NPR - CS -VBAC Index ~ 2002

ACDM

College of Midwives

National Public Radio
12/18/02 News story “Caesarean Births Hit
High Mark”

Resources and Hyperlinks
for Reporters

Who Speaks for Science in Court? Peter Huber, Attorney
~ The "gadgets and knives" phenomenon
George C. Marshall Institute ~ dedicated to providing rigorous, unbiased technical analyses of scientific issues which impact public policy Legal Scholar identifies the unscientific nature of obstetrical care, what he refers to as the ""gadgets and knives" phenomenon, perhaps most evident in obstetrics today".....

Cesarean Dangers - Greatly increases potentially fatal complications ~
Placenta Previa / Placenta Accreta /Percreta, Abruptions

Tort Law and its unintended consequences

Letter to Editor Santa Cruz Sentinel Newspaper
re: Associated Press stories on Midwifery Dec 2002

ONCE A CESAREAN, ALWAYS A CONTROVERSY - VBAC
article by Dr. Bruce Flamm. MD, reprinted Obstetrics and Gynecology

ACOG Guidelines -- in Oct of 1998 ACOG re-classified labor subsequent to
CS as the highest possible risk category, with mandatory continuous EFM and
the re-emergence of scheduled elective Cesareans for mothers who plan to give birth
in community hospitals which do no have 24 hours anesthesia and surgical scrub teams

Faith Gibson, LM, CPM
Director, California College of Midwives / Am College Community Midwives

NPR’s coverage of this article by Rob Stein published in the Washington Post on Monday, December 16, 2002; (Page A01) did nothing to reveal the nature of the controversy or the three most important facts.

(1) Cesareans are not “almost as safe as normal birth” when you count increased maternal mortality, emergency hysterectomy and the many long-term complications such as infertility, tubal pregnancy, miscarriage and abnormal placental implantation in future pregnancies. (Ob.Gyn.News Vol 36, Aug 1, 02) We won’t mention the huge cost of surgery and its many complications!

(2) The majority of Americans (apparently including NRP reporters) believe the self-serving myth of organized medicine that normal childbirth for healthy women is fundamentally dangerous and just too awful to bear and that massive medical intervention makes it so much safer and better – wrong on all counts!

(3) A minority of women have learned the hard way that this is not true and DO NOT want to be casually exposed to meddlesome medicalization (such as a Cytotec-inducted labor) or Cesarean surgery – especially women who had a previous Cesarean and do not want another one unless they have a genuine medical need. They are outraged at the idea of being forced into an “elective” Cesarean because obstetricians get cheaper malpractice insurance rates if they don’t permit spontaneous VBAC labors and hospitals find repeat CSs more profitable.

Organized medicine is delighted to have us believe that better living thru major abdominal surgery will save us all from the messiness of Mother Nature. This isn’t true – a fact that would have come quickly to light if your investigative staff had dug a little deeper. It is a matter of public record that childbearing women are three times more likely to die from complications of surgical delivery than from normal vaginal birth. The uncritical acceptance by the broadcast and print media of an escalating Cesarean surgery rate is as inexplicable as would an uncritical acceptance of escalating tobacco use, drunk driving or any other on-going public health problems.

According to a contemporary obstetrician from UC Davis (Dr. Elaine Waetjen) in an article on this topic published last year in Ob.Gyn.News “Cesarean surgery causes more maternal morbidity and mortality than vaginal birth. In the short term, C-Section doubles or triples the risk of maternal death, triples the risk for infection, hemorrhage and hysterectomy, increase the risk of serious blood clots 2 to 5 times and causes surgical injury in about 1% of operations. In the long term, cesarean section increases the mother’s risk of a placenta previa, accreta or percreta, uterine rupture, surgical injury, spontaneous abortions and ectopic pregnancies while decreasing fecundity. Babies delivered by cesarean have a higher risk of lung disorders and operative lacerations.” (Elective C-section Revisited by Dr. Elaine Waetjen, Ob.Gyn.News; April 1, 01, Vo l 36, No. 15) Cesarean babies also suffer triple the rate of asthma as adults. (Ob.Gyn.News, 6/15/01)

