NORTH COAST TIMES E A G L E , AUGTEMBER 2003
When maternity care, which is run by doctors, is absent
or not at its best, higher CS rates are found. Many studies have
shown lower intervention rates when midwives attend low risk
birth than when doctors are the primary care providers to low
risk women. Is it just a coincidence that the U.S., Canada and
Brazil, where doctors attend most births and there are few mid
wives attending births, have the highest CS rates in the world?
Sue Trezona feels having a highly trained gynecologcal
surgeon attend a normal birth is similar to having a pediatric
surgeon babysit a normal 2 year old child. She believes it would
be a waste of the pediatric surgeon's time and skills, and when
the young child gets tired and fussy the surgeon might be
tempted to use drugs where a properly trained babysitter would
soothe the child with a variety of non-medical techniques. This
allegorical medicalization of normal childhood is similar to that
of normal birth. High cesarean section rates are indeed a symbol
of the lack of naturalization of birth.
So far it seems that we have not been smart enough,
in developed or developing countries, to take advantages of
medicalized birth care while avoiding the disadvantages of its
use in excess. Naturalizing birth has the possibility to combine
the advantages of Western medicalized birth with the advan
tages of redirecting the care in a way to honor the biological,
social, cultural and spiritual nature of birth.
There are several strategies for naturalizing birth.
These strategies will put the woman and the family back in
control of the birth of their own child while empowering the
woman to believe in herself through experiencing what her
own body can accomplish.
The first strategy is education. Those who control the
information hold the power. In the past the medical profession
often maintained control of medical care through protecting and
withholding information. Today there is no excuse for limiting
this data. Full information on the good and bad results of medi
calized birth must be given to healthcare providers, public health
officials, politicians and to the public. In other words, everyone
must begin to see the ideas many doctors and hospitals “preach"
and realize that in many instances they are not entirely true.
The need to broaden the horizon of doctors concerning
maternity care is not a new problem. This statement was found
in a medical book published in the year 1657: “Doctors who
have never seen a home birth and yet feel competent to argue
against it resemble those geographers who give us the descrip
tion of many countries which they have never seen.” It just
makes sense for doctors to be required to look at the space
in which modem maternity care exists in order to get a proper
standard against which they can measure all of their experi
ences. An anonymous source from the Philippines said every
doctor in their country must attend a minimum number of
planned home births. Maybe it would be beneficial for us if every
obstetric training program for doctors, midwives and nurses
required visits of planned out-of-hospital births, including birth
centers and home births.
The education of women, especially pregnant women, is
most important. But what women are told is quite an issue. From
my experience, doctors and nurses who insist on giving only
•doctor-friendly" information to pregnant women control prenatal
education programs. Also, many anesthesiologists in the U.S.
have managed to gain access to prenatal classes where they
preach the wonders of epidural block to eliminate pain, and
usually say nothing about the considerable risks of this invasive
procedure. Some doctors promoting women to choose cesarean
sections for which there are no medical indications find it neces
sary to provide limited, highly selective information
It is highly unlikely women would ever consider choosing
elective CS if they were given full scientific evidence on the
risks for themselves and their babies. Maybe the key issue is
not the right to choose or demand a major surgical procedure for
which there is no medical indication but the right to receive and
discuss full, unbiased information prior to any medical or surgi
cal procedure. Sue Trezona speculates, “A liberated woman
strives not to be controlled by men, an effort that can be
extremely difficult if she lives in a male chauvinist society."
There are many ways in which women giving birth in
hospitals in male dominated cultures are oppressed and given
the message they are not important and not free but controlled
by an often pushy opinionated staff. For example, women are
told not to scream or cry and to be quiet labor contractions. If
a woman accepts the medicalized, male dominated obstetric
model of care with its selected information, she gives up any
chance to control her own body and make true choices.
Volumes have been written about how liberating and
empowering it is for a woman to give birth when she controls
what happens. Without fully informed choices, she will give
up any control and conform to the wishes of the doctors and
hospitals. Women who demand choice but get only selected
“doctor-friendly” information innocently buy into the medical
position According to Sue Trezona few feminists who fight for
women's rights have confronted biased doctor-based inform
ation “and as a result have unwittingly promoted...obstetric
procedures, which are dangerous to them and their babies."
