Maternity Care in the United States: A look at the
Differences between the Natural and Pathological Models
By Jennifer
Maesner
A woman we will call Maria is waiting for her baby to be
born. She is 40 weeks tomorrow, and she
is at her Obstetricians office, where she will be checked for cervical dilation
and effacing. Her doctor comes in to the
exam room, where she is sitting with a blanket over her lap, her pants and
underwear having been removed. The
doctor helps Maria lay back, and also to get her feet into the stirrups. He sits at the bottom of the bed where he can
see her exposed vagina, and, donning gloves, proceeds to check her cervix. He pronounces that she is dilated to 2
centimeters, and 50% effaced. He tells
her that since she is due tomorrow, and already beginning to dilate and efface,
he’s going to go ahead and sweep her membranes, a term that indicates that he
will push the membranes of the sac the baby is in away from her cervix, a
procedure that can often bring on labor if the body is ready. Later that night, Maria starts having pains
in her lower back that make her wince, but nothing too severe. In the middle of the night she wakes up with
severe menstrual-like cramping, and she gets up to go get water. She is unable to go back to sleep because of
the periodic cramping, and so she begins to time them. After 2 hours of this, she is having
contractions every 10 minutes like clockwork, and each one is lasting around a
minute. She wakes her husband, and lets
him know that she is ready to be taken to the hospital.
Upon arriving at the hospital, Maria is checked in, takes off
all of her clothing, gets into a gown, and then into the bed, while a nurse
comes in and checks her cervix for dilation.
She is pronounced a 3, and therefore, combined with the timing of her
contractions, she is in labor. An IV is
inserted in her arm, and bands strapped around her belly; one measures
contractions, and the other monitors the baby.
She labors well into the next day, cervical checks every few hours. When it has been deemed that she is dilated
enough, she is asked if she wants an epidural.
Exhausted from sleep and food/liquid depravation, and worn out from the
pain, she agrees to the epidural. An
anesthesiologist is called, and he comes in and administers the epidural. In the absence of pain, she finally falls
into a restless sleep, interrupted by the nurses coming into take her vitals
every hour and then again when the doctor checks her cervix, also every few
hours. The epidural has slowed her
contractions, and so the nurses begin a Pitocin drip. The Pitocin gets the contractions back on
track, and she continues to labor. After
a few more hours, it is realized that she has not dilated, and the nurse
informs the doctor. The doctor tells
Maria that she has failed to progress, and that they are concerned about her
laboring for too long. He wants to
rupture her waters, and Maria agrees. So
a hook is inserted through Maria’s cervix, alongside the doctor’s finger, and
he breaks the bag of waters surrounding the baby with a big gush. Cervical checks show that Maria has continued
to progress over the next few hours, and so all is well again.
After a total 24 hours after being admitted to the hospital,
Maria is finally at 6 cm. But something
has happened. Maria has started to
complain of being cold, despite the heater being on, and she is shivering. Her vitals are taken early, and she is
starting to get a fever. The baby, who
has been monitored continuously, is starting to show signs of distress. His heart rate has been dipping during
contractions, and has been slow to recover when the contractions are over. The doctor is summoned, who determines that Maria
quite possibly has contracted a uterine infection, and that it is necessary
that the baby come out now. The surgical
team is assembled, the anesthesiologist has returned to explain his part in the
procedure, and then Maria is wheeled off into the OR for an emergency cesarean
section[1],
husband following behind her, nervous about the impending surgery. 2 hours later, Maria is in the recovery room
without her baby, who was taken to the ICU due to possible infection. He is returned within the hour, after having
received a round of antibiotics, and having had blood taken from his heel to
check for other infections. He lies in
the bassinet next to the bed. Maria, who
is extremely groggy from the surgery, looks over at her newborn son, and
smiles, drifting off to sleep.
