Industry vs. Craft

Thanks, once again, to the wonderful husband, I've been handed an essay that gives some great insight into the world of obstetrics. You'll find the entire piece here, and it's a great one. It is by Atul Gawande, a physician who wrote the book "Complications." The book is another great find, giving amazing insight into the world of becoming a doctor.

The article from the 10/9/06 issue of The New Yorker, is entitled "The Score: How childbirth went industrial." The article summary says, "A piece examines the history of obstetrics and its progression from craft to industry. Weaving in and out of one mother's narrative about resorting to a C-section, the author details the numerous methods that have reduced the chances of death among full-term babies. The discovery in 1933 that two-thirds of maternal deaths were preventable led doctors to standardize childbirth. Anesthesia and labor-inducing drugs became common. Fetal heart-rate monitors gained currency. But it was the Apgar score—a simple measurement of a child's responsiveness immediately after birth—that pushed obstetrics into the realm of "evidence-based medicine."

I want to highlight three areas of the article in this post.

1)I was gratified, though saddened to find that my post on evidence-based medicine, in which I stated my belief that obstetrics didn't follow that path--was accurate.

" Ask most research physicians how a profession can advance, and they will talk about the model of “evidence-based medicine”—the idea that nothing ought to be introduced into practice unless it has been properly tested and proved effective by research centers, preferably through a double-blind randomized controlled trial. But, in a 1978 ranking of medical specialties according to their use of hard evidence from randomized clinical trials, obstetrics came in last. Obstetricians did few randomized trials, and when they did they ignored the results. Careful studies have found that fetal heart monitors provide no added benefit over having nurses simply listen to the baby’s heart rate hourly. In fact, their use seems to increase unnecessary Cesarean sections because slight abnormalities in the tracings make everyone nervous about waiting for vaginal delivery. Nonetheless, they are used in nearly all hospital deliveries. Forceps have virtually disappeared from the delivery wards even though several studies have compared forceps delivery to Cesarean section and found no advantage for Cesarean section. (A few found that mothers actually did better with forceps.)"

Though the study was in 1978, for many reasons, things have not changed in the area of evidence-based practice.

2) Gawande is able to find a positive to this approach to medicine. He likens OB's to car makers:

"In obstetrics, meanwhile, if a strategy seemed worth trying doctors did not wait for research trials to tell them if it was all right. They just went ahead and tried it, then looked to see if results improved. Obstetrics went about improving the same way Toyota and General Electric did: on the fly, but always paying attention to the results and trying to better them. And it worked. Whether all the adjustments and innovations of the obstetrics package are necessary and beneficial may remain unclear—routine fetal heart monitoring is still controversial, for example. But the package as a whole has made child delivery demonstrably safer and safer, and it has done so despite the increasing age, obesity, and consequent health problems of pregnant mothers."

God love him for giving them the benefit of the doubt, but I have to disagree that this "on the fly" approach has not been detrimental. When you choose to give birth in a hospital with an obstetrician, the general modus operandi is going to be that doing something is the benign approach, while wait and see is dangerous. The research does not support this, but it is what is taught, what is observed, and what is accepted. Just google "misoprostol ina mae gaskin" to read about the issues behind a drug OB's say is safe to use off-label, but the research points in the opposite direction.

3) This article cleared up a big issue for me. When it comes down to it, what is the main difference between choosing an MD or a Midwife? Gawande sums up the medical decision:

"The question facing obstetrics was this: Is medicine a craft or an industry? If medicine is a craft, then you focus on teaching obstetricians to acquire a set of artisanal skills—the Woods corkscrew maneuver for the baby with a shoulder stuck, the Lovset maneuver for the breech baby, the feel of a forceps for a baby whose head is too big. You do research to find new techniques. You accept that things will not always work out in everyone’s hands.

But if medicine is an industry, responsible for the safest possible delivery of millions of babies each year, then the focus shifts. You seek reliability. You begin to wonder whether forty-two thousand obstetricians in the U.S. could really master all these techniques. You notice the steady reports of terrible forceps injuries to babies and mothers, despite the training that clinicians have received. After Apgar, obstetricians decided that they needed a simpler, more predictable way to intervene when a laboring mother ran into trouble. They found it in the Cesarean section."

There it is, my friends, in black and white. And I say this with no sarcasm at all: OB's are factory workers. Things must be standardized so that anyone who wants to be an OB can do them. As a retired doc explained, “Forceps deliveries are very difficult to teach—much more difficult than a C-section,” Bowes said. “With a C-section, you stand across from the learner. You can see exactly what the person is doing. You can say, ‘Not there. There.’"

It reminds me of the old joke, "What do you call a medical student who is at the bottom of his class?"

"Doctor."



