Navigational short cut to: Part 2 Part Three
A natural partner with StepItUp2007.org in an effort to reduce global warming
April the 14th is the first National Day of Climate Action, with hundreds of rallies all across the country organized by the action group StepItUp2007.org.
Step It Up is a grass roots political action organization aimed at influencing the US Congress to pass legislation that will cut carbon emissions 80% by 2050. The usual culprits in climate changes caused by human activity include deforestation, carbon-based fuels, inefficient appliances, smog-producing cars, exploitive agri-business practice and other activities that cause or accelerate global warming.
A Three-Part Series
You are probably wondering what “Green Maternity Care” has to do with global warming and the National Day of Climate Action planned for April 14th by StepItUp2007.org?
The answer is plenty. Like many areas of modern life, maternity care for healthy women can be organized in two diametrically opposed ways. One is sustainable, socially–conscious, cost-efficient and has a small carbon footprint. The other is associated with a large carbon footprint and ever-increasing economic, ecological, and humanitarian burden. The current obstetrical status quo is unsustainable. The price in money and other finite resources fails the cost-benefit test. The status quo is also unacceptable in that it fails to meet the practical needs of the childbearing population.
The fundamental purpose of maternity care is to preserve the health of already healthy women. Mastery in maternity care means bringing about a good outcome without introducing any unnecessary harm. Green maternity care refers to science-based childbirth services that use the time-tested principles of physiological management to accomplish these traditional goals. Stedman’s Medical Dictionary defines ‘physiological’ as “in accord with, or characteristic of, the normal functioning of a living organism”. This artful blend of scientific disciplines is safe, economical, kind to mothers and babies and kind to the planet. It provides informed choice to childbearing women and ‘right livelihood’ to its practitioners.
Physiological management of labor and birth is associated with the lowest rate of maternal and perinatal mortality  and is protective of the mother’s pelvic floor. It has the best psychological outcomes and the highest rate of breastfed babies. The routine use of physiological principles results in the fewest number of medical interventions, lowest rates of anesthetic use, obstetrical complications, episiotomy, instrumental deliveries, and Cesarean surgery . As a result, the incidence of post-operative Cesarean complications and delayed or downstream complications of Cesareans in future pregnancies are greatly diminished or avoided all together.
Green maternity care stands in stark contrast to the current industrialized form of childbirth -- a capital intensive system that restricts patients and professionals to a one-size fits-all medicalized model dominated by the economic interests and medico-legal concerns of the industry. High-tech obstetrical interventions originally developed to treat complications are systematically -- and inappropriately -- applied as the “standard of care” to all women, including those who are healthy and have low risk pregnancies. Medicalized maternity care results in a vast misallocation of resources and is neither people nor planet friendly. Only green childbearing practices can help rehabilitate this dangerously unbalanced situation and reverse the climate-harming habits of the medical-industrial complex.
Green ~ Meeting the practical needs of families, caregivers and society
Green maternity care is a naturally-arising humanitarian service organized around the practical needs of mothers and babies. Midwives and family-practice physicians both provide this form of high-touch, low-tech care in community hospitals, independent birth centers, maternity homes or the family’s residence. Professional care for normal childbirth always includes the appropriate use of obstetrical interventions when required to treat complications.
Seventy percent of women who become pregnant in the United States are themselves healthy and their pregnancies are normal. This means physiologic care is appropriate for the majority of the childbearing population, although many women prefer and have a right to choose medical management. Green maternity care is an individualized and personal experience, for both childbearing families and birth attendants. This represents a tradition similar to family farming and other planet-friendly services. Right use of resources means a small carbon footprint and a correspondingly high value return to society. It is a win-win system.
According to a consensus of the world-wide scientific literature, the physiological or non-medical management of normal birth is the evidence-based form of maternity care. This non-interventive approach to normal childbirth is protective and careful not to disturb the natural process. It employs continuity of care, one-on-one social and emotional support and an absence of arbitrary time limits to help achieve these goals. It also takes normal biology into account, in particular, the positive influence of gravity on the stimulation of labor. Right use of gravity helps dilate the cervix and assists the baby to descend through the bony pelvis. To help the birth process move along, women are encouraged to walk around during labor. Being upright and mobile during contractions also diminishes the mother’s perception of pain, perhaps by stimulating endorphins.
