Letter # 6
Consortium for the Evidence-based practice of
Obstetrics
American College for Evidence-based Obstetrics
3889 Middlefield Road
Palo Alto, CA
650 / 328-8491
California First
Lady Maria Shriver
Office of the
First Lady
State Capital Building
Sacramento, CA 95814
Mothers’ Day 2004 Letter
RE: (1) Bringing the
attention of the public and the legislature to the profoundly
dysfunctional and economically wasteful nature of the current obstetrical
system for healthy women
(2) Establishing a
forum for public dialogue with obstetricians on the potentially harmful &
unscientific practices of contemporary obstetrical care, especially as
applied to healthy women
To First Lady Maria Shriver:
We’d like to introduce you to the Consortium for
the Evidence-based practice of Obstetrics (CEO) and enlist your
support in achieving its mission as stated above. You have publicly
affirmed the important but difficult role of mothers and children in our
society and expressed interest in supporting this cause. We concur and
share your hopes and dreams on behalf of California families and the
mothers that are so central to the wellbeing of their families.
The
Consortium for the Evidence-based practice of Obstetrics is a new and
broadly based organization of consumers, taxpayers and childbirth and
public health professionals. Our membership is acutely aware of the many
serious problems that healthy women with normal pregnancies face finding
appropriate care in a dysfunctional maternity care system that fails to
meet the needs of healthy childbearing women, practitioners, taxpayers or
society.
In
response to these problems, CEO is committed to reforming our
maternity care policy and dedicated to bringing science-based maternity
care to all childbearing women. A_CEO is an affiliated group for
physicians who wish to re-establish the scientific foundation of their
profession and reclaim their expertise in the use of physiological
management for normal birth.
The
CEO web site is
www.SciencebasedBirth.com.
In addition to the scientific literature cited on the CEO web
site, additional scientific research confirming the assertions of CEO is
published by the Maternity Center Association of NYC and available @
www.maternityWise.org.
CEO’s
kick-off political activity began on Mothers’ Day 2004 and is a letter
writing campaign to you as California’s First Lady. We ask that you extend
your influence as First Lady to the following:
(1)
Bringing about public discourse thru legislative hearings that
address the ever-climbing induction, cesarean section and maternal
mortality rates, the off-label use of Cytotec for labor induction, the
danger of promoting the ‘maternal choice’ cesarean as the so-called
‘ideal’ form of childbirth, lack of access to VBAC services and the
physically damaging effects on the pelvic floor and pelvic organs
associated with the current, medically-interventive & anti-gravitational
management of vaginal birth
(2)
Facilitating passage of legislation mandating that
physicians obtain true informed consent before substituting medical and
surgical interventions in place of the safer, evidence-based principles of
physiological management and that full information be provided about the
risks of medical or surgical interventions and the mother’s consent
obtained before being used during labor
Current Political Realties
Healthy childbearing
families, post-cesarean mothers, hospital-based nurse-midwifery programs
and professional midwives of all backgrounds face extremely serious
problems under our highly politicalized and deeply dysfunctional
obstetrical system. Interventionist obstetrics as applied to virtually all
healthy women introduces artificial and unnecessary harm. At present, the
obstetrical profession systematically fails in its most important job --
to preserve and protect already healthy childbearing women, which is 70%
of the childbearing populations.
A healthcare system
that over treats three-quarters of its patients is both expensive and
dangerous. According to the scientific literature and vital statistics
records, conventional obstetrics exposes healthy mothers and babies to
unnecessary physical and mental suffering and increased rates of
preventable death and disability. The medicalization of vaginal birth
causes stress incontinence and other long-term problems. Another area of
extreme concern is the ever-increasing Cesarean and maternal mortality
rate and the issue of non-consensual obstetrical treatments and procedures
and mandatory cesareans for healthy women with unusual circumstances.
False & Outrageous claims by A_COG
Recently the
obstetrical
profession has veered even further from common sense and science-based
maternity care. The American College of Obstetricians and
Gynecologists’ (A_COG) is publicly claiming that Cesarean section is
safer and better for mothers and babies than normal spontaneous birth. An
October 31, 2003 a press release by A_COG announced a decision by
their Ethics Committee that it was now considered "ethical" for
obstetricians to perform purely elective – that is, medically
unnecessary or so-called “maternal choice” cesarean surgery.
Substituting a euphemistic term like “maternal choice” can’t negate the
danger and pain of major abdominal surgery. The obstetrical profession
fails to see the connection between the routine use of drastic
interventions in normal birth and damage to maternal tissue. Convinced as
they are that pelvic floor dysfunction is merely the unpreventable
“collateral damage” of vaginal birth, many obstetricians predict that
cesarean will completely replace normal birth within the next 10 or 15
years as the official standard of care.
