Trying to Industrialize Biological Systems ~ part 2

by faithgibson on November 14, 2006

in Cesarean Politics, Contemporary Childbirth Politics

Read the New Yorker article first :

“THE SCORE – How childbirth went industrial” 

Click here for a web link to the original New Yorker article . Published October 09, 2006

Part Two — What happens when you attempt to industrialize our normal biology?

The last section of this 3-part essay focused on the industrialization of biological systems. A substantial list of unintended consequences is associated with mass production techniques of any kind, whether for farming, ranching, egg production or systemizing care for normal childbirth.

However, we can’t overlook the historical dangers associated with childbirth. Obviously, the absence of professional care does not, by itself, make normal childbearing better or any safer. This disturbing realization resulted in the development of a traditional system for providing maternity care that has existed since the dawn of humankind. As recorded by 5,000-year-old Egyptian Hieroglyphics, the principles of physiological care for normal childbirth were acknowledged and utilized by trained midwives as a formal discipline as long ago as 3,000 BCE. This means that midwifery truly is the world’s oldest profession. But we wouldn’t be debating the pros and cons of industrializing the care for normal birth if midwifery care were ‘perfect’.

At the cusp of the 21st century, the big question is whether industrialized childbirth results in the greatest level of safety, patient satisfaction and cost-effectiveness? Dr. Gawande refers to these practices as the “obstetrical package”, a term that describes the medicalization of normal maternity care as purposefully developed by the medical profession over the course of the 20th century.

The question so far unaddressed is the fundamental nature of childbirth in a healthy population. What is the optimal management for this healthy cohort? Is childbirth a normal and reasonably dependable aspect of our reproductive biology or, as the author of older obstetrical textbooks insisted, a “nine-month disease that requires a surgical cure“? Is it really a ‘disaster waiting to happen’? The obstetrical profession asserts that it is only ‘normal’ in retrospect. Is that a useful way to relate to the care of childbearing women?

Today’s essay (part 2) focuses on the biological nature of childbirth and its relationship with the right (or wrong!) use of gravity and the most frequent historical complication of normal birth. The classical or more frequent complication of childbirth as always been an inability by the mother to push the baby out under her own powers, a problem that gave rise to the first use of obstetrical instruments (forceps) that could make up for Mother Nature’s failures without having to sacrifice the life of either mother or baby.

From there we will look at how the industrialization of childbirth fits in the modern day picture of maternity care, starting with that first tool of obstetrical industrialization – obstetrical forceps. Our modern romance with obstetrical technology starts with the propriety development of forceps by the Chamberlain family in the late 1600s. Unfortunately, use of forceps eventually became a routine accompaniment of obstetrical practice for all childbirth, even when the mother was healthy and there was no ‘dystocia’ or disproportion between the size of the baby and her pelvis.

Identifying the basic nature of childbirth

When it comes to industrialized childbirth, it is obvious that the current system for providing care to healthy women has a variety of problems. No matter what the obstetrical profession or Dr. Gawande may believe, the majority of childbearing women are healthy and at the end of nine months, they are enjoying a normal pregnancy. Practically and statistically-speaking, normal childbirth in healthy women does not benefit from the routine use of medical procedures or surgery.

But for all the faults of a systematized approach to childbirth, a disturbing reality must constantly be acknowledged: Pregnancy and childbirth complications can and do occur, even for women with no obvious problems or risk factors. The industrialized childbirth of the early 1900s was fueled by this disturbing reality. It’s worthy goals were the complete elimination of all preventable complications and ‘bad outcomes’ in pregnancy and childbirth.

In THE SCORE, Dr. Gawande stated flatly that: “For thousands of years, childbirth was the most common cause of death for young women and infants”. This was presented as an undisputed ‘common sense’ fact. And yet, for all the certainty of Dr. G’s assertion, we do not actually know if it is true: Was childbirth was the most common cause of death for our ancestors? It certainly seems plausible. Without credible evidence to the contrary, the American public has always assumed that the obstetrical definition of childbirth as a serial killer of young women and newborn babies was a sad fact of a woman’s life before the 20th century. In the minds of most Americans, only the development and wide-spread deployment of modern obstetrics stopped the carnage of Mother Nature gone mad.

Childbirth – Normal Biology or Gender-specific Curse?

It is the belief that childbirth is a dangerous and dysfunctional aspect of female biology that underlies the philosophy of industrial obstetrics. Fear-based beliefs that medical and surgical interventions are necessary in every normal childbirth has what generated the policies and practice of 20th-century obstetrics.

