by Marsden Wagner, MD, MSPH
Marsden began his career in public health as a neonatologist and epidemiologist, first in California then Denmark. He retired from a distinguished career as head of Maternal and Child Health for the European Office of the World Health Organization (WHO). He now acts as a consultant for WHO in the emerging countries of central and eastern Europe. He chaired the three consensus conferences convened by WHO on appropriate technology around the time of birth and is in demand as an international speaker for his forthright support of midwifery and midwives.
Also by Dr. Marsden Wagner:
*Born in the USA: How a broken maternity system must be fixed to put women and children first
*Fish Can't See Water: The Need to Humanize Birth in Australia
The Active Management of Labour
What is Normal?
Active management illustrates the confusion in the medical approach as to what is normal and what is pathological in birth. A WHO publication states:
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 some of this may occasionally be necessary), the woman's state of mind and body is so altered that her ways of carrying through this intimate act must also be altered and the state of the baby born must equally be altered. The result is that it is no longer possible to know what births would have been like before these manipulations. Most health care providers no longer know what "non-medicalized" birth is. This is an overwhelmingly important issue.
Almost all women in most developed countries give birth in hospitals, leaving the providers of the birth services with no genuine yardstick against which to measure their care. What is the range of length of safe labor? What is the true (i.e. absolute minimum) incidence of respiratory distress syndrome of 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 these, and many more questions is the same: no one knows. The entire modern obstetric and neonatology literature is essentially based on observations of medicalized birth. (WHO 1985a).
The source of much of the confusion over normality found in medicalized birth is the mistaken idea that labor is something that happens to women rather than something women do (Rothman 1993). It is this idea which allows doctors to think they can intervene in what is happening rather than to assist the woman in what she is doing. Thus, it becomes the active management of labor, not the active management of women. Accordingly, the task for the woman becomes not to give birth but to learn to cope with what is happening to her. It is this line of thinking which results in an extraordinary distortion of the definition of "normal" birth. In reporting their perinatal statistics, the National Maternity Hospital in Dublin, Ireland, where active management originated, defines labor as normal even when it includes one or more of the following invasive interventions: amniotomy, induction, augmentation, epidural block, and/or eplsiotomy.
Medicalization also results in distortions of what is abnormal or pathological birth. How can it be that when the active management protocol is applied, over 40 percent of Dublin women having their first baby have a "dysfunctional myometrium" incapable of expelling a baby without the help of doctors and drugs? Active management was devised "for the early recognition and correction of inefficient myometrial activity" (O'Herlihy 1993), but the inventors of active management had never attempted to measure myometrial activity!
In active management, if a woman's labor was not progressing at a rate they arbitrarily defined as satisfactory, the doctors said she was suffering from "dystocia" and needed oxytocin. Confusion reigns in obstetrics over what should be labeled dystocia: it was originally defined as a mechanical failure but shifted to a time-bound failure to progress (Rothman 1993). A WHO study revealed enormous variation from country to country in the percent of births with the diagnosis of dystocia: Australia 23 percent, Canada 31.5 percent, Czech Republic 20 percent, Greece 17.4 percent, Israel 9.7 percent, Slovenjia 33.8 percent, United States 22.1 percent (Stephenson 1992). Does this variation in dystocia among countries reflect variations in the ability of the uterus or is there a variation in how much the doctors have sped up the clocks during labor?
There is no question that the clocks have been quickened. The definition of the normal upper limit to labor has been reduced from 36 hours in the 1950s to 24 hours in the 1960s to 12 hours in 1972 when active management was introduced. In describing active management, one of its practitioners says: "Twelve hours is considered the maximum safe duration of spontaneous labor and cesarean section is performed unless delivery is imminent at that time" (O'Herlihy). All of these time limits were arbitrarily based on clinical concerns and not on scientific evidence. Putting a stop watch to labor, as is done in active management, precipitates many problems. When to start the stop watch and declare the race on is difficult and subjective. "The final component of active management is taking care to diagnose labor only when progressive dilatation or effacement of the cervix is observed. This has never been evaluated by a randomized trial, and the "diagnosis" of labor is fraught with all the difficulties of trying to categorize a continuous variable" (Thornton and Lilford 1994).
Each labor is unique and idiosyncratic and frequently may not follow the linear thinking of the partogram which does not take into consideration such variations as the woman's normal biorhythms or the woman's natural need to occasionally "take a break" from the enormous effort of labor.
