I asked a couple weeks ago if anyone knew of where to find pics of twilight sleep for my project on midwifery and evidence based maternity care. i am done with my project and here is my research paper along with the Works Cited page. I will post a link to my video as soon as my nerd BF shows me how, lol. Warning, the paper is looong. 24 pages in MLA format
The Birth of an Idea
In the course of my research for this project, I was shocked and amazed by the number of people who have no idea what a midwife is. In the U.S., the general assumption is that a pregnant woman will have a physician to care for her during the pregnancy and birth process. However, in most other parts of the world the midwifery model of care is standard. Massive differences exist between the midwifery model of care and the standard obstetrical model in this country. The medical model of care is specialized in pathology and is best utilized for the care of pregnant women with serious health problems or complications in their pregnancies. It focuses on the potential for pathology in pregnancy and birth. In contrast, the midwifery model of care specializes in normal pregnancy and birth and focuses on the needs of pregnant women not relating to pathology. It maintains that birth is a natural process that should be treated as normal until evidence of a problem arises. The World Health Organization to this day maintains that “The midwife appears to be the most appropriate and cost effective type of health care provider to be assigned to normal pregnancy and normal birth” (Block 218). Despite this, the American College of Obstetrics and Genecology has adamantly opposed the licensure of non-nurse midwives (Block 218).
Before setting out to complete this assignment, I had two joyous, uncomplicated pregnancies, which resulted in two mostly uneventful births outside of hospital with minimal intervention. I was able to move about freely in labor. I was permitted to eat and drink as I pleased throughout labor. I was free of machines, monitors, tubes, needles, drugs, stirrups, or contraptions of any kind. No time restrictions were implemented, nor were any interventions used without my express knowledge and consent. I was not separated from my healthy offspring at any point after birth. After emerging, each child was given to me to hold and cuddle and breastfeed for as long as I desired before any measurements were taken or exams performed. Both my midwives and I understood that such hindrances are not necessary for normal, healthy birth resulting in a healthy mother and infant. With that understanding, another insight lay at the back of my mind. Most births in this country do not happen like mine. With these monumental experiences, these glimpses of my innermost capabilities as a human, I have been certain of my goal to become a midwife. Women and babies deserve safe, gentle birth whenever possible.
In this high-tech society, about 65% of women have their labors chemically induced or augmented. Two thirds have their amniotic sac broken manually. Even more alarmingly, one third or more of babies in this country are brought into the world via major abdominal surgery, half of which are scheduled before labor can even begin. The facts that I have both stumbled upon and painstakingly sought have posed some serious questions. How did we get to this point? Have women really lost the evolutionary ability to give birth safely and physiologically? What are the facts about how childbirth is handled in the United States? And, most importantly, what can I do about it as a midwife? How do I get to that point of effecting change?
No matter how many answers I seek, there tend only to be a million more questions. To many the senior culminating project is a burden dreaded, avoided, and suffered through in what appears to be the least detrimental and quickest way possible. Students want only to endure it and escape high school with their lives. Birth in our society has the same hauntingly familiar air of fear, confusion, and misunderstanding. As a student and a mother, I am deeply connected to both of these worlds. I can only hope that my enthusiasm for midwifery, fueled by the Senior Project, will encourage others to explore their own passions and dispel the foreboding appearance of this project. I also hope that it will give individuals the knowledge and encouragement to look at birth from the more resplendent angle that I do.
The History of Maternity Care
Throughout recorded history, women have sought care and support from one another during their childbearing year. At some unknown point in history, women experienced in childbirth came to be regarded as the ones with knowledge to care for women during their reproductive cycles. As early as Greek and Roman times, qualifications existed to become a midwife, such as the woman having borne a child herself. Biblical acknowledgment of midwives includes several verses referring to Hebrew midwives who defied the King of Egypt and refused to kill male infants, as well as several transitory references to midwifery. Midwifery has also been referred to in ancient Hindu records. The term “midwife” is translated to mean “with woman”, or in French sage femme, or “wise woman” (Brucker 1). Traditional Native American midwife Cynthia Caillagh insists that techniques such as urine analysis have been used since ancient times to screen pregnant women for complications. She reiterates, “Midwives would have women pee into buckets. They’d smell the urine; they’d drink the urine; they would pour it over a variety of herbs; they would add herbs to it. These are old skills. We’ve refined them, and we call them medical. But they are not new” (Block 222). Even throughout the Dark and Middle Ages midwives continued throughout the centuries to learn by the apprentice model, passing skills and knowledge from generation to generation. Today, midwives are still the most common birth attendant in the world (Brucker 1). The average child born in this world is born into the hands of a midwife.
In colonial America, women continued to attend one another in birth as it was considered indecent for men to be present for such an occasion. Midwives were seen as respectable professionals warranting priority on ferries to the Colonies. In 1765 Dr. William Shippen opened the first formal education for midwives (Feldhusen 2). The decline of witchcraft and the perpetuation of common beliefs that women were intellectually inferior to men slowly led to the belief among wealthy families that doctors could provide better care than female midwives by the end of the eighteenth century. This happened despite the fact that most doctors still had no formal training and practiced techniques such as bloodletting to treat illness. Hospitals were full of infection, and proper hand washing techniques were not implemented. It was not until 1880 the Louis Pasteur demonstrated that the epidemic of puerperal (childbed) fever was caused by strains of streptococci introduced due to poor hygiene on the part of doctors (History 3). The first cesarean section was performed in 1894 in Boston (History 4).
By 1900, physicians were attending half of the births in the U. S. Birth steadily moved into hospitals between the years of 1900 and 1960 from less than five percent, to ninety-seven percent births in hospital (History 4- 9) Infant and maternal mortality did not begin to decline in hospitals until 1930, and did in fact, increase in the years prior to WWII (Pushed, 214). In a 1913 report, S. Josephine Baker, MD noted that half as many women died in midwifery care as under physician care in childbirth, and that midwifery postpartum care was “infinitely superior”(Block 214). Even so, by 1935, less than 11 percent of births were attended by midwives (History 5) Midwifery all but died out in the United States. Midwifery care became solely associated with the foreign born and nonwhite populations. Dr. Joseph DeLee, in 1915, described Childbirth as a pathologic process that was not a normal function, and one in which midwives had no place (History 6). In the Victorian period, young girls wore soft corsets from very young and acquired stiffer boning at the age of early puberty; exactly the time at which the uterus is developing. Pregnant women wore even tighter corsets because it was believed that the “fragile female figure” needed such support. Historians now believe that this, combined with malnutrition and overuse of obstetrical interventions were the cause of the poor birth statistics of the era. After many years of oppression and pain via tight-lacing, women began to demand pain medication in labor. Access to twilight sleep is a large part of what drove so many women away from home and into the hospital to give birth. By 1920, doctors believed that normal births were so rare that interventions should be made in every delivery to prevent trouble.
In the 1920’s and 30’s the Frontier Nursing Service and Lobestine Clinic were established to train nurse-midwives according to the British model of care (Brucker 3). In 1940 Dr. Grantly Dick-Read presented an alternative to pain in labor. In his book, Childbirth without Fear, Dick-Read described his theory that pain in childbirth was not natural and was actually a result of fear and tension. Shortly afterward, in 1951 French physician Fernand Lamaze witnessed women in Russia who learned to subdue childbirth pain with relaxation techniques. Finally, Dr. Robert Bradley wrote Husband Coached Childbirth after witnessing difficult births made easy one the spouse was allowed in the delivery room. At the time the only options for birthing women were to be “awake and aware” as the three aforementioned physicians advocated, or to be totally anesthetized and out of control with no memory of birth and no contact with their babies for hours afterward. This was the beginning of the natural childbirth movement. Unfortunately, this movement was short-lived due to the invention of plastics and epidural anesthesia in the 1970’s. Women were now told that they could have the best of both worlds. To be awake and aware, and also pain-free was promised. The next section will discuss the truth about the risks of all birth interventions of past and present. Even the seemingly smallest alteration to a physiological birth can have catastrophic effects.
Birth Interventions: From Twilight Sleep to the Elective Cesarean
The very first substances used for sedation in childbirth were ether and chloroform, made popular by queen Victoria of England. This eventually evolved into what is now referred to as twilight sleep. In twilight sleep a concoction of morphine and scopolamine, then ether were administered to the laboring woman. The physician would then cut an episiotomy (a surgical incision to the vaginal opening) and extract the infant with forceps. After repairing the incision, more morphine and scopolamine were administered “to prolong the narcosis for many hours postpartum and to abolish the memory of labor as much as possible” (Block 22). By 1938, doctors used twilight sleep in all deliveries (History 7). During this process, women were restrained and brutalized.
