The Problem of Birth Philosophies

You'd think forming a consistent, reasonable philosophy of birth would be easy, but you'd be wrong. I haven't decided anything for certain, and I am still working through my thoughts on the subject.

Yesterday I was considering how a practitioner's outlook on birth affects how they treat laboring women.

Medical: The general medical view is based on handling the complications that may arise during childbirth. I suppose this is because they deal with the major problems of births, and they see firsthand the damage and terror of a birth that does not go well. However, this view results in seeing a normal, uncomplicated birth as a retroactive diagnosis; in other words, they treat all births as if they are likely to become high-risk at any moment. Many women believe the medical view, that even in uncomplicated deliveries, hospitals are a necessary part of the childbirth experience, that the birth process is inherently flawed. All births are dangerous, and only some proceed without medical need. That there is a risk at all of something going wrong means that all births should take place in a facility where caretakers are able to address the most serious of complications. This will save lives, and that is the most important thing.

Midwifery: The midwifery model of care (MMOC) sees all births as normal, unless a complication occurs. But midwifery believes that the normal is by definition the most prevalent circumstance. I should note that it is part of the MMOC to transfer any situation that is deviating from normal to medical care, resulting in midwives recognizing and caring for low-risk pregnancies and labors. Midwives see the process of birth as a healthy event, which is reinforced by witnessing mostly births that go well. They are highly trained to recognize any problem that falls outside their scope of practice and will act quickly to procure the appropriate medical care, but only if necessary.

That these two approaches result in significantly different care is a problem. Medical care providers, those who have the skills and training needed in case a complication arises, assume that deciding to give birth in any other environment than their own is irresponsible. They criticize midwives for not being able to handle serious complications (a premise not entirely justified, as midwives have extensive training in birth complications - it would be irresponsible to be a birth attendant who does not know what to do in case of, for example, maternal hemorrhage or infant respiratory difficulties), as if the only person qualified enough to be present at a birth is an obstetrician in a hospital. This fear of and mistrust in birth is not without consequences, as even normal birth is then treated as a perilous event. Interference in childbirth, distorting the birth process so that it fits the medical model, is part of the medical standard.

But how often do complications occur? If they are naturally rare, then perhaps the medical model is incorrect in treating all childbirth as life-threatening. The midwives would be justified in assuming that labor will go well, unless it doesn't.

The problem with the midwifery model is the unpredictable nature of some complications. Even low-risk, healthy women sometimes have unexpected trouble during labor, and require immediate medical assistance. For the most part, I believe this situation may not be as much of a dilemma as it is, if obstetricians and midwives were able to agree on how to work together. Often midwives fear to transfer care to a doctor because of the disdain many doctors have for midwifery - they see midwifery as a dangerous trend, one which erroneously convinces women that birth is safe, that they may not need medical care during birth, and when a complication does occur, it is blamed on the midwives for not recognizing the appropriate channels of care (women in labor belong in hospitals, and nowhere else). "Another mismanaged home birth!" the doctors will say, shaking their heads, believing that with the proper education, the woman would have come to the hospital first and avoided a bad situation.

But the problem with treating all births as potentially complicated, is that the care received is motivated by fear and not by best practice. What I mean is, at most hospitals labor is not respected as a healthy process. If labor fails to begin within an arbitrary timeframe, it is stimulated with dangerous drugs. If labor is not progressing as quickly as outdated gauges (since proven to be mistaken and unrealistic themselves) say it should, the labor is controlled by chemicals which have repeatedly been shown to cause fetal distress and severe maternal discomfort. But doctors have solutions for those complications, treatments for the very complications their active management of labor has caused. And if too many complications occur, they have the means to surgically remove the baby from the dangerous womb environment.

This model is accepted by many women, because of the doctor's ability to deal effectively with complications. Yet, how many labors, left to progress on their own, with women freely moving about and eating and drinking at will, would have a complication? We are so removed from the idea of birth being a good, healthy process that we cannot be certain. Yet it is reasonable that treating a healthy woman as if she has a life-threatening condition is not good practice. In no other field of medicine is pathology addressed before it occurs.

Hospital treatment of childbirth is laden with tension and discomfort. But out-of-hospital birth does carry the risk of unpredictable problems that might not receive medical attention quicjly enough.

This supports my previous ideal: a hospital with a birth center attached as the standard for maternity care. Obstetricians run the hospital part, while midwives are in charge at the birth center. All normal births are handled by midwives, and if something should go wrong, medical attention is down the hallway. No interference without medical need. All births are treated as normal and healthy unless they are proved otherwise.

I can think of no better way to manage childbirth. It is certainly several steps beyond where we are right now.