So why is it that, over a decade later, when the evidence still supports a low-interventionist type of pregnancy and birth management for low-risk cases, we’ve made virtually no inroads to making birth more scientific in the United States.
The Atlantic published a great piece yesterday titled “The Most Scientific Birth Is Often the Least Technological Birth” by Northwestern University’s professor of clinical medical humanities and bioethics Alice Dreger. I was both entertained and moved by this article to see a medical educator recognize the confusion that occurs between science and technology in relation to birth.
When I ask my medical students to describe their image of a woman who elects to birth with a midwife rather than with an obstetrician, they generally describe a woman who wears long cotton skirts, braids her hair, eats only organic vegan food, does yoga, and maybe drives a VW microbus. What they don’t envision is the omnivorous, pants-wearing science geek standing before them.
I can’t help but think of the Saturday Night Live skit on natural childbirth.
Many medical students, like most American patients, confuse science and technology. They think that what it means to be a scientific doctor is to bring to bear the maximum amount of technology on any given patient. And this makes them dangerous. In fact, if you look at scientific studies of birth, you find over and over again that many technological interventions increase risk to the mother and child rather than decreasing it.
Medical technology is almost always assumed to improve health, and it most often does. I am extremely thankful for the advances in medical technology that saved my son born with a congenital heart defect. That being said, if you have it, you use it. Just because the technological tools exist and are in an OB’s practice or hospital setting, their use is not warranted unless an emergency situation occurs.
One of my home birth midwives was from Denmark. She used a wooden pinard horn fetoscope to listen to the baby’s heartbeat. In contrast, every time I visited my parallel care provider, who was also a certified nurse midwife, a doppler was used. A doppler may make it easier for the parents and doctor/midwife to hear the baby’s heart beat, but unless the heart beat is difficult to hear with a less technologically advanced tool, why use it. My midwives used a doppler in labor. That was it.
But most birthing women don’t seem to know this, even if their obstetricians do. Paradoxically, these women seem to want the same thing I wanted: a safe outcome for mother and child. But no one seems to tell them what the data indicate is the best way to get there. The friend who dares to offer half a glass of wine is seen as guilty of reckless endangerment, whereas the obstetrician offering unnecessary and risky procedures is considered heroic.
I love the above comparison. We do all want the same thing.
According to the best studies available, when it came time to birth at the end of my low-risk pregnancy, I should not have induction, nor an episiotomy, nor continuous monitoring of the baby’s heartbeat during labor, nor pain medications, and definitely not a c-section. I should give birth in the squatting position, and I should have a doula — a professional labor support person to talk to me throughout the birth. (Studies show that doulas are astonishingly effective at lowering risk, so good that one obstetrician has quipped that if doulas were a drug, it would be illegal not to give one to every pregnant woman.)
In other words, if the regular low-tech tests kept indicating I was having a medically uninteresting pregnancy, and if I wanted to scientifically maximize safety, I should give birth pretty much like my great-grandmothers would have: with the attention of a couple of experienced women mostly waiting it out, while I did the work. (They called it labor for a reason.) The only real notable difference was that my midwife would intermittently use a fetal heart monitor — just every now and then — to make sure the baby was doing okay.
Giving birth is the hardest thing I have ever done physically. It is meant to be that way. Why do we always try to make things easy?
We did end up with one technological intervention: because my son had meconium in his fluid (this means he’d defecated in the womb), the midwife explained to me that right after birth, the pediatricians would be scooping him up to suck out his trachea (his windpipe). The idea was to prevent pneumonia. They did this, and three months later over breakfast my husband presented me the results of a randomized control trial that had just come out: it showed that babies in this situation who only had their mouths and not their tracheas cleaned actually had lower rates of pneumonia compared to those who got the tracheal intervention. Another intervention that turned out not to be worth it.
There is also a false assumptions that midwives are not capable of interventions. This is extremely inaccurate. In both of my births, the midwives responded appropriately and professionally to both my needs and my babes. I required manual contractions on my uterus when I was bleeding after a long labor. My son required oxygen. Midwives are trained.
Raymond De Vries, a sociologist in the University of Michigan’s Center for Bioethics and Social Science in Medicine, has compared birth in the U.S. to that in the Netherlands, where he is a visiting professor at the University of Maastricht. He finds that, in the U.S., “obstetricians are the experts and the experts have come to see birth as dangerous and frightening.” De Vries suggests that the organization of maternity care in this country — “the limited choices that American women have for bringing their baby into the world, what women are not told about dangers of intervening in birth, and the misuse of science to support the new technologies of birth” — actually constitutes an ethical problem, although we typically do not recognize it as one. Medical ethicists “would rather look to the [comparatively rare] problems of in vitro fertilization and preimplantation genetic diagnosis than to the every day issues of how we organize birth here in the U.S.; they would rather talk about preserving women’s ‘choices’ than to explore how those choices are bent by culture.”
I really like how this article makes the conversation about science and ethics.
I think of all the choices I made, the one that shocked my peers most was not getting a prenatal ultrasound. But just a few years before I became pregnant, a major U.S. study – involving over 15,000 pregnancies — published in the New England Journal of Medicine showed that routine ultrasounds did not leave babies safer. That work was led by Bernard Ewigman, now chair of family medicine at the University of Chicago and NorthShore University Health System.
I also did not have an ultrasound. My midwives explained the benefits, risks, and necessity of this “routine” test. I wrote about my thoughts on ultrasounds two years ago. It is nice to see them backed by science.
Our “fascination with technology” has interfered with rational decisions based on science when it comes to birth. When we take the emotions out of our birth plans, whether thinking our families will be safer with a midwife or an OB, and truly look at the studies, we can see where medical technology and science do not support each other for normal pregnancies and births.