Birth Misconceptions: Fact and Myth
The Medicalization of Birth
Myth: 'Birth is too risky and dangerous to be allowed to occur naturally.'
Fact: Childbirth is a highly evolved process that normally requires only the physical good health of the mother, adequate emotional support and privacy in labor, and the watchful attention of a skilled birth attendant. Given this, changing prevailing modern attitudes and practices regarding what is natural and normal in birth is essential.
Myth: 'No birth can be viewed as normal except in retrospect because pregnancy and birth are medical conditions.'
Fact: The majority of complications in pregnancy are related to socio-economic factors (inadequate diet, drugs and environmental toxins, and psychological factors such as excessive stress, abuse or neglect).
Research shows that the majority of complications in labor can be anticipated prior to the onset of labor and most of them can be avoided or successfully handled without medical intervention if a woman comes to birth in good physical health with a positive mental attitude and is attended by a skilled birth attendant.
Birth at Home or at the Hospital
Myth: 'The modern hospital is the safest place for all women to give birth. All other sites for birth are too dangerous. The bigger the hospital, and the bigger the baby intensive care unit, the safer the birth.'
Fact: Despite over 75 years of routine hospitalization for birth there are still no reputable studies or scientific evidence showing that hospitals are the safest option. In fact, there are numerous reputable studies showing the various risks and hazards of hospital birth and hospital based birthing centers.
For example, the mere presence of a laboring woman in a hospital has been proven to increase the likelihood that she and her baby will be subjected to routine tests and procedures. These interventions are based on convenience and hospital protocols rather than need. In addition, routine hospitalization for birth is extremely costly and leads to the inappropriate use of specialist physicians, medicine, and technology. The problems associated with hospital birth increase with the size of the hospital, especially those problems related to impersonalized care and the overuse and abuse of technology and medicine.
Hospitals are not safe places for newborns, whose liver, brain and immune systems are too immature to ward off the noxious or toxic effects of routine procedures and hospital-born infections. Today there are more than 25 strains of pathogens completely resistant to all known antibiotics and most of these are found in hospitals. Babies who are physically separated from their mothers and do not receive breast milk after birth are at increased risk.
Hospitals are essential places for addressing human physiological problems and damage. But this fact does not make the hospital environment ideal, preferable, or even adequate for a childbirth in which no physiological problems or damage are anticipated.
A healthy woman, entering labor with no complications, is safest birthing in her own home, assuming a skilled midwife attends her with hospital backup. Midwife assisted Homebirth has proven to be safer than hospitals for this population of healthy women, who are at low risk for complications in birth and comprises 80% of all birthing women in America.
As many as 20% of our nation's full-term healthy newborns currently spend time in intensive care for no medical reason. Most of them are there for "observation" or "just-in-case" treatment because of drugs or procedures done on their mothers.
The additional cost of each day a baby spends in intensive care runs $2,500-$7,500 (based on 1999 statistics). Intensive care baby units usually have a 90% or higher occupancy rate. As soon as an intensive care unit is expanded, the number of babies sent to it increases because there is little incentive to keep babies out of ICUs, especially in big teaching hospitals.
While in intensive care ~ even just for "observation" ~ babies endure numerous painful, risky and traumatic procedures in addition to maternal separation. The more aggressive the management of newborns in such nurseries, the greater the potential for long-term trauma.
Myth: 'Modern medical management and intervention in birth improves outcomes and therefore should be applied to all birthing women and their babies. In fact, the more technology used in birth, the safer the birth.'
Fact: There is now a large body of scientific evidence to the contrary. The entire medical management approach, including each and every obstetrical intervention (including confining a laboring woman to bed; doing a shave and enema; denying food and drink; electronic fetal monitoring; "hep-lock" or IV drip; artificial rupture of the membranes; artificial hormones to induce or stimulate labor; forced delivery of the placenta; narcotics, sedatives and anesthetics for labor; episiotomy; early cord clamping and cutting; and separation of mother and baby after birth-even for "observation," carries significant risk of harm to the natural process and to the mother and baby.