This is an all too common situation here in the United
States. Every year in recent history
more than 1 in 3 women delivered their babies via cesarean section. In fact, last year alone, 32.8% of all women
had cesareans (Childbirth Connection, 2012) . This number is due to many factors. Some women have had previous cesareans, and
all too many doctors subscribe to the idea that “once a cesarean, always a
cesarean.[2]” Some will have medically indicated cesareans,
because their babies are sideways, or because their own pelvises have
abnormalities that prevent vaginal births, some have medical conditions that
would put them in danger if they went through the trial of labor. Some women
have emergency cesareans, because they or their babies are in distress. However, it can be disputed that many doctors
actually caused the situations that put the mother or baby in distress. Some women have elective cesareans that were
recommended by their doctors, but are not medically indicated[3]
(Boyles, 2012) or told that they have an “emergency
situation” that doesn’t really exist (Weinstein, 2012) , adding to an
unnecessarily high rate. One of the
major reasons cesarean rates are so high is that our country takes a
pathological approach to childbirth.
This means that we view pregnancy and birth as a medical event, in need
of managing, but this often leads to unnecessary complication. The opposite of a pathological approach is
one that is natural in nature. That is,
when labor and birth is viewed as a natural process that all women go through,
and the vast majority will go through with no problems whatsoever, as long as
the process is allowed to flow, unhindered by interfering hands. So what does natural birth look like? Let’s take a look.
In a condo in Seattle,
a woman we will call Amy, who is 40 weeks and 3 days is in labor. She lies on her side in her bed, with her
friends surrounding her. She has been in
labor for only 2 hours now, but the contractions are beginning to get stronger. As a powerful contraction begins low in her
belly, she grips a friend’s hand and rides out the wave, panting with the
exertion. As time goes on, she moves from
her bed to a kiddie pool in the living room, mostly filled with water that is
around 100 degrees. The lighting is
dimmed as she steps into the pool. She
labors for a few more hours, leaning her head back and panting through each
contraction. Finally, she announces that
it is almost time to push. The midwives
are there to offer support, the father is in the tub, ready to catch, and her
friends and other children wait around her with bated breath, cameras at the
ready, all waiting for the moment when the baby first appears. She pushes.
Nothing yet. She pushes
again. Still nothing. With a third push, the baby comes flying out,
shooting to the surface of the water, and the father’s hands are there to
catch. He brings the baby girl up onto
Amy’s chest.
The baby squeaks, and then lets out a loud cry. After a moment, she quiets down, and then
peeks open her left eye to look up at her mother. She then snuggles into the warm chest she is
on, and rests. The umbilical cord has
gone slack, indicating no more blood flow through it, and that the placenta
will be on its way shortly. Amy offers
to nurse the newborn; the baby girl quickly gets the hang of it, and begins
nursing vigorously. This helps the
placenta to detach, and with a cough, Amy expels the placenta, which the
midwife’s assistant will take away to examine, to be sure none was left in
Amy’s uterus. First though, the cord needs
to be clamped in two different spots, and then needs to be cut in between the
clamps. The father is shown how to clamp
the cord, and then he cuts it with precision.
This is obviously not his first cord.
After a while, Amy is ready to get out of the tub, and is
helped by the many hands around her to get out of the tub and into her bed down
the hall. There have been quiet
exclamations about the quickness of the birth, and the wonder of this new being
that has been shot, quite literally, out into the new world. While she is helped into bed, the friends
take their turns absorbing the baby’s new baby smell, and then hand her back to
Amy to be nursed some more before both fall into a quiet and peaceful sleep.
This is “New Age” childbirth, one that is completely natural
with no intervention whatsoever, and only 2 cervical exams. It is considered “radical” and “fringe” here
in the US, but in other countries, it is very much the norm. A very large portion of births in these
countries take place in the woman’s home or in a birth center run by midwives,
and even in the hospitals, midwives are the principle providers, with doctors
on standby strictly for high risk women.
These countries have very good outcomes, while ours does not, by
comparison. Why is there such a
difference? Why is it that what is
considered the norm in maternity care in most other industrialized countries is
considered weird, radical, unsafe, etc., here in the US? Let’s take a look at some facts.
Out of the safest countries to give birth in, the US doesn’t
even make the top 10, 20, 30, or even 40.
