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Faith Gibson.Org http://faithgibson.org The Politics of Normal Childbirth ~ Helping to End the Hundred Years War btw Midwifery & Medicine Fri, 22 Apr 2022 19:21:57 +0000 en hourly 1 From the Achieve: Overview written in 2008 of the political impasse btw interventive obstetrics and non-interventive maternity care for healthy women by professional midwives & family practice physicians http://faithgibson.org/from-the-achieve-overview-written-in-2008-of-the-political-impasse-btw-interventive-obstetrics-and-non-interventive-maternity-care-for-healthy-women-by-professional-midwives-family-practice-physici/ Mon, 18 Apr 2022 19:09:18 +0000 http://faithgibson.org/?p=10694


Draft – originally written in 2008

~ Obstetrical Medicine in the US ~

is a stumbling stone and roadblock to an integrated maternity care system that promoted and supported normal childbirth & provided appropriately non-interventive services to healthy childbearing women with normal pregnancies, including access to the more cost-effective midwifery care

Re-posted April 2022 ~ The more things change,
the more they stay the same!

For all our idealism, enthusiasm and sustained effort as mothers, midwives and activists for normal childbirth services for healthy women, we remain locked out of an integrated maternity care system by factors that are political rather than scientific.

In the current configuration, women as mothers and midwives  have to lose in order for the obstetrical profession to win — a state of affairs defined as having a complete monopoly on all forms of maternity care and total control over all aspects of labor and childbirth in healthy women with normal term pregnancies.

If this obstetrical monopoly over all aspect of childbirth was able to provide superior outcomes — the virtual elimination of maternal and infant morbidity and mortality — we would all be celebrating their success rather than spending our time and effort trying to reform a broken and dysfunctional system.

Unfortunately, the massive amount of obstetrical intervention that healthy childbearing women are exposed to quite literally killing due to complication of unnecessary obstetrical interventions and leaving what some studies have identified as 80,000 new mothers with serious but preventable, often life-long complications

See 2022 report on 701 preventable perinatal deaths and 9 preventable maternal deaths in the UK attributable
to inappropriate care by obstetrical providers who ignored
information that came from the laboring woman

 

The resurgence of independent midwifery and PHB was the result of our and continues to be fueled by a collective inability to make a positive impact on our hyper-medicalized maternity system. As midwifery activists, we originally intended just to meet those specific needs the obstetrical profession couldn’t address or wouldn’t acknowledge. We didn’t intend or expected to create a free-standing parallel system of midwifery education and practice that remained permanently outside and separate from the health care system. Apartheid is never a satisfactory situation.

Any one who gets pregnant or provides services relative to pregnancy and childbirth knows all too well that it is impossible not to be drawn back into the political fray between obstetrics as the empowered class and midwives and mothers seeking non-interventive care as the disempowered and outlaw class.

Speaking as someone who has been doing this since the 1960s, when twilight sleep drugs, general anesthesia, episiotomy and forceps were still mandatory and universal, our activism has not been a happy or successful endeavor.

Yes, we have won a few battles and I am grateful for that, but it is an illusion of progress. Added to our individual pain and collective experience is the expansive time frame for a dysfunctional system that keeps changing but never actually fix the problem. These changes are inevitably to add additional types or layer of interventive protocols and even more intrusive obstetrical technology. For the entire 20th century and the first decade of the 21st, women and families have been swept along a conveyor belt that often took them to places they did not want or need to go.

The 95% rate of narcotics, scopolamine and general anesthesia in the 1960s has simply been replaced by a 90% epidural rate; the routine use of forceps has been replaced by the liberal use of Cesarean, which for the last 2 decades has hovered at approximately one third of all birth (current official rate is 32%). Normal childbirth is still being conducted and billed for as a surgical procedure.

The monolithic obstetrical model continues to be characterized by routine interference in normal biology (such as routine inductions), unnecessary interventions mandated by medical liability issues or physician preference. Painful, invasive or humiliating procedures that we neither need or want continue to performed on ourselves, our loved ones or on our clients. We stand by helplessly as influential members of the medical profession and the media promote the idea of scheduled Cesarean as the 21st century standard of care. Ultimately, we are losing the war.

As members of consumer and professional groups working for mother-baby friendly maternity care, it’s impossible not to get angry about this. Personally, it’s hard for me to be generous in the face of such daunting circumstances. But if we let our anger divide us into eternally warring camps, we will spend our time perpetuating instead of fixing an out-of-balance system.

What we need is a change of heart, starting with an acknowledgment that none of these groups – mothers, midwives or obstetricians — asked for these contentious problems. Contemporary obstetricians inherited a difficult situation not of their own making. They were schooled by a system that define the biology of normal childbirth to be a “pathophysiology” – that female reproductive biology was an inherently dysfunctional, and therefore dangerous, system. This not only justified the routine use of multiple medical and surgical interventions but legally required their use as the obstetrical standard of care in the United States.

Obstetrics as seen against the
historical backdrop of 1840 to 1940

Obstetrical textbooks and other professional publications in the last 19th and early 20th centuries described childbearing is seen as an undependable pathophysiology that literally used women up the way salmon are sacrificed during spawning. In must be remembered that without prenatal care and access to modern obstetrical services for those who develop complications during pregnancy or childbirth, high mortality rates are indeed the rule.

  • In 1900, the average married woman in the US had 16 pregnancies, 12 live births, but only 9 living children. Women expected to lose a tooth with every pregnancy. Poverty and high birth rate were associated with problem pregnancies, especially in very rural farming areas and for immigrants and ethnic minorities living in crowded urban tenements.
  • Racial discrimination and economic inequities resulted in chronic ill-health, which made childbearing women vulnerable to childbirth serious complications that obstetricians could not predict, prevent or treat. In the poorer sections of town, one new mother died for every 100 births and one of 10 infants did not live to see their first birthday. Many of the life-threatening complications childbearing required surgical solutions, giving rise to the ‘new’ obstetrics for the 20th century as a surgical specialty.

In the decades before the discovery of antibiotics, well-intentioned obstetricians had to respond to this grave situation any way they could.

The highly medicalized style of care introduced in 1910 was an attempt to eliminate puerperal sepsis (childbed fever) in hospitalized maternity patients and by sheer happenstance, this ‘perfect storm’ of events resulted in the single greatest change in childbirth practices in the history of the human species.

Labor began to be managed as a medically emergency. For the first time ever, normal vaginal birth was defined as a surgical procedure. As a surgical procedure, the ‘delivery’ was to occur in a restricted, sterile environment, routinely conducted as an operation by a surgically-trained physician. Due to the difficulty of maintaining strict surgical sterility, it was necessary to anesthetize labor patients. Once anesthetized, the delivery need to be surgical included the routine use of episiotomy, forceps, manual removal of the placenta and suturing of the episiotomy or other perineal wounds.

Obstetrical medicine against the backdrop of what we now call
“modern science”: 1840 to 1940

To understand why this happened, you have to see this unique era of obstetrical medicine against the backdrop of what we know call “modern science”: 1840 to 1940 – were the time of the biggest change in the biological sciences and by extension, allopathic medicine.

The most pivotal year in the history of ‘modern’ medicine was 1881. It was a time marked by the lightening fast shift of medical thinking and practice. Overnight, humanity was taken from the B.C.G. era — ‘Before the Common knowledge of the Germ theory of infection’ — to the brave new world defined by the new scientific disciplines of microbiology, bacteriology. These biological sciences developed antiseptic practices, disinfectants and eventually aseptic principles and sterile techniques. Other scientific disciplines — anatomy, biology, chemistry, immunology, physics, and physiology – all contributed to the practice of medicine, including obstetrics, as a modern science.

For obstetrics, the most radical and extraordinary time was the last 2 decades of the 1800s and first 2 decades of the 1900s – 1881 to 1920. This forty years period was smack in the middle of a metaphorical earthquake — the San Andreas fault of bio-medical science. The paint was barely dry on most important discovery in the history of the biological sciences and medical practice, which had transformed human knowledge and medical practice at one and the same time.

The biological sciences were no longer B.C.G. – the invisible but nonetheless lethal power of germs had been unmasked and beaten back — but unfortunately, humanity was still in the Before Antibacterial Drugs (B.A.D) pre-ambulatory phase of the soon-to-be but not-quite-yet ‘miracle’ of modern medical science that arose in 1937 with the marketing of the first sulfa drug. The 50 years between the discovery of germs and the ability to selectively kill bacteria and other pathogens inside of a sick human being was still a no-man’s land, one peopled by doctors, public health officials and the lay pubic, all of whom did not yet know that the story had a happy ending.

In addition to the many easily identifiable problems with our 1910 model of Listerized childbirth, there are an equal or greater number of real problems that real life obstetricians grapple with everyday. One major category is obstetrical emergencies – the kind of complications that kills one out of 57 women who don’t have access to or have decided not to make use of comprehensive obstetrical care, even when dangerously ill. These heartbreaking situations include very premature births, hemorrhage from placental abruptions or previa, high blood pressure, convulsions, stroke, amniotic fluid embolism, and a list of other equally rare but less dramatic life-threatening pregnancy problems.

A different but also vexing problem for obstetrical providers are psychological issues — childbearing women who either cannot or will not take responsibility for their own and their baby’s wellbeing, whether this is due to substance abuse, alcohol addiction or other mental or emotional illness. Sometimes laboring women can’t or won’t cooperate at all with the physiological process of normal labor and spontaneous birth and must be heavily medicated or even anesthetized.

As a former L&D nurse, ER nurse, and now as a community midwife, I have witnessed situations were births attendants had to provide care to women who are hostile, totally uncooperative, even combative. But no matter how outrageous the mother’s behavior, the physicians and midwives are ethically and legally required to provide the same high standard of care they would to anyone else.

As consumer advocates, we assume that every mother wants what we want and knows what we know and can’t imagine a pregnant or labor women who isn’t totally informed about all the possible side effects of interventions and drugs. Sadly, that isn’t the norm. Many of the patients that obstetricians deal with just want the baby about and they don’t want it to hurt and don’t want it to take too long.

For birth attendants dealing will an undifferentiated population and high volume of labor patients, obstetrics is the art of dealing gracefully with unexpected, everything from simple failure to progress, to a variety of vexing emergencies such as cord accidents, fetal distress, shoulder dystocia, retained placentas, inverted uterus and PP hemorrhage. Obstetricians know any of these problems could trigger a lawsuit for them and the hospital, so the actual treatment of emergencies is complicated by political pressure from within the ‘system’.

One of the craziest things about litigation is that patients who actually got very good care for a very bad problem are often the ones that sue. They wrongly believe that whoever was present when a complication was discovered, was somehow responsible for having caused the problem. This is an irrational “guilt by association”, that is, the doctor and nurses were standing there when it happened, so somehow they must have don’t something wrong by not preventing it.

At the end of a week of dealing with all these high stress situations, an obstetrician might also get paged to deal immediately with a transfer from a planned home birth that end with a life-threatening emergency – cord prolapse, placental abruption, maternal hemorrhage, etc. Whether that problem is due to an unpreventable complication or poor judgment by someone – parents, midwives or even other professionals that did not respond appropriately – it sometimes very hard to discern. What is for sure is the grieving parents and an extremely difficult situation for everyone involved and certain fuels the on-going hostility between community-based midwifery and hospital-based obstetrics.

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Birth Environments: Emerging Trends & Implication for Design ~ School Of Architecture & Urban Planning http://faithgibson.org/birth-environments-emerging-trends-implication-for-design-school-of-architecture-urban-planning/ Sun, 14 Nov 2021 18:43:35 +0000 http://faithgibson.org/?p=10601

School of Architecture and Urban Planning

BIRTH ENVIRONMENTS ~ Emerging Trends and Implications for Design

Alice Lerman, B.A., J.D., M. Arch ~ University of Wisconsin; School of Architecture and Urban Planning

A Project supported by the American Institute of Architects and the American Hospital Association Fellowship ~

pages 7 & 8:

“Obstetrics, over the past decade, has achieved renewed status among hospital departments.

The impetus for this development has been the advent of competition among hospitals as a result of changing health care economics and the acceptance of health care marketing as an ethical business activity.

(“Innovations in Obstetric Design” Hospital Administrations Currents, 1986, 30 (3): 9-14)

Obstetrics is now considered to be the service leader in establishing patient loyalty to the institution”.

Innovative maternity programs can increase the patient volume in other areas, through the woman’s influence. Since women tend to decide where the family will go for medical care (in 70% of families say some researchers), loyalty won through innovative obstetrics programs transfers to other patient areas.

page 15:

Marketing of its facility is very important to the hospital. A facility that is designed to be inviting, comforting and attractive …..will increase consumer response and improve its image and visibility in the community. Studies show that a positive hospital experience for maternity care leads to continued usage of the medical facility by the family consumer group.

It is estimated by Ross Planning Association that 10% to 28% in operating costs can be saved with the LDRP system over the traditional design. The programs below show that LDRP units do require more square footage than traditional programs. Initial equipment and construction costs can be offset by a decline in operating costs and an increase in revenues due to volume changes.

(Hospital Administration Currents, vol. 30, no 3, 1986)

page 34:

Women in today’s society are increasingly aware and sensitive to the fact that they compose a significant group of health care users. Medical facilities are competing for a greater market share of women consumers.

There is evidence that once a woman has a positive experience in the hospital she chooses for maternity care, she and her family will usually return to the same hospital for future medical needs.

A separate women’s health care facility is the optimal setting for obstetric care. This gives a woman a *sense of importance and dignity* as she faces the medical establishment. A distinct women’s medical center could be connected to the main hospital by physical proximity and or a sheltered bridge or tunnel for easy access to centralized labs or common services.

 


 

Classic hospital birth position with the mother laying flat on her back in lithotomy position, legs in stirrups, surrounded by hospital employees and medical students in scrub suits, caps, and masks.

Editorial Comment: Note the article talks about women having a “sense” of importance, which is not the same thing as having importanc

Actually having importance and dignity would mean having legitimate choices, including the ability to choose where you want to give birth and who will be present during her labor and birth

This includes the right to say “no” to elective inductions or Pitocin augmentation of labor, the use of continuous EFM, IVs (versus simply drinking water) and not being tethered to one’s labor bed. Having importance and dignity in regard to normal childbirth means being able to move around at will, walk, squat, and generally be in charge of one’s own physical body during the biological process of normal labor, and spontaneous birth.

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History, Theory & Practice of Auscultation – Stand-alone addendum to series “False Association-Failure of c-EFM to prevent cerebral palsy & protect OBs from lawsuits http://faithgibson.org/ia-addendum-to-false-association-routine-efm-prevention-cp_march2019/ Fri, 12 Nov 2021 07:31:03 +0000 http://faithgibson.org/?p=7729

Stand-alone Addendum for mfry educators,
students journalists and patients’ rights
and product liability attorneys

Easy Shortcut to share –> http://tinyurl.com/y3evnwwa   word count 4100

A brief history of monitoring  the unborn baby: Intermittent Auscultation ~ its verbs, nouns, and physician-inventors.

For information about fetal monitoring as an electronic device (i.e., noun instead of an action verb), please read Part 1, 2 & 3 of the Rethinking-the -Role-of-EFM-Report-2019_#1 {easy-to-share Tiny URL}

The False Association btw routine use of
continuous electronic fetal monitoring (c-EFM)
to
prevent Cerebral Palsy & Protect OBs from Lawsuits



Editor’s Note:
The first section, which is on the 400-year history of medical professionals listening to the unborn baby’s heart tones, and monitoring FHTs during labor, is a slightly more detailed version of the information given in the last part of the previous post (link to Part 1 immediately above):

Even if you read that previous post, reviewing this more detailed information is good preparation for the section on the historical form of Intermittent Auscultation — what it is, it’s history, why it should be the modern standard of care for healthy women with normal term pregnancies, and 2nd generation auscultation techniques that yield the best and most reliable results.

As members of a compassionate society, but one that nonetheless does NOT have unlimited funds, our goals is to inform the public about the ineffectiveness, unproductive expense, and potentially-fatal complications of continuous electronic monitoring when it is inappropriately used as the standard for healthy women.

At the same time, we must make the public aware that there is a safe, satisfactory and cost-effective ‘alternative‘ — Intermittent Auscultation — that provides the same four categories of information on status the unborn baby and IA includes the continuous presence of a midwife or L&D nurse through out labor. This mother-focused care provides eyes-on, ears-on and hands-on support and encouragement to the laboring woman, this reducing the likelihood that drugs will be need to to speed up labor or for pain relief.

In addition, the continuous presence of a nurse or midwife is so more cost-effective than the $400 per hour charge  billed to insurance companies or the federal Medicaid program for c-EFM. The average salary of nurses and midwives is under $50 an hour, or a saving of $350 an hour over the cost of c-EFM. The continuous presence of a trained labor and birth attendant also reduces the incidence of Cesarean or other operative delivery and all the expensive complications and increased maternal morbidly and mortality associates with Cesarean surgery.

Auscultation ~ Effective fetal monitoring without exposing the laboring woman to higher rate of Cesarean surgery and its complications

We need to dramatically change the thinking of the majority of Americans in two important areas.

The first is the extremely inaccurate idea that the US has the very best healthcare in the entire world. Actually the American healthcare system ranks near the bottom of developed countries.

Secondly, most Americans assume that maternity care in America is likewise the best in the world. Unfortunately, that’s also not true. Compared to other high-income industrialized countries, and in spite of spending two or three times money more on maternity care, the US has one of the highest maternal and neonatal mortality rates of all the developed countries. America is one of only eight countries disgraced by a high and increasing maternal mortality rate.

However, the majority of American are unaware of these grim facts. Instead they believe our obstetrical system is as good as it gets and from this perspective, electronic fetal monitoring seen as the crown jewel of the obstetrical profession. EFM is seen as the marvelous machine that allows OB doctors, assisted by L&D nurses, to monitor and record every beat of the unborn baby’s heart during labor and at the first hint of a possible problem, to rush the laboring woman off to the operating room and ‘rescue’ the baby by performing an emergency CS.

These people see continuous EFM as one of the very best life-saving technologies ever invented, able to save the lives of babies that otherwise would not have lived or would be born with terrible problems like cerebral palsy and permanent mental and physical handicaps.

Seen from this perspective, it’s logical to believe that any doctor who doesn’t use continuous EFM is guilty of medical malpractice and any childbearing women who refused to let her unborn baby be electronically-monitored during the labor is guilty intra-uterine child-abuse.

The suggestion that (a) routine continuous EFM of heathy women during labor actually makes both mother and baby less safe and (b) recommending instead that the nurse or midwife use a hand-held Doppler to monitor the baby’s health status during labor would be seen by many as a crazy, upside-down idea.  Nonetheless, second generation auscultation regularly listens to and records the rate and rhythm of the unborn baby’s heart rate, while also tracking the same four categories of data as EFM, is the safer and better choice for healthy women with normal term pregnancies than routine EFM.

According to forty-four years of studies that compared continuous EFM to the ‘control’ group, auscultation was consistently found to be as effective as EFM, while having a statistically-significant reduction in the cesarean section rate. One of the very first clinical trials of EFM reported 6% CS rate with auscultation compared to 16% Cesarean rate associated with EFF.

Action verbs of auscultation vs. the nouns that describe an electronic devise

We are asking the public to re-define the idea of “continuous” intrapartum “monitoring” as something provided by an ineffective machine that is extremely expensive (both in dollars and personal cost), and instead to systemize the continuous presence of a person who is professionally trained to provide intrapartum care that includes the use of IA as the standard of care for healthy women with normal term pregnancies.

