Chapter 10 ~ The Obstetrical Franchise In America: The 20th century Gender War btw Midwifery and Obstetrics (spoiler alert – obstetricans won, midwives and childbearing women lost!)

by faithgibson on January 16, 2025

in Contemporary Childbirth Politics

Word count 6687 Jan 2025

Editor’s Note-2-self –>this post is currently being edited ~ 01-17-2025 @7:20 pm WC 6676 (best not over 2,000 words — equal reading time of 15-16 minutes 

Chapter 10   “With sufficient repetition, perception becomes a reality”

Childbirth in 2005 ~ as childbearing women suffer needlessly from dangerous obstetrical excesses, midwifery continues to be an illegal act in many places and midwives are treated as criminals. While this carnage is ongoing, the obstetrical profession is flying high and enjoying the view from the top of the world!

In 21st century America, the clinical practice of obstetrics no longer uses the amnesiac drug scopolamine during labor, doesn’t routinely “perform” deliveries under general anesthesia, use forceps to extract the baby from it mother’s inert body, or introduce the dangers associated with the manually extracting placentas.

Nonetheless, the obstetrical “standard of practice” in the US in 2025 still legally defines “normal childbirth” as a surgical procedure, and that is a serious and potentially dangerous problem for healthy childbearing women.

When obstetricians bill an insurance company or the federal Medicaid program for having attended a normal childbirth billing code used is for the “surgical procedure” of a normal spontaneous vaginal birth. This means obstetricians are compensated at a higher rate than midwives who are not obstetricians, as obviously “catching
the baby” by a non-surgeon is not equated to a surgical procedure, which it obviously is not.

Obstetrics in America is still based on the fallacious idea that so-called “normal birth” is a disaster just waiting to happen but also a steady source of one’s income as an obstetrician!

Pregnant woman being prepared for childbirth as abdominal surgery

The philosophy of American obstetrics is still based on the 1910 conclusion that the biology of normal birth even in healthy women is so inherently dangerous that the use of multiple obstetrical interventions and surgical procedures are automatically justified.

Better safe than sorry!

This includes the idea that electively scheduled Cesareans are the safer and better way for a baby to be born. Surgical delivery continues to be promoted while the American obstetrical profession turns a blind eye to the dramatically increased maternal mortality rate associated with Cesarean surgery.

Unfortunately living through one Cesarean without any complications is not the end of Cesarean fallout. Having had Cesarean surgery leaves these new mothers with possible downstream dangers in future pregnancies, such as the issue of VBAC and needing to deal with a 6% secondary infertility following Cesarean surgery.

Today’s obstetrical profession has plenty of fancy new equipment, such as ultrasound machines and electronic fetal monitors, which makes the profession look very “modern” — light years away from the “bad old days! But that is just an optical illusion when it comes to providing care to healthy childbearing women who don’t benefit from the routine use of obstetrical interventions but do have to bear the burden of it — being urged by one’s obstetrician to schedule and elective induction at 39 weeks — that is before the baby’s due date.  There is a 10-day “optimal” window from 4 days before the due date to 6 days after in which healthy pregnant women are statistically most likely to have a normal spontaneous labor and a normal uncomplicated spontaneous vagina birth.

Functionally, the American obstetrical profession still uses an intensely interventive style of care for nearly every aspect of a hospital-based “labor and delivery”–  elective induction, the routine use of potentially dangerous drugs to speed labor up (uterine stimulants such as Picocin and prostaglandins) and/or the use of one or more surgical procedures during the “delivery”.

This includes episiotomies, vacuum extractions, surgical repair of the episiotomy incisions and the ultimate childbirth intervention — elective;y scheduled Cesareans. The one big and very important difference is finally having ended the manual removal of the placenta as a routine procedure. There is never any justification for manually removing the placenta as part of a routine vaginal birth and that by itself makes childbirth safer than it used to be.

*** Things you should know about placentas ***

Statistically, the majority of all placentas are naturally expelled by the mother’s body approximately six minutes after her baby is born. Typically the wait for the spontaneous detachment of the placenta is only five, six, or seven minutes. Without an activity by the new mother or her birth attendants, it comes away from the inner wall of the mother’s uterus on its own accord and simply slips out of the mother’s vagina. 

the procedure is unnecessary and incredibly dangerous

The physical removal of the placenta manually is not a routine part of normal childbirth. It’s actually an invasive surgical procedure that should ONLY be done to stop uncontrollable (therefore life-threatening) hemorrhaging in a postpartum patient.

