On Wednesday journalist Michelle Goldberg published a blog on The Daily Beast characterizing PHB as ‘dangerous’ and CPM midwives to be inadequately trained and incompetent birth attendants. This opinion was formed from interviews and documents about a midwife-managed OOH labor that was transferred to the hospital in 2nd state and had a poor outcome. At issue is whether the circumstances reported by Ms. Goldberg fully and accurately represented these events, and if so, whether this means that PHB under the care of a professional midwife is a failed model of maternity care that needlessly risks the lives of healthy women and babies.
On Thursday I posted the text of my email to Michelle Goldberg day. Today I am posting additional information to help readers sort the facts from the hysteria and (I hope) encourage childbirth activists to post more information-based rebuttals on the Daily Beast blog site.
In the next days and weeks I will explore the idea behind the “national home birth debate” as promoted and orchestrated by obstetrical organizations and organized medicine, science-based materials on the relative of PHB safety and a stand-alone critique of the Wax meta-analysis.
However here is installment #2 of the information I emailed to Michelle Goldberg:
The History and Politics behind our modern-day “Planned Home Birth Debate”
Most Americans believe we have a world-class maternity care system (best money can buy!) and that American obstetrics, as applied to a HEALTHY childbearing population, has created an effective form of childbirth-related healthcare based on medicalizing normal childbirth. The ‘pre-emptive’ or routine use of obstetrical interventions is credited with enabling American obstetricians to eliminate maternal and infant mortality and morbidity and to have done so without introducing any unnecessary harm or unproductive expense.
Seen from the perspective of modern obstetrics, the current system is the long-sought after and final solution to the age-old problem of childbirth-related complications. They feel justifiably proud of this system and see the only unsolved problem is increasing the reach of its services and solving, finally and for all times, the ‘midwife problem’. Under such circumstances, the blatant failure of any childbearing woman to use this safety system is seen as the ‘earliest form of child abuse’; many in the medical profession believe both parents and midwives should be criminally prosecuted.
I don’t know how many of you had the privilege of watching the first 10 minutes of the new HBO series “Newsroom” Sunday evening (June 24th), but the exact same impassioned ‘diatribe’ and fact-based response by its mythical news anchor (actor Jeff Daniels as ‘Will McAvoy’) in relation to the question of America being “the best country in the world” could (and should) be applied to the critique our maternity care system, along with the same (and very important) punch-line “we CAN do better”.
The United States is not the 1st, 2nd 3rd, 4th or even 20th in ANY of the relevant metrics of maternal infant health except for being 1st how much money we spend on maternity care (25% of our entire HC budget) and ranking 2nd in how many inductions and Cesareans American doctors perform each year.
Basically 1/3 of all babies — equal to the number of students that graduate from college every year in the US — are delivered by major abdominal surgery at a cost roughly equivalent to 4 yrs tuition at many public community colleges. This surgery rate is NOT accompanied by any reduction in cerebral palsy or equal improvement in neonatal outcomes.
However, complications of induction and surgical delivery (many totally elective) are associated with a substantial increase in maternal mortality in the US since the mid-1990s. This is a national issue for many reasons, including the fact that 40% of all births in the US are paid for by the federal Medicaid program — a real problem if our country is to remain competitive in a global economy.
Odd as it seems, the 1970s PHB/normal care for normal birth movement was triggered by obstetrical policies put in place in 1910. This is when influential obstetricians in the US decided to get rid of the ‘old obstetrics’ — the poor stepsister of medicine described as ‘man-midwifery’, since physician birth attendants were historically called man-midwives throughout out the 17th, 18th and 19th centuries. The medical profession saw attending women during normal birth as a low class form of “woman’s work”. Professionally supporting the normal biological process of labor and birth was not considered to be medical practice, or worthy of the attention of formally educated “medical men”.
In 1911, Dr Williams, author of one of the most famous American textbooks on obstetrics, described the ‘new obstetrics’ as an opportunity to gain the respect of their medical colleagues, while elevating the status of obstetricians among the lay public.
“… the ideal obstetrician is not a man-midwife, but a broad scientific man with a surgical training who is prepared to cope with most serious clinical responsibilities and at the same time is interested in extending our field of knowledge. No longer would we hear physicians say that they cannot understand how an intelligent man can take up obstetrics, which they regard as about as serious an occupation as a terrier dog sitting before a rathole waiting for the rat to escape.”
On that same note, Dr De Lee’s 1924 obstetrical textbook redefined normal birth as a surgical operation and expands role of the obstetrician:
“Let us pause here to take a glance back at the treatment of labor as a whole. It should be regarded as surgical operation: it really is such, and the obstetrician is really a surgeon.
