My one hope is that they don’t just focus on birth in the developed world (although, granted, we’re desperately in need of a birth revolution here in the developed world), but also tackle some of the ongoing issues in the developing world, too.  I can’t wait to see what comes next out of this! Viva la revolucion!

A few weeks ago, during a prenatal visit, a woman pregnant with twins told me she would love to have a home birth, but did not have the $4,000 cash required upfront to do so. She was afraid of potential interventions in the hospital. After a discussion of her fears as well as potential complications that can abruptly occur in a twin birth, she admitted she would prefer a hospital birth if she could maintain some control over the situation. This is not a woman who cares more about the birth experience than the baby, but she was tempted, and in some ways I can understand her concerns. My cousin’s wife had her twin induction halted at 4 cm because the new obstetrician on call did not do breech extractions for second twins. Her only option became cesarean delivery.

I recently received a phone call from a woman 2 hours away who had planned a home birth for her second baby after having an easy first birth. When the fetus, which was anticipated to be a little smaller, was found to be a breech, the midwife sent the woman to the local obstetricians. They would only deliver the fetus by cesarean delivery. The midwife offered the woman a home breech birth, but admitted she had only delivered one breech (stillbirth) in her career. The woman appropriately questioned the safety of this, and was referred to us. She met the criteria for our vaginal breech protocol, and had an easy vaginal breech birth in our hospital. Unfortunately, this is becoming a rarity. A colleague of mine in another state watched the residents she was supervising emotionally bully a young woman and her mother into a cesarean delivery. The young woman had a rapidly progressing active labor with a normal-sized frank breech fetus. Had the residents been open to the idea, my colleague easily could have taught them how to deliver a vaginal breech.

The running joke in our community is that the only way to get a vaginal birth after cesarean delivery (VBAC) is to have the birth at home. Unfortunately, this is a reality rather than a joke. Our small community hospital, owing to regional liability insurance constraints, stopped allowing VBACs in 2002 after many years of  successfully offering them. This has led many women to risk home birth rather than travel to a tertiary care center to attempt VBAC. I recently counseled a woman against having a cesarean delivery who had a BMI of 52 and who arrived in active labor at over 35 weeks of gestation with two previous successful VBACs. I spent the following months defending that recommendation, despite her considerable operative risks and high likelihood of success.

Recent news and media excitement about the benefits and increased safety of home birth over hospital birth have made the former seem like a very attractive alternative. A growing notion among women in our region, and perhaps across the country, is that hospitals and obstetricians are a more risky option than lay-home midwives for birth. Although my initial reaction is disbelief, perhaps we should look at how we, the  obstetricians, contribute to this trend.

Each of these women deserves an honest discussion about the fetal and maternal risks of each birthing option. However, our lack of experience as obstetricians colored by our fear of liability is narrowing women’s choices, and sometimes motivating them to ignore fetal and maternal safety in an effort not to be coerced into unnecessary interventions. I sense a mounting tension, because many obstetricians do not have the willingness, time, or skills to provide maternal choices.

I believe we are at a crossroad in maternity care in this country, and I am saddened that obstetricians are considered the culprits. Our contracting skill set as obstetric providers, as well as the prevailing risk-adverse culture among physicians and hospitals, have given support to home birth. We can all agree that VBAC, twins, and breech should not be managed at home, yet we frequently demand complete control of the situation and eliminate some appropriate choices in the hospital. I understand that it can be very unnerving to be ultimately responsible for the outcome, as we are, and yet pushed into situations outside of our comfort zones. However, our unwillingness to budge in these situations is causing us to lose the battle regarding what is really important to most obstetricians: safety for mothers and babies.

Certainly, we can be proud of the dramatic decrease in maternal mortality in the last century. But, despite the highest per capita expenditure of health care in the world, infant and maternal mortality rates in the United States are higher than in all of western Europe. We have the third-highest cesarean delivery rate in the world.

According to a recent study, nearly half of all primigravidas attempting vaginal delivery are induced, and half of cesarean deliveries for dystocia are done before 6 cm of dilation, presumably before active labor. It is amazing how many women begging for elective induction change their minds when told it doubles their cesarean  delivery risk.