Effective labor support always addresses the mother’s pain, her fears and her privacy needs. Only by adequately responding to the mother’s emotional and physical needs, can labor can progress spontaneously, thus reducing or eliminating the need for medical interventions. However, normal birth care does not deny mothers effective pain management. In addition to non-pharmaceutical methods such as walking, the use of hot showers and deepwater tubs, it also provides access to pain medication and epidural anesthesia for women who need or want such help. Normal maternity care is always articulated with obstetrical services for complications or when requested by the mother.
In addition to high levels of consumer satisfaction, green maternity care is also efficacious, that is, both safe and economical at the same time. Every dollar spent measurably increases the rate of good outcomes. It does this by being ‘preventative’ and ‘preservative’ -- by preventing the unnecessary use of interventions, especially instrumental and operative deliveries, it preserves the maternal pelvic floor and the fetal brain. That translates into millions of health care dollars saved every year on the direct cost of maternity care and due to the reduction in delayed and downstream complications. This is a great benefit to the uninsured, employers who pay the bill for employee health insurance and the government-funded Medicaid programs.
Global Forms of Green Maternity Care
Many first-world countries and virtually all of the third world already use this common-sense model as their standard of care for healthy women. As of 2009, the National Health Service (NHS) in the UK will adopt physiological management as the official form of care for healthy childbearing women. The NHS concluded that highly medicalized care for normal birth increased the rate and expense of obstetrical interventions and Cesarean sections without improving maternal-infant outcomes. Medicalized maternity care on average is two to ten times more expensive and often results in costly downstream complications, such as the damage to pelvic structures following episiotomy and instrumental delivery and placental abnormalities, emergency hysterectomy, or stillbirth in a pregnancy after a prior Cesarean.
When any society spends a high percentage of its national health care budget on excessive use obstetrical procedures, it reduces their ability to meet the general needs of its population while still remaining competitive in a global economy. In response to these economic issues, the NHS changed its maternity care policy and has begun to reconfigure its childbirth services for healthy women. By 2009 they will once again be using traditional forms of physiological management as the standard, with the majority of labor and births attended by midwives and family practice physicians in low-tech community facilities or the family’s home. In our expanding global economy, which needs to reduce the carbon burden in order to create sustainability, there is no doubt that other EU countries will soon follow.
Unfortunately, physiological care for normal birth has been on the ‘endangered species list’ in the US for the last 100 years, with its elimination carefully engineered over the course of the entire 20th century. This political controversy has nothing to do with the appropriate use of obstetrical medicine to treat the 30% of pregnant women who unfortunately develop complications. This is the right use of obstetrical medicine, for which we are greatly appreciative. But childbearing in healthy women is not fundamentally dangerous and does not routinely benefit from surgical skills. The question is the wisdom, safety and economic impact of using these same forms of medical and surgical interventions routinely or “prophylacticly” on the 70% of healthy women with normal pregnancies. Interventionist obstetrics for healthy women introduces artificial and unnecessary harm into normal birth. This type of complication is called ‘iatrogenic’ (doctor-related) or ‘nosocomial’ (hospital-related).
With motives and methods similar the agri-business, organized medicine has substituted a high volume, industrialized form of the “baby-business” in place of the traditional, human scale childbirth services. The obstetrical model as applied to a healthy population is organized around the institution’s perspective of efficiency and convenience for its professionals. Hospitals have become for-profit institutions over the last 30 years. The institution’s agenda has likewise been expanded to include a constant focus on cost cutting, so as to increase share holder value and maximize profit margins.
After a century of obstetrically-based maternity care, the US continues to spend far more than any other country in the world, while the countries with the best maternal-infant outcomes spend a half to a third of what the US does. The top five countries all employ physiological management as the standard for providing normal childbirth services to healthy women. Despite our unusual outlay of money and high level professional attention, the US is unable to match the better outcomes enjoyed by many other industrialized countries at a far less cost. At last count, we were 28th in perinatal mortality and 14th in maternal mortality.
