Faith Gibson, LM
From the archive,
originally posted October 11, 2003
Ending a Failed Medical Experiment:
A 100 Years of Flat Earth Obstetrics Based on Unsafe & Unscientific Maternity Practices
~ Our Goal ~
Principles of physiologically-based care as the American standard
for healthy women with normal pregnancies
~ Our Plan ~
To develop effective political strategies and
a long-term for their implementation ~
Topics & Synopsis:
Ending Flat Earth Obstetrics by rehabilitating obstetrical medicine –
via the most profoundly effective political activism in the last 100 years
Suggested Starting Point: Five Simultaneous Press Conferences, Presentation of a White Paper to Medical School Officials and a Ten-Point Plan for 21st Century Maternity Care – to be repeated five years in a row (or until we succeed!).
We plan on utilizing effective political strategies from a variety of sources including those used by the brave women of Nigeria (more about that later) in our efforts to right the wrongs of the last century and bring about non-medicalized, mother-baby-father-family friendly maternity care as the norm for healthy women with normal pregnancies.
What will be presented:
- Tactics and specific goals to rehabilitate and fundamentally restructure the quality of maternity care services as provided in the United States
- Our demand that the principles of physiological management be the foremost standard of care for all professional birth attendants, to be used by physicians and midwives both when caring for healthy women with normal pregnancies (70% of all childbearing women)
- Promotion of the legal and ethical necessity for medical educators to learn and medical schools to teach physiological management of normal childbirth to all medical students
- Our demand that hospital L&D units be primarily staffed by professional midwives
Definition of “physiological” – “To be in accord with or characteristic of the normal functioning of a living organism”; Stedman’s Medical Dictionary 1995
Physiological management of healthy women, as contrasted with medical management, is protective of both mothers and babies. This is particularly effective in preventing operative deliveries (forceps and vacuum extraction) and subsequent complications, such as pelvic floor dysfunction and incontinence, and the potentially life-threatening sequelae of Cesarean surgery including post-operative morbidity and mortality and post-cesarean pregnancy complications such as infertility, abnormal placentation (previa and percreta), blood transfusions, uterine rupture, emergency hysterectomy, maternal death, neonatal neurological damage or death.
=====================================================================
October 11, 2003
Dear Midwives and other Childbirth Activists,
Politically speaking, the issue of “home birth” is a red herring for doctors, midwives and the public. By causing everyone to focus on a statistically rare and non-representative issue – community-based midwifery services — that affects less than 5% of the childbearing population, we are as a country being distracted from the much more important and obvious issue of medically unnecessary obstetrical intervention.
Because organized medicine is constantly threatening midwives with punitive legal action, midwives and midwifery-related consumer groups have remained focused on defending home-based birth services (including a healthy woman’s right to choose her place of birth) instead of changing this outrageously dysfunctional and at times dangerous obstetrical system. The public vilification of midwives by the obstetrical profession, falsely claiming that “midwives kill babies”, provides physicians with a convenient scapegoat used by ACOG to distract the public from other and more important issues.
Obstetrics in the US is a dysfunctional system that does not “believe in” or support the principles of physiological manage of normal labor. Instead hospital obstetrical departments are organized around the routine or pre-emptive use of obstetrical interventions that are medically unnecessary and unwanted by the laboring woman. These interventions increase the cost of care, tether the labor patient to a hospital bed, are often painful and drastically restrict the woman’s mobility, which disrupts the normal process of labor. In many cases, obstetrical protocols also introduce iatrogenic and potentially-life threatening harm and/or lead to the use of even more invasive procedures and the ultimate obstetrical intervention of Cesarean surgery. According to the reports of childbearing women themselves, as well as various published sources, obstetrical interventions are used on approximately 99% of women who labor and give birth in the hospitals.
Regrettably, our society has permitted organized medicine to prejudice the question of safety and dominate the public dialogue about normal maternity care. As a result, we are all missing the point. It is not about the relative safety of home birth for one percent of childbearing families, but rather the risks of hospital birth for the 75- 80% of healthy childbearing women it serves. For childbirth activists, it needs to be about how we can make hospital birth safer and more satisfactory for everyone involved.
The Centrality of Hospital-based Childbirth Services and In-patient Postpartum Care
The place where the rubber meets the road for the vast majority of childbearing women and their babies is in acute care hospitals. Therefore, hospital-based maternity care must work for all its “stakeholders” – mothers, babies, fathers, families, hospital personal, doctors, HMOs, even health insurance companies, malpractice carriers, the Medicaid program and the taxpayers. It must bring benefit to each and cause harm to none.
