Shame on Us!

The June 2011 issue of Birth was stunning. Several issues were raised that penetrate to the heart of what is wrong with industrialized perinatal care today. For instance: Declercq et al’s (1) article highlights the rising cesarean section rates that are a global concern. Kotaska (2) clearly enunciates the flaws in current clinical guidelines and their application. Lawson (3), Kotaska (4), and Keirse (5) expose serious concerns that underlie both the rising cesarean section rate and the resulting guidelines that followed the fallacious interpretation of data from the Term Breech Trial (6). Klein et al (7) document increasing support for more interventionist birthing practices and less understanding of women’s birth experiences among young obstetricians in Canada. Arising from this unfolding tragedy of errors is the serious issue of caregivers shirking responsibility for the causes behind these linked events. Lawson (3) and Kotaska (4) report two cases where cesarean section for a breech-positioned baby resulted in death. In the first, Lawson (3) reports that the mother died after postsurgical hemorrhage. In the second, Kotaska (4) notes that the newborn died in hospital some days after the mother gave birth alone at home and then called for emergency help. She had earlier refused a cesarean section advised by two obstetricians, and was further denied care at home by her midwife. Kotaska suggests that if vaginal birth had been offered, both deaths would probably have been averted. Keirse (5) adds a third case of a mother giving birth safely to a breech-positioned baby vaginally while a cesarean section was being performed. Kotaska, Lawson, and Keirse all discuss the question of the appropriateness of the current guidelines with respect to cesarean section for breech-presenting babies. I shall explore the experience of the midwife who followed the stance of the College of Midwives of British Columbia (8) that directs midwives to terminate care for a woman who refuses to follow caregiver recommendations. Canada allows home birth for uncomplicated pregnancies with a trained midwife in close proximity to a hospital, although only 1.2 percent of women in the Canadian Maternity Experiences Survey chose this option in 2006–2007 (9). The British Columbia midwife faced a “choiceless choice” between helping the woman deliver at home despite her own College’s rulings, or following their prescriptions and learning of the resulting—“likely avoidable” (4)—infant death. It was a decision that will probably haunt her for the remainder of her life and should haunt those responsible for the College of Midwives of British Columbia guidelines. Had this birth occurred in the United Kingdom and not in Canada, the midwife would have been advised by the Royal College of Midwives to continue to give the best care possible, even if the woman refused the advice given to her (4). Is it not possible to find a reasonable compromise that, although not approving risky birthing settings, also allows for skilled care at birth and protection of the caregiver from adverse legal consequences? Such a compromise is possible in the United Kingdom but not in Canada (4). Why? This Canadian midwife faced an impossibly difficult choice: remain congruent with the law, or retain her moral integrity. The real problem, however, lies not just with the British Columbia guidelines or with the safety of home birth for breech-positioned babies. A continuum of dissatisfaction with the professional care in both the hospital and at home appears to exist. At its extreme, some mothers have chosen to give birth without skilled birth attendants at home. The findings of the Canadian Maternity Experiences Survey revealed that only about half (53.8%) of the women (97.9% of whom gave birth in hospital) reported their overall experience of labor and birth as “very positive” (9). Only 35 percent of women in the United States rated the quality of their maternity care system as “excellent” (10). Viewed in a different context, any business where one of every two or three customers was not fully satisfied with their service would soon cease to exist. Why would some mothers—in countries like Canada where (predominantly hospital-based) birth outcomes are good—choose to give birth at home with midwives in attendance? Why do some women in Canada and the United States even consider, or actually choose, to give birth at home without any skilled birth attendants? In 2006, 36 percent of 24,970 U.S. home births were not attended by a physician or midwife according to the U.S. Centers for Disease Control and Prevention (11). Approximately two-thirds of these were reported as “planned” (11). Although comparable Canadian figures do not exist, Vogel reported that on April 5, 2011, 15,000 active discussions on unassisted childbirth appeared on the popular website http://www.mothering.com/community (12). Simply put, it is obvious that many women are dissatisfied with the care they get in hospital. Two factors may be keys to understanding why this is happening: overmedicalization of perinatal care and caregivers’ attitudes. The move to demedicalize care has been evident for many decades. It was given a major boost in 1989 by A Guide to Effective Care in Pregnancy and Childbirth, which denounced overmedicalization of birth especially in its strongly worded Appendix 4 that recommended “Forms of care that should be abandoned in the light of available evidence” (13). Subsequent editions have used less strident wording—“Forms of care likely to be ineffective or harmful.” In addition, to my mind, more recent usage (or perhaps abuse) of the