Brave New World of Evidence-based Maternity Care ~ Chapter 6

by faithgibson on September 8, 2013

Chapter 6

~ The Scientific principles of Evidence-based health care and medical practice ~

faith gibson, LM (2005)

In regard to public safety, health and medical care, the bedrock of scientific theory is that those who wishes to introduce change into the system or substitute an artificial process or product for a naturally occurring one must prove, up front, that the proposed change is useful, that it is not harmful or dangerous and represents some form of improvement or advantage that one could describe as “value added”. The basic idea is that the burden of proof falls on those who develop a new product or process to establish its merits before they can claim its superiority.

For example, if you want to convince people that “Round-up” weed killer is better than bending over and pulling weeds by hand, you must at least prove that chemicals in your product, when properly used, will not kill the gardener, his family, their pets or poison the water or future vegetable crops. Once its promoters are able to establish its ‘safety’, it is left up to each individual to choose whether pulling weed is sufficiently onerous to make chemical ablation preferable. Another factor is the idea “superiority” of the new is one’s personal relationship with the issue of ‘cost-benefit ratio’ — the fully informed individual is free to decide whether they are willing to pay the price and take the risks.

In regard to “normal life” – our health and normal bodily functions such as eating, drinking, sex, conception, pregnancy, childbirth, breastfeeding, childrearing practices, etc — society normally holds the bar of “proof” quite high, requiring those who wish to introduce change, particularly changes that have an added economic cost or potentially dangerous substances, to prove necessity, safety and cost-effectiveness. An example of this idea is the drug approval process used by the Federal Drugs Administration (FDA), in which both safety and efficacy (effectiveness and favorable cost-benefit ratio) if factored in to whether or not a drug gets approval to be marketed.

Topics for this type of scientific scrutiny includes the conventional manner that biological functions are treated, such as public methods of sanitation and regulation of facilities like public bathrooms, restaurant kitchens, swimming pools, hospitals and nursing homes. In general governments recognize that it is unwise and sometimes harmful to use an unnaturally large share of finite resources or make something personally expensive that is otherwise free, natural or easy. For example, were the manufacturers of urinary bladder catheters to claim that their products represented a “modern” improvement to normal voiding we would be quite incredulous and demand proof.  In that regard we would all come from the “show me” state of Missouri.

Of course, there is not a shred of scientific proof that the cost of sterile catheter sets or the experience of attempting to use such a product that must be kept scrupulously sterile for self-catheterization 6 or more times a day is somehow easier or better than just going to the bathroom to empty the bladder normally. But more to the point, studies of catheterization reveal that approximately one out of every 100 times this sterile procedure is done, a bladder infection result, usually requiring antibiotic treatment. A small fraction of all bladder infections are resistant to these drugs or for other reasons result in a kidney infection (pyelonephritis), which is far more serious than simple cystitis. A small number of kidney infection also become resistant to antibiotics or side effects of the drugs trigger other problems that result in kidney failure or liver damage. Without dialysis or a kidney transplant, the unwitting victims will die of supposedly benign treatments originally described as “safe, simple” and “minor” medical procedures.

A slightly less extreme example can be make for the scientific duty of artificial baby formula manufactures in regard to promoting their product as a substitute for breast milk — a product that incidentally interferes with the bonding and breastfeeding relationships between mother and baby. Even baby formulas containers include a statement (somewhat similar to the one on the side of a pack of cigarettes) that informs parents that breastfeeding is, scientifically speaking, best for their baby and their artificial baby formula is for woman who cannot or do not want to breastfeed or to supplement when the nursing mother is unable to feed her baby.

This same scientifically mandated “burden of proof” applies to the entire premise of obstetrical care for healthy women with essentially healthy pregnancies. In particular, proof of efficacy has never been established for obstetrical routines, techniques and procedures such as bed rest, prone postures, IVs, restriction of oral fluids and food, EFM, labor induction, delivery while the mother is lying on her back, Cesarean surgery and pharmaceutical products such as narcotic drugs, labor accelerating hormones (Cytotec and prostaglandins), and obstetrical instruments such as forceps and vacuum extractors.

