Political controveries btw American Obstetrics, Midwifery & Physiologic Childbirth: Part 1~ for future historicians

by faithgibson on October 31, 2016

in Contemporary Childbirth Politics

This material was developed for investigative journalists & future historians

Creating a Factual Foundation:

  • To understand normal childbirth, and recognize what circumstances keeps it safe and what makes it dangerous in modern society
  • To acknowledge the original purpose of obstetrics, which was to provide medical treatments and surgical procedures to women with life-threatening complications of childbearing
  • To determine whether interventional obstetrics, which has an average Cesarean section rate in the US of 33%, is an appropriate and cost-effective standard of care when applied to a healthy population of childbearing women with normal pregnancies

Obstetrical vs. maternity care ~ “critical theories” & “intentional” use of language

Obstetrics: Historically, the discipline of obstetrics was simply part of a general medical education that prepared general practitioners (GPs) to provide non-surgical childbirth services to an essentially healthy childbearing population. Because these general practitioners were not trained in surgery, they were not able to perform the ultimate rescue operation, which is Cesarean surgery.

Instead they had to call a gynecological surgeon whenever one of their patients needed to be delivered by C-section. This resulted in intense interdisciplinary disagreements about timing and necessity, and fueled ill-tempered completion btw these different types of doctors. According to some accounts, the competition was so intense that it sometimes result in mutual character assassination and even an occasionally fist fight.

To eliminate this inappropriate professional rivalry, cooler heads decided that combining the medical discipline of obstetric with the surgical specialty of gynecology would be to the advantage of both disciplines. In the late 1890s, the brand new American hybrid surgical specialty of obstetrics & gynecology was founded.

The “critical theory” (or foundation) of this new surgical specialty was that normal childbirth in human females was intrinsically pathological – that is, harmful to both childbearing women and their babies. This period — early 1900s — was four long decades before ‘modern’ medical science as we know it today, and even longer time before women had reliable (and legal) access to contraception. Prenatal care did not yet exist, so doctors and midwives were unable to screen for major medical conditions in the mother, such as heart or kidney disease, high blood pressure, or placenta previa. In 1900, the average married women became pregnant 12-to-16 times, gave birth 9 times, but only 6 of those children survived infancy.

Before the age of modern medicine, obstetricians frequently faced dire, even hopeless situations while caring for pregnant women with undiagnosed or untreatable diseases. During the pre-antibiotic era of history (before 1945), these serious complications resulted in death for many new mothers and their newborns.

Given such circumstances, the obstetrical profession assumed that normal childbirth was a deeply-flawed biological process that ‘used up’ childbearing women. In this instance, Mother Nature was seen as a malevolent force. The spawning of salmon, which results in death as a part of the reproductive process, was cited as an example of reproduction as a sacrificial process.

It’s not surprising that in 1910 the new surgical specialty of obstetrics collectively defined normal childbirth as quasi-pathological process that required a surgical solution. It seemed to them that the only way to prevent tragic maternal death was through the modern science of obstetrics. As members of a surgical specialty, obstetricians saw themselves as legally obligated to eliminate, or at least greatly reduce, such the pathological harm of normal childbirth.

To accomplish such an extraordinary goal required complete control, which could only be achieved by medicalizing the biological process of labor and birth. Control combined with the routine use of obstetrical interventions was would allow doctors to eliminate, or at least greatly reduce, the anxiety, pain and emotional distress of labor, as well as physical exertion that would have been required if these women had given birth spontaneously.

In this new medicalized model, all obstetrical patients were to be hospitalized, with professional nurses providing all the care during the first stage and early pushing phase of labor. On admission to the hospital, laboring women were immediately isolated from their families and confined to bed for the duration. No matter how long the labor, husbands and others were not permitted to accompany them or even visit briefly. Labor patients were also not allowed to eat or drink, no matter how long they stayed in the labor ward.

Obstetrical protocols during the first half of the 20th century required that labor patients be medicated with a powerful and frequently repeated combination of narcotics (morphine or Demerol) and scopolamine. These “Twilight Sleep” drugs had a hallucinogenic effect and also produced amnesia, which left laboring women in a semi-comatosed state. Unfortunately, these drugs did not take the pain away; medicated still patients roused with each and every contraction, often moaning, crying out, sometime screaming, even becoming agitated and trying to climb out of the bed. Nurses who tried to calm them down were sometimes bitten or hit, and occasionally sported a black eye after such an encounter. At times, laboring women tumbled over the bed rails and chipped teeth or broke an arm in the fall.

In the hospital where I worked as an L&D nurse until 1976, protocols for preventing such accidents required that the nursing staff force agitated labor patients into a spread-eagle position on their back in bed, while their arms and legs put in four-point leather restraints and connected to the four bedposts for the remainder of the labor.

When patients began pushing effectively and the birth seemed imminent, L&D nurses had to notify the doctor, since only MDs were legally authorized to perform the surgical procedure of ‘delivery’. Vaginal birth as a surgical procedure was routinely conducted under general anesthesia and usually included cutting an episiotomy, using forceps to deliver the baby, manually removing the placenta and suturing the episiotomy incision.

