Imagine if the Royal College of Midwives (RCM) treated breast health the way they treat childbirth.
Imagine a Campaign For Normal Breasts.
It would be premised on the assumption that most women (8 out of 9) will go through life without developing breast cancer. It would be premised on the notion that a breast biopsy that does not end with a diagnosis of cancer is simultaneously a failure, a waste of money and an indictment of the technology that discovered the lump in the first place. It would rest on an ideological commitment to “trust breasts” and rely on the provision of care by those who are NOT experts in the diagnosis, treatment and cure of breast cancer. A breast cancer specialist would only be consulted in the event that the patient was near death from cancer.
What would happen?
Inevitably, women would die of breast cancer who didn’t have to die.
Why?
Because we would not diagnose breast cancer until the tumor was large or until it had caused other symptoms by metastasizing. That’s what happens when you deprive patients of the opportunity of early diagnosis and early treatment. That’s what happens when you refuse to use preventive care.
Yet the RCM has done precisely that in its Campaign For Normal Birth. The Campaign For Normal Birth = A Campaign Against Preventive Care.
The RCM Campaign for Normal Birth is a campaign against obstetric interventions and C-sections, but obstetric interventions and C-sections are the pillars of preventive care in childbirth.
Ceseareans are like breast biopsies; most are unnecessary in retrospect. When a woman finds a lump in her breast, the odds that is breast cancer are quite low. When a mammogram detects an abnormality the odds that it is breast cancer are quite low. Therefore, applying the reasoning that RCM applies to cesareans would mean that the rate of breast biopsies should be cut dramatically. In most cases, watchful waiting is all that is necessary to demonstrate that the lump or abnormality was not breast cancer.
Applying the reasoning that the RCM applies to obstetric interventions, women should never have mammograms because most of what they diagnose turns out to be benign. Women probably shouldn’t examine their breasts and if they find a lump, they should watch it until other, more serious, symptoms develop.
Think about how much money we could save. All those mammograms and biopsies cost a fortune; just waiting to see what happens costs nothing.
Think about women’s experiences. If we did far fewer breast biopsies, women would not have permanent scars on their breasts. There would be no need for pain medication, dressing changes, etc. if you just watch and wait to see what happens.
Think of the midwife’s experience. She could maintain control of the patient until the last possible moment. She wouldn’t have to call a breast cancer doctor until it was clear that the patient was dying.
Of course if you think that a policy of watchful waiting is inappropriate for breast lumps and mammogram abnormalities, even considering that most biopsies are unnecessary, why would you think a policy of watchful waiting is appropriate for C-sections simply because many of them are unnecessary in retrospect?
Preventive care is not defective, unnecessary or a waste of money just because we find out later that it wasn’t needed. There is nothing better about “normal breasts” as compared to those that have been scanned or those that have been biopsied. It would be wrong and deadly to campaign for normal breasts by eschewing preventive care.
In medicine, the reasons for a procedure are known as “indications.” So, for example, the indications for a breast biopsy would be a lump in the breast or an abnormality on a mammogram. There is no expectation when undertaking a breast biopsy that a woman would die without it; indeed there is every expectation that a woman doesn’t even have breast cancer. We expect that most breast biopsies will turn out to be unnecessary in retrospect.
There are a variety of indications for obstetric interventions. There is no expectation when emplying interventions that the baby would die without them; indeed there is every expectation that the baby would have survived an unmonitored vaginal delivery just fine. But claiming that a healthy baby means obstetric interventions were unnecessary is like claiming that a benign breast lump means a breast biopsy was unnecessary.
The RCM Campaign For Normal Birth = an RCM Campaign Against Preventive Childbirth Care.
Dead babies, such as those who died at the hands of midwives ideologically committed to “normal birth” in the Morecambe Bay horror, are the INEVITABLE result of any campaign for normal birth.
The RCM should immediately suspend the Campaign For Normal Birth as unethical and deadly. I predict, however, that they will do no such thing. They will emulate the midwives of Morecambe Bay in protecting their turf while babies and mothers continue to die.
This is a very good information for them to learn especially that it can help many people on how are they going to implement proper care which would surely give them enough knowledge about it.
“Normal” is at least a third of babies born not reaching adulthood. “Natural” is women dying by the score.
I’m not okay with “normal” or “natural.” I want SAFE. We *have* normalized safe birth. Unfortunately, rather like with how the normalization of children not dying in droves from infectious disease has resulted in parents fearing vaccination, mothers have come to fear the very technologies that created the atmosphere that lets them feel birth is worth trusting.
