Santa Cruz Sentinel Newspaper
PO Box 638
Santa Cruz, CA  95061

December 3, 2002

Letter to the Editor  ~

Re: AP Wire Service articles and editorial on community-based midwifery

Despite the extensive and emotionally provocative coverage of community-based midwifery, your stories still missed the real point – healthy families choose home-based care from midwives because it is virtually impossible to get the type of care they want, deserve and that is safest -- normal or “physiological” management of  labor and birth -- from hospital-based obstetrics. Our tort law system, which is 100 years out of date, requires that normal childbirth be managed by physicians as a medical or surgical ‘procedure’. This prevents medical institutions from utilizing physiological management -- 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 in hospitals, homes and birth centers around the world with excellent results.

Organized medicine in the US has prejudiced the issue of safety in maternity care by distracting us with the rhetorical question “is homebirth safe” Statistically speaking, the answer is a resounding “yes” (see enclosed studies and citations). But only one-half of one percent of women chooses this alternative. Ninety-five percent of women want or need to deliver in the hospital. The false focus on home birth prevents us from looking closely at the really important question: “Is our medicalized form of hospital birth safe and appropriate for healthy women with normal pregnancies?”   

I began my career as a Labor & Delivery Room nurse in the 1960s. I have been a close observer for more than 40 years of the struggle by healthy women to have control over the manner and circumstances of their normal births. We have gone from the “knock’em out, drag’em out” obstetrics of the 60s, which included ‘twilight sleep,’ general anesthesia, episiotomy and forceps delivery (with a Cesarean rate of only 4%) to the different but equally interventionist style of the last two decades. Now more than 50% of labors are routinely accelerated with Pitocin. Epidural anesthesia is the new standard. Otherwise normal pregnancies often culminate with operative delivery -- episiotomy and forceps or vacuum extraction. Far too many otherwise healthy babies spend days in the neonatal intensive care unit as a result. The bill for this interventive style of care is huge. 

For the less fortunate -- a staggering 25% -- a Cesarean is performed. Childbearing women are three times more likely to die from complications of this major abdominal surgery than from normal vaginal birth. But the problem doesn’t stop there. Post-cesarean complications include infertility, tubal pregnancies, miscarriage, placenta previa, placenta percreta (abnormal growth into the wall of the uterus), placental abruptions, uterine rupture, emergency hysterectomy and the need for extensive blood transfusions (Ob.Gyn.News Vol 36, Aug 1, 02, enclosed). 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. (Ob.Gyn.News Vol 36, Mar 1, 01 & Vol 36, Sept 15, 01; Elective Cesarean: An Acceptable Alternative to Vaginal Delivery? Peter Berstein, MD, MPH).

By contrast, only 10% of families who choose home-based midwifery will want or need obstetrical care during labor. The over-all Cesarean rate for women who began labor at home with a skilled professional is about 4% with approximately 2% forceps or vacuum extraction. The consensus of research on the relative safety of birth for healthy women with normal pregnancies concludes that perinatial mortality is virtually identical in all settings -- about 2 per 1,000 -- for home, hospital and birth centers [The Safety of Birth Alternatives;  Dr. Peter Schlenzka, PhD, Stanford University, 1999]. This means nine out of ten women deliver naturally at home with none of the risky medical and surgical procedures listed above and no downstream complications to cast a dark shadow over babies in future pregnancies. The protective nature of home-based care for both mothers and babies is one of the most important reasons people are attracted to out-of-hospital midwifery care.  Letters to Editor, ACOG Green Journal (Obstetrics and Gynecology) Jan 2003; Safety of Alternative Approaches to childbirth – PhD – Stanford University, Dr. Peter Schlenzka, 1990

As a professional midwife and spokesperson for the California College of Midwives, people may assume that I am biased. 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 under-use of certain practices that are safe and effective

~ The widespread use of certain practices that are ineffective or harmful

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

    enough awareness and consideration of the risks

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

   safety and effectiveness

According the MCA's “Listening to Mothers” survey conducted by the Harris polling service: “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 13% of babies were delivered via forceps or vacuum extraction, for a total operative delivery of 37%, excluding episiotomies. 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. A press release dated June 6, 2002 based on the NCHS report “Births: Preliminary Data for 2001”; NVSR Vol. 50, No. 10. 20 pp for the year 2001 http://www.cdc.gov/nchs/releases/02news/birthlow.htm), documents a 24.4% CS rate (with associated increases in maternal deaths, placenta percreta and emergency hysterectomy) and drop of 72% in the rate of VBAC births during in the last 5 years, down 20% in the year 2001.

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, which 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 home or hospital. While physiological management of labor reduces the requests for pain meds or epidural anesthesia, it does not mean that hospitalized mothers cannot receive pharmaceutical analgesia. 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’ preformed by physicians. This means that normal birth is not as profitable to the medical establishment. 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.

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, it 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, enclosed). The dirty little secret is that hospitals bill at $400 an hour for continuous EFM, which is applied to the entire 5 to 25 hour labor of 3,790,000 women each year (93% of annual births). That makes it a cash cow. I’m sure the current salary of L&D nurses in Santa Cruz hospitals is nowhere near $400.00 an hour.  

So dare I suggest that your newspaper 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”.

Can we count on your paper 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 California is facing a huge budget deficient, that bio-chemical terrorism would overwhelm our current interventionist and drug intensive obstetrical system, that maybe, just maybe the midwifery model of care as the foremost standard for healthy women  -- that is, normal or ‘physiological management’ in hospitals by doctors and midwives -- is an idea worth exploring.  The best solution to the ‘home birth’ controversy is to make maternity care in homes and hospitals equally safe and equally satisfactory so that families are not forced to choose home birth for want of appropriate, compassionate and cost effective care in hospitals.   

Click here for expanded material on Tort Law and its unintended consequences

Click here for photographic record of Physiological management of Normal Birth

Click here for photographic record of Medical / Surgical Management of Normal birth

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

============================================================================

Enclosures – citations, abstracts, excerpts and other supportive documentation

Front Cover: 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

=================== Section One / Physiological Management of Normal Birth=================

Physiology in Childbearing - text book – excerpt on physiological management of second stage (1999)

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

=================== Section Two / Statistical Resources  ===============================

Births: Preliminary Data for 2001; NVSR Vol. 50, No. 10.

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

Safe Motherhood 2002 – Department Health & Human Services – CDC

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

===================== Section Three / Citation safety of Home-based Midwifery =========

Outcomes of Planned Home Birth in Washington State: 1989-1996 – Letters to Editor responses as published in ACOG Green Journal (Obstetrics and Gynecology) Jan 2003

Safety of Alternative Approaches to childbirth – PhD – Stanford University, Dr. Peter Schlenzka, 1999

Midwifery care, social and medical risk factors and birth outcomes in the USA – abstract; Journal of Epidemiology & Community Health Vol 52, 1998

==================== Section Four / the EFM -- Cesarean Connection ==================

Auscultation vs. Fetal Heart Monitoring Ob.Gyn.News Nov 15 2001 Vol 36, No 22

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

====================== Section Five / Ultrasound / Pitocin / Cytotec =================

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

====================== Section Six / 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

Forceps Double Risk of Incontinence; Ob.Gyn.News Sept 15, 2001, Vol 36, No 18

======================= Section Seven / 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

======================== Section Eight / VBAC Topics =========================

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

Back Cover: Results of the “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