What to Reject When You're Expecting
Despite a health-care system that outspends those in the rest of the world, infants and mothers fare worse in the U.S. than in many other industrialized nations. The infant mortality rate in Canada is 25 percent lower than it is in the U.S.; the Japanese rate, more than 60 percent lower. According to the World Health Organization, America ranks behind 41 other countries in preventing mothers from dying during childbirth.
With technological advances in medicine, you would expect those numbers to steadily improve. But the rate of maternal deaths has risen over the last decade, and the number of premature and low-birth-weight babies is higher now than it was in the 1980s and 1990s.
Why are we doing so badly? Partly because mothers tend to be less healthy than in the past, “which contributes to a higher-risk pregnancy,” says Diane Ashton, M.D., deputy medical director of the March of Dimes.
But another key reason appears to be a health-care system that has developed into a highly profitable labor-and-delivery machine, operating according to its own timetable rather than the less predictable schedule of mothers and babies. Childbirth is the leading reason for hospital admission, and the system is set up to make the most of the opportunity. Keeping things chugging along are technological interventions that can be lifesaving in some situations but also interfere with healthy, natural processes and increase risk when used inappropriately.
Topping the list are unnecessary cesarean sections. The rate has risen steadily since the mid-1990s to the point that nearly one of every three American babies now comes into the world through this surgical delivery. That’s double or even triple what the World Health Organization considers optimal.
Some people say that the increase in C-sections and other interventions stems mostly from women, who may be requesting more of the procedures. That could be a contributing cause but it’s not the major one, says Carol Sakala, Ph.D., director of programs at Childbirth Connection, a nonprofit organization that promotes evidence-based maternity care.
“We see rates going up across all birthing groups, including all ages, races, and classes," Sakala says. "What we are seeing is a change in practice standards, a lowering of the bar for what’s an acceptable indication for medical interventions.
10 overused procedures
Of course, the idea is not to reject all interventions. The course of childbirth is not something that anyone can completely control. In some situations, inducing labor or doing a C-section is the safest option. And complications are the exception, not the norm. But when they’re not medically necessary, the interventions listed below are associated with poorer outcomes for moms and babies.
1. A C-section with a low-risk first birth
While C-sections are generally quite safe, “the safest method for both mom and baby is an uncomplicated vaginal birth,” says Catherine Spong, M.D., chief of the pregnancy and perinatology branch at the Eunice Kennedy Shriver National Institute of Child Health and Human Development.
The best way to reduce the number of C-sections overall is to decrease the number of them among low-risk women delivering their first child. That’s because having an initial C-section “sets the stage for a woman’s entire reproductive life,” says Elliott Main, M.D., chairman of the department of obstetrics and gynecology at the California Pacific Medical Center and director of the California Maternal Quality Care Collaborative. “In this country, if your first birth is a C-section, there’s a 95 percent chance all subsequent births will be as well,” he says.
A C-section is major surgery. So it’s no surprise that as rates for the procedure go down, so do the numbers for several complications, especially infection or pain at the site of the incision. Rare but potentially life-threatening complications include severe bleeding, blood clots, and bowel obstruction. A C-section can also complicate future pregnancies, increasing the risk of problems with the placenta, ectopic pregnancies (those that occur outside the uterus), or a rupture of the uterine scar. And the risks increase with each additional cesarean birth.
Babies born by C-section can be accidentally injured or cut during the procedure and are more likely to have breathing problems. They are also less likely to breast-feed, perhaps because of the challenges of starting in a post-surgical setting.
In some situations, such as when the mother is bleeding heavily or the baby’s oxygen supply is compromised, surgical delivery is absolutely necessary. But women can maximize their chances of avoiding an unnecessary cesarean by finding a caregiver and birthing environment that supports vaginal birth.
When choosing a practitioner and hospital or birthing center, ask about C-section rates, particularly rates for low-risk women having their first child. The target rate for that population should be around 15 percent, according to the American Congress of Obstetrics and Gynecology (ACOG). Although it can be difficult to find a hospital with a C-section rate that low, you might be able find one that meets the more modest goal of about 24 percent, which was set by the government’s Healthy People 2020 initiative.
