Dr. Marsden Wagner

Dr. Marsden Wagner is a medical doctor from California. He is not only a perinatologist and perinatal epidemiologist but an outspoken supporter of the midwifery model of birth as well.

For 15 years, Dr. Marsden Wagner was the director of Women's and Children's Health in the World Health Organization. He now resides in Takoma Park, Maryland. Dr. Wagner still travels the world to talk about improving maternity care, including the appropriate use of technology in birth and utilizing midwives for the best outcomes.

He is the author of many books on childbirth and maternity care. His books should be read by any mom to be and are:

Born in the USA

Creating Your Birth Plan

Pursuing the Birth Machine

Dr. Marsden Wagner's Educational Background

Dr. Marsden Wagner's Experience

Some of Dr. Marsden Wagner's Honors and Awards

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Dr. Marsden Wagner in His own Words

Following are excerpts from Chapter 14 from "Childbirth and Authoritative Knowledge: Cross-Cultural Perspectives", eds. Robbie Davis-Floyd and Carolyn Sargent. University of California Press.

One evening in the mid-1980s I found myself, a medical doctor, sitting in a small bar at a Swiss resort with three other speakers for a conference to begin the next morning: Rick Carlson, a lawyer, John McKnight, a sociologist, and Ivan Illich, a sociologist. While we came from different professions, we had in common that our recent writings were challenging the authoritative knowledge in medical care. Recognizing this, we began to chat about how we came to challenge that knowledge, and what the roots of such behavior might be. Although we found no common denominator in childhood, we came to see that by the time we reached graduate school, each of us was disenchanted with the system and looking for ways to avoid getting sucked too deeply into it. We found that after finishing graduate school, all four of us went through some kind of gestation period during which we quietly worked our way up through the system. Only after we had some experience in our field and had achieved some measure of professional success did we begin to challenge medical authoritative knowledge.

[...]

After medical school I marched through an orthodox speciality training in pediatrics and neonatology, eventually serving as chief resident in pediatrics at the UCLA hospital. Following several years of active pediatric and neonatology practice, I was dissatisfied and restless, feeling that I was just practicing rescue medicine, not solving the child health problems of the community. So I returned to UCLA for two years of postgraduate study in the science of medicine and public health.

The single most important thing that happened to me during those two years was being exposed to a different paradigm. While the medical paradigm focuses on the individual who comes for help, on sickness, on curing, and for the most part uses the biological approach, the public health paradigm focuses on populations, on health, on prevention, and uses a bio-psycho-social approach.

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Taking a job as Assistant Professor of Pediatrics and Public Health at UCLA, I found myself in two schools with two different paradigms. My attempts to merge the two were naive and ineffective. I was quickly marginalized in the Department of Pediatrics and the medical school. The only reason I was tolerated was because of my credentials as a clinician. During this period I had an important experience. I went on a medical anthropology expedition to a settlement of preliterate Indians living in the Sierra Madre mountains of Mexico.

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In our camp one day there appeared a young Indian family - mother, father, daughter about six years old and a baby of perhaps six months. The family had walked for several days to come to where we were camped and where an Indian healer also camped, because the baby was sick. They presented themselves first to us, and I got out my stethoscope and found a severe bilateral pneumonia. But before I could prepare the syringe of long-acting penicillin, the family left and went to the healer. After seeing the healer, they prepared to leave the camp and return home. Through an interpreter we learned that they thought that my use of the stethoscope was in fact our treatment. When we explained that we were not finished, they were adamant that they wanted no more treatment, as the healing was finished. What to do? The students asked my opinion on what would happen if the baby did not receive the shot of penicillin. I honestly replied that the baby would almost surely die. An argument ensued as to our course of action, sadly split along disciplinary lines.

The medical students said that we must save the baby's life with the shot, even against the parents' wishes. The anthropology students said that such a course of action would be yet another step in destroying this culture and this family, without which neither this baby nor any other baby could survive. The clash of the paradigms, even at graduate student level, did not bode well for our original idea of influencing students while they were still young. Our solution was a compromise which left no one happy. As the baby was being carried on the back of the six-year old sister, we seduced her into our camp with candy and while her attention was diverted by a student, I snuck up behind and quickly injected the baby without the sister's - or the parent's - knowledge. This whole experience pushed me further along towards a fuller understanding of the limits of the medical model and its inability, in its headlong pursuit of curing and saving lives, to solve the health problems of the community.

