Progress is often a tidal creek, not a river. Advancement is not inevitable. We gain in one era, or in one area, and lose in another.
The late 1970’s and early 80’s were good years for having babies in America. Women had rediscovered that childbirth is a good thing, a normal function, and were dragging their doctors along with them. Hospitals scrambled to keep up.We were the rebels, the revolutionaries. The children of the 60’s grown up. Our parents had been cheated by medical and cultural “advancement,” giving birth under anesthesia, flat on their backs on a delivery table, their legs unnaturally elevated. Labor was often artificially induced, and the cesarean section rate was high. Once born, the babies were whisked away to nurseries, tended by professional nurses and fed commercial formula. As soon as possible their diets included solid food—commercial baby food, loaded with sugar and salt to suit the mother’s taste.
We would have none of that. For our babies, there would be no drugs to affect their minds and bodies (some irony there for the 60’s generation). No anesthesia would dull our experience of labor. We were taught instead to manage the pain with techniques that I still find useful today. Labor and delivery would be arranged for the convenience and comfort of the mother, not the doctor. We rejected enemas, shaving, risky pre-natal testing, invasive fetal monitoring, and hospitals with an appalling 20% cesarean section rate.
After birth, our babies were to be with us whenever we wanted, even 24 hours a day—and when we let them out of our sight, we gave strict instructions to the nurses not to feed them formula, nor attempt to quiet them with sugar water. We knew that nothing was as good for a baby as his mother’s milk, and between La Leche League and sympathetic doctors, we had plenty of support through any difficulties with nursing. Our babies themselves would tell us when they were ready for solid food. (Our firstborn did this by downing a Dorito at a party.) Armed with blenders and ice cube trays, we made our own baby food—until the corporations took notice and began making commercial food without additives.
It was a good time. Not everyone felt this way, but enough so that we did not feel alone. Not all doctors and hospitals were helpful, but it was not hard to find ones that were. It was great, also, to feel that we were on the rising side of the wave. We had made a start in the right direction, and counted on the next generation to carry it forward. If we had made so much progress in a few years, how much better would it be when our children were having babies!
I don’t know when the wave crashed. One day, picking up a jar of baby food at the store, I noticed that it contained added sugar. I only thought, “How stupid,” and did not see it as a harbinger of worse to come. When we learned that the lovely birthing center where our youngest was born had been closed, I was saddened, but still didn’t see the handwriting on the wall. Nor was I concerned when people we knew had epidurals for pain relief during labor. That’s a personal choice and even back in our day some of our friends took that path. In truth, we were isolated from the childbearing world, immersed in our own concerns, and ignorantly complacent.
Tragedy destroyed that complacency. Our daughter gave birth at home to our first grandchild. Unfortunately, it was an unexpected, difficult breech birth and that beautiful little boy died two days later. Before he was born, I had understood only superficially our daughter and son-in-law’s desire for home birth. We had raised our children to think unconventionally in the area of education and could not fault them for seeing home birth as a logical extension of homeschooling. Knowing little about it, I could still see how—barring complications—it would be a more pleasant way to give birth, and possibly even safer than being in a hospital. Struggling to get good care for my father in his last months, and having known at least three people who had picked up nearly-fatal infections in hospitals, I did not see hospitals as particularly desirable places to be in if you could avoid them.
However, having been brutally alerted to what can go wrong in a home birth situation, I was prepared to concede that the risk in the hospital was less. What forced me to dig deeper into the modern childbirth culture was the realization that our daughter and son-in-law did not agree. What I had thought was primarily a matter of comfort and convenience turned out to have a far more serious side.
I will confess it now: I started my investigation with the intent of convincing them that they were wrong. If we, back in the dark ages, were able to find plenty of choice for childbirth options, and doctors and hospitals happy to go along with our wishes, surely there must be even more and better choice now. And certainly it would be worth giving up a few conveniences for the added safety of having the medical expertise and equipment readily available in the unlikely event it would be needed.
