Primal Health Research: A New Era in Health Research
Published quarterly by Primal Health Research Centre
Charity No.328090
72, Savernake Road
London NW3 2JR
Summer 2004 Vol. 12 No.1
An article of the same title appeared in The Journal of Prenatal & Perinatal Psychology and Health (JOPPPAH) Volume 19, Number 2, Winter 2004
Nowhere in obstetrics is there such a discrepancy between evidence and practice as in the matter of gestational diabetes. This diagnosis has been mentioned briefly in several issues of our newsletter, in order to illustrate the frequent “nocebo effect” of prenatal care. (1,2,3,4) I have recently received so many phone calls of sorely distressed women that I find it necessary to provide updated answers to frequently asked questions.
How to explain? How to explain with simple words the real meaning of this scary diagnosis? How to explain that it is not a disease like with symptoms leading to complementary inquiries, but the mere interpretation of a laboratory test?
It is essential to emphasize that such a diagnosis is made after the “glucose tolerance test” is included in the battery of tests routinely offered to pregnant women. It is easy to illustrate this fact by referring to the results of a huge Canadian study.(5) In some parts of Ontario routine screening was interrupted in 1989, while it remained usual elsewhere in that state. It became clear that the only effect of routine glucose tolerance test screening was to tell 2.7% of pregnant women that they have gestational diabetes. It did not change the statistics of prenatal mortality and morbidity.
Simple physiological explanations can also help reassure a certain number of women. One role of the placenta is to manipulate maternal physiology for fetal benefit. The placenta may be presented as the advocate of the baby, so that the transfer of nutrients to the fetus is optimized. It is via hormonal messages that the placenta can influence maternal physiology. The fetal demand for glucose increase gradually throughout pregnancy. The mother is supposed to react to this demand by reducing her sensitivity to insulin.(6) This leads to a tendency towards hyperglycaemia that is easily detectable after a meal or after ingesting glucose. Some women can compensate their peaks of hyperglycaemia more effectively than others by increasing insulin secretion. When hyperglycaemia peaks above a pre-determined conventional threshold, the term “gestational diabetes” is used. In general glucose tolerance will recover its usual levels after the birth of the baby.
Practical recommendations
The practical advice one can give to women carrying the label of “gestational diabetes” should be given to all pregnant women & another reason to question the practical benefits of such a diagnosis. This advice concerns lifestyle, particularly nutrition and physical activity.
Nutritional counseling should focus on the quality of carbohydrates. The most useful way to rank foods is according to their “glycaemic index” (GI). Pregnant women must be encouraged to prefer, as far as possible, low GI foods. A food has a high index when its absorption is followed by a fast and significant increase of glycaemia. In practice this means, for example, that pregnant women must avoid the countless soft drinks that are widely available today, and that they must also avoid adding too much sugar or honey in their tea or coffee. Incidentally, one can wonder if the tolerance test, which implies glucose consumption (the highest substance on the GI), is perfectly neutral and harmless. GI tables of hundreds of foods have been published in authoritative medical journals.(7) These tables must be looked at carefully, because the data they provide are often surprising for those who are still influenced by old classifications contrasting simple sugars and complex carbohydrates. Such classifications were based on the mere chemical formula.
From such tables we can learn in particular that breakfast cereals based on oats and barley have a low index. Wholemeal bread and pasta also are low-index foods. Potatoes and pizzas,(8) on the other hand, have a high index and should therefore be consumed with moderation. Comparing glucose and fructose (the sugar of fruit) is a way to realize the lack of correlation between chemical formula and GI. Both are hexoses (small molecules with six atoms of carbon) and have pretty similar chemical formulas. Yet the index of glucose is 100&versus 23 for fructose. This means that pregnant women must be encourage to eat fruit and vegetables, an important point since pre-eclampsia is associated with an oxidative stress.
The quantity of carbohydrates should also be taken into consideration. French nutritionists showed that, among pregnant women with reduced glucose tolerance, there is no risk of having high birth weight babies if the daily consumption of carbohydrates is above 210g a day.(9) This implies a moderate lipid intake. About lipids, the focus should also be on their quality, the ratio between different fatty acids. For example we must take into account the fact that monounsaturated fatty acids (such as the oleic acid of olive oil) tend to increase the sensitivity to insulin. We must also stress that the developing brain has enormous need of very long chain polyunsaturates, particularly those abundant and preformed in the sea food chain.(10)
Advice regarding physical activity is based on theoretical considerations and on the results of observational studies. Skeletal muscle cells initially use glycogen stores for energy but are soon forced to use blood glucose, thus lowering glycaemia in the short term.(11) In addition, exercise has been shown to increase the insulin sensitivity of muscles and glucose uptake into muscular cells, regardless of insulin levels,(12) resulting in lower glycaemia. The effect of exercise on glucose tolerance has been demonstrated among extremely overweight women (body mass index above 33). 10.3% of obese women who took no exercise had a significant reduction of glucose tolerance, compared with 5.7% of those who did any exercise one or more times a week.(13) “A walk in the shopping mall for half an hour to an hour a couple of times a week is all that is needed”, says author Raul Artal. According to what we currently know, the benefits of a regular physical activity in pregnancy should be a routine discussion during prenatal visits, whatever the results of sophisticated tests.
Looking for a disease
Almost everywhere in the world, “gestational diabetes” is a frequent diagnosis. We should therefore not be surprised by the tendency to assign it the status of a disease. This might appear as a feat, since this diagnosis is not based on any specific symptom, but just on the effects of an intervention (giving glucose) on blood biochemistry.
One of the ways to transform a diagnosis into a disease is to list its complications. The well-documented fact that women carrying this label are more at risk than others to develop later on in life a non-insulin dependent diabetes has often been presented as a complication.(14) But this “type 2 diabetes” is not a consequence of reduced glucose tolerance in pregnancy. It is simply the expression, in another context, of a particular metabolic type. One might even claim that the only interest of glucose tolerance test in pregnancy is to identify a population at risk of developing a type 2 diabetes. But when a woman is looking forward to having a baby, is it the right time to bother her with glucose intake and blood samples, and to tell her that she is more at risk than others to have a future chronic disease? It is probably more important to talk routinely about nutrition and exercise.
Gestational hypertension has also been presented as a complication of gestational diabetes. In fact an isolated increased blood pressure in pregnancy is a transitory physiological reaction associated with good perinatal outcomes.(15, 16, 17, 18) Once more the concomitant expression of a particular metabolic type should not be confused with the evolution of a disease towards complications.
Professor Jarrett, a London epidemiologist, made a synthesis of the questions inspired by such associations. He stressed that women who carry this label are, on average, older and heavier than the overall population of pregnant women, and their average blood pressure is higher. This is enough to explain differences in perinatal outcomes. The results of glucose tolerance tests are superfluous. According to Professor Jarrett, gestational diabetes is a “non-entity”.(19)
The concept of fetal complications is also widespread. Fetal death has long been thought to be associated with gestational diabetes. However all well-designed studies looking at comparable groups of women dismissed this belief, in populations as divers as Western European (20) or Chinese (21), and also in Singapore (22) and Mauritius.(23) High birth weight has also been presented as a complication. In fact it should be considered an association whose expression is influenced by maternal age, parity and the degree of nutritional unbalance. If there is a cause and effect relation, it might be the other way round: a big baby requires more glucose than a small one. It is significant that in the case of twins “when the demand is double” the glucose tolerance test is more often positive than for singleton pregnancies. Only hypoglycemia of the newborn baby might be considered a complication, although there are multiple risk factors.
Another way to transform a diagnosis into a disease is to establish therapeutic guidelines. Until now, no study has ever demonstrated any positive effect of a pharmacological treatment on the maternal and neonatal morbidity rates, in a population with impaired glucose tolerance. On the contrary no pharmacological particular treatment is able to reduce the risks of neonatal hypoglycaemia.(24,25) However gestational diabetes is often treated with drugs. The frequency of pharmacological treatment has even been evaluated among the fellows of the American College of Obstetricians and Gynecologists (ACOG).(26) It appears that 96% of these practitioners routinely screen for gestational diabetes. When glycaemic control is not considered acceptable, 82% prescribe insulin right away, while 13% try first glyburide, an hypoglycaemic oral drug of the sulfonylureas family.
