Updated 1:00pm EST to correct a factual error.
It seems every day there’s more evidence that points to the ways in which medical advancements in obstetrics do not necessarily help improve health outcomes for women and their babies, and may sometimes in fact be detrimental to maternal and infant health, when relied upon to be savior and protector both.
In an excellent piece published in the Philadelphia Inquirer today, “Test leads to needless C-sections,” Alexander Friedman, Maternal-Fetal Medicine Fellow at the Hospital at University of Pennsylvania, argues that fetal heart monitors – those belly strips placed on almost every laboring woman who births in a U.S. hospital – may be a contributing factor in this country’s astronomical c-section rate. He speaks from personal experience.
“I have performed hundreds of cesarean sections during residency, and many were the result of bad heart rate strips.”
By now, certainly, you’ve heard that one out of every three women who give birth in the United States, gives birth via cesarean section. This is an all- time high for the U.S. and it’s not a record that’s good for anyone – except maybe physicians for whom the knowns of a cesarean section subject them to less liability and the hospitals who profit off of expensive surgery, on the backs of women and their families. As Dr. George Macones, a spokesperson for the American College of Obstetricians and Gynecologists said in the New York Times last month,
“What we’re worried about is, the Cesarean section rate is going up, but we’re not improving the health of babies being delivered or of moms.”
And though this is not a post about the increase in c-sections, it is worth noting that the common reasons given for this rise: that more women are “requesting” the surgery and that the population of women giving birth has changed (older women are now giving birth), are not adequate to explain the increase. In fact, 40 percent of the total number of cesarean sections being performed are repeat c-sections. This is likely due, in large part, to what essentially is an across-the-board ban on VBACs (vaginal-birth-after-cesarean) in hospitals. Women who had a cesarean section for their first birth are being told, in subsequent pregnancies and labors, that they are now and never more “allowed” to give birth vaginally. Though an NIH consensus panel recently declared VBACs to be safe and encouraged hospitals and physicians to re-visit policies related to performing VBACs on women in this country, women are routinely denied VBACs in hospitals, forced to have cesarean sections though it is not necessarily the safer option.
This is all to say that any medical advancement, when thrown into a health care system that values profit over health, a system dictated by insurance companies, should not be assumed to be helpful or even safe without constant monitoring and frequent investigation into why it’s being used – and how; especially when these advancements are being used to bring new life into the world.
In the case of fetal heart monitors, writes Friedman,
“…fetal heart monitoring is an appallingly poor test. The test misses the majority of babies with cerebral palsy, the condition researchers hoped it would prevent. It causes increased rates of a painful and invasive surgery: cesarean section. Even worse, almost all women undergo continuous heart monitoring during labor, not just those at highest risk.” [emphasis mine]
The use of fetal heart rate monitors has increased markedly. In 1980, monitors were used on only 45 percent of women. By 2002, fetal heart monitoring was used in 85 percent of deliveries.
But in his piece Friedman argues that the use of fetal heart monitors for all laboring women is contributing to a staggering increase in cesarean sections without helping to prevent the deaths of babies during birth or shortly after birth. Friedman points to a 2006 Cochrane Review study that concludes, after a review of 12 trials, that the use of continuous fetal heart monitors during labor is associated with “…no significant differences in cerebral palsy, infant mortality or other standard measures of neonality mortality” but is associated with increased rates of cesarean sections and medical interventions in vaginal births (specifically the use of forceps).
And, Alex Friedman notes, obstetricians Steven Clark and Gary Hankins state clearly:
“A test leading to an unnecessary major abdominal operation in more than 99.5 percent of cases should be regarded by the medical community as absurd at best,” they wrote in the American Journal of Obstetrics and Gynecology. “Electronic fetal heart rate monitoring has probably done more harm than good.”
If continuous fetal heart monitoring in labor fails to reduce infant mortality but leads to an increased number of cesarean sections and forceps delivery, then why are these monitors strapped onto almost every single woman who births at a hospital in this country?
For some of the same reasons, it seems, that unnecessary cesarean sections continue to be performed on healthy women. Medical advancement is automatically seen as beneficial to women because the birth process can then be controlled – an event that actually does not need to be controlled for healthy women. As Friedman writes, “Our medical culture prizes technology and tests, even if they don’t work and can cause harm.”
Birth is a perfectly normal physiological process for healthy women. When you interfere with that process using medical tools, thinking you’ll somehow optimize the health and well-being of mother and baby when there is no reason to do so, you automatically affect the process in some way. In fact, it’s not a mystery at all. The use of one medical intervention generally leads to more medical interventions which often times ends up in a cesarean section.
It’s why, increasingly, healthy pregnant women are choosing out-of-hospital births. They want to avoid unnecessary medical interventions such as medication to induce labor or fetal heart monitors.
But it’s easier to think that a tool will tell us exactly what it is we need to know to birth a healthy baby and maintain the health of the mother as well. Friedman writes of his own experiences movingly. He tells the story of a pregnant woman in his care one evening, given medication to induce labor. She had high blood pressure and Type 1 diabetes. The fetal heart rate monitor belted on her automatically showed dangerous dips throughout labor:
“We would fight through the night to have a natural delivery. But ultimately that single heart-rate test, which is surprisingly unreliable, would be a key factor in whether my patient would get a C-section or not.”
She did have a cesarean section, finally. And, as Friedman experienced over and over again with so many c-sections he performed after fetal heart monitors showed “worrisome changes,” the baby was not unhealthy, blue or lifeless but “pink, happy and healthy.”
In our quest to ensure the health and well-being of mothers and newborns, we look to medical advancement to lasso this messy experience called childbirth and in some cases we are extraordinarily grateful for the access to these tools. But what happens when these tools are overused, misused or cause more harm than good? Is it a coincidence that as maternal mortality rates continue to increase in the United States, so do medical interventions like the use of fetal heart rate monitoring for all women and the ultimate intervention – unnecessary cesarean sections?
There may be no more magical moment for parents than hearing the first jumpy heartbeats of ones’ baby while still in-utero. The thump-thump-thump is the rhythm of the love exchanged between mother and baby; and it’s easy to understand why fetal heart rate monitoring is so enticing during pregnancy. But if this tool is increasingly recognized as having dangerous consequences for the health and lives of both mother and baby during labor, we should be rethinking its value as a compass that points us in only one direction during labor and birth.