American
Journal of Obstetrics & Gynecology 2006
Clinical Opinion by Dr. Ronald M. Cyr, MD
Fellow in the History of American Obstetrics and Gynecology
Excerpts
from the last two pages of this article -- p. 935 & 936
Public
Policy and the Cesarean Section Rate:
For the past 100 years, the
US
has lagged behind other industrialized countries in every measure of
health care quality, including maternal and neonatal mortality. It is a sad
indictment of our national priorities that millions of working American have
no healthy insurance and inadequate prenatal care.
In
Europe
, better perinatal outcomes are achieved with lower cesarean rates
and less spending on health
care. In those countries, midwives manage most low-risk pregnancies,
with obstetricians acting as consultants. How did procedure-oriented
specialists [i.e., obstetricians]
come to perform midwifery and
well-woman care in the
US
?
A hundred years ago,
most births occurred in the home. The apparent simplicity of obstetrics
contributed to its poor teaching (“see one, do one”), low status and
remuneration. DeLee – after Williams, the foremost academic leader of
the day – believed that obstetrics would never achieve respect as a
profession until “the pathologic dignity of pregnancy” was recognized.(19)
This meant accepting the premise that most pregnancies are potentially
abnormal, and must be managed by experts in order to achieve good results.
This view of parturition deliberately
excluded the midwives, who were systematically eliminated by organized
medicine on the grounds [unproven claim] that she was untrained, and a
threat to the developing “science” of obstetrics. Residency
training programs multiplied as births moved to hospitals during the 1920s
and 30s. Creation of the American Board of Obstetrics and Gynecology in 1930
formalized the notion that obstetrics was a specialty practiced by surgeons.
By the 1950s, birth in American had become a standardized
hospital ritual, presided over the procedure-oriented male doctors in solo,
fee-for-service practice. High-volume obstetrics was and remains the
bread-and-butter of community specialists – its drudgery offset by the
prospect of a busy gynecology practice in middle age.
For specialists, this was the golden era of obstetrics in
America
: having successfully promoted themselves as the sole purveyor of expert
maternity care in this country, obstetricians took credit for the
improvement n maternal and fetal welfare observed between 1940 and the
1970s. It has become apparent during the last few decades that more
sub-specialization, more technology – and more cesarean sections—have not yielded commensurate benefits to the population. They have,
instead, raised patient expectations
of perfect outcomes to unrealistic levels, further fueling litigation.
This impasse presents an opportunity to reexamine the way
obstetrics is practiced in the
US
. In contemplating change, a
major goal—after improving access to health care—would be to offer American women more maternity care options than exist
presently in most areas. Although
trained midwives provide safe obstetrics care, with lower cesareans sections
rates, they attend only 7% of births in the
US
– working mostly in environment where they don’t complete economically
with doctors.
So long as most women with health insurance are not
complaining about their care, there is little political incentive to change
the American way of birth and its high cesarean rate. However, other
forces are creating a shortage or mal-distribution of maternity care
providers, and this will spur a demand for alternative solutions” fewer
family practitioners delivery babies; increasing sup-specialization is
reducing the number of generalists and marginalizing their role in larger
centers.
In truth the average obstetrician-gynecologist compares
poorly to the family practitioner in the breadth of her training
for primary care, and there is little office obstetrics and gynecology that
cannot be performed competently by
midlevel practitioners. In teaching hospitals, the reduced work schedule
of residents is creating service needs that can only be addressed by
in-hospital personnel.
Because, by training
and inclination, obstetricians spend little time and support during labor –
why not phase out the generalist (non-perinatologist
OBs) altogether? A self-regulated
midwifery profession, working in collaborative practice with consulting
perinatologists, would appear to provide a better model
for *obstetric care [*actually
'midwifery' care, in the
global and historical sense of the term -- non-surgical maternity care to
healthy women].
In our “quick fix culture”(24),
one should not expect the cesarean
rate to drop without re-educating the public and the medical profession that
most births proceed uneventfully without interference, and that many
adverse outcomes can neither be anticipated nor prevented by cesarean
section.
Cultural changes take time; it
also requires inspired leadership and
grassroots support. In the meantime, let everyone practice the best
obstetrics [and midwifery!] they know and let the cesarean section rate seek
its own level.