This labor and birth attendant will monitor (as an active verb!) fetal well-being via intermittent auscultation (IA) during active labor every 15 to 30 minutes. This consists of using a pocket-sized fetal Doppler and watch or clock with a quartz movement (second-hand stops briefly with each tick) to gather information on the very same 4 markers of fetal well-being as is collected by EFM and used by doctors, midwives and nurse to determine the well-being of the fetus and to take action if it indicates a possible problem.

These are a:

  • Normal baseline
  • Normal variability
  • Presence of normal accelerations
  • Absence of pathological decelerations

This professionally-trained labor and birth attendant is able to continually observe and provide ears-on, hands-on support, encourage and assist the laboring mother, which greatly reduces the number of unplanned CS that result from iatrogenic (care-provider-related) or nosocomial (hospital-related) factors.

So expensive, continuous machine monitoring (EFM) is not good for healthy laboring women, while the continuous presence of a trained professional using the safer and more cost-effective techniques of IA to monitors fetal well-being is good.


 

The first person to report hearing the sound of an unborn baby’s heartbeat was a 17th century physician by the name of Dr. Marsac.

A contemporary of his, a Dr. Killian, was the first to ponder the possibility that the rate and rhythm of the fetal heart might be an indicator of how well the fetus was (or wasn’t) tolerating the process of childbirth.

 

Professor of Obstetrics, Dr. Jacques Alexandre Kergaradec, L’Academie de Medicine, Paris, Queen’s University of Belfast ~ early 1800s

However, this possibility went unnoticed for two more centuries, until 1818, when doctors Mayor and Kergaradec described a method of  auscultating fetal heart sounds by placing one’s ear on or very near the maternal abdomen. Dr. Kergaradec also suggested that fetal heart sounds could be used to determine fetal viability and proof of life in the months before ‘quickening’, that is, before the mother could feel the baby kick.

In 1833, an English physician, Dr. Evory Kennedy, published guidelines for fetal distress and also recommend auscultation of the fetal heart rate to monitor the well-being of the fetus during labor and birth.

A simple tool for counting the fetal heart rate

However, the big leap forward came in 1893, when Dr. Von Winkel established criteria for fetal distress. After listening to the hearts of many babies during many labor, he realized that the FHR of an unborn baby in trouble would often (but not always) become abnormal, and beat much faster or much slower, or become extremely erratic. Some of these babies died before the birth, other were born profoundly depressed and often died later.

With this understanding, Dr Von Winkel identified the signs of fetal distress, which included abnormal fetal heart rates (FHR):

  • tachycardia (a over 160 bpm);
  • bradycardia (under 100 bpm),
  • irregular heart rate, passage of meconium,
  • abnormal fetal movement (i.e. agonal spasms of a dying baby).

By the turn of the 20th century, maternal fever was recognized as a cause of fetal tachycardia; head compression and cord compression were also known causes of bradycardia, and hyper-stimulated uterine activity associated with an abnormal FHR patterns and asphyxia.

When these abnormal heart rates were discovered very late in the labor, doctors could sometimes perform a forceps delivery to rescue the baby. By the late 19th century, the development of general anesthesia, germ theory of infectious disease (resulting the principles of asepsis and sterile surgical techniques) made Cesarean surgery safe enough to use during labor to rescue babies with extremely abnormal heart rates.

 

By the early 20th century — 50 years before fetal heart monitoring was electronically automated by a computerized machine — doctors, midwives and nurses were using a special stethoscope called a Pinard Horn to regularly listen to the heartbeat of the fetus during labor. Pinard fetal stethoscope was developed in the 1880s and remained in use until the 1950s and is still used by some midwives, particularly in developing countries.

The medical protocol for auscultation at that time was to count the number of fetal heart beats per minute (bpm) and record the findings on the mother’s chart. This was done on a hourly schedule in early labor, and repeated with increasing frequency as the laboring mother got closer to giving birth.

Helpful as this information was, there were still a few babies with apparently “normal” FHR that were born with unexpected and unexplained problems that prevented the baby from breathing on its own. This usually resulted in death or severe handicaps.

As noted above, birth attendants and nurses were ‘monitoring’ these babies, but they  paid little or no attention to the rhythm of the fetal heart or other elements now known to be equally, if not even more important:  Variability, the presence of reassuring accelerations, absence of pathological decelerations, and noting the depth, timing, and duration of any decelerations that were detected.

Then in 1922, Dr. Joseph De Lee, the famous obstetrician that  founded the Chicago Lying-in Hospital and Chicago Maternity Center advanced the ability of birth attendants to prevent stillbirths. He and his colleague, Dr. David Hills, invented a hands-free fetal stethoscope for listening to fetal heart tones. This device became known as the DeLee-Hills Fetoscope.

Then Dr. DeLee went on to develop the process and protocols for the intermittent auscultation (IA) of the fetal heart rate during labor, which included the 1893 description of fetal distress by Dr. Von Winckel. Using his new fetoscope, the FHR was to be auscultated every 30 minutes during first stage of labor, every three or five minutes during second stage, and continuously if signs of fetal distress were seen as an indication for forceps delivery.

In 1924,  4th edition of Dr. DeLee’s obstetrical textbook Principles and Practice of Obstetrics includes a wonderful graphic that displays a fetal heart rate auscultated and charted in 5-second increments during a minute-long contraction.

It shows a normal baseline rate of 132 bpm at the beginning of the contraction (ranging from 120 to 144 bpm when computed in 5-second samplings) during the first 20 seconds.

As pressure on the fetal head builds up, there is a mild head compression decel, and we can see the FHR go down from 144 to 108 bpm over a span of 20 second during the middle of the contraction.

As the contraction wanes and the uterus relaxes during the last 20 seconds, the unborn baby’s heart rate speeds back up to its pre-contraction normal baseline of 132.

 

 

Copy of a page in Dr. Joseph DeLee’s 1924 obstetrical text book
entitled “The Principles and Practice of Obstetrics”

 

 

If you read Dr. DeLee’s comments below the graph, he refers to a pattern of decelerations during the pushing stage that we now know to be head compression decels — the result of triggering the mammalian diving reflex that has been extensively documented in whales.

Dr Joseph DeLee on TIME magazine Cover in 1936

Dr. DeLee somewhat anticipated this explanation by referring to the abnormally slow heart rate of men working deep under water in a “caisson” (a big metal contraption used during the underwater building of bridges and similar construction projects).

DeLee’s work is the theoretical precursor to both IA and EFM, as it is the first instance of dealing with variations in the FHR during the period of auscultation by using a timepiece with a second hand to count fetal heart beats in 5-second samplings. Prior to this, the only information on fetal heart activity that was gathered was the sum total of beats over a 60-second period and recorded as a baseline rate.

When is a minute not a minute? ~ Ending a bad habit by the medical, nursing and midwifery professions:

As unfortunate and inadequate as it was to ONLY gather baseline information on fetal well-being,  even more problematic is a long-time protocol for taking pulses and fetal heart rates. Both are stated in the universal language of beats per minute (bpm), but medical and nursing students are both taught that the proper way to take pulse and fetal heart rates is to palpate or lisent for only 15 seconds and then multiplied that number by 4 and state it the rate-per-minute, as if the care provider had listened or palpated for one whole minute.

In fact, this makes lay people think something that is not true and it deprived the practitioner of critically useful information. This in turn risks the well-being of the baby, as the baseline rate by itself is only a small part of the picture.  Depending on what is happening with the baby, the beats-per-minute count may not change dramatically until the baby is just a few minutes away from dying.

A Brief Aside: It’s crazy (as well as bad policy) for doctors, nurses, midwives and other healthcare professionals to be thinking in terms of shaving seconds off the time they spend in the presence of their patients. What bedevils the provision of medical services in the US is the constant attempt to spend less time with the patient and more time having one’s assistants and employees doing minor and impersonal activities such as taking temperatures, drawing blood, etc.

As a result, doctors miss so much information that would come directly and easily from listening to their patients, getting to know more about them, taking time to assess them them from the standpoint of eyes-on, ears-open, hands-on care.

 I hope midwives everywhere realize that it takes a full minute to gather the data that will be charted as the fetal heart rate per minute. This is a particular issue when using Dopplers that flash out a beats per minute number after only a few seconds. The point here is the same as the 15-second palpation of pulses and multiply by 4, except EFMs and hand-held Doppler calculate on a 2-second cycle.

Functionally, this is a throwback to a hundred years ago, when doctors and nurses first began to monitor the fetus during labor, but only listened to FHTs for a few seconds, and then wrote down a beats per minute rate (or made decisions on that number) but without having assessed for variability, accelerations or decels. It’s not IA  unless the midwife is accesses all 4 data point each time she auscultates.     

The only exception that I have found is the last few minutes of second state, just before the birth when so much is happening at the very same time that is hard to hear FHTs because the baby is so low in the pelvis. Then just when you start counting the FHR, the mother starts pushing again and moves away.

In those cases, if I get 5 or 10 seconds of a reasonably normal baseline, I consider that to be adequately reassuring that the baby is not in immediate distress and that’s as good as it get under such circumstances. 

Of course, I keep trying, but often the baby is born before I get to hear a whole minute of its fetal heart rate. In those case, I immediate put my hand on the cord to palpate the neonate’s heart rate and be sure it’s over 100 and regular.   

Returning to out topic of fetal monitoring

Dr. DeLee recognized a second-level source of valuable information that could be gathered by paying attention to the FHR changes that occurred (or failed to occur) within the one- or two-minute period that the FHR was routinely monitored by the L&D nurse, doctor or midwife. The more sophisticated 4-part criteria protocols for IA allowed care providers to intervention early and in most instances, prevent permanent damage.

The theoretical basis developed by Dr. DeLee and its 5-second sampling protocol, which yielded much a more useful picture of fetal wellbeing. This critical aspect of IA  was not widely acknowledged or integrated into standard obstetrical practice until the development of electronic fetal monitoring equipment in the late 1950s and 60s.

Auscultation ~ An alternative method of fetal monitoring proven be as effective as continuous c-EFM

Counting the unborn baby’s pulse (i.e. heart rate and rhythm)

The simplest example of IA is to compare it to counting the unborn baby’s pulse over the span of one minute and using the second hand of a clock or wristwatch to calculate the beats-per-minute (baseline) and the three other well-established attributes of fetal wellbeing: normal variability; presence of reassuring accelerations; absence of pathological decelerations.

All over the world and for many hundreds of years, doctors, nurses, and midwives have regularly collected a similar set of facts from infants, children and adults by physically palpating their pulse, counting the beats for 15 seconds and then multiplying by 4 to get a 1-minute rate (for example, 21 beats in 15 seconds is a heart rate of 84). When doing this, the care provider would also note whether the rate was regular or irregular.

If the rate is irregular, or the person/patient is being evaluated for cardiac disease, the medical professional would palpate and count for one or more full minutes in order to detect the presence or absence of irregularities and whether there was any discernible pattern noted in the abnormal pulse.

These same medical professions would be thunder-struct if told that the only way to take a person’s pulse was to purchase an electronic machine that cost many thousands of dollars, was the size of a large suitcase and required access to electricity to work. In terms of the ‘wrong use’ of medicalization, this is akin to having to catheterize someone every time a urine specimen is needed. This would be particularly bad news for those of us who made house calls and for EMTs.

Luckily for them and for midwives and the families who choose low-tech care in their own home or a free-standing community birth center, we don’t need a $15,000 electronic maternal monitor to check the mother’s pulse, and we don’t need a $15,000 electronic fetal to take the baby’s pulse.

The Nuts and Bolts of IA – what you need, how to do it, how to chart it

However, there is no way to hold the baby’s wrist before it’s born, so either a special fetal stethoscope or electronic Doppler is used to hear the heart rate.

To count the heart rate, a battery-operated timepiece with a quartz movement is used to count the heart beats in each of the 12 or more samplings.

The reason for choosing a watch or clock with quartz movement is that its second hand has a ticktick motion that moves once per second, while mechanical watches have a smooth, sweeping seconds motion.  This momentary stop as each second is ticked off is very helpful when auscultating FHR in 5-second units.

The video below demonstrates how a quartz movement works, with the red second hand darting forward and the rest for a second with each tick of the clock.

There is ambient sound in this video, but you can’t hear the tick of the clock unless you are very close, and it’s not the sound of ticking that is uses in intermittent auscultation.

The contemporary practice of IA, most practitioners use a relatively inexpensive hand-held Doppler ($300-$600 vs. $10,000 to $15,000), which amplifies the sound and has a speaker so everyone in the room can hear the baby’s heart rate. This also makes it easier for mothers, as they don’t have to lay down and try to stay still during a contraction while the midwife listens and the birth attendant can hear and count fetal heart tone while the mother is standing up (including in the shower or while sitting on the toilet).

The protocol for IA is to listen to the unborn babies of mothers with low risk pregnancies on a schedule of:

  • every hour in latent (very early) labor
  • every 30 minutes in active (progressive) labor
  • every 15 minutes in the first part of pushing stage
  • after every 3rd contraction (or more frequently if needed) as the baby is being pushed down and out of the vagina (perineal stage) and being born.

As noted above, the purpose of fetal monitoring (verb or noun) during labor is to either document the unborn baby’s condition as well-oxygenated and neurologically intact or detect that, for whatever the reason, the fetus requires immediate interventions.

The 5-minute video below provides the sound of the FHTs and a Quartz clock that allows the reader to play around with IA skills. This was recorded during a normal prenatal exam at 34 weeks gestation. You can hear a normal baseline, variability, accelerations and no decel. Since this video made, the mother had a normal spontaneous labor and gave birth to a healthy baby boy.

It begins with my explanation to the mother of why I first palpate the position of her baby before listening to fetal heart tones, and how IA helps midwives know if our assessment of fetal position is correct. If her baby is currently in the position that I think it is (LOT, LOP, ROT or ROP, the heart sound should be best heard in spot on her abdomen that I specified.

The specific criteria that IA depends on is gathered by L&D nurses and midwives by listening for an entire minute or longer during which they count the fetal heart rate in five-second sampling over the course of a minute. This equates to twelve 5-second units or ‘samplings’ per minute. Note: one minute is the shortest length of time needed to be relatively certain there are no FHR irregularities, but when listening for accelerations, it’s sometimes necessary to listen for 2, 3, 4 or even 5 minutes

** For example, the normal baseline range for a fetus at term is between 110 and 150 bpm, with 120, 132, and 144 bpm being the most typical normal baselines during 1st stage labor. FH baselines () that are over 150 for 10 minutes or more are considered to be a mild stage of tachycardia.

When using 5-second sampling over one full minute or longer, what is counted per 5-seconds is generally a combination of 10s, 11s, 12s, 13s and occasionally a 14.

So a …

  • normal baseline rate of 144
  • normal variability
  • one acceleration of 15 seconds {**}
  • no pathological decelerations

…. would generate a sequence of numbers such as: 12, 12, 11, 12, 13, 12, {**13, 14, 13}, 11, 10, 11, 12, 12.  ** The {13, 14 13} is an acceleration that momentarily elevated the baseline (if maintained) to 156, 168, 156 and then a return to the baseline of 144.

A preponderance of 12s for 5-second units indicate a normal baseline of 144 (12 X 12 =144), just as a preponderance of 10s is 120, 11s is 132, 13s is 156, and 14s would be 168.

That the slightly changing beat-to-beat rhythm is ‘varied’ documents the normal attribute of ‘variability‘, while a consecutive and elevated set of 13s (a cluster of 3 or more) indicates the presence of ‘reassuring accelerations’. Last but certainly not least, there were NO instances of 5-second units in which the 5-second sample was 9 or less for 30 at least 30 seconds. This tells us that the baby is not currently suffering from any pathological decelerations. **

For each hour and in most cases, each fraction of an hour of the mother’s labor, IA provides information that allows the primary birth attendant or L&D staff to determine if the FHR baseline is normal (or not), if the variability is normal (or not), whether reassuring accelerations are present (or not) and if any pathological decelerations are detected.

Charting IA data

All this is charted, so there is a record of the baby’s FHR over the course of the labor that accompanies information on the mother’s stage of labor, her progress and any other pertinent medical factors. Date from each auscultation can be plotted on a graph after every auscultation (particularly useful if its a longer labor or there are questions about something. But when the FHR is ‘boringly’ normal (the best kind!), most midwives just incorporate the FHR checks into the narrative notes.

I use a simple method that identifies the most frequent 5-second sampling number heard during the one-minute ausculations as the baseline (i.e. the rate for the majority of samplings).  I also note the range or variations of the less frequent numbers and record them.

If there is an acceleration is present, there will be 3 or more 5-second units that are higher than the baseline 11s (12s, 13s, occasional 14). If one or more deceleration is heart, it will be counts that are below 11, or 10s, 9s, 8, etc).

Let’s use the example in a few paragraphs above. The different numbers generated by 12 sets of 5-second samplings were –> 12, 12, 11, 12, 11, 12, {**13, 14, 13}, 11, 10, 11, 12, 12, which would be charted as a baseline of 144, with normal variability, one acceleration and no decels.  So here is how that conclusion was reached and how it would be charted.

  • First, the baseline of 144 was based on a preponderance of 12s.
  • Normal variability was established by a at least a few of those 5-second units being higher or lower than 12; in this case there were 4 lower (10s and 11s) and 3 higher (13s).
  • Accelerations were noted with a run of three consecutive sets above the baseline number of 12, in this case, two 5-second sets of 13, and one of 14 (over a total of 15 seconds).
  • There were NO decels.

So the baseline would be charted as the numeral 144, then would chart all the numbers counted over the course of one (or more) minutes. I don’t mean writing done each 5-second count, just the various number heard during the one minute auscultation. In this particular, but not necessarily typical instance, that was one 10, several 11s, 12s, 13s and one 14.

On my paper charts, I list all of them, which records the range of variation, then I put a vertical line of 3 small checks over the baseline (number heard most often that becomes that is charted as the baseline) and 2 checks over the next most frequent number (in this example, 11s) and 1 check over the least frequent, in the case a number lone 14.

@@@ IA graph for intrapartum charting (ACCM-1999) @@@

If  you use electronic charting, the special category for charting FHTs will not let you record these fine distinctions. However, you can put this same IA data in the narrative part of the record, and while you can’t put checks over number, you can list the as (a) most frequent, (b) next most frequent and (c) least frequent.

Outliers, Artifacts and Errors: The reason for these find distinctions is to avoid using a random high or low number — i.e. an outlier that could be an artifact or error –to make determinations that are not justified by the facts.

For example, after hearing a super low 5-second sampling of 6 or a super high of 16 is not by itself, it’s not appropriate to diagnose bradycardia, tachycardia or fetal distress all by themselves. To represent “actionable information“,  practitioners must first confirm this abnormality with additional monitoring. If they find them to be repeated with enough frequency to indicate a problem that needs to be evaluated or requires emergent treatment.

A Parting Comment on Quartz Watches and Clocks

For prenatal care in my own office, I use a typically use an inexpensive 7-inch quartz clock with big black numbers on a white background and a “tick-stop” second hand ($4.99 @ Target). I have a similar quartz clock that is part of my birth equipment. I set it upright somewhere in the room where the mother is laboring in a place that I can see AND (very important) is completely hands-free.

However, one of my midwife friends (thank you so much, Emily Deckenback, LM) told me about a handy smartphone app that has nearly all the wonderful feathers of my 7″ quartz. It’s great when the moms are somewhere else in the house (like the bathroom). I say nearly, because I have to handle it (extract from my pocket) before i can take FHT. This almost always requires at least two hands to retrieve it from my pocket and find a place to put it down where it won’t fall on the floor or slide into the tub while I am counting FHTs over the course of a minute or two or longer.

