Sierra Vista Regional Medical Center in Southeastern Arizona has recently partnered with Carondelet Health Network, a Catholic not-for-profit health care system that follows the doctrine of the Roman Catholic Church. Therefore, as a condition of the partnership, the hospital will stop performing sterilization procedures. The CEO of Sierra Vista insists that ‘we are not taking away anyone’s rights,” and states that these procedures can be done in a doctor’s office.

The obstetricians that perform tubal ligations at Sierra Vista (200 were performed in 2009) are up in arms and at least one is considering moving her practice out of Sierra Vista, and several are contemplating seeking privileges in other facilities because of this decision. Some OB doctors said that they would not perform a tubal in their offices and prefer a hospital setting. It is an invasive procedure and has its risks.

For me, this is yet another assault on a woman’s right to choose her preferred method of birth control. Sure, women can still choose sterilization, but must now recover from childbirth and then have yet another event to recover from thereafter. For those women who have c-sections, this is especially terrible as it’s relatively simple to quickly perform a tubal immediately after the baby is born as to avoid a second invasive surgery. It makes the most sense and is safer for the mother. Denying a woman this choice is indeed taking away her rights. It’s not even as if the women of Cochise County can even go anywhere else in their county to birth because according to the article, the other hospitals in the county don’t deliver babies.

The other problems here are these. There are other reproductive issues that the Catholic church takes a strong stand on. Birth control and abortion being two hot-button issues. Where will Carondelet draw the line? Will doctors be permitted to save a pregnant woman’s life at the expense of her unborn child if such a medical emergency arises? Will a woman be permitted to have an abortion if a medical condition related to pregnancy is threatening her life? Will doctors who offer women other methods of birth control be barred from providing that service to women and still be able to retain privileges at Sierra Vista? These are all rights and circumstances that women and their doctors have been accustomed to receiving-and rightfully deserve under the law, and in my opinion, under moral law. Denying women medical procedures because of religious beliefs of the entity running the hospital sets a dangerous precedent and who knows what other lines will be crossed.

Cochise County has 19 people per square mile and a total population of 129,000 people. This is a rural place. These women would have to go to Tucson to deliver and also receive a tubal. Tucson is 70 miles away.

I will pull some interesting figures:

-In 2007, there were more than 4.3 million births — the largest number ever registered — in the United States.
-Cesarean section was the most common operating room procedure in the country in 2007, with a cumulative increase from 1997-2007 of 85%.
-The rate of vaginal birth after cesarean (VBAC) within childbirth-related hospitalizations was 9.7% in 2006, a decline of 73% from 1997, when the VBAC rate was 35.3%
-In 2006, combined facility charges billed for “mother’s pregnancy and delivery” and “newborn infants” ($86 billion) far exceeded charges for any other hospital condition in the United States.

Childbirth is is most cases a natural event (not a sickness) which requires a pregnant mother, a bed, a knowledgeable birth attendee, and a couple of blankets. It should not be the single most expensive medical event in the US. Something is very wrong with this picture…..

Childbirth Connection used these stats and others to compile a report entitled Evidence-based Maternity Care: What It Is and What It Can Achieve.

The report states that “practices that are disproved or appropriate for mothers and babies in limited circumstances are in wide use, and beneficial practices are underused. Rates of use of specific practices vary broadly across facilities, providers, and geographic areas, in large part because of differences in practice style and other extrinsic factors rather than differences in needs of women and newborns”.

It is a nearly 70 page report and I hope to bring you the highlights here. Stay tuned!

On December 5, their son Marcus Anthony was born in Phoenix via an uncomplicated vaginal delivery, weighing seven pounds and 13 ounces.  YAY!

The story goes on to explain the reasons why c-sections are usually performed and that often the decision to have a c-section is made in the delivery room , by the doctor, for reasons that are not always emergent.

They go on to list all the typical scenarios that result in c-section and what you should ask your doctor in each of these cases.  Now, you can either print this out and bring it with you just in case……OR you can hire a practitioner that tries very hard to avoid interventions and c-sections.  This way you know that if you end up with a section, there was nothing else that could have been done.

And how do you decide what type of practitioner you might need?  Well, it seems that today the stars have aligned because the American College of Nurse Midwives just came out with a nifty little tool that I blogged about earlier today.  The “Who Should Deliver My Baby?” Quiz….

