Birth has transitioned historically from a natural and organic process to a procedure that is typically accompanied by medical intervention. This evolution of birth, its rights, its freedoms and its oppressions affect women and children on a national scale. And whether good or ill, medical intervention is a decision that should be purposeful, not routine.
Birth practices prior to the twentieth century utilized an organic approach to birth. Birth occurred in homes and women were aided by other women. By the turn of the century, hospitals were replacing homes, and by 1935 half of all women living in cities were giving birth in medical facilities. By 1950, only a quarter of births occurred outside hospitals. As birth moved from homes to hospitals, infant deaths did not decrease, but in fact rose seventeen percent. Deaths in hospitals did not begin to decline until the use of sulfa drugs became common and physicians finally agreed to improve their sanitation procedures (Goer, Thinking, 202).
As mothers birthed during the first years of the twentieth century, modifications on the natural process were rare. Medical interventions in labor and delivery and pain relief were initiated by the surgical branch of specialized medicine called obstetrics and women became the test subjects for medical interventions. Today, birth without any medicinal or physical intervention is rare and women and newborns continue to bask on the cutting edge for progressive advancement in labor and delivery protocols (Gaskin p 3).
With the advent of medicine and science, the biological process of what was once a natural occurrence has transitioned. Today most of us join the proponents of medical advancements to agree that medicine has improved many aspects of birth. From high-risk pregnancies, and the mortality of premature babies to medical advancements that impact couples who suffer with infertility, medical innovations have assisted those who suffer with physiological birth challenges. In addition, without the surgical specialization of the obstetric branch of medicine, life-saving, emergency surgical interventions like caesarians would be even more dangerous. Medical intervention appears to be the wave of the future.
Yet, within the current birth practices, which inventions and actions are the result of sound medical advancement and which interventions can actually cause birth complications (Carroll). Could our ignorance of these issues be contributing to an increase in the birth mortality rate of both mothers and babies in America (CIA)?
As medicine and nature blend, it has become increasingly difficult for consumers—parents-to-be, to make informed decisions based on a full evaluation of labor and delivery options. These decisions must include risks and benefits of birth interventions in these decisions because the method and manner of birth can affect the growth and development of children throughout life. However, individualized childbirth decisions can be difficult to make because comprehensive studies on birth practice are complex and nuanced and many times the studies seem too complicated for a consumer to evaluate in the process of deciding the best method for childbirth (Blanchette).
An evaluation of current birth strategies and care giver alternatives are important in taking responsibility for one’s one health choices. One of these is which professionals will attend the birth. 98% of births are now attended by obstetricians--physicians whose training is in the medicine and surgical interventions of childbirth (Goer, Thinking, 243). Family practitioners are medical professionals trained in all aspects of family medicine and who are typically birth attendants in rural areas who have minimal options available for pain relief and surgical interventions. The third labor class of delivery providers are certified nurse midwives—specially trained and more frequently, state certified to attend birth with minimal interventions.
The decision of birth facility is critical to birth outcome (Van Der Hulst). Birthing facilities must be evaluated, ie., hospitals, birth centers within hospitals and births in a home environment. An evaluation of the financial benefits and risks to the medical and insurance industries may be relevant in the birth decisions.
The primary focus of mothers, birth professionals and this paper’s examination is a positive birth outcome—the child. The birth process of a child has been proven to affect the growth and development throughout childhood. As medicine and nature meld, women and children’s health can benefit from solid, statistical information that focuses on obtaining relevant education and evaluating diverse information related to the physiology of birth. This knowledge is what empowers a personal birth experience.
It seems that this is a simple evaluation and that by making an effort to gain knowledge, women will become informed participants rather than merely patients. But the truth is more complicated. Less than 2% of births in America occur with no medical intervention (Gaskin, 5), and a review of the consequences of this casual acceptance of the current medical practices of birth intervention must be made to ascertain why.
As the medical facilitation of birth has increased so have the risks to the mother and the baby. A woman in America has a greater risk of dying from childbirth than do those in the 40 other industrialized countries and that risk is increasing. The maternal mortality rate has doubled in the last thirty years (Amnesty). These numbers are so alarming to birth professionals that recently an industry-wide call for the formation of a National Maternal Mortality Review Committee has been made. The request, published in the July 2017 issue of Obstetrics and Gynecology, makes the case that, “…these numbers are four to five times higher than that of the best-performing nations.” It goes on to state that, “In fact, the United States has the highest maternal mortality rate of any high-resource country” (Clark).
