I don’t think I’ve written a post in a while…more than a year? I’ve been busy. But something recently inspired me to come out of my “retirement,” and that something was Andre Picard’s piece in the Globe and Mail, “It’s time to stop treating pregnancy like a disease.”
It is so egregious, so ignorant and so dangerous to women that I feel I had to write a rebuttal simply so that I could sleep at night. I think that journalists should be held to some standard. And you might say to me, “but TAM, this is an opinion piece,” to which I will reply, “opinions should be held to some standard too.” We are all entitled to our opinion, but if you are going to shout your opinion from a large forum like a major national newspaper, then it stands to reason that some people are going to mistake you for an authority so you’d better be able to back up your opinion with facts and logic and if you are going to go on and use your opinion about something to suggest a bunch of sweeping health care reforms, that opinion should be based in a rational and correct assessment of the “current state.”
I want to go through Mr. Picard’s piece.
He starts with two statements:
“The No. 1 reason for hospitalization in Canada is childbirth.
The most commonly performed surgery in this country is the cesarean section.”
Mr Picard suggests these statements should be shocking to us. We should be upset that this is the case. Are we?
As far as I can tell these statements come from a June 3rd,2014 CIHI news release:
“Giving birth was the leading reason for inpatient hospitalization, accounting for 369,454 hospital stays. There were more Caesarean sections (C-sections) in Canada than any other inpatient surgery.”
If giving birth is the most common cause for hospitalization is that a bad thing? I do not buy the idea that there is something inherently wrong with being in hospital. Is there something inherently wrong with being in hospital on the one day in your child’s first 18 years where they are the most likely to die?
Not all hospitalizations are considered equal. While most of us could probably agree that hospitalizations for chronic diseases such as heart failure or diabetes might indicate a failure of good ambulatory care or otherwise function as a quality indicator of ambulatory care, I don’t think we can make the same leap for pregnancy. Consider that most women who have a vaginal delivery will leave the hospital 24 hours after the birth (6 hours if you have a midwife in some jurisdictions). Women who have had CS can be discharged in 48 hours. Of course, cases that are complicated by maternal disease or adverse events due to the birth will probably remain in hospital longer, but I think we can all agree that those women should be in the hospital.
No, I am not upset that giving birth is the most common reason for hospitalization. Look around, we have tons of pregnant women. Most of them seem to want to give birth in the hospital, or at least in a facility with life saving equipment and other cool stuff like analgesia, as opposed to home. If the most common cause of hospitalization was, say heart disease or diabetes, I would begin to wonder about our ambulatory health services.
Lets think about the other statement for a minute: that the most common (inpatient) surgery performed was CS. I think this would only be distressing to you if you thought that most of the CS were “unnecessary.” And Mr. Picard seems to think this is the case. He thinks that the CS rate should be around 15%. Okay, so from that CIHI data, drawn from 2012-13, there were 100 686 CS and an overall CS rate nationwide of approximately 26%. So let us just do a little thought experiment here…if we divide 100686 by 26% we will get an approximation of the overall births in Canada – 387 253. What’s 15% of 387 253? Answer: 58 088. The SECOND most common surgery was knee replacement at 57829 surgeries. Even if we decreased the overall CS rate to something Mr. Picard would be happy with, 15%, CS would STILL BE THE MOST COMMON INPATIENT SURGERY DONE IN CANADA. Simply because we be havin’ lots of babies, people! Lots of babies.
But all that aside, it’s nice how his intro is set up to induce fear and doubt right? Makes it easier to swallow his arguments and conclusions without having to think about them too much.
Now there is a series of questions he poses…let me try to answer them:
Is pregnancy a disease?
That depends on the definition of disease you use. Does it matter if we call it a disease or not? Whether its a disease or a state of altered physiology, what he’s really asking is, “does pregnancy require medical care?” And the answer to that is yes. Whether from your midwife, family doctor or obstetrician we KNOW that prenatal care improves perinatal outcomes and maternal health. We also know that a significant number of complications can develop during pregnancy or delivery that require medical help. There are plenty of things we see health professionals for that aren’t “diseases” such as:
shot gun wounds or really any trauma
acute pain crises (headaches, arthritis, etc)
All kinds of surgery…is your inguinal hernia a disease? What about the bone on bone in your knee from that old mountain biking injury?
Lets not get hung up on semantics. Call it a disease or don’t, but don’t use calling it something other than a “disease” in the place of a SOUND ARGUMENT that pregnancy and delivery/ giving birth do not require medial resources. Because they absolutely do.
