Posted by: emjb | November 25, 2006

Scenes from a class struggle

The two classes in question; midwives and OBs. They have a history of opposition from the earliest days of the invention of obstetrics, when men first began to enter the realm of birth, and targeted the women who were already serving there as their enemies and competition. 19th century ob’s ran the midwives mostly out of business, and set back our knowledge of birth and labor by refusing to record or learn from centuries of knowledge that those midwives had accumulated. A loss all women who give birth suffer from today.

The latest salvo, via Home Birth Talk’s blog; the American College of Obstetrics and Gyneocologists issues a stern reprimand to those who dare to think birth can be safe outside a hospital setting (i.e., one where they are getting paid):

ACOG Statement of Policy
As issued by the ACOG Executive Board

OUT-OF-HOSPITAL BIRTHS IN THE UNITED STATES

Labor and delivery is a physiologic process that most women experience without complications. Ongoing surveillance of the mother and fetus is essential because serious intrapartum complications may arise with little or no warning, even in low risk pregnancies. In some of these instances, the availability of expertise and interventions on .an urgent or emergent basis may be life-saving for the mother, the fetus or the newborn and may reduce the likelihood of an adverse outcome. For these reasons, the American College of Obstetricians and Gynecologists (ACOG) believes that the hospital, including a birthing center within a hospital complex, that conforms to the standards outlined by American Academy of Pediatrics and ACOG,1 is the safest setting for labor, delivery, and the immediate postpartum period. ACOG also strongly supports providing conditions that will improve the birthing experience for women and their families without compromising safety.

Studies comparing the safety and outcome of U.S. births in the hospital with those occurring in other settings are limited and have not been scientifically rigorous.* The development of well-designed research studies of sufficient size, prepared in consultation with obstetric departments and approved by institutional review boards, might clarify the comparative safety of births in different settings. Until the results of such studies are convincing, ACOG strongly opposes out-of-hospital births. Although ACOG acknowledges a woman’s right to make informed decisions regarding her delivery, ACOG does not support programs or individuals that advocate for or who provide out-of-hospital births.

1American Academy of Pediatrics and American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care, 5th Edition. Elk Grove Village, IL, AAP/ACOG, 2002.

*emphasis added

In response, the American College of Nurse Midwives cites their position on homebirth, referencing 28 citations from supportive studies about positive homebirth outcomes. Exactly how “rigorous” does the ACOG need study of this topic to get?

But of course, it’s not about evidence; it’s about money and control of the highly lucrative birth market. According to the CDC’s estimate, in 2005 4,140,419 live births took place in the United States. The cesarean rate rose 4 percent to 30.2 percent of all births.

30% of 4 million plus is a lot of operations, and a lot of employment for surgeons. If the c/section rate were to decline to the 10% recommended by the WHO…what would all those surgeons do for a living? How would they use their expensive skills?

I have to say this a lot: I don’t believe doctors are evil, OBs or any other kind. But even good people can be trained and coerced into doing unethical things. Often, to do the right thing is to risk your job. It is going to take pressure from outside, as well as from good people within, to change things.

Our system does not reward preventative, evidence-based medicine that can be peformed by midlevel professionals like midwives; it rewards expensive, emergency procedures requiring specialists with lots of fancy equipment and prescriptions for the complications afterward. Not just in birth, but everywhere. Health is not profitable, but chronic illness can be. Unless you count the well being of patients as more important than profit, which happens less and less.

I think this bias has severely skewed the system, and skewed the people forced to work under it, until “do no harm” is far less important than “protect your job and do more tests in case you get sued.” And partly it’s the lawyers’ faults, sure; but lawyers are responding to a need created by the system itself, for patients to regain some control over what happens to them inside it. Currently, they have almost none. They turn to lawyers because the healthcare system has stopped listening to them at all.

Anyway, a far more succint summation of this struggle can be found in this 2002 article from Midwifery Today magazine. I particularly found her information about conflicting presentation of evidence in the New England Journal of Medicine very interesting.

In the July 2001 issue was a study on vaginal births after cesareans (VBACs) that showed that the risk of uterine rupture (the complication that OBs usually cite when refusing to do VBACs) women faced climbed dramatically when hospitals used prostaglandin to induce labor–but otherwise remained nearly as low as for a woman who’d never had a c/section.

