As the care of women in childbirth has increasingly moved into the hands of obstetricians, the landscape has continued to change. Caesarean section is increasingly used as the solution to most problems, real or imagined, while the skill set to attend birth with forceps or approach vaginal breech births atrophies. Perhaps most alarmingly, birth has come to be feared, not just by the general public but by obstetricians and other birth attendants.
This trend is easy to understand. At the level of training, future obstetricians are little exposed to normal birth, but they spend a great deal of training on the pathological. Moreover, they spend no time with the evolving generation of regulated midwives. Family doctors are caught in the middle, having been taught by obstetricians that the field is better left to the experts and that attending birth is hard on office practice, not to mention the long hours, both day and night.
The rise of Caesarean section on demand became one of the foci for my ongoing research on birth attitudes of both the caregivers and women.22 It was an interesting dance between maternal autonomy, including the right to elective Caesarean, and doing the right thing in practice. The two concepts collided, with one school feeling that modern women, with their increasingly complex lives, had the right to decide on their mode of birth, even if there were no obvious indications for a Caesarean for themselves or their fetus—and even if their choice was more dangerous for themselves or their fetus.
The move to more general acceptance of Caesarean section as just another way to have a baby is illustrated by the comment of an old obstetrician colleague: “You know, Michael, it hurts me to have to admit that your study really did show that episiotomy does not do what we thought it did. But you know what the real problem is? It’s vaginal childbirth itself! ” At the time, I actually missed the point. At first I thought that it was good news that he acknowledged our research showing that episiotomy should be limited. But it was not long before I realized that vaginal childbirth was coming under attack.
As more and more obstetricians were becoming comfortable with Caesarean section to resolve increasing numbers of the presumed abnormalities of childbirth, many policymakers and the public were asking what had changed to lead to an increase in Caesarean rates from 3 per cent to 5 per cent in the 1950s to around 30 per cent at the end of the twentieth century.
The surgical approach of obstetricians is not at all surprising—they are surgeons. But pro-Caesarean biases begin early. When I surveyed obstetrical residents about why they chose to train as specialists in OB/GYN, 82 per cent indicated that it was the surgery that motivated them. When asked what they liked least, they replied: “Being with women in labour.” They saw that as somebody else’s job. Women’s health was not even on their radar. If obstetricians in their professional and personal lives are now governed by fear of childbirth, we as a society have to help them get over their fears, while at the same time addressing our own fears of childbirth.
North American obstetricians are even more inclined than UK or Scandinavian obstetricians to accept Caesarean section by choice, but whose choice? The issue is confounded by the growing trend to support women’s autonomy, such that the two issues are at war with each other. Female and younger obstetricians are more inclined to emphasize autonomy but are more fearful of bladder and sexual dysfunction after their own birth—this, even though overall maternal and perinatal mortality, and short- and long-term maternal and neonatal outcomes, favour vaginal delivery, with credible research showing that by six months post-delivery by any mode of birth, there is little difference in sexual functioning.
One of the wonderful anomalies in this discussion on mode of birth was that almost all Scottish female consultant obstetricians were selecting vaginal birth for themselves. Moreover, those who had experienced vaginal childbirth would have nothing else. This view, compared to their London female colleagues doing the same job, is fascinating. Guess it is time to go to Scotland to find out why.
In Canada, the SOGC is clear that vaginal birth is the preferred and safest route in first and subsequent pregnancies for mother and fetus. Nevertheless, it may be difficult to resist a request for Caesarean even if it seems unreasonable, as agreeing to it respects the views of women and the increasing complexities of their lives.
