I wrote this paper for my English course and now I have to publish it! I thought no better than this forum, where the members can appreciate it! I hope you enjoy!
Professor Ross Lambert
July 27, 2007
Obstetric and Midwifery Care During Labor in the United States.
An analysis of safety statistics.
In Ricki Lake’s new documentary The Business of Being Born the medical birthing industry is put under the microscope. In the film Marsden Wagner M.D. speaks boldly about our county’s maternity care system’s flaws. Wagner states “Maternity care in the United States is in crisis; it’s in many ways a disaster” (Epstein). Wagner is no stranger to the maternity system; he was the director of the World Health Organization’s (WHO) Women's and Children's Health division for 15 years. But what makes our nation’s maternity care system such a failure? Considering our country’s cutting edge maternity care technology, the fact that we have some of the most astounding cesarean section rates, intervention rates, neonatal and maternal mortality and morbidity rates in the industrialized world leaves many families wondering if we are missing the mark. Is obstetric care overkill? Perhaps it is. In birth, often what is seen in hospitals is the management of pregnancy and labor as opposed to the support of it. An obstetric model of care often "focuses on the pathologic potential of pregnancy and birth" (Mulder). Midwives focus on the normality of birth and pregnancy; a time - for most women - of great health and vitality. Taking into account that obstetric doctors do provide the best care possible for those women considered to be high-risk, out of hospital birth, and birth with midwives is a good option for low- risk women, and should be given due consideration.
Today, most people expect that with birth comes aid, and it comes in the form of intervention. According to the National Center for Health Statistics “the rate of inductions was 9.5% in 1990. In 2003, the rate more than doubled to reach 20.6%” (Lane). Induction is a procedure many women opt to receive today, even though the Food and Drug Administration (FDA) and the Physician’s Desk Reference are against its use for non-medical reasons. Regardless, the decision to induce is being frequently suggested and made, for non-medical reasons such as convenience, comfort, and nearing post-dates pregnancies. Women are not being informed of the risk that accompanies induction. The American Academy of Family Physicians published an article analyzing the connection between induction and the risk of cesarean section. It was concluded that "in the spontaneous labor group, the cesarean delivery rate was 7.8 percent. The rates for medical and elective labor induction were 17.7 and 17.5 percent, respectively" (Walling). In other words induction more than doubles the risk of cesarean section.
Our country's maternity care system's largest problem is cesarean section, and all the “unnecesareans” which occur far too frequently. WHO's official stance on the acceptable range of cesarean section rates is between 10 and 15%, with over 15% being excessive. According to the American Journal of Public Health the cesarean section rate in 1965 was 4.5% today it is nearing 35% (S. M. Taffel). How can we account for this change? Have women's birth canals gotten smaller? Our babies bigger? Marsden Wagner makes a good point in The Business of Being Born. He states "cesarean section is extremely doctor friendly,” it is quick, controllable, and easy. Cesarean section is everything a normal labor and birth is not. Can the rise in cesarean section be credited to the convenience it provides doctors? Yes ‒ in part ‒ it can be. A study was done several years ago revealing peak times for cesarean sections occurred at 4:00 p.m., when it is time for the doctor to go home, and at 10:00 p.m., when it is time for the doctor to go to bed (Epstein). A cesarean section in an emergency can go from knife to baby in 2 minutes, with a total of 5 minutes from the labor room to birth, respectively. A non-emergent cesarean will take around 20 minutes. In contrast, the average labor for a first-time mother will take around 12 hours, for many it will be much longer.
What about medical malpractice? In an extremely litigious society medical malpractice is a legitimate concern for physicians of all walks, obstetricians included. The increase in cesarean section rates can be seen in every age group and every race, across the country. In the obstetric textbook Legal Medicine, Victoria Green acknowledges that "nearly 77% of obstetrician/gynecologists have been sued at least once in their career and almost half have been sued three or more times. Moreover, virtually one-third of residents will be sued during their residency" (American College of Legal Medicine, 471). With the fear of lawsuits hanging in the air, doctors often make decisions and act in a self preserving way. The highest causes of lawsuits for obstetric doctors are related to the failure to perform a cesarean section. What is the obstetrician’s solution? If out of 15 women, 1 in 5 will genuinely medically require a cesarean section, and the doctor cannot anticipate which of the 5 women it will be, performing a cesarean on all of them solves the possibility for lawsuits related to the failure to perform a cesarean section. The four women who would not have medically required a cesarean section receive one anyhow because the doctor is making the decision to operate based on his own legal safety, and not the physical safety of the unborn child or it's, mother's physical, mental, or emotional safety. What can we speculate about cesarean rates if the majority of labors were allowed to unfold naturally? What might change if decisions were made based on genuine medical necessity instead of the convenience and comfort it offers physicians, by allowing labor to be somewhat predictable and assuaging their fear of malpractice? How many are forgetting cesarean section is major abdominal surgery? It is so common today it is the most frequent surgery performed on women. Cesarean section increases the mother's risk for infection, blood loss, clotting, and even death. Risks to the baby include injury, the need for intensive care and lung immaturity. With a direct connection between cesarean section, early induction, epidurals, and the need for pitocin to remedy epidural related labor stalling, are women making informed decisions when accepting pitocin and epidurals? Are they being given all the facts and warnings?
