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"If left alone in labor, the body of a woman produces most easily the baby that is not interfered with... If left alone, just courage and patience are required." Grantly Dick-Read1

As I wrap up three years of chiropractic education, my overall impression of the purpose of the chiropractic profession is to promote health and wellness by allowing the nervous system and the body to work to their maximum potential. We do not promote drugs or surgery, but as doctors,we recognize a time and need for referrals to appropriate health care providers for cases beyond the chiropractic scope of practice. Keeping those things in mind, I’ve been very surprised throughout my pregnancy to encounter numerous chiropractors (doctors and interns alike) who tend to view pregnancy and the birth process as a disease needing medical intervention instead of as a natural process. It’s rare for me to find a colleague with whom I can freely discuss my views on how I wish to proceed with my prenatal care as well as delivering through a home birth with the support of a certified professional midwife. In fact, the opposite holds true, and colleagues scorn me for some of the decisions that I’ve made, merely because they disagree with me and wholeheartedly support a medical model for the entire duration of care.

The purpose of this article is to provide insight into the status quo of women’s choices for births and their outcomes in America, and to contrast those choices with those of women in other countries. Primarily, this article will dispel some of the fears and concerns about home birth and the use of midwifery for delivery. As health care providers, we have the responsibility to serve and educate our patients to achieve their optimal potential in health. Health decisions ultimately reside with the patients, and we should seek to understand options available to them in order to provide suggestions or to be able to support their decisions. Whether or not you would personally pursue a home birth with a midwife for your pregnancy or that of an immediate family member, I hope you will at least consider the information presented in this article to better understand the options available to your patients.

Often, women scour numerous books to learn more about the metamorphosis of pregnancy, the birth process, and how to care for a newborn. The scores of books can be intimidating and full of a wide spectrum of opinions. I’ve read numerous books as well, and I find that most of the mainstream books2,3 on pregnancy that are valuable and extremely thorough tend to support the medical model of birth and hospital delivery. So, I was pleased to discover a full-spectrum book on birthing written by a former director of Women and Children’s Health at the World Health Organization. Dr. Wagner’s Creating Your Birth Plan4 is extremely supportive of midwifery and birthing centers. His book discusses all options of birthing available to women in America as well as a first-hand and somewhat critical perspective on the ob/gyn profession as it relates to child birth.

Wagner writes, “More than four million American women give birth each year, wither more than 95 percent of them in hospitals. They choose hospitals for a variety of reasons having to do with the incorrect idea that hospitals can provide the safest births. Although women sometimes choose to labor in hospitals because they have no access to a home-birth midwife, or because an insurance company mandates the decision, often it’s because they believe that a doctor can guarantee their safety in case of an emergency. Another reason women choose hospitals is to have access to strong pain medication—epidurals.”

According to Wagner, “the United States and Canada are the only countries in the world where highly trained surgeons (obstetricians) supposedly attend the majority of normal, low-risk births. The American obstetrician is expected to be all things to all women, from primary-care provider for 4 million normal, healthy pregnant women every year, to specialist in complications of pregnancy and birth for 400,000 women every year, to provider of preventative gynecology, such as cancer screening and family planning, to specialist in women’s diseases, and skilled surgeon. No other kind of doctor tries to maintain competence in so many areas.”4

“Is an obstetrician truly able to do six hours of painstaking gynecological surgery on a womanwith extensive cancer, and then rush to the office and do the best job of patiently counseling a healthy pregnant woman about her sex life? Not likely. Because obstetricians are surgeons, they often turn birth into a surgical procedure. Proof of this is that the birthing woman is treated as though she is a surgical patient by putting her on her back in a bed, which is really a modified surgical table, often with her legs up in surgical stirrups. . . this is the worst of all possible positions for the woman giving birth, as in this position the baby’s head compresses the woman’s main blood vessel supplying the womb and the baby.”

