The Common Good
December 2010

Reclaiming Childbirth

by Shafia M. Monroe | December 2010

How a resurgent movement is taking birth back from the medical establishment.

Through history, birth and delivery was a woman's affair, supported by the family and community midwives. Beginning early in the 20th century and intensifying through the next several decades, U.S. birth culture shifted from a women-centered to a paternalistic, medical model. Birth went from being a natural experience to an operative procedure. Medical institutions made themselves the birth experts and silenced women. As a result, women came to doubt their ability to birth naturally and began to believe that the doctor always knew what was best for them.

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One of the worst examples of this approach, practiced mostly from the 1930s through the 1950s, involved the use of "twilight sleep" on women in labor, a state induced by administering a combination of an analgesic (morphine) and an amnesiac (scopolamine). Women were often tied down during birth to prevent them from thrashing about due to the medication. They were so sedated that they could not recall giving birth; this made bonding more difficult for the mother and baby. The medication often caused neurological depression for the babies, who were sometimes kept from their mothers for days after their birth.

In opposition to such violent, medicalized births, obstetricians such as Grantly Dick-Read (Natural Childbirth, 1933) and Fernand Lamaze (Painless Childbirth: the Lamaze Method, 1956) introduced more-natural methods, laying groundwork for the contemporary birth movement. Nonetheless, unhealthy practices persist, such as women being made to labor in bed, instead of having mobility. Walking can be important for laboring women, because it enlists gravitational force to help the baby enter the birth canal, which can mitigate against prolonged labor, a common reason for initiating a Caesarean section. The medical model rejected squatting for birth, which is often one of the healthiest positions because it opens the pelvic outlet to its full potential. Instead, most women in this country now birth on their backs -- which is often the least-favorable position.

In response to this and other unhelpful or abusive practices, the contemporary birth movement has been built by women and men who want to diversify the options for how women give birth and how babies are welcomed into the world. They believe that birth should be a positive experience for women and their families, and that women should feel in complete control during this special time. The movement turns its philosophical and political will to seeing that women reclaim the normalcy of birth, empower themselves, and have the opportunity to give birth with dignity. The fundamental basis of the birth movement is that birth choice is a natural right of the woman and must be protected and legitimized.

Many women who have joined this movement have done so because of dissatisfaction with their personal experiences of giving birth. They speak of not being listened to, not being given choices, and feeling pressured to engage in obstetrical procedures they did not believe in, such as being made to stay in the bed, having continuous fetal monitoring, or being induced before their due date. Some women and families feel cheated out of having a natural birth experience.

A fallacy about the birth movement is that these are just matters of personal preference -- that some women just "prefer" natural birth, seek the sensation of birth, or desire unmedicated births. But many common institutional childbirth practices have been researched by the birth movement and recognized as abusive. These include denial of food and water during labor, women not being free to choose a birth position, the routine use of epidurals, a high rate of unnecessary C-sections, and others.

Such choices can become matters of life and death. A 1998 study by the National Center for Health Statistics of the Centers for Disease Control and Prevention found that "infant death was 19 percent lower for births attended by certified nurse midwives than for births attended by physicians. The risk of neonatal mortality (an infant death occurring in the first 28 days of life) was 33 percent lower." Birth outcomes when midwives are attending may be better because they are trained in the normalcy of birth. The study notes that midwives provide more comprehensive prenatal care and education than doctors and spend a lot of time listening to the mother. Also, "most certified nurse midwives are with their patients on a one-on-one basis during the entire labor and delivery process, providing patient care and emotional support, in contrast with physician’s care, which is more often episodic."

So the deeper purpose of the birth movement in America is to redesign maternity care on a platform of safety, women's rights, and autonomy, in order to allow for birth choice and equity between the health consumer and medical provider. This movement advocates for better access to midwives and doulas as health-care providers for pregnant women and promotes natural birth for low-risk pregnancies. The movement lifts up a paradigm that normalizes birth, breastfeeding on demand, and paid maternity and paternity leave.

Women still experience mistreatment for having homebirths, for extended breastfeeding, and for challenging hospital birth policy. Women are often forced to take legal recourse to get justice. They are going to court to argue for the right to have a vaginal birth after a C-section, fighting to bring their babies home, and writing letters to hospital administrations to challenge policies that disempower birthing women.

