Unfinished Draft
originally written in 2008
~ Obstetrical Medicine in the US is a stumbling stone and roadblock to an integrated maternity care system that promotes and supports normal childbirth & provides appropriately non-interventive services to healthy childbearing women with normal pregnancies, including access to the more cost-effective midwifery care
Re-posted April 2022 ~ The more things change,
the more they stay the same!
For all our idealism, enthusiasm and sustained effort as mothers, midwives and activists for normal childbirth services for healthy women, we remain locked out of an integrated maternity care system by factors that are political rather than scientific.
In the current configuration, women as mothers and midwives have to lose in order for the obstetrical profession to win — a state of affairs defined as having a complete monopoly on all forms of maternity care and total control over all aspects of labor and childbirth in healthy women with normal term pregnancies.
If this obstetrical monopoly over all aspect of childbirth was able to provide superior outcomes — the virtual elimination of maternal and infant morbidity and mortality — we would all be celebrating their success rather than spending our time and effort trying to reform a broken and dysfunctional system.
Unfortunately, the massive amount of obstetrical intervention that healthy childbearing women are exposed to quite literally killing due to complication of unnecessary obstetrical interventions and leaving what some studies have identified as 80,000 new mothers with serious but preventable, often life-long complications
| See 2022 report on 701 preventable perinatal deaths and 9 preventable maternal deaths in the UK attributable to inappropriate care by obstetrical providers who ignored information that came from the laboring woman |
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The resurgence of independent midwifery and PHB was the result of our and continues to be fueled by a collective inability to make a positive impact on our hyper-medicalized maternity system. As midwifery activists, we originally intended just to meet those specific needs the obstetrical profession couldn’t address or wouldn’t acknowledge. We didn’t intend or expected to create a free-standing parallel system of midwifery education and practice that remained permanently outside and separate from the health care system. Apartheid is never a satisfactory situation.
Any one who gets pregnant or provides services relative to pregnancy and childbirth knows all too well that it is impossible not to be drawn back into the political fray between obstetrics as the empowered class and midwives and mothers seeking non-interventive care as the disempowered and outlaw class.
Speaking as someone who has been doing this since the 1960s, when twilight sleep drugs, general anesthesia, episiotomy and forceps were still mandatory and universal, our activism has not been a happy or successful endeavor.
Yes, we have won a few battles and I am grateful for that, but it is an illusion of progress. Added to our individual pain and collective experience is the expansive time frame for a dysfunctional system that keeps changing but never actually fix the problem. These changes are inevitably to add additional types or layer of interventive protocols and even more intrusive obstetrical technology. For the entire 20th century and the first decade of the 21st, women and families have been swept along a conveyor belt that often took them to places they did not want or need to go.
The 95% rate of narcotics, scopolamine and general anesthesia in the 1960s has simply been replaced by a 90% epidural rate; the routine use of forceps has been replaced by the liberal use of Cesarean, which for the last 2 decades has hovered at approximately one third of all birth (current official rate is 32%). Normal childbirth is still being conducted and billed for as a surgical procedure.
The monolithic obstetrical model continues to be characterized by routine interference in normal biology (such as routine inductions), unnecessary interventions mandated by medical liability issues or physician preference. Painful, invasive or humiliating procedures that we neither need or want continue to performed on ourselves, our loved ones or on our clients. We stand by helplessly as influential members of the medical profession and the media promote the idea of scheduled Cesarean as the 21st century standard of care. Ultimately, we are losing the war.
As members of consumer and professional groups working for mother-baby friendly maternity care, it’s impossible not to get angry about this. Personally, it’s hard for me to be generous in the face of such daunting circumstances. But if we let our anger divide us into eternally warring camps, we will spend our time perpetuating instead of fixing an out-of-balance system.
What we need is a change of heart, starting with an acknowledgment that none of these groups – mothers, midwives or obstetricians — asked for these contentious problems. Contemporary obstetricians inherited a difficult situation not of their own making. They were schooled by a system that define the biology of normal childbirth to be a “pathophysiology” – that female reproductive biology was an inherently dysfunctional, and therefore dangerous, system. This not only justified the routine use of multiple medical and surgical interventions but legally required their use as the obstetrical standard of care in the United States.
Obstetrics as seen against the
historical backdrop of 1840 to 1940
Obstetrical textbooks and other professional publications in the last 19th and early 20th centuries described childbearing is seen as an undependable pathophysiology that literally used women up the way salmon are sacrificed during spawning. In must be remembered that without prenatal care and access to modern obstetrical services for those who develop complications during pregnancy or childbirth, high mortality rates are indeed the rule.
- In 1900, the average married woman in the US had 16 pregnancies, 12 live births, but only 9 living children. Women expected to lose a tooth with every pregnancy. Poverty and high birth rate were associated with problem pregnancies, especially in very rural farming areas and for immigrants and ethnic minorities living in crowded urban tenements.
- Racial discrimination and economic inequities resulted in chronic ill-health, which made childbearing women vulnerable to childbirth serious complications that obstetricians could not predict, prevent or treat. In the poorer sections of town, one new mother died for every 100 births and one of 10 infants did not live to see their first birthday. Many of the life-threatening complications childbearing required surgical solutions, giving rise to the ‘new’ obstetrics for the 20th century as a surgical specialty.
In the decades before the discovery of antibiotics, well-intentioned obstetricians had to respond to this grave situation any way they could.
