CCM Preamble to VBAC Statement: Part 1 ~ High CS rate & 50% hospitals ban VBACs: symptoms of an irrational maternity care system

This is a preamble to the
California College of Midwives’
formal statement on VBAC.

The high-profile need for VBAC services is a direct result of the high CS rate in the United States. VBAC has become particularly controversial because 50% of California hospitals ban VBACs; a large proportion of obstetrical practices refuse to provide obstetrical care for a normal vaginal birth after a previous Cesarean.

As spokesperson for the California College of Midwives, we see normal childbirth after a C-section as the tip of a huge and troubling iceberg in the realm of childbirth services in the US. The Cesarean-VBAC situation is just the most visible and well-documented aspect of a dysfunctional maternity care system — one that talks a good talk but doesn’t generally value vaginal birth, or provide appropriate & effective support for the spontaneous physiology of childbirth in healthy women.

Each decade of the 20th and 21st centuries has been accompanied by an ever increasing the level of obstetrical intervention that drastically expanded indications and dramatically lowered the bar for their use. As well-documented by statistics from the CDC,  induction and augmentation of labor in essentially healthy women and Cesarean delivery account for more than 50% of the care provided in hospital obstetrical units across the country.

In addition to the physical and emotional impact of surgical birth on the new mother and her family, these women bare a significantly increased risk of morbidity and mortality when compared to women who had vaginal births. For example, intra-operative and post-operative complications of Cesarean surgery include torrential hemorrhage and a 13-fold increase in emergency hysterectomies during or within two weeks of the C-section.

Post-operative mothers also face a longer and more difficult postpartum recovery, as well as an increased rate of admissions to the ICU immediately post-op and re-hospitalization after discharge. For the rest of their life, they will be at risk for delayed and downstream complications of their Cesarean surgery, (ex. bowel obstructions and secondary infertility), as well as complications in future pregnancies (ex. unexpected fetal demise from placental abnormalities, emergency hysterectomy at during a subsequent C-section).

Adding great insult to injury is the VBAC denial-of-services issue when it comes time to have their next baby.

Definitions and Explanations

The fundamental purpose of maternity care is to protect, promote and preserve the health of already healthy women during normal pregnancy, childbirth and new mother-baby phase of breastfeeding, newborn care and developing parent craft skills.

The fundamental purpose of obstetrics is to medically and surgically treat abnormal conditions and complications of female reproduction, including those associated with childbearing, and reduce or eliminate the suffering of those so afflicted. 

Maternity care is ideally a discipline that is concerned with promoting and maintaining states of wellbeing across the whole spectrum of normal pregnancy, childbirth, and care of new mothers and babies. This is accomplished by providing health education as well as routine prenatal care during pregnancy, and hands-on supportive services during labor, birth, and postpartum period. In the weeks following the birth, this also includes facilitating the family’s ability to support the new mother and help her care for their new baby .

Obstetrics is a surgical specialty focused on the compassionate treatment of medical complications and high-risk conditions of the female reproductive system. When such problems have been successfully addressed, the obstetrician-gynecologist has fulfilled his or her primary function.

When the same obstetrical model that is so easily able to provide potentially-life saving care to women with serious complications is an inappropriate form of maternity care when applied to healthy women with normal pregnancies. The educational process that prepares its students to practice the surgical specialty of obstetrics and gynecology does not prepare them to provide health education during routine prenatal and postpartum care for healthy pregnant women, nor does it teach doctors the skills required to provide physical and psychological support to laboring women and new mothers during their complex journey into motherhood in the weeks following normal childbirth.

Even when individual obstetricians are personally interested in providing supportive care for healthy maternity patients, the legal standard of practice for the surgical specialty of obstetrics defines physiologic care as provided by an obstetrician-gynecologist to be a substandard (therefore negligent) form of case that is outside the obstetrical surgeon’s scope of practice.

In addition, the billing codes for obstetrical services, which are specifically medical and surgical, do not economically compensate an obstetrician for physiologically-based childbirth care, since this type of services is neither medical or surgical and therefore not a “customary” aspect of obstetrical practice.

