Born in the USA (6 page)

There are many fascinating examples of ways that organized obstetrics puts the interests of tribal members before the interests of patients. One that is particularly blatant is ACOG's Committee Opinion number 207, “Liability Implications of Recording Procedures or Treatments,” published in September 1998. The opinion addresses the issue of hospital births videotaped by the family. It includes the statement, “Recording solely for the purpose of patient memorabilia or marketing is not without liability—the Committee strongly discourages any recording of medical and surgical procedures for patient memorabilia.” In essence, ACOG is recommending that doctors and hospitals refuse to allow women and families to videotape their babies' birth for fear of litigation. In ACOG's world, protecting its members is a higher priority than women's rights or family values. Its fear is so strong, it cannot accommodate the need of families to record one of the most important events in their lives. For this reason, recommendations from this organization cannot be considered the gospel. We must always consider them carefully in the light of their primary purpose—protecting the welfare of the tribe.

Here is another example of how tribal interests are protected in obstetrics. On a
Dateline NBC
program that focused on the widespread use of Cytotec for induction of labor—a use not approved by the FDA—an ACOG representative was asked whether an obstetrician should always
tell his patient if a drug is not approved by the FDA before administering it. The representative responded that to do so or not is at the discretion of the individual obstetrician. The answer was a cop-out. The organization did not want to go on record as opposing Cytotec for induction, because many members of the tribe use it all the time for this purpose. At the same time, it did not want to look foolish by saying that women do not have the right to informed choice and it's fine for obstetricians to ignore FDA recommendations.
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Naturally, tribal protection goes on at a national level as well. In the spring of 2002, ACOG hosted a meeting of the U.S. Safe Motherhood Coalition at its headquarters in downtown Washington, D.C. Safe Motherhood's mission is to lower maternal mortality rates, a particularly important effort in the United States, where for twenty-five years maternal mortality rates have been going up, not down. Furthermore, public health officials know that our rates are underreported. In one state in one year, one-third of the maternal deaths had not been reported, and one official suggests, “The actual pregnancy-related death rate could be more than twice as high as that reported.”
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Sitting around the table with the obstetricians from ACOG at the Safe Motherhood Coalition were representatives of several midwifery organizations that are members of the Coalition. Most of the midwives had come to the meeting on shoestring budgets and were staying with friends because they could not afford to stay at a hotel. At the meeting, ACOG had the gall to announce that it was dropping out of the Coalition due to “lack of funds.” Certainly, this national obstetric organization in its large, well-appointed headquarters does care about women dying around the time of birth. So why did it drop out? Is it possible that it cares more about tribal issues, such as liability risks to obstetricians if maternal deaths are monitored too closely?

Obstetricians are terribly frightened of having the deaths of their patients investigated. Not long ago, I talked with an obstetrician who at one time was a professor of obstetrics at a highly respected university hospital. He is known for writing and speaking on the importance of evidence-based obstetric practice, so he must be seen as among the more progressive American obstetricians. Yet, when I asked him if he would like to see a maternal death audit system developed in the United States (this idea is covered further in
chapter 7
), he responded by telling me about a lawyer in Texas who somehow got information from a maternal death audit and used it to get big bucks for the family of the dead mother. We must never underestimate the power fear of litigation holds over obstetricians. In my experience,
as a motivational force it overshadows their desire to lower the maternal mortality rate.

Occasionally, a group of obstetricians does try to get a handle on maternal deaths in their locale. A study reported in the year 2000 looked at ten hospitals in greater Chicago where the maternal mortality rate was twice as high as the national rate reported by the Centers for Disease Control and Prevention. The doctors looked at each case individually and found that 37 percent of the deaths were preventable, and, of those preventable cases, 80 percent of the time the cause of death was one or more mistakes by doctors and nurses. (Unfortunately, as is nearly always the case, the study made no attempt to determine how many of the deaths were related to obstetric interventions such as induction of labor, epidural block, and cesarean section.) The paper laments the fact that in the United States, maternal mortality committees that carefully review all maternal deaths are now largely defunct, and urges that these committees be revived.
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There are conscientious, concerned obstetricians out there trying to do something about the maternity care system, but it is an uphill battle, to say the least, as many of their colleagues would prefer to believe there is nothing wrong and will go to great lengths to perpetuate the myth.

