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The Hero's Journey

Neonatal Complications of elective CS, Maternal Complications, Methodological Questions VBAC Study, Complications of Single Layer Closure of Uterus, Political Motivators for Organized Medicine, a Cesarean every 39 Seconds and other Chilling Statistics, the Media & its Cone of Silence, Autism and Pitocin, Intrapartum Narcotics and future Adolescent Drug Addiction, Operative delivery and Postpartum Depression, Time for a Change -- Cesarean Prevention and other Successful Strategies, Request to the Media

This is an “Open Letter To the Press and the Media” concerning unsatisfactory coverage of a VBAC Study published in the July 2001 edition of the New England Journal Of Medicine (NEJM) entitled “Risk of Uterine Rupture during Labor among Woman with a Prior Cesarean Delivery”. It was reported by Associated Press and carried by newspapers all across the country under the headline “Labor Risky After Cesarean”. National Public Radio reported on it extensively the 3rd & 4th of July.

As a former L&D nurse (17 years) and now as a professional midwife I stopped being shocked years ago by the excesses and exaggerations of organized medicine, not only as it is practiced but especially as reported by the press and the media. But I admit that the biased coverage of the study on Vaginal Birth After Cesarean got my attention. Incredibly enough, the press identified the primary “danger” for VBAC mothers not as the use of powerful uterine stimulants to induce labor in women with a surgically-scarred uterus but rather as having a normal labor and spontaneous birth after a previous cesarean.

I am nearly speechless at the misrepresentation of this situation and the hazards that childbearing women would be exposed to should this misleading information propel the already excessive use of cesareans to even greater heights. Make no mistake about it -- it is the use of prostaglandin and other labor inducing drugs on VBAC women that should be abandoned – not normal labor. That is the real news, along with the public acknowledgement that use of Cesarean surgery carries added dangers not found after normal birth, a fact always well known by doctors but rarely admitted to the public. (1. ONCE A CESAREAN, ALWAYS A CONTROVERSY – VBAC; Dr. Bruce Flamm. MD) Our incredibly high Cesarean rate is fueled by the mistaken notion that it does not matter how the baby is born “as long as it is healthy”.

Comments by various physicians interviewed for the NPR story reflected the historical bias of obstetrical medicine for surgical solutions that ignore or downplay the complications, pain and expense of surgery. Media coverage included statements recommending that women with a prior Cesarean should not labor and instead, for “safety’s sake”, schedule a repeat Cesarean and suggested that perhaps a return to the policy of “Once a Cesarean, always a Cesarean” was in order. The story ended with an interview of Dr. Michael Greene, MD, Director of Maternal-Fetal Medicine, Massachusetts General Hospital who said “…if the question you’re asking is, ‘What is safest for the fetus?’ There’s no doubt repeat Cesarean is safest.”

One can only come to that dubious conclusion by focusing exclusively on the baby to the detriment of the mother and even still it is only a partial truth. There are serious health problems for post-cesarean babies not measured by this study, such as iatragenic prematurity and respiratory distress. Elective repeat Cesareans have a fetal mortality of 2 to 3 per 100 operations (2. Obstetrics: Normal and Problem Pregnancies Gabbe, 1991) An example of long-term health hazards was found in a recent study done in the UK which identified that being born by Cesarean triples the risk of adult asthma. (3. Journal of Allergy & Clinical Immunology 107[4[:732-33, 2001) Another factor is the detrimental impact on the mother-child relationship from an increase in postpartum depression (PPD) and post-traumatic stress symptoms associated with operative deliveries. PPD is more common and more sever after the added stress of a Cesarean or other operative delivery and when a baby is premature or must be in the intensive care nursery after the birth. (22. Predictors, prodromes and incidence of postpartum depression. Obstet Gynaecol 2001 Jun)

The news story completely failed to acknowledge the risks of elective surgery to the childbearing women at the time of the operation and complications in future pregnancies, including an increase in postpartum depression. Cesarean surgery increases maternal deaths by 2 to 4 times compared to normal vaginal birth. Maternal mortality associated with vaginal birth is only 1 out of 16,666 but jumps way up to 1 out of 3,225 after a Cesarean. (4. Lilford, 1997 et el) One popular obstetrical text reports Cesarean-related maternal deaths to be as high as one out of thousand. (1. Gabbe, 1991) In spite of these known dangers the US has a higher CS rate than any other country except for Brazil while remaining among the bottom five industrialized countries in perinatal safety. Irrespective of this dismal record we spend far more on childbirth services than any other country.

