Tuesday, March 25, 2008

The Business of Being Born

I've never mentioned it on this blog since I don't often use it for personal posting, so for those who are unaware: my wife is pregnant and I'll be a father on April 25. We're both terribly excited — me foolishly confident, her nervously thrilled — and it is particularly fun because we don't know the baby's sex, so there will be a bit of a surprise at the end. Or should I say the beginning? Or something. In any case, the entire experience so far has been awesome, though I'm not the one with a creature in my belly.

I'm obviously paying some above-average level of attention to pregnancy and childbirth-related material when I come across it, and in particular I noticed a post on Science-Based Medicine by Harriet Hall reviewing the documentary The Business of Being Born. If you haven't heard of this film, it is critical of the alleged medicalization of childbirth, and promotes unmedicated home birthing rather than what is at this point the traditional hospital birth.

I don't have a horse in the "natural" versus "medical" race. What my wife is doing or not doing is her own business for her own reasons, and I honestly support anyone in any choice they make regarding that topic. I neither think anesthesia and c-sections are destroying lives and families, nor that doing it the old-fashioned way is stupid and reckless. Your body, your choice. There are benefits and risks all around, and one person may place a higher premium on one benefit than another places on the risk associated with it.

First, I saw this:
They kept harping on empowerment, and made it seem like a woman had to endure great pain so she could feel she’d accomplished something so wonderful that now she knew she could do anything. This is unnecessary. We can provide good pain relief during labor with minimal risk to the baby, and I see no reason to have women screaming “I can’t stand this!” with a midwife telling her she has to tough it out. Despite their protestations, I wasn’t convinced that the midwives’ attitude was kinder to their patients than my obstetricians who made my labors and deliveries almost pain-free.
Again, whether or not some women find pain empowering is their own business. What struck me was the comparison between midwife and doctor being made not as one of natural versus medical, but of kindness. One area that I find myself disagreeing with the pro-natural faction on is the idea that giving unnecessary anesthetic, with admittedly minimal risks, is somehow inherently bad. While I am generally sympathetic to the spirit of the homebirth cause, it is never because of any perceived superiority of the "natural" way. Fetishization of nature just doesn't appeal to me. The impulse to "medicalize" birth, for good or ill, is based on the perfectly reasonable goal of reducing suffering. If that impulse is too often acted on, well, that is the unfortunate result of a capitalist economy that treats healthcare (and adjudication) like a business. Any business, including that of being born, must have insurance, and lawsuits drive insurance rates so high that, as Hall puts it, "No doctor wants to be on that witness stand explaining why he didn’t do an ultrasound or use a fetal monitor."

Ultimately, though, I wanted to point to this:
The movie dealt more with feelings and opinions, and didn’t talk much about evidence from controlled studies. There are many unanswered questions about how to achieve the best outcomes for babies and mothers. If you don’t think doctors are constantly trying to reassess and improve their methods, just read any obstetric journal. When I was an intern, episiotomies were standard practice. I was chastised for not doing an episiotomy on one patient, a multigravida who begged me not to do one and who really didn’t need one. Now routine episiotomies are no longer recommended. Not because women complained, but because controlled scientific studies re-examined the outcomes. We stopped shaving the perineum and giving enemas a long time ago. Maybe we will stop delivering our patients in a supine position – but only when evidence clearly shows a safer option.
What's important here is not the frequency of medical intervention, which Hall admits is inflated. What this paragraph exemplifies is the importance of science doing what science does best. When literally dealing with matters of life and death, the default course of action must be based on what will most likely result in the best outcome for those involved. People are autonomous, and may surely reject the default course of action. But any critique of that course of action itself, rather than one's personal decision to follow it, has to be mounted on the basis that there is a flaw in the reasoning that led to it. Even if it were the case that most women choose to reject them, if the evidence suggests certain procedures be followed, those should be the procedures that are recommended. Research can be wrong, but that is how science works: by continuously challenging theories and seeking to disprove them. Ironically, in the New York Times review of the film (I haven't seen it myself) it mentions that a history of now-abandoned medical interventions that proved harmful is described, presented as an argument against them in general. But that is in fact an argument for how science is self-correcting: when things don't work, they are discarded or replace by things that work better. The chief difference between "natural" and "medical" is that "medical" has the potential to improve with time as new things are learned.

The opposition to medical birth is like most oppositions to technological developments in that there are legitimate causes for concern and education (if not necessarily for full-blown opposition), but the majority of the opposition that I've been exposed to don't challenge the developments on those terms. If there are statistically significant reasons to suppose that routine medical interventions are dangerous enough for them to be made non-routine, present those reasons. But arguments based on subjective emotions like empowerment, or even on the attitude of the professionals involved, are ones that by nature can only appeal to individuals. They cannot be the basis for altering systems in a field that must seek first to maximize health rather than happiness. Ideally the two would go hand in hand, but those are decisions that people must make for themselves.

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