Is the Medical Model of Birth Really Better - Guest Writer Colleen Mahon-Haft

Since the 1940s and 1950s, the maternity care system in the United States has overwhelmingly involved hospital births and an increasing number of surgical and drug-related interventions, making birth a highly medicalized event.  With this paradigm shift towards use of our advanced medical technologies and well-trained doctors, why does the United States not have better maternal and neonatal outcomes? 

The use of hospitals in the United States for childbearing started in the early 19th century for women who did not have suitable homes. In 1900, less than 5% of women gave birth in hospitals (Starr1984).  The proportion of births occurring in hospitals rose from 37% in 1935 to 97% in 1960, and reached 99% by the 1970’s (Rooks, 1997). By the 1940's, the standard was set, and hospital births became the cultural ideal. The idea was that at the hospital the doctor had all the "tools of the trade" readily available. Unfortunately, this was and continues to be a major downfall of hospital birth. Included in those tools were medications, forceps, surgical instruments, confinement to bed, enemas, pubic shaving, arm and leg restraints, and hospital nurseries with rigid schedules. Birth came to be seen as an illness that required medical attention.

• The modern medical way of birthing is not producing better results; it is interfering with the instinctual process of birth. The World Health Report (from the World Health Organization) indicates that the neonatal death rate (death in the first twenty-eight days of life) is greater in the United States than in thirty-five other developed countries (WHO 2005).
• The maternal mortality rate in the U.S. is the highest it has been in decades, according to statistics released by the Center for Disease Control (Hamilton et al 2005). According to the figures, the U.S. maternal mortality rate was 13 deaths per 100,000 live births in 2004. In 2006 a shocking one in 4,800 U.S. women dies from complications of pregnancy or childbirth (United Nations 2006).
• The U.S. ranks 41^st out of 171 nations, behind even some nations without similar technology and resources, such as South Korea. Despite our enormous wealth and highly advanced technology, the United States lags far behind most other industrialized countries, and even some developing nations, in providing adequate health care to women during pregnancy and childbirth. 
  

In countries where laboring mothers are not subjected to the medical model, the maternal and neonatal death rates are significantly lower. In the five European countries with the lowest infant mortality rates, midwives (who practice holistic care) preside at more than 70% all births. More than half of all Dutch babies are born at home with midwives in attendance, and Holland’s maternal and infant mortality rates are far lower than in the United States (Otis 1990). The United States has more neonatologists and neonatal intensive care beds per person than Australia, Canada and the United Kingdom, but the newborn death rate in the U.S. is higher than in any of those nations (Lawn, et al 2005).  

The international standing of United States (in terms of infant mortality rates) did not begin to fall until the mid-1950s. This correlates perfectly with the founding of the American College of Obstetricians and Gynecologists (ACOG) in 1951. ACOG is a trade union representing the financial and professional interests of obstetricians who has sought to secure a monopoly in pregnancy and childbirth services. Prior to ACOG, the U.S. always ranked in 10th place or better. Since the mid-1950’s the U.S. has consistently ranked below 12th place and has not been above 16th place since 1975 (Stewart, 1993).

Today in the United States, not only do nearly all births take place in a hospital, but they often involve unnecessary medical procedures that can actually make the natural birth process more dangerous. Women are wheeled in to “labor suites” where they are hooked up to machines, strapped with monitors, given (usually) unnecessary intravenous fluids, and put “on the clock.” 

Home and birth centers definitely have opponents, but the statistical evidence states that if you are a healthy low risk woman, having your baby in a hospital is riskier than home or birth center. One set of midwives in Tennessee had 2,028 planned homebirths from 1970 until 2000.  Ninety-eight percent of them delivered vaginally with a 1.3% emergency transport rate and a 1.4% Cesarean rate (Gaskin 2002).

There is not a hospital in this country with numbers as low as that. Why? Because the midwives let birth happen. They do not rush to induce, they do not perform unnecessary tests, they just let the mother birth her baby, and the majority of the time, it is uncomplicated and not a medical event. The paradigm shift towards medical birth is hurting this country, and unnecessarily killing and injuring many women and newborns each year.  

Waiting for Birth - Guest Writer Series from the Portland Birth Collective

There is a lot of anticipation involved in awaiting an upcoming birth, both for birth professionals and for excited families.  Birth is dynamic and diverse, and though we attempt to assign dates to this spontaneous process, the “due dates” are very rarely the actual date upon which the baby decides to arrive. We have no real power over the date when our baby comes. This is a challenge for families because often they expect to meet their baby after 40 weeks gestation, and because following their due date there may be pressure from their health care providers to induce labor. This article will provided suggestions and assurances for families awaiting the spontaneous birth of a baby.