Culture shock. As part of my effort to understand the enthusiasm of home birth advocates, I began reading books as well as checking out websites. Perhaps the most shocking realization was that what I was reading was modern. One book, Ina May’s Guide to Childbirth, by Ina May Gaskin, who is probably America’s best-known midwife, had a copyright date of 2003! If it had been written in the mid-70’s I would not have been surprised. Have we really lost all that we fought for? What happened to progress?
There have been medical advances. Preemies are living who would have died 20 years ago. In utero surgery is correcting defects even before birth. On the cutting edge, there has been progress. But what of normal childbirth? Where has it gone? It appears that there has been a deep division in the world of birthing babies. Progress was made in the areas that meant so much to us when we were having children, but mostly outside of the mainstream. Reading about it made me wish I could have another go at childbirth, even in these benighted days. Techniques for avoiding episiotomies; improved methods of non-drug pain management; the rise of the “doula” (a specially trained assistant and patient advocate); more encouragement to take advantage of different labor and delivery positions—hands and knees, squatting, vertical, hanging from a rope or bar, using a “birthing ball” (though I haven’t quite figured out how), and our daughter’s favorite, the labor pool; letting the umbilical cord stop pulsing before cutting it; quiet surroundings with dim lights to lessen the shock of birth. Even the World Health Organization now acknowledges that it is a good thing for a woman to eat and drink during labor. Having been allowed nothing to eat, it is no wonder I needed the support of some IV glucose toward the end of my 20-hour labor with our first child. (Reading the WHO recommendations is a scary thing, especially looking at all the things that probably would have happened to us if she had been born now instead of 25 years ago. With her posterior presentation and my consequent long labor, I wonder if a doctor these days would have the patience that ours did to let me do it all naturally.)
Ideally, all this advancement in natural and emergency childbirth procedures should be working together, but it doesn’t seem to have happened, at least not as a rule. It’s hard to tell just who’s to blame for it, but I suspect the insurance companies have to take a large share of responsibility. Not to mention lawyers and people who think that every negative medical outcome justifies a sky-high legal settlement. Obstetricians are distraught because of the high cost of malpractice insurance, and are trying to cover themselves legally by being aggressive with medical interventions where in earlier times they might have been more patient. Nor is patience seen as a virtue in the world of managed care, where doctors must see so many patients that they cannot give them the time they need. (I haven’t confirmed this myself with any obstetricians, but it accords so well with what I’ve heard from other doctors and nurses that I do not doubt it.) I understand that Certified Nurse Midwives have had some success in bridging the gap, but they, too, are being driven by their insurance companies, by the nature of their training and certification, and by their need to be under the authority of doctors and hospitals, to take a more medical approach.
What’s wrong with the medical approach? After all, birth is a very short time in a person’s life, and wouldn’t it be better to put up with a few annoyances, inconveniences, and even discomforts for the increase in safety? That was my argument, but there’s one glaring hole in it. What if a hospital birth isn’t really safer?
In some cases it is. Most of us know people who have needed medical intervention in childbirth. If our grandson had been known to be footling breech, and there had been a scheduled c-section, probably both mother and son would be fine. Probably—though not guaranteed, and that scenario presupposes knowledge that might not have been available. To my surprise, I learned that cesareans are not necessarily recommended even by doctors for all breech babies. Knowing people whose babies did a 180 degree turn in the few days between ultrasound and birth, and those whose ultrasounds misjudged the baby’s size by as much as two pounds, it’s not clear to me that even a doctor in a hospital would have known of the baby’s position in time for a planned c-section. Emergency cesareans are much riskier. It’s easy to lose track of the fact that even a planned cesarean section is major abdominal surgery with risks for mother, child, and subsequent children. One risk that I had not known about is that many doctors are now using a single layer of stitching to close the uterus after surgery instead of the traditional double layer. This is associated with increased complications in subsequent pregnancies, and is probably a large factor in the fact that the American College of Obstetricians and Gynecologists has reversed its previous policy in favor of VBACs (vaginal births after cesarean). Indeed, it’s fair to say that many of the recent changes in childbirth procedures have as a basic assumption that the mother will have no more than one or two children, and do not make adequate provision for future births.
