The Medicalization of Birth and Death

Lauren K. Hall’s The Medicalization of Birth and Death is a comprehensive overview of a complex and controversial topic. Containing extensive interviews with patients and providers and cited research, Hall traces the origin of medicalized obstetric care and end-of-life care, elucidates the shortcomings of the current system, and clearly outlines the need for reform.

Hall begins by crafting a metaphor of the medicalized apparatus of birth and death as a river, in which the currents of insurance reimbursements, risk aversion from the medical field, and historical trends have led to the inexorable centralization of the birth and death processes in sterile, impersonal medical facilities. While lacking the punch of Michel Foucault’s panopticon or medical gaze, the metaphor does a reasonable job of describing the current predicament. Through attempts at reform like the Flexner report (which modernized medical education) and the Hill-Burton Act (which modernized the American hospital system), Hall argues that birth and death were transformed from family-based, decentralized, culturally-specific processes to assembly lines driven by doctors, medical bureaucracy, and an ever-escalating number of interventions that produce little benefit compared to de-medicalized approaches.

One noteworthy chapter discusses the effects of this system on racial and ethnic minorities. Hall asserts that prior to desegregation, black patients often relied on traditional “granny midwives,” who had excellent outcomes even by modern standards. But, as black women were swept into the medicalized system in the 1960s, this led to worse outcomes than their white counterparts. Like their white counterparts, black women were subjected to continuous fetal monitoring, caesarean sections, cervical checks, and other invasive interventions that do not improve outcomes in otherwise healthy women. However, Hall contends that black women were made particularly vulnerable to the biased, invasive touch of usually white doctors, who often treated black patients with disdain.

Hall’s analysis of palliative care and hospice programs also contains interesting insights. She notes that hospice care suffers from underfunding by Medicare and Medicaid, resulting in too many patients dying in hospitals instead of more personalized and cost-effective residential facilities. She also notes the difficulty that palliative care and hospice teams have in integration and coordination—in particular, she describes how palliative care recommendations are not always followed by the primary team and specialists, who continue to focus on chasing lab values or addressing symptoms even when such measures do not extend life.

The final chapter of the book outlines some reasons for hope. Hall cites the example of new birthing centers, staffed by nurse midwives and doulas who practice evidence-based medicine and often headed by maternal-fetal medicine specialists, as a way of decentralizing and de-mechanizing the birth process. She notes also that residential hospice programs continue to grow, offering more culturally-sensitive and individualized care than ICUs. However, many political and legal barriers still exist to further decentralization, chief among them a reimbursement system that disproportionately favors hospital-based care.

Overall, The Medicalization of Birth and Death is a compelling call for de-medicalization of the birth and death process in order to increase individualized, culturally-sensitive care without sacrificing outcomes. It is an especially interesting read for those considering a career in OB-GYN, critical care, geriatrics, or palliative care.