This book review is reposted with permission from The Science & Sensibility Blog from Lamaze International. 

The next vital revolution in maternity care may well be the overhaul and redesign of the birthplace.
In “Birth Territory and Midwifery Guardianship,” writers describe the
relationship of the birth setting to the emotional-physiological state
of laboring women.  In this regard, ‘Birth Territory’ encompasses not
only physical space, but also personal relationships, power structures,
and access to knowledge.

Maternity care as we know it has evolved along divergent roads: the
midwifery, expectant-management ‘natural’ approach; and the obstetric,
interventive, ‘actively-managed’  model.  Midwifery care is a
woman-centered approach; it relies on relationships which support
women’s natural abilities to give birth. The obstetric model, designed
by and for doctors, operates on  principles of academic exclusiveness, described by Louis Menand:

It is a self-governing and largely closed community of
practitioners who have an almost absolute power to determine the
standards for entry, promotion, and dismissal in their fields. The
discipline relies on the principle of disinterestedness, according to
which the production of new knowledge is regulated by measuring it
against existing scholarship through a process of peer review, rather
than by the extent to which it meets the needs of interests external to
the field…

[T]he most important function of the system is not the production of
knowledge. It is the reproduction of the system. To put it another way,
the most important function of the system, both for purposes of its
continued survival and for purposes of controlling the market for its
products, is the production of the producers

Academic obstetrics is impervious to knowledge and input from other
disciplines; it exists in a closed, parallel world; it exists not for
the purpose of taking care of women, but for the purpose of taking care
of itself. The chief concern of any obstetrical unit is the viability
of the department, of the program; if outcomes figure into that, well
and good; but women’s actual experiences and opinions, because they are
not part of the published literature, are of no concern.  Small wonder,
then, that so little thought has been given to the environment of
hospital birth, other than for the convenience of hospital
practitioners.

Meanwhile, midwives have continually concerned themselves with what the authors of Birth Territory and Midwifery Guardianship
call ‘the elements in the geography, architecture, and metaphysics of
birth spaces to which women will consciously and unconsciously respond.’

In their book, the writers – midwives, and an architect of birth
spaces – asked women what they wanted in their birthing places.
Responses included:

• A pleasant place to walk
• Sufficient pillows, floor mats, bean bags
• Availability of snacks and drinks
• En suite toilet, shower, bath; a birth pool
• Comfortable accommodations for companions and families
• A homey, non-clinical environment
• Control over temperature
• Control over brightness of light
• Privacy; not being overheard by others
• Not being watched
• Control over who comes into the room

 

The majority of birthing women surveyed did not have these options.
The authors argue that lack of a woman-centered birthing environment,
and little control over that environment, are reasons for high rates of
obstetric intervention. Labor and birth are whole-being experiences;
the autonomic nervous system will shut the whole process down if the
woman perceives stress, threat, or danger.  In typical hospital
settings, with shift changes, strangers walking in and out, bright
lights, confinement to bed and monitor, and restricted oral intake, it
is no wonder that the process doesn’t go as smoothly as it could.
“Failure to progress” – the diagnostic reason given for 50% or more
cesareans – is largely an environmental issue.

 

Birth territory is also defined by relationships; yet medical
obstetrics has constantly worked to sequester birthing women away from
all sources of comfort, including non-medical practitioners; only in
the 1960s were fathers and partners invited into hospital delivery
rooms; and only lately, with the advent of doula practices, has
one-to-one attendance – the cornerstone of midwifery – become
recognized as a significant predictor of good outcome.  But few
hospital practices are relationship-centered. Prenatal visits are
fifteen or twenty minutes long, mainly focused on weight gain and lab
work. There’s usually a team of doctors and midwives; the person who’s
available at the time of one’s birth is not a matter of preference, but
of the practice’s call schedule.

Obstetrics is statistics-based, not relationship-based;
obstetricians know that the average due date is 40 weeks from the last
menstrual period; they know that if a woman is laboring (in a hospital)
with waters broken for over 12 hours, her chance of infection
skyrockets; they know that the Friedman labor curve shows that the
average progression of dilation is one centimeter per hour; they know
that the average pushing phase is under two hours. They are under
pressure to make everyone fit those statistical norms, and they have
the tools to make it so; and that’s what they do.

