Fish can't see water: The need to humanize birth in Australia
by Marsden Wagner (MD, MSPH)
Marsden began his career in public health as a neonatologist and epidemiologist, firstly in California then Denmark. He retired from a distinguished career as head of Maternal and Child Health for the European Office of the World Health Organisation (WHO), he now acts as a consultant for WHO in the emerging countries of central and eastern Europe. He chaired the three consensus conferences convened by WHO on appropriate technology around the time of birth and is in demand as an international speaker for his forthright support of midwifery and midwives.
Humanizing birth means understanding that the woman giving birth is a human being, not a machine and not just a container for making babies. Showing women---half of all people---that they are inferior and inadequate by taking away their power to give birth is a tragedy for all society. On the other hand, respecting the woman as an important and valuable human being and making certain that the woman's experience while giving birth is fulfilling and empowering is not just a nice extra, it is absolutely essential as it makes the woman strong and therefore makes society strong.
But we do not have humanized birth in many places today, including Australia. Why? Because fish can't see the water they swim in. Birth attendants, be they doctors, midwives or nurses, who have experienced only hospital based, high interventionist, medicalised birth cannot see the profound effect their interventions are having on the birth. These hospital birth attendants have no idea what a birth looks like without all the interventions, a birth which is not dehumanized. This widespread inability to know what normal, humanized birth is has been summarized by the World Health Organization:
"By medicalising birth, i.e. separating a woman from her own environment and surrounding her with strange people using strange machines to do strange things to her in an effort to assist her, the woman's state of mind and body is so altered that her way of carrying through this intimate act must also be altered and the state of the baby born must equally be altered. The result it that it is no longer possible to know what births would have been like before these manipulations. Most health care providers no longer know what 'non-medicalised' birth is. The entire modern obstetric and neonatological literature is essentially based on observations of 'medicalised' birth." - World Health Organization[1]
Why is medicalised birth necessarily dehumanizing? In medicalised birth the doctor is always in control while the key element in humanized birth is the woman in control of her own birthing and whatever happens to her. No patient has ever been in complete control in the hospital---if a patient disagrees with the hospital management and has failed in attempts to negotiate the care, her only option is to sign herself out of the hospital. Giving women choice about certain maternity care procedures is not giving up control since doctors decides what choices women will be given and doctors still have the power to decide whether or not they will acquiesce to a woman's choice.
Birth, which has been taken from the community and slowly but surly changed into hospital-based care during the last hundred years, must be given back to the community--- back to the woman and her family. Doctors are human; birthing women are human. To err is human. Women have the right to have any errors committed during their birthing be their own and not someone else's.
Labour and birth are functions of the autonomic nervous system and are therefore out of conscience control. Consequently there are, in principle, two approaches to assisting at birth: work with the woman to facilitate her own autonomic responses---humanized birth; override biology and superimpose external control using interventions such as drugs and surgical procedures---medicalised birth.
In practice, care during birth may include a combination of the two approaches: facilitation of the woman's own responses usually dominating out-of-hospital management of birth while the superimposition of external controls usually dominates hospital birth management. But whether the care is medicalised or truly humanized depends on whether or not the woman giving birth is in absolute control.
Why Medicalised Birth
The past fifteen years has seen a struggle between these two approaches to maternity care become intense and global. Today there are three kinds of maternity care: the highly medicalised, 'high tech', doctor centered, midwife marginalised care found, for example, in the USA, Ireland, Russia, Czech Republic, France, Belgium, urban Brazil; the humanized approach with strong, more autonomous midwives and much lower intervention rates found, for example, in the Netherlands, New Zealand and the Scandinavian countries; a mixture of both approaches found, for example, in Britain, Canada, Germany, Japan, Australia.
Before 200 years ago all birth care was humanized as it kept the woman in the center and, in general, respected nature and culture. Today in developing countries there are usually medicalised maternity services in the big cities while in the rural areas medicalised services have not yet penetrated and humanized services remain.
Today prevalent medical opinion is that 'modern', i.e. Western obstetric-intensive maternity care saves lives and is part of development and attempts to bring maternity care excesses under control are retrogressive. The present situation in developing countries reinforces the idea that the only reason out-of-hospital, midwife intensive birth still exists in places is because modern medical practice is not yet available.
But we override biology at our peril. For example, if we stop using our bodies, they go wrong. It is 'modern' to get around in a car or public transport resulting in little walking much less running. Then science finds out that our bodies need such exercise or we get cardiovascular problems. So today the post-modern idea is to go back to walking and running (jogging) and this is seen as progressive, not retrogressive. By the same token, humanizing maternity services is not retrogressive but post-modern and progressive.
Every change in the human condition, including development, has the potential for positive and negative effects. The positive effects of development overwhelm the negative effects until a level is reached where social and economic benefits reach everyone, then hidden negative effects begin to emerge. The data are overwhelming that social and economic development, most especially maternal education, brings down the infant mortality rate. But such development also increases the rate of sudden infant death syndrome (SIDS or 'cot death') by bringing 'modern' ways such as parental smoking and how the infant is placed for sleeping, factors associated with SIDS. So in highly developed places such as the Czech Republic SIDS rates are lower in less developed rural areas than in Czech cities and in Hong Kong SIDS rates are lower among the less developed families still following traditional Chinese ways.[2] The negative effects of development on infant mortality, always there, have now emerged.