This relates to my older post about Preterm babies and my inquiry as to why they weren’t talking about sections.  ”There are increases across the board,” she (CDC epidemiologist Joyce A. Martin) said — in all age groups, for most race and ethnic groups and in all states. Overall, the rate of preterm births increased from 6.8 to 8.1 percent, according to the report. The percentage of induced late preterm births more than doubled between 1990 and 2006, from 7.5 to 17.3 percent, according to the report. The percentage of late preterm births delivered by cesarean rose by 46 percent, from 23.5 to 34.3 percent.

The report goes on to highlight the problems with preterm births, including the higher instance of respiratory problems and long-term neurological problems.  They mention how advances in monitoring and subsequent identification of ‘problems’ with babies (distress) are leading to these higher rates, but also the fact that technological advances have made health care providers more ‘comfortable’ with delivering preterm babies.

I guess doctors feel it’s better to avoid the lawsuit involved with knowingly letting a premature ‘distressed’ baby keep going through labor than to potentially deal with the consequences of the long term effects of premature birth. (Most likely they won’t be held accountable there, after all, they can prove that they did everything to get that baby out.) No studies that I know of are addressing the issue of premature induction-which is causing most of these c-sections.

If a baby is not full term, and the mother is induced, could it be possible that the baby will experienced undo stress simply because they are not ready to come out?  Even if a mother is supposedly full term, and an induction of labor results in fetal stress, should we not attempt to stop the labor and wait another week or so (providing that the baby is not showing signs of distress in absence of contractions).  Could it be possible that the dates are wrong?  In other words, could babies experience stress during labor simply because they are not full term?

In many other aspects of our lives, we all know that ‘staying the course’ is not the best practice when evidence shows that there is a better way to achieve the goal.  Why is it that doctors feel the need to keep going-seeing their only option as c-section?  Why not stop the induction and wait?  We have the technology to do that.

Dr. James is aiming to take a bit of the ‘intuition’ out of medicine and replace it with evidence-based practice and his successes have been impressive. However, with evidenced-based practice comes protocols- and many doctors enjoy the autonomy of acting without specific rules which is why many people think that his approach will never catch on. Too bad, because he really is on to something.

One part of the article talks about how Intermountain Hospital (where his projects are taking place) has reduced the number of perterm deliveries and the number of babies who spend time in their neonatal-intensive-care unit. They did this by creating a committee back in 1998 whose prime success has been to reduce the number of elective inductions (births that are induced without medical reason). They felt that the risks to neonates outweighed the convenience that elective induction afforded doctors and patients, plus induced labors were generally longer and resulted in more C-sections. Since 1999 ACOG has recommended that no elective inductions be performed before 39 weeks, yet around the country roughly 30% of inductions are done before 39 weeks. Back in 1998, Intermountain shared that figure of around 30% early inductions. When the committee adopted the protocol, the rate began to fall and now hovers around less than 2%. YAY! The number of newborns with respiratory problems has also dropped as did the C-section rate of those doctors that complied to the protocol.

This was my favorite part: “One hospital in southwest Utah has gone so far as to allow nurses to refuse a doctor’s early induction orders unless the medical director gives permission” (!)

As I was reading this article, it really made me pause and think about autonomy and protocols. I basically quit nursing because I felt I didn’t have any autonomy. Nursing school teaches you to think critically and independently, yet on the job we are expected to follow a doctor’s order with no questions asked. We are expected to adhere to a very clear set of standards and protocols for each duty we perform. The doctor on the other hand is trained to ‘follow intuition’ and is given license to treat in any way he or she sees fit, almost balking at rules or protocol irregardless of the evidence. It makes me think that if we could move to a model of evidence-based practice, doctors and nurses would be able to work more as a team, nurses would be able to hold doctors accountable for crappy practices and it might result in happier nurses. I would even argue that a move to evidence-based medicine could even help solve the nursing shortage. Most smart women these days don’t want to be nurses- mainly because it’s hard work in a thankless environment. But if a nurse could be an important part of a medical TEAM whose goal was to provide good outcomes for patients, then maybe more people would be attracted to the profession.

Joy and Jeff Szabo will need to be separated by 300 miles, and most likely he won’t be at the birth of their child. Neither Jeff or Joy is in the military.  The Szabo’s live in a town whose hospital has decided to ban VBAC. (Vaginal Delivery after C-Section)  This town is PAGE, ARIZONA.  (sorry, had to put it in caps as a warning) but it could also be basically the entire southern half of New Mexico, and half the other places around the country.  Joy has had a successful VBAC already at this same hospital.  Joy was threatened with a court order, by the hospital’s CEO if she attempted to enter that hospital and refuse a c-section.  Although grateful for the c-section that saved her son Michael’s life, she refused to be forced to have a c-section and has instead elected to deliver vaginally at a hospital 300 miles away.

