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Profesor Wagner, could you at the beginning of this interview briefly recap your professional career?

After some years of medical practice, I returned to the University of California at Los Angeles on the full time faculty in Pediatrics, Obstetrics and Public Health. Then I was Director of Women’s and Children’s Health for the State of California, after which I was for fifteen years a Director of Women’s and Children’s Health for the World Health Organization (WHO). Near the beginning of my work at WHO, the countries requested me to investigate why they were spending more and more money on maternity servivces with little or no improvement in mortality rates for women and children. I formed a multidisciplinary WHO perinatal study group which collected information on maternity services. It was here we uncovered the big gap between obstetric practices and the scientific evidence and also the rush to medicalize birth, using more and more inadequately tested technology in obstetrics. So I started a series of WHO publications on appropriate maternity care services and these publications continue to this day. I am now retired from WHO, working as an independent consultant.

What was it that took you to your broad activities in the field of obstetrics?

I mean this was not your initial specialization…

My interest is in prevention. After training and practicing in neonatology, I realized that many problems of the newborn baby are related to what happens before birth so I returned for two years of post-graduate University training as a preinatologist (neonatology and obstetrics) and perinatology science. I trained as a scientist because there is a big gap between what obstetricians do and what science says should be done. More good research needs to be done and, more importantly, the existing research results need to be put in practice. My work focuses on improving the scientific quality of the practice of obstetrics.

So called „modern" obstetrics is being criticized for its excess medicalization and use of technology. What are the roots of this ill-balanced approach?

After World War Two came the technological age. If we can go to the moon, surely we can save all babies if we just have all the births in hospital with all the technology right there. Even today, most doctors believe that moving birth to the hospital was the reason for the falling rate of perinatal mortality. Thanks to scientists, we know that perinatal mortality has declined largely due to social factors such as better housing, better nutrition and family planning. And an important role in saving babies’ lives is also played by very basic medical factors such as antibiotics and safe blood transfusion. So it is not because of the move to hospital or because of any of the high tech interventions. But in spite of this and in spite of no scientific evidence that hospitals are safer for women with no pregnancy complications, birth was moved to hospitals and many interventions, including the use of new drugs and new machines such as ultrasound and electronic fetal monitoring, came into widespread use without adequate scientific evaluation.

The zeal for medical-guided birth declined in the democratic countries after several decades…

The reaction against the medicalization of birth began when women became aware of how their maternity had been stolen from them and when it appeared that the dehumanization of birth had a distinctly harmful influence on the mental health of the whole society. In western countries the 1980’s saw the recognition of what was evolving as two quite different approaches to maternity care: the medical model advocated by doctors and the social model advocated by most midwives, most perinatal scientists, many public health professionals and many women’s groups. The realization came that the medical model works quite well for disease and injury but does not fit well with life cycle and family events. Then the scientific evaluation of maternity services came in earnest and revealed startling truths about the use of technology, such as, giving only one example, that routine use of electronic fetal monitoring on every birthing woman sharply increases the rate of unnecessary cesarean section while not lowering the rate of dead babies. The fundamental change from peer standards of practice to evidence based practice had begun. And all the increasing evidence tended to support the need to expand the medical model to include the social model as well and to give all women a choice.

However, as it looks, the social model of birth has no appeal for most obstetricians…

But you can´t be surprised at all by that. My own experience as a physician helps to illuminate. The first time I attended a birth outside hospital, yes, I was invited by a midwife to a homebirth, I was shocked. I had already practiced medicine for years but this was the first time I witnessed the full power of a woman in control of her own body. Believe me, it’s a most scary experience for a man. It took me a long time to figure out the truth: men are afraid of women, afraid of unleashed nature, afraid of childbirth. We’ve all heard about "penis envy" but here’s "womb envy", an abiding sense of male inadequacy in the face of women’s unique child-bearing gift. You know, men are outsiders at birth, always have been, always will be. But watch out. Hell hath no fury like a man devalued. When men are afraid and angry at being afraid, they cope through denial of their fear and through controlling whatever they’re afraid of. So the male dominated obstetric profession tries to control birth, an impossible task unless you find a way to stop the process.

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To stop the process of birth???