The negative effects of development on maternal mortality are also emerging. Obstetric interventions such as caesarian section sometimes save lives and sometimes kills--- maternal mortality even for elective (non-emergency) caesarian section is 2.84 fold or nearly three times higher than for vaginal birth.[3] For fifty years the maternal mortality ratio in the US came down. Then in the 1980's the maternal mortality ratio began to rise and, according to the US Centers for Disease Control and Prevention, it rose from 7.2 in 1987 to 10.0 in 1990.[4] While this ratio continued to decline in other industrialized countries, in the US the maternal death rate continued a slow but steady rise through the 1990s and according to the World Health Organization is now higher than at least twenty other highly industrialized countries.[5]
Because WHO relies heavily on obstetricians from highly developed countries with little or no experience in developing countries, their programs in the past emphasized the role of doctors in birth care. This is a double edged sword---when Safe Motherhood Programs started in Brazil, it was gratifying to see maternal mortality fall significantly but meanwhile caesarian section rates soared, even in the poorest States. (see below)
Obstetricians often claim the use of 'high tech' medicalised maternity care in rich countries is real progress but the scientific evidence suggests it is sometimes otherwise. There has been no significant improvement in highly industrialized countries the past 20 years in low birth weight rates or cerebral palsy rates. The slight fall in the perinatal mortality rate the past 10 years in these countries is due, not to any fall in fetal mortality, but only to a slight improvement in neonatal mortality associated with neonatal intensive care and not with obstetric care. In highly developed countries, all attempts to show lower perinatal mortality rates with higher obstetric intervention rates have failed. A US National Center for Health Statistics study comments: "The comparisons of perinatal mortality ratios with caesarian section and with operative vaginal rates finds no consistent correlation's across countries". [6] A review of the scientific literature on this issue by the Oxford National Perinatal Epidemiology Unit states: "A number of studies have failed to detect any relation between crude perinatal mortality rates and the level of operative deliveries".[7]
This suggests that we are now at the point in maternity care in industrialized countries where the positive effects of development and technology are approaching the maximum and the negative effects are surfacing. This helps to explain why advances in technology and in development cannot lead to improvements in health unless the technology is in harmony with natural biological processes and is accompanied by humanized health care. Here a simple example. If an elective caesarian section is done after labour has started, it may in some cases facilitate natural processes. But waiting until labour starts means doctors lose the possibility of scheduling the procedure at their convenience. But if, as is almost always the case today, the doctor tries to circumvent natural processes by performing elective caesarian section before labour starts, there is a greater risk of respiratory distress syndrome and prematurity, both leading killers of newborn infants. We override nature at our peril.
All of this helps to explain why international development agencies such as the World Bank are now acknowledging that economic development cannot lead to improvements in the human condition unless accompanied by social development, including education.
The greatest danger with Western, medicalised management of birth is its widespread export to developing countries. Scientific evidence shows giving routine IV infusion to every woman in labour is unnecessary but such a practice in a rich country, while a waste of money, is not a tragedy. But I have seen such routine IV infusion during labour in small rural district hospitals in developing countries where the same hospitals have so little money they are reusing disposable syringes. Routine IV infusion during labour in developing countries is a tragic waste of extremely limited resources. When developing countries adopt Western obstetric practices which are not evidence based, the result is other women in those countries dying of cancer not found early enough because of lack of attention and funds for such unglamorous but essential care as outreach cancer screening programs for poor women.
Obstetricians, like all clinicians, work hard to help one patient at a time. In balancing efficacy and risks, doctors desire to help puts the focus on efficacy rather than risks resulting in a number of examples of interventions which went into widespread use before adequate scientific evaluation. Prenatal X-ray pelvimetry in the 1930s, di-ethyl-stillbesterol (DES) for pregnant women in the 1950s and thalidomide for pregnant women in the 1970s are examples of obstetric interventions which have had tragic consequences because they went into widespread use before adequate scientific evaluation. Routine electronic foetal monitoring during labour became widespread and yet scientific evaluation proves it does not lower perinatal mortality but does increase unnecessary caesarian section. And we are still not certain of the long-term consequences of routine prenatal ultrasound scans and routine epidural block for normal labour pain.
Behind these misunderstandings in interpreting scientific data is the reality that most practicing doctors have little or no training in science. Furthermore, there is a fundamental difference between the practice of science and the practice of medicine. To generate hypotheses, scientists must believe they don't know while practicing doctors, to have the confidence to make life and death decisions, must believe they do know.
Clinicians also have little or no training in public health and epidemiology and cannot understand how population based scientific data applies to individual patients, resulting in, for example, publishing in prominent clinical journals objections to using recommended rates for caesarian section.[8] This failure of some clinicians to understand public health and epidemiology is too often combined with the failure of public health professionals to confront clinicians regarding excesses in clinical practice because of their fear of the power of clinicians and their tribal loyalty to doctors.[9]
For guidance in practices, clinicians in most places still rely on peer review and community standards of practice. Using fellow doctors as a central element in developing and monitoring practice guidelines predictably has failed, in large part due to tribal loyalties. 'Community standards of practice', based on leading clinicians practices on individual patients, still are the gold standard even though they have been revealed as nothing more than "that's what we all do" leading to a lowest common denominator standard of care rather than a best care standard based on evidence.
The one approach clinicians can understand is single case, anecdotal evidence. This approach leads to the 'what if' scenario in which applying population data to their practices is rejected by clinicians because 'what if' this or that goes wrong with an individual patient. There is no better example of this than planned out-of-hospital birth.
Many clinicians and their organizations continue to believe in the dangers of planned out-of-hospital birth, either in a center birth or at home, rejecting the overwhelming evidence that planned out-of-hospital birth for low risk women is safe. The clinician's response to this evidence is "But what if there is an out-of-hospital birth and something happens?" Since most clinicians have never attended an out-of-hospital birth, their 'what if' question contains several false assumptions. The first assumption is that in birth things happen fast. In fact, with very few exceptions, things happen slowly during labour and birth and a true emergency when seconds count is extremely rare and, as we will see below, often in these cases the midwife in the birth center or home can take care of the emergency.
The second false assumption, that when trouble develops there is nothing an out-of-hospital midwife can do, can only be made by someone who has never observed midwives at out-of-hospital births. A trained midwife can anticipate trouble and usually prevent it from happening in the first place as she is providing constant one-on-one care to the birthing woman, unlike in the hospital where usually nurses or midwives can only look in occasionally on the several women in labour for which they are responsible. If trouble does develop, with few exceptions the out-of-hospital midwife can do everything which can be done in the hospital including giving oxygen, etc. For example, when a baby's head comes out but the shoulders get stuck, there is nothing which can be done in the hospital except certain maneuvers of the woman and baby, all of which can be done just as well by the out-of-hospital midwife. The most recent successful maneuver for such shoulder dystocia reported in the medical literature is named after the home birth midwife who first described it (Gaskin maneuver).[10]
The third false assumption is there can be faster action in the hospital. The truth is that in private care the woman's doctor often is not even in the hospital most of the time during her labour and must be called in by the nurse when trouble develops. The doctor 'transport time' is as much as the 'transport time' of a woman having a birth center or home birth. Even when a caesarian section is indicated, it takes on average 20 minutes for the hospital to set up for surgery, locate the anesthesiologist, etc. and during this 20 minutes either the doctor or the birth center or home birthing woman are in transit to the hospital. This is why it is important for a good collaborative relationship between the out-of-hospital midwife and the hospital so when the midwife calls the hospital to inform them of the transport, the hospital will waste no time in making arrangements for the incoming birthing woman. These are the reasons there are no data whatsoever to support the single case, anecdotal 'what if' scenario used by some doctors to scare the public and politicians about out-of-hospital birth.