One sixth of our GNP goes for healthy care services. Slightly more than 20% of our entire health care budget goes to pay for maternity care. Two-thirds of this money — approximately 14% of our total health care dollar– goes to provide birth-related services to healthy women with normal pregnancies and normal births, which is approximately *70% of the childbearing population (*P. Schlenzka, 1999, p. 62).
The United States spends more money on childbirth services than any other country in the world, and yet we have next to the lowest vaginal birth rate (i.e. highest Cesarean surgery rate) after Brazil). Currently, obstetricians are predicting the virtual elimination of VBAC and that the liberal use of “maternal-choice” Cesarean will double the present 31% rate in the next decade to more than half of all births. Despite this “liberal” use of Cesarean surgery, the US ranks 22nd (3rd from the bottom) in perinatal mortality out of the developed countries. These statistics are indicative of the many problems with the current system that beg for correction.
Unfortunately for community midwives like myself, the answer to this dilemma is not home birth midwifery. The place where the majority of mothers want to be for childbirth is where the corrections must be made. Women want to be in hospitals with ready access to labor stimulants, pain medication, epidural anesthesia and emergency surgery. The vast majority of mothers prefer a physician as their primary care provider, so the challenge is to rehabilitate our hospital-based maternity care system. This must be done in conjunction with changes in our national maternity care policies that underlie the provision of these services and the reimbursement system for its care providers.
Strategies & a Ten-Point Plan for 21st Century Maternity Care — Cost Effective, Beneficent and Mother-Baby-Father Friendly
What follows is an exploration of the major strategies for political change and a ten-point plan identifying tactics and specific goals to fundamentally rehabilitate and restructure the quality of maternity care services and how they are dispensed in the United States. This is background material for a “White Paper” to be presented to medical school officials during the Labor Day press conferences at five simultaneous locations. (Go to part 3 for the specifics of those events)
The Fundamental Problem — an obstetricalized, high-tech, one-size-fits-all system
The fundamental problem is that the obstetrical care system in the US as applied to a healthy childbearing population (which represents from 70-to-85% of all births) has not been scientifically based for the entire 20th century.
Obstetrics for healthy women in the United States became an ideology that for the last hundred-plus years has profoundly distorted the personal internal thought process and external behavior of obstetricians. That ideology, which is similar in its strength to a partisan political or religious point of view, gives rise to the illogical conclusion that normal childbirth is pathological and therefore, requires a constant stream of technological surveillance and medical-surgical interventions.
This unnecessarily introduces harm by exposing healthy mothers with normal pregnancies to the interventionist practices of contemporary obstetrics while depriving them of the protective and preventive strategies of physiological management. It is a one-two punch that consists of absence of the “right stuff” and the unwarranted and unhelpful use of the “wrong stuff.”
Putting healthy women who are still in very early labor into bed and hooking them up to continuous electronic fetal monitoring system not only starts labor management off on the wrong foot, but it also sets the mother-to-be up for a cascades of additional interventions that includes giving her intravenous fluid that contain Pitocin, then narcotics for the pain, and anesthesia for an interventive delivery that uses vacuum extraction, forceps or Cesarean surgery. For a “normal” healthy woman with a normal onset of labor, this is not “normal” care. Quite the opposites, it contributes to, and sometimes creates, serious medical complications for both mothers and babies.
The Problem of Interventionist Obstetrics
The problem of interventionist obstetrics is a combination of these two equally detrimental factors — the excesses of obstetrical interventions and absence of the protective effects of normal (physiological) care.
The medicalization of normal childbirth often results in complications that otherwise would not have occurred. By treating healthy childbirth as intrinsically pathological state is to inappropriately medicalized and actually increases the risk of complications, most especially for women with normal pregnancies. These iatrogenic complications include an increase in maternal morbidity (serious complications) and deaths associated with operative deliveries and post-cesarean complications in subsequent pregnancies, including abnormal placentation, emergency hysterectomy, as well an increase in perinatal deaths and neurological disabilities in neonates.
