According to recent data released by the Agency for Healthcare Research and Quality, the number of hospital stays for women with “normal” or “uncomplicated” births dropped by 43% between 1997 and 2007. While the number of hospital stays for childbirth increased 16% during that decade, the number of stays for certain complicated births increased disproportionately:
- 28% more women had pregnancies or births complicated by high blood pressure
- 22% more women had perineal trauma during childbirth
- 107% more women had history of a previous c-section
What is the significance of these data? The fact that 43% fewer of the births in the US were considered “normal” is frightening to me. In an era of evidence-based medicine, when we should be making great strides toward protecting normal birth, we are taking huge steps backward. The World Health Organization states that “midwives are the most appropriate primary health care provider to be assigned to the care of normal birth.”1
The World Health Organization publication goes on to state that external fetal monitoring (rather than listening intermittently to the baby’s heart rate) has been shown to significantly increase the number of interventions performed during a labor and birth, without improving outcomes. One large study did find that there were more neonatal seizures in the intermittent monitoring group, but further analysis showed that the majority of these were associated with pitocin induction or augmentation, which is definitely not a part of normal birth.2
Surprisingly, the World Health Organization recommends vaginal exams at a maximum of one every four hours, and states that experienced birth attendants may be able to do only one exam the entire labor! What a contrast with the typical US hospital birth, with exams occuring every hour. The counsel for managing slow progress in labor is not automatic intervention, but evaluation. Further, the statement is made that: ”In normal childbirth there should be a valid reason to interfere with the natural process”.
So how could all this be achieved in a hospital setting? Let’s follow Tori, who is pregnant with her first baby, as she arrives at the hospital in labor:
Tori is cheerful and talking through her contractions, which are every 6 minutes apart. The midwife talks with her about her symptoms, which began three hours ago. She has not had any bloody show yet. The baby’s heart tones are listened to carefully throughout several contractions, and are reassuring. Tori is encouraged to go for a long walk and return in a couple of hours if she feels contractions getting stronger and closer.
Tori returns 90 minutes later, stating that contractions are now every 2-3 minutes and much stronger. She looks much more serious and expresses concern that the contractions are harder than she’d anticipated. She is reassured by the midwife, who accompanies her to a birthing room. In the room there are a variety of cushions, bean bag chairs, rocking chair, ropes hanging from the ceiling, a labor pool, a birthing ball and a birthing stool, but no hospital bed. Tori is not told to change into a hospital gown. The midwife asks permission to perform one exam, and confirms that the baby is head down, in good position, and Tori is 5-6 centimeters dilated. She notes bloody show on her glove after the exam. The midwife talks quietly with Tori about finding her rhythm in labor, working with the strength of the contractions, and trusting her body to “learn” how to cope with the labor as she goes along. She then asks Tori whether she would prefer to be left alone a while, or wants the midwife to stay. Tori states that she would like some time alone with her husband, so the midwife checks baby heart tones and one blood pressure, then leaves them with the instructions to “ring the call bell if you need me”.
Except for intermittently slipping quietly into the darkened room to listen to heart tones, the midwife leaves Tori alone and does not speak when she enters the room. Tori does not seem to even notice when the midwife checks heart tones, because the midwife kneels on the floor or wherever she needs to in order to accomodate Tori’s chosen position without asking her to move. The midwife notices that Tori’s contractions are almost back to back now, and she is breathing very hard through them. Yet, she has not been asked to remain in the room, so she slips quietly back out.
A short time later, Tori’s call bell rings. When the midwife enters the room, Tori’s husband reports “her water just broke”. The midwife confirms the water is clear, and observes the next contraction. Tori spontaneously holds her breath and bears down at frequent, short intervals. Now Tori moves toward her husband and holds on to his shoulders as she sinks into the contraction. The midwife kneels on the floor with a small flashlight, the rest of the lights remaining dim. She can see the baby’s head appearing with each push. The nursery nurse is waiting outside the door, as Tori requested no extra persons in the room if not needed. The nurse will come in only if she is needed to help with the baby.