Maternal deaths associated with elective Cesarean surgery are estimated to be one out of 5,000 – more than 3 times the risk of a normal birth. (5. NEJM 5/9/85) Many complications of elective repeat CS are the very same as those of uterine rupture, such as maternal death, emergency hysterectomy and blood transfusion that may infect the mother with HIV or hepatitis. Other complications of elective Cesareans are wound infections, other antibiotic-resistant infections, medication errors, drug reactions, anesthetic accidents, surgical mistakes such as inadvertently cutting into the bladder or bowel, severing a uterine artery, accidentally tying off a ureter, surgical laceration of baby, neonatal respiratory distress and nosocomial (hospital-based) infection. (1. Gabbe, 1991)

The VBAC study and subsequent news reports also failed to mention the vast increase in placenta previa and abnormally adherent placenta in subsequent pregnancies that plague post-cesarean mothers. For example, the actress Madonna had a non-emergency Cesarean in her first pregnancy, followed by a placenta previa and emergency CS the next time. The risk of these potentially fatal problems increases with each CS, until it is a staggering 25% for a fourth post-Cesarean pregnancy. In its worst form - placenta percreta - it is fatal to 10% of mothers, even in the best of hospitals. Research says: “Given the known association between placenta previa and placenta accreta/percreta, it is not unreasonable to suggest that the increased cesarean delivery rate has directly contributed to the rising incidence of placenta accreta/percreta.” (6. Obstetrical and Gynecology Survey Vol 53, No 8, p 48, CME Review Article 24 1998).

The study also does not address the issue of routine inductions of labor when the mother reaches term (39-41 wks of pregnancy) or based on an above-average estimated fetal weight (macrosomia). Many excellent studies, including the bible of evidence-based maternity care “Effective Care In Pregnancy and Childbirth “ (7. published by the Cochrane obstetrical database 2001), do not support the efficacy of routine induction for healthy women with a normal pregnancy or a larger than average baby. A recently published study concluded that “Routine labor induction at 41 weeks likely increases labor complications and operative delivery without significantly improving neonatal outcomes.” (8. Forty weeks and beyond: pregnancy outcomes by week of gestation. The University of Texas) Many primary Cesareans were the result of a “failed induction” that was never medically necessary but recommended by managed care as “cheaper” than tests to assure fetal well-being or chosen by physicians as more convenient or as a hedge against malpractice litigation. (9. Induction of labor as compared with serial antenatal monitoring in post-term pregnancies Hannah, M.E. et al 1992, NEJM) This flawed logic is then repeated in the subsequent pregnancy in which the mother is asked to choose between the vastly increased risk of a VBAC induction or the increased risk of another Cesarean.

Contrary to the conclusion drawn by those reporting on this research, many childbearing women see the information in the July 2001 NEJM VBAC study as an excellent argument for “cesarean prevention”. The most efficient way to prevent Cesarean-related tragedies is to avoid CSs – whether that is the first time or in subsequent pregnancies.

The VBAC study by Dr Lyndon-Rochelle is a valuable, well-constructed (but limited) piece of research providing useful information but it breaks very little new ground. It is inaccurate to portray this research as having “discovered” the risk of vaginal birth after cesarean. For many decades researchers have noted that surgically incised uteri rupture more frequently than those that are intact and unscarred. This is not new “news” and is only useful when viewed holistically, in the context of all other known risks. There is no perfectly safe solution for previous CS women – a reason to try doubly hard to prevent the primary operation.

The important original data documented by the study was an order of magnitude increase in uterine rupture when prostaglandins are used as cervical ripening agents. The study’s second major contribution is data differentiating the specific percentage of VBAC risk between a spontaneous physiological labor, oxytocin-induced labor without prostaglandin and oxytocin-induced labor which includes the prior use of prostaglandins. It should be noted that prostaglandins are cervical softening agents designed to prepare the cervix and thus are a precursor to the use of the oxytocin hormone Pitocin (manufactured by Parke-Davis). Pitocin (not prostaglandin) is the drug that actually triggers progressive cervical dilatation and its use is always associated with an increase in uterine rupture, postpartum hemorrhage, and fetal distress, even for mothers with an unscarred uterus.

