Part 6 ~ STRIKE THREE – 21st Century AUDACITY ON STERIODS
“There is no alibi for not knowing what is known” — 1966 edition of Davis Obstetrics, statement by editor J. Rovinsky, MD
As you already know, Strike Three is the audacity of continuing to assume that it is medically appropriate for interventional obstetrics to displace normal childbirth practices in healthy women with normal pregnancies and that the resulting and ever-escalating Cesarean section rate is justified and beneficial. In this context, a 15-year old quote from the Medical Leadership Council (an association of more than 2,000 US hospitals) is revealing. In 1996, when the C-section rate was barely over 20%, the Medical Leadership Council report concluded that the US cesarean rate was:
“medicine’s equivalent of the federal budget deficit; long recognized as [an] abstract national problem, yet beyond any individual’s power, purview or interest to correct.”
That paints a pretty grim picture: a disjointed, economically-strapped and liability-burdened obstetrical system that is “beyond any individual’s power, purview or interest to correct”. In one of Rita Mae Brown’s books, she defines insanity as “doing the same thing over and over again and expecting different results”. By that measure, obstetrics is a non-scientific cult built around the personal and professional preferences obstetricians. That means it’s up to consumers and investigative journalists to stop the endless loop characterized by an institutionalized inability to learn.
If anyone is unsure of what normal (i.e., non-medical) care for normal birth means, there is a wealth of solid, evidence-based definitions and description of physiologically-based management in many highly respected contemporary sources. Such a list must start with the mother of all evidence-based maternity care publications — The Guide to Effective Care in Pregnancy and Childbirth by the Cochrane Review (Dr. Enkins et al). Next would be the ‘Mother-Friendly Childbirth Initiative’ by the consensus group ‘Coalition for Improving Maternity Services (CIMS) and of course, the wonderfully informative material for consumers produced by Childbirth Connection website (used to be the Maternity Center Association of NYC, founded in 1918).
If anyone is unclear as to what the proper role of midwifery is in a model of normal care for normal birth, I quote the published comment in a top obstetrical journal by another eminent obstetrician. He identified the future direction of the obstetrical profession and indirectly, that of midwifery by saying:
“It is no longer feasible for individual physicians who have invested 12 years in training at a cost of hundreds of thousands of dollars to dedicate extended periods to observing one normal woman in labor.” [Macer JA et al; Am J Obstet Gynecol 1992:166:1690-7].
Aside from the humanitarian issue of preventable MM, the use of interventive obstetrics as our standard for healthy women has a negative impact on our economy and on global climate issues. If the US is to compete successfully in the global economy of the 21st century, we can’t continue to spend 4.25% of our entire GDP (itself a huge number compared to GDP in other countries) to provide maternity care to an essentially healthy population.
We have to develop a cost-effective maternity care system that relies on physiologically-based management and is suitably “green”, that is, has a much smaller carbon footprint than our current system. Can you imagine the number of new brick-and-mortar medical schools, hospitals, roads, and supportive infrastructure that would be needed and the additional acres of landfills required to bury the bio-hazardous surgical waste generated by 4,000,000 electively scheduled Cesareans each and every year?
“We believe it to be the duty and privilege of the obstetricians of our country to safeguard the mother and child in the dangers of childbirth. The obstetricians are the final authority to set the standard and lead the way to safety. They alone can properly educate the medical profession, the legislators and the public.” [Boston Medical and Surgical Journal; February 23, 1911 p. 261]
I say it time for the obstetrical profession to put its money – and its resources of time and attention – where its mouth is and “lead the way” to safe AND cost-effective maternity care.
Putting Humpty-Dumpty Back Together Again – Gorilla Glue for the 21st Century
Obviously, we can’t eliminate the excessive use of Cesareans without providing an effective alternative — a plan that reduces the inappropriate reliance on technology, medical intervention and surgical delivery, while safely meeting the physical, emotional and psycho-social needs of childbearing woman and her family. To bring about the necessary changes, we must initiate a robust public dialogue and reassess the unproductive methods that have captivated everyone’s imagination for the last hundred years.
Most of all, we must end the era of obstetrics as an insular ‘old boys club’ and replace the institutionalized inability to learn with its polar opposite – an enthusiasm for using the wealth of evidence-based information that is already part of medical science.
This is what has been missing from ‘obstetrics as usual’ over the last 170 years. We look forward to a renewed spirit of innovation, cooperation and leadership from the obstetrical profession. We invite them to join midwives, mothers and other in creating a maternity care system for the 21st century that is able to provide safe, cost-effective care to healthy women with normal pregnancies.
The new model would require a return to the multi-disciplinary approach that was the norm in the US before it was purposefully eliminated by organized medicine in 1910. This multi-disciplinary model is the same type of cooperative and complimentary relationships that are used so successfully in other developed countries – obstetricians, family practice physicians, and professional midwives all working together and providing care in a variety of settings.
In such a system, the individual management of pregnancy and childbirth would always be determined by the health status of the childbearing woman and her unborn baby, in conjunction with the mother’s stated preferences, rather than the occupational status of the care provider (obstetrician, family practice physician, or midwife) or the planned location of care.
By sharing responsibility among different disciplines, creating transparencies between scientific evidence and actual practice, and by requiring accountability for the quality of care provided in addition to the life-death legal outcome (i.e., process as well as ‘product’), we can build a system that will not fall off the rails into a this too frequently repeated cycle of iatrogenic and nosocomial complications and preventable mortality. The new ‘new’ obstetrics should only use interventions and invasive procedures because the mother or baby requires them, not because birth attendants are in the habit of preemptively using these risky procedures or that hospitals are dependent on them as a revenue stream.
We need to integrate the traditional principles of physiological management with the very best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women. This model of care should apply to all categories of birth attendants and in all settings and include the use of best and most advanced obstetrical interventions whenever they are necessary to treat complications or if requested by the mother.
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. Ultimately, maternity care is always judged by its results — the number of mothers and babies who graduate from its ministration as healthy, or healthier, than when they started.
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Continued part 7 ~ Source material from ObGynNews on the dramatic increased in placental abnormalities and its association with our sky-rocketing Cesarean section rate:
