Adding Up 30 Years of Childbirth Advocacy: How Far Have We Come?

It is 30 years since I gave birth to our first child in the United States, 30 years working as a childbirth advocate, and 10 years working as editor of Birth. Looking back, I am struck by how far maternity care has come in some respects, but how little has been gained in others, especially in reforms that focus on healthy, normal pregnancy and birth. Thirty years ago midwives were illegal in New York state, and birth centers did not exist. So that my husband could be with me in the delivery room, I had to change hospitals and obstetricians. I felt lucky to achieve some other goals for a “natural” birth—to have my wrists not strapped to the delivery table, to have no drugs, to avoid an episiotomy, to room-in with my baby, and to ensure he did not receive formula when in the nursery. The other unnecessary indignities of the day, partial shave (with a very blunt razor), enema, legs in stirrups, and flat-on-the back delivery, could not be avoided. I won some issues, compromised on some, and lost others. So it was then, and so it is today. Some of the issues, the policies, and the care practices have changed over the past 30 years, but many of the struggles for women to have a safe and intervention-free birth are the same, and many of the changes in hospitals are only cosmetic. The power structure remains as before. Yes, it is certainly good that hospitals now offer family-centered birthing units and show greater sensitivity to a woman's and family's social and emotional needs than in the past. It is also especially good that more midwives and doulas are available in more hospitals than before ( 1), and that birth centers have opened across the United States. Prenatal care use is increasing, birth rates for teenagers are declining, and infant mortality has dropped—all positive trends. Other developments, however, some of them described in this issue of Birth ( 2-4), arouse real concerns. Of course the biggest change to all aspects of our lives, including health care, has been progress in technology. With it have come many benefits, including improved neonatal outcomes, but at the same time technology has become accepted as a “normal” part of childbirth for many women. They have become convinced that “more is better.” In North America some women choose and expect to have an ultrasound scan, an epidural, and a cesarean, all on demand, thus contributing to the high-tech, high-speed, pain-free trend for labor and birth. As one advocate noted, “Birth now seems just a means to an end.” Most women are content to be passive observers and performers, removed from the birth process as others take over the job for them. Cesareans are now increasing again, after dropping from a high of nearly 25 percent in 1988, report Curtin et al in this issue of Birth ( 2). Other countries are following the lead from North America. For example, in Brazil and other Latin American countries the epidemic of cesareans has become culturally accepted, despite safety concerns ( 5). Proponents argue, on the other hand, that “all women should have a choice” ( 6)—a choice, that is, between a vaginal and a cesarean delivery. If this is the way childbirth is headed, at least let us all make sure that women are given the facts about safety so that their choices can be informed. The rates for other obstetric procedures are steadily increasing in the United States ( 1). Induction and stimulation of labor, electronic fetal monitoring, ultrasound examinations, and epidural analgesia are all on the rise. Public debate about the trend continues between the medical profession and proponents for safe and noninterventive childbirth ( 7). But is it true that more is really better? A recent government report observes that “More research is needed to determine whether these changes are resulting in better maternal and perinatal outcomes ( 1). In addition, as Hoyert et al report, maternal mortality has not improved since 1982, the racial disparity between blacks and whites in access to care and birth outcomes is alarming, and the risk of black women dying in childbirth is nearly four times that of white women ( 3). Resistance from most medical professionals and institutions toward midwives, home births, and free-standing birth centers persists. Although it is true that today in the United States ( 1) and other developed countries, many women now have more choices for their caregiver and place of birth, many other women do not. A two-level system often exists in which those women at greatest need receive the poorest care and fewest choices. The inroads of managed care, hospital mergers, and other cost-containment strategies around the United States have resulted in the loss of some reproductive health services, cutbacks in nursing staff, loss of midwifery programs, and less education and support for women. Fewer nursing staff means that mothers and babies receive less high-quality care and attention. Those nurses who remain are overworked and exhausted. They rush from one room to the next, from one job to the next, and their joy in caregiving diminishes. They have little time for educating the new mother, and she goes home unprepared for her new role. Excellent, and undervalued, nurses leave the maternity care field, and sad to say, move on to other jobs, their dedication and expertise lost to future mothers-to-be and their babies. Those who remain face other challenges of working in hospitals that treat each childbearing woman as a sick patient, as Sleutel describes in this issue ( 4). Nurses face and must cope with moral dilemmas in practice and nurse-physician conflicts in caring for childbearing women in a system under medical control, where labor and birth are often hastened by various means to get the baby out ( 4). When nurses and midwives are in short supply, and caregivers work in a climate of fear of a potential lawsuit, it can change the way they practice. They may perceive that it is easier and more risk free for them to hook every woman up to a fetal monitor, to move labor along with oxytocin, to keep patients under control with epidural analgesia, and to have the baby delivered as soon as possible. In addition, nurses have so much paperwork, charting, equipment monitoring, and other jobs to do away from the bedside that it is no wonder that the amount of time spent giving support to the mother is less than 10 percent, as two Canadian studies showed ( 8, 9). By comparison, the one-to-one care given in a midwife-led birth center that focuses on normal childbirth offers women and families an altogether different experience, as women's and consumer advocacy groups affirm ( 10, 11). Even if women choose, as some do, to have all the technology that is available to them, they still need caring practitioners at their bedside. In a system where saving money and maintaining the medical model of care take priority, those health care professionals, childbirth educators, and consumer advocates who complain, “rock the boat,” or try to initiate changes often face threats to their job security and loss of professional credibility. They have to make compromises in what they say and how they practice if they want to keep working in their field. It is a balancing act that is all too familiar! To go far enough in suggesting reforms and raising consciousness, but not so far that they offend and antagonize the intended audience—that is the goal. As one consumer advocate said to me recently, “We always have to be assuaging the powers that be because otherwise we could make no inroads at all.” In her thoughtful commentary, Peters describes the findings of Sleutel's study as “disturbing,” and notes that solutions will be difficult to achieve ( 12). As she and childbirth reformers have urged, the reality of what is happening in today's hospitals in the United States and other countries needs to be openly acknowledged and discussed by health caregivers and the public. They need to come together in a nonthreatening forum to talk and to listen. Peters concludes that, “most important and challenging, there needs to be widespread professional and public resistance to the power of medicine,” a power that enables the practice of ethically questionable obstetric care by some physicians and nurses ( 12). It is clear that the current maternity care system will continue into the new millennium as it has for the past 40 years—with a medical, surgical, and technological orientation and with the power structure of the past intact. Those professionals, educators, and advocates who support normal pregnancy and birth know, and the evidence shows, that nonmedical births can be achieved safely for mothers and babies in a woman-centered, midwifery-led system with medical backup when needed. They owe it to the childbearing women of the future to pass on their knowledge and to continue their efforts toward maternity health care reform.

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