The Brave New World of Evidence-based Maternity Care ~ Chapter 5

by faithgibson on September 8, 2013

Chapter 5

~ Calling a spade a spade ~

faith gibson, LM (2005)

Recently a colleague of mine — Susan Hodges, president of Citizens for Midwifery — brought my attention to a study published in a British medical journal that has an important contribution to this debate. The May 11, 2002 volume of the Lancet (www.thelancet.com) carried a thought provoking article about violence against women as a frequent and even routine facet of obstetrical services around the world. It used language that frankly I would not have thought to include in this debate. However, I think it helps us see the tension between healthy childbearing women and conventional obstetrics in a new and more helpful light, to see ourselves as warriors rather than victims. We are not crazy … but the system sure is!

The study is entitled “Violence against women in health-care institutions: an emerging problem” and was mainly conducted in central and South America. It revealed problems more extreme than what we typically see here. In the US, healthcare workers rarely threaten the mother outright with physical harm but harm is indirectly produced when deficiencies in the care offered results in the need for drugs and operative delivery. While the authors of this study offered no universally agreed-upon definition of obstetrical violence against women, it did highlight four types of retrograde behavior including neglect, verbal abuse, physical and sexual abuse. The study specifically identified the “excessive or inappropriate medical treatments in childbirth such as Cesareans performed by doctors for reasons related to the physician’s social or work schedules or financial incentives (4,34,35) or adhering to obstetric practices that are known to be unpleasant, sometimes harmful and are not evidence-based” as a from of violence against women relative to a healthcare setting. (1,2,20,21).

Most people don’t see these medical procedures as an expression violence, as they certainly are not meant to be harmful, but seen as necessary to help the mother to have a safe delivery and a healthy baby. Virtually any intervention, no matter how violently it disturbs the normal biological process of spontaneous labor or birth, can be excused as ultimately a mechanism to facilitate neonatal well being, even when it ultimately harms the mother or even the baby.

As used by the authors of the Lancet article, violence against women in childbirth and other gender-related circumstances is not necessarily a gender issue for the perpetrators. Nurses and even midwives, as employees of an institution, may well be the instrument off its delivery by simply reiterating the socializing of women and the medical/nursing educational programs that have control and dominance over patients built into their definition of what it means to be a effective healthcare professional. The authors identified structural violence as institutional customs and protocols that have perhaps been used for generations and are accepted without question but require the staff and other employees to become unwilling perpetrators of violence, carrying out protocols and procedures that are harmful, hurtful or humiliating.

The BMJ article does not specifically mention medical treatments or surgery recommended and performed based on medical-legal criteria but I would include that in the idea of structural violence as it applies to the United States. Articles in obstetrical journals frequently acknowledge that the main advantage of certain recommended procedures is to safeguard the physician or medical facility from future litigation. The failure of the obstetrical system to maintain their skills in vaginal breech delivery would fall into this category, as the effect is to force women into Cesarean deliveries based on the physician’s lack of skill rather than the mother or baby’s current medical need. Continuous EFM, induction for “post-dates” or “big baby” and repeat Cesareans are the most common examples of medical or surgical procedures recommended to insure the physician’s “legal” safety. Other examples of institutional violence against women include disrespect, lack of truly informed consent, being left unattended during active labor, intimidation to agree to unwanted medical treatments and the use of rituals of subjugation. Unfortunately excessive and inappropriate medical treatment and adhering to obstetric practices that are not evidence-based apply to 50% or more of hospitalized women, as this dominates our current system.

The list of procedures that lack a suitable evidence base is long indeed and includes routine induction, routine use of continuous EFM and frequent use of episiotomy to name but a few. One only has to read the Cochran Data base – the bible of evidenced-based practices relative to pregnancy and childbirth — and then visit a local hospital or interview newly delivered hospital patients (or note the medical practices as used on mothers featured on cable TV such as the Baby Story and Maternity Ward) to know that only lip service is paid to evidence-based maternity care in the typical hospital. I was particular intrigued by the idea that ‘disrespect’ of the laboring mother or her treatment choices (including the choice of ‘no treatment’) is a ‘soft’ version of violence against childbearing women. This includes failing to provide the labor women with professional attendant during active labor and shouting at women to push, all of which are ‘business as usual’ in American hospitals.