As for those mothers who somehow delivered without having such interventions, well, the official explanation is that they were “just lucky this time”, alluding to the idea that the narrowly missed catastrophe would fall next time unless they took the appropriate evasive action. The obstetrical profession has always believed that nosocomial (hospital-based) or iatrogenic (practitioner-based) harm that resulted was far outweighed by the ‘obvious’ benefits and therefore, neither the theory nor the practice of routine obstetrical intervention required any further study.

The obstetrical profession’s fear of childbirth gave rise to the second central belief — that childbearing women can only be saved thru the universal application of the “obstetrical package”. The confluence of these concepts decides what the ‘rules of the factory floor’ are in 2007. Regrettably, one can predict that factor-floor childbirth will inch forward, year by year, towards what is believed to be the ultimate mechanism of obstetrical reliability – the progressive elimination of vaginal birth.

The active verb ‘to give birth’ will eventually be replaced by a purely obstetrical vocabulary, in which the obstetrician is the means of production, the baby is the product and the parental- consumers are compliant, complacent, well-insured and grateful.

Looking at Historical Documents for Clues

Just for the sake of argument, let’s assume that the process of childbirth, with its propensity for unexpected problems, was a bad mistake by Mother Nature. If this is the case, analysis of vital records and birth certificate data over the last century should be able to easily document the superiority of industrialized obstetrics. Statistics comparing the maternal-infant outcomes of medical versus physiological management would demonstrate that the higher the rate of intervention (i.e., use of the obstetrical package) lowered the morbidity and mortality and conversely, failure to employ the “pre-emptive strike” would be accompanied by very high rates of complications and fatalities.

Were that the case, industrialized obstetrics would clearly be associated with dramatically improved outcomes.

However, this hypothesis is not substantiated by worldwide scientific literature or the obstetrical history included in Dr. Gawande’s account. As readers will recall, Dr. G. described how the level of mortality of mothers and babies was just as high in 1940 as it was in 1910, when obstetrics first imposed a medical and surgical model on normal childbirth. Here is an excerpt of that section of THE SCORE in Dr. G’s own words:

“By the early twentieth century, the problems of human birth seemed to have been largely solved. Doctors could avail themselves of a range of measures to insure a safe delivery: antiseptics, the forceps, blood transfusions, a drug (ergot) that could induce labor and contract the uterus after delivery to stop bleeding, and even, in desperate situations, Cesarean section. By the nineteen-thirties, most urban mothers had switched from midwife deliveries at home to physician deliveries in the hospital.

But in 1933, the New York Academy of Medicine published a shocking study of 2,041 maternal deaths in childbirth. At least two-thirds, the investigators found, were preventable. There had been no improvement in death rates for mothers in the preceding two decades; newborn deaths from birth injuries had actually increased. Hospital care brought no advantages; mothers were better off delivering at home.

The investigators were appalled to find that many physicians simply didn’t know what they were doing: they missed clear signs of hemorrhagic shock and other treatable conditions, violated basic antiseptic standards, tore and infected women with misapplied forceps. The White House followed with a similar national report. Doctors may have had the right tools, but midwives without them did better. ” [end excerpt]

This is hardly an affirmation for the ‘tools’ of industrialized childbirth.

Instead, physiologically-managed labors and births using classical non-medical methods and often occurring in non-medical settings, have maternal-infant outcomes equivalent to those of the obstetrical package, but with a rate of maternal and infant interventions two to ten times lower. If childbearing biology was indeed just a bad mistake of Mother Nature, this would be impossible. [Click here for ObGynNews report the BMJ study – June 2005].

Historical records and contemporary experience both give good reason to question the cultural belief that all childbirth is a disaster waiting to happen. However, attitudes and behaviors of physicians and midwives in many other industrialized countries do not reflect that belief, nor do they depend on policies such as the pre-emptive strike to manage normal childbirth. And yet, the cost of maternity care in these countries is far less than in our own and the maternal-infant outcomes in these countries are far better than the US. The experience of community midwives in the US and abroad is also the very opposite of these ideas. [see CNM studies by Patricia Anderson, CNM on the cost-effectiveness of planned home birth attended nurse-midwives – AJNM]

As for the historical record, anthropology researchers report strong evidence that many aboriginal societies, living lives undisturbed by civilization, have remarkably good health, with little or no discernable heart disease, cancer, diabetes, dental decay, etc. In those cultures, childbirth is neither greatly feared nor frequently complicated. Obviously, we can never know for certain what childbirth for early humans was like. But there are intriguing historical clues that call into question the 20th-century obstetrical conclusions that our childbearing biology is normally abnormal.