Forty percent of all
childbirth services are paid for out of public funds. Interventionist
obstetrics misdirects approximately 14% of our total health care budget
(2.4% of GNP) to healthy women. It also systemically creates expensive,
often long-term iatrogenic complications. This is a fiscal disgrace that
reduces medical services to the ill, injured and elderly; the increased
tax burden and inflated cost of employee health insurance also reduces job
growth and the ability of California businesses to compete in the global
economy.
Most of all, this is
a crisis for our daughters, granddaughter and all young women who face the
very real possibility that they will never even have the chance to have a
normal vaginal birth or if they do, they will be permanently harmed as a
result of the faulty understanding of normal birth by the obstetrical
profession and the massive use of damaging medical and surgical
interventions, episiotomy and instruments such as forceps or vacuum
extraction.
Criticism of these
serious systemic problems is not meant as a criticism of individual
obstetricians, many of whom do a superhuman job under very trying
conditions. Physicians too have been victims of organized medicine’s
historical agenda to discredit physiologic principles. Since 1910, medical
students have been taught that normal birth was a “nine month disease”
that required a medical and surgical “cure”. As a result, medical
educators did not teach the principles of physiological management to
medical students and OB residents. As practicing physicians, obstetricians
are unable to use the strategies of physiological management due to lack
of training and experience and because our tort laws require physicians to
do only what other physicians of the same specialty are doing. Obstetrical
practice is defined by A_COG, which universally promotes a highly
medicalized and interventive style as the official “standard of care”.
Obstetricians who fail to intervene do so at their peril, as they are
vulnerable to lawsuits and loss of their medical license for providing
so-called negligent or “substandard” care.
Truth does not need to be defended, only revealed
Physiological management is the evidenced-based
model of maternity care. It is associated with the lowest rate
of maternal and perinatal mortality, is protective of the mother's pelvic
floor, has the best psychological outcomes and the highest rate of
breastfed babies. Use of physiological principles results in the fewest
number of medical interventions, lowest rates of anesthetic use,
obstetrical complications, episiotomy, instrumental deliveries, Cesarean
surgery, post-operative complications, delayed and downstream
complications in future pregnancies.
By comparison, conventional obstetrics as applied
to healthy women is the opposite of evidence-based, physiological
management. Its associated with high levels of medical intervention,
obstetrical complications, anesthetic use, instrumental deliveries,
Cesarean surgery and post-operative complications including emergency
hysterectomy, delayed complications such as stress incontinence and pelvic
organ prolapse, downstream complications in future pregnancies such as
placental abnormalities and stillbirths, long-term psychological problems
such as postpartum depression, lower rates of breastfeeding and increased
rates of asthma in babies born by cesarean section. Conventional
obstetrics for healthy women is neither safe nor cost-effective.
A
long over-due, and much needed reform of our national health care policy
would integrate physiological principles with the best advances in
obstetrical medicine to create a single, evidence-based standard for all
healthy women. Physiological management should be the foremost standard
for all healthy women with normal pregnancies, used by all practitioners
(physicians and midwives) and for all birth settings (home, hospital,
birth center). This “social model” of normal childbirth includes the
appropriate use of obstetrical intervention for complications or
at the mother’s request.
The
most efficient response to the dangerous disconnect between science and
the obstetrical arts would be recognition by A_COG that
physiological management is the evidence-based model of maternity care for
healthy women and therefore, the official A_COG standard for this
population. This would prompt medical schools to teach the philosophy,
principles and skills of physiological management to medical students,
practicing physicians to learn and use the strategies of physiological
management and insurance companies to reimburse obstetricians for this
safe and cost-effective care. For this to occur, we need a fundamental
change in the public discourse and political dynamics between citizens,
A_COG and other representatives of organized medicine.
On behalf of
mothers and babies and the membership of CEO, I ask for whatever
assistance you may be able to offer in this regard. I look forward to your
reply.
Faith Gibson, California
Coordinator, CEO / A_CEO
Letter # 7
Holly
Mathews
1556 Plateau Ave. Apt #1
Los Altos Hills, CA 94024
Maria
Shriver
Office of the First Lady
State Capital Building
Sacramento, CA 95814
RE: Reforming
Maternity Care,
Holding Public Hearings about Obstetrical Excesses
June 29, 2004
Dear Ms. Shriver,
I am a new member of the
Consortium for Evidence-based practice of Obstetrics and convinced
that the way obstetrical care is provided to healthy women is a bad
system. It needs to change as soon as possible. Let me tell you why.
I haven’t had children
myself yet but my mom had all three of us normally, without drama or
trauma. The same is true for other, older relatives. I’ve seen normal
births with midwives. Now my women friends are having babies. I am
appalled at the many interventions and problems that they all describe.
