Born in the USA (39 page)

Midwives will also train first-year obstetric residents in the management of common complications that can be handled without resorting to surgical interventions—for example, turning breech babies late in pregnancy, managing VBAC, managing vaginal breech birth, managing shoulder dystocia, and managing other less common fetal birth positions such as posterior lie. This will also create frequent opportunities for information exchange between obstetricians in training and midwives. There is at least some precedent for this. Ina May Gaskin, the direct-entry, home birth midwife and author mentioned earlier, developed a special maneuver for managing shoulder dystocia (when a baby's shoulder gets stuck after the head is already out). This breakthrough maneuver has been published in the obstetric literature.
³²
Gaskin has also trained obstetric residents in this maneuver in a number of hospitals in the United States, and the “Gaskin maneuver” is now widely practiced by obstetricians.

In Scandinavia, Great Britain, and many other industrialized countries, first-year obstetrical residents are routinely trained by midwives, which not only passes on midwifery knowledge to young doctors but helps them to see the essential role midwifery plays in maternity care and encourages communication and respect between the two groups. There is a precedent for providing obstetricians in training with experience in planned out-of-hospital birth as well. In some training programs in the Philippines, obstetricians can't be certified until they've attended at least ten planned out-of-hospital births.
³³

One reason women have been so willing to give up their autonomy when it comes to childbirth is that they are afraid, and much of this fear is the result of ignorance. In modern American society, where most people live only with nuclear family members, there are rarely opportunities for young girls to actually witness childbirth and ask questions. What we have instead are a lot of childbirth books that tell women to trust doctors and turn their
care over to them because birth is a medical event and demands highly trained experts.

An educated public would grease the wheels of change in a number of ways, one being that it would make women better consumers when they considered birth options. Education would also make women feel more confident taking ownership of their own experience. When women begin to understand that maternity care is a women's issue, change really takes off.

Beginning early in elementary school, children would be taught the wonders of human reproduction, and this education would continue into high school. Midwives would be invited to schools to talk about conception, pregnancy, and childbirth. Girls and boys would see films on childbirth and go on field trips to the neighborhood women's center. Adolescent girls would have an opportunity to observe actual childbirth, just as they have throughout history until recently, when childbirth was moved to the hospital and girls were forbidden to join their mothers.

Midwives working in local women's centers would play a large role in educating children in local schools, and also in educating women. The center would facilitate self-help and support groups for pregnant women in which women can offer one another prenatal and postnatal care under the guidance of the midwife while learning about their bodies, pregnancy, childbirth, breast-feeding, early childhood care, and family planning. (See the discussion earlier in this chapter on self-help prenatal groups.)

The media also play an important role in educating the public. As the average birth experience changes in the United States, I would expect to see the media, especially television, depict childbirth as a normal part of family life, with scenes of childbirth as it occurs in women's centers, with midwives attending and with no medical trappings. I would also expect to see more books about pregnancy and childbirth that emphasize the social, cultural, and physiological aspects of normal birth and its place in the life cycle, and that show that women can take responsibility for what happens to them during pregnancy and birth.

The United States has a serious problem with unwanted teenage pregnancies. Denmark and the Netherlands share the honor of having the lowest rates of unwanted teenage pregnancy in the world. What is their magic? They both do an excellent job of educating young people about human reproduction and sexuality, starting in the first grade. By the time their citizens are twelve years old, they know how to prevent unwanted pregnancy. In many additional places in the world, public education about pregnancy
and childbirth is in place and there is no shame about the body, no shame about sexuality, no shame about birth. Shame leads to ignorance, which leads to more shame—and ignorance and shame also lead to unwanted pregnancies and higher rates of maternal and infant mortality. The solution to this vicious ignorance/shame cycle is education. Just say no to ignorance and shame.

Never doubt that a small group of thoughtful, committed people can change the world. Indeed, it is the only thing that ever has.

MARGARET MEAD

We Americans are consumed with the need to believe that we are number one. But here's a wrenching fact: forty-one countries have better infant mortality rates than the United States does. In 2002, our infant mortality rate went up, not down, and if the United States had an infant mortality rate as good as Cuba's, we would save an additional 2,212 American babies a year.
¹
And mothers? Women are 70 percent more likely to die in childbirth in America than in Europe, and the rate of women dying in childbirth in America has been going up every year for more than twenty years.
²

But things are changing in maternity care in the United States, and in this chapter I will look at how things are changing and how we can work to promote the vision of maternity care I described in
chapter 8
.

Just as those who never make mistakes can never learn from them, so too those who must always be number one can never learn from others. So to begin, it helps to view changes in maternity care from a global and historical perspective, paying particular attention to how services tend to improve or evolve. In the chart “Global Evolution of Birthing Practices,” I've focused on the autonomy of birthing women and midwives because I see that as the
key variable for determining where a country or region is in the evolutionary process. In countries at the top of the chart, women and midwives have a high degree of autonomy; in countries at the bottom, they have little or no autonomy. The chart illustrates where countries lie at this time. I've put them in these positions based on the knowledge of their maternity care systems I've gleaned from personal visits as well as from published reports, World Health Organization reports in particular. Of course the placement is a bit arbitrary—the evolution of maternity care is by no means static and one might argue that the Netherlands should be higher on the chart than New Zealand, for example—but the overall pattern is certainly valid.