The product insert that comes with every package of Pitocin lists 11 serious or fatal “adverse reactions” (complications) for the mother and 7 for the unborn or newborn baby, including uterine rupture. It also specifically cautions that Pitocin NOT be used on any women with a scarred uterus, including previous cesarean mothers. (10. Pitocin Insert, Parke-Davis 1996 Warner-Lambert Co) The prostaglandin cohort of women in the study would generally be exposed to the risks of both drugs, thus it is no surprise that they would have a risk of rupture 15 times greater than women who had no labor at all.

The data reported in the study is valuable to woman and their doctors, to aid them in separating out the various risks so they may be considered individually in arriving at truly informed consent decisions. However the study must be faulted for not factoring in any of the well-known risks for both mothers and babies of elective CS or its sequelae in future pregnancies. There are also some methodological questions and deficiencies since this was a retrospective study over a long period of time that could not control for a number of factors. For example, there is no way to know if the medication protocol used by the many different hospitals and different doctors were the same or consistent with what is being used in the year 2001. We don’t know if the timing, dose or drug used (e.g. Cytotec) would still be judged appropriate today. We don’t know whether the mother received one-on-one nursing or midwifery care so as to catch emerging complications early in the curve, such as hyperstimulation of the uterus or tetanic contractions (dangerously long or hard contractions increase the risk of rupture and fetal distress).

Did not account for experimental technique -- Single Layer Surgical Closure --
associated with increase in Placenta Percreta and 5-fold increase in uterine rupture

Nor did the study account for the change in operative technique in the early 1990s. On the basis of a study published in a professional journal obstetricians changed suturing technique for the uterine incision from the traditional two layers method to a “single layer closure”. This experimental method is promoted as saving about 5.6 minutes and reducing the surgeon's exposure to HIV/AIDS. It has been so widely accepted that it is often not even noted on the operative report. Dr. Steven Clark of the University of Utah Medical School recently conducted a study indicating this abreviated technique accounts for the increased frequency of ruptures seen in the last few years (30). Dr. Kurt Bernischke, a Boston pathologist and author of Pathology of the Human Placenta, believes it is also responsible for a huge increase in placenta precerta. The results and conclusion of one study state: "Women with a previous 1-layer closure (n=398) had a rate of uterine rupture of 3.3%, whereas those with a previous 2-layer closure (n=1251) had a rate of uterine rupture of 0.6% (p<.001) ..... A 1-layer closure at the previous low-transverse CS is associated with a 5-fold greater risk of uterine rupture during a trial of labor for the subsequent delivery than a 2-layer closure." (11. Uterine rupture during a trial of labor after a one- versus two-layer closure of a low transverse cesarean. Emmanuel Bujold, American Journal of Obstetrics and Gynecology (supplement) 184(1):S18, 2001)

The NEJM VBAC study did not factor in new information such as the increased risk of rupture from a very short time between pregnancies. Delivery in less than 18 months is known to triple the rate of uterine rupture. (12. Interdelivery Time Affesct Uterine Rupture Risk During trial of Labor abter Prior Cesarean, Obstet Gynecol 2001;97:175-177) It also had no way to factor in newer methods of risk reduction such as the use of ultrasound in late pregnancy to check for uterine scar integrity and thickness of lower uterine segment (extreme thinning of the lower segment is associated with increased number of uterine ruptures). Real world recommendations must take all these factors into account.

“Once a Cesarean always a Cesarean” trades but does not prevent complications

A return to elective, pre-labor repeat CS as a safety measure is convoluted logic, similar to saying that women should have elective mastectomies to prevent breast cancer. Yes, of course it would prevent most (not all) but at what cost of otherwise unnecessary pain, dysfunction and financial expense. Neither does scheduling repeat CSs prevent all uterine ruptures. The risks for a previous cesarean mother are never zero – in the study 11 out of 91 women (about 12%) had a rupture BEFORE labor, meaning that just having had a CS is itself dangerous in future pregnancies. When Dr. Greene says there is “no doubt” that repeat Cesarean is “safest for the baby”, he obviously was not talking about the safety of the baby in the next pregnancy.

