Brave New World of Evidence-based Maternity care ~ Chapter 8
Chapter 8
~ A Marriage Made in Hell —
the Media as a Platform for Obstetrical Excesses….
Maternal Choice Cesarean, VBAC Issues
faith gibson, LM (2005)
In June of 2000, Dr Ben Harer, who was at the time the president of American College of Obstetricians and Gynecologists, was interviewed by Diane Sawyer on Good Morning America. The topic was ‘maternal choice’ Cesarean, a curious notion based on the fallacious idea that normal vaginal birth is dangerous to mothers and babies and that the choice of an “elective” and medically-unnecessary Cesarean is the ultimate in ‘freedom of choice’ for women. In particular, pelvic floor dysfunction and pelvic organ prolapse were portrayed by the good doctor as the inevitable “collateral damage” of normal birth. Cesarean surgery, a major operation that circumvents vaginal delivery, elective Cesarean was promoted as preventing pelvic structure dysfunction and actually a “safer” option than normal birth.
On the issue of safety and the wisdom of defining “maternal choice” as a suitable reason for performing major abdominal surgery, Dr Ben Harer stated: “For the baby, the risks are far higher for vaginal delivery than for an elective cesarean section at term. For the mother, the immediate risks for a cesarean section are a little higher, but the longer term risks of pelvic dysfunction, urinary incontinence, anal incontinence, pelvic dysfunction–those risks are higher for vaginal birth and over the long time I think that the risk balance out that there really is no big difference.” Perhaps Dr. Harer was unfamiliar with the last 100 years of his own professional literature.
The scientific record on this claim speaks for itself – Cesarean surgery by any statistical measure is neither safer than normal birth (for either mother or baby) nor does it actually prevent pelvis floor dysfunction.
According to Dr. Elaine Waetjen, in a quest editorial published in Ob.Gyn.News, Cesarean surgery does not prevent all or even the greater part of pelvic organ prolapse, which occurs in about 1% of women who have carried a pregnancy to term, regardless of the method of delivery. (Ob.Gyn.News Aug 1, 2002, Vol 36, No 16 “Elective C-Section Revisited”) According to one study, women undergoing elective C-section have a 2 or 3 fold higher risk for pelvic organ prolapse and incontinence compared with women who have never carried a pregnancy to term. A recent study in Brazil showed a 3.5 fold increase for urinary incontinence later in life after elective C-section, roughly equivalent to the rate after one vaginal delivery. In a study in Australia of more than 3,000 patients, pelvic floor dysfunction was significantly associated with all modes of delivery. Another study reports that about 11% of women have surgery for urinary incontinence.
Using the above figures on incidence of surgery for prolapse or incontinence it would be necessary to perform 23 cesareans to prevent one pelvic floor surgery later in life. The best strategy to prevent post-pregnancy pelvic floor dysfunction is Physiological Management of labor and birth for healthy mothers with normal pregnancies
The claim that it does can only be described as a “false” – an assertion by a scientist with a PhD in obstetrical medicine that is self-serving rather than factual, advantageous to the physicians (in time, money and convenience) that is being misrepresented as serving the highest interests of mothers and babies. While this is to be decried, it is still somewhat “understandable”. People are often motivated by self-interest and trade organizations such as ACOG are no exception. Unfortunately for us all, the practice of corporate medicine dominates all aspects of health care and reiterates many of the worst aspects of partisan politics and market place competition. It is not really a surprise that its promoters would pull their punches.
The bigger and more dangerous issue to us all was (and is) the utter failure of any meaningful outcry by public or press over these outrageous and self-serving claims by a partisan, parochial obstetrical medicine. As a culture we have become so ignorant of normal biology and as childbearing women so disassociated from our bodies that when told by obstetricians that normal birth is dangerous and major surgery the ‘safer, better’ choice, we it accept it hook, line and sinker, without the slightest question or critique. That is the same quality of incredulity that at one time was accorded to the promotion of cigarette smoking by the tobacco companies who claimed tobacco use to be safe and sexy.
