risk.
We need to draw lines around patient safety, but must they be so
rigid? Most
midwives know from experience that Friedman's curve is too strict.
A recent
study validates that knowledge.4
<
http://journals.lww.com/greenjournal/Fulltext/2011/05000/An_Obstetrician_s_
Lament.25.aspx#P27> I sincerely hope it is taken seriously.
Expectant
management of ruptured membranes at term has been declared unsafe
and of no
benefit.5
<
http://journals.lww.com/greenjournal/Fulltext/2011/05000/An_Obstetrician_s_
Lament.25.aspx#P28> The study that settled the question did not
account for
the number of vaginal examinations women received, and group B
strep was not
treated, both important variables.6,7
<
http://journals.lww.com/greenjournal/Fulltext/2011/05000/An_Obstetrician_s_
Lament.25.aspx#P29> Most women do go into labor in 24 to 72
hours.8
<
http://journals.lww.com/greenjournal/Fulltext/2011/05000/An_Obstetrician_s_
Lament.25.aspx#P31> The Cochrane systematic review concludes
that, because
the differences in outcome are not substantial, women need to be
given the
appropriate information to make a decision.9
<
http://journals.lww.com/greenjournal/Fulltext/2011/05000/An_Obstetrician_s_
Lament.25.aspx#P32> This very rarely occurs in the hospital
setting. The
Term Breech Study10
<
http://journals.lww.com/greenjournal/Fulltext/2011/05000/An_Obstetrician_s_
Lament.25.aspx#P33> closed the door on vaginal breech delivery
even for the
lowest-risk women in most obstetricians' minds (including the
residents I
mentioned above). This, despite the opinion of the College that it
may be
appropriate in carefully selected situations.11
<
http://journals.lww.com/greenjournal/Fulltext/2011/05000/An_Obstetrician_s_
Lament.25.aspx#P34> In any case, vaginal breech delivery is not
completely
avoidable, and should not be relegated to the history books with
vaginal
delivery for previa and high forceps.
Our mission has become more difficult in the last 20 years as
mothers have
become older, heavier, and of lower parity.12
<
http://journals.lww.com/greenjournal/Fulltext/2011/05000/An_Obstetrician_s_
Lament.25.aspx#P35> Many women, admittedly, do have unrealistic
expectations. Although I am eternally grateful for the obstetric
skills I
learned in residency, I have been amazed in my 14 years of
practice to see
much of the dogma I also absorbed disproven with experience and
patience
(both my own, my colleagues', and the midwives I have worked with
in the
hospital setting).
Collaborative practice with midwives is a good start, but in order
for
obstetricians to be more than providers of cesarean deliveries (a
thankless
and, in most cases, technically simple procedure) we need to have
conversations with our patients that are not one sided and allow
for true
informed consent. Many of the obstetric disasters we have all seen
and which
color our perspective (which David Grimes has called "numerators
in search
of denominators")13
<
http://journals.lww.com/greenjournal/Fulltext/2011/05000/An_Obstetrician_s_
Lament.25.aspx#P36> are at least in some part iatrogenic if
examined deeply
enough. That failed induction for convenience with early
artificial rupture
of membranes and chorioamnionitis. The first cesarean delivery
done at age
15 after 2 hours of pushing with an epidural that then leads to
the fifth
cesarean years later, and then accreta and life-threatening
hemorrhage, are
both typical examples. We need to recognize and own those aspects
of
obstetric management that are driving our skyrocketing cesarean
delivery
rate but having no positive effect on maternal or infant morbidity
and
mortality.
Admitting what is truly evidence based versus what is tradition
and culture
is a good start. It is essential that we offer real choices to our
patients.
We need to recover and disseminate the skills that make obstetrics
an art
and a privilege. Seek out mentors skilled in forceps, vaginal
breeches, and
breech extractions before it is too late. Then learn to be
patient, so that
you very rarely need to use them.
-------------------------------------------------------------------------------------------------------------------------------------------
Even better was this reply to the article posted.
For more of the thread, visit
www.theunnecesarean.com/blog:
An Obstetrician's Hope
<
http://www.theunnecesarean.com/blog/2011/5/13/an-obstetricians-hope.htm\
l> [Date] Friday, May
13, 2011 at 6:26AM By David Hayes, MD
I am encouraged by Dr. Fineberg's recognition and admission that
the current standard of practice of obstetrics in the United States
is
in fact lamentable. I am encouraged that she has felt the need to
make
a public declaration of her concern over the disconnect between the
information available in the obstetrical literature (not to mention
the
midwifery literature – which obstetricians rarely even concede
exists) and the routine practices in virtually every hospital in the
country.
