http://www.aimsusa.org/academic.htm Alliance for the Improvement of Maternity Services (AIMS) [1]Return to Home Page HOSPITAL BIRTHS AND ACADEMIC PERFORMANCE: IS THERE A CONNECTION? By Estelle Cohen Editors Note: The following article was written by an insightful mother who has worked tirelessly to call attention to the lack of scientific support for the use of the obstetric drugs and procedures commonly employed in hospital births, and their potential to adversely affect academic performance and human potential. In 1975, the College Entrance Examination Board commissioned an advisory panel to examine the possible reasons for an alarming continuing decline in the scores of high school students on the Scholastic Aptitude Tests or, "SAT's," a decline which had started with the 18-year-olds born in 1945 and thereafter. From 1963 to 1977, the score average on the verbal part of the SAT's fell 49 points. The mathematical scores declined 31 points. (1) The advisory panel's report entitled "On Further Examination" was completed in 1977. It stated: "The SAT is designed to be an unchanging measurement. Considerable effort has been made to keep the test a sufficiently constant measure so that any particular score received on a current test indicates the same level of ability to do college work that the same score did 36 or 20 or 5 or 2 years ago. The SAT measures individual students' capacities not only in comparison with their peers in the particular group but also in comparison with those who took the test in earlier years .... The SAT score decline does not result from changes in the test or in the methods of scoring it." (2) A letter to the editor in the New York Times of April 25, 1981 pinpointed the most disturbing aspect of the score decline. The writer, Steven M. Cahn, said: "Amid our chuckles at the discovery of a faulty question in the mathematics portion of last October's Preliminary Scholastic Aptitude Test, let us not forget a far more serious problem. In 1966-67 a total of 55,500 takers of the mathematical portion of the Scholastic Aptitude Test scored 700 or higher, but by 1979-80, with a slightly larger total pool, the number had fallen to 38,900. During that same period the number scoring 700 or higher on the verbal portion of the test fell from 33,200 to 12,300. No matter how many alternative solutions are proposed to the faulty pyramids question, the critical issue remains the astonishing decline in the verbal and mathematical skills of today's students." Among the possible reasons for the declining scores, the advisory panel mentioned the pervasive influences of television, the probable effects of an enormously broader test-taking population due to the opening of educational opportunities, and the extraordinary disruptions of American life in the 60s and 70s. In response to suggestions that there might be medical reasons for the declining scores, a separate study was commissioned to examine that possibility. The study, hastily done and "viewing the problem through a glass darkly," concluded that: "the decline in SAT scores is not likely to result from physical environmental factors .... the most likely alternative explanation to a disease-oriented or an environmental hypothesis is a change in the test-taking population itself. If, for example, the level of education of the parents of the test-taking population were to have declined parallel to the SAT score changes, the SAT decline would not be surprising." (3) That conclusion ought to be re-examined in light of the increasing evidence that every aspect of our traditional hospital births is a threat to the intactness of the fetus and newborn whose healthy mother is capable of delivering her baby unaided if necessary. While it is certainly true that there is no way to clearly prove that the unwise and unsafe obstetric care of the last few decades has had subtle long-term effects on the intellectual and emotional functioning of our population, there is certainly very good reason to examine that hypothesis with far greater care. What happened around 1945 that might have contributed to declining academic performance in the United States in the years that followed? Consider this brief history: According to figures from the National Center for Health Statistics, hospitals were the setting for only 36.9% of American births in 1936. By 1945 that figure had more than doubled to 78.8%. In 1950, 88% of Americans were born in hospitals. In 1960 the figure was 96.6% and in 1970, 99.4%. In the 1930s, most babies were being delivered either by doctors who were general practitioners or by midwives. In the 1940s, with the increase in hospital births, many of those people left obstetrics (or were pushed out) and obstetricians took over, particularly in our large cities. The hospital assembly-line birth became the norm. World War II ended in 1945. The soldiers came home and there was an explosive surge in the birthrate. Obstetricians and hospital personnel were overwhelmed and what developed came to be described as "chaotic." A reading of the obstetric literature indicates that there had always been philosophic differences among doctors regarding normal childbirth. There were those who felt it was best to allow nature to take its course and there were those who felt that intervention was better. In the years