Though the use of twilight sleep gave way to the spinal, and later, the epidural one disturbing aspect of twilight sleep is still widely practiced today. Episiotomy was first introduced in the eighteenth century as a last resort to free a stuck baby. A survey in 1915 indicating that episiotomies were performed only 5 percent of the time (Pushed, 28) By the 1930’s episiotomy was prevalent and it was believed that “the tissues of the modern women do not well withstand the tension and stretching incident to the average normal labor” (Block 29). An episiotomy is performed in at least one third of vaginal births in the United States as of 2005 (Block xiv). Women are often told that the procedure is done to “prevent worse tearing” however an episiotomy is automatically a second degree tear when no tear may have occurred at all. One study in the 1990’s found that episiotomy, in fact, makes a third or fourth degree tear nine times more likely. Episiotomy has been associated with higher rates of infection, incontinence, prolonged pain, and sexual problems. Techniques such as perineal support and birthing positions that open the pelvic outlet are proven to reduce the incidence of tearing. Yet one third of women are still getting a procedure included among “forms of care likely to be ineffective or harmful” by a review of all available medical evidence outlining effective maternity care (Block 276), and only about half of them are given a choice in the matter (Block 154).
The other wolves in sheep’s clothing when it comes to obstetrical interventions are the routine administration of intravenous fluids and continuous electronic fetal monitoring for all laboring women. IV fluids are totally unnecessary unless a woman is unable to drink water to keep hydrated. The exception would be if she requires medication to be administered via an IV. The routine IV has been listed among “forms of care unlikely to be beneficial”. It dilutes the blood, thus weakening the effect of the hormones and endorphins that are a part of physiological labor. Yet again, the majority of women in the U.S., 83% according to the Mothers survey have an IV inserted upon admission to the hospital while in labor (Block 35).
Continuous electronic fetal monitoring was introduced in 1960 (History 9) and is now employed in nearly all U.S. births. This technology has not been proven to improve outcomes compared to intermittent monitoring with a Doppler or fetoscope, yet it is used routinely in hospitals for a few reasons. One cause is that the technology became so widely used by the time any studies were done proving its inefficiency it is hard to do away with because it has become such a commonality. In a randomized controlled study in which either EFM or intermittent monitoring with a fetoscope was assigned to a group of high risk women it was shown to double or triple the cesarean rate (Block 33). Legal fears are also at the root of such widespread use of technology with no clear benefit. The little strip indicating fetal heart tones provides a paper trail of “proof” in the event of a lawsuit. Also, in a hospital setting there are more patients to care for than staff to care for them. With EFM technology a doctor or nurse can monitor many women without needing to even be in the same room. It is easier and more efficient to care for a machine than a person. Additionally, a study of over 150,000 births in California concluded that EFM falsely predicted cerebral palsy 99.8% of the time. So why on earth are 93% of mothers having these devices strapped around their bellies and told they must lay in bed because the monitor will not read properly if they move around (Block 35)? The primary reason women in the 2005 study gave for being immobile was not because they were numb from medication, or that they were in pain, it was that they were “connected to things” (Block 35). In all, a laboring woman in a typical U.S. hospital may have up to 16 different tubes, drugs and/or attachments (Block xiv).
Though the CDC reports that the rate or labor induction has risen from 9.5% in 1990 to 21.2% in 2004, expert opinion and independent studies have found that the majority of women in the United States are receiving Pitocin at some point during labor to either induce or augment contractions (Block 5). Pitocin is an artificial form of the hormone oxytocin, which got its name in 1909 when physiologist Sir Henry H. Dale discovered that an extraction of the hormone resulted in a very fast labor for a pregnant cat. The name comes from combining the Greek words “oxy” (fast) and “tocos” (birth). Prior to the use of animal derived oxytocin, derivatives of ergot, the toxic fungus from which LSD was eventually synthesized, were used to induce labor (Block 18). Other experimental induction methods of the nineteenth and twentieth centuries included insertion of various items into the cervix to achieve dilation as sit ups, fasting, enemas, intrauterine douches, intravenous lipids, and electricity to name a few. The forerunner of Pitocin was Pitutrin, the postpituitary extract of cattle. Though Pituitrin was a more predictable means of inducing labor compared to previous methods, complications such as reactions to the animal proteins, uterine rupture due to over stimulated contractions, embolisms, and maternal and fetal deaths resulted from the drugs’ use (Block 18). By 1928, the substance was purified and sold by the pharmaceutical company Parke Davis under its current name.
Routine use of Pitocin was first introduced in a 25 year study of 200,000 first time mothers in Dublin, Ireland as a way to reduce “prolonged labor” and the cesarean rate (which was 4%, by the way) (Block 19). This protocol was dubbed “active management of labor”. Contrary to its intended purpose, this modus operandi actually increased the cesarean rate by 5% as well as amplified twelve times over the use of epidural anesthesia (Block 20). Neonatologist Marsden Wagner points out that the definition of the upper limit of normal labor went from 36 hours in the 1950’s to 24 hours in the 1960’s to twelve hours in 1972 when active management was introduced (Block 21). Obviously, a narrower range of “normal” would result in a greater number of births diagnosed as anomalous. Thus, the rate of “failure to progress” increased from 3.8% in 1970 to 11.6% in 1989 and continued to climb, now accounting for half of primary c-sections. Along with this the number of cesarean operations performed for “fetal distress” rose from 1.2% in 1980 to 6.3% in 1989 (Block 21).
Many doctors and nurses admit that pitocin is used more often for convenience and ease on the part of the doctor, rather than for the safety and health of mothers and babies. Marsden Wagner talks of “daylight obstetrics” citing birth to be the biggest problem on the already full plate of an American obstetrician. Nurse Kathleen Rice Simpson describes it this way:
Let’s say you have a very busy practice, and you’re trying to have a quality of life, maybe you’ve got a young family, you don’t want to be running out every night to deliver a baby…So what happens is you try to get all the births in between 9 and 5, and to do that, you have to make sure that nobody goes into spontaneous labor, and to make sure of that, you have to induce them all early.
Or let’s say this is the day you have to be on call, its best then for you to induce three or four people on that day…Those…people are not going to call you on the weekend, they’re not going to call you in the middle of the night, they’re not going to interrupt your office hours, they’re not going to give birth at any time that’s inconvenient. (Block 42)
People are often unaware that the mere passage of time in labor is not a risk factor. As long as mother and baby are well, labor can pretty much progress indefinitely on its own. In fact, even labors in which the waters break prior to labor, (PROM) one of the main reasons given for inductions usually end just fine allowed to start on their own, despite many provider and hospital policies requiring birth within 24 hours of rupture. In 1996, a study of 5000 women identified that there was no increase in neonatal infection in premature ruptures of membranes watched up to four days after rupture (Block 12). To make sure infection is not introduced; vaginal exams should be kept to a minimum. Sixty percent of women will go into labor within 24 hours of their water breaking, and 95% will within 3 days. Similarly, 96.5% of women will go into labor before 42 weeks (Block13). The “normal” duration of pregnancy is defined as ranging from 38 to 42 weeks in length. The “due date” is merely an estimate, a range of normal. However, hospitals often still feel the need to get things moving faster, sometimes imposing time limits of 12 hours or less after rupture, (Block 13) and the “due date” is becoming synonymous with a deadline.
Last but not least, synthetic oxytocin does not work the same as that which is
naturally produced by the brain. Oxytocin is secreted during orgasm, emotional connection, birth, and lactation. For this reason, it is referred to as the “love hormone”. Unfortunately, Pitocin produces vigorous contractions, but does not cross the blood-brain barrier (Block 135). This fact means it does not provide for the emotional connection that natural oxytocin does. In addition, it suppresses the body’s own oxytocin production. Thus the love is removed from the artificial “love hormone” (Block 135). Furthermore, the contractions derived from Pitocin do not possess the natural crescendo and decrescendo of the body’s own devices. The contractions are fast, strong, and irregular without rest in between. One randomized study of women who labored with or without synthetic oxytocin found that 80% of those who received it felt that it increased their pain (Block 135). Pitocin in a patient on epidural anesthesia poses another risk of hyper stimulation and twice the risk depravation of oxygen to the fetus because the dose can be increased without the natural pain threshold kicking in (Block 136). In the worst case scenario, such unnatural stimulation can lead to uterine rupture or placental abruption, and nearly half of umbilical cord prolapses are precipitated by the interventions the accompany induction, such as manual rupture of the amniotic sac (Block 137). The ACOG conducted a recent study revealing that Pitocin was to blame in 43% of malpractice suits associated with neurologically damaged infants (Block 137).
It was Queen Victoria who first popularized chemical means of pain relief during labor (Block 23). First it was chloroform, then ether, then the twilight sleep mentioned earlier. The total immobilization due to heavy narcotic anesthesia is what led to the use of interventions once only used in critical cases as a last ditch effort to save a baby when labor was abnormally hampered. For example, forceps were first invented by a barber surgeon in the seventeenth century as a means of freeing a stuck baby that did not necessitate crushing the term infant and extracting it in pieces (Block 24). But as birth moved toward all women being heavily drugged during childbirth, episiotomy and forceps became necessary to deliver a child whose mother could not push him out. The spinal was a single shot of anesthetic injected into the spinal fluid that became popular after twilight sleep ceased. This was often used in conjunction with IV pain medication such as Demerol. A physician recalled the spinal and forceps delivery common before today’s epidural to be something like this “You’d have an IV of Demerol or whatever, and the OB would give the spinal. You had a nurse on either arm, you’d put on the forceps, you pulled a lot, she screamed a lot, and then the baby was out…The patient was so out of it she didn’t know why she was screaming, and she couldn’t push anyway (Block 24).” In 1979 the FDA held a special to discuss a large national study that found lingering motor and behavior deficits in children whose mothers had been given large doses of analgesics such as Demerol (History 11).