I appreciate that she understands and delineates at least portions
of
the various chains of events that lead to an increase in the number
of
unnecessary cesarean deliveries. I appreciate that she describes the
role that dogmatic adherence to the long discredited Friedman curve,
overly aggressive management of rupture of membranes at term, and
the
irrational discontinuance of performing and even training future
obstetricians to perform vaginal breech deliveries plays in driving
up
the numbers of these unnecessary cesarean deliveries.
I am positively thrilled that she recognizes and calls out the
extent
to which obstetricians routinely ignore the doctrine of informed
consent, except to pay lip service to the satisfy the legal
requirements
for their own protection.
But then, just when I think she might scale those rarified heights
and
suggest that we actually consider those options that make prenatal
care
and delivery safer for mothers and their babies in virtually every
developed country on the planet, she retreats squarely inside the
obstetrical dogma.
"A growing notion among women in our region, and perhaps across the
country, is that hospitals and obstetricians are a more risky option
than lay-home midwives for birth. Although my initial reaction is
disbelief, perhaps we should look at how we, the obstetricians,
contribute to this trend."
Perhaps? Really? Yes, perhaps we should!
Consider first the state of obstetrics in our self-proclaimed best
medical system in the world:
"The United States' rate for maternal mortality is 1 in 2,100
– the highest of any industrialized nation. In fact, only three
Tier I developed countries – Albania, the Russian Federation and
Moldova – performed worse than the United States on this indicator.
A woman in the U.S. is more than 7 times as likely as a woman in
Italy
or Ireland to die from pregnancy-related causes and her risk of
maternal death is 15-fold that of a woman in Greece."(1)
And:
"Similarly, the United States does not do as well as most other
developed countries with regard to under-5 mortality. The U.S.
under-5
mortality rate is 8 per 1,000 births. This is on par with rates in
Latvia. Forty countries performed better than the U.S. on this
indicator. At this rate, a child in the U.S. is more than twice as
likely as a child in Finland, Greece, Iceland, Japan, Luxembourg,
Norway, Slovenia, Singapore or Sweden to die before reaching age
5."(2)
The women who are increasingly asking for out of hospital care are
doing so because they are informed, intelligent, and empowered women
who
are concerned about their health and the health of their baby.
Indeed,
the international human rights organization Amnesty International
took
the extraordinary step just last fall of issuing a report in which
they
referred to the "maternity health care crisis in the USA" in
calling world wide attention to the state of obstetrical care in the
U.S.(3) The only people who seem not to see it are the obstetricians
who are at the root cause of it.
Any thinking woman who bothers to look should be disturbed by what
she
sees. There is something very wrong here. Part of the problem
certainly arises from the for-profit health care system that even
now
makes access to health care impossible for millions of Americans.
But
the problem is much deeper than even that. The statistics cut
squarely
across racial and socio-economic lines and there is no indication
that
it can all be accounted for by access.
Yes, women are increasingly avoiding the medical model of childbirth
and the hospital setting for deliveries. They are fully capable of
reading and of obtaining good, accurate information. They are well
aware
that the decisions their obstetricians are making on their behalf
often
are not supported by the literature and do result in worse outcomes.
They do understand the problems endemic in the US obstetrical
system.
And as a result they are well aware, if Dr. Fineberg is not, that
their
risk of morbidity and mortality is significantly lower when
delivering
their baby with a skilled birth attendant in their own home than it
is
in any hospital in the United States.(4, 5, 6, 7) The fact is, 90%
of
births in the US could be accomplished at home, at lower cost, with
better outcomes, and with more satisfied moms and babies.
We debate the causes, bemoan the rise in cesarean delivery rates,
but
through it all we are missing a hugely important fact – a fact that
is not lost on a generation of intelligent, educated women. Outcomes
are better in a home birth attended by a skilled birth attendant
than a
hospital birth attended by ANY attendant, midwife or
obstetrician.(4)
Until we admit that basic premise, we will make no progress.
Physicians are admonished to "first do no harm." In practice
that implies we should do nothing unless we have evidence it may
improve an outcome. Yet for the vast majority of things we do in
obstetrics, we do not have that evidence. In fact we often have
evidence to the contrary. We routinely order continuous monitoring
that
has shown no benefit at all to fetal morbidity and mortality but
dramatically increases the rate of unnecessary interventions thereby
dramatically increasing maternal morbidity and mortality. We,
without
thinking, perform or order invasive cervical exams that have very
poor
prognostic value, have never been shown to improve any index of
maternal or fetal morbidity, yet have been shown to increase the
risk
of fetal and maternal infection. Indeed, we routinely order or
perform
dozens of procedures in every labor and delivery unit in the country
that have no proven benefit and in many cases fly in the face of
evidence in our own literature that they worsen maternal and fetal
outcomes.(8)
I cannot agree more with Dr. Fineberg's observation that "each
of these women deserves an honest discussion about the fetal and
maternal risks of each option." But she should not stop with that
discussion. After that discussion is held, each of these women
deserves a birth attendant that respects and supports her regardless
of
the option she chooses. That is where the U.S. obstetrical culture
has
utterly failed its clientele. We, as obstetricians, have entirely
lost
sight of the fact that our first obligation in ethical medical
decision-making is to respect patient autonomy. We routinely order
and
perform procedures against our patients' wishes, often exploiting
the vulnerability of our patients, enforcing our authority through
intimidation, fear mongering, and occasionally even obtaining court
orders that are virtually always invalid and overturned when it is
too
late.