While the obstetrics establishment is masterful at protecting tribal members, it is equally effective at controlling them. It has devised a number of ways to make sure members comply with the obstetric omertà and other unwritten tribal rules, the most common being the threat of punishment. And the punishment can be severe. An offending doctor can be completely ostracized. Other doctors in the community may stop referring patients to him. He may be brought before a hospital peer review committee, where, behind closed doors in a tribal kangaroo court, he will face everything from humiliation to loss of staff privileges, making it impossible to practice. Put simply, an offending doctor can be thrown out of the tribe.

I know an obstetrician who witnessed blatant malpractice while assisting at surgery, and the case resulted in a dead baby. In private, she told me that she was shocked by what she saw. But when I asked what she was going to do about it, she said, “Nothing.” Now I was shocked, as I knew her to be a caring, compassionate, competent obstetrician. “Why do nothing?” I asked. She explained that hers was a small city, and all the obstetricians knew one another. If she stepped out of line, she would put her practice in serious jeopardy and the women she served could lose her services. On the other hand, by doing nothing, she allowed the obstetrician guilty of serious malpractice to get off without so much as a reprimand
and to remain in practice in that community. Don't underestimate the power of the tribe.

I have personally experienced the wrath of the tribe when I have disobeyed the obstetric omertà. While I was with the World Health Organization, I spoke in Scotland at a public meeting on maternity care. During my talk, I mentioned that data show that in Scotland (as in the United States) birth occurs much less frequently on weekends than during the week, and suggested that perhaps Scottish doctors were influencing time of birth for reasons of convenience.
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The following Sunday, a leading newspaper in Edinburgh ran an article quoting me on this topic of birth by day of the week and convenience.

The next day, the director of health for Scotland called my boss at the World Health Organization to insist that I be reprimanded, if not fired, and to demand that I publicly retract what I had said. My boss called me in and asked if I could produce data to substantiate my statements. I showed him the data, and he called the director in Scotland, quoted the data, and said that there would be neither reprimand nor retraction. (The data on time of birth in Scotland indicating convenience had existed for some time, but no one had spoken about it in public.) Because the obstetric tribe in Scotland couldn't employ the usual methods of tribal punishment (that is, bring me before a hospital committee), they tried another age-old tactic. They tried to get me in trouble with my boss.

ACOG also uses fear of litigation to control doctors and hospitals. If doctors and hospitals go against one of their recommendations, they are more vulnerable to litigation. At a policy level, ACOG uses another brand of fear to control women, politicians, and the media. They justify many of their statements (for which there is little or no scientific support) by calling their position a matter of “safety.” One example: in its 2002 publication
Guidelines for Perinatal Care
, ACOG states that home birth is “not safe.” The publication doesn't even try to reference data, because the statement flies in the face of overwhelming scientific evidence showing that planned births at home and in out-of-hospital birth centers are perfectly good options for the vast majority of women.
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This irresponsible talk of safety is misleading, most importantly, to women and their families. If the obstetric tribe says that out-of-hospital birth is not “safe,” the implication, of course, is that a hospital birth is safe, which is not true. Newborn babies die in hospitals every day, sometimes because someone made a mistake. When the obstetrics establishment implies that this doesn't happen, the family naturally feels deceived when it does happen.

Another way that organized obstetrics uses tribal loyalty is to protect its territory, that is, to maintain its monopoly in American maternity care. I saw this in action at a local level when I visited Des Moines, Iowa, to speak at an evening meeting of the local medical association. Every person in the room was a doctor. In my talk, I said that I found it tragic that the only out-of-hospital birth center in the area that offered midwifery care—an important and safe option for women—was in danger of closing. The general practitioner who provided backup consultation (required by law in Iowa) was retiring and not one other doctor was willing to replace him.