After plastics became more commonly used epidural anesthesia became the most common anesthesia in childbirth going from 22% in 1981 to 66% in 1977, now reaching an estimate of 80% today (Block 170). An epidural is a signature concoction of anesthetic and narcotic (not two anesthesiologists use the same mixture) that continuously “bathes” the spinal nerves via a flexible nylon catheter inserted into the space between epidural space surrounding the spinal cord. Doses of medication required are much less than that of medication administered via IV, including a very low dose coined the “walking epidural”. Despite the name of this popular medication, three quarters of mothers according to the “Listening to Mother’s” survey either cannot or do not move around after being admitted to the hospital in labor, and more than half of the participants remained on their backs, pelvises tipped against gravity (Block 24). Also, similar to artificial oxytocin, artificial pain relief inhibits the body’s natural methods of pain relief including endorphins that in physiological birth induce an altered state of consciousness toward the end of labor. Then the endorphins are unable to trigger the release of adrenaline and nonadrenaline, which prime the baby’s lungs and protect its brain against the stress of being born (Block 172). Studies have also correlated epidural use with a drop in prostaglandin, which is another hormone crucial to the birth process. The diminishing of this particular hormone can result in a less productive, or “lazy” uterus, an unfavorably positioned baby, longer labor, and hemorrhage (Block 173). Additionally, the risks of fever and a rise in blood pressure are greater in women who receive epidural anesthesia (Block 172).The final energy release of physiological labor does not occur, thus there is no “fetal ejection reflex” present to help the mother expel her baby quickly and easily (Block 173).
Many people don’t realize that when one intervention is done, it greatly increases the risk of the need for other interventions, and the possibility of complications. When a woman “chooses” and epidural for labor pain relief, she is may not only be choosing the pain relief but every other intervention that comes along with being nearly paralyzed from the waist down. This is often referred to as “the slippery slope” or “the cascade of interventions”. An epidural almost always means a catheter because you can’t get up, restriction of movement, an IV, continuous monitoring because you cannot feel your own contractions, and no fetal ejection reflex, meaning an increased risk for tearing and potential induction or cesarean for “failure to progress”. In fact, the very first randomized controlled trial on the effects of epidural anesthesia resulted in cessation of the study after analysis of the first group after noting the high rate of cesarean section. The study was deemed unethical to continue after finding the cesarean evidence (History 12).
The biggest thing that people seem to be missing is that, in the words of French obstetrician Michel Odent, “The pain of labor is part o the physiological process”. He agues that without pain, endorphins are not released, and without endorphins, prolactin (the chief hormone involved in lactation) is not produced. Labor is a very complex biofeedback mechanism that scientists are barely beginning to understand (Block173). This does not mean, however, that women have no options for pain relief. Pain is a signal from the body that something is happening, and requires a response. The natural reaction to pain is to move to improve one’s comfort. To do something different, take a shower, get a massage, being upright, ever anticipating the emergence of the child and working with the body to accomplish that goal. In labor it is to move to help get the baby out easier, but when a woman is all but tied to a bed, narcotic pain relief is a kind of last ditch effort for the woman to feel relief from what her body is telling her to do. British midwife, Trisha Anderson elaborates on this point:
Let us bring them into harsh rooms with bright lights, let us make them lay on their backs on hard narrow beds. Lets us tether them to machines so they cannot move. Let us make them stay silent and make no noise with their pains. Let us expose their most private parts and threaten them with cold steel. Let us make them push their babies upward, against the pull of the earth…In these conditions, labour swiftly becomes unbearable and pain relief becomes a woman’s only hope…This is not the natural cry of a woman in labor bringing a child to birth, although if you have only ever witnessed childbirth in a medicalized setting you might be forgiven for thinking so. This is the screaming plea of a tethered animal in pain. (Block 174)
As anyone can plainly see, routine medicalized birth restricts women from being able to birth naturally at all. There is a dangerously unfair comparison of vaginal versus surgical birth. Women are often given only the option of highly interventive births in which everything is working against their bodies, or surgical birth. In a system such as this, more women are opting for cesarean sections with no medical indication perhaps as a means of being in control of their experience, and often out of fear induced by their healthcare providers (Block 50). This gradual infiltration of birth by numerous routine medical interventions has caused some women and healthcare practitioners alike, to believe that surgical birth is desirable over the body’s millennia-tested evolutionary mechanisms. Obstetrician Peter Bernstien of New York called the desire for a medically unnecessary cesarean “a failure of modern medicine and society at large”. The number of cesarean surgeries tripled between the years of 1968 and 1976, when it then made the list of top ten most frequently performed surgeries in the U.S., and has now reached number two on this list (Block 34).
Cesarean section in a pregnancy with no risk factors carries 4 times the risk of death to the mother as a vaginal birth, and nearly three times the risk of death within the first month of life to the infant (Block 49). Cesarean also increases the risks of adhesions, scar tissue, uterine rupture, placenta implantation problems, organ damage, infertility, and hysterectomy (Block 55). Still, many women are denied a chance at vaginal birth after cesarean (VBAC) due to the position of the American College of Obstetrics and Gynecology (ACOG) that VBACS should not occur unless a physician and operating staff were capable of performing a cesarean “immediately”, leading many hospitals to ban VBAC totally (Block 85-86). This position was introduced after a period of supporting VBAC when a study showed an increased risk of uterine rupture for VBACs in comparison with planned cesareans. What apparently happened in the study was what is called “distortion of risk”. In fact, the risk of uterine rupture is only 1 in 200, even in women with multiple cesarean scars, and the neonatal death rate is 1 in 2000, half the rate of death in “low risk” pregnancies. Also, the only complications that require immediate surgical attention, cord prolapse and placental abruption, are just as likely to happen in an unscarred Woman (Block 88). The true risk analysis comparing planned VBAC and planned repeat cesarean are as follows: If you plan a VBAC, there is about a 75% chance of a vaginal birth and a 99.5% chance of not having a uterine rupture. If you schedule a repeat cesarean, there is a 100% chance a major abdominal surgery, and all the risks that come along with it and a 99.8% chance of not having a uterine rupture.
The other area in which there are discrepancies regarding risk is that of breech birth. I have heard from the midwives here that there is not a single doctor in Washington State who will attend a vaginal breech birth. This is due mostly to the fact that practitioners are loosing skill in this area. There are no North American programs to teach the attendance of breech birth, so many doctors who wish to gain breech experience travel to Klinikum Nurnberg in Germany, where 62% of breech birth are vaginal (Block 76).There are many methods of trying to coax the fetus into a vertex presentation. These include external version, a chiropractic adjustment called the Webster technique, acupuncture, acupressure, and even the Chinese practice of moxibustion in which a roll of herbs is burned near the outer edge of the mother’s pinky toe. Believe it of not, moxibustion showed a 75% success rate in clinical trials (Block 75). Most of these methods are not used in the United States however, and about 3% of babies will still be in breech presentation at term.
Breech babies have always seemed to get hurt, stuck, and die more throughout history. About 1 in 20 American breech babies died in the 1940’s. However, we know now know that the high death rates recorded then were due to assisted breech delivery, which involved heavy anesthesia, manual pressure on the uterus, traction on the baby’s body, and controlled delivery of the head with forceps (Block 78). A 1953 review of the breech delivery techniques used at the time found that “the more manipulation is performed and the earlier this manipulation is instituted, the greater the fetal mortality and morbidity, to say nothing of maternal injuries” (Block 78). This conclusion led to the development of the Bracht technique by a German obstetrician. The Bracht technique involved waiting for spontaneous delivery with minimal manipulation and supporting the baby’s body with a force equal to that of gravity if the woman were upright. Bracht presented his technique, and an analysis of 206 successful breech births without one fetal injury or death, to a congregation of physicians in Amsterdam in 1938. Dramatic decreases in breech-related injury in studies all over the world resulted. Unfortunately, not one study was translated into English (Block78).
As time went on, the breech technique in Europe constantly improved, while vaginal breech delivery merely “fell out of fashion”, and between 1978- 1990 the number of breech cesareans increased form 60% to 85%. After a RCT study published in The Lancet stated that planned cesarean breech babies had only 1.6% “serious neonatal morbidity” compared to 5% of planned vaginal breech births it led to a huge decrease in vaginal breech births, even in Holland, where nearly half of breech births were vaginal. The inaccuracy of the study lies in that some countries with high overall neonatal deaths were involved as well as the fact that several of the most experienced centers offering breech birth were excluded. From this information, it can be concluded that the deaths were more a result of the care in particular countries and centers, rather than of breech birth itself. Countries with low neonatal death rates showed no significant difference in outcomes (Block 79-81).Also, two years following birth, there was no neurological difference between the vaginally and cesarean born children, indicating that the definition of “serious neonatal morbidity” did not predict damage. A woman at term has a 97% chance of having a healthy 2-year-old regardless of whether her baby is born vaginally of by cesarean (Block 82). The evidence notwithstanding, the majority of women with a fetus in breech presentation, or multiples, (due to the possibility of one or more being breech) are being told they cannot have a vaginal birth.
