I know I’m like a decade late here, but having just finished my labor & delivery rotation at the hospital I thought it would be interesting to watch a controversial documentary about hospital births that I remember being told about several years ago. I decided to start with the trailer.
Wow. Okay, so let’s go through this together:
0:10 – “Hospitals are businesses, they want those beds filled and emptied….”
I think the argument here is that we want women in and out in a timely and efficient manner to maximize profits. In reality we were at less than half-capacity the entire time I worked there, and yet we regularly turned women away who thought they might be in labor because they were still a day or two out. I’d have to come back in September when all of those Christmas babies are showing up to see how a full ward influences decision making, but I certainly didn’t see anything of the sort. More on this later.
0:17 – Technology is technology. It’s not stopping, so if you’re going to have good stuff you might as well use it to get the best outcome.
Hey, no disagreements here! Even in just the recent past, if we were worried about fetal anemia (a regularly fatal condition with a variety of causes) the only way to test for it was to use a needle to get a sample of amniotic fluid or cord blood directly: both invasive procedures with a small but measurable risk of miscarriage. Now we can look for patterns in fetal heart rates or in fetal blood flow via doppler ultrasound, both techniques that are vastly less invasive and correspondingly carry a much lower risk of complication to the mother and baby. Just a few days ago we watched a fetal heart tracing gradually become sinusoidal, and performed a c-section to deliver the baby. It came out about as white as the background of this blog, and its hemoglobin level turned out to be just over 3 g/dL. For reference, that means that its blood had less than a quarter of the oxygen-carrying capacity it should have had. The baby had been slowly bleeding into the maternal bloodstream, and if we hadn’t been monitoring it that baby would have died. An urgent c-section and blood transfusion saved its life, both made possible only because mom was in a facility with a trained staff of professionals and cutting-edge technology. So what’s wrong with using technology in the pursuit of achieving better outcomes again?
0:26 – “Maternity care in the United States is in crisis.” “People don’t have the information.”
Sure, education is important. I always try my best to educate my patients on their situation as much as possible. I want them to have access to the best information available, and to the maximum extent possible the ability to make reliable, informed medical decisions. Every single doctor I’ve worked with so far attempts to do this, although to be fair some are better at it than others.
0:32 – “Medical decisions are being made for monetary and legal reasons, not because they’re good for the mother and the baby.”
Wait, what? Over the past several weeks I’ve been privy to a lot of discussions between doctors concerning the options for patient care, and not one single time can I recall the primary focus being on anything other than carefully weighing the risks and benefits of those options for both mother and baby. Financial and legal concerns certainly exist, but in every case they have ever been mentioned around me so far they have taken a distant back-seat to concerns about the health and well-being of those under our care. I’m sure it happens, but it’s definitely not the norm where I’m being trained.
0:38-0:51 – Several completely decontextualized snapshots of doctors talking about administering pitocin, followed by the question “is this an improvement, or are we making things worse?”
That’s an excellent question, and the type of question that doctors following the principles of evidence-based-medicine should routinely ask themselves and seek answers for. As it happens, doctors do routinely discuss questions like this in medical journals, usually with a solid attempt at using evidence, reason, and ethics to approach them from multiple directions. So let’s discuss some of the reasons why we do and don’t use pitocin in various situations, perhaps we’ll find something we can improve on!
0:52 – text display: “The United States has the second-worst newborn death rate in the developed world.”
Wait, huh? I thought we were talking about pitocin! Anyway, citation? Judging from previous experiences I’m guessing that they’re actually talking about the infant mortality rate (a number which includes all infant deaths from birth up to one-year of age), and that’s not exactly a great way to compare the efficacy of obstetric medicine across different countries given that, among other reasons, different countries use very different criteria to establish what a “life birth” is. As one example, something we’re not very good at is substantially delaying pre-term labor. As a result, we deliver and attempt to save a lot of babies at 24-26 weeks of gestation, when their mothers spontaneously went into labor prematurely. All of these babies would have died before the advent of modern interventions like betamethasone and oxygen therapy, and many of them still die anyway despite immediate access to advanced neonatal intensive care because they’re simply too immature. In the US, every one of those counts as a neonatal or infant death. In most other developed countries, they wouldn’t even have counted as a live birth. So there’s some pretty significant counfounding going on, and it needs to be looked at much more carefully and with much more nuance than is being offered here.
0:55-1:02 – To a panel of people wearing white coats: “How often do you get to see a fully natural birth?” Answer: long pause – “Rarely.” “Almost never.”
