Wherever they look, American women giving birth today are faced with unprecedented challenges due to the widespread fears surrounding childbirth: sensational media coverage, horror stories from friends or relatives, pressure from their care provider, even biased literature that encourages interventions, such as epidural anesthesia. No wonder they are scared of giving birth and have lost trust in their bodies’ innate wisdom, and bought into the widespread belief that high-tech deliveries and cesareans are the safest ways to have their babies.

    Furthermore, according to an article published in Mothering Magazine (2007, p.53), the U.S. ranks third worldwide in c-section rate (31.1% in 2006), preceded only by Brazil (70%) and Taiwan (33%). This is discouraging, considering the 5% to 10% recommended by WHO – World Health Organization. According to a survey (2008) published by the non-profit organization Childbirth Connection, the highest rates in the U.S. occur in Louisiana (36.8%) and Mississippi (35.1%), and the lowest are in Alaska (21.9%) and New Mexico (22.2%), two states that support midwives and have low induction rates. The same survey also mentions that c-sections have increased by 50% over the past decade and that this procedure is now the most common in U.S. hospitals.

    Meanwhile, compared to other industrialized countries where health care costs are a fraction of those in the U.S., and where outcomes greatly surpass ours, American women seem crippled and increasingly unable to deliver their babies as nature intended. Thus, in order to improve maternity care in the U.S. we must stop and evaluate what motivates current obstetric practices, and consider a more holistic approach that has been time-honored by a community as ancient as humankind: women themselves.

    So, how exactly did we get in this situation? According to Childbirth Connection (2007), “the national U.S. c-section rate was 4.5% and near [The World Health Organization] WHO’s range in 1965 when it was first measured.” That was only 44 years ago! What happened between 1965 and 2009? Identifying what brought us to where we are might help us find our way back to the ideal rate recommended by WHO.

HOW DID WE GET HERE?

    A. Technology: technology boomed this past century, affecting many sectors, including the medical field. Ultrasounds and fetal monitors became obstetrics’ favorite diagnostic toys, with the blessing of insurance companies which, now rely almost exclusively on these wonderful machines, and disregard the good old “hands-on” approach of the past. This, unfortunately, has turned against obstetricians, who now must, in order to maintain malpractice coverage, perform the whole gamut of tests required by insurers.

    B. Fear of litigation: in order to avoid raising already exorbitant malpractice premiums, obstetricians persuasively justify diagnostic tests to women who go along with it, convinced they are doing what’s best for a safe outcome. Once in labor women soon discover that their bodies are “failing to progress” (the number one reason for c-section), their babies’ heart rate are “dropping dangerously” (so says the continuous fetal monitor), or that their blood pressures reached levels that compromise their babies. What they didn’t know is that the wonderful epidural they were promised has serious side effects. Dr. Marsden Wagner (2006, p.38,39,190), former director of Women and Children Health for WHO, believes that “obstetricians have a number of reasons for encouraging women to have c-sections…There is a clear evidence that we can count on organized obstetrics to put fear of litigation ahead of family values and women’s rights.”

    C. Induction/Convenience: the rate of inductions is on the rise. Why? Convenience, fear of big baby, miscalculated due date, preventable hypertension, to name just a few reasons. According to Dr. Wagner (2006, p.39), “Federal studies that analyze birth certificates tell us that the percentage of U.S. births that happen Monday to Friday, nine to five, is rapidly increasing; even emergency c-sections are more common Monday to Friday, nine to five…” A woman on her own hormones will take an average of 13 hours to deliver her first baby; c-sections, on the other hand, take only twenty minutes. Also, women are partly responsible as many prefer a scheduled induction in order to accommodate family plans.

    D. Specialist-oriented care: doctors are trained to handle obstetric emergencies and most have never seen a physiological birth. They rely on procedures that are supposed to prevent complications, yet these same procedures are conductive to complications in the first place. Prevention is not taught in medical schools and, up to very recently, nutrition was not part of the curriculum either. Both are the cornerstone of the midwifery model of care. As Dr. Wagner (2006, p.40) points out, “Most obstetricians have experienced only hospital-based birth managed with a medical model; they have never seen a natural birth.”

    E. Financial incentives: as mentioned earlier, it takes an average of 13 hours for a woman to delivery her first baby. Some births, when left to their natural course, can take more time, and can definitely mess up a provider’s schedule. The financial incentives are obvious, as demonstrated in a survey from Childbirth Connection (2008, p.15):

  • Uncomplicated vaginal delivery - $ 6,724.00
  • Complicated vaginal delivery - $ 8,604.00
  • Uncomplicated c-section - $12,544.00
  • Complicated c-section - $15,960.00
  • These numbers, from 2005, can easily be projected to a complicated c-section costing around $20,000.00 today.

        F. VBAC – Vaginal Birth after Cesarean – According to a new survey (2009) conducted by ICAN – International Cesarean Awareness Network:

        There is an alarming disconnect between what medical research says about the safety of VBAC, and the way that hospitals and their doctors practice medicine…For physicians, repeat cesareans are often considered more convenient, more lucrative and better insulation from lawsuits. VBACs are inconvenient and costly because they require the physician to be on-site and be available to care for the mother. ACOG created clinical guidelines that are, in effect, good business.

        The adage “once a cesarean, always a cesarean” is apparently making a comeback. A recent Time Magazine (2009, p.37) article on VBACs reported:

        Among obstetricians, many solo practitioners are unable to stay for what could end up being a 24-hour delivery; others calculate the loss of unseen patients during that time and instead opt to do hour-long cesareans, which are now the most commonly performed surgeries on women in the U.S.