Much of the decisions made by doctors pertaining to cesarean section involve the fact that in the courtroom, a cesarean holds up as the doctor having “done all he could” to save the baby. Unfortunately, that is not always the case. A death due to a breech in labor is indefensible in court; so many doctors err on the side of caution in that regard. They cannot afford one bad outcome because society will not accept on bad outcome. But, we must remember that no matter how much technology or expertise is involved, there will still be a couple of births per thousand that no one can prevent a bad outcome in. Congenital anomalies sometimes exist that are untreatable and undetectable in infants, and sometimes a mother will have an embolism or other complication that cannot be prevented or treated at all. But when doctors need to get a certain number of births in to pay $90, 000 a year malpractice insurance rates (Block 60) as well as insure that not a single bed outcome can be attributed to something they had done for fear of loosing their right to practice, can we really blame them? Especially when it appears that more and more women are showing preference for surgical birth?
I believe the biggest thing doctors and the medical community at large is missing is that the high cesarean rates in the U.S. are not generally a result of mothers being “too posh to push”. Is there really such a thing as “maternal request” cesareans with no other factors? The Listening to Mothers Survey says no. out of 1500 women surveyed about their cesarean experiences, just one of them said she requested a primary elective cesarean (Block 56). It can often be assumed in medical reviews that this rate is much higher due to that fact that cesareans are only labeled as “elective” or “emergency”. This means that any plethora of situations that do not meet the criteria of being emergent are lumped into this category of so called “maternal request” (Block 59). A 2006 study resulted in the findings that “a geographic variation in the number of c-sections performed is driven mostly by nonmedical factors, such as provider density and local malpractice pressures, and is mostly unrelated to the mother’s medical condition” (Block 9).
It is getting more and more difficult for women to have a safe, physiological birth with a skilled care provider. Poor maternity care in this country has reached such epidemic proportions that women are resorting to such efforts as traveling hundreds of miles in labor to reach a competent care provider who will not give her unnecessary surgery, they are laboring parking lots of hospitals with no VBAC or no breech birth policies until crowning in an attempt to not have unnecessary surgery. Some are scouring the country to find illegal midwives to attend them in states with unfavorable midwifery laws. Even so, some women are strapped down and given a cesarean without their consent, sometimes under a court order even when there is no medical reason for the cesarean (Block 142-148). Women with the least options or the least resources usually make one of two choices; they go it alone without a care provider to avoid all of the harmful procedures they do not want, or they choose what appears to be the only thing they can do when they have no other options. They choose what appears far safer and easier than what is defined as “normal” birth in this country. “Just give me a cesarean”, these women are saying.
Complicated Questions with Simple Answers
Birth ties into the world as I know it in many ways. As I look around me I see evidence of our disconnected society. I’d venture to guess that half of Havermale students are “unaccompanied youths”. This term is defined as a high school student not residing with their parent or guardian. These students often fall through the cracks without anyone to tell them not to be afraid and not to give up. Teachers and other adults need to reach out to these adolescents and help them before it gets that bad. If I had not had several teachers and staff at Havermale to convince me to keep going when I felt like I simply couldn’t do it anymore I would not be standing here today. I would have been one of those lost teenagers everyone hates for being born into a society that intellectually, emotionally, creatively, and spiritually starves them until they can’t take it anymore. Influential psychiatrist Karl Menninger said that “What's done to children, they will do to society.”
I attended the Chase Youth Commission Dropout Prevention Summit as a youth panelist. During that meeting all of the businesspeople, government and school officials, students, parents and others present came to the conclusion that the failing education system was producing a 1/3 dropout rate because the societal structure lacked the systems and networks necessary to nurture children into thriving, compassionate adults. The problem was not the curriculum but the fact that so many students are assigned to so few teachers such that each student often becomes just another face of name with little other connection. In this same way our society is failing childbearing women. The doctors that care for healthy pregnant women often do not have the time to connect with each mother individually.
Thankfully I had no such experiences. Each of my teachers at Havermale, and many who never were my teachers, has gotten to know me on a personal level. They have interest in my well-being and call to check on me if I am not at school. They remind me constantly that I deserve all of the achievements I have made thus far in my life. They mean a lot to me. In the same way my midwives were there in all aspects of my pregnancies, births, and postpartum experiences. Even now they have been immensely helpful and giving of their time to aid me in the completion of this project as was their assistant. In the words of midwife Christine Harrington, interviewed for my production, “You are their go-to person”. Everybody needs at least one of those, especially during such vital periods as birth and high school. School shouldn’t be about grades or test scores or staying in line or having the same opinions as “everyone else”. It should be about the things you truly learn and gain from the experience.
Pregnancy and birth should not be about what is best for the care provider. Birth is not owned by doctors or midwives. It is owned by mothers; by families. It is the mother’s experience so she should have a say in the forming of that memory. It’s not really about whether a mother had interventions (even though midwifery-type care automatically lowers the use of interventions). It is about the fact that having at least one person who cares about you and your life looking after you in such a pivotal time in life makes a huge difference. Midwives support mothers, who support children, who are the future of our society.
Sometimes even I think that I am crazy for having spent so much time on this project. I often feel like I have spent the most time on any Senior Project in the entire history of the Senior Project, but I really enjoyed it. All but a couple people I talked to about their Senior Culminating Project responded as though it were either torture or, at very least, a huge task they did not look forward to or enjoy undertaking in the least. However, my work was truly a labor of love (pun absolutely intended). To my dismay, most of the birth stories I have heard in my life have a similar tone of aversion or dismissal. It nearly makes me weep every time. Education is about preparing for life as birth is about preparing for life and birth is about preparing for family. Both are of at least equal importance. Some people still won’t understand me but nonetheless, midwifery isn’t something I want to do; it is something I need to do. At times I wonder why I put so much effort into a good many things that I do, but every time I see one of my children smile I am hit with an overwhelming sense of personal understanding.
Contrary to popular belief, I am not some obscure superhero, nor am I brave, radical, dense, unscrupulous, or a raving lunatic. I merely stand up for what I believe in. Even so, I wouldn’t have gotten this far without all my teachers and friends who have been here for me through the most treacherous of life circumstances. It has been my experiences chiefly with midwifery and Havermale High School that have led to all of the other things I love and respect so deeply now. Those intertwined experiences remind me that there are still people out there who really care about other people. They have made me who I am. Now and again I think that people just need to slow down and realize we are not machines. We are not all going to fit in the same little box no matter how carefully constructed. Our bodily functions do not occur on a schedule that is identical to everyone else’s. Each of us interprets our surroundings in a different manner. We are human! We are alive. We thrive on emotional, intellectual, and spiritual connection. Love is the most powerful thing in the world, perhaps in all existence. Use it, embrace it. The key to peace is just caring about one another. I want to effect change. A society where the people hold each other up during hard times is what we need again. I figure, why not start at the beginning?
It takes a village to raise a child, right? Well if the village wants the children to grow into compassionate, intelligent adults, they need to show the children from birth that the world can be a safe, happy, gentle, loving, beautiful place. I may not be able to change the world, but I can change my community. I can at least make such a precious life experience better for a few people. Every person, every family, is worth it. I won’t ever stop. Outside of my own aspirations I can only hope that people will start taking it upon themselves to make the world a better place, instead of waiting for some arbitrary authority figure to do it for them. I can also be optimistic that more students will linger on the Senior Project’s potential to open a doorway into what they want to devote their lives to. One can fight for what they feel is right in many ways, and this is how I’m doing it. It just feels right to me. No matter how much opposition I face, I truly believe that peace on Earth begins with peaceful birth.
Works Cited
1. “About NARM CPM Certification.” The North American Registry of Midwives 2009. NARM 2000-2009 <http://www.narm.org/edcategories.htm>.
2. Block, Jennifer. Pushed: The Painful Truth About Childbirth and Modern Maternity Care. Cambridge, MA: Da Capo Press, 2007.
3. Brucker, M. “History of Midwifery.” 19 June.2000. Parkland Health & Hospital System. 2000 <http://www3.utsouthwestern.edu/midwifery/mdwfhistory.html>.
4. Curriculum Overview.” Seattle Midwifery School. 2009 <http://www.seattlemidwifery.org/midwifery-education/curriculum-overview.html>.
5. “ FAQ for Students.” .Midwifery Education Accreditation Council. 2009 <http://www.meacschools.org/prospective_students.php>.
6. Feldhusen, Adrian E. “The History of Midwifery and Childbirth In America: A Time Line.” 2000. Midwifery Today, Inc. 1987-2009 <http://www.midwiferytoday.com/articles/timeline.asp>.
7. Gordon, Wendy. ”The Netherlands Home Birth Study.” Apr 2009. Midwives’ Association of Washington State. 1998-2009 <http://washingtonmidwives.org/netherlands-study.shtml>.
8. “Midwifery Education Program Courses.” Seattle Midwifery School. 2009 <http://www.seattlemidwifery.org/midwifery-education/course-descrip.html>.
9. Rooks, Judith. “The Midwifery Model of Care.” Journal of Nurse-Midwifery. July/Aug 1999. <http://www.ourbodiesourselves.org/book/companion.asp?id=21&compID=121&page=2>.
