What does Dr. Helen Sandland have to do with our goal to help you be an educated health care consumer? For the most part we all tend to be interested only in what affects us at the moment so for those women new to the birth scene and just reading our most recent posts we include here the story of a doctor who quit rather than be fired for refusing to adhere to her hospital’s medicolegal requirement to do more cesareans. In continuing the struggle to give American women the best maternal care: the midwifery gold standard.:
Doctor Won’t Make The Cut:
Feeling pressure from hospital for more c-sections, she leaves
Wilmington Star Newspaper, 5 June 2005
Surrounded by a house full of cardboard boxes, Wilmington obstetrician Helen Sandland discussed how giving birth Mother Nature’s way is in jeopardy.
Dr. Sandland – known for the past decade as the doctor local women went to if they desired natural, vaginal deliveries – moved to Mississippi last week after being told by New Hanover Regional Medical Center administrators to do more c-sections.
“I leave NHRMC with my morals and backbone absolutely uncorrupted,” Dr. Sandland wrote in her resignation letter dated May 15. “I am going to practice with a long-time friend, whose scruples I admire, and in a place where unnecessary surgery is not encouraged.”
During a time when national health officials have sounded the alarm that the cesarean section rate is at an all-time high and needs to be sliced, Dr. Sandland’s case raises questions about what factors are pushing the numbers higher.
Since history has been recorded, cesarean sections have always been a procedure used on mothers. The procedure was given its current name when, under Julius Caesar’s reign, Roman law decreed that all women dead or dying from childbirth were to be cut open to try to save the baby.
Until the 1800s, when formal anatomy education arose, the procedure rarely saved the mother’s life. It was used as a last resort until the 1940s, when antibiotics became available, and into the 1950s, when most women switched to giving birth in hospitals instead of at home.
Considered major abdominal surgery with complications that can lead to death, c-sections became used more commonly for abnormally positioned babies or when the mother or baby is in distress. During a c-section, mothers are given anesthesia, an incision is made through muscles of the abdomen, organs are moved aside and the baby is pulled from a cut in the uterus.
By 1970, 5.5 percent of babies were delivered through c-sections.
The rate doubled in five years and continued to increase until 1990, when it peaked at 22.7 percent. It held steady and slightly declined through the 1990s before picking up again in 1998. The rate now sits at 26.1 percent of 4,021,726 births nationally. North Carolina’s rate is 26.4 percent.
“I don’t see any end in sight right now,” said Dr. Bruce Flamm, regional chairman of The American College of Obstetricians and Gynecologists, saying there’s little concrete data on how many c-sections are unnecessary. “All of the current pressures seem to be going in the direction of more c-sections, not less.”
He and other national medical experts are concerned with the trend; a trend they believe is pushed by medical liability issues, convenience for both doctors and patients, and perhaps hospitals’ financial and staffing pressures.
“There are some doctors who say the only cesarean section I have ever been sued for is the one I didn’t do,” Dr. Flamm said. “It’s a sad but \true situation.” Not only is there a decreased chance of getting sued if a c-section is performed, but it’s less time consuming to perform c-sections instead of waiting out long and sometimes difficult labor.
“It’s a very vulnerable time,” said Deanne Williams, executive director of the American College of Nurse Midwives. “The increased demand is really a reflection of being told this is a quick fix, there’s no risk, why wouldn’t you? And that’s by the medical community.”
But, as many obstetricians will point out, pressure by doctors or hospitals is only part of the equation. Some women, they say, really are looking for a c-section because they fear the pains of labor or want to schedule it when grandparents are in town or around holidays.
“It’s called doctor shopping,” Dr. Flamm said, discussing how women will go from one doctor to another until they get what they want. “You have to be responsive, within reason, to the desires of the patient.”
Regardless of the reason, health officials across the country are concerned with the rates.
Leading medical groups such as the Centers for Disease Control and Prevention, National Institutes of Health and the World Health Organization have all spoken out against the increase, demanding the medical community investigate ways to lower the rate to 15 percent or below. C-section culture Dr. Sandland thought she was doing just that.
In the decade she has delivered babies and cared for their mothers in New Hanover County, she has always had a rate below 10 percent.
“I’ve always maintained I’m a midwife with a MD behind my name,” she said from her two-story Pine Valley home last week while preparing to move. “It’s better for Mother Nature to decide when it’s time, not the doctor. My philosophy is you don’t interfere unless you really have to.”
Her philosophy, admittedly different from the mainstream, attracted many patients who wanted the best chance of having a vaginal delivery. Dr. Sandland became known as one of the few doctors in the area who would try to deliver breech babies naturally or pursue a vaginal birth with a woman who already had one child with a c-section. Her solo practice boomed.
If her lack of medical malpractice lawsuits and gratitude of patients are of any account, she was not only popular, but also successful.
Fellow Wilmington obstetrician Dr. Joshua Vogel said though she was considered too set in her ways or a renegade by some doctors, he admired her talents to deliver naturally in situations when other doctors would have automatically pushed for a c-section. “She was a valuable asset for patients,” he said.