Natural labor and birth is the most risk free method of delivery. Natural meaning, without medical necessity, interventions like pitocin, epidurals, forceps, and vacuums, are not used. In hospitals, certified nurse midwives (CNM) are trained in natural birth. A CNM does not operate and they do not take women who are deemed "high-risk". However a CNM will provide constant support through the entirety of labor for those women who are considered low-risk and do not require surgical delivery. Aside from surgery, a CNM is able to do virtually anything a doctor can, from ordering tests to prescribing medications. A nurse midwife is a nurse with a master’s degree in nursing with an emphasis in midwifery; many nurse midwives have doctorates. A study published in the Journal of Nurse Midwifery in 2005 analyzed cesarean section rates for low-risk expectant women cared for during labor by nurse-midwives and compared those women to low-risk women managed by obstetricians. The study found that "women cared for by nurse-midwives had a lower cesarean section rate, fewer interventions, and equally good maternal and infant outcomes when compared with those cared for by physicians" (Davis LG).
In the Netherlands approximately 30% of births occur at home. A Dutch study on midwife-managed births reviewed 321,500 home births. The study was published in The International Journal of Obstetrics & Gynecology (BJOG) in 2009. The study concluded “that planning a home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low-risk women” (de Jonge A). Another study published in the British Medical Journal (BMJ) in 2005, analyzed the safety of Certified Processional Midwife (CPM) supported homebirth in the U.S. The BMJ study concluded home birth has no increase in neonatal mortality when compared to in-hospital birth. Home birth also shows a decrease in cesarean section rates, at 3.7% for the home birth group compared to 19% for the in-hospital group. Intervention rates were also better in the home birth group. Home birth saw a 2.1% episiotomy rate, compared to a 33% rate for the in-hospital group (Kenneth C Johnson). On “The Farm” in Tennessee ‒ where Ina May Gaskin pioneered the home birth movement in the 1960s ‒ another home birth study was conducted between 1979 and 1981. The Farm study was published in The American Journal of Public Health, and compares the outcomes of 1,707 home birthing women “with outcomes from 14,033 physician-attended hospital deliveries.” Based on the results it was concluded that “under certain circumstances, home births attended by lay midwives can be accomplished as safely as, and with less intervention than, physician-attended hospital deliveries” (Duran). What can we conclude about these findings? CNM attended hospital births have equally good outcomes as physician attended birth with significantly lower intervention rates. It can also be concluded that home birth is as safe and may be safer than in-hospital birth. In Japan midwives attend 70% of births. In the Netherlands midwives are the primary care providers for pregnant women; obstetricians are necessary only when a woman is deemed high risk. The United States is one of the very few industrialized countries where midwives are uncommon in the care of expecting women.
Birth is normal and not something to fear. Birth is not a pathological experience. Though vomiting may occur and a woman may feel out of sorts, for most women during the 40 weeks of pregnancy there is nothing physically wrong. So why are women cared for as if they are ill? Why then are there so many tests a woman must undergo, so much management necessary, and oddly, such poor results? Why is there so much fuss about birth in hospitals? Aside from physicians being trained to see pathology often where it does not exist, we can find money at the core of intensive pregnancy, labor and birth management. The average cost of birth alone is upwards of $11,000. Managed Care Magazine concludes "pregnancies, deliveries, and care for newborns accounted for 8.8 million hospital stays and $68.4 billion in aggregate charges in 2003" (Cross). The cost of labor can triple if a cesarean section is performed. For care with most home birth midwives, total costs are between $1,000 and $5,000; this includes the birth and all prenatal care. We cannot deny that within the medical system decisions are being made in pregnancy and birth for financial gain. Labor and birth are unpredictable. In order to create steady financial flow in hospitals, it becomes essential to manipulate birth so it is as predictable as possible. In order to manipulate the hurricane of birth, the wild and untamable occurrence must be intervened upon and very strong intervention is required to manipulate birth. Common interventions are so common, many do not stop to consider how harsh most labor interventions are.