Decisions by the obstetrical profession to conduct labor as a pending medical emergency and normal birth as a surgical procedure represents the most profound change in normal childbirth practices in the history of the human species.

Canonization of the obstetrical model

During the early 20th century, the obstetrical profession was absolutely convinced that the highly medicalized model of obstetrical care taught in medical schools and used by practicing obstetricians was the one and only way to make the pathological process of childbirth safe. Given this perspective, they were firmly convinced that no other healthcare profession had the advanced medical education, experience and understanding of how truly pathological so-called ‘normal’ childbirth could be. As a highly specialized surgical discipline, obstetrical profession believed that feedback from the public or debate with general practitioners and midwives was a waste of their time.

As a result 21st century obstetrics, with an ever-so-slight change in vocabulary, is still bound by the ‘critical theory’ of its founding fathers. True to these roots, the contemporary obstetrical professionals unquestionably maintains an uncritical acceptance of the premise:

  • That normal childbirth in healthy women is so undependable as to be a quasi-pathological process in which ‘normal’ can only be defined retrospectively
  • That a high rate of medical interventions is universally necessary
  • That the routine use of medical and surgical interventions makes obstetrical care safer than all other models of care and all other alternatives.

Normal childbirth in healthy women has been routinely medicalized at higher and higher rates over the course of the 20th century, with new interventions added each decade to those already in use. The methods used today are may be different than some of the ones used in 1910, 1930 or 1950, but the quality of medical and surgical dominance of labor and birth remains the same. Since the 1970s, the total number and invasiveness of routine obstetrical interventions and procedures has increased to an astonishing level, with 99% of all hospitalized maternity patients being subjected to seven or more significant medical and surgical interventions.

Time moves on, while obstetrics marches in place

Over the last hundred years, the standard of living in the US has risen, public sanitation has become the norm and the percentage of well-educated and economically-advantaged citizens has dramatically increased. As a result, the general health and lifespan of Americans has greatly improved as since the early 20th century. For women of childbearing age, the many dangers of forced and frequent childbirth is a thing of the distant past. Legal access to effective contraception has dramatically reduced unwanted and unplanned pregnancies over the last hundred years. This is accompanied by society’s formal acknowledgment of the many benefits of wanted and planned pregnancies.

During the first half of the 20th century, modern medicine developed effective treatments for most of the serious complications of childbirth. Over the course of the first four decades of the 20th century, the rate of women dying as a result of terminating a pregnancy or giving a birth was slowly reduced all over the world by orders-of-magnitude. In the US, it fell from about 1 death for every 200 births in 1910, to 1 in 5,700 live births in 2014.

Despite the greatly improved health of childbearing women, and the success of modern medicine, including obstetrical treatments for serious complications, the obstetrical model in the US is still wedded to its 1910 perspective of childbirth as needing to be medicalized and controlled by the pre-emptive use of multiple medical and surgical interventions.

When applied to healthy childbearing women in the 21st century, this medicalized model still includes hospitalization, only now women labor in an intrapartum intensive care unit technologically equipped for laboring women. A variety of machines continuously and electronically monitor the mother’s blood pressure and the fetal heart rate (EFM) throughout the labor. This medicalized model includes the routine use of drugs to induce or augment labor (i.e. reduce its length) and administration of pain medications and regional anesthesia to eliminate the pain normally associated with childbirth.

Except to go to the bathroom, over 90% labor patients spend the entire length of their labor lying in a special high-tech bed while hooked up to different types of monitoring equipment (automatic blood pressure cuff, EFM, IVs, epidural anesthesia pump, in-dwelling bladder catheter, etc). If there is the slightest worry over the unborn baby’s well being, as communicated by a less-than-perfect EFM tracing, an oxygen mask over the mother’s nose and mouth will be added to this profusion of medical equipment.

Surveys of healthy women who have recently given birth in American hospitals in 2002, 2006 and 2013 found that approximately:

  • 93% had 7 or more significant medical interventions during labor
  • 70% had one or more surgical procedure performed during the birth — episiotomy, vacuum extraction, forceps or Cesarean surgery

By canonizing the 1910 opinions of the new surgical specialty of obstetric and gynecology – the idea that childbirth was inherently pathological (or in more modern terms, abnormal until proven otherwise) — the obstetrical profession in the US spent the last 100 years developing the most highly medicalized and most expensive system for providing normal childbirth in the entire world.

It must be noted that all this entire system was put in place in 1910 without ever having conducted any scientific studies that contrasted the physiologic management of normal childbirth in healthy women with a similarly healthy group of women whose obstetrically managed labors and included the routine use of medical treatments and surgical procedures. Our highly-obstetricalized standard of care for healthy women was based on an ‘authority’ or ‘expert’ system that reflected the opinion of obstetrical ‘experts’. The American obstetrical profession continues to insist that obstetricians are the only ‘experts’ when it comes to the management of normal childbirth.

Its now a hundred years later and the US now spends more on maternity care than any other country. Despite this huge amount of money, the US ranks 50th in neonatal deaths and 60th in maternal deaths, and is one of only 8 countries worldwide that has an INCREASING rate of maternal deaths.

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