Labor is a function of the autonomic nervous system. Even the woman herself has no control over it. The way, then, to control birth is to override normal uterine function with drugs to start or accelerate labor, inhibit the normal physiology of labor with epidural block and turn birth into a surgical event by pulling or cutting the baby out. Birth must be in hospitals because the hospital is doctor´s territory and doctors have absolute control here. Doctors fear out-of-hospital birth because they are afraid of birth and because they have no control outside the hospital. The two overriding characteristics of the vast majority of obstetricians which result in their reluctance to respect the natural birth process, are in my opinion, their dire need to be in control of the birthing woman and the deeply emotional fear of childbirth coming from a conviction that childbirth is dangerous. If you don’t believe me ask obstetricians to tell you about all the risks of childbirth and all the women and babies they have pulled back from the precipice of death during childbirth. What goes on in the hospital during childbirth is driven by fear. Dovetailing with obstetricians´fears of natural, normal birth is that if the birth is under way spontaneously and does not require any actions from the outside and when, moreover, it takes place in a freestanding birth center or (God save us!) at home, the doctors have lost all control, all power and – all the money. Because don´t forget that maternity services can be a big money maker for a hospital.

How widespread is the use of the medical and social model in the world?

The past twenty years have seen a struggle between these two approaches to maternity care and it has become intense and global. Today there are three kinds of maternity care: the highly medicalized, "high tech", doctor centered, midwife marginalized care found e.g. in the U.S.A., Ireland, Russia, France, Belgium, Brazil, Hungary and – yes, in the Czech Republic; the humanized approach with strong, more autonomous midwives and much lower intervention rates found, for example, in the Netherlands, New Zealand and the Scandinavian countries; and a mixture of both approaches found, for example, in Britain, Canada, Germany, Japan and Australia. The question always is if the legal system of a country sees the relationship between the obstetrician and midwife as one of supervision, control and liability or rather as a collegial relationship like e.g. the family physician and cardiologist. Let us take America as an example: obstetricians mostly "supervise" midwives here and so doctors are liable for what midwives do or don’t do. Most American obstetricians insist that even if the birth takes place in an alternative birth center or in the woman’s home, the doctors are still responsible if something goes wrong and therefore liable. As a result, the obstetrician’s insurance premiums go up if they agree to back-up out-of-hospital birth and they fear getting sued. But who said obstetricians are always responsible, even with planned out-of-hospital birth? It was the obstetricians themselves. The thruth is that organized obstetrics in the U.S. could rather quickly change the present system so that they are no longer responsible for or liable for midwives. But they don’t want to change this system because they don’t want to give up control of midwives. So the American reality is quite sad. Caesarean section is the most common major surgery performed in this country, and even the consensus of the medical literature is that half of these operations were not needed. At many American hospitals today almost every labouring woman has an epidural. Virtually no pregnant woman managed within the conventional medical system escapes without having tests, drugs or procedures that studies often show as risky.

How does the manipulative attitude of the American obstetricians that you described conform with the general principles of American democracy?

In America, the hospital is the last remaining place with an autocratic organization and a dictatorial hierarchy of doctors. A big struggle is taking place today in American hospitals as women and families fight for control over their own bodies and their own care. Earlier doctors could perform a „forced" cesarean section against the woman’s wishes but now the courts have ruled against such absolute power of doctors and hospitals. The earlier "informed consent" forms signed by women on admission to hospital giving doctors permission to do whatever they want to her are changing to „informed choice" in which the doctor is required by law to give absolutely full information on the possible risks of any procedure before the procedure is done, what alternatives are possible to this procedure and the choice for each procedure is given to the woman. Democracy, individual freedom and the sanctity of the family is gradually coming into American hospitals and health services again.

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And what about American women? How frequent is their wish to have birth without medical interventions?

American women have had decades of brain washing by doctors about how dangerous birth is and how they can’t possibly begin to understand pregnancy and birth much less do it themselves. The result is a generation of women totally dependant on doctors and running to the doctor every time their baby has a runny nose. But gradually women are being educated to the truth about their bodies and what they can do. Midwives everywhere understand this and midwifery care, unlike doctor care, supports and empowers the woman in believing in her own intuition and own body and abilities. And research shows again and again that midwives do far less unnecessary medical interventions, all of which carry some degree of risk. This is why primary care during pregnancy and birth must be given to midwives, not doctors. And excellent research by the Centers for Disease Control in America proved that for the 85% to 90% of women who have no serious medical problems in their pregnancy, midwives are safer than doctors as the one to assist at the birth. This is why in those countries where midwives do give all the care for most women during pregnancy and birth without any doctors around, they loose the fewest babies and women around the time of birth, fewer deaths than in the U.S. and in the Czech Republic. So more and more American women are learning these facts and choosing midwives and choosing to give birth without all the unnecessary interventions pushed on them by fearful doctors. They are learning that birth is something they do, not something that happens to them.

