The Brave New World of Evidence-based Maternity Care ~ Chapter 4

by faithgibson on September 8, 2013

Chapter 4 –

“The Truth, the Whole Truth and Nothing But the Truth”
~ the ethics and obligations of having a Doctorate in Medicine ~

faith gibson, LM (2005)

Midwives are acutely aware of the crucial role that obstetricians play in our lives and those of our clients. Generally speaking, midwives have a natural affection for obstetricians and are seeking to dramatically improve the quality of the debate between our respective professional groups and the public at large. There are many areas of agreement, such as a mutual desire to contribute to the well being of mothers and babies. There are also areas of controversy and disagreement, such as home-based maternity care as provided by midwives and the wide-spread need to demedicalize hospital care as provided by obstetricians to healthy women, which is the majority of all births.

In particular, we are interested in improving the working relationships between midwives and physicians, so that mothers and babies do not suffer as a result of the historical tension between obstetrical medicine and midwifery. Ultimately midwives of all educational backgrounds desire to live and work in harmony with obstetrical medicine. We are committed to providing high quality care to healthy women and to augment, compliment and supplement the care of obstetricians when mothers need or want more than the midwifery model of care can offer by itself.

However, it seems that physicians as a group do not share our interest in increasing cooperation or other attempts to bring our respective professions into better alignment. It also appears that organized medicine is not particularly interested in getting the story straight when it comes to publicly promoting studies on the relative risks of routine obstetrical interventions in childbirth. In the last few years virtually 100% of syndicated newspaper articles and media coverage of obstetrical interventions and location for birth (home, hospital or birth center) have included major misrepresentations and/or disinformation. Topics for these misleading statements include the risks of elective inductions, Cytotec use, continuous fetal monitoring, epidural anesthesia, vacuum extraction, “maternal-choice” cesarean section, the issue of post-cesarean labors (VBAC), non-institutional birth services and most recently, normal vaginal birth itself which is now being portrayed as “dangerous” and old fashioned.

In spite of the unending rhetoric of organized medicine against midwives, the real issue is neither the relative safety of midwifery or home-based maternity care. Its the relative risks of obstetrical management and hospital-based birth services as currently configured. For nearly a century, the obstetrical profession has distained the science-based physiological (i.e. normal, non-interventive) management of labor for healthy women with normal pregnancies, preferring instead to define childbirth as intrinsically pathological and in need of constant meddling. This self-serving definition has never been accurate.

The reduction in pregnancy and birth-related mortality over the last century was not the result of obstetrical medicine for the masses but instead reflected economic and public health improvements in the US that raised the general standard of living and educational level of the public. Unfortunately, the “normal birth is dangerous/doctors save babies” was the story preferred by the obstetrical profession. This institutionalized a total failure within medical education to teach, learn and utilize physiological methods and perpetuates a system that is systematically failing to serve the actual needs of the healthy childbearing public.

The problem is that physicians are the natural spokespersons for the scientific discipline of medicine, a circumstance that places a societal burden of candor and accuracy on doctors by virtue of their advanced education. The obligation intrinsic in this education creates a higher standard of conduct than mere recitation of personal preference or professional self-promotion. The very fact that physicians are the holder of a doctorate (a PhD) in the science of medicine gives the public every good reason to believe that all statements made by physicians about matters of health, safety and medical care are unbiased, scientifically-based and factually correct. This would include the duty to communicate only scientifically valid information in a public forum unless such statements are identified as merely a personal opinion.

For want of a better term, the relationship between a medical professional and the well-being of those who depend on this medical expertise must be described as a “covenant” of sorts, which includes a duty “above and beyond” ordinary commercial transactions. It seems reasonable that the legal concept of “false and misleading” claims would apply to recommendations by individual doctors and spokespersons for organized medicine that are being promoted as unbiased scientific data but instead are a prejudiced rendition of half-truths and manipulated data used to accomplish hidden agendas or self-serving economic goals. Surely our medical care providers should be as accountable for accuracy and truthfulness as the Arthur Anderson accounting firm and CEOs of publicly traded companies such as Enron and World Com.