When manual removal of the placenta is done because a physician, resident, intern, or medical student wants to “save time”, I would describe such a choice to be blatent malpractice. Unless there are extenuating circumstances, this is reasons for a obstetrical provider  to lose his or her license to practice medicine. ( typical wait for the spontaneous detachment of the placenta and is naturally expelled)is only five, six, or seven minutes before from the inner wall of the mother’s uterus the procedure is unnecessary and incredibly dangerous.

I am relieved that such an invasive, painful, and potential trigger of a fatal postpartum hemorrhage has finally and permanently been removed from the “obstetrics-as-usual” repertoire.

I look forward to the day when healthy women with normal-term pregnancies who do not need or want obstetrical interventions will all be routinely cared for by trained and experienced midwives and/or general practice physicians in well-staffed birth centers and the homes of some childbearing parents.

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Back to so-called “modern obstetrics” and its do,

What the obstetrical profession is doing now is just a more upscale version of the massively interventive type of obstetrics that the profession was practicing and promoting at the turn of the 20th century.  It’s the same old story in which the obstetrical profession, hospital administrators and ACOG all assume that more obstetrical interventions and more surgical procedures are always “more better” because doing more “things” (drugs and procedures) is more profitable.  Later in the century (1976) malpractice litigation became an expensive problem for the medical field in general and obstetrics and obstetricians in particular. 

If “doing more” had been lowering our embarrassingly high maternal mortality rate, this might have been a reasonable policy in certain circumstances, but the United States has had the very highest maternal mortality rate of all wealthy industrialized countries and has since the earliest decade of the 20th century. The profession just dressed up the massively interventive 1910 model of routine obstetrical interventions and surgical deliveries in prettier and more fashionable “clothing”.

This is especially true for their newest toy — the use of continuous electronic fetal monitoring (EFM) for all labor patients, even healthy women with normal term pregnancies, which is over 70% of all births in the US.

Psst — it doesn’t do what the manufacturer promised

  1. EFM does not save the lives of babies,
  2. EFM does dramatically INCREASE the number of emergency Cesarean surgieies
  3. More Cesareans result in more intraoperative and post-op complications, longer hospitalization, rehospitalizations
  4. Use of continuous EFM is directly associated with significant increase in C-section rate
  5. Increased number of C-section increases in the number material mortalities and permenate complications such as a 13%  emergency C-section rate relative to Cesarean surgery

EFM equipment came on the market in 1969. The very first scientific study comparing EFM with auscultation  (Haverkamp, 1976). It’s authors concluded that:

There were no differences in the infant outcomes in any measured category between the electronically monitored group and the auscultated group. The cesarean section rate was markedly increased in the monitored group (16.5 vs. 6.8 per cent in the auscultated patients). The presumptive benefits of electronic fetal monitoring for improving fetal outcome were not found in this study.

Since then, virtually all subsequent studies came to the same conclusion — no difference  in heath outcome for babies but statistically significant increase in the number of women who had unplanned Cesareans during labor  without any benefit to their babies and great detriment to women who wanted to have more children after their  Cesaeasn surgery (a VBAC or vaginal birth after Cesarean).

Google search on neonatal outcomes that comparing for auscultation to continuous EFM ”

  • Higher cesarean rates with continuous EFM:
    While no clear benefit in terms of improved neonatal outcomes is consistently found, studies often report a higher rate of cesarean deliveries when using continuous EFM compared to intermittent auscultation. 

Since then, more than hundred studies have scientifically confirmed  that the continuous EFM is not one centilla safer or better then listening the the unborn baby heart rate and rhythm with a fetoscope (acoustical stethoscope) or an inexpensive hand-held Doppler that electronically picks up and amplifies the fetal heart rate. 