The highly medicalized style of care introduced in 1910 was an attempt to eliminate puerperal sepsis (childbed fever) in hospitalized maternity patients and by sheer happenstance, this ‘perfect storm’ of events resulted in the single greatest change in childbirth practices in the history of the human species.
Labor began to be managed as a medically emergency. For the first time ever, normal vaginal birth was defined as a surgical procedure. As a surgical procedure, the ‘delivery’ was to occur in a restricted, sterile environment, routinely conducted as an operation by a surgically-trained physician. Due to the difficulty of maintaining strict surgical sterility, it was necessary to anesthetize labor patients. Once anesthetized, the delivery need to be surgical included the routine use of episiotomy, forceps, manual removal of the placenta and suturing of the episiotomy or other perineal wounds.
Obstetrical medicine against the backdrop of what we now call
“modern science”: 1840 to 1940
To understand why this happened, you have to see this unique era of obstetrical medicine against the backdrop of what we know call “modern science”: 1840 to 1940 – were the time of the biggest change in the biological sciences and by extension, allopathic medicine.
The most pivotal year in the history of ‘modern’ medicine was 1881. It was a time marked by the lightening fast shift of medical thinking and practice. Overnight, humanity was taken from the B.C.G. era — ‘Before the Common knowledge of the Germ theory of infection’ — to the brave new world defined by the new scientific disciplines of microbiology, bacteriology. These biological sciences developed antiseptic practices, disinfectants and eventually aseptic principles and sterile techniques. Other scientific disciplines — anatomy, biology, chemistry, immunology, physics, and physiology – all contributed to the practice of medicine, including obstetrics, as a modern science.
For obstetrics, the most radical and extraordinary time was the last 2 decades of the 1800s and first 2 decades of the 1900s – 1881 to 1920. This forty years period was smack in the middle of a metaphorical earthquake — the San Andreas fault of bio-medical science. The paint was barely dry on most important discovery in the history of the biological sciences and medical practice, which had transformed human knowledge and medical practice at one and the same time.
The biological sciences were no longer B.C.G. – the invisible but nonetheless lethal power of germs had been unmasked and beaten back — but unfortunately, humanity was still in the Before Antibacterial Drugs (B.A.D) pre-ambulatory phase of the soon-to-be but not-quite-yet ‘miracle’ of modern medical science that arose in 1937 with the marketing of the first sulfa drug. The 50 years between the discovery of germs and the ability to selectively kill bacteria and other pathogens inside of a sick human being was still a no-man’s land, one peopled by doctors, public health officials and the lay pubic, all of whom did not yet know that the story had a happy ending.
In addition to the many easily identifiable problems with our 1910 model of Listerized childbirth, there are an equal or greater number of real problems that real life obstetricians grapple with everyday. One major category is obstetrical emergencies – the kind of complications that kills one out of 57 women who don’t have access to or have decided not to make use of comprehensive obstetrical care, even when dangerously ill. These heartbreaking situations include very premature births, hemorrhage from placental abruptions or previa, high blood pressure, convulsions, stroke, amniotic fluid embolism, and a list of other equally rare but less dramatic life-threatening pregnancy problems.
A different but also vexing problem for obstetrical providers are psychological issues — childbearing women who either cannot or will not take responsibility for their own and their baby’s wellbeing, whether this is due to substance abuse, alcohol addiction or other mental or emotional illness. Sometimes laboring women can’t or won’t cooperate at all with the physiological process of normal labor and spontaneous birth and must be heavily medicated or even anesthetized.
As a former L&D nurse, ER nurse, and now as a community midwife, I have witnessed situations were births attendants had to provide care to women who are hostile, totally uncooperative, even combative. But no matter how outrageous the mother’s behavior, the physicians and midwives are ethically and legally required to provide the same high standard of care they would to anyone else.
As consumer advocates, we assume that every mother wants what we want and knows what we know and can’t imagine a pregnant or labor women who isn’t totally informed about all the possible side effects of interventions and drugs. Sadly, that isn’t the norm. Many of the patients that obstetricians deal with just want the baby about and they don’t want it to hurt and don’t want it to take too long.
For birth attendants dealing will an undifferentiated population and high volume of labor patients, obstetrics is the art of dealing gracefully with unexpected, everything from simple failure to progress, to a variety of vexing emergencies such as cord accidents, fetal distress, shoulder dystocia, retained placentas, inverted uterus and PP hemorrhage. Obstetricians know any of these problems could trigger a lawsuit for them and the hospital, so the actual treatment of emergencies is complicated by political pressure from within the ‘system’.
One of the craziest things about litigation is that patients who actually got very good care for a very bad problem are often the ones that sue. They wrongly believe that whoever was present when a complication was discovered, was somehow responsible for having caused the problem. This is an irrational “guilt by association”, that is, the doctor and nurses were standing there when it happened, so somehow they must have don’t something wrong by not preventing it.
At the end of a week of dealing with all these high stress situations, an obstetrician might also get paged to deal immediately with a transfer from a planned home birth that end with a life-threatening emergency – cord prolapse, placental abruption, maternal hemorrhage, etc. Whether that problem is due to an unpreventable complication or poor judgment by someone – parents, midwives or even other professionals that did not respond appropriately – it sometimes very hard to discern. What is for sure is the grieving parents and an extremely difficult situation for everyone involved and certain fuels the on-going hostility between community-based midwifery and hospital-based obstetrics.