In addition, the birth mortality of newborns in the United States has dropped below seventeen of the high-resource countries in the world (Hamilton), and caesarian rates have increased drastically in the last three decades (Osterman). One-third to half of all babies born today (Goer, Thinking, p 202) are caesarian births. This is “in spite of the fact,” states Dr. Louis Weinstein, chair of the obstetrics and gynecology department at Thomas Jefferson University, “that a Caesarean is 6 to 20 times more dangerous than a vaginal delivery” (Donaldson). Nearly one in four American women gives birth by cesarean section and “one-half to two-thirds of these major abdominal operations were not needed.” (Goer, Myths, 17)
Birth is no different than any other consumer based commodity. Supply and demand are precursors for the wave of medical birth alternatives. Labor/delivery techniques have changed to meet the demands of a free market economy that caters to the consumer and feeds the need as it grows. Obstetricians are aware of the prevailing trend and because their specialty is trained specifically in the surgical aspect of birth, these physicians are positioning themselves to be aptly suited to meet the market demands with labor and birth efficiency.
To get a jump on the prevailing trend, a preemptive study on optional caesarian birth was conducted in Texas in 2006. It investigated how much on-demand caesarians (c-sections) at 39 weeks could benefit babies. This conclusion was based on extrapolation of the number of injuries suffered by vaginal birth babies multiplied by the estimated increase of babies that would be born c-section if women were allowed to opt for an optional c-section at 39 weeks. The conclusion was that injuries to babies that occur during vaginal birth would be greatly lessened with the optional request for caesarian birth at 39 weeks, because the baby would not be delivered vaginally (Hankins). This study neglects to address the significantly increased dangers to the child of c-sections.
In response to trends, advocates for fewer caesarians have statistics that counterbalance the positive effects of optional caesarians with studies of their own. A 1992 Dutch study proved that over the course of one decade between 1982-1992, that c-sections caused 700% more deaths than vaginal births, 28 per 10,000 (Goer, Thinking, 23) Henci Goer, a birth researcher and pregnancy and birth educator and the author of Obstetric Myths versus Research Realities: A Guide to the Medical Literature, challenges studies like the optional c-section one and considers them to be spurious and merely created to promote the intervention of major surgery without valid statistics garnered from accepted birth study protocols (5). Ms. Goer, invites women to consider that, “Cesarean section is the most common major surgery performed in this country… despite the health risks, pain, recovery time and expense.” She also claims again in a subsequent book, The Thinking Woman’s Guide to a Better Birth that, “The consensus of medical literature is that half of these operations were not needed” (1).
In addition, epidurals continue to be the drug of choice for birth. Proponents minimize the risk to babies suggesting that with the large numbers being performed, that epidurals have been improved and are safe (Thorpe). The average rate of epidurals in the US is 61% (Osterman) yet “an epidural increases the odds of cesarean for lack of progress somewhere between 2- and 8-fold, especially in first-time moms and causes fetal distress in about 10% of babies,” (Goer, Myth, 3).
In addition, numerous studies on the effects of labor analgesia and infant brain development have proved that epidural analgesia is connected to increased duration of labor, medical interventions in instrumentation related to vaginal delivery and in birth by cesarean (MacArthur; Eddleston; Thorpe).
Advocates for the medical industry say they are just giving women what they want, and of course it’s up to the consumer or insurance providers to ask, “At what cost?” A hospital makes significantly more on surgeries and epidurals vs. natural birth. Doctors also make significantly more and therefore the suggestion to limit or eliminate birth intervention is going to come from that direction. Jenene Turley, a prenatal birth educator felt compelled to publish a peer-review paper for the Journal of Prenatal Education entitled, “How I Teach Evidence-Based Epidural Information in a Hospital and Keep My Job” (Turley).
The two sides, medical interventionists and natural birth advocates who are debating the issue ostensibly join in empowering mothers, but each differ on what “birth empowerment,” actually means. Medical professionals argue that empowering women is accomplished through alleviating the discomforts associated with birth, i.e., the inconvenience, pain through drug intervention and the benefits of cutting edge technology. Natural proponents offer a biological and organic alternative to low-risk birth situations and insist that this empowers women through education and involvement. Their model of care is not based on the obstetricians “normative standards” of the progression of labor occurring on some prescribed schedule, but instead on a pattern that is individual to each patient. Midwives follow the tenants of noted French physician, Michael Odent. “One cannot help an involuntary process. The point is not to disturb it” (Goer, Thinking, 199).
More discussion on the impact of knowledge on the empowerment of the personal birth experience is called for and insight on what may happen when the patient takes an active interest and more responsibility in health care could be the subject of subsequent research. What might be the result to the mortality of babies in America and the mortality rates of mothers if education encouraged them to transition from patients to proactive participants in evidence-based labor education?