Dr. Sandland said she became the target of the hospital’s professional review and credentials committees. Because it is confidential by law, she could not legally discuss the peer review process.
But the Star-News viewed two letters addressed to her from committee members. Written on New Hanover Regional letterhead dated July 6 and July 7, 2004, the letters discuss the conversation committee members had with her.
The first letter, written by Dr. Cobern Peterson, chairman of the Professional Review Committee, stated “concerns” regarding her practice. They include higher than average infant birth weights, much lower than average c-section rates and later than average gestational age of neonates at delivery.
The letter states “the main concern reiterated several times was an overall practice attitude rather than any individual case.”
The next letter, written by Dr. Janelle Rhyne, acting chairman of the Credentials Committee, states Dr. Sandland’s privileges at the hospital would be reappointed for a period of six months but monitoring would continue.
It reads, “Your c-section rate is to be within an acceptable range as determined by the NHRMC OB/GYN Department with a plus or minus deviation of two.”
No reason was given in the letters, other than adding the committee would be watching other outcomes like collarbone fractures – something experts say is a minor, common complication of vaginal deliveries.
New Hanover Regional spokeswoman Kendra Gerlach said two standard deviations equates to five or six percentage points above or below the average.
The c-section rate at New Hanover Regional is 27.9 percent. At the time, Dr.. Sandland said, it was about 26 percent. That meant the committee was requiring her to reach at least a 20 percent c-section rate. To do so, she’d have to more than double her current rate.
“It’s just not something I could see happening,” she said. “You just don’t change your practices overnight. I certainly wasn’t going to change them to meet some arbitrary quota.”
Jack Barto, chief executive officer of New Hanover Regional, said he was not familiar with the letters but that it sounded to him more like a “guideline” than a “quota.”
“To me, a quota is, ‘You will be at X percent,'” he said. “I think it gives a range to allow physicians to have discretion.”
When asked if other doctors who deliver patients at the hospital are given the same guideline, he would not answer the question. He did not say why a guideline would be necessary.
But Dr. Sandland said that in a March conversation with Mr. Barto, part of the reason became clear.
“Barto said in a separate meeting that a c-section rate of 25 percent would reduce the likelihood of getting sued,” she recalled.
Mr. Barto confirms he had a meeting with Dr. Sandland but would not discuss the conversation.
“I had a private conversation with one of my physicians,” he said, asserting he did not recall discussing liability issues. “I talked with her about a variety of topics.”
Dr. Sandland also said the decree put a “seed of doubt” about other things going on during labor and delivery.
One time, she said a fellow physician called her to tell her she had a woman who was attempting to vaginally deliver a breech baby and, when Dr. Sandland explained the patient was aware of the risks and wanted to at least try, he said maybe he should go talk to the mother and try to “bully her” into a c-section.
Other times, especially when the unit was overrun with laboring moms, she said, there was pressure from department heads to speed up labor or consider a c-section.
“Quite a lot of c-sections are being done for so-called failure to progress,” Dr. Sandland said. “If you haven’t progressed in a couple of hours, a c-section’s waiting. There’s certainly a pressure to keep patients moving on through.”
Fellow obstetrician Dr. Vogel said he never felt pressured by New Hanover Regional administrators but he knows it goes on from time to time, mostly at for-profit hospitals for financial reasons.
The hospital’s chairman of the OB/GYN department, Dr. Bora Duruman, declined to comment on Dr. Sandland but said doctors are not pressured to do c-sections nor do they pressure patients toward c-sections unless the procedure is medically necessary.
“There’s no guideline at New Hanover Regional,” he said. “I take that back. There’s absolutely a guideline at New Hanover Regional. The guideline is healthy mother, healthy baby. The c-section rate then falls where it falls to achieve that.” Concerns for future Emily Lanier’s greatest fear when she went into labor Mother’s Day with her first child was of getting a c-section.
“My main thing was c-sections are not natural, and I wanted to experience natural delivery and I did not want to go through the recovery time,” the 29-year-old said.
But when her son’s head got stuck in her pelvis, her blood pressure shot up and his heart rate plummeted, she understood the necessity of the operation.
Nearly a month later, she said she’s saddened New Hanover Regional has put a c-section “guideline” on at least one doctor.
“Something like that really doesn’t surprise me,” she said. “Kind of like at the end of the month, a cop has to give more tickets.
Everybody has quotas. I feel like if it happens at one hospital, it’s going to happen everywhere, so there’s really no escaping something like this.”
Ms. Williams said members of her nurse midwives organization have long suspected hospital administrators may be driving the c-section rates behind the scenes, but she was shocked to hear a hospital actually put a quota in black and white.
“It’s likely happening,” she said. “If one person has the guts to come forward and say this has happened to me, it means it is happening a lot.”
Ms. Williams said hospital administrators would probably be happy to schedule all c-sections because it would control costs of staffing a labor and delivery unit around the clock.
“They want to put women on the conveyor belt,” she said. “They could save tremendous amounts of money.”
New Hanover Regional administrators said there’s no such movement at their hospital.
