The Downward Spiral of Obstetrics

I have always enjoyed Red State Moron's blog as it is often thought provoking. Last week's posting on defensive medicine touched home as I have seen the ramifications of this in obstetrics. Indeed I commented on it, stating, "As a matter of fact, defensive medicine is seen in almost every facet of obstetrical care. So much so, obstetrics has become so perverse in it's treatment of a normal physiological process, it has obscured the entire birth process."

In my years supporting birthing women and focused on cesarean reduction, I have long pondered the causes for the climbing cesarean rates. I am not talking as much since 2000 when defensive medicine has indeed skyrocketed the cesarean surgery rates as I am in the 1990's when VBAC was a viable option for childbirth. Indeed it is the safest option, by viable I mean readily available to birthing women in North America. This option has quickly disappeared thanks to ACOG's decision to reduce its members liability concerns and make this option only available in high-risk hospitals.

It started innocently enough, physicians trained to save lives stepped into childbirth only when it became a life threatening to mother or baby. Then, as medical schools increased, this role slowly eroded with physicians not finding enough work so they started to see attending normal birth as a way to increase clientele. Putting anyone trained to intervene to save lives in charge of a normal physiological process naturally led to interventions, some believed needed, most only causing more problems. Pain medication, episiotomy and Friedmann's curve were the first red flags of this "support." Birth did not become safer because of this support, indeed it became riskier. Infection and medication side effects took many lives and actually afforded the need of specialists - pediatricians to care for the newborns grossly affected by labour medications and obstetricians to attend to the highest risk mothers.

Which brings us immediately to the next topic, fear. Women historically have not looked forward to labour. It is not a walk in the park and all women knew it hurt, for most it truly set the bar on pain. There was also the fear of death, though (with the noted exception of iatrogenic infection) that is something we face every day, and birth is truly as safe as life gets. Anyway, it grew from the kind of fear one faces when making an important decision (you know, that stressful "I don't know what to do" fear) to paralyzing fear, the kind that leaves you in your tracks, unable to move.

How did this happen? Because we moved from birth as being a normal process all women go through to have children to a "condition" that must be "treated" by a qualified physician. My mother believed that, as did her mother. To do otherwise was indeed not an option without the belief that is was risking the life of mother and baby. I too believed that, engrained as I was with the sales pitch of modern medicine. Congratulations on the marketing campaign, you have indeed captured your intended audience physicians!

Add to that the media who inundate us with the sensationalized perils of medically managed labours on popular reality TV shows, where physicians save all in a single bound after leaving viewers on the edge of their seats with, "will she survive? find out after these messages."

Let us top it off shall we? Almost every obstetrical intervention is not evidence based. Episiotomy, once almost universally done and touted as necessary, has only recently been devalued by physicians... though women have long known its risks and outcomes. EFM (electronic fetal monitoring) was touted to save lives and yet the evidence has only shown that it increases intervention and surgery rates, not benefited babies. Pinnard horns are as reliable, and indeed safer. Heck, there have been NO long term studies on the effects of EFM ultrasound waves on anyone, let alone fetuses. Thalidomide comes sharply to mind too. But we have not learned our lesson, we still have cesarean for breech, almost every induction (very rarely for life-threatening situations), GBS and GD managment during pregnancy and labour, prophilactic cesarean for prior cesarean, prophilactic cesarean for macrosomia... I could go on, but the list is endless. All of these are not based on evidence at all and often the evidence refutes these common interventions.

The fear of facing a medically managed labour is very real. I was naive when I had my first in 1991. I didn't have the Baby Story to show me the fallicy of this option or I most certainly would have feared childbirth much more. No wonder women are requesting elective cesareans!! The alternative to these to options is homebirth, but even that is not always known or even available. Homebirth midwives are too often constrained in their practices, not being "allowed" to catch breech, twin or VBAC babies. I have heard of many women who, in lieu of these options, birth unassisted or travel great distances to find the support they want.

