SociPap

Throughout history, women have managed to carry a pregnancy to term and give birth with support from family and social systems, but without requirement for medical intervention. So why have pregnancy and birth become so heavily medicalized, and is this transition to greater intervention good or bad? We argue that medicalization is a double- edged sword with both benefits and costs. A number of factors, including medical advancement, but also historic shifts toward paternalistic control of medicine, fear-inducing media, market-driven insurance, and litigation have driven the shift toward increased medicalization. This shift has occurred at a rate that has not afforded space to reflect on medicaliza- tion’s broader implications, both positive and negative (Sagrestano & Finerman, 2012).

THE LURE OF MEDICALIZATION

Medicalization is credited with saving the lives of women and newborns, providing a sterile environment and pain relief, and making childbearing

Chapter 1

Pregnancy and Birth as a Medical Crisis

Ruthbeth D. Finerman, Adriane M. F. Sanders, and Lynda M. Sagrestano

18 The Wrong Prescription for Women

both safer and more comfortable. Between 1920 and 1950, maternal deaths in the United States fell by nearly 75% due to improvements in public health and medical science (Loudon, 1991; Omran, 1977). For instance, contemporary cesarean sections have been credited with reduc- ing postpartum complications in high-risk cases, saving mothers’ lives, and resolving fetal distress (Villar et al., 2006). Similarly, prematurity, low birth weight, and infant mortality have decreased in the industrialized world, where infant deaths now average just 4 per 1,000 live births (OECD, 2013).

At the same time, interventions often introduce unnecessary risk of complications in what would otherwise be routine pregnancies and births (Chen & Wang, 2006; Spong, Berghella, Wenstrom, Mercer, & Saade, 2012; Tracy, Sullivan, Wang, Black, & Tracy, 2007; Villar et al., 2006). Despite ever-increasing technological and medical interventions, maternal mortality in the United States has doubled over the past three decades and complications have increased; for instance, serious complica- tions (severe maternal morbidity) more than doubled between 1998 and 2011 (from 78 cases to 163 cases per 10,000 pregnancies) (CDC, 2014a, 2014b). The United States also has one of the highest rates of maternal death among all industrialized nations (CIA, 2013; Hogan et al., 2010; WHO & UNICEF, 2012a). Similarly, declines in U.S. infant death rates have been slower than in other industrialized nations, and rates have actually increased in some years. Furthermore, infant death rates differ dramatically by race and income level (Healthy People, 2014; OECD, 2013), and increases in health care spending do not consis- tently translate into fewer infant deaths (Kiely, Brett, Yu, & Rowley, 1995; OECD, 2013; Retzlaff-Roberts, Chang, & Rubin, 2004). Medical science has also failed to find effective ways to prevent prenatal risks, such as tox- emia, or effective treatment for prenatal conditions, such as many neural tube defects (Maynard & Thadhani, 2009; Sahin, 2003). Moreover, health care is not easily tailored to the psychosocial needs of individual women with diverse backgrounds and cultural heritage (Sagrestano & Finerman, 2012).

Why has the United States made slower progress than other nations, and why have some risks actually increased for American women and children? We argue that the lure of medicalization introduces new oppor- tunities for complications in otherwise normal pregnancies and births, particularly as interventions in the United States are not reserved exclu- sively for high-risk cases. Medicalization and technological advances are inextricably bound to shifts in place, person, and process in the birthing experience—from home to hospital, from individualized and relaxed to regimented and schedule-driven, and from female midwives to male phy- sicians (although currently almost one-half of obstetricians and gynecolo- gists are women) (ACOG, 2012).

