Excerpts from "Confessions of a Dissident"
by Marsden Wagner, MD
Following are excerpts from Chapter 14 of
Robbie Davis-Floyd's book "Childbirth and
Authoritative Knowledge: Cross-Cultural Perspectives".
Go here
for the full text.
Note that titles are supplied by LLM, BirthLove site editor, and do
not appear in the original text.
Doctors didn't want it known that midwives
were saving lives
"While in California I had heard of an
amazing experiment in a rural town which recruited
two midwives (at that time such midwifery was
illegal in California) to work in the public
hospital. During the three years in which they
handled most of the births, the incidence of
prematurity dropped almost by half, and neonatal
mortality dropped from 23.9 per thousand to
10.3 per thousand- less than half of what it
had been before the midwives arrived. This success
was followed, nonetheless, by a medical backlash--
the program was discontinued, and the perinatal
mortality rates returned to its previously high
levels (Levy et al. 1971). But, as an American,
I knew essentially nothing about midwifery and,
while curious about this experiment, I had failed
to see its importance."
Cheated out of his own births
"I had also experienced the births of
my own four children. The obstetricians were
so nice to me that it was not until the fourth
birth that I realized that I had been patronized
and denied the opportunity to be present at
the births. So I asked the obstetrician at the
UCLA hospital where I was on staff to allow
me to be present, and he said no. To my everlasting
chagrin, I complied. While I had questioned
some of the workings of the maternity system,
I had not questioned its fundamental authority."
"...only approximately 10% of all
routine obstetrical procedures had an adequate
scientific basis."
"...I decided to form a perinatal study
group to work with me in evaluating maternity
and neonatal services in Europe...I started
by including only obstetrics and neonatology
in the study group, but as we worked I realized
we needed other viewpoints, and so I gradually
added nursing, midwifery, social science, and
finally consumers. We started by reviewing the
scientific literature and soon came across the
gap between science and practice. To confirm
this observation, we recruited a scientist not
in the group to survey routine obstetrical procedures.
We were shocked when the report from this scientist
concluded that only approximately 10% of all
routine obstetrical procedures had an adequate
scientific basis (Fraser 1983).
The group decided to do cross-national surveys
of present maternity care practices. We found
that...there was little or no monitoring of
maternity services. Our surveys showed great
variation in obstetrical practices with little
or no relationship to perinatal outcome (Bergsjo
et al. 1983). The variation was among countries,
within countries, within districts, between
hospitals. In other words, obstetrics reflected
the opinions and wishes of the Chief of Obstetrics
in a given hospital. The variations also reflected
custom: every continental European country preferred
the vacuum extractor, while Britain and every
former British colony preferred forceps. Such
findings went a long way to disenchant me not
only with "authoritative" knowledge
but with authoritative practice (AP) as well."
The homebirth that changed his life
"After asking the pregnant woman for
permission, [the midwife] took me along to a
prenatal visit so I would not be a stranger
at the time of birth. Already I was beginning
to see that this was very different from the
obstetrical approach, that the medical and social
models of birth were completely distinct. It
would be impossible for me to exaggerate the
influence of my experience with homebirth on
my opinion of obstetrical authoritative knowledge
and practice. Home birth is as different from
hospital birth as night is from day. Trying
to describe home birth is like trying to describe
sexual intercourse- you can give the outlines,
but you can never adequately describe the personal
dynamics, feelings, ambience."
Holland: a thorn in OBs' sides
"The fact that the Netherlands has never
had a home birth rate under 30% and has birth
outcomes equivalent to or better than neighboring
countries is a huge thorn in the side of obstetrical
authoritative knowledge."
OBs are unwilling to change their practices
"We soon learned that when it came to
questions about control (including home birth
and midwifery) and technology, obstetricians
were adamant and unwilling to consider change,
even in the face of compelling evidence."
Why medicalized birth doesn't work
"By medicalizing birth, i.e. separating
a woman from her own environment and surrounding
her with strange people using strange machines
to do strange things to her in an effort to
assist her (and much or all of this may sometimes
be necessary), the woman's state of mind and
body is so altered that her way of carrying
through this intimate act must equally be altered.
The result is that it is no longer possible
to know what births must have been like before
these manipulations. Most health care providers
no longer know what non-medicalized birth is.
