Context

The need for birth advocacy is based on the knowledge that current standard practice in American maternity care is not evidence-based and often denies the right to informed consent. During labor and childbirth, women are often (subtly or not-so-subtly) encouraged to act in ways that have not been proven the safest or most effective in medical research. For example, according to Henci Goer (1995), in such cases medical evidence may be "solidly, often unequivocally, against whatever 'the doctor said,' without access to that evidence the pregnant woman is quite reasonably going to believe her doctor, who she presumes is the expert" (p. 1). The entire childbirth experience, then, becomes one of myth propagated by those who should know better, in their own interest based on fear, time, tradition, or antiquated training practices. As a result, women come to believe that they are in danger during their birth, but helpless to have any power over the decisions that govern their care.

One of the most common myths surrounding women in childbirth involves the cesarean section procedure. This life-saving procedure is surrounded by fear, with many myths concerning its use--namely, that obstetricians only perform the procedure when it is medically necessary and that the procedure is necessary in the 30% of births where it is performed (Goer, 1995; CIMS, 2010). In fact, there are many misunderstandings about cesarean section, including increased risks for both mother and baby, maternal-infant attachment, and future pregnancies (CIMS, 2010). Goer (1995) reports that many cases of cesarean section are due to factors unrelated to medical indication, such as obstetric management of labor, provider philosophy, convenience, the patient's socioeconomic status, and fear of litigation, among others. Even more worrisome, this procedure, which is purported to prevent morbidity and mortality, actually causes more problems than it solves at such high rates; evidence and education have not changed these practices, either (Goer, 1995).

Cesarean section is major abdominal surgery that can be the culmination of a cascading sequence of medical interventions (many of which are medically unnecessary) during the labors of women under the care of medically aggressive practitioners--this is known as obstetric management. As alluded to by Goer (1995), socioeconomic status (SES) has an effect on this process, but not in ways that are usually seen in American culture. Since there are profit motives and need for streamlined service in healthcare, the women who hold high-priced insurance plans often hire high-risk obstetricians to oversee their labors, which makes waiting for nature a long (and therefore, expensive) process. To streamline the process, drugs are used to start or speed up labor according to convenient schedules and to provide comfort for women in understaffed labor wards. Electronic fetal monitoring, which has never been shown to improve outcomes (Goer, 1995), is used to allow nurses to monitor women from one central location. Since drugs and monitoring interfere with the natural progress of a woman's labor, women of higher SES are often found facing an authoritative obstetrician who describes a potentially dangerous situation if labor continues for a longer period of time. Since her labor may not be progressing well or her fetus may be in distress due to the introduction of drugs, such women will gladly heed the doctor's warning and proceed with a "necessary" procedure that will save them from unknown consequences of such a long and arduous journey. Meanwhile, their well-paid doctor will complete a fast and relatively easy procedure that will assure a good night's rest, and freedom from litigation from failing to do everything they could to save the unborn child.

Interestingly, women of a lower socioeconomic status do not often suffer such a fate. When it comes to the birth itself, such women are often in the care of midwives who cost less and who are trained to wait for nature to proceed. Since they are not billing an expensive insurance policy, drugs and expensive procedures are less likely to be introduced, and in a freestanding birth center or homebirth, they are simply unavailable. Women with lower means, therefore, may not experience the disadvantage of a lucrative insurance policy--and here we see the irony.

This social change project will seek to develop a framework to continue to inform women of the realities of obstetric management and lack of evidence-based care, particularly in the hospital birth setting. This project will build upon the work that is being done by organizations such as the Coalition for Improving Maternity Services (CIMS; www.motherfriendly.org) and Birth Network National (BNN; www.birthnetwork.org), among others.

References:

Coalition for Improving Maternity Services (CIMS) (2010). The Risks of Cesarean Section: A Coalition for Improving Maternity Services Fact Sheet. Retrieved 10/5/10 from http://www.motherfriendly.org/pdf/TheRisksofCesareanSectionFebruary2010.pdf.

Goer, H. (1995). Obstetric Myths Versus Research Realities: A Guide to the Medical Literature. Westport, CT: Bergin & Garvey.