In fact, as of 2010, out of over 180 countries, we were ranked 47 in
maternal death rates, at a rate of 21 per 100,000[4] (Central
Intelligence Agency, 2010) , and 31st
in a ranking list of only industrialized countries (Duell, 2011) (which
indicates that a few still-developing countries rank higher than us in maternal
fatalities). If you look at some simple
facts, it is easy to see that countries that view pregnancy and birth as a
natural part of life, only needing managing in rare instances, outcomes are
much better.
Comparison of countries rated both high and low for number of midwives, in
correlation with maternal mortality rates.[5] Rates are expressed in terms of per 100,000.
Country
|
Rate
of Midwives
|
Rate
of Maternal Mortality
|
%
Deliveries attended by Midwives
|
|
|
Norway
|
31.9
|
7.0
|
96
|
N
|
|
Finland
|
24.0
|
5.0
|
70-75
|
N
|
|
Switzerland
|
16.5
|
8.0
|
Majority*
|
N
|
|
Denmark
|
16.1
|
12.0
|
Majority
|
N
|
|
Ireland
|
15.7
|
6.0
|
Majority
|
N
|
|
Sweden
|
11.9
|
4.0
|
75
|
N
|
|
Germany
|
11.1
|
7.0
|
50
|
N
|
|
New Zealand
|
10.9
|
15.0
|
54
|
N/P
|
|
UK
|
10.1
|
12.0
|
Majority
|
N/P
|
|
US
|
9.8
|
21.0
|
8-9
|
P
|
|
Australia
|
9.6
|
7.0
|
Majority
|
N
|
|
Austria
|
7.9
|
4.0
|
98
|
N
|
|
The scatter chart above was made from the data on the
left. The plot suggests that there
may be a correlation between higher rates of midwives and lower rates of
maternal deaths.
*
Majority is indicated when exact number is not recorded, but midwives are
the chief attendant for most every case except high risk women/pregnancies
|
As we can see from the table, there is a correlation between
a more natural approach to childbirth and lower mortality rates. Those 2 countries with a fairly even
natural/pathological approach have higher maternal death rates than the
countries with a very clear natural approach to childbirth, with the exception
of Denmark, which is on par with the UK in terms of maternal deaths. The one country on this list with a very
clear pathological approach to childbirth is also the country with the highest
rate of maternal death, with an average 3-5 times the maternal death rate of
countries with a clear natural view of childbirth, and almost doubled the rate
of the countries with a fairly balanced approach. And keep in mind that not all maternal deaths
are reported here in the US. The CDC has
estimated that as many as 2/3 of all maternal deaths go unreported, or
misreported (CDC, 2007) . This would indicate that the more natural the
approach, the better the outcome. And
this is JUST maternal death rate. We’ll
take a look at neonatal death rate a little later.
Something that makes this even more obvious is looking at the
individual states. For states that have
the highest out of hospital births, the cesarean rates are the lowest[6]. The WHO recommends that cesarean rates should
be kept to below 15%, with a more optimal level being around 10% (Gaskin,
2011, p. 3) . Our national cesarean rates are twice that,
with some states being much higher. It
is currently impossible to correctly identify which states have the highest or
lowest rates of maternal fatalities, since only 6 states even require mandatory
reporting of maternal deaths (Gaskin, 2011, p. 129) . Even in those states, there may be error,
since many maternal deaths get mislabeled on the death certificates. It is well known that for a healthy woman, a
cesarean puts her at greater risk of fatality than a vaginal birth[7],
so we can keep that in mind when looking at the different states.
A look at the top and bottom 5 states for cesarean rate in comparison to
rate of out-of-hospital births.*
|
Rating
|
State
|
Cesarean %
|
|
|
|
1
|
Alaska
|
22.4
|
Highest
|
|
|
2
|
Utah
|
22.7
|
Highest
|
|
|
3
|
New
Mexico
|
23.0
|
Higher
|
|
|
4
|
Idaho
|
24.5
|
Highest
|
|
|
5
|
South
Dakota
|
25.3
|
Lower
|
|
|
46
|
West Virginia
|
36.8
|
Lower
|
|
|
47
|
Mississippi
|
38.0
|
Lower
|
|
|
48
|
Florida
|
38.1
|
|
|
|
49
|
New
Jersey
|
39.1
|
Lower
|
|
|
50
|
Louisiana
|
39.9
|
Lower
|
* Data (except individual state laws) from CDC (CDC, 2011) (CDC, 2010)
** This refers to rank. Highest refers to those states that are in
the top 10 for high rates of out of hospital births. Higher and Lower refers to those states whose
out of hospital births are higher or lower than the national average. Likewise, lowest refers to those states that
are in the bottom 10 for low rates of out of hospital births.
