If all you have is a hammer, everything looks like a nail

Or, if all you have is a scalpel, everything looks like a surgery.

If you follow the debate about our culture of birth, you may be wondering how two sides can see the same physiological process so differently. OBs say birth is only normal in retrospect; midwives say birth is normal, period, until proven otherwise. Are women who birth at home unusually reckless or wise? Are obstetricians lying about the potential dangers of birth, or do they see scary developments in healthy women every day? Which side is right?

Here's the problem -- both sides are right. Midwives and supporters of natural birth are absolutely correct when they say birth is normal, safe, and healthy. Obstetricians and malpractice lawyers are correct when they say things often go wrong in birth, and that it often requires constant vigilance and management. When American obstetricians and midwives talk about birth, they're talking about completely different processes. In the words of Marsden Wagner,

"[W]e do not have humanized birth in many places today. Why? Because fish can’t see the water they swim in. Birth attendants, be they doctors, midwives or nurses, who have experienced only hospital based, high interventionist, medicalized birth cannot see the profound effect their interventions are having on the birth. These hospital birth attendants have no idea what a birth looks like without all the interventions..."

Recently I came across an interesting New Yorker article. "The Score," by Atul Gawande, seeks to explain the industrialization of birth using the Apgar score as a template by which other outcomes, obstetric and otherwise, can be improved. Sounds great, right? After all, who doesn't want a practitioner who strives to be the best s/he can be?

But in practice, industrialization focuses not on being the best an individual can be, but on producing the best results from as large a group as possible.

"The question facing obstetrics was this: Is medicine a craft or an industry? If medicine is a craft, then you focus on teaching obstetricians to acquire a set of artisanal skills... But if medicine is an industry, responsible for the safest possible delivery of millions of babies each year, then the focus shifts. You seek reliability. You begin to wonder whether forty-two thousand obstetricians in the U.S. could really master all these techniques... Obstetricians decided that they needed a simpler, more predictable way to intervene when a laboring mother ran into trouble. They found it in the Cesarean section."

Basically, it's easier to teach someone to perform cesarean than to manage complications with less interventive techniques, especially since some MDs will not have the aptitude to learn those arts.

Shoulder dystocia provides a handy example in the article. He explains what it is, and lists several techniques that can be used for dealing with it, including Woods, McRoberts, Rubin, and breaking the baby's clavicles. But where is the Gaskin maneuver, a simple, extremely effective, and safe technique that simply has the mother flip over onto all fours, and which has a success rate of somewhere between 80% and 100%, depending on the study you're looking at? (For a clear and concise explanation of shoulder dystocia management techniques, see this post on The Lactivist.) Well, if you're attending a typical hospital delivery, the mother has likely had an epidural placed, and she's hooked up to various monitors, IVs, catheters, etc. In other words, even if she were capable of flipping over without serious assistance, nothing in the environment even suggests that as an option to her doctor. Apparently, it makes more sense for an obstetrician to push the baby back inside its mother and deliver it surgically (the Zavanelli maneuver) than it does to execute a simple position change. Midwives, on the other hand, are presented with a woman who may be upright, lying down, in the water, or supported in a squat by her partner, or some other variant of woman-led birthing. When the midwife is presented with shoulder dystocia, the Gaskin maneuver can be the very first thing she tries. Shoulder dystocia is shoulder dystocia... except that it's potentially very different depending on the setting and the attendant.

Gawande's article acknowledges that there is a downside to trying to regulate a human physiological process:

"And yet there’s something disquieting about the fact that childbirth is becoming so readily surgical. Some hospitals are already doing Cesarean sections in more than half of child deliveries. It is not mere nostalgia to find this disturbing. We are losing our connection to yet another natural process of life. And we are seeing the waning of the art of childbirth. The skill required to bring a child in trouble safely through a vaginal delivery, however unevenly distributed, has been nurtured over centuries. In the medical mainstream, it will soon be lost...

Against the [Apgar] score for a newborn child, the mother’s pain and blood loss and length of recovery seem to count for little. We have no score for how the mother does, beyond asking whether she lived or not—no measure to prod us to improve results for her, too."

And there we have it. Variations in the course of labor are approached in such disparate ways by different groups of practitioners that we end up with two versions of birth that barely even resemble each other. An OB who sees technocratic birth every day can't imagine why someone would want to do something so difficult and dangerous at home. She isn't wrong in her assessment that the births she attends are potentially dangerous, but she is made ignorant by her education and training. Unfortunately, mothers and babies suffer the consequences of this ignorance. If only the obstetrical community would stop taking the results of their interventions for granted as normal, and start focusing on how to make birth as normal and safe as possible.

Where does this leave us? Sadly, in our current climate I don't believe we are near reconciling the polarities of our birth culture. In my ideal world, all OBs would spend part of their internship with homebirth midwives seeing what birth can be like. In the real world, activism is vitally important, whether that takes the form of lobbying your state legislature, or simply sharing positive birth stories with every woman you meet. But for practical advice on how to have a good birth, I'll once again quote Dr. Wagner, "The best thing to do if you want a humanized birth is get the hell out of the hospital!"