We need to draw lines around patient safety, but must they be so rigid? Most midwives know from experience that Friedman’s curve is too strict. A recent study validates that knowledge. I sincerely hope it is taken seriously. Expectant management of ruptured membranes at term has been declared unsafe and of no benefit. The study that settled the question did not account for the number of vaginal examinations women received, and group B strep was not treated, both important variables. Most women do go into labor in 24 to 72 hours. The Cochrane systematic review concludes that, because the differences in outcome are not substantial, women need to be given the appropriate information to make a decision. This very rarely occurs in the hospital setting. The Term Breech Study closed the door on vaginal breech delivery even for the lowest-risk women in most obstetricians’ minds (including the residents I mentioned above). This, despite the opinion of the College that it may be appropriate in carefully selected situations. In any case, vaginal breech delivery is not completely avoidable, and should not be relegated to the history books with vaginal delivery for previa and high forceps.

Our mission has become more difficult in the last 20 years as mothers have become older, heavier, and of lower parity. Many women, admittedly, do have unrealistic expectations. Although I am eternally grateful for the obstetric skills I learned in residency, I have been amazed in my 14 years of practice to see much of the dogma I also absorbed disproven with experience and patience (both my own, my colleagues’, and the midwives I have worked with in the hospital setting). Collaborative practice with midwives is a good start, but in order for obstetricians to be more than providers of cesarean deliveries (a thankless and, in most cases, technically simple procedure) we need to have conversations with our patients that are not one sided and allow for true informed consent. Many of the obstetric disasters we have all seen and which color our  perspective (which David Grimes has called “numerators in search of denominators”) are at least in some part iatrogenic if examined deeply enough. That failed induction for convenience with early artificial rupture of  membranes and chorioamnionitis. The first cesarean delivery done at age 15 after 2 hours of pushing with an epidural that then leads to the fifth cesarean years later, and then accreta and life-threatening hemorrhage, are both typical examples. We need to recognize and own those aspects of obstetric management that are driving our skyrocketing cesarean delivery rate but having no positive effect on maternal or infant morbidity and mortality.

Admitting what is truly evidence based versus what is tradition and culture is a good start. It is essential that we offer real choices to our patients. We need to recover and disseminate the skills that make obstetrics an art and a privilege. Seek out mentors skilled in forceps, vaginal breeches, and breech extractions before it is too late. Then learn to be patient, so that you very rarely need to use them

I find this letter to be very brave and commendable, and while this may sound strange, I am actually really proud of ACOG for publishing it in the first place.  Kudos to Dr. Fineberg for writing this, especially given that she may very well experience a backlash from her colleagues for even suggesting that VBACs, vaginal breech deliveries and vaginal twin deliveries (with breech extraction for the second twin) are things which OBs should be offering their clients, let alone her suggestion that OBs may be partially responsible for driving women with complications to seek homebirth in the first place.

Even more fascinating to me, though, are the commentaries which are going up on The Unnecesarean right now, all written by a collection of different obstetricians who are willing to step forth and give their unvarnished opinion on the true state of things (and huge kudos to them, as well!).  Here are links to their articles:

Lamenting the System, by Dr. Jill Arnold

Lament in Stereo, by Dr. Lauren A. Plante

A Comeback for VBAC?, by Dr. Poppy Daniels

Another Obstetrician’s Lament, by Dr. Gustavo San Roman

An Obstetrician’s Hope, by Dr. David Hayes

The VBAC comments I found particularly compelling, given the sorry state of VBACs in this country right now (see my post below on the new NIH Consensus Guidelines).  The sad truth is, VBACs are no longer being offered as a viable option simply because of politics and a growing culture of fear (aided by our culture of litigation) which states that just because uterine rupture is (occasionally, super rarely) possible, there needs to be 24-hour on-call anesthesia, and an obstetrician on-call ready to brandish a knife at the drop of a hat…and because of this (occasional, super rare) risk, it’s better to not offer VBACs if you don’t have these emergency measures in place.  Nevermind the increasing risks associated with repeat cesareans, the growing rate of cesarean complications, placenta percreta/ acreta etc. etc.  But Dr. Poppy Daniels has addressed this on The Unecessarean more eloquently than I have time to right now, so I’ll let you follow the links.

Besides, I have much more exciting news to share! Stay tuned for a very personal birth story, coming up next!

A consensus panel of 15 non-advocate representatives (i.e. not lobbyists) from different disciplines (obstetrics, gynecology, pediatrics, maternal and fetal medicine, midwifery, clinical pharmacology, medical ethics, nursing, anesthesiology, risk management etc. etc.) got together and performed a thorough literature review and listened to presentations by experts, and then drafted the consensus report, posted above.  Pretty nifty, given the amount of information they had to wade through, and the fact that not all of the research available is good research.  I really liked the fact that the statement divides all of its research up into “High Grade of Evidence”, “Moderate Grade of Evidence”, “Low Grade of Evidence” and “Insufficient Evidence”.  My only complaint is that there isn’t actually a reference list at the back of the statement, and none of the research papers they are discussing are actually cited, so it makes it much harder to find and look at the research yourself.