The best birth territory requires the best attendants. Fahy and her
coauthors argue that birth is a reflection of relationships – with
oneself, and with others; that relationships depend on love, and
spiritual development (words you will never see in any obstetrical
textbook).  In developing the best birth attendants, they see
open-heartedness as a requirement for good practice; they describe the
characteristics of a good practitioner in Buddhist terms of ‘right
relationship’: empathy; ethical behavior; self-awareness; capacity for
love. In a chapter called “Reclaiming the sacred in birth,” they
describe the conditions for nurturing ideal midwives: ‘to know and
nurture themselves within their own families and communities,’ and
emphasizes working on personal development, as well as clinical skills,
with a supervisor or professional partner. The training environment of
midwives should encourage the development of nurturing and intimate,
though professional, relationships with her clients; it is that
relationship that forms a necessary part of optimal birth territory.

The territory of obstetrics residents is largely devoid of
patient-relationship considerations; it is rather consumed with
concerns about on-call hours, clinical rotations, numbers of
procedures, and one’s place in the departmental hierarchy. The
knowledge itself is based in pathology – ‘problem-oriented’ – a
diagnostic/treatment approach that assumes there’s trouble, and goes
about finding it. This works well in the rest of medicine, which is
really about disease; but colors the teaching approach to the normal,
healthy event of childbirth.  The knowledge that’s important – taught
and practiced – is all within the limits of academic obstetrics, which
ignores, if not devalues, ‘nonscientific’ knowledge. The ‘permitted’
knowledge supports what the authors call the ‘metanarrative’ of
academic medicine: the postmodern myth that the safest and best place
to give birth is under obstetric management. Any knowledge that
counters that myth is disputed or ignored.

The history of obstetrics is also viewed differently from within the
specialty than without. The obstetricians’ view, reproduced in most
obstetrical textbooks, is the development of one intervention after
another, all by men – from forceps to vacuum extractions. The authors
present a larger-scale view:

Medicine in the late 19th and early 20th centuries was
composed almost entirely of men who shared the same power base as other
dominant males: they were white, well-educated and from economically
richer families. It was these males who owned or managed every
institution of society: the army, the church, the law, the newspapers,
the government, etc. These privileges, combined with an informal
brotherhood of dominant men, created a powerful base for the success of
the medical campaign to subordinate midwifery.

The authors describe the territory of hospital birth as disputed
ground, where the biological requirements of birthing women are at odds
with the design of institutions.  They provide ample evidence about how
the dominance of obstetricians’ needs over women’s welfare has
contaminated the culture of birth. In a wonderful section on oxytocin –
the hormone of love, bonding, social interaction, birth, and lactation
– they describe the effects of this natural hormone:

[T]he higher the level of Oxytocin, the more calm and
social the mother; thereby stress is reduced; levels of the stress
hormone cortisol drop; pain threshold is increased…  body temperature
is regulated… and heart rate and blood pressure are lowered… Women’s
response to stess may not be the automatic ‘fight or flight’ response
seen in men, but is more likely to be the ‘calm and connection’ system
integrated by Oxytocin.

These oxytocin-mediated events are most necessary during labor and
birth; they are best enabled if the birth territory includes
oxytocin-positive relationships.  Oxytocin is thought to be the source
of women’s power to endure labor and birth; and its pathways are the
most likely to be deranged by the institutional birth environment – the
lack of oxytocin-facilitating relationships of trust and love, as well
as the routine administration of oxytocin-blocking drugs such as
epidurals and Pitocin – a form of artificial oxytocin that has never
been proven safe in long-term outcome studies. Blocking oxytocin,
whether through fear, disturbance, or Pitocin, leads to disrupted or
painfully difficult labors.  These authors suggest that disruption of
normal oxytocin pathways, and supplanting them with intrapartum Pitocin
exposure, may also result in serious mental health problems on the
love-and-relationship axis: schizophrenia, autism, drug dependency,
suicidal tendencies, and antisocial criminal disorders. It’s not just
the mother who’s affected by the birth territory.