An expert in the field of obstetrics calculated that 500 Cesareans would have to be performed to save a single baby from the rare but acute problems of labor. That exposes 500 mothers to the risks and complications of major surgery and exposes 500 future babies to the complications of post cesarean pregnancy, resulting in the predictable (but preventable) death of at least one baby and maybe one or more mothers. As this physician put it “so you lose one to save one”. C-Section to Prevent Cerebral Palsy: Results May Be a Wash by Dr. Hankins Ob.Gyn.News; Apr 15, 02) No matter how noble the intentions, dying as a result of “friendly fire” is still dead. In the last couple of years the obstetrical profession has been promoting the “maternal-choice cesarean” as safer and better than normal birth (Dr Ben Harer, past president of American College of Obstetricians, Good Morning America interview, Jun 2000) but it is a warped idea of safety that discounts these many long-term complications. This includes mortality in a post-cesarean pregnancy -- 10% for women who develop placenta percreta and about 1/2% for newborns. The risks of Cesarean rise with each successive surgery. Elective Cesarean: An Acceptable Alternative to Vaginal Delivery? Peter Berstein, MD, MPH).

In addition to the human suffering caused by inappropriate Cesarean surgery, the routine medicalization of maternity care diverts scarce healthy care dollars to the “worried well” without improving perinatal mortality. Should the US ever face the aftermath of a bio-terrorist attack, we will be put in the miserable position of diverting life-saving medical and surgical resources away from the critically ill and injured to healthy pregnant women because doctors no longer know how to physiologically manage a normal labor and have trained society to be dependent on drugs and surgery for childbirth.

Organized medicine benefits greatly from having us all think that pelvic organs prolapse and incontinence is the inevitable “collateral damage” of normal childbirth. The problem is not the normal biological of childbearing women but rather the ‘abnormal’ (i.e., non-physiological) aspect of medical management. Obstetrics has become a kind of “agra-birth” business in which labor is hormonally accelerated and mechanically “managed” to maximize profitability.

Agra-birth practices gives rise to a cascade of subtle and overt interventions, such as too-early hospitalization, routine use of continuous electronic fetal monitoring, IVs -- all accompanied by the disuse of natural or non-drug pain management strategies such as showers, walking and deep water tubs. At least 50% of the time labor is induced or accelerated with artificial hormones (Pitocin and prostaglandins), which frequently causes an unnaturally strong and frequent contractions pattern without sufficient recovery time. Pitocin use almost inevitably makes labor too painful to tolerate without narcotics or epidural anesthesia. The benefits of “right use of gravity” are unavailable to a bed-ridden, medicated or anesthetized woman. For her the norm is an anti-gravitational position for birth in which she lays back in the bed while trying to push her baby uphill against a partially closed door (due to bearing weight on her sacrum). This wrong use of gravity brings unnecessary and unnatural harm to the supportive ligaments of pelvic organs and result in increased rates of incontinence.

These and other counter-protective obstetrical practices often bring about the necessity to use forceps or vacuum extraction. A forceps delivery is associated with a 20% incontinence rate. The medical profession’s response to these iatrogenic problem is to recommend greater use of the “maternal-choice” cesarean. In response to this dubious notion Dr. Elaine Waetjen commented:

“…why shouldn't we offer prophylactic C-sections to prevent this problem later in life? The answer is that the evidence does not support this approach. Preventive strategies should cause no more harm than the disease or problem that they are trying to prevent. Ideally, they should incorporate some kind of screening to identify people at risk. They should be cost effective and based on very good evidence of benefit. Elective C-section to preserve pelvic floor function fails on all these measures.” In documenting the failure of CS to prevent pelvic problems she calculated that one: “…would have to do 23 C-sections to prevent one such [pelvic] surgery later in life. …So instead of offering elective cesarean in an attempt to prevent future prolaspe or incontinence, we should be examining what we can do in our management of vaginal deliveries to protect pelvic floor function”. (Ob.Gyn.News; Elective Cesarean Revisited; April 1, 01, Vol 36)

As a professional midwife and spokesperson for the California College of Midwives, you may be suspect of the picture I have painted. So let me tell you about an important national survey from an impeccable source -- the well-respected Maternity Center Association (MCA) of New York City, a non-profit organization established in 1918. It promotes safer maternity care and develops educational materials for expectant parents on ‘evidenced-based’ maternity practices -- that is, policies that are based on a scientific assessment of the safety and effectiveness of commonly used methods and procedures.