Pitocin is probably the most commonly administered drug during labor in hospitals. Pitocin is a synthetic form of oxytocin, a hormone women naturally produce during labor. Oxytocin encourages contractions and during labor a woman’s body naturally supplies her with it in bursts. Pitocin, which is given to approximately 80% of laboring women, works in a similar way as oxytocin, except instead of being introduced in bursts, it is provided through a continuous I.V. stream which is regularly "upped" every 30 minutes or so. Pitocin makes contractions, harder, longer, faster and stronger. One result of these "super contractions" is a labor that quickly becomes unmanageable without pain medication. When an epidural is administered, labor will sometimes slow as a result. The staff – with its regimented laboring time frames – will then administer additional pitocin to facilitate a steadier labor pace. More pitocin can then result in what many know as fetal distress, or decelerating fetal heart tones. By their nature pitocin contractions squeeze the infant inside the contracting uterus relentlessly. After the additional administration of pitocin a mother will often require an epidural. A mother may retain pain relief from an epidural however the contractions remain as strong and as regular as they were before the epidural was placed. Under the influence of pitocin induced contractions, the infant ‒ who’s oxygen supply is being tirelessly compressed with each contraction – often begins to show signs of stress with irregularly decelerating heart tones during contractions. The labor and delivery staff recognizes the stress and works towards relieving it, by repositioning the mother and providing her with oxygen. If the baby continues to show signs of stress a cesarean section will then be ordered. The family breathes a sigh of relief as the doctor becomes the savior of the distressed infant, when what they fail to realize is the cesarean section was necessitated as a result of the interventions ordered by the doctor.
Amniotimy is another common labor intervention. It is performed by inserting a long stick with a hook at the end through the cervix and into the opening of the uterus in order to rupture the bag of waters. In labor when the bag of waters ruptures spontaneously it typically signals the beginning of active labor, a period when natural contractions intensify and become more regular. Active labor is the shortest segment of labor. It occurs when the cervix has only the last bit of dilation to complete before the urge to push begins. When the bag of waters is ruptured, the mother can expect contractions similar in nature to pitocin contractions: harder, longer, and stronger. If the bag is ruptured before the cervix is near full dilation, the mother can expect the hardest of labor contractions to last much longer than they would have if the bag had been left intact until the cervix was more fully dilated. To compound the issue now the watery cushion which was protecting the baby from the force of contractions is no longer there, which may lead to fetal distress. The difficulty in coping with labor without pain relief will also often accompany amniotomy. When an epidural is placed, it may counteract the effects of the amniotomy contractions which will require pitocin, and the snowball continues. Amniotimy also increases the risk of infection to the mother. With the over-use of antibiotics today, infections are getting more and more difficult to treat. What it boils down to is, all these common interventions used to simplify labor actually wind up complicating it and introducing unnecessary risk.
"We have a secret in our culture, and it's not that birth is painful, it's that women are strong." (Laura Harm). In our society today, there is a strange trend; birth has become something to be afraid of. "Twilight sleep,” the drug combination of scopolamine and morphine, was given to women in the 1920s for pain relief. "Twilight sleep" had side effects such as the loss of inhibitions during labor, which essentially drove laboring women mad; so mad in fact, they often needed restraining. The drug provided no loss of pain, only loss of the memory of pain. Thalidomide is another drug that was commonly prescribed to women in the 1950s in order to treat severe nausea; its side effects left babies severely deformed often with missing or malformed limbs. Cytotec was used "off-label" by doctors for inducing labor in the 1990s. The use of the drug in this way had catastrophic consequences. Many women who had had a previous cesarean section(s) were given the drug for labor induction. The strength of Cytotec induced contractions would sometimes cause the uterus to rupture, which would then require an emergency hysterectomy and even result in the mother's death. A ruptured uterus is one of the worst complications imaginable during birth. It puts the mother at risk for losing her entire blood volume in a matter of minutes, the blood that is also providing oxygen to her unborn baby. Many babies died in the 1990s due to the "off-label" use of Cytotec (Marsden Wagner). Who can blame the average American woman for her birth related fears in the wake of obstetric practices like these? Our mothers have been telling us for generations birth is the worst pain imaginable, it is scary, it is not safe and we need doctors. Every woman's mothering friends, her sisters, her own mother, most the women she knows ‒ with few exceptions ‒ receive epidurals. It is estimated that anywhere from 70% to 90% of women receive epidurals. We have lost sight of our birthing power, and our ability to do it on our own, but by not birthing on our own we are putting ourselves and our babies at risk. How do we cure the fear so many associate with birth? We cure it through education.