Focusing on the obstetricians alone neglects the role of women in society, and the influences all around them. Normal childbirth has become jeopardized by inexorably rising interventions around the world. In many countries and settings, Caesarean surgery, labour induction and epidural analgesia continue to increase beyond all precedent, and without convincing evidence that these actions result in improved outcomes. Use of electronic fetal monitoring is endemic, despite evidence of its ineffectiveness and negative consequences for most women when used routinely. In fact, routine use of electronic fetal monitoring only increases the Caesarean section rate, without helping the fetus, unless the fetus is clearly in severe distress. Even then it is unreliable technology, as what we really want to know is what is going on in the fetal brain, but we measure the fetal heart rate. No wonder we get it wrong so often.
Despite increasing appreciation of the need for evidence to govern practice, episiotomies are still routine in many settings despite clear evidence of their danger when used indiscriminately. Many other medical procedures that have been disproven in studies—un-physiological positions for labour and birth, pubic shaving and enemas, routine intravenous lines, enforced fasting, overuse of drugs and early mother-infant separation—are still used regularly in some settings.
Unfortunately, our research has shown that family-centred maternity care can only have a limited effect if the system is designed to remove women from their own decision making. The midwifery contribution to improved outcomes, in my opinion, is to a great extent based on the midwives’ ability to keep women out of hospital until women are in active labour. Doulas (birth coaches) can also keep women out of hospital until they are in well-established labour. Keeping women out of hospital to a large extent mitigates the anxiety of both staff and women that is so central to the medicalization of childbirth and the increasing rates of Caesarean section and other procedures. Our research has shown that various methods used by the hospitals to delay admission until labour is established have all failed to demonstrate reduction in procedures and Caesareans. Although they’re important, these are small interventions compared to the large intervention of having a midwife or a doula. Our research has demonstrated that once women come to hospital early, before the onset of active labour, they seem doomed to care in a rigid institutional system where anxiety over potential problems undermines maternal confidence and leads to a self-fulfilling prophecy.
Why aren’t more women complaining? Because we are a terrified, risk-averse society, and birth is no more immune to the societal trend to “Ask your doctor for…” something for your high cholesterol, arthritis, thinning hair, facial wrinkles or lousy sex life. Pop a pill and carry on being fat and out of shape, then die suddenly at age ninety in the middle of sex.
We demand perfection of society, the medical profession and ourselves. Meanwhile, women—more and more often pregnant for the first time at thirty-five to forty years of age, with a profession and infertility problems because of delayed childbearing—are asking for a pre-emptive Caesarean section despite no indications for themselves or their fetus. Unsupported, induced, monitored, epiduralized, vacuumed, forcepped and ultimately C-sectioned—and all within an environment hostile to vaginal birth.
Recent studies have contributed to this dystopic birth environment: the post-term induction study and studies of vaginal birth versus Caesarean section for breech babies are good examples of research that changed practice so that important professional skill sets were lost, while mindless inductions clutter up the birth suites to the detriment of women in spontaneous labour. These destructive changes happened because we let them happen.
Society’s fear of birth in the early 1920s, during Dr. DeLee’s time, was based on the actual experience of negative outcomes. Fear was logical, as both mothers and babies were indeed dying. Thus, at the time, it seemed reasonable to cede control to surgeons, who routinely employed episiotomy and outlet forceps. Later, when safer Caesarean sections became available, they began to use the procedure more regularly to solve the very real problems of childbirth at the time.
As a society, we want to believe that all problems can be predicted and prevented. When perfection fails to happen, patients and their families take it out primarily on obstetricians, legally mostly, but in many other ways too. A famous obstetrician summed it up: “When you want to play God, don’t be surprised if you are blamed for natural disasters.” Women and their partners go along with this stuff because they are afraid, and many believe, falsely, that the “perfect” child will be born by elective Caesarean section. Women also often lack knowledge of the options available to them. The most risk averse of them select obstetricians for normal pregnancy and birth. The least risk averse select midwives for home birth and those in between want a midwife and an epidural. These select hospital birth with a midwife or a like-minded family doctor. And those who are confused or uninformed, or have no choice—or love their family doctor—choose a family doctor. In the end, everyone is happy in their niche-market world.