This semester I had to write a research paper for one of my political science classes. We were able to choose a topic of our choice dealing with ethnicity or nation-building. Ever since I watched the documentary
The Business of Being Born, I've wanted to learn more about the American birthing system and why it differs so heavily from that of other countries. For that reason, I chose to write about women's right to natural birth in the United States. Since I put a lot effort into this paper, I decided to post it on this blog (even if it won't be published in a journal or somewhere notable, maybe a handful of people will read it). Here you go!
Women’s Right to Natural Birth in America
Allie Smith
Introduction
In the United States, our birthing system has been primarily geared toward an intervention based structure. Historically, however, before hospitals and doctors were accessible in the United States, home births attended by midwives were the norm. This research paper’s intent is to examine the United States’ maternity care establishment, from past to present, and offer a possible alternative that would result in reduced healthcare costs and healthier mothers and babies.
In this article it will be determined when and why America has been dramatically altered toward intervention based delivery. Potentially negative effects from this child-bearing system will also be examined. For the purposes of this report, interventions in the birth process will include the use of synthetic oxytocin, epidurals, and cesarean sections. There will be three main sections. The first will give a brief history of birthing in America with a more focused section on the emergence of modern intervention methods. The second section will discuss midwifery, it’s acceptance in America, and the positives and negatives associated with home births and birthing centers. The final section will compare our system of birthing to that of the Netherlands, a country where about one-third of all births occur in their homes and are attended by a midwife (Rooks 1997, 411). This will provide a perspective of how possible it is to revert back to a more natural system of birthing in the United States. Finally, to conclude, possible alternatives will be discussed that would significantly alter the method of maternity care currently being used in the America.
A Brief History of Birthing in America
The practice of medicine throughout the ages has largely been a series of trials and errors until some amount of success has been reached. The case is no different when specifically narrowed to the early days of birthing in America.
The first major problem to arise with birth in American hospitals was the prevalence of puerperal fever in the 1800’s. Puerperal fever or “childbed fever” would occur in women who had recently given birth and often resulted in the death of the mother. “The leading cause of maternal mortality at the beginning of the 20th century was puerperal sepsis” (Dawley 2000, 51). Initially, the cause of the fever was blamed on the women infected for reasons spanning from the mother’s milk having “gone astray” to the mother causing the infection by “fretting” (Cassidy 2006, 57-9). It took some time to determine that the fever was being caused by the lack of hand washing among doctors performing vaginal exams on multiple patients. When the true cause was determined to be derived from the doctors’ fault and not that of the mothers’, it took some time before hand washing was a regular practice in hospitals.
The 1800’s also saw the use of chloroform and ether for pain relief during childbirth. In 1877, it was determined that ether was transferred to the infant. This was discovered by smelling the breath of the baby and sensing the distinct aroma of ether. Even before this discovery, the use of such drugs was not widespread due to religious concerns with the idea that women are meant to be in pain during childbirth according to the story of Adam and Eve. Although, after the use of chloroform by the head of the Church of England, Queen Victoria, its popularity spread rapidly as a more acceptable practice. The main downside to the use of chloroform was the window of time available to use it. It had to be taken right before the baby was born “because taking it sooner could ease the contractions and stall the birth. There also were dangerous side effects, including maternal hemorrhage and breathing difficulties for the newborn” (Cassidy 2006, 89).
In the early 1900’s a new type of pain suppression to be used during labor came to the United States from Germany. It was called Twilight Sleep. Twilight Sleep was discovered “by combining the amnesiac scopolamine--later called ‘scope’ or ‘the bomb’--with morphine, a woman in labor could be made to fall into a semiconscious state and emerge hours later with a baby in her arms, remembering nothing that happened in between” (Cassidy 2006, 91). So, while the woman would indeed feel pain and discomfort, she would not have any memory of it. This was an extremely appealing practice once it spread to the United States. During this period in history, the use of Twilight Sleep overlaps with the period of time associated with the women’s suffrage movement. This made the use of Twilight Sleep more widely utilized because it was linked to women’s newfound rights. Women wanted the opportunity to make birthing pain free.
