by Pavithra Venkataraman, March 20, 2021
“The United States provides the world’s most expensive maternity care but has worse pregnancy outcomes than almost every other industrialized country”
(Feldhusen, 2000).
When analyzing the differences between how America approaches birth, and how other developed countries approach birth, there is one that stands out: medicalization. Medicalization is a process by which human problems come to be defined and treated as medical problems. It consists of acts such as using medical language to describe a problem, adopting a medical framework to understand a problem or using a medical intervention to treat it (“The Medicalization of Childbirth,” 2016). The transition from home to hospital has brought with it opportunities that have created an increasing number of negative outcomes. These can easily be attributed to the industrialization of childbirth into hospitals. Demystifying and advertising the much more beneficial and safe option of midwifery would greatly increase and make more comfortable pregnancy outcomes across our country.
A Brief History of Birth in the United States
The birthing process has changed dramatically through the centuries. To properly identify the time periods where change occurred, scholars often split this transition from home to hospital into three stages. The first stage, social childbirth, was extremely community oriented, “laboring and delivering with the assistance of female family, neighbors, and midwives” (Martucci, 2017). This stage lasted from the early 17th century to the mid 18th century. Birth was a female occurrence; men were not involved unless there was an emergency situation. During this stage, the only birthing style that was practiced was a ‘normal’ birth, defined as “a vaginal birth in which labor starts spontaneously [and] labor progresses without assistance or specific drugs and forceps [are] not used” (“The Medicalization of Childbirth,” 2016). In effect, there are no drugs that are used to induce, ease, or speed up the process; the woman’s body does the work and that is all. Midwives were the only resource that women had if they wanted assistance.
This natural birthing process was interrupted by the invention and introduction of several medical apparatuses, especially the obstetrical forceps. Tong-like instruments, these were used to assist in delivery as opposed to either cesarean sections or other less-safe and more damaging devices. With this invention, university-educated doctors flooded the birthing process. During this transitional period, from the middle of the 18th century into the 19th century, there was an equal mix of hospital and home births, and therefore an equal mix of doctors and midwives being used. The rise of the forceps created a necessity for obstetrical education, to teach physicians the proper way to use them.
In addition to the forceps, reports published in 1910 and 1912 stated that the practicing American obstetricians at the time did not have the proper training: “To improve obstetrics training, one report recommended hospitalization for all deliveries and the gradual abolition of midwifery. Rather than consult with midwives, the report argued, poor women should attend charity hospitals, which would serve as sites for training doctors” (Rooks, 2012). An important addition to the hospitalization process, the ‘twilight sleep,’ was created in 1914. Considered a sign of progress at the time, this process used a mix of several drugs and an amnesiac, scopolamine, to induce a long sleep that also took away any memories of giving birth. During this period of time, the natural child birthing process was criticized by scholars and doctors who wanted childbirth to be seen as a ‘destructive pathology’ in order to encourage medical intervention. Consequently, the medical focus of birth shifted from “responding to problems as they arose to preventing problems through routine use of interventions to control the course of labor” (Rooks, 2012). With this shift, instead of only using medical interventions in cases that had immediate and pressing problems, these interventions were used in every single case of pregnancy, whether or not there was an issue naturally.
This leads to the third stage of birth: medical authority. In the present day, around 99% of births happen in hospitals, with the process of pregnancy now beginning with doctors of gynecology. In this stage, the cesarean section rate is close to 30%, both elective and emergent, even though the ideal rate according to the World Health Organization is 15% or less (“The Medicalization of Birth”). Specifically, celebrities are electing to participate in a procedure called designer birth, according to the film The Business of Being Born (2008). This procedure involved a scheduled c-section delivery followed immediately by a procedure that involves the removal of excess fat and skin, better known as a tummy tuck. Other assisted delivery procedures include an episiotomy, “a surgical incision made in the perineum… to allow the baby’s head to pass through more easily; an amniotomy, “an artificial rupture of the amniotic membranes, which contains the fluid surrounding the baby… to induce or augment labor;” induction of labor through “Pitocin, a synthetic form of the drug oxytocin given intravenously;” and vacuum extraction, which uses a pump that pulls the baby ‘down the birth canal with the help of the instrument and with the help of the mother’s contraction” (“Pregnancy: Types of Delivery,” 2018). Each one of these procedures were created with the aim of helping the pregnant person and the baby and yet has large risk factors associated with the outcomes.
From Home to Hospital
In theory, it seems that it must be a good thing to have medical research and professionals improve and create new processes to help ease the birthing process. I argue that because of the following societal systems we have in place, medicalization no longer prioritizes the pregnant individual and child, instead favoring the hospitals and medical organizations that profit from them. It would be wrong to assume that all these procedures have improved birthing outcomes. In actuality, “a scholar who conducted an intensive study concluded that the 41 percent increase in infant mortality due to birth injuries between 1915 and 1929 was due to obstetrical interference in birth” (Rooks, 2012). I believe there are two levels to the systems in place in the United States that have obstructed the improvement of birthing results. On the individual level, I believe that pregnant people and their bodies are no longer seen as such, even during individual interactions with doctors; rather, they are seen as commodities of flesh to be used and are treated that way. On a collective level, I believe the birthing process as a whole was seen as a business opportunity and therefore has been industrialized for the purpose of making the most profits.
