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Amazed or Appalled, Apathy or Action?
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EDITORIAL
Amazed or Appalled, Apathy or Action? Ianyadmit that I am not a 30-something professional longer. My graduate students frequently hear the words I remember when . . . in relationship to issues that we no longer typically face in obstetric care and outcomes. For example, I remember the multiple losses experienced by mothers with insulin-dependent diabetes or Rh isoimmunization; I also remember approaching the care of preterm infants with two basic modalities, warmth and oxygen “until pink.” I am in awe of the medical advances that have solved or dramatically ameliorated these problems and applaud my medical colleagues for these successes. However, I also remember a national 5.5% cesarean section rate and the caution with which a physician made the decision to open a woman’s abdomen to surgically extract her infant. In my early days, a physician, even an obstetrician, was required by policy to seek consultation from an independent obstetrician before performing a cesarean section in all but the most emergent situations. All cesareans were reviewed at the monthly departmental meeting for indication and outcome. Admittedly, there were also difficult vaginal births, but those too seemed to be the exception. The answer to how far we have come or how far we have fallen since that time depends on your worldview and care philosophy. We are again faced with a rising cesarean rate in the United States, a rate that rose to 24.4% in 2001. This recent trend has been fueled by a growing abandonment of vaginal birth after cesarean section and an increasing tolerance and even promotion of elective cesarean section. It is this latter trend that I find most difficult to accept. The dilemma became clear to me recently when I heard a young physician say that it is probably time that women should be “consented” for the procedure of vaginal birth the same as they must be consented for the procedure of cesarean section. This is a problem, not of clinical decision making and optimizing health outcomes, but of the worldview one has of women, their bodies, and their physiology. Vaginal birth is not a medical procedure, and any health care provider who believes that it is must view life itself as pathology. The belief that a major
May/June 2003
surgical procedure is preferable to a normal vaginal birth is used to justify an assault on women and a total disregard for normal physiology. The distressing social reality is that a number of women seem to accept and even welcome the assault. I have followed this issue with concern, dismay, and amazement. Concern, because I believe that young women in the United States have systematically been stripped of confidence in their own bodies and their own power as birth givers. Dismay, because I used to have confidence that people in health care were fairly intelligent and clear-headed. I now have little of that confidence. Amazement, because we have become so calloused to the wonder of birth that we have allowed the industrial model that produces first-rate manufactured products to reduce labor and birth to a series of controls, measures, monitors, and interventions, rather than embrace it as the unique process that it is for each woman and her baby. Birth is sacred; it is the first bookend of life. I am convinced that our current situation in American obstetric care is deeply troubled and fundamentally flawed. It is troubled by the shadows of litigation, rising costs, fragmentation of care, and a cavalier attitude to intervention in normal processes. It is flawed because it is not founded on respect for women, their bodies, their basic physiology, or their strength. Our system of care for pregnancy and childbirth is founded on the search for pathology and the exercise of control, rather than on the assumption of normalcy and the fostering of health and personal growth. The reality that surgeons (obstetricians) are in control of the care of the majority of American women during pregnancy and childbirth is a system factor that has profound effect on the entire spectrum of care for childbearing women. I highly recommend the book Expecting Trouble: The Myth of Prenatal Care in America by Thomas H. Strong, Jr., MD (2000), as a starting point for discussion on the systemwide changes that are needed. As long as we continue on our current course, intervention in normal childbirth and the incidence of cesarean section will escalate without an improvement in outcomes.
JOGNN 281
Do we need a revolution in the childbearing aspects of women’s health care? I believe that we do, and I believe that nursing values are core to the cause. Those values include belief in childbearing as health and well-being, health promotion for women and their children, the fostering of family growth and psychosocial development, nonintervention in normal processes, and advocacy for women and children within and outside of the system. If nothing changes soon in our system, we could see a 50% cesarean section rate in the United States, a rate that some physicians believe is totally acceptable and even desirable.
282 JOGNN
Nurses are the largest group of health care providers. Will we remain silent and apathetic? Can we and should we not act to change this course? Nancy K. Lowe Editor REFERENCE Strong, T. H. (2000). Expecting trouble: The myth of prenatal care in America. New York: New York University Press.
