Following the #MeToo movement came the #violence_in_obstetrics movement, which started in 2018. In fact, the mistreatment of women in maternity wards is so widespread that some countries have already enacted, or are trying to enact, laws against it. Venezuela’s law concerning violence against women incorporates obstetric violence (OV) and defines it as “health care personnel’s appropriation of women’s bodies and reproductive processes, expressed through dehumanizing treatment, an abuse of medicalization and pathologization of reproductive processes, bringing about women’s loss of autonomy and the capacity to freely make decisions about their bodies and sexuality, negatively impacting women’s quality of life.”
OV encompasses a range of actions, including physical, psychological, and emotional violence. It includes not allowing a woman to choose her birthing positions, companions, or interventions, epistemic gaslighting (reminiscent of Naomi Wolf’s “crazy-making experiences”), shaming a woman into complying with procedures (or “you are a bad mother that endangers her baby”), fear-based health campaigns not based on scientific evidence, and practices that add health risks for birthing women and babies. In this blog post, I will argue that one instance of obstetric violence is the routine use of the electronic fetal monitor (EFM) for continuous auscultation (listening to a baby’s heartbeat) in low-risk births, since its use as the Standard of Care (SOC) actually harms patients. In the U.S., SOC is a legal term that refers to treatment that is accepted and widely used by a reasonable (“minimally competent”) professional. While it is reasonable to think that SOC practices benefit patients, this is not the case with the EFM.
The case of the EFM is an interesting story, and how it got into the labor room is baffling. But before I tell this story, a caveat: I have taught birthing ethics for over a decade, and writing about this topic is challenging. There is an ocean of misinformation about birth. Birth is personal. Specialists on birthing ethics will note that I am not saying anything new about the EFM. Indeed, the story I tell is old news even in the popular press. And yet, scholars who know less about it, and obstetrical residents, claim that I could not possibly be right. French psychoanalyst Clotaire Rapaille argues the symbol for ‘doctor’ in the U.S. is ‘hero’ – thus, reading criticisms of routine practices of the ‘baby heroes’ might be difficult. But as a philosopher, I follow Socrates’ example of engaging in critical thinking about the status quo and the ‘common sense’ of our times. To understand the story of the EFM, we must question our present-day view of ‘technology as progress’ and the medicalization of life as we know it, as well as the connections between the medical profession, the private market, and the law.
The EFM monitors a baby’s heart rate and the mother’s contractions. The original assumption was that data obtained from continuous assessment of the fetal heart rate with the EFM — displayed electronically on monitors in a patient’s room as well as being recorded on a “monitor strip” — would be an improvement for newborns’ wellbeing over intermittent assessment by a human, or “hands-on listening,” where a provider listens for a short time at regular intervals and documents the fetal heart rate, rhythm, any accelerations, and the depth, timing, and duration of any decelerations.
So how did the EFM become the SOC? Introduced in the 1970s, EFM-use was limited to high-risk pregnancies. Then the device was included in every delivery room, before the FDA’s Medical Device Amendments of 1976 required that medical devices be evaluated before putting them in use. Before this law, devices could be used without studies showing whether they benefited (or harmed) patients.
Philosopher of technology Langdon Winner argues that the most important point for ethico-political deliberation about technological innovation is before its implementation. This deliberation did not happen with the EFM. In the U.S., by 1976, and without any studies, 75% of physicians believed that EFMs should be used in all deliveries. It is now used in 85-90% of births in the U.S., with similar numbers in other industrialized countries.
And yet, the routine use of EFMs for constant auscultation has never shown benefits for women or babies in deliveries categorized as low-risk. Attorney Thomas Sartwelle argues that “Five decades of overwhelming evidence prove that EFM is not only unscientific, but also has driven the C-section rate to unprecedented levels—one-third of babies in the United States and a quarter in the United Kingdom and Australia are delivered by C-section—despite evidence that EFM and cesareans have not altered in the least the rate of CP [cerebral palsy], which was the primary aim of EFM, nor has it altered the rates of perinatal death, neonatal death, intrapartum stillbirth, low or very low Apgar scores, need for special neonatal care, or the rate of neonatal encephalopathy.”
In fact, continuous EFM-use adds risks by increasing the chances of a cesarean or a vaginal delivery using instruments, such as forceps or a vacuum. WHO deems cesarean rates over 15% a public health problem because major surgery significantly increases risks for mothers and babies. Incredibly, birthing women in the U.S. today have a higher risk of death than their mothers did.
The American Congress of Obstetricians and Gynecologists (ACOG), the American College of Nurse-Midwives (ACNM), and the Association of Women’s Health and Neonatal Obstetric Nurses (AWHNON) have acknowledged that continuous fetal monitoring offers no benefits over intermittent auscultation. For healthy pregnancies, ACNM recommends intermittent auscultation, ACOG states that either method is acceptable, and AWHNON states that the choice should be guided by women’s preferences and clinical presentation while noting that consideration should be given to less invasive methods.
Historian Judith Kunisch explains that Corometrics Medical Systems, Inc., the company with 75% of the EFM’s market share (their only product) declared as its goal to have fetal monitoring from several months after conception until birth, to achieve a billion-dollar-range market for equipment and disposables. Corometrics’ marketing strategy was similar to pharmaceutical companies’: focus on large city hospitals (which are then copied by small rural facilities), include two physicians from Yale and one from Harvard in its Board of Directors, and offer training in desirable locations, such as Florida and Las Vegas. Physicians returned to their hospitals and requested EFMs.