Historically this “burden of proof” as applied to medicine was known as “positivism” and is one of the foundational principles of the Scientific Age (cite Cry and the Covenant). Individuals holding or wishing to promote a particular theory were required to prove the validity of their theories on objective grounds. In the “big picture” of maternity care for a healthy population, it would be necessary to evaluate the overall necessity and safety of obstetrician management versus physiological management. In the small picture is the need to look at each and every procedure and products to determine its direct safety and the potential for their use to lead to a cascade of complications. This burden of scientific proof cannot be met for the routine medicalization of normal birth any more than for the routine medicalization of bladder function, as each of these interventions introduces unnecessary and unnatural risk when applied to healthy women with normal pregnancies.

A very small example of the problem associated with what appears to be ‘minor’ interventions is the association between epidural anesthesia and bladder infections. Most women with an epidural are not able to spontaneously empty their bladder because they have lost feeling in their lower body. They are also receiving large quantities of IV fluids to counteract the blood pressure lowering effects of the epidural drugs. So the majority of anesthetized women require urinary bladder catheterization. Sometimes are given what is called an indwelling or “Foley” catheter that is left in place during the many hours of labor and even while the mother is pushing (a practice that can damage the mother’s urethra). At a minimum, 1% of these mothers will develop a bladder infection during the postpartum; a few will wind up with a kidney infection and the potential for all the other complications that are associated with pyelonephritis.

However Foley catheterization is not the only danger the mother will be exposed to, as each increment of intervention has the potential to trigger a cascade of complications. In addition to the rubber urinary catheter, she will also have an small plastic epidural catheter taped to the her back, an automatic blood pressure cuff that goes off automatically every 15 minutes. In many hospitals, she will also have a pulse oximetry devise on one of her fingers. There are usually two intravenous lines (the second for Pitocin which is a frequent accompaniment of epidural anesthesia), two external EFM belts (or an internal fetal monitor leads and sometimes, even a uterine pressure catheter) and of course, the Foley catheter and its bag clamped to the lower side of the bed. Entanglement in this massive quantity of equipment (8 wire leads and plastic tubes) that effectively chain the mother to the bed and frequently result in her lying prone and immobilized for most of the hours she is in labor. According to the obstetrical profession, however, none of this interferes with the natural function of the pregnant uterus or ‘spontaneous’ nature of childbearing – at least not in their minds. The opinion of mothers might well be different, especially if those who finds themselves in the unlucky 30% of healthy women who wind up with operative deliveries – forceps, VE or Cesarean surgery.

Pharmaceutical and mechanical interventions do provide a way for physicians to control the interaction between themselves and the mother as well as the timing and the manner and circumstance of normal birth. Our 20th century technological society has been having a romance with control with over our biology  –  a natural desire to reduce the unexpected and inconvenient. We firmly believe that our superior intellect and the superb technological capacity of the US makes it possible to control everyone and everything, that we positively deserve to be in control, particularly over our own normal biology. Over the course of the last 100 years, that propensity to control bodily functions has included the use of various drugs on a routine or casual basis to manipulate bodily functions.

In the early 1900s the idea of controlling normal bowel function through the use of laxative was very popular. Eventually a public education campaign was undertaken to disabuse the public of the notion that laxatives were an “improvement” and teach that an appropriate diet and drinking water was safer and better than drug dependency. There was a period of time when the casual use of prescribed sleeping pills was very “in”. Eventually the down-side of their use became apparent, which was disturbed sleep patterns in which the deep dreaming phase of sleep (responsible for feeling refreshed the next morning) was missing. These problems spawned a public re-education campaign exposing the dangers of barbiturate use.

For a while women were instructed that a proper lady must douche after a menstrual period and more often if she wished to be fastidious or welcomed into polite company – also a notion that was without merit and caused many unintended side effects. Many Americans have sought out aphrodisiacs of various kinds and now we have the dubious benefits of Viagra available to the male populations. And of course, the control of appetite and eating is our biggest favorite with various prescription and OTC diet pills abounding. With the possible exception of Viagra, virtually all these medicinal interventions designed to manipulation of normal bodily function has been debunked, at least among the more well informed public.