How exactly would you explain the term "humanized birth"?

Humanized birth means putting the woman giving birth in the center and in control so that she and not the doctors or anyone else makes all the decisions about what will happen. Humanized birth means understanding that the focus of maternity services is community based primary care, not hospital based tertiary care. Humanized birth means maternity services which are based on good scientific evidence including evidence-based use of technology and drugs. Humanizing birth means understanding that the woman giving birth is a human being, not a machine and not just a container for making babies.

Would you then label the medical birth as "inhuman"?

I do not want to maintain that the doctors in hospital will not be polite to you but the problem is that this alone does not suffice. The problem is that no patient has ever been in complete control in the hospital. Giving women choice about certain maternity care procedures is not giving up control since doctors decide what choices women will be given and doctors still have the power to decide whether or not they will acquiesce to a woman’s choice. As a matter of fact in the hospital, induction is frequent and uses powerful drugs which increase the pain and have many risks. In the hospital, staff are not always present but come and go and change every eight hours. In the hospital, the new baby is taken away from the mother for various reasons such as doing a newborn examination when the scientific data is clear that the baby should never be taken from its mother at any time unless the baby has a serious medical condition. In the hospital, when the woman and baby are discharged, there is no follow-up in the community for the family with the new baby. Another problem is that birth attendants, be they doctors, midwives or nurses, who have experienced only hospital based, high interventionist, medicalized birth cannot see the profound effect their interventions are having on the birth. These hospital birth attendants have no idea what a birth looks like without all the interventions. It is tragic but true that many times when I give lectures to a room full of obstetricians and I present the scientific data proving the safety of out-of-hospital birth, the doctors in the room are angry and reject the best data, insisting that birth centers and home birth are dangerous. Then I ask that every doctor in the room who has ever in their life been at a home birth to please raise their hand and not one hand goes up. They are afraid of the unknown. If a patient disagrees with the hospital management and has failed in attempts to negotiate the care, her only option is to sign herself out of the hospital.

Now we have changed to the very delicate topic of out-of-hospital births … An important strategy in the obstetricians’ fight against any kind of planned out-of-hospital birth is to say it isn’t safe. What is out-of-hospital birth really like and - is it safe?

If we speak of births outside hospitals, chiefly we mean two main themes: births in out-of-hospital alternative birth centres (ABC) and planned home births. Let´s start with choosing an alternative birth center: Here the birthing women can be in control of giving birth, be empowered by birth, be assisted by a midwife and still feel comfortable and protected by an institution. But the type of care provided in an ABC is different from a hospital. In a hospital the doctor is always in absolute control while in an ABC the woman is in control. In the hospital the emphasis is on routines while in the ABC the emphasis is on individuality and informed choice. Hospital protocols are designed with all the possible complications in mind while ABC protocols focus on normality, screening and observation. In hospitals, pain is often defined as an evil to be stamped out with drugs while in the ABC it is understood that labor pain has a physiological function and can be relieved with scientifically proven, non-pharmacological methods such as immersion in water, changing position and moving about, massage, presence of family, continuous presence of the same birth attendant and so on. The question as to whether the ABCs are a safe place for a woman to give birth if she has had no complications during the pregnancy is a key question because in the struggle between the medicalized and humanized approaches to maternity care, the ABC is a big threat to doctors and hospitals and the industry producing all the obstetric technologies. As I have already said - medicalized birth is very expensive with costly hospital stay, highly paid obstetricians using so much costly high tech intervention and so on. The doctors and hospitals must convince the public and those who control funding of health services that their way is the only safe way. Otherwise they will quickly lose much of their business. So obstetric organizations usually fight against all births where they are not in control. Their first line of defense against any planned out-of-hospital birth is to label it unsafe. But the only way to determine if ABCs are safe is to turn to the scientific evidence. The safety of ABCs has been confirmed by many studies done since 1980 until today. You can read them. In all of them the outcomes of ABC births were as good or better than the outcomes with hospital births. But the first essential characteristic of an ABC must be that it is free of any control by a hospital.

