by Diana Korte and Roberta Scaer
Trends in Childbirth
Eight years ago, when the first edition of this book was published, we told you that the two trends in childbirth were moving in opposing directions. They still are.
One trend is the growing number of hospitals providing homelike accommodations, including Jacuzzis and microwaves, plus the more than 140 out-of-hospital birth centers (with more than 40 in the works), which numbered in the dozens only a few years ago.
The other trend is high-tech childbirth. We've had routine IVs, labor induction, and cesareans for years. Now there's a growing emphasis on tests and procedures of all kinds. It starts early in many parts of the country, with pregnant women of all ages being encouraged to undergo prenatal testing. It continues with the use of the electronic fetal monitor (EFM) during labor for 75 percent of women (and before labor for some), as well as the ubiquitous ultrasound offered routinely in at least three ways (scans, Dopplers, and external EFMs).
And in the last eight years, the cesarean rate has increased from one in five births to nearly one in four. However, the good news about cesareans is that the rate has begun to drop, due primarily to the increase in the number of vaginal births after previous cesareans (VBAC).
What about home births, the defenders of all-natural, no-interference pregnancies? They have shrunk even more in the last eight years from 2 to 3 percent of all births to less than one percent today, according to a 1991 report from the National Center for Health Statistics. However, high tech is present in some home births, too, with the use of the Doppler instead of the traditional low-tech fetoscope. (Both are hand-held devices used to listen to the fetal heart tones, but the fetoscope doesn't use ultrasound.)
Which trend is growing the fastest? No doubt about it: Despite the leveling off of our cesarean rate and the upswing in the number of VBACs, high tech continues to dominate childbirth. If you're like most pregnant women, it's as much a part of your pregnancy and birth today as is your big belly. For most of you, your decision making about high tech is likely to be when and for how long you will use which of these pregnancy and birth tools, not whether you'll use them at all. The issue now is to use birth technology wisely and not be seduced by it.
Childbirth in the USA
Though there are more choices in the United States for birth attendant and place of birth than probably anywhere else on this planet, women mostly give birth one way here -- with a doctor in a hospital. And over the last eight years, despite the availability of these choices and with the exception of an increase in the use of midwives and VBACs, options in the birth process have become less -- not more -- flexible.
Birth plans, for instance, with their list of mothers' preferences during labor, birth, and hospital stay, were designed to help women get what they want. But today birth plans often carry little punch except for those women whose requests match their physicians' usual obstetrical routine. And the change in insurance coverage for those of you who have prepaid plans (with their limited choice of health-care providers and hospitals) can curtail your options even more -- unless you're willing to pay additional cash out of pocket.
Each nation's culture is reflected in how women experience birth, and that' s true here as well. Most American women expect labor to be painful and anticipate using a variety of drugs. And both expectations are met. However, women always vary widely -- no matter where they live -- about the "normal" amount of pain they experience, just as the "normal" length of labor and the "normal" number of days vary widely in pregnancies.
A 1988 study comparing labor pain experienced by women in teaching hospitals in the Netherlands and the United States found that the Dutch women did not expect to experience as much pain and used far fewer drugs for pain relief than American women. "There is in Dutch birth participants a deep-seated conviction that the woman's body knows best and that, given enough time, nature will take its course, whereas birth in America was characterized as much more of a 'medical event," noted one of the study's authors. In the Netherlands most women are cared for by midwives, which suggests that women are helped and encouraged in a variety of nondrug pain relief methods; 35 percent of Dutch births still occur at home. As old-fashioned and unscientific as that sounds to many of you, nearly twice as many Dutch babies survive per capita (even after allowing for racial differences) than in the United States.
But we don't live in the Netherlands; we live in medically oriented North America, where birth conjures up much fear and anxiety. And too many laboring women have been told we are going to give you Pitocin (or a cesarean)," which can increase their discomfort and pain, sometimes leading to panic and a body's total shutdown of labor.
Due no doubt in part to stories like this, we found that many of the original 2,000 survey mothers weren't satisfied with their birth experiences. According to the questionnaire responses we've received from readers, most women giving birth in traditional hospitals with obstetricians today still aren't satisfied. (See Chapter 3 for an entirely different reaction from those women who gave birth elsewhere with midwives.)
Although most of you used a variety of tests and procedures during your pregnancy and birth, many also worry about the effects some of these interventions can have on your infant. And the older your child gets, the more critical some of you become. For those of you who had been looking forward to an unmedicated birth, some now feel guilty or defensive about erroneously believing that you "flunked" childbirth because you used drugs for pain relief.
Several dozen of you wrote early on to say that you were interested in organizing surveys or consumer groups. More often than not, those plans changed, and some of you decided to train as childbirth educators or midwives instead.