“Official statistics report that doctors are the primary birth attendants in more than 90 percent of births. In reality, for most hospital births, the real birth attendant is the labor-and-delivery nurse. . . in the maternity ward, she is usually responsible for simultaneously monitoring several women in labor, and she can rarely provide an individual woman with continuous one-on-one care. Eight-hour shift changes among the staff also means there is no possibility for continuous monitoring by the same nurse during a woman’s entire labor.”4

“Data prove that unfragmented care from the same birth attendant correlates with shorter labor, less pain, fewer complications, and better outcomes. Unfortunately, the only woman likely to get this safest, most effective type of care during labor and birth are the less than 10 percent who have chosen to be attended by a midwife rather than an obstetrician and his or her hospital’s team of labor-and-delivery nurses.”4

“Having an obstetric surgeon attend a healthy birth is like having a pediatric surgeon baby-sit a healthy two-year-old. Both are going to be tempted to apply medical solutions to everyday situations, such as using drugs to stimulate normal labor or narcotics to put a fussy toddler to sleep. Unfortunately, using highly trained surgeons to handle normal life experiences, such as childbirth, increases unnecessary and risky interventions, decreases women’s satisfaction, and wastes huge amounts of money.”4

“A major problem arising from the obstetric near-monopoly over childbirth in America is the extreme medicalization of normal pregnancy and birth. . since obstetricians have been specially trained to manage the few cases of truly high-risk birth—[they] often end up fearing the birth process. . . A pervasive sense that “trouble is imminent” leads some obstetricians to jump in way too early with interventions. Some obstetricians promote radical, invasive interventions [due to] their fundamental belief in machines and fundamental lack of belief in women and their bodies through use of ultrasound technology to estimate the length of pregnancy rather than trusting a woman’s knowledge about her body.”4

Wagner continues, “As a result of our reliance on hospitals and doctors, birth in America has come to be perceived as a medical event rather than a natural one. We spend twice as much as any other country in the world per birth, because medical technology and drugs are highly esteemed and widely available, and we want to purchase the best care. Even in normal pregnancies, our rate for interventions, like electronic fetal monitoring, labor induction and augmentation, and cesarean section, is skyrocketing. Nonetheless, many other countries get better results than we do using less technology and fewer medications.”4

How does the United States compare with other countries for reproductive care and neonatal health?
“After years of steady progress toward improved health in the U.S., there are signs of a downturn that may soon translate into movement in the wrong direction, according to a report released at the 132nd annual meeting of the American Public Health Association (APHA). The report, "America's Health State: State Health Rankings," uncovers key troubling trends: one including the first rise in infant mortality rates in four decades. The increase in infant mortality from 6.9 to 7.0 births per 1,000 puts the U.S. 28th internationally in infant mortality, as well as the finding that 14 states have preterm birth rates that exceed 13%.”6

‘"Birth today has become a technological experience where a natural process has been replaced with artificial procedures and schedules. Without the necessary support during pregnancy, women enter the birth process with fear and are led to rely on drugs instead of their bodies’ ownnatural strengths. These drugs weaken her body’s ability to function and lead to even further interventions. The more interventions used in birth, the greater the risk of injury to both the mother and baby.6

“The U.S. has significantly greater neonatal intensive care resources per capita, compared with three other developed countries, without having consistently better birth weight-specific mortality. Despite low birth weight rates that exceed other countries, the United States has proportionately more providers per low birth weight infant, but offers less extensive preconception and prenatal services. This study questions the effectiveness of the current distribution of U.S. reproductive care resources and its emphasis on neonatal intensive care.”8

The Reality of C-Sections
“The number of Cesarean sections performed in the United States has more than quadrupled since 1970, making C-sections the most frequently performed surgical procedure. Today mostmoms can say they either know someone who has had a Cesarean section or have had one themselves. It’s no wonder, because C-section rates are higher than ever—the procedure is performed in more than 30 percent of all deliveries.”7,9

There are multiple reasons for the increase including a complexity of medical, legal, and social issues. Infertility treatments result in more multiple births which are commonly delivered surgically. Increased rates of obesity and diabetes have lead to larger babies and more difficult deliveries. “As a society, we’ve moved further away from ‘natural’ labor. Much of early labor can safely take place at home, but many first-time moms rush to the hospital at the first signs of labor, creating an artificial timeline. Once a woman checks in, the clock starts ticking. If labor isn’t progressing, an ob/gyn may insist on interventions—such as rupturing membranes and Pitocin—to move the birth along. ‘Once you start intervening, it’s a snowball rolling down the hill. One intervention begets another, and eventually, a C-section is just one more.’”9

“For medical necessity and convenience, labor is frequently induced [in a hospital]. Failed inductions, however, account for a big chunk of first-time C-sections. To activate labor, cervical ripening agents, Pitocin, and artificially rupturing membranes are used . . . but they may not ultimately work if mom and baby aren’t physiologically ready. A cervix that is not ripe and ready might not dilate. Rupturing membranes when baby’s head isn’t properly aligned in the pelvis can lead to a difficult trip down the birth canal.”9