Maternity Care is a rational responsibility of society

A rational, science-based system maternity care system provides personalized, cost-effective care for the healthy majority of a country’s childbearing population (approximately 70%), as well as meeting the medical needs for a minority of mothers or babies who develop complications (approx. 30%).
In a perfected system, the science-based principles of physiological management are integrated with best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women with normal pregnancies, with obstetrical interventions reserved for those who develop complications, or if medical treatments or procedures are requested by the mother. This promotes the right use of obstetrics, which is the compassionate treatment of abnormal and high-risk conditions and complications of pregnancy and childbirth and whenever the childbearing woman asks for medicalized care.
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/surgical procedures and least expense to the health care system. No healthy woman should ever have to choose between a midwife and a physician or between home and hospital in order to have a normal, physiologically-managed childbirth.
The individual management of pregnancy or childbirth should be determined by the health status of the childbearing woman and her unborn baby, in conjunction with the mother’s stated preferences, and not by the occupational status of the care provider (physician, obstetrician, or midwife). At present, who the woman seeks care from (obstetrician vs. family practice physician or midwife) determines how she is cared for, which is illogical.
Ultimately, all maternity care is judged by its results — the number of mothers and babies who graduate from its ministration as healthy, or healthier, than when they started. This is the goal and general standard for maternity services in the majority of developed and developing countries both.

The good news is that maternity care in the US has many of the elements required for a rational and cost-effective system when midwives and family practice physicians use physiologically-based care, as well as the right use of obstetrical and perinatal resources when indicated.

Over the course of the last century we have been blessed by the greatly expanded abilities of medical science. These scientific advances, combined with new obstetrical techniques and new technologies, created a cornucopia of new and effective medical and surgical interventions. This allows obstetricians to successfully treat a long list of infrequent but nonetheless serious complications of childbearing, to save lives and reduce suffering.

We are always grateful for the extraordinary expertise of obstetricians in these difficult situations.

Not-such-good news

Dozens of other, often less wealthy, countries have better maternal-infant outcomes than the US and achieve these vastly improved outcomes at a fraction of the cost of our current maternity care system.

The US ranks fiftieth for perinatal mortality. This means that 49 other countries (including Canada and Cuba) have dramatically better outcomes for unborn and newborn babies. The maternal mortality rate in the US is even more disturbing. We rank thirty-ninth (one excellent source says 60th) for the rate in which American women die of pregnancy and childbirth-related causes. In the US that number stopped improving in 1982 and began climbing in 1996.  

How could the United States possibly rank in 50th and 39th place, given the scientific discoveries and masterful expertise of modern obstetrical medicine in treating the complications of childbearing? How could we not have the very best maternity care system in the world?

Truthfully, the US doesn’t actually have a rational maternity or ‘mother-centered’ system for childbirth services for healthy women, and hasn’t had since early in the 20th century (circa 1910). What we have instead is an obstetrical system. Obstetrics is designed to provide medical and surgical treatments for serious problems. As a surgical speciality, it is primarily organized around the complex needs of it own profession rather than the practical needs of healthy pregnant women and new mother and babies.

When surgical specialists are the primary providers for a healthy population, it creates a drastic mis-match for both doctors and mothers. The primary needs of healthy childbearing women are more social and emotional than medical, while the forte of obstetrical providers, by temperament and training, is in performing surgery, and not the time-consuming skills of physiologically managing a long normal labor and  facilitating a spontaneous birth.

What this healthy population of childbearing women most need are professional birth attendants who have training and skill in the physiologic childbirth practices, and function in a role similar to a life-guard, that is, an educated observer with emergency response capacity. This cost-effective type of mother-centered maternity care was historically provided by non-obstetrician physicians (family doctors) and midwives. 

Dark Side of the Moon

In the field of American obstetrics, the wonderful and life-saving scientific innovations of the early 20th century also had a darker side that changed the direction of our ‘maternity’ care system compared to the rest of the world. Without knowing the historical background of obstetrics in the United States, it would be very hard to understand today’s high Cesarean section rate, the VBAC controversy and other problematic aspects of obstetrical care as currently provided to health childbearing women.

Prior to 1900, obstetrics in the US was not the high-powered, stand-alone profession it is today, but simply a non-surgical discipline that was part of the general practice of medicine. Routine obstetrical care was provided by GPs, while female reproductive surgery was always performed by the surgical speciality of gynecology. Whenever a GP’s maternity patient required a Cesarean or other surgical intervention, the GP had to transfer her to a gynecologist.

Ordinary doctors who provided routine maternity care and the gyn surgeons who handled complications often disagreed about the care of these patients. Over time a professional rivalry developed between the two groups and they came to dislike and be increasing distrustful of each other. By the last decade of the 19th century (1890-1900), the long-smoldering turf war between the ordinary medical discipline of obstetrics and the surgical speciality of gynecology spilled over into public insults that were degrading to both disciplines. 

