A Quiet Place by Peggy O'Mara

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	a quiet place by peggy o'mara

Peggy O’Mara is the mother of four grown children. She has gained international celebrity as publisher, editor and owner of Mothering Magazine. She is also the author of four books: Having a Baby Naturally: The Mothering Magazine Guide to Pregnancy and Childbirth, Natural Family Living: The Mothering Magazine Guide to Parenting, The Way Back Home: Essays on Life and Family, and A Quiet Place: Essays on Life and Family. A dynamic speaker, she has lectured and conducted workshops in conjunction with organizations such as the Omega Institute, Esalen, La Leche International, and Bioneers. She has appeared on numerous television and radio programs and has been featured in national publications including The Wall Street Journal, USA Today, The Washington Post, Chicago Tribune, Mother Earth News, and Utne Reader

A Birth Renaissance
Issue 147 - March/April 2008
by Peggy O'Mara, Editor and Publisher

In the fall 1980 issue of Mothering, we reprinted "The Cesarean Epidemic," by Gena Corea, originally published in the July 1980 edition of Mother Jones. In her article, Corea bemoaned the rising rate of cesarean sections in the US, which in the previous ten years had tripled, to the 1980 high of 16.5 percent: "As recently as 1965, doctors who exceeded a five percent C-section rate were generally suspected of gross incompetence."

The cesarean rate was rising largely because of the increase in medically unnecessary, repeat C-sections. In 1983, the landmark book Silent Knife, by Nancy Wainer Cohen and Lois Estner, encouraged women to have "vaginal births after cesareans," coined and popularized that term and its initialism (VBAC), and provided research to support the safety of VBACs. By 1988, cesarean birth rates had begun to fall, in concert with a fourfold increase in VBACs.

This trend continued until the late 1990s—and then was reversed, largely because of stricter VBAC guidelines issued in 1999 by the American Academy of Obstetricians and Gynecologists (ACOG), guidelines that still stand today: the hospital must have anesthesia available 24/7, a dedicated operating room and crew, and, ideally, an in-house blood bank. These stricter guidelines have caused greater restrictions on VBACs because only the largest hospitals can meet them. Since they were issued, more than 300 hospitals have stopped "offering" VBACs, which have decreased from nearly 25 percent of births in 1999 to less than 10 percent today. This has led, in turn, to a 49 percent increase in cesareans in the last nine years: In the US today, one in three women gives birth by cesarean. Tragically, 25 percent of these women felt pressured by a health-care practitioner to have the procedure (Listening to Mothers II national survey).

Here are some questions you can ask your prospective birth practitioner to decrease your chances of birth interventions:

What percentage of the births you attend are cesarean births? Vacuum extractions? Forceps deliveries?

How often do you attend vaginal births after cesareans?

What do you consider legitimate reasons for a cesarean?

What is your hospital's rate of cesareans? VBACs?

What percentage of the births you attend are induced? What percentage of women receive episiotomies?

Some practitioners will resent your asking these questions, but you shouldn't have to ask them at all. Practitioners and hospitals should be legally required to disclose their rates of birth intervention and C-section, and in the state of New York, they are.

Revered birth activist and author Doris Haire faced tough opposition when, in 1989, she fought for passage of New York's Maternity Information Act. This act directs all hospitals that offer maternity services in the state of New York to provide prospective parents with a brochure clearly disclosing precise information about the hospital's current rates of cesarean, induction, and episiotomies, so that women can make more informed choices. Even so, only one hospital in New York City was complying with the law until the city's Public Advocate, Betsy Gotbaum, and the organization Choices in Childbirth brought the issue to public attention, which in turn resulted in compliance. Because of this, Choices in Childbirth has been able to compile labor statistics and rates of C-section from New York City hospitals for the years 2000 through 2005. They also publish the downloadable pamphlets The New York Guide to a Healthy Birth and The Philadelphia Guide to a Healthy Birth.

These efforts to compile birth statistics build on the work of my generation, which has been warning of the dangers of unnecessary medical interventions in childbirth since the 1970s. And yet the C-section rate just keeps climbing. It's been hard to stay hopeful—until now. Something is different. A new generation has shown up, with new tools ?of persuasion: art, music, drama, and film.

Karen Brody's Birth: The Play, first staged in 2006, was performed 75 times in 2007, in 35 different locations. At 36 of those performances, Birth on Labor Day (BOLD) Red Tent events were also held. In a Red Tent event, women gather to tell their birth stories, and then write about them, or draw or film them. The events are also opportunities to showcase local birth resources (www.birthonlaborday.com/home.html).

Film has long been an important component of birth education, but recently it has morphed into something new. At the same time that Lamaze International reports that only 11 percent of women consider childbirth education a routine part of pregnancy, documentary films in general are up 90 percent since 2002. Is it any wonder that the birth documentary has become our most important new teaching tool?

