In the past several decades there have been incredible advances in medicine, particularly medicine involving childbirth. In the developed world, infant mortality is at near-historic lows and the ability of hospitals and physicians to treat labor emergencies and even problems in the womb is amazing. That said, there is a growing movement in the United States (as well as other Western countries) of women who want to have their children naturally and at home.
It seems counter-intuitive that at a time of great medical development and technology, women would seek to return to a method of childbirth practiced before these advances in medical technology.
Readers may be curious as to why a man may be interested in this subject. I first became acquainted with the issue when my wife told me she wanted to have our children at home, so it developed a somewhat personal importance to me.
The reasons for choosing a home birth are varied, depending on the woman. In some cases, for example in Amish or Mennonite communities, there are religious reasons behind avoiding medicalized birth. Many other women, however, are avoiding a system in which their wishes are often secondary, if considered at all. For instance, in most of the United States obstetricians refuse to perform vaginal births after C-sections (VBAC for short), no matter how long ago the C-section was or how many vaginal births took place previously. Simply put, if they choose to use a doctor or give birth in a hospital facility women are given no choice whatsoever as to how the birth occurs.
The refusal to perform VBACs stems primarily from reasons of liability. There is an extremely low possibility of complications from VBACs, but when complications do occur it usually involves the use of labor-inducing drugs or cases where the C-section was performed in a less-than-ideal fashion. C-sections provide a measure of control that can be used to prevent legal liability if “things go wrong”. Never mind “informed consent”; the patient is simply given no choice in the matter because the lawyers say so.
The post caesarean birth is not the only issue; many women have had a hospital birth and simply did not like the experience. Before admission they are given a list of restrictions and few choices as to how their birth experience will be handled. Many times they are told how long they will be “allowed” to labor before interventions are undertaken. It is a well-documented fact that hospital birth is intervention-heavy in the United States. Instead of lettings things progress normally, various medical interventions are performed to mold the birth to an artificial timetable. To be fair, not all doctors treat birth in this fashion, but many are subject to various tort laws and legal environments that force their hands. Some are more reasonable than others in the way they manage these constraints.The result is that women who are looking for other options often decide on avoiding doctors and hospitals altogether unless a medical emergency develops.
The practice of medicine has not always been as risk-averse (or at least risk-managed) as it is today. Largely, that is a factor of the increased litigation that is well-known in the United States, in particular. Many groups have detailed the costs of a lawsuit-hungry society but those groups are advocating for provider’s bottom lines. There is really no group out there arguing against the costs of patient choice as a casualty of a litigious society. Before doctors see any patients, they have to drop a large amount of money on a liability insurance policy that costs tens (if not hundreds) of thousands of dollars. That liability insurance policy, like any insurance policy, down to car insurance, comes with terms that restrict the physician’s choice in how they practice. Those policies are written to ensure actuarial predictability of liability in insuring doctors.
When patients walk in the door, doctors agree to take particular medical insurance policies on behalf of those patients. Those medical insurance companies set terms on how procedures are ordered and, more importantly, what they will or will not pay for.
A side-effect of the health insurance policy of the US is that health insurance companies, under the guise of “managed care”, are the primary decision-maker when it comes to health-care decisions. Again, the insurance company is concerned with actuarial stability. This leaves the physician answering to two external entities (at least) which dictate the terms of how he or she will treat the patient, before even entering the consulting room.
In addition, physicians (in particular, management of large physician groups) tend toward the practice of defensive medicine, that is, medicine not designed to treat medical conditions but to establish a documentary record that every conceivable adverse condition has been ruled out no matter how remote the chance that it is occurring.
This leaves women who are giving birth — one of the most unique and sacred moments for many mothers — being treated not as patients but as a variable plugged into a risk management formula. You aren’t a mother, you are a 1 per cent chance of uterine rupture, a 5 per cent chance of needing a C-section, and so on. A patient in a risk management model is little more than a potential future plaintiff.
Many women accept this treatment because “that’s what you do”, or because they still prefer a hospital birth to other alternatives. Others, however, refuse to play a part in this system and have opted for home birth so they can experience the birth of their children free of the mandates of lawyers and accountants. Typically, they use trained midwives who assist them at home.
Despite this, in most of the United States the use of midwives is illegal. Doctors are technically free to assist with home births, but the aforementioned liability issues usually preclude all but perhaps a dozen physicians in the entire country from doing so. Many of our grandparents were born at home with the assistance of a midwife was the norm. Now it is a practice that has, for all intents and purposes, been outlawed. (As of this writing, only 27 US states license midwives).
It is ironic that in modern day America that prides itself on choice, particularly in female reproductive matters, that laws and the medical community not only dictate the way childbirth services may be provisioned, but actively opposes choosing alternative means of childbirth.
As modern medical development continues to advance, and along with it entrepreneurial litigation developing new ways to find doctors liable for medical problems, patients are treated less as patients and more as risks to be avoided. With something as special, intimate and sacred as childbirth, this should not be.
John Bambenek is an incident handler at the Internet Storm Center and blogs at Part-Time Pundit. He is the father of three children, two of whom were born at home.
