Atul Gawande, assistant professor of surgery at Harvard Medical School said, in an article in The New Yorker Magazine (The Score: How childbirth went industrial.10/9/2006): "And yet there's something disquieting about the fact that childbirth is becoming so readily surgical. Some hospitals are already doing Caesarean sections in more than half of child deliveries...We are losing our connection to yet another natural process of life. And we are seeing the waning of the art of childbirth...In the medical mainstream, it will soon be lost." There was a revolution in medicine during the first third of the 20th Century that presaged all this. Whereas most urban women had been delivering babies at home with the help of a midwife, by about 1933 most urban babies were delivered by doctors in hospitals. Yet, hospital care brought no advantages to the mothers or newborn. In fact, newborn deaths from birth injuries had increased over the preceding two decades! The author cites "incompetence" as the most consistent factor.
As he observed, practitioners of medicine needed to do something to standardize the process of childbirth (make it easy as A-B-C!), and improve their numbers or they'd lose their credibility. Even without the advanced tools and techniques of the physicians, midwives were showing more consistently good results! Cesarean section's place in this, at the time, was as a last-ditch emergency surgical procedure. Historically, it almost always killed the mother through blood loss and infection. In the space of a quarter century, however, all that would really shift. The turning point came in 1953 in the form of a standardized evaluation scale of the newborn called the Apgar score. At about the same time, surgical techniques and antisepsis were coming into their own. The score became a beacon upon which statistical studies could rely. The immediate health and longer-term prognosis of an infant became measurable, thus reflecting back to institutions and their practitioners the efficacy of their approaches and procedures. But, if two procedures are equal in efficacy (when the personnel are adequately trained), how do you determine which to endorse, and at whose convenience?
Cesarean section is a procedure. The use of forceps in a delivery is a skill. Gawande refers to it as an art. Here lies a great example of where the path of least resistance is taking precedence over a push to raise the skill level of practitioners. Because of that, mothers may be suffering unnecessarily.
In the wake of statistics that endorse C-section as a viable option, studies of the longer-term impact on the women who are affected by it have been few and of little consequence to the direction that obstetrics is heading. Gawande cites forceps as having completely revolutionized childbirth. Their use drastically reduced infant mortality. The problem with forceps is that it is believed too many doctors are unable to master the instruments and technique well enough to make it effective. Physicians who are well trained in the techniques, however, have success rates equal to Cesarean section in difficult births.
Working with an instrument to guide an infant safely through an un-altered birth canal is considerably different and more challenging than cutting through tissue, stopping the bleeding, scooping the child out and then sewing the traumatized tissue back up. One is facilitation of a natural, not always predictable, process. The other is a paint-by-the-numbers excision.
You would think that C-sections would be used only in dire emergencies. They are not. They are now being offered more and more often as a featured special on the menu of childbirth!
The Apgar score is newborn-oriented, which means that the goal is to produce live and healthy births. It is also designed to catch the endangered infant and medically intervene before it's too late. What it's not designed to do is to place equal emphasis on the health and future well being of the mother AFTER she leaves the delivery room.
Cesarean section is just the most indicative of the procedures that have been integrated into the typical delivery. Today, it is more routine than not to include IVs, fetal heart-monitoring, Pitocin (to "drive" contractions), and spinal block anesthesia in the procedure of childbirth. Many of these in the course of a delivery, are chosen to beat the odds and smooth out the rough edges; almost like saying, "We'll make this convenient for both of us today...and let's not talk about tomorrow." Of course, it's the mother and family that pays for this all, but in how many currencies?
What once was the miracle of childbirth has become a technical procedure. It is dependent upon its distribution by an industrialized, assembly line, male-dominated hospital system that has yet to really understand, let alone acknowledge, the intricacies of a woman's experience. Has the woman's role become to deliver a healthy Apgar score? Gawande says: "Against the score for a newborn child, the mother's pain and blood loss and length of recovery seem to count for little." Was he able to cite a study that shows the statistics for the women's experience? No, it is something that "seems" to count for little. Cesareans are far more brutal to the mother than the use of forceps. Recovery is prolonged. Healthy tissue is damaged. The sense of dissociation from a natural birth process where you are delivering a newborn (as opposed to undergoing a procedure to remove a growth!) may very well produce traumatic beginnings in the bonding of mother and child. Of course, that's only extrapolation on my part drawn from conversations with women who have undergone it. But what do I know; I have no statistics to back me up.
Maybe someone should ask.
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