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Technology in Birth: First Do No Harm

by Marsden Wagner, M.D.

Recently a woman in Iowa was referred to a university hospital during her labor because of possible complications. There, it was decided that a cesarean section should be done. After the surgery was completed and the woman was resting post-operatively in her hospital room, she went into shock and died. An autopsy showed that during the cesarean section the surgeon had accidentally nicked the woman's aorta, the biggest artery in the body, leading to internal hemorrhage, shock and death.

Cesarean section can save the life of the mother or her baby. Cesarean section can also kill a mother or her baby. How can this be? Because every single procedure or technology used during pregnancy and birth carries risks, both for mother and baby. The decision to use technology is a judgment call-it may either make things better or worse. We are living in the age of technology. Ever since we succeeded in going to the moon, we have believed that technology can do everything to solve all our problems. So it should come as no surprise that doctors and hospitals are using more and more technology on pregnant and birthing women. Has it solved all the problems that can arise during birth? Hardly. Let's look at the recent track record.

Has the recent increasing use of technology during pregnancy and birth resulted in fewer damaged or dead babies? In the United States there has been no decrease in the past thirty years in the number of babies with cerebral palsy. The biggest killer of newborn babies is a birth weight that is too low, but the number of too-small babies born has not decreased the past twenty years. The number of babies who die while still in the womb has not decreased in over a decade. While the past ten years has seen a slight drop in the number of babies who die during their first week after birth, the scientific data suggest an increase in the number of babies who survive the first week but have permanent brain damage.

Is the increasing use of technology saving the lives of more pregnant and birthing women? In the United States the scientific data show no decrease during the past ten years in the number of women who die around the time of birth (maternal mortality). In fact, recent data suggest a frightening increase in the number of women dying during pregnancy and birth in the United States. So it may be that the increase in use of birth technologies is not only not saving more women's lives but is killing more women. This possibility has a reasonable scientific explanation: cesarean section and epidural anesthesia have both been used more and more in this country and we know that both cesarean section and epidural block can result in death.

We should not be surprised with the recent poor track record of high tech birth. For many decades in the middle of the twentieth century the number of babies dying around the time of birth was decreasing but this was due not to medical advances but mainly to social advances such as less severe poverty, better nutrition, better housing and, most importantly, to family planning resulting in fewer women with many pregnancies and births. Medical care also was responsible for some of the decreasing mortality of babies but not because of high tech interventions but because of basic medical advances such as the discovery of antibiotics and the ability to give safe blood transfusion. There has never been any scientific evidence that high tech interventions such as the routine use of electronic fetal monitoring during labor decrease the mortality rate of babies.

What this means is that putting yourself in the hands of a high tech doctor and a high tech hospital does not guarantee you the safest birth. You must yourself take responsibility for your own birth, including the decision to have technology used on you and your baby. Remember, technology is not good or bad. How technology is used can be good or bad. Airplanes can be used to carry you to visit your family or can be used to drop bombs on women and children. How technology is used on you during pregnancy and birth is of great importance because it can help you and your baby or harm you and your baby.

How to Get the Right Technology

Choosing Your Maternity Care Provider

How do you go about being pregnant and giving birth where the use of technology is appropriate and right for you, your baby and your family? The first step is to get the right health care professional to assist you during the pregnancy and birth. A key decision is to decide if your primary maternity care provider is to be a midwife, a family physician or an obstetrician.

The United States and Canada are the only countries in the world where highly trained surgeons called obstetricians attend the majority of normal births. The American obstetrician is to be pitied. He or she is trying to be all things to all women--primary maternity care provider for normal, healthy pregnant and birthing women, specialist in complications of pregnancy and birth, specialist in women's diseases, and highly skilled surgeon. No other doctor anywhere in the realm of healthcare tries to maintain competence at all these levels and in so many areas because it is totally unreasonable to expect this from one human being. Can an obstetrician do a six hour "pelvic clean out" gynecological surgical procedure on a woman with extensive cancer, then rush to his or her office and do the best job quietly and patiently counseling a pregnant woman about her sex life? Not likely.

