Saturday, July 3, 2010

Words of Sense in the Boston Globe: Now Apply Them to Women of Size

Check out this great new op-ed opinion in The Boston Globe from Judy Norsigian (of Our Bodies, Ourselves) and Dr. Timothy R. B. Johnson (Bates professor and chair of the Department of Obstetrics and Gynecology at the University of Michigan).

In the op-ed, the authors discuss the high costs of cesareans, both financial and medical, and the non-medical factors that lead to more cesareans. 
Even though caesareans are associated with higher rates of complications than vaginal births, they are becomingly increasingly common. Problems range from infections, including the more serious antibiotic-resistant ones, to blood clots, prematurity, respiratory problems for the baby, and more complications with subsequent pregnancies. There is even a small but measurably higher risk of death for the mother...

There are also cost consequences for taxpayers — the caesarean rate for Massachusetts mothers on Medicaid is increasing at a faster pace than among privately insured mothers. Nationally, in 2008, average hospital charges for an uncomplicated caesarean section were $14,894, while such charges for an uncomplicated vaginal birth were $8,919.
In the media, most of the blame for the increasing cesarean rate has been placed on the mothers, rather than on doctor practices and medico-legal concerns.  Mothers are blamed for being too old, too fat, too high-risk......supposedly that's why the cesarean rate is rising.  But the article quickly skewers this reasoning:
Between 2000 and 2006, while the Massachusetts caesarean rate climbed from 16th to 10th highest among all states, the state’s ranking on neonatal mortality has slipped from 4th best to a tie for 9th. Six hospitals in the state have caesarean rates greater than 40 percent for first time mothers, yet none of these hospitals is designated as a high-risk center. So much for the argument that high-risk pregnancies are the reason for these rates.
Now, I would like to have seen more from the authors addressing (and questioning) the issue of obesity "causing" high cesarean rates, but I love how succinctly they suggest commonsense options for improvements in the overall cesarean rate (emphasis mine).
What can we do to lower the caesarean rate? Considerable media attention has focused on how extreme obesity can raise the risk of having a caesarean, but more emphasis is needed on these system-based approaches:
  • More hospitals need to institute policies that restrict the induction of labor, unless there is a good medical reason...
  • Obstetricians and hospitals should follow the new National Institute of Health recommendations to offer the option of vaginal birth after a caesarean for those women who want to avoid repeat surgery...
  • Hospitals could expand access to nurse-midwifery care. In Boston, statistics for hospitals that care for women facing the same risk of complications show that hospitals with nurse-midwifery services tend to have lower caesarean rates than those without a significant midwifery presence.
These suggestions are so common-sense that they have a big "DUH" factor.....yet they are not routinely used in many hospitals. 

The induction rate today is completely out of control....and it's not all "inductions of convenience" just because the mother is tired of being pregnant, as some doctors claim.  For the most part, doctors are behind the epidemic of inductions these days, for reasons of fear, of convenience, and because they are in denial about the very real risks of induction.  WE MUST STOP INDUCING LABOR SO OFTEN.

Denying women the right to VBAC is a violation of human rights, pure and simple.  No one should be forced into surgery they don't want or need.  Everyone, including pregnant women, has the the right to bodily autonomy and the right to informed consent/refusal.  Even ACOG's own position paper says that women have the right to make their own decisions on their medical care.  This should include the right to choose a VBAC and/or refuse a planned repeat cesarean:
Once a patient has been informed of the material risks and benefits involved with a treatment, test or procedure, that patient has the right to exercise full autonomy in deciding whether to undergo the treatment, test or procedure or whether to make a choice among a variety of treatments, tests, or procedures.  In the exercise of that autonomy, the informed patient also has the right to refuse to undergo any of these treatments, tests, or procedures...Performing an operative procedure on a patient without the patient's permission can constitute "battery" under common law.  In most circumstances this is a criminal act...Such a refusal [of consent] may be based on religious beliefs, personal preference, or comfort.  --ACOG Committee Opinion #237, June 2000
Finally, access to midwifery care should be the right of every woman, but more and more hospitals, doctors, and insurance companies are closing down midwifery-friendly hospitals, phasing out nurse-midwifery practices, and trying to restrict/outlaw out-of-hospital midwifery.  Midwifery is a more economical choice and has equivalent or better outcomes for most women and babies....yet it is not available to many women, and some authorities are trying to actively cut off access for still more women.  This makes NO financial or ethical sense!

In particular, I would like to see the above systematic suggestions applied to women of size.  Women of size are routinely induced at extremely high rates, and are increasingly being denied access to VBACs and to midwifery care.  Let's see if restricting inductions, allowing (and encouraging!) VBACs, and expanding access to low-intervention midwifery care might lower the rate of cesareans in "obese" (and "extremely obese") women as well. 

If these suggestions work as systematic solutions for lowering the cesarean rate in all women, they should help lower the cesaran rate in women of size too.  Funny how folks have blinders on in applying these suggestions to "obese" women, though, eh?

1 comment:

Mary and Eden Z said...

So glad to be living in Canada where (although not perfect) midwifery is expanding and included in our healthcare coverage for most provinces.