This article series examines the field of obstetrics as commonly understood in the United States. Part one briefly reviews some of the evidence that serious problems exist in our current birth system.
Please notice the following ethical themes woven through this examination:
- What’s done bodily to women and babies
- How they are treated, both verbally and implicitly
- How power, knowledge, and consent are navigated
- How practices are chosen
- Who’s allowed to practice and why
- How practitioners are trained
- The impact this has on everyone involved
And please note that this analysis leaves aside very important elements such as class privilege, access to care, health disparities, and institutionalized racism.
Evidence of a Problem
There are a number of pieces of evidence that we have a serious problem.
The U.S. has high rates of
- Infant mortality
- Maternal mortality (Rising)
- Healthcare cost (Rising, $98B in 2008)
- Unnecessary procedures and their complications (Rising)
- Standard practices lacking supporting evidence
- And women reporting traumatic experiences and abusive treatment
In the accompanying graph of Infant Mortality vs Per Capita Health Spending of over 100 countries, would you have guessed which bubble represents the U.S.?
The United States is this outlier of the far right hand side of the graph, with the highest spending per-capita of any country on healthcare, and yet higher infant mortality than 38 other countries.
Maternal mortality tracks similarly.
To understand why this is happening, one must look at how the field responsible for birth care operates.
Origin and Training by Field
It turns out there are in some sense two models of birth care: midwifery and obstetrics. (One could further divide things, but this will do for this treatment.) The vast majority of births today are in a hospital and attended by an obstetrician.
Midwives have served for millennia been the primary birthcare providers. The archetypical approach of midwifery centers on attending to and responding to the mother and child, on seeing birth as a natural process, on providing relationship and support through that process, and on intervening as needed.
One midwife describes the midwife’s approach this way:
“The essence of midwifery is staying sensitively in the moment – in other words, being humble and paying attention. But this simple focus can easily be destroyed by the desire for control.”
–(An American Midwife quoted in The Midwife Challenge 1988)
In contrast, obstetrics has arisen over the last few hundred years, and has a surprising history of experimenting on women and infants (more on this in part 2). It is a provider-centric model that has encouraged its practitioners to view birth as a mechanical process, to emphasize efficiency and control over the process, and to normalize a large number of interventions.
Here are quotes from two women describing their experience of being controlled in an obstetrical setting:
“I was given an episiotomy after I told them I didn’t want one. Then, the doctor pulled on the umbilical cord ‘til it broke from the placenta, and then there was fear of me bleeding to death. I asked the doctor to let the placenta deliver at its own time, but she was in a hurry, so she wanted it out as soon as the baby was delivered. I feel that everything we had talked about before the labor didn’t matter. She did what was best for her, not me.”
–Anonymous mother, Listening to Mothers II Survey
When I [pregnant woman] attempted to discuss the birth plan with you [obstetrician], you became defensive…, saying, “If I want to do something to you I will do it and you will not interfere. I have delivered hundreds of babies and you have not delivered any.”
–Zeller R. It was all for nothing. The Clarion. 2004;19(4):5
The paradigms seem to be especially divergent in terms of the relationship developed with the mother.
A typical pre-labor visit with a midwife lasts an hour or longer. These visits give time and space for Mom and the midwife to develop a relationship which then both increases trust during labor and allows the midwife to provide more individualized care. This time also allows room for considered well-pregnancy counseling.
In contrast, for many women, getting sufficient time with their obstetrician is a challenge, or simply impossible. Because of the economic and institutional pressures within our medical field itself, a visit with an obstetrician often lasts less than ten minutes, and the mother is one on a long list of patients for that obstetrician to see.
One Mom expressed her experience this way:
“The worst thing for me was not being able to see the same provider each time I went and not meeting the delivery doctor until I was already in labor.”
Part two of this series will be published soon, and will briefly examine how obstetricians came to be the prominent birth care assistants in the U.S., the history of obstetrics, and the evidence basis for contemporary practices.
Meanwhile, in 2013, Maryland is examining a pilot program to allow Certified Professional Midwives to legally practice again in the state (House Bill 1202). Want to voice your support?