This determination is based on the published work of Drs Ian Chalmers and Murray Enkins, the bible of evidenced-based maternity care, known as “A Guide to Effective Care in Pregnancy and Childbirth”(GEC). It is a review of all pregnancy and childbirth related studies published in the English language in the last 30 years. It identifies six levels of effectiveness/efficacy, ranging from the positive end of “clearly beneficial” (category 1) to the negative end (category 6) of “likely to be ineffective or harmful.” Using the preponderance of available evidence, Drs Chalmers and Enkins rate the safety and efficacy of each standard maternity-care practice and regularly used medical/ surgical intervention. Based on these categories, the Guide to Effective Care cautions that:

"Practices that limit a woman's autonomy, freedom of choice and access to her baby should only be used if there is clear evidence that they do more good than harm"

"Practices that interfere with the natural process of pregnancy and childbirth should only be used if there is clear evidence that they do more good than harm"

The Maternity Center Association has documented a significant gap between scientific evidence and standard obstetrical practice. Healthy, low-risk women in the United States often receive maternity care that is not consistent with the best research. According to the MCA, many people are not aware of the following major areas of concern:

~ The widespread use of certain practices that have both benefits and risks without

~ The widespread use of certain practices that have not been adequately evaluated for

According the MCA's “Listening to Mothers” survey published October 24, 2002: “There were virtually no natural childbirths among the respondents with the small exception (under 1%) of births that took place at home”. Of healthy women who delivered at term in the last 24 months, the MCA survey documented that 93% were exposed to continuous electronic fetal monitoring (associated with increased Cesarean sections rates without improvement in perinatal mortality), 86% had IVs while being prohibited from drinking or eating, 74% were required to give birth lying on their back, 71% were immobilized / confined to bed / not permitted to walk during labor, 67% had artificial rupture of membranes, 63% had labors induced or accelerated with artificial oxytocin (Pitocin), 63% had epidural anesthesia, 58% had a gloved hand inserted into their uterus after birth (increases uterine infection), 52% had bladder catheterizations (increases bladder / kidney infections), 35% had episiotomies, 24% had cesarean surgery (increases maternal mortality 2-4 times, increases abnormal placentation / emergency hysterectomy in subsequent pregnancy) and 11% of babies were delivered via forceps or vacuum extraction, for a total operative delivery of 35%, or 70% if episiotomies are included.

Please note these statistics are for healthy women at term with normal pregnancies. Intervention rates would be much higher for women with premature labor, multiple pregnancies or medical complications. (See full report @ www.maternity.org) This accounting is consistent with data from the CDC’s National Center for Health Statistics Vol. 47, No 27, The Use of Obstetric Interventions 1989-97 (enclosed), which documents a steady annual increase since 1989 in each of these interventions and the recent report on Cesarean rate for 2001 published by the CDC.

The Maternity Center Association recommended “more physiological and less procedure-intensive care during labor and normal birth”. The beneficial practices identified by the Guide to Effective Care are protective and reduce medical and surgical interventions and yet they are absent for the majority of women giving birth in this country under obstetrical management. These protective methods are based on the physiological management of labor and birth and requires a respect for the normal biology of reproduction and a commitment not to disturb the natural process.

The elements of success for normal labor and spontaneous birth are the same for doctors, nurses or midwives. While physiological management of labor reduces the requests by laboring women for pain meds or epidural anesthesia, it does not mean that hospitalized mothers cannot receive pharmaceutical analgesia whenever necessary. The only down-side of physiologically-based care is that hospitals can’t bill as much for the nurse or midwife’s professional services as they can for medical or surgical ‘procedures’ performed by physicians. This means that normal birth is not as profitable to the medical establishment as inductions and operative delivery. In a tight economy like ours, the cost savings from normal management should be turned into a ‘plus’.

In particular, the obstetrical community’s 30-year romance with continuous electronic fetal monitoring (EFM) should carefully scrutinized. False positive rate for abnormal fetal heart patterns quoted in medical journal is 99.98%. (N.Engl. J. Med 334[10:613-19, 1996). Despite this extremely low rate of accuracy, two of every three cesareans done during labor are for fetal distress as indicated by continuous EFM. However, listening to fetal heart tones with an electronic Doppler every half hour for one full minute immediately after a contraction (called Intermittent auscultation or ‘IA’) is equally effective as continuous EFM, with a greatly reduced CS rate. Thankfully intermittent auscultation (IA) unhooks healthy mothers from machines and replaces faceless electronics with the warm hand of a friendly helpful nurse or midwife.

