For a course that I'm currently taking, we're reading Andrew Abbott's The System of Professions: An Essay on the Division of Expert Labor. Abbott is a sociologist at Chicago whose work is utterly impressive... extensive, measured, and well-established. I've been struck by accounts of medical professions in particular that have been discussed. Medical and legal work end up being the favorite professions for researchers to examine, and are often presented as typical. What's especially impressive about medicine is the extent to which it has so effectively gained various monopolies of professional expertise, despite shortcomings of method and practice of medicine as "science", or questionable practical relationships of medical professionals with pharmaceutical or other partners. Doctors strike me as aggressive and tenacious in their pursuit of this public recognition; this seems to be the primary reason why they enjoy current prestige. Whether or not this position is salutary is another question.
My wife and I have maintained concerns about the medical profession primarily with regard to childbirth. When our daughter was born in May 2008, nurses from around the hospital came in to “see the woman who went through labor without any medication (epidural, etc.)”. While the attention was flattering (not that I did anything special), it’s appalling that simply giving birth to one’s child without severe anesthesia (with numerous risks and side-effects) was so surprising to the medical community. It's not as if women haven't been giving birth for thousands of years without it. Today, however, the medical community tends to advance both implicitly and explicitly a much more limited sense of women's empowerment and intelligence. The result is that people submit themselves to medical practice in a helpless and so relatively uncritical condition. We are used to hearing talk of "empowering women" within the abortion debate, but I worry sometimes that such lip service can be rather trivial and ignore the much more extensive sense in which people are kept ignorant about their own well-being and decision-making.
Childbirth in the United States is an odd thing. On the opening page of Marsden Wagner’s Born in the U.S.A.: How a Broken Maternity System Must be Fixed to Put Women and Children First, there is a delightfully provocative quote from the late Ronald Laing stating, “We do not see childbirth in many obstetric units now. What we see resembles childbirth as much as artificial insemination resembles sexual intercourse.”
While the WHO recommends an optimum cesarean rate of 10-15% of all births, in the United States over 30% of births are by C-section. This means that invasive surgery is being practiced in normal childbirth situations, where there is no good reason to do so. A culture of medical ignorance on the part of the public and failure to empower women on the part of the medical community is turning the most natural event of a person’s life into a clinical disruption of care for one’s body and one’s family. These are just a few anecdotes and data points; My wife is now working as a doula largely because of her childbirth experience, and could address the concern much better than I. The general problem, however, should be clear, and is probably familiar to most who have children, even if they didn’t recognize it as a problem.
My concern is not with invasive medical procedures for exceptional situations. At times, a vaginal birth is simply not possible or safe for the mother. Sometimes it really is necessary for an MD to be present in the room to attend to an emergency (and if only they were! More often we hear stories of nurses telling laboring mothers “don’t push!” because the doctor is down the hall at the vending machine, or chatting with the receptionist, or taking a leak). In the majority of pregnancies, however, nature works as it should. It’s not as if the human race is new to the experience of propagation. In certain parts of the “developed” world we’ve had a generation or two of amnesia brought on by the awe of new medical technologies (many now illegal and obsolete because of how dangerous they were), but it’s still within our capabilities, folks.
With the rise of the medicated and surgical extraction of our children, we’ve seen a decline in the practice of midwifery. There is a sense today that women and those who partner with them do not have the power or the ability to finish their pregnancies, and that specialized intervention is necessary. Oddly enough, this focus on specialization has also led to a decrease in attention from the very doctors who cling so strongly to their professional jurisdiction. Doctors see expectant and laboring mothers for minutes at a time; they are typically not available to work at length with the woman the way that midwives and doulas do. This is because their training isn't for maternity care, but for specific medical eventualities and procedures. It's no wonder that cesarean births and scheduled elective inductions are so prominent.
I'll close with another quote from Wagner's Born in the U.S.A. that sums up the present situation of childbirth and medical practice in the United States:
Below are some helpful resources for further investigation. Readers from Illinois should also read about the Home Birth Safety Act currently under consideration (and follow the news about it), and write to their representative in support of the rights of midwives to practice freely (our state has some of the most restrictive laws on midwifery in the U.S.)
Midwives Alliance of North America (professional association for all midwives, overseeing certification for CPM's)
American College of Nurse Midwives (professional association for CNM's)
ICAN: International Cesarean Awareness Network
The Business of Being Born
My wife and I have maintained concerns about the medical profession primarily with regard to childbirth. When our daughter was born in May 2008, nurses from around the hospital came in to “see the woman who went through labor without any medication (epidural, etc.)”. While the attention was flattering (not that I did anything special), it’s appalling that simply giving birth to one’s child without severe anesthesia (with numerous risks and side-effects) was so surprising to the medical community. It's not as if women haven't been giving birth for thousands of years without it. Today, however, the medical community tends to advance both implicitly and explicitly a much more limited sense of women's empowerment and intelligence. The result is that people submit themselves to medical practice in a helpless and so relatively uncritical condition. We are used to hearing talk of "empowering women" within the abortion debate, but I worry sometimes that such lip service can be rather trivial and ignore the much more extensive sense in which people are kept ignorant about their own well-being and decision-making.Childbirth in the United States is an odd thing. On the opening page of Marsden Wagner’s Born in the U.S.A.: How a Broken Maternity System Must be Fixed to Put Women and Children First, there is a delightfully provocative quote from the late Ronald Laing stating, “We do not see childbirth in many obstetric units now. What we see resembles childbirth as much as artificial insemination resembles sexual intercourse.”