Pregnancy and Birth as a Medical Crisis 19

THE RISE OF MEDICALIZED PREGNANCY AND

BIRTH IN THE UNITED STATES

Before the 18th century, women gave birth at home, attended by mid- wives. If birth complications arose, colonial Americans would summon a barber-surgeon, even though such intervention was largely unsuccessful. These rare but vivid experiences began to build a culture of fear related to childbirth. This, coupled with the availability of professional male health practitioners, provided a rationale for displacing female midwives with “man-midwives” and surgeons. This transition was furthered by the ex- clusion of women from attending medical school and the use of new birth- ing techniques, such as pain-reduction medications and technologies, thus shifting the locus of childbirth expertise from women and lay midwives to professionally trained male physicians (Cheyney, 2011; Davis-Floyd, 2004). This reflected a paternalistic movement to control women’s bodies and women’s access to reproductive knowledge (Cahill, 2001; McCool & Simeone, 2002; Stone, 2009). In addition, the biomedical establishment made a conscious effort to discredit Black midwives as “witch doctors” and instead encouraged their would-be patients to seek care from hospital-sanctioned physicians, often aided by female nurses assigned to the wards, many of which were racially segregated until the 1960s (Wailoo, 2001).

Early hospital delivery attended by physicians did not yield anticipated improvements in maternal and child well-being. Rather, the frequency of complications rose among low-risk women; for instance, rates of deadly puerperal infection or “childbed fever” soared with hospitalization as compared to the lower rates with home birth and midwifery (Hallett, 2005; Wertz & Wertz, 1989). Despite the limitations of hospital-based birth, home births in the United States fell into disfavor. In 1940, nearly one-half of all births took place outside hospitals, and by 1970, this had declined to only 1%, where it remains today (CDC, 2012). Contemporary home and alternative birth movements are regarded with skepticism in the United States (Cheyney, 2008). For example, certified professional midwives are legally authorized to practice in just 28 states, some of which allow them to practice only within a hospital and under the supervision of a licensed physician (Certified Professional Midwives NOW, 2014).

MEDIA, FEAR, AND MEDICALIZATION

Information about pregnancy currently comes not only from medical pro- fessionals and social support networks, but also from popular media sources, such as television, magazines, and the Internet (Jordan, 1993). Today’s increasingly connected and data-driven environment facilitates access to information on pregnancy, yet provokes uncertainty and anxiety.

20 The Wrong Prescription for Women

Such diverse, readily available, and at times contradictory sources create information overload that can support or confound informed decisions. Media sources also foster two disparate impressions of pregnancy and motherhood: one an unrealistic ideal, the other an exaggerated danger. Both impressions feed into a culture of fear (Lagan, Sinclair, & Kernohan, 2010; Morris & McInerney, 2010).

Further, media sources promote medicalization by localizing authority for pregnancy care in the hands of physicians (Song, West, Lundy, & Dahmen, 2012). For instance, an analysis of reality-based birth television showed that birth is often portrayed as unpredictable and dangerous and that the optimal solution is a regimented labor process. Moreover, women who fail to conform to prescribed, time-sensitive benchmarks or who question interventions, such as pain management or episiotomy, are de- picted as uncooperative (Morris & McInerney, 2010). Media portrayals can be key sources of information that allow parents to visualize the birthing process; yet, framing birth as both dangerous and idealized may create unnecessary fears and undermine a woman’s confidence in her natural abilities. This heightened fear, compounded by anecdotal “war stories” from friends and family, can reinforce dependence on medicalized inter- ventions (Fisher, Hauck, & Fenwick, 2006; Geissbuehler & Eberhard, 2002; Jordan, 1993; Morris & McInerney, 2010; Reiger & Dempsey, 2006).

MARKET-DRIVEN INSURANCE, LITIGATION,

AND MEDICALIZATION

Medicalization in the United States is also propelled by the economic pres- sures of commercialization and litigation. Providers profit from the use of new and costly reproductive technologies, procedures, and products. These are advertised to create demand among consumers with the re- sources to insist on the highest level of care. Yet this consumer-patient population is shrinking as voluntary fertility rates decline, which has in- tensified competition among providers. At the same time, the growing number of procedures exhausts the ability of governing agencies to over- see quality and safety, which poses a potential for substandard care. When this occurs, the most affordable and efficient means for patients remains malpractice lawsuits (Sloan & Hsieh, 2012).

