by Kim Wildner
Imagine if you will, a woman who has just discovered she’s pregnant. If she lives in the United States, one of her first thoughts will likely be that she has to make an appointment with her obstetrician.
From that first appointment the woman usually acquiesces to test after prenatal test throughout the pregnancy. She will likely accept a plethora of interventions throughout her labor and birth that in many cases are, at the very least, uncomfortable or stressful (or both), and in some cases painful. She may be facing a fear of the unknown with courage henceforth unknown to her. She does so for the sake of her baby. She sacrifices privacy, and in some cases dignity, because she believes it will keep her child safe and herself healthy.
What if the vast majority of women and babies are delivered safely because birth is a reasonably safe, healthy, physiological function of the mammalian body? In other words, what if the end result could be the same in a way that focused on the joy and wonder of the process of procreation…not on every possible thing that could, but is not likely to, go wrong?
In the U.S. today, most people assume that medically managing birth makes it safer. It is widely accepted that the interventions in pregnancy and birth serve a purpose…in effect, that they are safe and effective. Does the evidence support these beliefs?
To assess whether birth is safer medically managed as opposed to expectantly managed, I believe we must first examine how obstetricians became the primary caregiver for birthing women. As an experienced childbirth educator, I’ve discussed this with parents, and without exception, the belief has been that birth originally shifted from a midwife monitored event at home to a medically managed hospital occurrence due to safety reasons. That is an erroneous assumption.
According to The Official Plan to Eliminate the Midwife: 1900-1930 (Gibson, n.d.), at the time that birth moved to the hospital, there was little doubt that midwifery was the safer option. Through early professional journals such as Transactions for the Study and Prevention of Infant Mortality (1910 – 1915), which Gibson obtained through Stanford University Medical Library, we have a unique glimpse into history. She quotes Dr. Ira Wile as saying in 1911, "In NYC, the reported cases of death from puerperal sepsis occur more frequently in the practice of physicians than from the work of the midwives’"(as cited in Gibson, 2006, Part I), and she attributes the following to a Dr. Levy in 1917, "Of the babies attended by midwives, 25.1 per 1000 ... died before the age of one month; of those attended by physicians, 38.2 per 1000 .... died before the age of one month; and of those delivered in hospitals, 57.3 per 1000 died before the age of one month. These figures certainly refute the charge of high mortality among the infants whose mothers are attended by midwives, and instead present the unexpected problem of explaining the fact that the maternal and infant mortality for the cases attended by midwives is lower than those attended by physicians and hospitals" (ibid.). This, despite the fact that 80 years prior, Dr. Ignaz Philipp Semmelweis had admonished physicians for not washing their hands before attending women after handling cadavers, which he suspected was one reason for their high rate of childbed fever, and subsequently higher mortality rate (CDC, 2001). He was ridiculed.
Midwives would have had no idea their vocation was systematically being eliminated to provide “clinical material”…pregnant women…to obstetricians (as cited in Gibson, 2006, Part II). Even if they had known they couldn’t have done a thing about it. Women didn’t even have the right to vote.
Since that time, there has never been a definitive study showing medically managed birth with obstetricians to be safer than expectantly managed birth with trained midwives, though there have been those that have tried (Pang, 2002). The conclusions and methodologies, however, have been called into question (MacCorkle, 2003; Vedham, 2003; Citizens for Midwifery, 2002; Gibson, 2006; Strong, 2000, pp. 222-223). In fact, Jock Doubleday (Doubleday, 2005) has been offering progressively larger amounts of money, with $50,000 being the last offered in December of 2005, for anyone who can provide such a study. The reward has stood unclaimed since he first offered it in 1998.