Two recent Harris polls of childbirth practices in the US revealed that medical and surgical interventions had become the norm for healthy women who gave birth under obstetrical management. More than 90% of this healthy low risk population had seven or more medical and/or surgical interventions done during labor or birth. [2: Listening to Mothers Survey, MCA, 2002 & 2004]. This astonishing rate of obstetrical intervention in low-risk labors is also confirmed by agencies of the US government [NIH; Agency for Healthcare Research and Quality (AHRQ)]. Interventionist practices are fueled by the large number of costly malpractice claims for obstetricians and by the basic fact that medical and surgical procedures, which represent “billable units”, are more profitable. Under current policies and fee structures, there is little or no profit to be made from the natural and unadorned biology of normal birth as managed by midwives and family practice physicians.
In the Untied States, the most common reason for hospitalization is pregnancy and childbirth. Each and every year, Cesarean section is the single most frequently performed hospital procedure, performed more than twice as often as the next contender. The Cesarean section rate in 2004 was 29.1% at a cost of 14.6 billion dollars. By 2006, the C-section rate was over 30%.
The foreword of a 1970 obstetrical textbook (Williams Obstetrics) enthusiastically described how the new technology of ultrasound and electronic fetal monitoring (EFM) meant that finally the fetus, instead of the mother, could (and should!) become the "primary patient" of the modern obstetrician. Since the 1970s, the maternity wing of hospitals has been referred to as the ‘obstetrical department’. About this time, the new sub-specialty of perinatology arose, which were obstetricians that specialized in pregnancy and birth from the fetus and newborn baby’s perspective.
Unfortunately, 30 years of intensive focus on the fetus, via aggressive use of electronic fetal monitoring and a steadily increasing rate for Cesareans, has not improved perinatal outcomes. The cerebral palsy rate is exactly the same as it was in the 1970s, [3-ACOG’ 2003 encephalopathy task force] despite the routine use of electronic fetal monitoring and the liberal use of Cesarean based on interpretations of EFM tracings. The only unambiguous result of this policy was a dramatic increase of emergency C-sections during labor which were ascribed to fetal distress, but without any substitutive improvement in neonatal outcomes.
Nonetheless, many official representatives of the obstetrical profession are now publicly claiming that Cesarean section is the better way -- safer and more satisfactory for mothers and babies than spontaneous birth. Having debunked the ‘prophylactic’ use of Cesarean to prevent cerebral palsy in babies, elective C-section is now being promoted as a prophylactic procedure to eliminate pelvic floor problems later in the woman’s life.
Medically Complexity in Vaginal Birth Increases the Use of Cesarean Section
One reason for the ever-increasing Cesarean rate is the three preceding decades of increasing obstetrical intervention in so-called “normal” vaginal births. About every 5 years, beginning in the early 1970s, some additional intervention has become ‘standard of care’. One by one, old and new medical procedures and restrictive protocols have been added to the labor woman’s experience, a situation heavily influenced by the malpractice litigation issue. Epidural has become the norm and induction of labor is close behind. You can’t put a laboring woman in bed and hook her up to seven (or more) IV lines, electrical leads, automatic blood pressure cuff, catheter tube, and other equipment without disturbing the normal spontaneous biology of spontaneous labor.
Over 90% of healthy women now find themselves routinely immobilized in bed with continuous EFM, IVs, Pitocin, narcotics, epidural, anti-gravitational positions for pushing, episiotomy, vacuum, forceps, etc. Unplanned Cesareans during labor are much more frequent. Even when the mother delivers vaginally, everything has become so complicated that her birth is turned into a nightmare for the patient and the obstetrician. As a result, increasing levels of morbidity are associated with vaginal birth, including increase in pelvic organ dysfunction and incontinence. Compared to a very complex vaginal birth with an uncertain outcome, Cesarean surgery begins to look pretty good – that is, not that much more dangerous. So why not “have it your way”, especially since Cesarean surgery can be scheduled in advance and is so much more convenient for obstetricians and profitable for hospitals?