Waiting for your baby: Surpassing 40 weeks gestation in your pregnancy

Expected gestational age of an infant is approximately 40 weeks. This is the basis upon which an estimated due date is calculated. Due date is 40 weeks after the last menstrual period and based on an average cycle of 28 days. While in calculating averages and quantifying biologically processes this is fairly accurate, it is not necessarily always the case. Menstrual cycles are not all 28 days long, and not all babies take exactly 40 weeks to mature. Rather than considering the estimated due date a helpful tool to help us understand when to expect a baby, we have begun to consider it a rule for when the baby must come. It is this misuse of the 40 week marker that presents unnecessary challenges for birthing families. 

Consider that in the United Kingdom gestation is considered complete after 42 weeks. Are our babies biologically different than babies in the United Kingdom? No, rather our interpretations of what gestational age means are. Consider also that this is a country where homebirth is a widely accepted norm. 

Gestational age is a helpful guideline. Much like two pieces of fruit do not ripen at precisely the same time, women are unique and diverse and the way that their bodies function, while remarkably similar, are different and we should allow those differences to exist, appreciate and embrace them. 

Once a 40 week due date is surpassed most women will be asked to have regular ultrasounds and non-stress tests to ensure the health of their baby. If these tests show a healthy baby there should be absolutely no reason to suggest intervention at that time. A myth that babies will grow to be too large for us to birth is often perpetrated by birth practitioners and frightens many women into unnecessary inductions. This is widely believed misinformation. Our bodies are wise and we must trust that we are not going to grow babies too large for us to pass. Our species is extremely efficient and functional, and believing in that is the key to a healthy birth. 

There are more natural and more medically interventive means of inducing childbirth, but unless there is a medical indication to do so, both should be avoided. Women can safely go many weeks over 40 weeks gestation as long as their health is monitored by supportive birth practitioners. Women have the right to refuse any intervention.  I encourage you to do your own research regarding the risks of induction versus post-dates pregnancies. You can then make a decision that suits you. 

While, after 40 weeks, pregnancy can be uncomfortable and the anticipation of meeting your newborn can be a great motivator for induction, it is important to allow nature to take its course and not to attempt to artificially hasten the process. In doing that we are sending our bodies a strong message about their efficacy and setting ourselves up for a potential cascade of unnecessary interventions following the first. 

All of that being said, when medically indicated, induction can be a lifesaving procedure. When it is necessary it often works efficiently and provides necessary results. It is essential for you to be aware of what presents a real medical indication for induction and what does not. Do not be afraid to ask for a second opinion. Your birth is in your hands, and you are the one who needs to decide what is best based on information from professionals, good science and intuition. 

Tips for anxious parents awaiting a post-dates child:

-Speak to your health care provider in advance about their protocols regarding post-dates pregnancies
-Ensure your due date is accurate by calculating it yourself based on the length of your cycle, or ideally your date of conception
-Abandon your attachment to a specific due date. Think more in terms of “due week”, or “due month”
-Trust your body. It is wise and knows just what to do. Your baby will come when they are ready
-Keep yourself occupied. Pregnant women often do not schedule activities beyond their due date because they expect to have their babies. When the babe has not arrived they find themselves idly waiting for their upcoming birth. Scheduling self care appointments such as massages and pedicures can be a nice treat and something to look forward to post-due date. Appointments can be cancelled. Projects such as crafting, making things for the baby, and cooking and freezing foods for the postpartum period are pleasant and useful distractions for the post dates period
-Get exercise. Lots of exercise helps prepare for the physical act of childbirth, gets the baby in an optimal position for birth, and can hasten the onset of labour. Long walks, yoga, and swimming are enjoyable and gentle exercises for late pregnancy
-Enjoy some alone time. If this is your first child you are about to enter into a period of your life where you will have very little time to yourself compared to what you may be used to. Take the last weeks of your pregnancy to enjoy some quiet solitude
-Indulge. Spoil yourself with some of your favourite self-centered activities such as eating lots of chocolate or going shopping. Obviously activities should not be harmful to your health or that of the baby.
-Communicate with your baby. If you are getting uncomfortable in late pregnancy and want the baby to come, explain to the child that you are excited to meet them, that you have a warm and safe place outside for him or her, and that the passage out will be safe and peaceful.
-Process any emotions or fears you have about birth or mothering. Occasionally fear about birth or uncertainty about parenting can prevent the onset of labor. Welcoming birth and motherhood can help. Discussion and emotional work with your partner, Doula, midwife or therapist will benefit you in your transition into parenthood

Congratulations on the upcoming birth of your child. Trust yourself. Women’s bodies are infinitely wise.

-By Stephanie Elliott
Portland Birth Collective

Breast is the Best, Even if You’re Three - Guest Writer Series

The following article, written by Colleen Mahon-Haft, is an informative piece on extended breastfeeding. Welcome Colleen to Healing Midiwfery!