In addition, the use of any intervention tends to lead to other interventions, in a cascading effect. Once any intervention is used it is likely to alter the natural course of the labor. For all of these reasons ~ as well as the impact interventions can have on the mother and baby's psychic well-being ~ intervention should only be applied in instances of true complications and, ideally, after safe, non-interventive measures have been tried.
Myth: 'Electronic fetal monitoring is necessary to insure the safety of the baby.'
Fact: Electronic fetal monitoring has never been scientifically proven either safe or effective for determining the well being of a baby during labor ~ even among women at high-risk for complications. Extensive research, as early as 1985, including a Harvard study of 10,000 women, showed no more than 1 baby's life might be saved for every 10,000 women electronically monitored. Internal monitoring (done most commonly) requires rupturing the amniotic sac and screwing a scalp electrode into the baby's head.
This expensive device was introduced in the early 1970s and, following an aggressive marketing campaign in which nurses were hired to promote its "safety," were bought by every hospital in the country within a few years. In most hospitals such monitoring is still used routinely. Hospital administrators see the monitor as a way to cut down on the nursing staff.
The reliance on electronic fetal monitoring rather than nursing or midwifery care was largely responsible for the 300% increase in the U.S. cesarean rate. Now hospital attorneys and administrators and most obstetricians continue to insist upon electronic monitoring for malpractice protection.
Myth: 'The length of a woman's labor, the existence of medical complications requiring drugs, mechanical or surgical intervention, as well as her desire for narcotics, sedatives and anesthetics drugs in labor, has to do with factors often beyond a woman's control (e.g. her innate pain threshold, her body's ability to function properly, her physical build and genetic predisposition).'
Fact: Numerous recent studies have shown that all of these can be dramatically affected by the nature of the birthing environment (e.g. the dominant presence of equipment, and the lack of privacy or support). The attitudes of the mother and her caretakers are even more important. Every person who comes in contact with a birthing woman either increases or diminishes her levels of fear and self-confidence. Doula and midwifery studies have shown that the rate of medical intervention as well as length of labor are dramatically reduced with competent doula or midwifery care. Note: Although rare, a physician can provide midwifery care, just as a midwife can be highly interventionist. The difference has to do with training, attitude, and the system in which they work.
Myth: 'Any birth that is not a cesarean is a normal birth.'
Fact: This year more than 50% of birthing women in many American hospitals will have their labors artificially induced or speeded up with drugs. 90% will be hooked to electronic fetal monitors during labor. It is estimated that 80% of all women who have vaginal births will be drugged and/or anesthetized for pain relief and an equal number will have an episiotomy. 75% of our mothers and babies will then be separated before breastfeeding has even begun.
Myth: 'Cesarean surgery is now very safe, poses a minimal risk, and is only done when medically necessary.'
Fact: Cesarean surgery carries the same immediate risks that all major surgery entails ~ unstoppable bleeding, unexpected and catastrophic drug reactions, and infection in the mother ~ as well as additional ones for both the baby and the mother.</font></span>
Cesarean surgery denies the mother and baby the experience of completing the birth vaginally, which has numerous physiological and psychological benefits for their health and development. Cesarean born babies are much more likely to have immediate problems with breathing, for example, and often end up in intensive care separated from their mothers during the critical first hours after birth.
When cesarean is performed by schedule, without labor, there are even more risks, including the additional complication of the baby being pre-term. Cesarean-born babies are more likely to require intensive care after birth and to have more difficulty establishing breastfeeding.
For these reasons, and because cesarean requires the greatest expenditure of resources, it should only be done when medically necessary and other measures are not possible or have not worked. Research shows that there is little significant improvement in outcomes if an overall cesarean rate is higher than 7%.
This year over 1 million babies ~ more than 1 out of every 3 ~ will enter this world by abdominal surgery. Eighty percent of these ~ more than 600,000 ~ will be medically unnecessary. The majority of these cesareans will be performed on healthy middle and upper class women, not poor women or pregnant teens, the ones at higher risk for problems.
