Henci Goer

Introduction

1. Obstetric Management: What's Wrong with this Picture?
   1. Why the Gap
   2. Why this Book
   3. About the Book
2. Bibliography

Obstetric Management: What's Wrong with this Picture?

You're expecting a baby or planning to become pregnant. Congratulations, you are embarking on a challenging and potentially highly rewarding journey. Without question, you want to have a safe and satisfying birth experience. I want that for you too, and I wrote this book because achieving that goal isn't as straightforward as it ought to be. Over the past 30 years, obstetric management has converted what should, in most cases, be a healthy, normal process into a high-tech event. Without anybody intending it to happen and with little recognition that it has happened, things have gone terribly wrong with maternity care in this country. Consider the following:

• Cesarean section is the most common major surgery performed in this country. Every year in the U.S. one in five -- nearly one million -- pregnant women have a cesarean section despite the health risks, pain, recovery time, and expense. The consensus of the medical literature is that half of these operations were not needed.
• Doctors now use electronic fetal monitoring, a machine that records the baby's heart rate in conjunction with the mother's contractions, on four out of five laboring women. The percentage has risen steadily in the face of a stream of studies showing its use doesn't improve babies' health. In fact, its routine use threatens the mother's health by increasing the odds of forceps or vacuum extraction deliveries and cesarean section.
• At some hospitals, almost every laboring woman has an epidural. Meanwhile, studies document a host of epidural complications affecting mother, baby, or both.
• Half of women giving birth vaginally still have an episiotomy, a snip at the bottom of the vaginal opening. The research proves up, down, and sideways that, with rare exceptions, this procedure does no good and often does harm -- sometimes serious and permanent harm.
• Most women who have a cesarean section automatically have them for subsequent babies. Reams of data show that vaginal birth after cesarean (VBAC -- pronounced vee-back) is safer for mothers, has advantages for babies, and will work for nearly three-quarters of women.
• Few women in this country give birth attended by a midwife. Yet studies consistently find that mothers and babies cared for by midwives experience fewer complications and have fewer tests and procedures compared with similar women managed by obstetricians. Midwives in several large studies have cesarean rates as low as 4%.
• Virtually no pregnant women managed within the conventional medical system escape without having tests, drugs, procedures, or restrictions that studies show offer little or no benefit when used indiscriminately but which introduce risks.

In short, there is a gap, between how the typical obstetrician practices and what the medical literature supports. This gap goes largely unrecognized by obstetricians themselves. The obvious question becomes, "How can this be?"

Why the Gap?

Obstetric practice does not reflect the research evidence because obstetricians actually base their practices on a set of predetermined beliefs. If you start from this premise, everything about obstetrics, including the inconsistencies between research and practice, makes sense.

There is nothing unique in shaping the care of childbearing women according to what one believes. Every culture does it. The problem is that obstetric beliefs don't fit the realities of pregnancy and childbirth. Obstetrician-gynecologists are surgical specialists in the pathology of women's reproductive organs. The typical obstetrician is trained to view pregnant and laboring women as a series of potential problems despite the fact that pregnancy and childbirth are normal physiologic processes that are no more likely to go seriously wrong than, say, digestion. Obstetric belief tends to become a self-fulfilling prophecy. It has been said that a healthy person is someone who hasn't undergone enough testing by specialists.

Obstetricians work within the medical model, a model that says drugs and procedures are the answer to whatever goes wrong. However, labor difficulties usually resolve themselves with tincture of time or simple remedies. Sterner, riskier measures are rarely required.

Obstetricians are also influenced by the broader culture in which it is believed that technology is superior to nature and machines are more reliable than people. This explains why they will not back off from technologies that have proven to be failures except to replace them with the next new and untested expensive technology that comes down the road. It also explains why not intervening has the burden of proving itself rather than the other way around.

Finally, until recently nearly all obstetricians were male, and even today, women obstetricians train in curriculums devised by and mostly supervised by men. This means gender bias permeates the system as indeed, it permeates all of medicine, only here all the patients are women, which intensifies its effects. One tenet of gender bias is that womens bodies are weak and defective and cannot be trusted to do what they are supposed to do. Little wonder, then, that the foundation of obstetrics is that obstetricians are needed to rescue babies from their mother's bodies. Little wonder too that obstetric remedies rarely involve the mother's actions but are things done to her. If you see the mother as the problem, you don't see her as the solution. Gender bias also values the masculine qualities of control, efficiency, and predictibility. This explains why obstetricians define normal within ever tighter limits around average, although as with any bodily process, normal, covers a wide range. It values action over inaction, hence the obstetric inclination to do something -- anything -- rather than nothing, even when nothing is the best thing to do. And it values top-down relationships, which explains why many obstetricians treat any questioning of their actions as a challenge to their authority and why they will not learn from any other source -- midwives or nurses, for example -- besides each other.