Last year a Delta Airlines employee asked a nursing mother to put a blanket on her child’s head, because she said seeing the toddler nurse was“weird” and made her uncomfortable. The flight attendant reacted in this manner simply because extended nursing, when a baby nurses past a year old, is not the norm in United States culture. As a result, virtually any mother of a nursing toddler can recall dirty looks she has received while nursing in public and is likely to have horror stories of more confrontational judgments from strangers, like the mother on the plane.

 

Mothers in the US generally wean before twelve months, most at six months or earlier.  A mere 14% of mothers still nurse their babies at seven months of age (Le Leche League International 1997).  However, breast milk is the optimal food not only during infancy but also into toddler-hood, and if more mothers were aware of the benefits of extended nursing, they would not look at it as “weird” and would be proud to offer their baby the best nutrition possible.  U.S. culture, many American doctors, and the mainstream media discourage extended breastfeeding, in the process attaching shame and embarrassment to a natural feeding process that is extremely beneficial to the child’s well being.  

A child can only absorb 10% of the iron from cow’s milk, while 50% of the iron from breast milk’s can be absorbed (Eiger and Olds 1999).  Additionally, “human milk contains living cells, hormones, active enzymes, immunoglobulins and compounds with unique structures that cannot be replicated in infant formula" (Benson, Masor March 1994).   For this reason, when both mother and baby are healthy, the Food and Drug Administration, the Center for Disease Control, and the World Health Organization all advise nursing for a year or longer, as long as mother and baby are comfortable.

 Beyond the nutrient content of breast milk, extended nursing also provides a crucial boost to children’s immature immune systems. Until the age of six a child's immune system isn't functioning at adult level, which leads parents to shield them from sick neighbors, bundle them up during the winter, and make sure they don’t leave the house with a wet head.  Still, by nursing for a limited time, many mothers pass up the opportunity to directly provide young children with what it needs to fight off a cold or the flu. The composition of mother’s milk provides infants and toddlers with vitamin E, which is crucial for immune system development, along with enzymes, proteins and already developed antibodies that are essential to developing and maintaining good health. For this reason, breastfeeding has been directly associated with fewer infant illnesses, and extended breastfeeding subsequently with fewer toddler illnesses (Gluiuk 1996).

Not only does extended nursing have great health benefits, it also plays an important role in mother/child bonding and later social bonding. Extended breastfeeding gives mothers and toddlers special time to be together, experiencing each other’s closeness. Getting a toddler to slow down can be challenging, so the time spent nursing is needed and enjoyed. Oxytocin and Prolactin are released into the mother’s body during nursing,  Both hormones have been referred to as the "love hormones" or the "bonding hormones.”  Those hormones provide a sense of calm to the mother, promoting bonding and creating desire for further contact with the child.  

Adversaries to extended nursing suggest that extended nursing makes weaning more difficult and leads children to be overly dependent, therefore advocating that mother’s force their babies to wean on a set time frame.  In reality, forced weaning can be a frustrating experience for both, as it requires fighting biological instincts to continue nursing. On the other hand, child-led weaning tends to be much easier on the mother and toddler as all children will eventually give up the breast when they feel the cues to do so.  Often, they will set their own time frames, such as “when I’m four” or “after Santa comes.” 

There is evidence that child-led weaning is beneficial for the social development of children. Dr. William Sears (The Breastfeeding Book 2000), having studied the long-term impacts of the weaning process on thousands of children, reports that “children who had timely weanings… are more independent, gravitate to people more than things, are easier to discipline, experience less anger, radiate trust.… [After] studying the long-term effects of long-term breastfeeding, the most secure... and happy children we have seen are those who have not been weaned before their time” (Sears 2000).  Thus, despite what opponents of extended breastfeeding suggest, research on childhood development shows that toddlers who nurse will not be clingy and overly  dependent, and are actually likely to be more trusting, independent, and happier than children who are force-weaned.

Additionally, extended nursing benefits children in ways that extend all the way to school age. One study found that school age children who were breastfed as infants and toddlers have I.Q. scores averaging seven to ten points higher than formula-fed infants (Dr. Sears 2000). Breastfed babies and toddlers also have the privilege of receiving high levels of DHA (docasahexaenoic acid), which is a brain boosting fat, found in cold water fish and in seaweed.  DHA is essential for the proper development of the nervous system and vision (Memmler’s 2005). DHA levels are highest in babies who are breastfed the longest. The cognitive development of babies fed formula does not equal that of those who are breastfed (Dr. Sears 2000).  

Mothers who nurse their babies into toddler-hood are doing themselves and their little ones a great service physically, socially, intellectually and emotionally.  They are providing comfort and nourishment that will affect the children their entire lives. Breastfeeding is also a life-affirming act of love. If you have ever observed an older baby or toddler nursing, you can see that there is something almost magical, something very special about the mother/ child bond.  With such strong evidence of the positive effects of extended nursing, the pattern of limited breastfeeding in the United States is puzzling.