I'll be discussing more aspects of this New Yorker article in other posts, because it has so much fascinating information in it. But the key point is this: If you are afraid of worst-case scenarios, no matter what the small likelihood of them occurring, and, you believe you can live with the mindset of "at least you have a healthy baby" no matter how your labor and delivery are handled, then just pick a doc and head for the hospital. (Now obviously I'm being slightly flip here, realizing some medical issues limit women's choices.)

If you want to be treated as an individual, spending time with an artisan who will get to know you, your situation, your body, and your plans, as well as getting outstanding care, then choose a midwife.

Because the main difference between a midwife and an obstetrician is: an OB figures she can fix any problem that comes up, a midwife keeps the problem from coming up in the first place.

Evidence-based medical practice

I listened to a fascinating podcast from ABC Radio National "The Health Report." If you listen to podcasts at all, "The Health Report" needs to be on your list of ones to listen to.

This podcast was a two-parter focused on Evidence-Based Medicine. Here's the transcript for part one of the two-part series. It was a fascinating view into what Australia is attempting to do to get health practitioners of all varieties; physicians, nurses, naturopaths, etc., to use evidence-based medicine rather than just personal experience, or, my favorite, "It's what my colleagues are doing." Interestingly, the report used stats on the United States to show how many people are harmed or not helped by the way medical decisions are made in the U.S. In other words, we are keeping track of people being harmed, but what about the flip side of the coin?

Making time to read the transcript or listen to the podcast would be beneficial, but until you have the opportunity, here are the three questions suggested by Karen Carey Hazell, who is the Former Chair Health Consumers Council of Western Australia and Member Consumer Health Forum Canberra Perth, WA.


"What are my options?

What are the expected outcomes? And

What's the likelihood of each of those outcomes?

We know from decision making models across a lot of different industries that where probability is involved the minimum amount of data that you need to have is really the answers to those three questions. What are my options? What are the outcomes and what's the likelihood each outcome will occur? And that goes for you know if you're playing roulette at the casino, or you're buying a house, or wherever there's probability, so a lack of certainty, that's the minimum amount of data that you need to know."

The good thing this podcast reminds us is that we are the consumer. It is our responsibility to assure ourselves that our medical partners are giving us evidence-based information. If they are not, then we must do the research ourselves. Actually, even if they are giving us evidence-based information, we still need to be doing the research ourselves.

One final caveat, if you run into a health care partner who does not welcome your questions, encourage your research, and listen when you ask for this information, look elsewhere for a partner, and tell them why you are going to join with someone else. The system will not change until we make it change.

AAFP's stance on VBACs

Thanks to VBAC.com, I just discovered that the American Association of Family has revisited their stance on VBACs. You can read the whole study here, but I am highlighting the part where they diverge from the American College of Obstetricians and Gynecologists on Trial of Labor after C-section (TOLAC.)



What management strategies influence outcomes? (Any emphasis added is mine.)

Recommendation 4: TOLAC should not be restricted only to facilities with available surgical teams present throughout labor since there is no evidence that these additional resources result in improved outcomes. (Level C)

At the same time, it is clinically appropriate that a management plan for uterine rupture and other potential emergencies requiring rapid cesarean section should be documented for each woman undergoing TOLAC. (Level C)

Much of the controversy on VBAC has centered on the management of labor, the timeliness of operative delivery, the risk of uterine rupture and its attendant consequences, and the potential for infant morbidity and mortality. Concerns have been raised about the impact of the immediately available policy on access to VBAC services. One consequence of the immediately available policy appears to be that some hospitals have discontinued VBAC services entirely, forcing women to present late in labor, to travel to another facility that allows VBAC, or to submit to a scheduled repeat cesarean delivery that they may not have wanted. This could result in adverse outcomes for women and babies beyond inconvenience. Some have questioned the assumptions that seem to underpin the immediately available policy. For example, the policy assumes that having a surgical team immediately available will reduce morbidity or mortality from uterine rupture. The AAFP TOLAC Panel felt this was a debatable assumption. Similarly, the ACOG policy suggests that one rare obstetrical catastrophe (e.g., uterine rupture) merits a level of resource that has not been recommended for other rare obstetrical catastrophes (e.g., shoulder dystocia, abruptio placenta, cord prolapse) that may actually be more common.

However, it may be argued that, while these other catastrophes are largely not predictable, permitting a TOL in a mother with a previous cesarean is a planned event that may demand a different degree of preparedness.

While adverse consequences of a TOLAC are distinctly uncommon and must be balanced against attendant risks associated with ERCD, current risk management policies across the United States restricting a TOL after previous cesarean section appear to be based on malpractice concerns rather than on available statistical and scientific evidence. The TOLAC Panel found no systematic evidence suggesting that improved outcomes for TOLAC patients resulted from restricting a woman’s ability to undergo a TOLAC based on the availability of resources not usually present for other women in labor, the institutional setting, or the timeliness of operative delivery.