Unfortunately, a lot of false or misleading claims about ‘appropriate’ care for normal childbirth, universal hospitalization and the ever increasing medicalization of maternity services for healthy women are being fed to the press by the obstetrical profession with no public acknowledgement that obstetrical management and routine use of these popular interventions introduces unnatural risks into normal childbirth. These practices unnecessarily increase both the cost and the number of complications, especially for the mother and for both mother and baby in post-cesarean pregnancies.

Simultaneously with this propensity by an uncritical press to so generously hype up ‘medical miracles’, there is what amounts to a media black-out of accurate and reliable information made available to the public on the normalcy of childbirth. In spite of laudable improvements in maternal health and safety over the course of the last century, our culture seems to be controlled by an exaggerated and debilitating fear about childbearing, combined with a dearth of useful information about normal birth. 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 Midwifery Model of Care for healthy women.

The routine practice of contemporary obstetrics, at least as it applies to normal childbearing by healthy women, does not meet its burden of proof for even the least level of medical practice – ‘primum non nocere’ or “in the first place, do no harm”. It also does not meet even the minimum standard of 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 in a scientific discipline – factually correct and scientifically valid information communicated in a public forum, unless such statements are identified as merely a personal or political opinion.

For a variety of reasons, the American public, the American press, agencies of state and federal governments and the courts have never required that the obstetrical profession’s incredible claims of the last 100 years and the drastic and dangerous treatments routinely applied to healthy women in hospitals through out American be proven safe and effective or at the very least, that they do no harm or at the very, very least, the known risks are communicated to and freely chosen by the childbearing family with fully informed consent. Were the obstetrical profession to attempt to advertise the present configuration of interventionist maternity care on television, the Federal Trade Commission could not permit them to do so, as they would not able to provide the  “reasonable proof” of these advertisements as required by law. Obstetricians cannot meet this burden of proof because it simply does not exist

What’s Missing, What’s Needed

For the last century, an unbiased examination of the scientific literature, national vital statistics data and other universal measures of maternal infant well-being have always identified danger, unnecessary expense and increased risk when drugs and surgery were applied to healthy women and normal birth. To quote the editor of a well-respected obstetrical textbook (Davis) published in1966, “There can be no alibi for not knowing what is known.” Doctors are formally educated and highly paid to know the scientific literature and be aware of the full spectrum of consequences associated with medical and surgical interventions. It is not unreasonable to expect their advice, both to the public and to individuals, to be objective, even though that would require them to take their own self-interest out of the equation.

Instead, self-interest has blinded organized medicine, dominating the model for obstetrical practice in the 20th and now the 21st century, by uniformly ignoring what is “known” to introduce unnecessary danger. This has produced a version of medicalized care that is detrimental to the classical goals and purpose of maternity care – protection of the childbearing women and their babies from both the mistakes of Mother Nature and unwise meddling of Man, that is, care providers whose ignorance or disregard of sound biological principles introduce unnatural and unnecessary harm.

For healthy women who are well-fed, well-housed, well-educated, and well-cared for during pregnancy, the greatest realistic danger today is obstetrical over-treatment and its many complications. For a healthy woman, her most pressing needs during a normal pregnancy are primarily social and psychological. Relative to labor and birth, her greatest needs are met by the philosophy and principles of physiological management – the midwifery model of care– which includes continuity of care providers and the full time presence of a skilled and caring practitioner during active labor.

Physiological management includes the right use of gravity to naturally promote progress and psychological support helps the mother to cope without the need for drugs to accelerate the labor or to manage pain made intolerable by forced immobilization. This traditionally successful strategy avoids the multiple side effects and complications that accompany artificial hormones, narcotics, anesthesia and operative delivery.

One study of L&D nursing care discovered that nurses were only present at the bedside, providing one-on-one labor support, 6% of the time.  The failure of obstetrical management to provide psychological support and routinely make right use of gravity virtually guarantees that medical interventions will become necessary, creating a domino effect or a “cascade” of additional interventions to the mother. The lack of emotionally appropriate labor support simultaneously with the mother’s severely-limited mobility (usually lying down in bed), almost inevitably bring about the need for drugs and anesthesia for pain, which retard progress further, necessitating the use of labor stimulants and the string of complications that engenders.