Childbirth is safer than it was 100 years ago (Johanson, Newburn, & Macfarlane, 2002). Undoubtedly, it is safer to give birth in the U.S. than it is in many places throughout the world. However, to assume that if obstetricians now attend birth, then improved outcomes must be due to that development alone is a fallacy that does not take into account improved nutrition, sanitation, disease control, birth control or any number of other variables. There are many contributing factors to improved health and well-being in the childbearing year (Wagner, 1994). In fact, countries that enjoy the modern advancements mentioned above in addition to midwifery care have the best outcomes in the world (Strong, 2000), and “…there is never a doctor in the room” (Wagner, 1994, pp.124). Where exactly does modern obstetrical management place the U.S. in comparison to the rest of the world? There are 42 countries with lower infant mortality rates (Central Intelligence Agency, 2006) and 29 countries where fewer mothers die (World Health Organization, 2004, pp.23).
While this may be surprising to some, certainly, it is not to suggest that the practice of obstetrics is unnecessary. We need surgeons and experts in pathology for a small number of cases that might be deemed high risk, such as mothers who have pre-existing medical conditions or mothers with addictions. The evidence suggests that number should be a very small percentage (Johnson & Daviss, 2005; Declercq, Skala, Corry, Applebaum, & Risher, 2002).
In essence, the system under which the U.S. currently operates could be analogous to hiring a cardiologist as a personal trainer. Could heart attack deaths be reduced by having surgeons immediately available in the event that a normal, but strenuous, activity turned tragic? It’s very likely. However, would a game of tennis be imminently more difficult, if not impossible, if mobility were restricted by an assortment of electrodes and devices strapped to the player to assess every biological function and make the job of the cardiologist easier?
If this seems like an absurd analogy, consider this: the image that most of us have of birth is of a woman in bed, usually on her back, pushing out her baby, possibly with her feet in stirrups, or her legs being pulled toward her ears by herself, her partner or a nurse.
The path the baby follows is called the ‘curve of Caras’. Mothers are expected to push baby uphill in typical hospital birth. Why? Is there some physiological reason that mothers are expected to lay on their backs? No. The reason mothers are restrained to bed is so that the monitors can be hooked up and so that the doctor can sit comfortably at the end of the bed.
Women are told throughout pregnancy to avoid laying on their backs because oxygenation to the uterus can be impeded by the weight of the baby resting on the vena cava. Does the position suddenly become safe in labor? No. This position is detrimental to babies, and it creates pain for the mother because the weight of the baby rests on her tailbone (Lamaze, 2005). The position also makes the pelvic outlet considerably smaller by resting the mother’s weight on the tailbone, this flexing it inward. It makes the final stage of labor much harder than it needs to be. It almost guarantees the perineum will tear(Walsworth & French, 1998). Therefore, episiotomies are done to prevent tears. This means healthy perineal tissue is cut to prevent tears that would be unlikely to occur if the mother were not in a position that creates conditions for tears. Does it work? Think about it. If you try to rip a piece of whole fabric, it remains strong. If you first cut the fabric a tiny bit, it rips easily. The same is true of the human flesh. Fourth degree lacerations (where the perineum rips through to the rectum) happen almost exclusively with episiotomies (Goer, 1995).
All of this so the baby could be continuously monitored, and for the convenience of the provider, without any regard for how it impedes the process of birth, the danger it introduces into the process, or the comfort of the mother. It is not supported by evidence as safe, is not backed by common sense or evidence as effective for, well, anything. Yet it is a nearly universal intervention.
At this point, it might be argued that by constantly monitoring the baby, we can avert a terrible tragedy by knowing moment by moment what the state of the baby is. Except that what the evidence says is that the routine use of continuous electronic fetal monitoring does nothing but increase the rate of surgical birth without any improvement in outcomes (Goer, 1995; Wagner, 1994).
The act of giving birth becomes more difficult, and in some cases impossible, due to the assortment of wires and devices meant to assess every biological function.
Each obstetrical intervention was created for a specific medical indication for which, when used appropriately for that indication, it is effective. Unfortunately, instead of being used selectively in exclusively pathological situations, many interventions are used routinely within a healthy population, in part due to the litigious environment in which physicians must operate (Carpenter, 2004).