Historically, malpractice awards were limitless and often punitive (Budetti & Waters, 2005). High awards have the potential to spur increases in malpractice premiums, forcing providers to pass along costs to patients in order to stay in business (Hellinger & Encinosa, 2006). Many states have responded by instituting award caps (Fairchild, 2010), which has led to a reduction in malpractice premiums since the 1970s (Hellinger & Encinosa, 2006). However, providers’ fear of litigation remains and fosters an atmo- sphere of defensive medicine. In this way, physicians have expanded

Pregnancy and Birth as a Medical Crisis 21

testing that was initially indicated only for high-risk patients to a standard of care for all patients, regardless of their risk level (Fairchild, 2010). This is exemplified by a plethora of screening, testing, treatment, and other in- terventions in the reproductive domain, as discussed below.

THE MEDICALIZED PREGNANCY

In much of the world, pregnancy and birth are viewed as natural stages in the lifecycle and embedded within a more humanistic, holistic approach to health. Yet, U.S. health systems regard all aspects of reproduction as invariably risky medical conditions, which almost always require profes- sional and technological intervention to ensure the well-being of mothers and infants (Lock & Nguyen, 2010; Stone, 2009; Unnithan-Kumar, 2004). In the United States, each phase of pregnancy is associated with different medical risks, which are subjected to tests and interventions that grow more numerous and complex each year (Browner & Press, 1995; Jordan, 1997). Moreover, the emphasis has shifted to prevent any possible risk, even among low-risk women. Activities that would otherwise appear in- nocuous, such as eating unpasteurized cheese, relaxing in a sauna or hot tub, tending a garden, or having an occasional glass of wine or cup of cof- fee, have been recast as perilous—and even illegal during pregnancy in select states. The only behaviors not subjected to distrust are prenatal vis- its, which create the impression that physicians can resolve all risks, a promise that remains unfulfilled.

Fear, the desire to control the unknown, and the quest for “perfect” babies (in terms of health, gender, or other desirable traits) underlie prena- tal testing, interventions, and new reproductive technologies (Boardman, 2014; Buchbinder & Timmermans, 2011; Davis-Floyd & Dumit, 2013; Press, Browner, Tran, Morton, & LeMaster, 1998; Press, Wilfond, Murray, & Burke, 2011; Rapp, 1999, 2014). This fear drives the desire to detect preg- nancy at the earliest possible stage, and the pregnancy test-kit industry exploits these fears. Multiple brands of at-home pregnancy tests bank on the profitable and persistent (albeit remote) fear of birth defects and com- plications, which are promoted as “common” outcomes of maternal mis- steps (e.g., smoking, use of alcohol) during the first three months of pregnancy (CDC, 2014c). In reality, at-home pregnancy test reliability var- ies, depending on the length of time since conception and the time of day when the test is conducted. Once pregnancy is positively “diagnosed,” women are given an estimated due date (EDD), which is an estimate in every sense; the length of normal pregnancy differs from woman to woman and can vary by as much as 37 days (Jukic, Baird, Weinberg, McConnaughey, & Wilcox, 2013). As ultrasound technology grows more advanced, physicians seek to zero in on the EDD with greater precision. The EDD then serves as the benchmark for determining overdue and

22 The Wrong Prescription for Women

induction dates, despite the normal variation among women (Hunter, 2009; Jukic et al., 2013).

The positive pregnancy test initiates a regimen of personal and medical management of pregnancy, including the adoption of social norms that inform the “do’s and don’ts” of pregnancy, as well as the seemingly end- less repertoire of prenatal tests, which can reveal manageable health con- ditions. For example, gestational diabetes and hypertension might be controlled through a combination of behavior change and medical inter- vention. A comprehensive physical examination and a repertoire of blood, urine, and ultrasound tests are routinely conducted to detect everything from dietary and metabolic imbalances, Rh incompatibility, infections, and pregnancy complications to hereditary and congenital defects. Pregnant women are further instructed on “proper” diet, weight, and be- havioral practices. These tests and practices reinforce a culture of fear, which has sometimes culminated in criminalization. Some states have passed legislation criminalizing drug use in pregnancy, even though few substance abuse programs reportedly accept patients who are pregnant (ACOG, 2001; Gregory, 2010; Nash, 2001; Steverson & Rieckmann, 2009).