While American obstetricians have worked hard to convince the public they are the safest person to assist at all births, the scientific evidence does not support them. For example, a large scientific study published in 1998 looked at all births in the United States in one year-over four million births. Because doctors really do need to manage the few births that develop serious complications, the study eliminated complicated births and only looked at low risk births. Compared with physician attended low risk births, midwife attended low risk births had thirty-three percent (one-third) fewer deaths among newborn infants. Furthermore, midwife attended births have thirty-one percent (nearly one-third) fewer babies born too small, which means fewer retarded and brain damaged infants.

There is not a single report in the scientific literature that shows obstetricians to be safer than midwives for low risk or normal pregnancy and birth. So if you are among the over seventy-five percent of all women with a normal pregnancy, the safest birth attendant for you is not a doctor but a midwife.

If you are considering a hospital birth with an obstetrician as your primary birth attendant, ask him or her how much time he or she will spend with you during your labor. One of the reasons a midwife is generally a better choice to attend your hospital birth than an obstetrician is because the midwife is there in the hospital with you during your labor while the obstetrician is not. It is an incredible irony that the obstetrician insists that the woman who is his or her client give birth only in the hospital while the obstetrician who should attend her birth is not in the hospital. If your obstetrician is not with you in the hospital during labor, then where is your obstetrician?

For fifty years now the United States has had a system of maternity care in which the woman goes into labor, goes to the hospital, is admitted by the labor and delivery nurse (L & D nurse) who examines the woman, then calls the obstetrician who is either home or in his or her office (usually seeing normal, healthy pregnant women). The obstetrician gives orders over the telephone to the nurse, who then assists the woman during her labor. The obstetrician may or may not come by the hospital sometime during the labor to briefly check the woman. But it is the job of the L & D nurse to monitor the labor and call the obstetrician when the birth is imminent so the doctor can rush in, catch the baby at the last minute and get all the credit (and money) for "delivering" the baby. If the nurse calls the obstetrician too soon and the doctor has to hang around the hospital waiting for the birth, the doctor is angry with the nurse for wasting his time. But if the nurse calls the obstetrician too late and the baby is born before the doctor gets there, the doctor is furious with the nurse.

Why is it important to insist that your obstetrician be with you during your labor as well as at the birth? In a study of obstetrical malpractice cases involving permanent brain damage of the baby, the absence of the obstetrician from the hospital during the labor played a central role in causing the tragedy in approximately two-thirds of the cases. This research showed that telephone conversations during a hospital birth between nurses at the hospital and the doctor who was not in the hospital gave rise to misunderstanding or miscommunication that caused adverse effects for the mother or baby. If you choose an obstetrician as your primary birth attendant and he/she cannot guarantee that he/she or another obstetrician will be physically present (not just on call) during your labor as well as the birth, you are wasting your money and putting your baby in danger, and you need to get another birth attendant.

If you doubt this description of hospital birth, ask any of the over twenty-five thousand L & D nurses in the United States. These nurses are highly skilled professionals who do what is really an impossible job. They must monitor the laboring woman and assist at the birth, all the while keeping the doctor happy and covering up for the fact that the doctor is not there most of the time and in most cases makes a minor contribution to the birth. The fact that defines and limits these nurses is that they have no autonomy and can do nothing without doctors' orders.

Because American obstetricians have always had L & D nurses to do their bidding, and now that midwifery is gradually but steadily returning in this country, obstetricians have developed a distorted understanding of midwifery. Obstetricians believe midwives are obstetrical assistants and keep trying to give them orders. But the practice of midwifery is very different from the practice of nursing.

Midwives are autonomous professionals who provide primary maternity care and are analogous to family physicians who provide primary healthcare. If the family physician hears a heart murmur and refers the patient to a specialist cardiologist, this does not mean the family physician is the cardiologist's assistant and somehow less competent, but only that the cardiologist has a different expertise than the family physician-an expertise for certain complications. The cardiologist makes suggestions for treatment of the family physician's patient which the family physician and patient may or may not choose to follow. The cardiologist and the family physician are professional equals who collaborate with mutual respect in order to provide the best quality care for the patient.

By the same token, a specialist obstetrician does not give orders to a midwife any more than a cardiologist gives orders to a family physician. The midwife may refer a woman to an obstetrician because of a complication but this does not make her the obstetrician's assistant. The midwife and obstetrician then collaborate as professional equals.