This is an overwhelmingly important issue."
Modern obstetrical knowledge is based on how
women give birth in medical cages
"Almost all women in most developed countries
in Europe give birth in hospital, leaving the
providers of the birth services with no genuine
yardstick against which to measure their care.
What is the range for length of safe labor?
What is the true [i.e. non-iatrogenic- doctor-caused]
incidence of respiratory distress syndrome in
newborn babies? What is the incidence of tears
of the tissues surrounding the vaginal opening
if the tissues are not first cut? What is the
incidence of depression in women after "non-medicalized"
birth? The answer to all these, and many more,
questions is the same: no one knows. The entire
modern obstetric and neonatological literature
is essentially based on observations of medicalized
birth. [WHO 1985:85]"
What comes first: furthering public health,
or furthering one's profession?
"Furthermore, as a group they often focus
on concerns irrelevant to people's health. I
remember being somewhat taken aback when I first
realized as a young doctor that the American
Academy of Pediatrics, of which I was a member,
had two goals: to advance the health of children,
and to advance the wellbeing of pediatricians.
In this second role, the Academy functioned
like a labor union, and if the two goals came
into conflict, as sometimes happened, the second
goal almost always took precedence. It became
more and more clear that there were many determinants
of medical practice, some having nothing at
all to do with health. This realization about
the nature of doctors and what makes them tick
was another revelation for me that became part
of the paradigm shift I was making."
Money makes the machine run
"I saw that commercial pressures are ever-present.
For example, the International Federation of
Obstetrics and Gynecology organized a meeting
to make recommendations for the use of the electronic
fetal monitor. The travel and local costs of
the participants were paid for by the industries
making the monitors, and in order to get into
the room, it was necessary to pass through a
large commercial display of monitors. When I
wrote to the obstetrician who had organized
the meeting, expressing my concern for possible
conflict of interest, he wrote back, indignantly
assuring me that he was at all times "objective."
My concern remained, since the meeting recommended
routine electronic monitoring of all births,
although the scientific literature did not and
does not justify such a recommendation (Leveno
et al. 1986, Prentice and Lind 1987; see Goer
1995:131-153 for summaries of 39 medical studies
relevant to EFM)."
Doctors find it very difficult to admit fault;
therefore change is just as difficult
"Custom and habits are determinants of
practice; how else to explain that for operative
vaginal birth, forceps are used in Britain and
her former colonies while the rest of the world
uses the vacuum extractor? Convenience is the
best explanation for the fact that induction
of labor is so common in many countries that
there are statistically significantly fewer
births on weekends and at night. Willingness
to change involves willingness to admit that
you have been doing it wrong. This may help
to explain why most obstetricians still prefer
the woman to deliver on her back with her legs
up during birth even though we have known for
decades that, scientifically speaking, that
is the worst possible position.
About "doctor-bashing"
"When I speak about such non-medical determinants
of practice, I am told I am "doctor-bashing."
Any criticism whatsoever of physicans is called
"doctor-bashing." Whence comes this
term? I can criticize my auto mechanic and I
am not "bashing." (Note the paucity
of doctor jokes, most of which are about how
godlike doctors are.)"
Doctors as societal gods
"From long personal experience I can assure
the reader that being called Doctor morning,
noon, and night has a profound effect on one's
self-image. For some years now I have carried
out an interesting experiment. I have tried
to excise 'Doctor' from my name- from everyday
conversation, from letters, from participant
labels at meetings, etc. It is difficult to
do so. If I say to someone, 'Please don't call
me Doctor, as that is not what my mother named
me,' they are confused and embarrassed, and
often I get the impression they think I am a
crackpot.
But the most difficult problem, sad to say,
has been with myself. Normally I find it a relief
not to be called Doctor, but from time to time
I am sorely tempted. When I am trying to get
action from someone, all I have to do is use
'Doctor' and things happen. This is especially
true if I am dealing with a hospital or physician's
office where the use of "Doctor" immediately
creates an atmosphere of subservience around
me. Small wonder that "Doctors" soon
come to believe that they and their authoritatve
knowledge and authoritative practic eare beyond
reproach."
Making the "patient" an equal
"Why do doctors have 'patients'? Other
professionals have "clients," something
very different. Clients hire professionals to
perform services for them- they call the shots.
