Dec 8, 2010

Reducing Unnecessareans

OK, this paper could have been better, but I just didn't have any TIME. So I totally turned in my rough draft. Don't judge me. I have a 98% in this class.

In the United States today, an unborn child has almost a one-in-three chance of coming into the world via surgical birth. The 32%2 rate is over twice the upper limit recommended by the World Health Organization. It’s one of the highest rates in the developed world. What’s more, this increase in cesareans hasn’t markedly improved fetal outcomes and has drastically increased the risk of maternal mortality. It is time to address the issue of “unnecessareans”.
            In 2003, The United States fetal mortality rate was over 7% with a cesarean rate at 21.1%. In contrast, during the same time period, The Netherlands had an infant mortality rate of 5% and a cesarean rate of 12.7%. They also had better maternal outcomes.1 The most current statistics for cesarean in the United States put it at 32%.2
An article in the October 2010 issue of “OB.GYN News” by David Priver, MD goes over some of the reasons the cesarean rate in the United States is so high. They include professional liability, the demise of operative obstetrics, impatience, lack of an analytic approach to VBAC (vaginal birth after cesarean), and no one teaching the skills to do vaginal breech births to today’s obstetricians. (Luckily, midwives are still teaching new midwives this skill set and Canada has recently asked its midwives to teach new OBGYNs these skills.)
The ethical dilemma facing healthcare providers is, how do we provide the best outcome for mothers and infants, while also providing care that is above reproach and therefore, immune to litigation. One part of healthcare that has changed in recent decades is the belief that the fetus is a patient, too. Prior to sonograms, we didn’t care as much if the fetus lived or died, it was much more important that the mother live to birth another day, hence the advent of the crochet hook abortion for fetus’ too large to fit through a malformed pelvis, or for term fetal demise. Abdominal surgery just wasn’t a viable option if you wanted the mother to live.  This changing view occurred simultaneously with a skyrocketing litigious movement, making physicians less likely to practice evidence-based medicine, and more likely to perform what was deemed “best practice” by lawyers, regardless of the personal convictions of the physician, or what research showed to be the best course of action in a certain situation (i.e. breech vaginal delivery over primary c-section for a woman who hasn’t even gone into labor yet).
Medical schools began to train new obstetricians not in the management of normal birth, but in the pathology of abnormal birth. New OB’s looked for, and found, pathology everywhere they looked because that’s what they were trained to see.  This new way of teaching coincided with the introduction of fetal heart-rate monitors; a device strapped to the laboring woman that supposedly gives a realistic readout of fetal distress. Health care workers began to treat “the machine that goes ‘ping’”, not the patient. Studies have shown, and even the American College of Gynecology and Obstetrics agrees, that the use of continuous fetal monitoring doesn’t improve the outcome for most infants, and has quite a marked effect on decreasing outcomes for the mothers, namely in the form of cesareans and their vast and varied complications.5
We start to see now that doctors have forgotten their oath to do no harm to the mother, in their haste to prevent perceived harm to the fetus. One can only surmise the foremost thoughts in the mind of the physician are the lawsuits he’s evading by following “best practice”.  The real question is, in whose best interest are decisions being made?
When we approach this dilemma from the viewpoint of an absolutist metaethical theory we can ask ourselves, what known truths are being subverted by the physicians in their push for unnecessary surgical births?  There are several answers: the innate autonomy of the woman to make informed choices about her body and her birth, the duty of the physician toward primum non nocere, and the duty of the physician to ensure informed consent. All of these innate rights are being violated in the push for surgery to “cure” what might be “wrong”, not with the primary patient, but with the fetus.
We can look to other countries for ideas to drastically lower our surgical birth rate while maintaining or improving patient outcomes for both mother and child.
The first thing health care providers could do is to spend more time with patients educating them prior to conception, and throughout pregnancy. This would not only allow time to educate, but also foster trust between the mother and the person she has chosen to see her safely through birth. Currently, mothers receive no prenatal counseling and physicians spend on average four minutes per visit with each mother. This means the average healthy mother spends 22 minutes with her provider between conception and the start of month eight. By the time birth is eminent, a mother will have spent less than an hour total with her doctor. Contrast that to the midwifery model of care that has the patient spending, on average, one hour per visit and that hour is frequently in the mother’s home. In addition, many midwives adopt a model of group prenatal care that allows for additional time spent with a group of women in similar gestation, fostering a community of trust and support between both the provider and other pregnant women. This model has been shown to drastically reduce the fear and pain associated with childbirth.  Obviously most doctors are not in a position to offer this level of care, and most people couldn’t afford for a physician to provide it. An alternative would be to let doctors provide the care for truly high risk patients, and shift to midwifery for healthy women.
Another factor in the high cesarean rate in the United States is an epidemic called “failure to wait”. In our need for instant gratification, we forget that babies are not parcels delivered by UPS. They do not have an “arrive by” date, nor do they expire if not delivered within a prescribed time limit of 39 weeks, 6 days. The latest research surmises labor begins when the baby’s lungs send out a signal saying “we’re ready!” and not a moment before. For prima gravid patients, this is 41 weeks, 3 days! Cervical ripening agents and pitocin not excepted, a baby simply won’t be born before it is ready. Pitocin isn’t even an FDA approved medication for labor induction without medical cause, yet women request it, and doctors prescribe it and health care providers abuse the dosing schedule, increasing the rate too quickly or using a starting dose exceeding the package insert, all to make the baby come before the ball game/vacation/holiday/dinner. There is even a movement called “pit to distress” which basically says we’ll ramp up the pit until the baby can’t handle the intensity and frequency of contractions, at which point we’ll tell the mother her baby is going to die unless we do a cesarean. This isn’t even a lie because at that rate, the baby WOULD die—squeezed to death by the womb.
A third idea for reducing the cesarean rate in the United States would be to not only discuss, but educate and encourage women with previous cesareans to birth vaginally. Set up support groups and classes to make sure mothers make informed decisions about their options. You would be hard-pressed to find a surgeon who discussed all the risks of repeat cesareans with mothers. Just a few are adhesions, baby having to spend time in NICU because the cesarean was performed prior to spontaneous labor so baby has difficulty breathing, and placenta acreta (a disorder where the placenta grows into the scar tissue from the previous incisions and won’t let go when the surgeon determines it’s time; this frequently leads to hemorrhaging and subsequent hysterectomy).
In healthcare today, women need to demand better care from their providers. If our physicians won’t do the job of educating, we must find our education elsewhere. ICAN, the International Cesarean Awareness Network has many good resources and chapter leaders can be found in most parts of the country. Healthcare workers must act as guardians of labor and laboring women, ensuring the proper management of normal labor. Meaningful tort reform MUST pass, to give doctors the freedom to do what is best for patients, not the malpractice insurance agency, and every person must realize birth is a delicate dance between the baby and the mother. Health care providers are there simply to make sure the two of them do what they were designed to do, and nothing more.  
The risk of complications up to and including major abdominal surgery to birthing mothers can be reduced if our society takes a step back and remembers to treat birth as a physiological process to be watched and guided, rather than a pathological condition in need of treatment or management; birth by design, rather than birth as cure. Teaching the nation’s birth attendants the normal processes of labor in its many variations, rather than a set form of numbers that MUST be adhered to, “or else” will go far in reducing unnecessareans.

2.      Ob.Gyn News August 2010, p.1

No comments: