Wrong Use of Obstetrics – Cornucopia of topics ** Drs. Pohlman & Macer, physiological billing code, “Pit to distress”
The most Profound Change in
Normal Childbirth Practices in the History
of the human species
Bottom line: Returning Obstetrics to its proper historical place
as a surgical discipline devoted to treating serious complications
NOTE: The follow historical information is not meant to denigrate or undermine the contemporary practice of obstetrics or diminish the value of the obstetrical profession’s contributions to making childbirth safer for women with high risk pregnancies, who develop complications, experience an obstetrical emergency, need an operative delivery, or require ongoing treatment for women’s reproductive issues.
Speaking as a former L&D nurse, currently a community midwife, a spokesperson for childbearing parents and the wider midwifery community, we are all, myself included, are profoundly grateful for the life-saving skills of American obstetricians.
This is an academic and synoptic version for midwifery-related “insiders” and not directly suitable for the popular press
As a young bride, I benefited greatly from the art and science of obstetrics and gynecology. Without the diagnostic and surgical abilities of a wonderfully compassionate obstetrician-gynecologist, I would never have been able to have a family.
Thanks to the diagnostic skills of Dr Louis Pohlman, and the gynecological surgery techniques developed by modern medicine to treat “polycystic ovaries”, he was able to fix my infertility problem and also provide obstetrical care during my first pregnancy. I now have three healthy adult children and two wonderful grandsons, one of whom recently graduated from medical school. I continue to be profoundly grateful and want to see the obstetrical profession to thrive as a noble undertaking.
20th Century American Obstetrics ~ newer, not better!
Unfortunate, the history of American obstetrics in the first half of the 20th century was a dysfunctional system of obstetrical interventions. Its new and intensely interventive “standard of care” applied universally to healthy childbearing women as well as those with medical problems and obstetrical complications. Doctors ordered nurses to medicate all labor patients with the Twilight Sleep drugs scopolamine and morphine. When the baby was about to be born, their obstetrical protocols mandated the routine use general anesthesia, episiotomy, forceps deliveries and manual removal of the placenta.
The predictable result was a very high rate of stillbirths and deaths of newborn babies from the narcotics and chloroform anesthesia given to its mother, and fatal hemorrhages and infections that killed their mothers. This acts of needless interventions and invasive procedures were responsible for the Unites States having one of the highest maternal mortality rate of all industrialized countries.
This massive quality of bodily interventions would be dangerous today with access to broad-spectrum antibiotics, intensive care units and and life-saving technologies. But we are talking about a dozen or so unnecessary invasive procedures forced on a healthy population without any informed consent during a pre-antibiotic era of human history. As a result infection following childbirth annually killed 10,000 newly-delivered American mothers every year from 1900 to 1937. That is the year that sulfa, which is very the first antimicrobial drug became available in America.
During this period, the maternal mortality rate (MMR) in the US was 2 to 5 times higher than Western Europe, which had been using a midwifery-centric system for more than two centuries. European midwives were professionally trained in state-run schools. After graduation they attended all normal births and enjoyed a mutually complementary relationship in which the general practice physician in the district provided medical back up and received transfers of care.
Modern Obstetrics ~ doing more of what doesn’t work, never learning from mistakes, never saying “sorry”, never promising to stop using harmful practices!
The contemporary problems of the American obstetrical profession are very different than those of a hundred years ago. While the interventions are dramatically different, the current practice of obstetrics is just as routinely interventive as obstetricians in 1910. The idea that more of what wasn’t working all that well (as evidenced by having one of the highest maternal mortality rates) seemed to keep obstetricians entranced by the idea of doubling down, doing more interventions and/or doing them ever earlier in the course of events, the motto being “If at first you don’t succeed, just try, try again!”
In 1910, the Wrong Use of Obstetrics became the new American standard of care and a hundred years later this inappropriately interventive model is still ruling obstetrical practice in America!
In spite of my gratitude for Dr. Pohlman’s surgical skills, I take issue with an American standard of care that continues to ignore the well-known dangers associated with the routine use of obstetrical intervention in the labors and births of a healthy childbearing population (>70% of all births in the US). As a matter of policy, obstetrical departments all over American are still unnecessarily and routinely medicalizes normal labor and birth in healthy women with normal pregnancies. Every labor patient is hooked up to an electronic fetal monitor as soon as she walks in the door of the labor room. Over half of all labor patients are given Pitocin IVs to induce or speed up a normal labor.
A report on hospital obstetrics in America published in Wall Street Journal found that some hospitals routinely use a practice described as “Pit to Distress“. This is an obstetrical department policy in which virtually all labor patients have Pitocin IV started when they are admitted, and then the number of drops per minute is repeatedly increased until the mother either delivers vaginally or the baby goes into fetal distress and an emergency C-section is done.
Nice work if you can get it, but I sure wouldn’t want to be an L&D nurse in hospital that had institutionalized a criminal practice as their definition of ‘business as usual’. Patients in these hospital should keep their attorney’s number on speed dial!
I wonder how many of them have children damaged by these dangerous practices that they never consented to and for the most part did not realize were being used on them.