following the 40s and under the stresses of the population explosion, there was a tremendous acceleration of intervention in obstetric care. Instead of adapting to the time-consuming demands of normal childbirth, the obstetric community (with very few exceptions) changed normal childbirth to conform to the comfort of the mothers and the convenience of the doctors, hospital staffs and hospital routines -- all at the expense of the fetus and newborn. Doris and John Haire of The American Foundation for Maternal and Child Health have sponsored a number of very important meetings on the subject of obstetric care. In 1974 one of the speakers was Dr. Roberto Caldeyro-Barcia, an internationally renowned research perinatologist, Director of the Latin American Center for Perinatology and Human Development, a unit of the World Health Organization, and President-Elect of the International Federation of Gynecologists and Obstetricians (FIGO). He cautioned: "It is a fact that in the last forty years, more artificial practices have been introduced which have changed labor from a physiological event to a very complicated medical procedure in which all kinds of drugs are used and maneuvers are done, sometimes unnecessarily, and many of them are potentially damaging for the baby and even for the mother.....I am going to refer specifically first to the effects of the artificial rupture of the ovular membranes or amniotomy, which is a procedure commonly done in the Western world in most hospitals as a routine procedure and try to discuss what are the effects on labor, on the fetus and on the newborn.....I will also discuss the abuse of oxytocic drugs and also I will discuss the problem of the position of the mother where usually, in most hospitals, the mother is confined to bed in a non-physiological position ". At a meeting in 1981, Dr. Caldeyro-Barcia described the non-interventionist approach to normal births in his hospital in Montevideo, Uruguay. He said: "Our main task is to preserve the healthy condition of the mother, the fetus and the neonate in an environment which is most similar as possible to a home environment, even if it occurs inside a hospital." He further reported that the biochemical condition of his newborns -- the oxygenation of their umbilical cord blood at birth, the pH, the pCO2, is "better than that which has been reported as 'normal' up to the present in the traditional way of attending labor." Dr. Caldeyro-Barcia ascribed this to the fact that the mothers of those babies are educated early in the processes of childbirth; they are accompanied into the hospital by family or friends of their choice; hospital personnel make every effort to avoid the provoking of anxiety in the laboring women; they are permitted complete freedom of movement and are encouraged to walk during labor; they are undrugged and are allowed to eat and drink as they wish; they choose their own position for birth, generally delivering in an upright position in a special chair; they are NOT instructed to bear down or push harder or longer than the normal physiological urge to push the baby out. Dr. Caldeyro-Barcla cautioned that the artificial prolongation of the pushing urge beyond the norm of about 5 seconds might produce fetal hypoxia. He demonstrated this with newly developed instrumentation. Dr. Caldeyro-Barcia also cautioned; "the main cause of fetal distress is iatrogenic and it is the abuse of oxytocin all over the world. Oxytocin is given in most cases when it is not needed at all and the result, the effect, is the reduction in the blood flow through intervillous space." All of this is in startling contrast, and a frightening contrast, to our hospital births of the last few decades. By the millions, American women in labor were left alone and in fear among strangers, forced to remain in bed during their labors, deprived of food and drink, and routinely drugged. By the millions they were forced to give birth flat on their backs, with their legs up in stirrups -- a most unnatural position that is potentially dangerous for the infant, difficult for the mother but convenient for the doctor. By the millions mothers were separated from their babies immediately after birth and discouraged from breast feeding. All of this is an assault against the intactness of the fetus and newborn. The elective induction of labor, the artificial forcing of birth purely for convenience, is of particular interest to me. In 1951, without my knowledge, I became a subject in a research project at a prestigious New York City teaching hospital. The research involved the administration of Pitocin via the intravenous drip method which had been suggested in 1943 as a means of better controlling the dosage of that very dangerous oxytocic drug. My second child was born in one tetanic contraction after I was induced. He was a seemingly whole, normal baby but his unusual difficulties in learning and behavior as he matured eventually led, at the age of nine, to the diagnosis of "brain damage that was probably sustained at birth." In the late 1950s and in the 60s, parents of children with difficulties like those of my son organized groups all over the country in order to find appropriate educational help and other services for the great numbers of these "in-between" children who were appearing in our