I was struck by my good friend Johannes' impassioned response to my post of yesterday, and feel that it deserves more serious treatment than I initially gave it. First of all, in over two years of blogging, ocassionally you will strike the wrong tone for a post, and I feel that I probably did that yesterday. I tossed off some remarks (especially the "golf game") in an attempt to make a more serious point, and probably weakened my point in the process. Johannes was right to pounce. BUT (and there is always a "but"), I have valid points in this unsettled debate that I think came through better in the subsequent discussion in the comments section.
So, this post is to clear some of those up. (If you don't know what I'm talking about, just read the post and comments below). First, I apologize if I offended my friends and readers in the medical profession. I know many of you do God's work, much like I do in the classroom. I firmly believe that. At the same time, and I've known Johannes for a very long time, he tends to put medical folk on a pedestal that perhaps is a bit unrealistic. These are human beings afflicted by human weaknesses just like anyone else. Some can be greedy, some can be lazy, some can be careless. I have lawyer friends who make very good livings on that very fact. As fellow members of the human race, they can be these things. In my long experience with Johannes, my impression is that he is sometimes too close to the profession (himself, his brother, both of his parents) to realize that all medical professionals do not walk on water. I could be wrong. This is just my impression after over 20 years of hanging with Johannes. Fair, Johannes? Now, if I may brag for him, Johannes' father is acknowledged as one of the very best in his field. And I know Johannes and his brother personally, and I would trust my life in either one of their hands if need be.
Now, there are many respected studies, as the Anonymous person who commented pointed out, that show that we have one of the highest C-Section rates in the civilized world and that many of the C-Sections are performed for non-life threatening reasons. Or, that they could have been avoided had the doctors not started the platoon of medications that are sometimes used to push the birth process along. Pitocin (sp?) is one of the most common used, and pitocin when it is administered so early, will many times require further medications to fix its side effects, and on down the line until a C-Section becomes necessary when it would NOT have been necessary had the doctor held off on administering medications. Other induction methods cause similar issues.
Can I blame the doctors for all of this? Not entirely. The patient is the customer afterall, and often the patients demand the pain medications immediately. There are some extreme cases where people will schedule a C-Section ahead of time simply for a predictable and convenient delivery. That is major surgery. Doing that ahead of time when it is not necessary is unconscionable.
C-Sections ARE necessary sometimes, no doubt. They are needed to save the mother or baby's life in some cases. Absolutely. But the statistics speak for themselves. According to some statistics, we are delivering by C-Section up to 1/3 of deliveries in this country. Are you telling me that 1/3 of all baby deliveries have become life threatening situations? No way. As I said, many of these C-Sections become necessary only because of the cocktail of drugs administered earlier in labor.
Birth is a natural process. Often patients too quickly opt for pain relief too early which snowballs and leads to further inteventions, slows the progress of labor, increases intensity of contractions, which then leads to more complications and interventions to where, inevitably, the C-Section is needed to "save the day." And, in my view, the medical profession too easily caters to this practice, in part, because there is profit in C-Section deliveries. The insurance company pays out more for them, the patient must stay in the hospital longer to recover, which racks up more costs. Johannes may not want to admit it, but hospitals and doctor practices ARE businesses afterall. I'm not even saying that in most cases this is a conscious decision based on profit. But it seems that doctors will too easily fall back on the C-Section or other medical interventions to speed the birth along vs. allowing it to take its natural course. Why? Patients want it that way, profit, avoid law suits for other complications that could arise...I don't know. Maybe a subconscious mix of all of these things. But it happens. The facts are there.
In my view, and it is a view shared by many intelligent and informed people, including some in the medical profession, that the medical profession has turned the pregnant woman from an empowered woman in control of a natural process to treating pregnancy as an illness that needs to be treated.
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16 comments:
I have some pressing commitments which will limit my ability to fully comment on your post, but a few points for now:
- No one will argue with you that there has been a significant increase in the cesarean rate in the US over the last 30+ years (although I will point out that there is an increase in cesarean sections in other developed countries as well, such as Canada, which has nearly a 20% c-section rate); however I feel like you are attempting to oversimplify the etiology behind the increase by attributing the bulk of increase to physician financial incentives and schedule incentives, which just isn't accurate.
- The etiology of increased c-section rates is multi-factorial:
1) the introduction of continuous electronic fetal heart monitoring - introduced to labor units in the 1970s, and becoming a ubiquitous part of hospital labor and delivery care by 1980 despite NO clinical trials demonstrating its efficacy. It was hoped that continuous electronic fetal monitoring would reduce cerebral palsy rates; instead, it has increased cesarean section rates and done nothing to cerebral palsy rates.
