Over the past century, childbirth has become safer for mothers and
babies in the United States. From 1900 to 1999, the risk of a baby
dying during birth or in the first year of life plummeted from 1 in 10
to less than 1 in 100. The risk of a mother dying from
pregnancy-related complications or childbirth decreased even more
dramatically, from 850 deaths to less than 8 in every 100,000 births.
In addition, changes in the later 20th century, such as childbirth
education and encouraging women's partners or other close friends and
family members to be present during labor and birth, have helped many
women better understand the process of childbirth and enjoy more
support through it.
Yet despite this progress, mothers and babies still face many
challenges. Unlike most other industrialized countries, the U.S. has no
guaranteed paid family leave, no guaranteed health care and little
affordable high-quality child care. Our country has the highest infant
mortality rate among affluent nations, and higher maternal mortality
rates than all but five economically industrialized countries. Mothers
and babies of color, especially African-Americans and Native Americans,
are at higher risk.
The health care that is provided to women during pregnancy, childbirth
and the early postpartum period-what is known as maternity care-is also
in need of improvement. Far too often, maternity care practices are not
based on the best scientific research on safety and effectiveness.
Procedures that are useful-and sometimes even lifesaving-when applied
to women and babies with specific high-risk conditions are often
extended liberally to other women and babies, "just in case." Such
unnecessary medical interventions are not helpful and can even be
harmful.
Too much or too little
A national survey of mothers who gave birth in hospitals in 2005 found
that nearly all women experienced some combination of interventions
that can interfere with the normal progression of birth. Most of the
women surveyed had continuous electronic fetal heart rate monitoring,
urinary catheterization, administration of intravenous fluids, and
epidural or spinal analgesia. One in two received synthetic oxytocin to
either start her labor or make her contractions stronger and more
frequent, and slightly more than three in 10 had a Cesarean section.
The United States' C-section rate (31 percent) is more than twice the
maximum rate recommended by the World Health Organization; this means
that more mothers and babies are exposed to the negative effects of
surgical birth. Most women also experienced practices that may do more
harm than good, such as not eating or drinking anything during labor
and lying on their backs during labor and while giving birth.
Other practices that have been shown to improve birth outcomes and
increase women's satisfaction are widely underused. These include
receiving continuous one-on-one support during labor; being able to
change positions, get out of bed and walk during labor; and using
comfort measures such as massage, warm baths and birthing balls.
Advocates for improving maternity care in this country point to the following roadblocks to change:
Obstetrical training Obstetrics is a surgical specialty, and
doctors training to become obstetricians learn, among other things, to
perform Cesarean sections, apply forceps, and cut and repair
episiotomies. They generally receive less instruction in the natural
progression of childbirth or in birth techniques that minimize perineal
tearing. In many training programs, obstetricians are not even required
to sit with a healthy woman throughout her entire labor or observe one
birth without any interventions.
The widespread use of epidurals A woman who has an epidural is
usually restricted in her movements and for safety reasons must be
monitored continuously by electronic fetal monitoring (EFM). The
resulting restricted movement and muscle relaxation can cause babies
who are facing backward to stay that way, which results in a longer
second stage of labor and a higher incidence of forceps and vacuum
deliveries. Use of epidurals also can lead to less effective pushing.
Continuous fetal monitoring Because the fetal heart rate
patterns seen when the heart rate is continuously recorded are
sometimes difficult to interpret, EFM has increased the number of
labors considered "complicated" or "risky." For women who do not have
labor interventions such as epidurals that make continuous monitoring
necessary, intermittent monitoring appears to be as effective as
continuous monitoring at detecting true problems, and is not associated
with an increased risk of Cesarean birth or of vaginal birth assisted
by vacuum extraction or forceps.
Changes in nursing care In the past, personal one-on-one care
was the hallmark of obstetrical nursing. Today, for a variety of
reasons, including nursing shortages, budgetary constraints and less
training in the natural progression of birth, labor nurses increasingly
rely on continuous EFM to help them care for more than one woman at a
time.
Economic incentives Many payment systems offer a single or fixed
fee to doctors regardless of whether a baby is born vaginally or by
Cesarean, and others offer a larger fee for a Cesarean. Doctors who
patiently support natural labor, which starts at unpredictable hours
and generally requires more time, are penalized financially. Inducing
labor instead of waiting for it to start on its own also helps doctors
control their hours. Elective Cesarean sections and scheduled induction
of labor help hospitals make nursing staff schedules more predictable
and shift more of health care providers' work to convenient weekday
hours.
Fear of lawsuits If something goes wrong, doctors may be blamed
for not doing something, but rarely are they blamed for doing something
that is not necessary. For example, malpractice lawsuits for not
performing a Cesarean section are much more common than lawsuits for
doing one when it wasn't necessary. To avoid litigation, many doctors
and some midwives feel compelled to do "too much" rather than be
accused of doing "too little."
A rushed, risk-averse society U.S. society today has an aversion
to risk that contributes to a climate of doubt in which all labors are
treated as potential problems and women with low-risk pregnancies
receive treatments designed for use by women with very high-risk ones.
In addition, women sometimes are not allowed sufficient time for labor
to progress and a vaginal birth to occur. Women's own expectations can
contribute to rushing labor.
Often motivated by personal experiences, some of us have become
involved in groups working to change birth practices (for one
patient-turned-activist's story, see "Not in My State!").
If you are healthy and have no medical complications that call for a
"high-risk" approach to your care during pregnancy and birth, you can
increase your chances of having a safe and satisfying vaginal birth by
trying the following strategies:
- Find a doctor or midwife and a birth setting with low rates of intervention.
- Create your own birth plan and discuss it with your caregivers.
- Arrange for continuous labor support from someone with experience.
- Explore all your pain-relief options.
- Avoid continuous electronic fetal monitoring and other medically unnecessary interventions when possible.
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