2. An automatic second C-section
Just because your first baby was delivered by C-section doesn’t mean your second has to be, too. In fact, most women who have had a C-section with a "low-transverse incision" on the uterus are good candidates for a vaginal birth after cesarean (VBAC), according to ACOG. (Note that a "bikini scar" on the skin does not indicate the type of uterine scar.) About three quarters of such women who attempt a VBAC are able to deliver vaginally.
Yet the percentage of VBACs has declined sharply since the mid-1990s, particularly after ACOG said in 1999 that they should be considered only if hospitals had staff “immediately available” to do emergency C-sections if necessary. And some obstetricians don’t do VBACs because they lack hospital support or training or because their malpractice insurance won’t provide coverage. So women seeking a VBAC delivery might have trouble finding a supportive practitioner and hospital.
“It’s tragic, really,” Main says. “In many parts of the country, the option has all but disappeared.”
In response, ACOG recently relaxed its guidelines. For example, it makes clear that while it’s preferable for staff to be at the ready, hospitals can make do with a clear plan for dealing with uterine ruptures and assembling an emergency team quickly. Experts we spoke with say it’s too early to tell if the move will lead to a change in clinical practice.
Although some women turn to home births as an alternative, our experts say that isn’t a good idea in this situation. “The risk of uterine rupture is low,” Main says, “but if it happens, it can be catastrophic.”
Instead, if you had a C-section, find out whether your obstetrician and hospital are willing to try a VBAC. Let them know that you understand that you your baby will be monitored continuously during labor, and ask what the hospital would do if an emergency C-section became necessary.
3. An elective early delivery
A full-term pregnancy goes to at least 39 weeks, but over the last two decades many doctors have come to think they can deliver babies sooner than Mother Nature intended. Between 1990 and 2007, births at 37 and 38 weeks increased 45 percent, according to the March of Dimes. At the same time, full-term births dropped by 26 percent.
Because nearly all late preterm babies survive and eventually thrive, many doctors see no harm in moving up a delivery date to fit a schedule. “Although we knew 39 weeks or later was the optimal time for delivery, until recently there wasn’t a good evidence showing that a lot of maturation took place after 37 weeks,” says Ashton of the March of Dimes, who terms research from the last five years “eye opening.”
Late preterm babies “may look like full term babies,” she says, “but they are different in important ways.”
It turns out that carrying an infant to term has health benefits for both moms and babies. Research shows that babies born at 39 weeks or later have lower rates of breathing problems and are less likely to need neonatal intensive care. Full-term babies may also be less likely to be affected by cerebral palsy or jaundice, have fewer feeding problems, and have a higher rate of survival in their first year. Some research even suggests that full-term infants benefit from cognitive and learning advantages that continue through adolescence.
Perhaps because late preterm infants have more problems, mothers are more likely to suffer from postpartum depression. In addition, the procedures required to intentionally deliver a baby early—either an induced labor or a C-section—also carry a higher risk of complications than a full-term vaginal delivery. “There is just much more chance of things going wrong if you interrupt the normal course of pregnancy,” Spong says.
Of course, some babies arrive sooner than expected and complications during pregnancy, such as skyrocketing blood pressure in the mother, can make early delivery the safest option. But hastening the conclusion of an otherwise healthy pregnancy—even by a couple of days—is never a good idea.
The rate of early deliveries varies widely among hospitals, as demonstrated in the table below of all six hospitals in Utah that report that data to Leapfrog Group. It shows the percentage of early deliveries in each hospital that were done without medical reason. See the rates of planned early deliveries for the hosptials in your state on Leapfrog's website.
4. Inducing labor without a medical reason
The percentage of births resulting from artificially induced labor more than doubled from 1990 to 2008. “In many ways the system has become centered on convenience rather than evidence-based care,” says Sakala of the Childbirth Connection. She points out that it’s no coincidence that more babies are born on Tuesdays than any other day of the week. “The births are scheduled so that parents and providers can all be home by the weekend.”