While practitioners are keen on drugs, there are more and more studies comparing the advantages of human insulin and synthetic insulins lispro and aspart,(27, 28) or comparing the effects of twice-daily regimen with four-times-daily regimen of short-acting and intermediate-actinginsulins.(29) Meanwhile the comparative advantages of several oral hypoglycaemic drugs are also evaluated. The criteria are always short- term and “glycaemic control” is the main objective.(30) The fact, for example, that sulfonylureas cross the placenta should lead to caution and to raise questions about the long-term future of children exposed to such drugs during crucial phases of their development.
The nocebo effect of prenatal care
After reaching the conclusion that the term “gestational diabetes” is useless, one can wonder if it is really harmless. Today we understand that our health is to a great extent shaped in the womb.(31) Furthermore we can interpret more easily the effects of maternal emotional states on the growth and development of the fetus. In the current scientific context we can therefore claim that the main preoccupation of health professionals who meet pregnant women should be to protect their emotional state. In other words the first duty of midwives, doctors and other practitioners involved in prenatal care should be to avoid any sort of “nocebo effect”.
There is a nocebo effect whenever a health professional does more harm than good by interfering with the belief system, the imagination or the emotional state of a patient or of a pregnant woman. The nocebo effect is inherent in conventional prenatal care, which is constantly focusing on potential problems. Every visit is an opportunity to be reminded of all the risks associated with pregnancy and delivery. The vocabulary can dramatically influence the emotional state of pregnant women. The term “gestational diabetes” is a perfect example.
When analyzing the most common reasons for phone calls by anxious pregnant women, I have found that, more often than not, health professionals are ignorant of or misinterpret the medical literature, and that they lack of understanding and respect for one of the main roles of the placenta, which is to manipulate maternal physiology for fetal benefit.
Prenatal care will also be much cheaper on the day when the medical and scientific literature will be better interpreted!
Michel Odent
Références :
1 - Odent M. The Nocebo effect in prenatal care. Primal Heath Research Newsletter 1994; 2: 2-6.
2 - Odent M. Back to the Nocebo effect. Primal Heath Research Newsletter 1995; 5 (4).
3 - Odent M. Antenatal scare. Primal Heath Research Newsletter 2000; 7 (4).
4 - Odent M. The rise of preconceptional counselling vs the decline of medicalized care in pregnancy. Primal Health Research Newsletter 2002;10(3)
5 - Wen SW, Liu S, Kramer MS, et al. Impact of prenatal glucose screening on the diagnosis of gestational diabetes and on pregnancy outcomes. Am J Epidemiol 2000; 152(11): 1009-14.
6 - Vambergue A, Valat AS, Dufour P, et al. Pathophysiologie du diabète gestationnel. J Gynecol Obstet Biol Reprod (Paris) 2002 ; 31(6 Suppl) : 4S3-4S10.
7 - Foster-Powell K, Holt SH, Brand-Miller JC. International table of glycemic index and glycemic load values. Am J Clin Nutr 2002; 76(1): 5-56.
8 - Ahern JA. Exaggerated hyperglycemia after a pizza meal in well-controlled diabetics. Diabetes Care 1993; 16: 578-80.
9 - Romon M, Nuttens MC, Vambergue A, et al. Higher carbohydrate intake is associated with decreased incidence of newborn macrosomia in women with gestational diabetes. J Am Diet Assoc 2001; 101(8): 897-902.
10 - Odent MR, McMillan L, Kimmel T. Prenatal care and sea fish. Eur J Obstet Gynecol Biol Reprod 1996; 68: 49-51.
11 - Chipkin S, Klugh S, Chasan-Taber L. Exercise and diabetes. Cardiol Clin 2001; 19: 489-505.
12 - Wojtaszewski JP, Nielsen JN, Richter EA. Invited review: effect of acute exercise on insulin signaling and action in humans. J Appl Physiol 2002; 93(1): 384-92.
13 - Dye TD, Knox KL, Artal R, et al. Physical activity, obesity, and diabetes in pregnancy. Am J Epidemiol 1997; 146(11): 961-5.
14 - Kim C, Newton R, Knopp R. Gestational diabetes and the incidence of type 2 diabetes: a systematic review. Diabetes Care 2002; 25: 1862-8
15 - Symonds EM. Aetiology of pre-eclampsia: a review. J R Soc Med 1980; 73: 871-75.
16 - Naeye EM. Maternal blood pressure and fetal growth. Am J Obstet Gynecol 1981; 141: 780-87.
17 - Kilpatrick S. Unlike pre-eclampsia, gestational hypertension is not associated with increased neonatal and maternal morbidity except abruptio. SPO abstracts. Am J Obstet Gynecol 1995; 419: 376.
18 - Curtis S, et al. Pregnancy effects of non-proteinuric gestational hypertension. SPO Abstracts. Am J Obst Gynecol 1995; 418: 376.
19 - Jarrett RJ. Gestational diabetes : a non-entity ? BMJ1993 ; 306 : 37-38.
20 - Roberts RN, Moohan JM, Foo RL, et al. Fetal outcomes in mothers with impaired glucose tolerance in pregnancy. Diabet Med 1993; 10(5): 438- 43.
21 - Lao TT, Ho LF. Impaired glucose tolerance and pregnancy outcome in Chinese women with high body mass index. Hum Reprod 2000; 15(8): 1826- 9.
22 - Tan Y, Yeo GS. Impaired glucose tolerance in pregnancy_is it of consequence ? Aust NZ J Obstet Gynaecol 1996; 36(3): 248-55.
23 - Ramtoola S, Home P, Damry H, et al. Gestational impaired glucose tolerance does not increase perinatal mortality in a developing country: cohort study. BMJ 2001;322: 1025-6.
24 - Jensen DM, Sorensen B, Feilberg-Jorgensen N, et al. Maternal and perinatal outcomes in 143 Danish women with gestational diabetes mellitus and 143 controls with a similar risk profile. Diabet Med 2000; 17(4): 281-6.
25 - Hellmuth E, Damm P, Moldted-Pederson L. Oral hypoglycaemic agents in 118 diabetic pregnancies. Diabetes Med 2000; 17(7): 507-11.
26- Gabbe SG, Gregory RP, Power ML, et al. Management of diabetes mellitus by obstetrician-gynecologists. Obstet Gynecol 2004; 103(6): 1229-34.
27 - Jovanovic L, Ilic S, Pettitt D, et al. Metabolic and immunologic effects of insulin lispro in gestational diabetes. Diabetes Care 1999; 22: 1422-7.
28 - Pettitt D, Ospina P, Kolaczynski J, et al. Comparison of an insulin analog, insulin aspart, and regular human insulin with no insulin in gestational diabetes mellitus. Diabetes Care 2003; 26(1): 183-6.
29 - Nachum Z, Ben-Shlomo I, Weiner E, et al. Twice daily versus four times daily insulin regimens for diabetes in pregnancy: randomized controlled trial. BMJ 1999; 319: 1223-7.
30 - Langer O, Conway D, Berkus M, et al. A comparison of glyburide and insulin in women with gestational diabetes mellitus. N Engl J Med 2000; 343: 1134-8.
31 -La banque de données du Primal Health Research Centre est spécialisée dans les études explorant les conséquences à long terme de ce qui se passe au début de la vie.
Bonding: A Simple Wonder
By David Chamberlain
Bonding is simple enough, but not always easy; it can happen but may not; and, as wondrous as it is, some have misunderstood the idea and made it seem unnecessary.
Growing out of the loving heart-connection mothers and fathers have with each other is their heart-connection to the babies they co-create. When conception occurs, parents naturally turn their thoughts to the baby who is coming to join them. Even if they are initially surprised (which is frequently the case) they usually adjust quickly, embrace the child emotionally, celebrate, and begin to re-organize their lives around this big event. The scientific word for this process is bonding.