The following graph (Wildner, 2006) illustrates some of these. It shows the percentage of women who will experience the selected interventions under different caregivers, with no substantial difference in outcomes. (I created a chart to use as a visual comparison of the frequency of interventions used by obstetricians and midwives, but was unable to convert the format to insert on this blog. However, it showed a high rate of 6 different common interventions for doctors and nearly nonexistent rates of the same interventions by midwives.)
If we can obtain virtually the same results without performing them (and we can), why are they being done? How many of these common procedures proven safe and are they effective?
Two interventions deserve special consideration. These are procedures deemed ‘elective’, which is a bit misleading, because a woman may ‘elect’ to have them, but should she ‘elect’ to refuse them, they may be performed under court order (Irwin & Jordon, 1987).
These two procedures, induction of labor and cesarean section, while they are extremely important life-saving measures when used for medical indication, are perfect examples of obstetrical technology gone awry when used for convenience.
The World Health Organization suggests that induction is medically indicated no more than 10% of the time (as cited by The Coalition for Improving Maternity Services, 2003). Yet, according to the Listening to Mothers survey, (Declercq, et al, 2002) 55% of mothers were induced, even though there is acknowledgement that induction increases risk (Baxley, 2003; Rubin, 2006) and the chemical agents, such as Cytotec, used for elective induction are not approved by the FDA for such use (Haire, 2001; Physician’s Desk Reference, 2003). In fact, not only is Cytotec not approved for elective induction, it carries a serious warning not to use it for induction at all (U.S. Food and Drug Administration, 2005), which does not seem much of a deterrent to the American College of Obstetricians and Gynecologists (ACOG) or the American Academy of Family Physicians who “…supports the safety and effectiveness of vaginal misoprostol (Cytotec) for cervical ripening and labor induction” (Weaver, 2006) contrary to the scientific evidence.
The Centers for Disease Control, (CDC, 1993) and the World Heath Organization, (as cited by The International Cesarean Awareness Network, 2004) recommend rates of surgical birth not to exceed 12-15%. The U.S. is currently at 29.1% (Dress, 2005), meaning at least half of these surgeries are medically unjustified. Obstetricians contend (Rubins, 2003) that the increase is due to ‘maternal request’ surgeries, to avoid such things as urinary incontinence later in life, or sometimes due to fear of pain, supposedly the case with Britney Spears. Yet, vaginal birth is not a factor in urinary incontinence (Albers, 2003; ACOG, 2005), despite what some doctors may suggest (Healy, 2006). If women are requesting surgery over natural birth, which some sources doubt (Lamaze International, 2006), then one would wonder if they are being apprised of the significant risks (Thornton, 2006). Risks that are perhaps worth taking if the life of mother or baby are compromised…but not worth introducing where none previously existed.
People often say that in the end, all that really matters is that the mother and baby are okay. Is that really all that matters? What if the mother and baby could have been safe without adding insult to injury?
While some authors merely tell women they should expect care with no basis in science (Murkoff, Eisenberg, & Hathaway, 2002) others defend over-treating in order “To be sure that not even one baby will be harmed during delivery” (Tuteur, 1994; Part III-Common Obstetrical Practices). Is that a realistic goal? Is it being realized? Not as evidence by the many people who have studied obstetrical management versus midwifery attended pregnancy and birth for the last 25 years or so (CIMS, 2003; Johnson & Daviss, 2005; Enkin, Marc, Keirse, Renfrew, & Neilson, 1995; Gibson, 2003; Goer, 1995, 2002; Wagner, 1994, 2003; Stewart, 1981; Keefe, 2001; Tillett, 2005). If success is measured by results, the U.S. obstetrical system could do better. In those 25 years, infant mortality has actually worsened, (Kristof, N., 2006) and maternal mortality has remained unchanged (CDC 1998; CDC, 2003).
