Wednesday, September 19, 2007

Interventionist birth: the new normal

Anyone who knows me, or has been reading this blog for very long, probably knows that natural childbirth is something I care very much about. So I was fascinated by this article, which discusses the "new normal" of interventions in birth. Induction, pitocin to "speed things up", artificially rupturing membranes (again, to "speed things up"), episiotomies, forceps, often culminating in an "emergency" c-section, have become the new normal.

But it doesn't have to be this way. The article notes that during Hurricane Charley (back in 1994) the c-section rate at Florida Hospital Heartland Medical Centre dropped from 29% to 17% (and only 6% if you exclude the scheduled c-sections from the data). Why? Because the power was out, and although the hospital had a generator, it was limited. So women were told to go back home until they were in active labor. When they were admitted to the hospital, they had their babies within hours and with minimal intervention.

The article also refers to a 2005 study (yes, this is the full study) published in the British Medical Journal, that looked at over 5,000 midwife-attended low-risk births. 12% of those babies were sent to the hospital; only 1/4 of those for urgent reasons. The cesarean rate was less than 4%. No mothers died and 1.7% of babies the babies died either during labor or in the next thirty days...which while incredibly tragic, is comparable to low-risk hospital births.

So why do we, as a nation, accept so many interventions? How did this become the new normal? Back in the 40s and 50s, there was a trend away from anesthetized births and toward "natural" (un-medicated but still in hospital) births. In the 70s and 80s, the use of midwifery for home births soared, only to crash in the 90s. Twenty years later our national c-section rate is pushing 1/3 of all deliveries and interventions such as pitocin augmentation are so routine they are sometimes given without even asking the mother's permission.

What happened? And why? And where should we go from here?

Please do discuss, but keep it nice, ok? This is a hot topic and I don't want to have to moderate my comments. :)

Hat tip to Amy for the link to the original article.


Rebecca said...

The fact that I will most likely (when the time comes) have a high-risk pregnancy and birth aside, I must say that the idea of limiting the amount of pain one has in delivery is a very inviting idea. So, at that point, you'll find me in the hospital.

All that aside, I think there are two main reasons behind the increase in interventions. I think the first has to do with the fact that OB/GYN docs are some of the most sued doctors there are. The slightest thing went wrong? The baby isn't perfect? The mother hurt a little too much? Bam. You've got a law suit. So, doctors do what they consider the safest thing. Sometimes that means safest for the mom and baby. Sometimes that means doing what the mom wants to avoid the aforementioned suits (which means a great deal of scheduled c-sections).

I think the second reason has to do with patient education. I think that doctors don't have enough time to educate their patients about various options and their risks (how could they when insurance companies expect them to see each patient in 15 minutes or less?). This means that patients often come in having read a great deal on the internet and unwilling to listen, even though their doctor spent (and spends) tons of money receiving an education that would make them able to advise and treat well. Whenever we go to see a physician (in the hospital, or at the clinic) we tacitly agree to let them, as the one with the most information, make the decisions. This doesn't mean that the doctor should be the only one deciding, but just that a patient has to remember their responsibilities as well as their rights (for the HIPPA patients' bill of rights, click here:

Just my thoughts...

Jessica said...

I'd agree with Becca about the lawsuits having a lot to do with it.

I'd also point out that you really can't compare the mortality rates of a "low-risk" group with the mortality rates in the general population that the hospitals treated. In other words, the hospital had the same low mortality rate, and their population INCLUDED the high-risk pregnancies. Which means: the hospital is still safer.

I think it's very hard to strike a balance between low-intervention and high-intervention. It all comes down to the "what if?" question. "What if this actually is necessary?" Because sometimes it is (often, actually, if you compare our birth-associated mortality rates to those of 100 or 200 years ago). But the truth is, we have the ability to almost guarantee a good outcome for mother and baby, at the cost of a high-intervention birth. Most people will take the downside of the high-intervention birth in trade for the excellent upside of near-guaranteed safety. I can't say they're wrong.

peace of Christ to you,
Jessica Snell

Sarah said...

It seems like we accept more medical attention across the board, not just regarding pregnancy and giving birth. So maybe this is something to think about on a greater level than this.

It seems like this question comes up when there are medical advances--we CAN do this safely, so SHOULD we? I'm not sure the answer is particularly cut and dried, either. Honestly, I think I would be ok with the process as long as it produced a healthy baby at the end. But that process might look very different between me and someone else, and I wouldn't want them to be tied to my process, if that makes sense.

I think the biggest problem I see in all of this extra intervention, in all areas, is that doctors forget to see each case individually, to see each person as an individual system that may or may not fit well into predefined categories. Like Becca said, doctors don't have time to give that kind of care. But that doesn't mean that they shouldn't.

Kelly said...

Regarding the studies; the hospital studies compared to homebirth/midwifery studies are usually limited to hospital births where the moms were considered 'low risk' based on their prenatal care/appointments. So, I think the studies still hold.

I am also passionate about natural birthing. I do think their are exceptions where I disregard my pet-peeves with hospital births (like wiht high risk moms).

For me, one of the biggest reasons why I think it is worth having a fully natural birth is a spiritual one. The curse of childbirth was given by God. However, I think, like hte curse of death, that there is a redemptive element through the incarnation, death and resurrection of Christ. I think that motherhood is a path to salvation and the physical laboring of children is a major facet to that. I'm not saying I'm a better Christian because I've had my children naturally, but I do think mom's who birth naturally gain something unique through the experience. I say this based on mom's I 've talked to who've experienced both and based on my own experience. Labor really puts you at the mercy of God and teaches you humility and faith. A lot of my passions regarding natural birth I can't even put into words yet and this post is already getting too long for me to try now.

kel said...

I loved this article!

I think one of the biggest misconceptions is that all of these interventions and c-sections give the mom and baby a safer outcome. They don't. If you look at the facts, they have more side effects and lead to other complications - more so than a low-risk mom having a natural child birth.

I think it's just a symptom of things wrong in our whole society. We're a quick-fix culture. People are willing to trade lots of benefits for the ability to have less pain, to schedule things, to make things go faster... even just to have some sense of control in a situation we can't otherwise control.

Amber said...

I know I'm coming a little late to this, but I really second what Kelly had to say. I also think that childbirth can also be incredibly transcendent and I would hate to have missed out on that because of expediency and the fear that something might go wrong even in my very low-risk situation.