Historical Support for Alternative Theories

An example of ‘simpler times’ can be found in the historical records of the early settlers of Colonial American. A detailed bibliography of John Adams provides an interesting record of the dozens of large families of the founder of our country and their wives during the American Revolution and early years of the new American government. In these accounts, which span the 50 years before, during and after the Revolution, more children and women of childbearing age died from virulent forms of influenza and TB and epidemics of smallpox, cholera and typhoid fever than childbirth-related complications.

Martha Ballard, a midwife who practiced for 30 years in rural parts of the New England colonies, delivered 3,000 women during this same period. The detailed diary of her midwifery practice became the subject of academic study in the 1990s. The author searched the birth and death records of the day in order to determine the accuracy of Martha Ballad’s information. According to her personal diary and cross-referenced official records, there was not a single maternal death recorded among the births she attended.

Nonetheless, childbirth in centuries past is of little help to us today, in our own very different and highly developed civilization. So I will stipulate the obvious. In the distant history of the human species, in a world with NO emergency medical or surgical services, in which entire populations were subjected to floods, forest fires, pursuit by wild animals and periodic starvation, childbirth was an additional serious danger to a significant number of childbearing women and infants.

Optimal management of Childbirth in the 21st Century

Does the industrialization of obstetrics provide optimal management of Childbirth in the 21st Century? Is the standardization of childbirth helpful to the majority of the contemporary childbearing population – that very important 70% who are healthy and have normal pregnancies?

What happened when the traditional social and professional structures that supported physiological management of normal birth for five thousand years were purposefully dismantled and eliminated during a 10-year period of time (1910-1920) and replaced by an expensive and capital-intensive childbirth ‘industry’? What is the nature of this new idea – the unopposed, unexamined ‘industrialization’ of American childbirth? Has childbirth been industrialized in other developed countries and if not, what is their experience with normal birth?

A comment by a contemporary obstetrician is instructive:

“… The hallmark of obstetrical quality is the prevention of the rare disaster rather than the optimal conduct of the many normal cases” [Dr. Brody 1981]

By its very nature, industrialized birth must be influenced by economic factors above everything else. In order to maintain an economy of scale, industrialized childbirth must try to fit individuals into predetermined norms. This applies to hospital patients and hospital staff alike. In an effort to predictably provide good outcomes or defend itself against unpredictable bad outcomes, it generates a medically aggressive process that revolves around the mentality of the ‘pre-emptive strike’. Its methods require the routine use of medical procedures – intensive care hospitalization, aggressive obstetrical management of labor, immobilization in bed, liberal use of drugs, anesthetics, episiotomy, operative delivery, etc.

Seventy percent of the time, these medical and surgical procedures are not done because the laboring woman actually has a present-tense complication or even a high likelihood of developing one, but ‘just in case’. The rare future possibility trumps the actuality of the moment. Since there is a rather lengthy list of rare but possible complications in the index of every obstetrical textbook, the list of ‘just in case’ maneuvers is likewise lengthy. Whether one is being medically treated for a heart attack or ‘treated’ for normal labor, the medical ministrations are remarkably similar, at least as defined by the serious looking hospital personnel coming and going from the room, the number of medical devices attached to the patient and the many different charges appearing on the patient’s hospital bill.

The unexamined issue for the 21st century is what does it mean to eliminate physiological childbearing and then standardize ‘normal’ childbirth care predicated on these ‘worst case’ scenarios? What impact do these policies have on healthy childbearing women? One of the characteristics of industrialization – automobile manufacturing for example – is that the actual product itself doesn’t have a role in the industrialized process — it is simply a passive part of the system, acted upon by others, like a toy doll being assembled.

In the industrialized model of modern childbirth, there is no active role for the childbearing woman. Her duties are restricted to being a good patient – passive and compliant. Surgical delivery by Cesarean Section renders the mother totally inert and virtually irrelevant, as the entire process can go on without her even being conscious.

What is the impact of this learned helplessness on society? What public policies and individual actions are appropriate? What should we do personally?

Above all, where exactly is the delicate line in which a society balances the benefit of new technologies and new ideas, while protecting the integrity and quality of our personal lives?

So far, the quality of the public debate on these important topics has been very poor. One of the reasons is that the near universal lack understanding of normal biology and normal physiological care for normal birth among the public. And despite anyone’s understanding, the question still remains as to whether or not childbirth had always been and remains fundamentally dangerous.

