Childbirth and Over-Medicalization

I’ve been waiting to write something on this particular topic for a long time. After I delivered my last child at home, I find myself in a position where I can finally delve into a comprehensive account of two wildly different approaches to the process of having a baby. Over-medicalization is a very broad topic, particularly in the United States, but I’m going to try to keep this limited to childbirth as much as possible. There is probably a very narrow audience that will find this interesting, primarily parents and medical providers themselves.

My first child was born at a hospital equipped with a “birth-center” and staffed with nurse-midwives. I was extremely hands-on to the point I had IV access initiated before we even arrived at the facility, much to the surprise of my wife’s doctor. The second childbirth also occurred at the same facility, in roughly the same exact fashion. Both were vaginal births, both were relatively uncomplicated in raw terms. On the third childbirth, my wife wanted to labor at home as long as possible in order to avoid unnecessary time spent in the facility. This resulted in a homebirth, but as you’d probably assume by now, I was more than sufficiently equipped to manage the situation.

Defining the Problem
In the United States, most childbirth occurs within a hospital setting. In recent years home-births have only just now climbed above 1 %, which should illustrate just how uncommon the practice is in America. In the year 1900, 95 % of births happened at home. Given the near complete eradication of homebirths over the course of a century by an industry notorious for medicalizing every aspect of the human experience, one would have to ask if this is necessary. I think Denmark makes a good countervailing example. Comparing like for like (Non-Hispanic White women), Dutch women have a maternal mortality rate of 4 per 100,000 versus 17.9 per 100,000 for American women. Total C-section rates for Non-Hispanic White women in America are currently 31 %, versus 21 % for the Dutch. When you consider that 30 % of births in Denmark happen at home, we can easily conclude that the United States is doing something seriously wrong. America has a much more medicalized, intensive system for childbirth but the outcomes are clearly inferior to countries that take a more hands-off, relaxed approach.

Causes
There’s several reasons for why more medical supervision produces inferior outcomes. First of all, every medical intervention entails an iatrogenic burden of some kind. In theory the benefits should outweigh the risks, but that only remains true if there’s benefits in the first place. Medicalizing natural processes that typically don’t require intervention will necessarily start skewing towards iatrogenic harms outweighing clinical benefits. For example, the healthcare system could screen everyone for lung cancer at a given age, but the complications from performing invasive biopsies on what turns out to be a harmless nodule would quickly outweigh any advantages of early cancer recognition. The basic gist is that introducing healthy, medically stable individuals to clinical diagnostics will likely result in more harm than good. Like anything else, the Law of Diminishing Returns applies to healthcare.

The next problem with medical supervision is it suffers from some significant clinical decision-making and epistemological challenges regarding risk management. I dare you to find a single doctor in this country that can even begin to define what “high risk” entails in the first place. “Risk” in medical speak is just a huge question-begging exercise that typically falls apart under the slightest scrutiny. It’s an amorphous blob of a term that frequently describes “risks” that barely rise to the level of statistical noise. The healthcare establishment routinely describes things as “dangerous” when they have an absolute risk value of less than a tenth of a percent. Moreover, because the healthcare system has moved towards treating “patient populations” instead of individual patients, they are incentivized to pursue very marginal gains in risk reduction. You as a patient might not even blink at a 1 % chance of a bad outcome, but when a system processes millions of patients, even very slight improvements could “save thousands of lives”. The tension between the needs of the individual and the desires of a vast bureaucracy could fill volumes, suffice it to say intellectuals from Michel Foucault to Ivan Illich have been criticizing this trend for at least fifty years now. Finally, because providers operate in a system that exposes them to critically sick patients and human disasters, they are subject to extreme bias from the Availability Heuristic. They know what CAN go wrong, and because Survivorship Bias in this case means they never even see what goes right, their cognitive prejudice becomes exacerbated over time. Contrary to public perception, medical providers are probably some of the most biased and sloppy thinkers in any profession.

