Born in the USA (3 page)

A second reason Dr. E's treatment of Ms. C must be considered abusive is that she was given an unnecessary episiotomy. Though it is a common procedure in the United States, episiotomy is actually called for only in rare cases, such as when the baby's head has come out but the shoulders are stuck. There are numerous scientific studies on the risks of episiotomy. One of the proven risks is long-term painful sexual intercourse, a condition which Ms. C has suffered from since this birth.
¹⁴

Pulling the baby out with a vacuum extractor meant even more unnecessary risks, such as an increased risk of permanent urinary and fecal incontinence for Ms. C and an increased risk of brain hemorrhage for her baby. It is ironic that Dr. E said he used an extractor out of concern for the baby, when any difficulties the baby was having almost surely resulted from Dr. E's delaying the birth; if Dr. E had honored Ms. C's body, the birth would have happened an hour and a half earlier.
¹⁵
With no other explanation available, it is fair to assume that the birth was delayed on Dr. E's orders, so he could rush in, catch the baby, and take the credit. Delaying birth for convenience is abusive. I first saw this happen as a medical student, and it is still common today, decades later. Based on his behavior, we can speculate that Dr. E was having a busy day (which explains why it took him so long to come when Ms. C was ready to give birth) and, though Ms. C and her baby waited for him, when he finally arrived he was in a hurry to get the birth over with.

Dr. E's management of the case is also abusive on a deeper level. When Dr. E gave Ms. C a drug without her knowledge, he violated her fundamental human right to be fully informed and to consent to any medical intervention prior to it being used on her body.
¹⁶
Beyond not giving consent, Ms. C and her husband had made it clear to Dr. E that they did not want Pitocin when he offered it a week earlier. Beyond not giving consent to an episiotomy, Ms. C explicitly said she did not want one. Ms. C was not informed of the risks of using a vacuum extractor nor was she asked for her consent. However, given that she had made her desire for a natural birth very clear, it is safe to assume that if she had been asked she would have refused.

Dr. E blatantly rejected his patient's wish for a natural childbirth, and instead applied a surgical routine that by every standard was unnecessarily aggressive and interventionist. He turned what could have been a happy family event into a miserable surgical event. After the birth, Ms. C tried repeatedly—and unsuccessfully—to get information from Dr. E about why so many interventions were used. After her attempts to get information failed, Ms. C felt so betrayed and abused by Dr. E that she and her husband looked for a lawyer who could help them get some degree of closure. However, because the baby was apparently okay, and Ms. C suffered “only” from sexual problems and mental anguish, no lawyer was willing to take the case. Dr. E's damaging style of practice in this case must be called dishonest and unethical—and, sadly, as this book will show, it is quite common in the American maternity care system.

In a country where consumer rights are taken seriously and legally protected,
it's hard to accept that a doctor like Dr. E can practice outrageous “false advertising” and expect to get away with it. But as we will see in the next chapter, obstetricians in the United States have great lobbying power, and they have fought hard to prevent regulations and laws that would hold them accountable for their actions. In forty-eight of the fifty states, doctors and hospitals are under no obligation to disclose maternity care statistics (rates for cesarean section, labor induction, episiotomy, and so on) to the public, which makes it very difficult for a women to find out in advance how she is likely to be treated.
¹⁷
When something goes wrong with her treatment, it is all but impossible to find out what happened or who is to blame—without filing a lawsuit. A severe lack of information is one of several reasons that in the United States obstetricians are sued more than any other medical specialist.
¹⁸

The maternity care problems discussed in this book have profound costs for our society. Organized obstetrics groups such as the American College of Obstetricians and Gynecologists tell us that we have the “Cadillac” of maternity care. This is certainly true in one respect, since we pay much more per capita for maternity services than any other country in the world does. There are also good data showing that when obstetricians attend normal births, maternity services are far more expensive than when midwives attend normal births.
¹⁹

But are we getting more bang for all those bucks? Are we number one in providing high-quality care? Hardly. Twenty-eight countries have lower maternal mortality rates (women dying around the time of birth) than we do,
²⁰
and for more than twenty-five years, the number of women dying around the time of birth in the United States has been increasing.
²¹
Every year, at least one thousand women—that is, three jumbo jets full of our sisters, daughters, and mothers—die around the time of childbirth, and at least half of those deaths could have been prevented. Forty-one countries have lower infant mortality rates (babies dying before their first birthday).
²²

As you'll see in the coming chapters, our lousy track record is not caused by poor training. Obstetricians in the United States receive high-caliber education and training, and most also have good intentions. The problem lies not with individual doctors but with a system in which stretched-thin doctors have an unjustified monopoly and women and babies are left to pay the price.

It is important to note that in every country that has a lower maternal mortality rate than the United States—or a lower infant mortality rate—it is midwives, not obstetricians, who manage normal pregnancies and births.
²³
In some of these countries a significant percentage of births take
place in homes and out-of-hospital birthing centers.
²⁴
Studies that allow us to compare low-risk births attended by obstetricians and low-risk births attended by midwives show midwives to be safer, less expensive, and more likely to facilitate a satisfying experience for the mother and family.
²⁵
In the United States, however, most obstetricians are vehemently opposed to midwives and have gone to great lengths to drive them out of business. Far beyond a mere territorial battle between two groups of health care professionals, the persecution of midwives in this country has taken on the fervor of an old-fashioned witch hunt. The result is fewer options for women. In many regions of the United States, a pregnant woman who wants the care of a midwife can't get it unless she's willing to go outside mainstream health care channels, and, in some areas, even risk being persecuted and/or prosecuted herself. See
chapter 5
.
²⁶

