In a perfect world, healthy women with normal pregnancies would not be forced to choose between an obstetrician and a midwife or between hospital and planned home birth. Regardless of the category of caregiver or planned place of birth, they would be able to get acceptable, appropriate, accessible and affordable maternity care.
The core issue for the 21st century is the appropriate use of physiological management versus a national maternity care policy that promotes the inappropriate and medically-unjustified use of obstetrical interventions in the care of healthy women who do not want or need them.
Some in the obstetrical profession continue to promote Cesarean surgery as the de facto standard of care for the 21st century. You might say that normal birth itself is on the endangered species list and women who insist on having at least the opportunity for a normal (non-medicalized) labor and a spontaneous birth are accused of engaging in the ‘extreme sport’ of biological childbirth to the detriment of their unborn babies.
I will continue to utilize this little corner of cyberspace as a safe place for people to comment on and grapple with the needless and ever-escalating medicalization of normal childbirth and all the problems associated with such a model. The rules of debate apply, which is a focus on the exchange of ideas and not the personhood of the speaker. Honorable people can have divergent opinions based on different interpretation of same data. In addition, different values inevitably bring participants to different conclusions.
For any blogger who is not sure what that means, it is the old-fashioned Golden Rule – don’t do (or say) to others what you would not want said or done to you. Love does not kill to save. Killer conversations include sarcasm, name-calling, and a basic attitude of contempt for the other person (as distinct from rejecting ideas you believe to be wrong) Also, please no text message / email abbreviations for Rolling on the Floor Laughing or similar derogatory cross-talk aimed at a third person. Such posts will be deleted from this blog.
Please also note that the blog is not per se devoted to the topic of midwifery in its many forms (lay, licensed direct-entry and certified nurse midwifery), nor is it devoted to promoting either home or hospital birth as a universal national policy.
Although I am a midwife, I see the problems of childbearing women and normal birth itself are a much higher priority than those of midwifery. I don’t think that the difficult issues that all midwives faces today (nurse midwives included) can be corrected until the fundamental problem with our national maternity care policy is adequately addressed.
The core issue is an obstetrical Dark Ages of a 100-years duration that has devalued and eliminated the principles of physiological care by defining them as not appropriate to be included in a medical school education or permitted to be used in obstetrical practice. It was (wrongly) assumed that physiological management was ‘women’s work’ and as such, it was old-fashioned, inferior and inadequate to the problems of childbirth at the end of the 19th century. It must be remembered that the discovery of antibiotics and many of the diagnostic tools that allow us to detect and correct problem pregnancies were decades away. Detrimental effects of poverty, overwork, forced childbearing, close–spaced pregnancies, high parity and general status of public health in the U.S. was very low when compared to Europe and other developed countries.
Many of the decision make in the early 1900s were genuine attempts to address these problems at a time when so-called "modern medicine" was still in its infancy and had few effective tools. The issue for us now, in the first decade of the 21st century, is to reassess these historical decisions and reevaluate the principles, policies and practices that inadvertently gave rise to our contemporary form of care -- the universal application of interventionist obstetrics as the standard of care for healthy women.
Until we rehabilitate our national maternity care policy, these long-standing conflicts will be un-resolvable. Advancing levels of medicalization by the obstetrical profession are in sharp contrast to the persistent pull towards physiologically-based care by a growing number of vocal women who are deeply disenchanted and distressed by business-as-usual obstetrics. This highly unstable political situation poisons any attempt to reconcile the conflict between the disciplines of medicine and midwifery.
So here is the first installment of a chapter from an unpublished manuscript. While this chapter describes events that took place decades ago, I can testify to how the fundamental issue remains pristinely unchanged – narcotics, general anesthesia and routine use of forceps have morphed into epidural, vacuum extraction or Cesarean section, but it is still a system that fails to acknowledge the mother as the central and primary ‘actor’ in the events of childbirth, the one who gives birth. Instead, normal birth continues to be defined, as it has since 1910, as a surgical procedure ‘performed’ by an obstetrically-trained specialist. The identified role of new mothers is to be appropriately grateful afterwards.
How Normal Childbirth
Got Trapped on the
Wrong Side of History
The perfect storm
that turned healthy women
into the patients of a surgical specialty
and normal childbirth into a surgical procedure:
The Last and Most Important UNTOLD Story of the 20th century
Notes on Vocabulary ~
Linguistically, childbirth is a slippery sloop as soon as the word ‘child’ is separated from the word ‘birth’. I specifically use the word “childbirth” to encompass the whole biological process of laboring and giving birth as a continuum of activities that originate with the mother. As a biological category, it is the mother who gives birth, which includes being pregnant and the entire physiological process of laboring, including the birth of the baby. After the fact, the baby is said to have been born and the occasion is said to be the baby’s ‘birthday’.
The qualitative difference we have created in our minds and in our medical system between ‘labor’ and ‘birth’ is one of language rather than biology. Only in language, hospital architecture and obstetrical billing codes, does a bright line between ‘labor’ and ‘birth’ actually exists. Biologically-speaking, labor is the on-going process of uterine contractions that dilates the cervix and helps (along with the mother’s abdominal muscles and her voluntary efforts) to push her baby down into her pelvis and through the birth canal. As the mother labors to push her baby out, the baby's head will finally slip over her perineum and out into the world. During these few minutes, we say the mother is “giving birth” and after the baby is free of its mother’s body, we say the baby was born -- a passive state of affairs from its perspective. But the reality of laboring and giving birth is a process that lies on a continuum and remains intrinsically intertwined.
However, language and obstetrical billing codes do allow the last few minutes of labor -- those moments when the baby is being born -- to be renamed ‘the delivery’ and subsequently categorized as a separate activity or ‘procedure’ performed by the birth attendant (instead of the mother) and controlled by institutional policy. When the act of giving birth is defined as a medical procedure, hospitals have a legal right to refuse to perform the ‘procedure’ of vaginal birth. Currently, the definition of childbirth as a ‘procedure’ is used to deny some women the fundamental right to give birth normally, which is reflected as a hospital policy that forbids the procedure of vaginal delivery when the mother-to-be has had a previous Cesarean, or her baby is breech, is thought to be bigger than average, is a twin pregnancy, the baby is overdue, etc. In these cases, hospital policy requires that obstetricians on staff perform the invasive surgical procedure of Cesarean section. The take-home message is that words surrounding childbirth are a big deal and it matters how they are defined and who does the defining.
One last linguist note: There is no such stand alone verb as “birthing”, unless you are quoting dialogue from the Civil War movie “Gone with the Wind”, when the maid tells ‘Miss Scarlet’ that she “don’t know nothin’ ‘bout birthin’ no babies!” In real life, the active verb is “to give” and ‘birth’ is the object of that action. The mother is the source and giver of the energetic efforts that produce the baby. Birth is what happened, passively, to the baby.
Having been born myself at one time, I am grateful to my mother for all her hard work. Having given birth three times myself (preceded by painful fertility surgery), I remember all that hard work! Out of respect for all the women who gave birth gazillions of time over the untold millennia of to the human species, I decline to diminish the mother’s central role and cheat her out of this accomplishment by using a linguistic short-cut that skips over the ‘giving’ and substitutes the bastardized passive verb: birthing. I encourage others to likewise remember and honor the verb: To Give Birth.
Tomorrow -- excerpts from Chapter One