The combined effect of narcotics and/or epidural anesthesia increase the likelihood of an episiotomy and the use of forceps or vacuum extraction for vaginal delivery (25% to 60% of the time, in addition to a 24.9% Cesarean rate). The epidural rate in many urban hospitals is 95%. The detrimental side effects of labor and birth interventions care can and often do extend to the baby, resulting in its admission to the neonatal intensive care unit, especially for a post-epidural fever work-up and antibiotics. One study noted that 86% of all babies in the NIC for a post-epidural septic work-up and 87% of all babies receiving antibiotics were post-epidural fever babies. For post cesarean pregnancies, iatragenic complications follow the mother into the next pregnancy & birth and can result in uterine rupture, emergency hysterectomy and a neurologically damaged baby.

Long-term GYN complications of vaginal deliveries made more “difficult” through unscientific, anti-gravitational management (with or without the use of forceps or vacuum extraction) include pelvic floor dysfunction or pelvic organ prolapse. (cite Ob.Gyn.News articles) This greatly increases the risk of incontinence in the later years of the woman’s life. It is considered by organized medicine to be the “collateral damage” of “normal” vaginal birth, having nothing to do with their failure to employ physiological principles. Obstetricians have been very generous to themselves and very critical of female biology, confusing cause with effect by defining the woman’s childbearing body as defective while exonerating themselves of any role in or responsibility for those “failures” which, in many instances, are actually iatragenic complications.

Consumer activists, concerned about these problems, misrepresentations, and deficiencies inherent in the obstetrical treatment of normal birth (but still promoted by an uncritical media), have made many valiant attempts to interest the obstetrical community in a mutual dialogue. We are trying to bring about a long-over due change to a mother-friendly system, such as enjoyed in many other parts of the world. An entire organization – the Coalition for the Improvement of Maternity Care (CIMS) – exists expressly for this purpose. CIMS has an extensive membership of many widely-know professionals such as Marshall Klaus, PhD, Marsden Wagner, MD and birth activist and well-known author, Suzanne Arms plus 29 major birth-related professional organizations such as Lamaze, the Am College of Nurse Midwives and Maternity Center Association of New York. The members of CIMS crafted and ratified the “Mother-Friendly Childbirth Initiative” (www.motherfriendly.org ). In the main, all these good-faith attempts have been consistently rebuffed. The bottom line is that the obstetrical community, when provided with corrective information, consistently fails to take corrective action.

This fatally flawed medical model reached its zenith this year in an article published in the Wall Street Journal in which obstetricians claim that normal vaginal birth is intrinsically so dangerous that it should be replaced by the “safer and better” obstetrical version – medically unnecessary elective surgery euphemistically described as the “maternal choice “ Cesarean.  This dubious recommendation is predicated on the potential for obstetrically-managed vaginal birth to create unnatural stress on the mother’s pelvic floor and pelvic organs and completely ignores all the well-documented dangers of Cesarean surgery and post-cesarean pregnancies.

The June 4, 2002 Wall Street Journal article by Tara Parker-Pope was entitled “Growing Number of Physicians Warn of Serious Risks from Vaginal Deliveries“. It stated that vaginal delivery carries such risks as “pelvic pain” and goes on to say that, “One reason for the high incidence of birth injuries is the decades-long…effort to reduce the nation’s C-section rate.” The article was heavily skewed towards the “silent epidemic” of vaginal birth and vaginal birth injuries. (can be accessed at www.wsj.com but you have to be a WSJ online subscriber to view it). The crux of the story was that woman are being damaged because doctors are providing “normal” (vaginal) births services instead of cesarean deliveries. Considering that obstetrician management for normal birth is basically non-physiological, it is true that that medically “managed” vaginal births contribute to the problem of pelvic floor dysfunction. However, the proposed “solution” – elective cesarean –offends common sense while suggesting that historical medical educational deficiencies of the 19th and 20th centuries should be ‘remedied’ by performing major surgery on unsuspecting women in the 21st century.

