Work-n-Progress ~ last edit Aug 18, 2015
The Magnitude of the Post-Cesarean Problem in California and its affect on childbearing women and their midwives
Over 600,000 babies are born in California every year. With a 33% Cesarean section rate, around 200,000 women are added to the post-Cesarean/potential VBAC pool each year. Not all of them will become pregnant in any one year, but the aggregate statistic of previous-CS women having a second or subsequent pregnancy, and therefore being a ‘candidate’ for a normal vaginal birth is approximately ____ (Google this number). That is a huge number of women that will become enmeshed in the current quagmire of VBAC bans in the state of California.
One would expect a problem of this magnitude to mobilize a very large segment of obstetrical community to use its considerable influence to find a suitable solution. According to published policies by ACOG, this shouldn’t be hard.
Several formal statements by ACOG already acknowledge and support the right of childbearing women to self-determination. These Committee opinions say that forcing women into unwanted medical or surgical procedures, which logically would include repeat Cesareans, would violate the mother-to-be’s right to determine for herself what is in the best interest of herself and her unborn/newborn baby.
ACOG’s Committee Opinions #166, on “Informed Refusal”, notes that:
Almost universally, informed consent laws have been liberalized … from the relatively paternalistic “professional or reasonable physician” standard to the “materiality of patient viewpoint” standard. …
In the “patient viewpoint” standard, a physician must disclose … the risks and benefits that a reasonable person in the patient’s position would want to know in order to a make an “informed” decision.
ACOG Committee Opinion #214 — “Patient Autonomy: The Maternal-Fetal Relationship” states that:
… medical knowledge has limitations and medical judgment is fallible. Existing methods for detection … are not always reliable indicators of poor outcome, and there is often insufficient evidence for risk-determination or risk-benefit evaluation
The role of the obstetrician should be one of an informed educator and counselor, weighing risks and benefits …. and realizing that tests, judgment and decisions are all fallible.
Abiding by the patient’s autonomous decision will provide the best care for the pregnant woman and the fetus in most circumstances.
In the event of an emergency … the obstetrician must respect the patient’s autonomy, continue to care for the pregnant woman, and not intervene against the patient’s wishes regardless of the consequences.
ACOG Committee Opinion #214 also identifies serious negative consequences when a patient’s autonomy is violated:
A woman is wronged and may be harmed, whether physically, psychologically or spiritually.
The patient’s subsequent loss of trust in the healthcare system may reduce the health care provider’s ability to help her and may deter others from seeking care.
There may be other social costs associated with this violation of individual liberty.
Its gratify to see that ACOG’s published policies acknowledge the logical and practical necessity of respecting the autonomy of childbearing women.
Walking the Talk ~
Its gratifying to read these noble statements by ACOG that appear to genuinely support a childbearing woman’s right of self-determination. Such enlightened policies are welcomed but corrective action is badly needed to actually implement these policy statements. In order for ACOG to walk-their-talk, policies that result in the systematic overuse of Cesarean surgery must be eliminated, while the professional organization actively supports and promotes VBAC. This requires ending all hospitals and obstetrical groups bans on VBAC. It also means repulsing the economic pressure by insurance carriers to do repeat Cesareans, which is a dangerous policy that actually adds unnecessary and unnatural danger.
Unfortunately when consumer groups, public health officials, family-practice physicians, midwives and childbearing families ask the obstetrical profession to honor or implement these statements — that is, to realistically support the right of childbearing to make medically-unpopular choices, including VBAC — ACOG’s Committee Opinions are not merely disregarded but actually disavowed.
Frankly, the “VBAC problem” has almost nothing to do with delivering babies and nearly everything to do with the personal preferences of physicians, defensive practice of obstetrics, and the sad fact that society, as well as doctors, lets medical malpractice carriers get away with using its own economic self-interest (without the informed consent by patients!) to deny essential services via insurance company policies that ban obstetrical care by hospitals and obstetrical groups for women who had a previous Cesarean.
Realistically, ACOG’s commendable Committee opinions upholding the rights of childbearing families to determine what is in their best interests was long ago lost in the avalanche of economic and political forces. The effects of organized medicine and for-profit insurance carriers are like an enormous glacier rolling on and on, gobbling up anything in its way. Every decade they consume a larger proportion of the political pie and ultimate suck all the oxygen out of the room for everyone else — doctors as well as childbearing women.