Reinstating the policy of “once a Cesarean always a Cesarean” trades the rare complications of spontaneous VBAC labor for increased maternal deaths from elective surgery or placenta percreta and equal number of neonatal deaths or disability from iatragenic prematurity, and does so without any truly informed consent. This assumes that it is somehow morally superior to die or be damaged from aggressive surgical “over treatment” rather than from the equally reasonable choice of “under treatment”, that is planning a non-induced normal labor. This notion only addresses the physician’s fear of malpractice litigation and also reflects a subtle sexism, in which the baby, as the “product” of obstetrical services, is assumed to be the real prize and more important than the woman.

Recognition of these facts brings into question a plethora of other “routine” obstetrical interventions (such as routine induction and the imposition of arbitrary time limits) and lack of effective labor support for the mother (continuous, one-on-one caregiving, non-pharmaceutical pain management such as showers and deep water) and failure to use upright and mobile positions for pushing. These dubious practices all increase the likelihood of an unnecessary cesarean delivery and preventable maternal death. It is widely acknowledged by public health officials and the CDC that maternal mortality is under reported by anywhere from one third to double the amount reported now. (12. Maternal Mortality Rate Grossly Underestimated Dr. James Gell, Michigan Maternal Mortality Study, ObGyn News Jan 13, 2000 ) According to the CDC maternal deaths rates has not fallen since 1982 in spite of medical “improvement” and in the availability of legal abortion, which used to be responsibility for 50% of all maternal deaths. However this does not figure into the equation the a high level of underreporting which in one study revealed deaths three times the expected rate (13. Maternal deaths in an urban perinatal network, 1992-1998. Am J Obstet Gynecol 2000 Nov;183(5):1207-12) Curiously, this time frame tracks exactly with the ever-increasing CS rate. Might there be the same correlation with medical errors or excesses in obstetrics as the Institute of Medicine has documented in the 80,000-plus iatragenic deaths each year from mistakes in other areas of medicine? These are the issues the media completely missed, an oversight that I hope will be speedily rectified.

The Story Behind the Study – Political Tension between Obstetrics and Managed Care

Unfortunately the media coverage of this story reads like an advertisement for the increased and uncritical use of Cesarean surgery. The story circulated by the Associated Press and reported on National Public Radio did not mention the political tension between the obstetrical profession and health insurers, although this was inferred by one of the doctors interviewed on the air. Nor did the press coverage reveal the long-held hidden agenda of organized medicine for an easier life and bigger piece of the economic pie by an increased use of cesarean surgery. Obstetrical organizations promote the casual use of Cesarean surgery as insurance against malpractice litigation, with the added bonus of reducing the doctor’s time commitment and the convenience of daylight scheduling. When faced with any potential problem in pregnancy, obstetricians readily remark (in print and in person) “When in doubt, cut it out”. This explicitly refers to the notion that Cesarean surgery solves every dilemma for physicians but ignores the pain and problems created for the mother. No question that “daylight obstetrics” is an advantage for obstetricians -- however the point of maternity care is suppose to be the well being of mother and babies. As John Stossel says every week on 20/20 “Give Me A Break!”

The real news is the story behind the study. Obstetricians are extremely displeased with managed care for many things but especially for insisting that doctors offer a trial of labor to previous CS women when they would prefer to do a repeat CS or the mother would prefer to have an elective CS. Several obstetrician authors and position papers by the American College of Obstetrician and Gynecologist (15. ACOG Practice Bulletin #2 on VBAC ~ Oct 1998) have been written in an attempt to reassert the absolute right of doctors to make all these decisions independently from insurers. Doctors would like a return to the day when repeat Cesareans were the rule and VBAC the exception.

While I agree with the wisdom of doctors making medical decisions, I must note that ACOG’s favorite strategy has been to emphasize the riskiness of VBAC (without providing the circumstance to reduce the number of primary CS performed) and to recommend a return to elective CS unless extremely tight criteria can be meet. This includes the full-time presence of the obstetrician as well as paying on-call fees for an anesthesiologist and OR scrub team to stand-by while a previous CS mother is in labor, thus making VBAC more expensive to insurers than scheduled elective surgery. A recent position paper written jointly by ACOG and the American Society of Anesthesiologist (ASA) recommends closing all maternity departments in hospitals that have less than 500 births a year, a conclusion based in part on the issue of anesthesia coverage for VBAC labors. (16. http://www.collegeofmidwives.org/news01/ACOG_AnesPolicy01.htm)