Women need to be encouraged to pursue natural birth, because it is normal. Women who want natural birth need more support. Women who want a natural birth need to educate themselves about the risks and benefits of every aspect of labor she can think of, seek out second opinions and develop a plan she is unwilling to compromise. The doctor a woman sees throughout pregnancy, a person she develops a trusting and caring relationship with, may likely not be the doctor who catches her baby. The doctor will certainly not be there to hold the laboring mother's hand as she crosses the plains of "laborland." If a women desires to see, to feel, natural labor and birth accomplished, support is essential. So many women rely solely on their husbands or significant others for labor support. When the big day arrives the support the couple prepared for comes in the form of a man who is at a complete loss for how to help or be supportive. He holds a hand and looks on in sympathetic awe, with only Lamaze classes to guide him, and Lamaze is not enough. Educated labor support becomes absolutely necessary to aid a laboring woman; midwives provide this support. The strong and caring relationship that was established throughout pregnancy, remains intact as the midwife helps guide a woman through labor. A midwife will hold the mother up in the dark hours when she wants to lie down; a midwife will hold a laboring mother’s hand and guide her when she has lost her way. Just as a mother rests at the side of a daughter giving birth, a lover holds the hand of the woman giving birth to their child, as a sister, a friend, or a husband, all at the side of a women as she brings forth life, so shall the knowledgeable midwife be at the side of the laboring women through every minute and hour of labor, ever watchful. Surrounded in love by those who love them, these two people ‒ mother and infant ‒ work together in harmony to give birth and be born in a calm, quite, gentle and peaceful way. And let's face it; the world could stand a lot more peace.
The interventions associated with hospital birth carry a weighty risk. When subject to these interventions women are not always giving educated consent. The need for natural birth to run forefront in the labor and birthing world is becoming critical. The over-care so many doctors provide today is sending birth in the wrong direction, and things are beginning to spiral out of control. A typical hospital birth sees support in the form of management, through the epidurals which should be traded in for birthing pools and helping hands. Pitocin should be traded in for time and patience. Amniotomies traded in for walks and squats. With the cesarean section rates ever increasing, midwives need to be given back the reigns of natural labor support. What might happen if we see a near total loss of natural birth? How can we ever imagine the importance of the undisturbed process? We are seeing the present consequences of the lack of labor support, of intervention, and haven't even stopped to consider the unknown long term consequences. What might they be? Birth is a life-altering experience that has little to do with pain, and everything to do with transformation and life. Embracing it is the first step.
Peace on earth begins at birth.
American College of Legal Medicine. Legal Medicine. C.V. Mosby, 1998.
Cross, Margaret Ann. "Pregnancy+Birth=$$$." February 2010. managedcaremag.com. 15 July 2010 <http://www.managedcaremag.com/archives/0602/0602.birthcosts.html>.
Davis LG, Riedmann GL, Sapiro M, Minogue JP, Kazer RR. "Cesarean section rates in low-risk private patients managed by certified nurse-midwives and obstetricians." Journal of Nurse Midwifery (1994): 1.
de Jonge A, van der Goes BY, Ravelli AC, Amelink-Verburg MP, Mol BW, Nijhuis JG, Bennebroek Gravenhorst J, Buitendijk SE. "Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births." BJOG: An International Journal of Obstetrics and Gynaecology (2009): 1.
Duran, A M. "The safety of home birth: the farm study." American Journal of Public Health (1992): 1.
Kenneth C Johnson, senior epidemiologist, Betty-Anne Daviss, project manager. "Outcomes of planned home births with certified professional midwives: large prospective study in North America." British Medical Journal (2005): 1-20.
Lane, Brenda. "Labor Inductions on the Rise." 13 August 2006. pregnancychildbirth.suite101.com. 25 July 2010 <http://pregnancychildbirth.suite101.com/article.cfm/labor_inductions_on_the_rise>.
Marsden Wagner, MD, MS. "Cytotec Induction and Off-Label Use." Fall 2003. Midwifery Today. 20 June 2010 <http://www.midwiferytoday.com/articles/cytotec.asp>.
Mulder, Kathi. Research Project Aubrey Hatch. 7 July 2010.
S. M. Taffel, P J Placek, and T Liss. "Trends in the United States cesarean section rate and reasons for the 1980-85 rise." American Journal of Public Health (1987): 1.
The Business of Being Born. Dir. Abby Epstein. 2008.
Walling, Anne D. "M.D." 15 February 2000. AAFP.org. 10 July 2010 <http://www.aafp.org/afp/20000215/tips/39.html>.
WHO. "Health Status Statistics: Mortality." 7 July 2010. World Health Organization. 15 June 2010 <http://www.who.int/healthinfo/statistics/indneonatalmortality/en/>.