The birth movement has successfully moved its agenda forward on some issues. Birthing rooms are more common, fathers are now routinely allowed in the delivery room, labor tubs are available in many hospitals, and the role of the midwife in birth is becoming better understood.

But serious problems remain with the quality of maternity care in the U.S. (and worldwide, in many cases, the situation is much worse). The extremely high incidence of C-sections is one. This is major surgery with numerous risks, meant for use in life-threatening emergencies; when used otherwise, it can unnecessarily put mothers and infants at risk. The World Health Organization recommends an upper rate of C-sections of 15 percent. Above 15 percent, studies have shown an increase in the risk of maternal and infant injury and death. Nearly one in three U.S. births in 2007 was by C-section delivery.

According to the CDC, infant mortality (death of a child before one year of age) is "associated with a variety of factors such as maternal health, quality and access to medical care, socioeconomic conditions, and public health practices." In 2006 the infant mortality rate per 1,000 live births for African-American babies was 12.9, more than twice as high as that of white babies (5.57 per 1,000). In 2005, 46 percent of black infant mortality was related to preterm birth, which can be related to stress, poverty, poor nutrition, and lack of health care.

In a spring 2010 report, "Deadly Delivery: The Maternal Health Care Crisis in the USA," Amnesty International USA notes that "maternal mortality ratios have increased from 6.6 deaths per 100,000 live births in 1987 to 13.3 deaths per 100,000 live births in 2006." U.S. women have a higher risk of dying of pregnancy-related complications than women in virtually all other industrialized countries. And, according to Amnesty International, "African-American women are nearly four times more likely to die of pregnancy-related complications than white women."

With this higher infant mortality and maternal mortality rate, especially for women of color, the birth movement must address inclusivity and cultural sensitivity to be successful. Historically the movement has been driven by upper- and middle-class women and has not brought sufficient attention to the high rate of infant and maternal mortality in various ethnic groups. Social injustice helps create higher infant mortality rates for communities of color because they suffer from higher rates of poverty, racism, and lack of health-care options (including access to midwives and natural childbirth).

The birth movement must expand its political agenda to ensure that every woman's birth story and tradition is honored, and that every baby has the best start possible. The birth movement has to focus on grassroots outreach, so that every voice is at the table to push for education, autonomy, and safe births for all women, whatever their socioeconomic status.

The movement has galvanized private health consumers to move their agenda forward. Collectively they have proven that most healthy women can birth their babies without intervention and that when a woman is allowed to follow her body cues and intuition she usually has a better birth experience. The birth movement will consider itself successful when the U.S. infant and maternal mortality rates are reduced, when more mothers breastfeed, when "midwife" is a household word, and when women are once again in control of the birth experience.

Shafia M. Monroe, founder and president of the International Center for Traditional Childbearing, is a community activist devoted to infant mortality prevention, breastfeeding promotion, and increasing the number of midwives of color.

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By the Numbers

Every 90 seconds a woman dies in childbirth. Ninety-nine percent of those women live in developing countries. The severity of these statistics is why the United Nations made "improving maternal health" one of the Millennium Development Goals. While the United States spends more money than any other country on health care, it ranks 39th in maternal mortality rates -- worse than most comparable European countries and Canada.

  • The 2008 maternal mortality ratio in the U.S. was 16.6 per 100,000 births, compared to 8.2 in the U.K. and 3.9 in Italy.
  • The child mortality rate in the U.S. was 6.7 per 1,000 live births, compared with 4.9 in Canada and 2.6 in Iceland (2000 to 2010).
  • Out-of-hospital births dropped from 44 percent in 1940 to around 1 percent in 1969, which is still the current rate.
  • An average, uncomplicated vaginal home birth costs 68 percent less than in a hospital (1999).
  • In 2005, home births increased 5 percent in the U.S.
  • 1 percent of U.S. home births were delivered by midwives in 2005.

SOURCES: The U.S. Centers for Disease Control and Prevention; The Lancet; The Guardian; Journal of Nurse-Midwifery; World Health Organization.

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