[...]

My years in the Department of Maternal and Child Health of the California State Department of Public Health provided me with a whole different set of frustrations. My colleagues now feared both doctors and politicians. The politicians used the public health services as a sop to the poor and as a way of keeping the poor in their place. The doctors saw to it that our public health services used the one-on-one - doctor-patient - clinical model and blamed the victims, poor families, who failed to "comply" with us. Public health practice turned out to be a confusing mix of the medical model and the public health model with no room to maneuver, and no possibility for innovation.

It was when I started working as Responsible Officer for Maternal and Child Health for the World Health Organization that, at last, I felt I had the right job.

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Shortly after I started at WHO in 1979, at an annual meeting the 32 countries in the European Region complained that their perinatal services were costing more and more with not much evidence of improved benefits and little evaluation of efficacy. They suggested that our Regional Office evaluate birth services and report back to them. Since perinatal services were part of my responsibility, I was told to do such an evaluation.

I was less than enthusiastic because I had not been involved previously in maternity services. I had been imbued with obstetrical authoritative knowledge during my years of medical training, and never had any reason to doubt its validity. On the other hand, when I worked in the U.S. I had not been blind to some of the evils of the system - nurses doing most of the work and obstetricians getting most of the glory and the money; a double standard of care, one for private and another for publically funded hospitals.

While in California I had heard of an amazing experiment [...] Click here to read the study.

Since I had no experience with maternity care systems, I decided to form a perinatal study group to work with me in evaluating maternity and neonatal services in Europe.

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We started by reviewing the scientific literature and soon came across the gap between science and practice. To confirm this observation, we recruited a scientist not in the group to survey routine obstetrical procedures. We were shocked when the report from this scientist concluded that only approximately 10% of all routine obstetrical procedures had an adequate scientific basis (Fraser 1983).

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At this time I began to make acquaintances and connections in the Danish midwifery community. Primary among them was a midwife, Susanne Houd. She played an instrumental role in exposing me to a system of knowledge radically different from obstetrical AK authoritative knowledge.

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I began to study midwifery, and learned how it was a key profession in birthing in every country in the world outside of North America. I visited midwives in many settings in many countries to learn more about their work. Susanne worked in a hospital - as do most European midwives - but also did some homebirth. She asked me if I would like to accompany her to a homebirth and I agreed.

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It would be impossible for me to exaggerate the influence of my experience with homebirth on my opinion of obstetrical authoritative knowledge and practice. Home birth is as different from hospital birth as night is from day. Trying to describe home birth is like trying to describe sexual intercourse - you can give the outlines, but you can never adequately describe the personal dynamics, feelings, ambience.

I went to homebirths in a number of countries to try to learn what I could about this way of birthing. I began to look at the scientific literature on home birth, and soon discovered that home birth had been a pivotal issue in the formation of obstetrical authoritative knowledge. It became clear that obstetrics had taken a completely irrational approach to homebirth which was most curious. The scientific data showed it to be as safe as hospital birth for a woman with an uncomplicated pregnancy, and yet obstetricians roundly condemned it.

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Eventually it became clear to the Group that there were two central issues in the debate over maternity services. The first issue concerned who was to control maternity services. Home birth was a sub-issue, since the hospital is doctor territory, where physicians have control, whereas they are not in control in the family territory of the home. A much larger and more central issue of control was the place of midwifery in maternity care. We gradually realized that the midwife-obstetrician controversy had been going on for at least two centuries. All over Europe, the obstetricians were succeeding in marginalizing midwives and gaining rather complete control of maternity services, in spite of clear evidence of benefit from midwifery.

The second issue was appropriate use of technology. The Group soon uncovered the large gap between the scientific evidence and the widespread use of obstetrical technology.

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We soon learned that when it came to questions about control - including home birth and midwifery - and technology, obstetricians were adamant and unwilling to consider change, even in the face of compelling evidence.

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The Study Group decided to do a cross-national survey of these alternative services, and recruited a midwife and a medical sociologist to do the study. The midwife, although fully accredited after orthodox training and practice, had also been involved in some alternative practices, and the sociologist had extensive experience with research in reproductive health. To our knowledge, such a survey of alternative birth had never been done, and the findings made it apparent that there was a vast knowledge completely outside of obstetrical authoritatice knowledge.