Recently there is a desirable movement towards basing medical practice on evidence but still today many doctors are not familiar with recent evidence nor with the means to obtain it. In a 1998 British study 76% of practicing physicians surveyed were aware of the concept of evidence based practice, but only 40 % believe that evidence is very applicable to their practice, only 27% were familiar with methods of critical literature review and, faced with a difficult clinical problem, the majority would first consult another doctor rather than the evidence.[11] This helps explain the continuing gap between clinical practices and the evidence.
Although obstetric care is gradually becoming more evidence based, there is a tendency not to evaluate obstetric interventions for their subtle and/or long term risks. For example, evidence suggests an increasing incidence of certain neurological problems such as attention deficit disorder, dyslexia and autism. While attempts are being made to find causes for these problems, I know of no attempt to determine any correlation's with simultaneously increasing obstetric interventions such as prenatal ultrasound scanning, pharmacological labour induction, epidural block for normal labour pain, elective CS.
Another reason for the gap between evidence and practice is the excuses often given by physicians for why they reject evidence in their medical practice. These excuses include: the evidence is out of date; collecting evidence is too slow and prevents progress; I use clinical judgment and my experience; using anecdotal 'horror stories' to try to prove the need for an intervention which the evidence has found unnecessary; quoting evidence which is of poor and/or inadequate quality; 'trust me, I am a doctor'; 'stop doctor-bashing'; evidence erodes physician autonomy. In addition to these excuses, in maternity care common excuses include: our women have smaller pelvises (no evidence), our babies are getting bigger (no evidence), our population is not as homogenous (no evidence).
Obstetricians, as members of society, tend to blind faith in technology and the mantra: technology = progress = modern. The other side of the coin is the lack of faith in nature, best expressed by a Canadian obstetrician: 'Nature is a bad obstetrician.' So the idea is to conquer nature and results in the widespread application of attempts to improve on nature before scientific evaluation. This has led to a series of failed attempts in the twentieth century to improve on biological and social evolution. Doctors replaced midwives for low risk births, then science proved midwives safer. Hospital replaced home for low risk birth, then science proved home as safe with far less unnecessary intervention. Hospital staff replaced family as birth support, then science proved birth safer if family present. Lithotomy replaced vertical birth positions, then science proved vertical positions safer. Newborn examinations away from mothers in the first 20 minutes replaced leaving babies with mothers, then science proved the necessity for maternal attachment during this time. Man-made milk replaced woman-made milk, then science proved breast milk superior. The central nursery replaced the mother, then science proved rooming-in superior. The incubator replaced the mother's body for care of low-weight newborns, then science proved the kangaroo method better in many cases. If more doctors experienced an earthquake or volcano, they would realize their ideas of controlling nature are nothing more than stories to rewrite insignificance.
Unnecessary Caesarean Section: Symbol of Dehumanization
The quintessential example of medicalisation and dehumanization of birth is unnecessary caesarian section (CS) in which the surgeon is in charge and the woman no longer has any control. CS saves lives but there is no evidence that rising CS rates the past two decades in many countries has improved birth outcomes.[6,7] How can this be? As indications for CS broaden and rates go up, lives are saved in a smaller and smaller proportion of all CS cases. But the risks of this major surgical procedure do not decrease with increasing rates. It is only logical that eventually a rate is reached at which CS kills almost as many babies as it saves.
Women and their babies are currently paying a big price for the promotion of CS. The scientific data on maternal mortality associated with CS suggest the rising maternal mortality rates in the US and Brazil may be, at least in part, the result of their high CS rates.[3] Both these countries need to carefully audit all maternal deaths to test the strong hypothesis that rising rates of maternal death are associated with high rates of caesarian section. The data on other risks for both woman and baby associated with CS mean both are paying a big price both in the current birth and in future pregnancies as well.[12]
So why so much unnecessary CS? When maternity care is controlled by doctors and midwives are marginalised or absent, higher CS rates are found. Many studies have shown lower obstetric intervention rates when midwives attend low risk birth than when doctors are providing primary birth care to low risk women.[13] It is no coincidence that in the US, Canada and urban Brazil, where obstetricians attend the majority of normal births and there are few midwives attending few births, the highest CS rates in the world are found. Having a highly trained gynecological surgeon attend a normal birth is analogous to having a pediatric surgeon baby-sit a normal two-year old child. It would be a waste of the pediatric surgeon's time and skills and, when the young child gets tired and fussy, the surgeon might be tempted inappropriately to use drugs, where a properly trained baby-sitter would soothe the baby with a variety of non-medical techniques---the medicalisation of normal childhood similar to the medicalisation of normal birth. High CS rates are a symbol of the lack of humanization of birth.
The overuse of elective CS and other unnecessary obstetric interventions also threatens the larger community. Not even the richest countries in the world have the financial resources to transplant all the hearts, dialyze all the kidneys, give new hips to all the people who might benefit from these procedures. Choices must be made about which medical and surgical treatments to fund and these choices will determine who shall live. A CS which is done without any medical indication but only because a woman chooses it requires a surgeon, possibly a second doctor to assist, an anesthesiologist, surgical nurses, equipment, an operating theatre, blood ready for transfusion if necessary, a longer post-operative hospital stay, etc. This costs a great deal of money and, equally importantly, a great deal of training of health personnel, most of which is at government expense, even if the CS is done by a private physician in a private hospital. If a woman receives an elective CS simply because she prefers it, there will be less human and financial resources for the rest of health care.