Equally important, Intermittent Auscultation permits laboring women to move around, change positions frequently, walk, use showers or deep water for pain relief and make “right use of gravity” to reduce the need for Pitocin, anesthesia and operative delivery. Organized medicine often complains that IA is impractical as it requires one-on-one nursing care and that it “isn’t being taught any more.” (ObGynNews Vol 37, Oct 01/02). The dirty little secret is that many insurance companies reimburse hospitals at $400 an hour for continuous EFM, which is applied to the entire 3 to 33 hours of labor for 3,790,000 women each year (93% of annual births). That makes it a cash cow. The salary of L&D nurses in hospitals is nowhere near $400.00 an hour.

The practice of Flat Earth Obstetrics is a 21^st century version of a medical Dark Ages, in which contemporary medicine has forgotten the traditional knowledge base for normal birth. What we “know” from all sources – both historical and contemporary science -- is that the medicalization of normal birth always makes it more dangerous than it would otherwise be. We “know” that the safest management is “physiological” – a form also known as the “midwifery model of care”. This type of normal care is associated with the best maternal-infant outcomes and is provided by physicians and midwives around the world with excellent results.

So dare I suggest that NPR devote an equal amount of time and space to an inquiry on why the majority of childbearing women do not receive the safer and more satisfactory type of care established as beneficial in the Guild to Effective Care and instead are routinely exposed to a plethora of practices in the bottom three categories rated as of “unknown or unproven effectiveness, unlikely to be effective or known to be harmful”, including ever expanding excuses to take that most drastic and dangerous of actions – elective Cesarean surgery.

Can we count on your publicly supported organization for a thoughtful, unbiased inquiry into this important topic? This scandal is hidden in plain sight, impatiently awaiting the application of common sense. The documentation is massive and impeccable and traces back to the early 1900s. Do you perhaps have a bright ambitious reporter on your staff that is looking for a unique opportunity to investigate something of great importance to society, someone who wouldn’t mind being recommended for a Pulitzer Prize in investigative journalism?

Considering that maternity care is 20% of the national health care budget, that 40% of all births are paid for by the federal Medicaid program, that we are facing a huge budget deficient, that bio-chemical terrorism would overwhelm our current interventionist and drug intensive obstetrical system, that maybe, just maybe the normal or ‘physiological management’ by physicians and midwives as the foremost standard for healthy women is an idea worth exploring.

I am a “robust” supporter of KQED radio, my local public broadcasting station, to the tune of many hundreds of dollars every year. I hope my faith is justified that publicly support radio is a voice for those important aspects of American life that are beyond or above the commercializing of the news. You are our last best hope.

I suggest that you contact a spokesperson at the American College of Nurse Midwives in DC (Karen Fennell RN, MS; Senior Policy Analyst kfennell@acnm.org (202) 728-9871), Maternity Center Association (www.maternity.org ), Coalition to Improve Maternity Services (www.motherfriendly.org), the International Cesarean Awareness Network (Tonya Jamois 760 / 744-5260) and Susan Hodges (888 / 236-236-4880) of Citizens for Midwifery (www.cfmidwifery.org ). Within the next 24 hours I will put a direct link on the College of Midwives web site (www.collegeofmidwives.org) that leads to many of the professional references and resources that would be helpful to an in-depth story. Simply go to the home page for our web cite and look for a “NPR Reporter -- Click Here” hotlink under the large photograph.

Executive Director,
California College of Midwives, State Chapter,
American College of Domiciliary Midwives
3889 Middlefield Road
Palo Alto, Ca 94303
650 / 328-8491

Instructions for eOb.Gyn.News web site < www.eobgynnews.org> This trade paper advertises itself as the “Leading Independent Newspaper for Obstetricians and Gynecologists”. It is the equivalent of the “Reader’s Digest” for docs as it is synoptic reviews of journal articles and “poster presentations” by physicians at various obstetrical conferences.

Register as “other” or “Press” and use site search to enter the title of the article. If you only have the topic or the date, enter that and scroll down the list of articles until you find it. You can print out any of the 1 or 2 page articles.