At the same time, contemporary obstetrics has great disdain for the scientific principles of physiological management and is largely ignorant of and/or distrustful of its strategies and techniques. Physiological management of labor and birth by physicians and professional midwives is a safer, more satisfactory and cost-effective form of care for normal childbearing. Unfortunately, the principles of its non-interventive management and normal childbirth practices is not part of the medical school curriculum, nor it is it taught in obstetrical residency programs.
Physiological management is to the benefit of healthy women and their babies and to the economic benefit of society in general. Normalizing childbirth care does not mean forcing women into an unwanted “natural” birth by depriving them of pain relief drugs or anesthesia. However, it is a well-documented fact that physiological management, which by definition includes appropriate social and psychological support, reduces the need for drugs and other medical interventions.
Secondary & Associated Problems:
Interventionist obstetrics historically has focused solely on the medical aspects of pregnancy and birth. Its interest is mainly in the last few hours of active labor and the very few minutes surrounding the emergence of the baby. This restriction of time and attention, and associated expansion of costs to purely physical/medical dimensions, robs the system of any ability to develop a wide and deep response to the many psychosocial issues that are so central to the health and wellbeing of new mothers and their newborn babies.
The social and psychological well being of pregnant women and new mothers, breastfeeding, child development, familial relationships and other aspects of effective parenting are all areas of great importance. At present, they are getting little or no attention in our maternity care system.
Importance of the Second Nine Months for both mother and baby
Childbearing women and their unborn or newborn babies do best with appropriate physical, emotional, social support, which includes educational services and long-term support. This reduces the incidence of postpartum depression and/or provides for early detection so that effective treatment can be instituted before harm comes to mothers or their children. A balanced and effective maternity care system acknowledges that the on-going value of motherhood is greater than just the 1- and 5-minute Apgars scores of the baby at the time of delivery. The second nine months are ultimately as important as the first nine months and deserve similar attention and support by childbirth professionals. Our current system has no time, money or interest in meeting these significant social, psychological and developmental needs.
Interventionist obstetrics also has inadvertently trapped us in a legal quagmire of tort law in which doctors (and by extension professional midwives with a hospital practice) must use interventionist management in order to avoid charges of “substandard” care or malpractice litigation. These legal issues are not visible to the public, but none-the-less are at the heart of many of the egregious practices such as the infamous obstetrical mantra of “When in doubt, cut it out” – i.e. Cesareans for every minor deviation of labor — that litter the landscape of hospital birth, which is ruled by aggressive and anticipate management techniques. This means the “pre-emptive” use of interventions based on the often-remote possibility of a problem.
If an obstetrician thinks a pregnant patient might not deliver by her due date, he recommends a scheduled induction. If the labor isn’t advancing at a rapid clip, he asks the nurse to start a IV Pitocin. If that doesn’t throw things into high gear, he recommends a Cesarean for her “failure to progress”.
The three R’s of Restoration, Restructuring, and Rehabilitation
It all starts with acknowledging the principles of physiological management as the science-based standard of care for all healthy childbearing women. That means restoring physiologically-based care to its rightful place – smack in the middle of every labor and delivery unit in every American hospital!
That would of course require rehabilitating the obstetrical definitions of ‘normal’ to encompass the full range of normal childbearing biology, as well as the mother’s accompanying psychology and the sociology of the situation. Women do not go into labor or make progress in labor when they are afraid or otherwise not getting their basic physical and psychological needs met. While attempts to ‘scare’ women into labor occasionally works, it much more often has the opposite effect and shuts things down.
This requires restructuring of hospital and physician-centered maternity services so the ‘norm’ for that 70-plus percent of normal healthy laboring women is non-interventive care that is safe, cost effective, mother-baby-father and family friendly.
Talking Points and Strategies Relative to Midwifery and Planned Home Birth (PHB)
- Recognition by the midwifery community that home birth is a distraction that derails us from promoting the most important public good – improving our hospital-based maternity care system for the 99% of American women prefer or require hospital-based maternity care and are, for the most part, cared for by obstetricians
- Recognition that the only way to eliminate the structural injustices that are harmful both to childbearing women and to midwives as a gender-related class is to restructure the relationship between community-based (OOH) midwifery and the medical profession is to rehabilitate hospital-based obstetrical departments as part of the process for integrating professional midwives into the maternity care system based on the scientifically-proved merits of midwifery care as a cost-effective method for maximizing good outcomes while reducing the rate of interventions, surgical births, other complications and problematic outcomes
Talking Points and Strategies Relative to the Issues
- The underlying problem with obstetrical care in the US is the uncritical acceptance of a thoroughly unscientific assumption — that normal childbirth in healthy women is an inherently pathological process requiring the care of a surgical specialist and the use of multiple medical and surgical interventions that include the routine use of narcotic drugs, general anesthesia and operative delivery by forceps or Cesarean surgery.