Too many obstetricians still don't get it and continue trying to boss midwives around, hiring and firing them from their practices, pushing them off hospital staffs and accusing them of practicing medicine without a license. If you are pregnant, don't allow yourself to get in the middle of this professional turf struggle. If you want a midwife to provide your primary maternity care, find one who has as much autonomy as possible in her practice. If you are considering having a particular obstetrician provide your primary maternity care, a good way to measure that doctor's openness and attitude toward you and women in general is to inquire what his or her opinion is of midwifery.

Another reason midwives are safer than doctors is because midwives use far less unnecessary technology. Because obstetricians are surgeons, they turn birth into a surgical procedure. Proof of this is that the birthing woman is treated as though she is a surgical patient: she is put on her back in a bed that is really a modified surgical table, often with her legs up in surgical stirrups. For over twenty-five years we have known scientifically that this is the worst of all possible positions for a woman giving birth; in this position the baby's head compresses the woman's main blood vessel that supplies the womb and the baby and reduces the blood and oxygen going to the baby. If the woman is in a vertical position (sitting, squatting or standing) more blood and oxygen flows to the baby, the woman's bony pelvis opens more to let the baby out and she gives birth downhill instead of uphill against gravity. One way to find out if a hospital is practicing modern maternity care or not is simply to see what position women are put in during birth. If hospital staff are still putting women on their backs during birth, they are ignoring all scientific data and still pretending birth is a surgical procedure.

Between fifty percent and eighty percent of births in most American hospitals involve one or more surgical procedures, further proof that obstetricians have turned birth into a surgical event. Those procedures include drugs to start or speed up labor, episiotomy (cutting the genitals with surgical scissors to widen the vaginal opening), placing metal forceps or a vacuum extractor on the baby's head to pull the baby out (you can imagine the risks involved in this), and cesarean section to cut the baby out. In reality, any of these surgical procedures is necessary in no more than twenty percent of all births. And since all surgical procedures carry risks, the high frequency of their unnecessary use in physician attended births leads to more dead and damaged babies than would ever occur in midwife attended births. Large numbers of research reports document that midwives use far fewer surgical interventions than doctors. A case in point is the use of episiotomy. From half to three-quarters of all women in America birthing their first baby in the hospital with the assistance of a doctor have this surgical cut done to their genitals. It is scientifically proven that no more than twenty percent of women will need this cut; the best rate is about 5 percent. Among midwives in independent practice in the United States (that is, when doctors are not ordering midwives what to do), between two percent and twenty percent undergo episiotomy.

Is the fact that midwives cut far fewer episiotomies than doctors important? Scientific evidence shows that having an episiotomy means more bleeding, more pain, more permanent deformity of the vagina, more painful sexual intercourse for months or even years. As well, unnecessary episiotomy is a form of sexual abuse. Some women's groups in America are rightly concerned about the practice of female genital mutilation in parts of Africa. They need to be equally concerned about the millions of American women who have suffered female genital mutilation-unnecessary cutting of the genitals at birth at the hands of doctors.

While midwives trust women's bodies, use low tech assistance such as the skilled use of their hands, and understand the importance of preserving normalcy, doctors in general do not trust women but trust drugs and machines, use high tech assistance and focus on the pursuit of abnormality. So having a highly trained surgeon obstetrician assist at your birth is about as sensible as hiring a pediatric surgeon as a baby sitter for your healthy two year old when you go out in the evening. Like the obstetric surgeon who gives the normal woman a shot to hurry her labor, the pediatric surgeon baby sitting your normal child will focus on medical management: when your robust two year old gets tired and fussy, the pediatric surgeon will give him or her a shot to hurry the child to sleep. The result? In the one case the medicalization of birth (remember, birth is not an illness) with a lot of unnecessary risky interventions and very expensive medical care, and in the other case the medicalization of childhood (being two years old is also not an illness) with unnecessary risky interventions and very expensive baby sitting.