The conduct of labor is not a simple matter, safely entrusted to everyone. Let the people know that having a child is an important affair, deserving of the deepest solicitation on the part of friends, needing the watchful attention of a qualified practitioner and that the care of even a normal confinement is worthy the dignity of the greatest surgeon.” [p. 341]
As could be expected from these comments, the new obstetrics in American turned healthy women into the patients of a surgical speciality and normal childbirth into a surgical procedure ‘performed’ by physicians. This was the most profound and far-reaching change in childbirth practices in the history of the human species, as invasive medical and surgical procedures replaced principles such as ‘patience with nature’ and ‘right use of gravity’.
Sentient women no longer gave birth under their own power, but instead they became passive vehicles from which the doctor (not the mother!) delivered the baby. The mother’s only job was to be appropriately grateful afterwards. However, none of the policies, practices, protocols and invasive procedures that made up the ‘new obstetrics’ in 1910 were based on any prior or subsequent scientific evaluation.
Unfortunately this historical fluke, which provided the basis of our so-called ‘modern’ or scientific system, was not able to deliver on its promise to improve on the biology of normal childbirth and safe-guard healthy mothers and babies. During the decade that obstetricians successfully eliminated the practice of midwives in much of the US (1915-1925), maternal mortality sky-rocked by 15% a year and neonatal birth injuries went up by 40% as physiologically-based care of midwives was replaced by risky medical procedures on healthy maternity patients.
In 1925, 25,000 newly delivered mothers died — 1,200 per 100,000 live births — which was the highest maternal mortality of any industrialized country at any time in history. This represented a doubling of the maternal death rate prior the imposition of the new obstetrics (prior to 1910). In 1900 the MMR 600 per 100,000 in the US was 3 times higher than Sweden’s (MMR of 200 per 100,000) for the same time period.
What made maternity care in Sweden three time safer than childbirth in the US in the early 1900s was a state-regulated system of maternity care in which midwives and physicians worked together as equal partners. Both types of birth attendants used non-interventive (physiologic) care as the standard for normal childbirth, with physicians available to provide obstetrical interventions whenever necessary.
In the US, it was not until after the new medical discoveries of the early 1940s that maternal and infant mortality finally began to fall. This was, in part, because the complications so frequently associated with the intensive medicalization of normal birth (the same ones that resulting in a MMR of 1,200 per 100 K in 1925) were able to be prevented by using a safer anesthetic or successfully treated with the new antibiotics and blood transfusions.
Worldwide, the goal of maternity care has always been to protect and preserve the health of already healthy childbearing women and their unborn or newborn babies. This is the area in which we rightfully expected modern American obstetricians to have the most mastery. However, these are the very attributes most missing from our current system of medicalized maternity care.
One of the biggest stumbling blocks to a science-based model of maternity care in the US is the current medio-legal system. For the last 100 years, obstetrical policies have been defined by organized medicine (ACOG, etc). These policies and practices legally reflect a ‘standards of care’ that requires obstetricians, as members of a surgical speciality judged by other members of the same surgical speciality, to use a surgical standard of care.
However, this is not the fault of individual obstetricians. The problem lies with policies that first originated in the pre-antibiotic era of 1910 that have never been re-examined. This perspective of birth as a pathologic event continues to block modern-day obstetricians from providing physiologically-based care, lest they be accused of ‘substandard’ (i.e., negligent) care.
This also prevents obstetricians from having an open and collegial relationship with community-based midwives and keeps midwives as a group from being integrated into mainstream health care system and obtaining hospital privileges. This is the polar opposite of the system that served Sweden so well in 1900 and continues to make it one of very safest places on earth to have a baby and one that has the highest levels of satisfaction by new familes.
This problem needs to be fixed by changing the ‘system’ to acknowledge physiological management as the universal standard of care for healthy women with normal pregnancies. As mothers and midwives, the heart of our counter-culture movement is to do just that — reverse the ever escalating ‘medicalization’ of intrapartum care and re-orient it towards the normalization of labor and birth, irrespective of the category of birth attandent (physician, midwives, obstetrician) or the setting (home or hospital).
Stay tuned for additional material ….
Resources:
For anyone interested in a fuller exploration of normal childbirth from a historical and practical perspective event, i recommend reading an essay of mine published in the September 2011 edition of professional journal BIRTH. Its called “A Time-Traveler’s Perspective on Normal Childbirth“.
The original (longer) version was called: “How Normal Childbirth in the US Got Trapped on the Wrong Side of History: The last and most important UNTOLD story of the 20th century — how healthy women in American were turned into the patients of a surgical speciality and normal childbirth into a surgical procedure”.
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