Have you seen Al Jazeera’s new documentary – “Birthrights” – about cesarean and VBAC in the United States? It features ICAN of Atlanta and others in our birthing community. Check it out!
By Desirre Andrews, President of ICAN
A woman’s pregnancy should be a positive time as she prepares for the birth of her baby. Unfortunately, in this age of defensive medicine, a pregnant woman must arm herself with evidence-based information and self-advocacy skills. She must be willing to act in a self-protective way to be certain she is getting individualized patient care versus the cookie cutter care modern medical practice normally affords.
This phenomenon of defensive medicine may largely be born out a very human response to the expectation of perfection we have in society today, especially with care providers. We have developed a willingness to hand personal authority over to our care providers.
For years, doctors have been deified, treated as being better than everyone else. Perhaps it is in their ability to save lives. We simply expect them to be able to do everything, but they can’t. They are human.
Doctors and patients might be able to see the human face of medicine if the traditional practice style that valued provider-patient relationship came back into use.
Today, with OB appointments being no more than ten minutes each visit, how can a personal, trusting relationship build between the two parties? It cannot. A woman can not be sure she can fully rely on her provider to know her well and help her make decisions that are in the best interest of her and her baby. The provider must rely on what he or she is comfortable with offering and doing to patients instead of taking each mother and baby into consideration individually. It is no surprise the circle of distrust and fear is palpable by all sides.
Prior to ever practicing medicine, the defensive attitude comes with the education a physician receives in medical school and the training in residency. The lesson is that your patients are not as educated as you are, always practice to defend yourself and get the patient to agree to the course of action you want no matter what.
With this attitude, what sort of “care” practices is a woman facing? Higher induction rates to lessen the rare fetal demise that can occur “post dates”. Higher cesarean rates because a physician does not want to incur risk of a VBAC mother going for a vaginal birth, even though catastrophic uterine ruptures are not common place. Viewing all OB patients through a lens of high risk or as an emergency waiting to happen.
All aspects of managed and medicalized birth occur because a physician is not comfortable, has fears, has worries and/or is not willing to practice outside of that mode because tolerate risk has been depleted. The physician desires to create a zero risk environment because of a lowered risk threshold either by training or by an adverse outcome in the years of practice. The humanness of the mother has been left out of the equation, while the ideal of a “healthy” baby is elevated in this physician centered point of view.
We as ICAN believe that every mother has the ability, responsibility and intrinsic right to make medical care decisions for her pregnancy, labor birth and baby. She should be able to obtain true and complete informed consent from her provider. We believe it is unethical for a physician to recommend and/or perform non-medically indicated cesareans (elective), to refuse to support VBAC (vaginal birth after cesarean) across the board without individualized assessment, or to skew cesarean as the easier, safer choice as a standard course of practice.
In the big picture no one truly benefits from a defensive medicine practice style. Providers and patients all lose.
MyHealthNewsDaily recently reported on the rising rate of cesareans, especially among first-time mothers.
“The most concerning problem is the high rate in first-time mothers,” said Dr. Jun Zhang, a medical researcher at the National Institutes of Health and co-author of a new report on cesarean delivery practices.
In his study, published in the American Journal of Obstetrics & Gynecology last month, Zhang looked at medical records of 228,668 women who had delivered babies in 19 hospitals across the country, to determine the factors involved in cesarean deliveries.
The study underscored a shift — one that has been in the making since the mid-twentieth century — in how hospitals approach the birth process. The shift is toward a more streamlined labor and delivery, and profoundly affects mothers-to-be.
In the case of rising C-sections, Zhang wrote in the report, this shift is not likely to reverse any time soon.
The study cites “failure to wait” as one medical practice impacting cesareans among first-time moms.
In Zhang’s study, however, he found that many patients weren’t given a sufficiently long time period to allow their labor to progress. In other words, doctors were calling it quits on waiting and opting for a C-section too soon — often before the patient’s cervix was dilated to 6 centimeters.
This was especially true in cases of induced labor, during which a woman is given the hormone oxytocin (also called by its brand name, Pitocin) to initiate labor: Almost half of the C-sections in these women occurred before they were 6 centimeters dilated, Zhang found.
Defensive medicine is also at work when it comes to VBAC.
Another factor contributing to the record-high cesarean rates is a drastic decline in vaginal births after cesarean (VBAC). Zhang found that 70 percent of women in his study who had previously undergone a cesarean delivery had C-sections with their subsequent pregnancies, without attempting vaginal delivery.
One reason for this is a fear of lawsuits. If a physician doesn’t perform a C-section, and something goes wrong with a patient who previously had a C-section, the law often does not protect the physician, said Dr. Daniel Roshan, an obstetrician and gynecologist (ob-gyn) at New York University Langone Medical Center.