This dangerous drain on financial resources, as noted earlier, is far greater when CS practices in places like the US and Australia are exported to developing countries with far fewer resources for health services. For example, in one State in Brazil 59 hospitals have CS rates over 80%, three health districts have CS rates over 70% while an additional 13 health districts have CS rates over 60% and the entire State has a CS rate of 47.7 %.[14] Clearly this is a huge drain on Brazil's limited health resources. And the women of Brazil also are paying another price. The data given above proving the higher maternal mortality with elective CS in the UK is further substantiated by data showing a recent rise in maternal mortality rates in those areas of Brazil with these shockingly high CS rates.[15] CS on demand is an expensive and dangerous luxury.
In the light of these issues, the Committee for the Ethical Aspects of Human Reproduction and Women's Health of FIGO (the international umbrella organization of national obstetric organizations) states in a 1999 report: " Performing caesarian section for non-medical reasons is ethically not justified."[16]
Is Hospital Birth Safe in Australia?
While many obstetricians are prone to ask "Is home birth safe?", a more appropriate and urgent question in Australia is: "Is hospital birth safe?". Many Australian obstetricians fortunately have jumped on the bandwagon urging evidence based practice. This is an encouraging trend but there is an enormous gap between what the scientific evidence says is the best practice and what goes on in Australia as illustrated by table 1 "No evidence based practice in low-risk primips".
At least 80% of all women are capable of a normal birth without intervention but we see in Table I that among low-risk Australia women having their first birth in private hospitals only 18% are judged by doctors as capable of a normal birth without serious intervention. Over half of low-risk Australian women having their first baby are judged by doctors as incapable of initiating their own labour: 47% of low-risk primips in private hospitals in Australia have spontaneous labour. These figures are truly shocking.
That half of low-risk primips in private hospitals in Australia have an epidural block for labour pain can only mean two things: doctors and hospitals increase labour pain; women are not told the truth about the risks of epidural block.
To understand why there is now an epidemic of epidural block for normal labour pain, it is necessary to understand what happens to the woman before she is offered the epidural. The care she receives when she comes to the hospital to give birth markedly increases the pain she will have. Scientific evidence shows labour pain is significantly increased: by laboring in an unfamiliar place; by being surrounded with unfamiliar people; by having unfamiliar procedures done; by being left unattended during labour; by being put in a horizontal position and not allowed to freely walk about; by having the membranes artificially ruptured; by having induction or augmentation with drugs. So the woman comes into the hospital in labour, has a number of things done which all increase her pain, is then offered an epidural and is so grateful to the staff for the relief of the pain, much of which the staff created.
The epidemic use of epidural block for normal labour pain has closely followed on the rapid increase in the use of powerful and dangerous drugs for induction and augmentation. The Australian obstetric cascade of the past 10 years has been pharmacological induction leading to increase pain leading to epidural block leading to operative birth with forceps or vacuum extraction. Since each of these interventions carry significant risks, this cascade multiplies the risks for both the woman and the baby. For example, the contractions induced by the drugs have a different intensity and different interval which not only increases the pain but also increases the risk of fetal hypoxia.
Why does epidural block lead to operative birth? Two reasons. First, with the woman already having lost all feeling from the waist down because of the epidural, the temptation is great for the doctor to go right ahead and carry out surgical procedures. The second reason is fundamental to the basic understanding of the birth process. The pain of labour is an essential component of normal labour as it stimulates the brain to release hormones which, in turn, stimulate the uterus to contract at normal levels of intensity and at normal intervals so that placental blood flow will be maintained and there will be no fetal hypoxia. This is a delicate feedback process. With an epidural block there is an interruption of this process leading to a slowing or cessation of normal labour. Attempts can be made to overcome this with more and more stimulation of the uterus with more and more doses of drugs such as oxytocin---a rather typical scenario found in high tech birth where one intervention requires another intervention to try to overcome the complications of the first intervention. Nevertheless the scientific evidence is clear---- even with such efforts to overcome the slowing of labour caused by epidural block, there is still a four times greater chance forceps or vacuum extraction will be necessary after epidural block and at least a two times greater chance caesarian section will be required. This is no surprise---this is the inevitable result of using an intervention, epidural, which essentially stops the birth process in its tracks. The only way an epidemic of epidural block for normal birth has been able to happen is because the procedure has been given a very 'hard sell' to women by doctors. The only way that so many women agree to an epidural for normal labour is if they are told it is 'safe'.
Is epidural block safe? The single most important new trend in modern obstetrics is a universally agreed principle that all obstetric practice must be based on the best scientific evidence. What is the evidence on the safety of epidural block? A thorough literature review of the scientific evidence for risks of epidural block as discussed above and below is found in two books[17,18].
First, a procedure can hardly be called 'safe' when close to a quarter (23%) of women receiving epidural block have complications. The risks to the woman are many and serious, starting with the possibility the woman will die because of the epidural. The maternal death rate for women having epidural block for normal labour pain is three times higher than for women with normal labour not having the block. For every 500 epidurals performed there will be one case of temporary paralysis of the woman and the paralysis will be permanent in one of every half million epidurals. The woman has a fifteen to twenty percent chance of fever after receiving an epidural, necessitating a diagnostic evaluation for possible infection in the woman and baby which can sometimes be invasive such as requiring a spinal tap of the baby. Between fifteen and thirty five percent of women given an epidural will suffer from urinary retention after the birth.
How effective is epidural block in relieving pain? In around 10% of epidural blocks it doesn't work and there is no pain relief. Even when it works, around a third of women given an epidural will trade a few hours of pain-free labour for days or weeks of pain after the birth. Thirty to forty percent of women receiving an epidural during labour will have severe backs pain after the birth and 20% will still have back pain a year later.
A great deal of scientific research has shown that women receiving epidural block for normal labour pain will have a significantly longer second stage of labour. This, in turn, results in a four times greater risk of using forceps or vacuum extraction and at least a two times greater risk of caesarian section and these operative interventions during birth carry their own serious risks as well. While many women might be willing to take risks with their own bodies to gain pain relief, it is highly unlikely they are willing to put their babies at risk. One common complication in the woman after an epidural is started is sudden loss of blood pressure leading to a sharp drop in blood flow through the placenta to the fetus, resulting in mild to severe lack of oxygen to the fetus as shown on a fetal heart rate monitor. In another typical high-tech strategy of using a second intervention to try to stop the bad effects of the first intervention, doctors give the woman a great big dose of fluid through an IV to try to prevent the drop in blood pressure from the epidural but this does not always work. So lack of oxygen to the baby during the epidural remains a possibility and the American College of Obstetricians and Gynecologists reports that the electronic fetal heart monitor shows severe fetal hypoxia in eight to twelve percent of infants whose mother's are given an epidural block for normal labour pain.