There were some major drawbacks to the use of Twilight Sleep which led to its disappearance in the 1970’s. Once babies were born, they were frequently unconscious or would not immediately start breathing on their own. Also, mothers had an increased danger of delayed labors and hemorrhaging following childbirth. Lastly, the care administered to women under the influence of Twilight Sleep was poor at best. Since they would not remember the experience, they were oftentimes left for hours on end without care and handled without what we call a bedside manner today. Also, since the women had no control over themselves in the Twilight Sleep, they would be strapped down to their beds and would be surprised to find during their altered state, they had been screaming or lashing out at nurses attending to them.
As Twilight Sleep left the mainstream for pain relief during labor, the replacement quickly became the epidural. This is an injection made into the lower back in the area which gives the shot its name, the epidural space in between vertebrae. This method of pain relief is the most successful thus far, as it does not have an impact on the woman’s degree of consciousness. There are many complications associated with the procedure. Epidurals result in “less effective contractions and an increased likelihood that the baby’s head will not rotate into the optimal position for delivery. As a result, women who have epidurals experience higher rates of both cesarean sections and operative vaginal deliveries (use of forceps or vacuum to extract the baby)” (Rooks 1997, 472). Women who are given an epidural “are also more likely to have their blood pressure drop; develop a fever; and have difficulty passing urine, and so are regularly catheterized” (Cassidy 2006, 101). There is also the concern of the epidural blocking key hormone production during the labor process. Hormones that make the labor process easier and shorter are adrenaline and the endorphins that keep oxytocin flowing. Also, research shows epidurals cause “a drop in prostaglandin, yet another hormone involved in the birth process, which keeps the uterus supple enough to contract and bounce back. This can result in a less responsive uterus, a malpositioned fetus, longer labor, and a higher risk of hemorrhage” (Block 2007, 173). One last argument is that the lack of pain felt in the labor process means necessary endorphins are not released. With that, a hormone called prolactin is not released which “may explain recent data suggesting that epidurals hamper breastfeeding” (Block 2007, 173).
Along with the less effective contractions associated with epidurals comes the use of artificial stimulation, such as a synthetic form of oxytocin, to keep the contractions powerful enough to progress the labor. One problem with artificial oxytocin is that it does not stimulate the emotional release that natural oxytocin does. Another result of artificial oxytocin is its cue for the creation of natural oxytocin to cease in the body. “One randomized study of women who labored on their own or with synthetic oxytocin found that 80% in the latter group felt it had increased their pain” (Block 2007, 135). During a regular labor process, a contraction is followed by an interval of downtime. Unfortunately, artificial oxytocin does not cause the labor process to operate naturally. “And with an epidural deadening the body’s natural pain threshold, staff can keep upping the dose, which can lead to contractions that fire like a machine gun or that last for minutes, during which time the fetus is oxygen-deprived. This is called hyperstimulation...In half of the cases of hyperstimulation, the fetal heart rate drops below normal” (Block 2007, 137). With the loss of the natural production of oxytocin during labor much research has been established around the connection to the rising rate of autism in children. “A 2004 study out of Australia found that autistic children were twice as likely to have been born without natural labor, either by elective cesarean or induction” (Block 2007, 139).
When epidurals and synthetic oxytocin are not effective, when the baby has breeched, when there are complications that are making the labor process unsafe for the mother and/or baby, or when a woman elects to bypass the labor process all together, cesarean sections are performed. In the beginning, cesarean sections almost always resulted in the death of the mother. Throughout history, doctors have developed a highly effective procedure that can be done with little risk of fatality to the mother or child. The modern cesarean section procedure is done by giving the mother an anesthetic (sometimes if an epidural has already been administered, this is a sufficient anesthetic). Then, an incision is made into her lower abdomen through the uterus. Moments later, the baby is removed and the mother is sewn back up again.