A resolution by the Virginia chapter of NOW for change in our maternity care policy sums up many of these problems and proposed solutions quit well:

Whereas, there is *no clinical indication for, or evidence to show the safety of, most medical interventions and standard practices and procedures typically visited upon childbearing women and newborn infants in hospitals, and *these actions generally are carried out without any genuine informed consent; and, Whereas, these attitudes, actions, interventions and standard practices and procedures are often *abusive in nature, and in at least some cases constitute violence against women or newborn infants; and, Whereas, the quality of a woman’s choices are *dependent upon timely access to relevant and comprehensive information about the nature of any given condition or procedure, including the potential risks and benefits associated with all available options for care or treatment, including non-treatment of the condition; Therefore, be it resolved that Virginia NOW shall actively and publicly support policy reforms and other *efforts to ensure genuine informed consent regarding all maternity-care standard practices, procedures and medical interventions.   *emphasis added

Neglect, disrespect, verbal abuse and incidents of rough treatment (especially if the mother is black or does not speak English) occur routinely enough that they are incidentally documented in reality-based TV programs with video scenes of real labor and delivery in hospitals. I have been present when episiotomies were done without any medical indication, maternal knowledge or permission. One obstetrician I worked with as an L&D nurse routinely did episiotomies which he purposefully extended thru the rectal sphincter (without using anesthesia) to punish the mother for having a “natural” birth – a fact he readily admitted to. I have also seen medically unnecessary Cesareans performed because the doctor didn’t want the patient’s lawyer husband in the delivery room or the on-call doctor “only does Cesareans on home birth transfers”.

These incidents are infrequent but not unusual. The loyalty (abet misplaced) of nursing staff and even community midwives (who must be careful not to rock the political boat) usually prevents reporting these extreme violations of trust to the authorities. When they are reported, nothing is done. According to the California Medical Board, in response to a consumer complaint about a medically unnecessary Cesarean done subsequent to a home birth transfer, the performing of medically unnecessary and unwanted Cesareans routinely on all homebirth transfer patients is only an “ethical problem” that does not fall within their jurisdiction. They said there was no legal cause to discipline the offending physicians, who is free to continue performing unnecessary Cesarean surgery, because he doesn’t approve of home birth.

Soft Violence – Attacks on the Spirit and Self-Esteem

Thankfully, overt violence at this level is rare in American hospitals but “soft” abuse which does violence to the spirit and the self-esteem is not. Recognition of these soft forms of violence in obstetrical settings gives new impetus to our efforts to demedicalize normal birth and normalize maternity care. It also casts the institutionalized lack of compassion in a cold light. A wide-spread deficiency in compassion is more than just an unfortunate artifact of modern life — it is a symptom of a deep and pervasive social injustice that begs for immediate attention and correction. As a former labor and delivery room nurse and frequent observer of obstetrical care while providing labor support for hospital births (over 4 decades), I have witnessed literally hundreds of conversations with laboring patients in which doctors or nurses were patently disrespectful, untruthful, subtly threatening or undermining of the mother’s confidence in her own abilities or her choices.

Symptoms of a pervasive disrespect includes failing to include the mother as an equal partner in decision making about her care and failing to provide any truly effective labor support or pain management that is not drug or anesthesia dependent. In part this reflects deficiencies in medical and nursing education and partly is to be blamed on the economic framework of obstetrical practice as a “for profit” activity. Since there is a near universal failure of the medical profession to teach, learn or utilize the physiological management of labor, there is a dearth of exposure to or skills in non-pharmaceutical comfort measure. This includes strategic use of maternal mobility, hot showers and deep water tubs to facilitate an unmedicated labor and right use of gravity to facilitate a non-instrumental natural birth.

A frequently used form of “soft” threats include telling women in active labor that awful things will happen if they don’t immediately agree to a medical intervention that the mother clearly doesn’t want. These conversations revolve around authoritative pronouncements such as “you’ll split wide open if I don’t let me do an episiotomy” or “your baby could die if you don’t let me” (fill in the blank with ‘put the electronic fetal monitor on you’, ‘start an IV’, ‘accelerate labor with Pitocin’,  ‘give you some pain-killing medicine’, ‘use forceps’, ‘do a CS’, etc).

Violence, Trust and Continuity of Care

One reason that healthcare practitioners find it necessary to use intimidation in order to convince laboring women that unwanted interventions are urgently needed is because they so frequently do not have a personal caregiver relationship with the mother to be and therefore, there has been no opportunity to develop interpersonal trust. The lack of continuity of care is an aspect of the institutionalized lack of compassion and the structural violence against women inherent in modern healthcare systems. Because there is little or no relationship between patient and caregiver, it is hard for the patient to trust the recommendations of the doctor or nurse who is urging what appears to the mother as “drastic” or painful procedures. Very quickly the caregiver, almost always under an intense time pressure, must turn to intimidation to be effective (at least as judged by medical-legal conventions).

A softer and yet more subtle form of violence to the mother’s self-esteem is purposefully or even accidentally undermining maternal confidence through use of the “pregnant” phrase “Mighty big baby you have in there…”. The idea is quickly communicated that the nurse or doctor is sure the mother will never be able to have the baby normally because its so big or the mother is so wimpy. They think that if the mother is ‘smart’, she will acquiesce to drugs or surgery right up front and not waste their time or try their patience.