What’s more, I’m now convinced that one of the reasons I’ve heard so many stories of people who have needed medical intervention in their childbirth experiences is that many such emergencies are actually iatrogenic—that is, medical interventions made necessary because of previous medical interventions. For example, with epidural anesthesia, which is very common, muscle tone is relaxed, the urge to push is reduced, and the ability to judge how to push is lessened; consequently the rates of vacuum and forceps deliveries, and of c-sections, is increased. What’s more, in a significant number of women (I’ve seen estimates varying from 20 to 40 percent), epidural anesthesia causes an otherwise harmless increase in body temperature that cannot be distinguished (fast enough) from fever caused by infection, which would be very dangerous for the baby. When labor is induced or augmented with drugs, the contractions are stronger and more painful, which leads to an increased need for epidurals (with their attendant problems), and in itself can induce fetal distress, maternal hemorrhage, uterine rupture, and other situations that require further intervention. Epidurals, induction and augmentation, routine intravenous lines, and electronic fetal monitoring restrict the mother’s ability to move, which has a negative effect on the efficiency of labor, which can lead to further need for augmentation with drugs, pain relief, vacuum/forceps deliveries, and cesarean sections. What’s more, the mental attitude of the mother is critical to effective labor and delivery: fear, embarrassment, mental distress, and the presence of strangers—I’ve just described a typical hospital scene—increase pain and inhibit labor, which opens the door once again for further medical intervention with its attendant consequences. In the friendly atmosphere of home, or a homelike birthing center, with birth attendants who have been trained in non-medical ways of assisting birth, these interventions are usually avoidable and unnecessary.
It’s been a long journey, and I’m still traveling. I still find it astonishing and frustrating that it is so hard to find the “midwives model of care” approach in a hospital setting. But one thing I think I finally do understand is why our daughter and son-in-law, after all they’ve been through, still want to take this approach to childbirth, and are willing to go out of town to get it. Or at least why I would want that choice if I were giving birth. “Home birth” ideally takes place at home, but it is not primarily about location any more than “home education” is about learning in the home. Whether education or childbirth, the basic philosophical difference lies in focus and responsibility. The homeschooling family knows that the student is well-equipped to learn, and the home birthing family knows that the mother is well-equipped to give birth. When these natural functions become institutionalized, the focus tends to shift from the student to the teacher, from the mother to the doctor. A home birth is not something that happens to you—it is something you do. You are responsible, you are in control, you are laboring at a good work, together with your baby, your husband, at least one birth attendant who can guide and encourage you through the process, and any other cheerleaders you’d like to bring along.
There are still risks, as we all know too well. But nothing in life is risk-free. If I thought too much about risk, I’d never get into a car again. When our children were young, they climbed a lot. They climbed trees, they clambered up to the top of the jungle gym, they climbed along the top bar that holds up the swings. On our trips away from flat Florida, we had to stop by the side of the road so that they could climb rocks. Sometimes we had to close our eyes to keep from calling them down, or saying things that would have made them afraid. If one of them had fallen and broken her neck, it would have been an unthinkable horror. Nonetheless, we let them climb, we encouraged them to climb, because we believed that the benefits to be gained in self-confidence, in strength and agility, and in conquering fear outweighed the risks.There is danger in childbirth, no matter how it’s done. However, it is significant that the risks with the midwives model of care are in the unusual, the exceptions. With the medical model of care so prevalent these days, the risks are inherent in the system. Surgery, IV lines, epidurals, catheterization, and episiotomies provide routes of entry for dangerous hospital-associated infections, and carry additional risks in and of themselves. Nurses and doctors have patient loads too heavy in most cases to allow for proper care. Interfering unnecessarily with the natural functions of the body wreaks havoc on the whole system. There are definitely times when these risks are lower than the risk of not being in the hospital, and I’m very glad that their new midwife has a comfortable, mutually respectful, working relationship with a nearby hospital and ambulance service. Nonetheless, my journey, which began with an effort to persuade our new grandchild’s parents to choose a hospital birth this time, has taken an altogether unexpected direction.