Cochrane Collaboration database has tended to emphasize a “scientific” rather than a “humanistic” approach to perinatal care. Yet even today, some 20 years after the emergence of evidence-based perinatal care, and according to the findings of the Maternity Experiences Survey (9), some procedures for which there are no medical indications continue to be performed. In Canada, for example, among mothers having a vaginal or attempted vaginal birth, 19.1 percent had their perineal or pubic hair shaved and 15 percent reported that someone “pushed on the top of their abdomen to help push the baby down” (9). Worse still, these procedures were performed more often in women who were young (teenage), poorly educated, and low income than in those who were older, better off, and better educated (9). Some interventions, such as continuous electronic fetal monitoring, giving birth in a supine position, and episiotomy (all nonevidence-based as routine procedures) were reported by 62.9, 47.9, and 20.7 percent of women, respectively (9). The wide range in incidence of each intervention across the 13 provinces and territories of Canada (9) suggests that standards vary not according to evidence-based guidelines but according to local fashion. Satisfaction levels among the 4.3 percent of Canadian mothers who were attended in labor and birth by midwives, averaged 71.1 percent, with ratings of “very positive” compared with those of obstetricians (52.3%) and family doctors (58.3%) (9). Given that younger obstetricians favor interventionist and less humanistic approaches to care in Canada today (6), and that midwifery care is available for only a small percentage of women (9), the prognosis for women and their appreciation of their birthing experiences is gloomy. This situation is not unique to Canada. Women reported even higher rates of interventions in the United States: 57 percent reported lying flat on their backs for vaginal births, 49 percent reported inductions for vaginal births, and 25 percent had episiotomies (10). At the same time, only 35 percent reported that the maternity care system was excellent (10). The blame for the current state of overmedicalized and undersensitive perinatal care can be laid on many factors. We readily blame mothers for not listening to the doctor’s advice when it results in their baby’s death (as in the disastrous home birth case (4)), thus justifying a medicalized approach to birth. We blame mothers for increasing the rates of cesarean sections and other interventions when they comply with our endorsement of medicalized care by requesting cesareans, epidurals, inductions, or even nursery-based infant care. It is also easy to blame the College of Midwives of British Columbia guidelines when they disallow a midwife to care for a woman who strongly opposes medical advice, or to blame the Term Breech Trial when cesarean section rates creep upward, or to blame obstetric practice guidelines that are based on false premises. We can even blame current evidence-based medicine that emphasizes a “scientific” or technologically biased approach. We avoid blaming ourselves—the caregivers—for what might actually be the underlying reasons why some mothers are dissatisfied with their care and even choose unassisted home births. Caregivers are comfortable with a medicalized approach: we are taught that is how births should occur. We also regard technology as more important than sensitive care. Good intervention is seen as good medicine. Being emotionally supportive and empathetic may be viewed as unimportant, time consuming, or not authoritative. Three-fourths of Canadian women gave “very positive” ratings of their caregivers’ competence (75.9%), but only two-thirds reported similar ratings for caregivers’ compassion and understanding (65.4%) (9). Caregivers should not be surprised. We do not train perinatal caregivers to be sensitive to the emotional, cognitive, or spiritual aspects of perinatal care—or if we do, we are obviously not succeeding. Banaszek (14) recently reported that only 69 of 133 accredited medical schools in the United States required students to take courses in medical humanities. None of the 17 medical schools in Canada requires this course, although a few offer an elective option (14). Of great concern, and only recently receiving the attention it deserves, is the premise that women may regard overmedicalization of perinatal care as abusive, exemplified in the recent Society of Obstetricians and Gynaecologists of Canada publication on Improving Sexual and Reproductive Health: Integrating Women’s Empowerment and Reproductive Rights (15). The document lists the right to health, free from nonconsensual medical treatment, from violence, and from harmful practices, as second only to the right to life (15). Authors in the recent issue of Birth have pointed out some serious shortcomings in current maternity care and guidelines that have forced some caregivers to use unsafe interventions and practices (1-5, 7). Insensitivity to women’s emotional experiences of birth—as clearly expressed by women’s satisfaction ratings—contributes to such guidelines and practices. Caregivers should heed the messages from these authors and others (13, 14), draw on women’s feedback, and take greater responsibility themselves rather than blaming a multitude of other sources, including women, for the excessive use of many obstetrical practices. They need to explore on a more non-interventionist and sensitive basis how they teach and practice if they want to improve the safety and satisfaction of women’s birth experiences.

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