Directly listening to the FHR with fetoscope or Doppler is described as “auscultation” (aus-cul-ta-tion). It inexpensive, easy to do, does not tether the laboring women to the very large EFM console sitting at her bedside of her bedremain in bed so she will be within the feet of and    

As noted above,  what makes the current American obstetrical profession so remarkably faithful to the original 1910 model used during the first seven decades of the 20th century is what I would be so bold to describe as a “quaint” idea the right place for a laboring woman is passively lying down in bed. The idea that women need to lay in bed while they are in labor is a sad leftover from the Victorian era, in the same misogynist category as “smell salts”, bustles, and the

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This is a great opportunity to look at the big picture of childbearing from the historical perspective of successfully propagating the human species in the natural world via pregnancy, labor, and spontaneous birth at such a high level that the homo-sapiens species has populated the entire Planet Earth many thousands of years ago. If childbirth was an inherently dysfunction aspect of the human species, this third rock from the sun would be uninhabited and we simply would not exist.  That is not what happened.

Historical information provided by paleontologists and historical records such as Egyptian hieroglyphics and the Judeo-Christian bible reveal the obvious biological reality that childbirth in our species as revealed by is

that labor for homo-sapiens sexually mature females has always been something done while the childbearing mother was upright and moving around.

While reducing the perception of pain, moving and being upright used the positive effects of gravity to slowly move the baby deeper into the pelvis. Unerine contraction continued to retract the cervex over the baby’s head until it began to progress incrementally through the birth canal and eventually the baby’s head became visible at the introious of the mother’s vaginia.

At the point, we homo sapiens gave birth in an upright position  — standing and leaning forward on a tree, squating down with our feet placed on two “birth stones” over a hollow out place in the ground or floor that provided a space for the baby to come down and out, or sitting on the lap of another adult “helper” or the baby’s father while a women

20,000 human history and usurpation of normal childbirth by the America obstetrical profession in the early 20th century

I’ve  already written a lengthy segment on pre-historic childbirth (20,000 years or more) when the only type of childbirth-related care was by older women whose experience in giving birth themselves gave them some understanding of the process and allowed them to be helpful and supportive of young women have a first baby or having a labor that was somehow dysfunction.

About 5,000 year also, the more advanced civilization of Egypt left historical records in the form of hieroglyphics and drawn pictures provided information about how to care for  laboring women during childbirth. There also a few scattered historical references about childbirth in the Judeo-Christian bible and other historical sources.  These records include detailed drawings that show how trained midwives worked with  then normal biology and right use of gravity, in which the childbearing women walked around during labor and gave birth spontaneously in an upright position. midwives showing how midwifery by and also by a few male physicians. They show a sophisticated understanding of the mechanical aspects of labor and birth along with trained

They show midwives and doctors who were faced with an difficult obstructed birth often had no other choice than to reached up into the mother’s uterus to pull the baby out as a last-ditch effort or an attempt to save the baby after its mother’s death.

 

According to historical records the historical use of obstetrical was who, this was first used in Egypt by physicians more that 5,000 years ago. Other desperate and often fatal attempts to rescue either mother or baby began to be used in Ancient Greece about 500 BCE and surfaced again in 17th century in Western Europe. However, the historical origin obstetrics was always as medical discipline – a form of physician care that did not routinely use surgical operations.

 

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20,000 human history and usurpation of normal childbirth by the America obstetrical profession in the early 20th century 

 

I’ve  already written a lengthy segment on pre-historic childbirth (20,000 years or more) when the only type of childbirth-related care was by older women whose experience in giving birth themselves gave them some understanding of the process and allowed them to be helpful and supportive of young women have a first baby or having a labor that was somehow dysfunction.

About 5,000 year also, the more advanced civilization of Egypt left historical records in the form of hieroglyphics and drawn pictures provided information about how to care for  laboring women during childbirth. There also a few scattered historical references about childbirth in the Judeo-Christian bible and other historical sources.  These records include detailed drawings that show how trained midwives worked with  then normal biology and right use of gravity, in which the childbearing women walked around during labor and gave birth spontaneously in an upright position. midwives showing how midwifery by and also by a few male physicians. They show a sophisticated understanding of the mechanical aspects of labor and birth along with trained

They show midwives and doctors who were faced with an difficult obstructed birth often had no other choice than to reached up into the mother’s uterus to pull the baby out as a last-ditch effort or an attempt to save the baby after its mother’s death.

According to historical records the historical use of obstetrical was who, this was first used in Egypt by physicians more that 5,000 years ago. Other desperate and often fatal attempts to rescue either mother or baby began to be used in Ancient Greece about 500 BCE and surfaced again in 17th century in Western Europe. However, the historical origin obstetrics was always as medical discipline – a form of physician care that did not routinely use surgical operations.