There are other risks to the infant including some data suggesting poor neurological function at one month of age in some babies whose mothers had epidural block. More recent innovations in epidural block, such as changing the type of drugs used or the drug doses used or the 'walking epidural', do not eliminate these risks to the woman and her baby.
One reason for the epidemic of epidural in many countries is that women are not told the scientific facts about all of the risks to them and their babies when epidural block is used for normal labour pain. Indeed, at one meeting of obstetric anesthesiologists in the US, discussions were held on how to prevent any information on risks of epidural from reaching the public. The excuse used was the typical patronizing approach of some doctors: "We don't want to scare the ladies." It is absolutely essential that any women offered epidural must be told all the scientific facts about the risks before she gives informed consent to the procedure.
With all these risks of epidural block to woman and baby, why are doctors urging women to use it? Research shows that doctors prefer the woman to have an epidural because then she is quiet and compliant. Furthermore, it is the frequent use of epidural for normal labour which has created a new specialty, obstetric anesthesiology, which is highly lucrative and flourishing---witness that obstetric anesthesiology journals contain advertisements urging doctors to purchase private jet airplanes.
Table 2 shows the tragic Australian obstetric cascade starting with overuse of drugs for induction and augmentation leading to the excessive use of epidural block inevitably resulting in the extreme rates of forceps and vacuum extraction found in Australia---the highest rates recorded anywhere in the world. How can it be that a third of babies born in Australia must be pulled out of their mothers? Such aggressive extraction results in damage to the neonate including swelling and bruises of the head. Using a surgical instrument also means frequent episiotomy and all these invasive surgical procedures on the woman results in damage to the woman still evident six months postpartum including 54% with perineal pain, 18% with urinary incontinence, 19% with bowel problems, 36% with haemmorrhoids and 39% with sexual problems. This is why it is appropriate to define rates of episiotomy over 20 % (it is 46.6 % in Table 1) as female genital mutilation.[19]
Table 3 shows the situation in Australia regarding caesarian section. The rate of 25.9% in private hospitals is double the rate recommended by the World Health Organization and double the rate found in a number of countries with far lower perinatal mortality rates than Australia. The emergency caesarian section rates are not extreme but the elective rates are indeed extreme. One third of all caesarian section is because of "failure to progress/ disproportion" [20], a loose, imprecise diagnostic label which has been shown to be very popular among private obstetricians who have become impatient with the length of a perfectly normal birth.[21]
Because, as shown in Table 3, women in private care have far higher rates of caesarian section than women in public care, the Australian National Parliament held an inquiry. As shown in Table 4, repeated submissions to the inquiry claimed without presenting any scientific evidence that these higher rates in private care is because many women at high risk take out private health insurance. A subsequent Australian study[22] has shown that the claims made at the inquiry were false testimony as women in private care have fewer medical and obstetric complications which might require caesarian section.
So why is there more caesarian section with private patients? The cascade shown above also results in excessive unnecessary caesarian section and women in private care are given more epidural and induction which leads to caesarian section. In addition, fewer midwives attend births in private care and, as we will soon see, there is good scientific evidence that there is far less unnecessary intervention when the midwife is the principle birth attendant. And the convenience factor must be mentioned. Caesarian section can be scheduled for the convenience of the doctor and hospital and, instead of taking 12 hours, can take 30 minutes. The latest excuse given by obstetricians for excessive unnecessary caesarian section is that women prefer caesarian section and are asking for it---an unfounded and unethical excuse I address at length in a paper "Choosing caesarian section".[12]
Is hospital birth safe in Australia? After reviewing the above information, the only rational answer must be a resounding no, most especially for women in private care.
Solutions
So far we have not been clever enough, in developed or developing countries, to take the advantages of medicalised birth care while avoiding the disadvantages such as the drift to obstetric excesses. Humanizing birth has the potential to combine the advantages of Western medicalised birth with the advantages of redirecting the care so as to honor the biological, social, cultural and spiritual nature of human birth. There are several strategies for humanization of birth---- strategies which will put the woman and the family back in control of the birth of their own child while empowering the woman to believe in herself through experiencing what her own body can accomplish.
The first strategy is education. Those who control information hold the power. In the past the medical profession has maintained control of medical care through protecting and withholding information. Patient confidentiality, a legitimate excuse for limiting access to information on individual patients, is now understood not to be an excuse for limiting information on grouped data such as hospital data and community data. The information revolution is profoundly changing medical care. The advent of the internet and world wide web is having a profound effect on bringing medical information to everyone. In the new millenium a global movement is demanding accountable and transparent health care practitioners and health care facilities (including hospitals) as a basic requirement of any democracy. Several years ago during a lecture in Australia I gave data on the excessive obstetric interventions in private hospitals in Queensland. The next day irate obstetricians in Queensland called the State Health Department trying to find out where I got my data on their private hospitals. Their concern was not their excessive practices but their need to hide these practices from the public. The days of practice secrets are gone. Complete and honest information must be given to the public, even when it means giving up power and, in some cases, can be dangerous to the continuation of certain practices.
Full information on the good and bad results of medicalised birth must be given to health care practitioners, public health officials, politicians and the public. In other words, everyone must begin to see the water that many doctors and hospitals are swimming in and see that in many cases it is full of sharks which may not eat the doctors but may sometimes eat women and babies.
The need to broaden the horizon of doctors concerning maternity care is not a new problem. In a medical book published in the year 1668 is the statement: "Doctors who have never seen a home birth and yet feel competent to argue against it resemble those geographers who give us the description of many countries which they never saw." We must start by requiring doctors to look at the water in which modern maternity care exists in order to get a physiological standard against which they can measure all their experiences. In an obstetric training program in The Philippines, every doctor must attend a minimum number of planned home births. Every obstetric training program should require visits to planned out-of-hospital births, including birth centers and home births. Midwives and obstetric nurses in training need the same experience.
The education of women, especially pregnant women, is of paramount importance but here the issues is: what are the women told. In some places prenatal education programs are controlled by obstetricians who insist on giving only doctor-friendly information to pregnant women. Anesthesiologists have managed to gain access to prenatal classes where they preach the wonders of epidural block and usually say nothing about the considerable risks.