And what does it say?  Basically, that the VBAC rate is still plummeting, and more research is needed.  Big surprise there.  The VBAC rate has been plummeting for decades, ever since its record high in 1996 of 28.3%.  It also seemed to suggest that ACOG could play a much bigger role in encouraging the practice of VBACs again, but maybe that was just my wishful thinking.

The statement begins by systematically reviewing the evidence behind the short-term and long-term benefits and harms of trial of labor v. repeat cesarean from the perspective of both mothers and babies.   Some of the benefits of trial of labor for mothers includes a decreased risk of maternal mortality when compared to repeat cesarean (high grade of evidence).  There is also a lower risk of hysterectomy (moderate grade of evidence), lower incidence of placental complications with future pregnancies, such as placenta previa, and placenta accreta/ increta/ percreta, (moderate grade of evidence), and shorter hospital-stays, with possible decreased risks of DVT (low grade of evidence).  Among the risks of trial of labor for mothers includes incidence of uterine rupture (moderate grade evidence), which is increased if there is a classical incision, i.e. a vertical uterine scar (however, there was only low-grade evidence to support this).  It’s also interesting to note that there was insufficient evidence to support the claim that repeat cesareans help avoid future pelvic floor dysfunction.

From the babies perspective, the perinatal mortality rate and neonatal mortality rate were observed to be lower in babies receiving repeat cesareans as opposed to trial of labor (moderate grade of evidence), and slightly higher rates of hypoxic eschemic encephalopathy in babies receiving a trial of labor (low grade of evidence).

To my way of thinking, though, the more important part of this statement is the fact that it also looked into many of the non-medical factors that are influencing the declining VBAC rate, such as professional association practice guidelines (ACOG’s 1999 Practice Guideline on VBAC being a big one), hospital and health-insurance policies, and professional liability concerns among physicians and hospitals.  I have heard my OB colleagues joke among themselves that the only bad cesarean is the one that isn’t done.  The general outlook that I have observed seems to be that doing a cesarean is always the right way to go from a medical-legal perspective; cesareans are perceived as being safer, by doctors and patients, no matter what the situation, and if in doubt, it’s better to err on the side of doing a cesarean than not.  This attitude can be found all over the place.  To quote a comment made by an obstetrician on KevinMD.com: “You never get sued for doing a cesarean section, you get sued for not doing one. So given the scenario with a questionable fetal heart rate tracing where any “expert witness” can find fault with, (even if there is none) I would rather perform a cesarean section than not. It comes down to a matter of staying in practice and making a living.”

The last Practice Guideline that ACOG has issued on the subject came out in 1999, and reversed its prior encouragement of VBACs, instead saying that women should be “offered” (rather than “encouraged” to have) a trial of labor if there are no contraindications, but basically asserting that it’s a personal decision, and can be decided on between doctor and patient on a case-by-case basis.  The 1999 Practice Guideline also stated that trials of labor should only be done in hospitals ready to respond to emergencies with on-call physicians always available to perform an emergency cesarean, as well as 24-hour on-call anesthesiology coverage (a standard which many rural and smaller hospitals find very difficult to comply with).   It’s important to note that this recommendation was rated as a Level C in the ACOG Guideline (i.e. based on consensus expert opinion, with no hard evidence to support it).  Nevertheless, many hospitals and providers have cited the lack of these emergency provisions as the reason that they no longer offer women trials of labor.

In it’s conclusion, the NIH consensus report directly addresses this issue:

Given the low level of evidence for the requirement of “immediately available” surgical and anesthesia personnel in current guidelines, we recommend that the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists reassess this requirement with specific reference to other obstetric complications of comparable risk, risk stratification, and in light of limited physician and nursing resources.

We now know so much more about the causes of uterine rupture and the safety of VBACs than we did 20 years ago when the practice was first encouraged.  We know that the use of prostoglandin induction agents such as cytotec and cervadil were a chief cause of uterine rupture, and that women with low-transverse uterine incisions actually have a pretty low rate of uterine rupture.  With this in mind, it’s probably time for ACOG to finally issue a new Practice Guideline on VBACs.