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“Obstetrics as usual” in America has always consisted of a ward full of labor patients lying still in their hospital beds. In the first half of the 20th century, the about-to-be new mother was moved to a surgical delivery room for the “delivery”.   Nowadays we usually bring the “delivery room” to the mother through surgically equipped LDR rooms and electronically enhanced labor bed that converts into an OR-style delivery table.

Of course, the 21st-century woman is still giving birth in an impersonal hospital gown, held hostage in bed by a half dozen or more medical devices — blood pressure cuff on one arm, IV line in her arm, two continuous EFM cables around her belly, indwelling catheter in her bladder a pulse oximeter on one of her fingers and epidural line in her spine tapped to her back and running up to another machine attached to yet another IV pole at the side of her hospital bed.

 

Combined with a supine position (i.e. lying in bed), plus the depressive effect of multiple drugs and anesthesia increases the likelihood of fetal distress.

Obviously maternal mobility, right use of gravity and other aspects of physiological management are still not a part of standard obstetrical care. Meeting the social and psychological needs of the mother has yet to be acknowledged as having any real importance in regard to safe, satisfying and non-surgical outcomes. The arena of bonding and breastfeeding, parent-craft and the long-term relationship between mother and child are not even on ACOG’s radar. T

he only real changes from the previous eras are the inclusion of fathers (if they so choose) and Cesareans performed as a ‘first resort’. The risk of immediate post-op complications — hemorrhage, infection, etc — and delayed and downstream complications continue to be functionally ignored, despite the clear legal duty to of the physician to: “…disclose all information which is ‘material to the patient’s decision of whether to proceed”, that is, “that information which the physician knows or should know and would be regarded as significant by a reasonable person in the patient’s position when deciding to accept or reject the recommended procedure.”

While women may be ‘permitted’ to walk around in early labor, once things become active (or an induction is started) they are still required to labor in bed (74%), not permitted to eat or drink and IV running (87%). The mother will be subjected to the artificial rupture of membranes (67%), Pitocin acceleration of her labor (63%) and EFM leads will routinely tether her to the bed (93%). An epidural catheter will be in her back (63%), a Foley catheter taped to her leg a urine bag and hanging from the bedrail (52%), a blood pressure cuff on one arm and pulse oximetry on a finger of the other hand (63%).

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As to the legal dynamics of hospital birth, the physician is still the “captain of the ship” and the nurse is still a “borrowed servant”, loaned to the physician by the hospital as his assistant. L&D nurses are not in the labor room 79% of the time, serving the “system” instead of the mother. According to this study of L&D nursing, only 6% of the nurse’s time is devoted to the personalized care of the mother. [The Preventable Cesarean Section Program – Reducing C-Section Rates on the Front Line by Transforming Nursing Practice, p. 4; Outcome Management Associates; 1998, Mayri Sagady, CNM]

 

And the delivery is still a ‘surgical procedure’ performed by the physician with 63% of labor patients under epidural anesthesia. The mother will push lying flat on her back (71%) and she is still expected to be prone and passive during ‘the delivery’. Delivery is a highly technical surgical procedure assumed to be accomplished by the doctor while the mother lies on her back in some version of a lithotomy position. The physician will still be  “scrubbed in” and wearing a surgical gown, scrub cap, shoe covers and facemask (with splash guard), with ready access to an array of gleaming surgical instruments at his side. The use of some form of anesthesia is the statistical norm (63%). The mother’s participation is optional, as should she not want to or be unable to push her baby up hill and around the corner, episiotomy (36%) and forceps (or vacuum extraction) will be provided (12%). Failing that, a CS will immediately be done (25%).

 

After the baby is out, a gloved hand is often inserted up into the uterus after the delivery to check for  placenta or remove blood clots (58%). As soon as the physician puts in the last stitch, his/her official duties as a surgeon are completed and the mother’s  “post-op” recovery will be assigned to the nursing staff.  And the mother still believes, for the most part, that she could not have ‘done it’ without the physician’s advanced technical skills. Thus her own sense of self-esteem is not enhanced, — instead she is grateful to the doctor for  ‘delivering’ her.