For women that know they will be giving birth by cesarean section, it is usually because of one of the following factors: they are “carrying twins, past their due date, or have preeclampsia (dangerously high blood pressure, which could lead to convulsions), herpes, diabetes, or a placenta problem” (Cassidy 2006, 118). And although cesarean sections can be completely necessary at times, research shows that the majority are not. One of the appeals of elective cesarean sections is being able to schedule the due date for a time that is convenient for the mother. A new phrase has been coined because of elective cesarean sections, “too posh to push,” named after Victoria Beckham (Posh Spice of the Spice Girls) who has had three cesarean sections (for all three of her sons) scheduled around her husband’s soccer schedule (Cassidy 2006, 123). This creates a great debate on whether cesareans should be given electively or if they should only be performed in times of need. “For 1 in 3 American babies born each year” (Block 2007, 49), cesarean section is their method of arrival into the world. However, with most medical procedures, there are dangers involved. “The risk of maternal morbidity is between 8 and 12 times higher for caesarean delivery when compared to vaginal delivery” (Pai 2000, 2756). Some of the hazards behind cesarean sections include “hemorrhage, infection, organ damage, and threats to future fertility” (Block 2007, 55). With repeat cesarean sections, the risks include “scar tissue, adhesions, uterine rupture, and catastrophic placenta implantation problems, where the organ grows into the uterine scar or through the scar--grave threats to both mother and baby” (Block 2007, 55).
Along with the threats to the mother and baby, hospitals stand to benefit from performing cesarean sections. “A significant body of research supports the notion that physician behavior is at least partially motivated by financial considerations” (Spetz et al. 2001, 536). An additional debate in whether to perform a cesarean section or not is time. As we’ve all heard before, time is money. When labor perpetuates too long, research has shown that the physician may make the decision to deliver the baby by cesarean section. The extra money coming in from performing surgery has its benefits as well. Yet, there is a solution for this appalling revelation. If physicians were paid a consistent salary and provided incentives for preventing intervention based methods, the rate of cesarean sections would undoubtedly decrease. As it stands currently, most physicians are paid on a fee-for-service system which provides them with a larger paycheck from performing surgeries, such as the common cesarean section.
Another finding to consider when discussing our current maternity system is while “infant mortality rates in the United States declined between 1962 and 1994, the relative position of the United States in the ranking of developed countries with a population over 2.5 million residents has steadily worsened for most of this period, decreasing from 12th best in 1962 to 21st in 1994” (Gabay and Wolfe 1997, 389). Currently, according to the World Factbook hosted by the CIA online, the United States’ infant mortality rate is 6.06 per 1,000 live births. To give a perspective, the Netherlands’ infant mortality rate is 4.59 per 1,000 live births. That is a 24.26% difference in infant mortality rates. According to this evidence, the United States has noteworthy improvements to be made in our approach to giving birth.
Midwifery and Home Births in America
Throughout history, midwives have been active in aiding women through the child birth process every step of the way. “Midwife, from the Old English, literally means ‘with woman’” (Cassidy 2006, 29). “Midwives were responsible for the care of almost all pregnant women during the first 250 years of life in the colonies of the United States. In part, this was because few American colonists were of the educated, elite classes of Europe and Great Britain and the settlers included few university-educated physicians. In the absence of physicians, midwives were often the sole source of health care; as such, many were highly respected members of their communities” (Rooks 1997, 17-8). Midwifery continued to be the norm for most women giving birth until the early 1900’s. The beginning of the twentieth century saw an emergence in the amount of hospitals in America, medical advances in anesthesia (as previously discussed), and an increasing number of physicians who desired “to solidify their status and authority” (Rooks 1997, 23). This movement toward giving birth in hospitals led to a severe decrease in the amount of births attended by midwives. “In 1900, about 50 percent of American births were attended by midwives; by 1935 the rate had fallen to 12 percent, and most of those were in the black population of the Deep South. By 1986, only about 4 percent of pregnant women were getting nurse-midwife care” (Mitford 1992, 166).
In modern times, there are nurse-midwives. A nurse-midwife “is a licensed registered nurse who has completed an accredited graduate level program in midwifery and has passed a certification exam” (Gabay and Wolfe 1997, 388). There are also direct-entry midwives that practice without a nursing degree. The lack of use of midwives by American women lies largely in the misunderstood nature of the practice of midwifery. Of the births attended to by midwives in America, 95% are attended to by nurse-midwives, “70 percent of whom have master’s degrees, many from the country’s leading universities” (Rooks 1997, 464). There is also a concern for hazards that may arise and the pain associated with natural child birth.