But what is the best birth environment?  In a chapter called
“Mindbodyspririt architecture: Creating birth space,” architect Bianca
Lepori describes her designs for hospital-based birth rooms that are
meant to enhance, not counteract, women’s abilities to give birth. She
created suites of rooms with “Space and freedom to move; to be able to
move to the dance of labor; to respond to the inner movements of the
baby; to walk, kneel, stretch, lie down, lean, squat, stand, and be
still.” The rooms have “Soft and yielding surfaces; or firm and
supportive surfaces; different textures; the right temperature; soft
curves; darkness or dim light.” A birthing woman can be ‘immersed in
water, flowing or still; respected, safe, protected, and loved.” 
Access to the suite is through an antechamber; the bed is farthest away
from the lockable door, and not visible from it, so that privacy is
respected.

Lepori’s birth architecture reproduces the comforts of home. There
is access to the outdoors, and private walking places. There are birth
stools, exercise balls, bean bags, hooks for hammocks or ropes for
stretching. Tubs and beds are large and accessible from both sides.
There are accommodations for families. There are comfortable chairs for
nursing. Medical equipment – supplies, oxygen – is tucked behind a
screen or put in a closet. A refrigerator and light cooking equipment
is available. This ‘birth territory’ certainly outshines the typical
hospital OB floor; though it begs the question: Why not just stay home?

The answer, of course, is that, for those four to ten percent of
births that truly need intervention, the OR is right there. It’s better
not to have to transport a woman whose labor has turned complicated; it
makes sense – for many – to have all the birth territory under one roof.

This birthing-suite design indeed takes into account the
all-encompassing, body-mind-spirit event of childbirth. It honors
laboring, birthing women and families; it respects the process. It
worked well for a designated maternity hospital in New Zealand
– a facility already designed for childbearing. But most US hospitals
are multi-use facilities; and though obstetrics is among the best
money-makers for hospitals, childbirth is the only event that occurs
there that is not related to illness or trauma.

The real question is, why not remove birth completely from the pathology-centered hospital model?
Why not redesign birth territory to maximize best outcomes, minimize
intervention, and replace the present medicalized view of birth as a
disaster waiting to happen with the more normative,
expectant-management, midwifery view? Move the whole shebang, from the
waiting room to the surgical suite, out of the hospital and back into
the community where it belongs.

Why not indeed. The major obstacle to any redesign of the territory
of birth is resistance from the field of obstetrics. The American
Congress of Obstetricians and Gynecologists (which recently changed its
name from the American College of Obstetricians and Gynecologists,
reflecting a major shift in interest from academics to politics) has a
23-member lobbying arm, “OB-GYNS for Women’s Health PAC”, which
describes itself on its web site:

Ob-Gyns for Women’s Health and Ob-Gyn PAC help elect
individuals to the U.S. House of Representatives and Senate who support
us on our most important issues. Individuals who understand the
importance of our work, who care about the future of our specialty, who
listen to our concerns, and who vote our way. In only a few short
years, Ob-Gyn PAC has helped elect ob-gyns and other physicians to the
U.S. Congress, and has become one of the largest and most influential
physician PACs in America.

Only five of the 23 members
are women; all ten of its board of directors are men. Current issues
occupying the group are “Stopping Medicare payment cuts, ensuring
performance measures work for our specialty, preserving in-office
ultrasounds” (though there are still no long-term studies on the
effects of ultrasound on the developing fetus, or on women, for that
matter); and “winning medical liability reform,” which means limiting
liability for malpractice.
Meanwhile,  the Medicaid Birth Center Reimbursement Act – Senate Bill
#S.1423 (House Bill HR 2358) – is not on the list of bills that ACOG
supports, even though this expansion of birth territory would probably
better outcomes, and certainly cost less than the hospital OB model.

The only bad thing about “Birth Territory and Midwifery Guardianship” is that obstetricians will not read it.