Historically speaking, obstetricians also have been having a romance with control. In particular, they have long desired to have total control over the physical act of childbirth through the use of labor stimulating drugs and narcotics so that the mother could better tolerate other surgical interventions such as instrumental delivery and manual removal of the placenta. The obstetrical profession has always seen itself as revolutionary and responsible for defining all aspects of pregnancy and birth care, including the politics of childbearing and our national maternity care policy. A historical example of this is a quote from the February 23, 1911 edition of the Boston Medical and Surgical Journal, page 261]

We believe it to be the duty and privilege of the medical profession of American to safeguard the health of the people; 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”

What we must first do is arouse public sentiment and first of all we must have the enthusiastic support and united action of the medical fraternity…. We feel that the most important change should be in the laws governing the registration of births. The word “midwife” as it occurs, should be at once erased from the statute books. … [Boston Medical and Surgical Journal, Feb. 23, 1911, page 261]

The Constitutional Nature of Obstetrics: One could say that the obstetrical profession felt a certain divine appointment as if their “right” to control dominate and monopolize all things related to childbearing and  maternity care was constitutionally established.

According to obstetrical folklore:

“We hold these Truths to be self-evident:

That normal birth is abnormal and dangerous

That doctors and hospitals make normally abnormal birth safer

That the intrinsically pathological nature of birth routinely requires the skills
of a surgical specialist and the use of drugs and anesthesia

That healthy women cannot cope with normal labor

That normal birth is too painful to occur without anesthesia

That midwives are naturally inadequate to handle normal birth

That the care of midwives introduces additional and unnecessary dangers

That midwifery care is inherently unsafe because it prevents women from being cared for by an obstetrician”

Obstetrics for Healthy Woman – Value Added or Value Subtracted?

Historically, the obstetrical profession established itself as ”value added” over what had traditionally preceded it, which was midwifery as an organized profession or vocation.  Before anyone can thoughtfully examine the merits of their claim to superior abilities, one must first define the foundational “value” of midwifery as the standard for maternity care to which obstetrics becomes the “added” quality.

Midwifery has traditionally been a combination of services relative to both childbearing and childrearing. The mother’s physical safety was addressed through prenatal care, one-on-one labor and birth management. The ‘soft’ side of birth services include providing the emotional and social services so central to the development tasks of childbearing women. Meeting these “soft” needs, which addressed the quality of motherhood itself, are built into the midwifery model of care. The midwife’s role included ‘mothering the mother’ so that the mother was empowered to better ‘baby the baby’. This included the provision of “comfort measures” during labor, help with the new baby, preparing or serving food and drink, helping with personal hygiene and bodily function (such as perineal care, getting the mother up to go to the bathroom and changing soiled linens) and educating the mother about milk production, breastfeeding, newborn care (diapering, dressing and bathing the baby), normal child development and when to seek out healthcare services or emergency medical care relative to her or her baby’s well being.

Midwifing as a verb was an extension of mothering and practiced mostly by older women who were experienced mothers themselves. They were pleased to be able to contribute the benefits of their personal experience back into the system by becoming a professional caregiver later on, after having raised a family. At this point, the average midwife has developed a depth and breadth of mother-friendly abilities that are of great cultural value. Her ability to bring to these services to other women and families during the childbearing years is at the heart of the art of midwifery.

Obstetrical version of “value-added” was, from the start, only half a loaf. Doctors immediately jettisoned all professional responsibility for “soft” services – the intimate personal care of the mother during the long hours of labor and care of her and the baby after the birth. These “soft” or feminine services were considered to be beneath the dignity of a male doctor, as well as a waste of a medical education. When faced with patients in need of this type of care, obstetricians enlisted other “helpers” to provide the nursing/caregiving aspects of midwifery during labor and the postpartum period. Nurses and other para-professionals were employed to assist the mother with all aspects of recovering from childbirth, establishing breastfeeding and care of herself and the new baby.

This paved the way for doctors to focus solely on “adding value” to the medical management of pregnancy and the last few minutes of labor, delivery of the baby and placenta. It is immediately clear that this is a very diminished version of ‘maternity’ care. In a simple contrast between the two systems, obstetrics would come off badly, as the services they provide would have to be augmented by many other assistants and members of other professions. Reduced to “face time” their contributions would seem trivial. This certainly would not be economically competitive, were it seen as a comparison of “like with like” – obstetrician versus midwife as equal provider of normal childbirth services.

