On High Rates of Cesarean Section and Electronic Fetal Monitoring (EFM)
Why does the reality of everyday, routine care for birthing women diverge so radically from best-evidence practice?
It’s probably the money. The routine use of continuous fetal monitoring is a fine example, because continuous monitoring for every woman all the time is not best-evidence care, but once a hospital owns a fetal monitor for every L&D room, it becomes “hospital policy” to do just that: monitor every woman, all the time. The monitors are little cash-producing machines that crank out nice profits along with those paper strips.
The CDC just released the latest data on the c-section rate in the U.S., and alarmingly, it has risen to twice the rate recommended by The World Health Organization, and there is undisputed evidence that continuous EFM has a direct effect on the increasing cesarean rate. Here’s a quote from the 2005 Practice Bulletin #70 of the American College of Obstetricians and Gynecologists: “Despite its widespread use, there is controversy about the efficacy of EFM. Moreover, there is evidence that the use of EFM increases the rate of cesarean and operative vaginal deliveries. Given that the available data do not clearly support the use of EFM over intermittent ausculation, either option is acceptable in a patient without complications.” (Obstetrics and Gynecology, Intrapartum Fetal Heart-Rate Monitoring 106 (6), 1463-1561.)
No OB tells a patient that it’s just fine to have someone listen to her baby’s heart every half hour, and that she can request, and even insist upon, intermittent monitoring. Nor are mothers told that if they stay connected to the EFM all through labor they have a greater chance of winding up with a cesarean. Why would ACOG even recommend EFM as an “acceptable option” when evidence shows that option increases the rate of c-sections?
The evidence for the effect of EFM on the c-section rate has been around since the ‘80s, and in December of 1987, the Lancet published a review of 8 prior PRCTs (prospective randomly controlled trials) and reiterated the conclusions of all of those studies: the ONLY statistically significant constant effect of continuous EFM was to raise the rate of c-section. The studies showed that there was no beneficial effect on fetal health, on fetal outcomes. NONE. But there was that pesky effect on mothers…more cesareans. If the effect of a procedure is neither neutral nor beneficial, if it has indeed been shown to have risk, i.e., lead to increased, and by implication, unnecessary c-section, how can the use of EFM on every woman every day in this country have any ethical justification, and why is no one sounding the alarm? It’s probably the money.
Take a look at the Coalition for Improving Maternity Services (CIMS) press release about the new c-sections rates under "Press Room" at birthsurvey.com and take the survey to contribute to transparency in maternity care by sharing your birth experiences.