Born in the USA (25 page)

In the 1980s, the scientific evaluation of maternity services began in earnest. Many studies revealed startling truths about technology, such as that routine use of electronic fetal monitoring on every birthing woman does not lower the perinatal mortality rate, but sharply increases the rate of C-sections. This led to a fundamental shift away from peer standards of practice, in which the standard of practice in a given community is whatever the physicians in that community do, to evidence-based standards of practice, and as more studies have been done, the findings continue to support the need to expand the medical model of birth to include the social or humanized model and give women the choice of a planned out-of-hospital birth.

The maternity care establishment in the United States has been seriously challenged by the trend toward evidence-based practice in medicine. Control, status, and, for many obstetricians, financial benefits have been threatened. The struggle is on, and place of birth has become a central issue. Why do obstetricians get so emotional about home birth? My own experience as a physician may shed some light on the situation.

The first time I attended a home birth, I was shocked. I had been a practicing physician for years, but this was the first time I had witnessed the full power of a woman in control of her own body. Believe me, it's a scary experience for a man. It took me a long time to come to grips with the truth: we men are afraid of women, whether consciously or unconsciously. We're afraid of unleashed nature, we're afraid of childbirth. We've all heard Freud's theory of “penis envy,” but it isn't necessary to be an adherent of psychoanalytic theory to believe that many male obstetricians experience “womb envy,” a term introduced by a German psychoanalyst, Karen Horney, to refer to an abiding sense of male inadequacy in the face of women's unique childbearing gift.
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Put simply, men are outsiders at birth—always have been, always will be. So watch out. Hell hath no fury like a man marginalized. When men are afraid and angry at being afraid, they cope through denial of their fear and through controlling whatever they're afraid of.
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In light of this theory, it makes sense that the male-dominated obstetric profession would try to control
birth—though it is an impossible task, given that labor is a function of the autonomic nervous system, something even the woman herself has no control over. The only way to control the birth process is to override normal uterine function—introducing drugs to start or accelerate labor, inhibiting the normal physiology of labor with epidural block, and turning birth into a surgical event by pulling or cutting the baby out. And the only way to use these interventions is to have birth in hospitals. Hospitals are doctor territory, the only place where doctors have nearly absolute control. Doctors fear out-of-hospital birth because they are afraid of birth and because they have no control outside the hospital.

With few exceptions, obstetricians in the United States are against out-of-hospital birth, even though they have never seen a planned birth in a home or in a freestanding birth center, and are unwilling even to look at the evidence on the matter. I believe this is due to a dire need to control women and birth and a deep fear of childbirth. It's easy to see what I'm talking about. Just ask an obstetrician to tell you about the risks of childbirth or about all the women and babies he has pulled back from the precipice of death during childbirth. So what we have is an obstetrician's basic conviction that childbirth is dangerous dovetailing with the fact that if a birth takes place in a freestanding birth center or a home, he has lost control, power, and money.

Obstetricians campaign against out-of-hospital birth with a variety of strategies. As discussed in
chapter 5
, in many places obstetricians have fought to make it a requirement that nurse-midwives have an obstetrician “supervisor” and licensed direct-entry midwives have an obstetrician “consultant.” Obstetricians want to supervise or consult for midwives in order to control them. But, as a result, obstetricians now claim that insurance companies may charge higher premiums for an obstetrician who provides backup for out-of-hospital births and that, at least in theory, they are liable if something goes wrong.
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So now obstetricians (even those who have never provided backup to midwives) complain that if a birth takes place outside of a hospital, a doctor is still responsible if something goes wrong and is therefore liable. In other words, obstetricians fight for control, and then when they win these fights and get control, they complain because with the control comes responsibility and liability.

Almost everywhere in the world outside of the United States, obstetricians do not “supervise” midwives and are not liable for what midwives do or don't do. Even in the United States, some judges do not see the relationship between an obstetrician and midwife as one of supervision, control,
and liability, but rather as a collegial relationship. Judicial opinions like the one by Judge J. R. Roman in California (see
chapter 5
) make it clear that obstetric groups in the United States could rather quickly change the present system so that they are no longer responsible or liable for midwives. But they don't want to change the system. They don't want to give up control of midwives. They would rather use their high insurance premiums to gain sympathy from politicians and get them to pass laws that make obstetricians sue-proof and their practices beyond the reach of regulation and litigation.

With all the frightening propaganda about how dangerous birth is, even women who want the freedom to control their own birth experience sometimes feel that they need the “security” of an institution. These days for such women there is a way to have it all. A woman can choose to be assisted by a midwife, control her birth experience, and still feel protected by an institution by choosing an alternative birth center (ABC) that is “freestanding” (i.e., not in a hospital) and staffed by midwives.

That an ABC is free of control by a hospital is essential. Some hospitals have something called a birth center in their maternity wards, but a hospital claiming to have a “birth center” is like a bakery claiming to sell “home-baked” bread. In a real birth center, a birthing woman always has the final say about everything that happens to her, and that is unlikely ever to happen in a hospital unless she fights for it. It is also essential that an ABC be staffed by midwives who use protocols or standard procedures that have been established by midwives, not doctors.

The type of care provided in an ABC is different from the care provided in a hospital in significant ways. In a hospital an obstetrician is in control, whereas in an ABC the birthing woman is in control. In a hospital the emphasis is on routines, whereas in an ABC the emphasis is on individuality, education, and informed choice. Hospital protocols are designed with all the possible complications in mind and are then applied to all women across the board, whereas in an ABC, protocols focus on normality, screening, observation, and when to transfer. In hospitals, pain is defined as an evil to be stamped out with drugs, whereas in the ABC it is understood that labor pain has a physiological function and can be relieved with scientifically proven, nonpharmacological methods such as immersion in water, changing positions, massage, the presence of family, and the continuous presence of the same birth attendant.