 

Last, but surely not least, normal childbirth is still defined by a surgical billing code that charges by the quarter hour. As a form of care technically defined as ‘surgical procedure, it must be performed by (and billed for) by a licensed physician (or physician extender such as a Physician’s Assistant or CNM). Since the obstetrical profession does not values physiological management, the customary and usual charges for labor and birth care do not include any monetary compensation for normalizing labor thru professional activities such as patience with nature, one-on-one social and emotional support, non-drug methods of pain relief and the right use of gravity.

 

Instead, it is the nurse’s job to keep the mother labor progressing by up-ing the Pitocin on a regular schedule during first stage labor while keeping an eye on the baby for signs of fetal distress via the EFM. Then in second stage, it’s the nurse’s job to keep the mother from pushing too effectively, lest the baby be born precipitously, before the physician arrives, as insurance reimbursement is unevenly focused on the ‘surgical procedure’ aspect of obstetrical care. If the mother delivers before the obstetrician’s arrival, the doctor is put in a very unpleasant position of not getting paid, since he/she can’t bill for the surgical procedure of ‘delivery’ if s/he wasn’t scrubbed in and present. Nor can the hospital bill for the nurse’s services as a ‘birth attendant’, because she is not a licensed practitioner who is authorized to “perform” surgical procedures. For the doctor and hospital a really fast, easy birth is a serious economic loss for everyone involved, while for the mother, it may have been her “perfect’ birth, a dream come true.

 

In a population that is essentially healthy (95% +/-), an astounding 55% of women, that is more than half, will have some form of surgery performed – episiotomy, forceps, vacuum extraction or Cesarean section. What this tells us is that all of the incentives in obstetrical care for healthy women are wired in reverse – the more the obstetrical interventions that become “routine”, the more the obstetrical profession benefits economically. The more they intervene, the higher the rate of complications. Then those unnecessary complications feed back into the system as additional opportunities for further “billable units” of medical services.

 

While economics plays an increasingly important part in modern medicine, obstetrics is still a humanitarian pursuit with a beneficent goal. What is most disturbing is how close the management of today tracks with that of the early 1900s. Changes for the most part are just more, more, more of everything – more diagnostic tests, more technological evaluations, more interference in labor (such as prostaglandins cervical ripening and labor induction) and more operative deliveries. Being trapped in an echo chamber inside of a maze, while going around in circles can’t be very satisfying for obstetricians. And saddest of all, these interventions, which are so clearly an attempt to eliminate complications such as stillbirth, cerebral palsy and damage to the mother’s pelvic floor, have not been able to achieve these goals. However, if you list the intractable problems in childbirth that gave rise to obstetrical medicine – pregnancy-related hypertension and toxemias, premature birth, fetal distress, cerebral palsy – we see that so called ‘modern medicine’ is no closer to an answer than they were a hundred years ago. We don’t still even know what causes labor to start or how to prevent its premature onset. We are no closer to predicting or preventing the toxemias of pregnancy. All and all, obstetrics is still stuck in a crisis intervention mode.

 

How could this happen?

 

The answer is simple. The science of obstetrics was and is organized around detecting and treating the rare complications. It never was not designed or structured to promote normal birth or reduce the incidence of medicated labors or surgical interventions in normal births. Nor has it any desire to promote ‘natural’ birth or even to simply reduce the incidence of medical interference. It has no positive association with ‘normal’. Instead, 20th century obstetrics is idealized as saving women from the brutality of Mother Nature, whereas normal physiology is seen as the source of that brutality. Therefore physiologic process and physiological management are seen as a backward steps – choosing a substandard form of care – malpractice — when one could, with little effort, give “high quality”, value-added obstetrical care. In this system, physiologic care is seen as irrational, negligent, incompetent, even criminal. However, this is not a science-based conclusion based on statistically valid evidence. According to all scientifically validated sources, physiological care if the safest and most satisfactory form of care for a healthy population.

 

 

Obstetrics Divorced ‘Science’ from the Scientific Method of Inquiry

 

A well-conducted scientific study requires the researcher to first develop a theory. Then a hypothesis must be developed that permits the theory to be tested by using the sound scientific methods of data collection and comparison. Next is the unglamorous legwork – setting up an experimental model and faithfully recording and collecting the data and sorting it into meaningful data sets. It will be many months (or years) before the scientist can finally arrive at conclusions to be published in peer review journals, defended by the data and duplicated by other scientists. It is this process that scientifically either validates or disproves the original theory.