A last comment about the NIH report: they left a laundry list of critical gaps missing from the research, highlighting the places where more information is desperately needed, which was nice to see.  They also issued a few choice words about the “cesearean as best defense” mentality:

We are concerned that medical-legal considerations add to, and in many instances exacerbate, these barriers to trial of labor.  Policymakers, providers, and other stakeholders must collaborate in developing and implementing appropriate strategies to mitigate the chilling effect the medical-legal environment has on access to care.

I couldn’t agree more!  Thank you, NIH, for a well-written and informative report.  Maybe this will help swing the momentum back in favor of VBACs again!

Cesarean births are not “safer”. Numerous studies have demonstrated, again and again, that cesarean births carry more risks than vaginal delivery, and these risks multiply with each cesarean birth. Sure, the woman in this article had a “safe” and uncomplicated primary cesarean, but no attention is given to what happens when this same woman comes back for her second or third repeat cesarean—how difficult it is to perform surgery on the same site, to cut through scar tissue, how the risks for abnormal placentation such as placenta previa or placenta acreta increase exponentially with each cesarean, how the risk of hemorrhage increases dramatically. There’s also no discussion about how painful recovery from a cesarean is compared to recovery from a vaginal delivery, and how statistics have shown that this poorly affects bonding and breastfeeding rates in women who’ve given birth by cesarean. (Not to mention the fact that the motivation for elective cesareans for many women is a fear of pain, and in fact, the entire process is often much more painful, for a much longer period of time, post cesarean).

Vaginal delivery can, for example, lead to future incontinence and pelvic damage, while babies born by C-section may suffer from respiratory problems because of not being exposed to certain hormones during the birthing process.

Where is the author, Alice Park, getting this information from? How come there are no articles or references cited? I thought we were well beyond the argument that cesareans prevent pelvic floor damage. While injury to the pelvic floor can and does occur during vaginal delivery, it’s often caused by practices such as episiotomy, vacuum-extraction, forceful pushing and lithotomy position during deliveyr, all of which can be (and are being) minimized during vaginal birth. Routine episiotomy, for example, is now by and large a thing of the past. Furthermore, there is no conclusive evidence which demonstrates that cesarean section prevents pelvic floor damage. To quote from What Every Pregnant Woman Needs to Know About Cesarean Section (2006), published by the Maternity Center Association:

Is vaginal birth in and of itself harmful? It is common to hear that “vaginal birth” causes pelvic floor problems. Of hundreds of studies examined, however, not one attempted to avoid or limit the use of practices that can injure a woman’s pelvic floor to try to determine whetehr vaginal birth itself plays a role. It is wrong to conclude at this time t hat the cause of pelvic floor problems is giving birth through the vagina….

Is “vaginal birth” the culprit in the high levels of incontinence that women experience later in life? Studies that take a longer view find that new problems with urinary incontinence that appear after birth lessen over time. These problems tend to completely disappear by the time of menopause. Older women experience high rates of incontinence, but this appears to be due to other factors. For example, excess weight and smoking play a role.

Does cesarean section prevent incontinence? Routine cesarean section would only prevent continuing symptoms of incontinence in a small portion of birthing women. For most women, it would pose numerous risks without benefit. And it would offer no protection against experience incontinence in later years. As no research has found that vaginal birth itself causes incontinence, there are more sensible ways to prevent these problemss: 1) avoid when possible the use of birth interventions that can injure the pelvice floor, and 2) focus on keeping a healthy weight, avoid smoking and other risk factors.

(Still not convinced? Check out the following studies:

[1] Shorten, A, Donsante, J. & Shorten, B. (2002) Birth position, accoucheur and perineual outcomes: Informing women about choices for vaginal birth. Birth, 29(1), 19-27.

[2] Terry, R, Westcott, J, O’Shea, L., & Kelly, F. (2006). Postpartum outcomes in supine delivery by physicians versus nonsupine delivery by midwives. The Journal of the American Osteopathic Association, 106(4), 199-202.

[3] Soong, B., & Barnes, M. (2005) Maternal position at midwife attended birth and perineuam trauma: Is there an association? Birth, 32(3), 164-169.)

The point being, I can’t believe such a mainstream publication could write such an imbalanced, one-sided and poorly researched article. I think I feel a letter to the editor coming on!

Obviously, other people feel similarly, and in a landmark case decided in Massachusetts, a court ruled in favor of the plaintiff, Mary Meador, a woman who gave birth via cesarean section and claimed that the risks of VBAC were misrepresented to her and that she was coerced and misled into having a cesarean—so, basically suing for receiving an unecessary cesarean section. (Editor’s note 1/6/07: It has come to my attention that this case is from 1993, so not really landmark these days, although it’s nice to know a precedent like this exists. I wish it had made more of an impact.)

