Imagine that I published a paper crowing that the US had reduced the use of chemotherapy.
Chemotherapy is expensive, arduous and has a plethora of terrible complications up to and including death. We would save lots of money and prevent lots of serious complications. A victory, right? Wrong!
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Lowering death rates is an achievement; lowering intervention rates is not.[/pullquote]
You don’t have to a rocket scientist to understand that simply reducing the use of chemotherapy is meaningless in and of itself. It might be meaningful be but ONLY if the death rate from cancer held steady or dropped. If the cancer death rate rose, the reduced use of chemotherapy wouldn’t be an achievement; it would be an indictment of skewed priorities. At worst, it would reflect an appalling eagerness to save money instead of lives.
There’s a principle being illustrated here: chemotherapy is a process not an outcome. Improving outcomes is an achievement. Changing process is not.
The same thing goes for rates of intervention in childbirth. That’s why I despair when I see papers like the one published today in JAMA, Temporal Trends in Late Preterm and Early Term Birth Rates in 6 High-Income Countries in North America and Europe and Association With Clinician-Initiated Obstetric Interventions.
The authors found:
Between 2006 and 2014, late preterm and early term birth rates declined in the United States, and an association was observed between early term birth rates and decreasing clinician-initiated obstetric interventions. Late preterm births also decreased in Norway, and early term births decreased in Norway and Sweden. Clinician-initiated obstetric interventions increased in some countries but no association was found with rates of late preterm or early term birth.
ABC News reported:
The rate of cesarean sections and induced births in the U.S. has declined, reversing a decades-long trend of increased rates of obstetric interventions, according to a study published today in the Journal of the American Medical Association.
Researchers from multiple institutions … found measurable drops in the amount of obstetric interventions taking place in babies delivered both late pre-term (34-36 weeks of pregnancy) and early term (37-38 weeks of pregnancy). Researchers found there was a decrease in obstetric interventions from 33 percent in 2006 to 21 percent in 2014 for early-term infants and a slight decrease — from 6.8 percent to 5.7 percent — for infants born in late pre-term births during this time period.
Dr. David Hackney is quoted:
It always feels good to have a long-standing public health and educational campaign [of decreasing medical interventions],” he said. You “can actually see the change in … public health findings.”
Wrong, wrong, wrong!
No one should feel good about anything until they determine how many babies were injured or died to reach those lower intervention rates. I find it utterly appalling that no one even looked. Crowing about process while ignoring outcomes reflects two deeply disturbing trends: the pressure to save money and the obsession with “unhindered” birth.
The pressure to save money is at least understandable; we don’t have unlimited money to spend on healthcare. But the glorification of birth without interventions has no basis in science. It reflects the values of the midwifery and natural childbirth communities who demonize interventions they cannot provide because that is how THEY profit.
Dr. Jennifer Spong wrote an editorial accompanying the JAMA piece. The title, Improving Birth Outcomes Key to Improving Global Health, sounds promising. Our goal should be improving birth outcomes and thereby improving global health. Sadly Dr. Spong barely mentions outcomes and only in the last lines:
However, physicians cannot become too devoted to decreasing late preterm and early term birth rates. For pregnancies in which there is a complication and when delivery will optimize the pregnancy outcome, delivery should occur and will require an obstetrical intervention.
That’s because decreasing early birth rates is NOT an appropriate outcome. The outcome of childbirth can only be measure by death and injury rates and no one has bothered to do that here.
It saddens me that I have to repeat the obvious:
Any birth that results in a preventable injury or preventable death is a failure REGARDLESS of whether it is a vaginal birth at term without interventions.
Obstetricians have a legal and ethical obligation to maximize health in mothers and babies; they have no obligation to minimize interventions or maximize term births.