 

The most radical changes to maternity care in the history of the human species were all publicly attributed to the ‘scientific method’. But the theory of obstetrically interventive management for healthy childbearing women was never subjected to scientific scrutiny by obstetricians in the early part of the 20th century. No scientific process ever established the superiority (or even the neutral safety) for managing labor as a medical condition or normal birth as a surgical procedure. In the eagerness to medicalized normal birth in the US the scientific process was skipped entirely. Prospective studies comparing the two systems in a side-by-side basis were not done. Retrospective studies that compared mother-baby outcomes for the decade prior to the imposition of the obstetrical system, with those of the first 10 years after its imposition, were never done. This untested experimental model was turned into widespread clinical practice within a single decade and without a single study to verify its efficacy.

 

With a few very notable exceptions, the lack of intellectual rigor was just ignored by the medical profession. The lay public didn’t understand scientific method enough to question this state of affairs. Had the normal scientific process been employed, it would have revealed that the medicalization of a healthy population was associated with a drastic increase in difficult labors and births, including the fatal complications associated with these interventions.

 

The tiny handful of valiant souls who did study the topic easily documented an ascending danger to childbearing women as the non-interventive care of midwives was replaced by the interventive medical management of physicians. However, the commendable actions of these courageous physicians were dismissed as ‘wrong headed’. In the “too little, too late” department, others uncovered statistical records for the 1920s and 1930s showing that the elimination of the physiological care of midwives did not, as the medical profession and lay public supposed, make birth any safer. In fact, the takeover of normal maternity care by physicians resulted in maternal mortality that rose 15 % per year for more than a decade and birth injury rate for newborns rose 44% over the same 10-year period.

 

Bottom line is that a few influential 19th century obstetricians with an unproven hypothesis – an experimental model if you will – imposed this model on an entire nation as the core “Truth” of childbearing biology. The notion was that normal birth was inherently pathological and obstetrical management was necessary to save even healthy women from the defective biology of their gender. This unproven experiment was then used to eliminate the physiological management of normal birth in institutions all across the country. By the end of the 20th century, this never-proven experimental model had been successfully ‘franchised’ around the world through the training of foreign medical students in US medical schools. In many instances, these are students from third world countries are sent here to learn the “best of the best” and bring it back to back to their developing countries. Under this strange system, Mexico now has a 40% Cesarean rate (95% rate in urban areas), which is a direct result of exporting ACOG’s version of obstetrical education to countries who believe they are elevating the care received by women in their country whenever they do it “the way its done in El Norte”.

 

Birth in “El Norte” ~ Cesarean on Steroids

 

The National Center for Health Statistics data for births in the U.S. in 2003 (released 2004) reported that our  cesarean delivery rate was the highest level ever reported in the United States — 26.7 percent. This means that more than a fourth of all babies born in 2003 were delivered by cesarean. The cesarean rate in the US has been on the rise since 1996, while the rate of vaginal births after previous cesarean delivery (VBACs) dropped by 23%.

 

Has this resulted in better outcomes for mothers and babies? No.

 

As of 1998 (most recent year available), the US ranked 28th in infant mortality among industrialized nations, which puts us behind Cuba and the Czech Republic. [Child Health USA 2002, Maternal Child Health Bureau, Health Resources and Services Administration, US Department of Health and Human Services] As for maternal mortality, the US ranked 21st in the world for maternal death. However maternal deaths are underreported by one half to two thirds according to the Center for Disease Control (CDC), which also estimates that half of the maternal deaths in the US are preventable. The rate of maternal deaths due to childbirth has not decreased since 1982, and actually began a small increase in 1999.  As for what a reasonable cesarean section would be, the World Health Organization concluded that a CS rate above 15 percent cannot be medically justified. It is useful to note that studies of hospital-based nurse midwives found C-section rates of 10 percent or less. A Cesarean rate of 7 percent or less was documented by 29 studies of care provided by community midwives. [Cesarean section: What you need to know; Goer; www.parentsplace.com/print/0,,241096,00.html]

 

Ecology, GNP in a Global Economy (need better heading –  rewrite!)