What is even more disturbing is that the obstetrical profession keeps encouraging and advocating for this kind of maximum interference under the false flag of “greater safety”. For many obstetricians in AOCG’s the policy-making committees, the answer is always more interventions and to plan their use earlier in the pregnancy — elective CS at the end of the 38th week, then induce everyone that is left during 39th week — basically before the baby’s due date. Surely under those circumstances, no one could possibly sue you for not having intervened as early or as much as “possible”. Maybe we should just have lawyers delivery babies!
As a result of too much intervention in the labors and birth of healthy women and too few life-saving obstetrical services available to women (often low-income) whose lives depend on scarce but desperately needed interventions, the US ranks 128th (out of 183 countries) in maternal deaths. Healthy laboring women are safer having a baby in Uruguay, Tajikistan, Saudi Arabia, Russia, Iran, Albania, Bahrain, Chile, Hungary, Kuwait, Korea-South, Kazakhstan, Canada, Bulgaria, Bosnia-Herzegovina, Estonia, Qatar, New Zealand, Portugal, and Croatia that in the good ‘ole USA!
In addition to having the highest maternal mortality rates in the developed world, the US also has one of the highest Cesarean surgery rates, and an economic cost for maternity care that is orders-of-magnitude greater than the rest of the developed world.
Personally, I think higher costs and poorer results are nothing to be proud of!
During the recent years of Covid, and now in the post-Roe era where doctors are afraid to provide care to any woman who has a complication of pregnancy, the MMR for childbearing women in America has increased by a third and a that great increase is primarily maternal deaths in very low-income families, immigrants and women of color.
Obstetrics can and should be a noble profession. In those places where it currently is not, it needs to open itself up to the kind of historical, statistical, and evidence-based information provided in this series of essays and make the appropriate “adjustments” and policy changes.
As a wife, mother, former ER and L&D nurse and professional midwife, I can tell you with certainty that more of what isn’t working won’t work either.
After 120 years of promoting of the wrong use of obstetrics by systemizing and institutionalizing it as the American standard of care for healthy childbearing women, I can also say with certainty that the current and ever-increasing rates for inducing labor ever earlier in term pregnancies (i.e. before the baby’s due date), in concert with our already over-the-moon C-section, scandalous maternal mortality rate and sky-rocketing hospital bills for normal birth that have begun to rival those for an organ transplant and they all represent the wrong use of obstetrics.
This is not a workable plan for a better future or affordable healthcare system.
Obstetricians currently deny any professional responsibility for providing direct support or guidance to laboring women who prefer to avoid the standard obstetrical interventions of Pitocin and epidural anesthesia. But with very rare exceptions, obstetricians are not willing (or able) to be personally present or even make sure that one-on-one physiologically-based midwifery care is available to these mothers.
The obstetrical profession takes no responsibility for the mother’s experience during active labor. Helping the mother to cope with pain and strain of labor without resorting to medical interventions makes a big difference in her experience and can prevent a normal labor from turning into Cesarean surgery.
And yes its good that epidural anesthesia is available and it certainly can be a ‘god-send’ in certain unusual situations. Nonetheless, lying in bed for hours and hours with Pitocin is not the best “first option” mothers or their babies. As often acknowledged: “It’s not nice to fool Mother Nature“. When it comes to childbirth, if the mother can’t get up and move around, things are just not going to work the way Mother Nature intended. This always includes the “right use of gravity”, which means a laboring woman who is able to be upright and mobile for most of the labor.
Obstetrics in America is still about obstetricians & not healthy childbearing women!
Unfortunately obstetrics in America is all about obstetricians, obstetrical department policies and hospital attorneys, with little time or attention for the welfare of its childbearing patients beyond that they be able to pay their obstetrician and the hospital.
“How it’s supposed to be”, as defined by obstetrical profession, was clearly (and disturbingly!) identified by an obstetrician in a paper published the American Journal of Obstetrics and Gynecology: Macer, J. A. 1992:166:1690-7.
“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.”
Notice this obstetrician-author does not describe the role of the obstetrician as “helping” women in labor. Instead he only refers to the passive act of “observing” these labor patients as if they are an exotic species on display in a zoo. He sees spending time in the same room as his labor patient to a colossal waste of the obstetrician’s time and money (i.e. 12 years of medical school and hundreds of thousands of dollars to pay for his medical education), hence my claim that obstetrics is organized around the needs and desires of obstetricians instead of their childbearing patients.
A Critical Billing Code Problem ~ A code for “normal birth”
The United States desperately needs a new physiologically-based (non-surgical) billing code for care provide during a normal birth. Since the 1930s, when billing codes were first invented, childbirth has been classified as surgical procedure. As a result, the only way to bill for normal childbirth services in the US was to use a surgical billing code for the “surgical procedure” of “delivery”.
That means obstetricians have to bill for childbirth as a surgical procedure if he or she wants to get reimbursed for his time and talents. The obstetrician’s physical presence during many hours of labor, watching carefully and suggesting various ideas to make labor advance better might very well prevented the need for potentially dangerous surgical interventions such as forceps or Cesarean.