Tori instinctively reaches down to the baby’s head, and as it slowly stretches through the tissues, Tori delivers her own baby. The midwife has padded the floor with a pillow and blanket and is prepared to help hold onto the baby if needed. No help is needed, however, and Tori pushes once more and her baby slips out. She lifts him to her breast as she sits down on the cushions. The baby makes no cry, but the midwife can see that he is breathing and turning pink. She feels the umbilical cord and notes a heart rate of 125. Tori smiles at the midwife: ”I’m glad you were here, but I could have done it all by myself!” And the midwife replies, “You did do it all by yourself.” Soon mother and baby are tucked in skin-to-skin on a huge bean bag cushion. The placenta has delivered, and the midwife notes a normal amount of bleeding. She tells Tori, “I’m not going to rub your uterus unless you are bleeding too much. If you notice that you are gushing a lot, please call and let me know.” As she leaves the new family for uninterrupted bonding time, she thinks to herself, “I wasn’t needed at all. Another job well done.”
1. World Health Organization. Safe Motherhood: Care in Normal Birth. Retrieved 12/28/09 from: http://whqlibdoc.who.int/hq/1996/WHO_FRH_MSM_96.24.pdf
2. Ibid.
What a beautiful story (true or meant just for an example). I’m forced into a hospital birth despite my husband and I’s wishes, and such a story almost makes me weep, I can only pray for a tenth the consideration as Tori had!
I wish I could have a birth experience like that!
Thank you for such a beautiful website, and for your ongoing, insightful observations regarding the present course of obstetrics which is veering precipitously away from the known medical evidence.
The trend towards re-defining normal pregnancies as abnormal is problematic on a number of fronts.
True story: I once worked with a fellow maternal-fetal medicine specialist who did not want to make a mistake and miss a sick baby. (As we all do). In order to avoid missing an abnormally sized (too big or too small) fetus she would take the normal definition of “small” (intrauterine growth restriction or IUGR) which falls at the 10th percentile and add a category of borderline IIUGR at the 10th to 25th percentile. To the category of large for gestational age (> 90th percentile), she would add a category of borderline LGA at the 75th to 90th percentile. She would then offer the same type of fetal testing and surveillance to these groups of “small” and “large” babies. While her goal was to not miss a problem, you can imagine that eventually her approach caused more problems than it solved.
I pointed out to her that her scheme essentially labeled 1/2 of all pregnancies as “abnormal” and that from a statistical point of view this was completely invalid. Indeed, many would say that the true cut-offs for abnormal should acually be 97th percentile or, only if there were another complicating factor.
The problem with re-defining abnormal as normal is that it actually drains necessary services from patients who truly need high risk care to patients who do not. I can vouch that the time that a high-risk specialist has is not limitless. Moreover, such definition problems result in needless anxiety (for the patient) and a bias toward intervention (in the physician).
Tori’s story is beautiful and (in my opinion) it should and could be more of the norm in modern obstetrics.
However, to make that real, it will require a great deal of education and re-education for physicians. It will also require women to educate themselves and to question what their care providers offer as the accepted standard.
I’d like to thank you for your contributions in this regard.
Thank you for your comments, Dr. Onyeije. I would like to post them because I feel you have really defined in a nutshell what much of the problem with obstetrics is today. We all want to save every baby, and find every problem, but obviously that is not possible. I agree with you that we can be overly vigilant to the point where we are redefining normal and creating more problems than we solve.
Many doctors are trained to hear horse hooves and assume they are zebras.
For all birth practitioners it is a tricky dance to take the cultural fear surrounding birth, and personal fears from having witnessed the small percentage of births that don’t go smoothly, and not spin that fear outwards onto every mamababy.
Then there is the issue of informed consent. Pregnant women gaze at a tapestry of misinformation, televised drama and trauma, their friends’ experiences, their family stories, childbirth classes, and all-too brief visits with their OB. Then they take the ideas which resonate most deeply, which fit into their already constructed paradigm of birth, and fly with those, leaving the rest. We all hear birth myths and accept them as truth. Very few wake up from drinking this koolaid of mis-managed birth, and if they do it’s usually after a horrid first birth experience. “What was THAT? I’m not going through THAT again!” Women who reject disempowered birth experiences are branded freaks, hippies, selfish, or worse. The gulf is indeed widening.
Thank you for sharing these comments. It is true that the gulf is widening. . .how to turn that around?