The Power and Politics of Birth
By Kelley Guiney
Childbirth is perhaps the most important emotional, physical and spiritual of human experiences. It is also one of today's most controversial health care issues.
The controversy begins with the prevailing belief in the dominant medical establishment-which has been successfully embedded in mainstream thought-that childbirth is a dangerous, risky business that is best handled in the traditionally high-tech hospital setting, often with interventions that are considered standard protocol.
A quite different perspective is presented by the midwifery model of care, which views birth as a natural, normal, empowering process that most healthy women are perfectly capable of performing, if they choose to do so. Mention this in casual conversation, especially with conventional health care professionals, and you might well be met with scorn, disbelief, or statistics on various family members who "would be dead right now" if it weren't for the miracle of modern hospital technology. It is unfortunate that uninformed prejudice, fear-based bias, misinformation and downright denial of evidence often play major roles in the contemporary drama of childbirth. After exhaustive research on this subject it is my personal opinion that as more and more American women understand the facts and options, there will be a tremendous shift in the way our culture views childbirth and in the standards and protocols that govern the process.
The facts of birth clearly state that not only are most healthy women quite capable of natural, spontaneous labor and delivery, but that the hormones secreted during an intervention-free labor and delivery provide pain relief, engender feelings of love and connection with the birthing baby, facilitate communication between the physiology of baby and mother, and can assist women in achieving a transcendent, empowered state.1 Midwives are experts at preparing women for this type of experience, and their main function, ideally, is simply to support the woman and allow the birth to happen. They guard the process, monitoring the baby's heart rate and keeping the parents informed of their options if any complications arise. Most, if not all, midwives have a working relationship with one or more obstetricians and are prepared to transport a birthing mother to a hospital if it becomes medically advisable and necessary. However, most birth complications can be anticipated, and because of the empowered rather than fear-based foundation of their training, midwives are able handle many situations that would be considered complications in a conventional medical setting.2
Hormones and the Sexuality of Birth
There are four important hormones secreted during an undisturbed labor and delivery that play a major role in allowing the natural process to unfold. They originate in the middle brain, which is the primitive (non-thinking) as opposed to the rational (thinking) part of the brain. It is crucial, therefore, that a birthing mother be in an atmosphere where she feels completely safe and relaxed in order to allow this part of the brain to take over. In a more relaxed, intuitive state, a woman will be able to instinctively choose which positions and breathing will be optimal for her birth experience.
It is of profound interest that oxytocin, the hormone that governs labor, is also the hormone that governs love. It is secreted during birth and breast-feeding, as well as sex. It facilitates the contractions of male and female orgasm and the contractions of birth. This fact lends credibility to the claims by many midwives and other childbirth authorities that the conditions for an optimal birth are similar to those required for optimal lovemaking. Authors in the field who have made this comparison have evoked images of a couple attempting to achieve orgasm in the bright lights of a hospital room with observers, frequent examinations and monitors, to try to adequately convey how intervention can interrupt the instinctive flow of labor and birth.
The other hormones involved in labor and birth are beta-endorphine, epinephrine (adrenaline), norepinephrine (nonadrenalin) and prolactin. In addition to other functions, beta-endorphine acts as a natural pain reliever and relaxant. It is a natural opiate and is present during pregnancy, birth, breastfeeding and sex. Beta-endorphine can be released in response to stress and pain, and interestingly, during labor this release can inhibit the release of oxytocin, thereby allowing the woman's pain level to somewhat ration and regulate the contractions of her labor. This hormone also engenders feelings of dependency and euphoria, thereby enhancing the bonding experience with both baby and partner. Beta-endorphine also assists with the baby's final stages of lung maturation before birth. There is a higher incidence of respiratory distress syndrome (RDS) in babies who are born by cesarean or c-section (surgically cutting through the abdomen to remove the baby), where there is often no labor or a shortened labor and thus no release of this critical hormone.
The fight or flight hormones, epinephrine and norepinephrine, are released by the adrenal glands as a reaction to both excitement and stress. Interestingly, this process can slow labor by inhibiting the release of oxytocin, thus nature's way of providing a chance to escape should the laboring woman feel endangered. (All the more reason why a woman must feel safe and comfortable in order for her labor to proceed.) Toward the end of labor these hormones, especially norepineprine, assist with the final contractions and can engender mothering instincts.