The July 2001 NEJM VBAC study is being promoted as ammunition in this fight for supremacy between doctors and health insurers, complete with orchestrated media coverage and spin doctoring. This on-going effort by organized medicine included an earlier article published by obstetricians in the NEJM “questioning” the recommendations made by the National Institute of Health’s Task Force on Cesarean Childbirth, which state that the Cesarean rate in the US is too high and sets a target rate of under 10%. Obstetricians insisted that no one knows what the safest rate for CS might be and maybe more babies would be saved if it was even higher that the current 23% (note – many developed countries with lower CS rates have better perinatal outcomes). In the NIH’s original 1980 Cesarean recommendation, the principle author, Dr. Norbert Gleicher, estimated that each percentage point increase in Cesarean rate added $63 million additional expense for maternity care. This figure would no doubt be doubled today’s economy, for an estimated $126 million per percentage point.

Instead of promoting these well-reasoned recommendations, obstetricians are instead promoting the idea of “Cesarean on demand”, typifying them as “safer”, “better”, “maybe should even be routine” and touting it simply as a matter of a “woman’s right to choose”. (17. Good Morning America, 6/20/2000 interview of ACOG president Dr Benson Harer) On Good Morning America, Dr. Harer answered Diane Sawyer’s question on relative safety between normal birth and elective CS by saying: “For the mother, the immediate risks for a cesarean section are a little higher, but .. over the long time I think that the risks balance out … there really is no big difference.” Perhaps Dr. Harer is unfamiliar with the last 100 years of his own professional literature or maybe “excess” maternal mortality is no big deal to him. Personally I’m glad he’s not my daughter’s doctor, as it would be a big deal to me if she died as a result of a medically-unnecessary Cesarean.

There are 4 million births a year in the US, with a 23% cesarean rate (900,000+ CSs annually), the most frequently performed major surgery in the US. Or as a product advertisement in obstetrical journals proclaims (“For Problem Scarring” of cesarean incisions), “a scar is born every 39 seconds”. Yes, you read that right – every 39 seconds! (18. ReJuveness by RichMark International Corp – statistics based on 1995 CS rate) In 1995 there were 80 Cesareans every hour, round the clock, 365 days a year. In 2001 it’s probably one CS every 29 seconds! We spend 20% of our entire healthcare budget on maternity services. Clearly management recommendations for post cesarean pregnancies is not a trivial topic, either economically or for the families involved. Unfortunately for us all, a lot of the recommendations by medical groups are either shortsighted or self-serving. This propensity for partisan politics is absolutely consistent with the history of organized medicine and should come as no real surprise to news organizations. Exercise of free-speech rights by trade groups requires that these parochial pronouncements be balanced by on-going and critical inquiry by the press and media.

An example of how far the perspective and the agenda of the medical community is from the expectations of the public and interests of childbearing women is offered in an article also published NEJM, May 1985, by George B. Feldman, MD, Jennie A. Feldman, MD entitled Prophylactic Cesarean Section at Term? This article brings into sharp contrast how much we all need unbiased investigative reporting by media to explore these conflicts of interest. As did the ACOG president on Good Morning America, the Doctors Feldman make the “case” for Cesarean on demand and seriously promote the idea that a 100% scheduled or “prophylactic” cesarean become the norm for all women. This drastic idea is seen as a preemptive strike to protect the baby from the “dangers” normal labor and birth and would change the professional focus of doctors to determining when fetal lung maturity was achieved so that the CS could be scheduled before (gasp!) the mother went into spontaneous labor (a mistake of course!) and (gulp!) gave birth naturally!.

The Doctors Feldman make a statistical case for cesarean surgery as “saving” babies with only a little “excess” or “extra maternal mortality” and opin that the “low cost of excess maternal mortality” may be a price worth paying. Here is a short excerpt:

p. 1266 ….the number of extra women dying as a result of a complete shift to prophylactic cesarean section at term would be 5.3 per 100,000…. This may be the proper moment to recall that the number of fetuses expected to suffer a disaster after reaching lung maturity is between 1 in 50 to 1 in 500. … if it could save even a fraction of the babies at risk, these calculations would seem to raise the possibility that a shift toward prophylactic cesarean section at term might save a substantial number of potentially healthy infants at a relatively low cost of excess maternal mortality.

