Page 1 of 2
There’s a saying that birth is as safe as life gets. There are times when birth can become dangerous for the baby or, very rarely, for the mother. This is when hospital-based maternity care really shines, and we’re able to save mothers and babies who a hundred years ago might have died. Thank goodness that there are skilled surgeons who can come to the rescue when truly necessary.
There’s also another saying: When you’re holding hammer, everything looks like a nail. Likewise, for hospital-based birth attendants, it is easy to become accustomed to treating every birth as a disaster waiting to happen. Many obstetricians have lost touch with the possibility of normal birth, so much so that even labor that includes a pitocin induction with an epidural, a fetal scalp electrode and a vacuum extraction is called a “natural” birth. Some hospital staff seem offended by the idea of minimizing interventions, as if preferring not to have a needle the size of a house nail inserted near your spine is the same as declining to have a second piece of Aunt Sally’s fruitcake. Sadly, some of today’s younger doctors may never even have seen a truly physiological labor and birth—a birth completely without medical intervention.
This is how the saving grace of the hospital can become the scourging disgrace of maternity care. In their rush to prevent problems that aren’t happening, hospital personnel may aggressively push procedures and drugs that can actually cause problems. Pitocin can cause uterine contractions so strong that they stress the baby and cause fetal distress. IV narcotic drugs can affect an infant so strongly that he might not breathe at birth— a second drug is used to counteract the narcotics to help these drugged babies breathe. There is considerable debate as to how epidurals affect the progress of labor, but they certainly diminish a woman’s ability to get into a squat, which opens the pelvic plane by 20 to 30 percent; anyone can understand that this could affect the possibility of the baby’s fitting through the pelvis. Epidurals can lower the mother’s blood pressure so that the baby isn’t getting enough oxygen through the placenta. This can cause fetal distress and the need for an emergency caesarian section to rescue the baby.
In addition to the specific dangers of individual obstetric intervention, hospital births suffer the effects of any form of institutionalized care. Perhaps the best-known risk of hospital birth is hospital-acquired infections. The people most susceptible to such infections are those with compromised immune systems, such as newborns. In particular, a baby is born with a sterile skin and gut that are supposed to be colonized by direct contact with the mother’s skin flora. If antibiotic-resistant hospital germs colonize the baby’s skin and gut instead, the baby will be at high risk of becoming very sick from infections that are very difficult to treat. The overall infection rate for babies born in the hospital is four times that of babies born at home, and these infections are more likely to be antibiotic-resistant.
Ninety thousand people die every year from hospital-acquired infections. That’s more than from all accidental deaths put together: 70,000 people die from motor vehicle crashes, fires, burns, falls, drownings and poisonings combined. An additional 98,000 people die each year from general medical error.
Division of Labor
Another obvious risk of institutionalized care arises from the piecemeal nature of the care. Because there are so many different kinds of personnel performing so many different procedures, there is a lot of potential for miscommunication about critical matters. In an astoundingly progressive admission of institutional shortcomings, Beth Israel Hospital in Boston published a paper about a tragic miscommunication that resulted in a baby’s death. To their great credit, instead of covering up this horrible mistake, Beth Israel used it as a wake-up call to revise their protocols, in an attempt to reduce miscommunication and increase safety. Unfortunately, other hospitals are slow to adopt their reforms.
One of the most dangerous aspects of hospital care is that those providing most of the direct care (i.e. nurses) are hierarchically subservient to those managing the care from a distance (i.e. doctors). This power structure can prevent knowledgeable nurses from mitigating potentially dangerous actions of a misunderstanding doctor.
Many people feel that a hospital must be the safest place to give birth because of all the equipment it has. But equipment is only as good as the people using it. In many hospitals, there are not enough registered nurses to cover all the patients, so they use medical technicians, who are trained to perform procedures but not necessarily trained to interpret fetal heart tracings. Most labors start at night, especially for women birthing second or subsequent babies. This is the time when the senior staff are off-duty, because their seniority allows them to opt for the more desirable daytime shifts. A recent study confirmed that birth outcomes are worse during the night. Even the most sophisticated equipment is useless in the wrong hands.
(For the record, many homebirth midwives now carry equipment that is as sophisticated as that in most hospital birth rooms. This includes continuous electronic fetal monitors and equipment for performing neonatal resuscitation if necessary.)
Institutionalized care also suffers from the economic pressures of running an efficient organization, regardless of how this might interfere with the normal process of labor and birth. Sometimes doctors recommend pitocin without true medical necessity, simply to hasten the birth. This may be due to a need to free up a birth room to make room for other patients, or because the doctor has other responsibilities elsewhere. Stimulating labor artificially overrides a baby’s ability to space out the contractions if the labor is too stressful. This increases the risk of fetal distress.
Hospital staff have a strong bias towards confining laboring women to the bed and requiring them to push in a reclining position. This often puts a baby’s weight on the placenta or umbilical cord, possibly restricting the baby’s supply of oxygenated blood from the placenta. In contrast, upright positions put the baby’s weight downward, toward the open cervix and away from the placenta and umbilical cord, reducing or eliminating fetal distress caused by cord compression.
A rush to clamp and cut the umbilical cord within seconds after birth is one of the most dangerous hospital practices. This premature severance of the umbilical cord cuts the flow of oxygenated blood to the baby before the baby has established the lungs as the source of oxygen. Premature cord clamping also deprives the baby of the blood that would naturally fill the pulmonary vasculature as it expands in the minutes immediately after the birth. This practice has been documented to increase the risks of neonatal hypoxia, hypovolemia and anemia, thus increasing the need for blood transfusions.
There is some very new research showing that placental tissue itself may be a rich source of pluripotent stem cells (cells which can give rise to any cell type) in addition to the blood stem cells in blood drawn from the umbilical cord. We do not yet know whether premature cutting of the umbilical cord halts the migration of pluripotent stem cells from the placental tissue into the baby’s body to repair damage from even minor birth trauma.