10. “Types of North American Midwives.” Seattle Midwifery School. 2009 <http://www.seattlemidwifery.org/midwifery-education/north-amer-mws.html>.
The Birth of an Idea
In the course of my research for this project, I was shocked and amazed by the number of people who have no idea what a midwife is. In the U.S., the general assumption is that a pregnant woman will have a physician to care for her during the pregnancy and birth process. However, in most other parts of the world the midwifery model of care is standard. Massive differences exist between the midwifery model of care and the standard obstetrical model in this country. The medical model of care is specialized in pathology and is best utilized for the care of pregnant women with serious health problems or complications in their pregnancies. It focuses on the potential for pathology in pregnancy and birth. In contrast, the midwifery model of care specializes in normal pregnancy and birth and focuses on the needs of pregnant women not relating to pathology. It maintains that birth is a natural process that should be treated as normal until evidence of a problem arises. The World Health Organization to this day maintains that “The midwife appears to be the most appropriate and cost effective type of health care provider to be assigned to normal pregnancy and normal birth” (Block 218). Despite this, the American College of Obstetrics and Genecology has adamantly opposed the licensure of non-nurse midwives (Block 218).
Before setting out to complete this assignment, I had two joyous, uncomplicated pregnancies, which resulted in two mostly uneventful births outside of hospital with minimal intervention. I was able to move about freely in labor. I was permitted to eat and drink as I pleased throughout labor. I was free of machines, monitors, tubes, needles, drugs, stirrups, or contraptions of any kind. No time restrictions were implemented, nor were any interventions used without my express knowledge and consent. I was not separated from my healthy offspring at any point after birth. After emerging, each child was given to me to hold and cuddle and breastfeed for as long as I desired before any measurements were taken or exams performed. Both my midwives and I understood that such hindrances are not necessary for normal, healthy birth resulting in a healthy mother and infant. With that understanding, another insight lay at the back of my mind. Most births in this country do not happen like mine. With these monumental experiences, these glimpses of my innermost capabilities as a human, I have been certain of my goal to become a midwife. Women and babies deserve safe, gentle birth whenever possible.
In this high-tech society, about 65% of women have their labors chemically induced or augmented. Two thirds have their amniotic sac broken manually. Even more alarmingly, one third or more of babies in this country are brought into the world via major abdominal surgery, half of which are scheduled before labor can even begin. The facts that I have both stumbled upon and painstakingly sought have posed some serious questions. How did we get to this point? Have women really lost the evolutionary ability to give birth safely and physiologically? What are the facts about how childbirth is handled in the United States? And, most importantly, what can I do about it as a midwife? How do I get to that point of effecting change?
No matter how many answers I seek, there tend only to be a million more questions. To many the senior culminating project is a burden dreaded, avoided, and suffered through in what appears to be the least detrimental and quickest way possible. Students want only to endure it and escape high school with their lives. Birth in our society has the same hauntingly familiar air of fear, confusion, and misunderstanding. As a student and a mother, I am deeply connected to both of these worlds. I can only hope that my enthusiasm for midwifery, fueled by the Senior Project, will encourage others to explore their own passions and dispel the foreboding appearance of this project. I also hope that it will give individuals the knowledge and encouragement to look at birth from the more resplendent angle that I do.
The History of Maternity Care
Throughout recorded history, women have sought care and support from one another during their childbearing year. At some unknown point in history, women experienced in childbirth came to be regarded as the ones with knowledge to care for women during their reproductive cycles. As early as Greek and Roman times, qualifications existed to become a midwife, such as the woman having borne a child herself. Biblical acknowledgment of midwives includes several verses referring to Hebrew midwives who defied the King of Egypt and refused to kill male infants, as well as several transitory references to midwifery. Midwifery has also been referred to in ancient Hindu records. The term “midwife” is translated to mean “with woman”, or in French sage femme, or “wise woman” (Brucker 1). Traditional Native American midwife Cynthia Caillagh insists that techniques such as urine analysis have been used since ancient times to screen pregnant women for complications. She reiterates, “Midwives would have women pee into buckets. They’d smell the urine; they’d drink the urine; they would pour it over a variety of herbs; they would add herbs to it. These are old skills. We’ve refined them, and we call them medical. But they are not new” (Block 222). Even throughout the Dark and Middle Ages midwives continued throughout the centuries to learn by the apprentice model, passing skills and knowledge from generation to generation. Today, midwives are still the most common birth attendant in the world (Brucker 1). The average child born in this world is born into the hands of a midwife.
In colonial America, women continued to attend one another in birth as it was considered indecent for men to be present for such an occasion. Midwives were seen as respectable professionals warranting priority on ferries to the Colonies. In 1765 Dr. William Shippen opened the first formal education for midwives (Feldhusen 2). The decline of witchcraft and the perpetuation of common beliefs that women were intellectually inferior to men slowly led to the belief among wealthy families that doctors could provide better care than female midwives by the end of the eighteenth century. This happened despite the fact that most doctors still had no formal training and practiced techniques such as bloodletting to treat illness. Hospitals were full of infection, and proper hand washing techniques were not implemented. It was not until 1880 the Louis Pasteur demonstrated that the epidemic of puerperal (childbed) fever was caused by strains of streptococci introduced due to poor hygiene on the part of doctors (History 3). The first cesarean section was performed in 1894 in Boston (History 4).
By 1900, physicians were attending half of the births in the U. S. Birth steadily moved into hospitals between the years of 1900 and 1960 from less than five percent, to ninety-seven percent births in hospital (History 4- 9) Infant and maternal mortality did not begin to decline in hospitals until 1930, and did in fact, increase in the years prior to WWII (Pushed, 214). In a 1913 report, S. Josephine Baker, MD noted that half as many women died in midwifery care as under physician care in childbirth, and that midwifery postpartum care was “infinitely superior”(Block 214). Even so, by 1935, less than 11 percent of births were attended by midwives (History 5) Midwifery all but died out in the United States. Midwifery care became solely associated with the foreign born and nonwhite populations. Dr. Joseph DeLee, in 1915, described Childbirth as a pathologic process that was not a normal function, and one in which midwives had no place (History 6). In the Victorian period, young girls wore soft corsets from very young and acquired stiffer boning at the age of early puberty; exactly the time at which the uterus is developing. Pregnant women wore even tighter corsets because it was believed that the “fragile female figure” needed such support. Historians now believe that this, combined with malnutrition and overuse of obstetrical interventions were the cause of the poor birth statistics of the era. After many years of oppression and pain via tight-lacing, women began to demand pain medication in labor. Access to twilight sleep is a large part of what drove so many women away from home and into the hospital to give birth. By 1920, doctors believed that normal births were so rare that interventions should be made in every delivery to prevent trouble.
In the 1920’s and 30’s the Frontier Nursing Service and Lobestine Clinic were established to train nurse-midwives according to the British model of care (Brucker 3). In 1940 Dr. Grantly Dick-Read presented an alternative to pain in labor. In his book, Childbirth without Fear, Dick-Read described his theory that pain in childbirth was not natural and was actually a result of fear and tension. Shortly afterward, in 1951 French physician Fernand Lamaze witnessed women in Russia who learned to subdue childbirth pain with relaxation techniques. Finally, Dr. Robert Bradley wrote Husband Coached Childbirth after witnessing difficult births made easy one the spouse was allowed in the delivery room. At the time the only options for birthing women were to be “awake and aware” as the three aforementioned physicians advocated, or to be totally anesthetized and out of control with no memory of birth and no contact with their babies for hours afterward. This was the beginning of the natural childbirth movement. Unfortunately, this movement was short-lived due to the invention of plastics and epidural anesthesia in the 1970’s. Women were now told that they could have the best of both worlds. To be awake and aware, and also pain-free was promised. The next section will discuss the truth about the risks of all birth interventions of past and present. Even the seemingly smallest alteration to a physiological birth can have catastrophic effects.
Birth Interventions: From Twilight Sleep to the Elective Cesarean
The very first substances used for sedation in childbirth were ether and chloroform, made popular by queen Victoria of England. This eventually evolved into what is now referred to as twilight sleep. In twilight sleep a concoction of morphine and scopolamine, then ether were administered to the laboring woman. The physician would then cut an episiotomy (a surgical incision to the vaginal opening) and extract the infant with forceps. After repairing the incision, more morphine and scopolamine were administered “to prolong the narcosis for many hours postpartum and to abolish the memory of labor as much as possible” (Block 22). By 1938, doctors used twilight sleep in all deliveries (History 7). During this process, women were restrained and brutalized.
Though the use of twilight sleep gave way to the spinal, and later, the epidural one disturbing aspect of twilight sleep is still widely practiced today. Episiotomy was first introduced in the eighteenth century as a last resort to free a stuck baby. A survey in 1915 indicating that episiotomies were performed only 5 percent of the time (Pushed, 28) By the 1930’s episiotomy was prevalent and it was believed that “the tissues of the modern women do not well withstand the tension and stretching incident to the average normal labor” (Block 29). An episiotomy is performed in at least one third of vaginal births in the United States as of 2005 (Block xiv). Women are often told that the procedure is done to “prevent worse tearing” however an episiotomy is automatically a second degree tear when no tear may have occurred at all. One study in the 1990’s found that episiotomy, in fact, makes a third or fourth degree tear nine times more likely. Episiotomy has been associated with higher rates of infection, incontinence, prolonged pain, and sexual problems. Techniques such as perineal support and birthing positions that open the pelvic outlet are proven to reduce the incidence of tearing. Yet one third of women are still getting a procedure included among “forms of care likely to be ineffective or harmful” by a review of all available medical evidence outlining effective maternity care (Block 276), and only about half of them are given a choice in the matter (Block 154).