The main negatives associated with home births are the absence of advanced medical equipment and pain relief. If the woman changes her mind during labor, an epidural cannot be administered. Also, if the pregnancy is of high risk and something does go wrong, it may be too late in the labor process to transfer the mother to a hospital for emergency care.
There are many positive aspects of home births attended to by trained midwives for low risk pregnancies. One of which is the greatly lowered risk of using intervention methods. In an exert from an article written by Ina May Gaskin of The Farm Midwifery Center in Tennessee she says, “Our techniques were well enough developed early on that our cesarean section rate has remained below 2 percent and our forceps and vacuum extraction rates below 0.5 percent for over 2,000 births.” “Deliveries at home and in birth centers have been statistically proven to be as safe as those in hospitals, where, not incidentally, one’s chances of having a cesarean soar just because you walk through the door” (Cassidy 2006, 75). “Although there has been much controversy about the safety of births attended by midwives (or physicians) in out-of-hospital locations, there is substantial evidence that births in homes and free-standing birth centers can be as safe as hospital births when a system of quality assurance is in place” (Rooks 1997, 465). This research would conclude that the dangers and fears associated with home births are largely a misconception among Americans today. As a matter of fact, “midwives deliver the majority of infants worldwide, but in the United States in 1997 only 6.7% of births were attended by nurse-midwives” (Dawley 2000, 55).
Furthermore, midwives offer a more personal experience for mothers giving birth. They get to know their patients much better and can often assess changes and possible risks more so than an overworked obstetrician with many more patients under their care. Obstetricians often avoid being on call twenty-four hours a day, seven days a week by alternating night shifts with other obstetricians. This practice increases the probability that a woman going into labor in the evening will not have her baby delivered by her own doctor. And, “while patients’ own obstetricians may be quite adept at diagnosing pregnancy problems and may be current regarding the care of such problems, their on-call peers may not” (Strong 2000, 77).
In addition, the significant cost difference between nurse-midwife care and obstetrician or physician care should be addressed. Research found that “[nurse-midwives] were over $1,300 cheaper for total maternity care. If we convert the professional fees for obstetricians and nurse-midwives into hourly wages, the cost differences become even more striking, given that nurse-midwives tend to spend more time with their patients than do obstetricians” (Strong 2000, 84). With this study, it becomes apparent that Americans stand to save a significant amount in healthcare costs along with being granted an opportunity to receive more personal care from a nurse-midwife.
Childbirth in the Netherlands
The system of birthing in America differs substantially from that of the system in the Netherlands. “One-third of all births in the Netherlands are home births attended by midwives. The Netherlands has long had one of the lowest rates of infant mortality in the world” (Rooks 1997, 465). Actually, according to a study of midwifery practices of the Dutch, “research has shown that, for the women with low risk pregnancies in the Netherlands, choosing to give birth at home is a safe choice with an outcome that is at least as good as that of planned hospital birth” (Wiegers et al. 1996, 1313).
In the Netherlands, midwives are respected and protected by legal status. Another sizable difference is that “every Dutch citizen is covered by health insurance. Approximately two-thirds obtain their coverage through the national health insurance system; those with incomes above a certain level have private health care. A pregnant woman covered by the national insurance system must use a midwife unless none is available in her area or she has a complication that requires an obstetrician” (Rooks 1997, 411). This creates an exceptionally different situation from that of American citizens who often find it intensely difficult to get their insurance provider to cover the care of a midwife.
“The Netherlands has about 200,000 deliveries a year, 43% of which are conducted independently by midwives, 14% by general practitioners, and 43% by obstetricians” (Oppenheimer 1993, 1400). In the Netherlands, a pregnant woman is examined to determine the risk criteria of the pregnancy. This will then determine if she should seek sole care from a midwife, general practitioner, or obstetrician. “Thus the basic philosophy of the Dutch system holds that the midwife or general practitioner cares for normal pregnancies, freeing the obstetrician to provide care for women who have specific medical or obstetric indications” (Oppenheimer 1993, 1400-01). In America, nurse-midwives are “subordinate to the physicians in charge” (Mitford 1992, 181). We lack a vital acceptance of midwives that could benefit our country immensely. If physicians and midwives were able to work together, midwives could care for women with low risk pregnancies and there would be less pressure on physicians to make births happen rapidly, thus reducing the use of intervention methods.