From time to time, I wander through old graveyards. You’ll see rows of small headstones; entire families wiped out in now preventable epidemics. And there are always at least a few headstones of young women, set beside the smaller monument to the child whose birth killed them.
wandering through biographies of pre-20th century people has some of the same effect for me.
I wonder if it would be useful to contact this guy, Dr. Amy, and make sure he’s aware of what’s going wrong.
http://www.buzzfeed.com/jamieross/nha-party
This is quite possibly the best post you’ve ever done. I cringe at the way birth sites toss around the word “false positive” for screening tests. No, it’s not a “false positive.” It’s a positive that you need a diagnostic test to determine your status. Was it a pain in my ass to take the 4 hour diabetes test? yes. Was it wonderful to learn that I did not have GD? Also yes. Was all of this better than having undiagnosed GD? Hell to the yes.
I personally don’t get the obsession with “Normal” birth. If life has taught me anything, it’s taught me that “Normal” is highly overrated. Normal is dull and monotonous. Personally, I strive to be “Abby Normal.”
And ‘normal’ is also pretty judgmental, because if it isn’t normal we’re talking about ‘abnormal’.
That’s why I prefer the term “natural.” Because the opposite is “miracle of modern science.”
Love it.
Well, that depends—in reality, there IS normal and abnormal, though I agree, its odd to apply to birth. I think “normal” birth is one where a healthy baby is born to a healthy mother—the how isn’t important. There’s no reason to assign a moral value to how a baby gets from inside to outside. An abnormal birth would be if the baby came out the mother’s ear or something.
If the pregnancy is complicated, I guess it could be argued that it is abnormal. It is certainly not TYPICAL to carry mono-di twins, or be T1D going into the pregnancy, and often people mean “typical” when they say “normal.”
And then, if a baby is born with 3 arms instead of two, no one is going to believe that is normal because it isn’t. Two arms is normal, 3 would be a congenital defect. It would be judgemental to then say that that baby (or its mom) were lesser people because of the 3 arms, but to note that having 3 arms is not normal is not judgemental.
Well, my husband was born with cataracts. That is definitely not normal. I sort of see “normal” as a spectrum, and things about humans that lay a little outside that spectrum as “unusual.” I save abnormal for things like pedophilia. Or jokes about being Abby Normal. (Love Young Frankenstein!)
Having had too much math in my background, I think of ‘normal’ as ‘perpendicular.’
Having had WAY too much math, I think of “normal” as a probability distribution clustered around its mean. But that, too.
Yes! Math/stats/science have so many context-specific meanings for normal(ize). I tend to think of a Gaussian distribution- “campaign for normal birth” sounds like one side of a disagreement about which statistical distribution fits best.
I think they should use Pitocin carefully to ensure that labor lengths are normally distributed. Then you’d have normal births.
If you use the vector definition of ‘normal,’ this would appear to be a campaign for transverse positions…
or C-sections, depending on what your vectors are.
If we want birth to be normalized, we could make sure the integral over all space is = 1
WE have all of this Technology all of these brilliant Doctors…let them help us…doing everything all natural is for the uneducated and ignorant.
Exactly! For example prenatal care is the very definition of unnatural, and yet this technology has reduced perinatal and maternal deaths to tiny fractions of what they were under all natural conditions.
I mean think about it, drawing blood with a hollow needle and analyzing it in a computerized machine to detect problems– 100% unnatural, and a total lifesaver! Only the uneducated and ignorant would reject something like that.
The only part of what you wrote that I might quibble with is your idea that all doctors are brilliant. Doctors, in my experience, do tend to be reasonably smart, and they are certainly all highly educated and trained. But I wouldn’t call most of them brilliant. I reserve superlatives like that for Science itself. The Scientific Method, yes that is Brilliant! It has transformed Birth, the previous #1 killer of babies and young women, into a day that women can look forward to. Amazing.
Yeah, doctors are human, too. Most of them are pretty awesome though, which makes the few that pander to crap so dangerous. They ride on the respect the rest of the profession earns.
Yes, this! And with ordinary doctor you can walk away if you suspect that provided care is substandard and seek for other opinion and other doctor, whereas midwife and/or OB during delivery is one shot deal and with first birth you can not know what is “normal” and what’s not. Great if you can have the same care provider who was with you during prenatal care but it’s not always possible.
Doctors are the worst possible deliverers of medical care…except all the others. I’m actually kind of looking forward to the day when the robots put us out of business.
Tricorders, baby.