In all seriousness, the obstetrical profession’s response to the high level of morbidity that accompanies excessive intervention in vaginal birth is to propose the ultimate iatrogenic intervention – medically-unnecessary Cesarean surgery. The public is told that such a plan will ‘save’ the mother’s pelvic organs from the horrors of normal birth, but they are not told that the scientific literature identifies obstetrical intervention themselves as directly associated with those very complications.
The usual suspects include non-physiological pushing, which starts with the mother on her back (wrong use of gravity!) and the so-called “directed” coaching policies routinely used by the labor room staff. This is also known as the “shout-it-out” method, in which the mother is instructed to hold her breath as long as possible and push till she is purple in the face, while everyone in the rooms counts to ten, cheerleader-style. Other practices detrimental to the integrity of the mother’s pelvic structures (and to the unborn baby’s brain) include induction, casual use of Pitocin to speed up (augment) labor, accompanied by the inevitable need for epidural anesthesia associated with Pitocin use and the increased need for forceps and vacuum extraction. All of these biologically unnecessary intervention subtlety and negatively effect the outcome.
However, these facts don’t seem to matter, as the obstetrical profession is always inching us closer and closer to the idea of Cesarean as just another way to have a baby, indicating by their casual tone that Cesarean surgery is “no big deal”. One nationally-based obstetrical organization recently announced that it was “ethical” for obstetricians to perform cesarean surgery for convenience or medically unnecessary reasons, the so called “maternal choice” Cesarean [4 ACOG Ethics Committee, October 31, 2003]. Some obstetricians are predicting that within a generation, cesarean surgery will completely replace normal birth as the official standard of care for the American obstetrical profession.
Acting on the idea of the Cesarean as the 21st century standard, a popular Michigan hospital is remodeling its maternity wing by replacing half of its labor rooms with surgery suites, in anticipation of a 50% CS rate by the time the new unit opens in 2011 (“build it and they will come!”). One shudders to think of the finite, non-renewable resources that will be sacrificed to this outlandish policy and the inevitable detriment to the global climate associated with three million unnecessary Cesarean surgeries performed every year.
Economic Meltdown – When Politics Instead of Science Determines Policy
Government figures currently identify total health care expenditures in the US to be approximately 1/6th or 17% of our gross domestic product (GDP). The average ratio of GDP devoted to healthcare in other developed countries is significantly less – only 11 to 14%. Twenty percent of our already super-sized American healthcare budget is spent on obstetrical services, with a third of all hospitalizations or about 4.4 million hospital stays each year for pregnancy and birth-related conditions.
The majority of these hospitalizations reflect an interventionist type of obstetrical care for normal childbirth. Maternity care itself accounts for 3.4% of GNP, with a whooping 2.38% of our total GDP spent on medical services for the healthy portion of the childbearing population. Based on the increased expense and inevitable downstream complications, Cesarean as the obstetrical standard of care would more than double that ratio, to about 5% of GDP. To put this question in a better context, readers should know that the cost of stopping the inexorable march of global warming is estimated to be only 1% of GDP.
GM and other American auto manufactures report that the of cost employee health insurance adds $1500 to the price of every car manufactured in the US. Taken together, this double-whammy puts American companies at a distinct disadvantage in the global economy. Left unchecked, the policy of medicalized maternity care would be a dark day for the manufacturing and service industries, as it hobbles the ability of American business to compete successfully in a global market.
When birth is promoted as a surgical procedure, it creates unrealistic expectation and thus makes doctors and hospital more vulnerable to litigation. This requires more expensive malpractice insurance premiums. High levels of interventions associated with birth as a surgical event also increases the rate of iatrogenic/nosocomial complications. This results in a large pool of mothers and babies with chronic problems or permanent disabilities, which often means lawsuits and large jury awards. All of these unproductive expenses must be added to the cost of the US products and services.
Isn’t it odd that our country, which is awash in a flood of otherwise productive citizens who are disabled by the illicit use of drugs and a democratic government that readily spends billions to wage an expensive war in far away countries against drug smuggling, is so attached to a form of maternity care that systematically sensitizes every fetus in utero, in the important hours just before it is born, to narcotics and/or the cocaine family of drugs administered thru the umbilical cord by medicating or anesthetizing its mother as the ‘treatment of choice’ for the normal pain and stress of labor? Seen in the light of our current epidemic of mood disorders, depression and addictions, perhaps physiological childbirth practices, with their emphasis on non-medical methods to meet the physical and psychological needs of childbearing women, has societal benefits not previously recognized.
