Born in the USA (7 page)

It is disturbing to find that a policy with such a serious impact on women is not backed up by scientific evidence. There are no studies showing that fewer women and babies die in certain types of hospitals. One study, which, ironically, ACOG included in its reference list, looked at VBACs and repeat cesarean section births in three types of hospitals—community, regional, and tertiary care (large regional referral hospitals)—and found no difference in mortality rates between the two procedures by type of hospital.
¹⁵

Another problem with the ACOG recommendation on VBAC is that it is based on the unproven assumption that a cesarean section can be accomplished faster if a women undergoes labor at a large specialty-care hospital. It sounds logical, but in truth it takes considerable time to prepare for the operation and transport the woman to the surgical ward when she is already on a labor ward in the hospital. A study conducted at a large specialty hospital found that in 52 percent of emergency cesarean sections done because of fetal distress on women already in that hospital, the time between the decision to do a cesarean section and the incision exceeded thirty minutes.
¹⁶
One reason for the delay, of course, is that the doctor is not on the premises but is instead monitoring the labor by telephone. ACOG's recommendation “to have a physician immediately available” must be taken as inadvertent criticism of a system in which a laboring woman's doctor is not usually available and must be called and asked to come in when there is an emergency.

The elegant solution to the issue of VBAC is not to take away valid choices for woman and families, as ACOG recommends by insisting that a woman having a VBAC be transported at the beginning of labor to a big hospital away from her home, family, friends, and primary care physician. Instead, it is to create an effective communication and transport system, as highly industrialized countries where mortality rates are lower than ours have done. When there is good communication between a woman's local care providers (at home, in a birth center, or in a small hospital) and a larger regional hospital, if the woman needs to be transported for surgery, in most cases the “decision to incision” time need be no greater than if she were laboring in the specialty hospital and needed to be transported from the delivery ward to the surgical ward.

The ACOG recommendation on VBAC illustrates a double standard often found in the organization's recommendations. Policies that have no evidence to support them but are “doctor-friendly” (of benefit to obstetricians)—such as VBAC only in hospitals with surgeons standing by—are recommended by the organization. Other solutions to the problem that are
not obstetrician-friendly—such as facilitation of communication, collaboration, and transportation between local hospitals and big regional hospitals—are not recommended even though they would benefit many women.

Very rarely, ACOG is forced to make a recommendation that is not doctor-friendly, such as when it finally recommended against using Cytotec induction in VBAC cases. But that was only after overwhelming scientific evidence of serious risks and years of damage to women and babies.

ACOG's practice bulletin on VBAC includes a number of recommendations for managing VBACs. When we take a closer look at who made the recommendation that limits where VBAC births can occur—the recommendation we've been discussing—we find that it was placed in a category “Level C.” The summary says that Level C recommendations are not based on scientific evidence but rather are based “primarily on consensus and expert opinion.” So who are the experts and who was involved in the consensus? I contacted ACOG, but the organization was unwilling to say. Evidently, this particular tribe does not accept that in a democratic society transparency in these matters is a necessity.

When a policy affects the care of a large group of women, we might hope that a “consensus” would include not only obstetricians but also midwives, nurses, family physicians, perinatal epidemiologists, and consumers. This is particularly important when a recommendation, such as this one, is of the “you need more of us” variety. Since ACOG's policy gives an advantage to obstetricians and a disadvantage to family physicians, midwives, and many women, the recommendation could easily be seen as self-aggrandizing for obstetricians—or, worse, an attempt to drum up more business.

The following editorial was published in the
Lancet:

Since ACOG's VBAC guideline was made public, other interested parties—midwifery organizations, family practice organizations, women's groups—have come out against it.
¹⁸
While visiting hospitals in Maine, I was told by a leading family practitioner that small hospitals and family practitioners in that state are violently opposed to the recommendation but are too afraid to go against it because of fear of litigation. More recently, the American Academy of Family Physicians released its own report on VBAC. Based on a more careful and thorough review of the literature than the ACOG recommendation, the Academy's report explicitly states that there is no scientific evidence to support the ACOG restriction on VBAC location. It goes on to recommend, just as the National Institutes of Health does, that women be given the right to choose VBAC, regardless of place of birth.
¹⁹
But while progress is being made to overcome the scientifically unjustified ACOG restriction on VBAC, the attitude of the hospitals in Maine is a good example of how ACOG—not women, not insurance companies, not HMOs, not government agencies—controls American maternity care.

Why does ACOG have so much power? Because it is very effective at protecting and promoting an obstetric monopoly—and simply because it assumes power. In a citizen petition delivered to the FDA in November 2000, ACOG argued its case for Cytotec induction (which will be covered in detail in
chapter 4
). In a transparent attempt to establish power over the FDA, the petition states: “The American College of Obstetricians and Gynecologists is an organization representing more than 41,000 physicians dedicated to improving women's health care. ACOG is also the body which establishes standards of care for the ob-gyn profession.” First the petition says how big ACOG is and then says that the organization sets standards. Who says? No one, not any government agency or any other official, has assigned ACOG standard-setting responsibility. Practicing obstetricians in this country are under no official obligation to be members of ACOG (many are not). They are not obligated even to read this organization's recommendations, much less required by any law or regulation to abide by them. ACOG has simply pronounced, “We set the standard.” ACOG no longer has the moral authority to set standards in maternity care, however. It has made too many self-aggrandizing and self-protective recommendations (e.g., against home birth, videotaping birth, and VBAC) that limit the freedom of American women and families.