No wonder there is a great fear today, there is a huge downward spiral of non-evidence based defensive medicine happening here. Where will this spiral end?

Exciting Projects

I need to focus, or at least I tell myself that at least twenty times a day. I also have to realize more fully that I am at heart an idea person and as such find it difficult to not have at least 10 lightbulb moments a day concerning the projects I am working on.

Today I am working on the first affiliation agreement for ICAN as they formally expand to include ICAN/AIIC Canada. As both ICAN International Director and ICAN/AIIC Canada's President, I very much have a vested interest in not only the success of this agreement, but the continued expansion successes of ICAN and the growth of ICAN/AIIC Canada. So many great ideas, enhanced by the input from our current board. I have to sit down and add them to the agreement for our next meeting on Friday.

I also just completed an expansion/renovation proposal for the healing centre and reception area of my church. This is after many hours of discussion with all involved, most of it informally, with awesome ideas as a happy consequence of "visiting." It is very exciting and now that I have the preliminary proposal finished, I can wait and see if it is accepted. Or not. I am more likely to start the interior design plans in anticipation of its acceptance.

There is also the mundane part of parenting life, a visit to our family physician for a referral to a podiatrist for my son, the continuing (and seemingly neverending) saga of potty training, heal insurance forms to be photocopied and submitted, meals to be made and homeschool to be taught. This is all flavoured with a dash of sitting down with son number two and having a heart-to-heart about friends and perspectives and a board game with son number three while daughter number one (child number four) "helps" while greatly hindering.

How is your day going?

You are Joshua!


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Neural Tube Defect Cause

Again a new study, as I have been noting over the years, reveals nutrition is a critical key to healthy offspring...

Corn mold may have fed NTD outbreak
Source: Environmental Health Perspectives 2006; 114: 237-41

Investigating whether maternal exposure to fumonisin, a mycotoxin that often contaminates corn, increases the risk of neural tube defects in offspring.

Tortillas made from corn containing a toxic mold may have caused the high prevalence of neural tube defects (NTDs) seen on the Mexican-American border in the early 1990s, research suggests.

Scientists have for decades been trying to determine why the incidence of NTDs among Mexican-American women doubled in 1990-1991. No chemical links to the affected infants have been confirmed. But the researchers note that the period began the same crop year as an outbreak in corn mold and that Mexican Americans in Texas consume a lot of corn, largely in the form of tortillas.

To investigate whether a toxin produced by corn mold, fumonisin, may have been responsible for the outbreak, Stacey Missmer (Harvard School of Public Health, Boston, Massachusetts, USA) and colleagues conducted a population-based case-control study.

They found that, after adjusting for confounding factors, a moderate (301-400) compared with a low (100 or less) intake of tortillas during the first trimester of pregnancy was associated with an increased likelihood of having a NTD-affected pregnancy (odds ratio = 2.4). No increased risks were observed, however, with higher intakes.

"Our findings suggest that fumonisin exposure increases the risk of NTD, proportionate to dose, up to a threshold level, at which point fetal death may be more likely," the researchers conclude.

Posted: 16 February 2006

Sick, sick, and sicker

Sorry I have been so quiet, quite unlike me I know. Well between preparing for the inaugural ICAN/AIIC Canada board meeting and being so sick that to pry me off the couch was a feet neither birth child nor husband could do, I haven't spent much time on the computer. With both of these now mere history (with the noted exception of severely cramped upper back muscles from the coughing and sneezing which nearly loosed my head from its moorings on many an occasion), I am making a brief appearance. Now I am off to get the 2005 finances in order for ICAN/AIIC Canada to give to our ICAN Int'l finance officer... catch you soon at a blog near you!

Prenatal Depression

It grieves me greatly that newborns are facing withdrawal due to the medications their mothers take. I truly understand the need that some mothers have for treatment of depression, though there are alternatives to SSRI's which many feel are way over prescribed.