In a hospital, labor is frequently induced or stimulated using powerful drugs that increase labor pain and have many risks. In an ABC, labor is very
rarely induced, but may be stimulated using nonpharmacological methods such as walking around and various types of sexual stimulation such as massaging the nipples. In a hospital, there is intermittent attendance by the doctor, with nurses changing shifts every eight hours. In an ABC, the woman's midwife is present for the entire labor and birth. In a hospital, the family does not know the staff, whereas in an ABC, the family knows the staff. In many hospitals, new babies are often taken away from their mothers for various reasons, for example to allow a doctor to perform a newborn examination, whereas in ABCs, babies are never taken from their mothers. In the hospital, when a woman and her baby are discharged, there is no follow-up at the family's home, only a visit to the doctor's office six weeks later. After an ABC birth, in contrast, there are follow-up visits in the ABC or in the family's home.

ABCs are naturally a threat to doctors and hospitals, as well as to the manufacturers of obstetric technologies. Because medicalized birth is so expensive (with a costly hospital stay and highly paid obstetricians using costly high-tech interventions), physicians and hospitals try to convince the public and those who control funding for health services that giving birth in a hospital is the only safe option.

Are ABCs a safe place for a woman to give birth if she has had no complications during the pregnancy? Let's look at the scientific evidence.
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In the 1970s and 1980s, a number of descriptive studies of ABCs were done. Then, in 1989, a seminal paper was published reporting results of the U.S. National Birth Center Study, which looked at eighty-four ABCs and 11,814 births.
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Regarding safety, there were no maternal deaths at all in the U.S. National Birth Center Study. The rate of perinatal deaths (1.3 per 1,000 live births) is comparable to the rates among low-risk hospital births. Sixteen percent of ABC births were transferred to the hospital due to complications, a rate that compares favorably to the number of planned hospital births that are transferred from a labor ward to a surgical suite due to complications. The intention to treat analysis was used (if the intention was to have the birth in the ABC, then all subsequent events such as hospital transfer are recorded in the ABC category), so that all complications, interventions, and outcomes from ABC births that were transferred to a hospital are included in the ABC statistics. The results of this study are clear: ABCs are perfectly safe for the vast majority of pregnant women who have had no serious complications during pregnancy.

Around the same time, several other studies compared ABC birth with
hospital birth, one of which was a randomized, experimental trial.
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These additional studies confirmed the safety of ABCs. In these studies, the outcomes of ABC births were as good or better than the outcomes of low-risk hospitals births. These studies also went beyond safety and found that 99 percent of the women who chose an ABC birth said that they would recommend an ABC birth to their friends, and 94 percent said that they would return to the ABC for future births. These studies found significantly increased rates of successful breast-feeding among women who gave birth in ABCs. And one study found that 63 percent of women who gave birth in ABCs experienced an increase in self-esteem, whereas only 18 percent of women who gave birth in hospitals experienced an increase in self-esteem.

When rates of specific obstetrical interventions in the U.S. National Birth Center Study are compared with rates in hospitals in Illinois, 99 percent of ABC births were spontaneous vaginal births, compared to 55 percent of hospital births.
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Less than 4 percent of ABC births involved induction or augmentation of labor, with artificial rupture of membranes and/or use of oxytocin (Pitocin), compared to 40 percent of hospital births. Only 8 percent of ABC births involved routine use of electronic fetal monitors (i.e., used without a specific indication on all birthing women), whereas monitors were used routinely in 95 percent of hospital births. Anesthesia (including epidural block) was used in 13 percent of ABC births and 42 percent of hospital births. Forceps or a vacuum extractor were used in less than 1 percent of ABC births compared to 10 percent of hospital births. Because any births transferred from an ABC to a hospital were counted in the ABC group, studies were able to compare the percentage of ABC births that ended in C-sections (5 percent) and the percentage of low-risk hospital births that ended in C-sections (21 percent). When we see these results side by side, the logical question is not whether an ABC birth is safe, but whether a hospital birth is safe.

As the good news spreads, more and more ABCs are being established around the world. Between 1990 and 2000, Germany went from having one ABC to having more than seventy.
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In Japan, in the first half of the twentieth century there was a network of midwife-run “birth houses” that provided a significant percentage of maternity services in the country. But during the American occupation after World War II, U.S. Army doctors and nurses put pressure on the Japanese to close the birth houses and move birth to hospitals. Now, there is a resurgence of birth houses in Japan. Located in the homes of local midwives, these birth houses are not only places to give birth, but also places where women can meet other women
in the neighborhood and get restored and revitalized as women. They receive midwifery care during pregnancy and at the birth, which takes place at a birth house. All the women in the neighborhood receive information on pregnancy, birth, and other women's health concerns and also discuss women's issues and personal problems.
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In the United States, in spite of the scientific evidence showing that ABCs are a perfectly safe choice for most women, the aggressive obstetric campaign against out-of-hospital birth has taken a toll. In Illinois, ABCs are outlawed, and repeated efforts made by women's groups to change the law have failed. At a meeting of the Illinois Medical Society in Chicago (the Illinois chapter of ACOG), hospital organizations testified that ABCs are dangerous. They had no scientific data to back up their statements, just testimonials that they know ABCs are dangerous. When a bill on ABCs comes up, these organizations also testify before the Illinois state legislature. In collusion with these hospital and doctor organizations, the Illinois State Health Department insists that all ABCs must meet the same regulations as hospitals, a nonsensical strategy designed to keep ABCs out.