One has only to look at womens’ responses to cesareans that they know are unecessary to see how destructive and devastating this practice can be. How can anyone think that coercion qualifies as informed consent? What amount of pain and anguish can lead to art like this?

In my practice as a nurse, I cannot tell you how many times I’ve seen a cesarean performed for no good reason at all: for provider preference, because he or she wanted to go to sleep, or get to their office hours on time, or because of provider ignorance. Just last night at work, I was with a woman who was moderately preeclamptic with increasing amounts of protein in her urine (an ominous sign). I agreed with the obstetrician’s decision to deliver this baby immediately, but because her baby was breech, she was told that cesarean was her only option, end of story, sign on the dotted line, please. No informed consent, no weighing of the benefits and risks of induction and breech delivery versus cesarean. Forget the fact that this was her fourth baby, and that her first three babies were all uncomplicated vaginal deliveries. Forget the fact that she had a “tested” pelvis that was more than adequate to accomodate her baby (a tiny little peanut that ended up weighing 6 lbs. 8 oz.). Because of lack of provider skill, because of lack of provider education, because breech deliveries are so rarely performed any more, by any one, this woman had a primary cesarean.

Cesarean is increasingly becoming the correct response to any birth that deviates even slightly from “normal”. Cesarean is nine times out of ten (the Meador v. Stahler and Gheridian case aside) the trump card that will stand up to court scrutiny. Doctors are so concerned about not doing a cesaeran that it’s very easy to forget the other angle to it: cesareans are major abdominal surgery, with more risks associated with it than vaginal birth. Imagine what our world would be like if doctors felt more strongly about the possibility of being sued not for failing to do a cesarean, but for performing a cesarean that was unecessary? Imagine how much longer trials of labor would last, how much higher our VBAC rate would be, how much more time women who are being induced would be given to allow their bodies to go into labor. Imagine the increased time and attention that would be spent with true informed consent, and the weighing of options? Imagine how much lower our cesarean section rate would be.

Many women are willing to take the risk [of having a VBAC], and the hospitals’ stance has become a charged issue, part of a larger battle over who controls childbirth. Some women say their freedom of choice is being steamrolled by obstetricians who find Caesareans more lucrative and convenient than waiting out the normal course of labor. Doctors say their position is based on concern for patients’ safety.

Meanwhile, a story from yesterday’s New York Daily News charts the rising cesarean rate in hospitals, citing which five hospitals in New York city have the hightest rates: New York-Presbyterian Hospital Columbia (a whopping 39.6%, which still seems monumental even when you factor in that NY Presb handles many of the highest risk births in this city—the method of handling them is obviously cesarean), St. Vincent’s Hospital Staten Island (39.5%), Brooklyn Hospital Center (38.5%), New York Presbyterian Weill Cornell (37.1%) and finally, Flushing Hospital (37%).

Powerful numbers, indeed. If this continues, the Healthy People 2010 goal of a 15% cesarean rate for first time mothers and an increase the VBAC rate to 63% will seem laughable, rather than even remotely attainable.

And then, it never rains but it pours: Nabbed from Milliner’s Dream, who saw it first, a recent French study also found that having a cesarean more than triples a woman’s risk of death when compared to the risks associated with a vaginal birth. (Postpartum Maternal Mortality and Cesarean Delivery) The increased risk of death was found to stem from complications from anesthesia, puerperal infection and venous thromboembolism, all of which are risks associated with surgery.

So, how…vindicating. There is now a sudden spurt of evidence which suggests that cesareans aren’t nearly as safe or benign as common practice would indicate. Now the question is: how long will it take for the medical community to absorb this new information and begin to cite the risks involved to the women trying to schedule a primary cesarean when there is absolutely no medical indication for one? It took years for the medical community to acknowledge that routine episiotomy can cause more harm than good, but practic is finally beginning to change. And, I wonder who will be the first to try to refute these findings?

(By the way, have you noticed how chock-full of good stuff the September issue of Obstetrics & Gynecology is? In addition to the above French study on maternal mortality and c-sections, check out ACOG’s Committee Opinion on the HPV vaccine).