Is a hospital really the best place to give birth?
Yes. The best data we currently have, from the Netherlands*, from the UK**, from Sweden, from Australia, and here, and from NA (Oregon, Arizona, MANAStats, other, and here) show better perinatal outcomes for hospital birth over home. There have also been some new studies by Amos Grunebaum’s group that show hospitals provide better outcomes (http://www.ncbi.nlm.nih.gov/pubmed/24662716; http://www.ncbi.nlm.nih.gov/pubmed/24662716). The studies that are used in Canada to show that homebirth is “safe” are the 2009 study authored by Janssen et al***. which was underpowered to detect differences in perinatal mortality and the 2009 study by Hutton et. al. from Ontario.
The Janssen study authors used registry data and did not have access to information regarding the circumstances under which the seven perinatal deaths in their study population occurred. Their ability to draw conclusions about the safety of homebirth was limited. The Hutton study shows no difference between groups but there was no power analysis done. I am happy to see that the Hutton group has just published their meta-analysis protocol. They are going to pool data from multiple studies to try to quantify these questions better. I eagerly anticipate a well-done meta-analysis in this area so that women will have better data to consider when they make their decisions.
Are women ending up there by choice or by default?
While it is true that some women who desire a home birth are ending up in the hospital either because midwives are not available or covered by provincial health insurance in their jurisdiction or because there are too few midwives to satisfy the demand, I would argue that unless you have evidence to the contrary, your default position, if you don’t want to be considered a misogynist, is that most women chose their place of birth based on the information they have and their values. I.e. women are entirely capable of making a considered choice that best meets their needs. The way this question is phrased gives the impression that the pretty lil’ heads are just doing what the big men tell them because they don’t know better. It’s insulting.
Is surgery actually required to deliver one in every five babies?
No. Well, not if you don’t want the babies to be alive and neurologically intact. It would be very difficult to figure out the optimal cs rate for a population in a way that was ethical. One surrogate measure we can use is to look at CS rates by region and the corresponding perinatal morbidity and mortality, and also maternal morbidity and mortality and see if there is a sweet spot. Too many CS and maternal morbidity may rise, too few CS and perinatal outcomes get worse. If you look at this data and compare nations, then you do see that the best outcomes overall do occur at a CS rate of around 20%. But the data is incomplete at this time and I think there are still lots of questions here. Instead of asking this question, it might be better to ask a question like, “of the CS we are doing, how many of them had a good indication and how many of them were accompanied by morbidity/ mortality and what can we do to make that better?” But that would be the kind of question someone with extensive training and interest in maternal and perinatal health would ask, like an obstetrician for example.
Then there are some statistics…then there is this statement,
“Let’s face it, the vast majority of births are uncomplicated. That doesn’t mean easy – it means not requiring medical intervention.”
What is the “vast majority?” I would argue this isn’t the case. Our national, overall CS rate is 26%. So 1/4 births is not “uncomplicated.” And of the other 75% that delivery vaginally, some of those will require things like, pain relief, IV fluids, blood transfusions, IM pitocin and active third stage management, augmentation/ induction, continuous electronic fetal monitoring, IV antibiotics for GBS. Mr. Picard, do you think we can do away with those things? IV penicillin given at home by a midwife is still a “medical intervention” or do you just mean interventions like CS, forcep deliveries, manual removal of the placenta for hemorrhage, hysteretomy etc? I’m confused. And even if we got the overall CS rate down to 5-15% as you think the WHO seems to suggest (it doesn’t by the way – it has no such recommendation), would you really think that the “vast majority” of births are uncomplicated? Does having a 1-3/20 chance of needing an emergency operation seem UNCOMPLICATED to you? Does VAST MAJORITY now mean 95% of the time? I don’t think so. I suspect if you polled a bunch of people on what they felt “vast majority” mean they would say > 99%.
He then says that where and how you give birth matters. I agree. It matters to the fetus/ neonate. We know their outcomes are better in the hospital compared to home or a birth center (birth centers in Canada that are free standing are just like “someone else’s home” they have no equipment or personal beyond that present at a home birth). We also know that a planned prelabour CS is the SAFEST for the baby. It’s shocking, but true. The “how” also matters to women. It matters to their physical, mental and emotional health…but not every women is the same and not every woman’s ideal “how” is going to look the same or even be realistically achievable.
Then here’s a little gem:
“It’s worth recalling the old adage: “If all you have is a hammer, everything looks like a nail.” Similarly, put a perfectly healthy pregnant woman in a hospital and she becomes a patient – someone to be monitored, sedated, drugged, “assisted,” operated on and so on.”