The uncritical acceptance of an unscientific system of maternity care

The current configuration of highly complex medical care for well women with normal pregnancies – which are approximately 70% of all pregnancies — is a historical anomaly in the annals of health care. It is illogical, unnecessarily expensive and not used anywhere else in the world. It does not routinely address the psychological and emotional needs of the women it serves, nor does it deal directly with her developmental needs in taking on the complicated and demanding role of motherhood. The core of our problem in the US is the uncritical acceptance of unscientific principles as the foundation for our national maternal-infant health policies.

It is neither scientifically predicated nor cost-effective to employ a surgical specialist (with 9-plus years of post-secondary education at an annual cost of $200,000) and a high tech “intensive care” hospital setting to provide care to fundamentally healthy individuals experiencing a normal biological process with far-reaching emotional and social consequences. The ever-increasing use of drugs, surgery and sophisticated technology has not been able to live up to the promise of organized medicine to make normal birth safer than could be achieved by the common sense methods of social support and physiological management.

These statistically safer and historically effective natural methods – for example, continuous one-on-one labor support and the right use of gravity — have been replaced with obstetrical protocols that require intensive-care nursing and include the continuous use of electronic fetal monitors and a liberal use of artificial hormones, narcotics and surgical instruments. This intensively manipulated and drug-dependent model of hospital obstetrics is disturbingly similar to the methods used by the agra-business on chickens and dairy cows to force egg and milk production into an assembly-line time table. In this sense, the agra-business and the birth business have far too much in common. Sadly these commercial methods, while technically efficient and profitable for hospital share-holders, depersonalizes the birth experience to the detriment of the mother-baby relationship. Equally important, it has introduced unnatural and unnecessary risks that are not revealed to the childbearing couple through meaningful informed consent. When the cascade of obstetrical interventions go array and surgery must replace normal birth, it turns healthy low risk women into high-risk reproductive cripples.

This medical system does not include any realistic measures of quality care such as are applied to other aspects of medical practice. For example, the 6/28/02 edition of the NYT reports on a quality control program for Kaiser radiologists in Colorado who review mammography films. When their failure rates (missed breast cancers) rises significantly above the average for their peers, these low-performing doctors are identified and offered additional training or reassigned. Using this model, one would assume that OBs would be acknowledged and rewarded (economically and otherwise) for their skill in facilitating normal biological process and vaginal birth, especially in the face of complicating medical factors. One would also expect obstetricians to be “dinged” for a very high operative delivery and cesarean rate. However, the current focus on cesareans as the “superior” form of care reverses this common sense rule. Instead good doctors often find themselves criticized by other doctors, sued or loosing their hospital admitting privileges and sometimes even threatened with the lose of their medical license because their CS rate is “too low”. (cite woman OB in No. Cal)

Approximately 900,000 CSs are already performed annually. It is the most frequently performed major surgery in the United States and projected by obstetricians to double within the next generation (citation OBGYN NEWS, Bruce Flamm MD). A measure of what that means is revealed by an advertisement in obstetrical journals for a product to reduce the scarring from surgical incisions. The ad, which was published in 1995, proclaims that: “A Scar is Born Every 39 Seconds”, that is in 1995 a C/S was performed every 39 seconds. The obstetrical profession would like us to believe that mothers and babies will be safer still when a “scar” is born every 12.5 seconds – that is 7 ½ cesareans every minute, 450 operations an hour, 10,800 per day, a mere 3,942,000 surgical deliveries each year – by eliminating vaginal birth altogether in the name of safety and pelvic floor integrity! To those of us who understand the art and science of normal birth, this appears to be breech of trust of astounding proportions by medical “science” purporting itself in a most unscientific manner.

