Apparently, men have been writing the books (literally) on birth since the beginning even though they knew little about it, and were unable to attend childbirth for many hundreds of years or more. Not surprising. Having read many feminist books about the anthropology of birth, this is not news, but just the little she spoke about it in the interview shows that she has done her research. We can see medical involvement in birth evolve before our very eyes!

One point she brings up in the interview is that before the natural birth movement that reached its pinnacle in the 1970′s, women were demanding twilight sleep during birth and it was a feminist stance to demand that they don’t feel a thing during labor. It was their right. In the 1970′s, it became a feminist issue to have a natural birth, on their own terms and be present for it all. And now the pendulum swings……

The conclusion Ms. Hutter Epstein comes to is this: The issue is not pain medication or no pain medication. For decades, perhaps even millenia (I need to read the book) certain women have been dissatisfied with their doctor patient relationships and have demanded the opposite of what has been proposed to them thus creating a gradual swing in cultural thought around labor and birth. (See? My point all along. If women have power nowhere else, they can have it during birth.)

This is why it’s important in this day and age that midwives, nurse-midwives and doctors all be able to practice within their scope of practice, without restrictions and threats of legislation against one another. There are birthing women for every type of birthing practice and there should be truth and transparency about all the different approaches so women can make informed decisions about how they would like to (ideally) birth. Institutions build on a patriarchal platform like the AMA (and dare I say the ACNM) are fighting for more than their piece of the pie by putting down the ‘less educated’ practitioners. I think the evidence is pretty clear. Outcomes are nearly the same, and if anything, the medicalized ‘safe’ birth by ‘the most educated’ is in fact the least safe.

Assisting birth is learned best hands-on. It is a natural process that sometimes requires intervention which may or may not require classroom education. These organizations are missing the point, even after all these years. Women want choice. Some want an epidural after their first contraction. Some want a c-section on a certain date without ever going in to labor. Some want a natural hospital birth, some want a home birth- and everything in between. Many do not get what they want, but it should only be due to the circumstances of their particular birth situation, not because of lack of choice.

Perhaps Ms. Hutter Epstein’s book will open up a dialogue. Birthing women have been through countless atrocities and lack of power or choice at the hands of the medical profession and their interventions with birth. Medicine has also done great things and saved many women’s lives. Still, the maternal mortality rate is not what it should be, and we still need to be looking at why and try not to repeat mistakes made in the past, and identify mistakes we are making in the present. We need to be constantly and vigilantly looking at what works, and what doesn’t and grow and change and put our egos aside, our degrees in a drawer, and come to the table together to give birthing women the best possible care based on a combination of evidence of what works and what kind of birth they want.

“Cross-national comparisons from the World Health Organization and the Organisation for Economic Co-operation and Development clarify that many other nations are doing a better job with measures such as perinatal, neonatal, and maternal mortality, low birthweight, and cesarean rates. Nonetheless, per capita health expenditures for the United States far exceed those of all other nations. These outcomes, together with costly, procedure-intensive care, have been called the “perinatal paradox: doing more and accomplishing less.”

“Comparing current maternity care practice and performance in the United States to lessons from the best available research and to performance benchmarks reveals large gaps.”

The report found that “consistent with common patterns of innovation in medicine (McKinlay 1981), obstetric practices such as episiotomy (Graham 1997) and electronic fetal monitoring (Graham et al. 2004; Hoerst and Fairman 2000) were adopted prior to adequate evaluation. Many practices that are disproved or appropriate for mothers and babies only in limited circumstances are in wide use. Use of specific maternity practices varies broadly across facilities, providers, and geographic areas. This is primarily due to differences in practice style and other extrinsic factors rather than differences in needs of mothers and newborns.” As I have mentioned before, because of the way doctors are trained in US medical schools, the values of “autonomy” of practice reign supreme over evidence. This, coupled with a culture of medicalized birth where most woman believe that birth should take place in a hospital have created a very expensive and unnecessary reality that costs the US government billions of dollars a year in maternity care. Medicaid pays for 42% of the birth-related expenses in the US.

“With over 4.3 million births every year, childbirth is the leading reason for hospitalization in the United States, exceeding such prevalent conditions as pneumonia, cancer, heart failure, bone fracture, and stroke.”