While the WHO recommends an optimum cesarean rate of 10-15% of all births, in the United States over 30% of births are by C-section. This means that invasive surgery is being practiced in normal childbirth situations, where there is no good reason to do so. A culture of medical ignorance on the part of the public and failure to empower women on the part of the medical community is turning the most natural event of a person’s life into a clinical disruption of care for one’s body and one’s family. These are just a few anecdotes and data points; My wife is now working as a doula largely because of her childbirth experience, and could address the concern much better than I. The general problem, however, should be clear, and is probably familiar to most who have children, even if they didn’t recognize it as a problem.
My concern is not with invasive medical procedures for exceptional situations. At times, a vaginal birth is simply not possible or safe for the mother. Sometimes it really is necessary for an MD to be present in the room to attend to an emergency (and if only they were! More often we hear stories of nurses telling laboring mothers “don’t push!” because the doctor is down the hall at the vending machine, or chatting with the receptionist, or taking a leak). In the majority of pregnancies, however, nature works as it should. It’s not as if the human race is new to the experience of propagation. In certain parts of the “developed” world we’ve had a generation or two of amnesia brought on by the awe of new medical technologies (many now illegal and obsolete because of how dangerous they were), but it’s still within our capabilities, folks.
With the rise of the medicated and surgical extraction of our children, we’ve seen a decline in the practice of midwifery. There is a sense today that women and those who partner with them do not have the power or the ability to finish their pregnancies, and that specialized intervention is necessary. Oddly enough, this focus on specialization has also led to a decrease in attention from the very doctors who cling so strongly to their professional jurisdiction. Doctors see expectant and laboring mothers for minutes at a time; they are typically not available to work at length with the woman the way that midwives and doulas do. This is because their training isn't for maternity care, but for specific medical eventualities and procedures. It's no wonder that cesarean births and scheduled elective inductions are so prominent.
I'll close with another quote from Wagner's Born in the U.S.A. that sums up the present situation of childbirth and medical practice in the United States:
"The maternity care establishment in the United States has been seriously challenged by the trend toward evidence-based practice in medicine. Control, status, and, for many obstetricians, financial benefits have been threatened. The struggle is on, and place of birth has become a central issue. Why do obstetricians get so emotional about home birth? My own experience as a physician may shed some light on the situation.
The first time I attended a home birth, I was shocked. I had been a practicing physician for years, but this was the first time I had witnessed the full power of a woman in control of her own body. Believe me, it's a scary experience for a man. It took me a long time to come to grips with the truth: we men are afraid of women, whether consciously or unconsciously. We're afraid of unleashed nature, we're afraid of childbirth. We've all heard Freud's theory of "penis envy," but it isn't necessary to be an adherent of psychoanalytic theory to believe that many male obstetricians experience "womb envy," a term introduced by a German psychoanalyst, Karen Horney, to refer to an abiding sense of male inadequacy in the face of women's unique childbearing gift." (p. 131)
Below are some helpful resources for further investigation. Readers from Illinois should also read about the Home Birth Safety Act currently under consideration (and follow the news about it), and write to their representative in support of the rights of midwives to practice freely (our state has some of the most restrictive laws on midwifery in the U.S.)
Midwives Alliance of North America (professional association for all midwives, overseeing certification for CPM's)
American College of Nurse Midwives (professional association for CNM's)
ICAN: International Cesarean Awareness Network
The Business of Being Born
Posts
1. I'm not sure replacing bad penis-centric psychoanalysis with bad womb-centric psychoanalysis is a good idea, but I take the point.
ReplyDelete2. Milton Friedman was very supportive of the idea that medical licensing, which hinders a free market in medical care, was damaging to American health for a lot of these reasons. I can see where he's coming from to a certain extent. When I think about any division of labor I think about two opposing forces: the Smith-Stigler insight that "the division of labor is limited by the extent of the market", and the Coase insight that the division of labor increases transaction costs. Both are valid, and ultimately any division of labor is going to reach equilibrium at the point where the Smith-Stigler benefits are balanced out by the Coasian costs. You're really coming from a Coasian perspective here - excessive division of labor in medicine makes negotiating with medical professionals very hard for families. At the same time, I'm sure you wouldn't deny the fact that there's good reason for specialization - medicine is exceedingly complex. "House" plotlines may be largely bogus, but common situation on that show of a blustery patient presuming they know more than House rings true. It's a tradeoff. The real problem is when medical professionals INVENT transaction costs to protect their bottom line.