Most adverse outcomes discovered after the birth did not have anything to do with the labor or birth

Vast majority of adverse events during the perinatal period having nothing to do with the type of birth attendant (MD vs. midwife) or place of birth (home vs. hospital) but everything to do with prenatal problems of unknown origin.

The professional opinions of experts in this field have concluded that the origin of most unexpected bad outcomes (92%) traces back to prenatal problems for the fetus that arose during the pregnancy or were genetic in nature. These complications had nothing to do with how labor was managed or if an elective Cesarean was performed before labor started.

Cesarean section may be able to take the baby out of the mother’s body, but there is no operation that can take the metabolic acidemia or abnormal DNA (and damage it’s already done) out of the baby.

The scientific literature has repeatedly reported that IA has an equal or better outcome, a conclusion that is a combination of studies and the fact that IA has always been associated with fewer medical interventions and invasive obstetrical procedures than continuous EFM, including reduced operative delivery and CSs rates.

However, only midwives (whether in or out-of-hospital) are educated in the principles of IA, taught the technical skills during their clinical training and experienced in both the art and science and currently using it to monitor labors.

This is not because they couldn’t use EFM if they wanted or needed to, but because IA works so very well when used by practitioners who understand a fetus’s biological response to both normal and abnormal labor and who believe it’s their duty to “Do No Harm”. For community-based midwives, “Do No Harm” means not needlessly exposing the families we serve to the well-known risk of c-EFM and are willing to personally listen to fetal heart tones at least once an hour and for most of the labo, several times an hour.

In slightly more abstract terms, this means we are choosing not to reduce our own risks and the burden to ourselves by shifting the risk and burden to the mother and unborn baby.

 

Another video for anyone who wants to practice IA skills

 

 

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Part 3B~ Hx & Use of Auscultation to replace routine c-EFM in healthy labor patients with normal pregnancies ~ 3B http://faithgibson.org/part-3b-hx-use-of-auscultation-to-replace-routine-c-efm-in-healthy-labor-patients-with-normal-pregnancies-3b/ Wed, 10 Nov 2021 23:49:10 +0000 http://faithgibson.org/?p=9245

~ 3B ~

Index for this last post

  • Central Fetal Monitoring: The newest kid on the block half a century later
  • Trying to build a better mousetrap instead of building a better foundation
  • Why the subtle distinction btw acidemia & hypoxia matters
  • The Glaringly Obvious Effect of EFMturning healthy women into  passive & bed-ridden maternity patients
  • Photo Album ~Women disappearing into the obstetrical “system” — passive non-persons laying on their backs, covered by drapes while their “providers” peer out at them over surgical mask
  • Excerpt –> Violence Against Women in Health Care Institutions: an emerging problem ~  British Medical Journal /The Lancet, May 11, 2002

Central Fetal Monitoring: The newest kid on the block half a century later

The introduction of central monitoring allows hospitals to centralization the fetal monitoring function of their L&D units. This new system for transmits the data from individual EFM machines to a central display system;  it is just the latest iteration of this fever pitch to replace people with electronics.

Central fetal monitoring frees up nurses so they no longer have to be personally present in the mother’s labor room. They can skip the patient’s labor room altogether while they monitor several labor patients at one time from the comfort of their chair at the central nurses’ station in the hallway.

My first experience with central monitoring was a few years ago after I transferred 3 midwifery clients with minor complications to three mid-sized community hospitals
Every time I left the labor room to use the public bathroom or go out for a meal, the nurses on duty were sitting or wandering around the nurses’ station. I thought it odd that a L&D unit with 10 labor beds could have 12 staff nurses & one OB hospitalist all sitting at the nurses stations nearly all the time. So i ask a friendly nurse what was going on and she explain their central monitoring system and how they were all watching banks of fetal monitor screens.
While this may be pleasant for the L&D staff, central fetal monitoring is expensive to set up and maintain, and has not been shown to be of benefit in comparison to bedside EFM (Withiam-Leitch, Shelton, & Fleming, 2006).
In another study that compared central fetal monitoring with no central monitoring, (Weiss, Balducci, Reed, Klasko, & Rust, 1997), there was a statistically-significant increase in cesareans and operative vaginal births for non-reassuring fetal heart rates specifically associated with central monitoring.
An interesting factoid: the 2nd most frequent diagnosis for Cesarean surgery in a first-time mother is (drumroll please!) a non-reassuring fetal heart rate!
  • The guidelines for healthy women with uncomplicated pregnancies do not recommend continuous monitoring.

Trying to build a better mousetrap instead of building a better foundation

During the 1970s, EFM became the de facto standard for obstetrical care in the US. and replacing simple periodic auscultation (IA) with continuous electronic fetal monitoring. As noted in the many studies quoted above, the universal use of EFM did not turn out to be the answer to the obstetrician’s prayer as everyone hoped.

But this disappointment did nothing to dislodge obstetrical faith in electronic monitoring systems. The profession spent its a huge proportion of its resources trying to improve and refine EFM’s electronic circuitry and making other tweaks the machinery, alway anticipating that the perfected ‘magic bullet’ was just around corner.

Unfortunately, this blind faith in the ability of c-EFM to eliminate newborn neurological complications created a series of problems, not the least of which was a malpractice nightmare for obstetricians. Having extolled the virtues of obstetrical care augmented by c-EFM and Cesareans as a virtual guarantee of a ‘perfect’ baby every time actually set up a situation in which obstetricians got sued every time they didn’t deliver “the goods” — i.e. a perfect baby.

The annual premiums for an obstetrician’s professional liability insurance skyrocketed from a few thousands (5-8 K) to a ‘low’ of $85,000 and as much as $200,000. This is often a deal-breaker that keeps medical students from going into Ob-Gyn as a speciality, and results in early retirement of many practicing OBs who, having been sued one or more times, simply can’t stand the psychological strain or the economic cost.Directing the same high talent, money and other resources to find the real cause of cerebral palsy and similar newborn neurological disorders as currently spend on the expanding use EFM

The much bigger and more important picture is even more an issue for childbearing families and for society is developing effective way to do what EFM said it would do, but turned out not to be able to “delivery the goods”. This of course in to find the real cause and prevention of cerebral palsy and similar newborn problems.

The obstetrical profession’s fifty-year focus on refining and expanding the EFM system diverted attention away from studies that looked into other origins and explanations for the unexpected problems of cerebral palsy and neurologically-damaged babies subsequent to perfectly normal pregnancies and normal labors and births.

Nonetheless, a number of excellent studies have been done on these topics in the last decade or so. While its fifty years too late to have avoided this misadventure, these finding are still critically important. This research was able to determine that the great majority of adverse outcomes (92%) traced back to prenatal problems for the fetus that arose sometime during the pregnancy and and are related to conditions such as undetected maternal infection, prematurity, intrauterine growth-restriction and other fetal or maternal conditions that created metabolic acidemia for the unborn baby. No amount of fetal monitoring during labor could have prevented or changes these outcomes.

In addition, these researchers concluded that development of cerebral palsy and other forms of permanent neurological damage extremely rare during a normal labors. This held true even when some FHR abnormalities consistent with intrauterine hypoxia were recorded by the monitor tracing. The science identifying the biological origins of CP and newborn neurological damage found that metabolic acidemia (as differentiated from respiratory acidemia) was directly associated with a baby that developed CP. At the same time, researcher were able to determine that brief to moderate episodes of hypoxia (inadequate oxygenation at a cellular level) were not associated with increased rates of CP and newborn encephalopathy.


Why the subtle distinction btw acidemia & hypoxia matters

The distinction btw metabolic acidosis and labor-related hypoxia is subtle even for highly-trained medical professionals. But this is critically important, as the reasoning behind c-EFM was the assumption that fetal hypoxia during labor was the causative agent in cerebral palsy and similar neurological problems.

Continuous EFM was specifically developed to detect the slow development of hypoxia over long periods as the unborn baby was being exposed to less-than-adequate oxygenation (such as a placental insufficiency, post-mature pregnancy or maternal hypertension).

The other known cause for CP and neonatal encephalopathies are of course acute obstetrical emergencies, such as a placental abruption, cord prolapse or a life-threatening medical emergency for the mother. But again, these emergency have little or nothing to do with EFM, as they are usually diagnosed by other symptoms and monitoring the vital signs of the mother. No form of EFM, no matter how well ‘perfected’, can predict, prevent or treat these occurrences.

In acute intrapartum emergencies, anoxia (the most severe type of hypoxia) is terribly damaging to the unborn baby. But all and all, this type of intrapartum emergency is rare; we know because the use of c-EFM hasn’t eliminated them. However, the depressingly stable rate of CP hasn’t budged over the last 50 years in spite of c-EFM. Along with newer research, this tell us that pre-labor metabolic acidosis is the stubborn cause of 92% of all CP cases and other neurological problems not related to an intra-partum emergency.
At the risk of boring (or insulting) my readers, let me restate the fundamental purpose of fetal monitoring during labor (whether IA or EFM), which is to help the birth attendants or hospital staff distinguish between unborn babies that are well-oxygenated and neurologically intact and those that, for whatever reasons, are not.
For unborn babies that have an essentially normal baseline, variability, presence of reassuring accelerations and absence of pathological decelerations, the likelihood that such a fetus would suddenly ‘crash’ within the next 100 minutes is extraordinarily small unless there is an acute obstetrical complication, which we have already established is not prevented or treated by any system of fetal monitoring (the verbs or the machines).

If you are interested in learning how intermittent auscultations (IA) works, this link will take you to a stand-alone post on IA


Conclusion

As long as this essay is, I didn’t include many issues known to increase the problems associated with our highly-medicalized obstetric system.

The topic that got the short shift was the simple but profoundly important principles of physiological management. Physiologic methods aim to safely manage childbirth without depending on drugs like Pitocin to progress the labor, narcotics to manage pain, or surgical procedures to deliver the baby.

Instead of obstetrical interventions, midwives depend on the normal physiology of childbearing, which in turn depends on mothers being able to move around freely, receive one-on-one support, able to use upright positions and make right use of gravity, as well as non-drug methods of pain relief that include walking, hot showers, and submersion in a deep water tub.

Midwives believe in the innate ability of childbearing women to labor spontaneously,  push their babies out under their own power and properly take credit for this accomplishment.

As midwives, we do our part by fully present throughout active labor, eyes-on, ears-on, hands-on care and generous frequent encouragement. This includes but is not limited to monitoring the physical wellbeing of the mother, and intermittent auscultation (IA) of the fetus, to be as sure as possible that we would detect any problems for the unborn baby and take appropriate action.

Contrast this with allopathic medicine, which is officially defined as the use of drugs, surgery and ionizing radiation. American MDs are not interested in learning about ways to do things that don’t include the use of drugs or surgery. As a result, our medical schools don’t teach the physiological management of normal childbirth. Practicing obstetricians generally don’t know, don’t use, don’t like, don’t understand, don’t believe in and certainly don’t approved of physiologically-based care or practitioners (i.e. midwives) who use provide physiological management.

So it comes as no surprise that over 90% of women laboring in the obstetrical system are given epidural and are continually monitored. The blow-back from this creates a consistent set of other problems that require the same few interventions — IV Pitocin to speed up the labor, maternal oxygen mask as minor but non-reassuring changes begin to show up on EFM strip and far too often, the decision to do an emergent c-section based on a combination of slow or no progress and increasing signs of possible fetal distress as recorded by the EFM (i.e. non-reassuring fetal heart rate).

The Glaringly Obvious Effect of EFM — turning healthy women into  passive & bed-ridden maternity patients

What stick out most in my mind as I googled photos of electronic fetal monitors and laboring women as was how EFM turned healthy women into passive maternity patients, lying still and listless in bed, so as not to infer with working of the the machines they were hooked up.

Everything about the design of ‘modern’ obstetrical units and the ministrations of the  L&D  staff revolves around the hospital’s computer-based electronic fetal monitoring system. The nurses have to keep graph paper in the tray, unplug all the leads every time the mother has to go to the bathroom, and most time-consuming of all, repeatedly tweak the placement of the toco and monitor belts on the mother’s belly find the signal and be sure its being is recorded.

Everyone hopes that EFM tracing will keep the doctors and the hospital from being sued and the icy fear in the back of their mind that they might slip up and the EFM proof needed to prevent litigation can’t be found.

But the real tragedy is what c-EFM does to laboring women. They have been ‘disappeared’ from the system. Instead of healthy individuals experiencing the most important and joyous day of their lives, they have been dependably turned into faceless compliant patients doing their part to make the OB department into a profit center for the hospital.


Stand-alone version of the section on IA — principles and technical skills


Women disappearing into the obstetrical “system” — passive non-persons laying on their backs, covered by drapes while their “providers” peer out at them over surgical mask

Obstetrician using surgical scissors to cut an episiotomy

Obstetrical surgeons delivering the baby thru the Cesarean incision

Breech baby being extracted through the uterine incision after forceps were used to deliver its head

After the baby was delivered by C-section, the mother’s uterus was lifted out of her abdomen through the incision and placed on the outside of her body while the obstetrical surgeon sutures up the 4-inch incision into the uterus itself

 


Excerpt –> Violence Against Women in Health Care Institutions: an emerging problem ~  British Medical Journal /The Lancet, May 11, 2002

Other important forms of violence against women occur in reproductive health services and deserve more discussion than is possible in a short article.

These forms include excessive or inappropriate medical treatments in childbirth, such as doctors doing caesarean sections for reasons related to their social or work schedules or financial incentives or adhering to obstetric practices that are known to be unpleasant, sometimes harmful, and not evidence based, including shaving pubic hair, giving enemas, routine episiotomy, routine induction of labour and preventing women having companions in labour.

Shoulder Dystocia Rate Constant Despite Risk Factors – Medio-legal Implications Parity, C-Section, Birth Wt / Ob.Gyn.News, May 15, 2003, Vol 38, No 10;

Shoulder dystocia appears to occur at a constant rate, despite increased cesarean sections and variations in other risk factors, Dr. Michael Lucas reported at the annual meeting of the Society for Gynecologic Investigation.

“It seems counterintuitive,” said Dr. Lucas of the University of Texas, Houston, in an interview. “There’s this notion that if we manipulate the risk factors we should see a lower rate of shoulder dystocia, but that does not appear to be the case.”

His study of more than 12,650 births in two Houston hospitals showed a similar rate of shoulder dystocia, despite differences in the risk factors of parity, birth weight, cesarean delivery, and operative vaginal delivery between the two hospital populations. The findings could have implications in the defense of shoulder dystocia cases.

“The argument has always been that there are risk factors for shoulder dystocia, which the physician should have acted on,” he said. “Our data suggest this is not true. It may at least be argued that we can take a population with a much different rate of risk factors and have virtually the same rate of shoulder dystocia. This is important clinically, because it supports the notion that our options and our ability to avoid trauma with this complication are limited.”

Dr. Lucas researched the obstetric databases of an urban public hospital and a community teaching hospital … The community hospital had twice the rate of cesarean deliveries, fewer multiparous mothers, a lower operative vaginal delivery rate, and smaller babies, factors usually associated with lower rates of shoulder dystocia.

Still, both hospitals had virtually the same incidence of shoulder dystocia: 1.1% and 1.3% of vaginal births at the public and community hospital, respectively…The community hospital had a higher cesarean delivery rate than the public hospital (30% vs. 14%) and more babies weighing less than 4,000 g (59% vs. 41%).

Babies with shoulder dystocia tended to be smaller (3,844 g vs. 4,117 g) at the community hospital .. The operative vaginal delivery rate was higher at the public hospital than at the community hospital (11% vs. 8.5%).

… the high cesarean delivery rate, lower rate of multiparity, and lower birth weight at the community hospital were not associated with a reduced rate of shoulder dystocia.

“It seems intuitive to say if you avoid a vaginal delivery you can lessen the rate of shoulder dystocia, but this doesn’t appear to hold water,”Dr. Lucas said.

 

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Part 3A~ Hx & Use of Auscultation to replace routine c-EFM in healthy labor patients with normal pregnancies ~ 3A http://faithgibson.org/part-3-of-3-false-association-routine-efm-2-prevent-cp-n-baby-pelvic-floor-damage-mothers-protect-obs-lawsuits-mar2019/ Tue, 09 Nov 2021 20:00:56 +0000 http://faithgibson.org/?p=7533

Part 3A ~ 2019   Easy shortcut to share –> http://tinyurl.com/y65wzon5        word count 2,400


How did the extreme discordance btw the scientific studies and current obstetrical standard of care come about?

Unfortunately, the answer is “follow the money”, or i should say, follow the three biggest economic areas.

Two obviously positive revenue streams:  the manufactures who sell EFM machines, software, and central monitoring system, and hospitals which sell the service of continuous EMF, being reimbursed several hundred dollars each hour for each woman in labor by insurance companies and the federal MediCaid program (49% of US births are reimbursed by MediCaid).

The last aspect of ‘following the money’ leads us to the malpractice issue. In regard to EFM, the economics of professional liability insurance are two-fold.  First, manufacturers benefit enormously from the popular idea (often wrong) that using EFM is equivalent of “insurance” against lawsuits — buy and use our EFM machines and you (or your institution) will save a ton of money by not getting sued!

The second part of the money stream is the income it generates for professional liability carriers. Many obstetricians pay $150,000 in annual premiums. Companies, who obviously hope to get everyone business, sometimes offer the equivalent of a ‘good driver discount’ — that is, agree to reduce the annual premium if the OB follows all the policies of their hospitals and also agrees not to provide any planed vaginal birth services to mothers who previous had a Cesarean or who had a twin pregnancy or baby in a breech position.



A quick history of fetal monitoring: Intermittent Auscultation & EFM ~ verbs, nouns, and names of physician-inventors

 

The first person to report hearing the sound of an unborn baby’s heartbeat was a 17th century physician by the name of Dr. Marsac. A contemporary of his, a Dr. Killian, was the first to ponder the possibility that the rate and rhythm of the fetal heart might be an indicator of how well the fetus was (or wasn’t) tolerating the process of childbirth.

However, this possibility went unnoticed for two more centuries, until 1818, when doctors Mayor and Kergaradec described a method of  auscultating fetal heart sounds by placing one’s ear on or very near the maternal abdomen. Dr. Kergaradec also suggested that fetal heart sounds could be used to determine fetal viability and proof of life in the months before ‘quickening’, that is, before the mother could feel the baby kick.

In 1833, an English physician, Dr. Evory Kennedy, published guidelines for fetal distress and also recommend auscultation of the fetal heart rate to monitor the well-being of the fetus during labor and birth.

A simple tool for counting the fetal heart rate

However, the big leap forward came in 1893, when Dr. Von Winkel established criteria for fetal distress. After listening to the heart rate of many babies during many labor, he realized that  the FHR of an unborn baby in trouble would often (but not always) become abnormal, and beat much faster or much slower, or become extremely erratic. Some of these babies died before the birth, other were born profoundly depressed and often died later.

With this understanding, Dr Von Winkel identified the signs of fetal distress, which included abnormal fetal heart rates (FHR):

  • tachycardia (a over 160);
  • bradycardia (under 100),
  • irregular heart rate, passage of meconium,
  • abnormal fetal movement (i.e. agonal spasms of a dying baby).

By the turn of the 20th century, maternal fever was recognized as a cause of fetal tachycardia; head compression and cord compression were also known causes of bradycardia, and hyperstimulated uterine activity associated with an abnormal FHR patterns and asphyxia.