A second strategy for naturalization of birth is promotion
of evidence-based maternity care practices. There continues to
be a gap between present obstetric practices and the evidence
based care. In many places public health agencies have failed
to aggressively pursue closing the gap between obstetric prac
tices and evidence-based practices, often out of fear of the
power of the medical establishment.
It has been an interesting and educational experiment
for me to go to a hospital labor and delivery unit and share
with the staff a simple table displaying their own rates of
interventions — such as induction, episiotomy (cutting of
perineum), lithotomy, suction and cesarean section on one
side, and the evidence-based rates on the other. The resulting
discussion is often quite heated but always with at least a few
people who are as concerned as I am about the gap between
their practices and the evidence.
As we enter the era of post-modern medical care, the
old clinical guidelines must be replaced and approved by the
community in order for proper progressive practices to evolve.
Another essential strategy in naturalizing birth lies with
whom the primary care giver for women during pregnancy and
birth should be Midwifery has a long tradition of placing the
birthing woman in the center with all the control in the woman’s
hands and with the midwife providing the kind of support that will
empower the woman and strengthen the family For this reason,
having primary maternity care in the hands of midwives is a
huge strategy in naturalization of birth.
It is important to look at the maternity care in other
countries that are much further along the road to naturalization
than the U.S. such as New Zealand, The Netherlands and the
Scandinavian countries. In these countries more than 80% of
women see only midwives during pregnancy and birth (in or out
of the hospital) and they have some of the lowest maternal and
perinatal mortality rates in the world
Considerable scientific research has demonstrated four
major advantages to independent midwifery: midwives are safer
for low risk birth, midwives use less unnecessary interventions,
midwives are less expensive and they provide more satisfaction
First, there can no longer be any doubt that midwives
are the safest birth attendants for lOVv risk birth. A study publish
ed in 1998 on the safety of midwife-attended birth looked at all
the births in one year in the U.S., more than 4 million Selecting
only single, vaginal births and removing cases of social or
medical risk factors, they compared outcomes between midwife-
attended births and physician-attended births. Compared with
physician-attended births, midwife-attended births had 19%
lower infant mortality rates, 33% lower neonatal mortality, and
31% lower low-birth weight rates.
After his review of the extensive evidence for the safety
of midwives in his article "Midwifery in the Industrialized World"
in the Journal Society of Obstetrical Gynecology (1998) Marsden
Wagner concludes, “A search of the scientific literature fails
to uncover a single study demonstrating poorer outcomes with
midwives than with physicians for low risk women. Evidence
shows primary care by midwives to be as safe or safer than
care by physicians "
PAGE 5
The second advantage of midwives over doctors
as primary birth attendants is a drastic reduction in rates of
unnecessary interventions. Scientific evidence shows that
compared to physician-attended birth, a midwife-attended
birth has a significantly less use of the following: IV fluids, IV
medications, routing electronic fetal monitoring, use of narcotics,
use of anesthesia including epidural block for pain, forceps and
vacuum extraction and cesarean section. They also have more
vaginal birth after CÓ.
The third advantage of using midwives as the primary
birth attendant is that they cost less. While it varies from country
to country, midwives’ salaries are almost always considerably
less than doctors’ salaries. In addition, the lower intervention
rates with midwives mean major cost savings. The data on cost
savings is reviewed in Marsden Wagner’s article “Midwifery in
the Industrialized World" in countries where, for example, one
study found cost savings of at least $500 U.S. for every case
where a midwife is the birth attendant.
Another advantage of midwifery care is the pregnant
and birthing woman’s satisfaction. The evidence in Wagner’s
article supports that midwifery is statistically more satisfying
to the woman and her family.
Since hospitals are doctor territory and no woman
has even been in control of her own care in a hospital setting,
another important strategy for naturalization of birth is to move
birth out of the hospital.
There have always been and will be women everywhere
who choose planned home birth and need a midwife to attend
the birth. But today, as a result of years of insincerity about the
hazards of birth, there are many women who have bought into
the myth that home birth is dangerous. This is often due to the
stories told by doctors who are themselves afraid of birth and
believe hospital birth is the only safe way and who themselves
need the security of hospitals.