But turning a person into a 'patient'redefines
that person as someone who is sick and under
a doctor's supervision- automatically a dependent
position. Because pregnancy and birth are not
illnesses, I have worked hard the past ten years
not to use the word "patient" in maternity
care. For example, in Having a Baby in Europe,
the word 'patient' never appears. When speaking
or writing about maternity care, health professionals
often use 'mother,' again an unfortunate term
since it refers only to the woman in her role
as a mother and not to the whole person. So
I try to use 'woman.' Several years ago I finally
convinced WHO in Europe to change "'Maternal
and Child Health'(used everywhere in the world)
to 'Women's and Children's Health.'"
No whistle-blowers, please
"Another mechanism to protect medical
authoritative knowledge and practice is, as
we have seen, for all doctors to join together
into an extremely powerful private club known
as the medical profession. I have been a member
of this club since I took the Hippocratic oath
on the day of my graduation from medical school.
One central rule of this club is never to criticize
other doctors or medical authoritatve knowledge
or authoritative practice in public. As early
as medical school, we were told that the doctor
who does so is a traitor to the profession."
What it took to make midwifery legal in Ontario,
Canada
"One day about ten years ago I received
a call from a criminal lawyer in Toronto, Canada.
She was desperate because, for the first time
in her career, she had a case involving health
professionals and was having great difficulty
finding any doctor willing to testify in court.
Her clients were two midwives who had attended
a homebirth after which the baby died. Midwifery
had been illegal for the last 100 years in every
Canadian province and, with this death, the
local obstetricians went to the coroner demanding
an inquest. Several obstetricians had agreed
to testify for the prosecution at the inquest
but, although the lawyer had found several doctors
who told her, 'off the record,' that the midwives
had done nothing wrong and were not culpable,
they would not testify to this in a coutroom
open to the public.
I went to Toronto and in my testimony at the
coroner's inquest talked about midwifery. The
members of the jury knew nothing about midwifery
but were open, and listened while I talked about
the central role of midwives in maternity care
in the rest of the world. I was simply giving
the midwifery AK, as well as the AK developed
by our WHO Study Group. At the end of the trial
the jury wrote a ten-page report demanding that
the government investigate making midwifery
legal. The government eventually did so- in
1992, midwifery became legal in Ontario Province."
Making medical data available to the public
"A simple example will illustrate how
public health practitioners acquiesce to the
power of medical practitioners. In many countries
it is fortunately becoming more common to collect
data from hospitals and clinics on their practices.
This data is collated at the central level by
public health authorities who feed it back to
the practitioners. So far so good. But how about
giving this data to the public so they can make
informed choices about which hospital, clinic,
or physician to choose? Needless to say, the
doctors are against this: they don't want information
about their individual practices available to
the public ("who can't understand it anyway"),
as they are concerned about unfavorable comparisons
with other doctors. The result is that in many
places this data is still not available to the
general public, or, if it is available, it does
not identify the hospital, clinic, or doctor.
I have argued without success against this latter
strategy with public health practitioners in
Denmark, France, Luxembourg, Australia, and
the U.S."
No balance to discussions, please
"Several years ago I went to Leipzig to
an annual meeting of a European perinatal organization
attended by hundreds of obstetricians. A leading
obstetrician gave a lecture on the history of
maternity care which covered all the outstanding
medical breakthroughs and advances of the past
century, and the high level of current obstetrical
knowledge. The presentation was so unbalanced
that, during the ensuing discussion, I (naively)
tried to bring some better balance by noting
that some important history was left out, such
as the DES (diethylstilbestorol) and thalidomide
disasters. Immediately the speaker and audience
became quite hostile to me. Gradually, I have
come to realize that the central purpose of
medical meetings is not the presentation of
balanced reports but rather to provide a reconfirmation
of the correctness of the obstetrical authoritative
knowledge."
Women dying in childbirth is kept secret
"Maternal mortality audits and perinatal
audits, in which the deaths of women and babies
are analyzed, are always done in secret committee.
The fact that these committees find a significant
proportion of deaths to have been preventable
and to have resulted from mistakes in clinical
judgment does not usually reach public awareness.