Conclusion
Based on the research provided, it appears that America’s dramatic change toward an intervention based birthing system lies primarily in societal standards. Having a baby in a hospital with easy access to varying methods of intervention seems to be something that sets many Americans’ minds at ease. It is an interesting deduction in that a substantial amount of research shows that hospitals are not necessarily any safer than natural home births and that intervention in birthing has many potentially hazardous consequences. As Pai (2000) stated in his article studying the overuse of cesarean sections, “doctors wield too much power and unless the medical community decides to regulate itself, there is little that consumers can do.”
Even so, it is possible that the route America’s birthing system has taken can still change. This is much more of a possibility if scientific evidence emerges about negative long-term effects from some types of intervention methods (such as the 2004 study discovering autistic children to be twice as likely to have been born without natural labor as referenced previously). In the ever changing realm of medicine, it is possible that the next generation will see an emergence of natural birth in America.
As it was previously mentioned, nurse-midwife care in a home or birthing center environment is more cost effective than a hospital birth which has a substantial possibility of intervention methods being applied. If insurance companies and the public as a whole had better access to the information shared in this research paper, it would be a great opportunity for a considerable reduction in healthcare costs. Insurance companies could save money by covering the care of nurse-midwives and allowing families to choose to give birth at home or at a birthing center. This would also benefit the country as a whole by positively impacting our national deficit and healthcare expenses.
For women who consider planning a due date by scheduling a cesarean section more convenient, another change to our healthcare system could offer a solution. If insurance companies covered nurse-midwife care and birthing center delivery, there would be many more birthing centers in this country. Therefore, if birthing centers became more accessible than hospitals, when the time came to give birth naturally, women could have easier access to a birthing center near their home or place of employment. They would then experience delivery without the added complications and risks that can occur during a surgical procedure along with the convenience of a more accessible facility concentrated specifically on attending births.
A new system of birthing in the United States is completely attainable. It simply requires the spreading of knowledge and access to an opportunity for women to give birth naturally.
References
Block, Jennifer. 2007. Pushed: The Painful Truth About Childbirth and Modern Maternity Care. Cambridge: Da Capo Press.
Cassidy, Tina. 2006. Birth: The Surprising History of How We Are Born. New York: Atlantic Monthly Press.
Dawley, Katy. 2000. “The Campaign to Eliminate the Midwife.” The American Journal of Nursing 100:10, 50-56.
Gaskin, Ina May. 1996. “Intuition and the Emergence of Midwifery as Authoritative Knowledge.” Medical Anthropology Quarterly 10:2, 295-298.
Mitford, Jessica. 1992. The American Way of Birth. New York: the Penguin Group.
Oppenheimer, Christina. 1993. “Organising Midwifery Led Care In The Netherlands.” BMJ: British Medical Journal 307:6916, 1400-1402.
Pai, Madhuker. 2000. “Unnecessary Medical Interventions: Caesarean Sections as a Case Study.” Economic and Political Weekly 35:31, 2755-2761.
Rooks, Judith Pence. 1997. Midwifery & Childbirth in America. Philadelphia: Temple University Press.
Spetz, Joanne, Mark W. Smith, and Sean F. Ennis. 2001. “Physician Incentives and the Timing of Cesarean Sections: Evidence from California.” Medical Care 39:9, 536-550.
Strong, Jr., M.D., Thomas H. 2000. Expecting Trouble: The Myth of Prenatal Care in America. New York: New York University Press.
Wiegers, T. A., M. J. N. C. Keirse, J. Van Der Zee, and G. A. H. Berghs. 1996. “Outcome Of Planned Home And Planned Hospital Births In Low Risk Pregnancies: Prospective Study In Midwifery Practices In The Netherlands.” BMJ: British Medical Journal 313:7068, 1309-1313.
If you got all the way down here, thank you so much for reading. It really means a lot. :)
