Thursday, February 07, 2008

Defensive tightrope management

Many "natural" childbirth and homebirth advocates conflate two entirely different issues. The first issue is whether doctors treat ALL patients, not just pregnant women, as respectfully as they can. The second issue is whether childbirth interventions are necessary. One has nothing to do with the other, and it is disingenuous for "natural" childbirth advocates to suggest that they are the same.

"Natural" childbirth advocates make a lot of assumptions that are totally unjustified:

Unjustified assumption #1: The way doctors treat pregnant women is different from the way they treat others.

To the extent that lack of respectful treatment is a problem, and I believe strongly that it is, the people who suffer most are those who are seriously ill, non-white, and don't speak English as their native language.

Unjustified assumption #2: Many women are rejecting hospital birth.

Homebirth is a fringe of a fringe movement. In 2005, 0.24% of women gave birth at home with a DEM, and that proportion has not changed for decades. Homebirth advocates do NOT represent the average woman and it is incredibly self-aggrandizing for them to imagine that they do.

Unjustified assumption #3: If "natural" childbirth advocates don't understand the need for an intervention, it must be unnecessary.

"Natural" childbirth advocacy is based in large part on ignorance of childbirth, science and statistics. When "natural" childbirth advocates don't understand the need for an intervention, it tells us more about them than it tells us about the intervention.

Unjustified assumption #4: There is some magical way for obstetricians to tell in advance which women will have complications.

Serious obstetric complications are in many ways like train wrecks. Everyone knows they are going to happen, but no one knows exactly when, where or to whom.

Unjustified assumption #5: Defensive medicine is completely unrelated to good medicine.

For better or for worse, defensive medicine is nothing more than being unwilling to play the odds. Defensive medicine is only recognized as such in RETROSPECT. Every test ordered "defensively" is looking for a complication that definitely could happen. It is "defensive" ONLY because the chance of that complication is low, NOT because there is no chance of that complication.

At hospitals, we always go out onto the tightrope with a net underneath. Homebirth with a DEM has a giant hole in the middle of the net. UC is heading out onto the tightrope with no net at all. It makes no difference if you don't fall off the tightrope, of course. However, does it make sense to wander around murmuring tightrope "affirmations" like "I won't fall off the tightrope" and loudly insisting that the chances of falling off the tightrope are so small that using a net is just "defensive tighrope management"? I don't think so.

Unjustified assumption #6: There is something wrong with "hospital protocol".

Rules and checklists (hospital "policy") are good, not bad. Rules ensure that all patients receive necessary monitoring and care. Hospital protocol is the net! There is a growing body of evidence that suggests that medicine has too LITTLE in the way of rules and checklists, not too much.

Every high risk endeavor has and should have protocols. Pilots go through extensive preparations and checklists every time they fly. Is that because they expect to crash? No, they don't expect to crash, but they are trying to do everything possible to prevent a crash and checking everything, even the little things, most definitely lowers the risk.

Unjustified assumption #7: Tests and procedures used to prevent bad outcomes could be more accurate.

In medicine, monitoring means screening tests. Screening tests (like AFP, 1 hour glucola, electronic fetal monitoring, for example) are easier, cheaper and more convenient than the tests that make the actual diagnosis (amniocentesis, 3 hour glucose tolerance test, C-section for fetal distress, respectively). Screening tests, by their very nature, are not as accurate as diagnostic tests. Sure we could do amniocentesis on every woman and no woman would need to worry that her baby "might" have Down's Syndrome, she would know definitely. The tradeoff is that a lot of babies would be exposed to the risk of amniocentesis when very few of them actually have Down's Syndrome. Instead, that means that some women are going to have to endure the anxiety of an abnormal AFP test and have an amnio to find out whether or not their baby has Down's Syndrome.

In many ways, the rising C-section rate exemplifies the problem with these trade offs. Fetal monitoring is a screening test, nothing more. The only way to definitely diagnose fetal distress is a C-section. The rising C-section rate reflects the unwillingness of doctors and patients to accept simply screening for fetal distress. They want to be absolutely sure that the baby is not experiencing fetal distress at all. Electronic fetal monitoring has not changed in decades. What has changed is the willingess to accept a screening test.

So what do interventions have to do with respect? Nothing! Interventions are really about treating childbirth with the respect that it deserves. "Natural" childbirth and homebirth advocates confuse the two because they have so little understanding of interventions. I suppose that if you assume that screening tests are sloppily inaccurate, that rules benefit hospitals and not patients, that doctors really could tell in advance who is going to have complications, and that defensive medicine is the opposite of good medicine, then you would consider the current system disrespectful. However, those assumptions are wrong and therefore the conclusion is wrong.

Policy, in general, and interventions, in particular, are the net that every hospital and doctor uses. Does the fact that falls from the tightrope are rare mean that using a net is unnecessary? Does it indicate a lack of respect for the tightrope walker when the circus insists on a net? Does it indicate a lack of self confidence on the part of the tightrope walker when he or she refuses to work without a net? No, no and no. So why do "natural" childbirth and homebirth advocates act like a net is unnecessary? Why do they feel "disrespected" when doctors and hospitals insist on a net? Most importantly, why do they feel that only "fear" and lack of self confidence would make a woman want a safety net at all?

Trust the tightrope? Doesn't work for me. Trust birth? Makes no more sense than trusting the tightrope.


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