During the general plenary discussion following my talk, a doctor stood up and said, “Regarding that birth center, doctor, you just don't get it. We don't want the competition. We want that place closed, and we have seen to it that it will close. You can be sure no doctor in this area will give backup.” (This is how doctors talk behind closed doors.) The birth center did close soon thereafter. For me, the saddest thing about that meeting in Des Moines was that during the break after my talk, several doctors told me that they personally believe there should be an out-of-hospital birth center, but they didn't dare break rank and provide backup.

One of the most interesting recent examples of tribal protectionism and the ability of the obstetrics establishment to maintain its monopoly is ACOG's practice bulletin number 5, “Vaginal Birth after Previous Cesarean Section (VBAC),” issued in July 1999. Prior to the publication of this ACOG bulletin, there had been general consensus, even among obstetricians, that women should be encouraged to try VBAC. The federal Department of Health and Human Services even had a stated goal to increase the rate of VBAC births. The discussions leading up to this practice bulletin began in the 1990s, when cases of uterine rupture during labor among women who had previously had cesarean sections increased at an alarming rate. (As we saw in
chapter 1
, uterine rupture is an obstetric catastrophe, with a high risk of death for the baby and a significant risk of death for the woman.)

The phenomenon was almost certainly related to the fact that the percentage of births in which powerful drugs, such as Cytotec, were used to induce labor had doubled, given that studies show there is an increased risk of uterine rupture with pharmacological induction. But instead of acknowledging and addressing this connection by recommending that obstetricians not use Cytotec for induction, the organization recommended that a woman not be permitted to attempt a vaginal birth after previous cesarean section unless she was in a hospital where an obstetrician and anesthesiologist were always present. In other words, instead of preventing uterine rupture,
ACOG said that we should surround the woman with experts to deal with the rupture when it happens. This is like trying to solve the problem of children drowning at summer camp not by teaching the children to swim, but rather by putting a couple of life preservers in the lake.

The language of the bulletin makes it clear that fear of litigation is at the root of ACOG's policy on VBAC. Near the beginning, the document mentions that “physicians in the United States are facing increased medical-legal pressures” in general, and then focuses on VBAC litigation, saying, “Increasingly, these adverse events during trial of labor have led to malpractice suits.” The fear is further revealed in figure 1, which points out the need to “counsel the patient regarding the benefits and risks of VBAC,” but does not point out a similar need to counsel the patient regarding the benefits and risks of the other choice, cesarean section.

ACOG's recommendation on VBAC has a huge impact on maternity care in the United States. Where VBAC in compliance with ACOG's recommendation is not a possibility, such as in areas that have only a small local hospital, it means that every time a women has a cesarean section, all subsequent babies must again be born by cesarean section, resulting in a geometrical increase in the rate of cesareans. This is borne out by the rapid increase in the rate of cesarean section births in the United States, which is now approaching one-third of all births. The ACOG policy denies this rapidly increasing group of women who have previously had cesarean sections a choice of where they will give birth. If they want a VBAC, they will not be able to give birth at home, in an out-of-hospital birth center, or in a small local hospital.

Now, in many areas of the United States, no hospital or doctor will allow women to attempt a VBAC, despite evidence that it is no more risky than a repeat cesarean section birth. A study of eighteen thousand women shows that 75 percent of VBACs are successful (no surgical intervention needed).
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In addition, a National Institutes of Health study on VBACs found that uterine ruptures occurred in fewer than 1 percent of those who attempted VBAC.
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Because of all these data, the National Institutes of Health recommends that women be given the choice of having a VBAC. But many obstetricians are unwilling to take the legal risk of going against ACOG. In some states, the choice is effectively made for them, because malpractice insurance companies in the state will no longer cover claims resulting from VBAC. According to one insurance company CEO, physicians are for the most part pleased with their decision to drop the coverage “because it simplifies things for them.”
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