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Maternity Care in America: Rife with "Systematic Failures"

The problem is, most people — including doctors, nurses and hospital staff — don’t know what normal birth looks like anymore, let alone how to support it.

I was talking to a woman the other day who said that when she gave birth vaginally in her hospital, a whole group of nurses and residents came to watch because they had never seen a normal birth. Ever. These are people working in the labor and delivery ward.

In her Huffington Post article that has blown up in the birthing community overnight, Tammy Biddle writes, “Because so many women don’t have an image of what a natural, empowered birth looks like, there is a lot of fear surrounding the act of giving birth. Accordingly, the majority of women give their inner authority over to doctors in their birth process. They trust the doctors more than themselves. The problem with this is that many women aren’t aware that the majority of her doctor’s medical decisions are being made today for monetary and legal reasons, and not necessarily for the good of her and her baby.”

In hospitals, beds need to be turned over fast. These institutions, Biddle tells us, are big businesses and they may “not be as safe as you thought.” She quotes maternal and newborn mortality rates — the U.S. is not doing well. In the developed world, we’re way behind with the second-worst newborn death rate and one of the highest maternal mortality rates in industrialized countries.

So what are other countries doing? For one thing, midwives are involved in the vast majority of births with doctors only coming in if medical intervention is necessary. Here, midwives deliver only 8 percent of babies.

One reason Biddle gives for this low percentage is that doctors literally don’t allow midwives to get a strong enough foothold in hospitals. And so what’s happened? Normal physiological birth — which is what midwives are trained to support — is not seen all that much. The C-section rate has risen 50 percent since 1996. One in three women have major abdominal surgery to deliver their babies.

Biddle tells a story of a friend who intended to give birth naturally but when she arrived at the hospital, her doctor was not available and another doctor insisted she have a C-section for dubious reasons. She fought off interventions and had to literally squat in secret (her doctor wanted her in bed on her back) and had the baby without any medication. But she felt like it was a battle the whole time: “The birth was something that should have been beautiful, but degenerated into something that wasn’t.”

I have seen this with my own eyes. One birth I attended was ultimately really wonderful, but we had to fight to get out of the depressing, semi-public triage into a place where the woman could transition in peace. At one point the woman I was assisting ran — in her hospital gown, fluid running down her legs — away from the shocked nurses and residents so she could get in an elevator to a birthing suite with a tub in it. The staff had done nothing to help her labor whatsoever. And, in fact, the staff mostly put up obstacles to all that she was brilliantly doing to cope with her labor. The only thing they said was, “You can get an IV and an epidural whenever you want.”

This woman had previously experienced very bad reactions to narcotics and wanted to avoid medication. I had to state and restate this at every turn, mostly to blank stares.

Biddle quotes Nadine Goodman, a public health specialist, “What the medical profession has done over the past 40-50 years is convince the vast majority of women that they don’t know how to birth.”

Biddle reminds us that a doctor can never be blamed for doing a C-section. In the legal context, a C-section indicates that “everything was done” to help. This has to change. Since doctors are paying upwards of 200K per year in malpractice insurance, you can hardly blame them. The legal environment is no fun for doctors, and it’s definitely not helping mothers.

“The reality is that once the hospital starts with an intervention, it becomes a domino effect. They say: Thank God we were able to do all of these interventions to save your baby. But, as Eugene Declercq, Ph.D., Professor of Maternal and Fetal Health at Boston University School of Public Health has said, ‘…the fact of the matter is if they didn’t start the cascading of interventions, none of the rest would have been necessary.’”

Home birth is one great way to avoid this situation. At home, there isn’t one, lording medication over you. The environment is much more conducive to labor — you are in an intimate, familiar place, which has been proven to help labor get going. Also, you can move, eat, rest, squat, get in a bath, shower all you want. Home birth midwives cover the nine months of prenatal care, they order up whatever tests need to be done, and become very familiar with the woman’s health and pregnancy. They use a more holistic model of care and cater to not just the physical, but emotional needs of an expecting and laboring woman. They also do things like give shots of Pitocin and administer oxygen or drugs when necessary. They are medical professionals. Certified nurse midwives have been through nursing school and midwifery school. Even before they graduate, they’ve probably had more experience with normal birth than many obstetricians.

Home birth can be a truly wonderful choice and, like Biddle, I recommend that more women consider the option. But for lots of good reasons, it’s not for every woman or every pregnancy. Even if the U.S. home birth rate rose from 1 percent (where it is now) to 25 percent, we’d still have 75 percent of women laboring in hospitals.

Home birth is part of the solution to the crisis in maternity care. The other parts include changing the legal-financial environment that dictates how things are done. It also includes more midwives in more hospitals. And more birthing centers where the expectation is NORMAL VAGINAL birth.

We can sing from the roof tops that birth is normal and that women should trust their bodies — and believe me, I actually do this quite often — but it’s so much work. It’s so crazy that the things I’m saying are considered radical and fringe and “crunchy.” I will keep talking about the physiology of birth and trying to undo the damage done by the media, but I’d like a little help from some policy makers, too. And some progressive doctors who can help step aside for more midwifery care.

What can you do when you’re pregnant? Well, consider a midwife. Let’s move the number up from 8 percent and see how that helps. Maybe some consumer-driven activism will make a difference? Also “like” the BigPushForMidwives campaign on Facebook, sign their petitions and become familiar with the local campaigns. If you have a doctor, ask him or her what he or she can do to support normal birth. Hire a doula or get someone to support you in labor who is not afraid of birth. Don’t watch scary birth movies and reality shows. Take a childbirth education class.

But I must say, every time I list all the proactive things a woman can do in order to have a normal birth, I feel a little depressed.

We need the other side to meet us on this one. Women are always told to be “open” and “flexible” about birth. Wouldn’t it be nice if the majority of caregivers and policy makers were a little more open and flexible, too?

Read Tammy Biddle’s excellent piece here.

photo: eyeliam/flickr

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