The Politics of Women's Health
Why is Maternity Care Like This?
Many elements of the care most women receive during pregnancy and childbirth in the United States are not based on the most reliable research on what is safe and effective. Procedures that are useful—and sometimes even lifesaving— when applied to women and babies with specific high-risk conditions are often extended liberally to other women and babies—“just in case.” Such unnecessary medical interventions are not helpful and can even be harmful.
One procedure that is badly overused is episiotomy (cutting the perineum in order to make the opening to the vagina bigger). While episiotomy can help when the baby is very large or when the baby needs to come out immediately, its use should be limited to clear cases of need because it increases the likelihood of serious tears into or through the anal muscle.3 Other overused interventions include continuous electronic fetal heart rate monitoring (see page 174), induction of labor (see page 146), and cesarean section.
Overuse of obstetric interventions is a widespread problem. A national survey of mothers who gave birth in hospitals in 2005 found that nearly all women experienced some combination of interventions that can interfere with the normal progression of birth.4 Most of the women surveyed had continuous electronic fetal heart rate monitoring, urinary catheterization, administration of intravenous fluids, and epidural or spinal analgesia. One in two received synthetic oxytocin to either start her labor or make her contractions stronger and more frequent, and slightly more than three in ten had a cesarean section. Most women also experienced practices that may do more harm than good, such as not eating or drinking anything during labor and lying on their backs during labor and while giving birth. The United States’ C-section rate is more than twice the maximum rate recommended by the World Health Organization; this means that more mothers and babies are exposed to the negative effects of surgical birth. (For more information on C-sections, see Chapter 13, “Cesarean Births.)
While such procedures are overused, other practices that improve birth outcomes and increase women’s satisfaction are widely underused. These practices include receiving continuous one-on-one support during labor; being able to change positions, get out of bed, and walk during labor; and using comfort measures such as massage, warm baths, and birthing balls. The same national survey mentioned above found that of every one hundred women giving birth in a hospital, only three were attended by a doula (a trained labor companion), only four used a shower to help cope with labor pain, and only six relaxed in a tub or pool of warm water during labor.5
We need to turn these numbers around. Medical procedures that are potentially harmful should be used only when needed, and practices that are known to improve outcomes should be made widely available.
Most health systems struggle to ensure that people receive evidence-based care. It is difficult for busy health care professionals to keep up with and interpret a large and ever-growing body of studies. Even when providers understand lessons from the best available research, it is often hard to change established beliefs and routines. Many groups have a role in ensuring that mothers and babies receive high-quality care. These include health care providers and women ourselves, as well as policy makers, payers, administrators, educators, researchers, and journalists.
Why Is Maternity Care Like This?
Why are some medical interventions still being overused in the United States today, despite the evidence against them? And why aren’t approaches that are known to be helpful offered to all women? Advocates for improving maternity care point to the following roadblocks to change.
OBSTETRICAL TRAINING AND THE MEDICAL SYSTEM
Obstetricians provide care for the vast majority of pregnant women in the United States. Obstetrics is a surgical specialty, and doctors training to become obstetricians learn, among other things, to perform cesarean sections, apply forceps, and cut and repair episiotomies. They generally receive less instruction in the natural progression of childbirth or in birth techniques that minimize perineal tearing. The focus is on external management rather than on facilitating a woman’s own capacities for labor. In many training programs, obstetricians are not even required to sit with a healthy woman throughout her labor or observe one birth without any interventions. This training leads obstetricians to be far more comfortable managing childbirth with medication and technological interventions than without.
The widespread use of epidurals also has transformed childbirth in the United States. While epidurals are a very effective form of pain relief during labor, they sometimes have adverse effects and can alter the natural progression of labor. A woman who has an epidural is usually restricted in her movements and for safety reasons must be monitored continuously by electronic fetal monitoring (EFM). The restricted movement and muscle relaxation caused by the epidural can cause babies who are facing backward to stay that way, which results in a longer second stage of labor and a higher incidence of forceps and vacuum deliveries. Use of epidurals also can lead to less effective pushing. (For more information on epidurals, see page 208.)
The use of continuous EFM has also changed childbirth. Continuous fetal heart rate monitoring is used nearly universally in hospitals. Because the fetal heart rate patterns seen when the heart rate is continuously recorded are sometimes difficult to interpret, EFM has increased the number of labors considered “complicated” or “risky.” The widespread routine use of EFM has led doctors to overdiagnose complications, too narrowly define what is normal, and treat deviations from those norms as evidence that something is wrong.7 For women who do not have labor interventions such as epidurals that make continuous monitoring necessary, intermittent monitoring appears to be as effective as continuous monitoring at detecting true problems, and is not associated with an increased risk of cesarean birth or of vaginal birth assisted by vacuum extraction or forceps. (For more information on fetal monitoring, see page 174.)