Prolactin is known as the "mothering" hormone. It is secreted during pregnancy, labor, birth and during each breastfeeding, when it engenders both feelings of surrender and the classic fierce protection of motherhood. Together these four hormones assist the birthing process and create what obstetrician Sarah Buckley describes as an "ecstatic cocktail" in the moments after birth3 .
Safety of Out of Hospital Births
Planned out of hospital births usually take place either at home or in what are known as freestanding (non-hospital) birth centers. Most birth centers are staffed by midwives and have a consulting relationship with local obstetricians. They are commonly located near a hospital and hospital transport occurs when necessary. Birth centers, contrary to the belief and assumptions of many, have traditionally maintained excellent safety records and outcomes. In 1989 the New England Journal of Medicine published a study of freestanding birth centers throughout the United States, looking at a total of 11,814 births. The outcome concluded that "birth centers offer a safe and acceptable alternative to hospital confinement for selected pregnant women" and that the care offered resulted in a significantly lower level of c-section.4
The thought of planned home births can strike fear into the hearts of the uninformed; however, the evidence is reassuring. A meticulous study conducted in 1977 of 2,092 women-half of them planning home births and half planning hospital births-revealed that women in the hospital were nine times more likely to sustain perineal tears (the perineum is the skin between the opening of the vagina and the anus), three times more likely to have a c-section and five times more likely to have high blood pressure. The hospital-born babies were six times more likely to suffer fetal distress, four times more like to suffer infection and four times more likely to require respiratory assistance after birth.5 There are many other studies on home birth that corroborate these kinds of conclusions. In fact, in the comprehensive health care investigation book, Reclaiming our Health, by John Robbins, the author footnotes 16 studies of home birth to back up his similar findings.6
Common Hospital Interventions
The critical difference between obstetricians and midwives is that midwives are trained in normal birth, and obstetricians are trained in intervention. Furthermore, as Buckley has observed, hospital staff "are not prepared, practically or professionally, to deal with the irrationality, directness and physicality of a woman laboring on her own terms."7
The study results listed above make more sense when common obstetrical interventions are examined. An investigation into these practices illustrates that in addition to the risk of side effects, one intervention tends to lead to another, and usually the risks increase with each one. And any intervention, especially the introduction of pain relieving and labor inducing or augmenting drugs, will interfere with the hormonal "cocktail" described above as well interfering with the state of mind of the laboring mother.
The other factor to keep in mind is that many common medical, including obstetrical, practices and procedures, actually have no evidence to back them up. In 1995 a report from the U.S. Congressional Office of Technology and Assessment had this to say on the subject: "The longstanding estimate that only about 10-20 % of procedures have ever been formally evaluated for safety and efficacy remains a rule of thumb."8 In 1989 an exhaustive, 10-year study on obstetrical practices concluded that, "You may be shocked to find what little evidence exists in support of most obstetrical practicesThe evidence favors non-interventive management."9 Again, many studies have corroborated these conclusions.
Two initial interventions that begin the domino effect are requiring the woman to be confined to bed (this is becoming more rare but is still practiced in some hospitals) and the monitoring of the labor process. It is the collective opinion of midwives that it is just about impossible to have a normal labor in a horizontal position. It is imperative that the woman be allowed to move around freely and choose her laboring positions. It is also crucial that she not be rushed or otherwise made to feel that she is on a time clock. A common justification for intervention in general is "failure to progress," which often means that labor isn't moving forward according to the hospital's parameters. The Friedman Curve is one tool that has been used in hospitals to monitor the progress of birth, however, its developer, Emanuel Friedman, does not approve of its use. He has said, "There is no magic number of hours beyond which labor should not continue. The Friedman Curve is being abused."10
Electronic fetal monitoring (EFM) is common protocol in just about every hospital, although there is no evidence that it improves birth outcomes.11 Its basic purpose is to provide the hospital with a legal record in case of lawsuit.12 It is known to increase the risk of fetal distress, and has a 30 to 50% chance of giving false results. It is not uncommon for a c-section to proceed due to a false reading from an EFM.13 Studies show use of an EFM increases the risks for a c-section by 41%14 . Again, the inventor of the tool does not endorse its current use, and has commented, "Most women in labor are better off at home than in the hospital with the electronic fetal monitor."15
Another common intervention is the use of epidural drugs to relieve pain during labor. Epidural drugs are administered through a tube inserted into the mother's spinal fluid. The introduction of an epidural increases the chances for administering pitocin16 , a synthetic form of oxytocin used to assist with contractions. An epidural will interfere with the normal secretion of hormones as mentioned above, which will dilute what obstetrician Michel Odent calls the "fetal ejection reflex", the strong contractions at the end of labor that help the woman birth the baby quickly and easily. This can prolong the end of labor and increase the chances of an operative delivery by forceps or vacuum17 -both interventions that create risk for the baby. Operative, instrumental delivery increases the incidence of episiotomy, surgically cutting the perineum, which can cause the new mother weeks of acute and possibly long-term discomfort. You can see the domino effect that is created here.
