Born in the USA (8 page)

I recently testified before a state legislative committee in California on pending midwifery legislation. Among other things, I said in my statement that midwives are perfectly capable and that planned home birth is a healthy option for many women. I then presented scientific evidence to support both statements. I finished by suggesting that if anyone said otherwise to the committee, they should ask, “Where are your data?”

Thirty minutes later, a representative from the California Medical Association stood before the same committee and said that midwives are less safe than doctors for low-risk pregnant women and that home birth is not safe. Lo and behold! One of the legislators on the committee immediately asked, “And does the California Medical Association have any data to support your statements?” Not surprisingly, it did not (there are none). Instead, the spokesperson retreated to the familiar position: Trust us, we're the California Medical Association. That legislator took note, and the midwifery legislation was eventually passed. Slowly but surely, times are changing.

American maternity care, then, is under the control of tribal obstetrics. A small group, most of them men, are controlling birth in such a way as to preserve their own power and wealth while robbing women and families of control over one of the most important events in their lives. We cannot
expect ACOG to significantly change the way it operates; an organization built on special privileges is too invested in maintaining its privileged position to engage in soul-searching or self-examination.

Power without wisdom is tyranny. There are plenty of intelligent obstetricians who have lots of knowledge, but intelligence and knowledge do not guarantee wisdom. I have known wise individual American obstetricians, but I see no evidence of wisdom in organized obstetrics in the United States. The maternity care we have in what we like to believe is our free country is obstetric tyranny.

Today, many if not most obstetricians do not attend births: they perform fetal extractions through the vagina or through an abdominal cut.

FAITH GIBSON, MIDWIFE AND AUTHOR

And let the angel whom thou still hast served
Tell thee,
Macduff was from his mother's womb
Untimely ripp'd

SHAKESPEARE, “MACBETH,” V, VII, 43

After more than a decade of trying to bring down the number of cesarean sections (C-sections), some obstetricians are now reversing themselves and promoting more of them. In fact, a growing number of American obstetricians now urge women to “choose” a cesarean even when there is no medical indication that they need one.

The following statement is from a popular book titled
The Girlfriends' Guide to Pregnancy:

This illustrates the degree to which our society at large condones the concept of women choosing C-section, as well as doctors committing insurance fraud. A recent president of the American College of Obstetricians and Gynecologists (ACOG) took it a step farther in a paper titled “Patient Choice Cesarean,” in which he calls this major abdominal surgery “a life-enhancing operation.”
²

C-section is an essential surgical procedure that, when properly applied, can save the lives of women and babies. But giving pregnant women the option of choosing to have a birth by C-section when it's not medically necessary is another matter entirely. Put simply, C-section, even when it is “elective” (done by choice and not the result of a risky situation or an emergency), increases the chance that the woman and/or the baby will die. Contrast this last sentence, which is based on scientific evidence, with the glowing statement, quoted in the previous paragraph, on the advantages of choosing C-section.

Obstetricians have a number of reasons for encouraging women to have C-sections. First, though, we must recognize that when they say they are doing it because it is a woman's right to choose any kind of birth she wants, that is blatant spin-doctoring. It is ridiculous to suppose that obstetricians have suddenly discovered women's rights. For proof we need only remember the ACOG recommendation discussed in
chapter 2
in which doctors and hospitals are strongly urged to refuse when a family requests permission to make a birth video.
³
This is clear evidence that we can count on organized obstetrics to put fear of litigation ahead of family values and women's rights.

Why would obstetricians use the rhetoric of women's rights to get what they themselves want, a surgical birth? There are three compelling reasons. First, scheduling C-sections allows obstetricians to maintain their present overextended style of practice and bring the most time-consuming piece of it under control. It means that they can split their time between seeing patients in the office, doing gynecological surgical procedures in the hospital, and attending births, on a timetable of their choosing, and reduces the chance that they will be required to attend births at inconvenient times. For some, it is perhaps their only chance to have a decent personal life. Vaginal birth takes twelve hours on average and happens whenever—twenty-four hours a day, seven days a week. C-section takes twenty minutes, and most of the time it can be conveniently scheduled. Doctors may deny that they promote elective C-section for convenience, but their position is not believable. I appeared recently on the television program
Good Morning America
to debate the president of ACOG. When I suggested that obstetricians sometimes do things for their own convenience, the ACOG president indignantly replied that obstetricians never do things for their own convenience. But there is proof. Federal studies that analyze birth certificates tell us that the percentage of U.S. births that happen Monday to Friday, nine to five, is rapidly increasing. Even “emergency” C-sections are more common Monday to Friday, nine to five.
⁴

The second reason obstetricians want more women to have C-sections is to avoid litigation. Obstetricians are desperate to stay out of courtrooms where, unlike in hospitals, they are vulnerable and are not “top gun.”

The third reason for promoting more C-sections relates to the present crisis in American obstetrics. Politicians, HMOs, and the American public are rapidly realizing that it is wrong to have highly trained surgical specialists caring for healthy pregnant women and catching perfectly normal babies at low-risk births. Midwives cost much less and, unlike labor and delivery nurses, have had years of training. When obstetricians promote C-sections, they are protecting their territory by encouraging women to choose the one type of birth that only they can provide.

So when obstetricians succeed in talking women into choosing C-sections, in one fell swoop they gain enormous convenience, may reduce their risk of litigation, and win a point over the competition.