On its own, the birthing process began as an experience tailored to the needs of the pregnant person, based on the preferences of the family, and structured around the environment where the birth was happening. In the present day, the process in a hospital is unified, completely up to the discretion of doctors, and wholly dependent on what resources exist in that hospital. I compare this to the theory proposed by Hortense Spillers in Mama’s Baby, Papa’s Maybe: An American Grammar Book (1987), and expanded upon by Nirmala Erevelles in Disability as “Becoming”: Notes on the Political Economy of the Flesh (2011). Beginning from Spillers’ recognition of black bodies during the Middle Passage being treated as commodities of flesh, as opposed to bodies with purpose, Erevelles takes it one step further by conceptualizing ‘disabled’ bodies as similarly being viewed as ‘wounded’ flesh without considering the bodily aspects of mind and soul that also contribute to a body’s worth. It is easy to picture this occurring within the process of birthing: pregnant individuals are seen as vulnerable and weak, and at the very minimum, during the period when the birth is happening, they are only flesh that needs to be dealt with instead of bodies filled with emotions, preferences, and needs to be fulfilled outside of physical procedures.
For example, a procedure known as ‘the husband stitch’ was brought to light first by Sheila Kitzinger in her 1994 book, The Year After Childbirth, and then through Carmen Maria Machado’s short story called “The Husband Stitch” (2014). This “refers to the procedure of suturing the vaginal entrance narrower than necessary to repair trauma post-birth, with the presumption that this will enhance the sexual pleasure of a penetrating penis” (Halton, 2018). The stitching happens after the occurrence of an episiotomy, which on its own has been increasingly advised as unnecessary and non-essential by many medical guidelines both in the US and the UK. Women who share their birth stories often report not being aware that an episiotomy had occurred until months after the birth when they were experiencing extreme pain and searched for the cause. They relay not being properly informed about the procedure or told how to help and deal with the healing process that is to come. As a newly public procedure, there are no studies that exist to explore how often, how many times, or how recently this stitch is and has been added. The process itself turns a woman into Spillers’ definition of flesh: women exist sexually for their husbands even though the pain of recovery is increased exponentially by both magnitude and length of time. These women exist as vehicles for reproduction and are placed at the complete mercy of their doctor with much less freedom to make their own choices especially while their legs are forcibly spread.
When analyzing birth as a collective social institution, it is easy to see how industrialized the process has become. What was once a private experience is now a conveyor belt-style, in-and-out procedure where doctors and hospitals are praised and rewarded for their efficiency in terms of the number of births they can successfully complete in the least amount of time. I compare this to Lisa Lowe’s claim in her book titled The Intimacies of Four Continents. Lowe’s study of the effects of colonialism on the colonized lead her to claim that modern liberalism affirms the people in power “while subordinating [and erasing the history of] the variously colonized and dispossessed peoples whose material labor and resources were the conditions of possibility for that liberty” (Lowe, 2015, p. 6). Not only did settler colonialism remove and disadvantage Natives from their land, but the history books and archives ‘discourage’ these connections. Similarly, medical professionals capitalized on the birthing field, simultaneously discrediting midwives as untrained and incompetent and denying that this history of midwifery ever existed.
Not only does this industrialization disadvantage midwifery, but it equally, if not more so, disadvantages pregnant individuals. For example, the labor process has been streamlined to the point where the baby and pregnant person’s lives are put at danger over and over. Labor for a pregnant individual can naturally last anywhere from a single hour to 18-20 hours (“Pitocin,” n.d.). However, to hospital institutions, the more women they can care for in the least time possible, the more money they can make. Therefore, methods that speed up labor, no matter the cost or non-necessity, are introduced into the process: “Other wealthy, industrialized countries have national health services, in which elements of care that aren’t needed and don’t bring improved health tend to be dropped because of the cost. In the U.S. health-care industry, the more care that is provided, frequently more money is made by the doctors and the hospitals, so there is less incentive to not use these methods” (Rooks, 2012). One such method is the administration of the drug Pitocin, which mimics the natural hormone oxytocin by reducing the time between contractions, which in turn speeds up labor. This sounds like it would be favorable, but in reality, “Pitocin is the drug most commonly associated with preventable adverse events during childbirth” (“Pitocin,” n.d.). The most common negative outcome seen with Pitocin is hyperstimulation. In labor, contractions slow blood and oxygen flow in and out of the placenta to the baby, and the stages in between contractions allows the placenta to rest. When Pitocin is administered, the time between contractions is shortened which does not allow enough blood and oxygen to reach the placenta which creates a large risk, known as hyperstimulation, for the baby (“Pitocin,” n.d.). A common medicalized cycle of birth is as follows: (1) Pitocin is administered to speed up the labor, which creates pain and tension in the pregnant individual, which then leads to (2) heavy pain medication administered such as an epidural, which numbs the nervous system and therefore slows contractions and the time in between. 1 and 2 are repeated a couple of times, until the baby is in such distress that there is no option but to move to a c-section, which can be stressful and traumatic for both the baby and the pregnant person (“Pitocin,” n.d.).
