Book Review from Salon.com
A doctor assails obstetric care in America
as absurd, expensive and dysfunctional.
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By Annie Murphy Paul
Sept. 6, 2000
In a time of so many gleeful blasphemers and so few sacred cows, it was bound to happen. Most of the tempting marks
have already been hit -- America (agent of global capitalism),
baseball (strikes, spitting, Daryl Strawberry), even apple pie
(Alar-tainted apples, cholesterol-laden crust) -- but there's one
still standing: Mom.
It's a formidable target, and in his new book,
"Expecting Trouble," Dr. Thomas Strong
takes on just one of the cherished myths of
motherhood: the idea that prenatal care is on
the whole a useful and desirable thing.
There's no glee in the judgment Strong
delivers -- he is deliberate, grave, almost
sorrowful -- but there's no mercy, either.
"Much of what passes for prenatal care in
this country is unduly expensive,
unnecessarily high-tech and serves no
beneficial purpose," he declares, "consisting
of little more than a string of pointless, largely
ceremonial clinic visits which infrequently
avert the conditions we most want our
babies to avoid."
In an act of admirable honesty, or
professional masochism, this
second-generation obstetrician is particularly
hard on his own specialty: His colleagues are
too little concerned with patients, too taken
with toys and gadgets and charge inflated
fees for work that nurse-midwives could do just as well.
"Obstetricians," he announces, "are to routine prenatal care
what neurosurgeons are to simple headaches: overkill."
The crux of the problem, he says, is that we've turned a natural,
normal condition -- pregnancy -- into a disease requiring
doctors' intervention. Expectant mothers are "considered sick
until proven otherwise," their pregnancies regarded as
problems waiting to happen. The fact that they proceed
perfectly well 97 percent of the time allows obstetricians to
claim credit they haven't earned, but also obscures the grim
truth that when things go wrong there's often little medicine can
do. It's a deeply unsettling message: We'd all like to think that
our doctors are firmly in control and not, in Strong's ruthless
phrase, "hapless bystanders" -- "heroes if all goes well or
malpractice defendants if it doesn't."
Our need to believe that prenatal care really works has led us
to rewrite the history of public health, says Strong. Falling rates
of maternal death over the past century are often attributed to
the spread of such care, when really they're the result of more
general medical advances, like improvements in surgical and
blood-transfusion techniques and the development of
antibiotics. In our own time, prenatal care is promoted as an
answer to poverty, particularly among teenage mothers, but, as
Strong notes, the problems of the poor are far too complex
and deeply rooted to be addressed by a handful of visits to a
clinic. In any case, those who would make prenatal care
universally available are merely improving access "to a system
that doesn't work," he states bluntly.
That system, in Strong's view, is set up to benefit obstetricians,
managed-care companies, malpractice lawyers -- everyone but
mothers and their babies. The results show up in disturbing
national statistics: The United States ranks 31st among
developed nations in its rate of low-birth-weight babies; 22
industrialized countries have infant mortality rates that are lower
than that of the U.S.
"It is in the United States, where care is provided with such
high-tech flourish, that pregnancy outcomes are among the
worst," Strong concludes. "We spend more for it, provide
more of it and have intensified it more than any nation on Earth.
In return, our prematurity, low-birth-weight and very
low-birth-weight rates have accelerated."
The author has a long list of proposed remedies, most of which
boil down to this: "What is needed is a prenatal care system
that is simpler, less medicalized and more widely distributed
throughout our communities."
Strong isn't opposed to prenatal care itself, he emphasizes, just
the form it currently takes. He'd like to see more smaller clinics,
in convenient places like malls, churches and community
centers. Such clinics would be open nights and weekends, and
would be staffed with nurse-midwives rather than expensive
obstetricians. He would reduce the number of visits required of
women with low-risk pregnancies and would initiate
malpractice reform, limiting damage awards and lawyers'
All reasonable recommendations, and yet there's something
about Strong's exhortations that chafe and arouse resistance.
He's pushing for a more humane kind of care, but his own
manner is coldly austere, almost puritanical. In his zeal to
prosecute doctors with high-profit practices, he shuns all hint of
pleasure or sensuality, even ridiculing a magazine article that
describes a prenatal clinic's "comfortable, feminine, attractively
Likewise, Strong can see no rationale for using the tools of
obstetrics for anything other than strict medical necessity.
"Everybody likes ultrasound -- especially pregnant mothers,"
he concedes. "But obstetric ultrasonography is frequently
performed at the whim of obstetricians for no particular
Apparently, a pregnant woman's pleasure and peace of mind at
seeing her unborn baby don't rise to the level of a "particular
reason." Patients' state of mind, in fact, seems entirely irrelevant
to Strong, who bases his proposal to reduce prenatal visits on
evidence that an increased number of visits does not translate
into lower infant-mortality rates. Never mind that such sessions
are used not only to provide medical care but to allow
expectant mothers to ask questions and receive support and
reassurance. These intangibles are of no interest to Strong, who
prefers to peruse his tables and charts of pregnancy outcomes.
Being pregnant, after all, is not like having a broken bone
splinted or an appendix removed; it involves the utter
transformation of one body in the creation of another, a
profound and joyful outcome the rest of us know as a baby