And anabolic protoplasers. #GeekierThanThou 🙂
And, if we insist that “natcheral” is better, why don’t we walk everywhere, communicate only face-to-face and only eat what we can hunt or grow? Cars and aeroplanes, telephones, the internet and supermarkets are far from “natcheral” after all. As is health care.
Orac has written about the mammogram issue a lot: http://scienceblogs.com/insolence/2014/04/10/uncertainty-versus-certainty-in-the-mammography-wars/
Mammography isn’t really my favorite test. Unlike, say, pap smears and colonoscopy, it has no preventative component (you can’t remove precancerous lesions and prevent cancer with a mammogram, though you could argue that finding DCIS is the equivalent.) It uses radiation, which has its own risks. It has a high false positive rate, leading to excessive biopsy and anxiety (I had a mammogram that required repeat imaging last year…had my funeral all planned out before the repeat turned out to be almost comically negative…I may be a bit of a hypochondriac).
OTOH, late breast cancer kills. Early breast cancer quite often doesn’t. We need a better test for detecting breast cancer, but the one we’ve got isn’t useless.
I find the whole conversation about mammograms to be headspinning. When you say that late breast cancer kills, does that mean that if it had been detected earlier, the woman would not die of cancer? Or that if it had been detected earlier, she would have “lived longer” because there were more years between diagnosis and death? Or does it completely depend on the type of breast cancer — some cancers which have the potential to be deadly can be nipped in the bud for good early on and some can’t?
Um…yes? The five and ten year relative survival rates for stage I breast cancer are extremely stable (and over 100% for white women over age 50 at diagnosis) suggesting that there may be quite a lot of true cures for early diagnosis (though, hmm…maybe I should look at 25 year rates to be sure). OTOH, finding the cancer earlier does mean a longer time as a patient and that’s a known confounder in cancer epidemiology. A lot does depend on the type: hormone positive cancer tends to grow slowly and allow for long survivals…but pop back up many years after you think it’s gone. Hormone negative kills more often but if it’s gone it’s usually gone and a five year survivor with no evidence of disease is usually cured. Cures can only be obtained in people who do not have metastatic disease and the chances of cure are higher in early stage disease versus later, so if mammography can find hormone negative cancers earlier that would be likely to result in more cures…but hormone negative cancers grow rapidly and therefore are less likely to be develop between mamograms.
Does this help at all? Sorry, the short answer is still that it’s just not very clear.
And they will export their campaign to willing other countries by exporting thought leaders in the campaign (like Soo Downe) to places like Vancouver where they can give lectures at prestigious universities (like UBC). If ever there was a case for preventitive care, it would be pregnancy and childbirth – the time horizon over which the benefits accrue is just that large.
Interestingly, there is ambiguity about the exact indications for mammograms. Experts disagree on when to start (40 versus 50 for average risk women), what to consider an abnormality requiring biopsy, and when to stop screening. But no mainstream oncologist or radiologist, as far as I know, is suggesting that mammograms simply never be used. Instead the questions are all about risk/benefit ratio in marginal cases. The equivalent for c-sections might be asking whether c-section could safely be foregone in some cases of slow progression of labor or when VBAC is safest, not the “pregnancy is not a disease, no one needs c-section” thing the NCB movement is proposing.
And with breast cancer screening there are exceptions – strong family history, start screening sooner. However, those kinds of things are ignored when it comes to childbirth by midwives – strong family history of prolapse? So what. Strong family history of extensive tears during childbirth – again, woman up and repeat. In general, the approach to cesareans needs revision – there’s a whole lot of context that gets ignored in determining what is or isn’t an adequate justification for undergoing one and shared decision making and patient rights cannot be a one way street it can’t be you have a right to forego medical intervention, but no right to select it.
Or other factors for Csections like twins, breech, previous C section—those are considered high risk for pregnancy, just like a woman with a known BRCA mutation is considered high risk for breast cancer. Often, the above mentioned pregnancy risks lead to scheduled C section, just like someone with the BRCA mutation would likely have early screenings and may even get a preventive mastectomy. In both cases, watchful waiting to intervene when disaster strikes can be quite deadly.
Routine mammograms for breast cancer preventative care is also being challenged.
http://www.newsmax.com/Health/Health-News/mammograms-breast-cancer-benefits/2014/03/12/id/559061/
“it’s critical that women understand that mammograms do not necessarily reduce the risk of dying from breast cancer. She adds that mammograms may make sense for some women — those at high risk because of inherited and genetic factors, which can be identified through genetic testing.
But she also notes that cancer can be successfully treated, if it does develop.