2) increasing obesity rates among pregnant women. Up to 1/3 of the population is clinically obese and of the obese population, 50% are women of child-bearing age. Obesity and pregnancy lead to a host of health issues for mom and baby: bigger moms tend to have bigger babies (known in medical literature as fetal macrosomia), higher risk of class II diabetes or gestational diabetes in obese women which also leads to increased rates of fetal macrosomia, and increased rates of hypertensive disorders in obese women in pregnancy which lead to a host of potential serious health problems affecting mom and baby (preeclampsia/eclampsia, compromised fetal blood flow, intrauterine growth retardation, etc.)
What's the problem with big babies? Although moms may be getting more obese, that's not changing the structure and geometry of the female pelvis. Babies over 4200 gm in weight are at higher risk for labor dystocia (the progress of the labor stalls because the baby can no longer move forward in the pelvis, through the pelvic inlet, etc., and they are also at higher risk for shoulder dystocia during delivery - this is where the head of the baby is successfully pushed out past the vaginal introitus but the rest of the baby is too big to be easily pushed past the pubic bones. This quickly becomes a medical emergency requiring numerous maneuvers on the part of the patient, the OB and the nurses to successfully deliver the baby before oxygen, blood supply and heart rate become compromised. In these situations it is not usual for the baby's clavicle to be broken, or for significant stress to be placed over the baby's armpit leading to a condition known as brachial plexus palsy. This can lead to lifelong impairment of the child's arm - your child won't be able to play catch, won't be able to hold a pencil with that hand, etc.
To minimize the above complications, the American College of Obstetrics and Gynecology recommends that an elective c-section is offered to all diabetic patients with estimated fetal weights > 4250 gm, and all patients with estimated fetal weights > 4500 gm.
3) increasing age among obstetrical patients. Older obstetric patients are at increased risks for a lot of problems with pregnancy including gestational diabetes and preeclampsia, both of which can lead to increased rates of cesarean sections and inductions.
4) increasing use of assisted reproductive technologies resulting in multiple births such as twins, triplets, etc. With multiples there is a higher chance that at least one of the babies will be breech. Due to malpractice concerns and/or lack of training in delivering breech babies, numerous providers will recommend a scheduled c-section in these situations.
5) Malpractice concerns/fear of litigation. OB has one of the highest malpractice rates of any medical specialty, and its unrealistic to think that fear of litigation wouldn't affect the practices of some OB's. Papers that have looked at the malpractice effect show that it doesn't account for all of the rise in c-section rates, but that it does contribute, and that malpractice/tort-reform would likely help reduce the c-section rate.
This is tied back into my first point about continuous electronic fetal monitoring. Even though it was adopted into widespread use with little supporting evidence, it is now considered the standard in hospital-based obstetric care. Unfortunately, a lot of times, interpreting a fetal heart rate tracing is not black and white. You might see something concerning, but then things go back to "normal." Do you intervene with a c-section? Do you watch for a while longer? If you watch, how long do you watch a mildly troubling tracing before you intervene? In the back of the practitioner's mind, it's always a balance - the goal is a healthy mom and a healthy baby - are you closer to that goal if you intervene with a c-section earlier? If you wait and you're wrong, that's devastating to everyone involved.
6) Physician incentive. It likely plays a role, but the papers that have looked at it, such as those in the Journal of Health Economics, show that it likely contributes 1-4% points of the overall c-section rate.
To address your point regarding pain interventions occurring too early in labor - first off, a lot of labor units have guidelines regarding when a woman can get an epidural, and most units encourage women to wait until they are at least in active labor before receiving an epidural. Second, the effect of labor epidurals on the course of labor is a somewhat controversial topic, but the majority of recent studies (since 1998 and later) around the world have shown no causative effect between labor epidurals and increased c-section rates or instrumented delivery rates. In the 1970s and 1980s, stronger concentrations of local anesthetics were being used for epidurals, and those may have indeed contributed to arrests of labor and resulting c-sections. However, since that time, both the drug concentrations and total amounts of drugs used have been continually decreased to the point that women now routinely have what are referred to as "walking epidurals," and epidurals are not found to effect the mode of delivery. They may increase the time in labor, but they don't increase c-section rates, and satisfaction scores are typically higher in epidural groups than non-epidural groups.