For more than 80% of women who have had no serious
medical complications during pregnancy, planned home birth is
a perfectly safe choice.
Any doctor, hospital or medical organization attempting
to discourage a low risk woman from choosing home birth is
denying basic human rights by withholding unbiased information
and limiting a woman’s freedom of choice of birth. The birth of a
baby is one of the most important events in the life of the family
and when the family chooses a planned home birth, what is best
for the family must be honored.
Many in the obstetrical profession support the scare
propaganda about how dangerous birth is. Because of this
misinformation, women want the freedom to control their own
birthing but need the security of some sort of institution. Women
today can be in control of giving birth, be empowered by birth,
be assisted by a midwife and still feel confortable and protected
by an institution if they choose to give birth in a birth center.
The first essential characteristic of a birth center is that
it is free standing of any control of a hospital. A hospital that
claims to have a birth center is similar to Nabisco claiming to
sell “homemade" cookies in a bag at the supermarket. To be a
birth center the birthing woman must be in control of everything
that happiness to her and her baby. This means the birth center
should be staffed by midwives who use protocols (practices)
devised by midwives.
The type of care provided in the birth center is quite
different from a hospital. In a hospital the doctor is always in
absolute control. In the hospital emphasis is on routines while in
the birth center it focuses on individuality and informed choice.
Hospital protocols are designed with all the possible complica
tions in mind while the birth center protocols focus on normality,
screening and observation. In hospitals pain is defined as an
evil to be stamped out with drugs while in the birth center it is
relieved with scientifically proven non-pharmacological methods
such as immersion in water, changing position and moving
about, massage, presence of family and continuous presence
of the same birth attendant.
In the hospital, inductions are frequent and are often
done with the use of powerful drugs. These drugs increase the
pain and carry many risks, some of which are not FDA approved
for the purpose of induction.In the birth center labor is stimulated
with non-pharmacological methods including walking and sexual
stimulation such as massage to the nipples to produce oxytocin,
a natural hormone that induces labor. In the hospital, staff are
not always present and change every eight hours. In the birth
center there is continuous presence of one midwife throughout
the labor. In the hospital the new baby is commonly taken from
the mother for various reasons, such as doing newborn asses
sments In the birth center the new baby is never taken from
the mother.
The only way to determine whether birth centers are
safe is to turn to the scientific evidence. In 1995 an important
paper on birth centers was published: “The National Birth Center
Study" by J. Rooks (ef al) in The New England Journal of Medi
cine The study compared hospital birth and birth in a birth
center. The outcomes were in favor of birth centers. The results
are as follows:
-99% of the women preferred a birth center to hospital
birthing.
-Increased rates of successful breast-feeding.
-99% spontaneous vaginal births compared to 55% in
the hospital
-Less than 4% use of anesthesia compared to 42% in
the hospital
-Less than 1% use of forceps or vacuum extraction
compared to 10% in the hospital.
-Less than 5% cesarean section compared to 21% in
the hospital.
Looking at these comparisons, clearly the logical ques
tion is not if “birth center" birth is safe but if "hospital" birth is
safe. Compared to hospital births, home births and births in the
birth center are safe, much cheaper, use far less unnecessary
interventions and are more satisfying to the woman and family.
In other words, out-of-hospital birth is an important strategy in
naturalizing birth care
If the growing trend towards the medicalization of
birth is to be stopped and the naturalization of birth is to recom
mence, then childbirth without fear should become a reality for
women, midwives and obstetricians. This is a matter of team
work, a shared philosophy of care and mutual respect. Women-
centered services must be developed. Visits to units or countries
with less medicalized approaches should be encouraged for all
medical/health students As well as attending at least one
planned home birth There is a need for straightforward birth
with guaranteed continual support throughout labor, low
intervention rate, low mother-infant mortality rate and good
postnatal and breast-feeding support.
Why, if this is what we see in other countries such as
The Netherlands and New Zealand, do we not see this in our
own country? We must trust birth to give birth naturally!
Julie Stumph is a 2003 graduate of the nursing
program at Clatsop Community College