Any effort to limit the accessibility of TOLAC by requiring restrictive conditions during labor is likely to limit access to vaginal delivery for many women. Given the potential negative impact on access to care and the absence of evidence, no recommendations can be made as to whether a difference in intensity of care should be required for patients attempting a VBAC until more definitive evidence is provided demonstrating the benefits of more restrictive services for women undergoing a TOLAC.

Our recommendation significantly differs from current ACOG policy 14 because we could find no evidence to support a different level of care for TOLAC patients. Without good-quality evidence, we believe that different levels of resources cannot be advocated because their potential for unintended harms cannot be evaluated against their purported benefits.



The pdf of this review that I read was published in July, 2005. I just stumbled across it, I certainly did not see it covered in any major news source, as ACOG policy frequently is.

I am not a physician, but if medicine is akin to other professional fields, it is a big deal when one group strikes a stake so significantly different from a peer group. This would be like a group of physics teachers indicating that their peers in the Mathematics department weren't teaching what they should be nor using the methods they should be.

I attempted to search the ACOG website to find reference to this AAFP statement, but was unsuccessful.

One other issue struck me in reading the AAFP paper. Much of the research they found to use was considered only fair-poor based on the criteria they set up to judge a study's value. Much of what I have read and heard has given me the belief that obstetrics is the least well reasearched/evaluated, most based on common practice rather than evidence, area of medicine. This review by ACOG's peers certainly did not alter that belief.

VBAC.com

Thanks to Louisa, the administrator for our local Iowa Chapter of the International Cesarean Awareness Network, I just discovered the website, www.VBAC.com. In perusing that website, I came across at least two important discoveries:

1) The American Association of Family Physicians (AAFP) stance on Elective Repeat C-Section, or most importantly, their stance on whether a surgical team must be “immediately available” as the American Association of Obstetricians and Gynecologists guidelines for VBAC call for. (This important difference will be discussed in another post, along with a link to the AAFP study.)

2) The VBAC.com website is evidence-based, which is a critical factor. I am striving for an evidence-based blog, although I get so intrigued by the human factor side of things I stray down the subjective path. Evidence-based is explained clearly at the VBAC.com website here.

Evidence-based practice is what every woman should be requiring from her health care partner. It means that personal experience and expertise come into play, because we want a health care partner who can generalize experiences, but, and this is a big but, we, as health care consumers have the right to complete information, not just the opinion of the health care partner. There will be more on evidence-based practice in another post.

Can You Just Use the Abstract?

As I have struggled to get back to posting, despite my complete commitment and enthusiasm about this project, I have been plagued by thoughts about an editorial by Henci Goer. The editorial at: www.midwiferytoday.com/articles/disinformation.asp talks about the "conspiracy" behind obstetricians trying to control women and their births. Please read the complete article for all the insights Henci Goer offers. My point in mentioning it is that I have been troubled by it ever since.

I will tell you up front that my sympathies lie with Henci. Though I know of several outstanding, compassionate, intelligent OB's in my community, I have heard too many stories of lies, horror, bullying, and sheer stupidity on the part of docs to not realize something is amiss in the world of OB's. As I have said before, birth is being taken from women, and unless we stop it, nothing will.

Having said that, my question for myself has been: How the heck do I find the time to read, analyze, digest, and regurgitate the full study on all the issues I wish to research? I've been relying on the abstracts of studies for several reasons, not the least of which is that it saves my time so I can accomplish more, but also I have been trusting, since I'm using studies publishes in major, reputable journals, that the information is valid.

Now Henci mainly highlights where she thinks information has been pulled from studies and misrepresented. She points out several occassions where the study's authors find a different conclusion than what the main stream media represents. That gives me some solace.

After struggling with this for weeks, here's what I've come to as my personal choice. For issues that are most controversial, like elective c-section, home birth, midwifery model of care versus medical model of care, I will attempt to find the best, complete studies I can. For issues I don't perceive as controversial: eating during labor, episiotomy, laboring in water, I will use the abstracts. As with everything, not perfect, but the best compromise I can see.

What is Informed Consent?

Every woman who gives birth comes to a point of having to make decisions about that birth. It might be a seemingly simple decision: is it time to call the midwife, is it time to go to the hospital; or a very complex, difficult decisions: should we agree to an episiotomy, should we agree to a c-section. All of these decisions require information, and one of the ways patients in a hospital receive information is through informed consent.