Mom's antidepressants hit third of newborns: study
Feb. 6, 2006

CHICAGO (Reuters) - Nearly one in three infants born to women taking anti-depressant drugs exhibit signs of withdrawal and expectant mothers may want to limit the drugs they take, researchers said on Monday.

Symptoms such as high-pitched crying, tremors, gastrointestinal problems and disturbed sleep may show up in the first 48 hours after birth and were more pronounced in infants whose mothers had been taking higher doses.

A closer look at the 37 infants exposed in the womb to paroxetine hydrochloride, sold as Paxil by GlaxoSmithKline, showed the risk of symptoms disappeared if the mother's dosage was less than 20 milligrams daily while the risk was highest among those exposed to 27 milligrams or more.

Thirty percent of the 60 newborns exposed to one of the popular class of drugs known as selective serotonin reuptake inhibitors (SSRIs) in the womb were found to have withdrawal symptoms and the symptoms were classified as severe in 13 percent, said the study by Dr. Rachel Levinson-Castiel of the Children's Medical Center of Israel, in Petah Tiqwa.

Symptoms usually did not peak until after the first day of life but the long-term effects are not known, the study said.

Two of the exposed infants suffered seizures but they did not persist.

Previous studies into the effects of SSRIs on newborns have identified other symptoms such as rapid breathing, bluish skin color from lack of oxygen, feeding difficulties, low blood sugar and jitteriness.

Yet a study published last week by researchers at Massachusetts General Hospital in Boston said women who need an antidepressant cannot depend on hormonal changes in pregnancy to relieve their symptoms so may choose to continue taking the drug.

"Because maternal depression during pregnancy also entails a risk to the newborn, the risk-benefit ratio of continuing SSRI treatment should be assessed," Levinson-Castiel wrote in the journal Archives of Pediatrics and Adolescent Medicine.

Unfortunately, "the long-term effects of in utero exposure to SSRIs have not been demonstrated clearly," not even for those whose symptoms were severe early on, she wrote.

Both studies recommended pregnant women simplify their drug regimen to a single drug at the lowest effective dose.

Pre-eclampsia Concerns

Having seen the devistating effects of pre-eclampsia and it's much more dangerous cousin HELLP syndrome in my own clientelle, I echo Red State Moron's quest for the holy grail. Yet, outside of mainstream obstetrics, we have seen the dramatic reduction in pre-eclampsia, toxemia and HELLP (not to mention preterm birth, low birth weight and IUGR) in the late Dr. Tom Brewer's practice. Nay, not reduction, elimination of the above.

How on earth did he do this? Simply, it was nutritional counselling and adherance to his guidelines. The stunning results are found here. Ironically, nutrition is virtually ignored in allopathic medicine as having any impact on health. The reason? The easy answer is because nutrition is not taught in medical school beyond a basic level, and certainly not in the depth needed to effect pregnancy outcomes. Physicians cannot provide information on what they don't know. Why are they not taught? Because it isn't ethical to do RTC's based on nutrition because you may be compromising patient health.

Just like it isn't ethical to do RTC's on elective caesarean vs. vaginal birth... either primary or post-caesarean because it knowingly compromises patient health to subject a woman to unnecessary major abdominal surgery for a normal physiological process in the absence of indications. But I digress.

Dr. Brewer's nutritional basics stand up both in his studies and when compared to the newest nutritional studies, guidelines and information available. Midwives have long supported the critical aspect of nutrition, but in North America most women seek obstetricians or family practic physicans (if they can find any who are still catching babies). Interestingly, some obstetricians are now following suit by having nutritional guidelines for patients with excellent results. Notably, Dr. Motha does this in her Gentle Birth Method: The Jeryarani Way. But not nearly enough are doing this or providing any nutritional counselling at all.

I pray that each mother finds either guideline and follows it towards superior outcomes in spite of the lack of obstetrical training and knowledge in the field of nutrition.