There have been many great moments in women’s history. The invention of the Pill is near the top of the list, simultaneously allowing women to control their own bodies and saving millions of lives. Acquiring the right to vote and laws against gender discrimination are near the top, too.
Yet almost nothing else in medicine has saved lives on the scale that obstetrics has.
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Childbirth in nature killed as many women as breast cancer kills today.[/pullquote]
Those aren’t my words. They were written by Dr. Atul Gawande describing the history of the Apgar score in a famous piece in The New Yorker.
In certain circles it has become fashionable to denounce the medicalization of childbirth, but the truth is that the medicalization of childbirth is the best thing that ever happened to women.
The maternal mortality rate prior to the advent of modern obstetrics was approximately 1%. If that were still true, 40,000 women would die each year in childbirth (instead of less than 1000). That’s almost exactly the same number of women who die of breast cancer each year.
Think about that: Childbirth is nature killed as many women as breast cancer does today. And it’s far more dangerous for babies!
For most of human existence, midwives cared for women in childbirth, and for most of human existence, the grim death toll did not budge.
Obstetricians took a different approach.
As Gawande explained:
In obstetrics, meanwhile, if a strategy seemed worth trying doctors did not wait for research trials to tell them if it was all right. They just went ahead and tried it, then looked to see if results improved… But the package as a whole has made child delivery demonstrably safer and safer, and it has done so despite the increasing age, obesity, and consequent health problems of pregnant mothers.
Given that it saves so many lives, who would argue against the medicalization of childbirth?
The answer: midwives, who have been out competed by the life-saving advances of obstetrics. They have demonized those advances because they can’t provide them; it’s simple economics.
But it’s hardly persuasive for midwives to frame the issue as “Pay us even though we can’t prevent you from dying.” So in keeping with Marketing 101, they reframed the problem. Just as advertisers routinely promote their products by implying that they will improve your life experiences, midwives promote unmedicated vaginal birth as “Pay us because we will provide you with a better experience.” Over the years they’ve embroidered their marketing philosophy with claims that unmedicated vaginal birth is healthier, safer and superior to medicalized childbirth, though there’s no evidence for these claims.
That’s not to say that modern obstetrics is perfect. Far from it! But the central defect in obstetrics is NOT medicalization but paternalism. It isn’t the life-saving technologies; it’s the conceit that doctors should make choices for women instead of women themselves.
It’s not a coincidence that the heyday of medical paternalism, the 1950’s and 1960’s, was a time of increasing popularity for the philosophy of natural childbirth. Doctors had decided every detail of childbirth instead of leaving those decisions to women themselves. The original goals of the natural childbirth movement were quite laudable: being awake for birth, having a support person present, ending useless procedures like routine perineal shaving and enemas. That’s what midwives and natural childbirth advocates offered and women wanted it.
Those goals were achieved decades ago. Epidural anesthesia allows women to be awake and aware for childbirth AND pain-free. You can bring whomever you want to support you in labor. Routine perineal shaving and enemas went out with giant shoulder pads. Today, if you are looking for the safest, most comfortable, easiest childbirth, modern obstetrics is the obvious choice.
To compete, therefore, midwives have to convince you that you don’t want that; you are supposed to want to experience pain, want to dispense with technology that improves safety, and want to empower yourself through suffering. That’s why they decry medicalization, one of the two greatest achievements of women’s health of all time (along with the Pill).
But the dirty little secret of contemporary natural childbirth advocacy is this: women can’t reclaim their agency from doctors by giving it to midwives. That’s just a different form of paternalism.
Here’s what childbirth would look like if midwives and natural childbirth advocates were not so paternalistic:
- All possible choices would be represented because women have a broad spectrum of needs and desires.
- Medicalization would not be demonized; it would be lauded as life-saving.
- Birth plans would just as readily include maternal request C-sections as unmedicated vaginal births.
- Pain relief would have a prominent place in birth plans since most women want pain relief.
- No form of childbirth would be represented as better or more empowering than any other.
But that’s not what contemporary midwifery and natural childbirth advocacy look like. Why not? Because both are shaped by the economic needs of midwives and other birth workers and NOT by the needs of women.
Medicalization of childbirth is the best thing that ever happened to women. We ought to be very wary of those who demonize medicalization in order to improve their bottom line at the expense of women’s health and safety.