Monitoring is done both at home and at the hospital. Monitoring is an important part of ensuring a safe birth for mom and baby. Intermittant auscultation or doppler for fetal heart rate, vital signs for the mother. Cervical dilation via vaginal exam as clinically appropriate, determined by the provider. Vital signs for both after the birth. Sure there are some speical kinds of monitoring that can only be done in hospital such as continuous electronic fetal heart rate monitoring via doppler or scalp clip, fetal blood gases, maternal labs, etc…but those are not typically used in straightforward births. Monitoring standards for low risk pregnancies are the same home or hospital. The only difference in hospital is that if something is “iffy” you don’t have to undergo a transfer to get to the bottom of it.
Sedated? Drugged? Is this the 1950s? Are we still using twilight sleep? There is no widespread sedating or drugging of women in labour. Some medications may be offered and accepted by the women such as sleep aids or IV or IM narcotics in certain situations but they are not routine and shame on Mr. Picard for giving the impression that they are. And what would he do with the information that some midwives advise their clients in the early/ latent phases of labour to, “have a glass of wine and relax” or “take some gravol and try to get some sleep?”
If we are going to use the hammer-nail adage to form an argument, I think that it follows that the MORE TOOLS you have the more different kinds of things you can build. An obstetrician has more tools than a midwife or GP that does deliveries since they are trained to catch spontaneous vaginal births, assist with instruments like vacuums and forceps and perform CS.
“When someone is placed in an institutional setting, there is often a cascade of dubious and not-always useful interventions that occur: Shaving of pubic hair, fetal monitoring, IV drips, inducement, epidurals, forceps, episiotomy and, of course, a cesarean section. (Again, this is not to suggest that epidurals are unnecessary, and 58 per cent of women opt for one during delivery, but pain relief can be done outside the hospital, too.)”
Shaving of pubic hair is not routine. Shaving has been shown to increase infections so it’s been abandoned. Even for CS, if there is any hair overlying the incision site it may be clipped, but never shaved.
Fetal monitoring: see above. The fetus deserves monitoring whether delivery is being attempted at home or in hospital. Certain kinds of fetal monitoring can only be done in hospital but these are NOT routine. In addition, I often feel that continuous fetal monitoring gets a bad rap because there was a study that showed that when it was used more CS were done without a reduction in cerebral palsy…however the fact that when it was used there were less neonatal seizures (a marker of hypoxia and possible brain damage) and less intrapartum death has been downplayed.
The rest of his interventions are done for specific indications, not for kicks. So IV drips (fluids) are given for long labours, low BP, as carrier fluid for things like oxytocin. If those things are required some hospitals prefer a saline or hep lock IV is inserted, some don’t require this. IV meds can be given in some provinces at home by midwives too (example, antibiotics for group B strep). Epidurals are given on demand when women request them because they are in more pain then they would like or are exhausted, etc. Even episiotomies can, and have, been done at home by midwives where there is a need to get the baby out quickly because of worrisome features. I don’t think you can realistically make the argument that forceps are done for kicks.
What do I say about this statement that pain relief can be done outside the hospital to.
Just no. While non-pharm pain relief can be offered outside of the hospital (showers, baths, massage, TENS, etc.) pharmacologic pain relief cannot safely be done in the home setting. And no pharmacologic pain relief can be done without monitoring (which he seems to think is unnecessary). So no, your midwife cannot give you a shot of demerol or morphine in your kitchen or IV fentanyl or give you an epidural. This is true for birth centers as well. In fact, there is no freestanding birth center in Canada that I know of with an epidural service and I can’t even think how one would be safely and effectively provided. Any argument that favours home over hospital birth and any policy that favours home over hospital birth is one that DENIES easy access to effective pain relief to women in labour.
Childbirth is likely going to be the most painful experience of a woman’s life. Not all women are going to want to use pharmacologic pain relief and that’s fine. It is their choice. Women that want to avoid it if possible may very well chose to attempt birth at home to “avoid the temptation,” and again, that’s their choice. But do not push an ideology on pregnant women with falsehoods like” pain relief can be done outside the hospital too.” The most effective form of pain relief in labour is an epidural and it has an excellent safety profile for the mother and the fetus. However, it cannot be done outside the hospital. It requires an anesthesiologist. It requires some extra monitoring of mom and baby after placement to ensure that they are tolerating the associated hemodynamic changes and that rare but serious complications have not developed. It requires the presence of an individual with advanced resuscitation skills be immediately available and that all the equipment and drugs required for resusc be available as well. You can read about our standards here.
