In Improving Birth

Amy Tuteur has managed to score a commentary in the Washington Post entitled “How the natural birth industry sets mothers up for guilt and shame.” You would think that the inflammatory rhetoric would have given the Post’s editors a clue that they should get their fact checkers on the case. If they had, they would have realized that the piece cherry picks bits out of context, distorts and sensationalizes the data, and just plain makes statements that are factually incorrect, but perhaps the “Dr.” in front of her name gave her an automatic pass. Whatever the reason, they didn’t, so let me take on their job of awarding Post “Pinocchios.”

Is Dr. Amy Telling It Like It Is?

“A doula can improve labor, both physically and psychologically. A doula can rub a woman’s back, get cool cloths for her head and provide companionship and empathy. The benefits exist whether the doula is a family member, friend, or hired support person.” Tuteur seriously misstates the value of doulas, meaning women (and a few men) trained to provide continuous 1:1 supportive care to laboring women and their families. Only doulas reduce cesarean surgery (by 28%!), instrumental vaginal deliveries, and likelihood of dissatisfaction with the birth (Hodnett 2013). 4 Pinocchios

“The Midwives Alliance of North America . . . is a major professional organization for American midwives but requires no educational credentials of its roughly 450 members beyond a high school diploma.” MANA has nothing to do with the training or credentialing of direct-entry midwives, meaning women who have trained to be midwives without training to be nurses first. The credentialing body for Certified Professional Midwives is the North American Registry of Midwives. There are several pathways to achieve eligibility to sit for NARM’s credentialing exam, one of which is graduation from a school accredited by the Midwifery Education Accreditation Council, which derives its authority from the U.S. Department of Education. A high-school diploma is required for entry into training in the same way it is required for entry into a university or a college nursing training program. All pathways involve acquisition of broad-based didactic knowledge and mastery of a long list of midwifery competencies determined to be essential to the practice of midwifery as well as ample clinical experience. 4 Pinocchios

“Lamaze’s website states, adding with a note of pity that an epidural still might be needed if a mother ‘can’t move beyond [her] fear of labor pain.’ Rather than teaching strictly the facts about childbirth, Lamaze promotes one particular vision of labor as normal and therefore good.” Tuteur’s quote is taken out of context. It comes from “Is an epidural my only option?” which straightforwardly informs women about the well-established disadvantages of epidurals, lists situations in which epidurals may become a woman’s best option, and offers strategies to avoid their unnecessary use and to reduce likelihood of incurring their disadvantages when having one. 3 Pinocchios

“A study in Oregon found that the death rate for babies delivered in planned home births with midwives in 2012 was roughly seven times that of hospital-born babies.” Tuteur appears to be referring to Snowden (2015). After adjustment for maternal characteristics and medical conditions, the odds ratio for perinatal death in planned out-of-hospital birth was 2.4 times that of planned hospital birth, amounting to an absolute difference of 1.5 more deaths per 1000. Nowhere is there a mention of a 7-fold greater mortality rate. Furthermore, the study’s authors point out that U.S. home birth outcomes may differ from European results because unlike Europe (and Canada), home birth has not been integrated into the health care system, which would allow for collaborative care and for smooth transfer of care, factors that improve outcomes. They also note that the inability to obtain vaginal birth after cesarean in most hospitals has forced women wanting that option—a choice supported by the American College of Obstetricians & Gynecologists (2010), by the way—into birthing out of the hospital. For these reasons, any avoidable deaths arising from these causes are attributable to failures of the U.S. health care system, not inherent risks of out-of-hospital birth. 4 Pinocchios 5/19/16 Update: 2 Pinocchios*