The other wolves in sheep’s clothing when it comes to obstetrical interventions are the routine administration of intravenous fluids and continuous electronic fetal monitoring for all laboring women. IV fluids are totally unnecessary unless a woman is unable to drink water to keep hydrated. The exception would be if she requires medication to be administered via an IV. The routine IV has been listed among “forms of care unlikely to be beneficial”. It dilutes the blood, thus weakening the effect of the hormones and endorphins that are a part of physiological labor. Yet again, the majority of women in the U.S., 83% according to the Mothers survey have an IV inserted upon admission to the hospital while in labor (Block 35).
Continuous electronic fetal monitoring was introduced in 1960 (History 9) and is now employed in nearly all U.S. births. This technology has not been proven to improve outcomes compared to intermittent monitoring with a Doppler or fetoscope, yet it is used routinely in hospitals for a few reasons. One cause is that the technology became so widely used by the time any studies were done proving its inefficiency it is hard to do away with because it has become such a commonality. In a randomized controlled study in which either EFM or intermittent monitoring with a fetoscope was assigned to a group of high risk women it was shown to double or triple the cesarean rate (Block 33). Legal fears are also at the root of such widespread use of technology with no clear benefit. The little strip indicating fetal heart tones provides a paper trail of “proof” in the event of a lawsuit. Also, in a hospital setting there are more patients to care for than staff to care for them. With EFM technology a doctor or nurse can monitor many women without needing to even be in the same room. It is easier and more efficient to care for a machine than a person. Additionally, a study of over 150,000 births in California concluded that EFM falsely predicted cerebral palsy 99.8% of the time. So why on earth are 93% of mothers having these devices strapped around their bellies and told they must lay in bed because the monitor will not read properly if they move around (Block 35)? The primary reason women in the 2005 study gave for being immobile was not because they were numb from medication, or that they were in pain, it was that they were “connected to things” (Block 35). In all, a laboring woman in a typical U.S. hospital may have up to 16 different tubes, drugs and/or attachments (Block xiv).
Though the CDC reports that the rate or labor induction has risen from 9.5% in 1990 to 21.2% in 2004, expert opinion and independent studies have found that the majority of women in the United States are receiving Pitocin at some point during labor to either induce or augment contractions (Block 5). Pitocin is an artificial form of the hormone oxytocin, which got its name in 1909 when physiologist Sir Henry H. Dale discovered that an extraction of the hormone resulted in a very fast labor for a pregnant cat. The name comes from combining the Greek words “oxy” (fast) and “tocos” (birth). Prior to the use of animal derived oxytocin, derivatives of ergot, the toxic fungus from which LSD was eventually synthesized, were used to induce labor (Block 18). Other experimental induction methods of the nineteenth and twentieth centuries included insertion of various items into the cervix to achieve dilation as sit ups, fasting, enemas, intrauterine douches, intravenous lipids, and electricity to name a few. The forerunner of Pitocin was Pitutrin, the postpituitary extract of cattle. Though Pituitrin was a more predictable means of inducing labor compared to previous methods, complications such as reactions to the animal proteins, uterine rupture due to over stimulated contractions, embolisms, and maternal and fetal deaths resulted from the drugs’ use (Block 18). By 1928, the substance was purified and sold by the pharmaceutical company Parke Davis under its current name.
Routine use of Pitocin was first introduced in a 25 year study of 200,000 first time mothers in Dublin, Ireland as a way to reduce “prolonged labor” and the cesarean rate (which was 4%, by the way) (Block 19). This protocol was dubbed “active management of labor”. Contrary to its intended purpose, this modus operandi actually increased the cesarean rate by 5% as well as amplified twelve times over the use of epidural anesthesia (Block 20). Neonatologist Marsden Wagner points out that the definition of the upper limit of normal labor went from 36 hours in the 1950’s to 24 hours in the 1960’s to twelve hours in 1972 when active management was introduced (Block 21). Obviously, a narrower range of “normal” would result in a greater number of births diagnosed as anomalous. Thus, the rate of “failure to progress” increased from 3.8% in 1970 to 11.6% in 1989 and continued to climb, now accounting for half of primary c-sections. Along with this the number of cesarean operations performed for “fetal distress” rose from 1.2% in 1980 to 6.3% in 1989 (Block 21).
Many doctors and nurses admit that pitocin is used more often for convenience and ease on the part of the doctor, rather than for the safety and health of mothers and babies. Marsden Wagner talks of “daylight obstetrics” citing birth to be the biggest problem on the already full plate of an American obstetrician. Nurse Kathleen Rice Simpson describes it this way:
Let’s say you have a very busy practice, and you’re trying to have a quality of life, maybe you’ve got a young family, you don’t want to be running out every night to deliver a baby…So what happens is you try to get all the births in between 9 and 5, and to do that, you have to make sure that nobody goes into spontaneous labor, and to make sure of that, you have to induce them all early.
Or let’s say this is the day you have to be on call, its best then for you to induce three or four people on that day…Those…people are not going to call you on the weekend, they’re not going to call you in the middle of the night, they’re not going to interrupt your office hours, they’re not going to give birth at any time that’s inconvenient. (Block 42)
People are often unaware that the mere passage of time in labor is not a risk factor. As long as mother and baby are well, labor can pretty much progress indefinitely on its own. In fact, even labors in which the waters break prior to labor, (PROM) one of the main reasons given for inductions usually end just fine allowed to start on their own, despite many provider and hospital policies requiring birth within 24 hours of rupture. In 1996, a study of 5000 women identified that there was no increase in neonatal infection in premature ruptures of membranes watched up to four days after rupture (Block 12). To make sure infection is not introduced; vaginal exams should be kept to a minimum. Sixty percent of women will go into labor within 24 hours of their water breaking, and 95% will within 3 days. Similarly, 96.5% of women will go into labor before 42 weeks (Block13). The “normal” duration of pregnancy is defined as ranging from 38 to 42 weeks in length. The “due date” is merely an estimate, a range of normal. However, hospitals often still feel the need to get things moving faster, sometimes imposing time limits of 12 hours or less after rupture, (Block 13) and the “due date” is becoming synonymous with a deadline.
Last but not least, synthetic oxytocin does not work the same as that which is
naturally produced by the brain. Oxytocin is secreted during orgasm, emotional connection, birth, and lactation. For this reason, it is referred to as the “love hormone”. Unfortunately, Pitocin produces vigorous contractions, but does not cross the blood-brain barrier (Block 135). This fact means it does not provide for the emotional connection that natural oxytocin does. In addition, it suppresses the body’s own oxytocin production. Thus the love is removed from the artificial “love hormone” (Block 135). Furthermore, the contractions derived from Pitocin do not possess the natural crescendo and decrescendo of the body’s own devices. The contractions are fast, strong, and irregular without rest in between. One randomized study of women who labored with or without synthetic oxytocin found that 80% of those who received it felt that it increased their pain (Block 135). Pitocin in a patient on epidural anesthesia poses another risk of hyper stimulation and twice the risk depravation of oxygen to the fetus because the dose can be increased without the natural pain threshold kicking in (Block 136). In the worst case scenario, such unnatural stimulation can lead to uterine rupture or placental abruption, and nearly half of umbilical cord prolapses are precipitated by the interventions the accompany induction, such as manual rupture of the amniotic sac (Block 137). The ACOG conducted a recent study revealing that Pitocin was to blame in 43% of malpractice suits associated with neurologically damaged infants (Block 137).
It was Queen Victoria who first popularized chemical means of pain relief during labor (Block 23). First it was chloroform, then ether, then the twilight sleep mentioned earlier. The total immobilization due to heavy narcotic anesthesia is what led to the use of interventions once only used in critical cases as a last ditch effort to save a baby when labor was abnormally hampered. For example, forceps were first invented by a barber surgeon in the seventeenth century as a means of freeing a stuck baby that did not necessitate crushing the term infant and extracting it in pieces (Block 24). But as birth moved toward all women being heavily drugged during childbirth, episiotomy and forceps became necessary to deliver a child whose mother could not push him out. The spinal was a single shot of anesthetic injected into the spinal fluid that became popular after twilight sleep ceased. This was often used in conjunction with IV pain medication such as Demerol. A physician recalled the spinal and forceps delivery common before today’s epidural to be something like this “You’d have an IV of Demerol or whatever, and the OB would give the spinal. You had a nurse on either arm, you’d put on the forceps, you pulled a lot, she screamed a lot, and then the baby was out…The patient was so out of it she didn’t know why she was screaming, and she couldn’t push anyway (Block 24).” In 1979 the FDA held a special to discuss a large national study that found lingering motor and behavior deficits in children whose mothers had been given large doses of analgesics such as Demerol (History 11).
