Dr. Joseph DeLee, the grandfather of modern obstetric medicine in the United States, believed that childbirth is a dangerous disease that must be managed and controlled. "It strikes physicians as well as laymen as bizarre," DeLee wrote in 1920, "to call labor an abnormal function, a disease, and yet it is a decidedly pathological process." DeLee taught 11,000 nurses and doctors during his prestigious career, and institutionalized "The Prophylactic Forceps Operation" as the gold standard of American obstetrics.
According to DeLee's model, women were knocked unconscious (or, sometimes, semi-unconscious) with morphine, scopolamine, and ether. The doctor then performed a generous episiotomy (cutting the vagina and perineum), removed the baby with forceps, and sewed the incision. Variations of this routine were standard into the '70s. DeLee's guiding principle was that OBs shouldn't respond to emergency childbirth scenarios; rather, they should prevent these scenarios from unfolding by controlling birth from the outset.
Today, new methods have replaced DeLee's, and yet popular obstetric interventions (cesareans, amniotomies, labor-inducing drugs, episiotomies, epidurals) are still designed to transfer control from the woman to her labor assistant. 33% of births in the United States are by cesarean, a rate that has grown significantly during the previous decade, in tandem with increasing rates of maternal injury and death. Yet representations of childbirth in television and film rarely show cesareans. Which is why I was so grateful for Reagan's recent childbirth episode on Up All Night.
Recap: At 12:36pm, Reagan goes into labor. She and her husband Chris take a limo to the hospital and chat casually; the sense of fear and urgency that is so typical of childbirth on television was, thankfully, absent. Reagan is dismayed to discover that her female OB isn't available for the delivery. A handsome young male doctor arrives, and Reagan requests a female doc. "Do we even have a choice in this matter?" Reagan's husband, Chris, asks. "No," the doctor replies. Shortly thereafter, Chris plus doctor poke fun at Reagan's detailed birth plan. As Reagan's labor progresses, Chris pressures her to get an epidural, but she repeatedly declines. Her attachment to a drug-free birth is framed as irrational. She takes an epidural at 7:10pm. At 11:29pm, the doctor says, "Pushing's not working, Mrs. Brinkley. The baby's head may be too big. I'm recommending a c-section," to which Reagan says, "No thank you." The doctor says, "Actually, it's not optional." Reagan's disagreement with her OB is framed as a control problem. "Babe, you gotta let go of the plan," Chris says soothingly. "We have to listen to the doctor, OK?" At 12:37am, Reagan has a cesarean.
The story arc emphasizes Reagan's eventual relinquishing of control and surrender to the unpredictability of childbirth. This episode was similar to the Murphy Brown childbirth episode, during which Murphy finally learns that she can't control childbirth.
It's true that childbirth is a deeply unpredictable experience that requires emotional strength and versatility. However, pop culture's chronic portrayal of laboring women as "control freaks" who must be persuaded to submit to medical pressure reflects the problematic assumption that the women's requests are misguided or silly. The concept of control holds an inherent judgment of the circumstances. The "control freak" giving birth is the one who is wrong.
"The baby's head may be too big" is one of many reasons doctors give when pressuring women into cesareans. Cephalopelvic disproportion—in which the baby's head is too big to clear the mom's pelvis—is extremely rare. Or was he referring to macrosomia (a big baby), another vague diagnosis? The "big head" is cited by doctors in cases when there has been no confirmation whatsoever of actual cephalopelvic disproportion or macrosomia.
Increasingly, "emergency" cesareans are performed in the absence of an emergency. "Failure to progress" is the most commonly cited reason for an emergency cesarean, and yet the time cap on labor varies from hospital to hospital. Some doctors say eight hours of labor necessitates a cesarean. Others say ten, twelve, or eighteen hours. Failure to progress now accounts for as many as half of cesareans in first-time moms.
Meanwhile, many elective cesareans aren't actually elected. It's true that some moms request a cesarean early in their pregnancy. These "maternal request" cesareans—which are by far the safest type—are frequently reported in the media yet account for a tiny number of "elective" cesareans. Many women who have a "repeat elective" because they had a cesarean with their previous delivery and are never given the option of a vaginal delivery. Many hospitals and doctors won't assist vaginal deliveries for women who previously had a cesarean. In states where midwives are illegal or legally barred from assisting women who previously had a cesarean, women who desire a vaginal delivery must locate a hospital that will perform one, or travel to another state with different midwifery laws. Those who can't travel are essentially forced into "elective" cesareans, despite mounting evidence that repeat cesareans actually increase the likelihood of maternal death when compared to a vaginal delivery, even for women who previously had a cesarean.
Meanwhile, first-time moms are told that if they pass their due date, they need to either be induced or schedule an "elective" cesarean. One woman who I recently interviewed told me that her doctor informed her—two days before her due date—that she should schedule a c-section. His reason was that if she passes her due date, she will need to be induced, and if she's induced, there's a 75% chance that she'll end up having an emergency cesarean (a totally made-up number), which he explained are dangerous. Frightened by this hypothetical scenario, the woman agreed to schedule a cesarean—before her due date, and with absolutely no medical indication. "I didn't question the doctor's recommendation; I just assumed there was a good reason for it," she told me.
In "The C-section Boom," a recent article in Boston Globe Magazine, obstetrician Adam Wolfberg wrote that, "the truth is, an obstetrician can persuade almost any patient at any time that a caesarean is the best choice," and that "some cesareans are done for the wrong reasons: a fear of litigation or a doctor's convenience."
OBs are more likely to be sued after a poor infant outcome than after a poor maternal outcome, and cesareans are more likely to prevent various types of infant outcomes while upping the risks to mom. "The statistical translation of this fear (of litigation)," Dr. Wolfberg wrote, "is the rise in the number of caesareans done for 'fetal distress'—20 percent in seven years ... Babies aren't having more 'distress'; doctors are just more likely to make this diagnosis and operate because of it."
In many situations, cesareans are safer for baby and more dangerous for mom. Does anybody tell mom about this? No. Are women told that an epidural will increase the likelihood that they'll undergo an emergency cesarean? Not usually. Are moms told that if they're given an epidural, they'll almost certainly get an episiotomy as well? Not always. Indeed, some OBs perform episiotomies without warning, and there are stories of doctors who tell mom there was "tearing" instead of disclosing the episiotomy.
Up All Night's birth episode was realistic. Reagan and Chris' acceptance that an emergency cesarean was necessary reflects real-world attitudes about control and childbirth. Informed consent during childbirth care is not a well-publicized issue, and complaints about treatment during childbirth care are met with the same response: well-educated white women—women like Reagan—have a control problem, and if they complain about their experience, it means they're unappreciative of modern medicine. Few seem to notice that those who aren't like Reagan (people of color, queer people, people with disabilities, uninsured people, etc.) also face problems (far worse problems) in childbirth care; they're just not in a position to complain about it. Perhaps the biggest challenge in fighting injustices in childbirth care is that women themselves have accepted the prevailing attitudes toward maternal complaints, and very serious problems in childbirth care have rather successfully been ignored and deflected by our culture's glee in casting women as control freaks.
For comprehensive, evidence-based information and resources for planning labor and birth, visit http://www.childbirthconnection.org/—and spread the word!
Pushed: The Painful Truth About Childbirth And Modern Maternity Care is an excellent resource if you want to learn more about contemporary problems in childbirth care, as is The Business of Being Born .
Click here to support the Maternal Health Accountability Act of 2011.
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