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NATURALIZED BIRTH
CHILDBIRTH
WITHOUT FEAR
BY JULIE C. STUMPH
Over the past few centuries childbirth has become
increasingly influenced by medical technology. Today medical
intervention is the norm in most western countries. Interrupting
the natural process of birth with unneeded interventions, such
as drugs and surgical procedures, has become a widespread
problem. Although the use of “high tech” medicalized maternity
has saved lives, its unnecessary and unwarranted use has
proven to backfire. Childbirth without fear is a reality that needs
to be understood by women, midwives and obstetricians. What
is known about women's wishes and fears should be addressed,
so that a woman-centered, clinically effective service can be
developed. I am arguing that perhaps normal birth has become
too “medicalized" and that higher rates of normal uninterrupted
births are in fact associated with positive beliefs about birth.
Implementation of evidence-based practices within the
hospital along with communication between the providers and
clients are the other crucial factors for naturalization of the birth
process. Birthing families as well as health-care providers
should be able to make decisions derived from unbiased
evidence This will aid in the promotion of natural birthing
experiences. Whether in a hospital setting or at home, we need
to trust birth in order to give birth naturally.
Many families are not aware that in most cases the birth
process does not need intervention. Naturalized birth means
putting the woman back in control of her outcome and allowing
her to make the proper, educated decisions about what will or
will not occur during her birth. The midwife, obstetrician or any
one other than the family should not influence this decision.
Their role should be to merely “catch" the baby, unless compli
cations arise warranting their skills and interventions.
I recently interviewed Debra Barbie, a mother of six who
delivered her first child in a hospital via cesarean section due to
a breech (legs first) presentation. Her next child was delivered
vaginally at a birthing center, and the last four were delivered
at home by either her husband or a midwife. All but one of her
home births was in breech, but she chose to birth at home.
I had to ask: why would she choose to birth at home
even though she was at risk for complications?
The answer I received was simple; she did not feel she
had a choice. She said that her experience in the hospital with
her first child was an “absolute nightmare.” Her doctor refused to
try and turn the baby, admitted her into the hospital to lie flat on
her back for two weeks for no apparent reason, then proceeded
to take the baby out via cesarean section, at his convenience,
which was still five weeks early. Not to mention, the staff did not
allow her to see or touch her new child for four hours.
She complained that the staff was not attentive to her or
her husband's wishes, saying they gave formula to their newborn
against their demands to ensure proper breast-feeding. In addi
tion, the nurses would not let the newborn sleep with its mother
or stay in the room with her. She also claimed they served her
non-nutritious meals which were often full of sugars, fried goods
and fat.
Debra explained her view of the real reason why this
type of disaster takes place in our hospitals: “Insurance compan
ies put pressure on the physicians to take every caution possible
to decrease the liability of the establishment. What they do not
realize is that these 'cautions' can be detrimental to the women
giving birth.”
Labor and birth are functions of the autonomic nervous
system and are therefore out of conscious control. As a result,
there are two approaches to assisting birth:
~Medicalized birth: Override biology and impose
external control using interventions such as drugs and surgical
procedures.
-Naturalized birth: Work with the woman to facilitate her
own autonomic responses.
Naturalized birth also means that the service to the
mother and baby are based on worthy evidence-based use
of technology and drugs. Birth needs to be given back to the
woman and her family. Women need to have the right to have
any errors committed during their birthing to be their own and
not someone else’s. The widespread inability to know what
normal, naturalized birth is has been summarized by the World
Health Organization:
“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, the woman’s state of mind and body is so altered
that her way of carrying through this intimate act must also be
altered and the state of the baby must equally be altered The
result is that it is no longer possible to know what births would
have been like before these manipulations.
“Most health care providers no longer know what
'non-medicalized' birth is. The entire modern obstetric and
neonatological literature is essentially based on observations
of 'medicalized' birth."