After plastics became more commonly used epidural anesthesia became the most common anesthesia in childbirth going from 22% in 1981 to 66% in 1977, now reaching an estimate of 80% today (Block 170). An epidural is a signature concoction of anesthetic and narcotic (not two anesthesiologists use the same mixture) that continuously “bathes” the spinal nerves via a flexible nylon catheter inserted into the space between epidural space surrounding the spinal cord. Doses of medication required are much less than that of medication administered via IV, including a very low dose coined the “walking epidural”. Despite the name of this popular medication, three quarters of mothers according to the “Listening to Mother’s” survey either cannot or do not move around after being admitted to the hospital in labor, and more than half of the participants remained on their backs, pelvises tipped against gravity (Block 24). Also, similar to artificial oxytocin, artificial pain relief inhibits the body’s natural methods of pain relief including endorphins that in physiological birth induce an altered state of consciousness toward the end of labor. Then the endorphins are unable to trigger the release of adrenaline and nonadrenaline, which prime the baby’s lungs and protect its brain against the stress of being born (Block 172). Studies have also correlated epidural use with a drop in prostaglandin, which is another hormone crucial to the birth process. The diminishing of this particular hormone can result in a less productive, or “lazy” uterus, an unfavorably positioned baby, longer labor, and hemorrhage (Block 173). Additionally, the risks of fever and a rise in blood pressure are greater in women who receive epidural anesthesia (Block 172).The final energy release of physiological labor does not occur, thus there is no “fetal ejection reflex” present to help the mother expel her baby quickly and easily (Block 173).
Many people don’t realize that when one intervention is done, it greatly increases the risk of the need for other interventions, and the possibility of complications. When a woman “chooses” and epidural for labor pain relief, she is may not only be choosing the pain relief but every other intervention that comes along with being nearly paralyzed from the waist down. This is often referred to as “the slippery slope” or “the cascade of interventions”. An epidural almost always means a catheter because you can’t get up, restriction of movement, an IV, continuous monitoring because you cannot feel your own contractions, and no fetal ejection reflex, meaning an increased risk for tearing and potential induction or cesarean for “failure to progress”. In fact, the very first randomized controlled trial on the effects of epidural anesthesia resulted in cessation of the study after analysis of the first group after noting the high rate of cesarean section. The study was deemed unethical to continue after finding the cesarean evidence (History 12).
The biggest thing that people seem to be missing is that, in the words of French obstetrician Michel Odent, “The pain of labor is part o the physiological process”. He agues that without pain, endorphins are not released, and without endorphins, prolactin (the chief hormone involved in lactation) is not produced. Labor is a very complex biofeedback mechanism that scientists are barely beginning to understand (Block173). This does not mean, however, that women have no options for pain relief. Pain is a signal from the body that something is happening, and requires a response. The natural reaction to pain is to move to improve one’s comfort. To do something different, take a shower, get a massage, being upright, ever anticipating the emergence of the child and working with the body to accomplish that goal. In labor it is to move to help get the baby out easier, but when a woman is all but tied to a bed, narcotic pain relief is a kind of last ditch effort for the woman to feel relief from what her body is telling her to do. British midwife, Trisha Anderson elaborates on this point:
Let us bring them into harsh rooms with bright lights, let us make them lay on their backs on hard narrow beds. Lets us tether them to machines so they cannot move. Let us make them stay silent and make no noise with their pains. Let us expose their most private parts and threaten them with cold steel. Let us make them push their babies upward, against the pull of the earth…In these conditions, labour swiftly becomes unbearable and pain relief becomes a woman’s only hope…This is not the natural cry of a woman in labor bringing a child to birth, although if you have only ever witnessed childbirth in a medicalized setting you might be forgiven for thinking so. This is the screaming plea of a tethered animal in pain. (Block 174)
As anyone can plainly see, routine medicalized birth restricts women from being able to birth naturally at all. There is a dangerously unfair comparison of vaginal versus surgical birth. Women are often given only the option of highly interventive births in which everything is working against their bodies, or surgical birth. In a system such as this, more women are opting for cesarean sections with no medical indication perhaps as a means of being in control of their experience, and often out of fear induced by their healthcare providers (Block 50). This gradual infiltration of birth by numerous routine medical interventions has caused some women and healthcare practitioners alike, to believe that surgical birth is desirable over the body’s millennia-tested evolutionary mechanisms. Obstetrician Peter Bernstien of New York called the desire for a medically unnecessary cesarean “a failure of modern medicine and society at large”. The number of cesarean surgeries tripled between the years of 1968 and 1976, when it then made the list of top ten most frequently performed surgeries in the U.S., and has now reached number two on this list (Block 34).
Cesarean section in a pregnancy with no risk factors carries 4 times the risk of death to the mother as a vaginal birth, and nearly three times the risk of death within the first month of life to the infant (Block 49). Cesarean also increases the risks of adhesions, scar tissue, uterine rupture, placenta implantation problems, organ damage, infertility, and hysterectomy (Block 55). Still, many women are denied a chance at vaginal birth after cesarean (VBAC) due to the position of the American College of Obstetrics and Gynecology (ACOG) that VBACS should not occur unless a physician and operating staff were capable of performing a cesarean “immediately”, leading many hospitals to ban VBAC totally (Block 85-86). This position was introduced after a period of supporting VBAC when a study showed an increased risk of uterine rupture for VBACs in comparison with planned cesareans. What apparently happened in the study was what is called “distortion of risk”. In fact, the risk of uterine rupture is only 1 in 200, even in women with multiple cesarean scars, and the neonatal death rate is 1 in 2000, half the rate of death in “low risk” pregnancies. Also, the only complications that require immediate surgical attention, cord prolapse and placental abruption, are just as likely to happen in an unscarred Woman (Block 88). The true risk analysis comparing planned VBAC and planned repeat cesarean are as follows: If you plan a VBAC, there is about a 75% chance of a vaginal birth and a 99.5% chance of not having a uterine rupture. If you schedule a repeat cesarean, there is a 100% chance a major abdominal surgery, and all the risks that come along with it and a 99.8% chance of not having a uterine rupture.
The other area in which there are discrepancies regarding risk is that of breech birth. I have heard from the midwives here that there is not a single doctor in Washington State who will attend a vaginal breech birth. This is due mostly to the fact that practitioners are loosing skill in this area. There are no North American programs to teach the attendance of breech birth, so many doctors who wish to gain breech experience travel to Klinikum Nurnberg in Germany, where 62% of breech birth are vaginal (Block 76).There are many methods of trying to coax the fetus into a vertex presentation. These include external version, a chiropractic adjustment called the Webster technique, acupuncture, acupressure, and even the Chinese practice of moxibustion in which a roll of herbs is burned near the outer edge of the mother’s pinky toe. Believe it of not, moxibustion showed a 75% success rate in clinical trials (Block 75). Most of these methods are not used in the United States however, and about 3% of babies will still be in breech presentation at term.
Breech babies have always seemed to get hurt, stuck, and die more throughout history. About 1 in 20 American breech babies died in the 1940’s. However, we know now know that the high death rates recorded then were due to assisted breech delivery, which involved heavy anesthesia, manual pressure on the uterus, traction on the baby’s body, and controlled delivery of the head with forceps (Block 78). A 1953 review of the breech delivery techniques used at the time found that “the more manipulation is performed and the earlier this manipulation is instituted, the greater the fetal mortality and morbidity, to say nothing of maternal injuries” (Block 78). This conclusion led to the development of the Bracht technique by a German obstetrician. The Bracht technique involved waiting for spontaneous delivery with minimal manipulation and supporting the baby’s body with a force equal to that of gravity if the woman were upright. Bracht presented his technique, and an analysis of 206 successful breech births without one fetal injury or death, to a congregation of physicians in Amsterdam in 1938. Dramatic decreases in breech-related injury in studies all over the world resulted. Unfortunately, not one study was translated into English (Block78).
As time went on, the breech technique in Europe constantly improved, while vaginal breech delivery merely “fell out of fashion”, and between 1978- 1990 the number of breech cesareans increased form 60% to 85%. After a RCT study published in The Lancet stated that planned cesarean breech babies had only 1.6% “serious neonatal morbidity” compared to 5% of planned vaginal breech births it led to a huge decrease in vaginal breech births, even in Holland, where nearly half of breech births were vaginal. The inaccuracy of the study lies in that some countries with high overall neonatal deaths were involved as well as the fact that several of the most experienced centers offering breech birth were excluded. From this information, it can be concluded that the deaths were more a result of the care in particular countries and centers, rather than of breech birth itself. Countries with low neonatal death rates showed no significant difference in outcomes (Block 79-81).Also, two years following birth, there was no neurological difference between the vaginally and cesarean born children, indicating that the definition of “serious neonatal morbidity” did not predict damage. A woman at term has a 97% chance of having a healthy 2-year-old regardless of whether her baby is born vaginally of by cesarean (Block 82). The evidence notwithstanding, the majority of women with a fetus in breech presentation, or multiples, (due to the possibility of one or more being breech) are being told they cannot have a vaginal birth.
