I was so pleased to see Ina May Gaskin pop up in my news feed this morning writing a piece on childbirth choice for the Huffington Post’s Global Motherhood section. Gaskin is perhaps the most famous midwife in the US; her books including Ina May’s Guide to Childbirth and Spiritual Midwifery are a must read for anyone planning a natural birth (or I’d argue for anyone planning any sort of birth). I find Gaskin compelling because she advocates widely for home birth, natural birth, and midwifery in such a level headed and rational way.
In this most recent piece, Gaskin raises two points about birth politics that bear repeating – a focus on home birth as “dangerous” misses the birth issues that impact a much larger portion of birthing mothers and the continued medicalization of birth is causing a dangerous deskilling of birth professionals.
I wrote last month about the dangers of sensationalizing home birth, something we’ve seen rather a lot of lately. Gaskin notes:
If I had just dropped in from another planet, I’d find it fascinating that something that less than 0.7 percent of U.S. women choose has caused such a furor. Is the excitement because certain celebrities have been credited for causing an increase of home birth ? Do they realize that even counting the increase, the rate of home birth is still less than it was in 1969? Are the women who are so vocal in their opposition to other women choosing home birth aware that there is no danger that U.S. birth outcomes have been adversely affected by choices made by a fraction of one percent of birthing women?
A birth issue impacting far more birthing mothers is the ever increasing cesarian section rate; about one-third of all babies in the US are born via c-section, well above the 10-15% rate recommended by the World Health Organization. There are many factors contributing to this continued rise – and these should get at least as much if not more attention than the decision of a low-risk mother to seek a home birth. 33% is after all a much larger number than 0.7% if what we are really concerned about is a healthy outcome for mother and baby. Instead of sensationalizing one form of birth as “trendy” or “dangerous,” we should have an open and respectful dialogue about all birth choices, including the risks associated with each.
Intertwined in this issue is that of the increasing medicalization of birth. Without a doubt, c-sections save lives. Medical technology saves lives. But the majority of the time, birth is not a “medical procedure” so much as it is a natural human process. Sometimes our interferences, the intrusion of technology, actually complicate birth and lead to further interventions including c-sections. Childbirth is a precarious time for mother and child and certainly many woman and babies died in childbirth prior to our medical advances. But, the question needs to be asked…Would fully one-third of all mothers and babies have had a negative outcome had a c-section not been an option? There’s evidence to suggest (including this recent study) that in many cases more interventions do not equal healthier babies. Sometimes we do need modern medicine in childbirth. But that’s a much smaller percentage of the time than statistics suggest.
Technology becomes dangerous when we become dependent on it, unable to complete tasks that were once routine prior to a technological change. This is true for childbirth. Gaskin notes:
When there is little or no access to midwives in any country, obstetrics itself becomes deskilled to a degree that alarms wiser obstetricians, who acknowledge the need for better options in birth or a strong midwifery profession.
I began my first pregnancy with an obstetrician. When I told her I was switching my care to a midwifery practice, she encouraged that choice (in fact she had suggested it as an option knowing that I wanted a low-intervention birth) and noted that “we learn a lot about birth from them.” This particular midwifery practice was hospital based; in their orientation for new patients, they stressed the importance of having hospital based midwives as a way to de-medicalize low-risk birth and offer another birth option for expectant parents. I was fortunate to have providers – both an OB and midwives – who recognized that birth choices run a continuum and that wise providers have much to learn from each other as the work to provide the best care for mothers and babies.
In preparing for my first birth, I watched The Business of Being Born. Two things struck me most about the film: One, the interview with ob-gyn residents who remarked that they’d never seen a “natural” birth and two, the fact that director Abby Epstein’s pregnancy ends with a c-section. The first is remarkable as it highlights just how common the lack of “old school” knowledge about birth has become. The second demonstrates that even among those who are most vocal about the need for “natural” birth, there is a healthy recognition that sometimes medical interventions are necessary. Both “sides” are needed. Currently, the “medical side” has a louder voice in mainstream birth politics, sometimes to the point of ignoring “traditional knowledge” – that’s a problem.
As one example of the deskilling of modern obstetrics, Gaskin has written elsewhere about the vanishing art of vaginal breech deliveries and the importance of ALL birth providers knowing how to deliver a breech baby vaginally. The “medical” answer to the potentially complicated breech birth has been the c-section. Even if one feels that is the safest choice (and there’s debate even among obstetricians as to whether or not that is the case), there are situations where a vaginal breech delivery has to happen…or where a mother choses that option. Even simple bits of “traditional knowledge” – such as the ability to determine baby’s position and approximate size by palpating – are diminishing in the wake of an increasing reliance on technology.
I’ve often told Eleanor’s birth story as an example of the power of “traditional” birth knowledge. I chose a birth center based midwifery practice and a “natural” birth. Had I gone with a more medicalized practice or had I opted for common birth interventions such as an epidural, Eleanor’s birth would likely have progressed differently; in fact, I’m pretty certain that had I opted for an epidural or a more medicalized practice, I would have likely joined the one-third of mamas who have a c-section.
Eleanor was “late” and poorly positioned (asynclitic) going into labor. And while we didn’t know exactly how big she was, the midwife estimated 9 pounds (turns out she was 10; interestingly I did have an ultrasound a few days before delivery as part of my non-stress test – I’m not sure if they didn’t do a weight estimate or just didn’t note it as I was never given one – of course, late-term ultrasound weights are notoriously inaccurate). After a quick start, my labor stalled – so they made me move, and try new positions, and move some more. I was rebozo-ed, put on hands and knees, and walked. Finally something worked and Eleanor lined up ready to be born. It’s possible this still would have happened had I had an epidural or had I had practitioners that didn’t encourage as many positions as we tried – possible but not as likely. There’s a greater likelihood that I would have been labeled “failure to progress” at that point and sent off to surgery.
Eleanor was born in only three pushes – but there was a bit of excitement between pushes two and three. I was in the tub for push one – which got her head out – and push two which did nothing. My midwife quickly realized Eleanor’s shoulders were stuck. In no more than 30 seconds, I was flipped out of the tub on to hands and knees; push three brought Eleanor right out. Personal thanks to Ina May for bringing the Gaskin maneuver to the US (a simple move which she learned from midwives in Guatemala). Had I had an epidural (which would have made it impossible or at least extremely difficult to flip onto my hands and knees with a baby halfway out) or a practitioner lacking knowledge of this simple re-positioning technique, I’m sure Eleanor’s shoulder dystocia would not have been resolved so quickly. As it was, neither of us had any sort of injury – I didn’t even tear! If you’ve read my full birth story you know that Eleanor ended up transferring to the nearby NICU for transient tachypnea – a relatively common newborn issue of “grunty” breathing, one that was not related to her birth (aside from perhaps the fact that it was fast), and would likely have been exacerbated by a c-section (as c-section babies have a greater likelihood of retained fluid in their lungs since they don’t get “pressed” through the birth canal).
Needless to say, I’m a believer in the value of traditional knowledge about birth. As I argued in my previous piece about home birth, there is no one “best” birth option. What is best for ALL birthing mothers and babies is for all birth practitioners to engage in discussion and knowledge sharing. Just as there’s a time for medical intervention, including c-sections, there’s a time to employ age-old practices. Birth is a complex dance, a vulnerable time physically and emotionally. What birthing mothers need are practitioners who understand and value both traditional knowledge and the latest medical technologies – and know when to use each.