While this may seem an indictment of an entire system it truly isn’t. It is a call for reformation. Obstetrics have at their disposal the most advanced technology in the world. However, when you have a hammer, everything looks like a nail. By transferring care of healthy women and babies to midwives, only the actual ‘nails’ reach the ‘hammers’ through a referral from midwives, guardians of normalcy. Obstetricians are then able to use their considerable skills to benefit the women who really need their help. Under this new paradigm that views birth as a natural process, health care costs would be reduced, (Druley, 1998) maternal satisfaction would increase, (Villagran, L., 2006) outcomes would improve and obstetricians would get the recognition and respect they deserve for doing the job they were trained to do. Everyone wins.
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by Kim Wildner
The circumcision debate seems to me to be one of ethicality. In the United States, female circumcision, also often referred to as “female genital mutilation” or FGM, is vehemently denounced, while infant male circumcision is just as adamantly defended. I would suggest that it is only cultural perception that allows a person to view one a violation of human rights, the other a rite of passage or acceptable religious imperative.
The two procedures are really not as dissimilar as one might think. Both remove a part of the reproductive anatomy of a child who is too young to give informed consent. In both cases, the parts removed reduce sexual sensation and to one extent or another impair normal physiological function. The parts remove existed for physiological purpose, but were removed due to ignorance of these functions, or due to aesthetics and/or collective cultural or religious beliefs. Both are painful. In neither case is anesthetic usually used. What makes it abhorrent in one case should argue against the practice in both cases. However, infant male circumcision is still one of the most common surgeries in the U.S. (Stang & Snellman, 1998).
Where FGM is practiced, in Africa and the Middle and Far East, defenders insist that Westerners just don’t understand. Women will not be marriageable if they are not circumcised, as they will be unclean and no husband will want a wife that looks different from the cultural norm. They are indignant that arrogant Americans would try to stop something that is required of them in accordance with their understanding of their religious practices (World Health Organization, 2000).
When routine infant male circumcision discussion occurs between parents in the States, the debate is often heated. Defenders of the practice, usually parents who have circumcised or plan to, accuse anyone who opposes circumcision to be unfairly biased. The same people who might consider FGM barbaric consider the same procedure on a baby boy a ‘parenting option.’ Yet the most common reasons for choosing circumcision for a baby boy are essentially the same:
· I want my son to look like his father
· I think uncircumcised penises are ugly
· It’s cleaner
· It doesn’t hurt; babies can’t feel pain. Even if they did feel pain they won’t remember a ‘little snip’
· Religious reasons (oddly enough, often by Christian, not Jewish, parents)
Are not the first two simply variations on the argument for conformity with the cultural norm? The circumcised penis as ‘normal’ is so ingrained in our society that many anatomy textbooks don’t even show natural penises; they show circumcised ones as ‘normal.’
Even so, this is not justification for what amounts to baby’s first plastic surgery. We don’t reconstruct a baby’s nose if it doesn’t look like his father’s. If his father has an accident that results in amputation of a finger, we don’t remove the baby’s finger so they match. Surely, more people are likely to see his nose or hands than his penis.
According to the American Academy of Pediatrics, routine circumcision has no medical justification, although at one time it was recommended as was female circumcision, and for the same reasons (Rathmann, 1959). A natural penis is no harder to clean than the female labia (Fleiss, 1997). To suggest that boys cannot be taught personal hygiene of the body they were born with is, in my opinion, insulting.
The argument that amazes me the most though, is that babies cannot feel pain, or that if they do, they don’t remember it so it doesn’t matter. For those that insist it doesn’t hurt, I offer a video that is available on the internet (Intact, n.d.). Some say, “I don’t think I could stand to watch that.” It is too painful for them, as adults, to watch, but not too painful for their son to experience when he’s just hours old? If babies do feel pain but can’t remember, are other sources of unnecessary pain acceptable? I would argue that lit cigarette butts to the feet of a newborn certainly are painful. While the incident may not consciously be remembered it is still a repugnant and vile abuse.
