"Pushed" to Iatrogenic Prematurity

I am currently reading Jennifer Block's expose on modern maternity care titled "Pushed." It's a nice wrap-up from the midwifery and obstetric literature I have been scouring for truths and perspective over the last two months. It's an eye-opener, but that's mostly by design*. Still, it's a great book because it is bursting out the seams with information, from the history of maternity care to the new fashions and practices. The information is not organized like a boring textbook either; it is presented in a gripping writing style, weaved through stories, and neatly packaged under attention-grabbing subtitles.

Basically, there exists a clash of opinions in American modern maternity care**. The clash is between the obstetricians/gynecologists (representing the organized, insured, medical community as a whole) and the midwives/doulas/women (representing the people who feel that childbirth is a natural process: those who say that most women left to their own devices will be able to deliver their babies and survive without the aid of modern drugs and healthcare). With medical advances have come myriad interventions into American women's childbirth experiences; the perspective held by the midwives is that these advancements and the resulting adopted unnecessary procedures are harmful to women, specifically, and society, as a whole. 

The midwives will have you believe that the hospital is a horrible place to deliver because you will be vulnerable to hospital policies and routine interventions. The doctors will have you believe that you are not safe delivering anywhere else (because, as I have heard now at least three times from my OB, your baby could die).

The more I read, the easier time I have balancing the two perspectives. I am realizing that the true state of modern maternity care is somewhere in the middle: hospital procedures are being reformed to be more "mother-" and "baby-" friendly while American midwives are finding out that they are susceptible to (and influenced by) the same insurance pressures that have made OBs so focused on the active management of labor. 

In order to avoid malpractice suits, OBs are driven to act on, rather than support, the labor and childbirth process. This is one of Block's major points: active management of labor and delivery is defensible in the case of a bad outcome; waiting to see what happens is not. So, at the first sign of trouble, an OB must take action. This starts a cascade of interventions, which too frequently ends with a scalpel to the abdominal cavity. 

How does this relate to my experience? Three weeks ago, my OBs came to the conclusion (based on poor measurements taken by their bad sonographer) that my baby is growing asymmetrically*** and is four weeks smaller in the abdomen than she should be. They immediately referred me to a perinatologist (basically an OB for high-risk pregnancies). After much research and deliberation, I decided to see the perinatologist, if only to remove the categorization of "high-risk" from my pregnancy. At the perinatal care office, I learned that my baby is perfectly symmetrical, but small (measuring three weeks behind her OB calculated gestational age, which is wrong by the way). The perinatologist reviewed the measurements and recommended that we induce labor at 38 weeks. I found this to be quite befuddling. I have a small baby - she clearly needs more time to grow - so my recommended course of action is to take her out early??? 

We asked him why. He looked at me, and then at Kyle, and said "it's very likely that the baby is small because of genetics," however, he continued, with babies that are small for gestational age, sometimes this is due to inadequate nutrition in utero. Since there is no way to know with certainty why a baby is small, we recommend induction for all small babies. Huh.

The doctors have to protect themselves; they simply cannot not recommend induction. Why? Because if my baby is born at a deficit due to insufficient nutrition in utero, then I could sue them for not acting on information indicative of a problem with my pregnancy. I understand that, so I politely decline; it is my decision to make after all.

Iatrogenic prematurity is premature birth caused by the physician, usually via labor induction or scheduled cesarean. The popular belief is that, rather than waiting for labor to start spontaneously at an odd hour, OBs like to induce in the morning, deliver by dinnertime. My OBs have been gritting their teeth to induce me since the first ultrasound measurements came in to suggest that Holly may be growing asymmetrically (see IUGR). Thwarted on that front, now they want to induce me because she is small****. I won't let them.

Opposing the doctors (not taking their "serious" recommendations): that has been challenging, to say the least. They are forceful, persistent, and they have all sorts of nifty diagnostic gadgets on their side. I know that I haven't yet heard the end of the induction talks. Now I am just counting down the days (and appointments) left until my estimated delivery date, hoping that my labor starts spontaneously before the doctors find yet another reason to induce. After that happens, then the medical community and I can move on to battling about something else, like whether I stay strapped to the monitor and/or whether I push in a lithotomy position. 

Bring it on, medical community.

* Block is a journalist, after all. I would not openly call her credibility into question, but I don't think it's unfair to suspect that the information she presents is slightly shaded or exaggerated to heighten its impact on delivery. Furthermore, I trust the data she presents, but also know she may well be withholding data as well in an effort to strengthen her position. As my college suite-mate once remarked, "statistics will tell you anything if you torture them enough"; that is, the analysis of raw data still requires choice (of what's included, what's not, what's meaningful, what's not, etc) and interpretation. By tweaking the variables, thresholds, and analytic methods used, one can significantly alter the outcome of an analysis.

** What follows is a very simple interpretation of the current "issue". It's much more nuanced than what I will deliver here; but I want to make sure to get the basic point across (and I don't want this post to turn into a novel). I am happy to further discuss any aspect of modern maternity care and my findings with any interested readers.

*** At the time, the OBs insisted that it is the asymmetry that worries them, not the size. 

**** At 37 weeks, she weighed 5.5 lbs. That doesn't seem small to me...