However, the official strategy of organized medicine was to unilaterally change the definition of childbirth, thus eliminating the idea that childbirth was a normal aspect of healthy biology and thereby eliminating any basis of comparison between the two professions. During this same period of history, childbirth was seen by the public and by midwives as a normal biological process. This continues to be one of the officially unique aspects of midwifery as compared to obstetrics. The Maternity Center of New York, an organization that has been providing nurse midwifery services for more than 80 years, still uses the fundamental definition of childbirth as a “normal biological process” and not one benefiting from routine medical interventions. Midwives and most mothers saw the arduous aspect of labor and birth as having value in their own right and as contributing to the overall well being of the mother and baby. These biological processes were expected to occur “unaided by steel or brawn” (cite Alan Gutenbacher  book, 1937) unless a problem or complication arise that signaled the need for external help, in which case the obstetrician’s specialized surgical skills were solicited and appreciated.

Organized medicine formally turned this historical relationship upside down and backwards –  characterizing childbirth as intrinsically pathological and dangerous and requiring the skill of a surgeon. This medical model as generated in the early decades of the 20th century redefined pregnancy as a “nine-month sickness requiring a surgical solution”. In 1911 a well-known obstetrician stated: “For the sake of the lay members who may not be familiar with modern obstetric procedures, it may be informing to say that care furnished during childbirth *is now considered, in intelligent communities, a surgical procedure.” [1911-D, p. 214]. *emphasis added

In 1915, another famous obstetrician (Dr Joseph DeLee), incorporated a remark by a 19th century ethnographer of childbirth in primitive cultures (Engelman) in his own comments: “ ‘The parturient (i.e., laboring woman) suffers under the old prejudice that labor is a physiologic act,’ and the profession entertains the same prejudice, while as a matter of fact, obstetrics has great pathologic dignity —it is a major science, of the same rank as surgery”. [1915-C; De Lee MD p. 116]

In contemporary obstetrical parlance, this idea is restated as “birth is only normal in retrospect”. One of the major advantages of this notion is that it keeps the obstetrical profession from having to provide any personal care to the mother or assume any responsibility for the social dimension of childbearing – it redraws the lines of professional responsibility to the realm of high-tech medicine, confined primarily to a focus on the fetus and the delivery rather than either the mother or newborn baby once the delivery is completed. It also confuses the idea of obstetrics as “value-added” to the traditional childbirth services of midwifery, as it is no longer a comparison of “like with like”. By rejecting the whole idea of ‘normal’ (“birth is only normal in retrospect”) it obfuscates and confounds any outside examination of relative quality of care.

Like nuclear scientists and Federal Reserve chairman Alan Greenspan, these areas are portrayed as too complex and technical for ordinary folks to understand. Obstetricians insist that the lay public just doesn’t realize all the things that can go wrong. They are quite convinced that the public doesn’t appreciate how hard doctors must work to keep mothers and babies from being damaged or dying from what obstetricians describe as the “frequent and sudden disasters” that routinely befall “even the most normal of labors or births”. For the last 90 years the obstetrical profession has promoted the idea that all the problems of unpredictable Mother Nature (i.e., the flawed biology of the childbearing women) could and would be successfully eclipsed by “modern” obstetrical care. The implied (and sometimes stated) concept was that employment of a surgically skilled obstetrical specialist – that is an obstetrician and ONLY an obstetrician — was a virtual guarantee of a “good outcome”. This resulted in a biased presentation of the need for and value of obstetrical services for healthy women. Unfortunately, the claim to god-like powers also gave rise to a host of unrealistic (and unrealized) promises which only added to the likelihood of malpractice litigation, a nightmare come to roast in the last 25 years.

The fallacious idea of obstetrical surgeons snatching healthy women and their unborn or newborn babies back from the jaws of death permitted the obstetrical profession to side-step the issue of whether or not its standard (i.e., unscientific) management of normal birth is, in actual fact, as safe or “efficacious” as that of non-obstetrician maternity caregivers – general practitioner MDs, family-practice doctors and professionally licensed midwives. Most important, the fiction of obstetrical practice for healthy women as “value-added” continues to allow the obstetrical profession to charge extra for their pregnancy and birth services, just as the brain surgeon or cardiac specialist charges are higher than GPs or nurse practitioners. The myth of “value-added” services is all based on the idea that pregnancy and birth related services as provided by obstetricians to healthy women improved outcomes, was safer, was more technically complex, and more satisfactory to its recipients – than care as provided by non obstetricians, especially that of professional midwives.