When these abnormal heart rates were discovered very late in the labor, doctors could sometimes perform a forceps delivery to rescue the baby. By the late 19th century, the development of general anesthesia, germ theory of infectious disease (resulting the principles of asepsis and sterile surgical techniques) made Cesarean surgery safe enough to use during labor to rescue babies with extremely abnormal heart rates.

 

By the early 20th century — 50 years before fetal heart monitoring was electronically automated by a computerized machine — doctors, midwives and nurses were using a special stethoscope called a Pinard Horn to regularly listen to the heartbeat of the fetus during labor. Pinard fetal stethoscope was developed in the 1880s and in wide use in the 1950s.

The medical protocol for auscultation at that time was to count the number of fetal heart beats per minute (bpm) and record the findings on the mother’s chart. This was done on a hourly schedule in early labor, and repeated with increasing frequency as the laboring mother got closer to giving birth.

Helpful as this information was, there were still a few babies with apparently “normal” FHR that were born with unexpected and unexplained problems that prevented the baby from breathing on its own that resulted in death or severe handicaps.

At this early stage of development of fetal monitoring, auscultation was only used to count the heart rate for one minute (b.p.m, charted as a baseline for that period of time). However,  birth attendants and nurses paid no attention to the rhythm of the fetal heart or other elements now known to be equally, if not even more important — variability, the presence of reassuring accelerations and absence of pathological decelerations, as well as the depth, timing, and duration of any decelerations that are detected.

However, in 1922 Dr. Joseph De Lee, obstetrician, founder of the Chicago Lying-in Hospital and Chicago Maternity Center, invented, in conjunction with another obstetrician (Dr. David Hills) a hands-free fetal stethoscope for listening to fetal heart tones. This device became known as the DeLee-Hills Fetoscope.

Then Dr. DeLee developed the process and protocols for the intermittent auscultation (IA) of the fetal heart rate during labor, which included Dr. Von Winckel’s 1893 description of fetal distress listed above. Using his new fetoscope, the FHR was to be auscultated every 30 minutes during first stage of labor, every three or five minutes during second stage, and continuously if signs of fetal distress were seen as an indication for forceps delivery.

In 1924,  4th edition of Dr. DeLee’s obstetrical textbook Principles and Practice of Obstetrics includes a wonderful graphic that displays a fetal heart rate auscultated and charted in 5-second increments during a minute-long contraction.

It shows a normal baseline rate of 132 bpm at the beginning of the contraction (ranging from 120 to 144 bpm when computed in 5-second samplings) during the first 20 seconds. As pressure on the fetal head builds up, there is a head compression decel, and we can see the FHR go down from 144 to 108 bpm over a span of 20 second durning the middle of the contraction. As the contraction wanes and the uterus relaxes during the last 20 seconds, the unborn baby’s heart rate speeds back up to its pre-contracton normal baseline of 132.

 

If you read Dr. DeLee’s comments below the picture of the graph, he refers to a pattern of decelerations during the pushing stage that we now know to be head compression decels — the result of triggering the mammalian diving reflex that has been extensively studied in whales.

Dr. DeLee somewhat anticipated this explanation by referring to the observed effect of an abnormally slow heart rate of men working deep under water in a “caisson” (a big metal contraption used during the underwater building of bridges and similar construction projects).

DeLee’s work is the theoretical precursor to both IA and EFM, as it is the first instance of dealing with variations in the FHR during the period of auscultation by using 5-second samplings. Prior to this, the only information on fetal heart activity that was gathered was the sum total of beats over 60 seconds period, which was stated as beats per minute (bpm) and recorded as a baseline rate.

Dr. DeLee recognized a second-level source of valuable information that could be gathered by paying attention to the FHR changes that occured (or failed to occur) within the one- or two-minute period that the FHR were routinely monitored by the L&D nurse, doctor or midwife.

The theoretical basis developed by Dr. DeLee and its 5-second sampling protocol, which yielded much a more useful picture of fetal wellbeing. This critical aspect of IA  was widely not acknowledged or integrated into standard obstetrical practice until the development of electronic fetal monitoring equipment in the late 1950s and 60s.


If you are interested in learning how intermittent auscultations (IA) works, this link will take you to a subsequent stand-alone post on IA   

Note: The historical background material on non-electronic fetal monitoring is repeated. To skip that part,  keep scrolling down until you see this photo and the heading:”How IA Works“.


The invention of electronic automated fetal monitors and its displacement of IA

With the clarity of hindsight, we now know that just recording the one-minute fetal baseline rate was not sufficient to identify subtle indicators of fetal distress.

In the decades before and after the ideas expressed in Dr. DeLee’s 1924 textbook,  untold numbers of unborn babies unexpectedly ‘crashed’ during labor or were born severely depressed.

It’s not surprising that American obstetricians and worried parents continued to wonder if better information on the biological status of the fetus — a way to know what the fetal heart rate was during every minute of the entire labor & birth — would allow them identify unborn babies in trouble in time to rescue them before damage was done.

The very first attempt to record a FHR by using an electric machine came in 1906, which was when Dr. Cremer invented the first ‘fetal monitor’, which  was an electro-cardiogram that used abdominal and intra-vaginal electrical leads. (!)

Other physician-inventors attempted to determine fetal status using a microphone to magnify the auscultated FHR and electronic phono-cardiography to record it. They ultimately decided that such devices could not provide the kind of consistent results that would allow them and other obstetricians to identify early indications of fetal distress.

But in 1958, Dr. Edward Hon, the pioneer of modern EFM, developed the first system for capturing continuously the fetal ECG and coined the terms early, late, and variable decelerations. I don’t know for sure that Dr. Hon knew about Dr. DeLee’s observations in the 1920s, but whether he did or not, he applied Dr. De Lee’s theories and methods.

In just five years (1964), Dr. Callagan had developed a commercially viable system for capturing the FHR with Doppler technology.

By the late 1960s, EFM systems by Dr. Hon were commercially available in the United States (1968). Other pioneers in these electronic systems include Dr. Hammacher in Germany who reduced noise-to-signal ratios and Dr. Caldeyro-Barcia from Uruguay, who was father of a number of fetal monitoring terms, including Montevideo units and long-term and short-term variability.

By the early 1970s, electronic fetal monitors had been purchased by 20% of hospital obstetrical units. Today, 100% of labor and delivery units have electronic fetal monitors and over 90% of hospital births include the use of c-EFM, along with an epidural anesthesia rate over 80%.

A web article called How to read a EFM on VeryWellFamily.com concluded its description of EFM (obviously from the perspective of hospitals) by saying that c-EFM:

“… also allowed the monitoring to be done without one-on-one care at the bedside.”

EFM: Really good for business

By the early 2010s, more than 3,400 hospitals in the U.S. had purchased approximately 28,000 fetal monitors. According to an article in BusinessWire in 2012, this was initial investment of over $700 million dollars. The global fetal monitoring market is expected to reach $3.6 billion by 2022 according to the Global Fetal Monitoring Report compiled by Allied Market Research (AMR).

 

The report about this enormous market costs a whopping $4,000, and that is only for a single person or company to read. As reported by AMR, the business in developing countries is a particular plum, very lucrative in just the sheer number of hospitals and to be perpetuated by ‘repeated business’, making it the equivalent of a ‘futures market‘ for electronic fetal monitoring devices.
Hospitals spend much more on electronic monitoring systems than handheld Dopplers. This is consistent with a decision NOT to hire enough nursing staff to do one-on-one intrapartum care that includes the use of IA.

 

Obviously hospital administrators did the math and quickly realized that making $400 each hour from insurances companies for each electronically monitored labor patient was far more profitable than losing $30-$45 each hour for each nurse’s salary who would instead monitor (the verb) the unborn baby using IA.
But the human and economic costs of c-EFM are so high: multiple obstetrical interventions and painful invasive procedures during labor, increased C-section and operative delivery rate  and its many complications:
  • blood transfusions
  • emergency hysterectomy
  • postpartum infections
  • rehospitalizations
  • all the downstream emergencies:
    • placenta percreta in future pregnancies that requires a Cesarean hysterectomy
    • ICU admission for as long as to 20 days
    • maternal death for 7 to 1o out of 100 women.

The routine use of electronic fetal monitoring as the standard of care for healthy women with normal pregnancies is high-tech, high-cost, non-evidence-based care.  [EvidenceBasedBirth.com]

Since the first EFM was purchased by the first hospital, the push to expand c-EFM has been ever up, up, upward, irrespective of the science, damn the torpedoes, full speed ahead! There is no doubt that a constant pitch for buying the latest hot new upgrade is being driven by the EFM manufactures, for whom the sale of EFM equipment is so profitable.

Interestingly enough, the economic goals of EFM manufactures fit perfectly with those of hospitals, for whom billing insurance carriers and the federal *Medicaid program hundreds of dollars an hour makes the use of c-EFM into one of their favorite “cash cows”.

As for the health insurance industry, they can afford to reimburse hospitals at this extraordinary rate because it’s just a pass-through for premiums paid by their customers. Anytime the insurance carriers aren’t making as much profit as they want, they can hike premiums up to the moon and back and there is NOTHING we, the public, can do — we either pay or become uninsured.  So “cost containment” is not a necessary aspect of health insurance as an unregulated industry.

[**Medicaid pays for half of all births in the US]

For hospitals, this profit-making scenario is the polar opposite of having to spend hundreds an hour to hire enough L&D nurses to provide one-on-one care (i.e. to ‘midwife’ as an active verb) each patient, using IA to monitor the fetus as an eyes-on, hands-on process performed in real time by a real person.

Continue: Part 3B~ Hx & Use of Auscultation to replace routine c-EFM in healthy labor patients with normal pregnancies ~ 3B

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Part 2B More on Cesareans and simple explanation of how Auscultation works ~ 2B http://faithgibson.org/next-in-series-part-2-false-association-btw-routine-efm-increased-c-sections-and-strategy-to-prevent-cp-and-obstetrical-malpractice-suits-2a/ Mon, 08 Nov 2021 21:38:12 +0000 http://faithgibson.org/?p=9197

A specially-designed placenta-percreta operating suite outfitted with the latest interventional radiological equipment for performing Cesarean-hysterectomy on previous C-section mothers. In addition to multi-million dollar equipment, there are over 20 doctors, OR nurses, neonatal nurses and specialty hospital staff.

~ 2B ~ Cesarean Surgery – the “gift” that keeps on giving!

Cesarean surgery: #1 scalpel incision into the skin

Cesarean surgery is the gift that keeps on giving, not only at the time the operation is performed but in all future pregnancies. Unfortunately for 6% of post-cesarean mothers, a downstream complication of their Cesarean surgery is infertility, usually a result of post-operative infections.

Life-threatening complications of this surgery can result in the need for blood transfusions, unplanned emergency hysterectomy for uncontrollable hemorrhage and days or even weeks in the ICU.

The postpartum recovery period is longer, harder, more painful and in some cases of prolonged post-op pain, exposes new breastfeeding mothers to opioid addiction as a result of the needed narcotic medication. In other instances, the problem is post-operative infections that have to be treated with IV antibiotics and may require new mothers to be readmitted to the hospital.

Obviously, none of this is conducive to bonding with one’s new newborn or learning how to care for and meet its needs, something that may be a make-it-or-break-it issue for post-op mothers trying to breastfeed for the first time.

Cesarean surgery: The skin incision is extend down thru the subcutaneous abdominal layer of fat

Then there is the long shadow that a previous C-section casts over all subsequent pregnancies. This begins with the risks of possible uterine rupture of the Cesarean scar either before or during labor. That is the primary source of controversy over vaginal birth after Cesarean (VBAC), as many doctors, hospitals and medical malpractice insurers do not want to risk being sued in these cases. As a result, they either decide not to  “do” VBACs, or hospital policies (often based on liability insurance contracts) won’t allow them to do so.

This sets up previous-Cesarean mothers for additional, often unwanted (and certainly not medically necessary) major surgeries by requiring that all future babies be delivered by repeat C-section. This exposes her to all the aforementioned risks, over and over again, and dramatically increases the likelihood of the placenta-related complications described below.

The most devastating and potentially deadly of the many delayed and downstream complications of Cesarean surgery is the propensity to develop abnormal placental implantation in future pregnancies, a risk that increases exponentially with each subsequent Cesarean delivery.

Cesarean Surgery: The peritoneum (tissue covering all abdominal organs) is surgically exposed

Even the very best of circumstances — the least invasive category of placenta accreta — can be life-threatening. Luckily. the majority of these new mothers come through without requiring blood transfusions, major surgery, or admission to the ICU.

But when the placenta grows into the uterine muscle (placenta increta), or worse yet, grows completely through the wall of the uterus (percreta) and attaches itself to other abdominal organs (usually bladder or bowel), it requires a highly risky preterm Cesarean-hysterectomy. This dire but mostly preventable emergency is fatal 7-10% of the time.

Unfortunately, the delayed and downstream complications associated with Cesarean surgery make any policies or practices that increased the C-section rate counterproductive in the extreme.

Vocabulary Review for types and levels of abnormal Placental attachments:

  • Placenta Previa is when the placenta implants at the bottom of the uterus. Depending on how close to the cervix, there are 4 levels of previa: (a) low-implantation (b) marginal (c) partial and (d) complete, which covers the cervix completely and makes vaginal birth impossible.
    In addition to the previa, the placenta may also grow abnormally deep into the uterus, which means the mother-to-be has both a previa and a perceta. 
  • The most serious levels of previa (c & d) or any level of accreta-percretarequire Cesarean delivery.
  • Placenta accreta is when the placenta grows abnormally into the superficial lining of the uterus and is the least serious level of invasion
  • Placenta increta is when it grows into the uterine muscle
  • Placenta Percreta is when it grows through the uterine wall and attachesto other abdominal organs.These are life-threatening complications that frequently require an emergency hysterectomy to stop the bleeding and has a 7 to 10% maternal mortality rate.

Cesarean surgery: The peritoneum has been surgically excised (cut and pushed aside) to expose the lower part of the mother’s uterus

What is the word for promising one thing & doing the exact opposite?

Now we come to the well-documented facts about the current national standard for obstetrical care in the US, which is organized around the universal use of c-EFM. There is no question that the frequent use of emergent C-section based on EFM tracings that are ‘non-reassuring’ increases our national Cesarean rate. In fact, “non-reassuring fetal heart tones” is the second most frequent diagnosis for Cesareans performed on first-time mothers.

Yet the raison d’etre for EFM — reducing the instance of cerebral palsy and other neurological disabilities — is NOT happening. What surely is happening is a decades-long medically-unnecessary increase in Cesarean surgery and its many intra-operative, post-op, delayed and downstream complications that remains an everyday reality for the four million laboring women (3.5 million of whom are healthy and have normal pregnancies).

These women will find themselves immobilized in their labor beds while they remain hooked up to continuous electronic monitoring equipment. This is almost always followed by a cascade of obstetrical interventions — IVs and epidurals for pain, automatic blood pressure cuff, pulse oximeter, foley catheter and far too often, the need for vacuum extraction or Cesarean delivery.

Cesarean surgery: After a four inch incision into the lower part of the uterus, the head of this breech baby is delivered by forceps (yes, you can have a C-section AND a forceps deliver both)

As if this is not problem enough, this “standard care ” predictably doubles or triples the cost of normal childbirth.

How could such a discordant practice have been perpetuated for the last 50-plus years? How come no one else had noticed?

Hospitals economics & the Nancy Reagan “Just Say No” policy

The professional journal publications quoted in this post and many other peer-reviewed articles clearly convey the obvious — the routine use of continuous EFM on low and moderate risk women is NOT a science-based practice AND has never been able to do what was advertised– eliminate or greatly reduce the rate of CP and other neurological pathologies of the newborn.

Nonetheless, the obstetrical profession and hospitals have masterfully ignored everything they don’t want to hear, decade after decade after decade, as they swept new studies under the rug to join all the earlier studies– something not to be talked about, and certainly not to be acted on!

 

In spite of the many complications associated with the universal EFM for healthy women with normal pregnancies, and well-established fact that c-EFM is not associated with better outcomes, the practice continues unabated in the 3,400 hospitals in the U.S. that provide obstetrical services.

EFM is now the single most frequently used medical procedure in the US, which is to say that the use a $15,000 electronic monitor system has outstripped every other medical device or procedure in America.

The official estimate is that 85 to 93 % of all childbearing women are hooked up to continuous EFM equipment during their entire labor. [citation L2M Survey 2002 & 2005; Martin et al 2003]

Many health insurance carriers reimburse hospitals $400 an hour for intrapartum continuous electronic monitoring. According to doctors and hospitals, this is the cheapest and best way to protect them from multi-million dollar malpractice suit for a damaged baby, and like one’s American Express card, you shouldn’t go anywhere without it!

The April 2011 article quoted in Part 1 acknowledges the lack of a scientific basis for c-EFM, but at the same time, they went on to say some version of:

“ya, but we have to keep using universal EFM because there are too fewnurses to use IA”

This means that hospitals in the US have systematically chosen NOT to hire enough L&D nurses to use the ‘alternative’ to EFM — a simpler but equally-effective monitoring method of known as Intermittent auscultation (IA). {full explanation and description of how it works follows in Part 3}

As noted, many hospitals bill health insurance companies and the federal Medicaid program up to $400 an hour for each labor patient who is hooked up to c-EFM. Each hospital is reimbursed many thousands of dollars for average labor (8-10 hrs = $3200-$4,000), multiplied by 3 to 12 labor patients in the unit at any one time (i.e. generating from $10,000 to $40,000 per shift).

L&D nurses certainly are NOT getting paid $400 an hour (average RN pay in the US is btw $28 and $45 an hr).  Obviously, hospitals in the US find it a whole lot more profitable NOT to hire enough L&D nurses to monitor (i.e. the active verb, not the machine!) the unborn baby using a hand-held Doppler and Intermittent Auscultation (IA) protocols.

While “auscultation” is a strange and hard-to-pronounce word, IA itself is a simple and straightforward screening process that collects essentially the same 4-points of information on the fetal heart rate and rhythm as EFM to determine the health status of the fetus at each specific point in time as either ‘reassuring’ or ‘NOT reassuring’. The use of low-level technologies similar to IA that are regularly used during labor includes a blood pressure cuff and thermometer to repeatedly check on the well-being of the mother.

In the case of intermittent auscultation of an unborn baby, the birth attendants or nursing staff are listening for four data point listed below and will use them, just as they would information about the mother’s BP or temp, to determine if everything is normal or if there is a problem that needs to be medically evaluated. These four data points for fetal well-being are:

  • normal baseline  (y/n)
  • normal variability (y/n)
  • the presence of reassuring Accelerations (y/n)
  • the absence of pathological Decelerations (y/n)

This screening process is repeated many times during labor, usually every 30 minutes during the 1st stage and every 15 minutes or more often during the 2nd (pushing) stage.

Whether this data is gathered by EFM or IA,  the ‘screening’ process uses the same binary data (yes/no) of four specific markers that provide a clinical picture of normal vs not normal. This tells the primary birth attendant (OB or midwife) and/or L&D staff whether an additional evaluation is indicated or if emergent interventions is necessary.

These four points of information as provided by IA on fetal wellbeing allows the unborn baby to be monitored without the many complications, expense, increase C-section rate and maternal mortality associated with c-EFM.

The dilemma that c-EFM poses to obstetricians are humorously described in this brief tongue-in-cheek editorial by Dr. Drosman to his fellow obstetricians.