[...]

At the end of the Perinatal Study Group's five years of work, it was my responsibility to pull it all together into a report. I decided to write it without the usual WHO jargon, and to write it so that anybody could understand it. The result was a WHO book, Having a Baby in Europe (WHO 1985).

[...]

The result was a body of knowledge about maternity care very different from obstetrical authoritative knowledge, as the former is based on the public health paradigm, while the latter is based on the medical paradigm. And this body of knowledge based on the public health paradigm would be hard to discredit, as it carried the heavy authority of the WHO.

By medicalizing birth, i.e. separating a woman from her own environment and surrounding her with strange people using strange machines to do strange things to her in an effort to assist her - and much or all of this may sometimes be necessary - the woman's state of mind and body is so altered that her way of carrying through this intimate act must equally be altered.

The result is that it is no longer possible to know what births must have been like before these manipulations. Most health care providers no longer know what non-medicalized birth is.

Almost all women in most developed countries in Europe give birth in hospital, leaving the providers of the birth services with no genuine yardstick against which to measure their care. What is the range for length of safe labor? What is the true [i.e. non-iatrogenic] incidence of respiratory distress syndrome in newborn babies? What is the incidence of tears of the tissues surrounding the vaginal opening if the tissues are not first cut? What is the incidence of depression in women after "non-medicalized" birth? The answer to all these, and many more, questions is the same: no one knows. The entire modern obstetric and neonatological literature is essentially based on observations of medicalized birth. [WHO 1985:85]

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Many times, I have witnessed how, if a midwife, nurse, or lay person - including social scientists - makes statements supporting the public health model of maternity services, the advocates of obstetrical authoritative knowledge assume a condescending posture and dismiss this person as ignorant, not worthy of attention. But because of my credentials as medical specialty practitioner, my earlier academic appointments, and my position with WHO - and also perhaps the fact that I am a man- this approach was obviously not appropriate for me. Something different was required. So the strategy in my case was to attempt to isolate me from the Study Group and from WHO and take away my authority by discrediting me. Most of the attempts at discrediting were carried out behind my back, so that I would have no chance to respond.

[...]

Similar skepticism was evident in the orthodox obstetric establishment in Germany. When the German Obstetrical Association wrote to their Ministry of Health demanding that homebirth be outlawed, I wrote to the same Ministry of Health suggesting that we organize a meeting in Germany to discuss the scientific information on homebirth. The Obstetrical Association replied that they would never meet with me because I was "subjective and incapable of rational discussion on home birth."

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Attempts to personally discredit me are usually of three types. First, I am not an obstetrian, and only obstetricians have the necessary expertise. My answer to this is to use an analogy that is easily understood by my - sports-oriented - critics. Maternity care is a football game and the obstetricians are the players running up and down the field. But every good team has a coach - reproductive scientist - who does not play but is on the sideline carefully watching the overall patterns of play.

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The second common accusation is that I am not objective. Doctors have been saying this to women, patients, and politicians for a long time. Such a strategy backfires, however, when it is identified as part of a discredited paradigm - the classical Cartesian model. It is extraordinary that medical education still fails to teach the scientific realities that there is no such thing as objectivity, and that every doctor is as subjective as his patient. How often I have heard that I am against progress. To criticize technology is tantamount to criticizing science and progress. The misunderstanding that technology = science = progress is widespread in medicine. A strange dichotomy exists in which, if I am not in favor of all technology, I am against all technology - you are with us or against us. I find it necessary to repeat often that the technology is not bad but can be misused, that doctors are not bad but can make mistakes.

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I am always met with the reasonable question, but why? Why would intelligent doctors continue practices which science has shown to be wrong? The public finds this difficult to believe, much less accept, and in the beginning so did I. But as the power of the profession was turned against me I came gradually to realize that I had misconstrued the medical profession. Doctors are not bad individuals, but they are human and members of their community and have all the biases and motivations that entails. Furthermore, as a group they often focus on concerns irrelevant to people's health. I remember being somewhat taken aback when I first realized as a young doctor that the American Academy of Pediatrics, of which I was a member, had two goals: to advance the health of children, and to advance the wellbeing of pediatricians. In this second role, the Academy functioned like a labor union, and if the two goals came into conflict, as sometimes happened, the second goal almost always took precedence.

