“Safety net” or trampoline?

What if there were no C-sections? What if that simply wasn’t an option? Do you think doctors would practice differently? I do.

No one discounts that C-sections can be beneficial, saving the lives of mothers and/or babies. However, our country is currently experiencing its highest C-section rate, with maternal mortality increasing right alongside the C-section rate (not saying necessarily that it’s causative; however, if these C-sections were life-saving to the mother, one would expect the maternal mortality rate to be decreasing or at least staying the same), and perinatal mortality not doing that much better either. [If you want some state-by-state breakdowns, Jill at the Unnecesarean has compiled several, with the most recent one being California.] Most people agree that the C-section rate is too high, and could safely be brought down. There are many factors going into the increase incidence — some of which may be valid and beneficial reasons, but others that are not.

Carla Hartley recently wrote a note in which she cleared up some misconceptions that have apparently been told about her and “what she believes.” Among other things, it appears that some have said that she thinks midwives ought not take Pitocin with them to home births (for postpartum hemorrhage). She said (paraphrasing), “But what if you as a midwife had no Pitocin in your bag? Would that change your practice style? Knowing that you didn’t have that as a backup, would you be less tempted to act in a way that might cause a postpartum hemorrhage?” That’s food for thought.

Taking this out of the birth realm, we see that when there is a safety net, it changes people’s behavior — how many of you would walk across a tightrope without a safety net below? Some do; but far fewer people would risk crossing if they knew that there was a real risk of death, as opposed to a slight risk of death and a real likelihood of safely bouncing on a net if they fell. There are always adventurous people, daredevils, pushing the envelope — doing things that are dangerous or downright deadly, just because they can. But most people only do something if they think or know that there is a reasonable chance for them to succeed and come back alive.

In another, much more mundane vein, we see banks and other companies loaning people money for various reasons, including education, buying a house, buying a car, etc. The more collateral you put up, the more they’ll lend you; the more you earn, the more they’ll give you; or if the government guarantees that they’ll pay the loan should you default or die, they’ll gladly loan you the money you ask. Why? There really isn’t that much risk involved, if the government is the guarantor; and the risk to the lender is dramatically lowered if you have something valuable that they can take if you can’t pay your bills. It’s a safety net for them.

Back to birth — I wonder how it would affect doctors’ practice style if they knew that there was no “safety net” of a quick, easy, safe Cesarean. I’m reminded of something one of my email doula friends said — she’s attended hundreds of births, many of which became necessary C-sections, but none of which were necessary at the outset of labor. This is not to say that the only time C-sections become necessary during labor is if they were interfered with — sometimes the most natural labors end up requiring C-sections, and sometimes interventions can help preserve a vaginal birth when otherwise a C-section might be necessary; but frequently, it is the interventions which lead to a C-section then becoming necessary. We all have heard of “Pit to Distress” — the practice of increasing the dosage of Pitocin until the baby is born, or becomes so distressed by the unnatural labor that the doctor then has a reason to call for a “necessary” C-section. What if doctors didn’t have easy access to surgery, in the event the baby was distressed? Do you think they’d be so quick to give Pitocin to a baby that is tolerating labor, just to speed things up? I don’t. It’s relatively easy to say that it’s no big deal if the baby becomes distressed due to X, Y, or Z, because “she can always be given a C-section.” But what if she can’t? Then, if the baby becomes distressed because of something the doctor did, it’s all on him if the baby is injured or dies.

If there were no C-sections, doctors would still be taught how to best manage vaginal breech births and vaginal twin births. I think of one snippet of media coverage I saw in the aftermath of the Haiti earthquake. An American woman (probably an OB, maybe not), was attending births in the street “hospital,” and a Haitian woman was in labor. Probably the baby began “crowning,” except that it wasn’t the head, but the rump that was presenting. The American wailed, “It’s breech! I don’t know what to do!!” She had probably never seen a vaginal breech birth before — even assuming she was a trained and practicing obstetrician, she likely was trained in100% C-section for breech, rather than how to safely assist a vaginal breech birth. All well and good for America, with plenty of hospitals and operating rooms, technology and antibiotics — but when the OB is removed from all of that, what skills does she really have to help make birth safe?

If there were no fetal monitors, doctors would not feel safe with administering Pitocin, particularly in high doses, because they would have no way of knowing how the baby was tolerating it. If there were no C-sections available should the baby become distressed, doctors would be more cautious to keep the baby from distress, don’t you think?

I’m afraid that our safety net of technology and interventions has become more of a “trampoline” — rather than being used only to save someone’s life or health in rare events, it is being used on a regular basis, as if it’s meant to be bounced on. And, no, I’m not calling for a complete ban on the use of Pitocin, C-sections, or any other intervention — they have their place. However, if they were reduced only to what was necessary (which we as fallible humans cannot know with 100% certainty which are truly necessary and which are not, so we could not truly reduce the rate of unnecessary intervention to zero; but looking at some things like mortality and morbidity with and without C-sections, and retrospective studies showing that most inductions were not medically necessary [and failed inductions certainly increase the rate of C-sections], we can see that it certainly can be reduced), we would see a very different (and, I think, better) picture in labor and birth, compared to what it is now.