Why the C-section rate is rising by Dr. Steven Drosman, MD, obstetrician-gynecologist in San Diego, CA; Editorial ~ Medical Economics, Oct 2000 ~

“Probably the biggest C-section motivator, however, is fear of a lawsuit. The rationale is simple: At worst, you’ll be criticized for performing a C-section but you can be roasted for delaying one!

When a patient is hooked up to a fetal monitor, it initiates an unholy trinity — the anxious patient, the hovering nurse, and the paranoid physician. The tension escalates as monitoring devices are added: the fetal scalp electrode, the fetal pulse oximeter, and intrauterine pressure catheter.  Add some more Pitocin to the mix, and the action begins.

The labor and delivery nurse watches the monitor and observes decreased variability and persistent late decelerations. The obstetrician is notified, wipes the perspiration from his forehead and pops a handful of antacids.

The patient and her family are informed of the potential crisis, and the can of worms has been opened. More likely than not this “electronically compromised” fetus will be delivered by emergency C-section, with perfect Apgar scores.

Continue to Part 3A

The failure of routine EFM to prevent Cerebral Palsy in babies or to protect OBs & Hospitals from lawsuits

 

 

 

 


Reference

1. The Permanente Journal

. 2011 Winter; 15(1): e108–e113.
Published online Winter 2011.
PMCID: PMC3138176
PMID: 21892344

Maintaining Optimal Oxygen Saturation in Premature Infants

Yoke Yen Lau, RN, BHSN, Yih Yann Tay, RN, BHSN, Varsha Atul Shah, MD, MBBS, MRCP, Pisun Chang, RN, and Khuan Tai Loh, PEN
…. retinopathy of prematurity (ROP) …. a disease of the retina that occurs after birth among premature infants who are born weighing <1500 g, when blood vessels in the vascular bed of the retina begin to grow abnormally.
ROP is a potential cause of blindness in children and accounts for up to 10% of cases of childhood blindness in developed countries.
The goal for clinicians is to deliver adequate oxygen to the tissue without creating oxygen toxicity.
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Part 1A ~ False Association btw continuous EFM & dramatically-increase Cesarean rate ~ a failed strategy that does not prevent cerebral palsy or reduce malpractice suits ~ Part 1A http://faithgibson.org/false-assoc-cont-efm-increased-c-sec-strategy-prevent-cp-malpractice-suits-part-1a-2019/ Tue, 02 Nov 2021 18:46:35 +0000 http://faithgibson.org/?p=9034

1A ~ Fetal Monitoring: Historic beginnings of America’s obstetrical conundrum — focus on the labor patient or stare at the EFM screen?

My husband, 7-year old daughter, me with my daughter newborn in my lap and my 5 yers old son, on a bench in front of Florida Hospital (Winter Park after the birth of my 3rd child on September 16, 1970 

This series is dedicated to fixing a problem that wastes millions of healthcare dollars every year and results in preventable maternal death.

Continuous EFM has no benefit to mother or baby when routinely used on healthy women with low-risk pregnancies.

However, this expensive and yet ineffective obstetrical intervention has a very serious side-effect. EFM is associated with a significant increase in the C-section rate. Unfortunately, Cesarean surgery results in many more serious complications and a higher rate of maternal mortality than vaginal birth.

Based on the scientific literature, the acknowledged “best practice” and better choice for healthy childbearing women with normal pregnancies is ‘hands-on listening”, also known as auscultation. This means the L&D nurse or midwife personally monitors the unborn baby by listening to its heart rate on a regular schedule during active labor.


word count 2.500

The historic backdrop of our current conundrum

For centuries, the obstetrical profession diligently searched for reliable ways to eliminate cerebral palsy (CP) and all similar neurological pathologies affecting newborn babies. In spite of many ‘miracles’ and ‘wonder drugs’ in other areas of modern medicine, and the successful launch of missiles into outer space carrying our astronauts, American doctors delivering babies in 1960s were no more able to predict or prevent babies being born with cerebral palsy or other permanent neurological disabilities than their counterparts in 1860.

When news of the first electronic fetal monitor was invented in 1958, American obstetricians were heartened, as they finally a good reason to believe they would soon get a nearly-perfect tool for preventing these birth-related tragedies. Unfortunately, it was more than a decade before the first continuous electronic monitor was ready for the real world.

In the meantime, the social distress for doctors that followed the birth of neurologically-damaged baby continued to depress obstetricians. As if that was not stressful enough, obstetricians were increasingly being named in malpractice lawsuit by its unfortunate parents. Worse yet, this trickle of litigation slowly turned into a flood after a US Supreme Court decision redefined the idea of a “community standard”.

1968 and much more than you ever wanted to know about the “Locality Rule”

For almost a century, the law that defined who was or was not allowed to give expert medical testimony in a malpractice case was defined by the “locality rule”, the result of an 1880 opinion in a Massachusetts case {Small v. Howard}. The locality rule required a physician to provide the same degree of skill and care as required of other physicians practicing in the same or similar community.

In medical negligence litigation, this placed a geographical dimension on the professional standard, since it limited the pool of medical experts to the same geographical area. This was a group of doctors often practiced at the same hospital, belonged to the county medical association, same country club, lived in the same neighborhood, had kids that went to the same schools.

When called to testify against their colleagues in malpractice cases, most physicians either declined to testify altogether or put an unbelievably positive spin on what in many cases was obviously negligent and incompetent actions or omissions. This made it really hard to win medical malpractice suits and most attorneys were not willing to waste their time on a “bad bet”.

But in 1968, the Supreme Court overturned the locality rule in a landmark decision that recognized the entire medical profession as non-geographical entity of like-minded, similarly trained doctors.

No matter where they lived in the country, the medical profession has, in legalese, become its own “community”. Now, plaintiff attorneys in New York could hire specialist doctors from as far away as California to serve as an expert medical witness.

Almost overnight, these new rules gave rise to a newly aggressive world of attorneys that could almost always find an MD somewhere in the United States that could and would (for a fee) testify that the doctor being sued had indeed violated the “community standard” for the competent practice of medicine. This usually meant winning their case and getting their one-third share of a big fat settlement from the malpractice carrier.

For obstetricians, this was devastating development, as they suddenly found themselves in the cross-hairs of an entire industry that was “out to get them” and yet, when the phone rang in the middle of the night, they had no choice but to get up and, ignoring the obvious the legal risks to themselves, trudge off to the hospital to attend a birth that might well be a ticking time bomb.

And in deed, the greater success of medical malpractice suit — greater in number and greater monetary awards — quickly got the attention of professional med-mal carriers, who turned around and started raising the premiums of doctors, particularly anesthesiology, orthopedists and obstetricians. This mounting crisis would boil over in the 1975 medical malpractice “crisis” in California and other parts of the country. American medicine would never be the same!

Obstetrics in the Post-Medical Malpractice Crisis World

By the 1970s, the obstetricians and their professional groups were looking to defend themselves from the obstetrical version of “ambulance chasing” lawyers. Their main strategy was do whatever was necessary to prevent malpractice lawsuits against them and the hospitals where they delivered babies. The idea of continuous electronic fetal monitoring, which provided a printed record of every minute of the mother’s labor — just in case they had to defend themselves — seemed to be an idea “whose time had come”.

New fetal monitoring technology & the plan to eliminate both cerebral palsy and malpractice suits

Officially, EFM is an obstetrical procedure that uses an electronic machine to continuously record the heartbeat of the fetus, matched with the frequency and length of the laboring mother’s contractions for the same period of time.

These two streams of data are simultaneously displayed on the monitor screen. Of course, this data is also recorded on moving graph paper, which creates a permanent legal record of the minute-by-minute status of the unborn baby’s health throughout the hours of labor and birth.

In the United State, the obstetrical protocol for c-EFM is to monitor every laboring woman continuously during the entire length of the labor and birth, no matter how healthy the mother or normal the pregnancy.

Greatly expanded use of Cesarean surgery ~ the 2nd half of this new obstetrical “miracle”

Electronic fetal monitoring itself was only half the answer the obstetrical profession was searching for. The equally critical second half was expedited operative delivery — the immediate use of forceps, vacuum extraction, or Cesarean surgery to rescue the unborn baby at the slightest hint of fetal distress as indicated by the EFM tracing.

Continuous EFM, with its ability to gather critical information about the wellbeing of the fetus, was now paired with the ability of obstetrical surgeons to quickly extract the baby from the mother’s body, most usually via Cesarean surgery. This combination of electronic monitoring and expeditiously-performed Cesareans was considered by most of the obstetrical profession to be the answer to their prayer, a marriage made in heaven.

Educating the Public to Embrace the “brave new world” ~ and see continuous EFM as a miracle technology that eliminates newborn brain damage

Under these circumstances, it’s no surprise that the obstetrical profession aggressively and quite successfully promoted the combined use of these two complimentary obstetrical procedures. Obstetricians repeatedly assured the American public that the routine use of EFM, combined with the liberal use of Cesarean surgery at the slightest indication of any fetal distress, could and would eliminate neonatal brain-damaged during childbirth.

This was accompanied by the obstetrical profession’s assumption that all babies should be born in an acute-care hospital setting under obstetrical management. The sub-text of this — sometimes verbalized, sometimes not, but always present below the surface — was the not-at-subtle inference that failure to hospitalize all laboring women for whatever reason, no matter how healthy, or any failure of the institution (hospital or birth center) to electronically-monitor the entire labor, represented obstetrical neglect.

Mother admitted for induction, IV started

The historical context behind this modern phenomenon is instructive. The 20th century history of American obstetrics is paved with other frequently used obstetrical interventions that became the standard of care without any scientific evidence that their benefit far outweighed an harm associated with their use.

During this period of time, obstetrical textbooks published in the US actually defined normal childbirth as a ‘patho-physiology‘ — that is, a biologically natural process that was fundamentally harmful (i.e. pathological).

This includes routine use of episiotomies(1910) and forceps (1920), elective induction of labor (1950s) and the liberal and/or elective use of Cesarean section 1990s. These interventions were seen as making up for the design flaws believed by the obstetrical profession to be a normal facet of female reproductive biology.

Biology as “destiny” — deep history of gender bias as it influenced the thinking of obstetricians

For the past hundred-plus years, there has been a strong (but very wrong) assumption in the United States that normal childbirth inevitably risks the life of unborn babies and regularly damages the pelvic floor of childbearing women. In the first decades of the 20th century, this negative view of normal childbirth perfectly fit the perspective of the newly emerging obstetrical profession, who mainly dealt with unhealthy mothers and complicated situations.

As noted earlier, obstetrical professors of that era authoritatively described pregnancy as a nine-month disease that required a surgical cure. This referred to childbirth-related damage to the new mother and/or her newborn that were not uncommon, However, there were many reasons for these problem, including malnutritions, lack of appropriate care and often, iatrogenic harm caused by the poor obstetrical practices of the day.

First-time mothers, in particular, had soft tissue bruising and what midwives describe as skid marks perineal laceration that required suturing. Dr. DeLee, one of the two Titans of American obstetrics in the early 20th century mocked the idea of childbirth as a normal aspect of biology, describing the ‘inevitable’ damage to the mother’s perineum to be a “normal as falling on a pitchfork”. Likewise, he believed that unborn babies suffered possible brain damage every time their mothers pushed, which repeatedly battered their delicate head against the unyielding obstruction of their mother’s intact, or as DeLee described it, her “iron perineum”.

The obvious “cure” for the pernicious nature of Iron Perineums and Fetal Battering Rams was, of course, routine episiotomy, and in many cases,

Female Troubles: Mother Nature or poor obstetrical practices or ? 

In addition to the pain, mothers were assumed to suffer from to “falling on a pitchfork”, there was trauma inflicted on the unborn baby from battering its “head against its mother iron perineum”, there was the gnarly issue of the mother’s pelvic floor and pelvic organs.

Obstetricians, we convinced this double-barreled assault on the mother’s pelvic floor was the origin of the ‘female troubles’ so many women complained of later in life. If questions about these assumptions I’m 99.44% sure they’d say:

“I see this happening right before my eyes, how could I believe otherwise?”

To the mind of obstetrically-trained doctors in the US system (which purposefully excluded midwifery), this justified the use any or all obstetrical interventions that would rescue innocent mothers and babies from the horrific damage of vaginal birth.

Unfortunately, the medical profession did not see the connection in women btw injured during obstetrical managed births and development of “female troubles”, especially the many unnatural  interventions used during a so-called ‘normal’ birth, most especially routine use of episiotomies and forceps.

Iatrogenic Harm: Unrecognized and Unacknowledged

Fig 661 Fig. 661

1924 edition of DeLee’s Principles & Practice of Obstetrics: “An injury to the anterior position of the levator ani due to crushing from the blade of the obstetric forceps and the ramus pubis. Very difficult to repair”.

Nature’s inadequacies vs. consequence of iatrogenic Interference 

Few people — doctors, patients or the American public — realized that so-called “biological weakness” of the female gender in America was so very often the result of unwise or unnecessary iatrogenic interventions that, which intended to heap, were instead harmful.

As a result, deep pelvic and perineal nerves were frequently damaged and supporting ligaments torn when obstetrical forceps sliced through the musculature of the mother’s pelvic floor, as illustrated in the accompanying graphic above  (Fig. 661). This left behind a host of other physical problems including fistulas and life-long incontinence. Nor does this take into account the same kind of damage to the babys head, face, ears, and (of course), its brain.

But from the perspective of a late 19th and early 20th-century male physician, it seemed that a woman’s reproductive biology was God’s mistake when compared to the biology of a man. For the male of the species, sexual reproduction never resulted in his death (except being shot by a jealous lover!) or physical damage to the man’s sexual organs, whereas women could be harmed or die from the complications of pregnancy and childbirth.

This supposed biological inequality was just one more brick in the wall that divided the sexes and resulted in an assumption that men were the ‘perfected’ half of the human species, while the female gender was the biologically and psychologically inferior half — nature’s mistake.

As for the newborn baby, doctors saw the pathophysiology of the female gender as making childbirth so hard on the fetus that newborn babies were often too tired to breathe and so they died or suffered a variety of birth injuries that might leave them physically or mentally handicapped for life.

Given the facts of this obstetrical perspective, the much higher C-section rate associated with EFM is was seen an unexpected benefit for women, as Cesarean delivery was the only sure way to save new mothers from developing ‘female troubles’.

21st Century Interventionist Obstetrics seen as “normal” by the public 

At this point in our history, the American public generally accepts our highly medicalized childbirth system as a welcome status quo — a wonderful use of the most modern and cutting edge technology to make life better for everyone. People don’t question our highly-medicalized obstetrical system any more than they wonder if telephones, personal computers, and air travel are a ‘good’ thing.

Are these assumptions about c-EFM & liberal use of C-section actually born out by the scientific literature?

  • Does the research actually identify the routine use of continuous EFM as the universal standard of care and associated liberal use of Cesarean surgery as substantially reducing neurological problems in newborns when compared to simpler methods of intrapartum monitoring?
  • Has medical science discovered reasons other than the management of the labor and birth that explain why some apparently normal birth result in CP and similar problems?
  • As for preventing ‘female problems’, no one wants new mothers to become incontinent or suffer pelvic damage as a result of childbirth, but does the high rate of Cesarean surgery in the US reliably prevent those problems?

Since c-EFM and elective Cesarean delivery were both incorporated into the American standard of obstetrical care in the 1980s, one world assumes the answer is “yes”.

Interestingly enough, the obstetrical profession’s own research, as published in its own peer-reviewed journals says “no” to both of the supposed ‘cures’ for CP and other imagined benefits of c-EFM and liberal use of Cesarean.

In fact, scientific studies identify many of the routine obstetrical practices associated with our highly medicalized model of childbirth to make matters worse for families and society when the unproductive expense is taken into account and the increase in medically-unnecessary operative deliveries and their well-documented complications and increased maternal mortality rate.


Continue to 1-B: In the first place “Do No Harm” ~ Conforming opinion to the facts and acknowledge scientific evidence

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The False Association btw EFM & increased use of Cesarean surgery ~ a failed strategy for preventing cerebral palsy or reducing malpractice lawsuits against doctors & hospitals ~ Intro & Overview http://faithgibson.org/false-assoc-efm-prevent-cp-intro-overview-aug-2019/ Mon, 01 Nov 2021 19:55:09 +0000 http://faithgibson.org/?p=8967

Originally published March 2019 ~ New Intro & Overview

Easy shortcut to share –> http://tinyurl.com/y4ezxjsz    ~ word count 2,866 ~ 

Identifying the false association (and failed strategy) surrounding the routine use of continuous electronic fetal monitoring (EFM) as the universal standard and the associated increase in Cesarean surgery performed for a ‘non-reassuring’ EFM tracing.

The purpose of this medical and legal strategy was to:

  • Prevent cerebral palsy and other permanent neurological damage in newborn babies

  • Protect hospitals and obstetrical professionals from childbirth-related malpractice suits

 


Intro & Overview  

This is a series of posts on the safety, expense, social consequences and ethical considerations of the current policies and protocols for electronic fetal monitoring in the US as the obstetrical standard of care.

The ‘what’ and ‘why’ of fetal monitoring

Listening regularly to the rate and rhythm of the unborn baby’s heart during the labor and birth is a standard protocol used routinely during the active labor and birth of babies born in developed countries. It’s clearly appropriate to monitor the unborn baby during the biological stress of labor.

The question is not if we should monitor the unborn baby during labor, but how — regularly scheduled listening with fetoscopes and Dopplers, or continuous electronic monitoring? What is the scientific evidence and does it provide the information we need to make the best decision for each laboring woman?

Fetal Monitoring Protocols, beginning with the verbs of Auscultation

From the invention of a special type of stethoscope known as ‘fetoscope’ in the late 1800s until 1973, the universal standard of care during labor required professional birth attendants to regularly listen, count and record the fetal heart rate, and if it was not within the normal range, to take appropriate action.

Monitoring the fetal heart rate with a fetoscope or doppler is called auscultation. This unfamiliar word, which is pronounced aw – skull – tah – tion— describes the simple act of listening to biological sounds in the bodies of human and animals, usually from hollow organs such as heart, lung, or bowel, and using a device such as a stethoscope, fetoscope or hand-held electronic doppler.

When listening to the fetal heart, auscultation also requires the use of a wristwatch or a wall clock with a second hand so the number of heartbeats per minute can be counted, as well as the presence or absence of other heart-related characteristics, such as regularity, variability, accelerations (transient speeding up of the FHR) and decelerations (a temporary slowing of the FHR).

Fetal heart sounds can also be heard by placing your ear directly against the mother’s pregnant abdomen, or rolling up a piece of paper and making it into a tube and then using that to listen. These simple ideas led to the invention of the stethoscope in 1816 by a Parisian physician (René Laennec) because it was embarrassing to place his ear directly on a woman’s unclothed chest in order to listen to her heart.

For healthy women with normal term pregnancies, the protocol for auscultation during active labor requires labor and birth attendants to listen with a fetoscope or hand-held Doppler for at least one full minute (longer if indicated) and from time to time, listening during a contraction and for 15 seconds after it has ended.

In addition to counting the baby’s heart rate per minute (beats-per-minute or bpm), birth attendants also note its rhythm (regular or irregular), listen for normal variability (slight transient increase in rate over several seconds and a return to baseline) and a significant or prolonged increase in the baseline rate (accelerations) or decrease (decels). When decels are heard, the frequency and pattern of repeating  decelerations is also noted.