Returning to the question, "Why the gap?" one characteristic of beliefs is that they unconsciously color what those who hold them think and do. Believers know that their way of thinking and doing is the only right way. This means obstetrics lacks a self-correcting mechanism. Research doesn't change practice because a primary characteristic of belief is that evidence to the contrary makes no difference: My mind is made up; don't confuse me with the facts. For this reason, anything that doesn't fit with the obstetric belief system will be denied or explained away while anything that fits will be accepted without question. This prevents the recognition that obstetric management frequently doesn't work, that alternative strategies do, and most important, that obstetric management can cause harm. In other words, science and logic can have no effect unless obstetricians first change their beliefs, which is unlikely because they are the underpinnings of obstetrics.

Why This Book

This brings me back to my reasons for writing The Thinking Woman's Guide. There is another model of care, one that, unlike obstetric management, fits the realities of pregnancy and childbirth. The midwifery model of care is founded on the belief that pregnancy and labor can be trusted to go right most of the time and that, as renowned French physician Dr. Michele Odent has said, "One cannot help an involuntary process. The point is not to disturb it." These terms indicate a philosophy, not a practitioner, although, of course, more obstetricians practice obstetric management and midwives offer midwifery care than vice versa. Emphasizing supportive rather than interventive care, the midwifery model demonstrably produces equally good and often better outcomes, a point I hope to prove to you in this book.

I also hope to give you the knowledge to make informed choices for yourself and your unborn baby. Unless you have medical background and a lot of free time, this will be knowledge that is hard to come by. As we have just seen, what your caregivers tell you may be biased, and it is only human for caregivers to tell you only as much as will get you to do what they think best; the very concept of informed consent implies that once you are informed, you will consent. Without medical background, you have no way to evaluate the quality of your care, pick caregivers who practice according to the best research, or question your treatment. Like Consumer Reports, I will present the data you need to choose wisely and to practice "informed refusal" as well as "informed consent".

Finally, I will give you strategies that will enable you to avoid unnecessary medical intervention. An editor for whom I once wrote told me there isn't a lot of point in giving information unless your readers can do something with it. You have to give them some "take-home pay." Consider the strategies your "take-home pay."

You have no doubt gathered that this book will not be neutral. I don't profess to be any more objective than anyone else about what I think makes for optimal care. Yes, I will be trying to persuade you to my way of thinking, but with a couple of differences. First, I will play fair. I will lay out the research data behind my thinking so that you can make up your own mind. You don't have to agree with me. Second, I want to give you the ability to decide what is right for you, not necessarily what I think would be right for me. To that end, I will offer a broad range of options and compare and contrast them.

I should add as well that I hold my opinions in good company. A Guide to Effective Care in Pregnancy and Childbirth, the summary of the conclusions of the Cochrane Database of Systematic Reviews, and Pursuing the Birth Machine, an analysis of the recommendations of the World Health Organization's consensus conferences on appropriate technology for care before, during, and after birth, agree with me pretty much on all points.

The problems with the medicalized, high-tech approach are well-known to many people involved with maternity care in this country. A number of these organizations and individuals, including me, have come together to form the Coalition for Improving Maternity Services (CIMS, pronounced kims). Over a series of meetings, CIMS developed a consensus statement entitled, The Mother-Friendly Childbirth Initiative. Twenty-six organizations representing in the aggregate thousands of childbirth professionals ratified that document, including the professional associations of nurse-midwives, direct-entry midwives, maternity nurses, childbirth educators, labor support professionals, and lactation consultants. Twenty-seven prominent writers, researchers, and childbirth reform activists also ratified it. I was proud to be one of them. Since publication, an additional 25 organizations and individuals have endorsed the document. The premises and conclusions of this book agree completely with the Mother Friendly Childbirth Initiative.

Still, because I have biases (although I hope I am not prejudiced), I think you should know up front what those biases are. Here is my full disclosure statement.

I believe that the unconscious principles and resultant conscious practices of obstetric management fail to meet the needs of women and babies and cause many of the problems they claim to prevent or cure.

I am not antitechnology, but I am opposed to the routine use of intervention. I have attended labors in which the judicious use of technology probably saved the baby and even in a case or two, possibly the mother, but the key word is "judicious." I believe the injudicious use of technology is doing considerable physical and psychological harm to mothers and babies.

I am not antiobstetrician. I know personally and by reputation many fine obstetricians. I also believe most doctors want to do well by their patients, although I have seen, experienced, and read about enough instances of arrogance, indifference, ignorance, and even cruelty to have no illusions. Still, the main problem is differing definitions of "doing well." Here is what I think defines good care. Good obstetricians, family practitioners, and midwives:

• Believe childbearing to be a fundamentally healthy and normal part of a woman's life.
• Treat women holistically, taking into consideration their thoughts, feelings, concerns, and priorities.
• Respect the right of women to make informed decisions for themselves and their babies.
• Respect labor as an experience with its own lessons and rewards.
• Offer supportive rather than interventive care.
• Evaluate individually and do not treat by rule.
• Start small when intervention becomes necessary.
• Keep abreast of the medical literature.