More invasive tests accrue with each trimester, and each test poses both benefits and risks. Benefits include the ability to detect conditions that might be treated or that allow parents to anticipate and make informed choices about the viability of a pregnancy. Indicators of fetal abnormality (e.g., open neural tubal defects or lung immaturity) can allow both doctors and parents to prepare for specialized infant care, which might include surgery or treatment prior to or immediately after birth. In these situa- tions, detecting an abnormality during the prenatal period can make the difference between life and death. However, prenatal testing also rein- forces a cultural fear of disability; it “publicly implies that disabled people are an outcome to be avoided” (Landsman, 2009, p. 44). In addition, tests can be costly, invasive, or harmful to the fetus. Some tests also have a high false-positive rate, which poses the potential that parents might abort a healthy fetus based on inaccurate test results. Moreover, only a few fetal conditions can be treated, and intervention may be culturally or reli- giously unacceptable for some parents, which makes the testing irrelevant for them (Rapp, 1999, 2014; Root & Browner, 2011).

Early tests (e.g., chorionic villus sampling, first trimester screen, and maternal serum alpha-fetoprotein) are particularly susceptible to a false- positive diagnosis and thus require further testing. Others (e.g., amnio- centesis, cordocentesis, and percutaneous umbilical cord sampling) may yield spontaneous miscarriage or other fetal damage (which indicates its own series of further tests). The American Congress of Obstetricians and Gynecologists’ guidelines recommend that all pregnant women be offered prenatal screening, but that such testing should be reserved for women with elevated risk factors (ACOG, 2007). Nevertheless, these tests are

Pregnancy and Birth as a Medical Crisis 23

increasingly becoming routine, independent of risk (Rapp, 2001; Root & Browner, 2011).

Screenings can also place disproportionate liability on mothers for fetal health. Parents, and especially mothers, may be held legally, socially, or personally responsible for fetal disability. Indeed, women who receive positive diagnoses of fetal abnormalities often feel pressured to prove to doctors that they are “doing everything right” (Landsman, 2009, p. 17). Women with a family history of disability are even more likely to volun- tarily seek prenatal testing, despite the invasive nature of the tests and their associated risks (Cappelli et al., 2008). Furthermore, public policy legitimizes the sense of maternal responsibility, as women can be prose- cuted for poor fetal health outcomes (Mills, 1998). Fear of judicial and so- cial repercussions may foster a greater dependency on the medical system.

The Medicalized Labor

The onset of labor initiates a new cascade of medicalized interventions. Although many pregnant women create a birth plan that includes free- dom of movement during labor, water birth, choice of attendants, or mini- mally invasive and medication-free childbirth, that plan is often abandoned soon after arrival at the hospital (Lothian, 2000). As a setting for birth, hospitals are foreign territory: The rules are obscure and complex, the staff unfamiliar, and the environment cold and clinical. Control over health care decisions is surrendered in the face of regimented policies and proce- dures that favor providers’ authority over patients’ wishes (Jordan, 1997). In high-risk births, this process saves lives. However, in routine labor and birthing, medicalization introduces unnecessary complications (Chen & Wang, 2006). This is especially the case for first-time mothers (Spong et al., 2012; Tracy et al., 2007).

Prior to admission, a woman in labor must pass the first litmus test: Her water must have broken, or her cervix must be at least three centimeters dilated. If neither benchmark is met, she will probably be sent home (and charged a fee for her visit). If at least one is met, hospital routine dictates how she is processed, admitted, and shown to a room. Alternatively, when the mother is believed to be well past her estimated due date or has had a prior cesarean section, intervention may be prescribed. In contrast, unnec- essary intervention may be introduced merely for the convenience of scheduling labor and birth. Elective induction or scheduled cesarean sec- tion allows a woman to bypass the litmus test for admission (Glantz, 2005).

Once admitted, the labor regimen begins (McCourt, 2010). For some women, surrendering to the physician’s care and a high-tech birth can be a reassuring and desirable experience, whereas others may prefer a

24 The Wrong Prescription for Women

less invasive process. Unlike a childbirth at home, hospital rooms feature limited privacy and are stocked with intimidating equipment (Jordan, 1993). Visitors are restricted, which leaves the woman to make many deci- sions alone or with only one family member or friend to advocate on her behalf. A parade of unfamiliar staff may feel her cervix every 30 minutes to check the speed of dilation; the number of staff and cervix checks varies by hospital, but tends to be highest in teaching institutions. Moreover, women in labor may not eat or drink in case cesarean section and anesthe- sia are indicated. In a prolonged labor, lack of sustenance might weaken a woman’s resolve and lower her stamina for the rigors of childbirth, which increases the potential for medical intervention.