Not only are pregnant people forgotten during a process in which they should be the focus, there is a disproportionate negative effect towards pregnant individuals of minority, whether that be by race, sexuality, trans-status, disability, and/or socioeconomic status, to name a few:
“Black women are 4 times more likely than white women to die from complications of pregnancy. In fact, black women have a higher risk than white women for dying from every pregnancy-related cause, including hemorrhag, pregnancy-induced hypertension, and pulmonary embolism… [B]lack infants… die at twice the rate of white infants… Other ethnic minorities also have higher infant mortality rates.”
(Anachebe & Sutton, 2003)
Women with pre-existing health conditions unrelated to pregnancy such as asthma, diabetes, depression, or substance use issues are already at a higher risk of negative outcomes. While there are few studies that focus on outcomes of trans individuals who have given birth, a simple search yields testimony after testimony of these individuals who have faced discrimination and intrusive questioning that fall outside of the realm of birthing, as well as the sense that the care being provided is not as thorough. Socioeconomic status and the outcomes that occur can be explained by locational, geographical, and monetary access to hospitals and quality of care. When the only known option is a hospital birth, the nearest hospital is miles and miles away, and insurance does not cover the cost of giving birth in a well-ranked hospital, the outcome will generally not be as positive.
Conclusion
I believe that these numerous negative outcomes and societal manifestations are a result of the medicalization process. To counteract these issues, we should return to the midwife-assisted, non-hospital-dependent birthing process that the majority of developed countries around the world still use. This transition would be a return to an age where birthing worked while still keeping the option of modern medicine in the extreme cases where the body is not functioning in the normal way. Midwife-assisted births would reduce the number of drugs administered, the number of c-sections performed, and cases of the ‘husband stitch.’ The focus would return to the individual giving birth, restoring continuity of care, tailor-made birthing timelines, and the ability and authority of the family to make their own health care decisions. Midwifery allows the pregnant people to choose which individual they would most like to work with during the pregnancy process based on comfort, particular skill set, and even cost associated. Although this system is not perfect, it greatly reduces risks attached and increases the likelihood that outcomes will be negative, allowing the birthing process to function on its own the way it is supposed to.
It is clear that there is an issue with our birthing system when we compare our outcomes to those of other developed countries. My argument lies in the way in which we, as a country, are choosing to fix it. Instead of compounding the issue by introducing medical solutions to fix medically-induced problems, I propose that we relinquish our need to keep the birthing process entrenched in the institution of hospitals. I believe a return to the way that the birthing process used to work will return us to outcomes that are much less negative and much less divisive along minority lines. Although medicine is important, its purpose, in simple terms, is to treat diseases that are not, for lack of a better word, ‘normal’ to a human body. The inclusion of pregnancy and birth, extremely ‘normal’ and necessary human bodily functions, into this category of medicine is not only unnecessary, but in practice detrimental to both pregnant individuals and the babies. I believe that midwifery is the right way to progress, and the best way to go about improving the birthing process in America.
References
Anachebe, N.F., & Sutton, M.Y. (2003). Racial disparities in reproductive health outcomes. American Journal of Obstetrics and Gynecology, 188(4), S37–S42. https://doi.org/10.1067/mob.2003.245
Erevelles, N. (2011). Disability and difference in global contexts: Enabling a transformative body politic. Palgrave Macmillan US.
Feldhusen, A.E. (2000). The history of midwifery and childbirth in America: A time line. Midwifery Today. https://midwiferytoday.com/web-article/history-midwifery-childbirth-america-time-line/
Halton, M. (2018, April 26). The ‘husband stitch’ leaves women in pain and without answers. Vice. https://www.vice.com/en_us/article/pax95m/the-husband-stitch-real-stories-episiotomy
Lowe, L. (2015). The intimacies of four continents. Duke University Press.
Martucci, J. (2017). Childbirth and breastfeeding in 20th-century America. Oxford Research Encyclopedia of American History, https://doi.org/10.1093/acrefore/9780199329175.013.428
The medicalization of childbirth. (2016, December 10). In UBC Wikipedia. https://wiki.ubc.ca/The_Medicalization_of_Childbirth
Pitocin (Oxytocin) induction risks and side effects. (n.d.). American Baby & Child Law Centers. Retrieved March 7, 2021, from https://www.abclawcenters.com/practice-areas/prenatal-birth-injuries/labor-and-delivery-medication-errors/pitocin-and-oxytocin/
Pregnancy: Types of delivery. (2018, January 1). Cleveland Clinic. Retrieved March 7, 2021, from https://my.clevelandclinic.org/health/articles/9675-pregnancy-types-of-delivery
Rooks, J.P. (2012, May 30). The history of midwifery. Our Bodies Ourselves. https://www.ourbodiesourselves.org/book-excerpts/health-article/history-of-midwifery/
Spillers, H.J. (1987). Mama’s baby, Papa’s maybe: An American grammar book. Diacritics, 17(2), 65–81. https://doi.org/10.2307/464747
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