VBAC has a risk of uterine rupture (at the site of the old incision) in less than 1% of cases.  Joy is aware of these risks and views them as less risky than complications from a c-section.  ACOG has not stated that they don’t recommend VBAC’s, just that they should be performed with 24/7 coverage of both physician and anesthesiologist-just in case.  That seems reasonable to me.

Yet since the ACOG guidelines came out in 2004, more and more hospitals have refused to do VBACs. Today, nearly half of hospitals won’t do VBACs, either because the hospital has banned them or because doctors won’t do them.  WHY?? All this for a less than 1% chance that something could go wrong. And what does a less than 1% chance mean exactly?

I believe this is a travesty and a public health concern.  Women are unnecessarily, and dangerously being subjected to surgery because they may not have access to a hospital that believes in VBAC. VBAC is a legal procedure which is being denied to women on the basis of…..um, what was the basis again?  Oh yeah, their ‘safety’.  Right. The risk of maternal mortality with repeat cesarean and VBAC is very low, but the risk is higher with a repeat cesarean: 0.04% vs. 0.02% per a 2004 National Institute of Health Study of 18,000 women. (thanks again vbacfacts.com)

Last I checked, abortion was still legal as well, and a different, but equally powerful group of people have been systematically denying women abortions by taking out doctors(physically, socially and financially) and limiting access.

Why is access being denied for VBAC?  The reason most often cited is the ‘malpractice environment’ but in essence women are lied to, misinformed, and made to feel bad for putting ‘their desires’ ahead of the safety of the baby.  They are rarely informed enough to fight.  C-section is more convenient for a doctor than VBAC because it is generally predictable and in their control from beginning to end.

Preterm birth is defined as a baby born before 37 weeks gestation.  In the United States alone, the cost of caring for preterm babies and their associated health problems tops $26 billion annually.  Second only to Africa, North America (US and Canada) has the highest instance of preterm births in the world!

What I found interesting about this white paper is that the key contributing factors were the rise in the number of pregnancies in women over age 35, and the increase in multiple births due to ‘assisted reproduction techniques’.   Not one mention of the increase in C-sections.  NOT ONE!

Now, I don’t even need statistics to know that C-sections were the single largest cause of pre-term birth at my little hospital here in Santa Fe.    If I had a dollar for each c-section baby whose gestational assessment came under 37 weeks, and who was sectioned for post-dates…..it makes me want to scream.  Oh, and for those of you who are statistics-minded, the c-section rate in the US hovers around 30%.  Another older study from the CDC and March of Dimes cited that most of those single premature deliveries — a staggering 92% — were by C-section, with the majority being born late preterm (between 34 and 36 weeks).

In my observations, the most frequent reason for c-section was induction for post-dates that lead to a ‘failure to progress’ (that cervix just wasn’t moving fast enough for said dinner date).  I would say maybe 5% of those babies were over-cooked.  Seriously.  There’s a reason why the cervix wasn’t opening.  The baby simply wasn’t ready to come out yet.

There are of course instances where c-section is a life saver, for either mom, baby or both.  Public health issues do need to be addressed.  The fact that american women are the heaviest they’ve ever been leads to heavy babies that can’t be delivered vaginally.  Maternal smoking leads to premature labor and birth.  Twins, triplets and octuplets (!) are more frequent with the advent of ‘assisted reproduction’ techniques.  Advanced maternal age certainly contributes to more difficult labor and delivery.

But someone needs to be looking long and hard at our astronomical c-section rate, and the real reasons why that rate is so high.  Moms and practitioners need to make a more concerted effort to pay attention to dates of conception… and like the article points out there needs to be an internationally accepted classification of preterm birth and better reporting and birth surveillance across the board.

Then there is the whole malpractice issue forcing practitioners to make the ‘safe’ decision to section. But that’s a whole can of worms for another day….

Preterm birth is not good for babies, and c-sections are definitely a contributing factor that needs to be looked at more closely.

If your a mom-to-be who wants to avoid going down the wicked road of possible c-section, consider a midwife. If you really need a c-section, you’ll still get one, but you won’t get one if you don’t need it!