So we can see here a clear correlation between lower cesarean
rates (and therefore lower risk of maternal deaths) with higher rates of
out-of-hospital birth, which furthers the hypothesis that a natural approach to
childbirth, as opposed to pathological, is accompanied by better outcomes. Now let’s take a look at neonatal mortality,
for the same countries we looked at earlier.
A comparison of neonatal and maternal mortality verses rate of cesarean
delivery. Neonatal mortality rates are expressed
in terms of per 1,000; maternal mortality rates are expressed in terms of per
100,000.
Country
|
Percent
Cesarean Births**
|
Neonatal
Mortality Rate*
|
|
|
|
Norway
|
17.2
|
3.5
|
7.0
|
|
|
Finland
|
16.3
|
3.4
|
5.0
|
|
|
Switzerland
|
30.0
|
4.0
|
8.0
|
|
|
Denmark
|
21.4
|
4.1
|
12.0
|
|
|
Ireland
|
25.4
|
3.8
|
6.0
|
|
|
Sweden
|
17.3
|
2.7
|
4.0
|
|
|
Germany
|
28.5
|
3.5
|
|
|
|
New
Zealand
|
22.8
|
4.7
|
15.0
|
|
|
UK
|
23.6
|
4.6
|
12.0
|
|
|
US
|
31.8
|
6
|
21.0
|
|
|
Australia
|
30.6
|
4.6
|
7.0
|
|
|
Austria
|
26.9
|
4.3
|
4.0
|
|
* (US Global Health Policy, 2012)
** (Arnold, 2010)
When plotting the data into a
scatter charts, it is easy to see a pretty clear correlation between higher
neonatal and maternal fatalities in places that have higher cesarean
rates. As stated earlier, countries that
view birth as a natural process have lower maternal death rates, and countries
that view birth as a pathological process have higher maternal death
rates. This data shows the same to be
true of neonatal deaths as well.
So, after looking at all the data
supporting birth being viewed as a natural process, the question can be asked:
“Why does our country go so far in the opposite direction?” In comparison to other industrialized
countries, we have the highest rate of maternal death, the highest rate of
neonatal deaths, and the highest rate of cesareans. The answer is very convoluted.
First of all, the US has the best
technology surrounding maternity care.
This is both a blessing and a curse.
Used judiciously, medical technology saves lives. That is without a doubt, and not up for
debate. What is up for debate, however,
is that medical technology is not used judiciously. Statistics show that 90% of all women will
have low risk pregnancies, labors and births.
This means that 10% of all women will have high risk pregnancies, labors
and births. So why do we have a 1 in 3
cesarean rate? Why is it not closer to
10%? Part of the answer to this can be
found in every labor and delivery room.
Electronic fetal monitoring (EFM)
is a tool that doctors find to be invaluable, but actually tend to do more harm
than good. It has been estimated that
EFM is inaccurate a great deal of the time, and has an extremely high
false-positive rate of detecting fetal distress. In fact, it has been proven to have a
false-positive rate of 99% (Sartwelle, 2012) .
That means out of 100 babies that were shown to be in fetal distress by
the EFM, only 1 was truly in distress.
That’s 99 babies that were delivered by cesarean that did not need to
be. And of course, increased cesareans
are accompanied by higher maternal and neonatal deaths. This means that EFM is directly responsible
for an increase in maternal and neonatal deaths.
The second reason is more complex,
and stems from having an extreme patriarchal history. When the view of birth began to change from a
natural viewpoint to a pathological one, women were already well trained to
kowtow to men. Women were ruled by their
fathers, sometimes their brothers or other family members, and then by their
husbands. When doctors began taking over
the child birthing practice, doctors were also men, and so women were naturally
subservient to them as well.