But some Czech obstetricians support the idea of so called „family rooms inside hospitals". And indeed some of these special birth centres really work within Czech hospitals and women travel to give birth here from over the whole country. So even in hospital you can experience a wonderful birth if the staff is „enlightened". What do you think of this?

Recently, when I was in the Czech Republic, I traveled to Vrchlabi, this beautiful small city in the hills, where I visited the hospital and saw their birth center. It was clear the head-obstetrician there was truly humanistic and was surrounded by a wonderful group of humanistic midwives so that their in-hospital birth center provided humanistic birth. This is ideal and in a perfect world every hospital in the Czech Republic could be like this. But it is absolutely clear that today nearly all obstetricians do not have the humanistic approach but the medicalized approach and when these doctors establish an in-hospital birth center or family room, it is not really a family room but a false family room. They may put a rocking chair in the room, curtains on the windows and "permit" the husband to be present, at least some of the time, but the reality is that the family is not in control, the doctors remain in absolute control. For them to call such a place a "birth center" or a "family room" is like the big bakery with the sign in the window "We sell home-baked bread". This is why it remains necessary today for most birth centers to be established outside the hospital if there is to be any hope of escaping the controlling influence of the doctors.

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Let´s change to homebirth now…

There have always been and always will be women who choose planned home birth and these women will need a midwife to attend the birth. Today, as a result of decades of obstetric propaganda you can hear everywhere the myth that home birth is dangerous. But when you read thoroughly and impartially serious studies that have been written about homebirth so far, you will find that, provided there is sufficient organization of services and communication between the home birth midwife and the hospital staff, these homebirth are quite safe. A study in the U.S. and Canada, reported in 2001, found that in over five thousand planned home births with midwives only in attendance, there were no more deaths of women and babies than in similar low risk hospital births. So the biggest barrier remains the irrational fear and anger that many doctors and nurses have about home birth, and there is often no communication between home birth midwives and hospital staff. If complications arise during the home birth, time may be lost if the hospital fails to prepare for the woman and baby when the midwife calls and says she is coming in. When the midwife arrives at the hospital with the baby, all her information about the pregnancy and what happened during the birth is lost if the hospital staff doesn’t believe the midwife has anything to contribute. Because hospital staff are often abusive to both the midwife and the parents, midwives may hesitate to call for advice or hesitate to transport early when signs of possible trouble first appear, a tragic effect of the marginalization of midwives and home birth by the punitive medical establishment. I have personally seen a number of examples where the obstetricians‘ and neonatologists‘ irrational fear of out-of-hospital birth has blinded them to seeing what was really going on and be willing to help. As if their head and even their heart have been literally petrified by that fear. In the Netherlands, where one-third of all birth is planned home birth with only a midwife to assist, there is wonderful communication between the home birth midwife and the hospital and in the Netherlands fewer women and fewer babies die at the time of birth than in the Czech Republic.

You have visited the Czech Republic several times on business and you have given lectures and interviews here. What are your impressions from the Czech obstetrics atmosphere? Have you often talked to Czech obstetricians?

I have been to the Czech Republic and to the former Czechoslovakia twenty to thirty times, often staying several weeks, traveling all over your beautiful country and visiting many hospitals and talking with many doctors. Czech obstetricians receive excellent orthodox medical and technical training and seem to me to be devoted to giving good care. The tragedy is that, with few exceptions, they have been indoctrinated with the old-fashioned, out-of-date traditional ideas about medicalized birth and all its dangers and the need for the doctors to "save" all the women and babies. Most of them have not had the opportunity to visit places like Scandinavia, the Netherlands, New Zealand to see with their own eyes how humanistic birth can be provided and still be perfectly safe and how midwives can be the only one giving care during pregnancy and birth, referring those few women with serious medical complications, and such a system of maternity care can still be perfectly safe. Humanistic birth is spreading all over the world, I have seen it with my own eyes - conferences on humanistic birth with thousands of participants in Brazil, Japan, China, the U.S., Great Britain, etc. Too often in the Czech Republic, an older Professor of obstetrics from Germany or Austria or Hungary is invited and brings all the old prejudices, myths, fears about birth to your doctors. Sadly, there is an orthodoxy among many obstetricians that gets passed on to the new generation and it is difficult to break up this vicious cycle. This is what is happening today in the Czech Republic. But don’t worry, the old "modern" ideas of high-tech birth will gradually disappear as the "post-modern" ideas of humanistic birth spread.