Where are the investigative journalists? What happened to all the other PhD scientists in other fields of medicine, biology, public health, sociology, child development, economic policy who are able to read the massive quantities of evidence and to question these claims and to call the obstetrical profession to be held accountable for both their self-serving policies and their inability or unwillingness to teach, learn and utilize physiological management of healthy women with normal pregnancies.
More Bad Press — Confusing Cause with Effect
A year later, in July of 2001, another foray by the obstetrical profession into the public occurred as the result of a study published in the New England Journal of Medicine (NEJM) entitled “Risk of Uterine Rupture during Labor among Woman with a Prior Cesarean Delivery”. Someone associated with this study notified the Associated Press about its publication and journalists were apparently convinced that the finding of this research amounted to a “watershed” event. As a result, this VBAC study got front-page publicity for all the wrong reasons. Out of the hundreds of VBAC studies ever published by reputable researchers, so far only this is the only one to be circulated by Associated Press, picked up by National Public Radio and given such extensive and explicit coverage.
The NEJM study documented an order of magnitude increase in uterine rupture when very strong drugs — prostaglandins — are used to artificially bring on labor (as cervical ripening agents and for induction). This risk increased by a factor of 15 when prostaglandins were combined with a type of artificial hormone known as an oxytocin – trade name Pitocin – is used in tandem to induce and accelerate labor. This particular study did make a meaningful contribution to scientific knowledge of VBAC safety by collecting is data that allows us to calculate the specific risk in a post-cesarean pregnancy between a spontaneous physiological labor, oxytocin-induced labor without prostaglandin and oxytocin-induced labor which includes the prior use of prostaglandins.
The product insert that comes with every package of Pitocin lists 11 serious or fatal “adverse reactions” (complications) for the mother and 7 for the unborn or newborn baby, including uterine rupture. It also specifically cautions that Pitocin NOT be used on any women with a scarred uterus, including previous cesarean mothers. (10. Pitocin Insert, Parke-Davis 1996 Warner-Lambert Co) Recently the manufacture of Cytotec (a type of prostaglandin added a caution about its use for labor induction in post-Cesarean pregnancies. (Letter from Searle 2002) The prostaglandin cohort of women in the study would generally be exposed to the risks of both drugs, thus it is no surprise that they would have a risk of rupture 15 times greater than women who had no labor at all.
Incredibly enough, the journalist for Associated Press and National Public Radio network both identified the primary “danger” not as the use of powerful uterine stimulants to induce labor in women with a surgically-scarred uterus but rather as having a normal labor and spontaneous birth after a previous cesarean. Newspaper stories urging a return to ‘once a Cesarean, always a Cesarean’ appeared syndicated newspapers all over the country and within a few weeks women were insisting on elective repeat cesareans for ‘safety reasons’. Comments by various physicians interviewed for the NPR story reflected the historical bias of obstetrical medicine for surgical solutions that ignore or downplay the complications, pain and expense of surgery. Media coverage included statements recommending that women with a prior Cesarean should not labor and instead, for “safety’s sake”, schedule a repeat Cesarean and suggested that perhaps a return to the policy of “Once a Cesarean, always a Cesarean” was in order. The story ended with a live interview of Dr. Michael Greene, MD, Director of Maternal-Fetal Medicine, Massachusetts General Hospital who said “…if the question you’re asking is, ‘What is safest for the fetus?’ There’s no doubt repeat Cesarean is safest.”
From the standpoint of the scientific data, it is the use of prostaglandin and other labor inducing drugs on VBAC women that should be abandoned – not normal labor. That is the real news, along with the public acknowledgement that use of Cesarean surgery carries added dangers not found after normal birth, a fact always well known by doctors but rarely admitted to the public. (1. ONCE A CESAREAN, ALWAYS A CONTROVERSY – VBAC; Dr. Bruce Flamm. MD) Our incredibly high Cesarean rate is fueled by the mistaken notion that it does not matter how the baby is born “as long as it is healthy”. One can only come to that dubious conclusion by focusing exclusively on the baby to the detriment of the mother and even still it is only a partial truth.
