Is it time to push yet? The challenges to advocacy in U.S. childbirth

Women in New Jersey in 2007 demonstrated outside the Underwood- Memorial Hospital in Woodbury. They demanded to know why two women had died in childbirth following cesarean sections at this hospital within a fifteen-day period.1 They sought, at a minimum, the publication of hospital and obstetrician cesarean rates; their efforts garnered regional media coverage and resulted in-very little. The hospital expressed its regret but did not begin publishing its cesarean rates. Ironically, several months after the protest the hospital received a national award for its childbirth services.2 The limited impact of the protest was characteristic of the difficulties faced by those trying to change the nature of childbirth in the United States and serves as a reminder of the challenges faced by patient advocates when the elements needed for successful advocacy are not present. Traditional interest group theory suggests preconditions for interest group development and involvement in the political system: A sense of felt need among individuals resulting from a shared focus on a common problem. To be successful in political advocacy, such groups need to join or develop an organizational structure that provides the institutional support critical to the long- Term commitment necessary for success. Consensus on an identifiable and, ideally, a simple solution to the problem of concern, and a clear place (bureaucratic entity, legislative branch) to target advocates' efforts, will greatly enhance their venture. As is often the case for childbirth advocates, almost none of these characteristics were part of the New Jersey demonstration. Activists had no leverage over the local hospital they were trying to influence and no connection whatever with the local obstetricians. Government officials were able to view this matter as simply a private tragedy. The case exemplifies childbirth's paradoxical dual status as at once a public and a private issue. Steven Epstein's chapter in this volume describes the various types of success patients have achieved in shaping the conceptualization of disease, research agendas, attitudes of professionals, and government policy. One can find examples of attempts at each of these in the case of childbirth, only they almost invariably fail. Efforts to humanize childbirth were largely co-opted by hospitals' adoption of the form but not the substance of change with the development of birthing centers and childbirth classes.3 Officials met with disdain attempts by activists to shift the National Institutes of Health (NIH) research agenda away from cesarean delivery on maternal request. A successful major effort at state reform of hospital practices-extending postpartum stays-was led not by consumers but by groups representing clinicians. Throughout the debates about childbirth policies and practices, the voices of women themselves have mostly remained silent.