Evidence-based education must begin at the ground-level. For example, while strolling through the New York City Natural History Museum, one may expect to see exhibits theorizing the evolution of man. In the children’s area is an exhibit explaining human birth with a scale model of a baby and the mother’s birth canal. The exhibit descriptor explains that due to evolution, the human brain has evolved such that the skull is so large that medical intervention has become necessary to complete the birth process. Aside from the inherent inaccuracies in the scientific theory of evolutionary process, (Darwin would say that if growth over time has forced an increase in skull size, then that same impetus would influence the evolution of the pelvis,) this exhibit in a prominent city museum is an indicator of the nation’s general opinion of the need for intervention in the natural process of birth as well as an indicator of the need for better birth education.
Current methods of birth practice may reflect scientific opinion, but medical practices fail to adapt when the studies manifest negative results. Surgical obstetrics is tradition based and has become so enmeshed in the economy of health care that any modification of these practices—even those evidence-based—does not motivate change. The question is how can that be? And a possible answer is offered by labor and delivery educator Henci Goer, “Obstetric practice does not reflect the research evidence because obstetricians actually base their practices on a set of predetermined beliefs. If you start from this premise, everything about obstetrics, including the inconsistencies between research and practice, makes sense.” (Goer, Thinking 4).
Neither extensive studies nor grass-roots advocacy has had an effect on obstetric labor and delivery techniques, yet maternal mortality and infant mortality rates continue to stymie medical interventionists. Kathleen Harper, an obstetrician practicing in Nevada wrote a paper calling for more obstetricians to be trained—blaming the increase in the maternal mortality rate in Nevada on the lack of obstetricians (Harper). The author of the paper failed to clarify what is causing the mother and infant mortality and is perhaps unaware of what is adding to the death statistics. Hemorrhage is the #1 reason for delivery-related deaths—and obstetricians rely on surgical intervention to treat this problem. Most hospitals, although mandated to provide operating facilities, are not prepared to facilitate emergency surgeries (Goer, Thinking, 206), and delivering mothers bleed out before they ever get to the surgery.
A significant majority of the deaths--African American women—are a 3-4 times greater risk (Bond). Substandard social structures is one contributor to the problem. Training more obstetricians will not solve the issue of social inequality—nor can their methods become part of the answer. The obstetrician’s traditional birth practice of vaginal delivery involves releasing the mother from the hospital within 12-24 hours and not seeing the mother again for a week. This practice exacerbates the risk to those in difficult social circumstances.
The Maryland study of maternal mortality identified drug use as the other major source of the mortality issue. (MDOHP) This problem can be addressed with the same answer, improved home health care professionals, trained and required to attend a pregnant mother in prenatal and postnatal visits in the home. A professional, like a midwife, identifies interventions for problems related to social inequality. Only midwives are required by law to make extensive before and after-care visits and only those visits can reveal on-going health situations that could be resolved through existing social programs. Until we begin to utilize the birth practitioner who is trained to address these failures, we can continue throwing doctors at the problem without ever experiencing a solution.
There is cautious optimism about the evolution to healthier birth practices. Smart consumers—made even wiser through clearer information and better education will grow to understand their responsibility in this issue and demand changes via the economics of supply and demand. Just last month a newscast was finally shown by CBS TV news, which quoted an Associated Press article from December of the previous year. It recommended to laboring mothers that they require that their doctors allow the umbilical cord to completely deliver all of the cord blood to the baby rather than clamping and cutting the cord immediately upon birth. This small change had been proven to positively affect the well-being of children as long as four years later (Andersson.) The newscast went on to say that although the new policy would cut into the hospital economics (which has a lucrative business in selling umbilical stem cell blood for research,) the long-term health of a child would benefit. But, that study was published back in 2015.
It’s easy to get lost in the mortality numbers and caught up in the birth statistics, but there is more at risk than our national standing in the World Health Organization’s mortality standards. Women are laboring and delivering babies along the cutting edge of technological advancement and consumers must become educated in the true facts of these medical options. Birth cannot always be managed, scheduled and manufactured with the precision of an assembly line; humans are not machines. Caregivers must take their focus off expediency, tradition and consideration of normative procedures and refocus on the individual’s simplistic progression through the birth processes. If even one child or mother is at greater risk because of the expediency of medical interventions, then consumers must respond more judiciously and advocate for safer alternatives. Safer birth demands it.