These conditions cannot be met at home. Oh, you don’t think that Mr. Picard could be so uninformed as to think that epidurals should be available at home? Consider his tweet:
Here’s an idea, if you don’t understand the differences between giving birth at home and at the hospital, including the risks to mother and child, the available equipment and options for pain relief….
DON”T WRITE AN OP-ED!
The rest of the piece is just as bad.
“Don’t buy the “too posh to push” nonsense. Yes, an increasing number of women are “choosing” a cesarean, but when you medicalize pregnancy and labour, and don’t offer reasonable alternatives, you create uncertainty and fear.”
Firstly, “too posh to push” is very insulting. Btw, posh spice’s first baby was breech. She wasn’t too “posh” to push either, although this seems to be where the phrase gained popularity, she had an obstetric indication for a cs. Women don’t choose elective CS because they are “posh” or because they fear hard work or getting sweaty while pushing. Women chose CS because they have a history of sexual abuse and can’t stomach the thought of being vulnerable and undergoing vaginal exams or the passage of a baby. Women chose CS because they prefer the known risks of CS over the known risks of a trial of labour. They chose CS because they wish to avoid higher degree obstetrical tears and any chance of FECAL incontinence. They choose CS because they are over 40 and have a statistically high chance of having an emergency CS. They choose CS for many reasons that are VALID and IMPORTANT and should not be BELITTLED with this “too posh to push” phrase.
I am also going to argue that uncertainty and fear and not created by “medicalizing pregnancy and labour.” The process of pregnancy and birth is inherently damaging for a subset of women and would damage even more without access to high quality medical care. Women die. Fetuses and babies die. Women are left damaged. Babies are left with disability. It is only rational to be afraid of this process and to fear that you might be the one that experiences a devastating outcome. I think this is an extraordinary claim that fear and uncertainty are created by medicalization. I would like to see evidence.
I agree that wide variability in CS rates might be concerning…but only if we are comparing “like” populations and only if the CS rates are connected somehow to outcomes. If a province or health authority has a 10% CS rate but high perinatal mortality compared to one with a 22% CS rate then I would argue, along with most rational people, that the second system is performing better. CS rates, in and of themselves, don’t tell us much. It is more useful to break CS down by indication and go after reducing CS that were unwanted or inappropriate.
So after some statements that are misleading or false, some random statistics without much context or analysis, Mr. Picard then gives us his “perscription” to fix the “problems” in current maternity care. Are they problems? He hasn’t quite made his case but rather just jumped straight into a “solution:”
“Physicians should be handling the complex, high-risk cases – women with conditions such as obesity and heart disease that compromise the pregnancy, mothers over 35 (though the risks to “older” women are debatable) etc.
Most births should be handled by midwives, preferably in a home-like setting, such as a birthing centre.”
I agree that physicians should be handling the complex high risk cases..and not just physicians but specialists, i.e. obstetricians. The risks to mothers over 35 are not “debatable” they are real. Not every pregnant women over 35 develops complications or risk factors other than age, but on average they are more likely to have problems compared to younger women. I do not think most births should be handled by midwives. The midwifery model of care is preferred by some women…but not all. Some of us would like a physician even if we are “low risk.” This might be because we already have a great relationship with our GP who happens to be one of the few that still delivers babies. It might be because we feel more comfortable with a physician. It might be, like myself, that we’d prefer to start our labour with an OB so that if it ends in a CS there is no delay in transfer of care from midwife to OB and so that we have a relationship with the OB that preceeds the surgery. It might be for any number of reasons and I would argue that women deserve the choice.
I don’t know what he means by “home-like setting.” If he means comfortable beds and nice decor as opposed to a cold sterile room with all kinds of scary equipment in it…I agree. If he means a setting such as you would get at home with a home birth or birth center with very little in the way of rescue equipement and personal…I disagree. Again, outcomes at home and in birth centers are NOT as GOOD as the hospital. So lets not push this as the “default.” Home and birth center births are a reasonable option for women who want them…but where else in medicine, other than birth, can you think of an example where patients, clients (whatever you want to call them) are being encouraged to take the LESS SAFE ROUTE? I can’t think of another example.
“Maternal mortality fell precipitously in the 20th century, but only a small portion of those improvements were due to obstetrical interventions.
We have a much higher standard of living (hence healthier mothers), we have contraception and emancipation (so the days of 17 children are mercifully behind us) and, most of all, we have better infection control, including vaccination and antiseptic environments.