For the mother, epidural drugs also have a risk of cardiac arrest, respiratory paralysis, body paralysis, headaches and possible urinary tract infection (due to the usual need for a catheter)18 . They also increase the risk of fever in the mother, which thereby increases the chances of what is called a sepsis workup for the baby after birth19 . A sepsis workup may include the following: a spinal tap, in which a needle is inserted into the spinal column and fluid is drawn, an arterial blood draw, and putting the baby on IV antibiotics for 48 hours until the lab results come back. In a local hospital survey for the year 2000, the Childbirth Education Association of Seattle (CEAS) reported epidural rates with an overall range of between 40% to 90%, with the majority of hospitals above 50%, and an average rate of 60%.
When a labor is viewed as "not progressing," it is not unusual for pitocin to be administered to augment labor. (It is also used to induce labor and to control bleeding after delivery.) Pitocin is a synthetic form of oxytocin, the "love hormone" described above. The introduction of pitocin will, first of all, reduce the body's production of oxytocin. Secondly, pitocin will not act as a "love hormone"20 and the subtle hormonal communication between the baby and the mother's body will be disturbed. Thirdly, the sometimes violent contractions produced by pitocin, which have been described by some women as "car crash" contractions, are titration-regulated, meaning that the body no longer regulates the contractions and the woman no longer has her body's natural "breathing space" in between them. If that's what's going on outside the uterus, imagine what's going on inside, which is where the baby is. The induced contractions decrease the flow of oxygen to the baby. Hospital protocol understandably dictates that once pitocin is administered, the birth is considered high risk. Pitocin will increase the likelihood of a requested epidural, as it is extremely difficult to endure pitocin-induced contractions without one. Considering the CEAS reported ranges for labor induction (10 to 60%) and the rates for augmentation (15 to 70%), a woman in the greater Seattle area has a 10 to 70%% chance that her labor will either be started for her (induction) or sped up for her (augmentation). In addition to other health authorities, The World Health Organization21 discourages the routine use of pitocin22 .
This is just a brief overview of basic, widely practiced interventions.
A Legacy of Bias & Conflicting Models
Midwifery is an ancient practice, and if you look beneath the surface of common assumption you'll find, as presented here, that it is a respected and highly valued profession. In 16th, 17th and 18th century Europe, however, midwives and other healers, mostly women, were in big trouble. Millions of women were persecuted and burned at the stake in one of the least glorious chapters of human history. Surviving documents attest to the fact that most of these women were skilled, respected healers whose outrageous crime was competently assisting other women. It takes a real leap of the imagination to accept that a similar dynamic could be operative today, but leap we must.
Systematic destruction is more subtle in our day, and probably takes longer, but it does exist. The frightening contemporary truth is that midwifery-a profession that provides an invaluable service and has evidence based science on its side-has had to continually fight for its existence, and is still in danger. As the previous discussion indicates, midwives follow a model of care that is different from that of physicians-midwives are in service to the birthing woman's power and assist her in fully claiming that power through honoring her choice to direct her own experience in what is perhaps the most profound of human birthrights. Midwives safeguard that experience. And women's freedom to choose that experience is in danger.22
It is a fact throughout the country that when a birth is primarily assisted by a midwife or in the event that the choices made for care-either by the midwife or the client-deviate from the "conventional standard of care" and the midwife is investigated that she is commonly judged by a model of care that is not aligned with her own and which is uninformed and biased. She is rarely "turned in" by parents, more often by a conventional health care professional who does not understand or follow the midwifery model of care. She often must then defend herself, at her own expense, against governing medical boards or state and local authorities.