An additional point about pain control and labor - some studies have shown that increased labor pain may increase the rate of cesarean sections. One thought is that these women have worse pain because there is some mismatch between size of the baby and size of the pelvis, and it's basically a sign that a normal vaginal labor is not going to happen. What I have seen anecdotally is that for some women, they refuse pain meds and/or an epidural for labor for various reasons, the pain of labor wears them out physicially and emotionally and when it comes time to push, they can't physically do it. They are literally exhausted by the pain. So, they are fully dilated, can't push and the only alternative left is a c-section at that point. I've seen this happen a lot.
Regarding pitocin - all I can say is that the vast majority of inductions I've seen happen for medically-indicated reasons (post-dates, non-reassuring fetal status, preeclampsia, prolonged rupture of membranes, etc.) and if the women is not in labor, if you are trying to avoid a c-section, you have to do something to get her into labor. I've seen couples try to go all natural - nipple/clitoral stimulation, etc., and it works for some, but usually the minority. The only thing you are then left with is pitocin.
I'm not sure what resources you have been using up to date, but if you are truly interested in these topics, I highly recommend doing a literature search on pubmed.gov for relevant articles. If you're looking for a more layperson-oriented site, I think the Mayo Clinic does a great job.
- Le Chat
Le Chat, thanks so much for the info. Obviously I am no expert, but I've spent a bit of time reading stuff and listening to what the Bradley folks have to say. I think your point about fear of litigation is key. When they might be able to allow it to progress longer, they probably cut it off and interfere precisely because of the "what if's" and the thought, somewhere in the back of their heads, that litigation could result.
I'm getting it from all sides over these posts. Now my wife is pissed at me for criticizing lawyers so much (since she is a very good one)! But being one myself, I think I have some room to be an authority there.
Interesting topic, and I would love to continue discussing it. One of our resources was a book called "The Thinking Woman's Guide to a Better Birth," in particular the chapter entitled 'The Cesarean Epidemic.'
After all this talk, let's hope that my wife can hold out and things go according to plan! If not, rest assured, we will be in good hands at the hospital with our very good physician on hand to do her job.
Normally I'm a big fan of the blog, Dez, but I cede to Johannes and (of course) my brilliant and accomplished wife.
As an ancillary point, among the least convincing of the arguments advanced in your post is the idea that because vaginal delivery without anaesthetic is natural, it is therefore good.
The natural state of mankind is horrifyingly painful, unpleasant, and short (not a deliberate allusion to Hobbes). It is also 'natural' to be infested with parasites, to suffer from diseases caused by vitamin deficiency, to starve, to lack sanitation, to die of Cancer, and to kill your rivals. The appeal to nature is all but worthless as a criterion upon which to base moral judgments.
Saxo, first of all, I am pleased that you still check out the blog regularly. Your point is well taken, but you fail to consider the possible consequences of these interventions. It has been shown that these drugs go through the body of the mother into the infant. Why introduce all of these drugs into the baby's system if they are not necessary? Also, as I explained in the post, many times once you start with the first drug, it becomes a domino effect with a need for other drugs to counteract certain side effects, and then the likelihood of more serious interventions (such as C-Section) grows.
So, my point is that it is not merely take pain or get the drugs. The drugs have some consequences many times.
Oh, Le Chat, we have already instructed our doctor that we do not want the continuous electronic fetal heart monitoring for precisely some of the reasons you mentioned. They see a blip and then jump the gun with all of their interventions when most of the time it will fix itself soon.
Sorry Dez, Saxo P. and Johannes are correct and I suspect, based on their blogging, somewhat more educated in this area than you are!
1. Uneducated: You are not a physician, much less an ob/gyn thus uneducated about the topic. Just because you have read a few articles and studied the biased pamphlets given to you by a high-school graduate midwife (or whomever), does not make you qualified.
2. Inexperienced: You are not a woman who has experienced childbirth first hand NOR are you YET a parent. Having not yet even been through the process of childbirth as the mother or as a husband does not even give you the benefit of first hand knowledge.
3. Accuracy: Do your homework properly. Have you ever checked on the numbers of post-natural birth pelvic repairs and bladder repair surgeries that need to be done to women in their 50's and how a c-section could have prevented it? Exactly how many different ob/gyn journals did you research, how many W.H.O. conferences have you attended to come up with these statement??
3b. Your statistics are out of context and misleading.
4. I HOPE to God for your sake your wife's childbirth goes smoothly because without the help of those physicians, IF something goes wrong, and it could... you're gonna be f****d.
