Benjamine Ribeiro Do Valle with Elizabeth Boyce, center, and Barbara Sellars, midwives, in their former Fifth Avenue location. Some people, Ms. Sellars said, have no idea what they do: “they think we’re witches who perform séances.”
June 15th 2012. NYTimes published an article called “The Midwife Becomes a Status Symbol for the Hip”. Demand swings back and forth between medicalized and unmedicalized ideals (e.g., twilight sleep versus the Lamaze natural birth push-back). What gives this birthing pendulum its momentum–what competing dynamics account for the push and pull?
- Professional or corporate interests / interests of the mother and baby
- Desire for natural birth / desire to have pain-free experience
- Trust in the medical system (“I will do what my physician suggests because I can trust him/her to always have my best interests at heart.”) / distrust of medical system (“Physicians are humans, and humans respond to incentives. Can I trust my physician to make the best choices for me? )
- Birth territory as defined by physicians / birth territory as defined by mothers or midwives
- Birth as natural process with default good outcome / birth as pathological process with default bad outcome
One in three women in the US undergo a cesarean section, with physician cesarean rates ranging from 10% to over 60%. Only a fraction of that difference in rates can be explained by differences in patient risk profiles (age, disease, etc.). Instead, a large (and currently unknown) fraction of the variability is attributable to “The Physcian Factor”, a phrase coined in the medical literature to refer to a physician’s ‘individual’ personality and practice style. What level of ‘uniqueness’, ‘individualism’ and subjectivity is scientifically and medically justifiable?
This gets to the age-old debate — is medicine a science or art? It’s time to move beyond that. The more important question should be — who has the most to gain by viewing medicine as an art versus a science? Pride lost, lives saved –what is at stake when variability in practice is acceptable from within the medical community and/or by consumers?
Cesarean rates are responsive to patient-payer type (mothers who are less able to pay are less likely to receive a cesarean), physician’s fear of malpractice lawsuit, and physician time-restraints. Profit, scheduling, and/or fear of malpractice are often variables in the ‘vaginal or cesarean?’ algorithm. Most women and their partners are unaware that these variables can and do factor in the equation. To what extent is informed consent for cesarean possible when a mother is told the surgery is performed due to risk to the baby when, additionally, time-constraints of staff are also a main factor? Is informed consent possible when obstetricians themselves are unable to assess fetal risk accurately (in the case of electric fetal monitoring for example)?
Similarly, most women are unaware of their provider’s cesarean rate or the vast variance across providers, with cesarean rates ranging from 10% to over 60% across providers. Elliot Main MD, Medical Director of the California Maternal Quality of Care Collaborative, said “providers seem to see no ‘downside’ to a high cesarean rate; and women seem increasingly accepting of the prospect of a cesarean”.
There are real costs to cesarean birth, for both mother and baby, and the cesarean rate steadily rises while the common explanations for this–rising obesity rates, increasing maternal age–are refuted by a large body of evidence. In the future, I forsee cost optimization for insurers (cesareans are much costlier than vaginal births on average) as a primary driver of cesarean reduction initiatives. Over six years, Mt. Sinai has succeeded in reducing their cesarean rate to 10%-12%, for example, without adversely impacting maternal or neonatal outcomes. How we tackle birth and death, fundamentally natural not pathological processes, reflect deep social and cultural currents. Women and their partners should be aware that hospital or physician incentives/dis-incentives, rather than best-evidence, could be the difference between cesarean and vaginal birth.