Much of the decisions made by doctors pertaining to cesarean section involve the fact that in the courtroom, a cesarean holds up as the doctor having “done all he could” to save the baby. Unfortunately, that is not always the case. A death due to a breech in labor is indefensible in court; so many doctors err on the side of caution in that regard. They cannot afford one bad outcome because society will not accept on bad outcome. But, we must remember that no matter how much technology or expertise is involved, there will still be a couple of births per thousand that no one can prevent a bad outcome in. Congenital anomalies sometimes exist that are untreatable and undetectable in infants, and sometimes a mother will have an embolism or other complication that cannot be prevented or treated at all. But when doctors need to get a certain number of births in to pay $90, 000 a year malpractice insurance rates (Block 60) as well as insure that not a single bed outcome can be attributed to something they had done for fear of loosing their right to practice, can we really blame them? Especially when it appears that more and more women are showing preference for surgical birth?
I believe the biggest thing doctors and the medical community at large is missing is that the high cesarean rates in the U.S. are not generally a result of mothers being “too posh to push”. Is there really such a thing as “maternal request” cesareans with no other factors? The Listening to Mothers Survey says no. out of 1500 women surveyed about their cesarean experiences, just one of them said she requested a primary elective cesarean (Block 56). It can often be assumed in medical reviews that this rate is much higher due to that fact that cesareans are only labeled as “elective” or “emergency”. This means that any plethora of situations that do not meet the criteria of being emergent are lumped into this category of so called “maternal request” (Block 59). A 2006 study resulted in the findings that “a geographic variation in the number of c-sections performed is driven mostly by nonmedical factors, such as provider density and local malpractice pressures, and is mostly unrelated to the mother’s medical condition” (Block 9).
It is getting more and more difficult for women to have a safe, physiological birth with a skilled care provider. Poor maternity care in this country has reached such epidemic proportions that women are resorting to such efforts as traveling hundreds of miles in labor to reach a competent care provider who will not give her unnecessary surgery, they are laboring parking lots of hospitals with no VBAC or no breech birth policies until crowning in an attempt to not have unnecessary surgery. Some are scouring the country to find illegal midwives to attend them in states with unfavorable midwifery laws. Even so, some women are strapped down and given a cesarean without their consent, sometimes under a court order even when there is no medical reason for the cesarean (Block 142-148). Women with the least options or the least resources usually make one of two choices; they go it alone without a care provider to avoid all of the harmful procedures they do not want, or they choose what appears to be the only thing they can do when they have no other options. They choose what appears far safer and easier than what is defined as “normal” birth in this country. “Just give me a cesarean”, these women are saying.
Complicated Questions with Simple Answers
Birth ties into the world as I know it in many ways. As I look around me I see evidence of our disconnected society. I’d venture to guess that half of Havermale students are “unaccompanied youths”. This term is defined as a high school student not residing with their parent or guardian. These students often fall through the cracks without anyone to tell them not to be afraid and not to give up. Teachers and other adults need to reach out to these adolescents and help them before it gets that bad. If I had not had several teachers and staff at Havermale to convince me to keep going when I felt like I simply couldn’t do it anymore I would not be standing here today. I would have been one of those lost teenagers everyone hates for being born into a society that intellectually, emotionally, creatively, and spiritually starves them until they can’t take it anymore. Influential psychiatrist Karl Menninger said that “What's done to children, they will do to society.”
I attended the Chase Youth Commission Dropout Prevention Summit as a youth panelist. During that meeting all of the businesspeople, government and school officials, students, parents and others present came to the conclusion that the failing education system was producing a 1/3 dropout rate because the societal structure lacked the systems and networks necessary to nurture children into thriving, compassionate adults. The problem was not the curriculum but the fact that so many students are assigned to so few teachers such that each student often becomes just another face of name with little other connection. In this same way our society is failing childbearing women. The doctors that care for healthy pregnant women often do not have the time to connect with each mother individually.
Thankfully I had no such experiences. Each of my teachers at Havermale, and many who never were my teachers, has gotten to know me on a personal level. They have interest in my well-being and call to check on me if I am not at school. They remind me constantly that I deserve all of the achievements I have made thus far in my life. They mean a lot to me. In the same way my midwives were there in all aspects of my pregnancies, births, and postpartum experiences. Even now they have been immensely helpful and giving of their time to aid me in the completion of this project as was their assistant. In the words of midwife Christine Harrington, interviewed for my production, “You are their go-to person”. Everybody needs at least one of those, especially during such vital periods as birth and high school. School shouldn’t be about grades or test scores or staying in line or having the same opinions as “everyone else”. It should be about the things you truly learn and gain from the experience.
Pregnancy and birth should not be about what is best for the care provider. Birth is not owned by doctors or midwives. It is owned by mothers; by families. It is the mother’s experience so she should have a say in the forming of that memory. It’s not really about whether a mother had interventions (even though midwifery-type care automatically lowers the use of interventions). It is about the fact that having at least one person who cares about you and your life looking after you in such a pivotal time in life makes a huge difference. Midwives support mothers, who support children, who are the future of our society.
Sometimes even I think that I am crazy for having spent so much time on this project. I often feel like I have spent the most time on any Senior Project in the entire history of the Senior Project, but I really enjoyed it. All but a couple people I talked to about their Senior Culminating Project responded as though it were either torture or, at very least, a huge task they did not look forward to or enjoy undertaking in the least. However, my work was truly a labor of love (pun absolutely intended). To my dismay, most of the birth stories I have heard in my life have a similar tone of aversion or dismissal. It nearly makes me weep every time. Education is about preparing for life as birth is about preparing for life and birth is about preparing for family. Both are of at least equal importance. Some people still won’t understand me but nonetheless, midwifery isn’t something I want to do; it is something I need to do. At times I wonder why I put so much effort into a good many things that I do, but every time I see one of my children smile I am hit with an overwhelming sense of personal understanding.
Contrary to popular belief, I am not some obscure superhero, nor am I brave, radical, dense, unscrupulous, or a raving lunatic. I merely stand up for what I believe in. Even so, I wouldn’t have gotten this far without all my teachers and friends who have been here for me through the most treacherous of life circumstances. It has been my experiences chiefly with midwifery and Havermale High School that have led to all of the other things I love and respect so deeply now. Those intertwined experiences remind me that there are still people out there who really care about other people. They have made me who I am. Now and again I think that people just need to slow down and realize we are not machines. We are not all going to fit in the same little box no matter how carefully constructed. Our bodily functions do not occur on a schedule that is identical to everyone else’s. Each of us interprets our surroundings in a different manner. We are human! We are alive. We thrive on emotional, intellectual, and spiritual connection. Love is the most powerful thing in the world, perhaps in all existence. Use it, embrace it. The key to peace is just caring about one another. I want to effect change. A society where the people hold each other up during hard times is what we need again. I figure, why not start at the beginning?
It takes a village to raise a child, right? Well if the village wants the children to grow into compassionate, intelligent adults, they need to show the children from birth that the world can be a safe, happy, gentle, loving, beautiful place. I may not be able to change the world, but I can change my community. I can at least make such a precious life experience better for a few people. Every person, every family, is worth it. I won’t ever stop. Outside of my own aspirations I can only hope that people will start taking it upon themselves to make the world a better place, instead of waiting for some arbitrary authority figure to do it for them. I can also be optimistic that more students will linger on the Senior Project’s potential to open a doorway into what they want to devote their lives to. One can fight for what they feel is right in many ways, and this is how I’m doing it. It just feels right to me. No matter how much opposition I face, I truly believe that peace on Earth begins with peaceful birth.
Works Cited
1. “About NARM CPM Certification.” The North American Registry of Midwives 2009. NARM 2000-2009 <http://www.narm.org/edcategories.htm>.
2. Block, Jennifer. Pushed: The Painful Truth About Childbirth and Modern Maternity Care. Cambridge, MA: Da Capo Press, 2007.
3. Brucker, M. “History of Midwifery.” 19 June.2000. Parkland Health & Hospital System. 2000 <http://www3.utsouthwestern.edu/midwifery/mdwfhistory.html>.
4. Curriculum Overview.” Seattle Midwifery School. 2009 <http://www.seattlemidwifery.org/midwifery-education/curriculum-overview.html>.
5. “ FAQ for Students.” .Midwifery Education Accreditation Council. 2009 <http://www.meacschools.org/prospective_students.php>.
6. Feldhusen, Adrian E. “The History of Midwifery and Childbirth In America: A Time Line.” 2000. Midwifery Today, Inc. 1987-2009 <http://www.midwiferytoday.com/articles/timeline.asp>.
7. Gordon, Wendy. ”The Netherlands Home Birth Study.” Apr 2009. Midwives’ Association of Washington State. 1998-2009 <http://washingtonmidwives.org/netherlands-study.shtml>.
8. “Midwifery Education Program Courses.” Seattle Midwifery School. 2009 <http://www.seattlemidwifery.org/midwifery-education/course-descrip.html>.
9. Rooks, Judith. “The Midwifery Model of Care.” Journal of Nurse-Midwifery. July/Aug 1999. <http://www.ourbodiesourselves.org/book/companion.asp?id=21&compID=121&page=2>.
10. “Types of North American Midwives.” Seattle Midwifery School. 2009 <http://www.seattlemidwifery.org/midwifery-education/north-amer-mws.html>.
