April 22, 2009

An Essay on the Factory Model of Childbirth

Obstetrician/gynecologist Lauren Plante has a remarkable essay in the International Journal of Feminist Approaches to Bioethics in which she condemns the rising cesarean rate and compares current U.S. childbirth practices to the industrial revolution.

Critical of the drive to standardize and medicalize obstetrics, a phenomenon that is reducing choices within hospital settings for childbearing women, she writes:

…despite the implied promise of safety if all the rules are followed — ID bracelets, intravenous lines, electronic fetal monitoring — labor may follow an unpredictable path. The definition of  ‘normal’ becomes ever narrower, and toleration of deviance ever lower. The final stage of this philosophy takes the process of birth away from the woman entirely and turns it into a surgical procedure performed by the doctor. Childbirth becomes a manufactured experience, shorn of any real risk or real power, one in which the woman is so far alienated from the capabilities of her body that she is only a package on an operating table for a professional to open.

Plante notes that while the “choice” may be available to have a “maternal request” cesarean (something that does not appear to happen in demonstrably high numbers), this does not equate to increased real choice or autonomy for women.

In the US, we have heard arguments that women are entitled to autonomy in making their birth choices, and that therefore it is ethical to perform cesarean for no reason other than maternal request. Curiously, this vaunted autonomy stops at the door of the labor room. Women are implicitly allowed, or encouraged, to make only those choices which increase the power of the physician and which decrease their own.

Plante explores some possible reasons for the narrowing of women’s choices.

The drive toward fewer delivery options appears at first glance to be supported by upper-middle-class women, who have the least number of social and economic obstacles to autonomy.  In fact, cynical staff at hospitals delivering large numbers of well-insured upper-middle- class women often refer to their institutions as baby factories: these are the places in which cesarean rates are highest. It is, after all, a paradox: women with higher incomes, higher levels of education, and commercial insurance have higher rates of cesarean delivery. If cesarean is a response to any perceived risk, why would women at statistically lower risk of a poor outcome have higher cesarean delivery rates? New Jersey has the highest cesarean rate among states, but no lower levels of maternal or perinatal mortality. What it does have, however, is the highest median household income.

Plante notes that a “new normal” has been created:

…seduced by the promise of pain-free, risk-free childbirth, women and their doctors are driving the cesarean rate ever higher. Rates approaching—or exceeding– fifty percent are now seen in some hospitals. This is the normalization of deviance. This is the new normal.

She describes what a full spectrum of childbirth choices entails:

Women can give birth at home unaided; at home with family or with trained assistance; in a birth center, either freestanding or hospital-based; in the hospital delivery room with trained assistance; or in the operating room where they are acted upon.

Then she remarks:

The American College of  Obstetricians and Gynecologists calumniates not only women who want a home birth but anyone who advocates leaving that option open. Once in the hospital, women who might like to exercise their right to self-determination by choosing vaginal birth after cesarean, or vaginal breech delivery, will have a hard time of it. Is it not the opposite of autonomy to support only those choices which increase the woman’s reliance upon the physician?

Plante includes a sober look at the challenges we face as we try to restore choices in childbirth:

The paradox is this: women wish to be treated as individuals, and assert for themselves a wish to exert control, yet in the commodification and industrialization of childbirth they are so much more likely to be treated as units of production. I know of one large community hospital revamping their labor floor and planning for a 50% cesarean delivery rate: and just as we learned in the 1989 movie, Field of Dreams, if you build it, they will come. The staffing and scheduling patterns for a 50% cesarean rate, as well as administration plans for hospital length of stay, can’t be turned on a dime. Hospital administrations like predictability, in patient patterns, patient care pathways, and everything else. If we normalize this industrialized approach to childbirth, we are likely to be stuck in it for a very long time indeed—and we can’t look to the medical profession to correct it.

Her conclusion is shared by those of us at Our Bodies Ourselves:

We must clearly understand that real autonomy does not mean cesarean on request, but instead a spectrum of birth options that honor women’s authentic choices. Real autonomy also means, to borrow a sentiment from Gandhi, that women should bring forth the change they wish to see in the world.

The full article is available online (for a fee).

Plante, an ob/gyn at the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology at Thomas Jefferson University, has written a number of other articles supportive of choice in childbirth.

For more information on how to preserve women’s choices in childbirth, see the OBOS statement Choices in Childbirth, now signed by more than 400 clinicians and educators in the maternal and child health field.

Citation: Plante, L. Mommy, What Did You Do in the Industrial Revolution? Meditations on the Rising Cesarean Rate. The International Journal of Feminist Approaches to Bioethics. 2009 Spring;2(1):140-147.


7 Responses to “An Essay on the Factory Model of Childbirth”

  1. Trisha Says:

    Thank you for the continuing coverage regarding the current trends in birthing/labor. I am encouraged by the studies and numbers that show the true picture of what women must endure around the country. Although the numbers are grim, I have hope that with education our country will turn itself onto a healthier path.

  2. liberality Says:

    Although doctors have been known to say they are just more cautious because they might get sued for malpractice, it is really just the profit motive that is involved. They make money every step of the way and women will continue to be victimized (chopped upon) until the profit motive is taken out of the equation for good.