In the example of childbirth, a “low risk pregnancy” (singleton, vertex, no health problems), will result in an uncomplicated and safe delivery at home the overwhelming majority of the time (90%) without medical support. Essentially the gist of the research is that while transfers to hospitals aren’t uncommon for first time mothers, they’re rare for women that have given birth before and are generally associated with less medical interventions across the board. As we dive further into the subject I think it’s possible to tease out why this is the case.

During a planned hospital delivery there’s essentially an invisible clock that starts as soon as you walk through the door. Assuming the patient isn’t sent back home for not being far enough along in labor, there’s almost immediate pressure to “get things going”. This is an obvious structural consequence of trying to mange available bed-space and labor resources within the hospital although providers are armed with a fairly long list of dubious statistics for why the patient should consent to Pitocin, membrane sweeps, and amniotomies to “speed things up”. These interventions typically lead to far more painful contractions, necessitating a completely reasonable desire for pain control, a service the hospital is more than happy to provide (and bill for) with an epidural. During the entire process, the patient has both their vitals monitored and the fetus’s heart rate recorded, often continuously. Needless to say, this creates a big opportunity for user error and the vagaries of electronic diagnostics to create false alarms. In addition to epidurals making the patient semi-paralyzed hypotension is an incredibly common side-effect due to the femoral arteries of the legs essentially no longer being under control of the sympathetic nervous system. In layman’s terms, the patient’s blood pressure crashes straight into the toilet after they get the epidural. To correct this requires the addition of fluids and/or a vasopressor.

At this point in labor, the mother has gone from being stable and ambulatory to paralyzed from the waist down with unstable blood pressures and is on half a dozen medications with at least two lines going and about as much telemetry as the typical ICU patient. Cervical dilation is checked relentlessly, and nurses will start hollering for a doctor and surgical prep the instant fetal heart rate dips below some arbitrary threshold.

Does that seem conducive to a good outcome? Does it sound at all reasonable to intentionally make a patient unstable while they’re under intense cardiovascular demands? In prehospital medicine, if a patient walked to the truck under their own power and was in this sorry condition by the time they reached the hospital, it would demand one Helluva an explanation.

This was exactly my experience, and as a medical provider myself, I found the entire “cascade of interventions” to be the most unnecessary charade I’ve ever seen inside of a hospital. It was devastating to watch them make my wife progressively less stable due to the actions of healthcare staff, and in both deliveries, I felt that we got away with a vaginal birth by the skin of our teeth.

Studies show that “failure to progress” and “fetal heart rate deacceleration” are the primary factors in choosing to perform a C-section. As I mentioned previously, it might be possible to tease out why home-births always result in less C-sections. Presumably, some number of transfers from home to a facility are because of “stalled labor”, which then resumes in the interim between transport and admission to a hospital. Similarly, fetal heart rate deacceleration often resolves spontaneously during the time it takes to get a woman in for an emergency C-section. Ergo, it’s fairly reasonable to believe that in addition to false positives from unreliable monitoring, a great deal of normal variation in labor progress and fetal heart rate is being over-diagnosed, particularly given how murky these categories are. Friedman’s Curve in particular has been outed as complete junk science, and similar problems have been found in accurately diagnosing cephalopelvic disproportion. The metrics used to detect “abnormality” in a laboring woman simply contain far too much gray area and leave the door wide open to over-diagnosis and over-treatment.

Furthermore, the types of providers working inside labor and delivery units are part of an insular medical specialty that has a very skewed perspective on childbirth itself. From my own experience, the nurses will say things like “Oh, everyone gets Pitocin.” as if IV administration of exogenous hormones is just a natural part of labor. They’re disproportionately exposed to legitimate childbirth emergencies and rarely see a natural, unmedicated labor. The end-point of these emergencies is transfer into an OR, so there is no opportunity to observe how many of these situations would spontaneously resolve without intervention.