An additional factor is the standard hospital practice of utilizing fetal heart monitors in labor/delivery rooms. Heart monitors are attached to the mother’s abdomen, and they’re used to determine the baby’s well-being. However, if the monitor indicates any red flags, there is often pressure to deliver via C-section. Studies suggest that fetal heart monitoring is actually an inaccurate indicator of hypoxia most of the time. Often, babies delivered by C-section because of “scary fetal heart tones” are born healthy.”9

One of the primary reasons ob/gyns resort to fetal heart monitoring is to avoid adverse birth outcomes that can lead to malpractice suits. According to James Stempel, M.D., an ob/gyn in Portland, Oregon “Hardly anybody sues for a C-section with a good outcome. The lawsuit comes when you didn’t do a C-section. Doctors can’t afford not to do one if they think there’s a problem.”9 “U.S. obstetricians average three lawsuits over the course of their careers, and at least one study found that physicians’ malpractice premiums, the number of claims against physicians and hospitals, and the physician’s perception of the risk of being sued were all positively correlated with the likelihood of cesarean delivery.”7

There are also many risks involved with a Cesearean. “Apart from the immediate operative risks—including infection, the need for blood transfusion, damage to pelvic organs, and postoperative pain—[there is also] concern regarding a mother’s future reproductive health, since later pregnancies are associated with increased risks of miscarriage, ectopic gestation, placenta previa, and placenta accreta. These risks are real and have been well described, yet when making decisions, patients and their providers often think only within the context of the current pregnancy, especially since future reproductive plans may be uncertain.”7

Home Birth vs. Hospital Birth for a Low-Risk Pregnancy
Wagner writes that while the primary factor in a planned home birth is that the mother is in charge of the childbirth process and everything that happens to her, in a hospital she won’t ever be in complete control. Wagner differentiates that having a choice about certain maternity careprocedures is not the same as having autonomy, since the doctors, nurses, nurse-midwives, and hospital administrators always retain the power to decide whether or not they will acquiesce to the mother’s choices. A doctor or hospital may try to pressure the mother to have a procedure she does not want. Mothers should know that they are entitled to deny specific services. Also, doctors are not required to do what the mother wants if the procedure goes against their professional judgment or preferences.4

The largest prospective study of planned home birth with a direct-entry midwife indicates that homebirth is as safe as hospital birth for women with low risk pregnancies, yet home birth accrues a much lower rate of medical interventions, including Cesarean section. Planning a home birth attended by a Certified Professional Midwife (CPM) offers as safe an outcome for low-risk mothers and babies as does a hospital birth. This study is the largest yet of its kind. The researchers used prospective data on more than 5400 planned home births in the United States and Canada attended by Certified Professional Midwives during the year 2000.10

The researchers analyzed outcomes and medical interventions for planned home births, including transports to hospital care, mortality rate, medical intervention during labor, breast feeding and maternal satisfaction and compared these results to the outcomes of 3,360,868 low risk hospital births.10 Findings include:

• 88% of the women birthed at home, while 12% transferred to a hospital.
• Planned home birth carried a rate of 1.7 infant deaths per 1,000 births, these rates were "consistent with most North American studies of intended births out of hospital and low risk hospital births. Medical intervention rates for planned home births were lower than for planned low risk hospital births.”
• There were no maternal deaths.
• “Compared with the relatively low risk hospital group, intended home births were associated with dramatically lower rates of medical intervention: episiotomy rate of 2.1% (33.0% in hospital), cesarean section rate of 3.7% (19.0% in hospital), forceps rate of 1.0% (2.2% in hospital), vacuum extraction rate of 0.6% (5.5% in hospitals), induction rate of 9.6% (21% in hospital), and electronic fetal monitoring rate of 9.6% (84.3% in hospital).
• 97% of over 500 participants who were randomly contacted to validate birth outcomes reported that they were extremely or very satisfied with the care they received. For a subsequent birth, 90% said they would choose the same midwife, 9% another certified professional midwife, and 1% another type of caregiver.