“I think we need to understand that cancer … is not a death sentence,” she says, “and we need to start really putting it into perspective because we’ve made such a big thing out of the mammograms saving lives.”
In addition, she recommends women take control of their health and reduce their risks of developing or dying from breast cancer as they age by engaging in healthy habits that have been clinically shown to offer protection against the disease.
Among them:
Engage in regular moderate exercise, 20 to 30 minutes each day.
Eat a healthy diet, heavy on fruits, vegetables, whole grains and other nutritious foods.
Manage stress effectively by some means.
Get regular sleep each night (average 7 to 9 hours); and
Consider taking bio-identical hormones to maintain a healthy balance of these key biochemical regulators of the body’s immune system, metabolism, and other key functions.
“Listen, I’m 64 years old, I take bio-identical hormones and I’ve been taking them for 16 years. I take really good care of myself and I eat well. I exercise, I sleep eight hours a night. I focus on something that I’m passionate about, which is helping women and men prevent disease,” she says. “I didn’t really think that having a mammogram … was actually helping me.
“I also think that you need to look at your life in general and look at what are you looking for. Well, I’m looking to be healthy and I’m looking to feel good. And getting a mammogram is not necessarily, for me … what will make me feel good.””
Dr. Schwartz in a celebrity wellness advocate who promotes bio identical hormones; she has her own agenda.
The parameters of routine mammography have been challenged and, as with any screening test, it is important to adjust the parameters to minimize both false positives and false negatives. No one is suggesting abolishing mammography screening altogether.
Moreover, no one is recommending forgoing biopsies just because most lumps are benign
This doctor is advocating skipping them unless you already know you are high risk, which is like skipping sonograms in pregnancy unless you already know you’re high risk.
My point is that the crazy is everywhere. It’s hard to find a direction to point in without hitting someone who is willing to take blood money selling “natural” something or other as the cure.
In fact, gynecologic care, including cancer screening would be a “logical” place for CPMs to move next.
The “village herbwoman” model of care.
What happens when this lady gets cancer of some kind anyway? What will she blame? I guess if its not breast cancer, she can say “See!! I prevented breast cancer! I never claimed that my advice would prevent skin cancer!”
I was going to say to just trust breasts, but I am here to say that they are wholly untrustworthy. 🙂
The evidence for “bioidentical hormones” doing anything positive is, as far as I know, virtually nonexistent. (Not to mention the risks involved in taking an essentially unregulated medical product.)
Did anyone else click on the link, only to wonder how many tanning booths that doctor has visited? She looks hyper-sunburnned to me. Not someone from whom I would seek out medical advice…
Ha! I didn’t even click the link when I made that comment about skin cancer below!
Didn’t Suzanne Somers promote bio-identical hormones, yet end up with breast cancer?
She promoted bio-identical hormones post-breast-cancer. She had local cancer and had it treated by surgery (lumpectomy) and went with radiation adjuvant, but declined chemo and tamoxifen adjuvant, which would have improved her relapse-free survival odds – but they were already pretty good with the cancer she had and the standard of care she got. Orac has the full low-down on her story.
“There is no expectation when emplying interventions” should be “employing.”
The finding by the British Supreme court that a diabetic should have been advised of the risks of vaginal birth and offered a CS might have an impact.
Informed consent means that patients have to be advised both of the risks and benefits of any treatment proposed AND of the risks and benefits of NOT offering treatment. This judgement means that women should be informed of the risks of VB in their specific case.
When it comes to childbirth that would actually mean the the current “benefit of VB vs risks of CS” conversation is going to have to be substantially expanded.
It would also appear to suggest that if anyone said “VBAC is unacceptably risky for me” and was denied an EM CS after presenting in labour that hospitals could find themselves on the hook for any foreseeable damage that resulted.
I agree with Dr. Kitty that it probably will change things for the better at least in the UK. Below is a link to an article about the case but basically…
Mom is a diabetic that had expressed concerns during her pregnancy about her ability to delivery vaginally. He doctor “told the court that despite the risk it was her practice not to spend a lot of time discussing the issue” because “the risk of a grave problem for the baby from the condition was very small, and if it was mentioned, most women would opt for an elective caesarean (Sic) section. She added that in her view it was “not in the maternal interests for women to have caesarean (sic) sections”. Baby had shoulder dystocia and was born with brain damage. The UK supreme court upheld the mom receiving damages of £5.25 million.
http://www.telegraph.co.uk/news/health/11464433/Mother-whose-son-suffered-brain-damage-wins-5.25-in-landmark-court-battle.html
Oh my god, that poor family.