population, children who are not retarded in the usual sense but who can not learn and/or behave within the usual limits of normalcy. In those early years one of the many diagnostic labels was "minimal brain dysfunction." Today the popular label is "learning disabilities" and the estimates of the prevalence of the condition are in the millions. An unanswerable question that must start being asked is: How many are obstetric casualties? If their nervous systems had been impaired for any one of a thousand reasons before birth, did obstetric insults in labor and delivery and artificial feeding postnatally add to their deficits? Induction of labor via methods other than the use of oxytocics had been practiced in this country prior to the post-war period. Dr. Caldeyro-Barcia has condemned amniotomy -- the artificial rupture of the mother's membranes -- as increasing the risk of brain damage for the newborn since the fluid within the intact membrane acts as a protective cushion for the head of the fetus as it descends in the birth canal. What does any degree of damage to cerebral tissues at the start of life do to later functioning? At this point in our profound ignorance of the complex brain with its millions of cells and trillions of biologic and chemical connections, surely amniotomy and fundal pressure (external pressure on the uterus) ought to be prohibited in our hospitals unless there is a clear medical indication for the procedure. In 1978 the Food and Drug Administration withdrew approval of elective inductions of labor with oxytocic drugs after a series of hearings at which Doris Haire and I and a number of others testified. I call particular attention to Mrs. Haire's statement on June 21, 1978 and that of Dr. Lewis E. Sullivan of the American Society for Psychoprophylaxis in Obstetrics (ASPO), describing in detail the hazards of the practice and reviewing the literature. That so dangerous a class of drugs came into such routine use in our obstetric care says a great deal about the appalling lack of wisdom and science in this field. How many births have been electively induced in the United States? How much harm has been done? More unanswerable questions, but a medical article in the January, 1957 McCall's Magazine started with the statement: "As an obstetrician, I am deeply concerned about a new fad which is sweeping obstetric practice. It is called elective induction of labor." In 1959 a paper in the Journal of The American Medical Association (Volume 169, No.11, March 14) by several doctors from the New York City Department of Health raised a number of disturbing questions about the "possible deleterious effects of intravenously administered oxytocin." Eight years later when there were still no answers to their questions, the obstetric consultant to the New York City Department of Health discounted my complaints about elective inductions and the possible relationship to impaired functioning and wrote me that "it can now be stated that this obstetric procedure is a totally well accepted therapeutic measure in the obstetrician's armamentarium. It may, in fact, be said that at the present time in this City approximately 50% of all deliveries are associated with the use of oxytocin in labor for either elective induction or stimulation of spontaneous labor." (I have underlined the 50% figure for emphasis.) I met Doris Haire in 1972. In the years since I have said many times that she has done more than anyone else in our country to call attention to the risks for our children inherent in our obstetric care. Her 1972 booklet, "The Cultural Warping of Childbirth" was monumentally important, as was her testimony on April 17, 1978 before the Subcommittee on Health and Scientific Research of the Committee on Human Resources of the U.S. Senate, her testimony on July 30, 1981 before the Subcommittee on Investigations and Oversight of the Committee on Science and Technology of the House of Representatives, and her 1982 report "How the FDA Determines the 'Safety' of Drugs -- Just How Safe is 'Safe'?" Mrs. Haire has called the administration of drugs to women in labor and delivery "obstetric roulette." The section on obstetric drugs in her 1982 report ought to be read by every expectant mother because most of our births are still not drug-free. It is understandable that most obstetricians are reluctant to face the awful reality that their medical training was based on many mistaken assumptions of safety, but face it they must. To tolerate business as usual in the obstetric units of our hospitals is to ignore growing evidence that more harm than good is being done and that is unconscionable. The educators of this country are, second to parents, the universal recipients of the problems of impaired learning abilities and behavior disorders. They ought to take another look at this issue and undertake some extraordinary measures to change the system! Footnotes 1. On Further Examination: Report of the Advisory Panel on the Scholastic Aptitude Test Score Decline, College Entrance Examination Board, p. 5 2. P. 8 3. Could There Be a Medical Basis for the Declining SAT Scores? Charles B. Arnold Director, Health Maintenance Institute, American Health Foundation, Jan.,1977 By Estelle Cohen, 100-28 Benchley Place, Bronx, New York 10475 References 1. http://www.aimsusa.org/default.htm