Contemporary obstetrical practices for healthy women with normal pregnancies are founded on a 19th century reductionist view of childbirth in which the rich tapestry of childbearing, with its emotional nuances and long-term social consequences, is reduced to whether or not the baby eventually leaves the hospital alive. Physical or psychological damage done to the mother or baby in these attempt to bring that about are not factored into the equation. This is like viewing conception from the narrow perspective of an infertility specialist who sees no difference between making love and being artificially inseminated – both result in pregnancy. With this kind of medical mindset, that is all that counts. This depressing situation is the predictable consequence of purposefully preventing the corrective and humanizing influence of midwifery and its principle of physiological management of childbearing from being applied to the field of normal maternity care. While midwifery management and standard obstetrical care produce equally good results in perinatal outcome – as measured by babies born without neurological damage –what is remarkably different and missing from obstetrical management is the opportunity to address the full spectrum of maternal, infant and societal needs.

Mother-centered “Maternity Care”
versus “Obstetrical Medicine” for Healthy Women

Pregnancy produces a mother as well as a baby (cite Judith Rooks). Traditionally, maternity care as provided by midwives and family doctors focused primarily on the mother and her relationship with the baby. Its services were largely supportive, preventive and aimed at the “big picture”. In this context, it was the mother’s job to “give birth”, which she did with the physical and emotional help of her caregivers. Once the baby was born, the active role of the caregiver was extended to include the well being of the new baby and a professional interest in the development of the mother’s ability to nurture her infant and function in her social environment.

Over the course of the last 60 years, this type of mother-friendly maternity care has slowly been replaced by obstetrics as the norm for all childbearing women, regardless of whether or not there was a genuine complication of pregnancy. The human touch has been replaced with institutionalized and depersonalized care characterized by pervasive and invasive technology. This sub-optiminal care was the ignoble result of more than a century of public posturing by organized medicine, which consistently misrepresented normal childbirth as horrifically dangerous for healthy women. This exaggerated fear, which was all out of proportion to the realistic danger for healthy women with good access to medical care, struck a near fatal blow to our psychological equilibrium and cast childbearing women as victims of their biology. This is as much of a gender-defined trap as Freud’s ill-conceived and misogynist idea that “biology is destiny”. This false premise sanctioned the “heroic” methods of allopathic obstetrics as necessary to rescue mothers from biology run amok. In contemporary times this is defined as the rigors of an unmedicated normal birth, now seen as requiring stamina way beyond the ability of modern women, who are wrongly assumed to only be able to labor and give birth with a great deal of medical help and only under the influence of drugs and anesthesia.

As contrasted with “maternity” care by both family doctors and midwives, obstetrical care focuses on the fetus, as if the primary job of the doctor is to decide when and how the unborn baby is to be rescued from it’s unfortunate and dangerous entrapment in the mother’s body. An example of this thinking is the introduction to the 16th edition of Williams’ Obstetrics, which excitedly proclaimed its enthusiasm over being able for the first time to have the fetus be the “primary” patient – a change in focus from the mother to the baby, brought about by the introduction of advanced technology, particularly ultrasound and continuous electronic fetal monitoring.  

Obstetrical services now largely consist of various types of technological surveillance, tests and medical/surgical interventions. Timing and technique are the name of the game. In this context, the labor is micro-managed by medical methods. Instead of the continuity of care, personal one on one labor support, non-pharmaceutical pain management, patience with nature and right use of gravity, these mother-baby friendly techniques were replaced by departmentalized care shared unequally between various doctors, office staff, hospital nurses impersonal care of a rotating shift of labor and delivery room nurses. As noted earlier, L&D nurses are out of the room 79% of the time and only providing bedside comfort measure 6% of the time. This results in the cascade of unscientific and anti-gravitational management techniques, such as being confined to bed, which virtually guarantees the use of non-physiological positions. This results in weight bearing on the maternal sacrum which closes down the bony pelvis by approximately one third, while requiring the baby to be pushed uphill against gravity at a 60 degree angle through a partially closed door. As a consequences labor stimulation and/or operative delivery often become necessary.