In 1976, this new word made a quiet entrance onto the world stage in the title of a book, Maternal-Infant Bonding by two American professors of pediatrics, Marshall Klaus and John Kennell. With updated publications in 1983 and 1995 the revolutionary importance of this concept became clear and today it is a household word in every language around the globe. Yet, people still ask, What is it? Is bonding real, true and necessary? And finally the practical question, How do we do it?
Bonding is as simple (and mysterious) and as easy (or difficult) as love itself. Normally, the love of parents for their babies is effortless and spontaneous, but, as Klaus and Kennel noted a quarter century ago, things can interfere with that precious connection and as a result, life can take off in the wrong direction. It's a fact: Some mothers and fathers never do form that expected attachment. Instead they say they feel unrelated to that particular child, although they don't know why. They can spend years anxiously searching for some way to establish the heart-connection that somehow failed at the beginning.
Failure to bond can indeed have painful consequences. An unexplainable lack of closeness hovers over their daily relationships like a shadow. Intimacy and genuine friendship seems beyond reach. As much as they try to please each other, a gap still separates them. Other kinds of damage can be subtle. Klaus and Kennell discovered mothers, separated from babies for an extended period after birth, were left wondering if they really did have a child: the birth was more like a dream. They doubted the hospital had given them the correct baby.
In unbonded mothers, breastfeeding was less successful, or if chosen, was cut short prematurely. These mothers appeared awkward rather than confident and had trouble learning the routines of everyday baby care. In more extreme cases, irritability and anger toward the baby grew to become child abuse: these babies of unbonded mothers were more likely to return to the hospital injured. A study of 8,000 women in 1994 showed that unwanted babies had two and a half times the risk of dying in the first 28 days after birth. Babies of unbonded mothers may unexplainably fail to thrive or became ill. A series of clinical studies in California during the last decade discovered a significant correlation between apparent bonding failures and the occurrence of asthma in the children. Such facts show that bonding is a profound reality and carries a variety of hidden consequences for good or for ill.
When first introduced, bonding literature emphasized the importance of a "critical period" immediately surrounding birth, when a chain of miracles, previously left entirely to Mother Nature, would be taking place. Body chemistry associated with labor and delivery brings mothers and babies into intimate contact, where the mere touch of a baby's lips to the nipple inspires a cascade of love hormones which bless both mother and baby. These hormones trigger expulsion of the placenta, help close and heal the uterus, reduce postpartum bleeding, and facilitate the initial flow of priceless colostrum and mother's milk. Meanwhile, the feeding baby would be in a rare "quiet alert" state that favors rapid learning and personal encounter for an hour or so after birth-before lapsing into long periods of sleep. During this narrow window of opportunity, baby and mother, if undisturbed, are entranced by mutual gazing, and experience pleasurable physical sensations and emotions amplified in the new environment outside the womb. Many facts of this kind pointing to the complex orchestration of life at birth gave bonding its wonder and urgency.
Such positive and natural sequences in birthing were the norm for most humans until the mid-20th century, when birth was suddenly moved from homes to hospitals, from care by midwives (mostly women) to care by doctors (mostly men), and from communal practices to medical protocols. These wrenching changes were more than a change in location; philosophy and practice changed as well. Birth was to become "managed care" by professionals outside the family who made (and enforced) all the rules. A veil of secrecy fell over birth as fathers, relatives and friends were forbidden to participate. For a generation, only nurses and doctors knew what happened behind closed doors, effectively canceling any natural education of children, young women, mothers and other potential support for future births. Hospital rules sent babies to nurseries immediately after delivery, often before mothers or fathers could see or touch them. The kind of privacy for the new family to interact with each other-a feature of birth from the beginning of time-was swept away as separation and isolation became a top priority.
Historically, when the arguments for bonding were first introduced in the 1970s, the brazen medical take-over of birth was at its zenith, having rendered parents powerless and made natural birth all but impossible. Birth as a "scientific" process had stripped away most of the human and personal meanings which nourished men and women for thousands of years. Violated were the essential psychological needs of both parents and babies.
If you wonder how such a radical new culture of birth could rise so rapidly, you will have to reckon with the enormous power and appeal of science in the 20th century. Add to this the undercurrents of fear always associated with the uncertainties of birth and you can appreciate that people wanted to look to science for a guarantee of safe and perfect birth-an illusion that has not yet been fully recognized.
Another facet of science helps to explain the sudden deconstruction of traditional birthing. During the late 19th century rise of scientific study of the nervous system and the scientific analysis of gestation, birth, and infancy, an over-confident science (this includes both medicine and psychology) taught that babies were essentially without physical senses and without mind.
Babies, the experts insisted, were not yet capable of pain and even if they seemed to be in pain, it was only a reflex, not a personal experience. This reasoning was used to justify major surgery in babies without pain-killing anesthetics until only sixteen years ago! To make things worse, the same authorities announced that babies could not possibly recall anything of their experiences in the womb or at birth-no matter what they were. Psychologists actually taught that newborns would not know their mothers as mothers but only as objects in a world of other objects.
Given this set of beliefs--all proven false since then--neither doctors nor parents had any cause to worry about a baby having bad experiences before or after birth. Because they were virtually deaf, dumb, and blind, obstetricians could treat them in any way that was considered necessary. Unfortunately, these views found their way into the routine treatment protocols followed by all obstetricians. A little later, the treatment protocols of the new specialty of neonatology, to be used with the youngest, most fragile babies, were constructed on the same false foundation. After all, if a baby had no senses and no psyche, how would it know it was having multiple needle punctures, cut downs and surgeries? And how could it know the difference between a breast and a bottle?
Many parents were tempted to accept the new scientific way of birth without question. From our perspective today, it is an unhappy fact that mothers and fathers rarely rebelled when experts advised them to give up rocking chairs, to give up normal labor for surgical delivery, to substitute cow's milk for breast milk, to feed on a strict schedule rather than when the baby was hungry, to ignore babies when they cried, and to create nurseries at home like those in the hospital. Today, this bad advice has been largely repudiated and most babies are spared the needless suffering they endured for a half century.
Hopefully, parents around the world today are more independent in their thinking and more ready to treat a baby (of whatever age) as a human being. Moreover, I hope they will avoid the common misconception of bonding as a quick-drying epoxy that could cement a family together only if applied during the hour after birth. (In the late 1970s, at a meeting convened by the American Medical Association, doctors actually decided that ten minutes was sufficient time to allow for bonding after birth-in retrospect, an amusing example of the epoxy theory being applied by physicians.)
As we now understand, bonding is not restricted to any one time period. Clearly, heart-connections can forcefully begin before conception or anytime afterward, meaning love is welcome at any time during pregnancy, and, of course, is completely appropriate in the moments after birth when the combination of physiological and psychological forces are so auspicious. This truth is especially important for parents who are arriving late in the process to adopt a baby. All the parties involved in an adoption should take care to provide heart-felt love to the baby at the earliest possible date.
This kind of reasoning rests on new and accumulating evidence that babies share with us the mysterious gift of human consciousness regardless of their age and physical limitations. They are able to receive and respond to the heart-connection we call bonding at any time, and the sooner the better. This understanding, although it contradicts traditional theories of developmental psychology, is coherent with the discoveries that voluntary body movement, personal expression, and sensory development all occur much earlier than previously predicted; that learning and memory are integral to each other and function long before the brain parts which are used to explain them; and, as the study of twins in utero now proves, babies are capable of having a relationship to a twin, and must be equally capable of bonding with a parent.
These data are also coherent with the evidence that babies sense telepathically whether they are wanted and loved or not and can receive and respond to urgent communications during amniocentesis, intrauterine surgery, labor, or during difficult procedures in Neonatal Intensive Care. This new and enlarged paradigm descriptive of babies obviously takes us into a realm of mind and spirit that is beyond the brain.
Parents who are ready to step into this 21st century frame of understanding of baby consciousness can assume their babies are already endowed with the profound intelligence needed for bonding. How to achieve this bond? Just start singing lullabies to them or sending those intentional and explicit messages of welcome and love from your heart to theirs. Make the quantum leap in your mind that this communication channel can bear all sincere and earnest messages. And wait patiently for the invisible "vibes" that come bouncing back!
Originally published in Ob Stare Midwifery Magazine, Tenerife, Spain
By Marsden Wagner, MD
© 2000 Midwifery Today, Inc. All rights reserved.