Need For Control
Another element of the medicalization of birth found in active management is the need for doctors to control. Since labor is involuntary and unpredictable, i.e. out of control, it is difficult for doctors to serve as control towers. How then, can doctors "manage" labor? The dictionary defines manage as "to have under effective control, to contrive, to persuade, to do what one wants" (Kaufman 1993). About the only thing doctors have had any success with controlling in labor is pain and length of labor (Rothman 1993).
Active management was invented by doctors, not midwives or birthing women. Birthing women were never asked if they wanted shorter but more intense and more painful labors. In active management the woman adjusts to the hospital, not visa versa, by giving up any semblance of control of her body and her birth. The appeal of active management among doctors is likely related to feelings of power and control, the imposition of order and conformity on the otherwise unpredictable birth process, and the ability to "do something".
It is impossible to conceive that midwives should have invented active management. Rather than needing to do something, midwives might be described as those health professionals who have good hands and know how to sit on them. One of the extraordinary facets to the active management story is the way in which the role of the midwife in the active management protocol has been minimalized and almost hidden. In a recently published three page description of active management, only a few sentences are given to the importance of "an individual midwife to each woman throughout her labor" (O'Herlihy 1993). Ironically, there is evidence suggesting that it is the continuous presence of the midwife that is the essential element in active management. While the most important current explicit justification for the use of active management is the reduction in cesarean section rates, an analysis of the components of active management for their ability to lower cesarean section rates is quite revealing.
Research by Fraser in 1992 has shown that amniotomy alone does not reduce cesarean section rates, and another meta-analysis of research (Fraser 1992b) shows that oxytocin alone does not reduce cesarean section rates. On the other hand, considerable research has shown that a personal birth attendant can reduce cesarean section rates. Meta-analysis of the 10 randomized trials of a continuous companion throughout labor shows such support "is effective in reducing analgesia requirements, lowers the incidence of cesarean section and operative vaginal delivery, and improves fetal outcome" (Thornton and Lilford 1994). In active management, as originally devised and still done in Dublin, but not in other places as we will see, the midwife is always there. In fact, the midwife is the sole birth attendant in 80 percent of births in the Dublin National Maternity Hospital, and yet this midwife seems nearly invisible to the doctors. Obstetricians come to Ireland to see active management of labor, return home and replicate active management without including the one-on-one midwife component and still call it active management. But if active management's invasive components, amniotomy and oxytocin, are removed but intensive midwifery, the only component which the evidence shows to be effective in reducing cesarean section rates, is maintained, it is not even called active management.
With medicalization of birth, if a problem develops with the use of technology, the solution is sought typically through the use of further technology. Active management has been justified for years because it is claimed to reduce the problem of excessive cesarean section rates. Often too many cesarean sections are performed because doctors misdiagnose the indications for them. Instead of changing the indications or improving the doctors' ability to diagnose the indications, the solution is to change the labor to fit the indications. If we define labor in primiparous women over 12 hours as dystocia, we will invent another technology to force women to hurry up their labor to less than 12 hours. It is similar to inventing cars that can be driven too fast and then, when the speed causes accidents and deaths, rather than change the cars or retrain the drivers, we invent speed bumps. And if the result of speed bumps is painful banging of heads on the car ceiling, we give pain medication.
The justification of active management, the reduction of cesarean section rates, is self fulfilling prophecy. If we decide that labor over 12 hours is an indication for cesarean section and we find a technology to hurry up labor, then, of course, the cesarean section rate will fall. But we have not questioned the 12 hour policy, and have not considered what factors may slow the labor, and have not considered less invasive and less risky alternatives. If the belief is that labor is happening to the woman, the focus is the uterus, not the woman, and the solutions considered are medical and pharmacological interventions directed to the uterus.
But active management is not the only way to lower cesarean section rates. If the belief is that birth is something that women do, then the focus is the woman, not the uterus, and the solutions considered are the means of rallying the woman's powers and improving her labor environment. A number of non-invasive, non-pharmocological solutions have been shown scientifically to be as effective as active management in lowering cesarean section rates: a companion in labor in the hospital (Thornton and Lilford 1994), midwives rather than doctors as the principle birth attendants in hospital births of women without complications (Wagner 1994), out-of-hospital birth centers (Rooks et al. 1990), and planned home birth (Wagner 1994). Indeed, an entire country, The Netherlands, has a cesarean section rate as low as the National Maternity Hospital in Dublin without resorting to active management.