The writer mentions wryly that an unbiased observer might then conclude a) don’t use prostaglandins on VBACs, and b) try to avoid those first cesareans at all, so as to reduce uterine rupture rates. Instead, the editorial accompanying the article castigated those who supported VBAC and made the case for “once a c/section always a c/section” despite the risk of surgical complications that far outweighed those of uterine VBAC rupture. The press, of course, mostly reported on the editorial’s message, and many hospitals have stopped doing VBACs at all in the years since.

There are more chilling bits further down in the article about the twisting of birth studies to support more and more interventions in birth regardless of the increased potential for complications…and inevitably, lives lost due to those complications.

Which means that for some women out there, this class struggle isn’t about privilege or autonomy…it could be the difference between life and death.

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Responses

  1. Open your mind please. THIS is why you shouldn’t birth at home: http://www.mothering.com/discussions/showthread.php?t=5678

  2. Ugh. Wrong link. Here: http://www.mothering.com/discussions/showthread.php?t=567839

  3. Hmm, Megan. Are you saying that no woman ever lost a child during a hospital birth? I am very sorry for this mama’s loss; there are no words that can make up for it. But it could have happened in a hospital; in fact it does, every day. There was no detail in her post as to cause of death–if it was a trapped umbilical cord cutting off the baby’s oxygen, that can happen at a point too late in labor for a c/section to occur–leading to a bad outcome wherever the mama is.

    The point is, I don’t know what happened, and neither do you. And studies–good studies–show that overall risk rates for healthy moms attended by midwives are just as good at home as at the hospital.

    There are no guarantees; we all gamble every time we give birth. The answer is not being imprisoned in a hospital, but more resources focused on diagnosing and preventing bad outcomes, instead of just relying on a c/section crutch–which doesn’t always work, by the way.

  4. Megan, thank you for the link to Mothering.com. However sad it is, it is only a testimony to the safety (or unsafety as it were) of UNATTENDED home birth. It is a very sad story and perhaps if the midwife for this woman had been called the outcome might be very different. We’ll never know.

    Thank you for the reminder to open our minds. Perhaps you should do the same!

    Thank you for the reference to Home Birth Talk, Grabapple! 🙂

  5. Megan, it sounds like you should birth in the hospital. Please don’t presume that one story with an undesired outcome is the be-all and end-all of the argument for the rest of us. if you were to frequent the MDC discussion boards or otherwise research birth issues beyond reading ACOG’s guide to pregnancy and their lapdog, WTEWYE, you might come to understand how it is that the hospital environment and routine management of birth creates dysfunction in birth. It is one thing to seek out safe conditions in birth, it is another to pay the price of dysfunction in exchange for that “safety”.

    The fact is that deaths happen at home and in the hospital, and it is naive to assume that all deaths that happen at home could have been prevented in hospital, and that all deaths that happen in hospital were unpreventable. I know that story you linked to. I also know of another story at MDC that was a hospital death, likely due to routine management of labor. I have lost count of the stories of women and babies who have been hurt and damaged by the medical establishment’s abominable lack of scientific understanding of physiological birth and what facilitates and interferes with its normality. By your process of reasoning (i.e., if a harm is known to have occurred in a certain setting, that setting is inherently unsafe for all women) then I guess I could conclude that no women should ever give birth in a hospital. I don’t conclude that, though, because I understand the flaw in that reasoning, namely that different women have different needs that are best served under different conditions. Even so, there are still no guarantees, no matter what choice one makes.

    In terms of numbers, ACOG is being intellectually dishonest. Matched-population studies show that mortality rates between midwife-attended homebirth and hospital birth are pretty much the same, and that complication rates in homebirth are significantly lower. Further, the one study that has showed a difference in mortality rate was not a matched-population study and had other serious flaws, as the study authors were candid about. It does not inspire trust that ACOG would laud such a study over the many that show homebirth to be a reasonable and even ideal choice for most women. The only way it could possibly make sense would be for there to be some conflict of interest, i.e., the good doctors’ need to protect their standard of living.

    Regarding unattended homebirth, the same arguments hold. There are benefits and risks to all choices, and the balance of these are going to be different in each situation. There is NO type of choice in which the risks always outweigh the benefits, and no type of choice in which the benefits always outweigh the risks. There are always going to be stories in which a mother would have been better off with an attendant, and stories in which a mother would have been better off without an attendant. The logically most reasonable choice is never going to be obtained by applying generalizations to individuals.


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