ICAN Education Director Krista Cornish Scott comments on ACOG’s revised VBAC guidelines:
“We’re hopeful that this statement will push hospitals to reverse their bans, but we haven’t seen significant change yet,” said Krista Cornish Scott, the education director of ICAN, who herself had two complication-free VBACs.
And again about the perils of the current medical model of birth and the need for change:
“It’s an intimidating system,” ICAN’s Scott said, “You almost need to bring a medical researcher and a lawyer with you to the hospital if you want to control how you give birth.”
“We’re fighting a cultural issue,” Scott said, that extends beyond C-sections.
She said, “We need to change the entire way we view birth and we have to be able to trust our caregivers. The alternative would be terrifying.”
A recent study published in the British Medical Journal has been making headlines in TIME and Salon, among other outlets. Headlines herald the findings as proof that women are “not too posh to push” and can’t be blamed for the rising cesarean rate. Instead, women are having cesareans for “medical reasons.”
From the BBC:
It is “unlikely” that women undergo caesarean sections to avoid the pain of childbirth, research suggests.
Most caesareans were carried out for medical reasons, the review of 620,000 births in England in 2008 found.
However, the study does not appear to question the “medical reasons” given for cesareans. According to TIME:
Further analysis of the reasons for c-section found they were mostly medical: about 90% of women with a breech baby opted for c-section, as did 71% of women who had had a previous c-section. Mothers who experienced serious medical problems during labor also chose surgical delivery following recommendations from their doctors.
Key among the “medical reasons” given are breech birth and previous cesarean, neither of which are inherent reasons for cesarean based on scientific evidence. Current obstetric practice, however, often forces women to “choose” cesareans in both cases by limiting availability of vaginal breech birth and vaginal birth after cesarean (VBAC).
Media reports about the study hint at the non-medical reasons that other studies have found to influence cesarean rates. Again from TIME:
Overall, however, the study did find a wide range in c-section rates between hospital trusts — from 15% to 32% — and suggested that the differences were to due to doctors’ individual decisions in emergency situations. It’s possible, then, that some doctors, faced with problems during labor, may choose c-section sooner than is necessary.
It bears noting that c-sections make more money for private hospitals than vaginal deliveries. And they’re cheaper than vaginal birth after cesarean section, or VBAC, which, thanks to liability issues, requires additional medical staff at most hospitals; doing the c-section also avoids potential lawsuits by patients.
While it is well worth acknowledging that women are not, in fact, driving the cesarean rate by requesting cesareans, clearly more needs to be done to remove barriers to true choice for birthing women.
The United States Agency for International Development (USAID) has published a report on disrespect and abuse in facility-based childbirth around the world.
From the Executive Summary:
Lack of respectful and non-abusive care at birth may encompass many points along a
continuum that spans dignified, patient centered care, non-dignified care, and overtly abusive
maternal care. Examples of disrespect and abuse include subtle humiliation of women,
discrimination against certain sub-groups of women, overt humiliation, abandonment of care and
physical and verbal abuse during childbirth…
Building on the results of an extensive review of the published and gray literature as well
as results from a structured group discussion and individual interviews with expert informants,
seven categories of disrespect are identified: physical abuse, non-consented clinical care, non-
confidential care, non-dignified care (including verbal abuse), discrimination based on specific
patient attributes, abandonment of care, and detention in facilities. Categories of disrespect and
abuse draw on human rights and ethics principles and are intended to help synthesize a complex
body of evidence. It is understood, however, that manifestations of disrespect and abuse often
fall into more than one category. Categories are not intended to be mutually exclusive but rather
to be overlapping along a continuum.
Coerced cesareans are one example of non-consented care cited in the report (emphasis added):
There is evidence of a widespread absence of patient information processes or informed
consent for common procedures around the time of childbirth in many settings (e.g. cesarean
sections, episiotomies, hysterectomies, blood transfusions, sterilization, or augmentation of
labor). Interviewees from LAC, sub-Saharan Africa and Eastern Europe regions all confirmed
the lack of routine patient information communication and consent protocols for obstetric
procedures in their respective settings, including the widespread practice of episiotomy without
patient notification or consent. Escalating and excessive rates of unnecessary cesareans have
been documented by many in the LAC, Asia, North American and other regions. Reports from
Kenya, the United States, Dominican Republic, and Peru document women‘s stories of feeling
coerced into a cesarean section (Center for Reproductive Rights & Federation of Women
Lawyers–Kenya (FIDA), 2007; S. Miller et al., 2003; Physicians for Human Rights, 2007;
Amnesty International, 2010).
Click here to download the full report.