All the woman-centered, non-active management means of preventing unnecessary cesarean section rates listed above do not involve increasing trends to invasive, technological methods of pain control during labor. But active management of labor, as practiced at the National Maternity Hospital in Dublin, has seen a 12-fold increase in epidural analgesia (O'Herlihy 1993), which is now used in over 50 percent of primiparous laboring women. Active management, with its focus on technological solutions, encourages further technology. If you get hold of the tiger's tail of technology, it is very hard to let go.
Lack of Scientific Evidence
Active management of labor, like other examples of medicalization of birth, lacks a scientific base. A WHO survey of routine obstetrical interventions found only 10 percent justified by scientific evidence (Fraser 1983c) Active management was started without any attempt to scientifically test the underlying assumptions nor to put the package of interventions to the acid test of a randomized control trial. More shocking is that, 25 years later, there is still not a single randomized controlled trial comparing the active management package with other methods of reducing cesarean section rates such as described above. One trial did compare active management with "standard care" and claimed a 26 percent drop in the cesarean section rate with active management (Lopez-Zeno et al. 1992). However, re-analysis of their data showed that simply doing the research caused an even greater drop in the cesarean section rate (30.3 percent) in the control group. Further, while active management produced a drop in cesarean section rates among women in private care, the active management did not produce a drop in women with public care. It is concluded: "the cesarean section rate is partly a product of how tightly watched physicians feel they are, and partly the well-documented bias toward over-treatment of private patients". Rothman called this the "active management of physicians" (Rothman 1993).
Anyone wishing to defend active management of labor is obliged to respond to the careful, thorough evaluation of the scientific evidence for and against active management in the recently published review article (Thornton and Lilford 1994).
"There have been no randomized trials of the total package of active management or of the use of strict diagnostic criteria alone, but trials of early amniotomy, early oxytocin, and these interventions combined do not suggest that these interventions are effective in reducing rates of cesarean sections or operative vaginal deliveries. In contrast, the provision of continuous professional support in labor seems to reduce both types of operative delivery, although the effects on cesarean section are confined to those settings where non-professional companions are not normally present in labor. Delivery units should endeavor to provide continuous professional support in labor, but routine use of amniotomy and early oxytocin is not recommended" (Thornton and Lilford 1994).
Hiding the Risks
As with other technological interventions used at the time of birth, those using active management of labor seem bent on playing down or hiding any risks and reassuring everyone that it is "safe". For example they claim, "On balance, active management of labor is safe for the fetus, notwithstanding any associated dystocia. It is also safe for the mother" (O'Herlihy 1993). First, it must be said that such statements reveal a failure to understand "safety". Since every medical procedure or technology has side effects and risks, no technology is 100 percent "safe". In every case, it is necessary to balance the chance of a good result (efficacy) with the chance of a bad result (risk). With any intervention under consideration, the chance of a good result or bad result can be scientifically determined. Instead of telling the woman that the intervention is "safe", she should always be told all information on the efficacy and risk. But the decision as to whether the good chance outweighs the bad chance should not be made by the doctor, who is taking no chances, but can only be made by the person taking the chance --- the woman. Therefore the doctor can never say that any procedure is "safe" but only tell the woman the chances and let her decide (Wagner 1994).
The risks of early amniotomy have been reviewed by a WHO consensus conference (Wagner 1994). Early rupture of the membranes may eliminate the cushioning effect of the bag of waters and result in more trauma to the fetal head (Caldeyro-Barcia 1974) and may increase the likelihood of prolapse of the cord with reduced maternal uterine blood flow (Martel et al 1976). Because of these risks, an official WHO recommendation states: "Normally, rupture of the membranes is not required until a fairly late stage in the delivery. Artificial early rupture of the membranes, as a routine process, is not scientifically justified" (WHO 1985).
The risks of oxytocin are too many and too complex for thorough review here. Again the WHO consensus conference reviewed the scientific evidence (Wagner 1994). The list of risks include: increased operative vaginal birth; increased neonatal hyperbilirubinaemia; uterine hyperstimulation with inadequate placental blood flow and fetal compromise; uterine rupture; iatrogenic preterm birth; increased incidence of neonatal seizures. With all the risks associated with oxytocin, using it when designing an intervention like active management to speed up labor is like designing a streamlined parachute --- you may get there quicker but you may pay a big price. Because of these and other possible risks, an official WHO recommendation states: "Birth should not be induced for convenience, and the induction of labor should be reserved for specific medical indications. No geographic region should have rates of induced labor over 10 percent" (WHO 1985b).