Burn Baby Burn – the Obstetrical Contribution to MAD*
*Mutually Assured Destruction
In addition to the human and economic cost, this aggressive obstetrical policy of “take our half out of the middle” perpetuates an oversized carbon footprint all out of proportion to its benefit to society.
The long list of blow-back associated with interventionist obstetrics for healthy women starts with its effect on medical education. Elective CS as the customary form of maternity care would require an increase in the capacity of medical schools. Many more anesthesiologists and obstetrical surgeons would have to trained to perform the additional two to four million Cesarean surgeries a year. Surgical deliveries increase the length of hospital stay by two to four times, which would require a massive increase in the infrastructure of health care. That entails the bricks and mortar construction of additional hospital space, increased energy use for heating and air conditioning, enormously increased use of professional staff and their travel back and forth to the hospital.
Biohazards are common to all institutions. Reducing cross contamination thru single-use supplies is essential to the health of the hospitalized patients, especially those exposed to surgical procedures. Unfortunately, what is good for patients can be bad for the planet. Of necessity, hospitals generate a veritable mountain of disposable paper products. This fills our garbage dumps with bio-hazardous material, while the endless stream of throw-away paper products contributes to deforestation. The loss of our forests is the single biggest contributor to global warming, even more detrimental to the climate than the use of fossil fuels.
Nosocomial infections are the most common complications of hospitalized patients, with 5–10% of patients in acute care hospitals acquiring at least one infection. Nosocomial infections occur in 2 million patients per year in the United States, causing 90,000 deaths and resulting in $4.5–5.7 billion in additional patient care costs. [BMJ http://qshc.bmj.com/cgi/content/extract/13/3/233]
Prevention of nosocomial infection requires the energy-intensive sterilization of massive quantities of supplies, instruments and linens. And in spite of the Herculean efforts to diminish the bio-hazards associated with hospitalization, nosocomial infections are common and result in a high level of antibiotics use. These drugs are excreted by the body but remain in the urine, which is carried into the sewers. Currently, our water treatment systems can’t filter out drug residue, so the water supply for humans and livestock eventually becomes contaminated with antibiotics. That inevitably results in more antibiotics-resistant pathogens, thus feeding the cycle of expensive hospitalization and additional counterproductive antibiotic use.
After pondering these issues, the only unanswered question is the obvious one: How does an entire society get seduced into believing this unbelievable story, one that belies common sense and every objective source of scientific evidence? For the entire last century, the American public has been told that normal birth was dangerous, a cruel twist of fate thrust on women by our gender, an idea associated with Freud’s insistence that for women, “biology was destiny”. To add insult to injury we are now being told that medically-unnecessary Cesarean section is safer, better and cheaper than a normal birth.
Can an educated adult possibly believe this? Did 9/11 terrorize us so profoundly that our critical thinking skills went down with the Twin Tower? If someone told us that it was better to have our healthy kidney removed and be hooked up to weekly dialysis, we would conclude that the speaker was nuts in less than a New York minute. Why is it so different when it comes to maternity care for healthy childbearing women? Is it a subtle misogyny? Or the harvest of a century of obstetrical propaganda carefully calculated to immobilize us with fear? Is it simply compassion fatigue?
And considering how incredible these ideas are, one must ask: “Whatever happened to investigative journalism?” When did “faith-based” journalism displace asking hard questions? Why doesn’t fact-checking apply to the self-serving answers readily supplied by organized medicine and others with an obvious economic agenda? While “better” is subjective interpretation of each individual, objective evidences established that elective use of Cesarean is not safer or and it is not cheaper. [CJMA Letters; M. Klein, MD; Not Safer and Not Cheaper; Nov 7, 2006]
The history of how normal birth, as a biological aspect of a healthy woman’s life, was usurped into a surgical procedure belonging to the obstetrical profession in 1910 is the last and most important untold story of the 20th century. Will we ever be ready to hear the truth?