We have spent most of our interview on the health or psychological aspect of birth. In closing, could we briefly consider birth as a topic with a profound political impact on society …

Birth is political. Showing women, half of all people, that they are inferior and inadequate by taking away their power to give birth is a tragedy for all of society. On the other hand, respecting the woman as an important and valuable human being and making certain that the woman’s experience while giving birth is fulfilling and empowering is not just a nice extra, it is absolutely essential as it makes the woman strong and therefore makes society strong. There are two real political issues connected with birth: Freedom of the woman and sanctity of the family. Freedom of the woman to control her own body and her own reproduction, to get accurate, full information on her choices for pregnancy and birth and to not consent to what some doctor says but rather to freely choose what kind of childbirth she will have. Family sanctity means an understanding that it is the family that has the right to decide what will happen not only to the woman but to their child. If there is solid evidence that a family is abusing a child, then society can step in but otherwise not. But too often today the claim is made that the obstetrician must protect the best interest of the fetus by overriding any woman’s choice not approved by orthodox obstetricians. So when some obstetrician says home birth is child abuse, he not only ignores all the scientific evidence, he is also using his own irrational bias and fears and the influence of his position to try to deny women and families their freedoms and human rights. To limit the information and choices in any way is to go down the road to medical fascism. An essential strategy for advocates of humanized birth is to be politically active. Politicians and government agencies make crucial decisions about maternity care and their education about and involvement in humanization of birth is essential. Advocates of humanized birth must warn politicians and policy makers of the use of scare tactics by some of the reactionary elements of the medical and nursing establishment who raise the issue of safety and claim without a shred of evidence that humanized birth is dangerous, that midwives are less safe than doctors and out-of-hospital birth is less safe than hospital birth. Central to their scare tactics is the approach "But what if something goes wrong?" If they only read the evidence they would see how inappropriate and false their attitude is. Often doctors attempt to overwhelm legislators with technical language which implies that only doctors can possibly understand, so the listener must simply accept "trust me, I’m a doctor". Politicians and policy makers should be urged to ask those making these scare statements to "Please show me the scientific data to prove what you are saying." So political battles are fought at the level of state boards for midwifery, for nursing, for medical quality assurance. But these battles are very important and inevitable. Maternity care needs turning around so that, instead of drifting away from physiology and from the social and cultural environment, the process moves toward respecting and working with nature and with the woman and family, turning control of medical care over to the people.

My last question: You have heard about the proposed new healthcare law, which is now in Czech Parliament and which will define the future of obstetrics and midwifery in the Czech Republic. According to this law midwifery should be strongly marginalized. ABCs and home-births should be made nearly impossible, because although not explicity forbidden, any professional helping a woman give birth outside hospital may be prosecuted. What are your opinions on this proposal, and how would you advise Czech lawmakers ?

Such a law would in no way improve the safety of birth in your country. Such a law would go against the best scientific data on safety and simply show that the doctors have succeeded in convincing the politicians that they, like the doctors, should fear childbirth, a fear for which there is no scientific evidence. This law would set the Czech Republic back many, many years to those tragic times when there was no real freedom or individual rights or respect for the family in your country. I visited your country many times during those years and saw how despondent the people were and how, underneath it all, they continued to dream of the day when they would have their freedom. Now you have this freedom and you must be very vigilant not to allow any forms of control to take these freedoms away. This new law, by marginalizing the very midwives who are so essential to providing an empowering birth experience for your women will result in a weaker, more dependant and less free new generation of Czech women. By putting any kind of barriers in the way of women and families to chose the place of birth they want, including out-of-hospital birth, such a law would be taking away the freedoms of your people and taking a big step backward in the bad direction. But you can’t fool all the people all the time and your people have struggled too hard and too long to allow any denial of their rights to control their own lives such as this law would do. And for those who fear chaos, remember Churchill’s warning: "Democracy is the worst form of government until one considers the alternatives."

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Profesor Wagner, thank you very much indeed for this interview.

Eva Labusova, Aperio, February 2003