Earlier in this series, I addressed many of the issues of labor, especially the psychological and social aspects and normal or non-medical methods to help women cope with the stress and pain of labor. But the basic mechanics of getting a baby thru the cervix, into the birth canal and out into the world is still the best-kept secret of the 20th century.

Biology 101 – Bones and Body Parts of Normal Birth

The childbearing pelvis – that is, the internal bones that the baby must pass through — normally creates a hollow space shaped like a lower-case letter “j”. Most people erroneously think of the birth canal as a straight chute (lower-case letter ‘l’), going straight down thru the lower half of the mother’s body.

In other words, if the mother was lying down and you were watching her from the side, her baby would pass through the pelvis and out of her body the same way a train comes out of a tunnel – a straight cylindrical object passing thru a straight cylindrical container.

But this idea is not anatomically correct. Imagine instead that you are looking at an upright pregnant woman from the side and that she will labor and give birth in this same upright posture. If you had x-ray vision, you would see that the long stem of the ‘J’ tracks with the mother’s lower spine and the curved foot of the letter ‘j’ bends forward to track with the lower half of the birth canal.

What this means is the pelvic outlet — last 1/3 of the journey – bends at a 60-degree angle, which requires the baby to go around a corner and emerge into the world going forward (into its mother’s arms!). If instead it were to go straight down towards the floor (the “I” theory of the childbearing pelvis), it would be extremely hard for the mother to reach it and the baby might be injured as it fell to the ground. Not doubt this “frontal delivery” is an important survival characteristic, as 99.99% of human history predates hospital obstetrics, which meant it was the mother herself who was responsible for ‘catching’ her baby.

Childbirth has been designed by biological selection to be successful all by itself, independent of any other person or medical interventions.

Were you to look down into the pelvis from the top, you would notice that the big triangle-shaped bone of the lower spine — the sacrum and coccyx — encroaches into the pelvic outlet about an inch or so. In this regard, the pelvis is like a hollow bowl with smooth walls on three sides but slightly bent in on the fourth side, making it impossible for anything that is the same size and shape as its circumference to pass through unimpeded.

However, in the second or pushing stage of labor, after the baby is squeezed out of the uterus thru the cervix and starts its trek down into the birth canal, you would see something remarkable happen. In pregnancy, the sacrum and coccyx are movable and able to be pressed back out of the way by the baby’s head, as it descends deeper into the birth canal and gets closer and closer to being born. Think of those little pet doors that open and move out of the way as the dog or cat passes through it. The human sacrum also is jointed or hinged where it join to the lower end of the spine and it to move slightly to provide more room for the baby to pass.

In addition, the hormones of pregnancy soften the cartilage that hold the two sides of the pubic bone together, so these pelvic joints become unusually elastic. This permits the pelvis to also stretch and widen side to side, which can give the baby an extra 1-2 centimeters of room to negotiate its passage into the world.

This is graphic of a mother giving birth without the added benefit of gravity while lying on her back.The baby must first negotiate its way under the pubic bone by rotating its head from sideways to an up / down orientation.

Then the crown of the baby’s head spins under the pubic arch and will be born pointing up, towards the ceiling.

Gravity – What a concept!

Childbearing women, when left to their own devices, almost universally chose to be mobile during labor and to assume some form of upright position during the birth of the baby. The right use of gravity naturally stimulates effective uterine contractions, helps dilate the cervix and assists the baby to descend through the bony pelvis. To help the birth process move along, women are encouraged to walk around during labor. Being upright and mobile during contractions also diminishes the mother’s perception of pain, perhaps by stimulating endorphins. On the rare occasions that require the mother to lie down, midwives also noted that the labor was much slower and the mother had to push longer and harder to get the baby out. Sometimes she wasn’t able to deliver unless or until she got back up into a gravity-friendly position.

For a laboring mother, is lying down can reduce the pelvic size by almost a third, while simultaneously requiring the mother to push her baby up hill, and around a 60-degree bend. Not only does this requires that she defy gravity, but she must do this with the doorway partially blocked, reducing the aperture of the pelvis. When the mother is bearing her own weight on her back and lower spine, such as lying with her legs held up in stirrups, the sacrum cannot move back out of the baby’s way.

If the baby is small or the mother’s pelvis is big, the normal forces of labor and extra effort by the mother can overcome this impediment. However, when the mother is on her back, the baby must still emerge at an angle heading upwards, towards the ceiling. Obviously this is a lot harder and takes a lot longer than it would if gravity were used to benefit mother and baby.