Obstetricians have been telling women for decades that doctors are the only people who can provide them with a safe birth. Fortunately, as Abraham Lincoln said, you can't fool all of the people all of the time. More and more women are finding the courage not to believe everything obstetricians say. The percentage of births attended by midwives in the United States is increasing. Today, the number is 9 percent, up from 5 percent just ten years ago.
²⁷

There are other encouraging developments as well. Health care in the United States is driven by the bottom line, and more and more HMOs are coming to realize that having midwives attend low-risk births saves money. Not only are midwives paid less than half what obstetricians are paid, but the number of risky, expensive,
unnecessary
interventions is cut in half as well.
²⁸

Another hopeful sign: in 1999, a new edition of
Danforth's Obstetrics
, a popular textbook, devoted the entire first chapter to the value of practicing “evidence-based obstetrics and gynecology,” that is, practicing medicine that comes as close as possible to what scientific studies show to be most beneficial and least risky for patients. The next year, a new edition of
Williams Obstetrics
, perhaps the most widely read obstetric textbook in the United States, followed suit. This emphasis on science was continued in the 2005 edition of
Williams
, leaving no doubt that obstetrics standard-bearers see it as the right direction for the field. As we will see in later chapters, today's actual obstetrics practices have a long way to go to meet the new standard, but a commitment in theory from the obstetrics establishment is certainly an important move in a positive direction.

Perhaps most promising of all, more women in the United States are coming to see the crisis in maternity care as a women's issue. It's about a
woman's rights to control what happens to her body and to have access to the best health care options available. For some time women have lobbied for the right to prevent—or end—an unwanted pregnancy, but a woman's right to control a wanted pregnancy and birth has received less attention. Now women's groups are taking on a wide range of issues related to maternity care, such as the need for transparency and accountability.

One example: after considerable struggle, women's groups in New York State got legislation passed requiring hospitals to report to the public on their maternity care practices, including the percentage of births by cesarean section. Several years after the law was passed, it became clear that few hospitals (if any) were complying with the law. An advocacy group called Choices in Childbirth brought the situation to light, which resulted in a public investigation. In their findings, New York City investigators expressed outrage at the high birth intervention rates in city hospitals and recommended that the law be amended to make failure to disclose required information a finable offense.
²⁹

Of course, it is also important to remember that maternity care is not just a women's issue—the level of interest and commitment of fathers to the birth of their children, generally, could not be higher. I am frequently reminded of the importance of childbirth to the father when I hear once again that one of those most macho of men, a professional sports star, missed an important game because he rushed home to be with his wife during the birth of their child. It's just about the only excuse coaches and teams accept for an athlete's absence, and I have never once heard of a complaint.

In every country in the world where I have seen real progress in maternity care, it has been women's groups working together with midwives, nurses, doctors, doulas, scientists, journalists, lawyers, and politicians that made the difference. In the United States, the movement for demedicalizing and humanizing birth is gaining momentum. The Coalition for Improving Maternity Services (CIMS) has taken the lead and now has more than fifty member organizations and more than ninety thousand individual members. Their mission: “to promote a wellness model of maternity care that will improve birth outcomes and substantially reduce costs.”
³⁰
These are the principles underlying this model:

•   Normalcy: treat birth as a natural, healthy process.

•   Empowerment: provide the birthing woman and her family with supportive, sensitive, and respectful care.

•   Autonomy: enable women to make decisions based on accurate information and provide access to the full range of options for care.

•   First, do no harm: avoid the routine use of tests, procedures, drugs, and restrictions.

•   Responsibility: give evidence-based care solely for the needs and in the interests of mothers and infants.
³¹

It's hard to find fault with these simple but profound concepts, yet they stand in sharp contrast with the reality millions of American women experience each year. If these principles were in place, neither of the real-life stories recounted in this chapter would have happened; women would not be faced with rates of cesarean section and drug induction of labor that are twice as high as science tells us are appropriate, using evidence-based care; and women and families would be free to have the childbirth of their choice.

This book is designed to further an understanding of problems in the maternity care system in the United States. In order to make changes, however, we need to begin envisioning solutions as well. I believe we can learn a lot by studying successful strategies developed in other countries and by looking at regions of the United States, such as New Mexico and Oregon, where important advances have been made. I will share my thoughts on best practices in obstetrics in
chapter 8
. The final chapter of the book will look at the movement for humanizing birth in the United States and suggest ways that all interested parties—from policy makers to pregnant women—can play an active role.

Keep medicine a profession instead of a service.

EDITORIAL, ACOG JOURNAL “OBSTETRICS AND GYNECOLOGY” (AUGUST 2002)

Nature is a bad obstetrician.

CANADIAN OBSTETRICIAN

While lecturing to a roomful of doctors, I will sometimes say, “I remember the first time I killed a patient.” The hostility in the room is immediate and palpable. I have committed treason. Although no doctor can practice for many years without at some point making a mistake that results in the death of a patient, when it happens, most doctors either go into intense denial or quickly come up with ten reasons why they are not at fault. My statement that I made a serious error goes against an unspoken rule among physicians—we must never admit to mistakes because it undermines our belief in ourselves and puts us in jeopardy of litigation. It also has the undesirable effect of reminding the doctors in the room that they too make mistakes. There is a saying: “It is better to beg forgiveness than to ask permission.” But physicians seem to believe the opposite. Some are finally learning to ask permission (fully informed consent is the law) but they have not gotten around to asking forgiveness for their mistakes. Being a doctor is never having to say you're sorry.