The study also does not address the issue of routine inductions of labor when the mother reaches term (39-41 wks of pregnancy) or based on an above-average estimated fetal weight (macrosomia). Many excellent studies, including the bible of evidence-based maternity care “Effective Care In Pregnancy and Childbirth “ (7. published by the Cochrane obstetrical database 2001), do not support the efficacy of routine induction for healthy women with a normal pregnancy or a larger than average baby. A recently published study concluded that “Routine labor induction at 41 weeks likely increases labor complications and operative delivery without significantly improving neonatal outcomes.” (8. Forty weeks and beyond: pregnancy outcomes by week of gestation. The University of Texas) Many primary Cesareans were the result of a “failed induction” that was never medically necessary but recommended by managed care as “cheaper” than tests to assure fetal well-being or chosen by physicians as more convenient or as a hedge against malpractice litigation. (9. Induction of labor as compared with serial antenatal monitoring in post-term pregnancies Hannah, M.E. et al 1992, NEJM) This flawed logic is then repeated in the subsequent pregnancy in which the mother is asked to choose between the vastly increased risk of a VBAC induction or the increased risk of another Cesarean.
Nor did the study account for the change in operative technique in the early 1990s. On the basis of a study published in a professional journal obstetricians changed suturing technique for the uterine incision from the traditional two layers method to a “single layer closure”. This experimental method is promoted as saving about 5.6 minutes and reducing the surgeon’s exposure to HIV/AIDS. It has been so widely accepted that it is often not even noted on the operative report. Dr. Steven Clark of the University of Utah Medical School recently conducted a study indicating this abreviated technique accounts for the increased frequency of ruptures seen in the last few years (30). Dr. Kurt Bernischke, a Boston pathologist and author of Pathology of the Human Placenta, believes it is also responsible for a huge increase in placenta precerta. The results and conclusion of one study state: “Women with a previous 1-layer closure (n=398) had a rate of uterine rupture of 3.3%, whereas those with a previous 2-layer closure (n=1251) had a rate of uterine rupture of 0.6% (p<.001) ….. A 1-layer closure at the previous low-transverse CS is associated with a 5-fold greater risk of uterine rupture during a trial of labor for the subsequent delivery than a 2-layer closure.” (11. Uterine rupture during a trial of labor after a one- versus two-layer closure of a low transverse cesarean. Emmanuel Bujold, American Journal of Obstetrics and Gynecology (supplement) 184(1):S18, 2001)
Clearly this was a massively effective campaign, convincing the lay public that labor was dangerous while cesarean surgery was safe. However, neither of these news stories acknowledged the realistic risks of elective surgery to the childbearing woman or her baby, either at the time of the operation or complications in future pregnancies. Cesarean surgery increases maternal deaths by 2 to 4 times compared to normal vagina l birth. In addition to physical safety is an increased incidence of postpartum depression in the weeks and months following surgical birth.
Instead the media coverage of this story read like an advertisement for the increased and uncritical use of Cesarean surgery. The story as circulated by the Associated Press and reported on National Public Radio did not mention the mounting political tension between the obstetrical profession and health insurers (especially HMOs), although this was inferred by one of the doctors interviewed on the air. Doctors don’t like being “forced” by third party payors to provide a trial of labor to women who did not want a vaginal birth or that the doctor considered to be less than an ideal candidate for vaginal delivery. In their mind this was a big waste of their time and an insult to their authority.
The July 2001 NEJM VBAC study is being promoted as ammunition in this fight for supremacy between doctors and health insurers, complete with orchestrated media coverage and spin doctoring. This on-going effort by organized medicine included an earlier article published by obstetricians in the NEJM “questioning” the recommendations made by the National Institute of Health’s Task Force on Cesarean Childbirth, which state that the Cesarean rate in the US is too high and sets a target rate of under 10%. Obstetricians insisted that no one knows what the safest rate for CS might be and maybe more babies would be saved if it was even higher that the current 23% (note – many developed countries with lower CS rates have better perinatal outcomes).
In the NIH’s original 1980 Cesarean recommendation, the principle author, Dr. Norbert Gleicher, estimated that each percentage point increase in Cesarean rate added $63 million additional expense for maternity care. This figure would no doubt be doubled today’s economy, for an estimated $126 million per percentage point of cesareans performed. A recent article in OB.GYN.News predicted that our Cesarean rate would double in the next generation, due in large measure to the NEJM article on the “danger” of VBAC combined with the notion that Cesarean surgery is protective of pelvic floor integrity.