In an effort to dispel concerns for the psychological risks to active management of labor, one proponent writes that active management: "... enhances the mother's participation in and control of her experience of her first birth" (O'Herlihy). Since with active management the woman loses all control, especially the over 40 percent receiving oxytocin, and since over 80 percent report that it increases pain and stress (Enkin et al 1989), one might be forgiven for questioning this unsubstantiated statement. A much more reasonable statement is given by Goer: "Active management introduces psychological hazards as well. By defining deviation from the average rate of dilatation as pathologic, it tells the 40 percent of women who have augmentations that they are abnormal Davis-Floyd (1992), and others describe and document the damage done by Western birth rituals that teach women to believe they are defective mechanisms from which their babies will be rescued by technology. Labor interventions, not unsurprisingly, bear a dose-dependent relationship to postpartum depression" (Goer 1993).
Benefit To Doctors And Hospitals
A final characteristic which active management of labor shares with other forms of medicalized birth is that the intervention is primarily for the benefit of doctors and hospitals, not women. When active management of labor was devised in Dublin 25 years ago, thousands of women were giving birth in a large hospital in a relatively poor country. "Processing mothers efficiently was a clear necessity to cope with facilities and those who depended on them" (Keirse 1993). In order to take care of all these women, what was needed was what the creator of active management called "military efficiency with a human face" (O'Driscoll 1986). Is this what the women wanted?
In truth, it never mattered what women wanted. Laboring women rank as privates in this scheme of "military efficiency" with a "human face". They are to take orders, not make a fuss, and not disrupt the labor unit by making what the creator of active management called "the degrading scenes that occasionally result from the failure of a woman to fulfill her part of the contract" (O'Driscoll 1986). One reason given for tying the oxytocin drip to the number of contractions is to prevent soft-hearted nurses from turning down the drip when women complain of pain (O'Driscoll 1986). Active management makes labor more efficient, but this benefits hospital staff, not mothers and babies. "The new-found ability to limit the duration of stay", say the Dublin doctors, "has transformed the previously haphazard approach to planning (staffing) for labor" (O'Driscoll 1986) (Goer 1993).
Those who dreamed it up have been quite candid in stating how active management of labor relieves staff of the frustration of waiting out "tedious hours" (O'Driscoll 1986). It is summed up well: "It would appear that there are a large number of situations in which augmentation of labor is not directed at correcting a perceived abnormality in a woman's labor, but at shortening the labor commitment of her care givers" (Keirse 1989).
A final note on the arrogance which underlies active management of labor. As stated in Pursuing the Birth Machine: "Anthropological data now suggest that the human species has experienced no significant physiological change for the past one to two million years. During this long history of evolutionary adaptation, human beings slowly evolved mechanisms and practices for childbirth. Meddling with these may result in unforeseen and unintentional harm, since biological adaptation is a very slow process. The seemingly harmless 'modern' practices of separating the woman from her new-born, placing all healthy newborns in a room together, giving artificial formula during the first day or two, and giving breastfed newborns to their mothers every four hours have all had unpredicted but scientifically proven deleterious consequences for both the woman and her baby" (Wagner 1994). So why meddle?
"Many Western doctors hold the belief that we can improve everything, even natural childbirth in a healthy woman. This philosophy is the philosophy of people who think it deplorable that they were not consulted at the creation of Eve, because they would have done a better job" (Kloosterman 1994).
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- Enkin M et al. A Guide to Effective Care in Pregnancy and Childbirth. Oxford: Oxford University Press, 1989.
- Davis-Floyd R. Birth as an American Rite of Passage. Berkeley CA: University of California Press, 1992.
- Goer H. Active management of labor: Not the answer to dystocia. Birth 1993; 20:99101.
- Keirse M. A final comment - managing the uterus, the woman or whom? Birth 1993; 159-161.
- O'Driscoll K, Meagher D. Active Management 2nd Ed. London: Bailliere Tindall, 1986.
- Lumley J. Events and experiences in childbirth: Is there an association with postpartum depression? Presented at the 10th Birth Conference, Boston, 1992.
- Keirse M. Preparing the cervix for induction of labour. In: Chalmers I, Enkin M, Keirse M (eds). Effective Care in Pregnancy and Childbirth. Oxford: Oxford University Press, 1989.
- Kloosterman G. Paper at Perinatal Conference, Barcelona, 1994.
Wow, that was very good and informative article. Thank you for posting it. I am in the process of becoming a doula. This really impacted me. Thank youReplyDelete