Over the years we have seen a struggle between these
two approaches to maternity care.Today it seems there are three
kinds of maternity care:
-The highly medicalized “high tech" doctor-midwife
hospital centered care found, for example, in the USA, Ireland,
Russia, Czech Republic, France, Belgium and urban Brazil.
-The naturalized approach with strong, more autonom
ous midwives and much lower intervention rates found, for
example, in the Netherlands, New Zealand and the Scandin
avian countries.
-A mixture of both approaches found, for example, in
Britain, Canada, Germany, Japan and Australia
Seventeen years ago in Brazil, the World Health
Organization Conference recommended birth be controlled,
not just by individual doctors and hospitals but also by evidence
based care monitored by the government Birth, which had been
taken from the community and slowly but surely changed into
hospital-based care during the last hundred years, was to be
given back to the community
This same conference considered the next step, giving
birth back to the woman and her family
J
Today, prevailing Western medical opinion is that
'modern' obstetric-maternity care saves lives and that attempts
to bring maternity care extremes under control are retrogressive.
Many with this view believe the only reason out-of-hospital
midwife-attended birth still exists in developing countries is
because modern medical practice is not available.
We override biology at a risk. For example, if we stop
using our bodies they go wrong. It is “modem" to get around
in a car resulting in little walking. Then science finds out that our
bodies need such exercise or we get cardiovascular problems.
The post-modern idea is to go back to walking, running or
cycling. This is seen as progressive, not retrogressive. Along
the same lines, naturalizing maternity care is not retrogressive
but post-modern and progressive.
Every change in the human condition, such as social
and technological development, has potential for both positive
and negative effects. It seems that the positive effects of such
development overpower the negative effects until a level is
reached where social and economic benefits reach everyone,
and then hidden negative effects begin to come forward.
In the same way birth interventions, such as cesarean
sections, sometimes save lives and sometimes kill. Maternal
mortality even for elective (non-emergency) cesarean sections
is approximately three times higher than for vaginal birth. For
about 50 years the maternal mortality ratio in the United States
came down. Then in the 1980s the maternity mortality ratio
began to rise and, according to the U.S. Centers for Disease
Control & Prevention, it rose from 7% to 10% in 1990. While this
ratio continued to decline in other industrialized countries, in the
U.S. the maternal death rate continued a slow but steady rise
through the 1990s and, according to the World Health Organiza
tion is now higher than at least 20 other highly industrialized
countries.
This suggests that we are now at the point in maternity
care where the positive effects of development and technology
are approaching the maximum and the negative effects are
surfacing. This helps to explain why advances in technology
and in development cannot lead to improvements in health
unless the technology is in balance with natural processes and
is accompanied by naturalized health care.
Here is an example: If an elective cesarean section is
done after labor begins, it may, in some cases, facilitate natural
processes. But waiting until labor starts means doctors lose the
possibility of scheduling the procedure at their convenience. If,
as is almost always the case, the doctor tries to get around the
natural process by performing cesarean section before the start
of labor, there is a greater risk of respiratory distress syndrome
and pre-maturity, both killers of newborns.
Many health care providers and the organizations they
represent continue to believe in the dangers of planned out-of
hospital birth, either in a birth center or at home. They reject
the overwhelming evidence that planned out-of-hospital births
for low risk women are safe. The response of providers to this
evidence is, “But what if there is an out-of-hospital birth and
something happens?” Since most providers have not attended
an out-of-hospital birth, their “what if?” question contains several
false assumptions.
The first assumption is that in birth things happen fast.
Actually, with very few exceptions, things happen slowly during
labor and birth. A true emergency, according to Sonja Gregg, a
direct entry midwife, is extremely rare and often the midwife in
the birth center or home can take care of the emergency.
The second assumption is that when an emergency
develops there is nothing an out-of-hospital midwife can do.