During this period of intense rivalry, the now famous Dr J. Whitridge Williams was a young gynecological surgeon charged with developing the gyn surgery department in the newly opened (1894) Johns Hopkins Hospital. Later Dr. Williams would also be appointed chief of  its obstetrical department, but is best known today for his obstetrical textbook “Williams’ Obstetrics”.

As someone with a foot in both camps, he was disturbed by this escalating rivalry and general lack of professional cooperation. He believed neither discipline would ever achieve preeminence in their respective fields as long as they were fighting one another. His description of the problem between physicians who provided obstetrical care   and the gynecological surgeons in the early 1900s are virtually identical to the obstetrical profession’s criticism of midwives twenty years later and one that still applies today:

“At present, (the profession of) gynecology considers that (the profession of) obstetrics should include only the conduct of normal labor, or at most … cases that can be terminated without radical operative interference, while all other conditions should be brought to him [the gynecologist] — in other words, that the obstetrician should be a man-midwife.

The advanced obstetrician, on the other hand, holds that everything connected with the reproductive process of women is part of his field, and if this contention were sustained, very little would be left for the gynecologist.”

Dr. Williams recommended that the obstetrical and gynecological departments of Johns Hopkins Hospital be consolidated and housed together in women’s clinic. He and other influential physicians in the two fields concluded that the only way to stop the inter-disciplinary fighting was to combine the medical and surgical disciplines into a new hybrid surgical specialty that came to be known as ‘obstetrics and gynecology‘.

In regard to the care provide by contemporary  ob-gyn ‘specialists’, one very modern obstetrician was unashamed to have his shocking explanation in a professional journal:

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.” [Macer JA et al; Am J Obstet Gynecol 1992:166:1690-7].

Missed opportunity to develop a full-service maternity care system in the US

At the end of the 19th and first decade of the 20th century there were two distinct groups of birth attendants that provided very different kinds of care to different types of women under different circumstances. Family doctors and midwives provided physiologically-based childbirth services to essentially healthy women in the family’s own home and small ‘lying-in’ hospitals (out-patients clinics or what we now call ‘birth centers’).

In contrast to that low-medical intervention approach, obstetrically-trained surgeons primarily provided highly medicalized care to women with complications, and wealthier families who could afford a specialist. This hospital-based care normally included the use of obstetrical interventions and surgical procedures, which had quickly become the standard for hospitalized maternity patients.

In theory (but not fact), respect between these two professional groups could have easily developed, leading to a mutually cooperative relationship in which the two sides exchanged useful information, tips and new techniques with their counterpart. Family doctors and midwives would have continued to provide care to the low- and moderate risk childbirth population, while obstetricians provided medicalized hospital care to the high-risk end of the spectrum, pleased to be called on by other doctors and midwives whenever their patients needed obstetrical services.

Unfortunately, that’s not what happened.

Instead the new hybrid of obstetrics and gynecology choose pursue a policy calling for the total elimination of the physiologic care — i.e. the type of supportive, non-interventive childbirth practices for health women with normal pregnancies that were historically (and in contemporary times) associated with a high level of normal spontaneous births and a low rate of medical and surgical interventions.

The new ob-gyn specialty rewrites the rules for 20th Century maternity care

By the second decade of the 20th century, non-medical obstetrics and the surgical discipline of gynecology had become a dynamic new speciality enjoying a remarkable level of control over professional childbirth services in the US. Convinced that medical and surgical interventions were absolutely necessary to the safe conduct of childbirth, obstetrician-gynecologists wanted to modernized their field as quickly as possible, and believed this required the elimination of all non-interventive forms of care.

As a result, the perspective and practices of the newly configured ob-gyn profession were starkly different from the low-intervention obstetrics/maternity care previously provided by family doctors. By 1910, the hybrid discipline of obstetric and gynecology had formally defined normal childbirth in healthy women as a pathological process (i.e. routinely injurious to mothers and/or babies). Obstetric and gynecology saw its professional role as out-smarting the malicious influence of Mother Nature via the aggressive use of obstetrical interventions.

Characterized as a dangerously flawed and harmful process, the normal biology of childbirth was seen as a potentially-fatal mistake of Mother Nature. Just as salmon naturally die after swimming upstream to spawn, the biology of childbirth in humans was seen as frequently sacrificing new mothers in the act of propagation

Pregnancy was described by the obstetrical profession to be a “9-month disease requiring a surgical cure”, one that could only be provided by physicians with training in obstetrical surgery. With such a low opinion, normal childbirth was believed to have little or no value to women or society. As a result the new profession saw no reason to protect, support or promote spontaneous labor and normal childbirth, or even teach its principles to subsequent generations of medical students.

