Part Two: The World After TBoBB

This is part two of a series entitled Intervention on Interventions which seeks to address the place of medical science, interventions, and public policy in the lives of women.  Using research done on interventions, pilot studies, and public policy interventions, this series will highlight whether or not interventions are to be feared and how public policy – not the distrust of doctors and medical professionals – can help women have safer, more empowering birth experiences.

As mentioned in the previous post, The Business of Being Born radically changed the way we talked about childbirth after its introduction to standard preparing-for-birth videos in 2008.  Most women my age have watched it.  Most of my friends have strong opinions about TBoBB – either good or bad.  I think it raises some important questions and has at least made us ask whether or not the status quo of childbirth at the turn of the past century is for better or worse.  In part one, I identified some issues.  However, I think it’s good to see what changes may have been made since TBoBB debuted.  In this post, I observe changes in maternal and fetal mortality over time, episiotomies, and rates of cesarean sections.

Maternal and Fetal Mortality

The key to birth for most women and medical providers is safety.  TBoBB argues repeatedly that birth is much safer than we observe it to be.  That is somewhat true.  Birth today is radically safer than it was 100 years ago.  But that is likely due to the medicalization of birth rather than just the passage of time!

However, since the early 90s and late 80s when my friends and I were mostly born, the risk of having a life-threatening pregnancy complication has increased.  In recent years, there has been a sad trend towards worse outcomes from mothers.  The CDC published a number of figures in 2012 (the last year data is currently available) that highlights a disturbing trend.  Women today are having worse health outcomes than their mothers

trends-pregnancy-related-deaths-2012_600px
Source: CDC

The above figure highlights this trend in the number of deaths per 100,000 live births.  It is important to note, however, that while the number of deaths has trended upward, the percentage of maternal deaths is less than .02% in the United States as of now.  The CDC report suggests that a number of things may be bringing this about (causes for death are highlighted below) – primarily bad health outcomes for overweight women, exposure to illnesses while in the hospital, and conditions that tend to be more common in older moms.  It is certainly the case that we are having our children older than ever before and women are more likely to be obese than ever before when having a baby.

causes-pregnancy-related-death-2011-2012_600px
Source: CDC

But a real problem is highlighted when outcomes are broken down by demographics.  In particularly, it is clear that black women and minorities experience worse outcomes than white Women.  Per the CDC, in 2011-2012, per 100,000 births, 11.8 deaths were experienced by white women, 40.4 deaths occurred in the population of black women, and 15.7 deaths were experienced by women of other non-white backgrounds.  There is a clear disparity in success for black and white women.  This may be due to the fact that black women experience a greater likelihood of heart problems and obesity and have worse care access than white women, according to a study by Creanga et al. (2012).

Fetal health shows an inverse trend over recent time periods.  Both prenatal and infant mortality have declined significantly in recent years, as shown below taken from a 2013 CDC report:

infantmort

But there is still a racial disparity in these outcomes.

It seems that minority children still fare more poorly than do white children.  Due to the explanation of SES factors and health risks that put their mothers in higher risk categories, it seems likely that these differences also play into this dynamic.

The takeaway from these trends is as follows.  Maternal deaths were increasing before TBoBB and are still increasing.  Fetal and infant deaths were declining before and are declining even more now.  Again, there is a trend that begins well before 2008 and continues even now.  TBoBB may suggest maternal health is being seriously harmed by the risks of in-hospital births (infection and c-sections) but it seems that the CDC and other studies suggest while these risks do occur they are not new and are not the biggest drivers of bad outcomes for moms.  Likewise, it seems that cesareans and other interventions appear to bring about better fetal and infant outcomes.  In summary, it seems as though there could be something to TBoBB’s criticism of hospital births due to infection outcomes (especially in cases of Influenza A or B outbreaks seen in recent times) but overall, it seems that other risk factors may be driving this train and babies are certainly benefitting no matter what.

 

Episiotomies

This is one that makes most of us feel really uncomfortable and, for me, was a really really important take away from TBoBB.  Episiotomies were, at one point, believed to be better for women and more preferable if a woman was risking a third or fourth degree tear during a vaginal delivery.  However, in the 80s and 90s, these procedures became almost a badge of honor and were considered “normal” for most vaginal deliveries.  Many of our mothers had one if they delivered vaginally as about 60% of women received one in the 1980s.  New evidence has pointed to the fact that these procedures were being overused, were largely unnecessary, and may be really harmful to women.  Because your vagina is a really complicated and important part of your version of “self”, a damaging procedure like this may contribute to a bad recovery and a bad birth experience.  That should not be discounted.  I feel like TBoBB made a really strong point here and it needs to be further discussed 8 years later.

Episiotomies matter.  40% to 85% of women do tear during childbirth, according to the American Academy of Nurse Midwives.  But, that said, most women end up with more minor tears which would be much less severe than an episiotomy.  The evidence often cited for why NOT to do an episiotomy (and which was referenced in TBoBB) comes from a study by Hartmann et al. (2005), which found that while some episiotomies may be medically necessary (in the case of severe tears), routine ones are not helpful and may lead to higher risks of sexual dysfunction, bladder trauma, and other adverse effects.

So have episiotomies decreased?   A recent study by Friedman et al (2015) showed that the episiotomy rate has decreased by more than 30% from 2006 to 2012 from about 18% to a rate of just 11%.  Thus, it seems like episiotomies are going away and are being performed in situations where the benefit and need for it outweighs the risk.  The American College of Obstetricians and Gynecologists, since 2006, has officially stated routine episiotomies are not beneficial or recommended.  ACOG is a large player in setting the standard for US practitioners and it seems like doctors are responding positively.