Volume 32, Number 3
EDITORIAL
Amazed or Appalled, Apathy or Action? Ianyadmit that I am not a 30-something professional longer. My graduate students frequently hear the words I remember when . . . in relationship to issues that we no longer typically face in obstetric care and outcomes. For example, I remember the multiple losses experienced by mothers with insulin-dependent diabetes or Rh isoimmunization; I also remember approaching the care of preterm infants with two basic modalities, warmth and oxygen “until pink.” I am in awe of the medical advances that have solved or dramatically ameliorated these problems and applaud my medical colleagues for these successes. However, I also remember a national 5.5% cesarean section rate and the caution with which a physician made the decision to open a woman’s abdomen to surgically extract her infant. In my early days, a physician, even an obstetrician, was required by policy to seek consultation from an independent obstetrician before performing a cesarean section in all but the most emergent situations. All cesareans were reviewed at the monthly departmental meeting for indication and outcome. Admittedly, there were also difficult vaginal births, but those too seemed to be the exception. The answer to how far we have come or how far we have fallen since that time depends on your worldview and care philosophy. We are again faced with a rising cesarean rate in the United States, a rate that rose to 24.4% in 2001. This recent trend has been fueled by a growing abandonment of vaginal birth after cesarean section and an increasing tolerance and even promotion of elective cesarean section. It is this latter trend that I find most difficult to accept. The dilemma became clear to me recently when I heard a young physician say that it is probably time that women should be “consented” for the procedure of vaginal birth the same as they must be consented for the procedure of cesarean section. This is a problem, not of clinical decision making and optimizing health outcomes, but of the worldview one has of women, their bodies, and their physiology. Vaginal birth is not a medical procedure, and any health care provider who believes that it is must view life itself as pathology. The belief that a major
May/June 2003
surgical procedure is preferable to a normal vaginal birth is used to justify an assault on women and a total disregard for normal physiology. The distressing social reality is that a number of women seem to accept and even welcome the assault. I have followed this issue with concern, dismay, and amazement. Concern, because I believe that young women in the United States have systematically been stripped of confidence in their own bodies and their own power as birth givers. Dismay, because I used to have confidence that people in health care were fairly intelligent and clear-headed. I now have little of that confidence. Amazement, because we have become so calloused to the wonder of birth that we have allowed the industrial model that produces first-rate manufactured products to reduce labor and birth to a series of controls, measures, monitors, and interventions, rather than embrace it as the unique process that it is for each woman and her baby. Birth is sacred; it is the first bookend of life. I am convinced that our current situation in American obstetric care is deeply troubled and fundamentally flawed. It is troubled by the shadows of litigation, rising costs, fragmentation of care, and a cavalier attitude to intervention in normal processes. It is flawed because it is not founded on respect for women, their bodies, their basic physiology, or their strength. Our system of care for pregnancy and childbirth is founded on the search for pathology and the exercise of control, rather than on the assumption of normalcy and the fostering of health and personal growth. The reality that surgeons (obstetricians) are in control of the care of the majority of American women during pregnancy and childbirth is a system factor that has profound effect on the entire spectrum of care for childbearing women. I highly recommend the book Expecting Trouble: The Myth of Prenatal Care in America by Thomas H. Strong, Jr., MD (2000), as a starting point for discussion on the systemwide changes that are needed. As long as we continue on our current course, intervention in normal childbirth and the incidence of cesarean section will escalate without an improvement in outcomes.
JOGNN 281
Do we need a revolution in the childbearing aspects of women’s health care? I believe that we do, and I believe that nursing values are core to the cause. Those values include belief in childbearing as health and well-being, health promotion for women and their children, the fostering of family growth and psychosocial development, nonintervention in normal processes, and advocacy for women and children within and outside of the system. If nothing changes soon in our system, we could see a 50% cesarean section rate in the United States, a rate that some physicians believe is totally acceptable and even desirable.
282 JOGNN
Nurses are the largest group of health care providers. Will we remain silent and apathetic? Can we and should we not act to change this course? Nancy K. Lowe Editor REFERENCE Strong, T. H. (2000). Expecting trouble: The myth of prenatal care in America. New York: New York University Press.
Volume 32, Number 3