In many hospitals, standard procedures also include inserting an intra- venous drip, urinary catheter, or an electronic fetal monitor (EFM), which evaluates the fetus’s condition. Traditional EFM also requires stripping membranes (i.e., manually opening the amniotic sac), which might intro- duce a risk of infection. All of these procedures interfere with the woman’s ability to stand and walk, which is a natural way to promote dilation; the result is a domino effect that increases a woman’s risk for cesarean section (Chen & Wang, 2006; Spong et al., 2012). Women may also be shaved and given an enema, procedures that have no demonstrated medical benefit; their continued use appears to serve the convenience of the attending physicians (Chen & Wang, 2006). The cumulative effect of these medical- ized interventions can slow the course of labor (Jordan 1997; Leggitt & Ringdahl, n.d.). If labor is slow, further intervention may be imposed, in- cluding medications such as oxytocin, which “ripens” or speeds up cervi- cal dilation. However, this process can be painful for women, poses risks, and is not always effective. Studies have shown that over one-half of all women who receive these medications remain in the slow or “latent” stage of labor far longer than other women, which places them at greater risk for cesarean section (Spong et al., 2012; Tracy et al., 2007).

Pain management is another component of medicalized labor. A skill- fully administered epidural can make labor a far more comfortable experi- ence without diminishing the ability to push. However, epidurals are risky, and their effects vary from woman to woman. An epidural may pro- long the latent phase of labor; can deaden the woman’s muscle response and sensation, leaving her unable to bear down; and requires that she lie flat on her back, which poses further challenges at the point of crowning (Anim-Somuah, Smyth, & Jones, 2011; Jordan, 1993).

The Medicalized “Delivery”

By the time a woman is ready to give birth to her baby, the original birth plan is likely to have been overridden, her partner sidelined with second- ary tasks, and the process subsumed so that the physician—rather than

Pregnancy and Birth as a Medical Crisis 25

the mother—“delivers” the baby. Women may have little voice in the en- tire context of the birth. For example, rather than moving into a posture that feels most comfortable for vaginal birth, the typical U.S. birth position is supine, with the mother flat on her back, her legs elevated, and her feet in stirrups. This practice again benefits the attendant by providing an un- restricted view, but forces the mother to fight gravity while attempting to push (Blaz, 2011; Jordan, 1993). Studies also indicate that supine deliveries are more likely to result in tearing of the perineum, the tissue between the vagina and anus (Terry, Westcott, O’Shea, & Kelly, 2006).

During vaginal birth, physicians may also perform an episiotomy (i.e., cut the perineum) in the belief that the procedure facilitates the infant’s passage. This may be deemed necessary because medication used to speed labor shortcuts the body’s natural ability to stretch and accommodate the infant. Episiotomies pose further complications because the incision fails to heal as effectively as a natural tear (should one occur) and it both delays recovery and increases costs (Hartmann et al., 2005; Jordan, 1993). The fi- nal episiotomy suture is dubbed by some as the “husband’s stitch” or the “love knot” as it tightens the vaginal opening. If these various interven- tions are not effective, the physician may apply forceps or use vacuum suction to pull the baby from the birth canal. All of this reflects regimented time constraints that are common in hospital births (Jordan, 1993; McCourt, 2010; Unzila & Norwitz, 2009).