But whether artificially induced or spontaneous, labor is labor, right? “Absolutely not,” says Debra Bingham Dr.PH., R.N., vice president of the Association of Women’s Health, Obstetric and Neonatal Nurses. She points out that women who go into labor naturally can usually spend the early portion at home, moving around as they feel most comfortable. An induced labor takes place in a hospital, where a woman will be hooked up to at least one intravenous line and an electronic fetal monitor. In addition, most hospitals don’t allow eating or drinking once induction begins.
"An induced labor may also occur prior to a woman's body or baby being ready," Bingham says. "This means labor may take longer and that the woman is two to three times more likely to give birth surgically." In addition, induced labor frequently leads to further interventions—including epidurals for pain relief, deliveries with the use of forceps or vacuums, and C-sections—that carry risks of their own. For example, a 2011 study found that women who had labor induced without a recognized indication were 67 percent more likely to have a C-section, and their babies were 64 percent more likely to wind up in a neonatal intensive care unit, compared with women allowed to go into labor on their own.
Induction is justified when there’s a medical reason, such as when a woman’s membranes rupture, or her “water breaks,” and labor doesn’t start immediately, or when she’s a week or more past her due date.
5. Ultrasounds after 24 weeks
Unless there is a specific condition your provider is tracking, you don’t need an ultrasound after 24 weeks. Although some practitioners use ultrasounds after this point to estimate fetal size or due date, it’s not a good idea because the margin of error increases significantly as the pregnancy progresses. And the procedure doesn’t provide any additional information leading to better outcomes for either mother or baby, according to a 2009 review of eight trials involving 27,024 women. In fact, the practice was linked to a slightly higher C-section rate.
6. Continuous electronic fetal monitoring
Continuous monitoring, during which you’re hooked up to monitor to record your baby’s heartbeat throughout labor, restricts your movement and increases the chance of a cesarean and delivery with forceps. In addition, it doesn’t reduce the risk of cerebral palsy or death for the baby, research suggests. The alternative is to monitor the baby at regular intervals using an electronic fetal monitor, a handheld ultrasound device, or a special stethoscope. Continuous electronic monitoring is recommended if you’re given oxytocin to strengthen labor, you’ve had an epidural, or you’re attempting a VBAC.
7. Early epidurals
An epidural places anesthesia directly into the spinal canal, so that you remain awake but don’t feel pain below the administration point. But the longer an epidural is in place, the more medication accumulates and the less likely you will be able to feel to push. Epidurals can also slow labor. By delaying administration and using effective labor support strategies, you might be able to get past a tough spot and progress to the point you no longer feel it’s needed. If you do have an epidural, ask the anesthesiologist about a lighter block. “Ideally, a woman should still be able to move her legs and lift her buttocks,” Main says.
8. Routinely rupturing the amniotic membranes
Doctors sometimes rupture the amniotic membranes or “break the waters,” supposedly to strengthen contractions and shorten labor. But the practice doesn’t have that affect and may increase the risk of C-sections, according to a 2009 review of 15 trials involving 5,583 women. In addition, artificially rupturing amniotic membranes can cause rare but serious complications, including problems with the umbilical cord or the baby’s heart rate.
9. Routine episiotomies
Practitioners sometimes make a surgical cut just before delivery to enlarge the opening of the vagina. That can be necessary in the case of a delivery that requires help from forceps or a vacuum, or if the baby is descending too quickly for the tissues to stretch. But in other cases, routine episiotomies don’t help and are associated with several significant problems, including more damage to the perineal area and a longer healing period, according to a 2009 review involving more than 5,000 women.
10. Sending your newborn to the nursery
If your baby has a problem that needs special monitoring, then sending him or her to a nursery or even an intensive care unit is essential. But in other cases, allowing healthy infants and mothers to stay together promotes bonding and breast-feeding. Moms get just as much sleep, research shows, and they learn to respond to the feeding cues of their babies. Allowing mothers and babies to stay together is one of the criteria hospitals must meet to be certified as “baby friendly” by the Baby-Friendly Hospital Initiative, a program sponsored by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF).
10 Procedures to think twice about during your pregnancy: from ConsumerReports.org