Introduction

Reviews

When Less is More: The Example of Childbirth

Timothy B. McCall, M.D.

The bright-light, high-tech, intervention-oriented world of modern obstetrics isn’t the most conducive environment for the normal progression of labor. Recently there has been a counter-current toward a lower-tech alternative.

A study in the New England Journal of Medicine has shown that if nurses or doctors regularly listen to the baby’s heartbeat by placing their stethoscopes on the mother’s stomach rather than using the invasive fetal monitor, the babies do just as well. More importantly, when the fetal monitor isn’t used, false positive readings of “fetal distress” that may scare the doctor into performing a C-section even though the baby is fine, are never obtained. The cascade that ends with a C-section can be stopped before it starts.

One approach, increasingly popular with women, is to use midwifes instead of obstetricians to deliver their babies. And studies suggest this may be a sensible approach. Researchers at Johns Hopkins University compared the rate of obstetric interventions at a large Philadelphia teaching hospital with that of a family-oriented maternity center staffed by midwives, backed by on-site physicians. The women in the two institutions were similar in age, race and education. The following table shows the percentage of time each intervention was employed:

Procedure	Maternity Center	Teaching Hospital
Induction of labor	9.7%	12.1
Pitocin administration	22.2%	32.1%
Electronic fetal monitoring	42.7%	63.3%
Anesthesia (an epidural for example)	24.5%	78.6%
Episiotomy	62.2%	86.4%
Forceps delivery	9.7%	27.0%
C-section	5.3%	18.2%
Normal vaginal delivery	83.0%	53.9%

Both institutions tended to intervene with high-risk pregnancies. Low risk women at the teaching hospital were 12 times more likely to have an invasive delivery (C-section or forceps) and 22 times more likely to receive an anesthetic. Despite all the intervention, infants born at the university hospital fared no better than infants born at the maternity center.

Lower-tech care, less driven by technology, can be more human, too. One difference between midwives and obstetricians is that midwives attend more to the women and better meet their emotional needs. The result can be better quality care.

Consider two studies from Guatemala that suggest that the presence of a supportive companion, a doula, during labor reduces the need for C-section and other interventions. Researchers from Case Western Reserve University studied whether doulas would be effective in the environment of a modern American hospital. The doula stayed at the woman’s bedside throughout labor, soothing and touching her, explaining what was happening and giving encouragement.

In every other sense the childbirth experience was typically American: the women were confined to bed as soon as they were admitted to the hospital to allow for electronic monitoring, an I.V. was started and the woman’s membranes were routinely artificially ruptured. Pitocin was started if labor didn’t progress fast enough, drugs and epidural anesthesia were given as deemed necessary by the doctors to relieve pain.

Marked differences were noted between the women who had doulas and those who didn’t. For the women with doulas, the total duration of labor was two hours shorter. Overall, 8 percent of women with doulas needed an epidural, compared with over 55 percent of the women in the control groups. The risk of an epidural, by the way, is that it tends to prolong labor, increases the use of forceps for delivery and makes C-sections more likely (another potential cascade).

Only 17 percent of the women with doulas needed Pitocin compared with 44 percent of the controls. Only 8 percent had C-sections compared with 18 percent of the control group. Forceps were used on 8.2 percent of the time versus 26.3 percent for the controls. Even the babies of supported mothers did better: 10 percent of them had to stay in the hospital for a medical complication compared with 24 percent in the control group.

Next: Weighing the Risks and Benefits of Medical Interventions

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