Epidurals and EFM have changed the kind of nursing care women receive. In the past, personal one-on-one care was the hallmark of obstetrical nursing. Today, for a variety of reasons, including nursing shortages, budgetary constraints, and less training in the natural progression of birth, labor nurses increasingly rely on continuous electronic fetal monitoring to help them care for more than one woman at a time. Therefore, fewer laboring women have access to this vital one-on-one support.
Surgical interventions can save doctors time and money. Many payment systems offer a single or fixed fee to doctors regardless of whether a baby is born vaginally or by cesarean, and others offer a larger fee for a cesarean. Therefore, those doctors who patiently support natural labor, which starts at unpredictable hours and generally requires more time, are penalized financially.8 Some systems provide increased payment for a cesarean section, making planned surgery the most cost-efficient and time-saving scenario for doctors. Inducing labor instead of waiting for it to start on its own also helps doctors control their hours. Elective cesarean sections and scheduled induction of labor help hospitals make nursing staff schedules more predictable and shift more of health care providers’ work to convenient weekday hours.
FEAR OF LAWSUITS
If something goes wrong, doctors may be blamed for not doing something, but rarely are they blamed for doing something that is not necessary. For example, malpractice lawsuits for not performing a cesarean section are much more common than lawsuits for doing one when it wasn’t necessary. To avoid litigation, many doctors and some midwives feel compelled to do “too much” rather than be accused of doing “too little.” Market forces, pharmaceutical advertising, and other medical industry marketing practices may also contribute to a drive to “do something” even when observation and emotional support would be better for mother and baby than an additional test or procedure.
A RUSHED, RISK-AVERSE SOCIETY
The desire to eliminate pain and control outcomes may cause both health care providers and expectant parents to embrace unneeded and potentially harmful procedures. U.S. society today has an aversion to risk that contributes to a climate of doubt in which all labors are treated as potential problems, and healthy women with low- risk pregnancies receive treatments that were designed for use by women with high-risk pregnancies. In addition, women sometimes are not allowed sufficient time for labor to progress and a vaginal birth to occur. Women’s own expectations can contribute to rushing labor.
THE LANGUAGE OF “CHOICE”
Labor and birth approaches are sometimes presented as equivalent “choices” without full, accurate information about their potential consequences. For example, elective cesareans (cesarean sections done without a medical need) are increasingly presented by the media and some doctors in a misleading fashion— as a “reasonable” option for healthy pregnant women. (For more information, see “Maternal Request,” page 43.)
ASSISTED REPRODUCTIVE TECHNOLOGIES AND OLDER MOTHERS
The use of assisted reproductive technologies is leading to more births by older women and more multiple births. In vitro fertilization has increased the number of births of twins, triplets, and other multiples, and such babies are often delivered by cesarean section.* Whether we have used assisted reproductive technologies or not, those of us who get pregnant when we are older are more likely to have medical conditions such as high blood pressure or diabetes that can make pregnancy more complicated. Women over age forty have higher rates of medical interventions, including cesarean sections. Nevertheless it is important not to assume that your pregnancy is “high-risk” and requires interventions simply because of your age; the majority of women over forty have healthy, uncomplicated pregnancies.
End of excerpt.
* Such complications could be reduced by implanting only one embryo rather than two or more, but that is not standard procedure in the United States. In the UK, new guidelines that call for implanting only one embryo (rather than two or more) will reduce the number of such multiple births and their associated complications as well. If a woman has only one embryo implanted each cycle, it may take her more tries (and therefore more time) to become pregnant. [return to text]
3. Randomized controlled trials have demonstrated that women who have had a routine episiotomy experience more anal and rectal tears and no difference in pelvic floor relaxation or incontinence compared to women who are not cut. K. Hartmann, M. Viswanathan, R. Palmieri, G. Gartlehner, J. Thorp, and K. N. Lohr, “Outcomes of Routine Episiotomy: A Systematic Review,” JAMA 293 (2005): 2,141–2,148. [return to text]
4. Eugene R. Declercq, Carol Sakala, Maureen P. Corry, and S. Applebaum, “Executive Summary,” in Listening to Mothers II: Report of the Second National U.S. Survey of Women’s Childbearing Experiences (New York: Childbirth Connection, 2006.) [return to text]
5. Ibid. [return to text]
7. J. T. Parer, T. King, S. Flanders, M. Fox, and S. J. Kilpatrick, “Fetal Acidemia and Electronic Fetal Heart Rate Patterns: Is There Evidence of an Association?” Journal of Maternal- Fetal and Neonatal Medicine 19, no. 5 (May 2006): 289–294. [return to text]
8. Carol Sakala, “Letter from North America: An Uncontrolled Experiment: Elective Delivery Predominates in the United States,” Birth 33, no 4 (December 2006). [back to text]
Excerpted from Chapter 16: Life as a New Mother in Our Bodies, Ourselves: Pregnancy and Birth © 2008 Boston Women's Health Book Collective.
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