If I’m being really uncharitable, I’ll add that “cookbook medicine” is completely endemic here and in the hospital in general. Nurses and doctors just go down the flowchart mindlessly checking off boxes and following algorithms. In emergency medicine the saying was “Treat the patient, NOT the monitor.”, but in obstetrics the mantra seems to be “Turn off your brain, open Epic, follow the onscreen instructions.” There were dozens of times when my wife was badgered about tests and procedures that anyone capable of doing a proper patient history would’ve found totally unnecessary. It doesn’t take much of a critical eye to see when clinical decisions are based on blanket protocols instead of common sense. 

The Alternative
On the other end of the spectrum, I have personally seen what’s it like to deliver a baby with an absolute minimum of resources. In the case of my third child, it was me, my wife, and an OB kit. Without all the extraneous staff, interventions, and high-tech monitoring, it was the same exact outcome as the first two births, except the experience itself was deeply personal, private, and rewarding. It also didn’t cost 14,000 dollars. I want to be very clear that this does not mean you yourself can purchase a 10 dollar OB kit off Amazon and fly by the seat of your pants. There are things that can definitely go wrong during even a routine delivery, and it would be needlessly risky to attempt it by yourself without the ability to recognize problems and manage them.

To use my own experience as an example, when my last son was born he was not immediately responsive like the previous two children. I’m certified as an Advanced EMT and we’re trained on childbirth and neonatal resuscitation, so I defaulted to what I was taught and started drying Cullen off and suctioning his airway immediately. He responded and started breathing and crying, but those 15-30 seconds between birth and his first gasps for air might as well have been an eternity. If you were an untrained individual in that situation, it would be a really, really bad time to go hunting for a YouTube video to tell you what to do. If it had not been for my training and experience I’m not sure if I would have a healthy baby right now.

Now that I’ve hopefully instilled a sobering level of trepidation about doing this at home, I’ll briefly summarize my personal recommendations.

Based on the available evidence, I think one can safely conclude that for low-risk pregnancies, a planned out-of-hospital birth attended by trained midwives will result in better outcomes for the mother regardless of where the child is ultimately born. The ideal candidate should be healthy, perform regular exercise, and go through some sort of prenatal screening or evaluation to identify potential problems. Trained midwives are the ideal standard, and I have a personal bias towards finding providers that have an emergency background simply because it’s been my experience these healthcare workers are faster at identifying and responding to shock and other complications. Ideally, transfer to a facility in an emergency shouldn’t be complicated, but from my research continuity of care between home and hospital is a big failure point in the American system. I don’t have anything to add about specific levels of midwife training, to be honest, in medicine as in anything, the experience, skill and mentality of the individual provider is much more important than the certificate hanging on the wall. There are plenty of nurses and EMTs out there I would trust over a doctor.

Exercise is important. Childbirth is a very physically demanding process and frequent cardiovascular training will also decrease your chances of having an oversized baby. My wife is a cyclist and rode thousands of miles while pregnant, and I absolutely credit that with the good outcomes we’ve had. I absolutely believe that tons of exercise is vitally important for pregnant women.

The obvious trade-off is that pain control and access to surgical intervention/blood products will be limited. For most women I’ve talked to, they prefer the experience of out-of-hospital birth even with the agony of unmedicated contractions. Being at home without constantly getting poked and prodded by strangers is conducive to actually relaxing during labor, which seems to make it more tolerable overall, even without an epidural. This brings me to my final point: For all normal parents, delivering a baby into the world is the most intense and magical experience you can have in this life, I know it certainly was for me. Doing it in a hospital is an alienating, dehumanizing and often traumatic stain on what should be the biggest day in your life. Even if the risks are higher on some purely instrumental, abstract level, doing it the old fashioned way is a defiantly human act of rebellion against a soulless institutional behemoth.

A life spent cradle to grave under the bootheel of some vast, Kafkaesque medical bureaucracy might just be a lot worse than risking post-partum hemorrhage in an inflatable kiddie pool.