Or as the baby’s head begins to crown, there is the often repeated comment by doctor or nurse on “how big that head” is. It is understandably hard to relax one’s perineum and thus reduce the likelihood of a perineal tear while people make remarks on the enormous size of the baby’s head or talk about how important it is to relax “cause you don’t want to RIP do you”, bringing images of horrible damage or excruciating pain to mind instead of actually help the mother to avoid perineal trauma. Psychologists teach us that it is the nature of the subconscious to be “programmed” by the words we hear, especially the language of those in positions of authority. In order to use this characteristic to the benefit of the mother, a caregiver would instead speak of how important it is to let herself relax “so your perineum will be soft and get real stretchy”. Then the mind is filled with the idea of “softness” and “stretchy”.

Common expressions of violence to the soul also includes:

Ø      Scolding women (why don’t you call me, why didn’t you come in sooner, etc)

Ø      Belittling their choices (especially the desire for a natural birth or when women are transferred into the hospital who had planned a home birth)

Ø      Sabotaging the mother’s efforts to have an unmedicated birth (asking repeatedly if the mother doesn’t want ‘something for pain’

Ø      Disparaging remarks about her unwillingness to let the nurse “help” by giving drugs or anesthesia)

Ø      Failing to provide any meaningful leadership in dealing with pain via non-drug methods (the nurse looking at the fetal monitor screen, instead of the mother, every time she has a painful contractions), not offering to breathe with the mother, help her out of bed or encourage her to walk around or put her in the shower, etc)

Ø      Sabotaging the parents desire for non-instrumental delivery thru non-physiological management (failing to get the mother out of bed or change positions in bed to those more gravity-friendly, telling the mother she isn’t allowed to get up to stand or squat at the side of the bed when she asks, etc)

Ø      Shouting (including shouting at women to push) and the wide dimensions of disrespect which includes failing to give real informed consent information, providing only half truths

Ø      Using some small unimportant factoid as if it were terribly important, such as a random variable decal on the fetal monitor strip that is otherwise normal (good variability and baseline, no deep reparative decals) but pointed out by hospital staff as proof that the baby is “getting tired” and a Cesarean should be immediately consented to by the parents

Many dimensions of this “soft” violence against women are frequently the very interventions that get the most enthusiastic press coverage with exaggerated claims of efficacy and total denial of dangers or serious side-effects and their portrayal as great improvements in safety. The question is why the uncritical acceptance of a form of health care that is so clearly harmful, painful and scientifically invalid?

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Amnesty International’s list of what psychological Terror is includes: (all are also against the Geneva Conventions accords)

1.  Isolating victim

2.  Sleep/food deprivation

3.  Threats of harm to partner/family (fetus/baby–my comment)

4.  Forced drug/alcohol use

5.  Altering victim’s state of consciousness

Re the profile of batterers/domestic abusers–includes:

  1. Using intimidation
  2. Using emotional abuse –Putting her down–making her feel bad about herself–making her think she’s crazy–playing mind games–humiliating her–making her feel guilty
  3. Using isolation –Controlling what she does, who she sees and talks to, what she reads, where she goes–limiting her outside involvement
  4. Minimizing, Denying, Blaming –Making light of the abuse and not taking her concerns about it seriously (C-Sections come immediately to mind)–saying the abuse didn’t happen–shifting the responsibility for abusive actions–saying she caused it
  5. Using Children–Making her feel guilty about the children–threatening to take the children away
  6. Using Male Privilege –making all the big decisions–acting like the “master of the castle”–being the one to define men’s and women’s roles
  7. Using Coercion and threats –Making and/or carrying out threats to hurt her– threatening to leave her–threatening to report her to welfare

Other quotes from the presentation papers– From “Characteristics of battering personalities/relationships”

Controlling behavior :..the  batterer may say the controlling behavior is because he is concerned for her safety, her need to use her time well, or her need to make good decisions…He may try to influence her decisions, what classes she takes etc

Verbal abuse:  In addition to saying things that are cruel and hurtful, verbal abuse serves to degrade the woman,…or minimize her accomplishments.  The abuser will tell [her] that she is unable to function without him.

Isolation: A batterer may try to cut [her] off from all resources.  He may accuse people who are [her] support network of causing trouble.

The description of Survivor Psychological Responses and the Stages of Rape Trauma /Syndrome are also suspiciously familiar to those who care for women who have had C/S in particular.

What I’m pointing out is not that every hospital birth is a case of abuse, but that an awful lot of the stories we hear from women–and see–fit these profiles, and I wonder if this particular spotlight might somehow be shone on the problem.