CCM Preamble to VBAC Statement: Part 3 ~ Developing a rational maternity care out of the ashes of our illogical system

Part 3 ~

Part 2 chronicled the the history of how Twilight Sleep drugs, episiotomy, forceps, manual removal of the placenta and other interventions became the standard for normal childbirth services in the US from 1910 to 1980.

The relationship of the obstetrical model to normal childbirth has changed very little since obstetrics was standardized in 1910. It still applies a fixed set of obstetrical interventions to both low and high risk women. Even though the modern rate of pregnancy complications is small fraction of what it was in the early 1900s, the rate of obstetrical interventions has increased every decade for nearly a hundred years. At this point in our history, it is dramatically disproportionate to the rate of complicated pregnancies.

Obstetrical game-changer: the many-headed monster of malpractice litigation

Despite an extraordinarily high rate of iatrogenic complications from the routine use of multiple invasive interventions, malpractice litigation was extraordinarily rare during most of these decades.

But in 1960, the US Supreme Court changed the medical litigation game by ruling that the ‘community standard of care’, for purposes of malpractice claims, was no longer restricted to just the physical location in which the physician being sued lived and worked, but functionally encompassed the entire profession of medicine.

That meant that plaintiff’s attorneys for a lawsuit being tried in California could hire a doctor from New York — someone who was not part of the local ‘old boys’ network’ — to testify as an expert witness. Prior to that, physicians living in the same community rarely testified against another doctor for fear of future reprisals.  However, without insider testimony on the very local ‘community standard of care’, it was nearly impossible to get a favorable verdict in a malpractice suit.

The Supreme Court’s new ruling was the starting gun of the new medical malpractice races, and all bets have been off ever since!            

Problems in Mudville

During the first part of the 20th century (1910-1960), leaders in the obstetrical community enthusiastically assured the public that the use of the right obstetrical techniques could and would guarantee a good outcome for both mother and baby each and every time. The obstetrical profession was lavishly in its promises to the public that simply engaging the services of an obstetrician (instead of a family doctor or midwife) would eliminate every problematic aspect of childbirth. Unfortunately for all of us, this was a promise that could not be kept.

Over the last quarter of the 20th century, as more and more medical and surgical interventions were being done to an every enlarging percentage of childbearing women, the number of medical malpractice suits began to soar. The idea that all bad outcomes were the consequence of ‘sub-standard’ care by the doctor and/or the hospital had inadvertently set obstetrical profession up as a target for malpractice lawsuits. By 1975 there true a ‘malpractice crisis’ all across the country. In an attempt to reduce the litigious risks to obstetricians, they began to practice defensive medicine.

One aspect of this preoccupation with avoiding malpractice litigation at all costs was a steady drumbeat over the last 40 years for obstetricians to stop waiting passively for spontaneous labor to begin. Instead routine induction suddenty found great favor. Replacing normal vaginal birth with elective use of Cesarean surgery was promoted as an easy and nearly risk-free way to save the lives of babies with only a very small increase in otherwise preventable maternal deaths*.

[*Prophylactic Cesarean Section, NEJM 1984]

Legal issues are also a huge factor in the profession’s normalization of routine repeat Cesareans in all post-cesarean pregnancies.

The result is a profoundly dysfunctional maternity care system, one that has a national Cesarean section rate of 33%, with a matching rise in the delayed and downstream complications of Cesarean surgery, as well as an increasing rate of maternal mortality. Another iatrogenic complication of defensive obstetrical medicine is the increase in the rate of prematurity in the US due to inducing mothers-to-be before their babies are due.

Regrettably,  this Cesarean-centric strategy did NOT, as was hoped and promised, dramatically reduced or eliminated maternal or have a positive impact on either perinatal mortality or lowering the rate of cerebral palsy cases.

The rate of Cesareans is currently three times higher than the WHO’s ‘optional rate of 10 to 15%, but despite all that cutting, the neonatal mortality rate has not improved, while the maternal mortality rate has actually risen from a low of 8 per 100,000 in 1982 to as high as 17 in 100,000 in 2007. Currently the MMR is 12 per hundred thousand.  

All and all, the obstetrical profession is now chasing its tail at a faster and faster pace, as the defensive practice of obstetrics has become the core organizer for obstetrical services based on the hope that legal ‘risk-reduction’ strategies will  reducing the risk of doctor or hospital getting sued.

As time moves forward, the legal strategies of attorneys are more and more are being substituted for good medical judgement by doctors, commonsense and proper informed patient consent to such treatments. 

WANTED: a Mother-Baby-Father-friendly maternity care system that both functions for childbearing families and is a cost-effective form of healthcare

The lived reality of our current obstetrically-centric maternity care system is neither rational nor logical. Statistics for mother-baby outcomes have never shown the medicalization of normal childbirth to provide superiors outcomes or more cost-effective care for healthy childbearing women with normal pregnancies.  

