Although this letter is addressed to a specific hospital, it applies to all hospitals and the issues facing pregnant families everywhere. The points Dr. Chavira makes here are fundamental issues with the entire maternity care system. This is why we continue to do the work of ImprovingBirth. We'll be holding a rally in front of this hospital Wednesday, September 7th, 2016 at 11am - 3pm to get this ban overturned. For more information about this event, visit the event Facebook page.
Dear Mr. Roberts, Dr. Cosgrove, and Dr. Landry:
I cannot sufficiently describe the profound sadness and disappointment I feel upon hearing that the OB Committee at Glendale Adventist Medical Center has recently banned vaginal breech birth. I wanted to write to you to express my thoughts on the matter. It is my sincere hope that you will reflect seriously on my comments, as the consequences of this decision are grave and impactful far beyond the catchment area of your medical center.
To begin with, a brief word about vaginal breech birth. This used to be a standard procedure in which all obstetricians were trained. As is also true with cephalic (head first) births, the breech birth was on occasion, difficult and fetal injury occurred. A landmark study published in the Lancet in 2000 reported adverse neonatal outcomes in 5% of vaginal breech births compared to 1.6% of cesarean breech births. This led to an immediate change in obstetric practice worldwide, and the American College of Obstetrics & Gynecology (ACOG) issued a Committee Opinion that breech-presenting fetuses should be delivered by cesarean section. Over the next few years, multiple problems with that trial came to light, and it became apparent that ACOG, our nation’s experts, had made a serious mistake. They reversed their stance in 2006, declaring that vaginal breech birth is a reasonable option in the hands of an experienced provider. Despite that reversal, the damage was done. To this day, the option of vaginal breech birth is afforded to a very small minority of women carrying a fetus in the breech presentation at term.
Other literature has yielded similar findings. Essentially, the overwhelming majority of vaginal breech births occur without incident, with poor outcomes in a small fraction of deliveries. Cesarean delivery may reduce this fraction by a few percentage points. However, the literature on breech birth only looks at short-term, physical endpoints. It does not address the long-term impact on the mother from cesarean delivery—recurrent cesarean delivery and the risks of life-threatening placenta accreta in future pregnancies. It does not look at the long-term health effects to the child from cesarean delivery, which are now well-documented—disturbance of the gut microbiome and increased rates of obesity, diabetes, asthma, allergies, and other concerns. The literature also does not address the issue of the impact of cesarean delivery on breastfeeding, bonding and attachment, and the psychological well-being of the mother. For many women, the cesarean delivery is a terrifying and traumatic experience, and some women suffer postpartum depression, as well as post-traumatic stress disorder, as a direct result of being forced into surgery. Thus, the small benefits of the cesarean delivery come at a substantial human cost.
As you can see, the risk versus benefit calculus is complex. The desirability of vaginal birth versus cesarean birth will vary greatly from one woman to the next. It will depend on her obstetric history, her medical history, her plans for future fertility, and her own personal views and values about vaginal birth versus surgical birth. An outright ban on vaginal birth will prevent a small number of birth injuries, but it will also eliminate the opportunity to individualize care, and it will expose hordes of women and children to the harmful consequences of cesarean delivery. In many cases, women will bear the burden of these consequences against their will, as they are forced into a surgery that they do not want.
I have empathy for the modern obstetrician. The stressors are tremendous, including financial, regulatory, and medico-legal pressures. Unfortunately, this is all too often re-directed at the patient, and much of modern obstetric care is delivered in a manner that is coercive, abusive, and traumatizing. As care providers, we must be attuned and sensitive to the damage that we are capable of doing. The American College of Obstetrics & Gynecology is acutely aware of this grim reality, to the extent that they have weighed in via official Practice Bulletins and Committee Opinions. They have expressed in explicit language that in honor of the ethical principle of patient autonomy, the mother is the ultimate decision maker in the setting of childbirth. They have stated explicitly that competent individuals have the right to accept higher degrees of personal risk. They have also stated that decisionally competent individuals have the right to refuse recommended care, even when needed to maintain life. They have stated explicitly that cesarean delivery is never to be forced upon a woman. They have expressed in explicit language in a recent Committee Opinion that obstetricians are never to attempt to influence patient care through the use of duress, coercion, physical force, or threats. The College also strongly discourages medical institutions from pursuing court-ordered interventions. The recently enacted ban on vaginal breech birth at Glendale Adventist Medical Center represents a de jure forced cesarean delivery and is in direct violation of the principles outlined above.
Prior to this ban, the OB Department at the Glendale Adventist Medical Center was a pillar and a beacon in a sea of indistinguishable and unremarkable obstetric units, thanks to the skill and years of dedicated service from Dr. Ronald Wu. At the Glendale Adventist Medical Center, the obstetric care provided approached the ultimate ideals of skill, compassion, true informed consent, and respect for patient autonomy. In essence, the Glendale Adventist Medical Center was a center of excellence—a rare and special place where women could go to have the birth that they felt was better for them and their children, the birth that nature designed, that ACOG endorses, and that ethical principles allow.
Now, sadly, your medical center has descended to the ranks of most other average hospitals where patients are not truly informed of the real risks and benefits of vaginal birth versus cesarean birth. Your patients will now be treated as they are at other medical centers: they will be misinformed, misled, not advised of their true options, and cajoled and even coerced into unwanted cesarean surgery. The shining light that once existed at your medical center has been extinguished.
As the leaders of an institution that is purported to help people live their healthiest and best lives, it is my sincere hope that you will reflect on the grave consequences of this poor decision. Just as ACOG made a mistake when it recommended cesarean section for all breech babies, your OB Committee has made the same mistake. It is my hope that you will engage your OB Committee in an open and earnest discussion about this policy, and consider reversing it. Please restore the shining light that you once were.
Emiliano Chavira, MD, MPH, FACOG
Dr. Chavira is a Maternal Fetal Medicine Specialist, treating high risk patients during pregnancy. He has a passion for caring for women with complex medical problems in pregnancy, especially those who thought they could never have a baby, or who have been told that it is too dangerous to do so. His goal is to provide objective and caring guidance to these women, without the language of fear that is so often introduced into the process of pregnancy and childbirth. In addition to caring for women with medical problems and complicated pregnancies, he also has an interest in supporting natural birth and breastfeeding for women and babies in general. He believes that medical interventions, which can be miraculous and life saving in some cases, should be reserved for those limited circumstances in which they are truly necessary.