We probably would not vary our procedures if the cost of saving the baby’s life were the loss of the mother’s. But what if it were a question of 2 babies saved per mother lost, or 5 or 10 or (as our calculations roughly suggest) as many as 36 or 360? …. Is there some ratio of fetal gain to maternal loss that would unequivocally justify a wider application of this procedure?

p. 1267….is it tenable for us to continue to fail to inform patients explicitly of the very real risks associated with the passive anticipation of vaginal delivery* after fetal lung maturity has been reached? If a patient considers the procedure and decides against it, must she then be required to sign a consent form for the attempted vaginal delivery? (*emphasis mine)

My answer to the Doctors Feldman is no, there is no “ratio of fetal gain to maternal loss that would unequivocally justify a wider application of this procedure”. That is a choice ONLY the mother and father can decide to take.

My question for doctors is quite different from the Doctors Feldman as I want to know if it is tenable for them to continue to fail to inform healthy women of the high risk associated with “obstetrics as usual”, what with its high rate of risky procedures such as induction of labor and cesarean surgery and its low or non-existent use of effective and low-cost methods to reduce these problems, such as staffing hospitals with nurse midwives, which, unlike physician care providers, enjoy both a low rate of interventions of all kinds (especially induction, episiotomy and Cesareans) while having excellent perinatal outcomes and achieving all this for a third less money? (19. Midwives Deliver Healthy Babies With Fewer Interventions Dr. Roger Rosenblatt, MD University of Washington )

My question for the media is why there is so little effective investigative reporting relative to obstetrical practices? The issue is not just VBAC induction (a very bad idea) versus automatic repeat CS (another very bad idea) but the entire cone of silence that permeates press coverage of these issues.

Several times a year news magazines and television broadcasts report on various health-care related topics that raise questions about “obstetrics as usual” but never seem to explore any of the potential answers or include any follow-up stories. For example, a July 2000 cover story for Newsweek was about an explosive increase in childhood autistic disorders, a severe problem in which the majority of these children wind up institutionalized by the age of 13. One of the possible explanations mentioned was a statistical link between the increase in autism and the increase in labors induced with Pitocin. It quoted Dr. Eric Hollander (director of an autism clinic at Mt Sinai Medical Center in New York) as reporting that 60% of his patients were the product of a Pitocin-induced labor. To my knowledge, not another word has been raised in public or in print about this potential drug connection, even thought the article identified that more children suffer from the scourge of autism than childhood cancer or Downs Syndrome – as high as 1 out of 500. I can appreciate the litigious nightmare for Parke-Davis if that observation turns out to have merit, as a lot of “Vitamin P” (as L&D nurses jokingly refer to it) is being used these days.

Drugs and surgery have many consequences beyond those desired in the moment. Genomic research has identified that some individuals have small errors in their DNA that result in a paradoxical or toxic effect from drugs that are otherwise helpful or at least without harmful side-effects. Just last week Newsweek (July 9 issue) carried a story about “Designer Drugs” in which it identified a study in which .3% of the population had a missing letter in their DNA code for a particular drug. People with this error had potentially fatal reactions to this drug.

Mothers in labor are routinely given several different drugs without any way to know if their unique DNA code makes them or their unborn baby vulnerable to toxic side effects. The propensity to have an adverse reaction must be multiplied by the number of drugs received, and then must be doubled as they are being given directly to the mother and delivered to the baby via the umbilical cord. For the baby, whose virgin brain is being influenced by these substances, the risk of side effects is both immediate and life long. Studies done in Scandinavia have concluded that narcotic use during labor (within 10 hours of birth) results in a statistically significant increase in drug abuse and addiction of narcotized fetusus as they become teens and young adults. (Jacobson, et al, 1990, Jacobson, Nyberg, Eklund, Bygdeman & Rydberg, 1988)

According to research by Doctors Thorpe & Breedlove, (1996), “80% of US women receive epidurals ... narcotics are added to epidural analgesia to speed and enhance pain relief. These drugs cross the placenta to the fetus”. In addition there is an increased risk of drug interactions when more than one drug is present at the same time, frequently the case during labor. Perhaps the epidemic increase in childhood autistic disorders is a result of drug interactions between pitocin used to accelerate labor and the cocaine-based drugs and narcotics used in epidural anesthesia that normally accompany induced or augmented labors. It should be noted that there is absolutely no testing of drugs on children less than 6 years of age. All drugs used on pregnant women have never been tested to determine if they are safe for fetuses and neonates. Not a single one. No one has a clue about the long-term consequences. Sadly there is no media coverage of these facts and their implications.