Cultural acceptance doesn’t make circumcision hurt any less, and it doesn’t restore the functionality of the organ. The inconsistency in attitudes is simply not justified. Either it’s an abuse of little girls and boys, or it’s a simple parenting option.
Fleiss, P.(1997). The case against circumcision. Mothering, 85(Winter). Retrieved February 2, 2007, from http://www.mothering.com/articles/new_baby/circumcision/against-circumcision.html
Intact. Circumcision Video. Retrieved February 2, 2007, from http://www.intact.ca/video.html
Rathmann, W. (1959, September). Female circumcision: Indications and a new technique.
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by Kim Wildner
When Ricki Lake appeared on The View at the time of the release of The Business of Being Born, Barbara Walters that interested me. Lake is explaining how having a natural birth at home with midwives empowered her. Walters is confused by that.
This started me thinking about how many women do (or don’t) take childbirth classes and why that might be. Of course, partially that is because at the time I had a poll on my blog asking people if they took classes and why or why not. At the time of this writing, 52% did not take a class, and most respondents who didn’t take class said it was because they didn’t need one.
Of course, you know I’m going to ask ‘why’ next, right? Did they feel they didn’t need one because they figured they’d blindly trust whatever their OB told them? Did they not understand the purpose of a childbirth class? (Hint, it has nothing to do with ‘breathing’…you must know how to breathe already or you’d be dead and I hate to say it, but there is no magic breath that gets babies out.) Did they have a midwife as a caregiver, and had everything explained to them (and had actually helpful books recommended to them so they could educate themselves) so that a childbirth class was redundant? Did the non-hospital childbirth classes not market themselves well?
It was this last question that was on my mind when Maslow’s Hierarchy of Needs came up in conversation. Now, this pyramid of needs has tickled the back of my brain on and off periodically. This time, I realized why it kept bothering me.
First, a nice visual of Maslow’s theory can be found following this link.
The basic idea is that when we make a decision about something, these are the factors that will motivate us. First, we are concerned with survival issues. If our basic needs are not being met, we don’t really care about the other stuff.
Next, we need to know we are safe and secure. We need some order in our life, some predictability and to be part of a larger whole. This is also about survival to a certain extent. Being part of the larger group is an evolutionary desire. We are tribal by nature. Solitary humans don’t do well, not just because we need others to be most effective at hunting, gathering, farming, etc., but we need social stimulation for the sake of our brains. If we don’t interact, we go a little bit nutty. Think of the movie Cast-a-way with Tom Hanks.
Beyond that even, we need to fit in with our family, peer and work groups. We have a need to feel appreciated and loved.
We can survive if the only the first two needs on the pyramid are met, but without the third, we probably would be slightly maladjusted.
Next, we have the need to feel special. We want to feel respected and to be able to feel pride in our accomplishments. Finally, we reach a state of enlightenment or our full realized potential. Some say not many of us get to that point.
Ok, so how does this relate to birth, childbirth classes and Barbara Walter’s bewilderment?
Here’s my theory:
Most American women are still making decisions at the first two or three levels. They believe birth is a dangerous, excruciating medical event. They want to be able to predict exactly what will happen each step of the way, even if the security is an illusion. If they do what every body else does, not only can they have a plan, but its familiar because it’s what everyone they know has done. They are following a blueprint. Sadly, because they do what everyone else does, they get the experience everyone else got, which is likely the painful medical event. But that’s ok with them, because they all have the same war story to tell. They fit in. They also get admiration for ‘surviving’ such a harrowing event.
Those of us who make the decision to birth at home, or who take a class that advertises gentle and empowering birth, are doing so because we are not operating from a place of fear. Make no mistake I am NOT saying we are ‘better’ or ‘higher’. I’m saying because we are confident that we are safe, and our babies are safe, we are not operating from survival need. Because we know what the research says BIRTH is safe, we are not operating at security need. Hence OUR confusion when someone says, “You birthed at home? Oh, you are so brave! I could never do that!” We, of course, are thinking, “Sure you could.” We don’t consider ourselves brave at all. We are just doing what makes sense, personally and per the evidence.