But our system of ‘sickness care’ doesn’t understand that the actual value of preventing health problems is a far better strategy, and so much less expensive (and more humane!) that waiting for people to get sick or injured and the treating them.
For the last century-plus, obstetrics has been a “sickness” discipline, having turned its back on “prevention”, which doesn’t pay anything. According to Egyptian hieroglyphics, midwives originated the very first “preventive” healthcare discipline over 5,000 years ago, pre-dating the scientific practice of medicine by a mere 4,000 years.
No wonder ACOG characterize midwives as “uppity women” and uniformly hate our guts!
However, a “preventive” activity such as the obstetrician’s physical presence could not be billed for because there was no billing code for “management of physiological labor”. As surgeons, obstetricians don’t “labor sit” since they can only be compensated for actively intervening in labor!
A very small change in this would be enormously helpful. We need a physiologically-based non-surgical billing code that would fairly reimburse physicians for their time and attention during the mother’s active labor. This simple modernization would provide better care during labor and help mothers avoid complications and operative deliveries, which makes it a “giant leap forward” for womankind!
A Rational Plan: Returning the surgical specialty of obstetrics to its historical role of treating complications and leaving normal childbirth in healthy women to professional midwives and family-practice physicians
The only logical plan, one I hope will be actively embraced by other Americans, is to rehabilitate the obstetrical discipline by returning the surgical specialty to its historically proper place – providing much needed life-saving care to women with high-risk pregnancies, those who develop complications, experience an obstetrical emergency, need an operative delivery or on-require going treatment for reproductive issues.
The goal is simple: Healthy childbearing women who do not want or need a medicalized labor should have unfettered access to a professional birth attendant who is trained and experience in the physiologic management of normal labor and birth.
High-quality, evidence-based, non-interventive and supportive care must be universally available to these women, irrespective of the category of professional birth attendant – obstetrician, family practice physician or professional midwife – and/or the location of the labor — hospital, birth center or planned home birth.
Now is the time to say good-bye to Dr. J. Whitridge Williams’ 1914 “Plan” for electively hospitalizing, drugging and massively intervening in the labors of healthy and wealthy childbearing women {insert link here} and start a new “21st century Plan”.
We must reverse or replace the many harmful decisions made in the 20th century a system organized around mother-baby-friendly, family centered care that includes the normalizing childbirth and providing access to professional midwifery care as a normal part of our mainstream maternity care system.
While this can and should be done, it won’t happen by magic. We have to expose the “Wrong Use of Obstetrics” for what is it — a terrible mistake to be exposed to the light of day, acknowledged, and then to be corrected by integrating the principles and practice of midwifery as a gender-neutral discipline that does care if its practitioners are OBs, family practice physicians, or professional midwives.
I recommend starting with the equivalent of a “Truth and Reconciliation Commission” such as the one used to reconcile historical racial segregation and punitive laws in South African and ongoing tensions between its politically dominate white population and its mostly disenfranchised black citizens.
As advocates and instruments of positive change, we must always remember that the reprehensible and century-long history of many detrimental obstetrical practice in America, that routinely used potentially fatal interventions as “business as usual” practices was done by people that died long ago.
We must not transfer our consternation about historic injustices to those obstetricians living now. Like us, they inherited a broken system, one that the AMA would like to perpetuate into eternity, but nonetheless, we can, we must, and we will eventually fix this problem. And in that brave new world, “midwifery” will no longer be the equivalent of a four-letter word, something that is meant to defame and thus triggers shame in us.
Starting right by starting early — Joint education of medical and midwifery students
To heal the nearly fatal split between obstetrical medicine and professional midwifery in the United States, we need the educational process for healthcare professionals — in particular, medical students and midwifery students — to sit side by side in the same classroom as they study the basic biology and physiology of female reproduction, and the normal physiology of spontaneous labor and birth. This should occur under the tutelage of wise professor who has hand-on experience with normal childbirth, therefore understands and respects childbearing in healthy women as a normal function of biology, one that does not need or benefit from routine obstetrical interventions.
And when these medical and midwifery students graduate and take their place in our health care system, they will speak the same language and both will have the same, sciences-based understanding of the normal biology of female reproduction. They will know that our job as maternity care providers is to trust and support the biological process by not interfering unless there is a significant medical need or the mother has requested the use of medical or surgical interventions.
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Identifying the Characteristics of Modern Maternity Care
for Healthy Women
with Normal Pregnancies
by Faith Gibson, LM
I ~ The fundamental purpose of maternity care is to protect and preserve the health of already healthy women.
II ~ For an essentially healthy population, the safest and most cost-effective form of maternity care is always the method that provides “maximal results with minimal interventions”.
This describes a beneficial ratio of interventions to outcomes for each childbearing woman.
III ~ Mastery in normal childbirth services means bringing about a good outcome without introducing any unnecessary harm or unproductive expense.
IV ~ The ideal maternity care system seeks out the point of balance where the skillful use of physiological management and adroit use of necessary medical interventions provides the best outcome with the fewest number of medical and surgical procedures and least expense to the healthcare system.
V ~ Maternity care in a healthy population is ultimately judged by its results — the number of mothers and babies who graduate from its ministrations as healthy, or healthier, than when they started.