ADDENDUM:

ACOG’s press release on the results of the French study in this month’s Obstetrics & Gynecology :

Though rates of maternal death in most developed countries are relatively low—US women have a 1 in 3,500 chance of pregnancy-related death—incidences of maternal mortality have not significantly decreased in the last two decades. These study results suggest that mode of delivery may be a modifiable risk factor, and in some cases, choosing vaginal delivery over non-medically indicated cesarean delivery could help lower maternal mortality rates.

Coercive C-Sections
Don’t get forced into having a surgery you don’t need
——————————————————————————–
By Lisa Collier Cool

Amber Marlowe anticipated an easy delivery when she went into labor on January 14, 2004. But after a routine ultrasound, doctors at Wilkes-Barre General Hospital, in Pennsylvania, decided that the baby — at what looked like 13 pounds — was too big to deliver vaginally and told her that she needed to have a cesarean. The mom-to-be, however, wasn’t convinced: After all, she’d given birth to her six previous kids the natural way, including other large babies. And monitoring showed that the fetus was in no apparent distress.

After she said no to surgery, doctors spent hours trying to change her mind. When that didn’t work, the hospital went to court, seeking an order to become her unborn baby’s legal guardian. A judge ruled that the doctors could perform a “medically necessary” c-section against the mom’s will, if she returned to that hospital. Meanwhile, she and her husband checked out against the doctors’ advice and went to another hospital, where she later gave birth vaginally to a healthy 11-pound girl. “When I found out about the court order, I couldn’t believe the hospital would do something like that. It was scary and very shocking,” says Marlowe. “All this just because I didn’t want a c-section.”

She and her husband, John, turned to the National Advocates for Pregnant Women (NAPW), in New York City, for help in contesting the judge’s ruling — the first of its kind in Pennsylvania. The couple is also considering legal action against the hospital. “It’s not about us,” says John Marlowe. “What’s going to happen to the next lady who goes there? We want everyone to know what’s going on. What they did was wrong, and our goal is to put a stop to it so that other women don’t end up with c-sections they don’t need.”

Coercive medicine
Increasingly in the United States, pregnant women are encountering legal or more subtle pressures to have c-sections. Currently, more than a million expectant women have the operation annually, as America’s rate of surgical deliveries has hit an all-time high. In 2003, cesareans accounted for nearly 28 percent of births in this country, compared with just 5 percent in 1970. Many factors contributed to this rise — increasing numbers of repeat c-sections, doctors’ fears of malpractice lawsuits, and women waiting longer to have kids (which is related to higher rates of complications), to name a few. But while the procedure is usually quite safe and can be potentially lifesaving for mother and baby, it also poses a number of potential risks, including severe bleeding, infection, injury to the fetus, blood clots, and even the mother’s death in extremely rare cases.

Yet hospitals in at least a dozen states have obtained court orders to compel unwilling women to undergo this major abdominal surgery. And while Marlowe was able to escape the scalpel, other patients were operated on — despite their verbal or even physical resistance. In a tragic 1984 case, staff at a Chicago hospital forcibly tied a pregnant Nigerian woman who had declined a c-section to her hospital bed with leather wrist and ankle restraints. The woman objected to the surgery because she planned to return to Nigeria where the operation wasn’t readily available, and she rightfully worried about health risks, including a ruptured uterus, if she became pregnant again and had another child vaginally back home. As she screamed for help and frantically tried to free herself, doctors, with a judge’s permission, wheeled her off to the O.R. to perform the procedure.

Defying doctors’ advice can even lead to criminal prosecution, as Melissa Rowland discovered last year. While pregnant with twins, the 28-year-old Utah mom initially declined a recommended c-section, even though doctors warned that without it her babies might die due to low levels of amniotic fluid and other problems. Several days later, on January 13, 2004, she changed her mind and had the operation. Her daughter, Hannah, survived after treatment with oxygen and antibiotics, but a twin boy was stillborn. Contending that the initial refusal caused his death, prosecutors charged Rowland with first-degree murder. After spending three months in jail, she accepted a deal in which the murder charge was dismissed in return for her guilty plea to two counts of child endangerment (unrelated to her c-section refusal). She’s now free, and serving 18 months of probation.

“This case is a tragedy compounded by a shocking abuse of legal authority,” contends Lynn Paltrow, executive director of NAPW and a lawyer specializing in reproductive issues. “It shouldn’t be a crime for pregnant women to disagree with doctors and make their own medical decisions. Nor should they be punished for a bad outcome when there’s always some risk to giving birth, regardless of whether it’s vaginal or by c-section.”

