Born in the USA tells:
* Why women are 70% more likely to die in childbirth in America than in Europe
* What motivates obstetricians to use dangerous and unnecessary drugs and procedures
* How the present malpractice crisis has been aggravated by the fear of accountability
* Why procedures such as cesarean section and birth inductions are so readily used
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Born in the USA
How a Broken Maternity System Must Be Fixed to Put Mothers and Infants First
By Marsden Wagner
UNIVERSITY OF CALIFORNIA PRESSCopyright © 2006 The Regents of the University of California
All rights reserved.
MATERNITY CARE IN CRISIS: WHERE ARE THE DOCTORS?
We do not see childbirth in many obstetric units now. What we see resembles childbirth as much as artificial insemination resembles sexual intercourse. RONALD LAING, PSYCHIATRIST
Scene: A large hospital in Oregon. (This is a real-life story, as are the other stories in this book.)
Grabbing the telephone from the maternity ward secretary, the nurse blurts out, "Doctor, I have tried and tried to find the baby's heart beat and then I got my charge nurse who tried and tried. We can't get a fetal heart tone at all. We need you. Please come quick!"
The obstetrician replies, "Right. I'm leaving home now. I'll be there in fifteen minutes, depending on traffic." Click.
"But doctor, what should we do in the meantime?! Oh damn, he's gone."
The nurse rushes back to the labor room, where a woman lies moaning in pain, her face pale and sweaty, classic signs of shock. The nurse throws yet another blanket on and turns up the flow of oxygen in the mask over the woman's face. Sadly, the nurse never consults another doctor, even though there is another obstetrician in the doctor's lounge just down the hall, perhaps because, in general, nurses are discouraged from consulting another doctor if it is a private patient.
The woman's obstetrician arrives twelve minutes later and quickly determines that there are indeed no fetal heart tones, and the woman is in shock. He realizes this is almost certainly a case of uterine rupture, a situation where the woman's uterus, after an especially hard contraction, blows out like a tire. Uterine rupture is a known risk of Cytotec, the drug he has used to induce the woman's labor. Now it is his face that turns pale as he finds himself confronted with the most feared of all birth catastrophes—one that could kill the woman and the baby. "Set up for emergency C-section," he shouts.
It takes twenty minutes to prepare the operating room for an emergency cesarean section, enlist the obstetrician in the lounge to assist, find the anesthesiologist, and get scrubbed. By the time the laboring woman's belly is finally cut open, the baby is floating free in the abdominal cavity, having escaped from the uterus through a large rip in the uterine wall.
Handing the deep blue, flaccid baby to the waiting neonatologist, the obstetrician orders, "Now let's cut out the damaged uterus."
The assisting obstetrician objects: "But we can repair it."
"No, it's quicker and easier to just remove it."
"But the husband is just outside the operating room door," replies the assisting obstetrician. "We should at least discuss it with him. Removing the uterus means they can't have another baby."
Perhaps because he doesn't want to face the husband, the obstetrician stops all discussion by turning back to the operating table and starting the removal of the damaged uterus.
Meanwhile, the neonatologist has determined that the baby is brain-dead, after nearly one hour without sufficient oxygen, due to the damaged uterus. The baby is rushed to the nearest neonatal intensive care unit, but dies twenty-four hours later. The mother is hemorrhaging from the ruptured uterus and receives a blood transfusion.
The outcomes of this story were tragic. A women nearly died and a family was left with a dead baby and no possibility of having another baby in the future. Most tragic of all, it need never have happened.
We doctors have a fancy word for the appalling outcomes in a case like this: they are iatrogenic, or caused by the doctor. Cytotec is a popular drug among obstetricians who use it to induce labor, even though it has not been approved by the drug manufacturer, or by the FDA, for that purpose, and to date there is no scientific evidence showing that it is safe for that purpose. On the contrary, in 1999, two years after this incident took place, studies proved conclusively that, while the risk of uterine rupture is higher than normal when Cytotec is given to "ripen the cervix" and induce labor, the risk of rupture is significantly greater still when it is given to a pregnant woman (like the woman in Oregon) who has had a cesarean section in the past and already has a weakness in the wall of her uterus at the scar.
Here is another story. This one is about a recent "normal" birth in Northern California.
Ms. C chose Dr. E, an obstetrician, to care for her during her pregnancy and birth. She wanted to have a natural birth and his printed flyers advertised that he "believes pregnancy is not an illness," "works toward making pregnancy a happy experience," and "provides natural delivery methods."
