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?