Auscultation protocols based on the Various Stages and Phases of Labor

Latent Labor: During the very early or latent (‘warm-up’) phase of first stage labor, regularly scheduled monitoring (hourly or more often) of healthy unborn babies is not necessary, since early contractions are brief in length, mild in strength, and not very frequent. This warm-up phase of labor, which typically lasts from 4 to 48 hours, generally isn’t stressful in a low-risk pregnancy with a healthy term fetus.  Also this period occurs before the mother-to-be is admitted to the hospital or birth center.

When the parents are planning a home birth, this early phase occurs before their birth attendants are physically present and have begun to provide standard intrapartum care, which is not until the mother is in an active labor pattern and has a cervical dilatation of 5-6 centimeter if a first baby, or 3-4 cms for mothers who have given birth one or more times before.

But if the mother-to-be in latent labor is admitted to a hospital L&D unit or birth center, or laboring at home and her birth attendant has begun monitoring the labor, the unborn baby’s heart rate will be listened to every hour as long as the mother is awake. In OOH settings, the mother-to-be is generally not awaken to listen to the baby.

Active First Stage Labor: After things have progressed to active first stage labor (contractions 5 minutes or less, lasting 60 seconds or longer and consistent for more than an hour)  the FHR is to listened to every 30 minutes, or more frequently if indicated.@@@

The protocol for auscultation also requires a labor room nurse, midwife or physician to be consistently present in the room during the active phases of the woman’s labor. In addition to listening and keeping track of significant changes in the fetal heart tones, auscultation includes direct observation of the mother’s physical and mental well-being and the nature and progress of her labor as it affects her and her fetus.

Second or Pushing Stage of Labor: After full dilation, the pushing stage begins. Generally this includes two distinct phases, with the frequency depending of fetal monitoring being based on the phase. As the mother pushes the baby’s down into the birth canal (the descent phase), birth attendants listen every 15 minutes or so.

During the perineal phase, when the baby is being pushed out of the birth canal and its head is subjected to more direct pressure, the fetal heart is listened to after every second or third other contraction or approximately every 5 minutes (more frequently if indicated).

Charting: Each time information is collected on the unborn baby’s heart rate and rhythm it is recorded on the mother’s chart. This data is carefully tracked and used to confirm the continuing well-being of the unborn baby or alert the birth attendants of a potentially problem. If a serious abnormality is in the fetal heart rate or its pattern is detected, the situation is evaluated and when needed, medical or surgical interventions are used.

Usually, the mother-to-be requires and greatly benefits from the support and assistance provided by labor and birth attendants. On-going one-on-one care helps her cope more effectively with the normal anxiety, pain, and physical stress of her labor, which helps reduce the need for medical and surgical interventions.

Studies over the last half-century that compared auscultation to electronic fetal monitoring show no difference in outcome (neither better or worse) for the newborn babies of healthy women with normal pregnancies.

The nouns of Electronic Fetal Monitoring

Development of Fetal Monitoring Machines

In the late 1960s, electronic equipment was developed that made it possible for a machine to continuously listen and record the activity of the fetal heart, as well as tracking the frequency and length of labor contractions.

EFM was originally designed to monitor the unborn babies of women with very serious medical diseases, high-risk pregnancies, and women who developed serious complications during labor.

The malpractice crisis of the mid-1970s changes everything

An unexpected, and in many ways irrelevant event — the malpractice crisis of 1975 — changed the way this technology was used in the US. Due to several unexpectedly large malpractice settlements, the companies that sold professional liability insurance dramatically increased their premiums. This provided a great hue and cry from the medical community and made the costs associated with malpractice insurance the topic of newspaper headlines for several weeks. Following this focus on litigation, there was a 6-fold increase in the use of continuous EFM in hospitals all across the country.

As more and more hospitals routinely used continuous EFM for all their labor patients, EFM was formally adopted as the standard of care in American hospitals. No long a special protocol reserved for women with serious medical complications and/or a very high-risk pregnancy, continuous EFM was used on all laboring women, no matter how healthy the mother or low risk her pregnancy.

The No 1 obstetrical procedure in the US is continuous Electronic Fetal Monitoring

According to an article published in April of 2011 by a practicing obstetrician:

“ . . . intrapartum fetal heart rate monitoring is the most common obstetric procedure performed in the United States.

Despite the widespread use of EFM, there has been no decrease in cerebral palsy. … trials show that EFM has no effect in perinatal mortality or pediatric neurologic morbidity. {1}

Citation #1. “Heart Rate Monitoring Update” 
The Female Patient, April 2011

In hospitals, the hourly reimbursement rate for continuous electronic fetal monitoring by many health insurance companies is several hundred dollars an hour, in some cases as much as $400. The routine use of this expensive technology, along with a significant increase in Cesarean surgeries associated with the routine use of c-EFM, is an economic double whammy that has contributed significantly to the high and continuously rising cost of childbirth services in the US over the last 50 years.

This is particularly an issue for larger hospitals that have central monitoring systems. In these hospitals, L&D nurses and obstetricians sit at the Nurses’ Station in the hallway and watch banks of computer screens simultaneously displaying the EFM tracing from several different labor rooms. Hospitals with central monitoring have an even higher C-section rate than those where monitoring the electronic monitor display is the direct responsibility of the L&D nurse assigned to that patient.

The universal use of c-EFM continues to make childbirth services disproportionately expensive in the US. In parts of the country, hospitalization for childbirth is approaching, and in some cases equals the cost of an organ transplant (over $100,000).

The obstetrical profession’s mistaken belief that not using continuous EFM equates to malpractice

As expert witnesses, obstetricians are frequently called on to testify in legal cases about electronic monitoring. As spokesmen for the obstetrical profession, they also funnel information to the news media about the role of EFM.

A majority of obstetricians spokesmen believe that any failure to utilize this potent combination of continuous EFM and nearly-instant access to Cesarean delivery for all childbearing women, no matter how healthy the mother or normal the pregnancy constitutes substandard or negligent care.

In the opinion of these individuals, this constitutes medical malpractice if the provider is a hospital or physician, and criminal neglect or the “earliest form of child abuse” if the decision to not be electronically monitored during labor is made by the parents or a midwife. While these opinions come from highly regarded professionals, they are nonetheless devoid of scientific support, untrue, and misleading in the extreme.

Based on a consensus of the scientific literature, the truly informative statement — the type of information legally required as part of the “informed consent” process, is that continuous EFM is NOT recommended when the mother-to-be is healthy and her pregnancy is normal.

Furthermore, a professionally licensed maternity care provider would be legally obliged to inform healthy childbearing women that auscultation protocols are the science-based ‘best’ choice, and that c-EFM is actually contra-indicated, that provide no benefit while introduces unnecessary risks and unproductive expense. 

The Future of Maternity Care in the United States

A new vocabulary, a new perspective, a new way to provide care during pregnancy and childbirth

The basic purpose of maternity care for healthy women with normal pregnancies is to protect and preserve the health of these already healthy women. The needs of healthy women are fundamentally different than those of women with serious complications and high-risk pregnancies. Maternity care is a different discipline, with a perspective very different from that of obstetrics, which is a surgical specialty.

It would be enormously helpful if we used a different vocabulary to distinguish and discuss this functional distinction, identifying maternity care as professional discipline focused on healthy childbearing, while obstetrics would continue to be recognized as the surgical specialty that it is, a discipline that focuses on the diseases and abnormal conditions of female reproductive biology, complications of pregnancy and management childbirth in women who have high-risk pregnancies or develop complications during labor, birth or postpartum period.

Relative to this 70-85% childbearing population, the goal for our healthcare system must be a cost-effective model that is able to preserve health of already healthy women and effectively prevent, or successfully treat, minor complications that arise during pregnancy and childbirth and in case of a serious complication, consult with, refer or transfer of care to high-risk obstetrical specialists.

What we need as individuals, as childbearing families and as a society is to be certain that all customary childbirth practices are scientifically sound, including the protocols for fetal monitoring used when providing childbirth services to healthy women with low-risk pregnancies. This means safe, cost-effective, and also meets the physical, social and emotional needs of childbearing families and their newborn babies.

Mastery in normal childbirth services for healthy women with normal pregnancies means bringing about a good outcome without introducing any unnecessary harm or unproductive expense.

The ideal maternity care system seeks out the point of balance where the skillful use of physiologically-based care, and adroit use medical interventions whenever necessary, results in the best outcome with the fewest number of medical/surgical procedures and least expense to the health care system.

Ultimately, the quality of maternity care must be is judged by its results — the number of mothers and babies who graduate from its ministration as healthy, or healthier, than when they started.

As the #1 obstetrical procedure in the United States — one that is uniquely expensive for those who pays these bills (including federal MediCaid program — we need to be sure that EFM does what its manufacturers say it does.

Based on the current consensus of the scientific literature amassed over the last 40-plus years, the “best practices” as defined by best outcomes for mothers and babies and least expense to the society both in money and human terms must be scientifically identified and implemented as the legal and ethical standard of care for healthy women with normal pregnancies who decline routine interventions during labor unless they become medically necessary.

Providing maternity care to healthy childbearing families 

If obstetrics, for whatever reason, is not configured to meet the real needs of childbearing women, then it must systematically reform itself. If unwilling or unable to do this, the obstetrical profession can and should change its focus by reclaiming its historic role as a doctor trained in a speciality to meet the needs of women suffering from diseases and pathological conditions associated with their reproductive biology, including hormonal issues, infertility, cysts, tumors, and complications of pregnancy, childbirth and the postpartum period.

In this context, it’s appropriate to stress how obstetrics as a surgical discipline differs from the basic purpose of maternity care — to protect and preserve the health of already healthy women.

Its a function of the health care system to create a cost-effective model of maternity care that is able to preserve health and effectively prevent or successfully treat non-surgical complications during pregnancy and childbirth.

This factors in the full spectrum of reproductive mortality and morbidity over the course of a woman’s entire reproductive life, including delayed and downstream problems, complications in subsequent pregnancies, future fetal or neonatal loss and the overall cost of care to individuals and society.

It is for this reason that continued routine use of EFM on healthy women with normal low-risk pregnancies cannot be permitted to continue.

The scientific evidence is overwhelming — routine EFM resulting in a sharply elevated Cesarean rate without any benefit to the mother or baby. Cesarean deliveries needlessly expose childbearing women to all the intra-operative complications of major surgery, a 13-fold increase in emergency hysterectomies within 14 days of the Cesarean birth, secondary infertility, and potentially fatal complication for both mothers and unborn/newborn babies in subsequent pregnancies.

The following series will address the why, when, how of both EFM and auscultation, including the diverse circumstances of their use and their cost in financial and human terms, the scientific literature and Action Plan to correct one of its most serious problems, which is the routine use of an obstetrical procedure — continuous EFM — which was designed to be used in very high risk pregnancies  but instead has been allowed by the medical profession and the public to become a universal standard of care used during the normal labors of healthy women with low-risk pregnancies.

faith gibson, LM ^O^

Former L&D nurse, California licensed professional midwife #41, author-editor of the California College of Midwives’ Standard of Care (2004); appointed to the Medical Board of California’s Midwifery Advisory Council, served 6 years, 3 as its first Chair (2007-2013); web-wife to 8 midwifery and childbirth-related websites

Favorite Publication: Time Traveler’s Perspective on Normal Childbirth published in the journal BIRTH in September 2011
BIRTH-PracPerspective_MyArticle_Sept11_2011

 


 

Continue to Part 1A ~ Fetal Monitoring ~21st-century Conundrum for the US

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http://faithgibson.org/10540-2/ Fri, 15 Oct 2021 23:24:33 +0000 http://faithgibson.org/?p=10540

Nurse-Midwife Kate Bowland and Santa Cruz licensed midwife

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Repost Journal article ~ Diabetes and Race ~ A Historical Perspective http://faithgibson.org/repost-journal-article-diabetes-and-race-a-historical-perspective/ Thu, 09 Sep 2021 17:38:46 +0000 http://faithgibson.org/?p=10520

 

Diabetes and RACE ~ Historical Perspective

Am J Public Health. 2011 January; 101(1): 24–33.
PMCID: PMC3000712
PMID: 21148711

corresponding authorAuthor information Article notes Copyright and License information Disclaimer

Abstract

Today, US government sources inform us that Native Americans, Blacks, and Hispanics/Latinos run the greatest risk of developing type 2 diabetes. One hundred years ago, however, Jews were thought to be the population most likely to develop this disease.

I evaluated the evidence that the medical and public health communities provided to support the purported link between diabetes and Jews. Diabetes was conceptualized as a Jewish disease not necessarily because its prevalence was high among this population, but because medicine, science, and culture reinforced each other, helping to construct narratives that made sense at the time. Contemporary narratives are as problematic as the erstwhile depiction of diabetes as a disease of Jews.

THERE IS NO RACE, WHICH is so subject to diabetes as the Jews,” wrote W. H. Thomas in 1904 in the eugenically obsessed language of his day.1
Thomas, a New York physician, was voicing an almost universally held belief in the United States that of all the “races,” Jews had the greatest likelihood of developing diabetes. At the same time, most members of the medical community considered the prevalence of diabetes among Blacks to be unusually low.
In the words of a Johns Hopkins physician in 1898,
“Diabetes is a rare disease in the colored race.”2
Such beliefs have long since disappeared. Today, Blacks, American Indians, and Hispanics/Latinos are believed to have the highest risk of developing type 2 diabetes, which makes up 90% to 95% of all diabetes cases. The National Institute of Diabetes and Digestive and Kidney Diseases estimates that roughly 15.1% of American Indians and Alaska Natives have diabetes, compared with 8.7% of non-Hispanic Whites. Non-Hispanic Blacks (13.3%) and Hispanics/Latinos (9.5%) are also disproportionately represented.3
Why did the medical community once believe that Jews were a race and, as such, at high risk for diabetes, and why is that no longer the case? The response to these questions has much to do with understandings of race at the beginning of the 20th century.
At the time when diabetes was so closely associated with Jews, Jews were considered to be one of hundreds of races populating the planet, and race itself was viewed as a combination of biological, linguistic, and cultural traits that distinguished particular groups of people—in sickness as in health—from other peoples of the world.4
The idea of race first came under serious attack in the years between World War I and World War II, when Franz Boas and his students challenged the validity of the alleged biological evidence.5 However, the idea has by no means been put to rest, and significant research continues to be committed to the search for genetic variants that might explain health disparities between purported racial groups.
Advocates of this research insist that race is a strong predictor of health outcomes, and that a better understanding of race-specific susceptibilities will increase the chances of reducing health disparities.6
Opponents counter that the focus on race ignores genetic diversity within groups; diverts attention from non-genetic explanations for group differences, which may better explain differential prevalence rates; contributes to racial stereotyping; and risks constraining diagnostic and treatment options in ways that can do harm.7
The historical example provided here is intended as a contribution to this critical literature. Highlighting the problems associated with race-based medicine, the story of Jews and diabetes reveals how stereotypes about an alleged racial group can shape the way medical communities define at-risk populations and the interventions they pursue.
After presenting and evaluating the evidence physicians provided in the first half of the 20th century to support the link between diabetes and Jews, I briefly discuss the narratives about race and diabetes being constructed today. Our contemporary picture of diabetes is, in important ways, as problematic as the depiction of diabetes that flourished 100 years ago.

JUDENKRANKHEIT

Around the turn of the 20th century, medical and public health communities began to grow concerned about the steady increase in the diabetes rate among the middle-aged and elderly populations.8 Most recognized that this increase was occurring in part because people were living longer, but few were satisfied that this was the only cause.9
A robust debate thus took place in which a host of factors were considered, including rising obesity rates, increased sugar consumption, and the greater stress of modern civilization. But one explanation drew near consensus: almost all agreed that Jews were particularly at risk and that the proportion of Jews in the population was increasing.
The link between Jews and diabetes had its origins in the European medical literature and particularly in the writings of Joseph Seegen of Vienna, Austria.10 After Seegen noted in 1870 that roughly one quarter of his 140 diabetes patients were Jewish, other studies started appearing alleging that Jews died of diabetes at a rate between two and six times higher than the rest of the population. In the German literature, diabetes even came to be known as the Judenkrankheit, or “Jewish disease.”11
Such views crossed the Atlantic and influenced the American medical community. William Osler, perhaps the most famous clinician in early 20th-century America, remarked that
Hebrews seem especially prone to [diabetes].”12 
The New York City physician Heinrich Stern agreed, commenting that “[t]he Hebrews, no doubt, are more commonly afflicted with chronic glycosuria than natives of the nation among whom they dwell.”13 And when J. G. Wilson, a physician with the US Public Health Service, tried to understand why the diabetes mortality rate in New York City had tripled between 1889 and 1910, he compared the rapid growth in the city’s Jewish population with the rise in the diabetes mortality rate. For Wilson, the correlation between these two sets of data was sufficient to demonstrate causation.14
To explain why Jews experienced such a high rate of diabetes, Wilson turned to racial traits, claiming that “some hereditary defect” made the Jews more prone to develop the disease.15 He did not elaborate on the nature of the “defect,” but others pointed to the supposedly sensitive nervous system of the Jews.
For Osler, it was the Jews’ particularly “neurotic temperament”; for the author of an article in the widely read Collier’s Magazine, it was the Jews’ “racial tendency to corpulence.”16 These racial traits were then exacerbated—or so many believed—by the Jews’ preference for “consanguineous marriages,” or the marrying of blood relatives.17
Not all agreed that the Jews had an inherited tendency to develop diabetes. Robert Saundby, a London physician, insisted that “modern life is in itself a cause of diabetes.” According to Saundby, the Jew, especially the well-to-do Jew, suffered from diabetes not because he was Jewish but because he lived in the city, where he ate too much, exercised too little, and strained his nervous system “in the pursuit of knowledge, business or pleasure.”18
Elliott Joslin, the most famous American diabetes specialist in the first half of the century, was more succinct. “The Jew,” he proclaimed, “is not prone to diabetes because he is a Jew, but rather because he is fat.”19
The explanations that circulated in the early 20th century to elucidate the Jews’ alleged propensity for diabetes were an eclectic set, including racial stereotypes, cultural practices, and lifestyle issues. Why, though, would anyone have believed these theories?
Of course, it is possible that Jews suffered disproportionately from diabetes at the time. But most of the articles published on this topic did not include statistics, and those that did drew primarily on experiences with very select populations. Perhaps most importantly, populations that had little contact with the formal medical community were not recorded.
Even if reliable statistics existed, they would not help us understand the stories that circulated to explain why Jews were so vulnerable. The vast majority of Jews in the United States in the early 20th century were poor immigrants from Eastern Europe, yet the “Jew” most often portrayed in the diabetes literature was the affluent Jewish urbanite.20 Indeed, by and large, diabetes was considered a disease of wealth, referred to by physicians such as Osler as a “disease of the higher classes.”21
At the very least, then, a considerable gap existed between the image of diabetes as a disease of affluence and the actual circumstances of the vast majority of Jewish immigrants. We can thus learn much about why diabetes was considered a Judenkrankheit by examining cultural assumptions and stereotypes.