A week before Ms. C's due date, Dr. E proposed that he induce labor with the powerful intravenous drug Pitocin. "Come to the hospital Friday at 7 a.m., and you'll have a baby by dinnertime," he said. What Dr. E did not add was "and I'll be home for dinner."
Inducing labor is medically indicated in rare cases, such as when the patient shows signs of preeclampsia (persistent, severe high blood pressure, edema or swelling due to an accumulation of fluid in the ankles, and protein in the urine)—or when the pregnancy is more than two weeks overdue and there are definite signs of fetal distress. In Ms. C's case, there were no medical indications for inducing labor. Ms. C and her husband refused Dr. E's offer and repeated their desire to let nature take its course.
A week later, Ms. C went into spontaneous labor and was admitted to the hospital at 11 p.m. Dr. E was informed by phone, but perhaps because it was 11 p.m., he did not come in to examine her. Over the phone he ordered the nurse to start Pitocin in the morning to "augment" or speed up the labor, though there was no medical reason to do so, as Ms. C's labor had not slowed or stopped.
The next day, at 8:30 a.m., Dr. E visited Ms. C in the hospital for the first time, nine and a half hours after her admission and two hours after a nurse had started her on a Pitocin intravenous drip. During that time, no other doctor had seen Ms. C, and she was not told she was being given Pitocin.
At 8:40 a.m., and again at 8:43 a.m., there were signs of distress on the electronic fetal heart monitor. Ms. C's chart indicates that her nurses were aware of these signs, but there is no indication that a doctor was called.
When drugs such as Pitocin are used to induce or augment labor, the pain of labor typically becomes much worse than normal. At 8:50 a.m., an anesthesiologist gave Ms. C an epidural block to relieve her pain. Administering an epidural block is a delicate procedure that involves putting a needle into the spinal cord just far enough for the tip to be in the spinal fluid and injecting an anesthetic. An epidural blocks all sensations below the injection site, leaving the lower half of the body without feeling.
Nurses notes indicate that at 8:55 a.m., Ms. C was completely dilated—a sign that it was time for her to push the baby out. However, Ms. C was not told that birth was imminent. A nurse called Dr. E, and on the phone he gave the order, "tell her don't push." But the urge to push is spontaneous and out of the woman's control—like trying not to vomit when the urge to vomit comes. For the next hour and forty-four minutes, the nurses tried to keep the baby from being born before the doctor arrived by urging Ms. C not to push and by pushing on the baby's head to hold it back. Nurses' notes indicate that Dr. E was called several times during this period and urged to come quickly. Nurses also gave Ms. C oxygen while she waited and told her it was for the baby, so we can assume that they were aware that holding the baby back was putting the baby at risk.
Ms. C had made it clear to Dr. E before she went into labor that she and her husband wanted a natural birth without surgical interventions, such as an episiotomy (the practice of cutting the vagina open supposedly to create more room for the baby). During her labor, Ms. C reinforced this point. She repeatedly told a nurse, "I do not want an episiotomy." Dr. E rushed in at 10:39 a.m., more than two hours since his last visit, and gave her an episiotomy, for no apparent reason and without telling her what he was doing. Since she was numb from the waist down, she did not know he was cutting her. When she reminded him that she did not want an episiotomy, he said, "too late." Dr. E then used a vacuum extractor to pull the baby out—again, for no apparent reason. (Dr. E claimed the reason was "fetal distress," but there were no signs of fetal distress on the electronic monitor just before the birth.)
These two birth stories—one with a disastrous outcome, one not at all unusual—illustrate many of the egregious errors that go on in maternity care in the United States. The fundamental flaw: in America, we have highly trained surgeons called obstetricians regularly "attending" normal, or low-risk, births.
The United States and Canada are the only highly industrialized Western countries in the world where this is true.4 And Canada is rapidly converting to the system used in all other industrialized Western countries, including Australia, the Netherlands, Great Britain, all Scandinavian countries, Germany, and Ireland, and in many other countries, where more than 75 percent of all births are assisted by trained midwives. It is a midwife who provides prenatal care, a midwife who admits a woman to the hospital when labor begins (or goes to her home), a midwife who attends the labor, a midwife who assists at the birth, and a midwife who discharges the woman from the hospital. In these countries, obstetricians serve as specialists. They are essential members of the maternity care team, but they play a role only in the 10 to 15 percent of cases where there are serious complications. Most women have babies without ever setting eyes on a doctor.