Alternately, the physician may decide that a cesarean section is indi- cated. This intervention is justified in high-risk situations, such as fetal or maternal distress; however, its use may be inappropriate, and even coun- terproductive, in low-risk situations. Caesarean rates increased tenfold between 1970 and 1990 (Villar et al., 2006) and continue to rise worldwide (OECD, 2013). Today the United States has one of the world’s highest rates of cesarean section, irrespective of risk level (34% in 2012; Meloni et al., 2012), despite recommendations by the ACOG and World Health Organization (WHO) to minimize its use (ACOG, 2014; Gibbons et al., 2010). Rate increases appear to be linked to defensive medicine and physi- cians’ convenience rather than medical need. For example, rather than au- tomatically resort to a cesarean for all breach presentations, providers can use techniques, such as external cephalic version, to move the baby into position for vaginal birth. Unfortunately, these techniques are no longer routinely included in the training of U.S. physicians, but they are a stan- dard part of professional midwife certification (North American Registry of Midwives, 2014). Women may have little choice in cesarean decisions; indeed, physicians have been known to obtain a court order to perform the procedure against the wishes of their patient (Curran, 1990; Deshpande & Oxford, 2012; Irwin & Jordan, 1987). Cesarean section delays recovery and increases the risk of maternal and infant morbidity, maternal mortal- ity, and complications in future births (OECD, 2013; Villar et al., 2006). It is

26 The Wrong Prescription for Women

also double the cost of vaginal birth (OECD, 2013), and the associated dis- comfort may interfere with mother–infant bonding and reduce the likeli- hood of breastfeeding (Zanardo et al., 2010). Moreover, few physicians support vaginal birth after cesarean because they fear possible uterine rupture and malpractice suits, even though the risk of rupture is less than 1%. This forces women into perpetual intervention in future births despite its risks (Agency for Healthcare Research and Quality, 2010; Romano, Gerber, & Andrews, 2010).

The Medicalized Recovery

Postpartum care is similarly managed and regimented both in the hospi- tal and following discharge in the United States. In hospital settings, physi- cians tend to clamp and sever the umbilical cord immediately after birth as a part of time management, whereas birth attendants in other settings allow the cord to finish transferring blood to the newborn before it is tied and cut. Attendants must also wait for the mother to expel the placenta. In many cultures, the placenta and cord are treated with respect and may be used in a variety of postpartum rituals. In hospital delivery, the placenta is treated as medical waste; it is discarded and incinerated. Depending on prior plan- ning, the cord may be incinerated, cryogenically frozen for future medical use, or donated for research (Lloyd, 2006; Stone, 2009).

The next step in medicalized postbirth care is to manage mother–infant interactions. Newborns in most societies are entrusted to the mother; in U.S. hospitals, the baby is cleaned, evaluated (the Apgar test of the new- born’s condition is conducted at one minute and five minutes after birth), and then handed to the mother to hold. At some point, the baby under- goes routine postnatal procedures. Depending on the mother’s condition, the newborn’s condition, and the hospital’s policy, babies may stay in the newborn nursery, which offers little time for bonding between mother and child. An increasing number of hospitals now allow a healthy newborn to room with the mother, a practice that makes it easier for a mother to bond and breastfeed while she is hospitalized (Kennell & McGrath, 2005; WHO & UNICEF, 2012b).

Exclusive breastfeeding for the first 6 to 12 months is recommended by numerous health organizations such as the WHO, the National Institutes of Health, and the American Medical Association. U.S. breastfeeding rates have increased in recent years but remain low relative to other industrial- ized nations (Bartick & Reinhold, 2010; CDC, 2013; Farrell, 2013). After a generation of primarily formula-fed babies, contemporary women may lack role models for breastfeeding. Although hospitals encourage mothers to breastfeed, they enable formula feeding by supplying parents with samples and resources for bottle feeding. Mothers who want to breastfeed exclu- sively may have to overcome the pressure to formula feed. Some hospitals

Pregnancy and Birth as a Medical Crisis 27

provide breastfeeding educators, but they are few in number and their availability varies. Some mothers are discharged before they can connect with an educator, and those who have undergone a cesarean may not re- ceive any guidance during recovery. At the same time, mothers may hold unrealistic expectations about the ease of breastfeeding, when the process can actually be challenging and even painful. Difficult or uncomfortable ex- periences may leave women unsure that they can successfully breastfeed a healthy baby. A number of cities in the United States have recently initiated campaigns to promote breastfeeding education, ban formula gifts in hospi- tals, and distribute free breast pumps; collectively, these actions hold prom- ise for more informed feeding choices (Perrine et al., 2011; Raphael, 2012).

