How ACOG is using Wax Meta-analysis to ignore JACHO’s directive to reduce medical interventions & Cesarean rate

by faithgibson on June 23, 2013

in Cesarean Politics, Contemporary Childbirth Politics

A few day ago I posted ACOG’s legislative agenda/wish-list for 2013. If you read them you already know that nationally ACOG is definitely NOT interested in complying with  JACHO’s (now called “The Joint Commission”) April 2010 directive that the obstetrical profession reduce medical interventions that lead to a large number of unnecessary Cesarean deliveries.

Here is the ‘backstory’ of how the Wax Meta-analysis “conclusion” statement — the infamous ““

Less medical intervention during planned home birth is associated with a tripling of the neonatal mortality rate”.

This one sentence is being used by ACOG to make the case that less medical intervention is actually dangerous, as it is associated with a dramatic increase in neonatal mortality and to resist and ignore JACHO’s directive and  national efforts by administrators of Medicaid to reduce medically-unproductive interventions. (see

(see Cesarean Delivery Rates Vary Tenfold Among US Hospitals; Reducing Variation May Address Quality And Cost Issues By Katy Backes Kozhimannil, Michael R. Law, and Beth A. Virnig Health Affairs March 2013 32:3)

How ACOG is using the flawed data in the Wax Meta-analysis (2010) & Pang study (2002) to justify continuation of expensive and harmful obstetrical practices associated with high C-section rate

To paraphrase Albert Einstein, we can’t solve the problems facing us today with the same kind of thinking that created them. The type of thinking that created 20th-century obstetrics insisted that :

“obstetricians are the final authority to set the standard and lead the way to safety” and that only obstetricians could “properly educate the medical profession, the legislators, and the public.” [Boston Journal of Medicine, Feb 23, 1911, p. 261]

Despite claims of ‘final authority’, nothing in modern science supports the idea that maternity care for healthy women benefits from the strict obstetrical model that has become the ‘norm’ in the United States since 1910. This notion makes healthy childbearing women into patients of a surgical specialty, and normal birth into a surgical procedure.

This represents the most profound change in childbirth practices in the history of the human species. After a century of more, more, and more interventions, which so far has made iatrogenic complications one of the most frequent causes of morbidity and mortality, it’s time the obstetrical profession to crawl from that high ledge and join the real world at ground level by reintroducing.

This represents the most profound change in childbirth practices in the history of the human species.

After a century of more, more, and more interventions, which so far has made iatrogenic complications one of the most frequent causes of morbidity and mortality, it’s time the obstetrical profession to crawl down from their ivory tower and join the real world at ground level by reintroducing common sense into the equation.

The time for talking about change is long past, now it’s time to move

For things to change, we have to change how we think about these things, which requires a spirited and on-going public debate.

Women do not give birth in isolation from their culture as if they were spinning around in outer space tethered to an oxygen mask. These problems cannot be resolved without once again including theses childbearing women and their families in the discussion, and by acknowledging that maternity care is a broad cultural issue. The issue is how to balance safety and cost-effectiveness in favor of mothers and babies and to the overall benefit of society.

The salient question is the nature of childbirth in a healthy population — pathological versus physiological — and the ability of society and science to meet the obvious biological and psychological needs of healthy childbearing women in a safe and cost-effective manner that is acceptable to healthy childbearing families.

From 1910 until the 1980s, the obstetrical model included an aggressive medicalization of labor with the use of the Twilight Sleep drug scopolamine and frequently repeated injections of narcotics and conducted normal vaginal birth as a surgical procedure ‘performed’ under general anesthesia and including routine episiotomy and low forceps deliveries.

The elephant in “modern” L&D units was introduced in the late 1970s and early 80s, as general anesthesia and low forceps deliveries were replaced by epidurals and the liberal use of Cesarean as the new standard of care. This resulted in a popular new obstetrical retort: “when it doubt, cut it out”.

The first question is whether elective Cesarean surgery is safer than vaginal birth conducted as a surgical procedure. The second is whether the lower rates of medicalization associated with physiological management is more dangerous than medically-managed vaginal birth.

I’d start by questing whether increasing use of Cesarean surgery is beneficial from the patient’s perspective?.

A 1984 peer-reviewed paper in the NEJM seriously proposed the prophylactic use of Cesarean section as the standard of care. [ref] The authors opined that:

“….the number of extra women dying as a result of a complete shift to prophylactic cesarean section at term would be 5.3 per 100,000….

… recall that the number of fetuses expected to suffer a disaster after reaching lung maturity is between one in 50 to one in 500. … if it could save even a fraction of the babies at risk, … a shift toward prophylactic cesarean section at term might save a substantial number of potentially healthy infants at a relatively low cost of excess maternal mortality.

We probably {??} would not vary our procedures if the cost of saving the baby’s life were the loss of the mother’s.