In the end, it appears that practitioners are addressing the call to change from ACOG and sources like BoBB by performing fewer episiotomies and being more discriminate in their use.

 

Cesarean Section Rates

The C-Section is the granddaddy of medical interventions.  It’s intensive, it heightens the risk of infection, and it’s probably the most villainized intervention by the natural birth movement.  It makes sense as the United States has one of the highest rates of c-sections.  In 2009, about 33% of all births – one in three, basically – was a cesarean birth.  Cesareans have a place and are known to save the lives of women who need them but they are also incredibly serious surgery.  Anytime a woman is wheeled into an operating room, there are risks involved and, thus, women who receive a section should consider the cost and benefit.  While some demonize c-sections, they certainly have a place.  But organizations like the World Health Org and ACOG are pressing for lower rates.

I don’t think anyone is disputing that c-sections are used too often.  Most medical bodies acknowledge this.  However, as will be discussed later in this series, the reasons natural birth advocates oppose them or feel most are not “medically necessary” are based many times on anecdotes as opposed to eveidence.  TBoBB at times makes cesareans seem like a thing doctors pressured their patients into scheduling prior to 40 weeks or as an easy way to get to a golf game or a holiday.  In reality, very few elective c-sections occur.  ACOG reports that only 2.5% of births are a scheduled or elective c-section with no medical indications (meaning there was no medical reason it was needed).

While c-section rates may not be quickly declining, professional organizations, hospitals, and women are listening.  While I personally feel that TBoBB far overstates the danger of c-sections and understates why they are often necessary, I think talking about this has been good for everyone.  Later in this series, I will more closely address what has been useful in curbing c-section rates, improving c-sections if they must occur for women’s health and comfort, and demystifying the recovery process from c-sections through maternal bonding, breastfeeding and the like.

 

Inductions

Inductions are also seen as counterproductive by the natural birth advocates who often tout the benefits of TBoBB.  They claim there are many risks and few rewards to the medicalization of birth rather than letting the baby come “naturally”.  But like c-sections, there are medical benefits to inductions and they also may save the lives of babies not prepared to come soon enough or who are simply growing too big for mom’s capacity.  Later in this series, I will explain how inductions impact maternal health outcomes and labor progression based on recent studies and explain why they may not be as evil as previously assumed.

Regardless, recent statistics show that inductions are declining in the United States.  While induction has increased from only about 6% of births to over 23% of births, rates are trending downward since 2010.  This is specifically the case, where big declines are seen amongst younger women and births before 38 weeks.  For births past term and births for women over 40, the rates remain steady.  As the average age of first birth inclines and more and more older mothers give birth, it is expected that more scheduled inductions will occur.  Thus, inductions are declining and have been since about 2010.

 

Epidurals

Epidurals were also argued to contribute to poor labor progression and a more negative childbirth experience for women who would require more consistent monitoring in The Business of Being Born.  The merits of those arguments will be brought to light later in this series but it’s important to talk about this procedure and whether or not the rate of use in US hospitals has changed.  Epidurals are seen as a common intervention that helps moms get rest and deal with the pain of labor in later stages of active labor.  And, due to the painful contractions brought about by Pitocin-induced births, they have become more and more common alongside inductions.

According to a 2011 report by the CDC, epidurals are not declining but instead are now the predominant method of pain management during labor.  More than 60% of women received this form of pain relief in 2008 when TBoBB was released.  No statistics were easily available by year or over a period of years but it doesn’t look that TBoBB and other natural birth advocates have deeply impacted the use of this intervention.  Whether this is good or bad will be addressed later in this series.

 

Homebirth and Birthing Centers

TBoBB strongly advocates the benefits of homebirth.  I will later in this series get into the benefits and concerns with this type of birth experience (primarily in terms of the lack of qualified providers and a lack of good selection criteria exercised by non-medical professionals who take on dubious caseloads).  However, I was curious as to whether homebirths have increased since the release of TBoBB.  In a similar way, as the statistics regarding “out of hospital births” also include medically-qualified birthing centers, I’ve grouped this topic together.  My post on Midwives will explain why this is a problem with the literature.

Recent data from the CDC shows that out-of-hospital births are on the rise:

homebirth

So, in some ways representations of natural birth culture like TBoBB may be bringing about increases in out-of-hospital births.  Whether this is positive or not will be discussed later in this series.

Overall, this post highlights trends over the past 8 years.  While the assumption is not that The Business of Being Born has caused change, I acknowledge that it is a very visible manifestation of the debate over the medicalization of birth.  It seems that current trends in obstetrics haven’t harmed but instead helped babies but that maternal mortality may be up (well, slightly as these rates are still incredibly low).  Likewise, many interventions, including elective c-sections and episiotomies may be less and less of an issue that in the past 30 years.  Despite this, c-sections, inductions, and epidural use still remains high.  The next sections will address these interventions for the good and bad and then, in conclusion, this series will look to show ways the birth experience can be improved with better hospital and, in large part, public policy choices.

Sources cited and not linked:

Creanga et al. 2012.  “Race, ethnicity, and nativity differentials in pregnancy-related mortality in the United States: 1993-2006.”  Obstet Gynecol. 2012 Aug;120(2 Pt 1):261-8.

Hartmann et al. 2005. “Outcomes of Routine Episiotomy: A Systematic Review.”  JAMA. 2005;293(17):2141-2148.

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