The Connection Between American and Third World Maternity Care


Last Weekend I went to an American Medical Women’s Association conference. I presented a poster from my undergraduate thesis called “Childbirth and the Internal Colonization of Women’s Bodies.” Basically my thesis is that misinformation/lack of information/biased information from medical authorities and popular culture construct American women’s childbirth choices as unhealthy ones.

“While medical authorities today do not force interventions on unwilling women, incomplete advice from them convinces women that obstetric interventions are required, even desirable. Such is “internal colonization,” where the oppressed perpetuate viewpoints of the oppressor even in absence of visible coercion.”

Of course if you don’t think there’s anything wrong with American maternity care, then the thesis won’t make sense to you. But the evidence is out there. America spends the most per women on maternal health, yet is 33rd in maternal mortality stats. All industrialized countries with better maternal and infant health employ midwives as birth attendants for the majority of births (except Canada). The small fraction of high risk births are attended by obstetricians. Rates of all intervention use (Pitocin inductions, epidurals, electronic fetal monitoring, episiotomies, C-sections) are very high in America yet the outcomes are worse than other industrialized countries. American maternity care is highly technologized, but it is not evidence-based-medicine. Some people, hearing my critique, point out that C-sections do save some lives and obstetricians are needed. Well DUH. I’m talking about excessive interventions, not medically necessary ones. Once labor has been induced by Pitocin, or once an epidural is given, the normal process of labor becomes pathological, so further interventions are needed when there was no need for any to begin with. Some people also equate the critique of American maternity care with the fear and ignorance of science, but they’re generally ignorant of better maternity care systems. Overuse of interventions is anything but scientific. For women with normal physiology, natural birth is the healthiest and therefore the most medical. Women have the right to choose unhealthy interventions, just like some women choose plastic surgery, but it’s also their right to be fully informed about the risks. 

So it was disappointing to me to hear the keynote speaker at the AMWA conference, Joia Mukherjee, perpetuate the ignorance of what good maternity care is. Dr. Mukherjee has done and continues to do good public health work in poor countries. Needless to say, I agree with her desire to share the healthcare privileges we have in America with the rest of the world. That’s probably why her narrow, non-scientific beliefs about maternity care were even more disappointing. Much of her speech revolved around how the high maternal mortality in developing countries is unjust and how access to C-sections would solve all that. Of course I know that many women in third world countries die from childbirth from lack of medical care – I’m from a third world country. I know how women’s opinions and their health concerns are ignored, and how patriarchal families often don’t value a woman’s life enough to invest in medical care. But C-sections alone are not the mark of good maternity care. Dr. Mukherjee commented to me that she isn’t concerned with the high rate of C-sections in the US because mothers aren’t dying from unnecessary C-sections. That’s not true. Maybe 500 mothers aren’t dying, but at least 5 are from unnecessary major abdominal surgery. As I wrote before, all developed countries have lower maternal mortality rates than America. In the US, poor communities have very high rates of interventions and C-sections, while wealthier women can assert their “birth plans,” or choose their birth place and attendant without insurance help. So C-sections are no more the sign of privilege in America, though good maternity care is. Dr. Mukherjee failed to make the connection between poor American mothers and poor Haitian mothers. Both groups are deprived of the rights over their bodies. Haitian mothers aren’t considered worthy of emergency surgeries, and American mothers aren’t considered worthy of human monitoring and social support during labor, which are much better forms of care than epidurals and C-sections. If C-sections were the mark for good maternity care, marginalized women wouldn’t have had the highest rates of use.

The WHO estimates that C-section rates between 10-15% indicates good maternity healthcare. It is unjust that many third world women don’t have access to safe and timely C-sections. But anyone whose work focuses on getting enough medical care to third world women should do it with the knowledge of the experiences of American women. Otherwise their stance becomes pro-cesarean and not pro-evidence-based-medicine. It indicates the ignorance of thinking American healthcare is the best healthcare, and promotes the least cost-effective and most inefficient model of maternity care in developing countries. That’s an imperialistic, patriarchal attitude, not a global feminist one. It’s all the more alarming to know how many women in Bangladesh are getting C-sections for no clear medical reasons, but because “that’s what doctors do nowadays.” People are aware of some doctors’ financial motives but they have the false belief that C-sections are best for the baby. (Even if that were true, this is yet another example of patriarchy valuing progeny over women).

Dr. Mukherjee also said that forty years of investing in skilled birth attendants in developed countries has not improved maternity health at all; that she has done “the whole holding hands and singing thing” but that hasn’t made a difference. That comment I find ignorant and offensive. Maternal mortality is high not just because  women aren’t birthing in hospitals, but also because of the malnourishment and early marriage that many third world women still face. Women need GOOD medical care, i.e. skilled midwives, prenatal care, continuous human monitoring during labor, social support, and adequate surgical referral for complicated labors. Talking only about surgery is tunnel vision. The problem to me isn’t just one of giving third world women C-sections, the problem is giving them full human rights. Women often don’t have autonomy of their sexual and reproductive health, both in developing countries and in America. Feminists who don’t make this connection are perpetuating harmful attitudes and practices, even if they think they’re helping.

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