How Childbirth Went Industrial: A Deconstruction

By Henci Goer
Web Exclusive - November 27, 2006

“The trouble with people is not that they don’t know but that they know so much that ain’t so.”
-- Josh Billings

Henci Goer, author of The Thinking Woman's Guide to a Better Birth, skewers a recent, ripe-for-the-deconstructing article in the New Yorker on the rise of cesarean sections. If you read Atul Gawande's article with mounting dismay, this brilliant, research-based riposte will leave you thoroughly restored.

Gawande’s history of obstetrics begins with the premise that childbirth is a complicated, dangerous business where, “At almost every step . . . the process can go wrong.” In particular, “obstruction of labor” poses a threat. To illustrate this, Gawande recounts the story of the English Princess Charlotte, who in 1817 gave birth to a stillborn boy after 50 hours of labor and then succumbed to a postpartum hemorrhage. The parallel with Rourke’s labor is surely intentional.

According to Gawande, yesterday’s tragedies can now be averted thanks to the development of new and improved obstetric procedures, drugs, and instruments. “By the early twentieth century,” he says, “the problems of human birth seemed to have been largely solved.” In the next paragraph, however, he retracts this statement. A 1933 report, he writes, found that most maternal deaths were attributable to medical mismanagement and that women were “better off delivering at home” with midwives who avoided using those same procedures, drugs, and instruments.

Faced with this “shocking” fact, the experts of that time concluded that the solution was not to study what midwives were doing right but to “standardize childbirth,” that is, to set rules for how to manage labors and deliveries. Standardization meant applying obstetric interventions to everyone, needed or not, and, according to Gawande, in our day has resulted in the vast majority of women having electronic fetal monitoring (EFM), IV fluids, and an epidural or ; half having Pitocin to speed up labor; and nearly 1 in 3 women delivering their babies via major abdominal surgery.

Gawande makes no case that these interventions improved outcomes. In fact, he notes that EFM has not been shown to benefit babies while increasing the likelihood of cesarean, and cesarean section carries the risks attendant on any major surgery plus the future reproductive risks of a scarred uterus. Despite this, Gawande has no quarrel with the increased use of cesarean surgery on the grounds that it is:

• easy to teach,
• is a “reliable” but not a better option,
• is “comfortable” for obstetricians,
• can be performed with “consistency,”
• is a “simpler, more predictable way to intervene,” and
• is believed by obstetricians to be less risky than “natural childbirth.” This, of course, is not the same thing as actually being so

Unfazed by his own statements on the hazards of inappropriate obstetric intervention, Gawande next claims, “The package [of obstetric interventions] as a whole has made child delivery demonstrably safer.” He then goes on to say, “In the next decade or so the industrial revolution in obstetrics could make Cesarean delivery consistently safer than the birth process evolution gave us,” and follows this with a leap to the conclusion that that time has already arrived. He asserts that scheduled cesarean surgery may have lower maternal mortality rates than vaginal birth, and there is “speculation” that it might lead to fewer problems in later life with incontinence and uterine prolapse.

Gawande applauds doctors for trying whatever appeals to them without “wait[ing] for research trials to tell them if it was all right.” It is sufficient that obstetric innovators “looked to see if results improved,” although how they would know this without a controlled evaluation of safety and effectiveness, he does not say. Neither does he bring up the obstetric disasters that have followed in the wake of this approach. DES, thalidomide, (blindness in premature newborns), and misoprostol (Cytotec) inductions come to mind as well as the damage caused by episiotomy (cutting the vaginal opening to enlarge it for birth).

The take-home messages of “How Childbirth Went Industrial” seem to be:

• Women can have an easy, safe cesarean surgery or they can undergo difficult, dangerous labors and then have cesarean surgery.
• Modern obstetric management is the key to healthy babies and mothers.

One hardly knows where to begin to correct the illogic, erroneous information, fallacies, self-contradictions, prejudicial language, and false dichotomies, but perhaps by deconstructing these messages we can highlight many of these along the way.