Current obstetric texts state that the "expected maternal death rate" from vaginal birth is 6 per 100,000. The risk for maternal death from a cesarean is four to seven times more than that of a vaginal birth. In these same texts the expected death rate from cesarean is 100 per 100,000. Yet "once a cesarean always a cesarean" is still the norm, despite the fact that between 75 and 80% of women who have a cesarean can have a normal vaginal birth the next time.
The average American vaginal birth (including prenatal care, professional fees, and hospital fees) costs $8-10,000 (this figure is based on 1999 statistics, however currently in our geographical region, it now costs $20-30,000) and the typical cesarean costs $12-20,000 (this figure is based on 1999 statistics, however currently in our geographical region, it now costs $60-100,000) and much more if the baby is in an ICU for extra tests.</font></span>
Pain and Epidurals
Myth: 'Modern women should not have to endure pain in labor; it has no value.'
Fact: The normal pain of labor serves several physiological functions: it alerts the pregnant woman that labor has begun and she needs to find a private, undisturbed place to birth. Natural, normal labor and delivery (physiological birth) fosters fiercely protective behavior on the part of the birthing and new mother. Interfering with this process tends to hinder the mother-infant bond and create worried, anxious or insecure mothers who are not confident in their own ability and doubt their innate knowing. When a mother lacks confidence in her own ability and judgment she is more likely to look to outside "experts" rather than pay close attention to what her own signals and her baby's signals are telling her to do. Women who have had their mothering undermined in this way can regain their confidence and trust in themselves and their babies, but it is not the same as never having lost it in the first place. Labor is physiologically designed to foster fiercely protective behavior in the birthing mother, without making her overly anxious. The pain of contractions is a result of the normal stretching of muscles and tissue. Anxiety and tension resulting from excessive fear intensifies the pain, makes contractions less effective and lengthens labor. Women can cope with labor pain if they have adequate privacy and support.
Physiologically it is impossible to artificially diminish or numb the sensation of pain without also diminishing the sensation of pleasure. However, our own natural hormones place a woman in an altered state where the pain is easier to bear.
Throughout history birthing women have always preferred to be cared for by another woman who is familiar to her. However, even the presence of a woman who is a stranger and does nothing but sit silently in the room, results in shorter, less painful and more effective labors. The woman's experienced labor pain is directly related to how comfortable she is with her body and how much support and privacy she is given. In repeated recent studies by pediatricians Marshall Klaus and John Kennell the continuous presence of a labor "doula" dramatically reduce the amount of drugs, anesthesia, cesarean surgery and the rate of all complication in labor in hospitals.
Myth: 'Drugs used in labor and delivery are necessary, safe and have no negative side effects on labor or on the well-being of babies.'
Fact: Any drug ~ including artificial hormones to stop, induce or speed up labor ~ given to a mother in pregnancy, labor, or while she is breastfeeding, will get into her baby's blood stream and settle in the baby's liver and brain. Drugs in birth get to the baby in higher proportion than to the mother because of the baby's small size. More than 80% of laboring women today get an epidural and most of them demand it.
The mother and baby each produce hormones that prepare them to handle the stress of labor and prepare them for the enormous physiological and emotional changes they must go through after birth.
The casual use of drugs in birth poses many immediate and long-term hazards, including compromising the establishment of breastfeeding and successful bonding.
Myth: 'Epidurals enhance normal birth and have no side effects.'
Fact: Epidural anesthesia can cause a rapid drop in the laboring mother's blood pressure, resulting in fetal distress and an emergency cesarean section. An epidural can also cause the baby to get stuck in the mother's pelvis, leading to the need for forceps, vacuum extractor or cesarean. Babies whose mothers have had epidurals frequently have a difficult time getting breastfeeding started, which all too often results in their mothers quitting breastfeeding.
96% of women who get a fever in labor have had an epidural. Since a fever in the mother may signify a dangerous infection in the baby, their babies are routinely sent to the intensive care nursery and aggressively treated for possible infection. Once there, these babies endure frequent painful blood drawings, spinal taps, and are given full-spectrum antibiotics while tests are being done to determine whether they even have an infection. Epidurals often lengthen labor and cause problems for mothers and babies.
