Researching the safety of natural childbirth yet again ~ here defined as spontaneous labor resulting in a vaginal birth over an intact perineum ~ I discovered an article regarding the use of technology in preventing low birth weight.  As I read it I was reminded of Dr. Marsden Wagner’s article, “Technology in Birth: First Do No Harm” (Midwifery Today, 2000).  In the opening of his article Wagner claims “The biggest killer of newborn babies  is a birth weight that is too low, but the number of too-small babies born has not decreased the past 20 years.”

     Considering “the advances in technology and the dependence that American trained obstetricians have on technology” (Ricciotti, Chen & Sachs) could the dismal statistics, no improvement in maternal or infant death in the past two to three decades, be true?  ACOG admits to being on the defensive right now and they don’t like it.  They should be feeling the heat to prove their recommended protocols are appropriate and safe.  Can we really prove their birth technology is inappropriately applied?  Every technology recommended to mothers is under the guise of keeping her baby alive, a goal to hand her a live baby.  We’ve written here before that America is a place where women have access to nutritious food, clean air, land to walk or otherwise exercise in and sanitary conditions under which to give birth.  Therefore, we surmise, the number of women who are not “healthy and low-risk” would be low and could not correlate with the high cesarean rate and high maternal and infant mortality rates. 

     We’ve never argued that technology is not appropriate for some risky births, but we do claim that midwives are the experts in normal birth.  It is the trained and experienced natural birth supportive midwife who is the most qualified to define what is a “risky birth.”  So, let’s tackle the issue of low birth weight, a birth health issue we all agree we must work together to improve.

     Ricciotti, Chen and Sachs write “While it is difficult to determine what proportion of preterm births might be prevented by obstetric technology, it is possible to evaluate these technologies to determine which of them might actually improve birth outcomes.”  They culled data and research on the following protocols related to the prevention of low birth weight:

  • Home Uterine Activity Monitoring: No large scale studies have been done but what is known is the cost of its use for women at risk for pre-term birth is about $7,000 per pregnancy.  Results: The favorable outcomes could be either the monitoring or the positive daily interaction between mothers and their nurses.
  • Tocoloytic Drugs:  These are drugs used to stop pre-term labor ~ betamimetics, inhibitors of prostaglandin synthesis, mag sulfate, calcium antagonists, combinations of the previous and/or oxytocin analogues.  Results: No evidence they are effective and use of these drugs associated with many potentially severe effects, moreover “scientific evidence of efficacy available for all of these drugs is surprisingly scarce given the frequency of their use.”
  • Steroid Use to Accelerate Fetal Lung Maturation: Evidence of a reduction in respiratory distress syndrome and subsequent neonatal mortality when given one to seven days prior to delivery; obstetricians are not appreciative of the effects as they occur after the birth at which point the baby is now under the care of another medical field.
  • Bed Rest for Twins:  Trials have excluded those that are at risk i.e. women with bleeding during pregnancy, PIH, polyhydramnios, previous cervical cerclage or previous cesarean.  For those that are actually healthy and low-risk there may be a decrease in the incidence of developing PIH (perhaps due to exposure to attention to good nutrition?) although no evidence was found that pregnancies were prolonged.  Twins account for 1% of pregnancies but 10% of all perinatal deaths therefore, it is surmised, bed rest is simply routinely advised w/o clear evidence of any benefits.
  • Cesarean Delivery: No evidence showing improved outcome for vertex presentations.  For breech delivery it cannot be determined if the results are “due to the intervention or the way the women were selected to undergo a cesarean or a vaginal delivery.”
  • Episiotomy:  No data demonstrating it improves neonatal outcomes.
  • Forceps:  No benefit; increases the incidence of brain hemorrhages.
  • Reduction in Multips:  There are complex ethical issues and studies favor increasing fertility technology to avoid this dilemma as there does appear to be a slight increase in outcomes for quadruplets reduction to two.
  • Cervical Cerclage:  There might be a benefit to a small number of women however who those women might be cannot be definitely selected in advance; further, its use is proven to increase the use of interventions as noted in the admissions records which show the use of tocolytics, induction, infection and cesarean delivery.

     “The reasons physicians use unproven technology or ignore proven ones is unclear.  At present there is no easy and effective way to modify physician behavior … it is difficult to remove familiar technologies before they are proven to be effective … in the current climate of cost consciousness, it is imperative that the widespread use of these unproven and ineffective technologies be abandoned and the use of proven technologies be encouraged.  In addition, we must be careful not to use technology in those situations where it does not improve outcomes.  Dissemination of technology into low-risk populations has the potential to do more harm than good.  Finally, physicians need to be educated to be wise consumers of medical technologies.” (Ricciotti, Chen & Sachs)

     Once again, we repeat, it is not so much that we are against the use of technology at birth nor is it correct that we do not believe medically trained obstetricians are not needed.  We are firm in our educated opinion that obstetricians today are not exposed enough to normal, natural childbirth and all of its variations including delivery positions other than supine let alone multiples, breech, posterior presentations.  ACOG is working hard to cloud the true issue: obstetrical training in America is a poor resource.

 

Ricciotti, Hope and Chen, Katherine and Sachs, Benjamin P., “The Role of Obstetrical Medical Technology in Preventing Low Birth Weight”, The Future of Children, Volume 5 Number 1

Wagner, Marsden, M.D. “Technology in Birth: First Do No Harm” Midwifery Today 2000