“Hospitalization is by far the largest component of health care costs, and hospital charges for the current style of childbirth are considerable. Combined hospital charges for birthing women (about$44 billion) and newborns (about $35 billion) totaled $79,277,733,843 and far exceeded charges for any other condition in 2005 (Agency for Healthcare Research and Quality 2008). 49 percent of all hospital procedures performed on all individuals aged eighteen to forty-four were obstetric procedures, and six of the fifteen most commonly performed hospital procedures in the entire population involved childbirth. These include medical induction, manually assisted delivery, and other procedures to assist delivery repair of current obstetric laceration, cesarean section circumcision, fetal monitoring, and artificial rupture of membranes.” Midwifery practices use these medical interventions sparingly and only when absolutely necessary-keeping the cost of labor and delivery down, and the outcomes the same or better than medicalized birth.

“The national cesarean rate rose by 50 percent from 1996 to 2006, setting a new record each year from 2000 onward. From 1990 to 2005, the proportion of medically induced labors rose by 135 percent, from 9.5 percent to 22.3 percent
the most common gestational age among singleton births in the United States fell from forty to thirty-nine weeks.” The drop in gestational age means an increase in health care costs to care for premature babies. The higher instances of c-section always mean longer hospital stays, greater chances of complications arising from major surgery and a much greater cost to US taxpayers.

Additionally “women who gave birth in U.S. hospitals in 2005 reported high rates of numerous new-onset physical and mental health problems in the first two months after birth, with many problems persisting to six months or more postpartum.” I attribute this to negative birthing experience, and a medical model of care (where doctor patient relationships are superficial, brief and generally unsupportive). There is already evidence that a midwifery model of obstetrical care where midwives build true relationships with their clients and are offer support during and after pregnancy really work and add to maternal wellbeing. As the saying goes…..it takes a village to raise a child. Well, it also takes a village to birth a child and deal with the often trying time of major adjustment right after the child is born. No one should do it alone, and with a midwife, no one will.

I had always heard that at our local hospital birth was a big money drain. Our unit (women’s services) was a liability rather than a money maker. With these statistics, I am perplexed. It sounds like hospitals and doctors would be losing a large revenue source if normal birth was moved out to the home or to birthing centers. What the general public doesn’t know or talk about is that we as US tax payers are paying for nearly 50% of these births through Medicaid, and allowing the doctors to perform unnecessary tests and interventions at alarming rates just jacks up the bill and makes birthing women feel scared and out-of control.

Of course the American Medical Association (AMA) is a huge, and strong lobby. And now, as sanctioned by our own lovely Supreme Court, they can lobby to their hearts content to keep their agendas intact. Their agenda includes limiting (or in a perfect world, eliminating) midwifery, or keeping us on a very short leash. Using fear, and baby-hating propaganda, they have systematically led women to believe that they are unable to birth effectively without intervention or drugs, that they are ‘selfish’ and irresponsible if they demand a birth experience on their own terms, and that birth outside a hospital is dangerous and reckless. These ideas and beliefs are now firmly entrenched in our society and it’s going to take a village to change people’s minds.

Thankfully, there are many women who value midwives and midwifery and home birth or natural birthing practices. Our own organizations are making efforts toward transparency in birth through things like The Birth Survey, and midwife-friendly reports based on evidence. If evidence-based practice does gain support and ground with the US government and the people, only then will we be able to start a real dialogue about what birthing practices are best for women, babies and the US pocketbook.

A quiz. We all know we love quizzes. Well here is the ultimate quiz brought to you by the American College of Nurse Midwives. : )   If you have recently found out you are pregnant, you should definitely take this quiz!  Who Should Assist You With Your Birth Quiz

Enjoy!

This relates to my older post about Preterm babies and my inquiry as to why they weren’t talking about sections.  ”There are increases across the board,” she (CDC epidemiologist Joyce A. Martin) said — in all age groups, for most race and ethnic groups and in all states. Overall, the rate of preterm births increased from 6.8 to 8.1 percent, according to the report. The percentage of induced late preterm births more than doubled between 1990 and 2006, from 7.5 to 17.3 percent, according to the report. The percentage of late preterm births delivered by cesarean rose by 46 percent, from 23.5 to 34.3 percent.

The report goes on to highlight the problems with preterm births, including the higher instance of respiratory problems and long-term neurological problems.  They mention how advances in monitoring and subsequent identification of ‘problems’ with babies (distress) are leading to these higher rates, but also the fact that technological advances have made health care providers more ‘comfortable’ with delivering preterm babies.

I guess doctors feel it’s better to avoid the lawsuit involved with knowingly letting a premature ‘distressed’ baby keep going through labor than to potentially deal with the consequences of the long term effects of premature birth. (Most likely they won’t be held accountable there, after all, they can prove that they did everything to get that baby out.) No studies that I know of are addressing the issue of premature induction-which is causing most of these c-sections.

