Midwifery is catching

Fascinating article at the NewYorker on the lack of evidence based care in child-birth, and the evolution of it over the past centuries.

"Three-quarters of a century later, the degree to which birth has been transformed by medicine is astounding and, for some, alarming. Today, electronic fetal-heart-rate monitoring is used in more than ninety per cent of deliveries; intravenous fluids in more than eighty per cent; epidural or spinal anesthesia in three-quarters; medicines to speed up labor (the drug of choice is no longer ergot but Pitocin, a synthetic form of the natural hormone that drives contractions) in half. Thirty per cent of American deliveries are now by Cesarean section, and that proportion continues to rise. Something has happened to the field of obstetrics—and, perhaps irreversibly, to childbirth itself."

"There are a hundred and thirty million births around the world each year, more than four million of them in the United States. No matter what is done, some percentage will end badly. All the same, physicians have long had an abiding faith that they could step in and at least reduce that percentage. When the national reports of the nineteen-thirties proved that obstetrics had failed to do so, and that incompetence was an important reason, the medical profession turned to a strategy of instituting strict regulations on individual practice. Training requirements were established for physicians delivering babies. Hospitals set firm rules about who could do deliveries, what steps they had to follow, and whether they would be permitted to use forceps and other risky interventions. Hospital and state authorities investigated maternal deaths for aberrations from basic standards."

There are no references or named articles for any reader to look further into the issue, and I think it does make some valid points about the loss of the art of childbirth and with it the increase in people seeking comfort from the "science" of medicalised birth. However - the entire article attempts to draw a link between the failure of birth to be risk free in its natural form, and the offering that obstetric care makes of a less risky (though not risk free) service. IMHO, if midwifery care was widely in place, and obstetrics used in the rare number of cases that truly warrant medical intervention for the life of the mother and/or the child (woh probably opening an ENTIRE can of worms there by that one comment), then the statistics about deaths and injuries during birth would be entirely different.

An article at mothering.com then deconstructs the entire NewYorker article, and most of it is interesting reading, though I don’t entirely agree that the parallels between the birth chronicled in the story, and the evolution of obstetric care, are made to scare the reader into thinking obstetric care is a bad thing.

In fact, I’m not sure what message is contained in the NewYorker article. It talks about birth becoming more medicalised but also that it hasn’t truly gotten much safer for reasons other than doctors learning to wash their hands, and the introduction of blood transfusions and other things to improve the situation of the mother.

"As for maternal mortality, Gawande himself acknowledges that the shift to obstetricians and hospital delivery had no effect on maternal mortality until restraints on doctors, better training, and new developments such as antibiotics and blood transfusions made operative delivery safer. In other words, improvement came when doctors were less likely to meddle, meddled more skillfully, and their meddling was less likely to prove disastrous."

People talk about intervention as a needs to happening - something needing to be fixed, and therefore classed as intervention. The intervention cascade then happens, and before long a c-section is on the cards for failure to progress. Every intervention carries a risk that it will not solve the problem, or make that problem worse, or create other problems. If the problem can be solved with simpler means, or with patience and a trust that, left to its own devices, a woman will birth a baby just fine in a vast majority of cases, then would the outcomes be better?

I wonder if there is a study on women birthing naturally, and the number of cases where intervention has been truly needed. I  doubt there is for a lot of reasons - it’s just ‘not natural’ to birth that way anymore, and any observation of birth alters it. But I’d be fascinated to see any research into the normal outcomes of birth, as research claiming that x or y improves outcomes are flawed as the research is only comparing to other forms of intervention so it’s just showing which is the lesser of two evils.

Having seen a friend of mine have to fight tooth, hand, nail, legs and brains to get something bordering on a natural birth in a birthing centre, and still be shot full of drugs when she wasn’t looking, and now arranging her own homebirth for her second bub as she knows she is meant to make babies that way, it frustrates me that many of my friends who are pregnant are ok with scheduled c-sections. These are major abdominal surgeries and are not safe!

"A 2006 study of all French women having babies between 1996 and 2000 agrees. After eliminating women with conditions that would both influence their likelihood of a cesarean and their risk of dying, women having cesareans were 3 1/2 times more likely to die than women having vaginal births.Excess causes of death related to surgery were anesthesia complications, infection, and deep venous clots."

More babies die because of c-sections that if they’d been born vaginally. The research shows this (Minkoff, H., et al. "Elective Primary Cesarean Delivery." N Engl J Med 348, no. 10 (2003): 946-50.) to be the case. Babies have double the risk of dying during a c-section.

The mothering.com article goes on to say:

"In fact, the disparity in maternal deaths with cesarean surgery is undoubtedly worse than it appears because:

Studies of this issue limit the cesarean population to planned cesarean deliveries or exclude women who have serious health problems but compare outcomes with all women having vaginal births: Women having scheduled cesareans are, by definition, not in danger, and excluding women with medical complications excludes high-risk women. By contrast, some women having vaginal births will be gravely ill.

Studies focus on delivery route and a limited time thereafter and exclude cases where there was no live birth: This means they don’t capture cesarean-related deaths that:

• do not result in deliveries, such as cesarean scar ectopic pregnancy,
• do not result in a live birth, such as deaths due to abnormal placental attachment,
• occur months or years after the surgery, such as bowel obstruction resulting from adhesions."

You could also take out the word c-section and replace it with ‘induction’, ‘epidural’, ‘episiotomy’, ‘monitoring’ and probably others.

For elective surgery, is one case of harm to either the infant or mother one case too many? Am I naive in thinking that a vaginal birth for the most part if done in a ‘physiologically representative of the way we’re built’ way will result in a good happy healthy outcome for mother and baby?

*sigh* I’ve not even started and already I can see this is a complicated area…