By the way,
Two weeks ago a friend of mine who was a "midwife" fanatic (no drugs, no MD's, no delivery room or fetal monitoring) was set for her delivery. A normal pregnancy (so it seemed), a normal onset of labor (so it seemed). Midwife (who is one of the most "respected, well known and experienced" ones in this country was suddenly with a situation she had not predicted. My friend lost her baby, she spent 1 week in the hospital due to complications and has since had to have at the ripe old age of 29, a hysterectomy. All, as it has been discovered would have been PREVENTABLE through proper diagnostic measures and hospital monitoring while in labor. Ask her how she feels now.. very very guilty and stupid for bashing the people who could have saved her baby's life and discovered the problem months ago.
Anonymous, if you had taken the care to read carefully, you would have noticed that I said we are going to have the birth in the hospital with an excellent doctor doing the actually delivery. No midwife. No home birth in a bathtub. No birthing center. So, read more carefully for details before firing off.
You also seem to follow the premise that unless you do something for a living, you cannot educate yourself on a topic. By your logic, the only people who can understand the law are lawyers, the only people who can understand government are politicians, and the only people people who can understand music are musicians who play it. That seems quite narrow-minded and shows a person unwilling to expand their horizons or educate themselves on anything other than their profession.
Also, as I said we are not using the services of a midwife. I am not an authority on whether most midwifes attend college or not.
Sorry for your friend's misfortune. That story obviously makes you biased. Much as someone who had an experience with a doctor who committed malpractice would have issues dealing with doctors.
I wonder if you work in the medical profession? Your condescension towards non-medical people learning about what choices they want to make is exactly why some people have problems dealing with the medical profession.
No, I do not work in or for the medical profession.
A girlfriend mentioned this entry and I was curious to read what you had to say. I am at her house typing this and she actually agrees with you more than me, but I felt that I had to write in.
The details of how & what you are planning and who you are using or are not using during this process are ultimately irrelevant - it was the main "feel" of your blog, the lecturing on this topic that I found disturbing, as both a woman and a mother.
**MY MAIN CONCERN IS YOU DELIVERING MIS-INFORMATION TO POTENTIAL PARENTS WHO ARE READING THIS BLOG**
I want it to be clear to those potential parents to that you are not well educated nor considered experienced on this topic and regardless of how many numbers you cut and paste. You are simply someone with a strong opinion.
True. I am simply a person with a strong opinion. And if someone actually follows my medical advice based on a blog that primarily deals with music and movies...well, I cannot imagine that happening. I guess I should include a disclaimer at the top.
strong opinions are good!
Dez, i have been reviewing the past couple of posts and don't have much to offer but these two points:
1) I would rely on the thoughts of your OB/GYN. If they are cool with it, then that is great. There are a couple of point that you did point out that are generally medically refuted (like the stuff about some of the drugs entering the baby), at least in terms of their significance. So make sure you have your medical reasons reviewed by your doctor before basing your decisions on them. I am not saying that you have not been doing this, but at least I want to get this off my chest.
2) It appears that you are making these decisions based on the health of the baby and not, like so many mothers do, " on the experience." Your job as parents is to deliver a healthy baby, not to enrich your lives. That is a very selfish notion that grew out of the baby boom generation. And you know how I hate them boomers. As the husband of a woman who gave birth "naturally" and with drugs, my wife would be happy to tell you that she much preferred the drugs. The natural episode was the result of my own arrogance after watching the birthing videos a few weeks before where they described the labor process taking around 18 hours. So when my wife woke me a 2 am saying that her water broke she was going into labor, I did the following things before getting the two of us in the car:
1) Took a shower
2) Called her mom
3) Called her dad
4) Called my parents
5) Packed a bag for myself
6) Called her mom back to help her make flight arrangements for that day
7) Called her brother
8) called my sister
9) Called her mother back to confirm which flight she wanted to take.
By the time we got into the car, my wife was screaming in pain as I flew around 610 at 4 am. When we got to the hospital, my wife was in a lot of pain and asking for drugs, but the doctor would not give them because my beautiful daughter was already crowning. She was born about 10 minutes after we got to the hospital.
All that to say is that we did not plan for a natural childbirth, but I made sure it happened. There is no lesson in here for you, except maybe to say that the docs should keep the drugs nearby. Oh, and those birthing videos are full of crap.
Wow, Dez. You're gone for a couple of weeks, but you come back with a vengeance. I don't really have anything to add since I am totally ignorant on this topic.
I'm not crazy about pockyjack's comment on baby boomers, but I'll let it slide. I don't think I know him, but I'm sure he's a groovy cat.
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