“Mommy, What Did You Do in the Industrial Revolution?”

An incredibly bold and insightful article from a US Obstetrician.  If there are physicians like this within the bureaucracy, then there is hope for our future.  Please pass this along and send this woman some huzzahs! The following wins the Midwife Monologues award for “Best Quote of the Year”:

Industrial obstetrics strips the locus of power definitively away from women. The history of childbirth in America reflects a persistent trend of increased control by physicians and increased medicalization. Childbirth moves, first, out of the home, and now out of the vagina. Stipulate that antibiotics and blood banks are good and necessary things, and that emergencies may, in fact, develop: still, the majority of births will be normal. Or they would be, without interference. The species that cannot birth its young becomes extinct. But fear has pushed nearly all American childbirth into the hospital, a campaign which continues even now that that battle looks to have been won. (American College of Obstetricians and Gynecologists, 2008)

Still, despite the implied promise of safety if all the rules are followed—ID bracelets, intravenous lines, electronic fetal monitoring—labor may follow an unpredictable path. The definition of “normal” becomes ever narrower, and toleration of deviance ever lower. The final stage of this philosophy takes the process of birth away from the woman entirely and turns it into a surgical procedure performed by the doctor. Childbirth becomes a manufactured experience, shorn of any real risk or real power, one in which the woman is so far alienated from the capabilities of her body that she is only a package on an operating table for a professional to open.

Plante LA. Mommy, What Did You Do in the Industrial Revolution? Meditations on the Rising Cesarean Rate. The International Journal of Feminist Approaches to Bioethics. Spring 2009;2(1):140-147. DOI: 10.2979/FAB.2009.2.1.140

More highlights:

The cesarean rate in the US has been rising for decades, and in 2006 hit an all-time high of 31% (Hamilton, 2007.) This record is likely to stand for only a brief time, that is, until figures are released for 2007. Can it really be that one-third of women are unable to birth without high-level technological support? And is there an endpoint in sight? “In the next decade or so the industrial revolution in obstetrics could make Cesarean delivery consistently safer than the birth process that evolution gave us.” (Gawande, 2006,8) Against such an argument, who could hope to stand?

Gawande makes a case for the standardization of obstetrics. “You seek reliability. You begin to wonder whether forty-two thousand obstetricians … could really master all these techniques … obstetricians decided that they needed a simpler, more predictable way to intervene when a laboring mother ran into trouble. They found it in the Cesarean section.” (7) He suggests that techniques for effecting vaginal delivery—maneuvers to reduce a shoulder dystocia, deliver a breech baby, assist delivery with forceps—are so subject to variations in skill that they cannot be standardized for reliably good outcomes, while the cesarean operation is commonplace and consistent. It is, if you will, the least common denominator: every obstetrician knows how to perform one. While this is a fascinating perspective on the changing of obstetrical practice, for those of us who actually work on a busy obstetrical unit industrialized childbirth conjures up images of the factory floor.

The drive toward fewer delivery options appears at first glance to be supported by upper-middle-class women, who have the least number of social and economic obstacles to autonomy. In fact, cynical staff at hospitals delivering large numbers of well-insured upper-middle-class women often refer to their institutions as baby factories: these are the places in which cesarean rates are highest. It is, after all, a paradox: women with higher incomes, higher levels of education, and commercial insurance have higher rates of cesarean delivery. If cesarean is a response to any perceived risk, why would women at statistically lower risk of a poor outcome have higher cesarean delivery rates? New Jersey has the highest cesarean rate among states, (Denk 2006) but no lower levels of maternal or perinatal mortality. (MacDorman 2007, CDC 1999) What it does have, however, is the highest median household income. (Census Bureau 2007)

And then she goes on to support the choice for homebirth!

Let us enumerate what a full spectrum of childbirth choices entails. Women can give birth at home unaided; at home with family or with trained assistance; in a birth center, either freestanding or hospital-based; in the hospital delivery room with trained assistance; or in the operating room where they are acted upon. But of all these choices, extending across the entire range of reliance upon the medical profession (from none to total), exercising the options at the end of the spectrum where the physician has the least sway will get women the least support. The American College of Obstetricians and Gynecologists calumniates not only women who want a home birth but anyone who advocates leaving that option open. (American College of Obstetricians and Gynecologists, 2008.) Once in the hospital, women who might like to exercise their right to self-determination by choosing vaginal birth after cesarean, or vaginal breech delivery, will have a hard time of it. (Leeman and Plante, 2006) Is it not the opposite of autonomy to support only those choices which increase the woman’s reliance upon the physician?