FISH CANT SEE WATER:

THE NEED TO HUMANIZE BIRTH
Part 1

     
 
: Marsden Wagner, MD, MSPH

INTRODUCTION
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 womans 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.
Humanized birth means putting the woman giving birth in the center and in control so that she and not the doctors or anyone else makes all the decisions about what will happen. Humanized birth means understanding that the focus of maternity services is community based primary care, not hospital based tertiary care with midwives, nurses and doctors all working together in harmony as equals. Humanized birth means maternity services which are based on good scientific evidence including evidence based use of technology and drugs.
But we do not have humanized birth in many places today. Why? Because fish cant see the water they swim in. Birth attendants, be they doctors, midwives or nurses, who have experienced only hospital based, high interventionist, medicalized 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 medicalizing 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 womans 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-medicalized birth is. The entire modern obstetric and neonatological literature is essentially based on observations of medicalized birth.
World Health Organization (1)
Why is medicalized birth necessarily dehumanizing? In medicalized 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 womans choice.
Fifteen years ago in Fortaleza, Brazil, a World health Organization Conference recommended birth be controlled, not just by individual doctors and hospitals but by evidenced based care monitored by the government. Birth, which had been taken from the community and slowly but surly changed into hospital-based care during the last hundred years, is to be given back to the community. Now the present conference will consider the next step---giving birth 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 elses.
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---medicalized birth.
In practice, care during birth may include a combination of the two approaches: facilitation of the womans 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 medicalized or truly humanized depends on whether or not the woman giving birth is in absolute control.


WHY MEDICALIZED 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 medicalized, high tech, doctor centered, midwife marginalized 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 medicalized maternity services in the big cities while in the rural areas medicalized 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 caesarean section sometimes save lives and sometimes kills--- maternal mortality even for elective (non-emergency) caesarean 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 1980s 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 relied heavily in the past on obstetricians from highly developed countries with little or no experience in developing countries, their programs tended to emphasize 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 caesarean section rates soared, even in the poorest States. (see below)
Obstetricians often claim the use of high tech medicalized 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 cesarean section and with operative vaginal rates finds no consistent correlations 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 caesarean 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 caesarean 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, medicalized 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. For example, in US publications there are 41 randomized controlled trials (RCT) on misoprostol (cytotec) for labour induction proving efficacy but not a single RCT is large enough to adequately measure risks. (8) So the Cochrane Library recommends not using midoprostol for this purpose. (9) But it works and is easy and cheap so it is used widely in the US, even though not approved by the FDA for this purpose. Now research is emerging showing serious risks for using misoprostol for cervical ripening or labour induction in women with a uterine scar. (10,11) But it is too late for the many US women with previous caesarean section whose uterus ruptured after induction with misoprostol and their many dead babies. So misoprostol for labour induction on women with previous caesarean section in the 1990s joins 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 as examples of obstetric interventions which have had tragic consequences because they went into widespread use before adequate scientific evaluation.
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 dont know while practicing doctors, to have the confidence to make life and death decisions, must believe they do know.
Most 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 cesarean section. (12) 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 loyalty to colleagues in the same profession. (13)
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 loyalties to professional colleagues. 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 thats 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 clinicians 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 babys 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). (14)
The third false assumption is there can be faster action in the hospital. The truth is that in most private care the womans doctor 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 in hospital births, when a cesarean section is indicated, it takes on average 30 minutes for the hospital to set up for surgery, locate the anesthesiologist, etc. In one study of 117 hospital births with emergency cesarean section for fetal distress, 52% of cases had a decision--incision time of over 30 minutes. (15) So during this 30 minutes either the doctor or the out-of-hospital 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 and many obstetricians work hard to bring their practices in line with the latest 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. (16) 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 correlations 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 given by some 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).
Some 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. 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 medicalization and dehumanization of birth is unnecessary caesarean 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 by some doctors. 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 caesarean 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. (17 )
So why so much unnecessary CS? When maternity care is controlled by doctors and midwives are marginalized 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. (18 ) 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 surgeons 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 medicalization of normal childhood similar to the medicalization 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 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 %. (19) Clearly this is a huge drain on Brazils 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.(20) 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 Womens Health of FIGO ( the international umbrella organization of national obstetric organizations) states in a 1999 report: Performing cesarean section for non-medical reasons is ethically not justified. (21 ) And there are individual obstetricians and some medical organizations working to bring down CS rates and humanize birth.

FISH CANT SEE WATER: THE NEED TO HUMANIZE BIRTH
Part 2




 
 


 
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