2020 Vision -
- A Plan for All Reasons
In its report on cesarean deliveries in 1996, the Medical Leadership Council, an association of more than 2,000 US hospitals, concluded that the US cesarean rate was:
“medicine’s equivalent of the federal budget deficit; long recognized as [an] abstract national problem, yet beyond any individual’s power, purview or interest to correct.”
That’s pretty grim -- a disjointed, economically-strapped and liability-burdened healthcare system unable to help itself. To turn this situation around will take a sustained and multifaceted approach. As professional and citizen proponents of normal birth for healthy women, green maternity care is an important part of the solution to an out-of-balance, out-of-control situation. In the spirit of StepItUp2007.org, our vision is to make childbirth services both family and planet friendly in the US by the year 2020. This describes a dynamic process that balances individual rights and preferences with the wise use of planetary resources.
A key missing ingredient in the current system is any broad-based acknowledgment of the basic human rights of childbearing families. In particular, this includes accessible, affordable, evidence-based maternity care. Birth is a normal physiological process. Women have the right to the information necessary for using medical technology and procedures judiciously. Mothers and fathers-to-be have the right to know what tests are being performed, to be told about the side effects of such tests and treatments and the right to decline any or all of these procedures. Informed consent is not merely a privilege; it is a right of all childbearing women and their families.
The healthy, mentally-competent woman has a fundamental human right to have control over the manner and circumstance of her normal labor and birth, including where and how she will give birth. Presently, our medicalized system is only willing to fight for a woman’s right to have an unnecessary Cesarean surgery.
To stop the epidemic of medically-unnecessary Cesareans, childbearing women and their families must be a part of the process. In order for consumers to make their voices heard, society must become broadly aware of the dual threat to the health of individuals and the health of the planet that results from excessive use of obstetrical interventions and unnecessary Cesareans. According to an obstetrician who has studied this topic extensively, one of the issues in the run-away Cesarean rate is the complete lack of push-back by the American public (and one might add, by the American press!). Perhaps the URL for green maternity care should be called “PushItBack2020.org”.
Obviously, we can’t eliminate the excessive use of Cesareans without providing an effective alternative -- a plan that reduces the inappropriate reliance on technology, medical intervention and surgical delivery while meeting the social, psychological and physical needs of childbearing women. Green maternity care has the ability to do both. However, the essential elements for its success must be acknowledged. Physiologic care is not just restraint from the unnecessary use of medical interventions or changing policies that interfere with physiological process. Important as correction of both those issues is, the biggest issue is actively meeting the needs of women during childbirth, so maternal-fetal health is reserved.
Physiological management is a not neutral or passive. It is a pro-active stance that requires knowledge and skills that address the mother’s very real needs. Elements for success include the full-time presence of the birth attendant during active labor, taking care not to disturb or interference with normal biology, patience with nature, non-drug methods of pain relief and right use of gravity. This plan works for the majority of laboring women and is compatible with society’s greater good.
To do all this will require that we reform of our national maternity care policy. Half measures will not work. Physiological principles must be integrated with the best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women. When providing care to a healthy childbearing population, physiological care must be the foremost standard, to be used by all birth attendants and in all birth settings.
The Central Importance of a Non-Surgical Billing Code
In order to provide continuity of care and to fairly compensate birth attendants, maternity care for this healthy population must have a non-surgical billing code for physiologically-based childbirth services. Because obstetrics is a surgical specialty, normal childbirth has unfortunately been classified as a surgical procedure for most of the 20th century. A surgical diagnostic category automatically generates a surgical billing code, which produces an entirely different kind of care and different form of reimbursement.
This surgical designation means the care provided during labor, birth and immediately after the birth, is divided up into billable units and parceled out between multiple service providers. This is the most expensive way possible to pay for maternity care. It also eliminates continuity of care and makes the use of physiologically-based practices impractical. Under our current system, non-medical forms of care are so poorly reimbursed that hospitals would quickly find themselves out of business if they did not purposefully increase the number of billable procedures done on each maternity patient.