In Pursuing the Birth Machine I wrote,
Three elements needed to improve maternity
services
The most effective collaboration seems to combine
three elements: a few doctors and scientists
who are knowledgeable about obstetrical authoritative
knowledge, midwifery authoritative knowledge,
public health authoritative knowledge, and the
current scientific literature, and who are willing
to go public; interested journalists not intimidated
by doctors; and consumer groups not controlled
by health professionals and not afraid to aggressively
go public."
The main difference between OBs and women/midwives
talking about birth issues
"The atmosphere of the two types of conference
is equally different. It is not unfair to describe
the ambience of obstetrical meetings as serious
self-importance. The participants are mostly
men who have exchanged their white coats for
dark suits and ties. The ambience of the birth
conferences is earnest joyfulness. Participants
are mostly women- it is difficult to get too
serious and stuffy with crying babies and breastfeeding
mothers everywhere to remind us what this work
is really all about."
The doctors didn't want a reality check
"The birth conferences can bring surprises
to some of the participants, especially physicians
only familiar with medical meetings. I remember
that during the first birth conference in Denmark,
the doctor who was head of the ultrasound department
at the University Hospital gave a glowing account
of the wonders of obstetrical ultrasound. There
followed a discussion in which participants
brought forward the lack of scientific documentation
for his assertions and the fact that not one
experimental trial had yet shown efficacy for
routine scanning during pregnancy. The physician
in question was most dismayed with what for
him was clearly an unusual reaction to his standard
speech.
Similarly, at one of the most recent birth
conferences, organized by the Midwives' Association
of Luxembourg in 1993, I presented data on how
the use of obstetrical interventions in Luxembourg
far exceeds the WHO recommendations, following
which there was a heated debate between the
obstetricians and the midwives over these practices.
At the end of the conference a local obstetrician
told me he was shocked, as the doctors had agreed
to come because 'we expected to have a friendly
chat with the girls.'"
Editors attempted to censor him
"Many attempts were made to stop or change
my writings. When I began to publish scientific
articles running counter to the medical authoritative
knowledge, I was told that all of my writings
must be approved by management before I submit
them to journals. I told them this was scientific
censorship and I would quit first, and they
backed off."
Midwives marginalized and ignored by medical
officers in WHO
"Some of WHO's work, for example, the
report on Primary Health Care from Alma Ata
(WHO 1978) and the Regional Targets for Health
for All (WHO 1986) from Copenhagen are based
on the public health approach and are outstanding,
but the organization has not been able to promote
these publications aggressively enough because
they contain ideas counter to medical orthodoxy
and therefore might displease Ministries of
Health and/or physicians. Both of these WHO
documents emphasize the important role of non-physician
health workers such as the midwife and the traditional
birth attendant (TBA). Yet for many years there
was no midwife on the regular staff in WHO headquarters
in Geneva or WHO European Regional Office in
Copenhagen.
There is very little possibility for WHO headquarters
to influence the Regional Offices or vice-versa.
The WHO headquarters’ programs for TBAs
always tended to emphasize how we might train
them, never honoring their indigenous knowledge
nor trying to empower them in an egalitarian
way as primary health care workers. Attempts
by the European Perinatal Study Group and the
subsequent WHO Consensus Conference recommendations
to empower midwives and bring back their central
role in maternity care in the industrialized
countries met with resistance from doctors both
within and outside of WHO."
Bringing birth back to the women
"In effect, all of my efforts at WHO,
as well as the efforts of many other dedicated
individuals, have been directed at expanding
the body of knowledge recognized as authoritative
in obstetrics, at opening it up to include the
authority of birthing women, midwives, scientific
researchers, and public health advocates and
professionals. These efforts are part of the
global struggle for control of maternity services,
which in turn is part of the much larger struggles
for (1) control of women in patriarchial cultures;
and (2) control of all health services.
In another paper, Patricia Stephenson, a health
service researcher, and I describe how the medical
profession is used by society to control women's
reproductive health (Stephenson and Wagner 1993b).
And in Pursuing the Birth Machine I describe
in much more detail how the struggle for maternity
services as part of all health services plays
itself out in different parts of the world.
I also point out a number of outstanding examples
of people, including doctors, midwives, and
scientists, who have broken out of the obstetrical
orthodoxy and made important contributions to
broadening both the authority and the knowledge
on the basis of which decisions about birth
can be made, and actions taken."