I found Dr. Fineberg's statement "This is not a woman who cares
more about the birth experience than her baby" very telling and
typical of the condescending attitude that has gotten us where we
are
today. They do care about their delivery experience, not entirely in
the sense that they are looking to make a spiritual or emotional
connection to one of the defining experiences of womanhood (although
that is certainly much more important than the dismissive derision
implied by the statement). They care about it also because they want
control over, or at the very least input into, the decision making
process involving their life, their health, and their baby. They
care
about it because they do not trust their obstetrician to make the
decision that's in their patient's best interest, rather than
their own. They care about it because they know the hospital
protocols
being blindly followed with little reason are not necessarily
applicable to their particular situation.
In my experience, no mother cares more about the "birth
experience" than they do their baby. It is precisely because they
care about their baby and their life that they are making the
completely rational decision to avoid a hospital birth at all costs.
Many of them are avoiding hospital births because they have had
hospital births, because they have been bullied into unnecessary
inductions, which failed, because they've had "emergency"
c-sections and suffered through difficulties in bonding, breast
feeding, post partum depression, because they have been treated with
condescension and had their own wishes about their own bodies
overruled
with coercion and fear tactics that were completely inappropriate.
There are many reasons we should encourage home deliveries attended
by
qualified birth attendants: it's more comfortable and convenient;
it's less expensive; we should respect patient autonomy. But there
is one reason why we cannot ethically avoid it — it is safer. The
outcomes, for mothers and babies, are simply better.
I am an obstetrician. I too lamented when, at the behest of risk
averse pediatricians, my local hospital stopped allowing trials of
labor
in women with prior cesarean deliveries. But I did more than just
lament. I studied the data carefully. I looked closely at the real
risks
and who might be appropriate candidates, and I began doing VBACs at
home. I have done this for several years and had many successful
VBACs
and no complications. I know the obstetricians reading this are
quaking
in their boots, but there is no rational reason to. In one classic
study, 3 of the 17,898 women undergoing a trial of labor after
cesarean
died, while 7 of the 15,801 women undergoing a repeat C/S died(9) It
is
likely that the trial of labor morbidity and mortality would have
been
even lower had the study participants refrained from inducing or
augmenting labor. But even those numbers are roughly half of the 2
in
10,000 risk that a woman will be killed in an automobile accident
during
the period of time she is pregnant.(10)
Furthermore, other studies suggest that while around 5/10000 serious
uterine ruptures may occur during a trial of labor, around 2/10000
uterine ruptures occur prior to the onset on labor. In other words,
any
pregnant woman who has had a prior C/S is at increased risk of
uterine
rupture even if she elects a repeat C/S. And as we well know, there
are
many other consequences of cesarean delivery that may be life
threatening. Why then are we not approaching performing a C/S with
even
a fraction of the trepidation that we approach normal vaginal
deliveries?
A woman choosing to have a home VBAC rather than be forced to have a
repeat C/S in her local hospital is making a rational decision given
the
data we have available, a decision which we should be prepared to
support if we cannot offer her a better alternative. I have
delivered
several hundred VBACs in the past several years without incident. In
the
same time frame, my local hospital has lost at least 3 mothers
during
or shortly following cesarean deliveries.
U.S. obstetricians have already come to the crossroads and have
taken
the wrong path. It can be fixed, but they need to start having
honest
and open discussions among themselves about the real maternal and
fetal
risks, about the rampant rate of unnecessary induction which leads
to
unneeded cesarean delivery, about the continued use of continuous
fetal
monitoring, restricted movement, withholding of nutrition, unneeded
augmentation of labor, artificial rupture of membranes, epidural
anesthesia and even multiple cervical exams, none of which have any
proven benefit and all of which contribute to increased morbidity
and
even mortality.