List of Citations, abstracts, excerpts and other supportive documentation

“Listening to Mothers” survey – Report of the First National US Survey of Women’s Childbearing experiences conducted for the Maternity Center Assoc. by Harris Interactive - Oct 2002

Guide to Safe and Effective Care During Labor and Birth, 2000; Maternity Center Association

The Rights of Childbearing Women, 1999, Topical Guides from the Maternity Center Association

Letter from obstetrical practice terminating care because the mother was planning a home birth, 1999

Physiological Management of Normal Birth

Upright Positions Offer Most Room for Delivery Ob.Gyn.News Feb 1, 2002, Vol 37, No 3

Delayed [i.e., Physiological] Pushing Doesn’t Increase Fetal Trauma Ibid above

Births: Preliminary Data for 2001; NVSR Vol. 50, No. 10 – Cesarean rate for 2001 24.4 %

National Center for Health Statistics Vol. 47, No 27, The Use of Obstetric Interventions 1989-97

Elective Cesarean: An Acceptable Alternative to Vaginal Delivery? Peter Berstein, MD, MPH

Violence Against women in Healthy-care institutions: an emerging problem The Lancet, 5/11/02

The Connection between Continuous Electronic Fetal Monitoring and Increased Cesareans

FDA Reviews Continue on New Fetal Monitor Ob.Gyn.News Oct 1, 2002, Vol 37, No 19

Who speaks for Science in Court - Attorney Peter Huber, George C. Marshall Institute, Excerpt

Ultrasound / Pitocin / Cytotec / Maternal/Baby Death

Ultrasound Comparable to Educated Guess in Predicting Birth Weight; Ob.Gyn.News Oct 1, 02,

Induction Rate Doubled in the US from 1990 to 1998; Ob.Gyn.News May 1, 2002, Vol 37, No 9

Package insert for drug Pitocin (Oxytocin , USP, Synthetic manufactured by Parke-Davis, 1996

Understanding Autism Newsweek July 31, 2000, association Autism and Pitocin induction

Un-Informed Consent – by Loren Stein, Cytotec use / mother-baby death, Oakland Tribune article

Episiotomies /Forceps / Incontinence

Episiotomies Still Favored by Private Physicians; Ob.Gyn.News July 1, 2002 Vol 37, No 13

Episiotomy Scars Have Increased Failure Rate; Ob.Gyn.News July 1, 2002, Vol 37, No 13

Frequency and Dangers of Cesarean Surgery

A Scar is Born – every 39 seconds – Cesarean rate in 1995 / medical journal advertisement for a silicone sheeting product to reduce scarring in Cesarean incision; Ob.Gyn.News, April 15, 1998

The Maternal Choice Cesarean – Excerpts from transcript of “Good Morning America” interview by Diane Sawyer of former ACOG president, Dr Ben Harer, MD; June 2000;

Why the C-section rate is rising – Guest Editorial, Medical Economics, Obstetrics-Gynecology, Oct 2000; Elective C-section Revisited by Dr. Elaine Waetjen; Ob.Gyn.News; August 1, 2002, Vol 36, No 15;

C-Section to Prevent Cerebral Palsy: Results May Be a Wash; Ob.Gyn.News; April 15,2002, Vol 38, No 8; Cesarean Rate Portends Rise in Placenta Accreta, Maternal mortality 7% Ob.Gyn.News Mar 1 01, Vol 36; Placenta Previa, C-section History Ups Accreta Risk; Ob.Gyn.News Sept 15, 2001, Vol 36, No 18;

Higher Rates of Respiratory Distress Seen with Cesarean; Ob.Gyn.News Dec 1, 2001, Vol 36, No 23;

Cesarean Birth Associated with Adult Asthma; Ob.Gyn.News Jun 15, 2001, Vol 36, No 12

Double-Layer Cesarean Closures May be Safer – Uterine rupture more likely with one-layer closure; Ob.Gyn.News, Mar 15, 2002, Vol 37, No 6; Experts Say Cesarean Section Rates are Headed ‘Sky-High”; Ob.Gyn.News, April 1, 2002, Vol 37, No 7; Trial of Labor, Repeat C-Section Equally hazardous, Ob.Gyn.News, Vol 36, No 8