But what if it were a question of 2 babies saved per mother lost, or 5 or 10 or (as our calculations roughly suggest) as many as 36 or 360? …. Is there some ratio of fetal gain to maternal loss that would unequivocally justify a wider application of this procedure?” [italics added]

In 2006, an article in New Yorker by Dr. Atul Gawande, a popular writer on medical reform, promoted the idea that the ‘industrialization’ of childbirth resulted in ‘added value’ for healthy women. He reported that the obstetrical profession was right on the cusp of making Cesarean surgery safer than the evolutionary biology as provided by Mother Nature. According to his theory, soon we won’t have to worry that the prophylactic use of elective Cesarean would result in any ‘excess’ maternal mortality. That put us on the fast-track to scheduled Cesarean surgery as the demonstrably safer model for both mother and baby and the new 21st century standard of care. [ref]

Until April 1, 2010, the issue of prophylactic CS was up for grabs, with many of the heaviest hitters in the obstetrical profession consistently making a strong and compelling argument for its efficacy. However, The Joint Commission for hospital accreditation (formally known as JACHO) came out with its new perinatal core measures’ in April 2010 that adroitly swept way the notion that anyone was winning the war against Mother Nature with the obstetrical idea of “when in doubt, cut it out” and other medical and surgical interventions.

Quite to the contrary, TJC found the liberal use of Cesarean to be neither justified nor safer. They identified its goal for American hospital to be a significant decrease in the number of Cesarean surgeries, particularly for first-time mothers a single fetus at term in a vertex position (NTSV).

Its rationale does not mince words:

“… removal of any pressure to not perform a cesarean birth has led to a skyrocketing of hospital, state and national cesarean section (CS) rates. Some hospitals now have CS rates over 50%. Hospitals with CS rates at 15-20% have infant outcomes that are just as good and better maternal outcomes (Gould et al., 2004). There are no data that higher rates improve any outcomes, yet the CS rates continue to rise.”

As for the reasons behind the ‘skyrocketing’ rate of Cesarean deliveries, TJC directive identified ‘physician preference’ as one of the main factors:

“Many authors have shown that physician factors, rather than patient characteristics or obstetric diagnoses are the major driver for the difference in rates within a hospital (Berkowitz, et al., 1989; Goyert et al., 1989; Luthy et al., 2003). Hospitals within a state and physicians within a hospital have rates with a 3-5 fold variation (Main, 1999). The dramatic variation in NTSV rates seen in all populations studied is striking according to Menacker (2006).”

As for TJC recommendations, they targeted elective induction and early admission to the hospital as directly associated with elevated rates of Cesarean surgery: “Alfirevic et al. (2004) also showed that labor and delivery guidelines can make a difference in labor outcomes. Main et al. (2006) found that over 60% of the variation among hospitals can be attributed to first birth labor induction rates and first birth early labor admission rates. The results showed if labor was forced when the cervix was not ready the outcomes were poorer.

The recommendations for decreasing the rate of surgical deliveries was accompanied by second TJC directive that also called for a reduced rate of elective deliveries under all circumstances, including the induction of labor. This directive stated that:

“almost 1/3 of all babies delivered in the United States are electively delivered, with 5% of all deliveries in the U.S. delivered in a manner violating ACOG/AAP guidelines. Most of these are for convenience, and result in significant short-term neonatal morbidity (neonatal intensive care unit admission rates of 13- 21%) (Clark et al., 2009). … compared to spontaneous labor, elective inductions result in more cesarean deliveries and longer maternal length of stay (Glantz, 2005).

The American Academy of Family Physicians (2000) also notes that: “elective induction doubles the cesarean delivery rate. Repeat elective cesarean sections before 39 weeks gestation also result in higher rates of adverse respiratory outcomes, mechanical ventilation, sepsis and hypoglycemia for the newborns (Tita et al., 2009).

TJC directive concluded that vaginal by-pass surgery was not cheaper by the millions. Instead of increasing support for medicalized labor and surgical deliveries that have been at the core of the obstetrical intervention in normal birth, the strongly worded and well-sited recommendation is to dramatically reduce induction, early labor admission, elective augmentation of labor and all non-medical, non-evidence-based elective use of Cesarean section.

JCAHO’s stand on this issue is a real game changer. This organization is a politically conservative, highly respected part of the medical establishment. JCAHO’s position on this issue is key ending the 40+ year romance with ‘prophylactic’ use of Cesarean section and casual use of induction, thereby changing public policy is the US.

Because ACOG has such an impact on maternity care policies worldwide, a change in US policy will have a ripple effect all over the globe. JCAHO’s website has well-referenced documents on this topic that provide great quotes and supporting citations for legislators, attorneys and reporters, journalists, etc.

This unlikely group has fearlessly exposed the ever-escalating rate of Cesarean deliveries, publicly pointed out that NN mortality rates are stagnant despite increasing number of operative deliveries and the rate of birth-related complications and maternal mortality are increasing. Confirmation of this vital information from such an impeccable source such as JCAHO has been sorely missing from the national policy debate on maternity care practices until now.