One time my sister was talking to a police friend of ours, and sort of complaining about getting pulled over for speeding tickets. [At the time, she did have a "cop magnet" -- a sweet little black T-top Thunderbird.] And our friend said, “Always drive like there’s a cop behind you.” That’s good advice, isn’t it? We often don’t — relying on radar detectors just to keep from getting caught; but if we drove safely and cautiously, within the speed limit, and obeying all laws, we’d likely never get a traffic ticket, and we’d reduce the likelihood that we’d end up in an accident. Maybe if doctors, midwives, and nurses would “practice like there are no C-sections,” we’d be able to safely reduce the C-section rate much closer to the minimum necessary.

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8 Responses

  1. Great thoughts, Kathy! Thanks for sharing!

  2. This is an interesting thought experiment.

    I particularly like the point you made in the paragraph about Haiti. “All well and good for America, with plenty of hospitals and operating rooms, technology and antibiotics — but when the OB is removed from all of that, what skills does she really have to help make birth safe?”

    I think that all birth workers should be taught how to deal with birth as it actually occurs (outside of the technocratic model), because that is like teaching “the basics” and everyone should start with the basics, shouldn’t they?

  3. True point! I also think a similar thing happens because of the easy availability of epidurals, constantly lurking in the corners of the subconscious. It’s so easy to run away, and I think because of the availability women are less likely to believe in their bodies, let go, more likely to give in to fear. Then I get more mothers coming to me because of a cascade of intervention at a previous birth and complications and side effects to epidurals and fear of birth….. *sigh*

  4. “What if there were no C-sections?”

    Thousands of mothers and tens of thousands of babies would die each and every year … just like they did before C-sections were used routinely, and just like they do in countries that don’t have access to C-sections.

  5. Ah, yes…but the real question here should be…what if there were no *lawyers*? ;)

    P.S. I am an American trained. practicing ob/gyn physician, and I know how to deliver a term breech. My first one was a transfer from a lay midwife laboring a patient at home, only she did not realize the baby was breech until the buttocks crowned. They drove that way, baby’s bottom crowning for at least half an hour to get to our hospital. Kiddo had a very purple bottom, but I was able to safely deliver the baby with no complication or head entrapment. Unfortunately, mom was more concerned that her “birth experience” was ruined by all of us mean jerks at the hospital stepping in when her chosen attendant was clearly in over her head. Thank goodness it was a good outcome, or I’m sure a suit would have followed.

    Try not to paint us all with such a broad, ugly brush. We, as physicians, do our very best to help women achieve safe, healthy deliveries. No one *wants* to cut you open. No one *wants* your baby to be in distress. Stop perpetuating fear of medical professionals under the guise of “advocating.” We are all doing the best that we can.

    • A very good question. As they say, one lawyer would starve — it takes two lawyers to make a living. I’ve advocated more than once on this blog (in addition to many comments elsewhere) that we need tort reform, so that lawyers have less power to make medical decisions.

      Some hospitals have 50-70% C-section rates (and these are not the super-duper major hospitals with all the bells and whistles that attend only high-risk maternal-baby births where the overwhelming majority of such couplets do actually need surgery — either a C-section for the birth or for the baby immediately after birth — but are “run-of-the-mill” hospitals). So you’ll have to do some convincing that “no one wants to cut you open,” especially when 27% of low-risk first-time moms in Ohio had C-sections. I’m not saying that there are no good OBs; however I do think that some doctors are much too quick to perform C-sections and other interventions for a variety of reasons that are not medical necessity, and the statistics back me up.

      Yes, everybody wants babies to be born healthy and safe — I’m not disputing that. However, I’m pretty sure that a 30+% C-section rate is not necessary for that, nor such a high rate of induction and augmentation. And that’s the point of the article — could we be doing less while still getting healthy and safe births? Nationally, yes, I think we can, although particular doctors may be excluded — “if the shoe fits, wear it,” y’know.

  6. Dr Whoo – absolutely there are some great docs out there. I, too, sometimes wonder at the ‘attack’ mode of the NCB community. Not really sure that it benefits women.

    I’m not saying that bad things aren’t happening – just that we need to be careful when making broad generalizations. I am a CNM and my midwifery service has a section rate of 6.7% for last year. We provide care for women who have pre-eclampsia and GDM. So not every woman we see is low-risk. Yet, our section rate is still, I think, pretty darn phenomenal! But it leaves a bad test in my mouth when ob/gyns (and sometimes midwives) are touted as ‘bad guys’. If it wasn’t for the awesome docs we work with, we might not have the statistics that we do.

    I know that lots of things need to change in our birth culture. I really get that. But lets just be careful about the tossing about of those generalizations….

    hospital birth is going to be horrible

    obs are evil and don’t care about the women they serve

    etc.

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