More recently, for doctors to succeed in promoting women choosing caesarian sections for which there are no medical indications it is necessary to provide limited, highly selected information.[12] It is highly unlikely women would ever consider choosing CS if they were given the full scientific evidence on the risks for themselves and their babies. The key ethical issue is not the right to choose or demand a major surgical procedure for which there is no medical indication but the right to receive and discuss full, unbiased information prior to any medical or surgical procedure.
A liberated woman correctly strives not to be controlled by men, an effort even more difficult if she lives in a male chauvinist society. There are many ways in which women giving birth in hospitals in 'macho' cultures are oppressed and given the message that they are not important and not free but controlled by an often belligerent staff. But if a woman accepts the medicalised, male dominated obstetric model of care with its selected information, she gives up any chance to control her own body and make true choices. Volumes have been written about how liberating and empowering it is for a woman to give birth when she controls what happens. Without fully informed choice, she will give up any control and comply with the wishes of the doctors and hospitals. Women who demand choice but get only selected doctor-friendly information unwittingly buy into the medical position and call it feminism.
A second strategy for humanization of birth is the promotion of evidence based maternity care practices. As mentioned earlier, using peer review and community standards of practice has failed to close the gap between present obstetric practices and the evidence. And in many places public health professionals and government agencies have failed to aggressively pursue closing the gap between obstetric practices and evidence, often out of fear of the power of the medical establishment.[9]
It has been an interesting and educational exercise for me to come to hospital obstetric units and present to the staff a simple table with their own rates of interventions (induction, episiotomy, lithotomy, operative vaginal, caesarian section) in a column on the left and the evidence based rates opposite in a column on the right---similar to Table 1 in this paper. The ensuing discussion is often characterized by more heat than light. As we enter the era of post- modern medical care, the GOBSAT (Good Old Boys Sit Around Table) clinical practice guidelines of yore, royalist in sentiment and pompous in tone, will be replaced by evidence based practice guidelines approved by the community.
Another essential strategy in humanizing birth is: who is the primary care giver for women during pregnancy and birth. The tradition of doctors insisting on controlling their own practices with little or no interference from the community or its representatives goes back a long time. During the course of the twentieth century, the practice of doctors going on 'house calls' disappeared for good reason---doctors are uncomfortable in the patient's home as the family is in control. As long as doctors provide primary care to normal, healthy pregnant and birthing women, women will not be in control and humanization of maternity care will not happen.
Countries must work hard not to allow doctors to try to take over the primary care of low-risk pregnant and birthing women. Data from the Victorian Perinatal Data Collection Unit show that in 1998 in that State, 58.7 % of all birth (public and private) was attended by either a GP or an obstetrician with no midwife involved.. Good scientific research shows that unnecessary interventions go up and women's satisfaction goes down when doctors rather than midwives attend low-risk hospital birth.[13] When doctors give primary care to over half of normal, healthy women giving birth, birth becomes a surgical procedure with high rates of unnecessary interventions. Women giving birth in such maternity care systems are disempowered and there are huge wastes of resources, financial and professional. Midwives are marginalised and more and more obstetricians are trained.
By contrast, midwifery has a long tradition of placing the birthing woman in the center with all the control in the woman's hands and with the midwife providing the kind of support which will empower the woman and strengthen the family. For this reason, having primary maternity care in the hands of midwives is a central strategy in humanization of birth.
Countries might want to study the maternity care in countries much further along the road to humanization such as New Zealand, The Netherlands, Scandinavian countries. In these countries, over 80% of women see only midwives during pregnancy and birth (in or out of hospital) and they have some of the lowest maternal and perinatal mortality rates in the world.
Considerable scientific research has demonstrated four major advantages to autonomous midwifery: midwives are safer for low risk birth, midwives use less unnecessary interventions, midwives are cheaper, midwives provide more satisfaction.
First, there can no longer be any doubt that midwives are the safest birth attendant for low risk birth. One meta-analysis of 15 studies comparing midwife-attended birth with physician attended birth found no difference in outcomes for women or babies except for fewer low birth weight babies with midwives.[23] Two randomized controlled trials (RCT) in Scotland[24,25] and 6 RCTs in the US all found no increase in adverse outcomes with midwife attended birth.[13]
The most definitive study of the safety of midwife attended birth, published in 1998, looked at all births in one year in the US---over four million births. Selecting only singleton, vaginal births and removing cases of social or medical risk factors, they compared outcomes between midwife-attended births and physician attended births. Compared with physician attended births, midwife attended births had 19% lower infant mortality, 33% lower neonatal mortality and 31% lower low birth weight rates.[26]
After reviewing the extensive evidence for the safety of midwives, a recent article in an obstetric journal concludes: "A search of the scientific literature fails to uncover a single study demonstrating poorer outcomes with midwives than with physicians for low-risk women----evidence shows primary care by midwives to be as safe or safer than care by physicians."[13].
The second advantage of midwives over doctors as primary birth attendants is a drastic reduction in rates of unnecessary invasive interventions. Scientific evidence shows that, compared to physician attended birth, midwife attended birth has statistically significantly: less amniotomy, less IV fluids or IV medication, less routine electronic fetal monitoring, less use of narcotics, less use of anesthesia including epidural block for labour pain, less induction and augmentation, less episiotomy, less forceps and vacuum extraction, less caesarian section, more vaginal birth after caesarian section.[13]
The third advantage of using midwives as the principal birth attendant for most births is cost savings. While it varies from country to country, midwives salaries are almost always considerably less than doctor's salaries. And of course, the lower intervention rates with midwives mean major cost savings. The data on cost saving is reviewed in a paper on midwifery in industrialized countries[13] where, for example, one study found a cost saving of US$500 for every case where a midwife is birth attendant.
Another advantage of midwifery care, often disparaged by advocates of medicalised birth, is the pregnant and birthing woman's satisfaction with her care. The midwifery approach emphasizes the importance of women's satisfaction. The evidence in the literature is overwhelming: midwifery care is statistically significantly more satisfying to the woman and her family.[13]
In order to maintain their hegemony over midwives, doctors attack midwives, especially midwives in independent practice where they are not under the control of doctors or hospitals. The past two decades has seen a global witch hunt of midwives.[27] One of the most frightening examples of a witch hunt against a midwife occurred here in Australia with an independent midwife Maggie Leaky-Thompson. Regardless of any individual opinion of this midwife's practices, the methods used to attack her ran roughshod over any chance of a just hearing, as described in my paper 'The Australian Witchhunt' found in the appendix to this paper.
