LAUSR

For humans, birth physiology—the biological process of labor and birth—has not changed in tens of thousands of years, yet birth practice—the manner in which that biological process is managed and modified by healthcare practitioners—has changed dramatically in just the last few decades. The widespread practice of the surgical removal of a fetus, known as cesarean section or cesarean birth, is one of the most provocative examples of that dramatic change in birth practice. The cesarean rate in the United States (U.S.) was 4.5% in 1965 (Wolf, 2018). Today, that rate is 31.9% (Martin, Hamilton, Osterman, Curtin, & Mathews, 2015). That overall number conceals challenging racial disparities. While cesarean rates have dropped for white women down to 30.9%, the rate for Black women is increasing and now stands at 35.9%, the highest for any group of women in the U.S. (Martin et al., 2015; Oparah, Arega, Hudson, Jones, & Oseguera, 2018). Current World Health Organization (WHO) recommendations indicate an international target rate of approximately 10%-15% for cesarean births (WHO, 2015). The current U.S. rates demonstrate the extent to which American obstetric practices are out of sync with international recommendations and the extensive evidence that cesarean rates above 10% do not improve maternal or neonatal outcomes (WHO, 2015). Black women and infants continue to experience the highest burden and incidence of poor maternal and infant health outcomes, including prematurity and maternal and infant mortality (Oparah et al., 2018). Change of this magnitude potentially signals an enormous cultural shift in the way pregnancy, labor, and birth are conceptualized and operationalized. The reasons for this shift are extensive and deeply intertwined, and include historical, economic, social, technological, geographic, bureaucratic, and racist power dynamics, an exhaustive synthesis of which is far beyond the scope of this single article (See Cooper Owens (2017), Davis-Floyd (1997), and Wolf (2018) for book-length treatises on this and adjacent subjects). Here we argue that the current high rate of cesarean birth as a modern industrial medical birth practice is out of sorts with ancient physiological processes, and that a midwifery model of care is key to dismantling the structures that support the deployment of unnecessary surgical interventions. We first provide a brief outline of the complicated choreography of parturition and birth, and the ways in which emotional state can shape physiological processes. We start here because the assessment of whether and how to intervene in labor requires a consideration of the process and timing of physiologic birth. This leads to a discussion of how laboring bodies are deemed failures according to clinical timelines that have been artificially constructed without a solid foundation in physiological principles of context and variation. Next, we will explore how the consent necessary for intervention is influenced by the concept of failure, reliant on broken technological windows into fetal physiology, and complicated by bias and racism. Finally, we will provide evidence that a midwifery model, that incorporates and honors knowledge of physiologic birth and an appreciation of more relaxed timelines, should inform practice to produce results that are consistent with both modern evidence and ancient processes. The term “midwife” used here refers to modern-era U.S. certified midwives, which includes nurse-midwives (certified nurse-midwives [CNMs]), who have training in nursing and midwifery, and direct-entry midwives (certified midwives Received: 27 July 2018 Revised: 7 February 2019 Accepted: 10 February 2019