Someone who has never observed midwives at out-of-hospital
births can only make this assumption. A trained midwife can
anticipate trouble and usually prevent it from happening in the
first place as she is providing constant one-on-one care to the
birthing woman, unlike the hospital where nurses or midwives
can only look in occasionally on several women in labor for
which they are responsible. Then when their shift ends a new
physician or nurse is there to take over.
With few exceptions, if trouble does develop, the out-of-
hospital midwife can do everything that can be done in the hosp
ital including giving oxygen, Pitocin (synthetic form of oxytocin,
which helps the uterus contract) and intravenous fluids. For
example, when a baby’s head comes out but the shoulders get
stuck, there is nothing that can be done in the hospital except
certain maneuvers of the woman and baby, all of which can be
done just as well by an out-of-hospital midwife. The most recent
successful maneuver for this event reported in medical literature
is named after the homebirth midwife who first deSCflbfed If th#
“Gaskin Maneuver" (J.Bruner, Journal of Reproductive Medicine
43, 1998).
The third assumption is there can be faster action in the
hospital. The truth is that in most hospitals the woman’s doctor
or midwife is not even in the hospital most of the time during her
labor and must be called in by the nurse when trouble develops.
The time it takes for a doctor or midwife to get to the hospital is
as much time as the transport of a woman having birth at a birth
center or at home. Even in hospital births, when a cesarean
section is warranted, it takes an average of 30 minutes for the
hospital to set up for surgery and to locate the anesthesiologist
or surgeon.
In one study of 117 hospital births with emergency
cesarean sections for fetal distress, 52% of the cases had a
decision-incision time of over 30 minutes. So during those 30
minutes either the doctor or the out-of-hospital birthing woman
are in transit to the hospital. This is why it is crucial for a good
collaborative relationship between the out-of-hospital midwife
and the hospital, so when the midwife calls the hospital to inform
staff of the transport, the hospital will not waste time in making
arrangements for the incoming birth woman. These are the
reasons there are no data to support a single case of the “what
if scenario used by some doctors to scare the public about out-
of-hospital birth.
Some members of society tend to put blind faith in tech
nology and the thought technology=progress=modem. On the
flip side is the lack of faith in nature. So it seems the idea is to
conquer nature. This results in many attempts to improve on
nature using scientific evaluation, yet science all too often shows
nature right instead. Doctors replaced midwives for low risk birth
but science proved midwives safer. Hospital replaced home for
low risk birth and then science proved home as safe with far less
unnecessary intervention. Hospital staff replaced the family as
birth support. Science then proved birth is safer if the family is
present. Lithotomy (lying down) replaced vertical birth positions,
and science proved vertical positions safer. Newborn examin
ations away from mothers in the first 20 minutes replaced
leaving mothers with babies, then science proved the necessity
for maternal-infant bonding during this time. Formula replaced
mother’s milk, then science proved breast milk most beneficial.
The central nursery replaced the mother, then science proved
rooming-in most beneficial.
The typical example of medicalization and unnatural
ization of birth is unnecessary cesarean section (CS in medical
idiom) where the surgeon is in charge and the woman no longer
has any control whatever.Cesarean sections save lives but there
is no evidence that the rising CS rates over the years have
improved birth outcomes. As indications for CS expand and
rates go up, fewer and fewer lives are saved. According to Sue
Trezona, a certified nurse midwife (CNM), “It's only logical that
eventually a rate is reached at which cesarean sections kill
almost as many babies as they save.” This statement is valid-
,
ated by the fact that the risks of this major surgical procedure
do not seem to decrease with its increasing use.
Women and their babies are currently paying a big price
for the promotion of CS by some doctors. The scientific data on
maternal mortality associated with CS suggest the rising matern
al mortality rates in the U.S. and Brazil may be, at least in part,
the result of their high CS rates. Both these countries need to
carefully look at all maternal deaths to test the strong belief that
rising rates of maternal death are associated with high rates of
cesarean section.
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The data on other potential risks for both woman and
baby associated with CS mean both are paying a big price in
current birth as well as in future pregnancies.