At a time of the doctor’s choosing, the baby is then delivered from the passive or anesthetized body of its mother, often aided by a surgical incision in the vaginal opening, forceps, vacuum extractor or even Cesarean section. Since the baby is ‘delivered’ by the doctor, the mother’s role is reduced to that of a spectator, her value accordingly diminished. She is suppose to be appropriately grateful to the doctor and thank him profusely for his professional efforts and his success in providing her with a highly desired and very expensive “product” – the obstetrically-obtained newborn.

In the obstetrical system, professional schooling, time and most of the money paid out directly by patients or indirectly by insurance companies is focused on the very few hours of labor and even fewer minutes of “delivery”. Time is money and only billable procedures really count. After having successfully rescued the fetus from potentially life threatening “mother-entrapment”, the obstetrician quickly concludes his legal liability by immediately handing the baby off to a nurse or pediatrician. This system has no formal training for and little interest in the “bigger picture” of human reproduction and its immediate social consequences – motherhood, parent craft and strengthening the social fabric. If mother is diagnosed with any problems after the birth — breastfeeding difficulties, postpartum depression, post-episiotomy pain, difficulty having sex or her infant suffers from a ‘failure to thrive’, the patient will handed off to non-obstetrician specialist.

Individualized Versus Institutionalized Care

The 100-year slide from mother-centered “maternity” care into a high-tech medical monopoly has institutionalized a lack of compassion as the norm. At present, hospital care does not generally admit the central importance of the mother’s physical and psychological needs as defined by her, preferring instead to focus on “billable units” – medical or surgical procedures that both make money and are deemed indispensable to prevent lawsuits. One of the most salient features of contemporary hospital obstetrics is its inability to organize its service around the practical needs of the mother and the unwillingness of the corporate world of the modern hospital to be held accountable for this failure. Compassionate care requires the near continuous presence of an experienced professional and yet neither doctors or nurses are currently trained to do this, nor are they provided with the physical space and time needed to provide individualized care, employ physiological management (upright and mobile mother) or utilized the many non-pharmaceutical comfort measures, such one-on-one labor support, access to hot showers, deep water tubs, etc, that address the mother’s pain and her natural anxiety without resorting to drugs.

In order for hospital obstetrics to be a money-maker, assembly-line principles must be applied. One hospital administrator candidly admitted that expensive 24-7 anesthesia coverage is considered necessary to give his hospital a competitive advantage over smaller community hospitals. However, it is acknowledge industry-wide that each institution must have an 80% epidural rate in order to break-even on the greatly increased costs of doing business and must have over 90% epidural rate to turn a healthy profit on their service. An email from a nurse in the mid-west reported that her hospital had just been bought out by a corporate hospital chain. The new head of anesthesiology held an introductory staff meeting for the L&D nurses and announced a department target of a 95% epidural rate. If we didn’t know better, we might think that the entire purpose of modern childbirth is to move money from the pockets of the health insurance companies into the pockets of the hospital and its suppliers through the maximizing of medical procedures.

Sexism in the Birth Chamber

When drugs and anesthesia are seen as the solution to all difficulties it is because we assume that there is no redeeming purpose in the hard work and sometimes painful nature of normal childbearing. This can be viewed as a subtle form of sexism, which perceives childbearing women as either biologically defective or psychologically unable to cope (or both). In so many other areas of a woman’s life — sports, schooling, professional, political, artistic or Olympic achievements — we honor her hard work, respect the determination it takes, we provide support for the difficult or painful aspects that are the expected accompaniment to such a grand undertaking and celebrate it as a victory when she succeeds.  For childbirth, we do the opposite — tell women they are crazy to even want a natural birth and sabotage the mother’s best efforts by asking every 20 minutes if she doesn’t want a “little something to take the edge off the pain” or repeatedly tell her that she can have “her” epidural anytime she wants.  We don’t value or respect the hard work of labor or provide the circumstances for its success, leaving her to blame herself when she is disappointed in her birth experience.

Obstetrics for healthy woman and normal birth serves everyone and everything but the real needs of the healthy mother and her normal baby. It achieves this by locking out the primary “state-holders” in maternity care – the women themselves — from being full participants in the process. This dramatically reduces or eliminates the mother’s opportunity to be empowered by the experience of normal labor and birth.