“Data collected by the Centers for Disease Control and Prevention from 2006 to 2009 revealed that babies delivered by midwives had higher death rates than hospital-born babies, whether they were born at home or in birthing centers.” Grünebaum (2014), which appears to be the source for this statement, uses birth certificate data to compare neonatal mortality rates in term singleton pregnancies with no recorded anomalies at births attended by home birth midwives, freestanding birth center midwives, hospital midwives, and hospital physicians. Neonatal mortality rates per 1000 were 0.32 for hospital midwives, 0.55 for hospital physicians, 0.59 for birth center midwives, and 1.26 for home birth midwives. Other analyses suggest that birth certificate data doesn’t adequately distinguish planned out-of-hospital births in eligible women with a qualified home birth attendant. Cheyney (2014), which uses forms designed for the purpose and tracks women from intake appointment through pregnancy, birth, and postpartum, reports substantially lower total neonatal (0.53 vs. 1.26 per 1000) mortality rates at home births. Similarly, Stapleton (2013) reports lower neonatal mortality rates (0.47 vs. 0.59 per 1000) in their study of freestanding birth centers. Tuteur, however, wouldn’t be looking for study limitations or weaknesses, and she accurately reports the study’s results. 0 Pinocchios

“A C-section, for instance, is typically done to save the life of a baby who may not survive without it, or whose risk of dying during a vaginal birth is much higher than usual—such as babies in unfavorable positions or those whose mothers have some obstruction to the birth canal.” Only a small percentage of cesareans are performed for reasons for which there is general agreement that cesarean is the safer mode of delivery. All studies of cesarean rate variation have concluded that cesarean rates depend mostly on practice variation and that the massive increase in cesarean rate hasn’t improved newborn outcomes. The most recent iteration of this can be found in the California Maternal Quality Care Collaborative’s: “Toolkit to Support Vaginal Birth and Reduce Primary Cesareans,” published a few weeks ago, but I have studies with the same finding going back to as early as 1980 (Minkoff 1980). Any assertion to the contrary rises beyond the level of “Pinocchios” to “Liar, liar, pants on fire.”

In short, Tuteur’s motto could be “Never let an inconvenient fact get in the way of a dogmatic opinion,” or, if you like, “My mind is made up; don’t confuse me with the facts.”

Is a “Natural Birth Industry” Defying Health & Safety?

According to Tuteur, all would be rosy if it weren’t for those irresponsible advocates for “natural childbirth” (which is code for anyone who objects to any aspect of conventional obstetric management on any grounds) who are leading women astray by filling their heads with crazy ideas such as something being seriously wrong with a system where 1 in 3 women delivers via major abdominal surgery; or that used injudiciously, medical intervention does more harm than good; or that women have the right to make decisions about their care and to have their decisions respected; or even that epidurals have a downside and women have a right to know that. Sorry, but that dog won’t hunt—and it isn’t just malcontents with a natural birth agenda who are saying so. Check out these reports and who authored them:

And it isn’t just U.S. obstetric professional organizations and highly-respected NGOs:

  • Society of Obstetricians & Gynaecologists of Canada; the Association of Women’s Health, Obstetric & Neonatal Nurses of Canada; the Canadian Association of Midwives, the College of Family Physicians of Canada, and the Society of Rural Physicians of Canada: “Joint Policy Statement on Normal Childbirth.”
  • International Federation of Gynecology & Obstetrics; the International Confederation of Midwives; the White Ribbon Alliance; the International Pediatric Association; and the World Health Association: “Mother-Baby Friendly Birthing Facilities.”
  • Royal College of Obstetricians & Gynecologists; the Royal College of Midwives; and the National Childbirth Trust: “Making Normal Birth a Reality.”

What about the “Obstetric Management Industry”?

Let’s turn the tables and take a look at the real problem in maternity care, the “obstetric management industry.” Let’s look at some reasons for subjecting women to medical interventions that have nothing to do with preserving the health or well-being of mothers and babies, which means exposing them to the potential harms with no counterbalancing benefits—or at least no benefits to them, as we’ll see in these quotations.