When deciding on your primary maternity care provider, it is important to ask midwives or doctors about their practices: find out if they prefer to put you on your back during birth, how often they do episiotomy, forceps or vacuum extraction, and cesarean section. If they don't know their rates of surgical interventions or refuse to tell you what their rates are, look out! Beware of any tendency to patronize you, to suggest that you cannot possibly understand all this technical stuff, or that you should just " trust me, I'm the doctor."

Choosing the Right Place to Give Birth

An important decision to make is whether to have your birth at home, a free standing birth center or a hospital. Overwhelming scientific evidence shows that the home is a perfectly safe place to give birth if you are one of the more than 80 percent of women who have had no serious medical complications during pregnancy. The evidence indicates that it is important to have a trained birth attendant for your homebirth, be it non-nurse midwife, nurse midwife or doctor. Your place of birth should also be within thirty minutes of the nearest hospital. The single most important advantage of homebirth is that the birthing woman is in control. Another important advantage is that in homebirth there is far less unnecessary use of technology. For a hospital to say it can be "home like" is like the sign in the bakery window: "We sell home baked bread."

A free standing birth center staffed with midwives is also a perfectly legitimate choice for the great majority of women who have had no serious complications during their pregnancy. But don't be fooled by the hospital that advertises its "birth center." If the birth center is not free standing-i.e. outside the hospital-it will still be under the supervision of the hospital and the doctors, and the birthing woman will not be in control. Plenty of scientific evidence confirms that a free standing birth center with midwives is a safe option. For example, a study of over ten thousand women giving birth in over eighty free standing birth centers in the United States showed birth in these centers to be just as safe as a matched group of low risk hospital births.

Be sure to investigate the practices in any hospital you may consider for your birth. Would you have the freedom to have the kind of birth you wish? Remember, freedom means being in control of everything that happens to you. Freedom is not being given permission to do this but not that. Can you invite anyone you want to be present at the birth? Some hospitals will limit who you can bring. Meanwhile they can-without asking you-bring anyone they want to your birth including, for example, a bunch of doctors in training. Can you come with a written birth plan which they will respect and honor or will they have an obvious attitude about such plans and consider you a "bad patient"? Many hospitals are competing for patients and will show pregnant women beautiful "birthing rooms." Remember, what is important is not a rocking chair and pretty curtains but whether or not you can be in control.

Always be aware that hospitals are under the absolute control of doctors and that the rules and regulations are for the convenience of the staff, not you. Hospitals are designed to care for sick people and since a birthing woman is not sick, much of what goes on in the hospital doesn't fit her needs. One simple example: Most birth takes from ten to twenty hours, during which there is one or more turnover of staff who are on eight hour shifts. While the data show the overwhelming importance of a woman having the continuous assistance of someone she knows throughout her labor, during your hospital birth you are likely to have to cope with one or more staff changes and lots of strangers coming into your room.

Ask the hospital if women are put on their backs during birth. Ask for the hospital's rates of episiotomy, forceps deliveries and cesarean section. Don't be satisfied with the usual answer-"it varies by doctor." Don't believe them if they say they don't have their hospital cesarean section rate; they are required in most states to report this rate to the State Health Department. In New York state a law provides the right to be given all this information, and an official pamphlet given out to all newly pregnant women includes a listing of the cesarean section rate for every hospital in the state.

Some of you belong to a health plan which may limit your choice of maternity care provider and place of birth. In this case you may have to get aggressive to get what you really want. Don't be afraid to demand what should absolutely be your right as a family and a birthing woman. Besides, a health plan is a business that needs to keep its customers happy. If your health maintenance organization (HMO) doesn't have a midwife and you want one, demand one. If you want an out of hospital birth and your HMO doesn't provide it, demand it. More and more HMOs now have midwives because they are discovering midwives are just as safe as doctors and cost the HMO a lot less. The largest HMO in New Mexico, for example, has more midwives than obstetricians on their full time staff and around eighty percent of all hospital births in this HMO are attended only by midwives.

Marsden Wagner, MD, is a neonatologist and perinatal epidemiologist. He was responsible for maternal and child health in the European Regional Office of the World Health Organization for fourteen years. Now living in Washington, D.C., he travels the world talking about appropriate uses of technology in birth and utilizing midwives for the best outcome.

Technology in Birth: First Do No Harm - Part 2

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