  3. Sheila Says:

    The staffing and scheduling patterns for a 50% cesarean rate, as well as administration plans for hospital length of stay, can’t be turned on a dime…If we normalize this industrialized approach to childbirth, we are likely to be stuck in it for a very long time indeed..

    I just threw up in my mouth a little.

    Please remember that Choices in Childbirth, an advocacy org in NYC, just released the national version of their city guides to a healthy birth. These free guides can help women become educated consumers before they step into the hospital. http://www.choicesinchildbirth.org/

    Thanks, Rachel, for your terrific eye on maternity care issues.

  4. Jill--Unnecesarean Says:

    “Is it not the opposite of autonomy to support only those choices which increase the woman’s reliance upon the physician?”

    Wow. That says it all.

  5. mrs spock Says:

    When I worked L & D, I found that most OBs had jam-packed schedules that included birth coverage, routine outpatient surgeries, rounds, and office hours. There was enormous pressure on we nurses to “get ‘em laboring, get ‘em delivered, and get ‘em out of there” in order to stick to those schedules as much as possible. The tone of a unit is set by the physicians who work there, and the hospital administrators that refuse to provide 1:1 nursing care throughout a labor to “control costs”, at the same time they are building new wings. There is a huge need to respect the individual timing of birth. What is so hard about having a “lazy day” of being scheduled at the hospital for any births, and refusing to have procedures scheduled that day as well?

  6. Lisa Says:

    The nonsense about prenatal care drives me crazy. I’m pregnant. I eat well. I get exercise. I try hard not to stress out (even though I’m having a c-section I don’t want, and it causes me a lot of anxiety). I try hard to get enough sleep. I don’t drink or smoke or sit in hot tubs, etc. etc. THAT is prenatal care. Going in once a month to stand on a scale, have my stomach measured, pee in a cup and have my blood pressure checked is prenatal *monitoring*. It may have its place, and it can certainly help identify some serious problems before they become life threatening…but it’s not “care”…not at all. I do my own prenatal care.

  7. JayBee Says:

    I am deeply alarmed and disappointed by the opinions of mainstream feminists when it comes to cesarean sections. I identify as a feminist and I completely understand the concern regarding forced cesarean sections and unwanted interventions. I also understand the need for a woman’s right to informed refusal when it comes to childbirth interventions. However, I cannot understand the vehemence with which feminists have continuously rejected the idea of cesareans on maternal request.
    The number of women who opt for a cesarean by choice might be small, but these women are real and they do exist (I am an example). By refusing to acknowledge our existence and by judging and invalidating our choice, the feminist movement is alienating us.

    I do understand that essentially, any procedure that requires dependence on a health care professional will never afford complete autonomy, given that health care professionals have free will of their own which might conflict with a woman’s demands. But can’t we say the same for abortion? The biggest barrier to abortion is the lack of willing, safe providers. So why don’t we start encouraging coat hanger abortions and do-it-yourself abortion kits? Wouldn’t that afford women more autonomy than relying on a doctor to perform the procedure?

    Reliance on doctors is a reality of any healthcare system and we have work within those limitations. Empowerment and autonomy in this context will mean making an informed choice and having the doctor respect it instead of overriding and ignoring it.

    And that choice can include an elective cesarean section! Yes, a cesarean has risks. But so does a vaginal birth. It is the woman’s choice alone to decide how she wants to give birth and which risks she would rather take.

    Your quote:

    “We must clearly understand that real autonomy does not mean cesarean on request, but instead a spectrum of birth options that honor women’s authentic choices.”

    And this spectrum of childbirth options INCLUDES AN CESAREAN ON REQUEST.
    If someone forced me to give birth vaginally when I certainly don’t want to, THAT would be disempowering for me.

    I feel strongly that home births with licensed midwives and VBACs should be more widely available for women in the USA. I completely agree that there should be a spectrum of choices. But what you don’t understand, is that the spectrum of choices that you speak of, for some women will include a cesarean section as well.

    Contrary to your assumption there are serious barriers that women face in accessing a cesarean by choice, with many providers refusing the request outright. If you truly supported a comprehensive set of childbirth choices as a woman’s right, then the rights of women who choose cesareans would feature equally on your agenda. Instead, you insult and alienate us by refusing to acknowledge our existence and by refusing to respect our choice.

    Let me educate you about a condition called “tokophobia” which 1 in 6 women in the UK suffer from (we don’t yet have stats for USA). It is a debilitating fear of vaginal birth and NO it isn’t caused by misinformation and TV shows. It is often caused by abuse or PTSD from rape or a prior birth experience. Do you honestly think that forcing these women to give birth vaginally will ‘empower’ them? Why don’t the rights of tokophobic women feature anywhere on your agenda? Research has repeatedly shown that these women do better with planned cesareans than forced vaginal births. Why not spend some time fighting their corner if you really are a proponent of choice?

    My feminism is not like yours- it isn’t about telling women how to give birth or judging their choices when they don’t agree with your own. Because that won’t be feminism- that would be patriarchy. My feminism subscribes to the thought that a woman’s vagina and uterus is her business and she should be able to do whatever she wants with it and to it- that includes a cesarean section.

    As a last thought: if you are really a proponent of informed consent, then perhaps you will devote some part of this website to detailing the benefits of cesareans as well instead of only focusing on the negatives.

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