Consider for a moment the natural and normal stresses that every mother can expect to face as a parent, wife, employee or even as a citizen in the post 9/11 world. Newborn babies get colic and cry, marital problems can arise, unemployment, spouses and children may become chronically ill, seriously injured or disabled. God-forbid, as wife and mother, she may have to deal with a tragedy like a family member dying or face days of on-going stress such as the wives of the 9 miners trapped in Pennsylvania. Faced with a sick child or unemployed husband will obstetrical care providers step in with narcotics or tranquilizers; will anesthesiologists be there to administer the equivalent of an epidural to “help” her through each of these difficulties?  If the answer to all biologically difficult situations is to be heavily medicated, where are the “natural” opportunities to develop and practice important coping skills, how will mothers experience successfully over coming adversity? Rising to the occasion of spontaneous labor, with its lost sleep, missed meals, pain and the hard work of pushing a baby out gives parents an opportunity to work together, to be tested and to experience themselves as competent and to become confident that they have what it takes to take care of their new baby.

The current style of interventionist obstetrics leads to routine use of epidural anesthesia with an increase in operative deliveries by 28% to 60% (and 5-fold increase rate of maternal incontinence). The sky-rocketing number of Cesarean deliveries carries with it an increased rates of infection, hemorrhage, blood transfusion complications and increased maternal deaths of 2 to 4 times greater than vaginal birth. Long-term complication of Cesarean surgery include uterine rupture, fetal death, placenta previa and percreta and emergency hysterectomy in future pregnancies. Operative vaginal deliveries and Cesarean Section are both associated with an increased rate of serious postpartum depression and PP psychosis. Pitocin use/epidural anesthesia is associated with increased rates of autism. Narcotic use during labor associates with increased frequency of drug addiction in offspring.

This type of care creates a negative feed-back loop as more and more women experience only medicalized and mechanized births which adds critical mass to the on-going public fear of normal birth. Ultimately this undermines the possibility that  correctionwill ever naturally occur, almost guarantying that prejudice and misinformation will be passed on to the next generation of childbearing women as we perpetuate an Obstetrical Dark Ages.

Normal Birth — Elements for Success

The elements of success for normal biological process includes a recognition of the quasi-sexual nature of childbirth. This means that the mother has an absolute need for privacy and the right to control the participation of persons and medical procedures that transgress the boundaries of her body or her sexual psyche. Likewise, she needs to be free from performance pressure and arbitrary time constraints. The spontaneous biology of birth is heavily influenced by psychological factors – both negative and positive states. This is a well-known aspect of normal sexuality which applies equally to labor as to sexual responsiveness. The childbearing woman has a right to the kind of care from her companions and her caregivers that does not disturb or interfere with the spontaneous progress of labor & birth.

By creating an environment in which she feels unobserved and yet secure, with emotional support by familiar people, midwifery care addresses the mother’s pain, her fears and her privacy needs. This includes an environment in which the mother feels free to make sounds of all sorts and to be unclothed if she chooses. Many women find that their labor cannot progress naturally without a supportive environment and encouraging companions.  It is also necessary to take into account the positive influence of gravity. Right use of gravity stimulates labor, dilates the cervix and helps the baby descend through the bony pelvis. Encouraging the mother to be upright and mobile not only helps labor process normally but also diminishes the mother’s perception of pain, perhaps by stimulating endorphins and prostaglandins to make labor more efficient. To ignore the well-known relationship of gravity to spontaneous progress is to do so at the peril of mother and baby.

The complex interplay of the physical and the psychological are a biological verity of childbearing. Women have an undeniable right to have their maternity care providers make right use of gravity and take into account the emotional needs of the mother-to-be and the sexual nature of spontaneous labor and normal birth. This is the historical core of the midwifery model of care, although one does not need to be an either woman or a midwife to acquire its skills or successfully employ its strategies, such as the ‘right use of gravity’. Physicians can and should utilize the midwifery model of care when they provide care to healthy women with normal pregnancies.