If a baby is not full term, and the mother is induced, could it be possible that the baby will experienced undo stress simply because they are not ready to come out?  Even if a mother is supposedly full term, and an induction of labor results in fetal stress, should we not attempt to stop the labor and wait another week or so (providing that the baby is not showing signs of distress in absence of contractions).  Could it be possible that the dates are wrong?  In other words, could babies experience stress during labor simply because they are not full term?

In many other aspects of our lives, we all know that ‘staying the course’ is not the best practice when evidence shows that there is a better way to achieve the goal.  Why is it that doctors feel the need to keep going-seeing their only option as c-section?  Why not stop the induction and wait?  We have the technology to do that.

Joy and Jeff Szabo will need to be separated by 300 miles, and most likely he won’t be at the birth of their child. Neither Jeff or Joy is in the military.  The Szabo’s live in a town whose hospital has decided to ban VBAC. (Vaginal Delivery after C-Section)  This town is PAGE, ARIZONA.  (sorry, had to put it in caps as a warning) but it could also be basically the entire southern half of New Mexico, and half the other places around the country.  Joy has had a successful VBAC already at this same hospital.  Joy was threatened with a court order, by the hospital’s CEO if she attempted to enter that hospital and refuse a c-section.  Although grateful for the c-section that saved her son Michael’s life, she refused to be forced to have a c-section and has instead elected to deliver vaginally at a hospital 300 miles away.

VBAC has a risk of uterine rupture (at the site of the old incision) in less than 1% of cases.  Joy is aware of these risks and views them as less risky than complications from a c-section.  ACOG has not stated that they don’t recommend VBAC’s, just that they should be performed with 24/7 coverage of both physician and anesthesiologist-just in case.  That seems reasonable to me.

Yet since the ACOG guidelines came out in 2004, more and more hospitals have refused to do VBACs. Today, nearly half of hospitals won’t do VBACs, either because the hospital has banned them or because doctors won’t do them.  WHY?? All this for a less than 1% chance that something could go wrong. And what does a less than 1% chance mean exactly?

I believe this is a travesty and a public health concern.  Women are unnecessarily, and dangerously being subjected to surgery because they may not have access to a hospital that believes in VBAC. VBAC is a legal procedure which is being denied to women on the basis of…..um, what was the basis again?  Oh yeah, their ‘safety’.  Right. The risk of maternal mortality with repeat cesarean and VBAC is very low, but the risk is higher with a repeat cesarean: 0.04% vs. 0.02% per a 2004 National Institute of Health Study of 18,000 women. (thanks again vbacfacts.com)

Last I checked, abortion was still legal as well, and a different, but equally powerful group of people have been systematically denying women abortions by taking out doctors(physically, socially and financially) and limiting access.

Why is access being denied for VBAC?  The reason most often cited is the ‘malpractice environment’ but in essence women are lied to, misinformed, and made to feel bad for putting ‘their desires’ ahead of the safety of the baby.  They are rarely informed enough to fight.  C-section is more convenient for a doctor than VBAC because it is generally predictable and in their control from beginning to end.

It is rebuttal directed at the recent ‘story’ aired on the Today show called “The Perils of Home Birth” (which was originally going to be titled “The Perils of Midwifery”.)

Although much of their commentary has been said before and cited in statistics from all over, they did make one key point that I thought was worth highlighting.

“While midwives and obstetricians will continue to debate the safety and appropriateness of home birth, less controversial is the fact that some women seek to give birth in alternative settings because they do not see hospitals as meeting their needs. This should be cause for reflection and action by hospital leaders, and result in measures to make hospitals safer for women to birth. Changing childbirth practices in hospitals will make them a welcoming place for families and will likely result in better care for all.”

It’s a great point.  Basically many doctors and the media are pointing fingers at midwives, citing women who choose home birth as reckless and irresponsible, and sensationalizing the rare cases of home birth gone bad, but no one is talking about WHY women choose home birth and how bad hospital birth really has become.

Women are consumers of health care and don’t want to subject themselves to unnecessary interventions and a one in three chance of having a c-section.  If faced with this as their only alternative, they often choose home birth. Seems logical to me.  (I will note that if a mom chooses to have a hospital birth with a certified nurse midwife, her chances of undergoing interventions or c-section decrease dramatically.)

Why are doctors and hospitals not trying to change hospital experiences to meet the desires of women?  I think it ultimately comes down to philosophy.  Most obstetricians look at pregnancy as an illness or condition to be ‘fixed’, not an natural event to be gently managed.  Hospitals (theoretically) are places that sick people go to get better.  Perhaps the better question to be asking then is “Why are healthy women who are predicted to have normal pregnancies sent to hospitals to give birth?”