About the Book

Here are the how's and why's of the book's organization.

Chapter 1 looks at the most pressing issue in maternity care: the cesarean epidemic. It serves as an overview and introduction to the rest of the book. The chapters that follow it discuss various issues of obstetric management in chronological order as you would encounter them during late pregnancy and labor. These prepare you for the last chapters, which give practical advice on how to choose someone who does professional labor support (doula or monitrice), a caregiver, and a birth site.

The chapters all follow the same pattern. Each one begins with an overview that critiques mainstream belief and practices followed by descriptions of any procedures, if relevant. Next comes "The Bottom Line". Here is where you will find summaries of the trade-offs of various approaches and strategies for avoiding unnecessary intervention. Every chapter other than Chapter 2, "The Cesarean Epidemic", closes with "Gleanings from the Medical Literature." This section lists the conclusions I think can be drawn from the research data. I have keyed the statements within this section to chapter appendices that contain summaries of the evidence supporting each conclusion. The summaries include footnotes and a reference list. I chose this arrangement so you can look up what interests you without being distracted by the mini-reviews of the literature. Other appendices give the full text of The Mother-Friendly Childbirth Initative and a list of organizations and resources related to pregnancy and childbirth.

I have tried to make this book responsive to many different needs. I wrote each chapter so that it can be read independently of any other chapter. This means you don't have to read sequentially and can skip around to whatever interests you. In particular, don't get bogged down in the research summaries if they aren't your cup of tea. I put them in for those of you who want to make your own evaluation and don't like taking anybody's word for it. You may also find them useful to show your doctor or midwife.

I have had to be selective in the data I presented, but I think I have included enough to make my case. For most chapters, I read two to three times the number of papers as appear in the bibliography and appendix reference lists. One tactic for dismissing a work like mine is to say that you can find a study to support any position, but that does not apply here. The data uniformly failed to support common obstetric practice for most of the topics I researched. (I should also point out that although studies will, of course, continue to be published after I complete this book, once there is a body of well-done studies that reach the same conclusion, future studies rarely reverse that conclusion.) Where there was surface agreement in the literature with what obstetricians typically do -- pregnancies that go past their due date comes to mind -- I think that agreement can be challenged by digging deeper and looking at the quality of evidence on which it is based. By contrast, while it was almost always clear that current practice should be abandoned, what ought to be done instead was often less clear. I incorporated the pros and cons in these cases into "The Bottom Line."

You may be wondering about my credentials to write this book since I am not a doctor -- either M.D. or Ph.D -- a midwife, or a nurse. I am a certified childbirth educator with a degree in biology from Brandeis University. Beyond that, I am self-taught. I am also the author of Obstetric Myths Versus Research Realities: A Guide to the Medical Literature. In that book, I organized and wrote hundreds of summaries of articles from the medical journals so that childbirth educators, midwives, and others could have at their fingertips the data supporting what most of them teach or practice. That book was well received. In fact, several midwifery schools have adopted Obstetric Myths as a textbook and some childbirth education certification programs have made it required reading.

To those who would argue that you need more letters after your name in order to write a book like this one, let me respond with a story. Penny Simkin, a well-known educator, writer, speaker, and editor, was called on the carpet by an anesthesiologist, irate that she had written a handout listing the potential trade-offs of epidural anesthesia when she was not a doctor (although he did not dispute her accuracy). "What are your credentials?" he demanded. "I can read," she mildly replied. So can I.

One final point: the things you are about to read may well worry or distress you or even make you angry. I have tried not to be needlessly alarmist, but I havent pulled any punches either. This book was written on the same principle as sex education, namely, I would rather that you be made uncomfortable than remain ignorant. My goal is for you never to have cause to say afterwards "But I didn't know that was an option," or "I never would have agreed if I had known that could happen."

While my intent is to enlighten you and to offer strategies to meet a wide range of individual needs, you may also find yourself feeling overwhelmed by the many possibilities I present and their various trade-offs. Think of them merely as jumping-off points for discussions with your doctor or midwife -- and, in fact, how he or she reacts to your raising these issues can tell you whether you have the right person. You can, of course, also leave all or most decisions up to your caregiver. That is a perfectly valid choice. The important thing is that it be a conscious choice, not one you felt constrained to make.

Bibliography

CIMS. "The mother-friendly childbirth initiative." Washington, D.C.: CIMS, 1996.

Davis-Floyd RE. Birth as an American Rite of Passage. Berkeley: University of California Press, 1992.

Enkin M et al. A Guide to Effective Care in Pregnancy and Childbirth. 2d ed. Oxford: Oxford University Press,1995.

Odent M. The fetus ejection reflex. Birth 1987;14(2):45-46.

Rooks JP. Midwifery and Childbirth in America. Philadelphia: Temple University Press, 1997.

Wagner M. Pursuing the Birth Machine. Camperdown, Australia: Ace Graphics, 1994.

© 1999 by Perigee Books