And there's nothing wrong with medical specialization, I'm not arguing against that. But there's no reason why we need MD's delivering babies in normal circumstances. Part of the success of medical professionalization has come through their ability to offer mundane tasks to subordinate professions yet retain a public sense of their own jurisdiction over these matters. My preference would be that midwifery, as its own bona fide profession, would grow a bit more and take over some of the territory that really doesn't need to be handled by MD's, and is really better handled by midwives. So it's not a question of rejecting professionalization, but rather of getting a situation of professionalization that works better.
ReplyDeletePart of the problem with patients presuming to know more than a doctor when they don't, however, has to do with a lack of openness about medical procedures with the public. There is a good deal that expectant parents should reasonably know about childbirth but don't, because no one talks to them about it. If a mother really needs a cesarean, for instance, she should be able to talk with her doctor about preferred suture method, and in later pregnancies should reasonably be able to advocate for herself in having a vaginal delivery. She should also feel safe calling bullshit when a doctor wants to schedule an induction that's completely unnecessary but fits his schedule. It is a difficult thing to negotiate, because as you point out, these things can be complex. But that isn't a reason to ignore empirical evidence about safer methods and shut out parents from the process of childbirth. Doing so adds complexity merely for the sake of preserving a monopoly over professional jurisdiction, and has nothing to do with the medicine that's being practiced.
Interesting post. Of course, modern medicine has also drastically reduced the occurence of death (in the developed world) for both infants and mothers that has been occuring for thousands of years, especially in cases where an apparently normal labor goes drastically wrong. Not saying your nor Tricia's choices are wrong, I guess the important thing you are arguing is to be informed and aware. The same thing isn't right for all people and while I haven't given birth I would say just based on PMS issues I'm not sure I could without some form of medical assistance (guess that is probably TMI coming from your little sister).
ReplyDeleteAlso I found it interesting that all the nurses were so amazed by Tricia refusing pain meds. As I recall Mom said that with twins you can't have pain meds, or at most a very minimal amount, so it doesn't seem like doctors would never encounter that.
BTW, I would say that your "we've been doing it for thousands of years" isn't really good evidence of best practices. Humans have also been killing each other, oppressing women and minorities, bleeding people as a medical cure, and generally running amok for thousands of years. But few are arguing that those are valuable practices.
On a side note I think there was a Home Improvement episode involving womb envy and Tim's need to build the hot rod because he couldn't give birth. I'm sure Wilson had some eleoquent statement that Tim totally botched in his explaination to Jill.
All good points, so let me clarify a few things...
ReplyDelete-First, I'm not trying to argue against "modern medicine". Too often I think this sort of advocacy is misinterpreted as a kind of primitivism or rejection of scientific and technological advances. Why people make that leap simply because the practice of doctors is criticized, I'm not sure. It's as if they're circling the wagons in order to protect "the system". But no, I'm not trying to criticize modern medicine or the fantastic advances that it has made in human well-being. What I'm trying to criticize is the idea that midwives and less invasive childbirth practices don't have a place in modern medicine... because they do. A similar example would be the sort of
"preventative care" focus that has become popular of late. Is that shift opposed to modern medicine? Of course not. It's just being smart about how medicine should be practiced, when and whether it should be practiced, and how normal, untrained people should be expected to engage with their own health. Nothing in that says that the genuine progress made by the medical profession is a mistake. What's being criticized is excesses, unscientific conclusions, and stupid practices within the system that should, for the sake of progress, be changed.
-Also, with the pain meds... I should say that part of women being able to make wise choices includes those decisions where pain meds or other invasive procedures are used. We have a number of friends about to have babies, and one thing that concerned me as I wrote this post was whether people like that would feel pressured or criticized by what I've said. So I do want to clarify that while I hope this can be good thoughts for people to consider as the approach childbirth, it's not my place or anyone else's to say what would be best in any particular situation. And part of women being empowered involves women not being ashamed of the decisions that they have made. It's not wrong to get pain meds, or to have a c-section, or schedule an induction. The problems come when larger trends amongst millions of births clue us in that something isn't right. On the individual level, though, I want to be clear that different decisions will have to be made in different contexts.
-On the "thousands of years" bit... yes, we've been doing horrible stuff for thousands of years. But be fair to me... when I say "we've been giving birth for thousands of years", the point is more comparable to "we've been pooping for thousands of years" or "we've been breathing for thousands of years". The reason why I pointed that out was obviously to say that childbirth is a normal biological function, not to offer an argument for a certain practice on bare historical precedent.
"it's not my place or anyone else's to say what would be best in any particular situation"
ReplyDeleteWell presumably it's SOMEONE'S place to say that.
Anyway - I think it was clear you weren't arguing against modern medicine. I certainly didn't think you were, and I didn't get the impression Kendra thought that either. It's just always something worth reinforcing.
Well, right. It's someone's place. And women can be wrong about the decisions they make just like anyone else can. I suppose what I mean is simply that you can't come at an individual situation (as a doctor, as a midwife, as an interested bystander) with an assumption that ideas about birth in general conclude anything decisively about any particular birth event.
ReplyDelete