A woman in Iowa was recently referred to a university hospital during her labor because of possible complications. There, it was decided that a cesarean section should be done. After the surgery was completed and the woman was resting post-operatively in her hospital room, she went into shock and died. An autopsy showed that during the cesarean section the surgeon had accidentally nicked the woman's aorta, the biggest artery in the body, leading to internal hemorrhage, shock and death.
Cesarean section can save the life of the mother or her baby. Cesarean section can also kill a mother or her baby. How can this be? Because every single procedure or technology used during pregnancy and birth carries risks, both for mother and baby. The decision to use technology is a judgment call—it may make things either better or worse.
We are living in the age of technology. Ever since we succeeded in going to the moon, we have believed that technology can do everything to solve all of our problems. So it should come as no surprise that doctors and hospitals are using more and more technology on pregnant and birthing women. Has it solved all the problems that can arise during birth? Hardly. Let's look at the recent track record.
Has the recent increasing use of technology during pregnancy and birth resulted in fewer damaged or dead babies? In the United States there has been no decrease in the past 30 years in the number of babies with cerebral palsy. The biggest killer of newborn babies is a birth weight that is too low, but the number of too-small babies born has not decreased the past 20 years. The number of babies who die while still in the womb has not decreased in more than a decade. While the past 10 years has seen a slight drop in the number of babies who die during their first week after birth, the scientific data suggest an increase in the number of babies who survive the first week but have permanent brain damage.
Is the increasing use of technology saving the lives of more pregnant and birthing women? In the United States the scientific data show no decrease during the past 10 years in the number of women who die around the time of birth (maternal mortality). In fact, recent data suggest a frightening increase in the number of women dying during pregnancy and birth in the United States. So it may be that the increase in the use of birth technologies is not only not saving more women's lives but it is also killing more women. This possibility has a reasonable scientific explanation: cesarean section and epidural anesthesia have both been used more and more in this country and we know that both cesarean section and epidural block can result in death.
We should not be surprised with the recent poor track record of high-tech birth. For many decades in the middle of the 20th century the number of babies dying around the time of birth was decreasing. This was due not to medical advances but mainly to such social advances as less severe poverty, better nutrition and better housing. Most important, the decrease in mortality was due to family planning, resulting in fewer women with many pregnancies and births. Medical care also was responsible for some of the decreasing mortality of babies, not because of high-tech interventions but because of basic medical advances, such as the discovery of antibiotics and the ability to give safe blood transfusions. There has never been any scientific evidence that high-tech interventions such as the routine use of electronic fetal monitoring during labor decrease the mortality rate of babies.
What this means is that putting yourself in the hands of a high-tech doctor and a high-tech hospital does not guarantee you the safest birth. You must yourself take responsibility for your own birth, including the decision to have technology used on you and your baby. Remember, technology is not good or bad. How technology is used can be good or bad. Airplanes can be used to carry you to visit your family or can be used to drop bombs on women and children. How technology is used on you during pregnancy and birth is of great importance because it can help you and your baby or harm you and your baby.
How to Get the Right Technology
Choosing Your Maternity Care Provider
How do you go about being pregnant and giving birth in circumstances where the use of technology is appropriate and right for you, your baby and your family? The first step is to get the right health care professional to assist you during the pregnancy and birth. A key decision is to decide if your primary maternity care provider is to be a midwife, a family physician or an obstetrician.
The United States and Canada are the only countries in the world where highly trained surgeons called obstetricians attend the majority of normal births. The American obstetrician is to be pitied. He or she is trying to be all things to all women—primary maternity care provider for normal, healthy pregnant and birthing women, specialist in complications of pregnancy and birth, specialist in women's diseases and highly skilled surgeon. No other doctor anywhere in the realm of health care tries to maintain competency at all these levels and in so many areas because it is totally unreasonable to expect this from one human being. Can an obstetrician do a six-hour "pelvic clean out" gynecological surgical procedure on a woman with extensive cancer, then rush to his or her office and do the best job of quietly and patiently counseling a pregnant woman about her sex life? Not likely.
While American obstetricians have worked hard to convince the public they are the safest people to assist at all births, the scientific evidence does not support them. For example, a large scientific study published in 1998 looked at all births in the United States in one year—more than four million births. Because doctors really do need to manage the few births that develop serious complications, the study eliminated complicated births and looked only at low-risk births. Compared with physician-attended low-risk births, midwife-attended low risk births have 33 percent (one-third) fewer deaths among newborn infants. Furthermore, midwife-attended births have 31 percent (nearly one-third) fewer babies born too small, which means fewer retarded and brain-damaged infants.
There is not a single report in the scientific literature that shows obstetricians to be safer than midwives for low-risk or normal pregnancy and birth. So if you are among the more than 75 percent of all women with a normal pregnancy, the safest birth attendant for you is not a doctor but a midwife.
If you are considering a hospital birth with an obstetrician as your primary birth attendant, ask him or her how much time he or she will spend with you during your labor. One of the reasons a midwife is generally a better choice to attend your hospital birth than an obstetrician is because the midwife is there in the hospital with you during your labor while the obstetrician is not. It is an incredible irony that the obstetrician insists that the woman who is his or her client give birth only in the hospital, while the obstetrician who should attend her birth is not in the hospital. If your obstetrician is not with you in the hospital during labor, then where is your obstetrician?
For 50 years now the United States has had a system of maternity care in which the woman goes into labor, goes to the hospital, is admitted by a labor and delivery nurse (L & D nurse) who examines the woman and calls the obstetrician, who is either at home or in his or her office (usually seeing normal, healthy pregnant women). The obstetrician gives orders over the telephone to the nurse, who then assists the woman during her labor. The obstetrician may or may not come by the hospital sometime during the labor to briefly check the woman. But it is the job of the L & D nurse to monitor the labor and call the obstetrician when the birth is imminent so that the doctor can rush in, catch the baby at the last minute and get all the credit (and money) for "delivering" the baby. If the nurse calls the obstetrician too soon and the doctor has to hang around the hospital waiting for the birth, the doctor is angry with the nurse for wasting his time. But if the nurse calls the obstetrician too late and the baby is born before the doctor gets there, the doctor is furious with the nurse.
Why is it important to insist that your obstetrician be with you during your labor as well as at the birth? In a study of obstetrical malpractice cases involving permanent brain damage of the baby, the absence of the obstetrician from the hospital during the labor played a central role in causing the tragedy in approximately two-thirds of the cases. This research showed that telephone conversations during a hospital birth between nurses at the hospital and the doctor who was not in the hospital gave rise to misunderstanding or miscommunication that caused adverse effects for the mother or baby. If you choose an obstetrician as your primary birth attendant and he/she cannot guarantee that he/she or another obstetrician will be physically present (not just on call) during your labor as well as the birth, you are wasting your money and putting your baby in danger, and you need to get another birth attendant.
If you doubt this description of hospital birth, ask any of the more than 25,000 L & D nurses in the United States. These nurses are highly skilled professionals who do what is really an impossible job. They must monitor the laboring woman and assist at the birth, all the while keeping the doctor happy and covering up for the fact that the doctor is not there most of the time and in most cases makes a minor contribution to the birth. The fact that defines and limits these nurses is that they have no autonomy and can do nothing without doctors' orders.
Because American obstetricians have always had L & D nurses to do their bidding, now that midwifery is gradually but steadily returning in this country obstetricians have developed a distorted understanding of midwifery. Obstetricians believe midwives are obstetrical assistants and keep trying to give them orders. But the practice of midwifery is very different from the practice of nursing.
Midwives are autonomous professionals who provide primary maternity care and are analogous to family physicians who provide primary health care. If the family physician hears a heart murmur and refers the patient to a specialist cardiologist, this does not mean the family physician is the cardiologist's assistant and somehow less competent, but only that the cardiologist has a different expertise—an expertise for certain complications—than the family physician has. The cardiologist makes suggestions for treatment of the family physician's patient, which the family physician and patient may or may not choose to follow. The cardiologist and the family physician are professional equals who collaborate with mutual respect to provide the best quality care for the patient.