Several factors contributed to the adoption of the EFM. Though the patent documents showed that the machine would routinely lead to errors in counting fetal heartbeats and noted the device could lead to a high number of unnecessary risky surgeries, Kunisch argues the lax patent process at the time helped legitimize its use given the inadequate regulation of medical devices. The EFM was welcomed as a sign of progress and improvement through technology. In the U.S., between 1970 and 1978, the number of cesarean deliveries tripled to 15.2 per 100 births (in 2020 the cesarean rate is 31.8%).
Second, the male body had been used as the model for health in medicine, which reinforced the view of a woman’s body as a defective machine that could not be trusted and had to be efficiently managed. The common-sense belief of technology as (linear) progress and a faith in technology as savior — what famous midwife Ina May Gaskin calls “technological myths” or “technological superstitions” — reinforced the belief that more technology means better medicine, and that a machine would be better at monitoring childbirth than a human being.
Third, trust in physicians, or the belief that if a physician uses the EFM it must be for a good reason, encouraged its acceptance by birthing women. Without studies on the effects of EFM during childbirth, physicians started using it as their main source for decision-making. Monitors located at a nurse’s central station allowed for centralized supervision; hospitals cut costs by reducing personnel. At this same time, fathers were allowed in the delivery room, consumer groups demanded more freedom during labor, and physicians seemed to lose epistemological authority: the need for the obstetrician’s knowledge during delivery began to be questioned. Introducing a device only an obstetrician could interpret restored physician authority.
Why does the routine use of EFMs continue? Some argue that the paper trail documenting fetal heartbeats serves (mostly) obstetricians in malpractice lawsuits. It also meets the psychological needs of physicians by reducing their fears and making them feel in control of birth (the same needs of birthing women!). Obstetrician Anne Lyerly, aware that routine EFM-use adds health risks, admits that obstetricians have “irrational beliefs” and thoughts of “magic realism” and use EFMs as a “safety blanket.” In A Good Birth, she explains the psychological needs EFMs satisfy: “In truth, watching a fetal heart racing is a source of comfort upon which we rely; it is what makes us feel safe and secure, that everything will be ok….To take the monitor away would make some of us feel, in short, out of control.” Arguably, obstetricians, rather than birthing women, are considered the users of childbirth technology: it is their legal and psychological needs and not the physical and psychological needs of women and babies that have taken priority.
EFM use also continues because of changes in obstetric training practices. Obstetricians no longer witnessed diverse vaginal births and they lost familiarity with the wide range of healthy/normal diversity in pregnancy and childbirth. Skills that were considered vital — such as turning a baby in utero or delivering breech babies vaginally — were no longer taught and were replaced by surgery (“preventive cesareans”). Historian Judith Kunisch argues that “just as Corometrics had planned, the third most common reason for cesarean deliveries was ‘lack of training in management of normal obstetrics residents, with an emphasis in training on use of sophisticated equipment such as EFM… practitioners simply could not get along without it.” Gaskin describes how, as an invited speaker to ob-gyn residents, she learned only one of the medical professionals had witnessed a vaginal breech birth: “I find it sad that obstetrics has been so dumbed down in the US….What astounded me was the speed of the change in the very content of the obstetrics curriculum…. I learned that the reason… was insurance companies that began threatening teaching hospitals during the seventies and eighties that they would deny them malpractice coverage if they provided opportunities for residents to witness a breech birth attended by an experienced practitioner…. these skills… could easily be taught using pelvic models and dolls in the way that breech skills are still taught in medical schools in other parts of the world.”
Public perception now is that EFM-use is safer for all births.
Sartwelle reminds us that there are hundreds of past and current examples of “widely held medical community fallacies” that persist without question; Michelle Oberman notes EFM-use is but one case of many examples of current SOC practices in medicine that increase risks to health. Let me reiterate: a SOC is not equivalent to evidence-based practices that improve health. The medical profession lacks a mechanism to ensure physicians are up to date with “best practices” and malpractice law fills the void by default. But this only identifies the most incompetent physicians. If a “respectable minority” of physicians still use certain procedures, the law protects them, and the SOC remains unchanged, even if it harms patients.
Neither Sartwelle nor Oberman are hopeful that EFM-use will change through litigation. There are no incentives to stop routine EFM-use: they are included in maternity packages and there are no adverse consequences for hospitals or for physicians who use them routinely. Oberman argues the best way to change the SOC is for insurance to stop paying for it. Even following ACOG’s recommendation of “adopting protocols and training staff to use a hand-held Doppler device for low-risk women who desire such monitoring during labor” would be an improvement for U.S. births.
Obstetric violence has many forms. Women in the U.S. who desire to make their own medical choices during birth should be aware of their options and know that the SOC in giving birth is not necessarily to their benefit.
The Women in Philosophy series publishes posts on women in the history of philosophy, posts on issues of concern to women in the field of philosophy, and posts that put philosophy to work to address issues of concern to women in the wider world. If you are interested in writing for the series, please contact the Series Editor Adriel M. Trott or Associate Editor Julinna Oxley.
Sara Gavrell
Sara Gavrell is Associate Professor of Philosophy in the Humanities Department at the University of Puerto Rico, Mayagüez. She works in applied ethics, normative ethics, and social and political philosophy.