And you can’t be legally compelled to undergo any other medical procedure for the benefit of another person. “You don’t have to donate your kidney, your bone marrow, or your blood, even if someone else might die without it,” explains Howard Minkoff, M.D., chair of obstetrics and gynecology at Maimonides Medical Center, in Brooklyn, New York, and coauthor (with Paltrow) on an analysis of the Rowland case published in the December 2004 issue of Obstetrics and Gynecology. You also can’t be prosecuted for murder if you refuse. “So why should c-sections be any different?” the doctor adds. “That’s saying pregnant women have fewer rights than anyone else, including a fetus.”

A subtle pressure
Of course, only a minute fraction of the c-sections performed in this country are court ordered. Far more women undergo the procedure at the recommendation of their doctor. The most common reason a woman is encouraged to have a c-section is if she previously delivered a child this way. These “repeat c-sections” have become so common that they now account for nearly 410,000 births annually in the United States, about 10 percent of births each year.

And it doesn’t seem that this number will be getting any lower, as an increasing number of hospitals that formerly permitted women to try for vaginal birth after cesarean (VBAC) now prohibit the practice, making a return trip to the O.R. mandatory for moms-to-be with a previous surgical delivery. Because it’s getting harder and harder to find medical centers that allow VBAC, the rate has plunged by nearly two-thirds, from 27.5 percent in 1995 to 10.6 percent in 2003.

Ask doctors what’s behind the ban, and you’ll hear the same answer: fear of lawsuits. Trying for a VBAC carries with it a 1 percent risk of uterine rupture. This dangerous complication is an emergency that requires surgical repair — or, in some cases, a hysterectomy — to stop potentially life-threatening blood loss. “Medical liability is a huge problem for obstetricians, because people are losing their practices over malpractice claims,” reports medical ethicist Anne Lyerly, M.D., assistant professor of obstetrics and gynecology at Duke University in Durham, North Carolina. “So it’s understandable that a lot of us practice defensive medicine by avoiding risky deliveries that might have adverse outcomes.” A 2004 American College of Obstetricians and Gynecologists (ACOG) survey bears this out, since 15 percent of its members say they’ve stopped doing VBACs to protect themselves from malpractice claims, and another 14 percent no longer deliver babies at all for the same reason.

In 1999, ACOG responded to concerns about VBAC risks with new practice guidelines, saying that the delivery should only be provided at hospitals equipped to do an immediate c-section if anything went wrong, instead of within 30 minutes’ notice, as was previously required.

That’s fine for big medical centers that have anesthesiologists and surgeons on duty 24/7, like the one where Dr. Minkoff delivers babies, but not for smaller hospitals. “Often, they can’t afford to have doctors standing by in case a woman who arrives in early labor needs surgery later on, so in many parts of the country, especially rural areas, pregnant patients can’t find anywhere to have a VBAC,” he explains.

An ethical debate
How far should ob-gyns go to save an unborn baby they consider at risk? Some of the very doctors you’d most expect to advocate for pregnant women actually support forced c-sections, a 2003 University of Chicago study found. When the researchers surveyed directors of 42 maternal-fetal medicine programs around the country, 14 percent reported that their hospital had used court orders to compel unwilling women to have O.R. deliveries. What’s more, 21 percent of these specialists in the care of pregnant patients consider coerced c-sections “ethically justified” to spare a fetus possible harm — even over the woman’s physical resistance, as long as her struggles weren’t strenuous enough to endanger her or the baby.

ACOG adamantly disagrees. In 2004, its ethics committee ruled that it’s never right for health care providers to subject pregnant women to physical force, even with a court order authorizing a c-section or other procedure. The committee also said that seeking such orders against a patient’s wishes is “rarely if ever acceptable.” The American Medical Association, another prominent doctors’ group, has a similar policy.

So what should happen if a doctor is convinced that a vaginal birth would be disastrous? “Personally, I’m willing to counsel women very strongly in that situation — and bring in another physician to offer a second opinion about the risks of not having a c-section,” says Dr. Lyerly. “I also tell patients that it’s a very safe operation — and I should know, since I’ve had three c-sections myself.”

However, doctors’ opinions can also be tragically wrong. Years ago, a Washington, D.C., hospital got a court order to perform a c-section on Angela Carder, who was gravely ill with cancer. Since the mom was in such poor health, the hospital’s doctors believed that delivering the 26-week fetus immediately would give it a better chance of survival than waiting for a natural delivery. The result? Carder and her baby both died soon after the operation. Later, in a landmark 1990 ruling, an appeals court overturned the order, finding that Carder had a right to make medical decisions for herself and her unborn child. Her family also received an undisclosed financial settlement from the hospital.

