Long Post 11/11

In the New Yorker article “The Score,” author Atul Gawande writes about the history of child birth and obstetrics, and how a once natural phenomenon, confined to the home, became an industry, involving doctors who have standardized the practice of delivering babies. First, Gawande explains the complex process of human childbirth. Unlike other mammals, which are born mature enough to walk and reach for food, humans are born prematurely, needing great care and nourishment. The process of childbirth is the same for most women, beginning with the uterus changing in shape to a funnel, with each contraction of the body pushing the child’s head further down the funnel. The cervix softens and relaxes, widening the whole through which the baby will be pushed. The contractions soon put enough pressure to break the amniotic sac, releasing its fluid, and active labor begins with contractions occurring closer and closer to each other. The contractions soon grow stronger and push the baby out of the mother’s cervix. Gawande is quick to remind us, however, that things can go wrong in childbirth, threatening both the child and mother's lives. Risks for the mother include hemorrhage, torn placenta causing torrential bleeding, ruptured uterus, and infection. A large risk for both the child and the mother is “obstruction of labor” in which the mother has trouble or is unable to get the baby out. This could be due to a number of reasons, like the woman’s pelvis is too small, the baby arrives at the birth canal sideways, the butt comes out first getting the child’s legs stuck up on the chest, the child gets stuck because the head comes out first titled the wrong way, or the shoulders get stuck behind the mother’s pelvic bones. In these situations, risks are high, as the umbilical cord, the child’s only source of blood and oxygen will become trapped and compressed, causing asphyxiation in the worst circumstances.

Gawande explains that in past centuries, midwives and doctors began to develop ways to save children from these dangerous situations. This process of development, she explains, marked the beginning of obstetrics, which today is a highly standardized specialization in medicine. The earliest tools developed to save mothers in these dire circumstances were hooks, clamps and other pointed instruments. The number one priority was to save the mother, which sometimes allowed the doctors to kill the child in risky situations. Several other maneuvers evolved, which sought to save both lives. One such maneuver involved the invention of the forceps, an instrument shaped like salad tongs, which were used to clasp the baby’s head between the two metal blades and yank the child out. And by the early twentieth century the forceps along with many other inventions like blood transfusions, drugs that induced labor and Caesarian section were commonplace in hospitals to solve problems associated with childbirth. In addition, with all these medical advances, midwives began to disappear and childbirth moved primarily into hospitals, involving specialized physicians performing delivery.

However, Gawande points out, the switch from midwives to doctors delivering babies did not prove to be any less risky. In fact, she cites a study published in 1933 by the New York Academy of Medicine, which showed there were 2,041 maternal deaths from childbirth, with at least two-thirds of these cases having been preventable. Further, there had been no improvement in the death rates for mothers in the preceding two decades and newborn fatality rates actually increased. While doctors developed instruments to avoid problems in childbirth, they seemed to not be using them in the most effective ways. To combat these failures, higher standards and tougher training was established in the field of medicine, demanding better results. Further, Doctor Virginia Apgar created a score to assess the health of a newborn child. Since most of the problems still persisting were due to the lack of care newborn children received at birth, Apgar implemented a system to numerically grade a child’s health. An infant got two points if it was pink all over, two for crying, two for taking good, vigorous breaths, two for moving all four limbs, and two if its heart rate was over a hundred. The system proved to drive doctors to demand better results for newborns and as a result, created higher standards of care.

Gawande warns, however, that this system also created demands on doctors to deliver successfully in every case. As a result, maneuvers that in the past worked, like the use of forceps, were eliminated, since the craft was difficult to teach the thousands of training obstetricians in medical school and residency. Further, the Caesarian section, a much easier maneuver to teach students, with clear steps and standard results, became the common trend, even in circumstances when it was not necessary. The question, Gawande poses, is: is medicine a craft or an industry? If it is a craft, she says, we should focus on teaching obstetricians artisanal skills like using forceps. If it is an industry, however, we should focus on teaching doctors the most reliable methods of delivering a child. Could the thousands of obstetricians receiving training truly grasp every complex artisanal method to deliver a baby, or is it more realistic to teach one maneuver, the Caesarian section, a reliable procedure?