In the United States, the numbers are reversed. Obstetricians "attend" 90 percent of births and have a great deal of control, essentially a monopoly, over the maternity care system.5 Obstetricians are taught to view birth in a medical framework rather than to understand it as a natural process. In a medical model, pregnancy and birth are an illness that requires diagnosis and treatment. It is an obstetrician's job to figure out what's wrong (diagnosis) and do something about it (treatment)—even though, with childbirth, the right thing in most cases is to do nothing. To put it another way, having an obstetrical surgeon manage a normal birth is like having a pediatric surgeon babysit a normal two-year-old. Both will find medical solutions to normal situations—drugs to stimulate normal labor and narcotics for a fussy toddler. It's a paradigm that doesn't work.
This book will show that by embracing a medical model of birth and allowing obstetricians control of our maternity care, we Americans have accepted health care for women and babies that is not only below standard for wealthy countries but often amounts to neglect and abuse.
Let's take a look at the stories above.
The birth certificate says that the obstetrician in Oregon "attended" the birth, but this is obviously a misstatement. It is a well-known fact among health care providers that in U.S. hospitals, "attending" obstetricians are almost never in attendance during a women's labor, except for occasional drop-in visits, and are often not even in the hospital building. An episode of the award-winning TV series ER showed a woman in labor having convulsions. The emergency room doctor asks the nurse where the woman's obstetrician is. The answer: "Across town in his office seeing patients." If a pregnant woman in America signs on with an obstetrician thinking she will have him around during her labor, she is almost certainly in for a rude awakening.
Doctors are not inclined to discuss the consequences of their absence, but a recent study shows a 12 percent increase in neonatal mortality in babies born between 7 P.M. and midnight and a 16 percent increase in neonatal mortality for babies born between 1 A.M. and 6 A.M.. Researchers believe the increased deaths may be attributed to "the availability and quality of physicians, nurses and support personnel, as well as the accessibility of diagnostic tests and procedures."
A review of litigation cases in obstetrics and gynecology, commissioned by the prestigious Institute of Medicine in Washington, D.C., reported that nearly two-thirds of labor and delivery injuries were caused by problems in medical management—that is, failure to adequately supervise or properly monitor.8 In the Oregon story, the obstetrician's "failure to adequately supervise and monitor" meant that treatment was delayed during a crisis—a crisis that was brought on by the use of Cytotec, a drug that has not been sufficiently studied to have been proven safe. Does that amount to neglect? I think it is neglect on at least two levels. To begin with, the physician ignored the most basic principle of medical practice: First, do no harm. Second, the woman was given a powerful drug, then left to go through the second stage of labor (when the risk of developing complications increases) without a doctor's continuous attendance but in the care of a nurse who was responsible for several women in labor and could check in only from time to time, as is usual in hospital maternity care,
It is no surprise that patients are neglected in a system where an obstetrician tries to be all things to all women. An American ob/gyn must be a primary care provider assisting normal, healthy pregnancies and births, a specialist in complications of pregnancy and birth, a counselor and family planning provider, a specialist in gynecological diseases, and a highly skilled surgeon. No other specialist anywhere in health care tries to maintain competence in so many areas. It is not humanly possible. Can an obstetrician do a major gynecological surgical procedure—such as a six-hour "pelvic clean-out" on a woman with extensive cancer—and then rush to his office and do a good job of quietly and patiently counseling a healthy pregnant woman about her sex life? Not likely.
In America, obstetricians' plates are full to overflowing. There is no way they can do it all. And of all the things they try to do, the most difficult thing to fit into their busy schedules is normal childbirth, which lasts twelve hours (on average) and, as we all know, can happen night or day, seven days a week. As in these stories, the actual attendant for the majority of births in the United States is a labor and delivery (L&D) nurse with a telephone.
On average, L&D nurses receive only six weeks of on-the-job training in L&D nursing after completing their basic nursing training. They have no autonomy, and so if problems develop they can do nothing without a doctor's orders. At the same time, L&D nurses are held responsible for accurately judging the moment of birth. If a nurse calls the doctor too soon, she may be accused of wasting the doctor's time. If she calls the doctor too late and the doctor misses the birth, the doctor is equally unhappy. It is no wonder that the thirty thousand L&D nurses working in American hospitals are frustrated and exhausted.