These are the big reasons obstetricians want to perform more C-sections. There are also several subtle but pervasive factors underlying this trend. For one, because obstetricians have been trained to manage the small percentage of cases of high-risk birth where things can and do go wrong, they end up afraid of birth. It's like an auto mechanic who sees only the Fords that have broken down and have been brought to his shop, so he ends up thinking that all Fords are in imminent danger of breaking down. He forgets that he never sees all the Fords on the road that are running just fine.

This fear of imminent trouble leads obstetricians to jump in and intervene too early with procedures that create complications, necessitating more procedures. One intervention leads to another in a cascade of interventions that all lead to Rome—C-section. In the past decade, the classic example of such a cascade is an induction of labor with powerful drugs, which leads to increased labor pain, which leads to an epidural block to relieve the pain, which leads to a slowing of labor, which becomes “failure to progress,” the number one diagnosis used to justify pulling the baby out with forceps or a vacuum extractor or performing C-section.

Another factor in the wave of high-tech, high-interventionist births is
that medicalized birth is all obstetricians know, and fish can't see the water they swim in.
⁵
Most obstetricians have experienced only hospital-based birth managed within a medical model. They have never seen natural birth. So they cannot see the profound effect their interventions are having on the entire process. This is put well in a World Health Organization (WHO) publication:

Another subtle factor driving some obstetricians to promote invasive interventions such as C-section is their fundamental belief in machines and technology and lack of belief in women and their bodies. Obstetricians tend to have blind faith in technology and the mantra technology = progress = modern. Here examples abound. Most obstetricians routinely use an electronic fetal heart monitor to observe the baby's heartbeat during labor in spite of clear scientific evidence that a good old-fashioned stethoscope is just as reliable.
⁷
When estimating the length of a pregnancy by measuring the fetus as seen in an ultrasound picture became popular in the 1980s, obstetricians dropped the tried-and-true method of asking the woman about her last menstrual cycle. But scientific evidence shows that when predicting the expected date of birth, ultrasound scanning is no more accurate than using the date of the woman's last period.
⁸

Women's bodies work best for giving birth when they are standing, sitting, or squatting. But when the obstetrics establishment began to realize that putting a woman on her back inhibited the birth process, instead of encouraging women to simply take a more natural vertical position, it set about designing a variety of high-tech adjustable birthing beds or chairs. These furnishings are typically made of metal, are mechanically complex, and allow for a number of positions. Each one costs thousands of dollars. And a beanbag chair works better than any of them, because the woman can mold the chair to fit her own body. But, of course, with a beanbag chair, or with the woman in a vertical position, the obstetrician would have to be
below the woman. I once visited a public maternity hospital where large numbers of women were in labor. When I suggested to the chief nurse who was showing me around the ward that they consider using vertical birth positions, she replied, “But that would require the doctors to get down on the floor. They would never consider doing that.”

Here is one last example of the lengths to which the medical-industrial complex will go to mechanize normal human functions. As we've seen, there are serious risks in using powerful drugs to induce labor or stimulate uterine contractions. There is another method for stimulating contractions that involves no risk whatsoever, but that is rarely, if ever, used in hospital obstetrics, perhaps because it is “too natural.” For centuries, midwives have relied on the woman's partner, the midwife, or the woman herself to stimulate the woman's nipples to promote uterine contractions. In 1990, an obstetrician working with a commercial firm sought FDA approval for a nipple stimulation device that includes an electric pump and a “suction hood” that fits over the nipple.
⁹
In machines we trust.

Throughout the twentieth century, this arrogant belief that obstetricians know better than nature has led to a series of failed attempts to improve on biological and social evolution, some of which we will examine more closely in later chapters. Doctors replaced midwives in the United States for low-risk births, and then later science proved that midwives were safer. Hospitals replaced home as the setting for low-risk births, and then later science proved that planned out-of-hospital births are as safe as hospital births and involve far less unnecessary intervention. Hospital staff replaced the family as the primary support providers for a woman in labor, and later science proved that a birth is safer when the family is present. The practice of taking newborns away from mothers in the first twenty minutes after birth replaced the practice of leaving babies with their mothers, and later science proved the importance of mother-baby bonding during this time. Putting normal newborns in a central nursery replaced rooming babies in with their mothers, and later science proved that rooming-in is superior. Man-made milk replaced woman-made breast milk, and later science proved that breast milk is far superior to any infant formula. If more obstetricians experienced an earthquake, a volcano, or a tsunami, perhaps they would realize that their ideas of controlling nature are ineffective, pathetic, and—most important—dangerous.

Beyond a general preference for technology over natural processes, there are social and economic factors that influence whether or not an obstetrician decides to do a C-section. These have been explored in at least seven
different studies in the United States, and have shown that the women most likely to receive C-sections are white, married, have private health insurance, and give birth in private hospitals, despite the fact that poor women have more health problems and are more likely to have complications justifying medically indicated C-sections.
¹⁰
These studies suggest that women in this group are more likely to have C-sections in part because of their attitudes about pain and vaginal tone. They also suggest that these women are more likely to want the convenience of a scheduled surgery, and, finally, because their private insurance is likely to pay a doctor who is in private practice in a private hospital, they do not have to fear that the surgery won't be covered. Women in this group are also more likely to be highly educated and are more likely to sue, encouraging doctors to perform “defensive” C-sections.