By the same token, a specialist obstetrician does not give orders to a midwife any more than a cardiologist gives orders to a family physician. The midwife may refer a woman to an obstetrician because of a complication, but this does not make the midwife the obstetrician's assistant. The midwife and obstetrician then collaborate as professional equals.
Too many obstetricians still don't get it and continue trying to boss midwives around, hiring and firing them from their practices, pushing them off hospital staffs and accusing them of practicing medicine without a license. If you are pregnant, don't allow yourself to get in the middle of this professional turf struggle. If you want a midwife to provide your primary maternity care, find one who has as much autonomy as possible in her practice. If you are considering having a particular obstetrician provide your primary maternity care, a good way to measure that doctor's openness and attitude toward you and women in general is to inquire what his or her opinion is of midwifery.
Another reason midwives are safer than doctors is because midwives use far less unnecessary technology. Because obstetricians are surgeons, they turn birth into a surgical procedure. Proof of this is that the birthing woman is treated as if she is a surgical patient: she is put on her back in a bed that is really a modified surgical table, often with her legs up in surgical stirrups. For more than 25 years we have known scientifically that this is the worst of all possible positions for a woman giving birth; in this position the baby's head compresses the woman's main blood vessel that supplies the womb and the baby and reduces the blood and oxygen going to the baby. If the woman is in a vertical position (sitting, squatting or standing), more blood and oxygen flow to the baby, the woman's bony pelvis opens more to let the baby out and she gives birth downhill instead of uphill against gravity. One way to find out if a hospital is practicing modern maternity care or not is simply to see what position women are put in during birth. If hospital staff are still putting women on their backs during birth, they are ignoring all scientific data and still pretending birth is a surgical procedure.
Between 50 percent and 80 percent of births in most American hospitals involve one or more surgical procedures, further proof that obstetricians have turned birth into a surgical event. Those procedures include drugs to start or speed up labor, episiotomy (cutting the genitals with surgical scissors to widen the vaginal opening), placing metal forceps or a vacuum extractor on the baby's head to pull the baby out (you can imagine the risks involved in this), and cesarean section to cut the baby out. In reality, any of these surgical procedures is necessary in no more than 20 percent of all births. And since all surgical procedures carry risks, the high frequency of their unnecessary use in physician-attended births leads to more dead and damaged babies than would ever occur in midwife-attended births. Large numbers of research reports document that midwives use far fewer surgical interventions than doctors. A case in point is the use of episiotomy. From half to three-quarters of all women in America birthing their first baby in the hospital with the assistance of a doctor have this surgical cut done to their genitals. It is scientifically proven that no more than 20 percent of women will need this cut; the best rate is about 5 percent. Among midwives in independent practice in the United States (that is, when doctors are not giving midwives orders as to what to do), between 2 percent and 20 percent of women undergo episiotomy.
Is the fact important that midwives cut far fewer episiotomies than doctors cut? Scientific evidence shows that having an episiotomy means more bleeding, more pain, more permanent deformity of the vagina, and more painful sexual intercourse for months, or even years. As well, unnecessary episiotomy is a form of sexual abuse. Some women's groups in America are rightly concerned about the practice of female genital mutilation in parts of Africa. They need to be equally concerned about the millions of American women who have suffered female genital mutilation—unnecessary cutting of the genitals at birth at the hands of doctors.
While midwives trust women's bodies, use such low-tech assistance as the skilled use of their hands, and understand the importance of preserving normalcy, doctors, in general, do not trust women but trust drugs and machines, use high-tech assistance, and focus on the pursuit of abnormality. So having a highly trained surgeon obstetrician assist at your birth is about as sensible as hiring a pediatric surgeon as a baby sitter for your healthy 2 year old when you go out in the evening. Like the obstetric surgeon who gives the normal woman a shot to hurry her labor, the pediatric surgeon baby-sitting your normal child will focus on medical management: when your robust 2 year old gets tired and fussy, the pediatric surgeon will give him or her a shot to hurry the child to sleep. The result? In the one case you get the medicalization of birth (remember, birth is not an illness), with a lot of unnecessary risky interventions and very expensive medical care, and in the other case you get the medicalization of childhood (being 2 years old is also not an illness), with unnecessary risky interventions and very expensive baby-sitting.
When deciding on your primary maternity care provider, it is important to ask midwives or doctors about their practices: find out if they prefer to put you on your back during birth and how often they do episiotomy, forceps or vacuum extraction, and cesarean section. If they don't know their rates of surgical interventions or refuse to tell you what their rates are, look out! Beware of any tendency to patronize you, to suggest that you cannot possibly understand all this technical stuff, or that you should just " trust me, I'm the doctor."
Choosing the Right Place to Give Birth
An important decision to make is whether to have your birth at home, a freestanding birth center or a hospital. Overwhelming scientific evidence shows that the home is a perfectly safe place to give birth if you are one of the more than 80 percent of women who have had no serious medical complications during pregnancy. The evidence indicates that it is important to have a trained birth attendant for your homebirth, be it non-nurse midwife, nurse-midwife or doctor. Your place of birth should also be within 30 minutes of the nearest hospital. The single most important advantage of homebirth is that the birthing woman is in control. Another important advantage is that in homebirth there is far less unnecessary use of technology. For a hospital to say it can be "homelike" is like the sign in the bakery window: "We sell home-baked bread."
A freestanding birth center staffed with midwives is also a perfectly legitimate choice for the great majority of women who have had no serious complications during their pregnancy. But don't be fooled by the hospital that advertises its "birth center." If the birth center is not freestanding—i.e., outside the hospital—it will still be under the supervision of the hospital and the doctors, and the birthing woman will not be in control. Plenty of scientific evidence confirms that a freestanding birth center with midwives is a safe option. For example, a study of more than 10,000 women giving birth in more than 80 freestanding birth centers in the United States showed birth in these centers to be just as safe as a matched group of low-risk hospital births.
Be sure to investigate the practices in any hospital you may consider for your birth. Would you have the freedom to have the kind of birth you wish? Remember, freedom means being in control of everything that happens to you. Being given permission to do this but not that is not freedom. Can you invite anyone you want to be present at the birth? Some hospitals will limit whom you can bring. Meanwhile they can—without asking you—bring anyone they want to your birth, including, for example, a bunch of doctors in training. Can you come with a written birth plan that they will respect and honor, or will they have an obvious attitude about such plans and consider you a "bad patient"? Many hospitals are competing for patients and will show pregnant women beautiful "birthing rooms." Remember, what is important is not a rocking chair and pretty curtains but whether or not you can be in control.
Always be aware that hospitals are under the absolute control of doctors and that the rules and regulations are for the convenience of the staff, not you. Hospitals are designed to care for sick people, and since a birthing woman is not sick, much of what goes on in the hospital doesn't fit her needs. One simple example: most births take from 10 to 20 hours, during which there is one or more turnover of staff, who are on eight-hour shifts. While the data show the overwhelming importance of a woman having the continuous assistance of someone she knows throughout her labor, during your hospital birth you are likely to have to cope with one or more staff changes and lots of strangers coming into your room.
Ask the hospital if women are put on their backs during birth. Ask for the hospital's rate of episiotomies, forceps deliveries and cesarean sections. Don't be satisfied with the usual answer: "It varies by doctor." Don't believe them if they say they don't have their hospital cesarean-section rate; they are required in most states to report this rate to the State Health Department. In New York state a law provides the right to be given all this information, and an official pamphlet given out to all newly pregnant women includes a listing of the cesarean-section rate for every hospital in the state.
Some of you belong to a health plan that may limit your choice of maternity care provider and place of birth. In this case you may have to get aggressive to get what you really want. Don't be afraid to demand what should absolutely be your right as a family and a birthing woman. Besides, a health plan is a business that needs to keep its customers happy. If your health maintenance organization (HMO) doesn't have a midwife and you want one, demand one. If you want an out-of-hospital birth and your HMO doesn't provide it, demand it. More and more HMOs now have midwives because they are discovering midwives are just as safe as doctors and cost the HMO a lot less. The largest HMO in New Mexico, for example, has more midwives than obstetricians on their full-time staff, and around 80 percent of all hospital births in this HMO are attended only by midwives.