It’s the woman’s right to decide what risks she is or is not willing to take with her own body and that of her child. I applaud this decision.
Exactly, that is the crux of the issue- informed consent means informed consent- it doesn’t mean “I get to inform you of the risks and benefits that are important to me”- it means “I inform you of the risks and benefits and you decide what is best for you”.
Which, also, IMO, means that women should be informed that while the ABSOLUTE risk of perinatal death remains low, homebirth and MLU birth substantially increase the relative risk of ending up with a dead baby…
Full judgement here:
http://www.bailii.org/uk/cases/UKSC/2015/11.html
I’m sure you’ll particularly enjoy Lady Hale’s supplementary judgement, at the bottom.
There’s also video of the Lords reading a shortened version of the judgement:
https://www.youtube.com/watch?v=t5NcXFwX23Q
On the substance of the case, I wonder whether the mistake wasn’t attempting a forceps delivery with a diabetic mother and large(ish) baby, when she failed to progress, rather than having a trial of labour in the first place- but then a large part of my obstetrics knowledge comes from watching One Born Every Minute (which featured at least one bad and lengthy shoulder dystocia from attempting forceps delivery of a huge baby: http://www.channel4.com/programmes/one-born-every-minute/on-demand/52556-006 from 23 mins- I don’t know whether the Youtube version is available outside the UK: https://www.youtube.com/watch?v=i-pMhEjmQMg).
It started with not doing an USS on the day of induction to see how much the baby had grown in the last five days, given that the EFW 5 days before was 3.9kg and the OB had already decided she would offer CS at 4kg, and got worse from that point onwards.
Never mind the gruesome details of how the SD was resolved….
Sam and Nadine Montgomery have my unreserved sympathy for difficulties they continue to face. I am sure the obstetrician has deeply regretted the outcome since the day of sam’s birth
BUT
3rd trimester ultrasounds are fraught with difficulty and nobody would do a second growth scan 5 days after a formal report (any variation is likely to be due to the inter operator / machine variability).
The counselling took place 16 years ago – the world has changed and patients are treated differently.
I have spent the past few days dealing nail bitingly with placenta accretas – should we consent women that their maternal request elective Caesarean may ultimately end up with a 17 unit transfusion, bladder injury and ITU during their 3rd pregnancy?
I am not a fan of pure maternal request Caesareans on the NHS and feel strongly that if that is what you want and at least 2 doctors remain unconvinced then the NHS should not offer this service for free (ignoring arguments about tax payers etc.)
While I agree with much of what is discussed here, especially regarding Morecambe Bay, there seems to be little discussion of the disadvantages from families dictating their medical care.
Absolutely advise women of the risks of accreta, but if you’re doing that, advise her of the risks of VB too.
And there are risks.
I’m really not happy with your suggestion, BTW regarding “two doctors”, and you know why- because in the UK you can’t request a specific consultant. If she is unlucky to see you and your colleague who feels the same she’ll get two no votes automatically. Then she’d be left without an option she finds acceptable unless she has £2k to spare (although the actual extra cost to the NHS of a CS over a VB once all downstream costs is taken into account is less than £250).
Meanwhile women can demand home births and birth centre births which are completely unsafe without being asked to fund that.
NICE already has the guidance, follow it.
Your job is to ensure the consent is informed.
Like any other medical decision, when there are two clinically acceptable treatment options (and current guidance is that CS and VB are both acceptable treatment options) the decision rests with the patient.
Lay out your case for VB, honestly, but trust your patient to decide.
Seriously, what would be a good idea, and the NHS would be in a uniquely favourable position to achieve this, would be an anonymised register of obstetric morbidity, interventions and outcomes. For example instrumental deliveries (what type, high, low, level of operator experience, estimated birth weight, actual birth weight, any pre-existing conditions), shoulder dystocias (same kind of details) and more.
This could inform how to configure these services to deliver the best outcome, potentially narrow down where problems are occurring, both for particular units and where interventions need to be targeted to minimise the burden of “unnecessary” ones, and give women more information.
This doctor gave me the creeps! I got the impression that she saw herself as the Almighty who can shape one’s fate because well, he’s the Almighty. It’s like Mommy knows best.
Wouldn’t that be an example of the paternalistic model that everyone thinks we should avoid?
Indeed.
OK, so what is ICAN’s response to that decision? I’m sure they are applauding it, right?
ICAN would only be advocating Maternalistic models.
Exactly. That doctor’s attitude was breathtakingly arrogant.
great decision, I hope this changes things in the UK so that women are no longer denied csections