The greatest risks to our foremothers were infectious diseases and excessive bleeding. Those are still the biggest risks today. But they are manageable risks.”
I don’t know if we can extrapolate the fact that a significant amount of reduction in maternal mortality was due to things like contraception and infection control to our present day situation and say that moving the majority of births to midwife care and the home or birth center setting would not affect maternal mortality. Maternal mortality is so rare that so many patients would need to be studied to find a difference. What we can do is look at the leading causes of maternal mortality NOW and see if homebirth or lower intervention birth would be helpful. The leading cause of maternal mortality right now is….HEART DISEASE. Mothers are older and they are dying from things like heart attacks, aortic dissections, strokes and heart failure. Those women need specialists. ICUs. Interventions. Heroics. Or they won’t survive.
Other common causes of maternal mortality are hypertensive diseases of pregnancy (pre-e, ecclampsia, hemorrhagic stroke), infection and bleeding. In some studies women who attempted homebirth were more likely to have a PPH and in other cases there was no difference. One of the predictors of PPH from uterine atony is a prolonged labour, prolonged pushing phase. Although we don’t know from available studies, my feeling is that is more likely with the midwifery model of care where striving for a vaginal birth is more important to both provider and client.
The problems associated with a higher standard of living include delayed childbearing, older first time mothers and a higher use of assisted reproductive technology. Those don’t sound like ideal candidates for home or birth center birth to me.
What does he mean by the statement that bleeding and infection are manageable risks? I would like to know. The way that the risk of infection is managed by those dreaded interventions…induction after a certain amount of time when the water breaks but labour doesn’t start, augmentation of labour, IV antibiotics, stopping a trial of labour or prolonged induction in favor of a CS, avoiding instrumental vaginal delivery (by CS? by time?). The way that the risk of bleeding is managed is also by interventions: not allowing prolonged labours and actively managing the third stage. When bleeding occurs, more interventions are needed: monitoring, manual examination of the uterus and removal of placental fragments or clots, operative removal/ D&C, hysterectomy, medications (oxytocin, ergotamine, prostaglandins, vasopressin), pressors, IV fluids, blood products, intubation, sedation, intensive care stays…After delivery bleeding to death can occur in 10 min or less…how far away does the hospital seem now?
‘In a bid to totally remove risk (which is not possible), we have made pregnancy and birth unnecessarily tedious and costly and created new risks to boot.”
Again, I think this is an extraordinary claim and it falls on Mr. Picard to support it. Tedious? Costly? New risks? Define them for me. What is the cost of a few interventions compared to the lifetime costs of caring for one child with severe hypoxic ischemic encephalopathy? What is the real cost attempting vaginal birth at home with a midwife compared to attempting vaginal birth in the hospital with an obstetrician? And when you do your analysis, please factor in all the costs. Women giving birth at home still need the hospital and the OB and anesthesiologist and nurses and respiratory therapists and ICU and blood bank etc etc as back up. Their share of the costs to have those resources in place should be included. The costs should also go beyond the postpartum 6 week period. We need to include costs associated with pelvic floor damage and reconstruction, for example. In an analysis done by NICE, when those costs were included the cost of an elective pre-labour CS was something like only 70 pounds greater than that of a trial of labour. So much for the “high” costs of CS. I have yet to see an economic analysis that convinces me that using midwives as the default for low risk pregnancies or increasing the proportion of home and birth center births will actually reduce costs. Show me some numbers. Convince me.
“Mothers and their babies deserve better.”
Mr. Picard, your READERS deserve better.
*Evers ACC, Brouwers HAA, Hukkelhoven CWPM, Nikkels PGJ, Boon J, van Egmond-Linden A et al. Perinatal mortality and severe morbidity in low and high risk term pregnancies in the Netherlands: prospective cohort study. BMJ 2010;341:c5639. A prospective cohort study published in 2010 from the Netherlands looking at over 37,000 births showed that low risk women giving birth outside of the hospital under midwifery care had higher levels of perinatal death and comparable levels of NICU admission than high risk women delivering in the hospital under obstetrician care
**Birthplace in England Collaborative Group. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ 2011;343:d7400 – The results of the Birthplace Study, a large prospective cohort study of over 64,000 women in the United Kingdom, showed an incidence of death and serious neonatal morbidity amongst planned home births that was double that of planned obstetrical unit births.
***Janssen PA, Saxell L, Page LA, Klein MC, Liston RM, Lee SK. Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. CMAJ 2009;181:377-383