- This false hypothesis gave rise to the uncritical acceptance of an unscientific model for maternity care – interventionist medical care for healthy women.
- Historically and in contemporary times, the physiological principles of midwifery have always been the safest form of care for healthy women. Medical and surgical interventions for healthy women have always been associated with an increase in maternal complications and maternal deaths, as well as an increased rate of birth injuries for babies. This is the underlying reason that interventionist obstetrics for healthy women is a 100-plus year old failed medical experiment (i.e., “Flat Earth Obstetrics”).
- The medical model of maternity care failed to assess its own hypotheses during the early years of its formation and continues to be unwilling to accurately measure its outcomes as contrasted with the principles of physiological management. The obstetrical profession refuses to acknowledge or be held accountable for the iatrogenic problems and increase rate of maternal deaths it introduces into the care of healthy childbearing women. The US currently has the *highest MMR of any developed country (*2022).When members of the obstetrical profession are provided with corrective information, they consistently fail to take any corrective action.Obstetrics in the US has never been organized around the practical needs of childbearing women, but instead is organized around the concerns of obstetricians. As a result, obstetrics has become a prisoner of its own project – the ever-expanding medicalization of normal birth — with the majority of all births in the US including the use of Pitocin to induce or augment labor and surgical delivery rate of approximately 45% (episiotomy, vacuum extractions, forceps, Cesareans). All this is based on the discredited notion that childbirth is a fundamentally pathological event requiring medical and surgical interventions.
- In the mind of the public, organized medicine prejudiced the question of relative safety as it related to interventive obstetrics and hospitals in the early 1900s. The obstetrical profession portrayed itself, and its hospital-based services, as the only safe and “scientific” choice for normal childbirth. Unfortunately, this was long before the discovery of antibiotics, and during an era when hospital-acquired fatal infections accounted for 40% of maternal mortality – the deaths of 10,000 new mothers each year out of an annual mortality rate of 25,000.In the early 1900s, nationally influential obstetricians participated in a self-serving public relations campaign in newspapers, women’s magazines and the radio that publicly endorsing the specious and scientifically invalid idea that normal pregnancy was a “nine-month disease” that required a “surgical cure”, while it slandered midwives and physiological management and promoted the motto “always a doctor, never a midwife”.
- In contemporary times the obstetrical profession has dominated all public dialogue with the spurious question “is home birth safe?”, which appears to be a convenient strategy to distract the public from the appalling fact the US has the highest MMR of any wealthy or developed country. Unfortunately, whoever controls the public discourse (the American Medical Association and American College of Obstetricians and Gynecologists), dominates the public dialogue.
- This anti-community-based childbirth services permits organized medicine to avoid the real issue — the current riskiness of interventionist obstetrical care for a healthy population.It also permits doctors to sidestep the really important question: “Is hospital birth safe for healthy women under the interventionist management of obstetricians?”So far this has successfully derailed both the media and the scientific community from any genuine scrutiny of the well-known risks of commonly used medical and surgical interventions while simultaneously ignoring the well-known benefits and protective qualities of non-medical supportive care associated with the midwifery principles of physiological management.
Talking Points and Strategies Relative to Solutions:
- Currently the biggest impediment to reform is the absence of investigative journalism by the media. Other related disciplines (medical anthropology, normal physiological, psychology, sociology, public health, etc) have also failed to scientifically assess the claims of obstetrical interventionists. Neither journalism or science had challenged the assertion of organized medicine that medicalizing healthy women is beneficial, safe, cost effective and a responsible national maternity-care policy.
- The appropriate response to the problem– improved media coverage and scientific scrutiny — is a PR issue that can be successfully addressed by mothers and midwives with the resources we already have at hand or can reasonably expect to develop.
- It is possible to bring the right kind of public and legal attention to this topic. It is also possible for this political activism to affect appropriate and permanent changes that will rehabilitate obstetrical practices in the US. These changes can reintegrate the principles of physiologic management and the midwifery model of care into the mainstream as the foremost strategy and standard for healthy childbearing women with normal pregnancies.