And yet the surgical speciality of obstetrics and gynecology has systematically, over the course of the last century, completely taken over the care of essentially healthy women and turned that highly medicalized model of care into the standard for all maternity care in the US.

What is both surprising and disturbing is that no one at a policy level has asked the obvious question: 

  • Does it make sense to turn healthy women with normal pregnacies into the patients of a surgical speciality and normal childbirth into a surgical procedure ‘performed’ by an obstetrically-trains surgeon

The critical missing element for maternity care in the US is systematically providing physiologically-based maternity care to the majority of the childbearing population (70-plus percent). 

Equally unexamined is the affect of society’s uncritical acceptance of this unscientific premise over the entire 20th century and well into the 21st. For the last half century, obstetrics has been a surgical specialty beleaguered by the need to practice defensive medicine. The uncritical acceptance of the idea of that obstetrical surgeons should be the primary provider for normal childbirth in healthy women has become more and more pernicious for families over the last 40 years, as efforts to reduce medical malpractice litigation have become the central organizing principle of modern obstetrical practice. 

For obstetricians and nurse-midwives that means following mandatory medicalized protocols impressed by hospitals, who are also trying to protect themselves against litigation, as well as tying to keep costs down. Under such conditions it is no surprise that obstetrical care is not longer focused on mothers and babies (the original meaning of ‘maternity’ care) and instead has turned inward and is mainly focused on the needs of obstetrical providers and institutions.

If that were not the case, the considerable influence of the obstetrical profession would have been used to both eliminate VBAC bans and to promote normal vaginal birth whenever and wherever possible, while working to remove economic roadblocks, instead of occasionally cluck their tongues over the ‘VBAC problem’, while quietly accepting of the self-serving behavior of hospitals and medical malpractice carriers that have instituted bans on VBACs.

Solutions to the VBAC Problem: Hospital-based physiological childbirth as provided by midwives and other professional birth attendants

If the obstetrical profession is in fact committed to reducing the number of Cesarean performed in the US (the very best answer to the ‘VBAC problem’), they will need to support the physiological management of normal childbirth for what it is — the science-based standard of care for healthy women with normal pregnancies.

This would require the following:

  • Passage of legislation that would create standard informed consent for obstetrical procedures by providing full, accurate, factual, and scientifically valid information about the known risks and benefits associated with the routine intrapartum use of the following: immobilization in bed during active stages of labor, continuous EFM, IVs, induction or augmentation of labor with drugs that speed-up labor, AROM, IUPC, narcotics pain medications, epidural and other forms of anesthesia for normal childbirth, episiotomy, forceps, vacuum extraction, and the specific risks of primary as compared to repeat Cesarean surgery. This would enable childbearing women and their families to provide fully and accurately-informed consent before these interventions and procedures are used during labor or birth, thus reducing the risk of subsequent malpractice suits and other kinds of legal action against their providers or the hospital.
  • Adding the principles of physiological management for normal labor and birth to the standard medical school curriculum
  • Teaching the skills and techniques that support physiologic childbirth during the training of obstetrical residents
  • Insisting that ACOG include physiologically management as a recognized aspect of the scope of practice for obstetricians OR that hospital L&D units be staffed by professional midwives who will physiologically manage the labor of all healthy laboring women unless obstetrical interventions are medically indicated
  • Facilitating hospital privileges for all California professional midwives (including midwives licensed by the California Medical Board)
  • Insisting that all hospitals eliminate VBAC bans and that medical malpractice carriers not financially discriminate (by fee hikes or refusing liability coverage) against the provision of VBAC
  • Acknowledge that a tiny minority of previous Cesarean women have a right, with fully informed consent, to choose to midwifery care in an OOH setting even though it is not the most optimal choice under such circumstances

Most women who previously had a Cesarean would not choose OOH midwifery care if they had access to in-hospital midwifery management.  For the few mothers who had such a traumatic experience that, as they put it, they: ” just can’t return to scene of the crime” can, with good informed consent, be satisfactorily cared for in a OOH setting by professional midwives.

So far as I know, the obstetrical profession in general and ACOG as its active spokesmen are currently promoting or supporting of any these vitally important solutions.

Until they do so voluntarily, or legislation is passed mandating these actions, we will continue to have an irrational, illogical, unproductively expensive, and ultimately unethical maternity care system that is the product of a special interests and not the least “mother-baby-father-family friendly.

This editorial is the preamble to the California College of Midwives’ position statement on the VBAC issues as it affects childbirth families and Ca LMs. Click here for CCM’s VBAC Statement,  Part 1.