Global evolution of birthing practices.

Until around three hundred years ago, all countries in the world were at the top of the circle, with almost all birthing women having control over their own childbirth. Midwives were autonomous care providers who assisted women during childbirth. Essentially, the woman and midwife worked together without outside interference because of the nearly universal cultural taboo against men getting involved in women's reproductive activities. Just as in the past menstruating women had been isolated, birthing women were isolated with no men allowed nearby.

With the gradual introduction of men and “barber-surgeons” (precursors of today's medical surgeons) into maternity care, both birthing women and midwives gradually lost their autonomy in childbirth, and as childbirth became less woman-centered, countries slowly moved down the left side of the circle. Today, many developing countries are in this early part of the maternity care evolutionary cycle. Their urban areas are “modernizing” maternity care by bringing in obstetricians and hospitals, while the women in rural areas still use indigenous midwives.

Eventually, a country reaches the bottom of the circle, where the global goal of “development” has penetrated and the government and the population are eager to be “modern.” China, Russia, and much of Latin America serve as examples here. Birthing women in these countries are no longer allowed to decide what happens during their pregnancy and birth, and midwives are nothing more than slaves to doctors.

I have worked in Russia for many months and have seen the conditions with my own eyes. All births take place in hospitals, with the woman giving birth placed on a cold, hard table with her feet up in stirrups, surrounded by doctors, with midwives running around doing doctors' bidding. A woman is assigned to a maternity hospital and has absolutely no choice about anything to do with her pregnancy and birth. No family members, husband included, are ever permitted into the maternity hospital, where the woman remains for ten to fourteen days after birth. It is not unusual to see husbands standing outside in the hospital yard waving to their wives, who are leaning out windows several stories up and waving back.

Then something happens in the countries at the bottom of the chart. It varies from country to country, but whatever it is, when things get really bad and women's reproductive freedom is abused severely enough, some precipitating factor or series of events finally brings women's attention to the power doctors hold over their reproductive lives. This leads to women's disillusionment, anger, and resentment and a call to action. This reaction
may go more quickly in developed countries, where there is at least some degree of freedom and women's rights in place, but it can also be the start of these rights and freedoms.

Although midwives in countries at the bottom of the chart tend to be divided into those who accept the status quo and those who want to change it, this precipitating factor angers the midwives as well. They join with the angry women (often forming coalitions that also include scientists, journalists, some politicians, and some doctors and nurses) to start the long, difficult process of regaining their women's autonomy in childbirth and reproduction, moving the country up the right side of the circle.

Looking at how this played out in particular countries can provide important lessons for us in how to go about getting the United States to where it needs to be. In
chapter 8
, I described how this happened in Canada, where the arrest of a home birth midwife in Toronto led to a coroner's inquest, which led ultimately to the government legalizing midwifery.

Germany is another good example of the struggle to regain autonomy. In the 1980s, the national organization of German obstetricians went to the federal government and demanded that all out-of-hospital births be forbidden by law. Suddenly, German midwives woke up, German women's organizations woke up; they formed coalitions and worked together to plan an opposition strategy. They collected ammunition in the form of scientific data and policy documents from other countries and from WHO and descended on their legislators and the media. It was a battle, but in the end they were successful. Out-of-hospital birth was not outlawed in Germany, and there is now a strong, wide-awake lobby of German women and midwives who stand ready to oppose any further attempts on the part of German obstetricians to take away birth options.

As a result of this struggle, a large number of German midwives have since left hospitals to become community midwives attending births at home and at out-of-hospital birth centers. Today, approximately one-quarter of the midwives in Germany are working primarily outside of hospitals, and the number of out-of-hospital alternative birth centers (ABCs) has increased from one in 1990 to more than seventy in 2003.
³
This happened despite fierce resistance from the German obstetric establishment, which repeatedly told women that out-of-hospital birth would put their babies in jeopardy. Germany demonstrates that it is possible to change a maternity care system without the blessing of obstetricians, an important lesson for the United States. It seems there is at least one thing more powerful than the medical establishment: women, when they are angry and get organized.

Around the same time, there was a similar angry reaction among women in New Zealand. A professor of obstetrics at a university hospital conducted an experimental, randomized trial to try to further confirm if a particular screening test for cervical cancer worked: the Pap test, named after the doctor who first described it, Dr. Papanicoleau.
⁴
The study looked at women who had positive Pap tests. The group with positive screening tests was divided in half: one half received follow-up and treatment for cancer, and the other half received no treatment. Over time, an increasing number of women in the group that received no treatment died from cervical cancer—but the experiment continued. Then a journalist got wind of the situation and wrote about the study. Women in New Zealand were outraged. The country's entire obstetric profession lost credibility.