At the top of the list is perverse economic incentives:

“Cesarean birth ends up being a profit center in hospitals, so there’s not a lot of incentive to reduce them.” Obstetrician commenter quoted in Girion 2009

“In the previous practice of doctors, it was frowned upon to not ‘get your patients delivered’ and if you didn’t do the delivery, you didn’t get paid. In many practices, the delivery is roughly half of the entire prenatal package compensation, and your profitability is monitored.” Obstetrician quoted in Rogozinski 2014

“NPR’s Shankar Vedantam provides a simple answer: ‘Obstetricians perform more cesarean sections when there are financial incentives to do so,’ citing a study conducted by the National Bureau of Economic Research (NBER), which analyzed the links between ‘economic incentives and medical decision-making during childbirth.’” Wesley 2016

“The best part about it is that you can block-schedule your nurses so that you have enough on hand. . . [I]f we start our inductions at 7 a.m., we know that we’re going to have X number of patients in labor being admitted by 4 p.m. That’s helped our hospital tremendously, . . . [Cytotec is] a great agent. It works very, very efficiently. . . . And it’s ungodly inexpensive: 27 cents per tablet.” Obstetrician quoted in Jancin 2004

“[Because it shortened labor,] if all 815 patients . . . had received high-dose oxytocin (compared with low dose), a total of $211,900.00 would have been saved.” Merrill 1999, p. 460

“While there may be problems with high epidural usage, in the presence of our nursing shortages and economic or business considerations, having a woman in bed, attached to an intravenous line and continuous electronic fetal monitor and in receipt of an epidural may be the only realistic way to go.” Anesthesiologist quoted in Leeman 2003

Economics is closely followed by defensive medicine:

“Increasingly, these adverse events during trial of labor have led to malpractice suits. These developments . . . illustrate the need to reevaluate VBAC recommendations.” ACOG 1999, p. 2

“The minute you see a deceleration on the heart monitor, you say maybe it’s fetal distress, better to do a cesarean. . . . A lot of that is driven by fear of liability.” Obstetrician quoted in Block 2007, p. 63

People tend to nod sympathetically when defensive medicine is raised, but in fact, it is an explicit violation of ACOG’s Code of Professional Ethics: “The welfare of the patient . . . is central to all considerations in the patient-physician relationship. . . . Conflicts of interest should be resolved in accordance with the best interests of the patient.” If wanting to avoid malpractice suits isn’t a “conflict of interest,” I don’t know what is.

Finally, there is plain old convenience:

“So I push that Pit. I try everything I can so she’ll hurry up and deliver, even though ethically, I feel horrible about it. And I can’t tell her, ‘Your doctor’s got a golf game and he said if you don’t deliver by noon you’re going to have a c-section.’” Nurse quoted in Sleutel 2000, p. 42

“By far the most pleasant events for all involved are those where the patients agree to an appropriately timed epidural, and then allow us to alert the patient when it’s time to push.” Obstetrician quoted in Goldberg 2014, p. 147

“It’s almost like . . . [some nurses] think, ‘Just get an epidural because I’m not here to babysit you.’” Nurse quoted in Carlton 2009, p. 53

“‘Scheduling an induction can make everyone’s life easier,’ [Dr. Leveno] said. . . . ‘I am not capable of constantly doing my best work in the middle of the night.’” Obstetrician quoted in Villarosa 2002, p. 76

If you want to know how far convenience can go, a U.S. government-sponsored conference report on elective 1st cesarean included this in a list of rationales considered acceptable for performing cesarean surgery on healthy women:

“Unpredictability of the timing and length of labor for a provider’s lifestyle and fatigue level . . .” National Institutes of Health 2006, p. 11

And if anyone thinks this doesn’t really happen, consider this woman’s story:

“[M]y doctor was out of town when my labor commenced early on Father’s Day weekend. Instead, I was left with a doctor who took one look at my previous C-section and began scrubbing in for surgery. I was given no chance to labor. I was bullied and told even though my child wasn’t in distress, the doctor would rather not wait for distress to occur (as if distress was inevitable).

