What's Wrong with Mr. Picard's take on Birth in Canada?

This weekend I read an article in the Globe and Mail http://www.theglobeandmail.com/life/health-and-fitness/health/its-time-to-stop-treating-pregnancy-like-a-disease/article19163808/ – and found myself seething. Seething because, here was yet another article bemoaning the use of intervention in childbirth – that seemed to be calling for women to be encouraged to use midwives and birth centres and homebirths. Questioning the real necessity of Cesarean delivery – and largely echoed what can be summarized as a “Campaign for Normal Birth” where normal is defined as vaginal and without intervention, including without epidural pain relief. Questioning the necessity of hospital use for 98 percent of births – and the supervision of physicians for the large majority of those births – Mr. Picard thinks fewer babies should be born in hospitals and more babies should be born under the supervision of midwives.

The man is entitled to his opinion – but it’s rather tragic that such a notable and respected health journalist has fallen for the ideology of natural childbirth, hook, line and sinker – and that his stance, and the campaign it reflects does ultimately harm the health and well-being of women and their children.

Let’s begin with the statement that the World Health Organization suggests that the optimum rate of Cesareans are between 5 and 15 percent. This is a zombie statistic – one of those numbers, that even though it has been debunked, simply refuses to disappear from the media. In 2009, the World Health Organization retracted this – stating in its “Monitoring Emergency Obstetric Care: a Handbook” publication http://whqlibdoc.who.int/publications/2009/9789241547734_eng.pdf that there is “no empirical evidence for an optimum percentage” and that an “optimum rate is unknown” and that world regions may now “set their own standards”. But perhaps Mr. Picard thinks that a higher rate of instrumental deliveries (they would be vaginal) and a higher rate of 3rd and 4th degree tears and their consequent risks of incontinence is worth it to have a lower rate of caesareans.

Mr. Picard notes the fact that 58 percent of women “opt for an epidural” – I want to correct Mr. Picard on this. Fifty eight percent of women giving birth in Canada actually get epidurals – we don’t track how many epidurals are wanted or needed but not available and I assure you, particularly in BC, there are plenty of women who would “opt for an epidural” but are denied access to one. But no worries – Mr. Picard assures us that “pain relief can be done outside the hospital, too.” Mr. Picard – exactly what kind of pain relief options are available outside of the hospital? Perhaps you should review the BC Perinatal Health Program’s Obstetric Guideline 4 “Pain Management Options During Labour” http://www.perinatalservicesbc.ca/NR/rdonlyres/BA552F69-560F-480A-8B6C-098BEED7CF55/0/OBGuidelinesPainManagement4.pdf - note outside of hospital you would be limited to the first 3 options. The next time you are having a kidney stone – how about you learn some breathing techniques? Get someone to rub your back? Or maybe you’d like some saline water injections? Maybe a hot shower? Or would someone just reminding you that your “body was made to pass kidney stones” be adequate? Epidural pain relief is the gold standard of pain relief – and the other options that are even moderately effective, are only available in the hospital setting (for good reason). Denying access to pain relief – or leading women on to believe pain relief outside of the hospital is available is cruel.

Worse – there is some evidence that is emerging that inadequately treated pain during labour and delivery is associated with the development of post-natal Post Traumatic Stress Disorder and other post-natal mood disorders. How are the women who perceived their childbirths to be painful – or extremely painful supposed to take Mr. Picard’s assertion that out-of-hospital measures to address that pain should be adequate?

Yes, the vast majority of births are not complicated, however, this is only known retrospectively. Retrospectively, the vast majority of automobile trips do not involve any collisions – that does not mean that we should abandon the use of seatbelts, because most of the time they are not needed. Which brings us to a very interesting finding out of the Netherlands: Low-risk women who were treated under the care of a midwife had worse outcomes (rates of death and disability) than high-risk women who were treated under the care of an OBGYN (ACC Evers, HAA Brouwers, CWPM Hukkelhoven et al.” Perinatal mortality and severe morbidity in low and high risk term pregnancies in the Netherlands: prospective cohort study.” BMJ 2010;341:c5639. (2 November.) The Netherlands has almost the highest perinatal mortality (death) rate in Europe – is this really the model Canada wants to emulate?

Mr. Picard then encourages us not to buy the “too posh to push” nonsense. Mr. Picard – I am that demographic that you are seeking to dismiss. Worse, I am that demographic who has had my needs dismissed and has suffered the consequences of that. Mr. Picard, the women who are choosing Cesarean are not doing so because, “when you medicalize pregnancy and labour, and don’t offer reasonable alternatives, you create uncertainty and fear.” They are doing so because they do not buy into the idea that vaginal birth is the best for themselves and their babies – they do not like the vagaries of vaginal birth itself. It is not the medicalization of birth that creates the uncertainty – it is the inherent nature of the process. Left to its own devices, birth maims indiscriminately. Some of the damage is not known for years – and that is what women who “Choose Cesarean” are seeking to avoid. Again, there is recent research that is demonstrating that when the needs of this demographic – the patient choice Cesarean demographic, are dismissed they are at an incredible risk of developing Post-Traumatic Stress Disorder (Garthus-Niegel, et. al. “The influence of women’s preferences and actual mode of delivery on post-traumatic stress symptoms following childbirth: a population-based, longitudinal study”, BMC Pregnancy and Childbrith 2014, 14:191 http://www.biomedcentral.com/content/pdf/1471-2393-14-191.pdf ). But let’s just call them “too posh to push” – and those who fail to have their needs met can be isolated and ridiculed. Mr. Picard – too little surgery, even on those who do not “medically need” it can be harmful too.

You declare that your article is not to harken back to earlier times – but that is exactly what you are advocating for when it comes to the care women and their babies should expect to get. You declare that only a small amount of maternal mortality is the result of obstetric interventions but do not provide any evidence to support that claim. You declare mothers are healthier as a result of a higher-standard of living and fewer pregnancies because of contraception.

Mr. Picard – that same high standard of living, has not exclusively done what you claim it has done. If you look at the women giving birth today – they are not in their early twenties. They are in their thirties and their forties. They are more likely to be obese prior to becoming pregnant. They are more likely to have used assisted reproductive technology to get pregnant. They are more likely to have underlying health conditions that make pregnancy and childbirth more risky. Further – many of these women are not willing to take the risks with the health of what may be their only one or two children. I beg to differ with your assertion that infectious disease and excessive bleeding are still the biggest risks facing mothers today.

To you birth has become unnecessarily tedious and costly but I would argue that much of that “tedium” and “cost” is money very well spent. Consider for a moment that those giving birth are likely to be actively engaged in the workforce – likely to have another 50 years or more of life to live after they have babies. Consider for a moment those babies who are likely to live 80 or more years. Now the consider the cost and tedium of raising a child who has been injured at birth – or living with the grief of a child who died at birth. Now consider that two out of three babies who die at a home birth (http://www.skepticalob.com/2011/12/2-out-of-3-babies-who-die-at-homebirth.html) might have lived had they been born in a hospital.

I am very much for a patient-centred health system – but to “stop treating pregnancy and childbirth like a disease” is very likely to cost mothers and their babies very dearly. Pregnancy and childbirth is a time of incredible health vulnerability – and to dismiss that is to deny an informed choice about the right care, in the right place, which for many mothers (the vast majority) is care under the supervision of a doctor in a hospital with access to all of the advances of modern technology. I agree a culture change in birth is needed – but that culture change is the recognition that every woman is entitled to make medical decisions (and they are medical) with respect to her pregnancy and childbirth – including the choice to avail herself of the technology available.