Another important reason organized obstetrics dominates in the United States is the sins of omission of many of its members. The chairman of
obstetrics at a large university hospital on the Eastern seaboard confided to me one day that he hates ACOG and all it stands for. He agreed with me that its recommendations are sometimes unscientific. But he has never said these things in public—one of the reasons he has made it up the ladder. Many obstetricians tell me in private that they disagree with the current obstetric dogma but they do not speak out. The silence of all these lambs allows their organization to proceed merrily on with its reactionary, sometimes destructive agenda.

To understand the absolute monopoly ACOG has established in American maternity care, it is helpful to look more closely at this organization. The American College of Obstetricians and Gynecologists is not a “college” in the usual sense: it is not an institution of higher learning. Nor is it a scientific body. With few exceptions, its members and leaders are not scientists but medical practitioners, and there is nothing in ACOG's mission statement about science. The ultimate proof that ACOG is not a scientific body? Too many of its policies and recommendations are not based on real science. For example, in May 2002, ACOG issued a news release with the title “Cytotec Given Orally Found Safe and Effective to Induce Labor.” The release reports on a study of 107 women randomly assigned to two groups.
²⁰
It is impossible to measure safety with such a tiny sampling. It would take at least thirty times that number to have enough statistical power to draw conclusions about the serious risks of induction with this drug. Putting the word
safe
in the title of the news release is a gaffe that demonstrates ACOG's lack of understanding of scientific methodology.

In truth, ACOG is a “professional organization,” which amounts to a trade union. Like every trade union, ACOG has two goals—to promote the interests of its members and to promote a better product, in this case, the well-being of women. But if there is conflict between these two goals, the interest of its members comes first.

ACOG, and all the other national obstetric organizations in other countries, belong to an umbrella international organization called the International Federation of Gynecologists and Obstetricians (FIGO). FIGO has no authority over ACOG; it can only make recommendations. Interestingly, I have rarely heard a practicing American obstetrician who is not involved in international activities even mention FIGO. ACOG collaborates with FIGO on key activities in other countries, but I have not seen any evidence that FIGO recommendations have any effect on maternity care policy in the United States One example: the FIGO Committee for the Ethical
Aspects of Human Reproduction and Women's Health stated in a 1999 report, “Performing cesarean section for non-medical reasons is ethically not justified” (see
chapter 3
).
²¹
But the following year, the president of ACOG published a paper urging that women have the right to choose cesarean section for no medical reason.
²²
So organized obstetrics at the international level is not able to apply any brakes on organized American obstetrics.

Sheltered by the all-powerful ACOG, with no authority to answer to and surrounded by people they control (midwives, nurses, clerks, patients), living in an obstetrician's world is like living as an animal with no natural predators. No one challenges obstetricians. I've seen the effects of this in all aspects of the profession, but it is especially frightening in a court of law. The tried and true defense for obstetricians who are sued is “only we can judge what we do.” I will never forget two obstetricians practicing in partnership in a small rural town in Idaho—the only obstetricians in town. When testifying in a deposition in preparation for a court case, they were questioned about giving a patient a dose of Cytotec for induction that was two to three times the maximum dose generally used. They replied that the dose was the standard of practice in their community. When asked where this standard of practice came from, the two obstetricians replied simply, “We are the standard of practice.” This insistence that only members of the tribe can understand what tribal members do and why they do it results in standards of practice that tribal members want—doctor-friendly practices. What it comes down to is that what is euphemistically called a “standard of practice” in a given community simply means whatever the local doctors do, regardless of whether or not it is good practice as defined by scientific evidence—a frightening level of power and control.

When obstetricians in the United States come together to strategize and decide how best to keep the wolves at bay, they tend to focus on two perceived threats: HMOs and lawyers. (I recently saw a printed flyer in a doctor's office waiting room that defended rising medical costs by blaming “greedy lawyers.”) However, most obstetricians are in essence practitioners, and their vision is limited. They do not see that, in the long run, the real threat is that women in the United States will find out that much of what obstetricians do—from putting a women flat on her back during labor and birth to cutting her vagina open—is done for the doctor's benefit, not the patient's.

A couple of years ago, I was interviewed by an obviously intelligent journalist for
NBC Dateline
television. At the end of the program, when we
were off camera, she looked at me with alarm and said, “But doctor, if what you are saying is true, we women can't really trust obstetricians. We must find out for ourselves what our situation is, what the science says about our situation, and whether or not what this obstetrician says is right for this situation.”

I answered: “That's exactly right. You must take responsibility not only for your own body for also for the care given to it.”

“My God,” she said, “I've never realized that before.”

“And that's why we need journalists like you to tell the truth to women.”

“Yes, I understand.”

Another real-life threat to obstetric territory is that health insurance companies and the government will discover just how many billions of dollars are wasted as a result of the obstetric monopoly. Though VBAC rates have dropped to single digits since ACOG's recommendation on VBAC, in a Healthy People 2010 report, the U.S. Department of Health and Human Services set a goal to triple the VBAC rate—acknowledging the cost to pregnant women and heath care resources of a policy that promotes unnecessary cesarean sections.