Since hospitals are doctor territory and no woman has ever been in control of her own care in a hospital setting, another important strategy for humanization of birth is to move birth out of the hospital. There have always been and always will be women everywhere who choose planned home birth and need a midwife to attend the birth. But today, as a result of decades of propaganda about how dangerous birth is, told by doctors who are themselves afraid of birth and are told how safe hospital birth is, told by doctors who themselves need the security of hospitals, there are many women who have bought into the myth that home birth is dangerous.
It is unbelievable that obstetric organizations in some highly industrialized countries such as the US still have the same official policy against home birth which they wrote in the 1970's. At that time planned home birth was not separated from unplanned precipitous out-of-hospital birth which, of course, had high mortality due to preemies born in taxis, etc. Then when scientists separated out planned home birth, it proved to have perinatal mortality rates as low or lower than low risk hospital birth. A large scientific literature documents this, including when the home birth practitioner is a nurse midwife[28] or when it is a direct entry midwife[29-31]. A meta-analysis of the safety of home birth, published in 1997, conclusively demonstrates the safety of home birth and includes an excellent review of the literature.[32]
It is important to be aware of attempts to distort home birth research findings in attempts to hang on to the untenable position that home birth is dangerous. Several years ago on the Australian television program 'Lateline' Dr Brunello attempted to defend his anti-homebirth position by giving data from research in South Australia which he claimed suggested homebirth has higher perinatal mortality.[33] He must not be a scientist as he was apparently unaware that the findings of this particular study are suspect for a number of reasons including: far too small a sample size, no matched control group and no data linkage to find lost cases. The authors themselves conclude: "Close examination of the individual deaths led to the conclusion that the majority could not directly be attributed to the place of birth."
Another more recent publication on homebirth in Australia[34] has methodological flaws so serious as to make their conclusions unjustified. The appendix to this paper includes my scientific critique of this Australian study in which I conclude: "It is well known in Australia that the reason for the several shifts in data collection methods in this study (which effectively eliminated any possibility of scientific validity) is because so many midwives felt betrayed by the researchers that they refused further participation in the research. It is intellectually dishonest not to report this fact in this paper."
In spite of all attempts by doctors to stamp out home birth, it has never disappeared and now is showing clear evidence of making a slow but sure comeback in a number of countries including Great Britain, Denmark, US, Japan (Birth Houses). And of course the great thorn in the side of anti-homebirth doctors has always been and still is The Netherlands where planned homebirths have never fallen below 30% with birth outcomes such as maternal and perinatal mortality rates comparable to Australia.
So the real issue with home birth is not safety but the issues are freedom and sanctity of the family. For the over eighty percent of women who have had no serious medical complications during pregnancy, planned home birth is a perfectly safe choice. Any doctor, hospital or medical organization attempting to discourage a low risk woman from choosing home birth is denying basic human rights by withholding full unbiased information and limiting a woman's freedom of choice of place of birth. Doctors who believe they know best how others should live and attempt to impose their beliefs on others are practicing medical fascism. The birth of a baby is one of the most important events in the life of the family and when the family chooses a planned home birth, the sanctity of the family must be honored.
Because of the frightening propaganda of the obstetrical profession about how dangerous birth is, many women want the freedom to control their own birthing but need the 'security' of an institution. How can women today be in control of giving birth and be empowered by birth and be assisted by a midwife and still feel comfortable and protected by an institution? By choosing an alternative birth center (ABC) which is 'free-standing' (i.e. out-of-hospital) and staffed by midwives.
The first essential characteristic of an ABC is that it is free of any control by a hospital. A hospital which claims to have a 'birth center' is like a bakery which claims to sell 'home-baked bread. To be a birth center, the birthing woman must be in control of everything that happens to her and her baby. This means the ABC must be staffed by midwives using protocols made by midwives, not doctors.
The type of care provided in an ABC is quite different from a hospital. In a hospital the doctor is always in absolute control while in an ABC the woman is in control. In the hospital the emphasis is on routines while in the ABC the emphasis is on individuality and informed choice. Hospital protocols are designed with all the possible complications in mind while ABC protocols focus on normality, screening and observation. In hospitals pain is define as an evil to be stamped out with drugs while in the ABC it is understood that labour pain has a physiological function and can be relieved with scientifically proven, non-pharmacological methods such as immersion in water, changing position and moving about, massage, presence of family, continuous presence of the same birth attendant.
In the hospital induction is frequent and uses powerful drugs which increase the pain and has many risks while in the ABC labour is stimulated with non-pharmacological methods including walking and sexual stimulation. In the hospital staff are not always present but come and go and change every eight hours while in the ABC there is the continuous presence of one midwife throughout the labour. In the hospital the new baby is taken away from the mother for various reasons such as doing a newborn examination while in the ABC the new baby is never taken from the mother.
Are ABCs a safe place for a woman to give birth if she has had no complications during the pregnancy? This is a key question because in the struggle between the medicalised and humanized approaches to maternity care, the ABC is a big threat to doctors and hospitals and the industry producing all the obstetric technologies. Because medicalised birth is so expensive with costly hospital stay, highly paid obstetricians using so much costly high tech intervention, the doctors and hospitals must convince the public and those who control funding of health services that their way is the only safe way. Otherwise they will quickly lose much of their business. So obstetric organizations fight against all birth where they are not in control. Their first line of defense against any planned out-of-hospital birth is to label it unsafe.
The only way to determine if ABCs are safe is to turn to the scientific evidence. A thorough review of the scientific evidence on ABCs [35] reports that in the 1970s and 1980s there were a number of descriptive studies on ABCs. Then in 1989 a most important paper on ABCs was published: 'The US National Birth Center Study' involving 84 ABCs and 11,814 births.[36] In the 1990s seven more studies compared ABC birth with hospital birth and one RCT was reported. The results of this research follows.