Financial difference between home birth and average hospital birth
“As health care costs increase and a growing number of women are without insurance, the one health service that every family needs deserves further attention. Even for the 40% of births covered by Medicaid, safe birthing alternatives that permit a reduction in the $150 billion Medicaid burden would allow the United States to devote more resources to other urgent priorities. Informed birthing decisions cannot be made without information on costs, success rates, and any necessary tradeoffs between the two. The average uncomplicated vaginal birth costs 68% less in a home than in a hospital, and births initiated in the home offer a lower combined rate of intrapartum and neonatal mortality and a lower incidence of cesarean delivery.”11

Understanding Midwifery
In 1452, the first law to regulate midwifery in Europe was passed. Ever since, and until the present, every young girl in Europe grows up understanding that if she ever has a baby, she will have a midwife to assist her. Midwifery is primary care for women. Although it’s often limited to maternity care, it may also include women’s reproductive health such as family planning and reproductive tract infections. “A midwife is analogous to a family physician in providing primary care and referring to specialist care as needed. A midwife transferring a laboring woman to an obstetrician when complications arise that may require surgery is analogous to a family physician referring a patient with blocked arteries to a cardiologist.”4

Midwifery migrated to the New World along with the Europeans. In mid-1600s, the king of France commissioned midwives working in New France (present-day Canada), and the British government paid for their services in the New World. Midwives were a valued part of the developing healthcare system and they often participated in the teaching of medical students in the mid-1880s. However, as the number of physicians in America increased, they attempted to monopolize healthcare through medical practice acts. By the end of the nineteenth century midwives were being accused of witchcraft and tried in court, and thus they began to disappear. As a result, nurses supported the medical domination of maternity care in America. An attempt to open a school of midwifery in Massachusetts in 1910 was defeated by opposition from both nurses and physicians.4

Yet, there will always be women who want to be midwives and women who want midwives at the birth of their babies. When officially-sanctioned midwifery disappeared in America, many midwives went underground. According to the previously referenced study10, midwives are actually safer than obstetricians for the 88% of births that “have no serious medical complications because the care they provide tends to be more “mother friendly”, with more continuous, one-on-one care than the care provided in the average hospital setting by doctors the teams of labor-and-delivery nurses that assist them. Midwives have had more training and more experience in normal birth than either obstetricians or labor-and-delivery nurses. Because midwives have had more experience with normal birth, understand variations of normal better, and are not constantly anxious that something may go wrong, they have far lower rates of interventions: induction, episiotomy, forceps and vacuum extraction, cesarean section—when compared with doctors who are also attending low-risk births.”4

“Midwives insist that pregnancy is not an illness. They know what can go wrong, how to identify problems early, and to cooperate with doctors in managing complications. They also know that while pursuing medical aspects of pregnancy is essential, it is not enough. They are trained to go beyond medical care and to support the pregnant woman [to] achieve her goals for herself and her baby. Midwives use low-tech assistance, such as the skilled use of their hands, and understand the importance of preserving normalcy in childbirth. Midwives believe in women’s bodies and their capacity to reproduce with little or no intervention in most cases.”4 Numerous surveys indicate a greater level of satisfaction with a mother’s birth experience if a midwife attends the birth rather than an obstetrician. A midwife will be with you from the beginning of labor until some time after the birth is completed. Also, whenever a doctor runs a test or gives a treatment to a laboring woman, it can be an unspoken vote of no confidence in her body. Yet, as the midwife uses every means possible to demonstrate her belief in the ability of the woman’s body to give birth successfully, the woman herself begins to believe in her abilities. The result can be an incredibly empowering birthing experience.4

Goals of Maternity Care
The Coalition for Improving Maternity Services (CIMS), established in 1996, is a United Nations-recognized nongovernmental organization and has more than fifty organizational members, including groups of midwives, labor-and-delivery nurses, doulas, childbirth educators, and others, all together representing more than 90,000 individuals. Their mission is to promote a wellness model of maternity care that will improve birth outcomes and substantially reduce costs.3,4

According to the “Ten Steps of the Mother-Friendly Childbirth Initiative” published by the CIMS, hospitals, birth centers, and home-birth services should not exceed the following rates of interventions: an induction rate of 10 percent or less; an episiotomy rate of 20 percent or less, with a goal of 5 percent or less; a total cesarean rate of 10 percent or less in community hospitals and 15 percent or less in tertiary care (high-risk) hospitals; and a VBAC rate of 60 percent or more with a goal of 75 percent or more.4,5

The CIMS, defined five philosophical keys to having the safest birthing experience.4,5

• Treating birth as a normal, natural process (not a disease)
• Exercising restraint and weighing scientific evidence before using drugs and other interventions (a.k.a. “First, do no harm”)
• Empowerment of mothers and families
• Recognition of the autonomy of women
• Everyone—care providers, administrators, and pregnant women alike—assumes responsibility for their role in the birth process