Nor did the press coverage reveal the long-held hidden agenda of organized medicine for an easier life and bigger piece of the economic pie to be achieved through an increased use of cesarean surgery. the casual use of Cesarean surgery are promoted by obstetrical organizations as insurance against malpractice litigation, with the added bonus of reducing the doctor’s time commitment and the convenience of daylight scheduling. There is no question that “daylight obstetrics” is an advantage for obstetricians, anesthesiologists and hospital scheduling. When faced with any potential problem in pregnancy obstetricians readily remark (in print and in person) “When in doubt, cut it out”.
This explicitly refers to the notion that Cesarean surgery solves every dilemma for physicians but ignores the pain and problems created for the mother. It also assumes that it is somehow morally superior to die or be damaged from aggressive surgical “over treatment” rather than from the equally reasonable choice of “under treatment”, that is planning a non-induced normal labor. This notion only addresses the physician’s fear of malpractice litigation and also reflects a subtle sexism, in which the baby, as the “product” of obstetrical services, is assumed to be the real prize and more important than the woman.
Contrary to the conclusion drawn by those reporting on this research, many childbearing women see the information in the July 2001 NEJM VBAC study as an excellent argument for “cesarean prevention”. The most efficient way to prevent Cesarean-related tragedies is to avoid CSs – whether that is the first time or in subsequent pregnancies.
The Beat Goes On
The most current expression of this romance between the media and the obstetrical lobby can be seen in a Time Magazine article (June 10, 2002) by Lisa McLaughlin entitled “SCHEDULED BIRTHS”
“Reports from Ob-Gyns show more moms-to-be are requesting scheduled C-section deliveries, even when there is no pressing medical need for the surgery. Cesarean rates in the U.S. have been climbing steadily, from 20.7% in 1996 to 22.9% in 2000, according to data from the CDC. For busy pregnant women, a scheduled birth can relieve anxiety, and grandparents can plan to be at the birth to provide support and extra hands for diaper duty.”
A response by a midwife to this casual promotion of non-medical elective c-sections:
“Women are not choosing C-sections, they are being sold on the idea. You published a short blurb about the growing demand for the elective procedures citing advance purchase airfare deals for grandparents as a valid reason to choose major abdominal surgery. What were you thinking?”
A Cesarean every 39 Seconds – the politics of a surgical epidemic
There are 4 million births a year in the US, with a 23% cesarean rate (900,000+ CSs annually), the most frequently performed major surgery in the US. Or as a product advertisement in obstetrical journals proclaims (“For Problem Scarring” of cesarean incisions), “a scar is born every 39 seconds”. You read that right – a Cesarean was performed every 39 seconds! (18. ReJuveness by RichMark International Corp – statistics based on 1995 CS rate) In 1995 there were 80 Cesareans every hour, round the clock, 365 days a year. In 2001 it’s probably one CS every 29 seconds! We spend 20% of our entire healthcare budget on maternity services. Clearly management recommendations for post cesarean pregnancies is not a trivial topic, either economically or for the families involved. Unfortunately for us all, a lot of the recommendations by medical groups are either shortsighted or self-serving. This propensity for partisan politics is absolutely consistent with the history of organized medicine and should come as no real surprise to news organizations. Exercise of free-speech rights by trade groups requires that these parochial pronouncements be balanced by on-going and critical inquiry by the press and media.
An example of how far the perspective and the agenda of the medical community is from the expectations of the public and interests of childbearing women was offered in another article also published NEJM, May 1985, by George B. Feldman, MD, Jennie A. Feldman, MD entitled Prophylactic Cesarean Section at Term?
This article brings into sharp contrast how much we all need unbiased investigative reporting by media to explore these conflicts of interest. As did the ACOG president on Good Morning America, the Doctors Feldman make the “case” for Cesarean on demand and seriously promote the idea that a 100% scheduled or “prophylactic” cesarean become the norm for all women.
This drastic idea is seen as a preemptive strike to protect the baby from the “dangers” normal labor and birth and would change the professional focus of doctors to determining when fetal lung maturity was achieved so that the CS could be scheduled before (gasp!) the mother went into spontaneous labor (a mistake of course!) and (gulp!) gave birth naturally!