We are working from the ‘esteem’ level, because we can. We feel a need for a sense of accomplishment like anyone else. We feel a need to be respected by our spouse or our home-birthing friends and to feel unique. Now, we all have these needs, but what I’m saying is that we can make our birthing decisions from this level because we don’t have to worry about the first three needs. To try to empower a woman who is operating at a survival or security level will not work. She has other things to worry about. Not to mention, if she is in an unsafe environment, or doesn’t have access to nutritious food, or is in some way actually not healthy, she actually is at risk for complications, which means she’s operating at exactly the level at which she needs to be operating. This is why it is absurd when people say homebirth supporters are trying to ‘make people feel guilty’. Even the most strident homebirth advocates realize hospital birth is the only place to be for about 10-15% of women. Homebirth should be an option because it’s safe, not because it’s right for everyone.
Think about it like this: You feel education is important. You improve the schools, and you make attendance mandatory. But one kid just doesn’t seem to care. He is often truant, and when he is there he doesn’t make much of an effort. You try to tutor him. You try special classes. You try rewards and punishments, but nothing works. He just doesn’t seem to value education.
What if you found out the kid was homeless? What if he’s being beaten at home, or doesn’t get to eat every day? What if he was convinced he was worthless because he was told he was, every day? If you met the more basic needs, from the bottom up, he might be more interested, and able, to operate at a higher level on the needs hierarchy. Otherwise, he simply can’t. He has to meet his basic needs first.
So, when we talk to women about the empowerment of natural birthing, they are confused. Sometimes they’re angry, but they may not be sure why. I believe it is because there is cognitive dissonance because on some level they know that the fear they feel is disproportionate to the actual risk. Because there is someone who doesn’t feel that same fear, it makes them question why they have it. Not consciously, of course, but if they become aware that some women can birth with dignity, comfortably, maybe painlessly, even ecstatically, and still be safe, but they believe that they must sacrifice all that for safety, it suggests that their suffering was for nothing. That’s not a comforting idea. It would make me angry too.
This brings us to the question of how we can help them meet their needs so they can feel the ecstasy and empowerment we know is so transformative. Right now they don’t even care about that. You don’t know what you’re missing if you’ve never had it. You won’t even try for it if you don’t believe it’s really possible for you. Can you see how bubbling over with enthusiasm about your positively transformational birth experience comes across as lunacy to someone who is convinced they “would have died” if they’d done what you did? It doesn’t matter if it’s true or not, it’s what they believe.
It doesn’t matter if they had an epidural that caused a sudden drop in blood pressure, that caused fetal distress that required a cesarean that saved their life. The only part of that equation that is important is the last part. It doesn’t matter that the medical management of their birth lead to the problem in the first place. What matters is the medical management saved their life…and it did.
It doesn’t matter that they almost died of hemorrhage due to an elective cesarean, what matters is that modern medicine saved their life. Undoubtedly it did.
It doesn’t matter that their baby almost died from a cord prolapse that coincidently happened just after artificially rupturing the membranes. What matters is that modern medicine saved their baby from certain death. It did.
And because they are operating at that place of survival, it makes sense that is what they would focus on, it’s what’s important. They aren’t even going to question it unless they are operating from the 4th level. If they are, they are going to wonder how things got so askew. Many do. These are the women who have a couple of horrible experiences and then come to a HypnoBirthing class. Or, the women who hire CNM for VBACs after questionable cesareans. Or, the woman who has seen several of her friends suffer from birth-related PTSD who decides to explore the option of homebirth. No one is right or wrong; they are just making decisions based on their individual needs as they perceive them based on their own experience and beliefs.
It's a theory anyway.
My name is Kim Wildner. I am the author of Mother's Intention: How Belief Shapes Birth.