 

According to the World Health Organization, physiological management is the preferred standard of care for healthy women. W.H.O. refers to this as the “social” model of childbirth; most countries depends on these low-tech / high-touch methods to provide cost-effective care. However, the US does that economic equation in reverse – high-tech and low-touch. Aside from the cost in human terms, there is the staggering economic drain from a behemoth system such as ours. Where else in modern life do we take over a normal bodily function and replace it with the expense of an intensive care unit of an acute hospital.

 

The ecological impact alone is impressive, as aggregating childbearing women in an institutional generates thousands of tons of single use plastic and paper trash. Tons of unnecessary garbage increases expense in several ways. In an attempt to cut their expenses hospitals order cheap sterile plastic & paper supplies from abroad, which reduces jobs at home. The mountain of disposal supplies adds cost to the bill for maternity care (passed on to health insurance companies or the government). Then there is the cost for disposal, which is also filling up the scare space in local garbage dumps.

 

Healthcare accounts for 17% (or 1/6th) of the Gross National Product. At present, maternity care is slightly more than 20% of our entire healthy care budget (equal to 3.4% of our GNP). Two-thirds of this money goes to provide birth-related services to healthy women with normal pregnancies and normal births (70% of the childbearing population). [Schlenzka, 1999]  This reflects cost of many routine obstetrical interventions (average of 7 each labor) and ‘elective’ surgical births, as well as the high rate of expensive complications associated with these interventions. Bottom line is that 7/10ths of the maternity budget (2.4% of GNP) is spent on medicalizing healthy women and normal birth. But the really bad news is that in spite of spends more money on childbirth services than any other country in the world, the US has next to the lowest vaginal birth rate (i.e. highest Cesarean section rate, after Brazil). We rank 22nd (3rd from the bottom) in perinatal mortality out of the 25 developed countries.

 

In addition to a lack-luster safety record is the secondary issue of a global economy that forces the US to compete with countries in the developing world that still use cost-effective forms of midwifery/physiological care as their foremost standard. To meet the practical needs of childbearing families while remaining competitive in the global free market, the US must utilize this same efficacious form of maternity care as the countries with the best, most cost-effective outcomes. The only way our healthcare system can meet the needs of our own healthy childbearing population, while remaining competitive in the global economy, is to implement the social model of pregnancy and childbirth care as the basis for our national maternity care policy.

 

However, if we were to move to ‘vaginal by-pass surgery’ as the default method for all childbearing in the US, we would only fall farther and farther behind in the global economy.

 

We Aren’t in Kansas Any More….

 

What is the explanation for the lack-luster record of the US? It seems that intellectually-honest scientific inquiry has slipped thru the cracks. This allowed the conventional system to institutionalize a chronic lack of applied science in exact opposition to the scientific data. And yet there is a very curious incongruity here. Educationally, an M.D. has the equivalent of a Ph.D. in medical science and therefore is an  “expert” in assessing technical information. Physicians use this highly developed skill every day in making medical diagnosis and planning complex medical treatments or surgical operations. As holders of a PhD-level education, physicians are also particularly skilled in reading and digesting the technical and statistical aspects of research articles and scientific studies published in professional journals.

 

It is not unreasonable to expect that the same level of intellectual inquiry and critical thinking skills will be utilized by physicians when analyzing the wealth of scientific research on evidence-based maternity care. This would apply to the many published sources including such as the ‘A Guide to Effective Care in Pregnancy and Childbirth’ and ACOG Task Force on cerebral palsy. Medical journals, textbooks and scientific sources all make it clear that routine obstetrical interventions in labor and normal birth conducted as a surgical procedure are always more dangerous for healthy women than the use of physiological principles. So why don’t doctors notice this, or if they do, why don’t they act on the information?

 

So far the routine practice of obstetrics as it applies to normal childbearing has not met its burden of proof for the basic level of medical practice – ‘primum non nocere’ (“in the first place, do no harm”) nor do they meet the minimum standard for truly informed consent. For the last hundred years no one has held the medical community to the standard of transparency and forthrightness appropriate for a PhD level education in a scientific discipline – factually correct and scientifically valid information communicated in a public forum, unless such public statements are identified as  merely a personal or political opinion.

 

Why this is so is less interesting than why we, the public, let it go by unchallenged, decade after decade. Where are our investigative journalists? Where are the objective scientists? Where are public educational organizations like the Pew Charitable Trust? Why doesn’t the FDA require obstetricians to file “physiological impact reports” (like an ecological impact reports) on the obstetrical interventions being routinely used?

