Video ~ “Unbreaking” the maternity care system for normal childbirth in the US

by faithgibson on December 6, 2013

in Contemporary Childbirth Politics

The video below is an August 2013 presentation by Ryan McAllister, PhD.  He’s a parent, a biophysicist, and research professor in medical ethics at Georgetown University.

Using Swedish statistician Hans Rosling’s “Gapminder” statistical graphics program, Dr. McAllister provides the perfect presentation of the disturbing facts we already know so well — that normal maternity care in the US is now (and for over a century), has been a profoundly dysfunctional system quite different from the physiological models used successfully by other countries.

Apparently we are the only industrialized country to use such an ineffective and unproductively expensive model to provide normal care for healthy childbearing women.

The many political and economic issues in contemporary maternity care that we face today are the direct consequence of a well-intentioned, but mistaken assumptions in 1910 made by but mistaken assumptions by influential leaders of American obstetrics as a brand new surgical specialty.

During the first decades of the 20th century, the obstetrical profession purposefully decided to ‘break’ with all previous caregiver traditions surrounding normal childbirth. Under this new system, healthy pregnant women became the patients of a surgical specialty, and normal birth became a surgical procedure only allowed to be ‘performed’ by physician-surgeons.

Normal labor and birth were officially redefined as pathological processes that was harmful to both mother and baby, no matter how healthy the woman, or how normal the pregnancy. Physiological management was declared to be dangerously inadequate and old-fashioned. Any thought to the contrary was seen by obstetricians as a barrier and unfair burden preventing them from providing the very ‘best’ kind of care.

According to this model the only way to make childbirth safer was to routinely use Twilight Sleep drugs during labor, and protocols that required a fully-qualified surgeon to use of a series of interventions during the birth. This is the most profound change in normal childbirth practices in the history of the human species.

The preemptive use of interventions formed the basis of obstetrics as a surgical discipline in the US, and this philosophy has been taught to successive generations of American medical students ever since.

During this long pre-antibiotic era (prior to the 1940s), fatal postpartum infections were the most frequent cause of childbirth-related deaths. In a noble attempt to reduce the incidence of puerperal sepsis (childbed fever) in hospitalized maternity patients, obstetrical leaders imposed a strict obstetrical regime on normal childbirth that included conducting the pushing stage of labor in a sterile operating room environment.

However patients in 2nd stage often wanted to moved about, talk, cough, even attempt to grasp the doctor’ hand, thus accidentally touching sterile equipment. To prevent this potential contamination of the sterile field, laboring women were routinely rendered unconscious under general anesthesia.

If a new mother should develop a serious infection afterwards, it was important that the doctor’s sterile technique could be documented as impeccable, to defend himself against any accusation that poor technique introduced bacteria (a claim of malpractice). As unconscious maternity patients, women would never be able to testify to anything that occurred during the birth, and of course fathers and other family members were also not permitted to be present in the delivery room.

The new protocol for normal birth as an MD-performed surgical procedure required that the labor patient be put in stirrups and leather wrist restraints so she wouldn’t fall off the OR table during the delivery and then covered with sterile drapes. After being anesthetized, a routine episiotomy was performed, followed by low (‘outlet’) forceps, manual removal of the placenta and suturing of the perineal incision.

Unfortunately, the combination of general anesthesia and this long list of invasive procedures — no matter how theorectially ‘sterile’ the OR environment —  were unable to prevent fatal postpartum septicemia in the decade prior to antibiotic drugs (sulfa not available until 1938 and penicillin in 1945).  During the period from 1910 to 1940, these systematic interventions resulted in a dramatic increase in maternal mortality.

For instance, the maternal mortality rate (MMR) for American mothers in 1925 was 6-fold more than Sweden’s had been decades earlier (1,2oo maternal deaths per 100,000 in the US in 1925, compared to only 200 in Sweden for 1900). Sweden’s maternity care system was 3 to 6 times safer. It depended on midwives to attend all normal births and general practitioners to provide hospital services as necessary.

A hundred years later, normal childbirth in the US is still legally defined and performed as a surgical “procedure” and still reimbursed under a surgical billing code. In a hospital, the ‘procedure’ of vaginal delivery can only be conducted by someone who is licensed to perform surgical procedure, which is why L&D nurses don’t ‘catch’ babies.

Its also why CNMs can only provide hospital-based birth services in a role legally defined as that of a ‘mid-level’ or ‘physician-extender under an MD sponsor.  The surgically trained physician is ultimately responsible for the nurse-midwife’s performance of the surgical procedure of NSVD (billing code for ‘normal spontaneous vaginal delivery’).

And it’s why hospitals are unwilling to offer practice privileges to professionally licensed direct-entry (non-nurse) midwives, who they believe are not adequate trained (or legally authorized) to ‘perform’ the surgical procedure of spontaneous childbirth.

This background information goes a long way towards explaining today’s national Cesarean section rate of 33% as the ultimate expression of the 19th century beliefs that modern obstetricians inherited as part of their training.

As a new surgical specialty, American obstetrics was founded on the belief that female reproductive biology was a badly ‘broken’ system that needed doctors to rescue even the healthiest of women from the cruelties of Mother Nature.

So far, they haven’t changed their mind, as the authors of Wax meta-analysis set out to prove with their classic conclusion that “low medical intervention” (i.e., physiological management) is 2 to 4 times more dangerous than medicialization.

However, Dr. McAllister is able to statistically demonstrates the brokenness of a system still based on 19th century ideology.

He also makes an equally informative case for integrating physiological management back into normal maternity care as the safe and cost-effective standard for healthy childbearing women who do not want or need to be medicalized for normal childbirth.


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