The Most Scientific Birth Is Often the Least Technological Birth

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If you look at scientific literature, you find over and over again that many interventions increase risk to mother and child instead of decreasing it.

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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.

Indeed, they become downright confused when I go on to explain that there was really only one reason why my mate -- an academic internist -- and I decided to ditch our obstetrician and move to a midwife: Our midwife could be trusted to be scientific, whereas our obstetrician could not.

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.

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.

Ethicists talk about birthing choices as if they are informed and autonomous, but I can't count how many women have said to me they "chose" pain meds during birth even though they were never told the risks.

When I was pregnant, in 2000, and my mate and I consulted the scientific medical literature to find out how to maximize safety for me and our child, here's what we learned from the studies available: I should walk a lot during my pregnancy, and also walk around during my labor; doing so would decrease labor time and pain. During pregnancy, I should get regular check-ups of my weight, urine, blood pressure, and belly growth, but should avoid vaginal exams. I should not bother with a prenatal sonogram if my pregnancy continued to be low-risk, because doing so would be extremely unlikely to improve my or my baby's health, and could well result in further tests that increased risk to us without benefit.

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.

My obstetrician and his practice had made clear that they were rather uncomfortable with this kind of "old-fashioned" birth. So we left, and engaged a midwife who was committed to being much more modern. And the birth I had was pretty much as I have described. Yes, it hurt, but my doula and midwife had prepared me mentally for that, assuring me that this kind of special pain did not have to result in fear or harm.

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.

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.

I put that question to a few scholars who work on this issue. One of them, Libby Bogdan-Lovis of the Center for Ethics and Humanities in the Life Sciences at Michigan State University, happens also to have been my doula. (Lucky me.) Libby noted that a big part of the problem is the way birth is conceived in America -- as "dangerous, risky, and in need of control to ensure a good outcome."

Libby pointed out that institutional strictures contribute to the problem: "Insurance companies generally cover hospital birth, not home birth, they are more inclined to compensate doctors over midwives, they compensate doctors and hospital-based midwives for doing something over doing nothing, and the health care system's risk management approach backs those who can demonstrate that they did everything possible in terms of intervention." All this in spite of the fact that, as Libby notes, "attempts to control birth are fraught with real medicalized risk and commonly lead to cascades of interventions."

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Alice Dreger is a professor of clinical medical humanities and bioethics at Northwestern University's Feinberg School of Medicine. She has written for The New York Times, The Wall Street Journal, and The Washington Post.

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