The Doctors Feldman make a statistical case for cesarean surgery as “saving” babies with only a little “excess” or “extra maternal mortality” and opin that the “low cost of excess maternal mortality” may be a price worth paying.
Here is a short excerpt:
p. 1266 ….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…. This may be the proper moment to recall that the number of fetuses expected to suffer a disaster after reaching lung maturity is between 1 in 50 to 1 in 500. … if it could save even a fraction of the babies at risk, these calculations would seem to raise the possibility that 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?
p. 1267….is it tenable for us to continue to fail to inform patients explicitly of the very real risks associated with the passive anticipation of vaginal delivery* after fetal lung maturity has been reached? If a patient considers the procedure and decides against it, must she then be required to sign a consent form for the attempted vaginal delivery? (*emphasis mine)
The answer to the Doctors Feldman is no, there is no “ratio of fetal gain to maternal loss that would unequivocally justify a wider application of this procedure”. That is a choice ONLY the mother and father can decide to take.
The Plain Unvarnished Truth on Surgical Mortality
Maternal mortality associated with vaginal birth is only 1 out of 16,666. By comparison, the death of childbearing women associated with Cesarean surgery is 1 for every 3,225 surgical deliveries (Lilford, 1997). Maternal deaths associated with elective Cesarean surgery are estimated to be one out of 5,000, which is more than 3 times the risk of a normal birth. However, one popular obstetrical text reports Cesarean-related maternal deaths to be as high as one out of a 1,000. (Gabbe, 1991). To put this into the post 9 / 11 perspective of global terrorism, the death rate in Israel from in its war with Palestine, reported in the news and on TV on a weekly basis, is actually only 1 per death per 10,000 Israeli citizens. (news broadcast 6/24/02) In spite of these known dangers the US has a higher CS rate than any other country except for Brazil while remaining among the bottom five industrialized countries in perinatal safety. Irrespective of this dismal record we spend far more on childbirth services than any other country.
Many complications of elective repeat Cesarean are the very same as those of uterine rupture, such as maternal death, emergency hysterectomy and d blood transfusion that may infect the mother with HIV or hepatitis. Other complications of elective Cesareans are wound infections, other antibiotic-resistant infections, medication errors, drug reactions, anesthetic accidents, surgical mistakes such as inadvertently cutting into the bladder or bowel, severing a uterine artery, accidentally tying off a ureter, surgical laceration of baby, neonatal respiratory distress and nosocomial (hospital-based) infection. (Gabbe, 1991)
And yet the VBAC study and subsequent news reports failed to mention the vast increase in placenta previa and abnormally adherent placenta in subsequent pregnancies that plague post-cesarean mothers. For example, the actress Madonna had a non-emergency Cesarean in her first pregnancy, followed by a placenta previa and emergency CS the next time. The risk of these potentially fatal problems increases with each CS, until it is a staggering 25% for a fourth post-Cesarean pregnancy. In its worst form – placenta percreta – it is fatal to 10% of mothers, even in the best of hospitals. Researcher on the topic report that: “Given the known association between placenta previa and placenta accreta / percreta, it is not unreasonable to suggest that the increased cesarean delivery rate has directly contributed to the rising incidence of placenta accreta / percreta.”
In addition to maternal complications, there are serious health problems for post-cesarean babies not measured by this study, such as iatragenic prematurity and respiratory distress. Elective repeat Cesareans have a fetal mortality of 2 to 3 per 100 operations (2. Obstetrics: Normal and Problem Pregnancies Gabbe, 1991) An example of long-term health hazards was found in a recent study done in the UK which identified that being born by Cesarean triples the risk of adult asthma. (3. Journal of Allergy & Clinical Immunology 107[4[:732-33, 2001) Another factor is the detrimental impact on the mother-child relationship from an increase in postpartum depression (PPD) and post-traumatic stress symptoms associated with operative deliveries. PPD is more common and more sever after the added stress of a Cesarean or other operative delivery and when a baby is premature or must be in the intensive care nursery after the birth. (22. Predictors, prodromes and incidence of postpartum depression. Obstet Gynaecol 2001 Jun)