Less than two per cent of what is routinely done on labor and
delivery
units in the US has been shown to have any positive benefit. Over
15%
has been shown to have demonstrably adverse impact. ACOG continues
to
spout, with no evidence, the tired old line that delivery is safer
in
hospitals or birth centers joined at the hip to hospitals.(11) At
the
same time, every EU member country is actively seeking to increase
the
numbers of home deliveries, increase the numbers of midwife managed
pregnancies, and work to ensure there is a seamless interface
between
home delivery practices and the hospital system. In the US,
virtually
all medical boards and obstetrical societies, and most obstetricians
and hospitals, are actively hostile to the idea of home delivery and
to
the practitioners and pregnant women who choose it.
Our maternal and infant mortality rates continue to climb. We
continue
to do the same things and expect different outcomes. Is it because
of
the "risk averse culture of doctors and hospitals"? Partly,
yes. But it is also pressure from their peers that prevents
obstetricians from actually practicing the evidence based medicine
we
have and from even considering the vast realms of international EBM
and
midwifery EBM. Obstetricians who attempt to practice based on the
literature rather than the "local standard of practice" run a
very real risk of losing their hospital privileges and possibly even
their medical licenses. If they practice according to the "local
standard of care" they almost invariably must violate all four of
the accepted principals of medical ethics: patient autonomy,
beneficence, non-maleficence, and justice.
We have the information to fix this problem. When we address the
culture of peer pressure, the local "standards of care" that
bear no resemblance to what the literature supports, when we
recognize
that many (including some among the top leadership and most
recognized
names in obstetrics) are more interested in procuring their
positions,
promoting their ideology, protecting their power, and preserving
their
market share than they are in really addressing the problems,
improving
maternity care, and truly supporting their patients, then and only
then
can we start to make headway towards creating a model of maternity
care
that is both world class and genuinely supportive of its clientele.
David Hayes, MD has been offering home births since 2005 and has
attended exclusively home births for the last three years. He is
closing his practice this month to devote his energies to the
international humanitarian aid organization, Doctors Without Borders
<
http://www.doctorswithoutborders.org/>
(MSF).
This post is featured as one of a series of posts
<
http://www.theunnecesarean.com/blog/2011/5/10/lamenting-the-system.html\
> by OB-GYNs in response to the May 2011 article, An
Obstetrician's
Lament, by Dr. Annette Fineberg.
BIBLIOGRAPHY
1. WHO. Trends in Maternal Mortality: 1990 to 2008. (Geneva: 2010).
whqlibdoc.who.int/publications/2010/9789241500265_eng.
2. UNICEF. The State of the World's Children 2011.
(New York: 2010) Table 1, pp.88-91.
www.unicef.org/sowc2011/
statistics.php
3. Deadly Delivery; The Maternal Health Care Crisis In The USA,
Amnesty International Publications, Nov 2010 Index: AMR 51/007/2010
ISBN: 978-0-86210-458-0
4. Patricia A. Janssen PhD, Lee Saxell MA, Lesley A. Page PhD,
Michael
C. Klein MD, Robert M. Liston MD, Shoo K. Lee MBBS PhD. Outcomes of
planned home birth with registered midwife versus planned hospital
birth with midwife or physician., CMAJ 2009. DOI:10.1503/cmaj.081869
5. de Jonge A, van der Goes B, Ravelli A, Amelink-Verburg M, Mol B,
Nijhuis J, Bennebroek Gravenhorst J, Buitendijk S. Perinatal
mortality
and morbidity in a nationwide cohort of 529 688 low-risk planned
home
and hospital births. BJOG 2009; DOI: 10.1111/j.1471-0528.2009.
02175.x.
6. Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwife-led
versus
other models of care for childbearing women. Cochrane Database of
Systematic Reviews 2008, Issue 4. Art. No.: CD004667. DOI:
10.1002/14651858.CD004667.pub2.
7. Kenneth C Johnson, Betty-Anne Daviss: Outcomes of planned home
births with certified professional midwives: large prospective
study in
North America
BMJ 330 : 1416 doi: 10.1136/bmj.330.7505.1416 (Published 16 June
2005)
8. Vincenzo Berghella, MD; Jason K. Baxter, MD, MSCP; Suneet P.
Chauhan, MD. Evidence-based labor and delivery management,
American
Journal of Obstetrics & Gynecology, NOV 2008, pp 445 – 454.
9. Landon, MB,
et.al.
Maternal and perinatal outcomes associated with
a trial of labor after prior cesarean delivery. NEMJ Volume
351:2581-2589 December 16, 2004 Number 25
10. National Highway Traffic Safety Administration, Fatality
Analysis
Reporting System.
www-fars.nhtsa.dot.gov/Main.index.aspx
11. AMERICAN MEDICAL ASSOCIATION HOUSE OF DELEGATES, Resolution:
205,
annual meeting 2008.
-- Ingrid Andersson, MSN, CNM
Community Midwives LLC
3530 Lucia Crest
Madison, WI 53705
608.231.1882
www.gentlehomebirth.org
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