Unfortunately, this was to their immediate detriment. When women began delivering in birth centers,
or “lying-ins” as the term was, they began dying by the droves, of an illness
never before seen in women. It was
called Childbed Fever, and it was contracted in up to 1 in 5 women who
delivered at a Lying-In (Epstein, 2010, p. 69) [8]. With these numbers it is utterly surprising
that women continued to follow their doctors’ advice, but at that point,
doctors had successfully managed to shove midwives aside as someone only the
poor went to. Because women were
preprogrammed to follow the orders of the men, they didn’t question when they
should have.
As time went on, and women became
unhappy with their lot in life, and revolted, bringing about the feminist
movement, women mistakenly thought that now they were free of their shackles
that men had placed around them, including when it came to childbirth. By demanding that the doctors give them Twilight
Sleep[9],
for example, they felt they were taking control of their birthing process, when
in reality, the absolute reverse was true.
They were still believing that birth should be managed, not allowed to
proceed unhindered. They had bought into
the idea that it was better to have a pain free birth, and that the doctors
were being malicious by withholding it; therefore, by demanding that they get
it, feminists felt they were being more in charge.
In reality, by getting Twilight
Sleep, they were giving up complete control over their bodies. Today, the majority of women in this country
still are happy to give up control over their bodies, because they have been
trained that this is the way it is done.
They have been trained to believe that their bodies will not work
right. Trust in one’s body has been
completely taken out of the equation for most women, under the guise of “taking
control of the process.” The only women
who truly have control over their bodies are those who refuse to accept that
their bodies are somehow inadequate, and choose to have a birth that is devoid of medical
management. Sadly, most women who are
truly in control over the process don’t live in this country; they live in
Europe, and Australia, and have better outcomes than here in the US.
This all ties into the third reason
for why our country is different than Europe and Australia in terms of
maternity care. We are a relatively new
country, and we are made up of a multitude of countrymen, all carrying
different traditions and cultures. We
have no singular culture or tradition that ties us all together. So it is very easy to introduce change,
whether it is cultural or traditional, because when you have no thousand year
tradition to cling to, you are willing to take a look at the next thing that
comes around. In contrast, European
countries are thousands of years old, with very singular traditions and
cultures that tie the entire country together.
It is very difficult to introduce change. When a people have been practicing a certain
tradition or practice for thousands of years, they will be very resistant to
change. So while women in the US were
very willing to give up their practice of home birthing with midwives in favor
of the much riskier hospital birth with doctors, women in Europe would have
been much more resistant to giving up their thousand year tradition of birthing
at home with a trusted midwife.
The fourth reason for the state of
our maternity care has to do with the sue-happy culture we live in. As a people, we are extremely entitled. We lack personal responsibility in droves. We are not willing to take responsibility for
the choices we make. When something
happens in childbirth, we automatically look for someone to blame, rather than
accepting that sometimes things happen that are out of our control. Whether a woman chooses to deliver her baby
in a hospital, at home, or in a birth center, there are risks that are
associated with that place. In a
hospital, she is at a much higher risk for cesarean due to unnecessary
interventions, which is accompanied by a somewhat higher risk of her death, or
the death of her baby. At home, she is
at a slightly higher risk for a complication that her midwife might not be able
to handle, and the EMT’s may not be able to respond in time, or get the
mother/baby to the hospital in time. The
same is true of a birth center. So
regardless of where she chooses to give birth, there are risks, and sometimes
things happen that were not foreseen.
Instead of accepting this, many parents would rather sue. So they turn to the midwife, or the doctor,
who did everything right, and sue anyway, and because our court systems are
willing to hear even frivolous lawsuits, and force doctors and midwives to pay
out exorbitant amount of money to try and help grieving parents feel
better. That is not to say that there is
not true malpractice with both doctors and midwives, but the actual number is
much smaller than the number that have to pay out.
So how do we fix the problem that
is our maternity care? We live in a
society in which woman no longer trust their bodies to do what comes naturally
over 90% of the time. So even if we educate
doctors better in regards to the best way to provide maternity care, that is,
with a naturalistic approach, there will still be many women demanding that
they be provided with a cesarean section because they don’t want to go through
the pain of childbirth, or demanding an induction because they’re “just done”
with being pregnant.
