Mind the Gap!
We rabble rousers believe that physiologically-based care should be the universal standard for healthy women with normal pregnancies unless the mother herself requests medicalized care.
We have worked tirelessly our entire professional life to transform the narrow focus of our interventionist obstetrical system into a broad based maternity care model able to respond to the practical needs a healthy population.
This is known as mother-baby-father friendly maternity care, thanks to the Coalition for Improving Maternity Services (CIMS).
But for all our idealism, enthusiasm and sustained effort, providers of physiological management remain locked out of the system by factors that are political rather than scientific. In the current configuration, the only way for the obstetrical profession to win is for physiological management to lose.
The resurgence of independent midwifery and PHB in the mid-1970s was the result of a collective inability to make a positive impact on our hyper-medicalized system. We intended to meet just those specific needs the obstetrical profession couldn’t re address or wouldn’t acknowledge.
None of us expected to create a free-standing parallel system of midwifery education and practice that remained permanently outside and separate from the health care system. Apartheid is never a satisfactory situation. Any one who gets pregnant or provides services relative to pregnancy and childbirth knows all too well that it is impossible not to be drawn back into the fray.
Even more than our frustration as activists, we continue to be personally affected by the painful schism between our values and our on-going experience of interventive obstetrics as applied to healthy women. Speaking as someone who has been doing this since the 1960s, when twilight sleep and episiotomy was still mandatory and universal, our activism has not been a happy or successful endeavor.
Yes, we have won a few battles and I am grateful for that, but it is an illusion of progress. Added to our individual pain and collective experience is the expansive time frame for a dysfunctional system that manages to change but never actually fix the problem. For the entire 20th century and the first decade of the 21st, women and families have been swept along a conveyor belt that often took them to places they did not want or need to go.
The routine use of narcotics, scopolamine and general anesthesia in the1960s (over 90%) has simply been replaced by a 90% epidural rate; the routine use of forceps has been replaced by the liberal use of Cesarean, which is at 31% and still climbing. Birth is still conducted and billed as a surgical procedure.
The monolithic obstetrical model continues to be characterized by routine interference in normal biology (such as routine inductions), unnecessary interventions mandated by liability issues or personal preference. Painful, invasive or humiliating procedures that we neither need or want continue to performed on ourselves, our loved ones or on our clients. We stand by helplessly as influential members of the medical profession and the media promote the idea of scheduled Cesarean as the 21st century standard of care. Ultimately we are losing the war.
As members of consumer and professional groups working for mother-baby friendly maternity care, it’s impossible not to get angry about this. For me personally, it’s hard to be generous in the face of such daunting circumstances. But if we let our anger divide us into eternally warring camps, we will spend our time perpetuating instead of fixing an out-of-balance system.
What we need is a change of heart, starting with an acknowledgment that none of these groups – mothers, midwives or obstetricians — asked for these contentious problems. Contemporary obstetricians inherited a difficult situation not of their own making. They were schooled by a system that taught female biology as destiny when it comes to reproductive.
Childbearing is seen as an undependable patho-physiology that uses women up the way salmon are sacrificed during spawning. In must be remembered that without prenatal care and access to modern obstetrical services for those who develop complications during pregnancy or childbirth, high mortality rates are indeed the rule.
- World health organizations identify a ‘natural’ level of approximately 1,100 maternal deaths per 100,000 pregnancies in areas without access to comprehensive obstetrical services. In the late 19th and early 20th century, when our interventionist model of American obstetrics was first developed, physicians were facing the same problems that developing countries grapple with today. In 1900, the average married woman in the US had 17 pregnancies, 12 live births, but only 9 living children. Women expected to lose a tooth with every pregnancy.
- Poverty and high birth rate were associated with problem pregnancies, especially in very rural farming areas and for immigrants and ethnic minorities living in crowded urban tenements. Racial discrimination and economic inequities resulted in chronic ill-health, which made childbearing women vulnerable to childbirth serious complications that obstetricians could not predict, prevent or treat. In the poorer sections of town, one new mother died for every 100 births and one of 10 infants did not live to see their first birthday.
Many of the life-threatening complications childbearing required surgical solutions, giving rise to the ‘new’ obstetrics for the 20th century as a surgical specialty,.
Well-intentioned obstetricians were responding to this grave situation decades before the discovery of antibiotics. The highly medicalized style of care introduced in 1910 was an attempt to eliminate puerperal sepsis (childbed fever) in hospitalized maternity patients. This resulted in the greatest change in childbirth practices in the history of the human species. Labor began to be managed as a medically emergency.
For the first time ever, normal vaginal birth was defined as a surgical procedure. As a surgical procedure, the ‘delivery’ was to occur in a restricted, sterile environment, routinely conducted as an operation by a surgically-trained physician. Due to the difficulty of maintaining strict surgical sterility, it was necessary to anesthetize labor patients. Once anesthetized, the delivery need to be surgical included the routine use of episiotomy, forceps, manual removal of the placenta and suturing of the episiotomy or other perineal wounds.
Reconciling the Irreconcilable — Learning to love the bomb?
Yes, we need to learn to love our maternity care system, dysfunctional as it is. We need to own it, to think of it as ‘ours’, to believe that it can and will be returned to balance. We need to use our energies to transform our national maternity care policies and to reconfigure the system at its most basic and practical level. We need to promote ideas like
- Maximal results with minimal interventions
- Skillful use of physiological management
- Adroit use of medical interventions as necessary
- Fewest number of medical/surgical procedures
- Least expense
- Best outcome to for mothers and babies
The form of care recommended by W.H.O. for a healthy population integrates the principles of physiological management with the best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women. This standard should apply to all categories of birth attendants and in all settings and include the use of standard obstetrical interventions to treat complications or if requested by the mother. When that is done, healthy women will no longer have to choose between an obstetrician and a midwife or between hospital and home.
No matter who provides maternity care, they can be confident of receiving appropriate, physiologically-based care for a normal labor and spontaneous birth and having the best obstetrical services if or when they desire or require them.