Regarding safety, the US National Birth Center Study had no maternal mortality and an intrapartum and neonatal mortality rate of 1.3 per 1000 live births, a rate comparable to the rates in low risk hospital births. The infant mortality rate and Apgar scores in the ABCs was also comparable to low risk hospital rates. Sixteen percent of ABC births were transferred to the hospital. Such rates of transfer of planned ABC birth to hospital because of complications compare favorably with the number of planned hospital births which are transferred to the surgical suite because of complications. The intention to treat analysis was used in which all complications, interventions and outcomes from ABC births transferred to hospital are included in the ABC statistics.
The safety of ABC birth is further substantiated by additional studies done in the 1990s in which the outcomes of ABC births---perinatal mortality, neonatal mortality, apgar scores, low birth weight rates---in all studies were as good or better than the outcomes with hospital birth.
In addition to the evidence for the safety of ABCs, these studies had further data on the characteristics of women choosing ABCs. After their ABC birth was over, 99% said they would recommend ABC birth to their friends and 94% said they would return themselves to the ABC for any future births. A RCT found that 63% of ABC women had an increase in self-esteem while 18% of women with hospital birth had an increase in self-esteem.[35]
With regard to the promotion of breastfeeding, studies in the US, Denmark and Sweden all found significantly increased rates of successful breast-feeding in ABC women.
Table 5 compares the intervention rates in the US National Birth Center Study[36] with the rates of obstetrical intervention in low-risk primiparous women in private care in Victoria presented earlier in this paper.[22] In ABCs, 99% were spontaneous vaginal births compared to 18% of low risk primips in private hospitals in Victoria. Less than 4% of ABC births had induction or augmentation with artificial rupture of membranes and/or oxytocin compared with 48.8% of low-risk private hospital births. Regional or general anesthesia (including epidural block) was done in 13% of ABC births and 50.8% of low-risk private hospital births in Victoria. Operative vaginal birth (forceps or vacuum) was done in less than 1% of ABC births and 33.9% of private hospital births in low-risk primips in Victoria. Caesarian section was done in less than 5% of ABC births and in 25.9% of all births in private hospitals in Victoria. Looking at these comparisons of interventions, clearly the logical question is not if ABC birth is safe but if hospital birth is safe.
As the news about the safety of ABCs spreads, more and more are being established. In the past ten years, Germany has gone from having one ABC to now having over 50 ABCs. In Japan, a network of midwife birth houses provided a significant part of maternity services the first half of the last century but during the American occupation, US Army doctors and nurses put pressure on the Japanese to close the birth houses. Now, however, there is a resurgence of birth houses in Japan.
Compared to hospital births, home births and births in ABC's are safe, much cheaper, use far less unnecessary interventions, are more satisfying to the woman and family. In other words, out-of-hospital birth is an important strategy in humanizing birth care.
Birth is political. An essential strategy is for advocates of humanized birth to be politically active. Politicians and government agencies make crucial decisions about maternity care and their education about and involvement in humanization of birth is essential.
Advocates of humanized birth must warn politicians and policy makers of the use of scare tactics by some of the more reactionary elements of the medical establishment who raise the issue of safety and claim without a shred of evidence that humanized birth is dangerous---that midwives are less safe than doctors and out-of-hospital birth less safe than hospital birth.
Another common scare tactic is for obstetricians to say that every out-of-hospital birth transported to the hospital is a 'train wreck'. The answer to this criticism is "of course". A competent out-of-hospital midwife will only transport those few cases where there is a serious problem requiring surgical interventions not available in the home. So for the obstetricians who have never attended a home birth (in many places this is nearly all obstetricians), these out-of-hospital transports with problems are their only experience with out-of-hospital birth and they erroneously assume these cases are representative of all out-of-hospital birth. This is like the auto mechanic who sees several Mercedes with mechanical problems and concludes all Mercedes are no good, forgetting that for every Mercedes he sees in his shop, there are a thousand Mercedes running fine and therefore not brought to his shop. This is why doctors need to experience out-of-hospital birth first hand.
These scare tactics are motivated by the attempt of some doctors to protect maternity care as their territory. Often doctors attempt to overwhelm legislators with technical language which implies that only doctors can possibly understand so the listener must simply "trust me, I'm a doctor". Politicians and policy makers should be urged to ask those making these scare statements "Please show me the scientific data to prove what you are saying." It can also be illuminating for legislators to ask those making scare statements how many out-of-hospital births they have attended.
Conclusion
The final solution is to evolve new social and political forms for the medical profession and for medical care. Maternity care needs turning around so that, instead of drifting away from physiology and from the social and cultural environment, the process moves toward respecting and working with nature and with the woman and family, turning control of medical care over to the people. For those who fear chaos, remember Churchill's warning: democracy is the worst form of government until one considers the alternatives.
This turn around has started in places with local public committees deciding on health care policies and priorities--- post- modern maternity care. Everything about pregnancy and birth----how it is perceived by society, how the pain of birth is endured by women, how birth is 'managed' by birth attendants---are highly cultural. Local control leads to empowerment of women which, in turn, leads to a stronger family and society---local women need to give birth in local waters. People have been swimming in the physiological, social and cultural primordial sea for a long, long time, can see the water, know where the sharks are and are adept at eventually finding their way forward to reclaiming humanized birth.
Eventually the new millennium will see a system of maternity services in Australia which are midwife-intensive, evidenced based, focus on out-of-hospital low-risk births, and honors the freedom of women and families. Why? Because:
"Never doubt that a small group of thoughtful, committed people can change the world. Indeed, it is the only thing that ever has." - Margaret Mead
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Tables
Is hospital birth safe in Australia? No evidence based practice in low-risk primips
Is hospital birth safe in Australia? Australian obstetric cascade
Is hospital birth safe in Australia? Caesarian section rates in Victoria in 1998
Is hospital birth safe in Australia? Obstetric false testimony
Is hospital birth safe in Australia? Interventions low-risk private hospital births versus alternative birth center births
Appendix
Wagner M "The Australian Witchhunt"
Wagner M "A Critique of: Bastian H, Keirse M, Lancaster P; Perinatal death associated with planned home birth in Australia: population based study". British Medical Journal Vol 317, 8 August 1998
© Marsden Wagner 2000. This paper was presented at the Homebirth Australia Conference, Noosa, Australia, November 2000