This permits “creative” bookkeeping – that is, the quality of deceptive accounting methods, recently made infamous by the firm of Author Anderson — in which information that is clearly detrimental is moved to the other side of the ledger and reported as a positive factor. Obstetrical sources (such as research published in peer-reviewed journals) consistently replace the simple reporting and honest accounting on such topics as spontaneous vaginal birth rate for healthy women under obstetrical management, Cesarean rates for OBs, GPs and midwives, the safety, long term side effects and cost-effectiveness of the dozen or so routine interventions (bed rest, IVs, ARM, electronic fetal monitoring, Cytotec use, elective induction, routine acceleration of labors, epidural anesthesia, episiotomy, vacuum extraction, etc) by not counting the things that actually “count” most – the falling rates of spontaneous vaginal birth and increasing need to use other medical and surgical treatments. This failure to mention what counts most is matched by counting the secondary or irrelevant issues in double digits (such as legal protection for the physician or reduced costs to the HMO).

A minor example of this “cooking the books” is an obstetrical study by on the relative benefit of “permitting” hospitalized women to walk during labor versus women who received the typical or “standard” hospital bed rest. It would seem that this research was an attempt to prove that midwifery management, which uses the upright and mobile mother as a mainstay of maintaining a spontaneously progressing labor, was all wrong. In the study the supposedly “walking” group of mothers in fact walked less than 50 feet over the course of their entire labor, as contrasted with the bed rest mothers that walked less than 25 feet. When women walk as a part of physiological management they are often on their feet and moving about during labor for many hours and typically walk more a ½ mile or so, sometimes as much as a mile or even two. Despite the fact that this obstetrical study did not actually contrast “like with like”, it was published with great fanfare as the “final” authority on the topic. According to its author, the issue had been decided once and for all by “debunking” the myth that walking during labor was helpful or made any difference at all as their study found no statistically significant difference in the rate of progress in labor or spontaneous births between the two groups.

A great deal of contemporary obstetrical medicine is organized around and devoted to concealing the incongruity between the idealized goals of “value-added” services in the form of greater safety and realistic reality of what obstetrical management actually does, which is the routine recommendation of a host of techniques and procedures that obviously introduce unnatural risks – often the very ones supposedly reduced by that very medical procedure. An example that comes instantly to mind is the routine use of continuous electronic fetal monitoring (EFM) to as a strategy to prevent fetal distress but which ignores (ig-nore — to not-know what is known) the deleterious effect of anti-gravitational positions its use entails and the total disruption of any opportunity for non-drug dependent pain management when continuous EFM is used. It is well established that when the mother is confined to bed in a prone position (lying down) this can be expected to interferes with blood circulation to the uterus. This creates or acerbates fetal distress and the need for emergency cesarean section, which a gift that “keeps on giving”, as the unborn baby in the next or “post-cesarean” pregnancy now becomes vulnerable to fetal distress resulting from uterine rupture – all in the name of reducing fetal distress via the wonders of continuous electronic fetal monitoring.

However, not even the obstetrical profession has been able to hermetically seal the border of our country or our minds from the world-wide realities of other, older health care systems that do not share this notion of birth as inherently pathological. Countries with the very best maternal-infant outcomes have been successfully providing safe maternity care, some for as long as 200 years, that was based on the midwifery model of physiological management. Whether from historical or contemporary sources, a scientific inquiry of safety in childbirth always documents the efficiency of normalizing labor and birth and minimizing the use of medical or surgical interventions. Studies that contrast specialist physician care versus professional midwives always favors the midwife. Studies that examine the relative safety of the co-management of doctors and midwives versus midwife-only care again favor the midwife as the solo primary caregiver.

Recognizing this immutable truism permits us to returns to the legitimate question, “can the obstetrical profession document that its typical ministrations to healthy women with normal pregnancies and spontaneous labor and births actually has ‘added-value’ over and above either professional midwifery care or an unattended birth?”  One must look at direct and indirect expenses (the cost of medical education plus maintaining institutions able to provided intensive care nursing) and examine the quality of the care provided – does it meet both the biological needs (such as right use of gravity) and the emotional and social needs of the new mother and her necessity to take on the expansive role of motherhood and to learn both parent craft as well as being supported in her efforts to maintain stable and satisfying relationships with her spouse and other family members.

For healthy women with normal pregnancies who do not want or need labor inducing or accelerating drugs, narcotics pain medications, anesthesia or operative delivery, the “standard” obstetrical care is value-subtracted from the Midwifery Model of Care.