“I was in and out of surgery within an hour of being admitted. As the doctor was stitching me up, he smiled at me and said, ‘Thanks for making that so quick. Now I can get home to my own Father’s Day celebration.’ Despite my wishes, I went through a major unwanted and, I believe, unnecessary surgery. For what—a little extra cash and a little more time at home for the doctor?” Woman quoted in Wesley 2016

Is a Natural Birth Cabal Setting Up Women?

So far, we’ve seen that Tuteur’s arguments against physiologic care in childbirth don’t hold water and that hospital staff demonstrably aren’t always motivated by what’s best for mothers and babies. What about her opinion on the causes of discontent with childbirth?

Tuteur’s position is that not only are women expected to submit to painful, invasive treatments or procedures, including major surgery, on behalf of their babies, but they aren’t supposed to have any negative feelings about it. If they do, this is the fault of the natural childbirth advocates. Really? Imagine you had a goal. You wanted to be a professional athlete or get into a particular college or get a promotion to a particular position. You did your level best to achieve that goal. At some point you realized that it wasn’t going to happen (think hours of grueling effort in labor to no avail), and you had to let it go. Might you second guess yourself or feel, however unreasonably, that you had failed? Alternatively, the goal was within your grasp, but the needs of someone you were responsible for superseded it, and you did what you had to do. Might you feel sad or disappointed or frustrated even while knowing you were doing the right thing? And would that be because some outside influence foisted those feelings onto you? Now suppose someone came along and instead of sympathizing or honoring your sacrifice, that person belittled your feelings. That person told you not to feel bad, that the goal wasn’t legitimate and that only the needs of that other person mattered. How would that make you feel? I thought so.

Implicit in Tuteur’s argument is that the reason women are disappointed with their births is because they had expectations of how their birth should be, and it didn’t happen that way. The solution, therefore, would be not to have expectations. If women would just give up any attachment to how they would like to give birth and turn themselves over to the medical system, the system will deliver them a healthy baby, and they will be pleased regardless of how events unfold. To paraphrase the old bumper sticker, they should “get in, [lie] down, shut up, and hold on.” That, in a word, is nonsense.

What Are Tuteur’s Hidden Assumptions?

Underlying Tuteur’s position is the assumption that when what women want for their births diverges from what medical staff want, it’s because women are after an idealized experience while medical staff want the safety and health of the baby. A follow-on assumption is that this gives medical staff the right to make all decisions because, unlike the foolish, misguided woman, they have the best interests of the baby at heart, and she does not.

To begin with, far more often than not, what women want is aligned with the research and what medical staff want isn’t:

“Unfortunately, hospital philosophies and policies are not always congruent with evidence-based childbirth education. . . . Hospital providers and nurses may find themselves in a conflicted position where the patient believes a certain type of care will or should be given (e.g. less routine intervention) and feels confused as to why, for example, they are not allowed to walk, must have continuous monitoring, or are encouraged to use pitocin. . . Changing certain hospital policies, such as instituting a freedom of movement policy, intermittent monitoring for low-risk women, or offering a full array of nonpharmacologic methods to promote comfort and coping may be necessary in order to practice high-quality maternity care in alignment with evidence-based childbirth education” (CMQCC 2016, p. 29).

Second, enshrined in medical ethics is the principle that people have the inalienable right to complete autonomy in medical decision making, a right not revoked by pregnancy. Under no other circumstances can someone be forced to undergo an invasive procedure, not even something so minor as donating blood, let alone submitting to surgery, to benefit another party, even when the other party is 100% certain to die without it, which is almost never the case with childbirth.