Throughout the article, Gawande interrupts the history of obstetrics with the story of Elizabeth Rourke, who is enduring a very long 40-hour child labor. While Rourke just wants to give natural child birth sans drugs or C-section, her difficult situation leaves her no choice. Hours pass as the pain worsens and she does not seem to be dilating any further. Despite her effort to give birth naturally, the pain becomes so bad that she demands an epidural and later agrees to C-section. While later Rourke was upset that she gave up her hopes of delivering a child without the help of medicine or forced labor, she later realized that her living, breathing and thriving daughter put all her regrets behind her. In the end, while medicine has become an industry, it seems that providing people with a safe, effective way to deliver a child, despite medicine or techniques that many be required to do so, is most important. 

In “How Childbirth Went Industrial: A Reconstruction,” Henci Goer responds to Gawande’s article, pointing out the authors contradictions, showing that new obstetric techniques do not necessarily provide better outcomes. Goer says she takes from the article the central points that “Women can have an easy, safe cesarean surgery or they can undergo difficult, dangerous labors and then have cesarean surgery” and “Modern obstetric management is the key to healthy babies and mothers.” She hopes to deconstruct this argument and first poses the question: “Has ‘fly by the seat of your pants’ obstetric management improved outcomes?” Citing many examples, Goer shows that in many cases obstetric packages offered in hospitals has not decreased infant mortality rate, but has instead increased fatality. She even shows statistics supporting this as recent as the 1990s. Goer also says that maternal fatality only decreased when doctors made training improvements, replacing their “meddling” with skill. She goes as far as pointing out that women are better off gaining care from a midwife than a doctor, since every procedure carries with it equal risks.

Goer also points out that the facts do not support Gawande’s argument that C-sections save lives. Citing multiple studies, she explains that in most cases, there are lower mortality rates associated with vaginal birth than with C-section. She says studies showing otherwise only take into account planned C-sections, in which the woman’s life is not at risk. In cases where the mother’s life is at risk, scarring, infant mortality, and bowel obstruction are common results of C-section procedures. She further cites common risks associated with C-section and not associated with vaginal birth, which can harm the both the mother and infant and lead to future reproductive problems. Standardizing medical care, for Goer, allows doctors to intervene with surgical deliveries, even when they are unnecessary, subjecting the mother and child to many risks. Some of the reasons for unnecessary C-section? Excess pain, convenience, and certainty of delivery.

In addition, Goer calls Rourke “foolish.” Goer argues that while we can’t know that Rourke's C-section could have been avoided, there are several factors accounting for why she finally underwent the procedure. The primary reason, Goer explains, is that her obstetrician did not provide full supportive care. She did not have a doula, which would have provided her with ways of coping with pain, shifting the baby’s body inside her and opening up possibilities to breast feed post delivery. Rourke also had unnecessary anxiety as a result of her doctor’s “anything can happen at any moment” philosophy, which could have negatively affected her ability to push the child out. Moreover, Rourke’s pregnancy was treated as abnormal and the mother was offered drugs to speed up her delivery, even though she was experiencing very normal contractions. These negative messages could certainly have had negative effects on Rourke’s labor. Further, each drug and procedure introduced into the labor caused other problems that required more drugs and treatment. These things, Goer suggests, could have been avoided by treating the birth as normal and having a positive attitude for both the doctor’s and the mother’s sake.

While I think Goer makes a strong argument that attitude has a strong role in delivering children, I think that she ignores the blatant facts: infant and maternal mortality has decreased by introducing obstetrics and standardized care for childbirth. As Gawande notes, if our number one priority is to deliver as many health babies as possible while protecting the mothers’ lives, the introduction of drugs and surgical procedures should be seen as necessary. We cannot rely on risky maneuvers that not every doctor can grasp, but we can certainly change our attitudes towards long or painful labors, eliminating the number of unnecessary surgical deliveries, which can end in risk.

Gawande, Atul. "The Score." The New Yorker, 9 October 2006.
Goer, Henci. "How Childbirth Went Industrial: A Deconstruction." Web Exclusive, 27 November 2006.