Not least in this litany of missed opportunities is the heartbreaking story of Andrea Yates and the fatal consequences of unacknowledged, untreated postpartum depression turned PP psychosis, which resulted in the death of all five of her children. According to Newsweek, these unimaginable demons cause mothers to kill some 200 children in the US each year. PPD can occur after the most normal of pregnancies but is more common and more sever after the added stress of a Cesarean or other operative delivery and when a baby is premature or must be in the intensive care nursery after the birth. (22. Predictors, prodromes and incidence of postpartum depression. Obstet Gynaecol 2001 Jun) On psychological tests, the self esteem of first-time mothers improves and measures highest for women who have normal vaginal births while showing a deterioration for mothers who delivery by Cesarean surgery. (20. Adverse psychological impact of operative obstetric interventions: a prospective longitudinal study Aust N Z J Psychiatry In spite of this we have an obstetrically-configured, highly medicalized system that induces or augments labor with pitocin up to 80% of all labors (21. Robbie DavisFlyod, PhD, Mothering Magazine Jan 2001), has as much as a 95% epidural rate in some hospitals and wants to raise our CS rate by returning to mandated repeat C-Sections and instituting “Cesarean on demand” – all things that predictably increase maternal stress and the number of babies separated from their mothers in intensive care nurseries. This is a recipe for future disasters.

The public erroneously assumes that detection and prevention of PPD is an important aspect of standard obstetrical care but is it not. With the exception of a single 6 weeks check-up, obstetricians don’t provide any postpartum care to a new mother nor does the baby’s pediatrician, despite a PPD rate of 12 to 20%. (22. Predictors, prodromes and incidence of postpartum depression. Chaudron LH, J Psychosom Obstet Gynaecol 2001) Except for community-based midwifery, there is no continuity of care for childbearing women or functional safety net to prevent PPD or to catch it early on, before it damages the parent-child bond, the woman ’s relationship with her husband or results in harm to herself or others. (23. Do not minimize signs of postpartum depression! Early intervention essential to prevent negative consequences for the child. [Article in Swedish] Wickberg B, Hwang P. 2001) There are also no studies to see if there is a connection between the many drugs routinely used in labor during the last half century and the development of postpartum depression (perhaps Andrea Yates mother was heavily drugged during her labor with Andrea, which made Andrea more vulnerable to the effect of drugs used during the fives labors with her own children – an adverse reaction of intergenerational proportion!).

While 70% of all births are normal and do not require the standard (interventive) obstetrical care (24. The Safety of Alternative Childbirth Methods, Peter Schlinzka, 1999), 95% of the many billions spent each year on maternity services go to support an obstetrical model of care which has no time or money for meaningful follow-up for new mothers. Unfortunately, when we spend the whole economic enchilada on the few hours of labor (with no improvement in perinatal outcome) it leaves nothing to address the social and psychological needs of new-mother-baby dyad, during the equally important first weeks and months of the postpartum. Again, a cone of media silence covers up the sins of obstetrical excess and omission.

With the enthusiastic support of organized medicine, the public thinks we already have one of the best maternity care systems in the world. Each new obstetrical interventions is obligingly portrayed by a the media as a “miracle” of modern medicine. Unfortunately, this notion is not supported by a critical examination of any of the parameters of excellence – in particular, the practical well-being of mothers and babies within a positive cost-benefit ratio. (25. “Rights of Childbearing Women” -- published by the Maternity Center Association) None-the-less, obstetrical medicine has been riding high on this wave for the last 100 years while turning its back on the time-tested principles and practices of midwifery, thus denying obstetricians suitable knowledge base to supports physiological management of labor. (26. The Thinking Woman Guide to a Better Birth, 1999, Obstetrical Myth Versus Reseach Realities, 1997 Henci Goer) Practical non-interventive skills and “patience with nature” have become a lost art in the medical world.