How can every one of my healthy friends, each with a perfectly normal
pregnancy, have so many problems? Out of ten new babies, not a one of them
had a simple “normal” birth. Although none of them or their babies
had any serious medical problems, all but one was induced. They were
usually told that being induced was easier or better than waiting for
labor to start naturally. Their OBs said a lot of things but a truthful
description of the facts didn’t seem to be one of them.
As a long-time friend, I
was with several of them in the hospital during labor and what I saw was
very upsetting. Being induced seems like a really hard way to have
a baby. It means having many different tubes and needles put in your body,
wires strapping you down to the bed, not being allowed to get out of bed
or eat or drink anything and lots of pain. For some of them, this
went on for more than 2 days. After days and nights of labor, no food and
no sleep, they were told to push their babies out uphill, while lying on
their back. Most of my friends weren’t strong enough to do that. It seems
that doctors don’t know much about the laws of gravity either.
Out of my ten friends, all
had epidurals, six of them had episiotomies and stitches, three had
unexpected C-sections, 2 had a vacuum or forceps used, and one of them got
an infection in her stitches. One of babies broke its collar bone during
the birth and was in the NICU for several days. Their hospital bills were
at least $20,000 dollars and that didn’t count the C-sections or the baby
with the broken bone. Maybe my friends were just unlucky but it seemed to
me that the care they received made things harder and actually caused many
of these problems.
I don’t know
exactly how to fix this but somebody needs to do something. Obstetricians
need to hear from women and explain why, after 14 years of medical school,
they can’t simply deliver a baby without doing major painful stuff to the
mother. I know many midwives and they do simple normal births all the
time, so a woman’s pelvis must still work OK. Why can’t doctors learn how
to deliver a baby normally? Let them explain that in a public hearing.
Thank you,
Holly Mathews
As a certified nurse midwife, I am committed to providing women safe
and healthy choices in regards to their maternity care.
I
beseech you to carefully read the research related to nurse midwives,
and I hope that you will support the autonomous role midwives deserve
when providing such excellent care to women and their families.
Sincerely,
Kathryn Newburn, RNP, CNM, PHN
Burlingame, CA
Journal of Epidemiology and Community Health, Vol 52, 310-317
Midwifery care, social and medical risk factors, and birth outcomes in
the USA
MF MacDorman and GK Singh
Centers for Disease Control and Prevention, National
Center for Health Statistics, Hyattsville, MD 20782, USA.
STUDY OBJECTIVE: To determine if there are significant differences in
birth outcomes and survival for infants delivered by certified
nurse midwives compared with those delivered by physicians, and
whether these differences, if they exist, remain after
controlling for sociodemographic and medical risk factors.
DESIGN: Logistic regression models were used to examine
differences between certified nurse midwife and physician delivered births
in infant, neonatal, and postneonatal mortality, and risk of low
birthweight after controlling for a variety of social and medical
risk factors. Ordinary least squares regression models were
used to examine differences in mean birthweight after
controlling for the same risk factors. STUDY SETTING: United
States. PATIENTS: The study included all singleton, vaginal
births at 35-43 weeks gestation delivered either by physicians
or certified nurse midwives in the United States in 1991. MAIN
RESULTS: After controlling for social and medical risk factors, the risk
of experiencing an infant death was 19% lower for certified
nurse midwife attended than for physician attended births, the
risk of neonatal mortality was 33% lower, and the risk of
delivering a low birthweight infant 31% lower. Mean birthweight
was 37 grams heavier for the certified nurse midwife attended
than for physician attended births.
CONCLUSIONS: National data
support the findings of previous local studies that certified nurse
midwives have excellent birth outcomes. These findings are discussed
in light of differences between certified nurse midwives and
physicians in prenatal care and labour and delivery care
practices. Certified nurse midwives provide a safe and viable
alternative to maternity care in the United States,
particularly for low to moderate risk women.
Letter #9
Santa Clara, California 95050
June 25, 2004
Maria Shriver
Office of the First Lady
State Capital Building
Sacramento, California 95814
Dear Ms. Shriver,
I am writing on
behalf of myself and all other women of childbearing age, both present and
future, and on behalf of the Consortium for the Evidence-Based practice of
Obstetrics to encourage you to use your considerable influence as First
Lady of California to improve our current maternity care system.
Physiological management of pregnancy, labor, and birth is the safest,
most cost-effective, and most ethical model for our maternity care system,
and I urge you to act to bring public awareness of the great need
to reform our current expensive and obsolete system of
maternity care to bring it in line with the science-based physiological
model.
Having experienced
both medicalized delivery in a hospital setting and natural
(physiological) birth at home, I can attest to the many benefits of the
physiological management of pregnancy, labor, and childbirth. I would
like to share with you some of my experiences to help you understand the
advantages of the physiological model of maternity care over the medical
model.