Furthermore, CIMS suggests that there are signs that you are receiving mother-friendly care:4,5

• Women should have unrestricted access to birth companions of your choice, including her spouse or partner, children, family members, and friends.
• Women should have unrestricted access to continuous emotional and physical support from a woman skilled in childbirth, such as a doula or labor-support professional.
• Women should have access to professional midwifery care if you want it.
• Women should be provided accurate descriptive and statistical information about practices and procedures for birth care, including how often different interventions have been used in other births and their outcomes.
• Women’s care should be culturally competent—that is, sensitive and responsive to her specific ethnic and religious beliefs, values, and customs.
• Women should have the freedom to walk, move about, and assume positions of her choice during labor and birth (unless a restriction is specifically required to correct a complication), and she should never be placed lying flat on her back with her legs elevated.
• It should be clear to the pregnant woman what procedures her caregiver will use to collaborate and consult with other maternity services before the birth and if transfer from one birth site to another is necessary during labor, including how communication will be handled between her original caregiver and a second caregiver.
• A hospital, birth center, or caregiver should not routinely employ practices and procedures that are unsupported by scientific evidence, including but not limited to shaving, enemas, intravenous (IV) drips, withholding food and beverages, early rupture of membranes/amniotic sac, and electronic fetal monitoring (EFM).
• A hospital or birth center should limit other interventions, including induction (artificially starting labor), episiotomy (surgical cutting to widen the vaginal opening for birth), and cesarean section.
• Women should be provided with information about non-drug methods of pain relief.
• Women should not feel that analgesic or anesthetic drugs are being promoted to them that are not specifically required to correct a complication.
• Women should be permitted, even if she have a sick or premature newborn or an infant with congenital problems, to touch, hold, breastfeed, and care for her baby to the extent that’s compatible with your condition.
• Women should be provided with breastfeeding support and linked with appropriate community resources for postnatal support.

Considerations for Choosing the Right Maternity Care
Pregnant women should be encouraged to talk with both midwives and obstetricians available to them. They should interview the prospective health care providers at length, and see if they become restless or uncomfortable. A woman should tell a health care provider that giving birth is one of the most important events in her life and that she will go to whatever lengths to have it done right. A woman should discern if the prospective provider is condescending or if (s)he seems resentful to her questions, or if the provider encourages her to take responsibility for her own pregnancy and birth. A woman should not be afraid to change care providers if after a few visits she doesn’t like how one is caring or is not caring for her.4

Regardless of the choice, every type of health care provider has some risks during the birth process. It is up to the patient to weigh to risks and benefits and to make a decision that is best for her.

RESOURCES:

1. G Dick-Read. Childbirth without fear: the principles and practice of natural childbirth.
2. H Murkoff., A Eisenberg., & S Hathaway. What to expect when you’re expecting. 3rd ed. New York: Workman Publishing, 2002.
3. V Iovine. The girlfriends’ guide to pregnancy: or everything your doctors won’t tell you. New York: Pocket Books, 1995.
4. M Wagner, S Gunning. Creating your birth plan: the definitive guide to a safe and empowering birth. New York: Berkeley Publishing, 2006.
5. Ten steps of the mother-friendly childbirth initiative for mother-friendly hospitals, birth centers, and home birth services. The Coalition for Improving Maternity Services (CIMS), 1996. Website: www.motherfriendly.org. Referenced from M Wagner, & S Gunning. Creating your birth plan. p. 11, 253.4
6. B Darves. Infant mortality, obesity increasing in the U.S. Medscape Today. 10 Nov 2004. Website: http://www.medscape.com/viewarticle/493512
7. JL Ecker, & FD Frigoletto, Jr.. Cesarean delivery and the risk-benefit calculus. N Engl J Med. 2007;356(9):885-88.
8. LA Thompson LA, DC Goodman, & GA Little. Is more neonatal intensive care always better? Insights from a cross-national comparison of reproductive care. Pediatrics. Jun 2002;109(6):1036-43. Website: http://pediatrics.aappublications.org/cgi/content/abstract/109/6/1036.
9. J Faulkner. C-sections. Pregnancy. 2007;(8)2:81-5.
10. KC Johnson, & B Daviss. Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ. 2005;330:1416-.
11. RE Anderson. DA Anderson. The cost-effectiveness of home birth. Journal of Nurse- Midwifery. Jan-Feb 1999;44(1):30-5.