“For most people, this is the most amazing, wonderful moment of their lives,” Dr. Duruman said, also denying the hospital is out to make more money by doing c-sections. “What crosses your mind the whole time is healthy mom, healthy baby.”
Mrs. Gerlach said the hospital charges $4,700 on average for noncomplicated vaginal deliveries and $14,200 for noncomplicated c-sections. Those amounts do not include doctor fees.
Consumer watch dog group Public Citizen has estimated that half of cesarean sections are unnecessary and result in 25,000 serious infections, 1.1 million extra hospital days and cost more than $1 billion each year.
Meanwhile, the procedures don’t seem to be making a difference, noted Dr. Flamm, explaining that while the c-section rate continues to climb, the number of fetal deaths remains steady.
Legally it’s safer, he said, but not necessarily safer medically. He added that he and other physicians debate constantly and can’t come to a conclusion of what the correct c-section rate should be.
Ms. Williams is concerned that the more c-sections become the norm, the riskier giving birth will be.
“We are going to see an increase in morbidity and mortality for the mothers,” she said, explaining how the first and even second c-sections are fairly risk-free but then scar tissue builds up and increases the surgery’s risk.
“Every subsequent cesarean section, the risk of a woman ending up with a severe hemorrhage, losing her uterus or ending up dying goes up,” she said. “By the time women figure that out, we’re going to be long
If you’re thinking of having a baby soon, have a friend, daughter, sister planning to have a baby: please take the time to learn what gives in America.
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
This post was prompted by another blog I read several days ago, in which the blogger said that we were. Although I have no intention of linking to said blog, you can take my word for it that this woman is well-known to natural-birth circles as being among the meanest anti-homebirth people out there, so this coming from her made me laugh.
But it got me to thinking. Undoubtedly, there are some mean pro-natural or pro-homebirth people — those who would demean the choices of women who choose to give birth in the hospital or to have drugs. But there are very many people who demean the choices of women to give birth at home or who refuse drugs. As a natural-birth advocate and a home-birth advocate, I am acutely aware of this kind of person, having had to explain myself and my choices numerous times to people who severely disagree with me.
This antagonism is not good. For either side. And it tends to exacerbate the differences until they seem to be huge and insurmountable, and indeed to make women who agree about a great many things into some sort of enemies, and to become super-sensitive to statements, when they ought not be. An example — on my own blog, one of my readers took exception to something I said about “not understanding why” a woman would choose an unnecessary Cesarean. She took it to mean, somehow, that I was saying that women who chose a C-section when they didn’t have to were somehow bad mothers. I meant nothing of the sort, and was just talking about practical, concrete matters like having a recovery of several weeks as opposed to several days, etc. Absolutely nothing about “motherhood”… but she read that into it. After my explanation, she commented again, thanking me for explaining my position and said she was sensitive on the subject, because of some harsh criticism she had endured in the past for her choice.
I know some people find that every difference in opinion or action must mean that they’re doing something either better or worse than someone else. But thinking about this further, let me take this to a ridiculous extreme. I had chicken enchiladas last night, did you? I’m planning on making pizza tomorrow night, are you? Do you feel like you made a bad decision to have tacos or spaghetti, or to go out to eat last night, now that you know that I made chicken enchiladas? I sure hope not! Do you think that I would have done better to have made what you had for supper last night? If you do, I beg to differ! I hope you’re at least smiling now. The point is, just because somebody does something different, it doesn’t always mean that we think we’re the best and you’re the worst because we’ve done it differently.
In our group of Independent Childbirth Educators, we have a several commonalities among us, but that doesn’t mean we’re all cookie-cutters in everything. Take diapering as an example. (It doesn’t come up much, so I don’t know for sure how many people do total cloth vs. total disposables, or are like me and do some of each, but I do remember at least one woman saying that after her emergency C-section, her baby was brought to her “in a disposable diaper, of all things!”) Why do some people use cloth diapers for their babies? Cost for one. (Does that mean that you’re a horrid spendthrift if you use disposables? No! That simply may not be a factor for you, although it might be for others.) Environmental concerns is another reason. (But that doesn’t mean that we think you’re “raping our beautiful planet” by using disposables.) Cloth diapers may possibly healthier for the baby — in terms of diaper rash (my sister-in-law’s son was horribly allergic to all disposables), or the chemicals used in making disposables being right on their skin 24/7. (But that doesn’t mean that we think you’re a dangerous mother for putting your baby in disposables.)
The point is, “different” doesn’t mean “bad”, and saying why we’ve chosen different things doesn’t mean that we’re “mean.” For one thing, our reasons for choosing the things we did may not be reasons for you. For another thing, we might be wrong in our conclusions, though based on the best research we could find at the time. And finally, in these types of choices, in the final analysis, it often just comes down to pure opinion. Just because you’ve chosen differently from me (and believe me, there are a lot of differences among the women of this group), it doesn’t mean that I think you’re a horrible person. And although I have reasons why I do the things I do, just because your conclusion is different, doesn’t mean your reasoning is faulty or your decision is wrong. Just different. And that’s okay.