Getting Information on the Technologies
How to Get the Information
When considering whether a given technology is appropriate for you, it is important that you understand the difference between facts and value judgments. The probability (chance) that using the technology will make things better (efficacy) and the probability (chance) that using the technology will make things worse (risk) are facts that can be scientifically measured. But benefit and safety are value judgments about the acceptability of those chances. To be appropriate, both the benefit and the safety of technology must be judged by those on whom it is used. Scientists can measure the efficacy and risks, midwives and doctors can inform the woman of the data on these two chances (better or worse) but the person taking the chances (the patient) is the only one who can legitimately decide whether one chance outweighs the other. It is thus inappropriate and dangerous for a doctor or midwife to tell a patient that something is "safe" when it is not the doctor or midwife taking the chances. Instead, the role of the doctor and midwife is limited to suggesting possible interventions and explaining the chances that the intervention will make you better or worse.
Whenever someone suggests using a technology on you, you must leave no stone unturned in finding out what your chances are for getting better or worse. It is the duty of any doctor, midwife or nurse to provide you with full information on these two chances. However, you must accept the responsibility for getting full information because you cannot always rely on your maternity care provider to volunteer such information. If it is not forthcoming and complete, you must demand it. Every effort must be made to get full, honest information. Because your wishes and the wishes of the doctor may often collide, it is sometimes difficult to get unbiased information. Too often, the doctor provides only that part of the information he or she thinks will make you a more compliant patient who will agree with whatever the doctor wants and, therefore, suggests. One way to get unbiased information is to insist on seeing the scientific data behind any information given you. "Show me the data" is a powerful strategy for eliciting better information. Another important way to get more unbiased information is to demand a second opinion, which can, one hopes, provide a second source of information.
A powerful shortcut to finding out if a particular technology is likely to be helpful to you is provided by the six tables at the end of a book by Enkin et al. titled A Guide to Effective Care in Pregnancy and Childbirth. All the most common interventions used during pregnancy and birth are classified as follows depending on a careful review of the scientific evidence for each intervention: 1) beneficial, 2) likely to be beneficial, 3) trade-off between beneficial and adverse effects, 4) unknown effectiveness, 5) unlikely to be beneficial, 6) ineffective or harmful. A glance at this last table is quite informative. You might want to check on how many of these ineffective or harmful interventions are still in use in any hospital you are considering.
Information on Prenatal Technologies
The process of getting information on a technology can be tricky, so a couple of examples will be given to illustrate how to go about it. While pregnant, you might find it a good idea to test your skills at getting information on a technology and to see how willing the midwife, nurse or doctor is to provide full, unbiased information.
It is likely that a routine ultrasound scan will be suggested fairly early in your pregnancy. This presents a perfect opportunity to ask a few questions" "What is the chance the scan will make things worse? Is such a scan safe?" If the answer is a flat "Yes, ultrasound scanning during pregnancy is safe," alarm bells should start going off in your head, because you are not getting the full information. You must then ask, "Show me the data on the safety of prenatal ultrasound," in order to check on what you may be told about the data on the safety of prenatal ultrasound. As a scientist I can assure you that the only correct answer to your question is, "We don't know because there is not sufficient scientific data to prove the safety of prenatal ultrasound." Some research has shown the possibility that ultrasound can cause slowed growth of the fetus while still in the uterus. Other research has shown the possibility that some children who have been scanned while still in the uterus may later have mild neurological deficits. We need more study of both these possibilities. But from a scientific viewpoint, it is impossible to say today that ultrasound scanning during pregnancy is perfectly safe.
The next question to ask when ultrasound scanning is proposed to you is, "What is the chance that a scan will make things better?" When you are told that one reason for the scan is to look for defects in the fetus, ask: "What is the chance a defect will be correctly identified (true positive screening test) and what is the chance a defect will be incorrectly identified (false positive screening test)?" If your provider cannot, or will not, answer this question, watch out! Again, so that you can check on what you may be told, here is the best scientific data: If 100 pregnancies are routinely screened with ultrasound to look for a defective fetus, two out of the 100 will have a true positive result (i.e., the scan says the fetus is defective, and it truly is defective), and one out of the 100 will have a false positive result (i.e., the scan says the fetus is defective, but it is not defective, it is a normal fetus). So if all women with a positive scan are offered therapeutic abortion, for every two defective fetuses aborted, one normal fetus will be aborted. How many women are told this before they are offered a routine prenatal ultrasound scan?
Your next question when ultrasound is suggested should be, "Is there a better chance my baby will survive the pregnancy and birth if an ultrasound scan is done, and what are the data?" The correct answer is that a large study in the United States of more than 15,000 regnant women showed no improvement in the mortality rate of the babies if ultrasound is routinely used during pregnancy.
One scientist published the following summary of the present state of the art on routine prenatal ultrasound scanning: "The casual observer might be forgiven for wondering why the medical profession is now involved in the wholesale examination of pregnant patients with machines emanating vastly different powers of energy which is not proven to be harmless to obtain information which is not proven to be of any clinical value by operators who are not certified as competent to perform the examinations." For all these reasons, the American College of Obstetricians and Gynecologists, the American College of Radiology and the U.S. government's Preventive Services Task Force all recommend against routine ultrasound screening of low-risk pregnancies. This is the type of unbiased, scientifically sound information you need to make informed choices about technology used on you during pregnancy.
Information on Technologies Used During Birth
Because a situation may arise during birth where time constraints limit the opportunity to get full information on a technology or procedure being proposed for use on you, it is wise to look long before your due date at the information on certain technologies used frequently during birth. Brief mention already has been made of episiotomy, the surgical cutting of women's genitals.
Since in American hospitals 20 percent or more of woman do not give birth but instead the baby is cut out with cesarean section, you need information on this technology in advance of your birthing. There is no better example of the surgical approach to birth than cesarean section, because it is the ultimate solution of all surgeons—cut it out. Some obstetricians are so enamored of this technical solution to birth that they are now promoting it as preferable to the normal way of giving birth through the vagina.
One recent article in a prominent medical journal seriously proposed the routine surgical removal, by cesarean section, of all babies, together with a policy that would require a signed release from any woman so foolish as to insist on vaginal birth. Another paper published in an authoritative medical journal tried to show, using very biased data, that efforts to reduce cesarean section in the United States below 20 percent would be dangerous, a proposal that goes against a massive amount of good scientific data. A third article in a medical journal insisted women have the right to demand cesarean section birth even when there is no medical reason for it.
Meanwhile, a recent popular book for the public urges women in the United States to request a routine cesarean section birth because they "want to maintain the vaginal tone of a teenager and their doctors can find a medical explanation that will suit the insurance company." So a tight vagina for your sexual partner should be your first concern, and it's okay for your doctor to lie and cheat the insurance company. The surgical approach to birth has run amok!
What is the truth, scientifically, about cesarean section? Compare what you are told with the following scientifically documented information. Again, while getting information on this major surgical procedure, the first question is, "How safe is cesarean section?" Always beware of any attempts to pooh-pooh the question or downplay the risks. We are talking about major abdominal surgery that carries major risks. Starting with the risks to the woman, she has a four to eight times greater chance of dying from a cesarean section than she does giving birth through her vagina. Even a routine, scheduled cesarean section with no medical complication as the reason for the surgery carries a two times greater risk that the woman will die from the surgery.
Even if the woman does not die, she is at risk for many serious complications from the surgery, such as the accidental cutting of her bladder or other internal organs and a 20 percent chance she will get an infection as a result of the surgery. Since the woman often gets a fever with this infection, her fever necessitates a fever diagnostic work-up of her infant, with blood tests and even spinal tap of the baby.
Having a cesarean birth also affects the future reproductive possibilities of the woman, because having a cesarean section means she has a decreased chance of ever getting pregnant again. And if she does get pregnant again, she is at higher risk that her pregnancy will occur outside her womb, a condition that will never result in a live baby and is life threatening for the woman. If in her subsequent pregnancies she succeeds in making it to the end of pregnancy and goes into labor, she is also at higher risk of two serious complications during the birth, both of which can threaten her own life and the life of the baby: a placenta that blocks the outlet for the baby or a placenta that detaches itself before the baby is born.