Perhaps the biggest trend we've seen in reader replies, particularly over the last few years, is the interest in and use of the doula, a woman who offers comfort and support during labor. And if you didn't have one of these compassionate women at your last birth, you plan to the next time.
Your stories have told us that for most of your births hospital routines are remarkably similar in the United States, from California to Maine. We noticed, however, that questionnaire responses show a big jump in the use of midwives in the last few years, and the births they attend are often more individualized. Your letters have also made it clear that your birth preferences can vary from pregnancy to pregnancy.
I had two very different experiences with childbirth. My son (number-one child) was a twenty-seven-week preemie. I am still grateful that the interventions used were available. I feel all were necessary, and I have nothing but praise for the hospital, nurses, doctors, and technologists who contributed to saving our son. Three years later I gave birth to a healthy, full-term baby girl. Same doctors, hospital, nurses, etc. Also some interventions. It was a nightmare. I felt so helpless. I checked myself and my daughter out of the hospital against medical advice thirty-six hours after her birth because of all the interferences.
Just as one woman's Dr. Right is another woman's Dr. Wrong, one woman's good birth experience is another woman's misery.
I was amazed how my body took control. With the first push or two, my water broke (I even got to do that myself!) while I squatted. A couple more pushes and I could see her head in the mirror. I reached down to touch my baby! Minutes later, she was nursing at my breast. The feelings of joy and awe at the experience of a natural delivery are hard to describe. But I can tell you that it was worth all the months of preparations, discussions with the doctors, and two days of contractions.
--Ohio (third birth, following two previous cesareans)
The information on anesthesia was extremely one-sided. You've pointed out only the negative aspects of it without giving examples of times when it is beneficial. I know from experience that an epidural can be a sanity saver, and turn what would otherwise be a nightmare of prolonged, unbearable, uncontrollable pain into a calm, happy, positive birth.
Though you were satisfied overall, nearly all of you had suggestions for more information you wish had been offered. Many of those suggestions had to do with information about pain relief ("realistic discussion of pain, not fairy tale") or discovering what options were really available ("not just what doctors want us to hear"). Many readers were especially critical of hospital-based classes, and thought that instructors "pushed drugs" and "didn't tell us about risks versus benefits of anything."
Reminiscent of our comments in previous editions, most of you found the best advice about breastfeeding came from friends, La Leche League, childbirth educators, midwives, and books. Now you also can get the help of more than 1,000 lactation consultants. (See "International Lactation Consultants Association" in Appendix D.) Family members still tend to give advice that falls either in the "really helpful" or the "really terrible" categories. Hospital nurses, obstetricians, and pediatricians fared the worst in the advice category overall, though there were some exceptions, and family practice doctors tended to be rated more helpful than not.
Nearly every chapter has new research confirming the conclusion we made in the first edition about a good birth being also a safe birth. We provide information about options that women want, including new data from reader questionnaires, and about the seldom discussed sexual pleasures of pregnancy, birth, and breastfeeding. Types of birth attendants (midwife and doctor) and of places of birth (hospital, birth center, and home) are compared. We present a demystified view of doctors and nurses so that you can understand why they do what they do. From cesareans to circumcision, from prolonged pregnancy to newborn jaundice phototherapy, the risks and benefits of modern American childbirth interventions are described.
We encourage you to appreciate your pregnant and new-mother feelings. As your best guarantee of having a normal vaginal birth once you're in the hospital, we suggest that you plan in advance to have helpers -- mate, doula, and perhaps a monitrice (your personal ob nurse) -- with you. And as "husband" doesn't compute for the 27 percent of you who are single when you give birth, unless the research specifically mentions husbands, we've used the words mate or partner.
Most of you who read this book will be working outside the home throughout your entire pregnancy and returning to your job within three to six months. Some of our suggestions may seem to be too much bother for the amount of time that you have, especially when you're interested in making your pregnancy and birth as easy as possible, not more complicated. We think the issue remains choice, not what you pick. Do what works for you, take what you want from this book, and ignore the rest. I believe the best environment in which to deliver a baby would be within the ob wing, but in a more casual, homelike setting. I think a new mother should be allowed to have as much interaction with family members as she feels up to -- including other children, parents, spouse. The new baby should be allowed in the patient's room during these family gatherings if the parents so wish. I would also encourage as much mother-infant interaction as possible during the stay, interaction hopefully commencing immediately after delivery. I also feel "standing orders" for medication prior to and following delivery should be replaced with individualized recommendations.
Diana Korte and Roberta Scaer are authors of A Good Birth, A Safe Birth
Copyright © Diana Korte and Roberta Scaer. Permission to republish granted to Pregnancy.org, LLC.