In the absence of this kind of support, the mother will frequently need narcotic medication for pain and additional drugs to overcome the labor-retarding effects of the narcotics. The need for episiotomy, forceps, vacuum extraction, cesarean section often represent the failure of the maternity care system, or individuals within it, to account for the influence of the mother’s psychological status in regard to the events of labor and birth. As a culture, this is our failure and not her’s.

A Plan for All Reasons –
Rehabilitating the biologically appropriate standard of care as the 21st Century Norm

In spite of the Internet and on-line medical education, the “usual and customary” practice of obstetricians often remains decades behind the best scientific evidence. This is particularly a problem in the area of episiotomy and Cesarean surgery, considering its potential mortality and far-reaching health consequences. For instance, several studies reported that that a significant percentage of Cesarean Sections done for “failure to progress” or “arrested labor” were done before the mother was in active labor and therefore were not medically justified. There is the issue of “single layer” closure – a widely-used but scientifically unvalidated method for suturing the uterus after a Cesarean that is associated with tripling the uterine rupture rate in subsequent pregnancies. Another study reported that a significant portion of Cesareans done for fetal distress were performed without first utilizing the simple criteria published years ago by American College of Obstetricians and Gynecologists to assure that the baby really was distressed and the surgery was truly necessary. This article noted that it takes many years for simple scientific adjustments in practice to be voluntarily adopted by ACOG members. In the mean time, obstetricians continue to use out-dated or inadequate criteria, and even harmful methods, with impunity.

The solution to these obstetrical dilemmas is certainly not expanding the rate of cesareans or greater use of technologically-intensive and expensive interventive obstetrics. The short comings of contemporary obstetrics for healthy women should not be blamed individual doctors either. Their actions are true to what they were taught. Unfortunately, what they were taught about normal birth was wrong. These problems are systemic, not individual. The elimination of these problems comes back to correcting the misogyny and the dysfunctional medical education that it gave rise to nearly a hundred years ago. We must work to bring about the day of reckoning, a time and place where organized medicine will be called to account for and correct these institutionalized errors. The medical system needs correction at several levels – educational as well as clinical. Dramatic changes are needed in the presentation and promises crafted by public relations experts hired by the obstetrical profession, which promise what they can’t deliver and thereby lay the foundation for inappropriate lawsuits. What we need instead of more blame and malpractice litigation is a national maternity care policy that applies the midwifery model of care as normative to normal pregnancy and birth.

In the 21st century world of science-based maternity care the institutionalized blind spots of conventional obstetrics must be replaced by a fully functional knowledge of physiological management and full disclosure of all known risks of obstetrical interventions. All providers of obstetrical services will gradually find themselves being held legally responsible for knowing and appropriately using standard midwifery principles and techniques when providing care to healthy women. Hospital labor and delivery units should be primarily staffed by professional midwives. In the event of malpractice litigation, physicians would be required to establish that they (or professional midwives in their employ) first used all the appropriate, common sense approaches that are historically associated with physiological management of normal birth. However, in this new configuration of maternity care for well woman, the actual number of complications should be vastly reduced by eliminating unwise and unnecessary interventions. Malpractice litigation would be further reduced by promoting more realistic expectations by childbearing families and by better meeting their psychological needs.

To meet this biologically appropriate standard of care – the irreducible minimum for science-based practice — physicians must first utilize gravity, patience with nature, one-on-one emotional support, oral hydration, upright and mobile mother, vertical delivery, hands and knees position (Gaskin maneuver) to resolve shoulder dystocia, etc, before embarking on drug-dependent or surgical solutions such as IVs, oxytocin, narcotics, epidural anesthesia, forceps, cesarean surgery, procto-episiotomy, fundal pressure or fracturing the baby’s clavicle to resolve a shoulder dystocia. To provide this improved standard of care medical education must routinely teach, learn and utilize physiological management as foundation for all obstetrical training, preceding and underlying all study of pathological states. A good medical school program would include medical students and interns working with hospital midwives and healthy women. Interns must be taught the physiological management of normal labor and birth by midwives before being exposed to obstetrical pathology as a part of their OB-GYN residency.

Note to Self — needs closing to tie chapter together