Probably no birth film has proved more effective for this purpose than The Business of Being Born (BOBB), directed by Abby Epstein and produced by Ricki Lake. No other birth film has been so blessed with publicity—and publicity about the state of maternity care in the US is exactly what we need. This publicity was no accident. Lake explained, on Larry King Live, how she undertook a weight-loss campaign in order to get the publicity she needed for the film. She and Epstein have a contract to write a book about birth, and want to take the issue of maternity care to Washington—which begs the question of what, exactly, the most effective legislation or congressional action might be. As of this writing, BOBB has been released in theaters in New York City, San Francisco, Santa Monica, Chicago, Palm Springs, Tulsa, and Seattle. The DVD can be rented from Netflix or purchased online.

Fortunately, national efforts are already underway to address the questions of quality maternity care raised by The Business of Being Born. In 1996, the Institute of Medicine (IOM) launched an ongoing effort to assess and improve the nation's quality of health care. Their report, Crossing the Quality Chasm: The IOM Health Care Quality Initiative, documents the wide gulf that separates ideal health care from the care actually experienced by many Americans. Pregnancy- and childbirth-related procedures are among the most common for infants, and for adults aged 18 to 44. The National Voluntary Consensus Standards for Perinatal Care, a project of the National Quality Forum, is expected to endorse final perinatal performance measures in June 2008. The National Quality Forum is a not-for-profit membership organization created to develop and implement a national strategy for measuring and reporting the quality of health care. Funded by the Hospital Corporation of America, the largest private operator of health-care facilities in the world, this project seeks to achieve national voluntary consensus on a set of effective, detailed performance measures to assess the quality of perinatal care services. The measures considered include care provided by physicians, midwives, hospitals, and freestanding birth centers.

In 2007, the nearly 90-year-old advocacy organization Childbirth Connection, formerly the Maternity Center, held a briefing on Capitol Hill, "Health Care for Pregnancy and Childbirth: Closing Gaps Between Best Evidence and Common Practice." Sponsored by the Congressional Women's Caucus, the briefing was intended to raise legislators' awareness of the need to improve the quality of and access to maternity care, and patient satisfaction. Childbirth Connection (CC) wants maternity care to be a priority on the national agenda. To this end, the organization is preparing a collaborative report on evidence-based maternity care and ways to achieve it, to be issued in 2008 by the Milbank Memorial Fund and the Reforming States Group. (The Milbank Memorial Fund, an endowed operating foundation, has engaged in nonpartisan analysis, study, research, and communication on significant issues of health policy since 1905. The Reforming States Group is a voluntary, bipartisan association of state leaders in health reform who work on practical solutions to pressing health-care problems.)

To promote quality maternity care at many levels, CC plans to establish a new Institute for Maternity Care Quality comprising national leaders in research, education, policy, and practice. In November 2008, CC will host "Maternity Care within a High Performance Health Care System," a national symposium of interdisciplinary experts, to create a blueprint for action to improve maternity-care quality, access, and cost-effectiveness.

The goal of these efforts is to identify a robust set of measures to evaluate the process and outcomes of maternity care, as well as mothers' experience of that care. This has never been done before in the US.

In addition to these new efforts to define high-quality maternity care are those that call for the national regulation and licensure of midwives. In January, the Big Push for Midwives campaign was launched in more than 20 states, with the ultimate goal of regulating and licensing Certified Professional Midwives (CPMs) in all 50 states. Currently, about 18 states recognize the CPM credential.

CPMs practice primarily in homes and birth centers. Since 1994, the North American Registry of Midwives (NARM) has certified 1,300 CPMs. Certified Nurse Midwives (CNMs) practice primarily in hospitals and are licensed in all 50 states; since 1971, the American College of Nurse Midwives (ACNM) has certified nearly 11,000 CNMs. In addition, the ACNM has certified 57 Certified Midwives (CMs), though not all states as yet recognize this certification.

We don't have enough midwives to meet the demand. As NARM says, "skilled and responsible midwives should be readily available to all families in North America." Efforts to extend midwifery licensure to include midwives who have learned their craft in different ways are important on both the state and national levels. Insurance companies and Medicare should be required to reimburse midwife-attended births in all settings, and reimbursement for all birth practitioners should be linked to how closely their performance conforms to evidence-based standards. We must also work to pass legislation in all states modeled on New York's Maternity Information Act.

When a birth doesn't turn out as we hoped it would, we often look for someone to blame. Sometimes we blame our practitioner, sometimes we blame others present at the birth, and often we blame ourselves. Someone recently asked me if I thought that homebirth was the only normal type of birth. I said, "No, of course not." Mothering publishes articles about homebirth to give people one image of normal birth. If we believe that homebirth is safe, then we will believe that birth itself is safe. And because birth in any setting can be safe, its integrity is based not on where it takes place, but on the quality of the experience. With this in mind, let us work together as parents and professionals to imagine and implement a high quality of maternity care in the US. The time is right.

Love,