 

What is conspicuously absent in the public arena is an examination of the risks of routine medicalization, a realistic appraisal of its cost-benefit ratio, facts on the relative safety of different birth settings and the universal efficacy of the physiological model of  care for healthy women.

 

Why isn’t there a ‘Blue Ribbon Commission on Science-based Maternity Care for the 21st Century’ that brings together an inter-disciplinary panel of experts and scientists from the pertinent disciplines of public health, epidemiology, sociology, anthropology, psychology, biology, child development, law, economics, midwifery, perinatalogy and obstetrics. Public exploration such as this must listen to childbearing women and their families as a class of ‘experts in the maternity experience’. Such a highly respected forum could study these problems and provide unbiased, fact-based news for the press and broadcast media to report. This panel could, after appropriately scientific study, provide interdisciplinary recommendations for a reformed national maternity care policy. Such a science-based recommendation would include methods to reintegrate midwifery principles and physiological practices into this expanded system of maternity care.  This would be far cry from the dysfunctional public discourse of today, which consists primarily of interviewing ACOG obstetricians on television as they promote vaginal by-pass surgery as the “best of the best”, the ‘way we do it in El Norte”.

 

Consider this: If planes landing at US airports crashed five times more often than when they landed at airports in England or Japan, we would demand an inquiry of our air traffic control system, since the laws of aerodynamics are the same worldwide. Each year in the US about 8 million mothers and babies ‘fly’ the united service of interventionist obstetrics.  Only a fraction — fewer than 30% — need and benefit from this type of medicalized treatment. Isn’t it time to inquire as to why the universal ‘laws of normal childbirth,’ which are the same all over the world, are being routinely suspended by American obstetricians and, as a result, American mothers and babies are crash landing at an alarming rate.

 

Promises Unfulfilled

 

The beneficial practices identified by the Guide to Effective Care in Pregnancy and Childbirth are protective and reduce medical and surgical interventions. At present these are absent for the majority of women giving birth in this country under obstetrical management. These helpful practices are based on the physiological management of labor and birth, which requires a respect for the normal biology of reproduction and a commitment not to disturb that natural process. The elements of success for normal labor and spontaneous birth are the same for home or hospital and include the tried and true methods of non-pharmaceutical pain management and promotion of a spontaneously progressive labor.

 

However, unsafe maternity care practices have dominated obstetrics for the entire 20th century and yet have gone unnoticed, unexamined and unchallenged in the public arena. Journalists have increasingly accepted expert systems as beyond scrutiny and above reproach. This has produced faith-based reporting, in which journalists never look beneath the surface. Based solely on obstetrical sources, print and broadcast media enthusiastically promote new obstetrical technologies, medical interventions, and now medically unnecessary cesareans. It would be refreshing to see journalists question their questionable relationship with a faith-based reporting system and instead ask real questions of the obstetrical profession.

 

The question for journalists is why the majority of childbearing women do not receive the safer, cost-effective and non-interventive type of care established as beneficial in the Guide to Effective Care and recommended by the highly respected Maternity Center Association of NYC.  The beneficial practices identified by the Guide to Effective Care are protective and reduce medical and surgical interventions and yet they are absent for the majority of women giving birth in this country under obstetrical management.

 

In a rational world, science-based birth care would be the standard and the primary care form of care for healthy women, which is approximately 70% of the childbearing population, would be physiological management. The providers of maternity care would be professional midwives, family practice physicians and obstetricians who like and want to provide “maternity” care, which is to say, the care of healthy women and the use of physiologic principles. The majority of obstetricians would no doubt maintain their expertise as medical and surgical specialists, which means they will get to do what they are trained for — focus on those suffering from the diseases and dysfunctions of fertility and childbearing and complications associated with labor and birth. In this is win-win solution for everyone – mothers, midwives, medical providers and society.

 

The challenge for our country is to make our hospital-based maternity care work for all its “stakeholder”  – mothers, babies, fathers, families, hospital personal, doctors, nurses, midwives, HMOs, health insurance companies, malpractice carriers, government-sponsored Medicaid program and for the taxpayers who foot the bill.

 

It is our job as citizens to fulfill that promise.

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