Third, these assumptions lead medical staff to believe that they have the moral authority to exert whatever pressure they deem necessary to get a woman to do what they think she should do, including threatening, bullying, or shaming her. They may even override her express refusal (Roth 2014). This has serious consequences. One in 5 women emerges from childbirth with symptoms of emotional trauma and 1 in 10 with full-blown PTSD (Beck 2011), despite, I might add, most women having epidurals, so this isn’t about inadequate pain relief. We’re talking about women trapped in intrusive memories, flashbacks, and nightmares; women experiencing panic attacks, anger, and even suicidal thoughts; women feeling disconnected from their baby and their partner; and women who are terrified of becoming pregnant again (Elmir 2010), many of whom opt for elective cesareans if they do (Puia 2013).

This isn’t because they missed the mark on some sort of fantasy birth. It’s because they felt frightened, vulnerable, and powerless. They were ignored, given no explanations, and were shut out of decisions (Declercq 2013; Roth 2014), leaving them feeling betrayed by the people they trusted to care for them (Elmir 2010). Women describe being treated “like a lump of meat” or a “slab on a table” and their births as being like a “violent crime” or a “rape” (Elmir 2010). Far be it from me to tar all doctors and nurses with the same brush, but inhumane treatment happens, it isn’t rare, and there is no accountability in the system to stop it when it does (Simpson 2009).

So, no, we don’t have a “cabal of natural-birth activists” whose goal is to persuade women to “reject pain relief, eliminate C-sections, . . . and even defy standard obstetric recommendations when they conflict with those goals.” And it isn’t about women “in search of the perfect experience” for whom “any medical intervention, even a lifesaving one, can become a source of bitter shame.” We have a system that serves the needs of mothers and babies poorly. We have serious problems affecting real people that need to be addressed.

Fortunately, there’s a movement afoot to do that, a movement involving advocates for reform both inside and outside the system who recognize that the system is broken. They are engaging in mutually respectful dialog and are working together to fix it. Here’s hopes that they soon prevail over those who allow their prejudices to overwhelm their responsibility to report completely and accurately and who demonize anyone who disagrees with them.

 

*I am revising my score based on the following exchange on CBU’s facebook page:

Tuteur: I wrote in WaPo: “A study in Oregon found that the death rate for babies delivered in planned home births with midwives in 2012 was roughly seven times that of hospital-born babies.” And Goer inexplicably replies: “Tuteur appears to be referring to Snowden (2015). After adjustment for maternal characteristics and medical conditions, the odds ratio for perinatal death in planned out-of-hospital birth was 2.4 times that of planned hospital birth, amounting to an absolute difference of 1.5 more deaths per 1000. Nowhere is there a mention of a 7-fold greater mortality rate.” No, I’m referring to the Rooks 2012 dataset from Oregon (https://l.facebook.com/l.php?u=https%3A%2F%2Folis.leg.state.or.us%2Fliz%2F2013R1%2FDownloads%2FCommitteeMeetingDocument%2F8585&h=qAQH8pLm2) and I’d be willing to bet serious money that Goer knows exactly what I’m talking about.

Goer: Sorry if I disappoint you, but there was no malicious intent. I was working off a hard copy of your commentary, and I now see that the online version has a hyperlink to a report made by a single person at a committee meeting that states a 6-8-fold excess. But that raises new questions about your choice of source: Why were you using Rooks’ report rather than an analysis published in a peer-reviewed journal that used the same dataset? Did you not know about the Snowden study? A journal article necessarily carries far more credibility. For example, Rooks failed to do any statistical analysis or make any adjustments for correlating factors, essential elements of a properly conducted study, which might explain why Snowden and colleagues found an absolute difference of 1.5 per 1000 whereas Rooks reported a difference of 4.2 per 1000. And, of course, peer review means that others have critiqued it. (That doesn’t, BTW, guarantee quality, but it is at least a benchmark.) In fact, given these weaknesses, it is misleading to call Rooks’ report a “study” as it elevates it to a status far higher than it merits. Still, point taken. If you like, I am willing to add your correction and this exchange to my blog post and reduce the number of Pinocchios from 4 to 2

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