I don’t know about them, but I saw fully natural births almost every day. If you wanted to ask about hospital births where the only intervention at all is an epidural, than that probably goes up to “most births.” And this is at a major academic hospital where we collect many of the most complicated and risky pregnancies from a population numbering millions. Two of those “completely natural” births even included babies born with gastroschesis, a condition where the abdominal wall fails to close and their intestines were hanging freely exposed as they were born. So I’m not sure what these ladies meant by “rarely” and “almost never,” or if there’s some extra context I’m missing, but I’ve had exactly the opposite experience. And more importantly, we don’t intervene without consent! If your labor isn’t progressing normally and you want an intervention like pitocin, membrane stripping, or artificial membrane rupture to help augment it, then we can give them to you after discussing them and obtaining your permission. If you don’t want them, you don’t have to have them. If you want to discuss the pros and cons of any of those beforehand, I’ll walk you through the relevant studies to make sure you can make the most informed decision possible. That most births don’t occur “fully naturally” isn’t because we coerce you to take all of these unnecessary interventions, it’s usually because women ask for them. I feel like this is an important point.
1:24 – “Cesarean is extremely doctor friendly. It’s 20 minutes, and I’ll be home for dinner.”
Are you kidding me? 20 minutes? At our hospital women usually labor with their friends/family/midwife/doula/etc. present to whatever extent they desire, and they have a nurse that pops in and out to check on them and keep them comfortable. They’re usually free to get up and walk around, drink water, and labor in whatever positions they feel most comfortable, and the longest period of physician contact occurs in the last few minutes before delivery when we gown up and assist in getting the baby out in case there are any problems. 10-15 minutes at most, usually, unless there’s an excessive amount of tearing that needs to be sewn up or a complication like shoulder dystocia. I’ve seen maybe one vaginal birth that took more than 20 minutes for the physicians to attend, and it involved both a significant tear and shoulder dystocia.
The shortest c-section I observed took about 40 minutes, with an average of probably around an hour and fifteen. If an intern was learning it might take 20-30 minutes longer, but 20 minutes just seems very unreasonable to me unless your surgeon is a complete hack who doesn’t care about doing a thorough job. Cesareans take longer for the mother to recover from, there are additional risks to the mother, and she doesn’t get to hold the baby right when it comes out. And now as a doctor you’re two hours behind on all the other stuff you have to do because you just spent it in the OR. My experience has been that the obstetricians I worked with disliked doing cesareans for a number of different reasons, and only performed them when all other options had been exhausted for legitimate, evidence-based reasons. You can’t even ask for one electively unless there’s a medical indication for it, so I’m really not sure where this argument is coming from.
And “I’ll be home for dinner?” Very few obstetricians work in single private practice, preferring instead to form groups that rotate call on a shift-based system because making a commitment to being present for the birth of every single one of your patients is murder on your ability to prevent your profession from consuming your personal life. So even if you decided for some abstruse reason to end a labor early and section a patient for personal convenience (I hope you have a good lawyer), you’re still not going home because your shift isn’t done until it’s done.
1:31 – “Basically, what the medical profession has done is convince the vast majority of women that they don’t know how to birth.”
What?? We offer free classes and tours to expectant mothers specifically to help them understand the process of pregnancy and childbirth, to enable them to become more informed participants in it. We’re not pulling the wool over anybody’s eyes here, and all of the doctors I’ve seen love it when patients ask questions with an earnest desire to learn and understand. A huge part of our job is patient education. One of the papers we hand out to expectant mothers is a study from the 1980s describing how interventions can occasionally lead to a c-section that otherwise wouldn’t have been necessary. We want mothers to know these things, because we think they’re important.
1:39 – “If I could do that, I could do anything. To me that’s the power of birthing. And that’s what we are taking away from women.”
Again, what? If you don’t want an epidural, you don’t have to have it. If you want to do your own research and ask questions to compare that with my professional opinion, I’m thrilled. If you feel comfortable having your breech twins at home, or not getting any ultrasounds and hoping you aren’t unlucky enough to go into labor with a term placenta previa, or if your membranes rupture prematurely and you hang out at home for a few days because you feel that the risk of chorioamnionitis is less important than the risks of antibiotics or the benefits of birthing your child into a bathtub full of coliform bacteria, then go ahead. I’m not going to stop you! But judging by this trailer, this film is nuts. And probably dangerous.