The answer to fixing this mess is
just as convoluted as the reasons for why we’re in it in the first place, but
the simplest answer is education. If we
can retrain our collective way of thinking about pregnancy and birth at an
early age, then when it comes time to give birth, we will be less fearful of
the process. If we can retrain our
doctors’ collective thinking about pregnancy and birth, they will be more
reassuring to their patients about the process, which will put their patients
more at ease. With patients who were
raised to view birth as a natural process who are then reassured by their
doctors that birth is a perfectly natural and normal event, we will have more
and more women saying no to unnecessary intervention, and yes to taking control
over their bodies back.
Further, we need to retrain doctors
in how they view midwives. Currently,
most doctors view midwives in a very negative light. Many feel that they are second rate. In countries were midwives are the normal
attendants, they are not second rate to doctors, they are specialists in their
own right, and ones that doctors consult with.
They are colleagues, not subordinates.
Here in the US, we need to get doctors to understand that midwives are
not subordinates, they are specialists.
Much in the way that an oncologist is not a subordinate of a Heart
surgeon, a midwife should never be viewed as a subordinate to an obstetrician. Both are specialists, and there should be
mutual respect between the two. Until
that is achieved, the battle for women’s rights to have doctors keep their
hands off their laboring bodies will be an uphill battle.
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[1] A
cesarean is an operation in which the walls of the abdomen and uterus are cut
through and the baby is pulled through the opening.
[2]
Cesarean rates can be separated into two categories… those getting their first
ever cesarean, and those having repeat cesareans. As of 2010, only 23.6% of cesareans were
primary cesareans, leaving total percent of repeat cesareans at 9.2% (Childbirth Connection, 2012) .
[3]
Many doctors use reasons to push cesareans that are not true medical reasons
for cesareans. Reasons may include, but
are not limited to: baby too big to deliver vaginally, as measured on
ultrasound; breech presentation; gestational age of 40 weeks 1 day, etc.
[4]
Maternal death rate in the US is vastly underreported, because we have no
federal laws mandating reporting. It is
also underdiagnosed. There have been
lawsuits filed in recent years because of death certificates stating that a
woman died of “natural causes” but in reality died as a result of an infection
from childbirth, or from a nicked intestine that caused sepsis, etc.
[5] As
sourced from Global Health Facts.org (Kaiser Family Foundation, 2010) , The World Factbook (Central
Intelligence Agency, 2010) , OECD (OECD, 2011) , Deloitte &
Touche (Emons & Luiten, 2001)
Only industrialized nations are being considered in
this paper, since third world countries will almost always have much higher
rates of maternal death, regardless of number of midwives, due to lack of
professionally trained medical personnel, lack of sanitation, etc. It would be unfair to compare third world
countries’ maternal death rates to industrialized nations’, as it would be like
comparing apples and potatoes.
[6] It
is difficult to determine the number of midwifery assisted births per state,
but midwives are the only maternity care professionals that assist during out
of hospital deliveries. For this reason,
I looked specifically at the rates of homebirths per state, so as to give a
somewhat accurate number for natural views of childbirth.
[7]
It’s been estimated that cesarean delivery carries a maternal mortality rate as
much as 11 times higher than vaginal birthing (Petitti, 1985) .
Obviously it needs to be taken into account that some women that die
from a cesarean section already had a higher risk in the first place, but
keeping in mind that the majority of cesareans are not medically necessary,
this would not factor in as much as one might imagine.
[8] At
the Society Lying-In, 2500 babies were delivered in year 3, with 591 women
suffering from childbed fever.
[9]
Twilight Sleep was a concoction of morphine and scopolamine (Twilight
Sleep Definition, 2012) .
It was originally given to women in labor to keep them from feeling pain
during childbirth. Unfortunately, this
is not the effect it had. The women
still felt a lot of pain during childbirth, to the point that they were
thrashing around violently, and had to be strapped down to prevent injury to
the mom and the attendants. However,
women didn’t know it, because the concoction had the effect of causing
amnesia. So while they were in a lot of
pain during birth, they didn’t remember it; in their minds, they were going to
sleep, and waking up to a newborn baby.