The definition of informed consent is pretty straightforward. It has three main parts:

1) The patient must have the ability to give consent. Meaning, is she old enough, is she lucid enough, and does she understand.
2) Patients must be able to consent voluntarily. (They can’t be under duress.)
3) The patient must receive information. This means, according to the law, accurate information and full disclosure about their medical diagnosis and prognosis; the potential risks, benefits, and alternatives to the proposed treatment; and the risks and benefits of refusing treatment.
(The source of this list was Nursing2005, Volume 35, Number 3, pg. 24)

These seem straightforward, but as with anything connected with pregnancy, labor, and delivery, they are not. I came across this fascinating study in the British Medical Journal that talks about what happened in two hospitals when women were given an information pamphlet on ultrasounds. The study used “informed choice” as its definition, but informed choice and informed consent are synonymous. You can read the study at: http://bmj.bmjjournals.com/cgi/content/full/313/7067/1251/
a?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=informed+consent+in+
pregnancy&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&
resourcetype=HWCIT

The gist of it is, the ultrasonographers thought the information pamphlets were biased and would cause too much anxiety in women. This is despite the data being based on findings of randomized controlled studies. There were to have been three hospitals in the study, but the ultrasonographers in the third hospital withdrew their support and refused to take part because: “Their objections focused on the credibility of the evidence reported in the leaflet (box 1); the likely effects on women's anxiety; reduced uptake of scans and disruption to the hospital's organisation; and reinforcement of ultrasonography's poor safety record as reported by some media (box 2).”

This study sums up many of the concerns about informed consent. Are women truly receiving “accurate information and full disclosure about their medical diagnosis and prognosis; the potential risks, benefits, and alternatives to the proposed treatment; and the risks and benefits of refusing treatment”? If you’ve ever had an epidural, were you told it could increase your chances of running a fever, which could lead to you and your newborn being treated like you have an infection, including a full sepsis work-up for the baby, including a spinal tap? Were you told that it would increase your odds of having a c-section? If you weren’t, than your rights of informed consent were not met.

In thinking specifically about VBAC (Vaginal Birth After Cesearean), when a hospital tells women they cannot even attempt a VBAC there, that is in direct violation of the second and third tenants of informed consent. There is no voluntary consent involved, and women who were given truly accurate information would know that VBAC is at least as safe as having a scheduled c-section.

Maybe you don’t care. Maybe you are okay with the doctor giving you just enough information to get you to agree to the procedure that your doctor truly feels is necessary. If that is the case, then you only need to say to your doctor, “I’ll do what you think is best.” The doctor might hem and haw, but she will give you an opinion eventually. Then just follow right down the golden path the doctor has laid out for you.

But for the rest of us, that isn’t acceptable. I choose to have a medical partner, not a surrogate parent. I want accurate, scientific data, then I will match and cross-reference that data with my values and experiences and judgements, then a decision will be made.

Really Ridiculous Story #2

Got a call from a friend this morning who had this story to share:

She had dinner with a 40 year-old friend the previous evening. This friend of a friend, whom we’ll call, Lisa, had given birth to her first child about 2 months prior, and was ready to share her birth story.

Lisa’s water broke. They went to the hospital where an induction was begun. Six hours later, she hadn’t progressed at all, so they gave her an epidural. She dilated a couple centimeters. Her doctor came in, said, “Well, you aren’t progressing, we’ll give it a couple more hours, then we’ll do a c-section.” As expected, nay even as requested, a couple hours later, the doctor comes in, “The baby isn’t handling labor well, let’s do a c-section.”

Obviously, this is an abbreviated version of what took many hours to occur. The baby was born with no problems, and mother and baby seem to be doing fine. The mother was effusive of her praise of her doctor and how the doctor “saved my baby.” And then Lisa said, “I didn’t know that walking around and moving, getting off my back, would have made a difference during labor. I just didn’t know.” Lisa is a sports medicine physician.

What is there for us to take from this story:

1) The doctor did not “save her baby.” The doctor and the medical interventions were at least part of the cause of any distress the baby may have had during labor. Laying flat on your back, in bed, as it seems must have been the case if she was hooked up to an iv receiving pitocin so she could be monitored, will cause distress to a baby. Good grief, we’ve all read the books that tell us not to even sleep on our backs, let alone lay on them for any length of time.
2) I will say it again, you cannot trust your doctor to “take care of you” during pregnancy, labor, and birth. Apparently none of the hospital staff: nurses, doctor, interns, even the janitor for goodness sake, took it upon themselves to tell this woman, moving during labor is going to make a big difference. Or, here’s a breast pump, let’s try and get those bodily hormones to work for you. She was flying blind and she didn’t even know it.

As my friend pointed out, this woman may still have ended up with a c-section, even if she had been up moving, doing everything “right.” But she’ll never know, will she.

Oh, and by the way, this is the same physician my friend is using to deliver her baby. Things could get very interesting.