86% of all babies given antibiotics in the ICU have mothers who have had an epidural.
Who should oversee the birth?
Myth: 'Obstetricians are trained to handle complications and therefore should supervise and be in charge of all births to ensure the best outcome. No other health worker is sufficiently skilled.'
Fact: Obstetricians are not trained to approach birth as a normal process and have little or no training in providing the pregnancy support and counseling and labor support that inherently keeps birth safe and normal. The average obstetric training includes one day on nutrition and no training on labor support. Numerous studies show that physicians, especially specialists such as neonatologists and perinatologists, are best used as back-up technical support for primary care community-based health workers, notably midwives.
Most obstetricians do not show up at a birth until the woman is fully dilated and pushing. Because of this they are more likely to rush to judgment and treat any normal variation in a labor as a crisis.
Most insurance companies and HMOs pay more money to the obstetrician for each intervention he or she performs and pay more when a cesarean is done. Juries tend to believe that doing a cesarean proves that a physician has done everything possible for the mother and baby. There is little incentive for using non-intervention labor aids and every incentive to do them for convenience, malpractice protection, and personal profit.
Myth: 'Midwives are not as competent as doctors and need direct supervision.'
Fact: When midwives attend women throughout pregnancy the rate of premature and low birth weight babies, and infant mortality and the re-admission of babies to hospitals in the year after birth, is as much as 75% lower than for women seen by physicians, no matter what the woman's risk level.
Midwives (and, where they exist, nurse practitioners and physician assistants) can better provide primary care to mothers and babies and do so at greatly reduced cost and increased safety. They spend more time with their patients, which translates into greater preventive care, more patient education, and a greatly reduced need for hospitalization and expensive (and risky) hi-tech care. The midwife model of care for birth has been proven optimal for immediate as well as long-term outcomes because midwife care protects and promotes normalcy. The midwife model of care includes training in preventing and treating complications in all sites, and using the least amount of medical intervention. Midwives can be trained to provide adequate emergency first aid care in any setting.
Midwives identify problems when they arise and handle them before they become serious complications or emergencies. They are trained to consult with physicians and transfer care to a physician when necessary.
The rates of cesarean, epidural and other interventions among patients of midwives practicing in hospital settings is a fraction of the rate for obstetricians. Midwives attending births at home have a 2-5% cesarean rate and employ natural, safe aids to keep labor progressing and help women cope with pain rather than drugs or anesthesia. Midwives seldom do episiotomies, preferring to protect a woman's tissues from the scalpel or serious tears by skillful hands-on care and positions that aid smooth delivery.
The Mother/Baby Relationship
Myth: 'It does not matter what kind of birth the mother and baby have, so long as the baby and mother appear to be healthy afterward.'
Fact: The long term health and development of a baby, as well as the health of the family, is directly dependent upon the quality and strength of the mother-baby relationship. Anything that makes their relationship more problematic is a serious personal and public health matter. In addition to their physical well-being, a mother and baby need to have the experience of success in birth. Anything that causes the baby to be separated from the mother after birth (which is more likely when there is intervention in the natural process) can result in birth trauma and difficulty with establishing trust.
Myth: 'Babies do not remember their birth and are thus not affected by it, and the mother's experience is quickly forgotten.'
Fact: A growing body of scientific and clinical evidence shows that babies do remember their experiences, including the time from conception through birth and until they learn to talk. This memory is stored in their nervous system and brain and many adults and children have had spontaneous birth memories, even including details of things that were said to their mothers during labor!
The experiences that happen to us from in the womb through the first hours after birth set physiological traces in the brain and nervous system that remain with us as definite patterns. For example: leading edge brain research shows: 1) there are likely two different ways memory is stored: things learned under extreme stress and things learned in an ordinary state; 2) the brains of babies and young children who have had too much stress may not know how to turn off the production of survival-based stress hormones for years to come.