In most hospitals, L&D nurses are asked to closely monitor several women in labor simultaneously. Some level of neglect is inevitable in this situation. When you consider the fact that nurses work eight-hour shifts, the chance that a women in labor will receive continuous, one-on-one care in the hospital is reduced to zero. This is distressing, since many studies have shown that one-on-one, continuous care by the same person throughout labor means a shorter labor, less pain, fewer complications, and better safety for mother and baby. Hospitals and health maintenance organizations (HMOs) say they don't have the money to provide continuous care to women giving birth. Yet somehow they do have the money to purchase and maintain expensive electronic fetal monitors and use them on all women—even those having low-risk births, without drugs to induce labor—despite the fact that there is no scientific evidence that routine electronic fetal monitoring improves birth outcomes. Most hospitals believe in machines, not bodies and not human contact, and that is where the money goes.
Excerpted from Born in the USA by Marsden Wagner. Copyright © 2006 The Regents of the University of California. Excerpted by permission of UNIVERSITY OF CALIFORNIA PRESS.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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Table of ContentsPreface
1. Maternity Care in Crisis: Where Are the Doctors?
2. Tribal Obstetrics
3. Choose and Lose: Promoting Cesarean Section and Other Invasive Interventions
4. Forced Labor: Induction or Seduction
5. Hunting Witches: Midwifery in America
6. Where to Be Born: Here Come the Obstetric Police
7. Rights and Wrongs: The "Malpractice Crisis," Legal Protections for Pregnant Women, and Regulation by Litigation
8. Vision of a Better Way to Be Born
9. How to Get Where We Need to Be
Most Helpful Customer Reviews
As Americans, members of the wealthiest nation in the world with access to the most advanced technologies, we are accustomed to believing that our healthcare professionals offer the best care available. What better example than modern maternity and obstetric services in the United States? Women can now deliver their babies in the safety of the hospital, free from pain, with skilled physicians at hand to safeguard their well-being... or so I thought prior to reading this scathing critique of the American obstetric establishment. Marsden Wagner's glittering credentials as a perinatologist and former director of women's health at the World Health Organization lend authority to his startling assertions. A medical student planning to enter obstetrics myself in a few short months, I was most shocked by the well-documented harm done to pregnant women by many unwitting obstetricians employing "accepted medical procedures": through Dr. Wagner's eyes, I began to see today's elective cesarean section akin to yesterday's bloodletting. I recommend this book to anyone with a passion for women's and children's health, healthcare reform, or the history of medicine.
Born in the USA discusses maternity care in the US from a policy perspective. Admittedly I read it because I am pregnant and looking for something a little more factual that the usual birth books. The author has served as both an obstetrician and an public health official, so he does bring multiple perspectives to the book. The chapter on the common off label use of an induction agent was excellent. As a scientist you can easily convince me to agree with his statements about inability of medical doctors to design experiments and interpret the results. In general, his conclusions are that only 10-20% of women (those who are "high risk") need an obstetrician and that the remainder are better served by midwives, a system that has been successful in most European countries. While he does put forward a compelling argument, he also ignores certain aspects of the data (i.e., how are mortality rates effected by the lack of universal health care and a national public health system as opposed to the obstetrician versus the midwife). I found many of his suggestions for change to be too dramatic to be considered realistic. His inter country comparisons were illuminating, but they also ignored factors that were different than maternity systems but that do affect health (i.e., levels of education, equality index). Worth reading for the information on policy that it contains - but not useful to a pregnant woman (which is not the author's point anyway). It worth noting, however, the reason I failed to find it not useful: with hind sight, it is easy to state that only 10-20% of all mothers are high risk and there for should use an obstetrician - however, the critical question at the time of care is how accurately can a midwife or an obstetrician define who is high risk.
This book is a must read for anyone who works with birth, politicians concerned with public health, and especially all women who will ever give birth. Wagner is an obstetrician and a former Director of Women's and Children's Health for the WHO, and as such he gives a unique insight to the state of maternity care, how we came to be this way, comparison with the rest of the developed world, and clear recommendations for how to improve maternity care. Even though I have been studying this issue for a couple of years, this book was eye opening and even painful at times to read. I am especially grateful for the last two chapters which discuss where the US should be in maternity care and how to get there.
My jaw was dropped at the stuff I read in this book. I read it after I had heard the author on NPR. This is a must read if you or someone you know are planning on having a baby.