However, a simple solution is at hand and that is a specific billing code for normal childbirth. A physiological billing code would permit primary birth attendants to be appropriately paid for their full-time presence during active labor as well as the birth and the time and professional responsibility taken for the immediate postpartum and newborn period of care. Rehabilitation of maternity care practices and reform of reimbursements categories are both necessary for a balanced, planet-friendly healthcare system.
What can be done about our “gas guzzling” maternity care system?
Now, in the 21st century, the health of the childbearing population is generally excellent. Even for older mothers, the problems associated with delayed childbearing are primarily infertility and prematurity, neither of which is relevant to giving birth normally at term. Twentieth century obstetrics plays an important role for those with complications of pregnancy and childbirth, but it is unable to make normal childbirth safer for those who are already healthy.
However the relationship of the obstetrical model to normal childbirth has changed very little since being standardized in 1910. It still applies a fixed set of obstetrical interventions to both low and high risk women. As a result, obstetrical interventions have sky-rocketed all out of proportion to the number of complicated pregnancies.
Our 1910 system of medicalized maternity care has never been reexamined, or held accountable for either scientific or economic integrity. It’s appropriate to question wisdom of using a surgical specialty to provide care to a healthy population. Were we to do that, many of the conditions that lead to excessive levels of obstetrical intervention – particularly the overuse of induction and Cesarean surgery -- will become clear, permitting us to reverse the current upward spiral of costly obstetrical interventions.
Physicians and midwives all over the world are taught to utilize physiological principles for normal pregnancy, labor and birth. The science supporting this is not controversial. Reliable evidence is neither lacking nor incomplete, nor is this data the subject of methodological disputes among experts in the worldwide public health field.
Mastery in normal childbirth services means bringing about a good outcome without introducing any unnecessary harm. Our present system of obstetrics for normal childbirth does not do this very well, as evidenced by our 90% intervention rate in otherwise normal vaginal births in healthy women and our 30% Cesarean section rate. As an “expert” system, obstetrics has failed most in the very area it was supposed to have the most mastery and expertise -- preserving the health of already healthy mothers and babies.
A rehabilitated maternity care policy for the 21st century would integrate the classic principles of physiological management with the best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women, used by all maternity care providers and in all birth settings.
A spirited public discourse, in conjunction with the scientific community and experts in the field of journalism, needs to examine these issues and question the decisions made unilaterally in the early 20th century by obstetricians, decisions that decreed that normal maternity care should be a strict obstetrical model and defined normal birth as a surgical procedure to be “performed” by a physician.
We need to revisit that odd notion and create a single standard of care for normal childbirth that utilizes the strengths of each system. This would deliver on the early promise of the 21st century to finally create an integrated or ‘best of both worlds’ model of green maternity care. This would provide us with an artful blend of scientific disciplines were safe, economical, kind to mothers and babies, kind to the US economy and kind to the planet. What’s not to like?
- the new, green standard for the 21st century.
Go on to Part Two
The middle section examines the history of obstetrics and practice of obstetrics in the US, focusing briefly important background events from the 1840s and largely on the public health issue for the early decades of the 20th century.
How did we stray so far from our planet-friendly, common sense traditions?
Strange Bedfellows, 1910 style ~Territorial Imperatives, Industrialization and the New Obstetrical Profession
Childbirth as a Medical Condition
The Pre-Emptive Strike as Policy
Defining Childbirth as a Dangerous Medical Condition - rational for expansionism
Delivering on the Obstetrical Promise of Perfection – Bad Timing
The Germ Theory of Contagion
Clinical Training -- Medical Education & Medical Ethics Crash into One Other
The Medical Education Dilemma for American Obstetrics
How Normal Birth Became a Surgical Procedure in 1910 & Why It Matters Now
The Continuing Legacy of DeLee and Williams’ Brand of Obstetrics
Part Three -- The final section examines “The Perfect Storm”, the intersection of unmet expectations, litigation and the obstetrical escape clause – “when it doubt, cut it out”
NIH wades in the elective Cesarean debate and muddies the waters
The Obstetrical Escape Clause – an explanation of ‘when in doubt, cut it out’
The Politics of Reconciliation -- a green rainbow coalition for a planet friendly happy ending, in which everybody wins
Normal Birth Blog Index and other web-based Resources
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