        VBAC bans have reached such proportions that the National Institute of Health is planning its first VBAC conference in 2010.

        The negative impacts of high-tech obstetrics are beginning to emerge, and many organizations are committing to help reverse this trend. Dr. Michel Odent, French obstetrician and founder of London-based Primal Health Research (2002, p.137-138), warns us:

        Can we survive the safe cesarean?...We are learning that the capacity to love develops through a long chain of early experiences, particularly in the period surrounding birth. The way babies are born is the critical link of the chain that is routinely disturbed. It is also the link of the chain on which it is possible to act. That is why the current industrialization of childbirth should become the main preoccupation of those interested in the future of humanity.

    Let us hope his words are heard far and wide.

    SOLUTIONS

        In view of its statistics, one European country, Holland, is a beacon of hope for the rest of the world. How do they do it? Midwives! Most women in Holland are cared for by midwives and never see an obstetrician. Almost half of those who are considered low-risk have their babies at home. Holland also has a national health care system. After their homebirth, Dutch women have a nursing assistant come to their home several hours a day for the first couple of weeks; they understand how critical the postpartum period is to ensure a successful transition into motherhood. As Dr. Odent (2004, p.132) notes:

    Countries with skyrocketing rates of cesareans are those where obstetricians outnumber the midwives to such a degree that they play the role of the primary caregivers…On the other hand, countries with good statistics, including moderate rates of cesareans, are those where the midwives outnumber the obstetricians and remain the primary caregivers.

        Another country that offers practical solutions is, ironically, Brazil. As Dr. Wagner (2006, p.194) points out:

    Wisely recognizing that it would be extremely difficult to change hospital obstetric practices under the circumstances, at the beginning of the twenty-first century the [Brazilian] government endorsed a plan to build a network of out-of-hospital birth centers and has agreed to help fund it.

    With our health care system in shambles, wouldn’t it be a wise investment for the U.S. to follow Brazil’s example? Alaska and New Mexico already have Medicaid reimbursement for out-of-hospital births attended by certified professional midwives. Furthermore, a BMJ – British Medical Journal – (2005) sponsored study about the safety of homebirth, concluded that “planned homebirth for low-risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intra partum and neonatal mortality to that of low-risk hospital births in the United States.”

        In the meantime, many organizations are actively reaching out though education on the world-wide-web. Besides the ones mentioned earlier, CIMS – The Coalition for Improving Maternity Services – has established (1996) a list of steps that include:

  • Normalcy: treat birth as a natural, healthy process.
  • Empowerment: provide birthing women supportive and respectful care.
  • Autonomy: enable women to make decisions based on accurate information and provide access to the full range of options for care.
  • First do no harm: avoid routine use of tests, procedures, drugs and restrictions.
  • Responsibility: provide evidence-based care only.
  • Humanized birth: putting women at the center and in control, not the doctors or anyone else.
  • Community-based (out of hospital) primary care, not hospital-based tertiary (specialist) care.
  • Midwives, nurses and doctors are all working together as equals.
  • Maternity services are based on good scientific evidence, including evidence-based use of technology and drugs.

    As of 2008, CIMS also set up the Birth Survey, an online feedback system where women from all over the U.S. can “grade” the level of satisfaction with their care provider. This information is there for everyone to see, and the goal is to help women make an informed decision when selecting a provider.

        Many organizations started at a grass roots level and are now well established. Others, such as Citizens for Midwifery, Alaska Friends of Midwives, and many more, are proactive in their communities. All of them were established by women who are aware that, in order to reverse the dangerous trend we are in, women must stand together as a united front and return to the gentle, fearless ways nature intended them to birth their babies. As mentioned earlier by Dr. Odent, the future of humanity depends on it. The time to act is here, now.

    References

    BMJ – British Medical Journal (2005): Outcomes of planned homebirth with Certified Professional Midwives: large prospective study in North America. Johnson, K., Daviss, B.A. 33.1416 DOI:10.1136/bmj.330.7505.1416. Retrieved 03/01/09 from:
    www.bmj.com/cgi/content/full/330/7505/1416

    Childbirth Connection (2007): Why does the national U.S. cesarean section rate keep going up? Retrieved 03/01/09 from:
    www.bmj.com/cgi/content/full/330/7505/1416

    (2008) Evidence-based maternity care: what it is and what it can achieve. By Sakala, C., Corry, M. Research sponsored by Childbirth Connection, The Reforming States Group and Milkbank Memorial Fund. Retrieved 3/14/09 from:
    www.childbirthconnection.org/article.asp?ck=10575

    CIMS (2008) The Birth Survey. Retrieved 03/01/09 from:
    www.motherfriendly.org

    ICAN (2009) ICAN 2009 survey of hospital and VBAC bans. Retrieved 03/01/09 from:
    www.ican-online.org

    Mothering Magazine (2007) Cesarean birth in a culture of fear, by Ponte, W.
    September/October issue, p.49-63

    Odent, M. (2004) The cesarean. London: Free Association Books Ltda.

    (2002) The farmer and the obstetrician. London: Free Association Books ltda.

    Time Magazine (2009) The trouble with repeat cesareans, by Pamela Paul.
    March 2009 issue, p.36-37.

    Wagner, M. (2006) Born in the USA. Berkley: University of California Press.