My first birth went
exactly by the book; each stage of my labor progressed just as the many
books I read had described the typical labor. I was confident in my
body’s ability to give birth and I was eager to experience it. I had
often expressed to my obstetricians my desire to have a natural birth
without any unnecessary interventions, but the medical idea of “natural”
and “necessary” are unfortunately not the same as mine. It was quite
upsetting to me to submit to the various “routine procedures” of the
hospital - having an IV, having to lie in bed with the belt of the
electronic fetal monitor strapped around my abdomen, not being allowed to
eat or drink, having my water broken, giving birth flat on my back with my
legs held up at a ninety-degree angle (which reduced my pelvic opening and
forced me to push my baby out against the force of gravity), being
directed to hold my breath and push while the doctor slowly counted to
ten, being given an episiotomy and the subsequent stitches to repair it,
having my baby whisked away to be cleaned and examined before getting even
one touch, having my placenta tugged from my uterus instead of allowing it
to be expelled naturally. The event as a whole was very traumatic.
My dissatisfaction
with that experience led me to seek midwifery care for my subsequent
pregnancies. I have received care from three midwives in three states
with three legal situations regarding midwifery – first in an alegal state
which had no laws governing midwifery care; second in an illegal state
where the practice of non-nurse midwifery is a misdemeanor crime; and
finally here in California where midwifery is licensed but the laws are
written in such a way that they are impossible to abide. Each of the
three midwives was certified by the North American Registry of Midwives
and was imminently qualified to provide care to a healthy woman with a
normal, low-risk pregnancy.
The care I received
from each of these midwives, in my opinion, far surpasses the care I
received from an obstetrician. Each prenatal appointment with a midwife
lasted an hour or more, while I was lucky to get five minutes of a busy
obstetrician’s time. The midwives treated me as a whole person,
inquiring about my emotional, financial, and marital well-being as well as
my physical health. The physical assessment of my and my baby’s health
was much more comprehensive than that I received during appointments with
an obstetrician. I had the same access to prenatal testing and was
encouraged to make my own informed opinion about which tests and
procedures I would like to have performed. I appreciated being an active
participant in my own prenatal care and I especially appreciated the fact
that my pregnancy was considered a normal part of my lifecycle rather than
a pathological condition fraught with danger which my lack of medical
training left me unable to comprehend.
With each of my
midwife-attended home births, I labored comfortably in my home, caring for
my family and going about the normal business of the day. I ate and drank
as necessary, allowing my body to be nourished and hydrated for the
strenuous work of giving birth. I checked in periodically by phone with
my midwife and decided when I was ready for her to come. Once she
arrived, she set up her equipment and performed an assessment and I
continued to labor in whatever place and position I felt most
comfortable. Her periodic assessments were not intrusive and were
performed in a manner that respected my needs and desires.
I chose to labor on
my feet, allowing the force of gravity to assist my labor, until my water
spontaneously broke. I gave birth upright or semi-upright supported by my
husband, positions which allow much easier descent of the baby through the
birth canal than a back-lying position. I pushed with the force of each
contraction – a very natural and irresistible impulse – instead of being
directed to push according to someone else’s arbitrary count. I didn’t
need an episiotomy, in spite of the scar tissue left from my first birth,
and I didn’t tear.
My newborn baby was
handed to me immediately, allowing my baby skin-to-skin contact with me
and the comforting, familiar sound of my heartbeat. The umbilical cord
was not cut until it had stopped pulsating, allowing my baby the full
benefits of the rich cord blood. My husband and I were able to examine and
enjoy our baby at leisure, even before the placenta was expelled, which
happened naturally with the help of a few mild contractions. My midwife
performed a thorough neonatal assessment with my baby always within reach
of my touch. She made sure everything was cleaned up and we were all
settled in comfortably before she made her departure, and she returned for
two home visits in the next few days to check on us and ensure our
continued well-being.
I recognize that
technological interventions have their place in compromised pregnancies
and am grateful that doctors have mastered techniques which allow them to
save lives of mothers and babies when complications arise. Too often,
though, medical interventions are performed when there is no real need and
they produce complications rather than prevent them. Labor is called
labor for a reason; it’s hard work. The healthy female body, however, is
wonderfully designed to withstand the rigors of labor and birth when
events are allowed to unfold naturally, and this fact seems to be ignored
or downplayed.
True necessity for
intervention in labor and birth is uncommon, yet it is even more uncommon
today to experience intervention-free birth in a hospital setting.
“Normal” has become something unnatural. The system that has allowed this
situation to develop is flawed and needs to be reformed.
In conclusion
I am asking you, as
First Lady of the State of California, to make the rehabilitation of our
maternity care system a priority. The standard of care for normal,
healthy mothers and babies must be made to conform to proven scientific
principles that recognize the superiority of the physiological model over
the medical model of maternity care.
Thank you for your
consideration of this matter.
Respectfully,
Lilah Monger
cc:
California Citizens for Health Freedom
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