JEWS, RACE, AND STEREOTYPES

Around 1900, few questioned the scientific and cultural legitimacy of the concept of race. As the sociologist Elazar Barkin has commented, “race was perceived to be a biological category” and racial differences were “regarded as matters of fact, not of prejudice.”22 Some Jews advanced this belief as well, writing of “Hebrew blood” and of the “Jewish race.”23
Still, exactly what characterized the “Jewish race,” or any race for that matter, engendered heated debates, revealing the high stakes in theories that were embedded in a logic of racial superiority and inferiority. Racial hierarchies situated Caucasians at the top and Ethiopians at the bottom, and many of the debates focused on where, exactly, a particular race belonged.24
A powerful example of this is the 1910 report by the Dillingham Commission, a US Congressional Committee set up to study immigration. Volume five of the report, entitled Dictionary of Races or Peoples, drew upon established anthropological works to compile listings of as many as 600 “branches or divisions of the human family”; the commission counted 45 races among the US immigrant population alone. The latter included, in addition to the Jews (or Hebrews), Celtics, Alpines, Lettics, Teutonics, Mediterraneans, and Slavonics, among others.25
To distinguish these populations, anthropologists relied on a combination of biological, linguistic, and cultural characteristics, including facial features, body type, language, customs, geography, religion, and history. But the most salient feature was skin color, which was considered a marker of a race’s level of “civilization”: the darker the skin, the closer a race remained allegedly to an earlier, “savage” stage of human development; the whiter the skin, the more “civilized” they were.”26
For this reason, one of the more contentious battles around the turn of the century was over the degree of “whiteness” of the recent immigrant groups.27 And one of the more controversial populations was the Jews.
In the 19th century, the United States Bureau of Immigration had classified Jews as “Slavonic,” a subgroup of the elite Aryan stock. However, the Dillingham Commission took issue with this, insisting that linguistic and physical criteria, including the “Jew’s nose,” placed them among the Semites, lower down on the Caucasian ladder.28
Why this should have mattered becomes clear in the context of the commission’s recommendation in 1911 that the government enact a restrictive immigration law.29  The Dictionary of Races or Peoples was intended, in other words, to guide the government as it tried to distinguish “desirable” from “undesirable” races, thus determining which immigrant groups would be permitted entry and which would be turned away.30
The link between racial classifications, racial status, and immigration politics is even more evident in the writings of a group of extreme nativists, who were determined to end the influx of eastern European Jews into the United States. Referring to the Jews’ physical stature, moral traits, and origins as a nomadic tribe, they insisted that the Jews not be classified as Caucasian at all, but as “thoroughbred Asiatics.”
One author could not hide his disdain for the “primitive, tribal, Oriental” character of the Jews. Yet another wrote disparagingly of the “Mongoloid traits” of the Jews, which he attributed to the blood of the Mongolian Khazars allegedly coursing through the Jews’ veins.31
Given that the Chinese Exclusion Act of 1882 all but forbade Asians from entering the United States, had Jews been redefined as “Orientals,” they would probably have been excluded as well.32
Anti-Semitic attitudes thus fueled many of the claims about the Jews’ racial traits. Significantly, though, those who challenged the negative stereotypes rarely questioned the validity of the concept of race. Instead, they argued that a different, more positive set of racial traits better characterized the Jews.
This literature thus emphasized the Jews’ native “genius,” their diligence and creativity, and their “unselfish service to nation and the world.”33 They were cast as major contributors to the arts and sciences, to medicine and the law, to politics and sports—in short, to all aspects of modern “civilization.”
As the Jewish composer Gdal Saleski commented, “the bloodstream of the Jew courses through the spiritual veins of every major art that modern civilization has risen to honor.”34
Discussions about Jews and diabetes took place against this backdrop. Those writing on this subject assumed that Jews made up a distinct race. There, however, any consensus ended. Indeed, the picture of diabetes as a Jewish disease flourished in part because the explanations were diverse enough to appeal both to those who viewed Jews as “racial aliens” and to those who were members of the Jewish community.35

DIABETES NARRATIVES

The diabetes literature in the early 20th century did not include many references to the Jews’ orientalism. Still, the image of the Jew that often appeared had disturbing elements. Haven Emerson, professor of preventive medicine at Columbia’s College of Physicians and Surgeons, linked Jews to what he called “this great luxury disease.”
In “Sweetness Is Death,” published in 1924, Emerson attributed the rise in the diabetes rate to the fact that Americans were “the grossest feeders among the nations … bulging with the money bags of the world, fairly oozing with wealth, eating every day much more than any of our allies or opponents of the war … and, as it were, dying of overeating.”36
Emerson did not mention Jews explicitly in these lines, but just a few paragraphs later he informed his readers that Jews had the highest rate of diabetes, and that in Europe the disease was even known as the Judenkrankheit. Thus, without being explicit, he left his readers with an image of the rich Jew, hoarding his wealth and indulging himself while the rest of the world struggled with hunger.37
Wilson, the US Public Health Service physician, painted a similarly harsh picture of the Jews, describing them once as “a highly inbred and psychopathically inclined race.”38  His insistence that Jews suffered from diabetes because of a hereditary defect was made while he was stationed at Ellis Island, the port of entry of most eastern European Jews.
Wilson’s sense of discomfort with this group of individuals, whose clothing, language, and mannerisms seemed so alien to him, manifested itself in two ways: in the speed with which he assumed that a correlation between the rising mortality rate from diabetes and the increase in the Jewish population meant that Jews were the cause of the increased mortality, and in the measures he proposed for reducing the diabetes rate.39
Whereas other physicians argued that Jews simply needed to eat less and exercise more, Wilson countered that the Jews’ high rate of diabetes had deep cultural and biological roots: “the practice of inbreeding which obtains among them,” he wrote with evident disgust, had much to do with the Jews’ high rate of diabetes. Thus, to reduce this rate, “the methods of right breeding” had to take precedence over those “of right living.”40
The image of the Jews as a diabetic race fit, moreover, into a long history of depicting Jews as a particularly diseased people, dating back at least to the Middle Ages, when they were persecuted for allegedly spreading plague throughout Europe. Casting the Jews as syphilitic or tubercular, as they often were, or as diabetic all reinforced the image of the Jew as inherently sickly.41
Certainly, for anyone who wished to stem the tide of Jewish immigrants from eastern Europe, the picture of Jews as a diseased race was particularly useful. Still, anti-Semitism alone cannot account for the widespread belief that Jews suffered disproportionately from diabetes, since Jewish physicians themselves believed diabetes posed a particular problem for those of Jewish descent.42
“Statistics prove conclusively that the disease occurs among Jews from two to six times as frequently as it does among non Jews,” wrote the anthropologist Joseph Jacobs and the physician-anthropologist Maurice Fishberg in an article on diabetes they coauthored for the Jewish Encyclopedia, published between 1901 and 1906.43 Hyman Morrison, a Boston, Massachusetts, practitioner, held this view as well, commenting that “[t]he testimony of observers, both in America and in Europe, goes to show that diabetes mellitus occurs more frequently among Jews than among their neighbors.”44
Yet Jewish physicians differed from many in the medical community in insisting that although diabetes may be heritable it was not a racial disease, if racial meant having been part of the Jews’ biological makeup since biblical times.45
By and large, Jewish physicians turned to the Lamarckian theory of the inheritance of acquired characteristics to explain the evolution of diabetes among Jews.46 The particular trait Jews were believed to have acquired over the centuries was not diabetes per se, but rather “an unstable nervous constitution,” which predisposed Jews to the disease.
The association between the nervous system and diabetes drew strength from experimental studies showing that the stimulation of nerves innervating the internal organs led to a release of adrenalin, which in turn caused the liver to break glycogen down into sugar and produce a mild glycosuria.47
According to the Philadelphia, Pennsylvania, physician Solomon Solis-Cohen, nervous derangements developed in response to the “cruel persecution” Jews had experienced over the centuries, which had “affected profoundly their autonomic nerve system; and autonomic-endocrine imbalance.”48 In a similar fashion, Jacobs and Fishberg blamed the high rate of diabetes among Jews on their “extreme nervousness, the Jews being known as the most nervous of civilized peoples.”49
The quotation from Jacobs and Fishberg suggests another, compelling, reason why Jewish physicians may have willingly embraced a picture of diabetes as a Jewish disease: the traits associated with the disease had some positive connotations. To a certain extent, this was because diabetes was associated with wealth, but note as well the link Jacobs and Fishberg made between diabetes, nervous diseases, and civilization.
They were drawing upon a widespread understanding of the relationship between disease and civilization, which held that as one moved up the evolutionary ladder from “primitive” to “civilized” races, the nervous system grew more complex. Such complexity permitted the development of the “higher faculties,” such as aesthetics and morality, but it also made the “civilized” races more susceptible to nervous ailments.50
Indeed, physicians frequently commented on the high incidence of diabetes where “wealth and culture” abounded, on its prevalence among “civilized humanity,” and on the way it increased “with the intensity of life.”51 Diabetes may have marked Jews as sickly, but it also symbolized their place among the cultured elite. It was the price they paid for having devoted themselves to a life of the intellect, of mental exertion, and of nonphysical activities and entertainments.52
There was little reason for dismay, however. Given that diabetes was an acquired and not a racial disease, exposure to different environmental conditions would lead eventually—or so Jewish physicians hoped—to the elimination of this trait from the population.

Edit Line f ^O^

Diabetes enjoyed popularity as a “Jewish” disease because science, medicine, and culture all worked together to produce believable narratives.

For some, diabetes revealed the Jews’ greediness and neuroses; for others, it marked the centuries of suffering they had endured; for yet others, it was a sign of the Jews’ modernity. But all were in agreement that the Jews differed biologically, whether they viewed that difference as anciently racial or recently acquired, and that biological differences correlated with disease patterns. That agreement did not last.

RACE AND DIABETES TRANSFORMED

In the 1930s, articles began appearing that questioned the link between Jews and diabetes. Some challenged the reliability of the statistics; others insisted that Jews simply visited their doctors more often, so their diseases were more often recorded; yet others attacked head on the biological validity of the concept of race. Still, articles that linked Jews and diabetes continued to appear for a few more decades. Then, in the mid-1950s, they basically stopped. What happened over this 20-year period?
We cannot ignore the possibility that changing diets and socioeconomic status contributed to a decline in the diabetes rate among Jews. However, no articles have been found that addressed this possibility. Instead, silence descended upon this topic, suggesting that changing understandings of race may have played a more important role. Between World War I and World War II, anthropologists such as Boas began a sustained attack on the concept of race, raising questions about the validity of the biological evidence that purportedly distinguished races from one another. Whether the evidence came from physical anthropology, craniometric measurements, or genetics, Boas and his school insisted that supposed divisions between the races on biological grounds were unsustainable. Any differences that remained were, rather, best studied through cultural analysis.53
Further challenges to traditional understandings of race occurred in these decades. As Matthew Jacobson has shown, debates about the relative whiteness of Jews, Celtics, Teutonics, and others, which had flourished in the early decades of the 20th century, gradually disappeared as these groups came to be viewed simply as “Caucasian.” As Jim Crowism continued its spread of terror throughout the South, and as the mass migration of Blacks to the North and West resulted in increased racial tensions and hostilities throughout the nation, race came to be seen in this country largely in terms of Black and White.54
During this time, the Jews “became white folks,” to quote the anthropologist Karen Brodkin.55 This transformation was helped along in the years following World War II by the Jews’ access to such federal economic and social programs as the GI Bill and Veterans Administration mortgages, which eased their entry into the White middle class. And as Jews lost their status as a separate race, the idea that they had a special proclivity for diabetes also abated.
To be sure, research exploring the link between Jews and particular diseases did not totally disappear. For example, Tay-Sachs disease is still linked to Jews. But as early as the 1930s, researchers recognized that although Tay-Sachs was prevalent among Ashkenazi Jews, its rate among Sephardic Jews was no different than in the rest of the population.56 Moreover, in subsequent decades, French Canadians and the Pennsylvania Dutch were shown to have high prevalence rates of Tay-Sachs as well. Thus, the presence of this disease in a population was no longer considered a racial trait but rather the result of a genetic defect that established itself in a population experiencing relative reproductive isolation.57
A focus on genetic frequencies and particular populations is a far cry from the characterological associations that flourished early in the 20th century. Diabetes had been considered a Jewish disease as long as Jews were considered a separate and particularly nervous “race.” As these ideas came under attack, fewer and fewer articles claimed that diabetes was a Jewish disease. But the near disappearance of discussions about Jews and diabetes did not take place until after World War II, as people learned with horror about the extremes to which the Nazis had taken racial notions of disease and degeneracy. To the Nazis, Jews had been little more than vermin, an inherently diseased race that threatened the purity of Aryan blood. As Robert J. Lifton’s interviews with Nazi doctors have revealed, many conceived of Auschwitz as a public health venture, designed to eradicate Jewish biological contamination at its source. In the wake of news reports about Nazi racial hygiene and the atrocities of the concentration camps, talk of Jews, race, and disease, and, with it, of Jews and diabetes, quietly slipped away.58
Talk about race and diabetes did not, however, disappear. For as talk about Jews and diabetes declined, articles began surfacing that drew attention, sometimes with alarm, to the prevalence of diabetes in the Black population. In 1951, for example, the Georgia Department of Public Health showed that among women aged 50 years or older, almost 8% of “colored females” had an abnormal blood sugar level compared with only about 4% of White females. The results, the authors claimed, were “completely unanticipated by us.”59 Twenty years later, the authors of a report from the US Public Health Service recorded with concern that a 44% increase in morbidity from diabetes had taken place among “the color groups” between 1950 and 1967 compared with a 5% increase for Whites.60
What was going on? Was diabetes increasing in the Black community? A small group of physicians certainly thought so, and they had been trying to draw attention to the problem since the 1920s. I. I. Lemann, for example, a medical school faculty member at Tulane University, published an article in the Journal of the American Medical Association as early as 1927 analyzing admissions data at the Charity Hospital in New Orleans. Between 1898 and 1926, he reported, the percentage of diabetes admissions increased eight-fold among Blacks and only four-fold among Whites.61 In the 1930s, physicians at Johns Hopkins and Emory University were finding similar increases, leading them to conclude that “diabetes in negroes is not different in any way from the disease as found among white people.”62 To justify their conclusion, they turned to a host of factors, including the increased migration of Blacks from rural to urban areas; increasing rates of obesity, especially among women; and the greater number of Blacks living to old age, when diabetes is more likely to develop.63
These studies, however, had little impact in the 1930s and 1940s. Diabetes may very well have been ignored—by Black and White physicians alike—because other health problems afflicting Black communities were attracting more attention. Tuberculosis and syphilis, for example, registered morbidity and mortality rates that far surpassed those of Whites. Maternal and infant mortality rates were also disturbingly high. And among the new chronic diseases that were claiming an increasing number of lives, heart and kidney disease took center stage. Indeed, a 1937 article on the 21 leading causes of death among southern Blacks did not include diabetes.64
It is also possible that cultural images surrounding diabetes—as a disease of wealth, girth, and a high-tension nervous system—contributed to the relative invisibility of diabetes in the Black community. Drawing on the racist discourse that claimed “primitive” peoples had less developed nervous systems, physicians, anthropologists, and evolutionists in the early decades of the 20th century contended that the nervous system of Blacks was different from that of Whites. Thus, in the infamous Tuskegee Syphilis Study, Black men were subjected to painful spinal taps to test whether their allegedly less evolved nervous system would explain why syphilis appeared to manifest differently in their bodies than in those of Whites.65 Angina was also believed to occur “usually in the sensitive, nervous type, as the Jew, or in the tense, efficient American, rather than in the dull, happy negro or the calm, accepting Chinaman.”66 In the same way, physicians who studied diabetes struggled to understand how the average “negro,” who was “happy-go-lucky” and lacking “nervous strain, intense application to business, mental shock and worry,” could possibly suffer from the disease.67 The “negro’s” more “carefree” nature was, in other words, believed to confer some measure of immunity to the disease.68
In 1942, the Black pathologist Julian Herman Lewis voiced his frustration that physicians continued to assert that Blacks had “a relative immunity” to diabetes, despite the absence of any evidence. Lewis, who was familiar with the work of Lemann and others who had been documenting the increased rate of diabetes in the Black community since the 1920s, had no idea whether the data signaled an actual increase in the diabetes rate among Blacks or whether it captured “a more accurate investigation of the real conditions,” rendering visible a problem that had been there all along. But whatever the explanation, Lewis insisted that no immunity protected against it and that diabetes in the Black community could no longer be ignored.69
But it continued to be ignored. In 1947, five years after Lewis’s complaint, the US Public Health Service set out to gather information about the estimated two million Americans living with diabetes. Fearing the consequences of inaction, it decided to conduct a survey that would provide an accurate picture of the threat diabetes posed to the American populace. The town chosen for the survey was the largely White town of Oxford, Massachusetts, which speaks volumes about the assumptions still prevalent at midcentury both about the disease and the populations most likely to be at risk. According to Hugh Wilkerson, who conducted the survey, Oxford was selected because it was representative of small towns in the United States.70 No wonder state and federal health departments later expressed alarm at the rapidly rising rate of diabetes among Blacks. The total lack of attention to a more diverse population was still evident in the 1960s, when public health educators produced a film, Diabetics Unknown, that targeted anyone who was not only “fat, forty, [and] familied” but also “fair.”71 The current diabetes “epidemic,” which appears to be affecting disproportionately people who would not be defined as “fair,” may stem at least in part from our country’s failure to recognize the problem of diabetes in non-White communities—and thus to intervene—until it was too late.

CONCLUSIONS

In the 21st century, the role of race in medicine remains contentious. The question is not whether one’s genetic makeup shapes one’s disease experience, but whether race provides a meaningful way of explaining the variations in human genotypes that influence the human experience of disease.72 Following Boas’s critical writings on race, most social scientists have abandoned the idea that biological race is a valid construct. As the molecular anthropologist Jonathan Marks has pointed out, “All human groups, however constituted, have particular medical risks. Blacks, Ashkenazi Jews, Afrikaners and Japanese, poor people, rich people, chimney sweeps, prostitutes, choreographers, and the Pima Indians all have their particular health risks.” The question is why this is so. According to Marks, whatever our answer may be, “race is not the cause of it, in fact, race will positively obscure it.”73
The history of diabetes brings to light many of the pitfalls of race-based medicine. It demonstrates how the conviction that Jews made up a separate race led to gross anti-Semitic stereotyping, a glossing over of intergroup differences, a search for racial and characterological traits that could explain the allegedly high prevalence of the disease among Jews, and the failure to recognize the disease in other populations. In diabetes research today, one finds a far more sophisticated understanding of race than in the past, one that eschews characterological assessments and seeks to identify genetic markers that might explain differences in susceptibility. Nevertheless, the conviction that differences in population prevalence reflect racial differences persists, stemming in no small measure from studies that assume that after such variables as income, insurance coverage, and education level are controlled for, residual effects can be assigned to genetic differences between the races.74
Once again, diabetes has a “racial profile,” but Jews have now been replaced by Native Americans, Blacks, and Hispanics/Latinos. The new image of diabetes is, moreover, reinforced by the US government’s policy of collecting information about race and ethnicity, but not about other confounding factors such as class.75 Thus, government Web sites, like that of the National Institute of Diabetes and Digestive and Kidney Diseases, draw attention to the high prevalence of diabetes among certain racial and ethnic groups, but include nothing about the situation in parts of Appalachia, where the predominantly White population has a prevalence rate that is higher than that for Hispanics/Latinos and just below that for non-Hispanic Blacks.76 The picture, in other words, that is being reproduced in the professional and popular literature of at-risk populations reflects the kind of data that are being collected, not necessarily the actual distribution of the disease.77
This is not to say that race is unimportant. A disproportionate number of people live in poverty and are denied opportunities because of their skin color, and these factors increase their chances of developing a host of different diseases. Race, in other words, remains a powerful social category, intimately connected to health.78 However, as the history of Jews and diabetes brings home, the stories we produce to explain such connections often tell us more about the cultural beliefs of those producing them than they do about the populations believed to be afflicted by the disease.