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Convenience is the best explanation for the fact that induction of labor is so common in many countries that there are statistically significantly fewer births on weekends and at night. Willingness to change involves willingness to admit that you have been doing it wrong. This may help to explain why most obstetricians still prefer the woman to deliver on her back with her legs up during birth even though we have known for decades that, scientifically speaking, that is the worst possible position.

Territory, power, and control are certainly involved in the way obstetrics has tried for a long time to suppress midwifery practice (see Arney 1982). Most recently, studies by medical anthropologists have shown me how many obstetrical routines have cultural rather than medical determinants (Kitzinger 1978, Rothman 1982, 1989; Martin 1987; Konner 1987). Davis-Floyd, for example, notes that the routine use of the electronic monitor conveys to birthing women the message that their bodies are defective machines dependent on these man-made machines and the authoritative knowledge vested in the technical experts who can manipulate and interpret them (1992:104-111). She suggests that these and other routine obstetric practices make not scientific, but ritual and symbolic sense as transmitters of technocratic core values. From my perspective, such insights are valid and useful, but they would be rejected out of hand by orthodox adherents.

When I speak about such non-medical determinants of practice, I am told I am "doctor-bashing." Any criticism whatsoever of physcians is called "doctor-bashing." Whence comes this term? I can criticize my auto mechanic and I am not "bashing." I can tell a joke about lawyers and I am not accused of lawyer-bashing. (Note the paucity of doctor jokes, most of which are about how godlike doctors are.) As part of my paradigm shift, I came to realize that the medical profession has a set of mechanisms meant to set them apart from the rest of society, to protect them from any outside interference and to make their AK and AP sacrosanct. To not be able to say something negative about doctors without being labeled a doctor-basher is just such a mechanism. Another is obvious - to insist that one cannot possibly understand the obstetrical paradigm unless one is an obstetrician.

The trappings of doctors are another mechanism to set us apart. Why do doctors wear white coats? There are certainly no hygienic reasons for it - white material is no cleaner than any other color of material, and darker colors would certainly be more practical. Yet I can go to any country in the world, visit any hospital, and there, without fail, are the white coats. When I was an intern at UCLA hospital there was even a strict hierarchy of white coats - one type for interns, another for residents, another for attending physicians. Of course, white is on top of the color scale in many countries, especially Western ones. It symbolizes refinement and purity, as in white flour, white rice, and white sugar (all of which have had their nutrients stripped away). It is the color of priestly vestments - as Robert Mendelsohn so aptly pointed out in Confessions of a Medical Heretic (1981), the hospital has become the cathedral of the 21st century.

Why do we put "Doctor" in front of physicians' names in everyday conversation? We don't say "Lawyer Jones." The only other profession with such an honorary title in everyday language, not surprisingly, is the priesthood. So often I have heard a doctor who is addressed as "Mister Brown" correct the speaker and say "It is Doctor Brown." From long personal experience I can assure the reader that being called Doctor morning, noon, and night has a profound effect on one's self-image. For some years now I have carried out an interesting experiment. I have tried to excise "Doctor" from my name - from everyday conversation, from letters, from participant labels at meetings, etc. It is difficult to do so. If I say to someone, "Please don't call me Doctor, as that is not what my mother named me," they are confused and embarrassed, and often I get the impression they think I am a crackpot.

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Since then I have testified in court in a number of countries and in every case involving a jury the midwife - or doctor practicing an alternative approach - has won while in every case involving only a judge, she has lost.

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The fact that caesarean section carries serious risks for both woman and baby seems to be one of modern civilization's best-kept secrets. Why is it that an article in a leading American obstetrical journal proving that elective repeat caesarean section has a 6 times higher maternal mortality than vaginal birth (Pettiti et al. 1982) had no apparent effect on the rapidly rising caesarean section rate in that country? Why can a leading medical journal, in all apparent seriousness, publish an article suggesting that all birth be caesarean sections (Feldman and Freidman 1985)? Why is it that when the possibility of caesarean section arises, women are not told as part of their informed consent that the procedure increases the chance of their dying and increases the chance that their baby will have a life-threatening illness? [1994: 185-186]

Dr. Marsden Wagner: Reviews

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