Amnesty International. “The Maternal Health Care Crisis in the United States,” March 2011, https://www.amnestyusa.org/reports/deadly-delivery-the-maternal-health-care-crisis-in-the-usa/
Associated Press, December 1, 2016, Web: https://www.cbsnews.com/news/dont-cut-umbilical-cord-too-fast-doctors-say-pause-benefits-newborns/
Andersson, Ola, MD., PhD., et. al., Effect of Delayed Cord Clamping on Neurodevelopment at 4 Years of Age, A Randomized Clinical Trial. Jama Pediatr. 2015;169(7):631-638. Doi: 10.1001/jamapediatrics.2015.0358 July 2015, Web https://jamanetwork.com/journals/jamapediatrics/fullarticle/2296145
Donaldson, Susan. “Trying to Take Back Childbirth.” ABC News, July 28, 2008, http://abcnews.go.com/Health/ Reproductive Health/story?id=5462833&page=1
Blanchette, H. “Comparison of obstetric outcome of a primary-care access clinic staffed by certified midwives and private practice obstetricians.” Am J Obstet Gynecol. 1993; 168(5);1407-1413.
Bond, S. “Maternal mortality rates increase in the United States with risk of death 3-4 times higher in African American women.” J Midwifery Womens Health. 2011 Jul-Aug;56(4):404-5. https://www.ncbi.nlm.nih.gov/pubmed/21861303
Carroll, JC et al. “The influence of the high-risk care environment on the practice of low-risk obstetrics.” Fam Med 1991; 23(3): 184-188.
CIA Central Intelligence Agency (US). https://www.cia.gov/library/publications/the-world-factbook/fields/2091.html. October 2017
Clark, SL. et.al., “The Case for a National Maternal Mortality Review Committee.” Obstet Gynecol. 2017 Jul;130(1): 198-202
CDC Home Birth Statistics. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6103a6.htm
Eddleston, JM, et.al. Comparison of the maternal and fetal effects associated with intermittent or continuous infusion of extradural analgesia. Br J Anesth 1992 Aug;69(2): 154-8
Gaskin, Ina Mae, Guide to Childbirth, Bantam Dell, Random House, Inc., NY, NY Mar. 2003
Goer, Henci. The Thinking Woman’s Guide to a Better Birth, Peregee Books, 1999
Goer, Henci. Obstetric Myths versus Research Realities: A Guide to the Medical Literature, Peregee Books, 1995, http://www.hencigoer.com/obmyth/
Hankins, GD, et.al. Cesarean section on request at 39 weeks: impact on shoulder dystocia, fetal trauma, neonatal encephalopathy, and intrauterine fetal demise. Semin Perinatol. 2006 Oct;30(5):276-87.
Hamilton, Brady, et.al. Center for Disease Control, National Vital Statistics Report, Vol 64, Number 6, June 17, 2015 Web. Retrieved 10-15-2017 http://www.cdc.gov/nchs /data/nvsr/nvsr64/nvsr64_06.pdf
Harper, Jenene, “Response to Nevada’s Incidence of Maternal Mortality with more Obstetricians,” Am. Jrnl Obstetrics and Gyn., May 2015
MacArthur, C, Lewis M, and Knox, EG. Investigation of long term problems after obstetric epidural anesthesia. BMJ 1992;304:1279-1282
MDOH Maryland Department of Health. State Maternal Mortality Review (MMR) Program Retrieved Oct. 2017 https://phpa.health.maryland.gov/mch/Pages/mmr.aspx
MDOHP Maryland Department of Health Poster for media release. https://www.acog.org/-/media/Sections/MD/Public/MarylandMMRposter2017.pdf?dmc=1&ts=20170927T1731113112
Osterman, M.J.K, Joyce A. Martin, MPH, Epidural and Spinal Anesthesia Use During Labor: 27-state Reporting Area, National Vital Statistics, Health and Human Service Department: 2008 Retrieved: https://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_05.pdf
Shapiro, Samantha M. “Ina May Gaskin and the Battle for at-Home Births,” May 23, 2012 Web http://www.nytimes.com/2012/05/27/magazine/ina-may-gaskin-and-the-battle-for-at-home-births.html
Thorp, JA, Breedlove G. “Epidural analgesia in labor: an evaluation of risks and benefits.” Birth. 1996 Jun:23(2):63-83
Tumblin, Ann, CD(DONA), LCCE, FACCE. “How I Teach Evidence-Based Epidural Information in a Hospital and Keep My Job,” J Perinat Educ. 2007 Fall;16(4): 69-69
Van Der Hulst LA, et al. “Does a pregnant woman’s intended place of birth influence her attitudes toward and occurrence of obstetric intervention?” Birth. 2004 Mar; 31(1):28-33.