Acknowledgments

I am grateful to the American Council of Learned Societies and Vanderbilt University for their generous support of my research.
This article has benefited from the comments of David L. Boyd, Tony Brown, Janet Golden, Pablo F. Gomez, David Schlundt, David Zolensky, and anonymous reviewers. I extend special thanks to Ted Brown for his careful reading of the article.

Endnotes

1. W. H. Thomas, “Medical Treatment of Diabetes,” Albany Medical Annals 25, no. 4 (1904): 358. This article was abstracted in the Journal of the American Medical Association 42 (May 28, 1904): 1451.
2. O. B. Pancoast, “Diabetes in the Negro,” Johns Hopkins Hospital Bulletin 9 (1898): 40–41.
3. National Institute of Diabetes and Digestive and Kidney Diseases, “National Diabetes Statistics, 2007,” available at http://diabetes.niddk.nih.gov/dm/pubs/statistics/#10 (accessed May 25, 2010). See also the poster “Diabetes Favors Minorities,” available at http://wwwihm.nlm.nih.gov/cgi-bin/gw_44_3/chameleon (accessed May 25, 2010)
4. G. Stocking, “The Turn-of-the-Century Concept of Race,” Modernism/Modernity 1 (1994): 4–16; Matthew Frye Jacobson, Whiteness of a Different Color: European Immigrants and the Alchemy of Race (Cambridge, MA: Harvard University Press, 1998); Karen Brodkin, How the Jews Became White Folks and What That Says About Race in America (New Brunswick, NJ: Rutgers University Press, 1988); John M. Efron, Defenders of the Race: Jewish Doctors and Race Science in Fin-de-Siècle Europe (New Haven, CT: Yale University Press, 1994); Sander Gilman, The Jew’s Body (New York: Routledge, 1991)
5. E. Barkin, The Retreat of Scientific Racism: Changing Concepts of Race in Britain and the United States Between the World Wars (Cambridge: Cambridge University Press, 1992); Richard H. King, Race, Culture, and the Intellectuals, 19401970 (Washington, DC: Woodrow Wilson Center Press, 2004); Mitchell B. Hart, Social Science and the Politics of Modern Jewish Identity (Stanford, CA: Stanford University Press, 2000)
6. See, for example, E. G. Burchard, E. Ziv, N. Coyle, et al., “The Importance of Race and Ethnic Background in Biomedical Research and Clinical Practice,” New England Journal of Medicine 348, no. 12 (2003): 1170–1175. For a particularly cogent description of the arguments for and against research on genetics and health disparities, see Michael J. Fine, Said A. Ibrahim, and Stephen B. Thomas, “Editorial. The Role of Race and Genetics in Health Disparities Research,” American Journal of Public Health 95, no. 12 (2005): 2125–2128. See also Andrew John Karter, “Race and Ethnicity: Vital Constructs for Diabetes Research [commentary],” Diabetes Care 26, no. 7 (2003): 2189–2193.
7. M. Gregg Bloche, “Race-Based Therapeutics,” New England Journal of Medicine 351, no. 20 (2004): 2035–2037; Stephen Epstein, Inclusion: The Politics of Difference in Medical Research (Chicago: University of Chicago Press, 2007); David R. Williams, “Race and Health: Basic Questions, Emerging Directions,” Annals of Epidemiology 5 (1997): 322–333.
8. Physicians did not yet distinguish between type 1 and type 2, but they recognized that the disease progressed differently in the young, where the telltale symptoms of polydipsia, polyuria, and glycosuria developed quickly and with great severity. Their concern about the rapid increase in diabetes was, however, restricted to the more chronic form that was much more common among the middle-aged and elderly.
9. See, for example, J. G. Wilson, “Increase in the Death Rate From Diabetes Mellitus—A Possible Explanation,” Medical Record 82 (1912): 6662–6663; Elliott P. Joslin, “The Prevention of Diabetes Mellitus,” The Journal of the American Medical Association 76 (1921): 79–84; “War on Diabetes,” Time (April 21, 1923): 21, available at http://www.time.com/time/magazine/article/0,9171,845911,00.html (accessed May 25, 2010)
10. W. Sternberg, Die Judenkrankenheit, die Zuckerkrankheit, eine Folge der rituellen Küche und orthodoxen Lebensweise der Juden? (Mainz: Joh. Wirth’sche Hofbuchdruckerei, 1903), 10. See also John M. Efron, Medicine and the German Jews: A History (New Haven, CT: Yale University Press, 2001), 133.
11. Albert A. Epstein, “Diabetes Among Jews; Its Cause and Prevention,” Modern Medicine 1 (1919): 269–275, 270.
12. W. Osler, The Principles and Practice of Medicine, 1st ed. (New York: D. Appleton & Company, 1892), 275.
13. Heinrich Stern, “The Mortality From Diabetes Mellitus in the City of New York (Manhattan and the Bronx) in 1899. Classified According to the Month, Sex, and Age; Also an Expose as to Nationality, Duration of Residence in the United States, Occupation, Direct Causes of Death, and Accompanying Diseases,” Medical Record 58 (1900): 766–774, 766.
14. Wilson, “Increase in the Death Rate From Diabetes.”
15. Ibid, 663.
16. Osler, Principles and Practice of Medicine, 275.
17. Wilson, “Increase in the Death Rate From Diabetes,” 663; Heinrich Stern, “The Mortality From Diabetes Mellitus in the City of New York (Manhattan and the Bronx) in 1899. Classified According to the Month, Sex, and Age; Also an Expose as to Nationality, Duration of Residence in the United States, Occupation, Direct Causes of Death, and Accompanying Diseases,” Medical Record 58 (1900): 766–774, 767.
18. R. Saundby, “Diabetes Mellitus,” in A System of Medicine, ed. Thomas Clifford Albutt (London: Macmillan, 1897), 167–212, cited in Sander L. Gilman, “Fat as Disability: The Case of the Jews,” Literature and Medicine 23 (2004): 46–60, 51.
19. Elliott P. Joslin, “The Diabetic Problem of Today,” Journal of the American Medical Association 83 (1924); 727–729, 727.
20. I. Howe, World of Our Fathers (New York: Harcourt Brace Jovanovich, 1976)
21. Osler, Principles and Practice of Medicine, 295. See also H. C. Riggs, “On the Treatment of Diabetes Mellitus,” Journal of the American Medical Association 18 (1892): 674–677, 675.
22. Barkin, Retreat of Scientific Racism, 2.
23. E. L. Goldstein, The Price of Whiteness: Jews, Race, and American Identity (Princeton, NJ: Princeton University Press, 2006), 1.
24. Jacobson, Whiteness of a Different Color.
25. 61st Congress, 3rd Session, document no. 662, Reports of the Immigration Commission, Dictionary of Races or Peoples (Washington, DC: Government Printing Office, 1911), 1–5.
26. Stocking, “The Turn-of-the-Century Concept of Race”; Jacobson, Whiteness of a Different Color, 78; Brodkin, How the Jews Became White Folks; Barkin, Retreat of Scientific Racism, 2, 19.
27. Jacobson, Whiteness of a Different Color.
28. Dictionary of Race or Peoples, 74.
29. 61st Congress, 3rd Session, document no. 764, Statements and Recommendations Submitted by Societies and Organizations Interested in Immigration (Washington, DC: Government Printing Office, 1911), 48.
30. E. L. Goldstein, “Contesting the Categories: Jews and Government Racial Classification in the United States,” Jewish History 19 (2005): 79–107. For an outstanding discussion of the political nature of current racial categories, see Stephen Epstein, Inclusion: The Politics of Difference in Medical Research (Chicago: University of Chicago Press, 2007), 148 ff.
31. Quotations are from Mary Clark Barnes and Lemuel Call Barnes, The New America: A Study in Immigration (New York: Fleming H. Revell Co, 1913); Burton J. Hendrick, The Jews in America (Garden City, NY: Doubleday, Page & Company, 1923); and Lothrop Stoddard, Racial Realities in Europe (New York, 1924); all cited in Robert Singerman, “The Jew as Racial Alien: The Genetic Component of American Anti-Semitism,” in Anti-Semitism in American History, ed. David A. Gerber (Urbana: University of Illinois Press, 1986), 103–129, 110, 117. See also Jacobson, Whiteness of a Different Color, 103, 180; Gilman, The Jew’s Body, 174.
32. Goldstein, The Price of Whiteness. 102–108.
33. Ibid, 170–177.
34. Ibid, 172.
35. On the notion of Jews as racial aliens, see Singerman, “The Jew as Racial Alien.”
36. H. Emerson, “Sweetness Is Death,” The Survey 53 (1924): 23–25, 24. For biographical information on Emerson, see Charles Bolduan, “Haven Emerson—The Public Health Statesman,” American Journal of Public Health and the Nation’s Health 40, no. 1 (1950): 1–4. Emerson served a term as president of the American Public Health Association in 1934; see “APHA Past Presidents,” available at http://www.apha.org/about/aphapastpresidents.html (accessed May 25, 2010)
37. This image of the Jew had a long history. See Gilman, “Fat as Disability.”
38. J. G. Wilson, “A Study in Jewish Psychopathology,” Popular Science Monthly 82 (1913): 264–271, 265.
39. Wilson was criticized for this at the time. See Hyman Morrison, “A Statistical Study of the Mortality From Diabetes Mellitus in Boston From 1895 to 1913, With Special Reference to Its Occurrence Among Jews,” Boston Medical and Surgical Journal 175 (1916): 54–57, 55.
40. Wilson, “Increase in the Death Rate From Diabetes,” 663.
41. Gilman, The Jew’s Body; Efron, Medicine and the German Jews; Efron, Defenders of the Race.
42. On the Jewish medical community’s general acceptance of Jewish diseases, see Mitchell B. Hart, “Racial Science, Social Science, and the Politics of Jewish Assimilation,” Isis 90 (1999): 268–297; Efron, Medicine and the German Jews; Efron, Defenders of the Race.
43. J. Jacobs and M. Fishberg, “Diabetes Mellitus,” Jewish Encyclopedia, available at http://www.jewishencyclopedia.com/view.jsp?artid=321&letter=D&search=diabetes%20mellitus (accessed May 25, 2010)
44. Morrison, “Statistical Study of the Mortality From Diabetes Mellitus,” 54.
45. Epstein, “Diabetes Among Jews.”
46. Ibid, 274. On Lamarckian notions of race in the early 20th century, see Stocking, “The Turn-of-the-Century Concept of Race.”
47. G. Graham, The Pathology and Treatment of Diabetes Mellitus (London: Henry Frowde and Hodder & Stoughton, 1923), 34–35, 82.
48. S. Solis-Cohen, “Society Proceedings. Adiposity and Other Etiologic Factors in Diabetes Mellitus,” Journal of the American Medical Association 84 (1925): 1775–1776, 1776.
49. Jacobs and Fishberg, “Diabetes Mellitus.”
50. C. E. Rosenberg, “George M. Beard and American Nervousness,” in No Other Gods: On Science and American Social Thought (Baltimore: Johns Hopkins University Press, 1997), 98–108; Barbara Sicherman, “The Uses of a Diagnosis: Doctors, Patients, and Neurasthenia,” Journal of the History of Medicine and Allied Sciences 32, no. 1 (1977): 33–54.
51. Carl H. von Noorden, “Diabetes Mellitus,” in Twentieth Century Practice: An International Encyclopedia of Modern Medical Science, ed. Thomas H. Stedman, 21 vol. (New York: William Wood and Company, 1895–1903), vol. 2: Nutritive Disorders (1895), 64; Emil Kleen, On Diabetes Mellitus and Glycosuria (Philadelphia: P. Blakiston’s Son & Co, 1900), 15. See also Morrison, “A Statistical Study of the Mortality From Diabetes Mellitus,” 56.
52. Kleen, On Diabetes Mellitus and Glycosuria, 17.
53. Barkin, Retreat of Scientific Racism; King, Race, Culture, and the Intellectuals; Hart, Social Science and the Politics of Modern Jewish Identity.
54. Jacobson, Whiteness of a Different Color; Nicholas Lemann, The Promised Land: The Great Black Migration and How It Changed America (New York: Vintage Books, 1992); James R. Grossman, Land of Hope: Chicago, Black Southerners, and the Great Migration (Chicago: University of Chicago Press, 1989)
55. Brodkin, How the Jews Became White Folks.
56. K. Wailoo and S. Pemberton, The Troubled Dream of Genetic Medicine: Ethnicity and Innovation in Tay-Sachs, Cystic Fibrosis, and Sickle Cell Disease (Baltimore: The Johns Hopkins University Press, 2006)
57. Ibid, chap. 1.
58. R. J. Lifton, The Nazi Doctors: Medical Killing and the Psychology of Genocide (New York: Basic Books, 1986); Robert Proctor, Racial Hygiene: Medicine Under the Nazis (Cambridge, MA: Harvard University Press, 1988); Paul Weindling, Health, Race, and German Politics Between National Unification and Nazism, 1870–1945 (Cambridge: Cambridge University Press, 1989); Wailoo and Pemberton, Troubled Dream of Genetic Medicine, 7.
59. Christopher McLoughlin, Lester M. Petrie, and Richard H. Fetz, “Diabetes Detection in Georgia,” Journal of the Medical Association of Georgia 40 (1951): 285–286, 286. [PubMed]
60. Data from the National Vital Statistics System, “Series 20. Number 10: Diabetes Mellitus Mortality in the United States, 1950–1967” (July 1971), 6, available at http://www.cdc.gov/nchs/data/series/sr 20/sr20 010.pdf (accessed February 11, 2008)
61. I. I. Lemann, “Diabetic Gangrene in the South,” Journal of the American Medical Association 89, no. 9 (1927): 659–662, 660.
62. Eugene J. Leopold, “Diabetes in the Negro Race,” Annals of Internal Medicine 5 (1931): 285–293, 292. See also Harold Bowcock, “The Diabetic Negro,” Diabetes 1, no. 4 (1933): 109–110, 118.
63. Leopold, “Diabetes in the Negro Race”; Bowcock, “The Diabetic Negro”; John Herman Lewis, The Biology of the Negro (Chicago: Chicago University Press, 1942); Louis I. Dublin, “The Problem of Negro Health as Revealed by Vital Statistics,” Journal of Negro Education 6, no. 3 (1937): 268–275, 274.
64. M. Gover, “Trend of Mortality Among Southern Negroes Since 1920,” Journal of Negro Education 6 (1937): 276–288. Indeed, in the 1930s and 1940s, the Journal of the National Medical Association, the National Negro Health News, and the Journal of Negro Medical Education published relatively few articles on diabetes.
65. J. H. Jones, Bad Blood: The Tuskegee Syphilis Experiment, new and expanded edition (New York: Free Press, 1993); Tuskegee’s Truths: Rethinking the Tuskegee Syphilis Study, ed. Susan M. Reverby (Chapel Hill: University of North Carolina Press, 2000); Susan M. Reverby, Examining Tuskegee: The Infamous Syphilis Study and Its Legacy (Chapel Hill: University of North Carolina, 2009)
66. Steward R. Roberts, “Nervous and Mental Influences in Angina Pectoris,” The American Heart Journal 7 (1931): 21–35, 23.
67. I. I. Lemann, “Diabetes Mellitus in the Negro Race,” Southern Medical Journal 14, no. 7 (1921): 522–525, 524.
68. L. Dublin, “The Problems of Negro Health as Revealed by Vital Statistics.”
69. Lewis, Biology of the Negro, 283.
70. Hugh Wilkerson, “Problems of an Aging Population: Public Health Aspects of Diabetes,” American Journal of Public Health 37 (1947): 177–188, 180. For the original study, see Hugh Wilkerson and Leo P. Krall, “Diabetes in a New England Town,” Journal of the American Medical Association 135 (1947): 209–216.
71. Diabetics Unknown [motion picture] (1962), sponsored by the Public Affairs Committee, Inc. and the Conference of State and Territorial Directors of Public Health Education. Copy viewed at the National Library of Medicine (NLM Unique ID 8800470A)
72. See, for example, “Is Race ‘Real?’ a Web forum organized by the Social Science Research Council,” available at http://raceandgenomics.ssrc.org (accessed May 25, 2010). See also Williams, “Race and Health,” and Wailoo and Pemberton, The Troubled Dream of Genetic Medicine.
73. J. Marks, “The Realities of Races,” in “Is Race ‘Real?’ ”
74. N. Krieger, “If ‘Race’ Is the Answer, What Is the Question? On ‘Race,’ Racism and Health: A Social Epidemiologist’s Perspective,” in “Is Race ‘Real?’ ”; Karter, “Race and Ethnicity”; Vivian Ota Wang and Stanley Sue, “In the Eye of the Storm: Race and Genomics in Research and Practice,” American Psychologist 60 (2005): 37–45. [PubMed]
75. V. Navarro, “Race or Class Versus Race and Class: Mortality Differentials in the United States,” Lancet 36 (1990): 1238–1240; Nancy Krieger, “Stormy Weather: Race, Gene Expression, and the Science of Health Disparities,” American Journal of Public Health 95 (2005): 2155–2160.
76. For the National Institute of Diabetes and Digestive and Kidney Diseases, see “National Diabetes Statistics, 2007.” For rates in Appalachia, see Centers for Disease Control and Prevention (CDC), “County Level Estimates of Diagnosed Diabetes,” available at http://apps.nccd.cdc.gov/DDT_STRS2/NationalDiabetesPrevalenceEstimates.aspx (accessed July 7, 2010). This new Web site, released by the CDC in 2008, provides data about diabetes rates by region. According to this site, Logan County in West Virginia has the highest percentage of diagnosed diabetes—14.2% of the adult population—in the country. On Logan County, see Dan Hurley, Diabetes Rising: How a Rare Disease Became a Modern Pandemic, and What to Do About It (New York: Kaplan Publishing, 2010), 77. On other regions in Appalachia, see Meghan Holohan, “The Diabetes Dilemma,” at the Diabetes Library at Ohio University, available at http://diabetes.boomja.com/index.php?ITEM=81574; and “Diabetes in the Big Sandy Area Development District, 2005,” available at http://chfs.ky.gov/NR/rdonlyres/D7D77EF6-FF86-4071-B566-BB7E1B694D54/0/BigSandy1.pdf (both accessed May 25, 2010)
77. For an excellent historical analysis of the way government data have created as much as recorded racial categorizations, see Melissa Nobles, “History Counts: A Comparative Analysis of Racial/Color Categorization in US and Brazilian Censuses,” American Journal of Public Health 90, no. 11 (2000): 1738–1745. For a recent study that found that racial differences in the prevalence of diabetes disappeared when populations of similar socioeconomic status were compared, see L. B. Signorello, D. G. Schlundt, S. S. Cohen, et al., “Comparing Diabetes Prevalence Between African Americans and Whites of Similar Socioeconomic Status,” American Journal of Public Health 97, no. 12 (2007): 2260–2267. See also Claudia Chaufan, “Poverty Versus Genes: The Social Context of Type 2 Diabetes,” Diabetes Voice 49 (2004): 35–37. For an example of an early 20th-century epidemiological study that linked class and disease but simultaneously rendered gender and race invisible, see Harry M. Marks, “Epidemiologists Explain Pellagra: Gender, Race, and Political Economy in the Work of Edgar Sydenstricker,” Journal of the History of Medicine and Allied Sciences 58, no. 1 (2003): 34–55.
78. Krieger, “If ‘Race’ Is the Answer”; Williams, “Race and Health”; Audrey Smedley and Brian D. Smedley, “Race as Biology Is Fiction, Racism as Social Problem Is Real: Anthropological and Historical Perspectives on the Social Construction of Race,” American Psychologist 60 (2005): 216–226. [PubMed]

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