Regardless of the answer to that, how did our ancestors manage this central aspect of human reproduction – labor, birth and the new baby? So let’s take a little excursion into the biology and sociology of birth. In order to do that we also have to acknowledge the role what really is the world’s oldest profession – midwives as helpers and guardians of mothers and babies.

Giving Birth with Grace and Gravity

Historically childbearing women themselves were the best (and only!) source of information about the biology and physiology of pregnancy and normal childbirth. For thousands and thousands of years, women gave birth normally with the support of their extended families and the help of experienced older women. For healthy women in safe surroundings, pregnancy and birth was generally successful for them and their babies. We know this statement is true because the human species has survived (and in fact, thrived) into the 21st century. Anyone alive in the 21st century is a direct descendent of women who were successful at giving birth normally, without the need for forceps or cesarean surgery.

Eve 2.0 ~ Nature’s program for normal birth

Midwifery as an organized body of knowledge and set of technical skills preceded the modern discipline of medicine by more than 5,000 years.

From the get-go of the human species, older experienced women always helped younger, inexperienced women during the hours of labor and during the moments of birth. This also included caring for the new mother afterward, as she learned to breastfeed and take care of her new baby. This kind of experienced assistance (Eve 2.0!) eventually became known as “midwifery”. Those women caregivers who developed specialized skills in managing childbirth and dealing with the needs of new mothers and babies were known as ‘midwives’. In the old world language of England, the word ‘mid’ meant “with” and the word ‘wife’ referred to “woman”. Thus a ‘midwife’ was someone who was ‘with woman’ during the events of childbearing.

“The practice of midwifery dates back to the beginning of human life in this world. At this supreme moment of motherhood, it is probable that some assistance has always been required and given. Its history runs parallel with the history of the people, and its functions antedate any record we have of medicine as an applied process. To deny its right to exist as a calling is to take issue with the eternal verities of life.” Dr. Josephine Baker, M.D. 1911-G, page# 232

The first record of midwifery as an established discipline can be found in the hieroglyphics of ancient Egypt in 3,000 BC. The first mention of midwives in Western culture (perhaps prophetically) is a story in the Old Testament of political intrigue and civil disobedience. The book of Exodus records the clash between the Egyptian Pharaoh, who ordered his midwives to kill all the first-born sons of the enslaved Hebrew population. The Egyptian midwives, at great risk to their own lives, declined to carry out such orders. When these midwives were called before the Pharaoh to explain why they did not do as directed, they answered that the Hebrew women, unlike the Egyptian women, were “lively upon the birth stool” and delivered before the midwives arrived.

“The practice of midwifery is as old as the human race. Its history runs parallel with the history of the people and its functions antedate any record we have of medicine as an applied science. Midwives, as a class, were recognized in history from early Egyptian times.” Dr. Hardin, M.D.1925-A; p. 347

During the first 5,000 years of recorded history, the discipline of midwifery was empirically-based and organized around meeting the practical needs of laboring women. These universal needs are primarily psychological, emotional, and social. The care of midwives included ‘patience with nature’, the right use of gravity and a commitment not to disturb the natural process. Again, we must accept as fact that this was a successful strategy, as the human species has survived and thrived under the care of their midwives.

No medical drug or device, no surgical instrument or procedure ever developed by medical science has been able to make birth better or safer in healthy women with normal pregnancies than spontaneous labor and normal birth attended by an experienced birth attendant.

These protective methods are what we now refer to as “physiological management” – that is, “…in accord with, or characteristic of, the normal functioning of a living organism”.

The classic principles of physiological management include a basic trust in biology and support for the normal process of labor and birth. It is a tradition that restricts the use of interventions to abnormal situations only. This non-interventive approach recognizes the mother’s need for physical and psychological privacy and to feel safe from unwanted intrusions and the prying eyes of strangers. Physiologic care encourages the mother to walk around at will and to be upright and mobile during both labor and birth. It also includes continuity of care by individuals known to the mother, one-on-one social and emotional support, non-drug methods of pain relief (such as movement, touch and warm water), patience, and the right use of gravity.

“…that trained midwives surpass the record of physicians in normal deliveries has been ascribed to several factors. Chief among these is the fact that the circumstances of modern practice induce many physicians to employ procedures which are calculated to hasten delivery, but which sometimes result in harm to mother and child. On her part, the midwife is not permitted to and does not employ such procedures. She waits patiently and lets nature take its course.” [1931 Testimony on midwifery care, White House Conference on Child Health and Protection by the Committee on Prenatal and Maternal Care]

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