Shocking, traumatic experiences can lead to lasting trauma which may need special attention and care for healing. Some trauma in some babies spontaneously resolves itself, especially when there is prolonged breastfeeding and intimate affectionate contact and stimulation with the mother or mother surrogate.
Even at the end of their lives, women will recall the experiences of their births (except for the parts where they were drugged) with greater vividness and detail than any other life experience. A woman's experience of birth is directly related to her sense of competence and confidence as a mother. A mother whose baby has been separated from her at birth is more likely to view her baby as delicate and feel more dependent on outside experts.
Myth: 'Any caring person can provide a baby what he or she most needs.'
Fact: Newborn babies recognize and prefer their own mother's scent and face to anyone else. They also prefer their mother's voice above any other even in the womb, because hers is what their own heart and ears are calibrated to. Their sense of whether the world is a safe place and whether they can trust is largely related to their experiences with their mother. A mother mirrors the world to her baby by the look on her face, the tone of her voice, the feel of her touch.
Breastfeeding is more than delivery of breastmilk into a baby's gut. Canada and Switzerland, recognizing the public health benefits of long breastfeeding, give financial incentives to encourage mothers breastfeeding for a year or longer.
The amount of time a mother spends in intimate physical contact with her baby in the days following birth is directly correlated to how confident and compassionate she is as a mother. In various studies, mothers of babies who are closely bonded because of early and prolonged intimate contact respond more quickly and more compassionately to their baby's cries.
This difference in mothers has been found to continue for 18 months and longer. A difficult and "high needs" baby's very survival is dependent upon the strength of its mother bond. The weaker the bond the more likely the mother is to be unprotective, neglectful or abusive when under extreme stress or to permit someone else to harm her children.
References for the above factual data:
Chard, Tim & Richards, Martin, Editors. Benefits & Hazards of the New Obstetrics. William Heinemann Medical Books/JB Lippincott, 1977
Duran, AM. "The safety of home birth: the farm study." Am J Public Health. 1992
Mar; 82(3):450-3 Enkin, M et al. A Guide to Effective Care in Pregnancy and Childbirth, second edition. Oxford University Press, 1995 Goer, H. The Thinking Woman's Guide to a Better Birth. Perigee Press, 1999
Greulich, B et al. "Twelve years and more than 30,000 nurse-midwife-attended births: the Los Angeles County University Southern California Women Hospital Birth Center Experience." J Nurse Midwifery 1994;39(4):185-96
Haire, DB and Elsberry, CC . "Maternity Care and Outcomes in a High-Risk Service: the North Central Bronx Hospital Experience" Birth 1991;18(1):33-37
Harvey, S et al. "A randomized, controlled trial of nurse-midwifery care" Birth1996;23(3):128-35
Jabaaij, L, et al. "Home births in The Netherlands: midwifery-related factors of influence." J Nurse Midwifery 1996 Sep;12(3):129-35
Klaus, Marshall, MD, Kennell, John, MD & Klaus, Phyllis, CSW, MFCC. Bonding. Addison-Wesley, 1995
MacDorman, MF, Singh, GK, 1998. "Midwifery care, social and medical risk factors, and birth outcomes in the USA" J Epidemiology and Community Health1998 May;52(5):310-7
Mehl-Madrona, L et al. "Physician and midwife-attended home births. Effects of breech, twin and post-dates outcome data on mortality rates" J Nurse Midwifery 1997, Mar-Apr;42(2):91-8
Rooks, J, CNM Midwifery and Childbirth in America Temple Press, 1997
Scott, Tunstall ME. "Serious Complications Associated with Epidural/Spinal Blockade in Obstetrics: a 2 Year Prospective Study" Int J Obstet Anesth 1995;4:133-9
Spitzer, MC. "Birth Centers. Economy, safety, and empowerment." J Nurse Midwifery 1995 Jul-Aug;40(4):371-5
Wagner MD. Pursuing the Birth Machine: The Search for Appropriate Technology. Ace Graphics, 1994 World Health Organization. "Appropriate Technology for Birth." Lancet 1985;2(8452):436-437
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