Following a routine birth, the mother is typically discharged within 24 hours. If her newborn is in distress, it will be admitted to a neonatal intensive care unit, where it may remain for some time. Such units greatly increase the chance for survival in infants with high-risk conditions (Lorch, Baiocchi, Ahlberg, & Small, 2012), although such care comes at a high cost (Muraskas & Parsi, 2008). However, pending doctor’s orders, even healthy newborns may be held for a longer period of observation and assessment after the mother is discharged. For example, about 50% to 60% of newborns display neonatal jaundice; although a fraction of these cases require care, jaundice is usually normal and adaptive, and it does not need medicalized intervention (AAP, 2004; Brett & Niermeyer, 1999). Novice parents may also engage more fully in the medicalization process by seeking reassur- ance for natural yet potentially alarming characteristics of newborns. For instance, vaginally birthed newborns may exhibit a number of normal con- ditions that can provoke concern in new parents, such as blue skin tone (cyanosis), a misshapen skull (molding), and irregular breathing.

Novice parents may be further alarmed by a fresh round of fear- inducing information when they leave the hospital. Parents may be handed discharge orders with a litany of medicalized “do’s and don’ts” related to diet, sexual behavior, secondhand smoke, and infant care and feeding. For instance, infants’ sleep is flagged as life-threatening; parents are instructed to place infants to sleep on their back, avoid soft bedding, and never bed-share if they are to avoid suffocating their newborn. These guidelines are evidence based (AAP, 2011), but they invoke fear and inse- curity. The taboo against bed-sharing also fails to accommodate both cul- tural tradition and pragmatics: it is likely that most mothers fall asleep with the baby in their bed at some point, which can induce feelings of guilt (Gettler & McKenna, 2011; McKenna & McDade, 2005). Indeed, first-time parents can grow so anxious that they may question their every action and decision. Yet, rather than turn to experienced family and friends, the med- icalized process of pregnancy and birth leaves them dependent on health care networks and the media as default experts, which extends medical- ization into childrearing.

28 The Wrong Prescription for Women

CONCLUSION

Advances in medical diagnosis, treatment, and technology have demon- strated value to save the lives of women and infants at high risk. At the same time, the universal application of these tools, regardless of risk, leads to a growing tide of interventions and complications in what would otherwise be routine pregnancy and birth.

With each phase of pregnancy and birth, the market-driven medical model yields fresh opportunities for commodification and expensive and defensive techniques, all of which lead to overburdened patients with greater uncertainty about their decision-making abilities (Thomas & Zimmerman, 2007). Furthermore, the United States is exporting this inva- sive model around the world, replacing and marginalizing existing sys- tems that can be safer and more effective for low-risk pregnancies (Cahill, 2001; Jordan, 1997; Selin & Stone, 2009). Controversy over this approach to “health” has sparked a growing movement in the United States to reverse medicalization and reinstate natural childbirth and a greater variety of potential birth attendants. Even so, the natural childbirth movement has exerted only minimal influence against the legitimacy of the medical model, and its impact varies by class, education, ethnicity, and state regu- lations (Davis-Floyd & Sargent, 1997).

An antidote to unwarranted medicalization is accessible, informed, and empowered decision making, as advocated by the reproductive justice movement (Chrisler, 2012; Sagrestano & Finerman, 2012). Accessible care re- quires the elimination of health disparities, universal health coverage, and the geographic availability of multiple and alternative reproductive care op- tions, including fertility and family planning services, midwives and doulas, birthing clinics, and quality hospital care (Walker & Chesnut, 2010). Informed decision making hinges on the availability of medically accurate, balanced, and culturally appropriate educational resources that outline women’s choices without provoking unnecessary fear and insecurity. Empowerment is contingent on social and legislative reforms that ensure reproductive health care choices for all women (Davis-Floyd & Sargent, 1997; Jordan, 1997; Machizawa & Hayashi, 2012; Sagrestano & Finerman, 2012). At present, these basic human rights remain unrealized for many women and their part- ners in the United States and worldwide. Accomplishing these aims will de- pend on collaboration, political will, and strategic action at all levels.

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Pregnancy and Birth as a Medical Crisis 29

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