When you put these critical of business-as-usual obstetrics policy statements by JACHO with similar critique in Amnesty International’s report “Deadly Delivery” (which identifies the risk of an overuse of risky interventions, such as inducing labor and delivering via cesarean section as a human rights issue) you have a nightmare for ACOG and a real chance to fundamentally transform maternity care for healthy women.

For the first time in a hundred years, the romantic medicalizing of normal childbirth is, being exposed for what it really is — NOT a plan for safer, better or more cost-effective maternity care.

Amnesty International is publicly critical of maternity care systems in both developed and developing countries. They point out a widespread failure of maternity care providers to meet the basic obligation to childbearing women — protecting and preserving the health of already healthy women. This failure consists of two extremes (1) lack of access to life-saving pregnancy and childbirth services in third world countries; (2) the overuse, misuse and inappropriate use of pregnancy and birth-related obstetrical interventions, invasive procedures and surgical delivery in developed countries.

ACOG Manipulates Politically-based “Research” to Defend Itself Against JCAHO’s directives 

In my opinion, it is not merely a coincidence that ACOG’s Green Journal took an aggressive role in promoting the Wax meta-analysis in July, just 3 months after JACHO’s April publication of its new perinatal core measures. ACOG has positioned itself to use the one-sentence “conclusion” in Wax’s meta-analysis as a sound bite or newspaper headline to continue business-as-usual medicalization of normal childbirth in healthy women, while rebuffing JCAHO’s  new perinatal core measures.

The sharp disconnect between the “Results” statement in Wax and its “Conclusion” statement conveniently represents the agenda of the authors to uphold the policy position of ACOG rather than a thoughtful and balanced work of science.

According to the dictionary, a ‘conclusion’ is an integration of all available information, data or evidence. The final conclusion in a journal paper should logically synthesize all the information in the “Results” section as well as other pertinent findings, and provide a statement that wasrelevantt new information in clinical practice or at the public policy level.

The “Results” paragraph in the Wax document uses PHB as a proxy for what it describes as a low medical intervention model of intrapartum care (i.e. physiological management), and then reports a statistically significant reduction in the maternal interventions as demonstrated by data taken from half million midwife-attended births. Wax reported that midwife-led labor and birth in non-medical settings resulted in far fewer medical and surgical interventions for mothers: [Wax Meta-analysis; 2011]

  • EFM
  • Infection
  • Episiotomy
  • Hemorrhage
  • Cesarean delivery
  • Retained placenta
  • Epidural analgesia
  • Operative vaginal births
  • 3rd-degree perineal lacerations
  • Electronic fetal heart rate monitoring
  • Over all rate of perineal and vaginal lacerations

In addition, the data in the Wax Meta-analysis reported improved neonatal outcomes that included:

  •  reduced rates of prematurity,
  • low birth-weight, and
  • assisted newborn ventilation.

Equally important, it acknowledges similar perinatal mortality rates both for low levels of medical intervention (OOH model) and high medical-surgical intervention rates (hospital model).

Logically-speaking, the final paragraph — the conclusion –would integrate all the data from the half million cohort of births, including the excellent “results” noted above, which amply demonstrated the value of physiologically-based care for healthy women. This should have been headline news.

Instead, the “conclusion” statement is a six-second sound bite (or newspaper headline) that reads: “

Less medical intervention during planned home birth is associated with a tripling of the neonatal mortality rate”.

This ‘conclusion’ totally ignores the improved healthcare measures for mother AND baby and reduced cost associated with the “less medical intervention” arm of the study. The term “less medical intervention” is a disingenuous and inaccurate way to characterize physiological management, which is positive activity, not merely refraining from the induction of labor or routine use of continuous EFM, IVs, and epidurals.

The improved well-being of childbearing women and the fact that perinatal outcomes were the same for both groups were ignored in their concluding statement. They virtually negated all the positive data gathered from the half million births, and instead substituted the notion that their meta-analysis definitively determined that “less medical intervention” (ie physiologic management) equates to a sharp increase in preventable newborn deaths.

Hard to believe, but the reduced rates of medical-surgical interventions, less adverse events, and eliminating unproductive expenses associated w/ unnecessary intervention doesn’t even make the final cut as far as ACOG is concerned. 

That is really sad. A hundred years from now historians will be horrified that obstetrical interventions developed to treat serious complications were institutionalized in the US as the universal standard of care for healthy women with normal pregnancies. These-harmful obstetrical practices – what i describe as the “wrong use of obstetrics” — will be described as 20th and 21st-century version of bleeding and the use of leeches.

If i were an obstetrician, I’d be the first on my block to study the principles of physiological management OR I’d hire midwives to provide care to all my healthy maternity patients.

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