“I hope that doctors and judges are humbled by this terrible mistake that never should have happened,” says Dr. Lyerly. “We can make dire predictions and think patients are too irrational to weigh the risks for themselves, but we’re not infallible. And since doctors and moms can both be wrong, and if they can’t agree on the best way to give birth, ultimately it has to be the woman’s choice.”

When surgery is being considered, experts say pregnant women need to feel confident that their wishes will prevail, whether they consent to an elective or emergency c-section or decline one they deem medically unnecessary, as Amber Marlowe did. In 25 years of delivering babies, Dr. Minkoff has learned to respect his patients’ decisions about how they want to give birth — even if he doesn’t always agree. “It’s my duty to fully explain why I think a c-section should be seriously considered and the risks of not following my advice,” he says. “But in the end, the strongest advocate for the safety and health of an unborn child is the baby’s mother. And that’s the way it should be, because she has the most at stake.”

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Lisa Collier Cool is an award-winning health journalist and mother of three from Pelham, NY.

You don’t see true stat c-sections like this that often, and afterwards, there’s a period of time where you sort of wander around for awhile with a glazed expression on your face, all pumped up on adrenaline, and wondering to yourself “what the hell just happened?” So, you can imagine our surprise when we had just begun to recover from the first nightmare when all of a sudden another woman’s baby bottomed-out into a prolonged decelleration and another stat c-section was called. There was this terrible sense of deja-vu as we were scrambling yet again to get another OR ready (it’s very rare that we have two ORs going at the same time!), although this time, the c-section was not quite as fast as the first one. We were able to do a proper count beforehand, and the woman was not put under general anesthesia.

Praise to all things holy, both babies turned out just fine. The first one went to the NICU with Apgars of 2/8 and the second one went to the well-baby nursery with Apgars of 8/9. It was a bit of a crazy night.

And the questions I am left with are these: how does one continue to believe in the beauty and safety and normalcy of birth in the face of experiences like this? If either of these bradycardias had occurred at home, there’s a good chance that the first baby wouldn’t have survived, and the second baby would have been severely damaged. When people tell you that homebirth is unsafe, they are thinking about incidences like this. And maybe they’ve got a point, if you just look at the last half-hour of both of these womens’ labor: their babies were in distress, and modern medicine was needed to save them. It really sort of leaves you hollow, and frightened, and questioning everything you believe in. But then, do you just ignore all of the things done to these women by modern medicine which may have been what put their babies into such stress in the first place? The inductions, the epidurals, the pitocin, the invasive monitoring, the IVs and near starvation of their mothers while they labored, the supine position, pushing in lithotomy, high forceps…what would these births have looked like if they had been allowed to go at their own rate and time? If the women had labored in different positions? If so many interventions hadn’t altered the course of their body’s rythym? Maybe instead of asking why birth is so scary, and unsafe, and always an emergency waiting to happen, maybe the question I should really be asking is: what are we doing to women in hospitals that causes so many bradycardias?

Now, I have two conflicting thoughts here. On the one hand, it’s her body, her choice, she’s a woman, and I have to respect her decision, even if I would have counselled her otherwise, or made a different decision myself. On the other hand, she’s an icon with a huge following and therefore an untold amount of influence and power, and therefore an extraordinary opportunity to create positive change and lead by example. Some celebrities use this power to its utmost (just look at Sean Penn in New Orleans in his own boat, doing what he personally could to save lives and ease suffering); others fritter it away and could care less, and still others abuse their power and influence to terrible ends.

Britney had an opportunity to educate herself about birth. Britney’s family had an opportunity to edcuate themselves about birth. Britney’s health care providers had an opportunity to educate her about birth. Her fans were watching her pregnancy and the decisions she made very closely. She could have created far-reaching positive change in the way young women in this country view birth. Instead, she upheld the status quo, and embraced the idea that childbirth is painful, not something a woman can or should go through, if she can afford not to, and cesarean birth is an easier and safer ideal. Why did she have to go to the far extreme of technological intervention? Why not show instead that women’s bodies are strong, capable of birth, and that babies don’t need an exit through the abdomen when one has already been so perfectly designed for them? I mean, c’mon…if she really wanted to avoid the pain of natural childbirth, why didn’t she just have an epidural? Then she could have still delivered vaginally, at least.

Golden opporunity pissed down the drain.

I guess while we’re at it, we can always encourage Britney to breastfeed.