Authorities in the field have widely compared this to the witch-hunts of past history. An example of this is presented by the case of local midwife Debra O'Conner, whose license has been suspended by the Washington State Nursing Quality Care Commission. After a full administrative hearing on the issue, no evidence introduced on O'Conner's behalf was refuted, and yet her license was suspended. Expert witnesses, including Marsden Wagner, M.D., M.P.H., past Director of the Maternal and Child Health Services for the World Health Organization, testified in her behalf that she had acted prudently and appropriately. All four members of the decisive Nursing Commission panel are practitioners of conventional medicine.
Reasonable common sense would dictate that at least one member of the panel should have been a professional who follows a similar model of care and understands that the true evidence favors non-interventive care. Why wasn't it mandatory that a midwife sit on this panel? Interestingly, there is only one midwife on the Nursing Commission, and she is not allowed to vote.
The profession is in danger-a situation with consequences that are having an impact on the availability and quality of this care now and in the future. The danger lies in the widespread and uninformed bias toward conventional medicine and misunderstanding of the midwifery profession. The consequences are that it is becoming more difficult to practice true midwifery and to find experienced care. Women claim tremendous power in birth, and will not be able to claim it fully on their own terms if they are denied the option of true midwifery care.
Midwives have varying philosophies that differ in the degree to which they are aligned with conventional medicine. The issues introduced above have required many midwives to restrict their practice to some degree, or to comply with standard medical protocol to a greater extent than they normally would if allowed to practice their profession more freely and purely.
There are many aspects and issues involved this topic, and a variety of resources available to those who would like to conduct a further exploration. Debra O'Conner is a veteran midwife, birth counselor and educator who speaks on these issues and can be reached at 206-285-4575. Wendy McGuire is a birth educator and doula who can be reached at 206-715-1743.
Recommended Books and Web sites:
The Thinking Woman's Guide to a Better Birth, Henci Goer; The Scientification of Love and Birth Reborn by Michel Odent; Reclaiming Our Health by John Robbins.
Citizens for Midwifery: http://www.cfmidwifery.org
Informed Birth Choices: http://www.informedbirthchoices.org
Comprehensive pregnancy and childbirth resources: http://www.birthlove.com
Midwives Association of Washington State: http://www.washingtonmidwives.org
American College of Domiciliary Midwives: http://www.goodnewsnet.org
1 Ecstatic Birth, Sarah J. Buckley, Mothering Magazine, March/April 2002, pg. 51-52.
2 Born in the USA, PBS documentary, by Marcia Jarmel and Ken Schneider.
3 This entire captioned section is a partial summary of Ecstatic Birth by Sarah J. Buckley as cited in note I, pg. 51-54.
4 Abstract, Outcomes of Care in Birth Centers, J.P. Rooks et al., New England Journal of Medicine (http://www.nejm.org).
5 Outcomes of Elective Home Births, Lewis Mehl et al., Journal of Reproductive Medicine, pg. 281-290.
6 Reclaiming Our Health, John Robbins, pg. 383.
7 See Note 1, pg. 56.
8Health Care Technology in the United States, Sean Tunis and Helen Gelband, Health Care Technology and its Assessment in Eight Countries, Congress of the United States Office of Technology and Assessment (http://www.wws.princeton.edu/cgi-bin/byteserv.prl/~ota/disk1/1994/9414/941404.PDF).
9 See Note 6, pg. 31.
10 See Note 6, pg. 46-47.
11Obstetric Myths Versus Research Realities, Henci Goer, pg. 131-135.
12See Note 2.
13 See Note 6, pg. 48-49.
14 What the Numbers Say, compiled by Tiffany Isaacson, Mothering Magazine, March-April 2002, pg. 40.
15 See Note 6, pg. 49.
16 Williams Obstetrics, 21st Edition, pg. 375.
17 See Note 1, pg. 52 & 56; see Note XVI, pg. 376; see Note XI, pg. 253.
18 See Note 11, pg. 254-255.
19 See Note 16, pg. 376.
20 See Note I, pg. 55
21 The World Health Organization is a directing and coordinating authority on international health work that strives to bring the highest level of health to the global population.
22 A Global Witch-Hunt, Marsden Wagner, M.D., The Lancet, Vol. 346 (http://www.gentlebirth.org/archives/globwtch.html ); also, See Note 6, pg. 58-86.