While some women might be willing to take risks with their own body, it would be very hard to find a woman willing to take risks with the life or health of her baby just for her own convenience or to avoid labor pain. So the following risks to the baby born by cesarean section are of great importance. There is about a 5 percent chance that when the surgeon cuts into the woman's body during a cesarean section, the knife will accidentally also cut her baby. Because all the water is not squeezed out of the baby's lungs as is normally done during a vaginal birth, more babies born after cesarean section develop serious respiratory distress syndrome, one of the biggest killers of newborn babies. Because doctors are not as good as they would like to be in estimating, even with ultrasound, the baby's gestational age—i.e., whether the pregnancy has gone long enough—too often a cesarean section is done too soon, resulting in a premature birth. Prematurity is a big killer of newborn babies and also carries a higher risk of brain damage to the baby. It is difficult to imagine that a woman who has been given full information on these risks to herself and her baby would still choose a cesarean section when there is no serious medical reason for it. Obstetricians have jumped on the "woman's choice" bandwagon, which in many ways is a good thing except for the tendency to push women's choice only for things the obstetricians want to do anyway. For example, for years the scientific evidence has favored vaginal birth after an earlier cesarean section (called VBAC) rather than a repeat cesarean section. Doctors, however, have never really pushed VBAC, but instead emphasize a repeat cesarean. Pushing women to have the right to choose major surgery for which there is no medical indication is ridiculous as well as dangerous. It has been established legally and ethically that patients have the right to refuse treatment even when medically indicated, but patients have never had the right to choose medical or surgical treatment that is not indicated. Doctors are under no obligation to do unjustified major surgery. Women's "choice" is clearly limited to medically valid options.
There has been an epidemic of unnecessary cesarean section births because doctors like a quick, surgical solution for birth. Now another birth technology—epidural block for labor pain— is seeing a rapid expansion of epidemic proportions because doctors are selling it to women as hard as they can. (Epidural block for cesarean section is another matter, as it is the preferred anesthesia for this major surgery.) A new subspecialty of doctors—obstetric anesthesiologists—is built entirely on the economic foundation of epidural block for normal labor pain. They need lots of birthing women to choose this form of pain relief if these doctors are to make a grand living. (Their professional journal contains advertisements for purchasing private jets.) These new specialists go to prenatal classes to sell epidural block and prowl the halls of hospital maternity wards, popping in on women in labor to sell their epidural block. Their hard sell includes telling women that epidural block is "safe." How safe is it really?
Twenty-three percent, or nearly one in four women, given an epidural block will develop a complication. One undesirable complication is death—epidural block for relief of normal labor pain results in a three times higher mortality rate for the woman than labor without epidural block. One out of every 500 epidural blocks results in temporary neurological problems, such as paralysis in the woman; and in one out of every half-million epidural blocks, this neurological damage to the woman is permanent.
These extremely serious risks of epidural block are not so common, but several less serious, but still significant, risks are much more common. Fifteen percent to 20 percent of all women given epidural block develop fever that results in the undesirable necessity of administering diagnostic tests and antibiotic treatment to the baby. Fifteen percent to thirty-five percent of all women given epidural block cannot urinate and must have a tube inserted into their bladder. Thirty percent to 40 percent of all women given epidural block have severe backache for hours or days after birth, and 20 percent still have severe backache one year later. So they have traded pain relief during a few hours of labor for severe back pain for a year or more! Because labor pain is an essential component of the normal mechanisms of the body for the progress of labor and since the epidural block eliminates this necessary pain, epidurals also eliminate the normal mechanisms for the progress of labor. So it is to be expected that considerable research documents a longer labor if the woman is given epidural block. As normal labor is no longer possible with epidural block, there is four times greater use of forceps or vacuum extraction and at least twice as much cesarean section after epidural block. These surgical interventions, of course, carry their own risks both for woman and baby. So the woman choosing epidural block trades less labor pain for a longer labor and, if a cesarean section is done, more pain for several days after the birth, as well as increased risks for both herself and her baby.
Thus, epidural block presents many serious risks for the woman. Are there risks for her baby? Since it is unlikely any woman would choose a form of pain relief that puts her baby at risk, women are not told that in 8 percent to 12 percent of labors in which the woman is given epidural block, severe fetal hypoxia (lack of oxygen to the unborn baby) is shown on the electronic fetal monitor. The American College of Obstetricians and Gynecologists, after acknowledging the frequency at which birthing babies suffer hypoxia after the woman is given an epidural block, recommends that all women given epidural block have continuous electronic fetal monitoring so that fetal hypoxia can be identified.
Does this lack of oxygen have any permanent effect on the baby? Research has found that 1-month-old babies whose mothers were given epidural block during labor may have neurological test results that suggest possible minor brain damage. While this is a finding not yet completely confirmed scientifically, it is a possibility that is certainly worrisome and should be told to women offered epidural block. Epidural block carries another risk that is found in many of the interventions and technologies used during birth: the "cascade effect." This means that the use of one intervention leads to the use of another intervention, and the use of that intervention leads to the use of yet another intervention, and so on. If, for example, a woman is given a drug to start labor or to make labor proceed faster, this leads to more painful contractions. This in turn leads to the offer of pain relief, usually with epidural block, which, as we have seen, leads to an increased use of forceps or vacuum extraction, which leads to episiotomy or to cesarean section, which leads to fever in the mother, which leads to tests and treatments for the baby.
There are other cascades of interventions during labor. For example, routine electronic fetal monitoring leads to more cesarean sections, which lead to babies with respiratory distress syndrome or prematurity, which leads to putting these babies into newborn intensive care units. Every one of these interventions carries risks for mother and baby! It is easy to see how the high-tech approach to birth actually creates many new problems. Rather than change their habits, however, doctors conclude that birth is quite risky, when in reality doctors have caused it to be risky. This is one important reason why homebirths, freestanding birth center births and having your own midwife as the primary maternity caregiver are all associated with fewer risky interventions and, therefore, safer care.
No honest doctor would ever suggest that drugs given for pain are without risks. But in their pursuit of relieving a laboring mother's pain, doctors inevitably resort to prescribing drugs, when in fact, there are many non-pharmacological ways to relieve pain. For example, scientific research has proven a number of drug-free techniques to be effective in relieving the pain of normal labor, including: the continuous presence during labor of a midwife, a doula or a loved one; sitting in a tub of warm water or standing in a shower; freedom to move about and assume any position; massage; acupuncture; reflexology. None of these techniques involves any risk to the woman or her baby, and they are often promoted by midwives, but rarely promoted by doctors.
Other harmful technologies aside from those already mentioned are frequently used during birth, such as the use of drugs to start or speed up labor, forceps or vacuum extraction, and cutting of genitals (episiotomy); but space does not permit a review of all of them. In my book you will find information on how to get the most reliable data on specific technologies likely to be used during pregnancy and birth.
Why the Unnecessary Use of Technology?
To understand why so much unnecessary technology is used during pregnancy and birth, it is necessary to understand how technology comes to be used. We must first ask, Is the use of a new technology preceded by careful scientific evaluation, then followed by official approval for use and requirements for education of doctors in its use? Sadly, the truth lies in another direction. An example of a recent birth technology now rapidly spreading in the United States will illustrate the reality.
Several years ago a drug with the generic name misoprostol (called Cytotec by the drug company that manufactures it) was approved by the Food and Drug Administration (FDA) as a prescription drug to be used for certain ailments of the stomach. It is known that one of its side effects is severe cramps or contractions of the uterus, and for this reason the label says it should never be used on pregnant women. Obstetricians, however, discovered that given orally or vaginally, Cytotec, because of its side effect of violent uterine cramping, can induce (start) or accelerate labor.