The other ‘big blue elephant’ hiding in plain sight right
As crucial as the Cesarean-VBAC issue is, requests for fundamental “walk-your-talk” change would be woefully inadequate if we didn’t talk about the equally urgent need for the obstetrical profession to acknowledge physiologically-managed labor and birth appropriate (science-based and cost-effective) standard of care for healthy women with normal pregnancies.
In this case, the issue is the official refusal of the obstetrical profession to acknowledge that physiologic care for healthy women with normal pregnancies is the scientific (evidence-based) model of care used worldwide with great benefit, and that physiological management of normal labor should logically also be the obstetrical standard for the healthy majority of the childbearing population.
Lets face it: It is both illogical and irrational to apply the same highly medicalized and extraordinarily expensive model of obstetrical interventions used to treat the 30% of women with medical complications and high-risk pregnancies to the 70% population of healthy childbearing women with normal pregnancies. The unproductive cost alone make this a completely unsustainable form of healthcare.
This misguided obstetrical perspective is nonetheless aggressively and repeatedly presented to the public in press releases to the media. These are picked up by Reuters, Associated Press and other news outlets and screamed out to the public in big headlines that insist non-medicalized childbirth practices (i.e. physiological management) and birth services in setting other than an acute-care hospital are dangerous, irresponsible and should be made illegal.
Its interesting to not that these biased press-releases and PR statements never mention the sky-high C-section rate and all iatrogenic complications that result from the overuse (and not infrequent misuse) of obstetrical interventions, or the obvious connections between our high C-section rate and VBAC issues such as the denial of service policies of 50% of California hospital and obstetrical groups. It almost seems that these anti-physiologic childbirth, anti-midwifery antics are are meant to be a distraction devise, to keep the public for asking embarrassing questions about the overuse or inappropriate use of obstetrical interventions in the US, including our 33% surgical birth rate.
When consumer groups, economists, midwives and childbearing families broach the subject of de-medicalizing childbirth for healthy women via physiologic care, we hear the same negative explanations promoted by the obstetrical profession in 1910. At that time, the new ob-gyn specialty characterized the obstetricalization of normal birth as the new, modern and practically risk-free way to make childbirth safer, while simultaneously insisting that any other form of care was old-fashion, inadequate and dangerous. Then as now, the profession still insists that the routine use of obstetrical intervention is orders-of-magnitude safer than physiologically-based care.
The model the obstetrical profession is working so hard to perpetuate is a defensive practice of medicine that includes routine use of induction or augmentation of labor (> 60%), continuous electronic fetal monitoring** (93%) as a total surgical intervention rate of 70% (episiotomy, forceps, vacuum, and Cesarean delivery), accompanied by hospital policies and physician preferences that result in only 10% of previous Cesarean mothers having a VBAC. As startling as those figures are, the really telling metric is the worldwide ranking of the US — 50th in perinatal mortality and 39th in the rate for new mothers who die of pregnancy and childbirth-related causes.
In this author’s opinion, this record is nothing to brag about.
** Electronic fetal monitoring (EFM) is a key element of the defensive practice of medicine worldwide. However when EFM is used routinely in low and moderate-risk labors, its only scientifically-validated affect is to dramatically increase the CS rate. The widely acknowledged reason for the association between EFM and increased CS rate is the paper printout or electronic record produced by the machine, combined with the ambiguous nature of EFM tracing.
Research on obstetrical interpretation of EFM information asked 130 obstetricians to determine whether or not the monitor tracing typically indicated the status of the fetus was normal, worrisome or ‘ominous’ (which indicates the need for emergent interventions). Inter-obstetrician comparison of individual results found that approximately 80% of the EFM finding were interpreted differently by different obstetricians.
Six months later these researchers returned to the same cohort of obstetricians and asked them again to categorize a set of EFM strips as OK, worrisome or ominous, but did not mention that these were the very same set of EFM tracing as before. An intra-obstetrician comparison (same doctor, same EFM strip, different time) found that a high percentage of obstetricians interpreted the same tracing differently on the second time around. Obviously this would occasion a nightmare of ‘second guessing’ between obstetrical ‘expert witnesses’ in a courtroom setting.
This ‘perfect storm’ of EFM records and their ambiguous interpretations makes it easy for plaintiff attorneys to find some tiny blip on an EFM tracing that can be claimed as ‘proof’ of obstetrical malpractice — that a Cesarean should have been done, or should have been performed earlier in the labor.
Routine use of EFM makes the obstetrical profession a prisoner of its own project.