For the last century, this systematic distain by the obstetrical profession for physiologic childbirth birth set a negative tone for obstetrical education in the US. American obstetrical books have not included the principles of physiological management for nearly a 100 years. Textbook authors frankly denigrated physiologically-based care, while enthusiastically promoting the ever more aggressive use of obstetrical interventions on an ever increasing number of childbearing women. 

For the four millions childbearing women who were to became patients of this surgical specialty every year for the next century, the medicalized obstetrical care they received would be dramatically different than the routine care provided to previous generations of childbearing women by GPs or midwives. 

However it would be 30 more years before obstetrics and gynecology achieved its goal of exclusive control over all childbirth services. During that time a significant number of pregnant women were still employing their trusty family doctor. Even more disturbing to obstetricians, they were having midwives, who were not authorized to provide obstetrical interventions, attend their normal births.

A PR plan to the rescue!

The obvious solutions to the new profession’s problem was a public relations campaign to inform the American people about the dramatically expanded abilities of the new hybrid surgical-obstetrical specialty, as well as telling them all about horrific risks of employing a non-medical care provider.

By 1910, PR materials began to trickle into in newspapers and popular women’s magazines promoting obstetricialized childbirth. These articles assured the public that the profession of obstetrics and gynecology had developed a medical or surgical solution to nearly all possible childbirth problem. Leaders of obstetrical organizations made themselves available to be interviewed by journalists, who faithfully reported the obstetrical promise to the public — that if they would entrust the care of all childbearing women to the obstetrical profession, everything would turn out well for everyone.

The profession’s PR campaign went on to caution the public about the pathological nature of female reproduction. They were told not to be seduced into thinking that childbirth was just a ‘normal’ biological event, and warned of dire consequences should any laboring woman not be in the hospital under the care of a surgically-trained obstetrical specialist. They also informed the public about the dangers of midwifery care, insisting that midwives should never be employed under any circumstances, while family doctors were not a suitable choice for women expecting a first baby. 

A one-size solution that really didn’t fit anyone

What later turned into a multi-generational offensive against physiological management (one that is still alive and well) began in 1910 with language that obscured the actual issue. Whatever their reasons, ob-gyn doctors didn’t talk directly about eliminating normal (i.e. physiologic) childbirth, but instead insisted that appropriate care for normal childbearing was simply a matter of standards, namely that there should be only one standard of care.

The maternity care system 1910 still included family doctors and midwives in addition to obstetrically-trained surgeons. In the minds of the obstetrical profession constituted two different standards for childbirth services, an idea that they found offensive and sought to correct. Its not a surprise that the obstetrical profession insisted that their medicalized care was obviously the superior and safer choice, while birth attendants who used physiological management during normal childbirth were clearly providing an inferior, thus “lower” or non-medical standard.

According to this theory, the lower or non-medical standard deprived poor and working class women of the wonders of the new medicalized services, which included Twilight Sleep drugs, and narcotic during labor, the “blessed relief” of being unconscious from anesthesia during childbirth, and the ‘protective effects’ of episiotomy, forceps deliveries, and manual removal of the placenta. This was characterized as both unfair and psychologically harmful.

What the profession of obstetrics and gynecology had in mind was an all-encompassing medicalized standard created by the obstetrical profession and applied universally to all childbirth women, regardless of how healthy the mother-to-be or how normal the pregnancy, thus making obstetrics THE standard of care in the US.

Having identified obstetrician-gynecologists as only the real “experts” in women’s reproductive health, they concluded that obstetrics was the ‘right’ standard and anything else (i.e. physiologic childbirth practices)  were wrong and should be eliminated as quickly as possible. By the early 1920s, highly risky and invasive interventions had became the standard form of obstetrical care.

Henceforth, failing to medicalize normal childbirth would be considered to be a form of substandard care. Any physician birth attendant who provided this substandard care would be considered negligent or incompetent; midwives who insisted on using physiologically-based care would be judged guilty of criminal acts.

By the late 1940s, the pre-emptive use of interventions on virtually all childbearing women — no matter how healthy or how normal their pregnancy — had become the national standard for maternity care in the US . 

Continue to Part 2 ~ Obstetrical management of normal childbirth ~ 1910-1980