When all you have is a hammer (medical and surgical skills) everything looks like a nail (pitocin, epidural, cesarean). For the last decade, scheduled inductions with continuous EFM and epidural anesthesia have been portrayed as the “Cadillac” of childbirth management. More recently, elective cesarean surgery (also under epidural anesthesia) has been spotlighted and is now being heavily promoted as the "Rolls Royce of childbirth". One thing is for certain - those in the medical profession are more likely to be able to afford to drive a Rolls Royce when they perform an increased number of these expensive procedures reimbursed by insurance and government programs but paid for by all the rest of us. Obstetrical and anesthesia organizations would like everyone to believe that normal childbirth is old-fashion and far too dangerous and should be replaced by conveniently scheduled surgeries. That would certainly solve the “VBAC dilemma”. Whether this means a 80% pitocin accelerated labor and 95% epidural rate or 100% CS rate, both represent a misguided a race to the bottom.

More of what isn’t working won’t either. The “answer” to the dangers of VBAC induction is not more scheduled CS. It begins with an accurate and realistic acknowledgement that all treatment choices include risks and that is not automatically superior to be medically over-treated. It requires a genuine commitment to cesarean prevention by the medical professions, whatever that takes, including the employment of time-proven midwifery techniques associated with a high rate of spontaneous vaginal births. This would require changes in medical education for physicians, hospital staffing practices and policies. The media has a major role to play in developing a proper recognition of the problem and its remedies and spotlighting the need for change.

Ultimately it requires rehabilitating our national maternity policy so the United States (like all other industrialized counties) utilizes the same evidence-based model of maternity care used around the world with excellent, cost-effective results and low CS rates. Midwifery is the evidenced-based model of maternity care. (27. Midwifery Care: The "Gold Standard" for Normal Childbirth? Albers, et al; Birth 26:1 March 1999) All around the world, especially in the countries with the best perinatal outcomes, the care of healthy women (70% of pregnancies) is in the experienced hands of professional midwives. (28. Marsden Wagner, MD,“Pursuing the Birth Machine”) Obstetricians are called upon to consultant when there is a question of well-being (or at the request of the mother) and to assume care in the event of complications. In these countries the CS rate is half of our and the issue of VBAC induction is rare. At $126 million per percentage point of Cesareans performed, we in the US should aspire to do as well. With all the money we save, perhaps we could afford to pay our teachers a living wage or provide effective health care and shelter to the mentally ill that are living on our streets and often fall victim to or are perpetrators of crime.

Please to rectify the misinformation and “pro-Cesarean” spin given this study by your news coverage. I implore you to examine the cone of media silence on these topics and consider what could be done to bring about a much need, long overdue inquiry about the inherent conflict of interest between the obstetrical profession and childbearing women and their families. Perhaps one day each week for the next year your news organization could give the kind of “royal treatment” that you gave to the NEJM VBAC study to any one of the hundreds of studies affirming the cost-effectiveness and other benefits of the Midwifery Model of Care. (29. "Your Guide to Safe and Effective Care During Labor and Birth", Recommendations by Maternity Center Association, 1998)

I pray to live long enough to see a national maternity care policy in which hospital labor and delivery units are routinely staffed by professional midwives and in which healthy mothers with normal pregnancies normally receive one-on-one care from a professional midwife, with a CS rate of say, 6% (or less!) and a low perinatal mortality rate that matches or exceeds that of Japan and the Netherlands. As Martin Luther King said so much more eloquently than I, “I have a Dream”. It is a big dream and I have had it for a long time. Fair and effective news coverage would be a great place to start and would head us in the right direction. I am 58. Please hurry!

I provided many citations in this letter to support factual statements. If your received an online electronic version, I have provided many hyperlinks to additional supportive material. I look forward to your replay.

CC:        Bill Moyer, Author, Television Producer,
            John Stossel, 20/20 ~ ABC News program
            Erin Brockovich, Legal Researcher and Advocate
            Senator Liz Figueroa, California State Senate
            Dr Neal Kohatsu, MD, MPH, Medical Board of California
            Robbie Davis Floyd, PhD, Author “Birth as an American Rite of Passage”
            Ina May Gaskin, CPM, author, president, Midwives Alliance of North America
            Marsden Wagner, MD, Author of “Pursuing the Birth Machine”
            Susan Hodge, President, Citizens for Midwifery
            Shelia Kitzinger, UK, Author “Rediscovering Birth”
            Henci Goer, Medical Researcher, Author “Obstetrical Myth Versus Research Realities”
            Suzanne Arms, Author “Immaculate Deception”, volumes I & II
            Frank Cuny, Executive director, California Citizens for Health Freedom
            American College of Nurse Midwives     International Cesarean Awareness Network
            Midwifery Today Magazine    Mothering Magazine