So without any prior testing of Cytotec for labor induction, obstetricians began to use it on their birthing women. Doctors on the Internet began to describe their experience with this new way of inducing labor. One doctor wrote, "I must say I have heard some great things about Cytotec myself. Just be careful. The stuff turns the cervix to complete mushie." A few studies have appeared in obstetric journals, but all the studies are too small to give adequate scientific evidence about this use of the drug. These studies did show some risks, such as a tendency for the fetus's heart to start racing, as well as other signs of fetal distress, and the explosion or rupture of the uterus in a few women. A review of the scientific evidence by a highly prestigious scientific body says that because of the lack of sufficient scientific evaluation and the reports of serious side effects, the use of Cytotec for labor induction "cannot be recommended for routine use at this stage."
The fact that Cytotec is not approved by the FDA for labor induction, is not approved for this use by the drug manufacturer (who still states on the label that it is not to be given to pregnant women), is not endorsed by either the American College of Obstetricians and Gynecologists or midwifery organizations, and is not approved by scientists for routine use has had no apparent effect on the enthusiasm with which doctors are starting to use it. And there is nothing to stop doctors from using Cytotec for this "off label" purpose, because although the FDA must approve a drug before it goes on the market, once it is on the market for a specified purpose, any doctor can use it in any dose for any purpose on any patient.
After one obstetrician in South Dakota proudly told me over lunch that he was the first doctor in his community to use Cytotec for labor induction and now urges other doctors to use it, he justified his actions: "We will wait forever for the bureaucrats at the FDA in Washington, D.C., to approve drugs, so we must try them out ourselves if we want progress." When asked, he admitted he doesn't tell the women to whom he is giving Cytotec that the drug is not approved for this purpose, nor does he ask for informed consent. He scoffed at my suggestion that he is experimenting on women without their knowledge, much less their consent. The Oregon State Health Department told me their records show Cytotec to be the most common way of inducing labor in that state, and it is used on thousands of laboring women.
The use of Cytotec on birthing women has spread like wildfire for a very simple reason, told to me by many doctors: its use brings back the possibility of "daylight obstetrics"—that is, women brought to the hospital first thing in the morning and induced with Cytotec will give birth by late afternoon and the doctor can be home for dinner. How many women will have their uterus ruptured before a court case finally applies the brakes to this practice? I personally welcome learning of cases where Cytotec induction was used without fully informed consent and there was subsequent uterine rupture, cervical laceration or other serious complications.
The unsystematic, untested way in which Cytotec for labor induction was introduced and disseminated is typical for the technologies used during pregnancy and birth. Ultrasound scanning during pregnancy and electronic fetal monitoring during labor are further examples of uncontrolled introduction and dissemination of untested technologies. There is a big gap between what we know to be the best scientific maternity care practices and what is actually practiced. As a result, there is no consumer protection except litigation. Doctors blame lawyers and women for the fact that more than 70 percent of American obstetricians have been sued one or more times, but litigation is the only way a woman and her family can protect themselves against malpractice.
Many of the motivations behind the use of technologies by doctors are non-medical. Several examples, all supported by scientific study, will illustrate this fact. Studies of birth certificates show that birth is more common Monday through Friday, 9 a.m. to 5 p.m. The only explanation that can be given is that doctors and hospitals use the induction of labor for their own convenience. More shocking is data that show emergency cesarean section to occur most commonly on weekdays during the daytime. Deciding to declare a labor an emergency situation requiring emergency surgery is influenced by the convenience of the staff.
Another non-medical factor that motivates the use of technology is money. Data from several states in the United States show cesarean section to be least common among women on Medicaid and most common among private patients in private hospitals. One would think the opposite, assuming that poor women have poor health and need more interventions. But doctors and hospitals make bigger profits if technology is used in cases where the patients or their insurance can afford to pay. Commercial interests also play a role—manufacturers of drugs and technologies have a variety of ways to influence doctors to use their drugs and machines, including bestowing a wide range of gifts and perks.
Doctors' fear of litigation is another non-medical motivation for using technology. Doctors are afraid both of having to go to court and of having to pay higher malpractice insurance premiums. Two prime examples of the unnecessary use of technology due to doctors' fear of litigation are routine electronic fetal monitoring during normal labor and cesarean section with little or no medical justification. A fundamental principle of medical practice is that whatever the doctor does must be, first and foremost, for the benefit of the patient, not the benefit of the doctor. But picking up a scalpel and cutting open a woman's body for a cesarean section because of fear of going to court or paying high insurance premiums is not the practice of medicine but the practice of fear and greed.
Many obstetricians have an unfortunate tendency to promise women a perfect baby if the women will make use of the doctor's expertise and the hospital's technology. But if you play God, you will be blamed for any natural disasters that ensue. A family with a dead or damaged baby or mother does not sue because some lawyer talks them into it, but because they feel deceived and are stonewalled by doctors and hospitals when trying to get full information on what happened. If you don't believe you will be stonewalled while trying to get information on what happened at a birth, try to get information on the 350 to 1,000 women who die every year in the United States around the time of birth (maternal mortality). Although individual states have regulations that require such deaths to be reported, no one, including you, me or scientists wanting to study why these women die, can get access to information on these maternal deaths. We do know that at least half these deaths are not reported, that black women have a four times greater risk of maternal death, that nearly all these women die in the hospital rather than at home, and that with adequate medical attention many, if not most, of these women need not have died. That last fact is why the doctors' fear of litigation builds the stone wall.
Another reason for the overuse of technology is the mistaken belief by many doctors that technology is science and the use of technology is the practice of scientific medicine. They confuse technological advances with progress. Scientific medicine is practice based on the best scientific evidence, not practice that uses technology. Practicing doctors are not scientists. Scientists must believe they don't know, while practicing doctors must believe they do know.
In other highly industrialized countries where midwives far outnumber obstetricians, the midwifery approach brings both an essential counterbalance to the high tech approach of obstetricians and a brake to unnecessary technology. For example, while the United States has 35,000 obstetricians and about 5,000 midwives, Great Britain has 32,000 midwives and less than 1,000 obstetricians. The midwives promote the far greater use of less invasive, less risky, low-tech approaches. In America no such counterbalance exists because organized obstetrics fights to keep midwives under their absolute control. So we find far higher rates of high-tech, unnecessary use of technology in U.S. maternity care than, for example, any country in Western Europe, even though the United States loses far more babies and women around the time of birth. Because of its obstetric-intensive maternity care, the United States spends twice as much per capita on maternity care than any of the other countries with lower mortality rates for women and babies around the time of birth. The financial waste of scientifically unfounded high tech obstetric maternity care in the United States is enormous. By changing to a far more modern, more scientifically based maternity care with 75 percent of the births attended by midwives, the elimination of routine electronic fetal monitoring and a cesarean section rate in compliance with the recommendations of the federal government, the United States could save $13 billion to $20 billion a year. As a taxpayer and consumer of maternity care, you need to be aware of this waste.
We see there are many reasons for the unnecessary overuse of technology during pregnancy and birth, most reasons connected to doctors. As a practicing physician for more than years, I have had long experience within the profession and can bring an important point of view to your understanding of doctors. We doctors are not evil people. Most doctors are hard working, caring professionals doing the best they know how to do. But it is essential to remember two fundamental facts about doctors. First, we doctors operate within a system that strongly influences what we do. Today's obstetricians are not the ones who decided a century ago to do away with midwifery in America. Almost without exception, they buy into the present system that insists obstetricians are the preferred providers of primary maternity care, even in the face of scientific data to the contrary.
The second fact about doctors is that they are human in every respect, not gods, and should not be put on a pedestal. If it is OK to bash your automobile mechanic who has done a bad job, then it is equally OK to bash a doctor you suspect of malpractice. Doctors should be as accountable to the public as any other group that serves the public. And to understand why doctors do what they do, you must accept their humanness and vulnerability to inappropriate influences. In 1992 the average take-home income of U.S. obstetricians was $250,000 a year, and today it is even higher. The present scientifically unjustified monopoly of maternity care by obstetricians in the United States is richly rewarding the obstetricians, and you can be sure they will fight to maintain the status quo, keeping out any competition such as midwives and out-of-hospital birth. This is why, as a consumer of maternity care, you must beware what you are told by doctors and hospitals and take full responsibility for ensuring you get the kind of pregnancy and birth experience best suited to your needs and no one else's.
How do you get the maternity care best suited to you and your family with the appropriate use of technology? You can take the following steps:
Sources of Information for Technology in Birth